Document:

exhibit10-6.htm

    
      
        
          

        

        Back
          to Form 10-Q

        Exhibit
          10.6

         

         

        STATE
          OF CONNECTICUT

      

      
        DEPARTMENT
          OF SOCIAL SERVICES

      

      
        

      

      
        CONTRACT
          AMENDMENT

      

      
        

      

      
        	
                Amendment
                  Number:

              	
                16

              
	
                Contract
                  #:

              	
                093-MED-WCC-1

              
	
                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

              

      

      
        

        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, 14 and 15 is hereby further amended
          as
          follows:

      

      
         

        
          	
                  1.

                	
                  Part
                    II "GENERAL CONTRACT TERMS FOR MCOs" dated December 12, 2003
                    are deleted
                    in their entirety and replaced with Part II "GENERAL CONTRACT TERMS
                    FOR MCOs" pages 1 through 115 dated 05/07 attached
                    hereto.

                

        

      

      
         

        
          	
                  2.

                	
                  Appendices
                    A through L are deleted in their entirety and replaced with the
                    following
                    appendices
                    attached hereto;

                

        

      

      
         

        A. HUSKY
          A Covered Services

      

      
        B.  Provider
          Credentialing and Enrollment Requirements

      

      
        C.  EPSDT
          Periodicity & Immunization Schedules

      

      
        D.  DSS
          Marketing Guidelines

      

      
        E.   Standards
          for Internal Quality Assurance Programs for Health Plans

      

      
        F.   Claims
          Inventory, Aging and Unaudited Quarterly Financial Reports

      

      
        G.   HUSKY
          A Medicaid Coverage Groups

      

      
        H    BLANK
          - RESERVED FOR POSSIBLE FUTURE USE

      

      
        I.     Capitation
          Payment Amounts

      

      
            1.           Table
          1 - HUSKY A Capitation Rates effective 01/01/06 - 06/30/06

      

      
            2.           Table
          2 - HUSKY A Capitation Rates effective 07/01/06 -
          06/30/07 

      

      
        J.     BLANK
          - RESERVED FOR POSSIBLE FUTURE USE

      

      
        K.   Inpatient/Eligibility
          Recategorization Chart

      

      
        L.    Pharmacy
          Reports M. Rate Certification

      

      
        N.   HUSKY
          Behavioral Health Carve-Out Coverage and Coordination of Medical and Behavioral
          Services

      

      
        O.   CTBHP
          Master Covered Services Table

      

      
        

         

        Page
          1 of
          2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

      
        
          	
                	
                  3.

                	
                   
                    Appendices A through G and K through O shall become effective
                    upon the
                    proper execution of this amendment by the Department and the
                    Contractor.

                

        

      

      
         

        
          	
                	
                  4.

                	
                   
                    Appendix I Capitation Payment Amounts -Table 1 - HUSKY A Capitation
                    Rates
                    shall be effective for the period
                    01/01/06-06/30/06.

                

        

      

      
         

        
          	
                	
                  5.

                	
                   
                    Appendix I Capitation Payment Amounts -Table 2 - HUSKY A Capitation
                    Rates
                    shall be effective for the period
                    07/01/06-06/30/07.

                

        

      

      
         

        
          	
                	
                  6. 

                	
                  Pursuant
                    to Public Act 07-1, An Act Concerning the State Contractor Contribution
                    Ban and Gifts to State and Quasi-Public Agencies the Department must
                    provide and each Contractor must acknowledge receipt of the State
                    Elections Enforcement Commission's notice advising state contractors
                    of
                    state campaign contribution and solicitation prohibitions. Through
                    the execution of this amendment the Department certifies that SEEC
                    FORM 11 - NOTICE TO EXECUTIVE BRANCH STATE CONTRACTORS AND
                    PROSPECTIVE STATE CONTRACTORS OF CAMPAIGN CONTRIBUTION
                    AND SOLICITATION BAN has been provided to the Contractor and the
                    Contractor acknowledges receipt of the
                    same.

                

        

      

      
        

         

        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.

      

      

      
        	
                WELLCARE
                  of CONNECTICUT, Inc.

                 

              	
                DEPARTMENT

              
	
                  /s/  Todd
                  S. Farha

              	
                5/30/2007

              	
                 /s/   Michael
                  Starkowski

              	
                5/31/2007

              
	
                Signature

              	
                Date

              	
                  Signature

              	
                Date

                 

              
	
                Todd
                  S. Farha

              	
                President
                  & CEO

              	
                Michael
                  Starkowski

              	
                Commissioner

              
	
                Typed
                  Name

              	
                Title

              	
                Typed
                  Name

              	
                Title

              

      

      
        

         

        Attorney
          General (as id form)    Date

      

      
        

         

        (  )
          This contract does not require the signature of the Attorney General pursuant
          to
          an agreement between the Department and the Office of the Attorney General
          dated:

      

      
        

         

        Page
          2 of
          2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

      
         (Part
          II, 3.01-3.35)  07 HUSKY A 05/07

      

      
        

      

      
        PART
          I: STANDARD CONNECTICUT CONTRACT TERMS 

      

      
        PART
          II:  GENERAL CONTRACT TERMS FOR MCOs

      

      
        1.          DEFINITIONS

      

      
        2.          DELEGATIONS
          OF AUTHORITY

      

      
        3.          FUNCTIONS
          AND DUTIES OF THE MCO

      

      
        3.1         Provision
          of Services

      

      
        3.2         Non-Discrimination

      

      
        3.3         Member
          Rights

      

      
        3.4         Gag
          Rules

      

      
        3.5         Coordination
          and Continuation of Care

      

      
        3.6         Emergency
          Services

      

      
        3.7         Geographic
          Coverage

      

      
        3.8         Choice
          of Health Professional

      

      
        3.9         Provider
          Network

      

      
        3.10       Network
          Adequacy and Maximum Enrollment Levels

      

      
        3.11       Provider
          Contracts

      

      
        3.12       Provider
          Credentialing and Enrollment

      

      
        3.13       Second
          Opinions, Specialist Providers and the Referral Process

      

      
        3.14       PCP
          and Specialist Selection, Scheduling and Capacity

      

      
        3.15       Women's
          Health, Family Planning Access and Confidentiality

      

      
        3.16       Pharmacy
          Access

      

      
        3.17       Mental
          Health and Substance Abuse Access

      

      
        3.18       Children's
          Issues and EPSDT Compliance

      

      
        3.19       Specialized
          Outpatient Services for Children Under DCF Care

      

      
        3.20       Prenatal
          Care

      

      
        3.21       Dental
          Care

      

      
        3.22       Other
          Access Features

      

      
        3.23       Pre-Existing
          Conditions

      

      
        3.24       Newborn
          Enrollment

        
          3.25      
            Acute
            Care Hospitalization, Nursing Home or Long Term Chronic Disease Hospital
            Stay 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       Marketing
          Requirements

      

      
        3.32       Health
          Education

      

      
        3.33       Internal
          and External Quality Assurance

      

      
        3.34       Inspection
          of Facilities

      

      
        3.35      
          Examination of Records

      

      
        3.36      
          Medical Records

      

      
        Part
          II

      

      
        1

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        (Part
          II,
          3.01-3.35)  07 HUSKY A 05/07

      

      
         

        3.37            Audit
          Liabilities

      

      
        3.38            Clinical
          Data Reporting

      

      
        3.39            Utilization
          Management

      

      
        3.40            Financial
          Records

      

      
        3.41            Insurance

      

      
        3.42            Third
          Party Coverage

      

      
        3.43            Coordination
          of Benefits and Delivery of Services

      

      
        3.44            Passive
          Billing

      

      
        3.45            Subcontracting
          for Services

      

      
        3.46            Timely
          Payment of Claims

      

      
        3.47            Member
          Charges for Noncovered Services

      

      
        3.48            Insolvency
          Protection

      

      
        3.49            Acceptance
          of DSS Rulings

      

      
        3.50            Fraud
          and Abuse

      

      
        3.51            Persons
          with Special Health Care Needs

      

      
        3.52            Behavioral
          Health Payment Adjustment

      

      
         

        4.          FUNCTIONS
          AND DUTIES OF THE DEPARTMENT

      

      
        4.1            Eligibility
          Determinations

      

      
        4.2            Populations
          Eligible to Enroll

      

      
        4.3            Enrollment/Disenrollment

      

      
        4.4            Default
          Enrollment

      

      
        4.5            Capitation
          Payments to MCO

      

      
        4.6            Retroactive
          Adjustments

      

      
        4.7            Information

      

      
        4.8            Ongoing
          MCO Monitoring

      

      
        4.9            Utilization
          Review and Control

      

      
         

        5.           DECLARATIONS
          AND MISCELLANEOUS PROVISIONS

      

      
        5.1           Competition
          Not Restricted

      

      
        5.2           Nonsegregated
          Facilities

      

      
        5.3           Offer
          of Gratuities

      

      
        5.4           Employment/Affirmative
          Action Clause

      

      
        5.5           Confidentiality

      

      
        5.6           Independent
          Capacity

      

      
        5.7           Liaison

      

      
        5.8           Freedom
          of Information

      

      
        5.9           Waivers

      

      
        5.10         Force
          Majeure

      

      
        5.11         Financial
          Responsibilities of the MCO

      

      
        5.12         Capitalization
          and Reserves

      

      
        5.13         Provider
          Compensation

      

      
        5.14         Members
          Held Harmless

      

      
        5.15         Compliance
          with Applicable Laws, Rules and Policies

      

      
        5.16         Advance
          Directives

      

      
        5.17         Federal
          Requirements and Assurances

      

      
        5.18         Civil
          Rights

      

      
        

         

        Part
          II

      

      
        2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        (Part
          II,
          3.01-3.35)    07 HUSKY
          A     05/07

      

      
        

         

        5.19           Statutory
          Requirements

      

      
        5.20           Disclosure
          of Interlocking Relationships

      

      
        5.21           DEPARTMENT'S
          Data Files

      

      
        5.22           Changes
          Due to a Section 1115 or 1915(b) Freedom of Choice

      

      
        5.23           Hold
          Harmless

      

      
        5.24           Executive
          Order Number 16

      

      
         

        6.            GRIEVANCE
          SYSTEM AND PROVIDER DENIALS

      

      
        6.1           Grievances

      

      
        6.2           Notices
          of Action and Continuation of Services

      

      
        6.3           Appeals
          and Administrative Hearing Processes

      

      
        6.4           Expedited
          Appeals and Administrative Hearings

      

      
        6.5           Provider
          Appeal Process

      

      
         

        7.            CORRECTIVE
          ACTION AND CONTRACT TERMINATION

      

      
        7.1           Performance
          Review

      

      
        7.2           Settlement
          of Disputes

      

      
        7.3           Administrative
          Errors

      

      
        7.4           Suspension
          of New Enrollment

      

      
        7.5           Monetary
          Sanctions

      

      
        7.6           Temporary
          Management

      

      
        7.7           Payment
          Withhold, Class C Sanctions or Termination for Clause

      

      
        7.8           Emergency
          Services Denials

      

      
        7.9           Termination
          for Default

      

      
        7.10         Termination
          for Mutual Convenience

      

      
        7.11         Termination
          for the MCO Bankruptcy

      

      
        7.12         Termination
          for Unavailability of Funds

      

      
        7.13         Termination
          for Collusion in Price Determination

      

      
        7.14         Termination
          Obligations of Contracting Parties

      

      
        7.15         Waiver
          of Default

         

      

      
        8.            OTHER
          PROVISIONS

      

      
        8.1           Severability

      

      
        8.2           Effective
          Date

      

      
        8.3           Order
          of Precedence

      

      
        8.4           Correction
          of Deficiencies

      

      
        8.5           This
          is not a Public Works Contract

      

      
         

        9.            APPENDICES

      

      
        Appendix
          A HUSKY A Covered Services

      

      
        Appendix
          B Provider Credentialing and Enrollment Requirements

      

      
        Appendix
          C EPSDT Periodicity & Immunization Schedules

      

      
        Appendix
          D DSS Marketing Guidelines

      

      
        Appendix
          E Standards for Internal Quality Assurance Programs for
          Health Plans

      

      
        Appendix
          F Claims Inventory, Aging and Unaudited Quarterly
          Financial Reports

      

      
        

         

        Part
          II

      

      
        3

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        (Part
          II,
          3.01-3.35)   07 HUSKY A  05/07

      

      
        

      

      
        Appendix
          G HUSKY A Medicaid Coverage Groups

      

      
        Appendix
          I   Capitation Payment Amount - Tables

      

      
        Appendix
          K Medical Acute Care Primary Inpatient/Eligibility Recategorization
          Changes

      

      
        Appendix
          L Pharmacy Reports

      

      
        Appendix
          M Rate Certification

      

      
        Appendix
          N HUSKY Behavioral Health Carve-Out Coverage and Coordination
          of Medical and Behavioral Services Appendix O CTBHP Master Covered Services
          Table

      

      
         

        Removed
          Appendices:

      

      
        Appendix
          H   MMC Policy Transmittals

      

      
        Appendix
          J    Physician Incentive Payments

      

      
        

         

        Part
          II

      

      
        4

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        (Part
          II,
          3.01-3.35)  07 HUSKY A  05/07

      

      
        

      

      
        

      

      
        

      

      
        Part
          I: Standard Connecticut Contract Terms

      

      
        

         

        Part
          II

      

      
        5

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        (Part
          II,
          3.01-3.35)  07 HUSKY A   05/07

      

      
         

        PART
          II:  GENERAL CONTRACT TERMS FOR MCOs

      

      
         

        1.        DEFINITIONS

      

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

      

      
         

        Abuse:

      

      
        Provider
          and/or MCO practices that are inconsistent with sound fiscal, business
          or
          medical practices and that result in an unnecessary cost to the HUSKY A
          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 A program
          also
          constitute abuse.

      

      
         

        Action:

      

      
        The
          denial or limited authorization of a requested service, including the type
          or
          level of service; the reduction, suspension, or termination of a previously
          authorized service; the denial, in whole or in part, of payment for a service;
          the failure to provide services in a timely manner, as defined by the
          DEPARTMENT; the failure of an MCO to act within the timeframes for authorization
          decisions set forth in this Contract.

      

      
         

        Administrative
          Services Organization (ASO):

      

      
        An
          organization providing utilization management, benefit information and
          intensive
          care management services within a centralized information system
          framework.

      

      
         

        Advance
          Directive:

      

      
        A
          written
          instruction, such as a living will or durable power of attorney for health
          care,
          recognized under Connecticut law, relating to the provision of health care
          when
          the individual is incapacitated.

      

      
         

        Agent:

      

      
        An
          entity
          with the authority to act on behalf of the DEPARTMENT.

      

      
         

        Appeal:

      

      
        A
          request
          to the MCO from a Member for a formal review of an MCO
          action.

      

      
         

        Behavioral
          Health Partnership ("Partnership" or "BHP" or
          "CTBHP"):

      

      
        An
          integrated behavioral health service system for HUSKY Part A and HUSKY
          Part B
          members, children enrolled in the Voluntary Services Program operated by
          the
          Department of Children and Families and may, at the discretion of the
          Commissioners of Children and Families and Social Services, include other
          children, adolescents, and families served by the Department of Children
          and
          Families.

      

      
         

        Behavioral
          Health Services:

      

      
        Services
          that are necessary to diagnose, correct or diminish the adverse effects
          of a
          psychiatric or substance use disorder.

      

      
         

        Capitation
          Payment:

      

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

      

      
         

        Capitation
          Rate:

      

      
        The
          amount paid per Member by the DEPARTMENT to each Managed Care Organization
          (MCO)
          on a monthly basis.

      

      
         

        Part
          II

        1

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        (Part
          II,
          3.01-3.35)   07 HUSKY A  05/07

      

      
        

         

        Chronic Disease
          Hospital

      

      
        Conn.
          Agencies Reg. § 19-13-D1(b). A chronic disease hospital is defined as a
          "long-term hospital having facilities, medical staff and all necessary
          personnel
          for the diagnosis, care and treatment of a wide range of chronic diseases
          and
          licensed as a chronic disease hospital.

      

      
         

        CMS:

      

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

      

      
         

        Clean
          Claim:

      

      
        A
          bill
          for service(s) or good(s), a line item of services or all services and/or
          goods
          for a recipient contained on one bill that 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.

      

      
         

        Cold
          Call Marketing:

      

      
        Any
          unsolicited personal contact by the MCO with a potential Member for the
          purpose
          of marketing.

      

      
         

        Commissioner:

      

      
        The
          Commissioner of the Department of Social Services, as defined in Section
          17b-3
          of the Connecticut General Statutes.

      

      
         

        Consultant:

      

      
        A
          corporation, company, organization or person or their affiliates retained
          by the
          DEPARTMENT to provide assistance in this project or any other project,
          not the
          MCO or subcontractor.

      

      
         

        Contract
          Administrator:

      

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

      

      
         

        Contract
          Services:

      

      
        Those
          services that the MCO is required to provide to Members under this
          contract.

      

      
         

        CPT
          Codes or Current Procedure Terminology:

      

      
        A
          listing
          of descriptive terms and identifying codes for reporting medical services
          and
          procedures for a variety of uses, including billing of public and private
          health
          insurance programs. The codes are developed and published by the American
          Medical Association.

      

      
         

        Date
          of Application:

      

      
        The
          date
          on which a completed application for the HUSKY A 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.

      

      
         

        DEPARTMENT
          or DSS:

      

      
        The
          Department of Social Services, State of Connecticut

      

      
        

         

        Part
          II

      

      
        2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        (Part
          II,
          3.01-3.35) 07 HUSKY A 05/07

      

      
        

        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.

      

      
         

        Emergency
          Services:

      

      
        Covered
          inpatient and outpatient services that are: 1) furnished by a provider
          that is
          qualified to furnish Medicaid services; and 2) needed to evaluate or stabilize
          an emergency medical condition. Such services shall include, but not be
          limited
          to, behavioral health and detoxification needed to evaluate or stabilize
          an
          emergency medical condition that is found to exist using the prudent layperson
          standard.

      

      
         

        Enhanced
          Care Clinics:

      

      
        Clinics
          that qualify for fees that are higher than the standard Medicaid fee schedule
          for outpatient mental health and substance abuse clinics. In order to qualify
          for such higher fees, clinics must meet special service requirements as
          determined by the CT BMP.

      

      
         

        Early
          and Periodic Screening, Diagnosis and Treatment (EPSDT)
          Services:

      

      
        Comprehensive
          child health care services to Members under twenty-one (21) years of age,
          including all medically necessary prevention, screening, diagnosis and
          treatment
          services listed in Section 1905 (r) of the Social Security
          Act.

      

      
        

         

        
          	
                  1.

                	
                  EPSDT
                    Case Management Services: Services such as making
                    and facilitating referrals and development and coordination of a
                    plan
                    of services that will assist Members under twenty-one (21) years of
                    age in gaining access to needed medical, social, educational,
                    and other
                    services.

                

        

      

      
         

        
          	
                  2.

                	
                  EPSDT
                    Diagnostic and Treatment Services: All health care,
                    diagnostic services, and treatment necessary to correct or ameliorate
                    defects and physical and mental illnesses and conditions discovered
                    by an interperiodic or periodic EPSDT screening
                    examination.

                

        

      

      
         

        
          	
                  3.

                	
                  EPSDT
                    Screening Services: Comprehensive, periodic health
                    examinations for Members under the age of twenty-one (21) provided in
                    accordance with the requirements of the federal Medicaid statute at
                    42 U.S.C. §1396d(r)(1).

                

        

      

      
         

        Enrollment
          Broker: The organization contracted by the DEPARTMENT to perform the
          following administrative and operational functions for the HUSKY A and
          B
          programs: HUSKY application processing, HUSKY B eligibility determinations,
          passive billing and enrollment brokering.

      

      
         

        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.

      

      
         

        Formulary:

      

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

      

      
         

        Part
          II

      

      
        3

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        (Part
          II,
          3.01-3.35) 07 HUSKY A 05/07

      

      
        

         

        FQHC-Sponsored
          MCO:

      

      
        An
          MCO
          that is more than fifty (50) percent owned by Connecticut Federally Qualified
          Health
          Centers, certified by the DEPARTMENT to enroll Medicaid
          Members.

      

      
         

        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.

         

      

      
        Grievance:

      

      
        An
          expression of dissatisfaction about the MCO on any matter other than an
          "action"
          as defined herein. Possible subjects for grievances include, but are not
          limited
          to, the quality of care or services provided by the MCO and aspects of
          interpersonal relationships such as rudeness of a provider or an MCO employee,
          or failure to respect a Member's rights.

      

      
         

        Health
          Employer Data 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 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.

         

      

      
        Institution
          for Mental Disease (IMD)

      

      
        Means
          a
          hospital, nursing facility, or other institution of more than sixteen beds,
          primarily for the diagnosis, treatment or care of persons with mental diseases,
          not including mental retardation.

      

      
         

        In-Network
          Providers or Network Providers:

      

      
        Providers
          who have contracted with the MCO to provide services to
          Members.

      

      
         

        Lock-in:

      

      
        Limitations
          on Member changes of managed care plans for a period of time, not to exceed
          twelve (12) months.

      

      
         

        Managed
          Care Organization (MCO):

      

      
        The
          organization signing this agreement with the DEPARTMENT.

      

      
         

        Marketing:

      

      
        Any
          communication from an MCO to a Medicaid recipient who is not enrolled in
          that
          entity, 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.

      

      
         

        Marketing
          Materials:

      

      
        Any
          materials produced in any medium, by or on behalf of an MCO that can reasonably
          be interpreted as intended to market to potential
          Members.

      

      
         

        Part
          II

        4

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        (Part
          II,
          3.01-3.35)  07 HUSKY A 05/07

      

      
         

        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.

      

      
         

        Medicaid
          Program Provider Manuals:

      

      
        Service-specific
          documents created by Connecticut Medicaid to describe policies and procedures
          applicable to the Medicaid program generally and that service
          specifically.

      

      
         

        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/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.

      

      
         

        Member:

      

      
        For
          the
          purposes of HUSKY A, a Medicaid client who has been certified by the State
          as
          eligible to enroll under this contract, and whose name appears on the MCO
          enrollment information that the DEPARTMENT will transmit to the MCO every
          month
          in accordance with an established notification schedule.

      

      
         

        National
          Committee for Quality Assurance (NCQA):

      

      
        NCQA
          is
          a not-for-profit organization that develops and defines quality
          and performance measures for managed care, thereby providing an external
          standard of accountability.

      

      
         

        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 (PRO):

      

      
        A
          professional medical organization that conducts peer review of medical
          care
          certified by HCFA or CMS.

      

      
         

        Pharmacy
          Benefits Manager (PBM):

      

      
        An
          entity
          that, through an arrangement with the MCO, is responsible for managing
          or
          arranging for one or more of the Medicaid pharmacy services provided by
          the MCO
          pursuant to this contract.

      

      
         

        Pharmacy
          or Provider Lock-In:

      

      
        An
          optional MCO program, subject to approval by the DEPARTMENT, to restrict
          certain
          Members to a specific pharmacy or provider in order to monitor services
          and
          reduce unnecessary or inappropriate utilization.

      

      
         

        Post-Stabilization
          Services:

      

      
        Covered
          services related to an emergency medical condition that are provided after
          a
          Member is stabilized in order to maintain the stabilized condition, or
          under the
          circumstances described in 42 CFR 422.114(3), to improve or resolve the
          Member's
          condition.

      

      
        

         

        Part
          II

      

      
        5

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        (Part
          H,
          3.01-3.35) 07 HUSKY A 05/07

      

      
        

         

        Potential
          Member:

      

      
        A
          Medicaid recipient who is subject to enrollment in a managed care organization
          but is not
          yet
a Member of a specific MCO.

      

      
         

        Primary
          Care Provider (PCP):

      

      
        A
          licensed health care professional responsible for performing or directly
          supervising the primary care services of Members.

      

      
         

        Prior
          Authorization:

      

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

      

      
         

        Revenue
          Center Code:

      

      
        A
          revenue
          code identifies a specific Medicaid billable service type. Facilities must
          choose
          the code that most appropriately describes the service to be billed to
          Medicaid.

      

      
         

        Risk:

      

      
        The
          possibility of monetary loss or gain by the MCO resulting from service
          costs
          exceeding or being less than payments made to it 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 emergent nor urgent
          nature.

      

      
         

        Subcontract:

      

      
        Any
          written agreement between the MCO and another party to fulfill any requirements
          of this contract, except a written agreement between the MCO and a
          vendor.

      

      
         

        Subcontractor:

      

      
        The
          party
          contracting with the MCO to manage or arrange for one or more of the Medicaid
          services provided by the MCO pursuant to this contract, but excluding services
          provided by a vendor.

      

      
         

        Third-Party:

      

      
        Any
          individual, entity or program that is or may be liable to pay all or part
          of the
          expenditures for Medicaid furnished under a State plan.

      

      
         

        Title
          XIX:

      

      
        The
          provisions of 42 United States Code Section 1396 et seq.. including any
          amendments thereto. (See Medicaid)

         

      

      
        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 for which treatment cannot be delayed without imposing undue
          risk on
          the Members' 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.

      

      
         

        Well-care
          Visits:

      

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

      

      
         

        Part
          II

        6

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        (Part
          H,
          3.01-3.35) 07 HUSKY A 05/07

      

      
        

         

        2.   DELEGATIONS
          OF AUTHORITY

      

      
         

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

      

      
         

        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 individuals enrolled under this contract,
                    directly or through arrangements with others, all of the covered
                    services described in Appendix A of this
                    contract.

                

        

      

      
         

        
          	
                  b.

                	
                  The
                    MCO shall ensure that the services provided to Members are sufficient
                    in amount, duration and scope to reasonably be expected to achieve
                    the purpose for which the service is provided. The services provided
                    under this contract shall be in an amount, duration and scope that is
                    no less than the amount, duration and scope of services for
                    fee-for- service Medicaid clients. The MCO shall not arbitrarily deny
                    or reduce the amount, duration or scope of a required service solely
                    because of the Member's diagnosis, type of illness or medical
                    condition.

                

        

      

      
         

        
          	
                  c.

                	
                  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 and Medically Necessary or Medical Necessity at Part II
                    Section 1, General Contract Terms for MCOs. As required by 42 CFR
                    438.236 and as more fully described in Appendix E, the MCO shall
                    adopt practice guidelines as part of its quality improvement program.
                    The MCO shall disseminate the guidelines to affected providers and to
                    Members, upon request. The MCO's utilization management decisions
                    must be consistent with any applicable practice guidelines adopted by
                    the MCO. In order to operationalize the medical necessity definition,
                    the MCO may use utilization management criteria or guidelines
                    developed by the MCO or a by a subcontractor or a third party. The
                    MCO shall only use such criteria or guidelines in conjunction with
                    the DEPARTMENT'S medical necessity and medical appropriateness
                    definitions. The DEPARTMENT'S definitions take precedence over any
                    guidelines or criteria and are mandatory and binding on all MCO
                    utilization management decisions. The MCO shall also ensure that its
                    subcontracts and contracts with network providers require that the
                    decisions of subcontractors and network providers affecting the
                    delivery of acute or chronic care services to Members are made on an
                    individualized basis and in accordance with the contractual definitions
                    for Medical Appropriateness or Medically Appropriate and Medically
                    Necessary and Medical
                    Necessity.

                

        

      

      
        

         

        Part
          II

      

      
        7

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        (Part
          II,
          3.01-3.35) 07 HUSKY A 05/07

      

      
         

        
          	
                  d.

                	
                  The
                    MCO shall provide twenty-four (24) hour, seven (7) day a
                    week accessibility to qualified medical personnel for 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.

                

        

      

      
         

        
          	
                  e.

                	
                  Changes
                    to Medicaid covered services mandated by Federal or State law, or
                    adopted by amendment to the State Plan for Medicaid, 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 Medicaid coverage were expanded to
                    include new services, such services would be paid for via the
                    traditional Medicaid fee- for-service system unless covered by mutual
                    consent between the DEPARTMENT and the MCO (in which case an
                    appropriate adjustment to the capitation rates would be made). If
                    Medicaid covered services are changed to exclude services, the
                    DEPARTMENT may determine that such services will no longer be covered
                    under HUSKY A 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 concerning the change to Medicaid covered
                    services, 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.

                

        

      

      
         

      

      
        
          	
                  f.

                	
                  Any
                    change regarding the provision of covered services that will
                    become effective during the term of this Contract shall be
                    implemented by the MCO within sixty (60) days of receiving notice of
                    the change from the DEPARTMENT, unless law requires earlier
                    compliance.

                

        

      

      
        

         

        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

                

        

      

      
        

         

        Part
          II

      

      
        8

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        (Part
          II,
          3.01-3.35) 07 HUSKY A 05/07

      

      
         

        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
          Part
          60-1 et seg., Obligations of Contractors and Subcontractors). The MCO shall
          also
          comply with Sections 4a-60, 4a-61, 31-51d, 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 HCFA publications, program regulations, and instructions
          to assure support for civil rights; and initiating orientation and training
          programs on civil rights. The MCO shall provide to the DEPARTMENT or to
          CMS,
          upon request, any available 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 by the contract, the MCO shall provide covered
                    services to HUSKY A Members under this contract in the same manner
                    as
                    those services are provided to other Members of the MCO,
                    although

                

        

      

      
        

         

        Part
          II

        9

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          
            	
                     

                  	
                    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 to Members 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 of HUSKY A and
                      other
                      Members of the MCO. The MCO shall ensure that its network providers
                      offer
                      hours of operation that are no less than those offered to the
                      MCO's
                      commercial members or comparable to Medicaid fee-for-service,
                      if the
                      provider serves only Medicaid
                      Members.

                  

          

        

        
          

          
            	
                    c. 

                  	
                    Nothing
                      in this section shall preclude the implementation of a pharmacy
                      or
                      provider lock-in program by the MCO, based on the DEPARTMENT'S
                      approval of
                      such program.

                  

          

        

        
          

          3.03            Member
            Rights

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall have written policies regarding member rights. The
                      MCO must
                      comply with all applicable state and federal laws pertaining
                      to member rights and privacy. The MCO shall further ensure that
                      the
                      MCO's employees, subcontractors and network providers consider and
                      respect those rights when providing services to
                      Members.

                  

          

        

        
          

          b.           Member
            rights include, but are not limited to, the following:

        

        
          

          
            	
                    1.

                  	
                    The
                      right to be treated with respect and due consideration for
                      the Member's dignity and
                      privacy;

                  

          

        

        
          

          
            	
                    2.

                  	
                    The
                      right to receive information on treatment options and alternatives in
                      a manner appropriate to the Member's condition and ability to
                      understand;

                  

          

        

        
          

          
            	
                    3.

                  	
                    The
                      right to participate in treatment decisions, including the
                      right
                      to refuse treatment;

                  

          

        

        
          

          
            	
                    4.

                  	
                    The
                      right to be free from any form of restraint or seclusion as
                      a means
                      of coercion, discipline, retaliation or
                      convenience;

                  

          

        

        
          

          
            	
                    5.

                  	
                    The
                      right to receive a copy of his or her medical records, including, if
                      the HIPAA privacy rule applies, the right to request that the records
                      be amended or corrected as allowed in 45 CFR part
                      164; and

                  

          

        

        
          

          
            	
                    6.

                  	
                    Freedom
                      to exercise the rights described herein without any adverse affect on
                      the Member's treatment by the DEPARTMENT, the MCO or the MCO's
                      subcontractors or network
                      providers.

                  

          

        

        
          

          3.04            Gag
            Rules

        

        
          

          
            	
                    a. 

                  	
                    Subject
                      to the limitations described in 42 U.S.C. Section 1396u-2(b)(3)(B)
                      and
                      (C), the MCO shall not prohibit or otherwise restrict a health
                      care
                      provider acting within his or her lawful scope of practice
                      from advising
                      or

                  

          

        

        
          

          Part
            II

          10

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          advocating
            on behalf of a Member, who is a patient of the provider, for the
            following:

        

        
          

          
            	
                    1.

                  	
                    The
                      Member's health status, medical care, or treatment options, including
                      any alternative treatment that may be
                      self-administered;

                  

          

        

        
          

          
            	
                    2.

                  	
                    Any
                      information the Member needs in order to decide among relevant
                      treatment options;

                  

          

        

        
          

          
            	
                    3.

                  	
                    The
                      risks, benefits and consequences of treatment
                      or nontreatment;

                  

          

        

        
          

          
            	
                    4.

                  	
                    The
                      Member's right to participate in decisions regarding his or
                      her health care, including, the right to refuse treatment, and
                      to
                      express preferences about future treatment
                      decisions

                  

          

        

        
          

          
            	
                    b. 

                  	
                    This
                      prohibition applies regardless of whether benefits for such
                      care or
                      treatment are provided under this
                      contract.

                  

          

        

        
          

          3.05   Coordination
            and Continuation of Care

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall have systems in place to provide well-managed patient
                      care that
                      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.

                  

          

        

        
          

          
            	
                    5.

                  	
                    Coordination
                      and provision of EPSDT screening services in accordance with the
                      schedules for immunizations and periodicity of well-child services as
                      established by the DEPARTMENT and federal
                      regulations.

                  

          

        

        
          

          
            	
                    6.

                  	
                    Provide
                      or arrange for the provision of EPSDT case management services for
                      Members under twenty-one (21) years of age when the Member has a
                      physical or mental health condition that makes the coordination of
                      medical, social, and educational services medically necessary. As
                      necessary, case management services shall include but not be limited
                      to:

                  

          

        

        
          

          Part
            II

          11

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          
            	
                  	
                    a)

                  	
                    Assessment
                      of the need for case management and development of a plan for
                      services;

                  

          

        

        
          

          
            	
                  	
                    b)

                  	
                    Periodic
                      reassessment of the need for case management and review of the plan
                      for services;

                  

          

        

        
          

          
            	
                  	
                    c)

                  	
                    Making
                      referrals for related medical, social, and
                      educational services;

                  

          

        

        
          

          
            	
                  	
                    d)

                  	
                    Facilitating
                      referrals by providing assistance in scheduling appointments for
                      health and health-related services, and arranging transportation and
                      interpreter services;

                  

          

        

        
          

          
            	
                  	
                    e)

                  	
                    Coordinating
                      and integrating the plan of services through direct or collateral
                      contacts with the family and those agencies and providers providing
                      services to the child;

                  

          

        

        
          

          
            	
                  	
                    f)

                  	
                    Monitoring
                      the quality and quantity of services
                      being provided;

                  

          

        

        
          
            
              

              
                	
                      	               g)	Providing health
                        education as
                        needed; and

              

            

             

          

        

        
          
            	
                    h)

                  	
                    Advocacy
                      necessary to minimize conflict between service providers and
                      to mobilize
                      resources to obtain needed
                      services.

                  

          

        

        
          

          
            	
                    7.

                  	
                    Provide
                      necessary coordination and case management services for children with
                      special health care needs.

                  

          

        

        
          

          
            	
                    8.

                  	
                    If
                      notified, PCPs will 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.

                  

          

        

        
          

          
            	
                    9.

                  	
                    The
                      MCO shall coordinate Members' care with the CT BMP, as outlined in
                      this Contract, including but not limited to section 3.17, and
                      Appendix N.

                  

          

        

        
          

          3.06    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.

                  	
                    The
                      MCO shall cover and pay for emergency services without regard
                      to prior authorization and regardless of whether the provider
                      that
                      furnishes the services has a contract with the
                      MCO.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO shall be responsible for payment for emergency department visits,
                      including emergent and urgent visits billed by the facility,
                      regardless of the Member's diagnosis. The DEPARTMENT and MCO will
                      jointly develop audit procedures related to emergency department
                      services when Members are admitted to the hospital and the primary
                      diagnosis is behavioral.

                  

          

        

        
          

          Part
            II

        

        
          12

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          
            	
                     

                  	
                    The
                      CT BHP shall be responsible for payment for the
                      following:

                  

          

        

        
          

          
            	
                    1.

                  	
                    Professional
                      psychiatric services rendered in an emergency department by a
                      community psychiatrist, if the psychiatrist is enrolled in the
                      Medicaid program under either an individual provider or group
                      provider number and bills the DEPARTMENT under that provider number;
                      and

                  

          

        

        
          

          
            	
                    2.

                  	
                    Observation
                      stays of 23 hours or less, billed as Revenue Center Code 762, with a
                      primary behavioral health
                      diagnosis.

                  

          

        

        
          

          
            	
                    
                      d.

                    

                  	
                     

                  	
                    The
                      MCO shall not limit the number of emergency
                      visits.

                  

          

        

        
          

          
            	
                    e.

                  	
                    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 medical
                      condition.

                  

          

        

        
          

          
            	
                    f.

                  	
                    The
                      MCO shall 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.

                  

          

        

        
          

          
            	
                    g.

                  	
                    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.

                  

          

        

        
          

          
            	
                    
                      h.

                    

                  	
                    
                       

                    

                  	
                    The
                      MCO shall not base its determinations on what constitutes an
emergency
                      medical condition on a list of diagnoses or symptoms. The determination
                      of
                      whether the prudent layperson standard is met shall be made
                      on a
                      case-by-case basis. However, the MCO may determine that the
                      emergency
                      medical condition definition is met, based on a list such as
                      ICD-9
                      codes.

                  

          

        

        
          

          
            	
                    i. 

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

                  

          

        

        
          

          
            	
                    j. 

                  	
                    The
                      MCO shall cover post-stabilization services obtained either
                      within or
                      outside the MCO's provider network, under the following
                      circumstances;

                  

          

        

        
          

          
            	
                     

                  	
                    
                      1. 

                    

                  	
                    The
                      services were pre-approved by the
                      MCO;

                  

          

        

        
          

          
            	
                    2.

                  	
                    The
                      services were not pre-approved by the MCO, but administered to
                      maintain the Member's stabilized condition within one hour
                      of
                      a request to the MCO for pre-approval of further
                      post-stabilization care
                      services.

                  

          

        

        
          

          
            	
                    k.  

                  	
                     The
                      MCO shall cover post stabilization services that were obtained
                      either
                      within or outside the MCO's provider network and not pre-approved,
                      but
                      administered to maintain, improve or resolve the Member's stabilized
                      condition in the following
                      circumstances:

                  

          

        

        
          

          Part
            II

          13

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          
            	
                    1.

                  	
                    The
                      MCO does not respond to a request for pre-approval of such services
                      within one hour;

                  

          

        

        
          

          
            	
                    2.

                  	
                    The
                      MCO cannot be contacted; or

                  

          

        

        
          

          
            	
                    3.

                  	
                    The
                      MCO and the treating physician cannot reach an agreement concerning
                      the Member's care and an MCO physician is not available for
                      consultation. In this circumstance, the MCO must give the treating
                      physician the opportunity to consult with an MCO physician and the
                      treating physician may continue with care of the patient until an MCO
                      physician is reached or one of the following criteria are
                      met:

                  

          

        

        
          

          
            	
                    b)

                  	
                    An
                      MCO physician with privileges at the treating hospital assumes
                      responsibility for the Member's
                      care;

                  

          

        

        
          

          
            	
                    c)

                  	
                    An
                      MCO physician assumes responsibility for the member's care through
                      transfer;

                  

          

        

        
          

          
            	
                    c) 

                  	
                    The
                      MCO and the treating physician reach an agreement concerning
                      the Member's
                      care.

                  

          

        

        
          

          
            	
                    I.        

                  	
                     If
                      there is a disagreement between a hospital or other treating
                      facility and
                      an MCO concerning whether the Member is stable enough for discharge
                      or
                      transfer from the emergency room, the judgment of the attending
                      physician(s) or the provider actually treating the Member 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
                      Member.

                  

          

        

        
          

          
            	
                    m.

                  	
                     

                  	
                    When
                      a Member's PCP or another MCO 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 Member's
                      condition meets
                      the emergency medical condition
                      definition.

                  

          

        

        
          

          
            	
                    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 appeal and the DEPARTMENT'S administrative hearing
                      processes.

                  

          

        

        
          

          
            	
                    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.

                  

          

        

        
          

          
            	
                    p.

                  	
                    The
                      MCO may not make payment for emergency services contingent
upon
                      the Member providing the MCO with notification either before
                      or after
                      receiving emergency services. The MCO may, however, enter
                      into

                  

          

        

        
          

          Part
            II

          14

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          contracts
            with providers or facilities that require, as a condition of payment,
            the
            provider or facility to provide notification to the MCO after Members
            are
            present at the emergency room, assuming adequate provision is given for
            such
            notification.

        

        
          

          
            	
                    q.        

                  	
                    The
                      MCO shall retain responsibility for payment for emergency medical
                      transportation, regardless of diagnosis. The MCO shall also
                      retain
                      responsibility for hospital-to-hospital ambulance transportation
                      of
                      members with a behavioral health
                      condition.

                  

          

        

        
          

          
            	
                    r.       

                  	
                    Effective
                      January 1, 2007, when the MCO reimburses emergency services
                      provided by an
                      out-of-network provider whether within or outside Connecticut,
                      the rate of
                      reimbursement shall be limited to the fees established by the
                      DEPARTMENT
                      for the Medicaid fee-for-service program, less any payments
                      for indirect
                      costs of medical education and direct costs of graduate medical
                      education.

                  

          

        

        
          

          3.07           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 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 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 the Medicaid
                      fee-for-service program.

                  

          

        

        
          

          
            	
                    b.

                  	
                    On
                      a monthly basis, the MCO shall 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.

        

        
          

          Sanction:
            In any sampling, if more than two (2) percent of Members reside
            in
            towns beyond fifteen (15) miles of a town containing a PCP the DEPARTMENT
            may
            impose a strike towards a Class A sanction pursuant to Section
            7.05.

        

        
          

          3.08           Choice
            of Health Professional

        

        
          

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

        

        
          

          3.09           Provider
            Network

        

        
          

          a.       The
            MCO shall maintain a provider network capable of delivering or arranging
            for the delivery of all covered health goods and services to
            all

        

        
          

          Part
            II

        

        
          15

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            H,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          Members.
            In addition, the MCO's provider network shall have the capacity to deliver
            or
            arrange for the delivery of all the goods and services reimbursable under
            this
            contract regardless of whether all of the goods and services are provided
            through direct provider contracts. The MCO shall submit a file of their
            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.

                  	
                    In
                      establishing and maintaining its provider network, the MCO
                      shall consider the
                      following:

                  

          

        

        
          

          
            	
                    1.

                  	
                    Anticipated
                      enrollment;

                  

          

        

        
          

          
            	
                    2.

                  	
                    Expected
                      utilization of services, taking into consideration
                      the characteristics and health care needs of the specific
                      Medicaid populations in the
                      MCO;

                  

          

        

        
          

          
            	
                    3.

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

                  

          

        

        
          

          
            	
                    4.

                  	
                    The
                      numbers of network providers who are not accepting new Medicaid
                      patients;

                  

          

        

        
          

          
            	
                    5.

                  	
                    The
                      geographic location of providers and Medicaid Members, considering
                      distance, travel time, the means of transportation ordinarily used by
                      Medicaid members, and whether the location provider physical access
                      for Members with
                      disabilities.

                  

          

        

        
          

          
            	
                    c.

                  	
                    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 shall 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, if the provider network
                      file fails to meet these
                      requirements.

                  

          

        

        
          

          
            	
                    d.

                  	
                    If
                      the MCO declines to include a provider or group of providers
                      in
                      its network, the MCO shall give the affected provider(s) written
                      notice of the reason for its
                      decision.

                  

          

        

        
          

          
            	
                    e.

                  	
                    The
                      MCO shall not discriminate against providers with respect
                      to participation, reimbursement, or indemnification for any provider
                      who is acting within the scope of that provider's license or
                      certification under applicable State law, solely on the basis of the
                      provider's license or certification. This shall not be construed to
                      prohibit the MCO from including providers only to the extent
                      necessary to meet the needs of the MCO's Members or from establishing
                      measures designed to maintain the quality of services and control
                      costs, consistent with its responsibilities. This shall not preclude
                      the MCO from using different reimbursement amounts for different
                      specialties or for different practitioners in the
                      same specialty.

                  

          

        

        
          

          Part
            II

          16

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          
            	
                    f.

                  	
                    The
                      MCO's provider selection policies and procedures shall
                      not discriminate against particular providers that serve high-risk
                      populations or specialize in conditions that require costly
                      treatment.

                  

          

        

        
          

          
            	
                    g.

                  	
                    The
                      MCO shall not employ or contract with any provider excluded
                      from participation in a Federal health care program under either
                      Section 1128 or 1128A of the Social Security
                      Act.

                  

          

        

        
          

          
            	
                    3.10   

                  	
                    Network
                      Adequacy and Maximum Enrollment Levels Primary Care Providers and
                      Dentists

                  

          

        

        
          

          
            	
                    a.

                  	
                    On
                      a quarterly basis, except as otherwise specified by 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 Medicaid fee-for-service experience in
                      order to ensure that access in the MCO is at least equal to
                      access experienced in the Medicaid fee-for-service 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 33.1%, nurse
                      practitioners of the appropriate specialties, and physician
                      assistants, 301 Members per
                      provider;

                  

          

        

        
          

          
            	
                    3.

                  	
                    Women's
                      PCPs, including obstetrics and gynecology specialists, nurse
                      midwives, and nurse practitioners of the appropriate specialty, 835
                      Members per provider;

                  

          

        

        
          

          
            	
                    4.

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

                  

          

        

        
          

          
            	
                    b.

                  	
                    In
                      the event that the number of Members in a given county equals
                      or exceeds ninety percent (90%) of the capacity determined in
                      accordance with section a noted above, the DEPARTMENT shall evaluate
                      the adequacy of the MCO's network on a monthly
                      basis.

                  

          

        

        
          

          
            	
                    c.

                  	
                    Maximum
                      Enrollment Levels: Based on the adequacy of the MCO's provider
                      network, the DEPARTMENT may establish a maximum HUSKY A enrollment
                      level for Members in 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.

                  

          

        

        
          

          Part
            II

        

        
          17

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01 -3.35) 07 HUSKY A 05/07

        

        
          

          
            	
                    d.

                  	
                    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 that would allow the MCO
                      to
                      serve additional 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.

                  

          

        

        
          

          Specialists

        

        
          

          
            	
                    e.

                  	
                    In
                      addition to the network adequacy measures described in
                      subsections (a) through (d) above, the DEPARTMENT shall measure
                      access to specialists by examining and reviewing confirmed complaints
                      received by the MCO, the Enrollment Broker, the DEPARTMENT and HUSKY
                      Infoline and taking other steps as more fully described
                      below:

                  

          

        

        
          

          
            	
                    1.

                  	
                    For
                      purposes of this section, a "complaint" shall be defined
                      as dissatisfaction expressed by a Member, or their
                      authorized representative, with the Member's ability to obtain an
                      appointment with a specialist that will accommodate the member's
                      medical needs within a reasonable timeframe or within a reasonable
                      distance.

                  

          

        

        
          

          
            	
                    a)

                  	
                    Member
                      requests for information or referrals to specialists within the MCO's
                      network shall not constitute a
                      complaint.

                  

          

        

        
          

          
            	
                    b)

                  	
                    The
                      DEPARTMENT will count more than one complaint to different entities
                      about a Member's inability to access a particular specialist, within
                      the same timeframe, as one
                      complaint.

                  

          

        

        
          

          
            	
                    c)

                  	
                    The
                      DEPARTMENT will count as separate complaints when a Member complains
                      about being unable to make appointments with more than one
                      specialist.

                  

          

        

         

        
          
            	
                    2.

                  	
                    The
                      DEPARTMENT will refer to the MCO all complaints for
                      resolution.

                  

          

        

        
          

          
            	
                    3.

                  	
                    The
                      DEPARTMENT will send the MCO a "Complaint Report" when it receives a
                      certain number of confirmed access complaints from HUSKY A and HUSKY
                      B members during a quarter regarding a particular
                      specialty.

                  

          

        

        
          

          
            	
                  	
                    
                      a)

                    

                  	
                    The
                      number of confirmed complaints that will initiate the DEPARTMENT'S
                      sending a "Complaint Report" will be based on the MCO's HUSKY
                      A membership
                      factored by the ratio of one complaint per 10,000
                      members.

                  

          

        

        
          

        

        
          Part
            II

        

        
          18

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          
            	
                    b)

                  	
                    For
                      purposes of this section, a "confirmed complaint" means that the
                      DEPARTMENT or another entity has received a complaint and the
                      DEPARTMENT has confirmed that the MCO has not provided a specialist
                      or dentist within a reasonable timeframe or within a reasonable
                      distance from the Member's home, or
                      both.

                  

          

        

        
          

          
            	
                    c)

                  	
                    In
                      determining whether a complaint will be confirmed, the DEPARTMENT
                      will consider a number of factors, including but not limited
                      to:

                  

          

        

         

        
          
            	
                  	
                    1)

                  	
                    The
                      Member's PCP or other referring provider's medical opinion regarding
                      how soon the Member should be seen by
                      the specialist;

                  

          

        

        
          

          
            	
                  	
                    2)

                  	
                    The
                      severity of the Member's
                      condition;

                  

          

        

        
          

          
            	
                  	
                    3)

                  	
                    Nationally
                      recognized standards of access, if any, with respect to the
                      particular specialty;

                  

          

        

        
          

          
            	
                  	
                    4)

                  	
                    Whether
                      the access problem is related to a broader access or provider
                      availability problem that is not within the MCO's
                      control;

                  

          

        

        
          

          
            	
                  	
                    5)

                  	
                    The
                      MCO's diligence in attempting to address the
                      Member's complaint;

                  

          

        

        
          

          
            	
                  	
                    6)

                  	
                    Whether
                      both the Member and the MCO have reasonably attempted to obtain an
                      appointment that will meet the Member's medical
                      needs.

                  

          

        

        
          

          Sanctions:

        

        
          

          
            	
                    1.

                  	
                    In
                      the event the DEPARTMENT deems that the MCO's provider network is not
                      capable of accepting additional enrollments and lacks adequate access
                      to providers as described in (a) through (d) above, the DEPARTMENT
                      may exercise its rights under Section 7 of this contract, including
                      but not limited to the rights under Section 7.04, Suspension of New
                      Enrollments.

                  

          

        

        
          

          
            	
                    2.

                  	
                    In
                      the event the DEPARTMENT determines that it has received sufficient
                      confirmed complaints regarding specialist access problems to initiate
                      a statewide default enrollment freeze, The DEPARTMENT shall advise
                      the MCO in the Complaint Report that it has received confirmed
                      complaints and that it will impose a default enrollment freeze on the
                      MCO in 30 days unless the MCO submits a satisfactory resolution of
                      the access issue in a corrective action
                      plan.

                  

          

        

         

        
          
            	
                    a)

                  	
                    The
                      MCO may request an opportunity to meet with the DEPARTMENT prior to
                      the imposition of the default enrollment
                      freeze;

                  

          

        

        
          

          
            	
                    b)

                  	
                    The
                      DEPARTMENT will impose a default enrollment freeze statewide, for a
                      minimum of three months. The
                      default

                  

          

        

        

        Part
          II

        19

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          enrollment
            freeze will remain in effect until the DEPARTMENT determines that the
            access
            problem has been resolved to the DEPARTMENT'S satisfaction.

        

        
          

          
            	
                    3.

                  	
                    The
                      MCO shall submit a corrective action plan to the DEPARTMENT when the
                      DEPARTMENT formally notifies the MCO that the number of confirmed
                      specialist complaints has passed the report threshold for that MCO
                      during the reporting period.

                  

          

        

        
          

          
            	
                    4.

                  	
                    If,
                      subsequent to the DEPARTMENT'S approval of the corrective action
                      plan, the network deficiency is not remedied within the
                      time specified in the corrective action plan, or if the MCO does
                      not develop a corrective action plan satisfactory to the
                      DEPARTMENT, the DEPARTMENT may impose a strike towards a Class
                      A sanction for each month the MCO fails to correct the deficiency,
                      in accordance with Section 7.05. This sanction shall be in addition
                      to any enrollment freeze imposed in accordance with (2)
                      above.

                  

          

        

        
          

          3.11    Provider
            Contracts

        

        
          

          All
            contracts between the MCO and its in-network providers shall, at a minimum,
            include each of the following provisions:

        

        
          

          
            	
                    a.

                  	
                    MCO
                      network providers serving the Medicaid population must meet
                      the minimum requirements for participation in the Medicaid program
                      as
                      set forth in the Regulations of Connecticut State Agencies, Section
                      17b-262- 522 to Section 17b-262-533, as
                      applicable;

                  

          

        

        
          

          
            	
                    b.

                  	
                    MCO
                      Members shall be held harmless for the costs of all Medicaid- 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 3.46 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 the
                      Medicare or Medicaid program in any
                      state;

                  

          

        

        
          

          
            	
                    h.

                  	
                    For
                      PCPs, the provision of "on-call" coverage through arrangements
                      with other
                      PCPs; and

                  

          

        

        
          

          
            	
                    i.

                  	
                    That
                      the MCOs and subcontractors require in-network Primary Care
Providers
                      to participate in the DEPARTMENT'S efforts to study access,
                      quality and
                      outcome.

                  

          

        

         

        Part
          II

        20

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          
            	
                    j.  

                  	
                    The
                      MCO shall not reduce its reimbursements to federally qualified
                      health
                      centers from the rate in effect as of the effective date of
                      this
                      contract.

                  

          

        

        
          

          
            	
                    k.

                  	
                    The
                      MCO shall increase the reimbursement rate to general hospitals
                      for
                      hospital outpatient visits for Clinic (Revenue Cost Center
                      Codes 510
                      series as listed below or CRT Evaluation and Management Codes
                      99200 series
                      as listed below) and for Emergency Room visits (RCC 450) by
                      adding the
                      following amounts to the rates the Contractor has had in effect
                      for dates
                      of service 7/1/06 forward. The increase will be added once
                      per episode of
                      care as indicated by the presence of one of the listed RCC
                      or CPT
                      codes.

                  

          

        

        
          

          
            	
                    1.

                  	
                    An
                      increase of $15.20 per visit for hospital outpatient visits
                      for the
                      following Revenue Center Codes (RCC) or CPT Evaluation and
                      Management
                      Codes (CPT E&M) for hospital outpatient clinic
                      visits:

                  

          

           

        

        
          
            
              a) RCC
                510 Clinic

            

            
              b) RCC
                514 OB-GYN Clinic

            

            
              c) RCC
                515 Pediatric Clinic

            

            
              d) RCC
                519 Other

            

            
              e) RCC
                456 Urgent

            

            
              f) CPT
                E&M 99201 - New Patient Office or other OP visit
                -10 minutes

            

            
              g) CPT
                E&M 99202 - New Patient Office or other OP visit -
                20 minutes

            

            
              h)
                CPT
                E&M 99203 - New Patient Office or other OP visit - 30
                minutes

            

            
              i)  CPT
                E&M 99204 - New Patient Office or other OP visit - 45
                minutes

            

            
              j)  CPT
                E&M 99205 - New Patient Office or other OP visit - 60
                minutes

            

            
              k)
                CPT
                E&M 99211 - Established Patient Office or other OP visit -5
                minutes

            

            
              I)  CPT
                E&M 99212 -Established Patient Office or other OP visit -10
                minutes

            

            
              m)
                CPT
                E&M 99213 - Established Patient Office or other OP visit -15
                minutes

            

            
              n)
                CPT
                E&M 99214 - Established Patient Office or other OP visit -25
                minutes

            

            
              o)
                CPT
                E&M 99215 - Established Patient Office or other OP visit -40
                minutes

            

          

           

        

        
          Part
            II

          21

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          
            	
                    2.

                  	
                    An
                      increase of $12.13 per visit for Emergency Room visits (RCC
                      450).

                  

          

        

        
          

          
            	
                    I. 

                  	
                    The
                      additional payment amounts shall be made retroactive to July
                      1,
                      2006.

                  

          

        

        
          

          
            	
                    m. 

                  	
                    No
                      later than September 30, 2007, the MCO shall submit a report
                      to the
                      DEPARTMENT that describes in detail and by individual hospital
                      how the MCO
                      reimbursed the general hospitals to meet the increased hospital
                      outpatient
                      payment requirements as stated in subsection (k)
                      above.

                  

          

        

        
          

          
            	
                    n. 

                  	
                    The
                      MCO's failure to pay the increased hospital outpatient reimbursements
                      to
                      the satisfaction of the DEPARTMENT and/or the failure to fully
                      report such
                      payments could result in the withhold from future capitation
                      payments by
                      the DEPARTMENT.

                  

          

        

        
          

          3.12   Provider
            Credentialing and Enrollment

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall have written policies and procedures for the selection
                      and retention of providers. 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
                      documentation to support that credentialing criteria have been met,
                      including licenses, Drug Enforcement Agency (DEA) certificates and
                      provider statements regarding lack of impairment. Credentialing files
                      shall be subject to inspection by the DEPARTMENT or its
                      agent.

                  

          

        

        
          

          
            	
                    b.

                  	
                    MCO
                      credentialing and recredentialing 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;

          

          
             

            Part
              II

          

        

        
          22

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          
            	
                    d)

                  	
                    Revocation
                      and suspension of hospital
                      privileges;

                  

          

        

        
          

          
            	
                    e)

                  	
                    A
                      history of malpractice claims;
                      and

                  

          

        

        
          

          
            	
                    7.    

                  	
                    Evidence
                      of compliance with Clinical Laboratory Improvement Amendments
                      of 1988
                      (CLIA), Public Law 100-578, 42 DSC § 1395aa et seg. and 42 CFR Part 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;

                  

          

        

        
          

          
            	
                  	
                    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 DEA certification; and

                  

          

        

        
          

          
            	
                  	
                    6.

                  	
                    Assurances
                      that any Advanced Practice Registered Nurses (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 in its
                      network.

                  

          

        

        
          

          
            	
                    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 in-network provider as
                      set forth above.

                  

          

        

        
          

          Part
            II

        

        
          23

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            H,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          
            	
                    g. 

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

                  

          

        

        
          

          Sanction:
            The DEPARTMENT may impose a Class B sanction pursuant to Section 7.05
            if, upon
            completion of a performance review, it is established that a provider
            in the
            MCO's network fails to meet the minimum credentialing criteria for participation
            set forth in (a) and (b) above or a PCP in the MCO's network fails to
            meet the
            criteria set forth in (d).

        

        
          

          3.13           Second
            Opinions, Specialist Providers and the Referral
            Process

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall provide for a second opinion from a qualified health
                      care professional within its provider network, or arrange for the
                      ability of the Member to obtain one outside the network, at no cost
                      to the Member.

                  

          

        

        
          

          
            	
                    b.

                  	
                    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 be in-network or out-of-network. The MCO
                      shall ensure that the Member does not incur any costs for such
                      referrals whether the referral is to an in-network or out- of network
                      provider. 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.

                  

          

        

        
          

          3.14           PCP
            and Specialist Selection, Scheduling and Capacity

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall implement procedures to ensure that each Member has
                      an ongoing source of primary care appropriate to his or her needs
                      and
                      a person formally designated as primarily responsible for
                      coordinating the health care services furnished to the
                      Member.

                  

          

        

        
          

          
            	
                    b.

                  	
                    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 notified to do so. The assignment must be appropriate
                      to
                      the Member's age, gender and
                      residence.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO shall ensure that providers in its network adhere to the
                      following 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;

                  

          

        

        
          

          Part
            II

        

        
          24

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 5/07

        

        
          

          
            	
                    4.

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

                  

          

        

        
          

          
            	
                    5.

                  	
                    Dental
                      screening and preventative visits shall be scheduled within
                      six (6)
                      weeks from the date of the
                      request;

                  

          

        

        
          

          
            	
                    6.

                  	
                    Specialists
                      shall provide treatment within the scope of their practice and within
                      professionally accepted promptness standards for providing such
                      treatment;

                  

          

        

        
          

          
            	
                    7.

                  	
                    EPSDT
                      comprehensive health screens and immunizations shall be scheduled in
                      accordance with the DEPARTMENT'S EPSDT periodicity and immunization
                      schedules;

                  

          

        

        
          

          
            	
                    8.

                  	
                    New
                      Members shall receive an initial PCP appointment in a timely manner;
                      (for those Members who do not access goods and services within the
                      first six (6) months of enrollment, the MCO shall identify and remedy
                      any access problems); and

                  

          

        

        
          

          
            	
                    9.

                  	
                    Waiting
                      times at PCPs are kept to a
                      minimum.

                  

          

        

        
          

          
            	
                    d.

                  	
                    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
                      PCP
                      is assured.

                  

          

        

        
          

          
            	
                    e.

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

                  

          

        

        
          

          
            	
                    f.

                  	
                    The
                      MCO shall track each Member's use of primary medical care services.
                      In the event that a Member does not regularly receive primary medical
                      care services from the PCP or the PCP's group other than visits to
                      school based health clinics, the MCO shall contact the Member
                      and offer to assist the Member in selecting a
                      PCP.

                  

          

        

        
          

          
            	
                    g.

                  	
                    If
                      the Member has not received any primary care services, the
                      MCO
                      shall contact the Member and offer to assist the Member in scheduling
                      a well- care visit if the Member's last well-care visit was not
                      within the appropriate guidelines for his or her age and
                      gender.

                  

          

        

        
          

          Performance
            Measure: Appointment Availability. The DEPARTMENT or its agent will
            routinely monitor appointment availability as measured by (c)(1) through
            (c)(9)
            above:

        

        
          

          
            	
                    a. 

                  	
                    Using
                      test cases to arrange appointments of various kinds with selected
                      providers. The DEPARTMENT shall require the MCO to submit a
                      corrective
                      action plan within thirty (30) days, outlining the steps that
                      the MCO
                      will take to rectify the problem, when less than ninety (90)
                      percent of
                      the sample make appointments available within the required
                      time,
                      or

                  

          

        

        
          

          Part
            II

        

        
          25

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

        

        
          

          
            	
                    b.

                  	
                    Tracking
                      complaints received by the MCO, the DEPARTMENT and HUSKY Infoline. If
                      the DEPARTMENT deems that the MCO's provider network is not capable
                      of accepting additional enrollments, the DEPARTMENT shall require the
                      MCO to submit a corrective action plan within thirty (30) days,
                      outlining the steps that the MCO will take to rectify the
                      problem

                  

          

        

        
          

          
            	
                    c.

                  	
                    If
                      the DEPARTMENT determines that appointment availability
                      is insufficient, the DEPARTMENT may exercise its rights under
                      Section
                      7 of this contract, including but not limited to the rights under
                      Section 7.04, Suspension of New
                      Enrollments.

                  

          

        

        
          

          3.15   Women's
            Health, Family Planning Access and Confidentiality

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall provide female Members with direct access to a
                      women's health specialist in network for covered care necessary to
                      provide women's routine and preventive health care services. This
                      access shall be in addition to the Member's PCP if that provider is
                      not a women's health
                      specialist.

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO shall notify and give each Member, including adolescents,
                      the opportunity to use his or her own PCP or utilize any family
                      planning service provider for 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, and shall reimburse providers for all
                      family planning services regardless of whether that provider
                      is
                      a participating provider. The MCO shall reimburse out-of-network
                      providers of family planning services at least the Medicaid
                      fee-for-service rate for the service. The MCO may require family
                      planning providers to submit claims or reports in specified formats
                      before reimbursing services.

                  

          

        

        
          

          
            	
                    c.

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

                  

          

        

        
          

          
            	
                    d.

                  	
                    Family
                      planning services that must be covered
                      include:

                  

          

        

        
          
            	
                  	
                    1.

                  	
                    Reproductive
                      health exams;

                  

          

        

        
          
            	
                  	
                    2.

                  	
                    Patient
                      counseling;

                  

          

        

        
          
            	
                  	
                    3.

                  	
                    Patient
                      education;

                  

          

        

        
          
            	
                  	
                    4.

                  	
                    Lab
                      tests to detect the presence of conditions affecting
                      reproductive health;

                  

          

        

        
          
            	
                  	
                    5.

                  	
                    Sterilizations;

                  

          

        

        
          
            	
                  	
                    6.

                  	
                    Screening,
                      testing, and treatment of and pre and post- test counseling for
                      sexually transmitted diseases and HIV;
                      and

                  

          

        

        
          

          Part
            II

          26

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            H,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          
            	
                  	
                    7.       

                  	
                    Abortions,
                      if the pregnancy is the result of an act of rape or incest
                      or in the case
                      where a woman suffers from a physical disorder, physical injury,
                      or
                      physical illness, including a life-endangering physical condition
                      caused
                      by or arising from the pregnancy itself, that would, as certified
                      by a
                      physician, place the woman in danger of death unless an abortion
                      is
                      performed.

                  

          

        

        
          

          
            	
                    e.

                  	
                    Pursuant
                      to federal law ("the Hyde Amendment," as reflected in the
                      federal appropriations for Title XIX) and 42 CFR Part 441, Subpart
                      E,
                      the DEPARTMENT may only seek federal funding for those
                      abortions described in (d)(7) above. The MCO shall cover all
                      abortions that fall within these circumstances. The MCO shall submit
                      a Form W-484 for any such abortions and comply with the DEPARTMENT'S
                      Medical Services Policy concerning
                      abortions.

                  

          

        

        
          

          
            	
                    f.

                  	
                    The
                      DEPARTMENT and the MCO shall enter into a separate contract
                      for all
                      medically necessary abortions that do not qualify for federal
                      matching funds, as described in subsection (d) and (e)
                      above.

                  

          

        

        
          

          
            	
                    g.

                  	
                    The
                      MCO shall ensure that the provisions of 42 CFR 441.250 - 259
                      and Section 173 G of the DEPARTMENT'S Medical Services Policy
                      and Provider Bulletin 2004-77 are strictly followed by the MCO
                      in
                      payment for sterilization and Hysterectomies. These requirements
                      include, but are not limited to, the submission of a completed W-612
                      informed consent form (sterilization) or a W-613 information form
                      (hysterectomy) prior to payment for either of these
                      procedures.

                  

          

        

        
          

          Sanction:
            If the MCO fails to comply with the provisions in subsection
            (e), and
            fails to accurately maintain and submit accurate records of those abortions,
            that meet the federal definition for funding, the DEPARTMENT may impose
            a Class
            A sanction, pursuant to Section 7.05.

        

        
          

          3.16    Pharmacy
            Access

        

        
          

          For
            purposes of this section, "prescription" shall include authorization
            for legend
            and over-the-counter drugs covered by Medicaid policy.

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall be responsible for payment for pharmacy services regardless
                      of a Member's diagnosis. The only exception is that the CT BHP shall
                      be responsible for methadone costs that are part of the
                      bundled reimbursement for methadone maintenance and ambulatory
                      detox providers. Prescribing behavioral health providers
                      participating in the CT BHP will follow the applicable pharmacy
                      program requirements, including the formulary, of the MCO. These
                      providers will provide the MCO with any clinical information needed
                      to support requests for authorization or the preparation of summaries
                      for administrative hearings. The MCO shall promptly inform the
                      DEPARTMENT of any changes to its pharmacy program
                      requirements.

                  

          

        

        
          

          
            	
                    b.

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

                  

          

        

        
          

          Part
            II

        

        
          27

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 5/07

        

        
          

          
            	
                    1.

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

                  

          

        

        
          

          
            	
                    2.

                  	
                    The
                      MCO may establish a pharmacy lock-in program for Members suspected of
                      abuse or excessive utilization. Any MCO pharmacy lock-in program will
                      be subject to DEPARTMENT
                      approval;

                  

          

        

        
          

          
            	
                    3.

                  	
                    Have
                      established protocols to respond to urgent requests
                      for medications;

                  

          

        

        
          

          
            	
                    4.

                  	
                    Monitor
                      and take steps to correct excessive utilization of
                      regulated substances, including but not limited to, restricting
                      pharmacy access pursuant to a pharmacy lock-in program approved by
                      the DEPARTMENT; and

                  

          

        

        
          

          
            	
                    5.

                  	
                    Require
                      pharmacists to utilize the Automated Eligibility Verification System
                      (AEVS) to determine client eligibility and MCO affiliation 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.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO shall require that its provider network of pharmacies
                      offer medically necessary goods and services to the MCO's
                      Members.

                  

          

        

        
          

          
            	
                    d.

                  	
                    The
                      MCO may have a drug management program that includes a prescription
                      drug formulary.

                  

          

        

        
          

          
            	
                    1.

                  	
                    The
                      MCO drug formulary must include only Food and Drug Administration
                      approved drug products and must be broad enough in scope to meet the
                      needs of all Members.

                  

          

        

        
          

          
            	
                    2.

                  	
                    For
                      each specific therapeutic drug class the MCO drug formulary shall
                      consist of a reasonable selection of drugs that do not require prior
                      approval.

                  

          

        

        
          

          
            	
                    e.

                  	
                    The
                      MCO shall obtain the DEPARTMENT'S written approval prior to deleting
                      any drugs from its formulary or issuing any communication regarding
                      its proposed formulary changes. In addition the MCO
                      shall:

                  

          

        

        
          

          
            	
                    1.

                  	
                    Submit
                      any deletions to its formulary and any new prior authorization
                      requirements for formulary drugs to the DEPARTMENT at least thirty
                      (30) days prior to making any
                      such change.

                  

          

        

        
          

          
            	
                    2.

                  	
                    Submit
                      all physician, pharmacist and Member letters, notices, e- mail alerts
                      or other electronic or written communications related to the proposed
                      formulary change to the DEPARTMENT thirty (30) days prior to issuing
                      or sending any such
                      communication.

                  

          

        

        
          

          
            	
                    3.

                  	
                    If,
                      however, the DEPARTMENT does not respond to proposed formulary
                      changes or communications submitted for approval
                      within

                  

          

        

        
          

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            II

        

        
          28

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
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          thirty
            (30) days of receipt from the MCO, the MCO may proceed with the change
            or issue
            the communication, as applicable.

        

        
          

          
            	
                    4.

                  	
                    Submit
                      subsequent additions to the formulary at the time the addition is
                      made without seeking prior approval by the DEPARTMENT and regardless
                      of whether the drug(s) to be added requires prior authorization. If
                      the MCO's formulary includes a legend drug that requires prior
                      authorization and the FDA approves the drug for over-the-counter use,
                      the MCO is not required to seek the DEPARTMENT'S approval to
                      substitute the over-the-counter version with a prior authorization
                      requirement.

                  

          

        

        
          

          
            	
                    5.

                  	
                    Notify
                      prescribing providers thirty (30) days in advance of any changes to
                      the MCO's formulary.

                  

          

        

        
          

          The
            DEPARTMENT reserves the right to identify clinical deficiencies in the
            content
            of or operational deficiencies of the MCO's 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 submission of the written response. If the DEPARTMENT is not
            satisfied
            with the MCO's response, the DEPARTMENT may require the MCO to add specific
            drugs to its formulary or to or eliminate prior authorization requirements
            for
            specific drugs. If the MCO disputes the DEPARTMENT'S determination, the
            MCO may
            exercise its rights pursuant to section 7.02 of this
            Contract.

        

        
          

          
            	
                    f. 

                  	
                    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.

                  

          

        

        
          

          
            	
                    1.

                  	
                    When
                      the MCO deletes a drug from its formulary or imposes
                      prior authorization requirements on additional drug(s), the MCO
                      shall identify to the DEPARTMENT which of the affected drugs the
                      MCO intends to treat as maintenance
                      drugs.

                  

          

        

        
          

          
            	
                    2.

                  	
                    The
                      DEPARTMENT may require the MCO to treat additional drugs as
                      maintenance drugs for purposes of this subsection and subsection
                      (e).

                  

          

        

        
          

          
            	
                    3.

                  	
                    If
                      the MCO treats all drugs affected by a formulary change
                      as maintenance drugs for purposes of this subsection and
                      for purposes of subsection (g) below, the MCO is not required
                      to designate specific drugs as maintenance drugs.   In
                      such circumstances, the MCO shall notify the DEPARTMENT that
                      all drugs affected by the formulary change will be treated in the
                      same manner.

                  

          

        

        
          

          Part
            II

          29

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
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                    g.        

                  	
                    If
                      a prescribing provider seeks authorization to continue a maintenance
                      drug
                      that is being removed from the MCO's formulary or subjected
                      to new prior
                      authorization requirements at any time prior to the effective
                      date of the
                      change, the MCO shall conduct a medical necessity
                      review.

                  

          

        

        
          

          
            	
                    1.

                  	
                    The
                      MCO shall conduct the review, and, if the MCO does not approve the
                      request, the MCO shall issue a notice of action in accordance with
                      the provisions of subsection (i)
                      below.

                  

          

        

        
          

          
            	
                    2.

                  	
                    If
                      the MCO denies the prior authorization request for the maintenance
                      drug, the MCO shall issue a notice of action at least ten days in
                      advance of the effective date of the
                      action.

                  

          

        

        
          

          
            	
                    3.

                  	
                    The
                      MCO shall automatically continue authorization for the maintenance
                      drug for at least the medical necessity review period plus, if the
                      MCO does not approve the authorization, for the ten (10) day advance
                      notice period, or the effective date of the action, whichever is
                      later.

                  

          

        

        
          

          
            	
                    4.

                  	
                    If
                      a Member requests an appeal and administrative hearing concerning a
                      denial or termination that results from or relates to the imposition
                      of new prior authorization requirements for or removal of the
                      maintenance drug from the formulary, the MCO shall continue to
                      authorize the drug for that Member pending a hearing
                      decision.

                  

          

        

        
          

          
            	
                    5.

                  	
                    If
                      the prescriber does not initiate the prior authorization
                      process prior to the expiration of the existing authorization period,
                      the Member shall receive a temporary supply of the maintenance
                      drug if the conditions described in subsection (i) are
                      met.

                  

          

        

        
          

          
            	
                    6.

                  	
                    If
                      the MCO grandfathers some or all Members affected by the formulary
                      changes for a period of more than ninety (90) days, the MCO shall
                      either:

                  

          

        

         

        
          
            	
                  	
                    a)

                  	
                    Send
                      a second advance notice letter at least thirty (30) days prior to the
                      end of the extended authorization period
                      or

                  

          

        

        
          

          
            	
                  	
                    b)

                  	
                    Ensure
                      that if the Member's prescriber requests authorization prior to the
                      end of the existing authorization period, that if the request is
                      denied and the Member appeals, that the authorization will continue
                      pending appeal.

                  

          

        

        
          

          
            	
                    h. 

                  	
                    The
                      MCO shall require that its provider network of pharmacies adhere
                      to the
                      provisions of Connecticut General Statutes § 20-619 (b) and (c) related to
                      generic substitutions for Medicaid
                      recipients.

                  

          

        

        
          

          
            	
                    i.        

                  	
                     If
                      the MCO maintains 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.

                  

          

        

        
          

          
            	
                    1.        

                  	
                    The
                      MCO shall develop a timely and efficient authorization process
                      to obtain
                      information from providers on medical necessity for a non-Part
                      II 30
                      formulary drug, a formulary drug requiring prior authorization
                      or a brand
                      name drug where a generic substitution is
                      available.

                  

          

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
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                    2.

                  	
                    The
                      MCO shall make an individualized determination concerning medical
                      necessity and appropriateness in each instance when a Member's
                      prescribing provider requests a non-formulary drug, formulary drug
                      requiring prior authorization or a brand name drug including request
                      made in relation to the provisions of (f)
                      above.

                  

          

        

        
          

          
            	
                    3.

                  	
                    If
                      the MCO or the Pharmacy Benefits Manager (PBM) does not receive a
                      request for prior authorization prior to the submission of
                      a prescription to a pharmacy, the pharmacist may contact
                      the prescribing physician and inform him or her of the
                      prior authorization
                      requirement.

                  

          

        

        
          

          
            	
                    j.        

                  	
                    Except
                      as provided in subsection (p) below, in the event that a provider
                      requests
                      authorization for, or prescribes a non-formulary drug, a formulary
                      drug
                      requiring prior authorization or a brand name drug where a
                      generic
                      substitution is available but elects during the prior authorization
                      process or in discussions with the pharmacist to prescribe
                      a formulary,
                      generic or alternate formulary drug that the provider agrees
                      will be
                      equally effective for the Member, the MCO is not required to
                      issue a
                      notice of action and is not required to provide a temporary
                      supply of the
                      drug for which the provider initially sought
                      authorization.

                  

          

        

        
          

          
            	
                    k.        

                  	
                    In
                      the event that a provider requests authorization, or prescribes
                      a
                      non-formulary drug, a formulary drug requiring prior authorization
                      or a
                      brand name drug where a generic substitution is available the
                      MCO must
                      approve or deny the request as expeditiously as the Member's
                      health
                      condition requires, but no later than 14 calendar days following
                      the MCO's
                      receipt of the request.

                     

                    An
                      additional 14 calendar days will be allowed if: 1) the Member
                      or the
                      requesting provider asks for the extension or 2) the MCO or
                      its PBM
                      documents that the extension is in the Member's interest because
                      additional information is needed for the MCO to authorize the
                      service and
                      the failure to extend the authorization timeframe will result
                      in denial of
                      the service. The DEPARTMENT may request and review such documentation
                      from
                      the MCO.

                  

          

        

        
           

        

        
          
            	
                    l.

                  	
                    In
                      the event that a provider certifies to the MCO or its PBM that
                      the drug is
                      necessary to address an urgent or emergent condition or that
                      the standard
                      authorization period could seriously jeopardize the Member's
                      life or
                      health or ability to attain, maintain or regain maximum function,
                      the MCO
                      or its PBM must make an expedited authorization decision and
                      provide
                      notice as expeditiously as the member's health condition requires
                      and no
                      later than 3 working days after receipt of the request for
                      service. The
                      MCO or its PBM may extend the 3 working days time period by
                      up to 14
                      additional calendar days if: 1) the Member or the provider
                      requests the
                      extension, or 2) if the MCO or its PBM documents that the extension
                      is in
                      the Member's interest because additional information is needed
                      for the MCO
                      to authorize the service and the failure to extend the authorization
                      timeframe will result in denial of the service. The DEPARTMENT
                      may request
                      such documentation from the
                      MCO.

                  

          

        

        
          
 

          Part
            II

          31

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            H,
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                    m.       

                  	
                    The
                      MCO or its PBM shall without delay authorize up to a thirty
                      (30) day
                      temporary supply of the drug if the provider certifies to the
                      MCO or its
                      PBM that the drug is necessary to address an urgent or emergent
                      condition.
                      The MCO is also required to authorize a thirty (30) day temporary
                      supply
                      of the drug on the day of submission of the prescription to
                      the pharmacy
                      if the MCO has been unable to contact the provider to discuss
                      an effective
                      formulary drug during normal business hours. The certification
                      shall be in
                      a manner to be specified by the MCO, subject to the DEPARTMENT'S
                      approval.
                      If the original prescription was for a period less then thirty
                      (30) days,
                      the temporary supply will be for the period
                      prescribed.

                  

          

        

        
          

          
            	
                    n.

                  	
                     

                  	
                    If
                      the Member, upon receipt of a termination, suspension or reduction
                      notice
                      of action, timely requests an appeal and administrative hearing
                      the MCO
                      shall continue to authorize the drug for the Member pending
                      a hearing
                      decision or other resolution of the dispute concerning the
                      prescription.
                      As used within this section, "timely" means filing on or before
                      the later
                      of the following: (1) within ten (10) days of the MCO mailing
                      of the
                      notice of action; or (2) the intended effective date of the
                      MCO's proposed
                      action. If the Member does not request an appeal and administrative
                      hearing, the MCO is not required to authorize any further
                      refills.

                  

          

        

        
          

          
            	
                    o.   

                  	
                    Notwithstanding
                      anything to the contrary in the preceding, the MCO shall not
                      cover drugs
                      used to treat sexual or erectile dysfunction, as set forth
                      in
                      1927(d)(2)(K) of section 1903(i) of the Social Security Act
                      as amended,
                      unless such drugs are used to treat conditions other than sexual
                      or
                      erectile dysfunction and the uses have been approved by the
                      Food and Drug
                      Administration.

                  

          

        

        
          

          
            	
                    p.

                  	
                    The
                      MCO shall, on a quarterly basis, submit the report at Appendix
                      L.

                  

          

        

        
          

          
            	
                    q.        

                  	
                    If
                      the DEPARTMENT or its agent determines that there is a pattern
                      of denials
                      for requested authorization for particular drugs, or any other
                      pattern
                      suggesting that the MCO's authorization process is one that
                      does not
                      appropriately consider each Member's individualized medical
                      needs, the
                      DEPARTMENT may require notices of action in circumstances other
                      than those
                      described above and/or may require the addition of a particular
                      drug or
                      drugs to the MCO's formulary as drugs that do not require prior
                      authorizations.

                  

          

        

        
          

          3.17    Mental
            Health and Substance Abuse Access

        

        
          

          
            	
                    a.     

                  	
                    Except
                      as otherwise identified in this section and this Contract,
                      mental health
                      and substance abuse services for HUSKY A Members will be managed
                      by the CT-BHP and paid for by the DEPARTMENT. The MCO shall
                      coordinate
                      services covered under this contract with the behavioral health
                      services
                      managed by the CT BMP as outlined in Appendix
                      N.

                  

          

        

        
          

          Part
            II

        

        
          32

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
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                    b.

                  	
                    The
                      MCO may track utilization, including, but not limited to, primary
                      care behavioral health, laboratory, behavioral health pharmacy,
                      emergency department, and transportation. The MCO shall bring any
                      increases in the utilization trend for any of these services to the
                      attention of
                      the DEPARTMENT.

                  

          

        

        
          

          
            	
                    c.

                  	
                    If
                      there is a conflict between the MCO and the BMP as to whether
                      a Member's medical or behavioral health condition is primary,
                      the
                      MCO's medical director shall work with the BHP's medical director
                      to
                      reach a timely and mutually agreeable resolution. If the MCO and BMP
                      are not able to reach a resolution, the DEPARTMENT will make a
                      determination and the DEPARTMENT'S determination shall be binding.
                      Issues related to whether a Member's medical or behavioral health
                      condition is primary must not delay timely medical necessity
                      determinations. In these circumstances, the MCO must render a
                      determination within the standard timeframe required under this
                      contract.

                  

          

        

        
          

          
            	
                    d.

                  	
                    Ancillary
                      Services

                  

          

        

        
          

          
            	
                    1.

                  	
                    The
                      MCO shall retain responsibility for all ancillary services
                      such
                      as laboratory, radiology, and medical equipment, devices and
                      supplies regardless of
                      diagnosis.

                  

          

        

        
          

          
            	
                    2.

                  	
                    The
                      MCO is not responsible for ancillary services that are part
                      of the
                      DEPARTMENT'S all-inclusive rate for inpatient behavioral health
                      services.

                  

          

        

        
          

          
            	
                    e.

                  	
                    Co-Occurring
                      Medical and Behavioral Health
                      Conditions

                  

          

        

        
          

          The
            MCO
            shall continue programs and procedures designed to support the identification
            of
            untreated behavioral health disorders in medical patients at risk for
            such
            disorders.   The MCO shall:

        

        
          

          
            	
                    1.

                  	
                    Contact
                      the BMP ASO when co-management of a Member's care by the MCO and the
                      BMP ASO is indicated, such as for persons with special physical
                      health and behavioral health
                      needs;

                  

          

        

        
          

          
            	
                    2.

                  	
                    Respond
                      to inquiries by the BMP ASO regarding the presence of medical co-
                      morbidities;

                  

          

        

        
          

          
            	
                    3.

                  	
                    Coordinate
                      with the BMP ASO, upon
                      request;

                  

          

        

        
          

          
            	
                    4.

                  	
                    Assign
                      a key contact person in order to facilitate timely coordination with
                      the ASO; and

                  

          

        

        
          

          
            	
                    5.

                  	
                    Participate
                      in medical/behavioral co-management meetings at least once a month,
                      with the specific frequency to be determined by agreement between the
                      MCO and the ASO.

                  

          

        

        
          

          
            	
                    f.

                  	
                    Freestanding
                      Primary Care Clinics

                  

          

        

        
          

          Part
            II

        

        
          33

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
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          The
            MCO
            shall be responsible for primary care and other services provided by
            primary
            care and medical clinics not affiliated with a hospital, regardless of
            diagnosis. The only exception is that the MCO shall not be responsible
            for
            behavioral health evaluation and treatment services billed under CRT
            codes
            90801-90806, 90853, 90846, 90847 and 90862, when the Member has a primary
            behavioral health diagnosis and the services are provided by a licensed
            behavioral health professional.

        

        
          

          
            	
                    g.

                  	
                    Home
                      Health Services

                  

          

        

        
          

          
            	
                     

                  	
                    1.

                  	
                    The
                      MCO shall be responsible for management and payment of claims
                      when home health services are required for the treatment of
                      medical
                      diagnoses alone and when home health services are required
                      to treat both
                      medical and behavioral diagnoses, but the medical diagnosis
                      is
                      primary.

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO shall also be responsible for authorization and payment of the
                      medical component of claims if a Member has both medical and
                      behavioral diagnoses, and the Member's medical treatment needs cannot
                      be safely and effectively managed by the psychiatric nurse or
                      aide.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO shall manage and pay claims for home health, physical therapy,
                      occupational therapy, and speech therapy, regardless of diagnosis, to
                      the extent such services are otherwise covered under this
                      contract.

                  

          

        

        
          

          
            	
                    d.

                  	
                    The
                      MCO shall be responsible for the management and payment of claims for
                      home health services for Members with mental retardation when the
                      Member does not also have a diagnosis
                      of autism.

                  

          

        

        
          

          
            	
                    h.

                  	
                    Hospital
                      Inpatient Services.

                  

          

        

        
          

          
            	
                    1.

                  	
                    The
                      MCO will share responsibility for inpatient general hospital services
                      with the BHP.

                  

          

        

        
          

          
            	
                    2.

                  	
                    The
                      MCO shall be responsible for management and payment of claims for
                      inpatient general hospital services when the medical diagnosis is
                      primary. The medical diagnosis is primary if both the Revenue Center
                      Code and primary diagnosis are
                      medical.

                  

          

        

        
          

          
            	
                    3.

                  	
                    The
                      MCO shall also be responsible for professional services and other
                      charges associated with primary medical diagnoses during a behavioral
                      stay.

                  

          

        

        
          

          
            	
                    4.

                  	
                    The
                      MCO shall also be responsible for ancillary services associated with
                      non-primary behavioral health diagnoses during a medical stay, as
                      described in subsection (a) of this
                      section.

                  

          

        

        
          

          
            	
                    5.

                  	
                    The
                      MCO shall not be responsible for ancillary services that are included
                      in the hospital's per diem inpatient behavioral health
                      rate.

                  

          

        

        
          

          Part
            II

        

        
          34

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
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          i.         Hospital
            Outpatient Clinic Services

        

        
          

          The
            MCO
            shall be responsible for all primary care and other medical services
            provided by
            hospital outpatient clinics, regardless of diagnosis, including all medical
            specialty services and all ancillary services.

        

        
          

          j.         Long
            Term Care

        

        
          

          The
            MCO
            shall be responsible for all long-term care services such as nursing
            homes and
            chronic disease hospitals, regardless of a Member's
            diagnosis.

        

        
          

          k.        Primary
            Care Behavioral Health Services

        

        
          

          
            	
                    1.

                  	
                    The
                      MCO shall be responsible for all primary care services and
                      all associated charges, regardless of diagnosis. Such
                      responsibilities include:

                  

          

        

        
          

          
            	
                    a)

                  	
                    Behavioral
                      health related prevention and
                      anticipatory guidance;

                  

          

        

        
          

          
            	
                    b)

                  	
                    Screening
                      for behavioral health
                      disorders;

                  

          

        

        
          

          
            	
                    c)

                  	
                    Treatment
                      of behavioral health disorders that the primary care physician
                      concludes can be safely and appropriately treated in a primary care
                      setting;

                  

          

        

        
          

          
            	
                    d)

                  	
                    Management
                      of psychotropic medications, when the PCP determines it is safe and
                      appropriate to do so, and in conjunction with treatment by a BHP
                      non-medical behavioral health specialist when necessary;
                      and

                  

          

        

        
          

          
            	
                    e)

                  	
                    Referral
                      to a behavioral health specialist when the PCP concludes it is
                      necessary, safe, and appropriate to do
                      so.

                  

          

        

        
          

          
            	
                    2.

                  	
                    The
                      CT BHP ASO will develop education and guidance for primary care
                      physicians related to the provision of behavioral health services in
                      primary care settings. The MCOs may participate with the ASO in the
                      development of education and guidance or they will be provided the
                      opportunity for review and comment. The education and guidance will
                      address PCP prescribing with support and guidance from the ASO or
                      referring clinic. The CT BHP ASO will make telephonic psychiatric
                      consultation services available to primary care providers. Any
                      primary care provider that is seeking guidance on psychotropic
                      prescribing for a HUSKY A or HUSKY B member may initiate
                      consultation.

                  

          

        

        
          

          
            	
                    3.

                  	
                    The
                      CT BHP ASO will work with the MCO and provider organizations to
                      sponsor opportunities for joint training to promote effective
                      coordination and collaboration. MCO policies, procedures and provider
                      contracts must support the provision of behavioral health services by
                      primary care providers and entry into coordination
                      agreements with Enhanced Care Clinics established by the
                      DEPARTMENT.

                  

          

        

        
          

          Part
            II

        

        
          35

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35) 07 HUSKY A 05/07

        

        
           

          l.         School
            Based Health Center Services

        

        
          

          The
            HUSKY
            MCOs will be responsible for services provided by contracted school-based
            health
            centers, regardless of diagnosis; however, they will not be responsible
            for
            behavioral health assessment and treatment services billed under CRT
            codes 90801
            - 90807, 90853, 90846 and 90847.

        

        
          

          3.18    Children's
            Issues and EPSDT Compliance

        

        
          

          In
            order
            to meet the requirements of the epsdt program as set forth in Sections
            1902(a)(43) and 1905(r) of the Social Security Act, the MCO
            shall:

        

        
          

          
            	
                    a.

                  	
                    Provide
                      EPSDT screening services in accordance with the periodicity schedule
                      attached to this contract as Appendix C. Any changes in
                      the periodicity 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 EPSDT screening
                      services;

                  

          

        

        
          

          
            	
                    b.

                  	
                    Provide
                      interperiodic screening examinations when medically necessary, or in
                      accordance with the provisions of Section 3.19(a), to determine
                      the existence of a physical or mental illness or condition, or
                      to
                      assist Members in meeting the medical requirements for certification
                      or recertification in WIC. Such interperiodic screens shall include
                      screens for anemia as recommended by the Centers for Disease Control
                      (CDC). The MCO shall not require prior authorization of interperiodic
                      screening examinations;

                  

          

        

        
          

          
            	
                    c.

                  	
                    Provide
                      EPSDT screening services 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);

                  

          

        

        
          

          
            	
                    2.

                  	
                    A
                      comprehensive unclothed or partially draped physical
                      exam;

                  

          

        

        
          

          
            	
                    3.

                  	
                    Appropriate
                      immunizations as currently recommended by the Connecticut DEPARTMENT
                      of Public Health;

                  

          

        

        
          

          
            	
                    4.

                  	
                    Laboratory
                      tests, as set forth in the periodicity schedule at Appendix
                      C

                  

          

        

        
          

          
            	
                    5.

                  	
                    Vision
                      and hearing screenings as set forth in the periodicity schedule at
                      Appendix C;

                  

          

        

        
          

          
            	
                    6.

                  	
                    Dental
                      assessments as set forth in the periodicity schedule at Appendix C
                      and

                  

          

        

        
          

          
            	
                    7.

                  	
                    Health
                      education, including anticipatory
                      guidance.

                  

          

        

        
          

          
            	
                    d.

                  	
                    Provide
                      all medically necessary health care, diagnostic services,
                      and treatment for Members under twenty-one (21) covered under the
                      federal

                  

          

        

        
          

          Part
            II

          36

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
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          Medicaid
            program and described in Section 1905(a) of the Social Security Act regardless
            of whether the health care, diagnostic services, and treatment are specified
            in
            the list of covered services at Appendix A of this contract and regardless
            of
            any limitations on the amount, duration, or scope of the services that
            would
            otherwise be applied.

        

        
          

          
            	
                    e.

                  	
                    Take
                      all necessary steps to ensure that its Members under the age
                      of twenty-one (21) receive EPSDT screening services and any
                      necessary diagnostic and treatment services, including, but not
                      limited to:

                  

          

        

        
          
            	
                  	
                    1.

                  	
                    Providing
                      assistance in arranging and scheduling
                      appointments;

                  

          

        

        
          
            	
                  	
                    2.

                  	
                    Providing
                      and arranging transportation;

                  

          

        

        
          
            	
                  	
                    3.

                  	
                    Following
                      up on missed appointments;
                      and

                  

          

        

        
          
            	
                  	
                    4.

                  	
                    Providing
                      interpreters to Members with limited English proficiency and Members
                      who are hearing and visually
                      impaired.

                  

          

        

        
          

          
            	
                    f.

                  	
                    No
                      later than sixty (60) days after enrollment in the plan and
                      annually thereafter, 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 EPSDT screening, diagnostic and
                      treatment services;

                  

          

        

        
          
            	
                  	
                    2.

                  	
                    Inform
                      its Members about the importance and benefits of EPSDT screening
                      services;

                  

          

        

        
          
            	
                  	
                    3.

                  	
                    Inform
                      its Members about how to obtain EPSDT screening services;
                      and

                  

          

        

        
          
            	
                  	
                    4.

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

                  

          

        

        
          

          
            	
                    g.

                  	
                    Coordinate
                      and enhance the services provided to Members under twenty- one (21)
                      through the development and execution of memorandums of understanding
                      (MOUs) with the following
                      programs:

                  

          

        

        
          
            	
                  	
                    1.

                  	
                    Nurturing
                      Families Network;

                  

          

        

        
          
            	
                  	
                    2.

                  	
                    Healthy
                      Start;

                  

          

        

        
          
            	
                  	
                    3.

                  	
                    The
                      Special Supplemental Food Program for Women, Infants, and Children
                      (WIC);

                  

          

        

        
          
            	
                  	
                    4.

                  	
                    Birth-to-Three;

                  

          

        

        
          
            	
                  	
                    5.

                  	
                    Head
                      Start;

                  

          

        

        
          
            	
                  	
                    6.

                  	
                    InfoLine's
                      Maternal and Child Health Project;
                      and

                  

          

        

        
          
            	
                  	
                    7.

                  	
                    Other
                      programs operated by the DEPARTMENTS of Children and Families,
                      Education, Public Health, Mental Health and
                      Addiction

                  

          

        

        
          

          Part
            II

        

        
          37

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            H,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          Services
            and Mental Retardation as designated by the DEPARTMENT.

        

        
          

          The
            MCO
            shall cooperate with the DEPARTMENT and the entities listed above in
            g.1-7 in
            the development and execution of the MOUs and any revisions or amendments
            thereto.

        

        
          

          
            	
                    h.   

                  	
                    Include
                      in the MOUs developed and executed under subsection (g) of
                      this section,
                      provisions that specify how the MCO will work with the program,
                      including,
                      but not limited to:

                  

          

        

        
          
            	
                  	
                    1.

                  	
                    A
                      description of the services provided by the
                      program;

                  

          

        

        
          
            	
                  	
                    2.

                  	
                    Designation
                      of a liaison at the MCO to work with the program on ensuring the
                      provision of medically necessary and appropriate covered services by
                      the MCO and the coordination of services provided by the MCO and the
                      program;

                  

          

        

        
          
            	
                  	
                    3.

                  	
                    Protocols
                      for referrals to the program by the
                      MCO;

                  

          

        

        
          
            	
                  	
                    4.

                  	
                    Protocols
                      for communication of information concerning individuals who are
                      Members of the MCO who are receiving services from
                      the program;

                  

          

        

        
          
            	
                  	
                    5.

                  	
                    Protocols
                      for the resolution of any issues that arise concerning the delivery
                      of services to HUSKY Members who are receiving services from the
                      program;

                  

          

        

        
          
            	
                  	
                    6.

                  	
                    Compliance
                      with HIPAA privacy rules if the agreement includes exchange of
                      members' protected health information;
                      and

                  

          

        

        
          
            	
                  	
                    7.

                  	
                    Any
                      other mutually agreed upon
                      provisions.

                  

          

        

        
          

          
            	
                    i.

                  	
                    The
                      MCOs shall require PCPs to obtain all available vaccines free
                      of
                      charge
                      from the DEPARTMENT of Public Health under the Vaccines for
                      Children
                      program.

                  

          

        

        
          

          
            	
                    j.        

                  	
                     Cooperate
                      with the Connecticut Immunization Registry and Tracking System
                      to track
                      childhood immunizations of its
                      Members.

                  

          

        

        
          

          
            	
                    k.       

                  	
                     In
                      order to carry out the responsibilities set forth in this section,
                      the MCO
                      shall identify children who are overdue for EPSDT screening
                      services, and
                      those who have missed EPSDT screening services. The MCO shall
                      work to
                      develop a plan for ensuring that Members under twenty-one (21)
                      years of
                      age who are overdue or late for screening examinations receive
                      their EPSDT
                      screening services and that other Members continue to receive
                      their
                      examinations on a regular
                      basis.

                  

          

        

        
          

          
            	
                    l.        

                  	
                     The
                      MCO shall attain an annual EPSDT participation ratio and an
                      annual EPSDT
                      screening ratio of at least eighty (80) percent for the period
                      from
                      October 1, 2002 through September 30, 2003. The DEPARTMENT
                      shall determine
                      the MCO's participation and screening ratio from the encounter
                      data as
                      reported to the DEPARTMENT or its agent(s) in accordance with
                      the
                      methodology established by HCFA or CMS for the HCFA-416
                      report.

                  

          

        

        
          

          Part
            II

          38

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            H,
            3.01-3.35) 07 HUSKY A 05/07

        

        
          

          Sanction:
            Failure to achieve a participation and/or screening ratio of eighty (80)
            percent
            may subject the MCO to a Class B sanction in accordance with the provisions
            of
            Section 7.05. However, no sanction shall apply if the MCO's participation
            and
            screening ratios, although less than eighty (80) percent, are greater
            than the
            participation and screening ratios for the MCO for the equivalent period
            one
            year earlier plus one half the difference between the ratios for the
            earlier
            period and eighty (80) percent.

        

        
          

          3.19    Specialized
            Outpatient Services for Children Under DCF Care

        

        
          

          
            	
                    a.     

                  	
                     The
                      MCO shall pay for a comprehensive multi-disciplinary examination
                      for
                      initial placement only, for each child entering DCF care, within
                      thirty
                      (30) days of placement into out-of-home
                      care.

                  

          

        

        
          

          
            	
                  	
                    1.

                  	
                    The
                      multi-disciplinary examination that shall consist of a
                      thorough assessment of the child's functional, medical,
                      developmental, educational, and mental health
                      status.

                  

          

        

        
          

          
            	
                  	
                    2.

                  	
                    Within
                      each area of the assessment, the evaluation shall identify any
                      additional specialized diagnostic and therapeutic
                      needs.

                  

          

        

        
          

          
            	
                  	
                    3.

                  	
                    Physicians
                      and other medical and mental health providers specializing in the
                      assessment areas shall conduct the multi- disciplinary
                      examination.

                  

          

        

        
          

          
            	
                  	
                    4.

                  	
                    Each
                      multi-disciplinary examination shall occur at a single
                      location.

                  

          

        

        
          

          
            	
                  	
                    5.

                  	
                    All
                      components of the examination shall be performed on the same day,
                      excluding additional needed examinations, unless
                      otherwise indicated.

                  

          

        

        
          

          
            	
                  	
                    6.

                  	
                    The
                      provider shall report the findings and conclusions of the examination
                      in a form acceptable to DCF. The report must be received by DCF
                      within fifteen (15) days of the examination. The provider shall also
                      provide for updates to DCF on any
                      additional examinations.

                  

          

        

        
          

          
            	
                    b   

                  	
                    The
                      providers of the MCO shall provide for training of foster parents
                      on the
                      use of special equipment or medications as
                      needed.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO shall require regular collaboration between providers and
                      DCF Regional Offices and Central Office medical, mental health
                      and
                      social work staff and consultants. The MCO shall assign staff to act
                      as liaisons to identify, address and resolve health care delivery
                      issues, barriers to comprehensive care and other problem areas. DCF
                      shall specify the contact persons by name, title and phone number who
                      will be available for quarterly meetings between DCF and the MCO and
                      shall facilitate the initiation of these meetings with the
                      MCO.

                  

          

        

        
          

          
            	
                    d.

                  	
                    In
                      addition to standard prescription coverage, the MCO shall
                      cover prescriptions in compliance with DCF policy for "Placement
                      Medications" that are additional prescriptions that may be needed
                      when children are placed
                      or change placements. The MCO shall cover "Home Visit Medications".
                      Home
                      Visit Medications are additional prescriptions, which may be
                      needed when
                      children placed in out-of-home settings leave the placement
                      for a home
                      visit. Home Visit Medications should include only those doses
                      that will be
                      needed during the home visit, plus one extra
                      dose.

                  

          

        

        
          

          Part
            II

          39

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35)   07 HUSKY A  05/07

        

        
           

        

        
          
            	
                    e.        

                  	
                    The
                      MCO shall deliver a notice of action to an identified person
                      at the DCF
                      Central Office when a service is to be reduced, denied or terminated.
                      DCF
                      will, in turn, distribute the notice of action to its appropriate
                      regional
                      and local personnel.

                  

          

        

        
          

          3.20    Prenatal
            Care

        

        
          

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

        

        
          

          
            	
                    a.

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

                  

          

        

        
          
            	
                    b.

                  	
                    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 of
                      postpartum;

                  

          

          
            	
                    c.

                  	
                    Refer
                      enrolled pregnant women to the WIC
                      program;

                  

          

        

        
          
            	
                    d.

                  	
                    Offer
                      case management services for assistance with obtaining prenatal care
                      appointments, transportation, WIC, and other support services
                      as necessary;

                  

          

        

        
          
            	
                    e.

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

                  

          

        

        
          
            	
                    f.

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

                  

          

        

        
          
            	
                    g.

                  	
                    Refer
                      any pregnant Member who is actively abusing drugs or alcohol
                      to CTBHP; and

                  

          

        

        
          
            	
                    h.

                  	
                    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.

        

        
          

          Part
            II

          40

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            H,
            3.01 -3.35)  07 HUSKY A 05/07

        

        
          

          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 including access to the dental specialties that include
                      endodontic, oral surgical and orthodontic
                      services;

                  

          

        

        
          

          
            	
                    2.

                  	
                    For
                      the purpose of enrollment capacity a dental hygienist meeting the
                      criteria of Connecticut General Statutes Section 20-1261, with two
                      (2) years of experience, working in an institution (other
                      than hospital), a community health center, a group home, a
                      preschool operated by a local board of education or head start
                      program, 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 diagnostic, restorative and treatment
                      services;

                  

          

        

        
          

          
            	
                    3.

                  	
                    Implement
                      a 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;

                  

          

        

        
          

          
            	
                    4.

                  	
                    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 every six (6) months
                      and scheduling occurs no greater six (6) weeks from the
                      appointment;

                  

          

        

        
          

          
            	
                    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
                      pediatric or general dentist as
                      appropriate;

                  

          

        

        
          

          
            	
                    7.

                  	
                    Implement
                      specific outreach strategies to educate Members about the importance
                      of regular dental care, with a focus on accessing age appropriate
                      preventive care such as evaluations, cleanings and fluoride
                      applications at least twice a
                      year;

                  

          

        

        
          

          
            	
                    8.

                  	
                    Provide
                      for sufficient access to dental services for different age groups;
                      and

                  

          

        

        
          

          
            	
                    9.

                  	
                    Devise
                      mechanisms to avoid unnecessary PCP visits related to dental
                      problems.

                  

          

        

        
          

          Part
            II

        

        
          41

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35)   07 HUSKY A   05/07

        

        
          

          Performance
            Measure: The MCO shall ensure that no less than eighty (80) percent
            of
            continuously enrolled Members two (2) to twenty (20) years of age shall
            receive
            one screening and dental cleaning per twelve (12) month period. On a
            quarterly
            basis, the DEPARTMENT shall, through the encounter data submitted by
            the MCO,
            review the MCO's performance under children's dental access.

        

        
          

          Performance
            Measure: The MCO shall ensure that no less than eighty (80) percent
            of
            continuously enrolled Members twenty-one (21) years of age and over shall
            receive one screening and dental cleaning per twelve (12) month period.
            On a
            quarterly basis, the DEPARTMENT shall, through the encounter data submitted
            by
            the MCO, review the MCO's performance under adult dental
            access.

        

        
          

          3.22   Other
            Access Features

        

        
          

          a.        The
            MCO shall have systems in place to ensure access to medically necessary
            and medically appropriate well care by its Members. The MCO shall develop
            procedures to identify access problems and shall take corrective action
            as
            problems are identified. These systems and initiatives shall include,
            but not be
            limited to:

        

        
          

          
            	
                  	
                    1.

                  	
                    Monitoring
                      new Members to ensure that a well-care appointment is scheduled
                      within six (6) months of enrollment for those whose last well-care
                      visit does not fall within the recommended age and gender appropriate
                      schedules;

                  

          

        

        
          

          
            	
                  	
                    2.

                  	
                    Monitoring
                      and ensuring that Members receive well-care visits based on age and
                      gender appropriate schedules;

                  

          

        

        
          

          
            	
                  	
                    3.

                  	
                    Contacting
                      and counseling Members who miss
                      scheduled appointments;

                  

          

        

        
          

          
            	
                  	
                    4.

                  	
                    Coverage
                      and provision of services to newborns from the time
                      of birth;

                  

          

        

        
          

          
            	
                  	
                    5.

                  	
                    Assisting
                      Members in accessing and locating linguistically and culturally
                      appropriate services, including but not limited to, appropriate
                      accommodation for Members with hearing
                      disabilities;

                  

          

        

        
          

          
            	
                  	
                    6.

                  	
                    Assisting
                      disabled Members in accessing and locating services and providers
                      that can appropriately accommodate their needs, for example
                      wheelchair access to provider's
                      office;

                  

          

        

        
          

          
            	
                  	
                    7.

                  	
                    Development
                      of special initiatives, case management, care coordination, and
                      outreach to Members with special or multiple medical needs, for
                      example persons with AIDS or HIV
                      infected individuals;

                  

          

        

        
          

          
            	
                  	
                    8.

                  	
                    Development
                      of goals and action plans for incremental increases in utilization of
                      services such as postpartum care, adolescent health, dental
                      care and other
                      health care measures agreed upon between the MCO and the
                      DEPARTMENT;

                  

          

        

        
          

          Part
            II

        

        
          42

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35)    07 HUSKY A  05/07

        

         

        
          
            	
                  	
                    9.

                  	
                    Encouraging
                      providers to offer extended business hours and weekend (Saturday)
                      openings.

                  

          

        

        
          
             

            
              	
                      10.

                    	
                      Monitoring
                        timely access to care as described in Section
                        3.14.

                    

            

          

        

        
           

          
            	
                    b.   

                  	
                    The
                      MCO's access systems will be assessed as part of the annual
                      performance
                      review of the MCO.

                  

          

        

        
          

          3.23            Pre-Existing
            Conditions

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall assume responsibility for all covered services as
                      outlined in Appendix A for of each Member as of the effective date of
                      coverage under the contract regardless of the new Member's health
                      status.

                  

          

        

        
          

          
            	
                    b.

                  	
                    As
                      outlined in Appendix K, for new Members who have
                      transferred enrollment from another HUSKY MCO, coverage of services
                      other than acute care hospitalization, nursing home care or care in a
                      long term chronic disease hospital shall be the responsibility of the
                      MCO as of the beginning of the month during which enrollment becomes
                      effective. Responsibility for acute hospitalization, nursing home or
                      long term chronic disease hospital care services at the time of
                      enrollment or disenrollment is described in Section
                      3.25.

                  

          

        

        
          

          3.24            Newborn
            Enrollment

        

        
          

          Within
            six (6) months of a child's date of birth, the MCO must notify the DEPARTMENT
            of
            newborns for which they have not received enrollment notification from
            the
            DEPARTMENT. The MCO shall use the notification form made available by
            the
            DEPARTMENT for this purpose. Should the MCO fail to report the child's
            birth,
            the MCO shall reimburse the DEPARTMENT for any fee-for-service claims
            paid for
            covered services that occurred for the newborn Members prior to processing the
            newborn's enrollment into the MCO.

        

        
          

          
            	
                    3.25

                  	
                     

                  	
                    Acute
                      Care Hospitalization, Nursing Home or Chronic Disease Hospital Stay
                      at Time of Enrollment or
                      Disenrollment

                  

          

        

        
          

          For
            acute
            care requiring inpatient stay at a hospital, nursing home or chronic
            disease
            hospital, financial responsibility for covered services shall be determined
            as
            follows:

        

        
          

          a.          Inpatient
            at time of
            enrollment

        

        
          

          
            	
                  	
                    1

                  	
                    Initial
                      enrollment in HUSKY A should not commence during a recipient's
                      inpatient stay at a hospital, nursing home or subacute facility
                      unless the
                      recipient is a newborn, born to a Member. Upon approval by
                      CMS of a waiver
                      amendment, this exemption from enrollment will not apply to
                      inpatient
                      stays with a behavioral or mental health
                      diagnosis

                  

          

        

        
          

          Part
            II

        

        
          43

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (Part
            II,
            3.01-3.35)    07 HUSKY
            A   05/07

        

        
          

          
            	
                  	
                    2.  

                  	
                    The
                      MCO shall notify the DEPARTMENT within sixty (60) days of the
                      MCO's
                      discovery of or from the date that the MCO receives information
                      from which
                      a determination can be made that initial enrollment will take
                      effect
                      during the course of a hospitalization. For those individuals
                      who are
                      inpatient in an MCO participating facility, the time period
                      in which an
                      MCO must notify the DEPARTMENT is limited to six (6) months
                      from the
                      enrollment effective date or sixty (60) days of discovery,
                      whichever comes
                      first. Upon timely notification to the DEPARTMENT by the MCO,
                      the
                      DEPARTMENT shall change the effective date to the first of
                      the month after
                      discharge. If the MCO fails to notify the DEPARTMENT of the
                      inpatient
                      status within the above specified time periods, the DEPARTMENT
                      shall be
                      relieved of its responsibility to change the enrollment effective
                      date and
                      the individual's initial enrollment effective date into the
                      MCO shall be
                      retained.

                  

          

        

        
          

          b.            Hospitalization
            at time of disenrollment

           

        

        
          Hospital
            costs for Members who are inpatient at the time of disenrollment from
            the MCO
            shall remain the financial responsibility of the MCO until discharge
            from the
            hospital. For purposes of this subsection, hospital costs shall include
            the per
            diem hospital charge. Hospital costs shall not include charges related
            to the
            inpatient stay, but performed and billed separately, such as the services
            of the
            attending physician or a consulting specialist. Upon discovery of the
            Member's
            disenrollment, the MCO shall notify the individual's new MCO of the inpatient
            status and coordinate care and discharge planning with the new MCO. The
            MCO
            shall assume financial responsibility for all non-hospital costs as of
            the
            enrollment effective date for new Members who change MCOs while inpatient.
            Individuals who are disenrolled due to recategorization of their Medicaid
            coverage to a non-managed care category shall revert to fee-for-service
            upon
            recategorization.

        

        
          

          
            	
                    c.

                  	
                    Disenrollment
                      during or resulting from a long-term chronic disease hospital
                      or nursing
                      home stay

                  

          

           

        

        
          
            	
                  	
                    1. 

                  	
                     Members
                      who are inpatient in a long-term chronic disease hospital facility
                      or a
                      nursing home will remain the responsibility of the MCO until
                      they are
                      discharged from the facility or disenrolled from the MCO. If
                      the MCO
                      reports to DSS or its agent, any patient in a subacute facility
                      or a
                      nursing home other than for the purpose of behavioral health
                      prior to the
                      ninety (90) continuous days from the date of admission, the
                      DEPARTMENT
                      will disenroll the Member at the end of the month, that the
                      Member has
                      been inpatient in the facility for ninety (90) continuous days.
                      If the MCO
                      reports to the DEPARTMENT beyond ninety (90) days, the change
                      will be
                      effective the end of the month during which the change was
                      reported to DSS
                      or its agent.   The facility's per diem (room and board)
                      costs for a Member who is inpatient in a
                      subacute

                  

          

        

        
          

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          facility
            or a nursing home will remain the responsibility of the MCO until the
            Member is
            discharged from the facility or disenrolled from managed care, whichever
            comes
            first.

        

        
          

          
            	
                  	
                    2.       

                  	
                     Upon
                      discovery of the Member's disenrollment resulting from a plan
                      change, the
                      MCO shall notify the individual's new MCO of the inpatient
                      status and
                      coordinate care and discharge planning with the new MCO. The
                      MCO shall
                      assume financial responsibility for all non-room and board
                      costs as of the
                      enrollment effective date for any new Member who changed MCOs
                      while
                      inpatient.

                  

          

        

        
          

          3.26           Open
            Enrollment

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall conduct continuous open enrollment during which the MCO
                      shall accept clients eligible for coverage under this contract
                      in
                      the order in which they are enrolled without regard to the need
                      for
                      health services, health status of the client or any other
                      factor(s).

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO shall accept membership of newborns born to a Member upon the
                      child's date of birth with the exception of newborns that are
                      placed
                      for private adoption or when the mother has indicated in writing
                      that
                      she does not wish Medicaid coverage for the child. The enrollment
                      effective date for newborns shall be the first of the month in which
                      the child was born.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO shall not discriminate against individuals eligible to
                      enroll on
                      the basis of race, color, or national origin and will not use any
                      policy or practice that has the effect of discriminating on the any
                      such basis. The MCO shall not discriminate in enrollment activities
                      on the basis of health status or the client'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 Medicaid
                      clients.

                  

          

        

        
          

          
            	
                    d.

                  	
                    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 comes first. Other than the case of a newborn
                      retroactively enrolled, failure to notify the DEPARTMENT or its agent
                      within the parameters defined in this section and within established
                      procedures will result in the retention of the Member by the MCO for
                      the erroneous period of
                      enrollment.

                  

          

        

        
          

          3.27           Special
            Disenrollment

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO may request in writing and the DEPARTMENT may
                      approve disenrollment of specific Members 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.

                  

          

        

        
          

          
            	
                    b.

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

                  

          

        

        
          

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                    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 Member or
                      others; 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.	The
                    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
                      effective date for an approved disenrollment shall be no later
                      than
                      the first day of the second month following the month in which
                      the
                      MCO files the disenrollment request. If the DEPARTMENT fails to make
                      the determination within this timeframe, the disenrollment shall
                      be
                      deemed approved.

                  

          

        

        
          

          
            	
                    e.

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

                  

          

        

        
          

          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, notices of action and grievance/administrative
                      hearing information in languages other than English. The MCO shall
                      notify its members that oral interpretation is available for any
                      language.

                  

          

        

        
          

          
            	
                    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 Members in any county 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'S Eligibility Management System (EMS) to determine the
                      percentage of Members who speak alternative languages. The MCO shall
                      inform

                  

          

        

        
          

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            II

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          members
            that written materials are available in these alternative
            languages.

        

        
          

          c.        The
            MCO shall also take appropriate measures to ensure access to services
            by persons with visual and hearing disabilities. This shall include the
            provision of information in alternative formats and in an appropriate
            manner
            that takes into consideration the special needs of Members with disabilities.
            Information concerning Members with visual impairments and hearing disabilities
            will be made available through the daily and monthly EMS enrollment
            data.

        

        
          

          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 7.05.

        

        
          

          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; website; newsletter; and other Member
                      educational materials. The MCO's written materials for members must
                      be in a language and format that may be easily understood. 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.

                  	
                    At
                      the time of initial enrollment, the MCO shall provide a
                      member handbook to each Member. If a Member loses eligibility and
                      re-enrolls in the MCO less than ninety (90) days after losing
                      eligibility, the MCO is not required to send a new handbook. If the
                      lapse in enrollment is more than ninety (90) days, the MCO shall send
                      a new handbook.   The MCO shall mail the Member
                      handbook and provider directory to Members within one week of
                      enrollment notification. At least once a year, thereafter,
                      the
                      MCO shall notify the Members of their right to request the Member
                      Handbook that shall address and explain, at a minimum, the
                      following:

                  

          

        

        
          

          
            	
                    1.

                  	
                    The
                      amount, duration and scope of covered services under the contract in
                      sufficient detail that the Member understands the benefits to which
                      they are entitled;

                  

          

        

        
          
            	
                    2.

                  	
                    Restrictions
                      on services (including limitations and services not covered) and
                      circumstances in which the Member could be held liable for payment
                      for services;

                  

          

        

        
          
            	
                    3.

                  	
                    Prior
                      authorization process;

                  

          

        

        
          
            	
                    4.

                  	
                    Definition
                      of and distinction between emergency care and urgent care and the
                      extent to which emergency coverage is available, including: the fact
                      that prior authorization is not necessary for emergency care, the
                      procedures for obtaining emergency services including the use of 911;
                      the locations of emergency settings
                      which

                  

          

        

        
          

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            II

        

        
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          provide
            emergency services and post-stabilization services; the fact that the
            Member can
            obtain emergency care in any hospital or other setting and the post
            stabilization rules;

        

        
          

          
            	
                    5.

                  	
                    Policies
                      on the use of urgent care services including a phone number that can
                      be used for assistance in obtaining urgent
                      care;

                  

          

        

        
          
            	
                    6.

                  	
                    How
                      to access care twenty-four (24) hours a
                      day;

                  

          

        

        
          
            	
                    7.

                  	
                    Assistance
                      with appointment scheduling;

                  

          

        

        
          
            	
                    8.

                  	
                    Member
                      rights and responsibilities, as described in Section
                      3.03;

                  

          

        

        
          
            	
                    9.

                  	
                    Member
                      services, including hours of
                      operation;

                  

          

        

        
          
            	
                    10.

                  	
                    Enrollment/disenrollment/plan
                      changes;

                  

          

        

        
          
            	
                    11.

                  	
                    Procedures
                      for selecting and changing
                      PCPs;

                  

          

        

        
          
            	
                    12.

                  	
                    Policies
                      on referrals for specialty care and other benefits not furnished
                      by   the PCP;

                  

          

          
            	
                    13.

                  	
                    Availability
                      of provider network directory and
                      updates;

                  

          

        

        
          
            	
                    14.

                  	
                    An
                      explanation of circumstances in which a Member is
                      responsible for making
                      co-payments;

                  

          

        

        
          
            	
                    15.

                  	
                    Restrictions
                      on the Member's freedom of choice among
                      providers;

                  

          

        

        
          
            	
                    16.

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

                  

          

        

        
          
            	
                    17.

                  	
                    Access
                      and availability standards;

                  

          

        

        
          
            	
                    18.

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

                  

          

        

        
          
            	
                    19.

                  	
                    Family
                      planning services and the availability of family planning from out-of
                      network providers;

                  

          

        

        
          
            	
                    20.

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

                  

          

        

        
          
            	
                    21.

                  	
                    The
                      MCO's appeal and the DEPARTMENT'S administrative hearing process,
                      including the right to a hearing, the method for obtaining
                      a hearing,
                      the right to representation; the right to file appeals and hearing
                      requests and the time frames for filing; the availability
                      of assistance with filing; the toll-free numbers for filing appeals;
                      the circumstances in which services will be continued pending
                      a hearing; the MCO's provider appeal
                      process;

                  

          

        

        
          
            	
                    22.

                  	
                    Procedures
                      to request non-emergency transportation and transportation
                      options;

                  

          

        

        
          
            	
                    23.

                  	
                    EPSDT
                      services for children;

                  

          

        

        
          
            	
                    24.

                  	
                    Coordination
                      of benefits and third party
                      liability;

                  

          

        

        
          

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            II

        

        
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                    25.

                  	
                    Description
                      of drug formulary, prior approval and temporary supply process, if
                      applicable

                  

          

        

        
          
            	
                    26.

                  	
                    Advance
                      directives;

                  

          

        

        
          
            	
                    27.

                  	
                    Information
                      on how to access services from the CT BMP;
                      and

                  

          

        

        
          
            	
                    28.

                  	
                    How
                      to obtain any other benefits that are available under the Connecticut
                      Medicaid Plan but are not covered under this
                      contract.

                  

          

        

        
          

          Upon
            request, the MCO shall also provide Members with information on the structure
            and operation of the MCO and physician incentive plans.

        

        
          

          
            	
                    d.

                  	
                    The
                      MCO's provider directory shall include, at a minimum, the
                      names, location, telephone numbers and non-English languages spoken
                      by current contracted providers in the Member's service area,
                      including identification of providers that are not accepting new
                      patients. The provider directory shall include, at a minimum,
                      information on PCPs, specialists and
                      hospitals.

                  

          

        

        
          

          
            	
                    e.

                  	
                    The
                      MCO shall make a good faith effort to give written notice to
                      members of termination of a network provider within fifteen (15) days
                      after receipt or issuance of the provider termination notice. The
                      notice to members shall apply to those members whose designated PCP
                      terminated from the Plan or for those members who had an established
                      relationship with any other provider including but not limited to
                      specialists or clinics.

                  

          

        

        
          

          
            	
                    f.

                  	
                    All
                      Member educational materials for distribution beyond the
                      MCO's membership must be prior approved by the
                      DEPARTMENT.

                  

          

        

        
          

          
            	
                    g.

                  	
                    The
                      following Member materials must be prior approved by the DEPARTMENT
                      Member handbook; Membership card; introductory and other text
                      language from the provider directory; and all communication
                      to Members that include HUSKY A 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. The DEPARTMENT reserves the right to request
                      revisions or changes in the material at any
                      time.

                  

          

        

        
          

          
            	
                    h.  

                  	
                    The
                      DEPARTMENT shall, to the extent feasible, notify the MCO more
                      than thirty
                      (30) days in advance of any significant change to the HUSKY
                      program, for
                      example a change in the scope of covered services resulting
                      from
                      legislation. The MCO shall give each Member written notice
                      of any
                      significant change, at least 30 days before the intended effective
                      date of
                      the change.

                  

          

        

        
          

          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 start date. The MCO shall distribute the
            Member
            handbook within six (6) weeks of receiving the DEPARTMENT'S written
            approval.

        

        
          

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            II

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                    i.  

                  	
                    The
                      MCO shall maintain an adequately staffed Member services office
                      to receive
                      telephone calls and to meet personally with Members in order
                      to answer
                      Members' questions, respond to Members' complaints and resolve
                      problems
                      informally.

                  

          

        

        
           

          
            	
                    j.

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

                  

          

        

        
          

          
            	
                    k. 

                  	
                    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.

                  

          

        

        
          

          
            	
                    l.   

                  	
                    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, a staff Member shall answer ninety (90) percent
                      of all
                      incoming calls 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.

                  

          

        

        
          

          
            	
                    m.

                  	
                     

                  	
                    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 appeal and administrative
                      hearing processes and, upon request, mail to them, within one
                      business
                      day, forms and instructions for filing a
                      grievance.

                  

          

        

        
          

          
            	n.	
                     

                  	
                    The
                      MCO shall maintain a grievance report in the format designated
                      by the
                      DEPARTMENT pursuant to Section 6.01. These reports shall be
                      made available
                      to the DEPARTMENT upon
                      request

                  

          

        

        
          

          
            	o. 	
                     

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

                  

          

        

        
          

          
            	p. 	
                     

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

                  

          

        

        
          

          
            	q.	
                     

                  	
                    The
                      MCO will participate in 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. The MCO's CAHPS survey shall continue
                      to include
                      behavioral health questions.

                  

          

        

        
          

          
            	r.	
                     

                  	
                    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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            II

        

        
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                    s. 

                  	
                    The
                      MCO shall make appropriate referrals of Members who express
                      the need for
                      or may require behavioral health services to the CT BHP. The
                      MCO shall
                      develop appropriate procedures for managing urgent or crisis
                      calls and
                      communicating client specific crisis management information
                      to the CTBHP
                      for effective coordination of
                      care.

                  

          

        

        
          

          Sanction:
            If either the incoming call response or call abandonment standards set
            forth in
            paragraph h are not met for ninety (90) percent of the days during the
            six (6)
            month review period, the DEPARTMENT may impose a strike towards a Class
            A
            sanction pursuant to Section 7.05.

        

        
          

          3.30            Information
            to Potential Members

        

        
          

          Informational
            materials for potential members shall also be provided in a manner and
            format
            that may be easily understood. The MCO shall make the following information
            available to potential Members, upon request: the locations, qualifications,
            non-English languages spoken by and availability of the MCO's network
            providers.
            The MCO shall provide a summary of this information to the DEPARTMENT,
            in a
            format to be approved by the DEPARTMENT. The DEPARTMENT shall provide
            the
            summary information to all potential Members.

        

        
          

          The
            MCO
            shall also provide oral interpretation services in all non-English languages
            to
            potential Members.

        

        
          

          3.31            Marketing
            Requirements

        

        
          

          The
            MCO
            may, at its option, market or promote their plan to potential members.
            All
            marketing and marketing related activities must be in compliance with
            the
            provisions of 42 CFR 438.104, guidelines and restrictions as set forth
            in this
            section and Appendix D. DSS marketing restrictions apply to subcontractors
            and
            providers of care and 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 D.

        

        
          

          
            	
                    a.

                  	
                     

                  	
                    Prohibited
                      Marketing Activities: Appendix
                      D describes permitted and prohibited marketing activities that
                      apply to
                      all forms of communication, regardless of whether they are
                      performed by
                      the MCO directly, by its contracted providers, or its
                      subcontractors:

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO shall prohibit any type of marketing activity that has
                      not
                      been clearly specified as permissible under the guidelines in
                      Appendix D. The MCO shall contact the DEPARTMENT for guidance and
                      approval for any activity not clearly permissible under these
                      guidelines.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO shall submit its annual marketing plan, revisions to
                      the marketing plan and all marketing materials to the DEPARTMENT
                      for approval. The DEPARTMENT will provide comments on the
                      marketing materials to the MCO within thirty (30) days of receipt of
                      the materials. MCOs, subcontractors and their providers must wait
                      until receiving DSS

                  

          

        

        
          

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            II

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          written
            approval or 31 days from submission to the DEPARTMENT, if the DEPARTMENT
            has not
            responded by the 30th day
            before
            disseminating any such information to potential Members. DSS reserves
            the right
            to request revisions or changes in marketing materials at any
            time

        

        
          

          
            	
                    d. 

                  	
                    The
                      MCO shall distribute only approved marketing materials and
                      such approved
                      materials shall be distributed on a statewide
                      basis.

                  

          

        

        
          

          Sanction:
            If the MCO or its providers violate marketing guidelines, the DEPARTMENT
            may
            impose a Class B or Class C sanction pursuant to Section 7.05 as it deems
            appropriate.

        

        
          

          Sanction:
            If the MCO engages in non-compliant marketing practices within one year
            of a
            marketing related sanction, the DEPARTMENT may impose a Class C sanction
            of
            $25,000 for each determination of a marketing violation following the
            initial
            sanction episode.

        

        
          

          Sanction:
            Each marketing sanction episode shall include a mandatory statewide default
            enrollment freeze of no less than three months in duration.

        

        
          

          3.32            Health
            Education

        

        
          

          The
            MCO
            must routinely, but no less frequently than annually, remind and encourage
            Members to utilize benefits including physical examinations that are
            available
            and designed to prevent illness. The MCO must also offer periodic screening
            programs that in the opinion of the medical staff would effectively identify
            conditions indicative of a health problem. The MCO shall keep a record
            of all
            activities it has conducted to satisfy this requirement.

        

        
          

          3.33            Internal
            and External Quality Assurance

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO is required to provide a quality level of care for all
                      services
                      that it provides and for which it contracts. These services are
                      expected to be medically necessary and may be provided by
                      participating providers. A Quality Assessment and Performance
                      Improvement program shall be implemented by the MCO 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 federal regulations and DEPARTMENT policies and
                      requirements concerning Quality Assessment and Performance
                      Improvement and utilization review set forth below. The MCO will
                      develop and implement an internal Quality Assessment and Performance
                      Improvement program consistent with the Quality Assessment and
                      Performance program guidelines as provided in Appendix
                      E.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO shall comply with all applicable federal regulations
                      concerning Quality Assessment and Performance
                      Improvement.

                  

          

        

        
          

          
            	
                    d.

                  	
                    The
                      MCO shall operate a Quality Assessment and Performance Improvement
                      system that:

                  

          

        

        
          

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            II

        

        
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                    1.

                  	
                    Is
                      consistent with applicable federal
                      regulations;

                  

          

        

        
          

          
            	
                    2.

                  	
                    Provides
                      for review by appropriate health professionals of the process
                      followed in providing health
                      services;

                  

          

        

        
          

          
            	
                    3.

                  	
                    Provides
                      for systematic data collection of performance and participant
                      results;

                  

          

        

        
          

          
            	
                    4.

                  	
                    Provides
                      for interpretation of these data to the
                      practitioners;

                  

          

        

        
          

          
            	
                    5.

                  	
                    Provides
                      for making needed changes;

                  

          

        

        
          

          
            	
                    6.

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

                  

          

        

        
          

          
            	
                    7.

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

                  

          

        

        
          

          
            	
                    8.

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

                  

          

        

        
          

          
            	
                    e.

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

                  

          

        

        
          

          
            	
                    f.

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

                  

          

        

        
          

          
            	
                    1.

                  	
                    A
                      Quality Assessment and Performance Improvement
                      plan.

                  

          

        

        
          

          
            	
                    2.

                  	
                    A
                      full-time 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 of all the MCO's
                      providers, as well as the MCO's
                      subcontractors.

                  

          

        

        
          

          
            	
                    3.

                  	
                    The
                      Quality Assessment and Performance Improvement Director shall spend
                      an adequate percentage 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. A Quality Assessment and Performance Improvement
                      committee that includes representatives from the following shall
                      provide oversight of the
                      program:

                  

          

        

        
          

          
            	
                    a)  

                  	
                    A
                      variety of medical disciplines (e.g., medicine, surgery, mental
                      health,
                      etc.);

                  

          

        

        
          

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            II

        

        
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                    b)

                  	
                     

                  	
                    Administrative
                      staff; and Board of Directors of the
                      MCO.

                  

          

        

        
          

          
            	
                    4.

                  	
                    Make
                      available case management training for PCPs designed by the
                      DEPARTMENT or
                      its agent.

                  

          

        

        
          

          
            	
                    g.  

                  	
                    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.

                  

          

        

        
          

          
            	
                    h.

                  	
                    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.

                  

          

        

        
          

          
            	
                    i. 

                  	
                    The
                      Quality Assessment and Performance Improvement activities of
                      the MCO's
                      network 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 in-network
                      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 in-network providers
                      and
                      subcontractors.

                  

          

        

        
          

          
            	
                    j. 

                  	
                    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.

                  

          

        

        
          

          
            	
                    k.

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

                  

          

        

        
          

          
            	
                    I.

                  	
                    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.

                  

          

        

        
          

          
            	
                    m. 

                  	
                    Where
                      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.

                  

          

        

        
          

          
            	
                    n. 

                  	
                    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
                      Quality Assessment and Performance Improvement contractor and
                      shall
                      provide access to the data and records requested for this
                      purpose.

                  

          

        

        
          

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            II

        

        
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            n,
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                    o.      

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

                  

          

        

        
          

          
            	
                    p.       

                  	
                     The
                      MCO will be an active participant in at least one of the EQRO's
                      quality
                      improvement focus studies each year and will cooperate with
                      the DEPARTMENT
                      in other studies of mutual interest initiated by the
                      DEPARTMENT.

                  

          

        

        
          

          
            	
                    q.

                  	
                     

                  	
                    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, encounter and medical data,
                      and/or making
                      data available to the review
                      organization.

                  

          

        

        
          

          
            	
                    r.  

                  	
                     The
                      MCO must conduct at least one performance improvement project
                      that:

                  

          

        

        
          

          1.           Focuses
            on one of the following areas:

        

        
          a)           Prevention
            and care of acute and chronic conditions;

        

        
          b)           High
            volume services;

        

        
          c)           Continuity
            and coordination of care;

        

        
          d)           Appeals,
            grievances and complaints;

        

        
          e)           Access
            to and availability of services; or

        

        
          f)           Other
            projects subject to DEPARTMENT approval.

        

        
          

          
            	
                    2.

                  	
                    Includes
                      the measurement of performance and quality indicators that
                      are:

                  

          

        

        
          a)           Objective;

        

        
          b)           Clearly
            and unambiguously defined;

        

        
          
            	
                    c)

                  	
                    Based
                      on current clinical knowledge or health
                      services research;

                  

          

        

        
          d)           Valid
            and reliable;

        

        
          e)           Systematically
            collected; and

        

        
          
            	
                    f)

                  	
                    Capable
                      of measuring outcomes such as changes in health status or Member
                      satisfaction or valid proxies of
                      those outcomes.

                  

          

        

        
          

          3.           Implements
            system interventions to achieve quality improvement;

        

        
          4.           Evaluates
            the effectiveness of the interventions;

        

        
          
            	
                    5.

                  	
                    Plans
                      and initiates activities for increasing or sustaining improvement;
                      and

                  

          

        

        
          

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            II

        

        
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                    6.   

                  	
                    Represents
                      the entire population to which the quality indicator is
                      relevant.

                  

          

        

        
          

          
            	
                    s. 

                  	
                    The
                      MCO shall maintain a health information system that collects,
                      analyzes,
                      integrates and reports data. The system must provide information
                      on areas
                      including but not limited to utilization, appeals and
                      hearings.

                  

          

        

        
          

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

        

        
          

          
            	
                    u.

                  	
                    At
                      the invitation of the CT BHP, the MCO may, at its discretion,
                      participate
                      in a joint quality improvement initiative on an area of mutual
                      concern.

                  

          

        

        
          

          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

                  

          

        

        
          

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            II

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            II,
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          receiving
            services and to the administration of this contract that the DEPARTMENT
            may
            request, in accordance with Part II, 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 II,
                      Section 3.34.

                  

          

        

        
          

          
            	
                    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. Section 1320
                      d-2 et seq. and the implementing privacy regulations at 45 CFR pts.
                      160 and 164.

                  

          

        

        
          

          
            	
                    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, 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.

                  	
                    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.

                  

          

        

        
          

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            remainder of this page left intentionally blank.

        

        
          

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            II

        

        
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          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
                      §§ 1320d-2 et seq.. and the implementing privacy regulations at 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 NCQA or other
                      national accrediting body with a recognized expertise in managed
                      care.

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO shall also simultaneously maintain, with the medical record,
                      a record of all contacts with each Member that the MCO will maintain
                      in a computerized database and make available to the DEPARTMENT,
                      at
                      its request. Claims and encounter records will be provided to
                      the DEPARTMENT in an electronic medium as specified by
                      the DEPARTMENT, and its agent(s). The medical record shall
                      demonstrate coordination of Member care; for example, relevant
                      medical information from referral sources and out-of-network family
                      planning providers shall be reviewed and entered into Members'
                      medical records. For those MCOs that are governed under Connecticut
                      General Statutes Chapter 705 Section 38a-975 et seg., known as the
                      "Connecticut Insurance Information and Privacy Act", such MCO shall
                      be required to observe the provisions of such Act with respect to
                      disclosure of personal and privileged information as such terms are
                      defined under the Act.

                  

          

        

        
          

          
            	
                    c.

                  	
                    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.

                  

          

        

        
          

          
            	
                    d.

                  	
                    The
                      MCO shall share information and provide copies of medical
                      records pertaining to a Member to the BMP ASO upon the request of the
                      Member, Department or
                      ASO.

                  

          

        

        
          

          3.37        Audit
            Liabilities

           

        

        
          In
            addition to and not in any way in limitation of the MCO's obligations
            pursuant
            to this 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.

        

        
          

          Part
            II

        

        
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          3.38   Clinical
            Data Reporting

        

        
          

          
            	
                    a.

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

                  

          

        

        
          

          Utilization
            reports shall cover the following areas:

        

        
          

          1.      Inpatient
            Care;

        

        
          2.      Preventive
            Care;

        

        
          3.      Dental
            Care;

        

        
          4.      Other
            Services;

        

        
          5.      Maternal
            and Child Health;

        

        
          6.      EPSDT,
            known as HealthTrack; and

        

        
          7.      Immunization
            Information.

        

        
          

          
            	
                    b.

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

                  

          

        

        
          

          
            	
                    c.

                  	
                    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 that 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.

                  

          

        

        
          

          
            	
                    d.

                  	
                    For
                      each report the DEPARTMENT shall consider using any HEDIS standards
                      promulgated by the NCQA, which cover 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 A program can be better served by using
                      other methods.

                  

          

        

        
          

          
            	
                    e.

                  	
                    EPSDT
                      (HealthTrack): The MCO shall submit to the DEPARTMENT reports on
                      compliance with screening requirements of the EPSDT program
                      sufficient to enable the DEPARTMENT to comply with its reporting
                      obligations under federal and state requirements and to assess and
                      evaluate the performance of the MCO in the screening requirements of
                      the EPSDT program. These obligations include, but are not limited
                      to, submitting reports to federal and state agencies.

                     

                  

            	 f. 	 Maternal
                    and Prenatal Care

          

        

        
          

                    :

        

        
          

          Part
            II

        

        
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          The
            MCO
            shall report aggregate summary data on outcomes of maternal and prenatal
            care to
            the DEPARTMENT no less frequently than quarterly. Such data will
            include:

        

        
          

          
            	
                    1.

                  	
                    Number
                      of deliveries during the quarter to women enrolled in the MCO at the
                      time of delivery;

                  

            	2. 	 Number
                    of live births;

            	3.	 Number
                    of fetal deaths;

          

        

        
          
            	
                    4.

                  	
                    Number
                      of very low birth weight babies, defined as weighing less than one
                      thousand five hundred grams;

                  

          

        

        
          
            	
                    5.

                  	
                    Number
                      of hospital inpatient/NICU days for very low birth
                      weight babies;

                  

          

        

        
          
            	
                    6.

                  	
                    Number
                      of moderately low birth weight babies, defined as weighing less than
                      two thousand five hundred
                      grams;

                  

          

        

        
          
            	
                    7.

                  	
                    Number
                      of hospital/NICU days for moderately low birth
                      weight babies;

                  

            	8. 	Number
                    of deliveries by cesarean section;

            	9.	 Number
                    of women who delivered and had no prenatal
                    care;

            	10.	Number
                    of women with inadequate prenatal care;

            	11.	Number
                    of women with deliveries who have received a postpartum visit;
                    and

            	12.	Aggregate
                    measures of weeks of pregnancy at the time of enrollment in the
                    plan.

          

        

        
                    
            

        

        
                     
            

        

        
          The
            report will be due within six (6) months after the last day of the quarter
            in
            which the deliveries occurred. The DEPARTMENT will specify the methodology
            for
            preparing the report, no less than ninety (90) days prior to the end
            of the
            quarter, which is the subject of the report and after consultation with
            the MCO.
            If the change requires the collection of additional data elements not
            currently
            being captured, the DEPARTMENT will notify the MCO no less than ninety
            (90) days
            prior to the beginning of the first quarter affected by the
            change.

        

        
          

          g.        Daily
            and Monthly Reports

        

        
          

          
            	
                    1.  

                  	
                    The
                      MCO shall provide to the BMP ASO daily and monthly reports
                      and/or data of
                      services as mutually agreed upon. Such reports shall be produced
                      in a
                      format as mutually agreed upon. Examples of the service subjects
                      for
                      reporting may include but not be limited to the
                      following:

                  

          

        

        
          a)            Behavioral
            health emergency department visits;

        

        
          b)            Behavioral
            health emergency room recidivism;

        

        
          c)            Substance
            abuse and neonatal withdrawal;

        

        
          d)            Child
            and adolescent obesity and/or type II diabetes;

        

        
          e)            Sickle
            cell;

        

        
          f)            Eating
            disorders; and

        

        
          

          Part
            II

          60

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
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          g)       Medical
            detox.

        

        
          

          
            	
                    2.

                  	
                    The
                      Department shall provide specific behavioral health encounter data to
                      the MCO upon request to support quality management activities and
                      coordination. The format of the data extract will be consistent with
                      the encounter data-reporting format, or other format mutually agreed
                      upon by the Department and the
                      MCO.

                  

          

        

        
          

          
            	
                    3.

                  	
                    The
                      MCO shall report medical and behavioral transportation data and
                      transportation related complaints to the DEPARTMENT and shall
                      distinguish behavioral health non-emergency medical transportation
                      from medical non-emergency medical
                      transportation.

                  

          

        

        
          

          h.        Encounter
            Data:

        

        
          

          
            	
                    1.

                  	
                    The
                      MCO shall provide the DEPARTMENT with an electronic record of every
                      encounter between a network provider and a Member within fifteen (15)
                      days of the close of the month in which the specific encounter
                      occurred, was paid for, or was processed whichever is later but no
                      later than 180 days from the encounter. Such encounters shall be
                      coded and formatted in accordance with the specifications outlined in
                      the State's Encounter Submission and Reporting Guide. The DEPARTMENT
                      or its agent shall analyze each month's encounter submission file.
                      The DEPARTMENT or its agent will reject those records that contain
                      invalid or missing data and result in a critical edit failure as
                      outlined in the Encounter Submission and Reporting
                      Guide.

                  

          

        

        
          

          
            	
                    2.

                  	
                    Encounter
                      data and any other types of data submitted by the MCO that the
                      DEPARTMENT designates as data relied upon by the DEPARTMENT to set
                      rates must be certified by one of the following: the MCO's Chief
                      Executive Officer or Chief Financial Officer or an individual who has
                      delegated authority to sign for and who reports directly to either
                      the Chief Executive Officer or Chief
                      Financial Officer.    The certification must
                      attest, based on the best knowledge, information and belief, as
                      follows: 1) to the accuracy, completeness and truthfulness of the
                      data and 2) to the accuracy, completeness and truthfulness of the
                      reports required pursuant to this section. The MCO shall submit the
                      certification concurrently with the certified
                      data.

                  

          

        

        
          

          Performance
            Measure: The overall volume of rejected encounters shall not exceed
            five (5) percent in any given month.

        

        
          

          
            	
                    3
                      a. 

                  	
                    The
                      overall acceptance rate in any given month shall not be less
                      than 95 % for
                      the initial submission of
                      encounters.

                  

          

        

        
          

          
            	
                    3
                      b. 

                  	
                    The
                      overall acceptance rate (initial and corrected encounters)
                      for any given
                      month shall not be less than 98% within 90 days of the initial
                      submission.

                  

          

        

        
          

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            II

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          3.c.      
            The overall acceptance rate (initial and corrected encounters) for any
            given
            month shall not be less than 99.6% within 120 days of the initial
            submission.

        

        
          

          
            	
                    4.

                  	
                    The
                      DEPARTMENT or its agent shall also analyze the MCO's encounter
                      submissions for completeness. On a quarterly basis, no less than six
                      (6) months from the date of service on the encounter, the DEPARTMENT
                      or its agent will compare encounter data utilization levels to the
                      MCO self-reported utilization levels in the reports specified in
                      Sections 3.38(a)-(f).

                  

          

        

        
          

          Performance
            Measure: Encounter data shall not be over or under the MCO
            self-reported utilization levels for the same time period by ten (10)
            percent or
            more.

        

        
          

          
            	
                    5.

                  	
                    The
                      DEPARTMENT or its EQRO, may choose a random sample of no more than
                      one hundred (100) encounters for each year. The MCO will make the
                      medical records of each encounter so chosen available to the
                      DEPARTMENT or EQRO at a central location upon reasonable notice. The
                      EQRO shall review the medical records and report to the DEPARTMENT on
                      the extent to which the information in each field of the encounter
                      record corresponds to the information contained in the medical
                      record. Prior to making its report to the DEPARTMENT, the EQRO shall
                      afford the MCO a reasonable opportunity to suggest corrections to or
                      comment upon the EQRO's
                      findings.

                  

          

        

        
          

          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
            7.05.

        

        
          

          3.39    Utilization
            Management

        

        
          

          
            	
                    a.

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

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO and its subcontractors shall develop and adhere to
                      written policies and procedures for processing requests for initial
                      and continuing authorizations of services.   The MCO
                      shall have mechanisms in place to ensure consistent application of
                      review criteria for authorization decisions. Authorization decisions
                      must be made by a health care professional who has appropriate
                      clinical expertise in treating the Member's condition
                      or disease.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO must provide a written notice of action, as described in
                      Section 6.02, of any decision to deny a service authorization request
                      or to authorize a service in an amount, duration, or scope that is
                      less than requested or any decision to terminate, suspend or reduce a
                      previously

                  

          

        

        
          

          Part
            II

        

        
          62

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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          authorized
            Medicaid-covered service. The provider requesting authorization shall
            also
            receive a copy of the notice of action,

        

        
          

          
            	
                    d.

                  	
                    The
                      MCO shall make authorization decisions and issue a written
                      notice
                      of action and notice to the provider as expeditiously as the Member's
                      health condition requires, but not to exceed fourteen (14) calendar
                      days following receipt of the request for
                      service.   This standard 14 day authorization period
                      may be extended one time only by an additional fourteen (14)
                      days if:

                  

          

        

        
          

          1.           The
            Member or requesting provider asks for an extension; or

        

        
          

          
            	
                    2.

                  	
                    The
                      MCO documents that the extension is in the Member's interest because
                      additional information is needed to authorize the service and the
                      failure to extend the timeframe will result in the denial of
                      the service. The DEPARTMENT may request such documentation from
                      the MCO.

                  

          

        

        
          

          
            	
                    3.

                  	
                    The
                      MCO gives the Member written notice of the reason for the decision to
                      extend the timeframe and informs the Member of the right to file a
                      grievance if he or she disagrees with the decision to extend the
                      timeframe.

                  

          

        

        
          

          
            	
                    e.

                  	
                    The
                      MCO shall expedite its authorization decision if a provider
                      indicates, or the MCO determines that following the timeframe in
                      subsection (d) of this section could seriously jeopardize the
                      Member's life or health or ability to attain, maintain or regain
                      maximum function. In such circumstances the MCO shall issue a
                      decision no later than three working days after receipt of the
                      request for service. This three-day period may be extended
                      for
                      an additional fourteen days if either criteria in (d)(1) or (d)(2)
                      above, are met.

                  

          

        

        
          

          
            	
                    f.

                  	
                    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 subcontracts will be
                      subject to the provisions of Section 5.08 of this contract. The
                      DEPARTMENT will review and approve the subcontract, subject to the
                      provisions of Section 3.45, 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.

                  

          

        

        
          

          
            	
                    g.

                  	
                    The
                      MCO shall not compensate any subcontractor or other entity performing
                      utilization management or utilization review functions to provide any
                      incentive for the individual to deny, limit or discontinue medically
                      necessary services to any
                      Member.

                  

          

        

        
          

          
            	
                    h. 

                  	
                    If
                      the MCO disagrees with a clinical management decision made
                      by the BMP ASO,
                      the MCO may raise the issue with the ASO on behalf of the Member
                      and seek
                      to resolve the issue informally. If the issue remains unresolved,
                      the
                      DEPARTMENT will conduct an expedited review of the issue at
                      the request of
                      the MCO.

                  

          

        

        
          

          Part
            II

          63

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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          3.40    Financial
            Records

        

        
          

          
            	
                    a.

                  	
                    Accounting:
                      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, for any subcontract that is a risk contract
                      as defined
                      in 42 CFR 438.2, any such subcontractors' 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
                      subsections (c) and (d) below or as otherwise directed by the
                      DEPARTMENT.

                  

          

        

        
          

          
            	
                    c.

                  	
                    Reports
                      specific to the MCO's Medicaid line of business shall be provided in
                      formats developed by the DEPARTMENT. All reports described
                      in Sections 3.40(c)(1) and 3.40(c)(2) shall contain separate sections
                      for HUSKY A and HUSKY 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 with an income statement by 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. § 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.

                  

          

        

         

        
          
            	
                    2.

                  	
                    Unaudited
                      financial reports, HUSKY line of business (formats shown in Appendix
                      F). 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.

                  

          

        

        
          

          Part
            II

          64

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
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                    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 C.G.S. § 38a-53. One copy of each statement shall be submitted
                      to the DEPARTMENT in accordance with the Department of Insurance
                      submittal schedule.

                  

          

        

        
          

          
            	
                    4.

                  	
                    Claims
                      Aging Inventory Report (format shown in Appendix F, or any other
                      format approved by the DEPARTMENT). The Claims Aging Inventory 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 Inventory 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.

                  	
                    Denied
                      Claims Report. The MCO shall also submit a Denied Claims report, to
                      include all HUSKY provider claims denied as of the end of each
                      quarter.

                  

          

        

        
          

          
            	
                    6. 

                  	
                    Claims
                      Turn Around Time Report (format shown in Appendix F, or any
                      other format
                      approved by the DEPARTMENT). For those claims processed in
                      forty-six (46)
                      days or more, the report shall indicate if interest was paid
                      in accordance
                      with Section 3.46 of this 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 in
                      the required format 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 that 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.

                  

          

        

        
          

          
            	
                    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 the said agency agrees that such information may be shared
                      with the DEPARTMENT.

                  

          

        

        
          

          
            	
                    f.

                  	
                    The
                      MCO shall submit to the DEPARTMENT on a quarterly basis, capitation
                      income and disbursement reports from mental health and
                      dental subcontractors with whom they have a risk arrangement. The
                      report shall be in a format specified by the DEPARTMENT and shall
                      include total

                  

          

        

        
          

          Part
            II

          65

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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          payment
            received for Medicaid members from the MCO and breakdown of payment by
            categories as specified in Sec. 3.45 (j)(2).

        

        
          

          3.41           Insurance

        

        
          

          
            	
                    a.

                  	
                    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 should 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.

          

        

         

        
          
            	
                    b.

                  	
                    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           Third
            Party Coverage

        

        
          

          The
            DEPARTMENT is the payer of last resort when third party resources
            are    . available to cover the costs of medical services
            provided to Medicaid recipients. Pursuant to this requirement, the MCO
            is
            required to comply with federal and state statutes and regulations regarding
            third party liability. The MCO shall be responsible for making every
            reasonable
            effort to determine the legal liability of third parties to pay for services
            rendered to Members under this contract. The MCO shall be responsible
            for
            identifying appropriate third party resources, and if questions arise
            they shall
            consult with the DEPARTMENT. The MCO shall pursue, collect, and retain
            any
            monies from third party payers for services to the MCO's Members under
            this
            contract, subject to the following terms and conditions:

        

        
          

          
            	
                    a. 

                  	
                    The
                      DEPARTMENT hereby assigns to the MCO all rights to third party
                      recoveries
                      from Medicare, health insurance, casualty insurance, workers'
                      compensation, tortfeasors, or any other third parties who may
                      be
                      responsible for payment of medical costs for the MCO's
                      Members.

                  

          

        

        
          

          The
            MCO
            may assign the right of recovery to their subcontractors and/or network
            providers. Notwithstanding any such assignment of the right of recovery,
            the MCO
            remains responsible for the effective and diligent performance of third
            party
            recovery.

        

        
          

          1.        Other
            Insurance, Cost Avoidance and Third Party Resources

        

        
          

          Part
            II
            66

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
            3.36-8.05)                                                          07
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          The
            MCO
            will have primary responsibility for cost avoidance through the coordination
            of
            benefits relative to federal and private health insurance resources including,
            but not limited to Medicare, individual health insurance, employment-related
            group health insurance and self administered or self funded health benefit
            plan,
            including ERISA (Employee Retirement and Income Security Act) plans.
            The MCO
            shall avoid initial payments of claims, as permitted by federal law,
            where
            federal or private health insurance resources are available. When cost
            avoidance
            is not possible, the MCO may utilize post payment recovery. If a third
            party
            insurer requires the Member to pay any co-payment, coinsurance or deductible,
            the MCO is responsible for making any such payments to the extent that
            the third
            party insurer's co-payment exceeds the co-payment applicable under this
            contract.

        

        
          

          The
            MCO
            or its assignee must initiate third party recoveries within sixty (60)
            days
            after the end of the month in which the MCO learns of the existence of
            the
            liable third party. The MCO or its assignees must maintain dated documentation
            of all claims to third parties. The MCO must document initiation of recovery
            by
            formal communication in written or electronic form to the liable third
            party,
            specifically requesting reimbursement up to the legal limit of liability
            for any
            services provided to the MCO's Member covered under the State Medicaid
            Plan.

        

        
          

          The
            right
            to pursue, collect and retain recovery from claims not initiated and
            documented
            within sixty (60) days as stated above, will revert to the DEPARTMENT
            and the
            MCO or its assignees will lose any right of recovery.

        

        
          

          2.        Tort
            Recoveries

        

        
          

          The
            DEPARTMENT or the Department of Administrative Services shares the right
            with
            the MCO to initiate recoveries from tortfeasors. The right to recover
            the cost
            of medical services from a tortfeasor goes to the first party that makes
            a valid
            and legal claim to recovery. The party making a claim to recovery must
            request
            reimbursement up to the legal limit of liability for any services provider
            to
            the MCO's Member covered under the State Medicaid Plan. Disputes between
            the
            State of Connecticut and the MCO as to which party first initiated recovery
            will
            be determined by written confirmation from the tortfeasor.

        

        
          

          When
            the
            MCO seeks recovery from a third party for care provided to a Member following
            an
            accident, the MCO may recover only its cost of care.

        

        
          

          
            	
                    b. 

                  	
                    In
                      pursing third party recovery, the MCO, network providers, and
                      subcontractors shall seek recovery of the cost of services
                      actually

                  

          

        

        
          

          Part
            II

        

        
          

          67

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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          rendered
            to the Member, notwithstanding the fact that the MCO may pay the subcontractor
            on a capitated basis.

        

        
          

          
            	
                    c.   

                  	
                    The
                      MCO shall maintain records of recoveries of all third party
                      collections,
                      including cost avoidance, and recovery actions. The DEPARTMENT
                      will
                      specify a schedule and format for reporting such collections.
                      The amounts
                      avoided or recovered by the MCO shall be considered in establishing
                      future
                      capitated rates paid to the
                      MCO.

                  

          

        

        
          

          
            	
                    d  

                  	
                    The
                      MCO shall fully cooperate with the DEPARTMENT in all third
                      party recovery
                      efforts.

                  

          

        

        
          

          
            	
                    e.

                  	
                    The
                      DEPARTMENT shall supply the MCO with a monthly file of Members where
                      third party coverage has been identified. The information shall
                      also be available to the MCO and its assignees from the
                      DEPARTMENT'S Automated Electronic Voice Response
                      System.

                  

          

        

        
          

          
            	
                    f.

                  	
                    The
                      MCO shall notify the DEPARTMENT within thirty (30) days if
                      the MCO or
                      its network provider or subcontractor discovers that a Member
                      has become eligible for coverage by a liable third party. The MCO
                      shall notify the DEPARTMENT within thirty (30) days if the MCO or its
                      in-network provider or subcontractor discovers that a Member has lost
                      eligibility for coverage by a liable third party. The MCO shall
                      notify the Department in a format specified by the
                      Department.

                  

          

        

        
          

          3.43   Coordination
            of Benefits and Delivery of Services

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall ensure that the rules related to the coordination
                      of
                      benefits in Section 3.41 do not present any barriers to Members'
                      access to the covered services under this
                      contract.

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO shall educate its Members on how to access services when
                      a third
                      party insurer covers a
                      Member.

                  

          

        

        
          

          
            	
                    c.

                  	
                    If
                      a third party insurer requires the Member to pay any
                      co-payment, coinsurance or deductible, the MCO is responsible for
                      paying the portion of the third party insurer's co-payment that
                      exceeds the co-payment applicable under this contract, not to exceed
                      the amount allowed per the MCO's fee schedule, even if the services
                      are provided outside of the MCO's provider
                      network.

                  

          

        

        
          

          
            	
                    d.

                  	
                    If
                      a Member's third party insurer pays for only some services
                      covered under this contract or for only part of a particular service,
                      the MCO shall be liable up to the allowed amount in accordance with
                      the MCO's fee schedule, for the full extent of services covered under
                      this contract, even if the services are provided outside of the MCO's
                      provider network.

                  

          

        

        
          

          
            	
                    e.

                  	
                    If
                      a third party insurer covers a Member, the MCO is bound by
                      any
                      prior authorization decisions made by the third party
                      insurer.

                  

          

        

        
          

          Part
            II

        

        
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            II,
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          3.44           Passive
            Billing

        

        
          

          
            	
                    a.

                  	
                    Capitation
                      payments to the MCO shall be based on a passive billing system.
                      The MCO is
                      not required to submit claims for the capitation payment for
                      its HUSKY A
                      membership. Capitation payments will be based on MCO membership
                      data as
                      reflected in the enrollment files provided by the DEPARTMENT
                      to the MCOs.
                      On a monthly basis ACS will provide the MCO with a detailed
                      capitation
                      remittance file.

                  

          

        

        
          

          3.45           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
                      their 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 the 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. Before delegating any of the requirements of this
                      contract, the MCO shall evaluate the prospective subcontractor's
                      ability to perform the activities to be delegated. 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, including any reporting requirements. The subcontract
                      shall also provide for revocation or other sanctions if
                      the subcontractor's performance is inadequate. All subcontracts
                      shall
                      also provide for the right of the DEPARTMENT or other 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 3.34, Inspection of
                      Facilities. All subcontracts shall comply with the requirements of 42
                      CFR 438.6 that are appropriate to the service or activity delegated
                      under the subcontract.

                  

          

        

        
          

          
            	
                    c.

                  	
                    With
                      the exception of subcontracts specifically excluded by
                      the DEPARTMENT, all subcontracts shall include verbatim the HUSKY
                      A definitions of Medical Appropriateness / Medically Appropriate
                      and Medically Necessary/Medical Necessity as set forth in Part
                      II,
                      General Contract Terms for the MCOs. 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 A
                      Members. All subcontracts shall also provide that decisions
                      concerning both acute and chronic care must be made according to
                      these definitions.

                  

          

        

        
          

          Part
            II

          69

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
            3.36-8.05)                                                         07
            HUSKY
            A                                                                 05/07

        

        
          

          
            	
                    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 shall be providing through a subcontract
                      and copies of the contracts between the MCO and the subcontractor.
                      The 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 subcontract, excluding
                      those of a technical nature, shall require the pre-review and
                      approval of the DEPARTMENT.

                  

          

        

        
          

          
            	
                    e.

                  	
                    All
                      dental subcontracts which include the payment of claims on
                      behalf
                      of HUSKY A Members for the provision of goods and services to
                      HUSKY
                      A 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 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
                      dental subcontracts which include the payment of claims on
                      behalf
                      of HUSKY A Members for the provision of goods and services to
                      HUSKY
                      A members shall require the submission of a capitation income
                      and disbursement report in a format specified by the DEPARTMENT.
                      The report shall be submitted quarterly and shall include the amount
                      of payment received for Medicaid members; amount paid directly
                      to providers of health services on behalf of Medicaid
                      members; administrative costs and
                      profits.

                  

          

        

        
          

          
            	
                    g.

                  	
                    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.

                  

          

        

        
          

          
            	
                    h.

                  	
                     

                  	
                    Prior
                      to the approval by the DEPARTMENT of any subcontract with a
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 dental subcontractor. Such plan shall meet the requirements
                      described in subsection (j)
                      below.

                  

          

        

        
          

          Part
            II

        

        
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            II,
            3.36-8.05)                                                          07
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            A                                                                  05/07

        

        
          

          
            	
                    i.  

                  	
                    The
                      MCO shall monitor all subcontractors' performance on an ongoing
                      basis and
                      subject the subcontractor to formal review once a year. AH
                      subcontracts
                      shall provide that if the MCO identifies deficiencies or areas
                      for
                      improvement, the MCO and the subcontractor shall take corrective
                      action.

                  

          

        

        
          

          
            	
                    j.

                  	
                     

                  	
                    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)(4) of this
                      contract,
                      with steps to ensure the resolution of the outstanding amounts.
                      This plan
                      shall be submitted prior to the DEPARTMENT'S approval of the
                      replacement
                      subcontractor.

                  

          

        

        
          

          
            	
                    k.  

                  	
                    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.

                  

          

        

        
          

          
            	
                    l. 

                  	
                    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.

                  

          

        

        
          

          
            	
                    m.

                  	
                    This
                      section shall not be construed as restricting the MCO from
                      entering into
                      contracts with participating providers to provide health care
                      services to
                      Members.

                  

          

        

        
          

          3.46    Timely
            Payment of Claims

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall pay providers in group or individual practices or
                      who practice in shared health facilities within the following time
                      limitations unless the MCO and its providers stipulate to an
                      alternative schedule in their provider
                      contracts:

                  

          

        

        
          

          
            	
                    1.

                  	
                    Ninety
                      (90) percent of all clean claims within thirty (30) days from
                      the date of receipt;

                  

          

        

        
          

          
            	
                    2.

                  	
                    Ninety-nine
                      (99) percent of all clean claims within ninety (90) days from the
                      date of receipt.

                  

          

        

        
          

          
            	
                    b.

                  	
                    If
                      the MCO or any 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
                      otherwise as stipulated by a
                      provider contract.

                  

          

        

        
          

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            II

        

        
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            II,
            3.36-8.05)                                                         07
            HUSKY
            A                                                                 05/07

        

        
          

          
            	
                    c.  

                  	
                    In
                      accordance with Section 3.40 (c)(4), Financial Records, the
                      MCO shall
                      provide to the DEPARTMENT information related to interest paid
                      beyond the
                      forty-five (45) day timely filing limit or otherwise stipulated
                      by a
                      provider contract.

                  

          

        

        
          

          3.47           Member
            Charges For Noncovered Services

        

        
          

          A
            provider shall be permitted to charge an eligible Member for goods or
            services
            which are not coverable only if the Member 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 not covered under the Medicaid state plan, services
            which
            are provided in the absence of appropriate authorization, and services
            which are
            provided out-of-network unless otherwise specified in the contract, policy
            or
            regulation (e.g., family planning, mental health or emergency room
            services).

        

        
          

          3.48           Insolvency
            Protection

        

        
          

          Unless
            the MCO is (or is controlled by) one or more federally qualified health
            care
            centers and meets the solvency standards established by the DEPARTMENT
            for those
            centers, the MCO shall meet the solvency standards established by the
            State of
            Connecticut for private health maintenance organizations, or be licensed
            or
            certified by the State as a risk bearing entity. 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.

        

        
          

          3.49           Acceptance
            of DSS Rulings

        

        
          

          In
            cases
            where there is a dispute between the MCO and an out-of-network provider
            about
            whether a service is medically necessary, is an emergency, or is an appropriate
            diagnostic test to determine whether an emergency condition exists, the
            DEPARTMENT will hear appeals, filed within one year following the date
            of
            service and make final determinations. The DEPARTMENT will accept written
            comments from all parties to the dispute prior to making the decision,
            and order
            or not order payment, as appropriate. The MCO shall accept the DEPARTMENT'S
            determinations regarding appeals.

        

        
          

          3.50           Fraud
            and Abuse

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall not knowingly take any action or fail 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 in preventing and prosecuting fraud and
                      abuse in the HUSKY
                      program.

                  

          

        

        
          

          Part
            II

        

        
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            II,
            3.36-8.05)                                                          07
            HUSKY
            A                                                                 05/07

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO acknowledges that the 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
                      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 applies to the MCO's
                      subcontractors.

                  

          

        

        
          

          
            	
                    g.

                  	
                    The
                      MCO shall have administrative and management procedures and
                      a mandatory compliance plan to guard against fraud and abuse.
                      The MCO's compliance plan shall include but not necessarily be
                      limited to, the following
                      efforts:

                  

          

        

        
          

          
            	
                    1.

                  	
                    The
                      designation of a compliance officer and a compliance committee,
                      responsible to senior
                      management;

                  

          

        

        
          

          
            	
                    2.

                  	
                    Written
                      policies, procedures and standards that demonstrate commitment to
                      comply with all applicable Federal and
                      State standards;

                  

          

        

        
          

          
            	
                    3.

                  	
                    Effective
                      lines of communication between the compliance officer and MCO
                      employees;

                  

          

        

        
          

          
            	
                    4.

                  	
                    Conducting
                      regular reviews and audits of operations to guard against fraud and
                      abuse;

                  

          

        

        
          

          
            	
                    5.

                  	
                    Assessing
                      and strengthening internal controls to ensure claims are submitted
                      and payments are made
                      properly;

                  

          

        

        
          

          
            	
                    6.

                  	
                    Effectively
                      training and educating employees, providers, and subcontractors about
                      fraud and abuse and how to report
                      it;

                  

          

        

        
          

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            II

        

        
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            11,3.36-8.05)                                                          07
            HUSKY
            A                                                                 05/07

        

        
          

          
            	
                    7. 

                  	
                    Effectively
                      organizing resources to respond to complaints of fraud and
                      abuse;

                  

          

        

        
          

          
            	
                    8   

                  	
                    Establishing
                      procedures to process fraud and abuse complaints;
                      and

                  

          

        

        
          

          
            	
                    9. 

                  	
                    Establishing
                      procedures for prompt responses to potential offenses and reporting
                      information to the
                      DEPARTMENT.

                  

          

        

        
          

          
            	
                    h.

                  	
                    The
                      MCO shall examine publicly available data, including but not
                      limited to
                      the CMS Medicare/Medicaid Sanction Report and the CMS 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.

                  

          

        

        
          

          
            	
                    k. 

                  	
                    On
                      or before January 1, 2007, the MCO's compliance plan shall
                      meet the
                      requirements of Section 6033 of the Deficit Reduction Act of
                      2005, P.L.
                      109-171, and any implementing regulations or guidance on those
                      requirements issued by the federal
                      government.

                  

          

        

        
          

          Sanction:
            The DEPARTMENT may impose a sanction, up to and 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 7 of this contract, including terminating
            or
            refusing to renew this contract or any other Sanction or remedy allowed
            by
            federal or state law.

        

        
          

          3.51    Persons
            with Special Health Care Needs

        

        
          

          
            	
                    a.  

                  	
                    The
                      DEPARTMENT will provide to the MCO information to identify
                      Members who
                      are:

                  

          

        

        
               

        

        
          
            	1.	Eligible
                    for Supplemental Security Income;

            	2. 	Over
                    sixty-five (65) years of age;

            	
                    3.

                  	
                    Children
                      who are receiving foster care or otherwise in an out of home
                      placement or receiving Title IV E foster care or adoption services;
                      and

                  

          

        

        
          

          Part
            II

        

        
          74

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
            3.36-8.05)                                                          07
            HUSKY
            A                                                                 05/07

        

        
          

          
            	
                    4.   

                  	
                    Children
                      who are enrolled in Title V's Children with Special Health
                      Care Needs
                      program.

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO shall conduct an assessment of these individuals and
                      other persons with special health care needs and make a referral
                      to
                      the Member's PCP to develop a treatment plan, as
                      appropriate.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO shall report to the DEPARTMENT, in a format specified by
                      the DEPARTMENT, on quality indicators such as utilization of
                      specialty services and case management to be developed jointly
                      between the DEPARTMENT and the
                      MCOs.

                  

          

        

        
          

          3.52    Behavioral
            Health Payment Adjustment

        

        
          

          
            	
                    a.

                  	
                    The
                      DEPARTMENT will seek reimbursement from the MCO for the behavioral
                      health portion of capitation payments for HUSKY A members for service
                      months of January 2006 through the final date that the Department's
                      capitation payment included behavioral health
                      services

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO will reimburse the DEPARTMENT the portion of its
                      capitation payment reflected in Appendix I - Capitation Amount - for
                      behavioral health services per the following
                      schedule:

                  

          

        

        
          

          
            	
                    1.

                  	
                    Upon
                      execution of this amendment for those payments the MCO received
                      between January 1, 2006 and June 30,
                      2006;

                  

          

        

        
          

          
            	
                    2.

                  	
                    By
                      March 31, 2007 for those payments the MCO received between July 1,
                      2006 and September 30, 2006,
                      and

                  

          

        

        
          

          
            	
                    3.

                  	
                    By
                      June 30, 2007 for those payments the MCO received between October 1,
                      2006 and the final date that the Department's capitation payment
                      included behavioral health
                      services

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      Department within one month from the execution of this amendment will
                      reduce the HUSKY A capitation rate to reflect the removal of
                      payments for behavioral health
                      services.

                  

          

        

        
          

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            remainder of this page left intentionally blank.

        

        
          

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            II

        

        
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            II,
            3.36-8.05)                                                         07
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            A                                                                  05/07

        

        
          

          4.  FUNCTIONS
            AND DUTIES OF THE DEPARTMENT

        

        
          

          4.01            Eligibility
            Determinations

        

        
          

          The
            DEPARTMENT will determine the initial and ongoing eligibility for medical
            assistance of each individual enrolled under this contract in accordance
            with
            the DEPARTMENT'S continuous and guaranteed eligibility
            policies.

        

        
          

          4.02            Populations
            Eligible to Enroll

        

        
          

          Appendix
            G contains a list of the Medicaid groups currently eligible for managed
            care
            enrollment. New eligibility groups may be added to the managed care population.
            The DEPARTMENT will notify the MCO of any changes in the eligibility
            categories
            to be included. Additional groups included by the DEPARTMENT may be served
            at
            the MCO's option.

        

        
          

          4.03            Enrollment/Disenrollment

        

        
          

          
            	
                    a.

                  	
                    The
                      DEPARTMENT through a central enrollment broker contract will handle
                      enrollment, disenrollment and initial selection of
                      PCP.

                  

          

        

        
          

          
            	
                    b.

                  	
                    Coverage
                      for new Members will be effective the first of the month and coverage
                      for disenrollments will terminate at the end of the
                      month.

                  

          

        

        
          

          
            	
                    c.

                  	
                    Members
                      remain continuously enrolled throughout the term of this contract,
                      except in situations where
                      clients

                  

          

        

        
          

          1.      Change
            health plans,

        

        
          2.      Lose
            their Medicaid eligibility,

        

        
          3.      Receive
            Medicare, or

        

        
          
            4.    
              Are recategorized into a Medicaid category not included in the managed care
              initiative.

          

        

        
           

          
            	
                    d.

                  	
                    Disenrollments
                      due to a Member's change in health plans will occur on the last day
                      of the month in which the Member makes a plan change and the Member's
                      enrollment in a new plan will occur on the first day of the following
                      month. The MCOs shall coordinate care to assure continuity
                      in accordance with applicable DEPARTMENT
                      policies.

                  

          

        

        
          

          
            	
                    e.

                  	
                    Disenrollments
                      due to loss of eligibility become effective upon on the last day of
                      the month in which the Member looses
                      eligibility.

                  

          

        

        
          

          
            	
                    f.

                  	
                    Disenrollments
                      due to receipt of Medicare become effective the month following the
                      month in which DSS receives information of the existence of the
                      Medicare coverage.

                  

          

        

        
          

          
            	
                    g.

                  	
                    The
                      Department will exempt adults who receive SSI form managed
                      care. The
                      Member's enrollment in managed care will end on the last day
                      of
                      the month, and the exemption from managed care will occur the first
                      day of the following
                      month.

                  

          

        

        
          

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            II

        

        
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            II,
            3.36-8.05)                                                          07
            HUSKY
            A                                                                  05/07

        

        
          

          
            	
                    h.  

                  	
                    The
                      DEPARTMENT determines Medicaid eligibility, and periodically
                      the
                      DEPARTMENT may reclassify a Member's Medicaid status from mandatory
                      managed care coverage to non-managed care coverage. When the
                      DEPARTMENT
                      reclassifies a Member's coverage to non-managed care coverage,
                      the
                      Member's enrollment in managed care will end on the last day
                      of the
                      month.

                  

          

        

        
          

          
            	
                    i. 

                  	
                    The
                      DEPARTMENT 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).

                  

          

        

        
          

          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
            full file
            can be accessed by the MCO electronically via dial-up.

        

        
          

          4.04            Default
            Enrollment

        

        
          

          The
            DEPARTMENT shall, on a rotating basis among all of the participating
            MCO's and
            as the MCO's enrollment capacity allows, assign default Members to the
            MCO.

        

        
          

          The
            default assignment methodology is structured to evenly distribute families
            among
            all the participating MCOs. However, due to variability in MCO service
            area and
            enrollment capacity, family size and loss of Medicaid eligibility, the
            outcome
            of the default assignment may not result in an even net default distribution
            among all the MCOs.

        

        
          

          4.05            Capitation
            Payments to 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 rates specified in Appendix I, as
                      amended.   The actuarial basis for the capitation
                      rates, as approved by CMS, is also attached at
                      Appendix I.

                  

          

        

        
          

          
            	
                    b.

                  	
                    Upon
                      validation of client eligibility and MCO membership, the DEPARTMENT
                      will pay the capitation payments in the month following the month to
                      which the capitation payments apply or for retroactive enrollments,
                      the month following the enrollment-processing month in accordance
                      with Connecticut General Statutes Section 4a-71 through
                      4a- 72.

                  

          

        

        
          

          
            	
                    c.

                  	
                    Payment
                      to the MCO shall be based on the enrollment data transmitted from the
                      DEPARTMENT to the Enrollment Broker each month. The MCO will be
                      responsible for detecting the source of any inconsistency
                      in capitation payments. 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

                  

          

        

        
          

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          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
            (representing reinstated recipients) for each month of coverage shall
            be
            included in the next monthly capitation payment, based on updated MCO
            enrollment
            information for that month of coverage.

        

        
          

          
            	
                    d. 

                  	
                    Any
                      retrospective adjustments to prior payments will be made in
                      the form of an
                      addition to or subtraction from the current month's capitation
                      payment.
                      Positive adjustments are particularly likely for newborns,
                      because the MCO
                      may be aware of births before the
                      DEPARTMENT.

                  

          

        

        
          

          4.06            Retroactive
            Adjustments

        

        
          

          
            	
                    a.

                  	
                    When
                      a Member loses Medicaid eligibility and managed care enrollment but
                      regains coverage within sixty (60) days, and the coverage is
                      made retroactive such that the entire coverage gap is eliminated,
                      the DEPARTMENT shall reinstate enrollment into the MCO retroactive
                      to
                      the time of disenrollment. The MCO will remain responsible for
                      the
                      cost of in- network covered services and the cost of emergency and
                      family planning services received by the Member during this sixty
                      (60) day period.

                  

          

        

        
          

          
            	
                    b.

                  	
                    In
                      instances where enrollment is disputed between two (2) MCOs
                      or
                      the MCO and Medicaid fee-for-service program, 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 be made to the MCO pursuant
                      to rules outlined in Section II, 4.05(d), Capitation Payments to
                      MCO.

                  

          

        

        
          

          4.07            Information

        

        
          

          The
            DEPARTMENT will make known to each MCO complete and current information
            that
            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.

        

        
          

          4.08            Ongoing
            MCO Monitoring

        

        
          

          
            	
                    a.

                  	
                    To
                      ensure access and the quality of care, the DEPARTMENT or its
                      agent shall
                      undertake plans to conduct monitoring activities, including
                      but not
                      limited to the following:

                  

          

        

        
          

          
            	
                    1.  

                  	
                    Analyze
                      the MCO's access enhancement programs, financial and utilization
                      data, and
                      other reports to monitor the value the MCO is providing in
                      return for the
                      State's capitation payments. Such efforts shall include, but
                      not be
                      limited to, on-site reviews and audits of the MCO and its subcontractors
                      and network providers.

                  

          

        

        
          

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                    2.

                  	
                    Conduct
                      regular recipient surveys of Members to address issues such as
                      satisfaction with plan services to include administrative services,
                      satisfaction with treatment by the plan or its providers, and reasons
                      for disenrollment and access.

                     

                  

            	 3.	 Review
                    the MCO certifications on a regular
                    basis

          

        

        
           

        

        
          
            	
                    4.

                  	
                    Analyze
                      encounter data, actual medical records, correspondence, telephone
                      logs and other data to make inferences about the quality of and
                      access to specific services.

                  

          

        

        
          

          
            	
                    5.

                  	
                    Sample
                      and analyze encounter data, actual medical records, correspondence,
                      telephone logs and other data to make inferences about the quality of
                      and access to MCO services.

                  

          

        

        
          

          
            	
                    6.

                  	
                    Test
                      the availability of and access to MCO services by attempting to make
                      appointments.

                  

          

        

        
          

          
            	
                    7.

                  	
                    At
                      its discretion, commission or conduct additional objective
                      studies of
                      the effectiveness of the MCO, as well as the availability of, quality
                      of and access to its
                      services.

                  

          

        

        
          

          4.09   Utilization
            Review and Control

        

        
          

          The
            DEPARTMENT shall waive, to the extent allowed by law, any current DEPARTMENT
            requirements for prior authorization, second opinions, co-payment, or
            other
            Medicaid restrictions for the provision of contract services provided
            by the MCO
            to Members.

        

        
          

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          5.   DECLARATION
            AND MISCELLANEOUS PROVISIONS

        

        
          

          5.01           Competition
            Not Restricted

        

        
          

          In
            signing this contract, the MCO asserts that no attempt has been made
            or will be
            made by the MCO to restrict competition by inducing any other person
            or firm to
            submit or not to submit an application to provide services.

        

        
          

          5.02           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 Part 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).

                  

          

        

        
          

          5.03           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 DEPARTMENT may terminate the contract 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.

        

        
          

          5.04           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.

        

        
          

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            II

        

        
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          5.05            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 consent of the Contract Administrator, except as specified in
                      this contract and as permitted by applicable
                      law.

                  

          

        

        
          

          5.06            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.

        

        
          

          5.07            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 that arise during implementation and operation
            of the
            contract.

        

        
          

          5.08            Freedom
            of information

        

        
          

          
            	
                    a.

                  	
                    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 interpretations resulting
                      there
                      from. 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's
                      subcontractor believes that any portions of the materials submitted
                      to the
                      DEPARTMENT are proprietary or confidential or constitute commercial
                      or
                      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

                  

          

        

        
          

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          are
            submitted to the DEPARTMENT. The rationale and explanation must be stated
            in
            terms of the prospective harm to the MCO's or subcontractor's competitive
            position that would result if the identified material were to be released
            and
            the reasons why the materials are legally exempt from release pursuant
            to the
            above cited statue. The final administrative authority to release or
            exempt any
            or all material so identified by the MCO or the 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.

        

        
          

          
            	
                    b.    

                  	
                    The
                      MCO understands the DEPARTMENT'S need for access to eligibility
                      and paid
                      claims information and is willing to provide such data relating
                      to the MCO
                      to accommodate that need. The MCO is committed to providing
                      the DEPARTMENT
                      access to all information necessary to analyze cost and utilization
                      trends; to evaluate the effectiveness of Provider Networks,
                      benefit
                      design, and medical appropriateness; and to show how the HUSKY
                      population
                      compares to the MCO's enrolled population as a whole. The MCO
                      and the
                      DEPARTMENT each understand and agree that the systems, procedures
                      and
                      methodologies and practices used by the MCO, its affiliates
                      and agents in
                      connection with the underwriting, claims processing, claims
                      payment and
                      utilization monitoring functions of the MCO, together with
                      the
                      underwriting, Provider Network, claims processing, claims history
                      and
                      utilization data and information related to the MCO and its
                      agents, may
                      constitute information which is proprietary to the MCO and/or
                      its
                      affiliates (collectively, the "Proprietary Information"). Accordingly,
                      the
                      DEPARTMENT acknowledges that the MCO shall not be required
                      to divulge
                      Proprietary Information if such disclosure would jeopardize
                      or impair its
                      relationships with providers or suppliers or would materially
                      adversely
                      affect the MCO's or any of its Affiliates' ability to service
                      the needs of
                      its customers or the DEPARTMENT as provided under this Contract
                      unless the
                      DEPARTMENT determines that such information is necessary in
                      order to
                      monitor contract compliance or to fulfill Part II Sections
                      3.33 and 3.34
                      of Part II of this contract. The DEPARTMENT agrees not to disclose
                      publicly and to protect from public disclosure any proprietary
                      or trade
                      secret information provided to the DEPARTMENT by the MCO and/or
                      its
                      Affiliates' under this contract to the extent that such information
                      is
                      exempted from public disclosure under the Connecticut Freedom
                      of
                      Information Act.

                  

          

        

        
          

          5.09   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,

        

        
          

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          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.

        

        
          

          5.10            Force
            Majeure

        

        
          

          The
            MCO
            shall be excused from performance hereunder for any period that it 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.

        

        
          

          5.11            Financial
            Responsibilities of the MCO

        

        
          

          
            	
                    a.

                  	
                    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.

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO's physician incentive plans must comply with the requirements of
                      1903(m)(2)(a)(x) of the Social Security Act and 42 CFR 422.208
                      and
                      42 CFR 422.210.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      DEPARTMENT reserves the right to inspect any physician
                      incentive plans.

                  

          

        

        
          

          
            	
                    d.

                  	
                    If
                      the MCO is not a federally qualified MCO or Competitive Medical
                      Plan, the MCO must complete a HCFA Section 1318 Financial
                      Disclosure Report, prior to the start of the
                      contract.

                  

          

        

        
          

          5.12            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 Department of
                      Insurance.

                  

          

        

        
          

          
            	
                    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

                  

          

        

        
          

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            II

        

        
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          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.

                  

          

        

        
          

          5.13    Provider
            Compensation

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall comply with CMS's Physician Incentive Plan
                      (PIP) requirements in 42 CFR 422.208 and 42 CFR 422.210. The MCO
                      may operate a PIP only
                      if:

                  

          

        

        
          

          
            	
                    1.

                  	
                    No
                      specific payment can be made directly or indirectly under a
                      PIP to a
                      physician or physician group as an inducement to reduce or limit
                      medically necessary services furnished to an individual Member;
                      and

                  

          

        

        
          

          
            	
                    2.

                  	
                    The
                      stop-loss protection, Member survey, and disclosure requirements of
                      42 CFR. 422.208 and 42 CFR 422.210 are
                      met.

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO shall disclose to the DEPARTMENT the following information
                      on PIPs in sufficient detail to determine whether the incentive
                      plan
                      complies with the regulatory requirements of 42 CFR 422.208. The
                      disclosure must contain:

                  

          

        

        
          

          
            	
                    1.

                  	
                    Whether
                      services not furnished by the physician or physician group are
                      covered by the PIP. If only the services furnished by the physician
                      or physician group are covered by the incentive plan, disclosure of
                      other aspects of the plan need not be made.

                     

                  

            	2. 	The
                    type of incentive arrangement (i.e. withhold, bonus,
                    capitation).

          

        

        
           

        

        
          
            	
                    3.

                  	
                    The
                      percent of the withhold or bonus if the incentive plan involves
                      a withhold or bonus,.

                  

          

        

        
          

          
            	
                    4.

                  	
                    Proof
                      that the physician or physician group has adequate
                      stop-loss protection, including the amount and type of stop-loss
                      protection.

                     

                  

            	5.	The
                    panel size and, if patients are pooled, the method
                    used.

          

        

        
           

        

        
          
            	
                    6.

                  	
                    In
                      the case of those MCOs that are required by 42 CFR. 422.208(h) to
                      conduct Member surveys, the survey
                      results.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO shall disclose this information to the DEPARTMENT (1) prior
                      to approval of its contract as required by federal regulation
                      and (2)
                      upon the contract anniversary or renewal effective date. The MCO
                      shall provide the capitation data required (see (6) above) for the
                      previous contract year to the DEPARTMENT three (3) months after the
                      end of the contract year. The MCO will provide to the Member upon
                      request information regarding whether the MCO uses a physician
                      incentive plan that affects the use
                      of

                  

          

        

        
          

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            II

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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          referral
            services, the type of incentive arrangement, whether stop-loss protection
            is
            provided, and the survey results of any Member survey conducted. See
            Appendix J
            for the applicable regulations and disclosure forms.

        

        
          

          
            	
                    d. 

                  	
                    The
                      DEPARTMENT may impose Class C sanctions pursuant to Section
                      7.05 for
                      failure to comply with 42 CFR 422.208 and
                      422.210

                  

          

        

        
          

          5.14           Members
            Held Harmless

        

        
          

          a.        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 Medicaid-covered services provided pursuant to this contract
                      to the Member if the DEPARTMENT does not pay the MCO or the
                      DEPARTMENT or the MCO does not pay the health care provider that
                      furnishes the services under a contractual, referral, or other
                      arrangement; and/or

                  

          

        

        
          

          
            	
                    3.

                  	
                    Payments
                      for covered services furnished under a contract, referral, or other
                      arrangement, to the extent those payments are in excess of the amount
                      that the Member would owe if the MCO directly provided the
                      service.

                  

          

        

        
          

          5.15         Compliance
            with Applicable Laws, Rules, Policies, and Bulletins

        

        
          

          The
            MCO
            in performing this contract shall comply with all applicable federal
            and state
            laws, regulations, provider bulletins and written policies, as set forth
            in the
            Department's provider manuals or issued as policy transmittals to the
            MCOs. This
            shall include but not be limited to compliance with licensing requirements.
            In
            the provision of services under this Contract, the MCO and its subcontractors
            shall comply with all applicable federal and state statutes and regulations,
            and
            all amendments thereto, that are in effect when the agreement is signed,
            or that
            come into effect during the term of the Contract. This includes, but
            is not
            limited to Title XIX of the Social Security Act and Title 42 of the Code
            of
            Federal Regulations.

        

        
          

          5.16           Advance
            Directives

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall comply with the provisions of 42 CFR 422.128 relating
                      to written
                      policies and procedures for advance directives. The MCO
                      shall:

                  

          

        

        
          

          
            	
                    1.

                  	
                    Maintain
                      written policies and procedures that meet the requirements for
                      advance directives in Subpart I of 42 CFR pt.
                      489;

                  

          

        

        
          

          
            	
                    2.

                  	
                    Maintain
                      policies and procedures for all adults receiving medical care through
                      the MCO;

                  

          

        

        
          

          
            	
                    3.

                  	
                    Provide
                      each adult Member with written information on advance directives
                      policies, including a description of Connecticut General Statutes §§
                      19a-570 - 19a-580d; and

                  

          

        

        
          

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            II

        

        
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          4.       Provide
            each adult Member with information on changes in Connecticut
            law regarding advance directives as soon as possible, but no later than
            ninety
            (90) days after the effective date of the change.

        

        
          

          5.17   Federal
            Requirements and Assurances 

           

          General

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall comply with those federal requirements and assurances for
                      recipients of federal grants provided in OMB 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.

                  

          

        

        
          

          
            	
                    b.

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

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO shall comply with all applicable provisions of 45 CFR 74.48
                      and all applicable requirements at 45 CFR 74.48 Appendix
                      A.

                  

          

        

        
          

          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 Part 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.

                  

          

        

        
          

          Balanced
            Budget Act and Implementing Regulations

        

        
          

          The
            MCO
            shall comply with all applicable provisions of 42 U.S.C. Section 1396u-2
            , 42
            U.S.C. Section 1396b(m) and 42 CFR Parts 431 and 438.

        

        
          

          Clean
            Air and Water Acts

        

        
          

          The
            MCO
            and all subcontractors with contracts in excess of $100,000 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 section 508 of the Clear
            Water Act (33 U.S.C. 1368), Executive Order 11738, and 40 CFR Part
            15).

        

        
          

          Part
            II

          86

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (PART
            II,
            3.36-8.05)                                                          07
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          Energy
            Standards

           

        

        
          The
            MCO
            shall comply with all applicable standards and policies relating to energy
            efficiency that are contained in the state energy plan issued in compliance
            with
            the federal Energy Policy and Conservation Act, 42 USC §§ 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 -
            ILL, "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 parity requirements
            of
            the Public Health Services Act, Title XXVII, Subpart 2, Part A, § 2704, as added
            September 26, 1996, 42 U.S.C. § 300gg-4, 300gg-5, insofar as such requirements
            apply to providers of group health insurance.

        

        
          

          5.18    Civil
            Rights Federal Authority

        

        
          

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

        

        
          

          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

        

        
          

          Part
            II

        

        
          87

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
            3.36-8.05)                                                          07
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          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 seg., 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) and Conn. Gen. Stat. § 17b-90. 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.

        

        
          

          5.19           Statutory
            Requirements

        

        
          

          
            	
                    a.

                  	
                    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 § 1395aa et seq.

                  

          

        

        
          

          5.20           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.

        

        
          

          5.21           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.

                  

          

        

        
          

          
            	
                    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.

                  

          

        

        
          

          Part
            II

          88

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
            3.36-8.05)                                                          07
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          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 II
                      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.

                  

          

        

        
          

          5.22            Changes
            Due to a Section 1115 or 1915(b) Freedom of Choice
            Waiver

        

        
          

          The
            conditions of enrollment described in the contract, including but not
            limited to
            enrollment and the right to disenrollment, are subject to change as provided
            in
            any waiver under Section 1115 or 1915(b) of the Social Security Act (as
            amended)
            obtained by the DEPARTMENT.

        

        
          

          5.23            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.

        

        
          

          5.24            Executive
            Order Number 16

        

        
          

          This
            contract is subject to Executive Order No. 16 of Governor John G. Rowland
            promulgated August 4,1999 and, as such, this Agreement may be cancelled,
            terminated or suspended by the State for violation of or noncompliance
            with said
            Executive Order No. 16. The parties to this contract, as part of the
            consideration hereof, agree that:

        

        
          

          
            	
                    a.  

                  	
                    The
                      MCO 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 subsection
                      (b).

                  

          

        

        
          

          Part
            II

        

        
          89

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
            3.36-8.05)                                                          07
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            A                                                                 05/07

        

        
          

          
            	
                    b.

                  	
                    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.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO shall prohibit employees from using, attempting to use
                      or threatening 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.

                  

          

        

        
          

          
            	
                    d.

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

                  

          

        

        
          

          
            	
                    e.

                  	
                    The
                      MCO agrees that any subcontract it enters into in furtherance
                      of
                      the work to be performed hereunder shall contain the provisions
                      (a)
                      through (d).

                  

          

        

        
          

          The
            remainder of this page left intentionally blank.

        

        
          

          Part
            II
            90

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
            3.36-8.05)                                                          07
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          6.   GRIEVANCE
            SYSTEM AND PROVIDER APPEALS

        

        
          

          The
            MCO
            shall establish and maintain a grievance system that meets all statutory
            and
            regulatory requirements. The MCO's grievance system shall include a grievance
            process, an appeal process and access to and participation in the DEPARTMENT'S
            administrative hearings process.

        

        
          

          6.01            Grievances

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall have a system in place to handle grievances. Grievances are
                      expressions of dissatisfaction about any matter, other than
                      those matters that qualify as an action. The subject matters of
                      grievances may include, but are not limited to, quality of care,
                      rudeness by a provider or MCO staff person or failure to respect a
                      Member's rights.

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO shall maintain adequate records to document the filing
                      of
                      a grievance, the actions taken, the MCO personnel involved and
                      the resolution. The MCO shall report grievances in a mutually agreed
                      upon format.

                  

          

        

        
          

          
            	
                    c.

                  	
                    A
                      Member, or a provider acting on a Member's behalf, may file
                      a grievance either orally or in writing. The MCO shall acknowledge
                      the receipt of each grievance and provide reasonable assistance
                      with
                      the process, including but not limited to providing interpreter
                      services and toll free numbers with TTY/TTD and interpreter
                      capability.

                  

          

        

        
          

          
            	
                    d.

                  	
                    If
                      the grievance involves a denial of expedited review of an appeal
                      or some other clinical issue, the grievance must be reviewed by
                      a
                      health care professional with appropriate clinical
                      expertise.

                  

          

        

        
          

          
            	
                    e.

                  	
                    The
                      MCO shall dispose of each grievance as expeditiously as the member's
                      health requires. If the Member filed the grievance orally,
                      the MCO
                      may resolve the grievance orally, but shall maintain documentation of
                      the grievance and its resolution. If the Member filed a
                      written grievance, the resolution shall be in writing. If applicable,
                      each grievance shall be handled by an individual who was not involved
                      in any previous level of decision-making. Each grievance shall be
                      disposed of in ninety (90) days or
                      less.

                  

          

        

        
          

          6.02            Notices
            of Action and Continuation of Benefits

        

        
          

          
            	
                     

                  	
                    a.        The
                      MCO or its subcontractor (as duly authorized by the MCO) shall
                      mail a
                      notice of action to a Member when the MCO takes action upon
                      a request for
                      medical services from the Member's treating PCP, or other treating
                      provider, functioning within his or her scope of practice as
                      defined under
                      state law. For purposes of this requirement, an "action"
                      includes:

                  

          

        

        
          

          
            	
                     

                  	
                    1.        The
                      denial or limited authorization of a requested service, including
                      the type
                      or level of service;

                  

          

        

        
          

          Part
            II

          91

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
            3.36-8.05)                                                          07
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                    2.

                  	
                    The
                      reduction, suspension or termination of a previously
                      authorized service;

                     

                  

            	3.	The
                    denial, in whole or in part, of payment for a
                    service;

          

        

        
           

        

        
          
            	
                    4.

                  	
                    The
                      failure to act within the timeframes for utilization
                      review decisions, as described in Section 3.39;
                      and

                  

          

        

        
          

          
            	
                    5.

                  	
                    The
                      failure to provide access to services in a timely manner as required
                      by 3.14(c)(1) through (c)(6) and 3.21 (a)(4) or the failure
                      to provide access to consultations and specialist referrals within
                      three (3) months.

                  

          

        

        
          

          The
            notice of action requirements shall apply to all categories of covered
            medical
            services including transportation to medically necessary
            appointments.

        

        
          

          The
            CT
            BMP will issue notices of action for behavioral health utilization review
            decisions. When a Member has both medical and behavioral health conditions
            and
            an MCO action affects both conditions, the MCO shall, as necessary, consult
            with
            the ASO in preparation for the hearing.   If the MCO issues a
            notice of action related to a request for pharmacy services and the prescription
            at issue was written by a Medicaid enrolled behavioral health prescribing
            provider, the MCO shall send the notice of action to the Member and the
            prescribing provider.

        

        
          

          The
            MCO
            is required to issue a notice for actions described in (a)(3) above if
            the
            denial of payment for services already rendered may or will result in
            the Member
            being held financially responsible. Such circumstances include, but are
            not
            limited to, the provision of emergency services that do not appear to
            meet the
            prudent layperson standard, the provision of services outside of the
            United
            States, and the provision of non-covered services with the Member's written
            consent as described in 3.47. The MCO is not required to issue a notice
            of
            action for the denial of payment for covered services that have already
            been
            provided to the Member if the denial is based on a procedural or technical
            issue, including but not limited to a provider's failure to comply with
            prior
            authorization rules for services that the Member has already received,
            incorrect
            coding or late filing by a provider for services that the Member has
            already
            received. In these circumstances, coverage of the service is not at issue
            and
            the Member may not be held financially liable for the services. Nothing
            herein
            shall relieve the MCO from its responsibility to issue a notice of action
            in all
            circumstances in which a provider requests prior authorization for a
            service and
            the request is denied in whole or in part, as required in (a)(1) above.
            Nothing
            herein shall relieve the MCO from its responsibility to hold a Member
            harmless
            for the cost of Medicaid covered services and

        

        
          

          Part
            II

        

        
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            II,
            3.36-8.05)                                                          07
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          its
            responsibility to ensure that the MCO's network providers hold a Member
            harmless
            for the cost of Medicaid covered services.

        

        
          

          The
            MCO
            is required to issue a notice of action for actions described in (a)(5)
            above,
            only if the Member notifies the MCO of his or her inability to obtain
            timely
            access to services. In such instances, the MCO shall provide the Member
            with
            immediate assistance in accessing the services. If the Member has been
            unable to
            access emergency services, the MCO shall issue a notice of action immediately.
            For non-emergent services, if a Member contacts the MCO concerning the
            inability
            to access a covered service within the timeframes referenced in (a)(5)
            above,
            and three (3) business days later the Member has not accessed or made
            arrangements for receiving the service that are satisfactory to the Member,
            the
            MCO shall issue a notice of action.

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO shall issue a notice of action if the MCO approves a good
                      or service that is not the same type, amount, duration, frequency
                      or
                      intensity as that requested by the provider, consistent with current
                      DSS policy.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO shall identify if the Member reads only a language other
                      than English.   For Members who do not read English,
                      the notice of action shall be provided in accordance with Sections
                      3.28(a) and 3.29(h).

                  

          

        

        
          

          
            	
                    d.

                  	
                    Except
                      as provided in (h) below, the MCO shall mail an advance notice
                      of action for a termination, suspension or reduction of a
                      previously authorized service to a Member at least ten (10) days
                      before the date of any action described in (a) above, consistent with
                      current DSS policy. The MCO may shorten the period of advance notice
                      to five (5) days before the date of action if: 1) the MCO has facts
                      indicating that the action should be taken because of probable fraud
                      by the Member; and 2) the facts have been verified, if possible,
                      through secondary sources.

                  

          

        

        
          

          
            	
                    e.

                  	
                    All
                      notices related to actions described in (a) above shall clearly
                      state
                      or explain:

                  

          

        

        
           

        

        
          
            	1. 	
                    The
                      action the MCO intends to take or has taken;

                     

                  

            	2.	
                    The
                      reasons for the action;

                     

                  

            	
                    3.

                  	
                    The
                      statute, regulation, the DEPARTMENT'S Medical Services Policy
                      section, or when there is no appropriate regulation, policy
                      or statute, the HUSKY A contract provision that supports the
                      action;

                  

          

        

        
          

          
            	
                    4.

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

                  

          

        

        
          

          
            	
                    5.

                  	
                    The
                      Member's right to challenge the action by filing an appeal
                      and requesting an administrative
                      hearing;

                  

          

        

        
          

          
            	
                    6.

                  	
                    The
                      procedure for filing an appeal and for requesting an administrative
                      hearing;

                  

          

        

        
          

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            II

        

        
          93

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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            II,
            3.36-8.05)                                                         07
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                    7.

                  	
                    How
                      the Member may obtain an appeal form and, if desired, assistance in
                      completing and submitting the appeal
                      form;

                  

          

        

        
          

          
            	
                    8.

                  	
                    That
                      the Member will lose his or her right to an appeal and administrative
                      hearing if he or she does not complete and file a written appeal form
                      with the DEPARTMENT within sixty (60) days from the date the MCO
                      mailed the initial notice of
                      action;

                  

          

        

        
          

          
            	
                    9.

                  	
                    That
                      the MCO must issue a decision regarding an appeal by the date that
                      the administrative hearing is scheduled, but no more than thirty (30)
                      days following the date the DEPARTMENT receives
                      it;

                  

          

        

        
          

          
            	
                    10.

                  	
                    That,
                      if the Member files an appeal he or she is entitled to meet with or
                      speak by telephone with the MCO representative who will decide the
                      appeal, and is entitled to submit additional documentation or written
                      material for the MCO's
                      consideration;

                  

          

        

        
          

          
            	
                    11.

                  	
                    That
                      the Member may proceed automatically to an administrative hearing if
                      he or she is dissatisfied with the MCO's appeal decision concerning
                      the denial of coverage of goods or services or a reduction,
                      suspension, or termination of ongoing goods or services, or if the
                      MCO fails to render an appeal decision by the date the administrative
                      hearing is scheduled;

                  

          

        

        
          

          
            	
                    12.

                  	
                    That
                      at an administrative hearing, the Member may represent himself or
                      herself or use legal counsel, a relative, a friend, or
                      other spokesperson;

                  

          

        

        
          

          
            	
                    13.

                  	
                    That
                      if the Member obtains legal counsel who will represent the Member
                      during the appeal or administrative hearing process, the Member must
                      direct his or her legal counsel to send written notification of the
                      representation to the MCO and
                      the DEPARTMENT;

                  

          

        

        
          

          
            	
                    14.

                  	
                    That
                      if the circumstances require advance notice, the Member's right to
                      continuation of previously authorized goods and services, provided
                      that the Member files a appeal/request for administrative hearing
                      form with the DEPARTMENT on or before the intended effective date of
                      the MCO's action or within ten (10) calendar days of the date the
                      notice of action is mailed to the Member, whichever is
                      later;

                  

          

        

        
          

          
            	
                    15.

                  	
                    The
                      circumstances under which expedited resolution is available and how
                      to request expedited resolution; and

                     

                  

            	16.	Any
                    other information specified by the
                    DEPARTMENT.

          

        

        
           

        

        
          
            	
                    f.

                  	
                    In
                      the case of a child who is under the care of the Department
                      of
                      Children and Families (DCF), the MCO must send the notice of action
                      to the child's foster parents and the DCF contact person specified by
                      the DEPARTMENT.

                  

          

        

        
          

          g.           The
            NOA shall be mailed within the following timeframes:

        

        
          Part
            II

          94

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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                    1.

                  	
                    For
                      termination, suspension, or reduction of previously
                      authorized Medicaid covered services, 10 days in advance of the
                      effective date;

                  

          

        

        
          

          
            	
                    2.

                  	
                    For
                      standard authorization decisions to deny or limit services,
                      as expeditiously as the Member's health condition requires, not
                      to exceed fourteen (14) calendar days following receipt of the
                      request for services;

                  

          

        

        
          

          
            	
                    3.

                  	
                    If
                      the MCO extends the fourteen day time frame for denial or limitation
                      of a service as permitted in Section 3.39d (1) and (2),
                      as expeditiously as the Member's condition requires and no later
                      than the date the extension
                      expires;

                  

          

        

        
          

          
            	
                    4.

                  	
                    For
                      service authorization decisions not reached within the timeframes in
                      3.39 (which constitutes a denial and thus is an adverse action), on
                      the date the timeframe
                      expires;

                  

          

        

        
          

          
            	
                    5.

                  	
                    For
                      expedited service authorization decisions as expeditiously
                      as the
                      Member's health condition requires and no later than three
                      (3) business days after receipt of the request for
                      services;

                  

          

        

        
          

          
            	
                    6.

                  	
                    For
                      denial of payment where the Member may be held liable, at the time of
                      any action affecting the
                      claim

                  

          

        

        
          

          
            	
                    7.

                  	
                    For
                      failure to provide timely access to services as expeditiously
                      as the
                      Member's health requires, but no later than three (3) business days
                      after the Member contacts the
                      MCO.

                  

          

        

        
          

          
            	
                    h.

                  	
                     

                  	
                    The
                      ten (10) day advance notice requirements do not apply to the
circumstances
                      described in 42 CFR 431.213. Notice of action need not be sent
                      to the
                      Member ten (10) days in advance of the action, but may be sent
                      no later
                      than the date of action and will be considered an exception
                      to the advance
                      notice requirement, if the action is based on any of the following
                      circumstances:

                  

          

        

        
          

          1           
            A denial of services;

        

        
          

          
            	
                    2

                  	
                    The
                      MCO has received a clear, written statement signed by the Member
                      that:

                  

          

        

        
          

          
            	
                    a)

                  	
                    The
                      Member no longer wishes to receive the goods or services;
                      or

                  

          

        

        
          

          
            	
                    b)

                  	
                    The
                      Member gives information which requires the reduction, suspension, or
                      termination of the goods or services, and the Member indicates that
                      he or she understands that this must be the result of supplying that
                      information; and

                  

          

        

        
          

          
            	
                    3

                  	
                    The
                      Member has been admitted to an institution where he or she
                      is ineligible for the goods or services. In this instance, the
                      Member must be notified on the notice of admission that any goods
                      or services being reduced, suspended, or terminated will
                      be

                  

          

        

        
          

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            II

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          reevaluated
            for medical necessity upon discharge, and the Member will have the right
            to
            appeal any post-discharge decisions.

        

        
          

          If
            the
            circumstances are an exception to the advance notice requirement as set
            forth
            above the Member does not have the automatic right to continuation of
            ongoing
            goods or services. In these circumstances, however, and in any instance
            in which
            the MCO fails to issue an advance notice when required, the reduced,
            suspended,
            or terminated goods and services must be reinstated if the Member files
            a
            written appeal form with the DEPARTMENT within ten (10) days of the date
            the
            notice is mailed to the Member.

        

        
          

          
            	
                    i.  

                  	
                    The
                      MCO shall follow the requirements for continuation of services
                      set forth
                      in 42 CFR 438.420. The right to continuation of ongoing goods
                      or services
                      applies to the scope of services previously authorized. The
                      right to
                      continuation of services does not apply to subsequent requests
                      for
                      approval that result in denial of the additional request or
                      re-authorization of the request at a different level than requested.
                      For
                      example, the right to continuation of services does not
                      apply:

                  

          

        

        
          

          
            	
                    1

                  	
                    When
                      a prescription (including refills) runs out and the Member requests a
                      new prescription for the same medication;
                      or

                  

          

        

        
          

          
            	
                    2

                  	
                    To
                      a request for additional home health care services following
                      the expiration of the approved number of home health
                      visits

                  

          

        

        
          

          The
            MCO
            shall treat such requests as a new service authorization request and
            provide a
            denial notice.

        

        
          

          
            	
                    j.

                  	
                    Notice
                      of action is not required if the member's treating physician
                      or PCP, using
                      his or her professional judgment, refuses to prescribe (or
                      prescribes an
                      alternative to) a particular service sought by a member. Notice
                      of action
                      is also not required if the Member's treating physician or
                      PCP, using his
                      or her professional judgment, orders the reduction, suspension,
                      or
                      termination of goods or services.   Such decisions do not
                      constitute an action by the MCO.   If, however, the Member
                      disagrees with the provider and contacts the MCO to request
                      authorization
                      for the service the MCO shall conduct an expedited review of
                      the request,
                      according to the timeframe in 3.39(e).   If the MCO affirms
                      the provider's action to deny, terminate, reduce or suspend
                      the service,
                      the MCO shall issue a notice of action. If the Member requests
                      an appeal
                      and hearing, the MCO shall continue authorization for the services,
                      to the
                      extent services were previously authorized, unless the MCO
                      determines that
                      continued provision of the services could be harmful to the
                      Member.    The MCO shall also advise the Member of his
                      or her right to a second opinion from another
                      provider.   Because only a licensed health care provider,
                      and not the MCO, may prescribe or provide medical services,
                      the Member may
                      not be able to receive some or all of the requested goods or
                      services
                      while the appeal is pending.    If the MCO approves
                      the Member's request for the

                  

          

        

        
          

          Part
            II
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          good
            or
            service, the MCO shall inform the Member of the approval and shall inform
            the
            Member of the right to a second opinion.

        

        
          

          
            	
                    k.   

                  	
                    The
                      DEPARTMENT will provide standardized notice of action forms
                      to be used by
                      the MCO and its subcontractors. The DEPARTMENT will also provide
                      standardized appeal/hearing request forms to be used by the
                      MCO and its
                      subcontractors. The MCO and its subcontractors shall not alter
                      the
                      standard format of either form without prior, written approval
                      of the
                      DEPARTMENT.

                  

          

        

        
          

          
            	
                    I.

                  	
                    The
                      DEPARTMENT will conduct random reviews and audits of the MCO
                      and its
                      subcontractors, as appropriate, to ensure that Members are
                      sent accurate,
                      complete and timely notices of
                      action.

                  

          

        

        
          

          Sanction:
            If the DEPARTMENT determines during any audit or random monitoring visit
            to the
            MCO or one of its subcontractors that a notice of action fails to meet
            any of
            the criteria set forth herein, the DEPARTMENT may impose a strike towards
            a
            Class A sanction. If the deficiencies which give rise to a Class A sanction
            continue for a period in excess of ninety (90) days, the DEPARTMENT may
            impose a
            Class B sanction.

        

        
          

          6.03   Appeals
            and Administrative Hearing Processes

        

        
          

          
            	
                    a.

                  	
                    The
                      MCOs shall have a timely and organized appeals process. The appeals
                      process shall be available for resolution of disputes between
                      the MCO
                      and its Members concerning the MCO's actions as defined in
                      6.02.

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO shall develop written policies and procedures for its
                      appeals process. Those policies and procedures must be approved by
                      the DEPARTMENT in writing and must include the elements specified
                      in
                      this contract. The MCO shall not be excused from providing the
                      elements specified in this contract pending the DEPARTMENT'S written
                      approval of the MCO's policies and
                      procedures.

                  

          

        

        
          

          
            	
                    c.

                  	
                    The
                      MCO shall maintain a record keeping system for appeals that
                      shall include a copy of the appeal, the response, the resolution
                      and
                      supporting documentation.

                  

          

        

        
          

          
            	
                    d.

                  	
                    The
                      MCO must clearly specify in its Member handbook/packet the procedural
                      steps and timeframes for filing an appeal and administrative hearing
                      request, including the timeframe for maintaining benefits pending the
                      conclusion of the appeal and administrative hearing processes.
                      The Member handbook/packet shall also list the addresses, office
                      hours, and toll-free telephone numbers for the Member Services
                      office.

                  

          

        

        
          

          
            	
                    e.

                  	
                    The
                      MCO shall ensure that network providers and subcontractors
                      are familiar with the appeal process and shall provide information
                      on
                      the process to providers and subcontractors. The MCO shall
                      provide information on the appeal process to its providers and
                      subcontractors at the time it enters into contracts or subcontracts.
                      The MCO must ensure that appeal forms are available at each primary
                      care site. At a minimum,

                  

          

        

        
          

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            II

        

        
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          appeals
            assistance must include providing forms on request, assisting the Member
            in
            filling out the forms upon request, and sending the completed form to
            the
            DEPARTMENT upon request.

        

        
          

          
            	
                    f.

                  	
                    The
                      MCO shall develop and make available to Members and potential Members
                      appropriate foreign language versions of appeals materials, including
                      but not limited to, the standard information contained in notices of
                      action and appeals forms. Such materials shall be made available
                      in Spanish, English, or any other languages if more than five
                      (5)
                      percent of the MCO's Members in any county of the State served by the
                      MCO speak the alternative language. The DEPARTMENT must approve such
                      foreign language materials, in
                      writing.

                  

          

        

        
          

          
            	
                    g.

                  	
                    A
                      Member may request an appeal either orally or in writing.
                      When requesting an appeal orally, unless the member is seeking an
                      expedited appeal review, the Member must follow up an oral request in
                      writing. The MCO shall advise any member who requests an appeal
                      orally, that the Member must file a written appeal within sixty (60)
                      days of the notice of action in order to receive an administrative
                      hearing and the member must file an appeal within ten (10) days of
                      the mailing of the notice of action or the effective date of the
                      intended action in order to continue previously authorized services
                      pending the appeal and hearing.   In all
                      other respects, the process for pursuing an appeal and for requesting
                      an administrative hearing shall be unified. The MCO and the
                      DEPARTMENT shall treat the filing of a written appeal as a
                      simultaneous request for an administrative hearing. The MCO shall
                      attempt to resolve appeals at the earliest point possible. If the MCO
                      is not able to render a decision by the time the administrative
                      hearing is scheduled, the Member will automatically proceed to the
                      administrative hearing.

                  

          

        

        
          

          
            	
                    h.

                  	
                    The
                      Member, the Member's authorized representative, or the Member's
                      conservator may file an appeal on a form approved by the DEPARTMENT.
                      A
                      provider, acting on behalf of the member and with the Member's
                      written
                      consent, may file an appeal. A provider may not file an administrative
                      hearing request on behalf of a Member unless the authorized
                      representative
                      requirements in DSS Uniform Policy Manual Section 1525.05 are
                      met. The MCO
                      shall request a copy of the written consent from the
                      Member.   Appeals shall be mailed or faxed to a single
                      address within the DEPARTMENT. The appeal form must state both
                      the mailing
                      address and fax number at the DEPARTMENT where the form must
                      be sent. If
                      the MCO or its subcontractor receive an appeal directly from
                      a Member or
                      the Member's authorized representative or conservator, the
                      MCO shall date
                      stamp and fax the appeal to the appropriate fax number at the
                      DEPARTMENT
                      within two (2) business days.

                  

          

        

        
          

          
            	
                    i.  

                  	
                    Upon
                      receipt of a written appeal, the DEPARTMENT will schedule an
                      administrative hearing and notify the Member and MCO of the
                      hearing date
                      and location. If a Member is disabled, the hearing may be scheduled
                      for
                      the Member's home, if requested by the
                      Member.

                  

          

        

        
          

          Part
            II

        

        
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                    j. 

                  	
                    The
                      DEPARTMENT will date stamp and forward the appeal by fax to
                      the MCO within
                      two (2) business days of receipt. The fax to the MCO will include
                      the date
                      the Member mailed the appeal to the DEPARTMENT. The postmark
                      on the
                      envelope will be used to determine the date the appeal was
                      mailed.

                  

          

        

        
          

          
            	
                    k.  

                  	
                    An
                      individual or individuals having final decision-making authority
                      must
                      conduct the MCO's review of the appeal. Any appeal stemming
                      from an action
                      based on a determination of medical necessity or involving
                      any other
                      clinical issues must be decided by one or more physicians who
                      were not
                      involved in making that medical
                      determination.

                  

          

        

        
          

          
            	
                    l. 

                  	
                    The
                      MCO may decide an appeal on the basis of the written documentation
                      available unless the Member requests an opportunity to meet
                      with the
                      individual or individuals making that determination on behalf
                      of the MCO
                      and/or requests the opportunity to submit additional documentation
                      or
                      other written material. The Member shall have a right to review
                      his or her
                      MCO record, including medical records and any other documents
                      or records
                      considered during the appeal process. The Member's right to
                      access medical
                      records shall be consistent with HIPAA privacy regulations
                      and any
                      applicable state or federal
                      law.

                  

          

        

        
          

          
            	
                    m.

                  	
                    If
                      the Member wishes to meet with the decision maker, the meeting
                      can be held
                      via the telephone or at a location accessible to the Member,
                      including the
                      Member's home if requested by a disabled Member or any of the
                      Department's
                      office locations through video conferencing, subject to approval
                      of the
                      DEPARTMENT'S Regional Offices, The MCO must invite a representative
                      of the
                      DEPARTMENT to attend any such
                      meeting.

                  

          

        

        
          

          
            	
                    n.

                  	
                    The
                      MCO must mail to the Member a written appeal decision, described
                      below,
                      with a copy to the DEPARTMENT, by the date of the DEPARTMENT'S
                      administrative hearing as expeditiously as the Member's health
                      condition
                      requires, but no later than thirty (30) days from the date
                      on which the
                      appeal was received by the DEPARTMENT. If the Member is dissatisfied
                      with
                      the MCO's decision regarding the denial, reduction, suspension,
                      or
                      termination of goods or services, or if the MCO does not render
                      a decision
                      by the time of the administrative hearing, the Member may automatically
                      proceed to the administrative
                      hearing.

                  

          

        

        
          

          
            	
                    o.

                  	
                    The
                      MCO's written appeal decision must include the Member's name
                      and address;
                      the provider's name and address; the MCO name and address;
                      a complete
                      description of the information or documents reviewed by the
                      MCO; a
                      complete statement of the MCO's findings and conclusions, including
                      the
                      section number and text of any contractual provision or DEPARTMENTAL
                      policy provision that is relevant to the appeal decision; and
                      a clear
                      statement of the MCO disposition of the
                      appeal.

                  

          

        

        
          

          
            	
                    p. 

                  	
                    Along
                      with its written appeal decision, the MCO must remind the Member,
                      on a
                      form approved by the DEPARTMENT,
                      that:

                  

          

        

        
          

          Part
            II
            99

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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                    1.

                  	
                    If
                      the Member is dissatisfied with the MCO's appeal decision,
                      the DEPARTMENT has already reserved a time to hold
                      an administrative hearing concerning that
                      decision;

                  

          

        

        
          

          
            	
                    2.

                  	
                    That
                      the Member has the right to automatically proceed to
                      the administrative hearing, and that the MCO must continue
                      previously authorized goods and services pending the administrative
                      hearing decision;

                  

          

        

        
          

          
            	
                    3.

                  	
                    If
                      the appeal pertains to the suspension, reduction, or termination
                      of goods or services which have been maintained during the
                      appeals process, and the MCO's appeals decision affirms the
                      suspension, reduction, or termination of goods or services, those
                      goods or services will be suspended, reduced, or terminated in
                      accordance with the MCO's appeals decision unless the Member proceeds
                      to an administrative hearing;
                      and

                  

          

        

        
          

          
            	
                    4.

                  	
                    If
                      the Member fails to appear at the administrative hearing,
                      the Member's reserved hearing time will be cancelled and any
                      disputed goods or services that were maintained will be
                      suspended, reduced, or terminated in accordance with the MCO's
                      appeals decision.

                  

          

        

        
          

          
            	
                    q.

                  	
                    If
                      the Member proceeds to an administrative hearing, the MCO must
                      make its
                      entire file concerning the Member and the appeal, including
                      any materials
                      considered in making its decision, available to the
                      DEPARTMENT.

                  

          

        

        
          

          
            	
                    r.

                  	
                     

                  	
                    If
                      the MCO fails to issue an appeal decision by the date that
                      an administrative
                      hearing is scheduled, but no later than thirty (30) days following
                      the
                      date the appeal was received by the DEPARTMENT, an administrative
                      hearing
                      will be held as originally scheduled. At the hearing, the MCO
                      must prove
                      good cause for having failed to issue a timely decision regarding
                      the
                      appeal. Good cause for the MCO's failure to issue a timely
                      decision shall
                      include, but not be limited to, documented efforts to obtain
                      additional
                      medical records necessary for the MCO's decision on the appeal
                      and the
                      Member's refusal to sign a release for medical records necessary
                      for the
                      decision on the appeal.

                     

                    The
                      MCO's inability to prove good cause shall constitute a sufficient
                      basis
                      for upholding the appeal, and the hearing officer, in his or
                      her
                      discretion, may uphold the appeal solely on that
                      basis.

                     

                    If
                      the MCO proves good cause for having failed to issue a timely
                      appeal
                      decision, the hearing officer may order a continuance of the
                      hearing
                      pending the issuance of the appeal decision by a certain date,
                      or the
                      hearing officer may proceed with the
                      hearing.

                  

            	s. 	 	A
                    representative of the MCO shall prepare the summary for the administrative
                    hearing, subject to approval by the DEPARTMENT prior to the hearing,
                    and
                    shall present proof of all facts supporting its initial
                    action

          

        

        
          
Part
            II

        

        
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          if
            the
            administrative hearing proceeds in the absence of an appeal decision.
            The MCO
            shall submit a final, signed hearing summary to the DEPARTMENT no later
            than
            five (5) business days prior to the scheduled hearing date. The MCO's
            representative shall also present any provisions of this contract or
            any
            DEPARTMENT policies that support its decision.

        

        
          

          
            	
                    t. 

                  	
                    If
                      the Member is represented by legal counsel at the hearing and
                      has not
                      notified either the DEPARTMENT or the MCO of the representation,
                      the MCO
                      may request a continuance of the hearing or may ask the hearing
                      officer to
                      hold the hearing record open for additional evidence or submissions.
                      The
                      decision as to whether a continuance will be granted or the
                      record will be
                      held upon is within the hearing officer's
                      discretion.

                  

          

        

        
          

          
            	
                    u.   

                  	
                    If
                      a representative of the MCO fails to attend a scheduled session
                      of an
                      administrative hearing, the MCO's failure to attend shall constitute
                      a
                      sufficient basis for upholding the appeal, and the hearing
                      officer, in his
                      or her discretion may close the hearing and uphold the appeal
                      solely on
                      that basis. This provision shall not apply unless the MCO receives
                      notice
                      of the hearing at least seven (7) business days prior to the
                      administrative hearing.

                  

          

        

        
          

          
            	
                    v. 

                  	
                    If
                      the DEPARTMENT is advised that the Member does not intend to
                      proceed to an
                      administrative hearing, the DEPARTMENT will fax such notice
                      to the
                      MCO.

                  

          

        

        
          

          
            	
                    w.  

                  	
                    The
                      MCO must designate one primary and one back-up contact person
                      for its
                      appeal/administrative hearing
                      process.

                  

          

        

        
          

          
            	
                    x.

                  	
                     

                  	
                    If
                      the DEPARTMENT'S hearing officer reverses the MCO's decision
                      to
                      deny,
                      limit or delay services that were not furnished while the appeal
                      was
                      pending, the MCO shall authorize or provide the disputed services
                      promptly, and as expeditiously as the Member's health condition
                      requires.

                  

          

        

        
          

          6.04    Expedited
            Review and Administrative Hearings

        

        
          

          
            	
                    a.

                  	
                    Subject
                      to Section 6.02 above, the appeal process must allow for expedited
                      review. If the appeal contains a request for expedited review,
                      it will be forwarded by fax to the MCO within one business day
                      of
                      receipt by the DEPARTMENT. The fax will include the date the Member
                      mailed the appeal. The postmark on the envelope will be used to
                      determine the date the appeal was mailed. If the MCO receives an oral
                      request for expedited appeal, the MCO shall notify the DSS liaison by
                      fax or telephone within one business day of the oral
                      request.

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      MCO must determine, within one business day of receiving the appeal
                      which contains a request for an expedited review from the DEPARTMENT,
                      or within one business day of receiving an oral request for an
                      expedited appeal, whether to expedite the appeal or whether
                      to perform it according to the standard timeframes. If the Member's
                      provider indicates or the MCO determines that the appeal meets the
                      criteria for

                  

          

        

        
          

          Part
            II
            101

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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          expedited
            review, the MCO shall notify the DEPARTMENT immediately that the MCO
            will be
            conducting the appeal on an expedited basis.

        

        
          

          
            	 	
                    1.  

                  	
                     An
                      expedited appeal must be performed when the standard timeframes
                      for
                      determining an appeal could seriously jeopardize the life or
                      health of the
                      Member or the Member's ability to attain, maintain or regain
                      maximum
                      function. The MCO must expedite its review in all cases in
                      which the
                      Member's provider indicates, in making the request for expedited
                      review on
                      behalf of the Member or supporting the member's request, that
                      taking the
                      time for a standard appeal review could seriously jeopardize
                      the Member's
                      life or health or ability to attain, maintain, or regain maximum
                      function
                      and if the DEPARTMENT requests the MCO to conduct an expedited
                      review
                      because the DEPARTMENT believes a specific case meets the criteria
                      for
                      expedited review.

                  

          

        

        
          

          
            	
                    d.

                  	
                    If
                      the MCO denies a request for expedited review, the MCO shall
                      perform the review within the standard timeframe and make reasonable
                      efforts to give the Member prompt oral notice of the denial and
                      follow up within two calendar days with a written
                      notice.

                  

          

        

        
          

          
            	
                    e.

                  	
                    An
                      expedited review must be completed and an appeal decision must
                      be issued within a timeframe appropriate to the condition or
                      situation of the Member, but no more than three (3) business days
                      from the DEPARTMENT'S receipt of the written appeal or three (3)
                      business days from an oral request received by the
                      MCO.

                  

          

        

        
          

          
            	
                    f.

                  	
                    The
                      MCO may extend the timeframe for decisions in paragraph e by
                      up to 14
                      days if: 1) the Member requests the extension or 2) MCO
                      can demonstrate that the extension is in the member's interest
                      because additional information is needed to decide the appeal and if
                      the timeframe is not extended, the appeal will be denied. The
                      DEPARTMENT may request this documentation from the
                      MCO.

                  

          

        

        
          

          
            	
                    g.

                  	
                    The
                      MCO shall ensure that no punitive action is taken against a
                      provider who requests an expedited appeal or supports a Member's
                      appeal.

                  

          

        

        
          

          
            	
                    h.  

                  	
                    The
                      MCO shall issue a written appeal decision for expedited appeals.
                      The
                      written notice of the resolution must meet the requirements
                      of 6.03(o) and
                      (p). The MCO shall also make reasonable efforts to provide
                      the Member oral
                      notice of an expedited appeal
                      decision.

                  

          

        

        
          

          
            	
                    i.

                  	
                     

                  	
                    The
                      DEPARTMENT also provides expedited administrative hearings
                      for HUSKY A
                      Members, where required. The DEPARTMENT shall issue a hearing
                      decision as
                      expeditiously as the Member's health condition requires, but
                      no later than
                      three (3) working days after the DEPARTMENT receives from the
                      MCO, the
                      case file and information for any appeal that meets the requirements
                      for
                      an expedited hearing. A Member is entitled to an expedited
                      hearing for the
                      denial of a service if the denial met the criteria for expedited
                      appeal
                      but was not resolved within the expedited appeals timeframe
                      or was
                      resolved within the

                  

          

        

        
          

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            II

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          expedited
            appeals timeframe, but the appeals decision was wholly or partially adverse
            to
            the Member.

        

        
          

          Sanction:
            If the MCO fails to provide expedited appeals in appropriate circumstances,
            the
            DEPARTMENT may impose a Class B sanction pursuant to Section
            7.05.

        

        
          

          6.05    Provider
            Appeal Process

        

        
          

          
            	
                    a.

                  	
                    The
                      MCO shall have an internal appeal process through which a health care
                      provider may appeal the MCO decision on behalf of a
                      Member.

                  

          

        

        
          

          
            	
                    b.

                  	
                    The
                      health care provider appeal process shall not include any
                      appeal rights to the DEPARTMENT or any rights to an administrative
                      hearing.

                  

          

        

        
          

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            remainder of this page left intentionally blank.

        

        
          

          Part
            II

        

        
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          7.    CORRECTIVE
            ACTION AND CONTRACT TERMINATION

        

        
          

          7.01           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. The DEPARTMENT will keep written minutes of such
                      meetings. 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 Article 7.02, 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.

                  

          

        

        
          

          7.02           Settlement
            of Disputes

        

        
          

          Any
            dispute arising under the contract that 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.

        

        
          

          7.03           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
            erroneous 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.

        

        
          

          Part
            II

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          7.04           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
            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.)

        

        
          

          7.05           Monetary
            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

        

        
          

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            II

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          $2,500
            after the first three (3) 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.

           

        

        
          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

                  

          

        

        
          

          
            	
                     

                  	
                    1.        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:

                  

          

        

        
          

          
            	
                    a)

                  	
                    Failing
                      to substantially authorize medically necessary items and services
                      that are required (under law or under this contract) to be provided
                      to an Member covered under
                      this contract;

                  

          

        

        
          

          
            	
                    b)

                  	
                    Imposing
                      a premium or charge on Members except as specifically permitted under
                      provisions of the approved Medicaid State Plan and the provisions of
                      this Contract;

                  

          

        

        
          

          
            	
                    c)

                  	
                    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 Title XIX, 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;

                  

          

        

        
          

          
            	
                    d)

                  	
                    Misrepresenting
                      or falsifying information that is furnished to the Secretary, the
                      DEPARTMENT; Member, potential Member, or a health care
                      provider;

                  

          

        

        
          

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            II

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                    e)

                  	
                    Failing
                      to comply with the physician incentive requirements under Section
                      1903(m)(2)(A)(x) of the Social Security Act and 42 CFR 422.208 and
                      422.210;

                  

          

        

        
          

          
            	
                    f)

                  	
                    Distributing
                      directly or through any agent or
                      independent contractor      marketing
                      materials that have not been approved by the DEPARTMENT or containing
                      false or misleading information;
                      and

                  

          

        

        
          

          
            	
                    g)

                  	
                    Failing
                      to comply with any other requirements of 42 U.S.C. 1396b(m)or 42
                      U.S.C. 1396u~2.

                  

          

        

        
          

          
            	
                    2.

                  	
                    Class
                      C sanctions for noncompliance with the contract under this
                      subsection
                      include the following:

                  

          

        

        
          

          
            	
                    a)

                  	
                    Withholding
                      the next month's capitation payment to the MCO in full or in
                      part;

                     

                  

            	b)	Assessment
                    of liquidated damages:

          

        

        
           

        

        
          
            	
                    1)

                  	
                    For
                      each determination that the MCO fails to substantially provide
                      medically necessary services, makes misrepresentations or false
                      statements to Members, potential Members or health
                      care providers, engages in marketing violations or fails
                      to comply with the physician incentive plan requirements, not
                      more than $25,000;

                  

          

        

        
          

          
            	
                    2)

                  	
                    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 or DEPARTMENT,
                      not more than $100,000;

                  

          

        

        
          

          
            	
                    3)

                  	
                    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;

                  

          

        

        
          

          
            	
                    4)

                  	
                    For
                      a determination that the MCO has imposed premiums or charges on
                      Members in excess of the premiums or charges permitted, double the
                      excess amount but not more than $25,000. The excess amount
                      charged in such a circumstance must be deducted from the penalty and
                      returned to the Member
                      concerned;

                  

          

        

        
          

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            II

        

        
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                    c)

                  	
                    Freeze
                      on new enrollment and/or alter the current enrollment;
                      or

                  

          

        

        
          

          
            	
                    d)

                  	
                    Appointment
                      of temporary management as described
                      in 7.06.

                  

          

        

        
          

          
            	
                    3.  

                  	
                    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 the
                      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 that
                      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.

                  

          

        

        
          

          d.           CMS
            Sanctions

        

        
          

          Pursuant
            to 42 CFR 438.730, the DEPARTMENT may recommend the imposition of sanctions
            to
            CMS and CMS may sanction the MCO as described in that section. In the
            alternative, CMS may independently initiate the sanction process described
            in 42
            CFR 438.730(a) through (d). The MCO shall comply with all applicable
            sanction
            provisions set forth in 42 CFR 438.730. CMS may deny payment to the DEPARTMENT
            for new Members under the circumstances described in 42 CFR 438.730(e)
            and
            capitation payments to the MCO will be denied so long as payment for
            those
            Members is denied by CMS.

        

        
          

          7.06   Temporary
            Management

        

        
          

          The
            DEPARTMENT may impose temporary management upon a finding by the DEPARTMENT
            that: 1) there is continued egregious behavior by the MCO; 2) there is
            a
            substantial risk to the health of the Members or 3) temporary management
            is
            necessary to ensure the health of the MCO's members while improvements
            are made
            to remedy the violations or until there is an orderly

        

        
          

          Part
            II

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          termination
            or reorganization of the MCO. For purposes of this section, "egregious
            behavior"
            shall include but not be limited to any of the violations described in
            7.05b(ii)(2) or any other MCO behavior that is contrary to Sections 1903(m)
            and
            1932 of the Social Security Act. After a finding pursuant to this subsection,
            individuals 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
            imposing temporary management. If however, the DEPARTMENT chooses not
            to first
            terminate the contract and repeated violations of substantive requirements
            in
            section 1903(m) or 1932 of the Social Security Act occur, the DEPARTMENT
            must
            than impose temporary management and allow individuals to disenroll without
            cause. The Department may impose temporary management without a
            hearing.

        

        
          

          7.07           Payment
            Withhold, Class C Sanctions or Termination for Cause

        

        
          

          The
            DEPARTMENT may withhold capitation payments, impose sanctions including
            Class C
            Sanctions set forth in Section 7.05 retain monies collected in pursuit
            of fraud
            or abuse, whether by the MCO, its providers, subcontractors or any other
            entity;
            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 A program and this contract and 2) failure to detect fraud or abuse
            and to
            notify the Department of fraud or abuse, as required by Section 3.51
            and 3) if a
            civil action or suit in federal or state court involving allegations
            of health
            fraud or violation of 18 U.S. C. Section 1961 et seq. is brought on behalf
            of
            the DEPARTMENT.

        

        
          

          7.08           Emergency
            Services Denials

        

        
          

          If
            the
            MCO has a pattern of inappropriately denying payments for emergency services
            as
            defined in Part II, Definitions, the MCO 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.)

        

        
          

          7.09           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."

                  

          

        

        
          

          Part
            II

          109

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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                    b.

                  	
                    If
                      after notice of termination of the contract for default, it
                      is determined
                      by the 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.

                  	
                    If
                      after notice of termination of the contract for default, it
                      is determined
                      by the DEPARTMENT or a court that the MCO was not in default or
                      that
                      the MCO's failure to perform or make progress in performance was
                      due
                      to causes beyond control and without the error or negligence of
                      the
                      MCO, or any subcontractor, the notice of termination shall be deemed
                      to have been issued as a termination for convenience pursuant to
                      Section 7.09 and the rights and obligations of the parties shall be
                      governed accordingly.

                  

          

        

        
          

          
            	
                    d.

                  	
                    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 A clients. 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.

                  

          

        

        
          

          
            	
                    e.

                  	
                    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.

                  

          

        

        
          

          
            	
                    f.

                  	
                    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.

                  

          

        

        
          

          
            	
                    g.

                  	
                    In
                      addition to the termination rights under Part I Section 8,
                      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 II Section 4.06 and Part II 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.

                  

          

        

        
          

          7.10   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 recipients through the termination of the contract.

        

        
          

          Part
            II

          110

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
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          7.11           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.

        

        
          

          7.12           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 Medicaid 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.

                  

          

        

        
          

          
            	
                    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 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 sixty (60) day determination and notification
                      period had not been completed, and the MCO will be held to the terms
                      of the executed contract.

                  

          

        

        
          

          7.13           Termination
            for Collusion in Price Determination

        

        
          

          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

        

        
          

          Part
            II

        

        
          111

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (PART
            II,
            3.36-8.05)                                                          07
            HUSKY
            A                                                                  05/07

        

        
          

          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.

        

        
          

          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.

        

        
          

          7.14   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
                      contract The DEPARTMENT shall give the MCO written notice of its
                      intent to terminate, the reason for the termination and the date and
                      time of the hearing. After the hearing, the DEPARTMENT shall give the
                      MCO written notice of its decision affirming or reversing the
                      proposed termination. In the event of a decision to affirm the
                      termination, the DEPARTMENT'S written notice shall include the
                      effective date of termination. The DEPARTMENT may notify Members of
                      the MCO and permit such Members to disenroll immediately without
                      cause during the hearing
                      process.

                  

          

        

        
          

          
            	
                    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 Medicaid
                      claims.

                  

          

        

        
          

          
            	
                    c.

                  	
                    Where
                      this contract is terminated due to cause or default by the
                      MCO:
                      1) 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 and 2) the MCO shall notify all
                      providers and be responsible for all expenses related to notification
                      to providers and members.

                     

                  

            	d.	 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 to members;

                  

          

        

        
          

          Part
            II

        

        
          112

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        

        
          

          (PART
            II,
            3.36-8^05)                                                          07
            HUSKY
            A                                                                  05/07

        

        
          

          
            	
                    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.

                  

          

        

        
          

          7.15   Waiver
            of Default

        

        
          

          Waiver
            of
            any default shall not be deemed 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.

        

        
          

          The
            remainder of this page left intentionally blank.

        

        
          

          Part
            II

          113

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          (PART
            II,
            3.36-8.05)                                                          07
            HUSKY
            A                                                                  05/07

        

        
          

          8.           OTHER
            PROVISIONS

        

        
          

          8.01           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.

        

        
          

          8.02           Effective
            Date

        

        
          

          This
            contract is subject to review for form and substance by the U.S. Department
            of
            Health and Human Services Centers for Medicare and Medicaid Services
            and the
            DEPARTMENT, and will not become effective until it is approved by those
            agencies.

        

        
          

          8.03           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 II shall prevail.

        

        
          

          8.04           Correction
            of Deficiencies

        

        
          

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

        

        
          

          8.05           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.

        

        
          

          9.0    APPENDICES

        

        
          

          The
            following appendices are attached and incorporated as part of this Purchase
            of
            Service Contract between the MCO and the DEPARTMENT:

        

        
          Appendix
            A   HUSKY A Covered Services

        

        
          Appendix
            B   Provider Credentialing and Enrollment
            Requirements;

        

        
          Appendix
            C   EPSDT Periodicity & Immunization
            Schedules,

        

        
          Appendix
            D   DSS Marketing Guidelines;

        

        
          Appendix
            E   Standards for Internal Quality Assurance Programs for Health
Plans;

        

        
          Appendix
            F   Claims Inventory, Aging and Unaudited Quarterly Financial
Reports;

        

        
          

          Part
            II

          114

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        

        
          

          (PART
            II,
            3.36-8.05)  07
            HUSKY
            A    05/07

        

        
          Appendix
            G  HUSKY A Medicaid Coverage Groups

        

        
          Appendix
            I   Capitation Payment Amount

        

        
          Appendix
            K  Inpatient/Eligibility Recategorization Chart.

        

        
          Appendix
            L   Pharmacy Reports

        

        
          Appendix
            M  Rate Charts

        

        
          Appendix
            N   HUSKY Behavioral Health Carve-Out Coverage and Coordination
of
            Medical and Behavioral Services

        

        
          Appendix
            O   CTBHP Master Covered Services Table

        

        
           

          

            Part
              II

            115

             

          

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          APPENDIX
            A

        

        
          

        

        
          HUSKY
            A COVERED SERVICES

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          
            	
                     

                  	
                    Appendix
                      A - MCO Contract
                      05/07

                  

          

        

        
          

          
            	
                     

                  	
                    HUSKY
                      A      Covered
                      Services

                  

          

        

        
          

          For
            purposes of this contract, the information contained in the Department's
            Medical
            Services Policy Manuals and Departmental regulations has been summarized
            to
            provide an overview for reference of the goods and services covered by
            the
            Medicaid program (see attached list of Medical Assistance Program policies
            and
            regulations). Any limitations or exclusions to these covered goods and
            services
            are also overviewed.

        

        
          

          Plans
            should be advised that, notwithstanding the following summary overview,
            guidance
            issued by the Department in the form of policy transmittals, regulations,
            provider bulletins, provider manuals, letters, and other written correspondence
            is the final authority regarding covered goods and services. The intent
            of the
            summary is to provide a quick working guide. These policies are available
            at the
            Connecticut Medical Assistance Program website: www.ctmedicalprogram.com.
            Whenever any questions regarding Medicaid policy occur, health plans
            should
            consult with the Department's Medical Administration Policy Unit for
            clarification.

        

        
          

          Health
            plans are required to cover identical goods and services that are covered
            under
            the Medicaid program. Health plans do not have the option of adding or
            subtracting from the 'benefit package'. These goods and services are
            included in
            plans' capitation rates.. Health Plans may provide unlisted support services
            when such services lead to either a better health outcome or result in
            a less
            restrictive and patient preferred treatment milieu.

        

        
          

          Under
            current Medicaid Fee-For-Service (FFS) reimbursement methodology, various
            administrative procedures related to payment for covered goods and services
            are
            in place. These procedures are not incumbent upon health plans under
            Medicaid
            Managed Care (MMC). For example, currently Medicaid FFS has administrative
            procedures related to physical therapy provided in the home. When physical
            therapy exceeds two (2) sessions per any consecutive seven (7) day period,
            prior
            authorization is required.

        

        
          

          Whether
            or not a given health plan requires prior authorization prior to physical
            therapy being provided in the home, or requires prior authorization after
            a
            certainnumber of visits, or does not require prior authorization at all
            is not
            prescribed. The management of the "benefit" is at the discretion of the
            health
            plan. However, a health plan cannot decide to limit a covered good or
            service
            (e.g., cut off all physical therapy home visits after a certain number
            of
            visits). The number of medically necessary visits will vary by member,
            and the
            health plan cannot set a limit for members unless the Medicaid "benefit"
            itself
            is specifically limited in Medical Services Policy.

        

        
          

          The
            Behavioral Health Partnership ("BHP") is responsible for providing services
            for
            behavioral health conditions. Appendix N, CT BHP Master Covered Services
            Table
            outlines the respective coverage responsibilities of the MCO and the
            Behavioral
            Health Partnership. No provision in this Appendix is intended to negate,
            supercede or contradict any provision of the HUSKY A contract
            or

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            A - MCO Contract

        

        
          
            05/07

          

        

        
           

          Appendix
            N. In the event of any such inconsistencies, the provisions of the HUSKY
            A
            Contract or Appendix N shall control.

        

        
          

          The
            summary overview is divided into three (3) sections. Section A contains
            a
            listing of covered goods and services included in the capitation rates.
            It also
            lists the major limitations and exclusions to these covered goods and
            services.
            Section B contains a listing of covered goods and services not included
            in the
            capitation rates. Section C contains a listing of noncovered
            services.

        

        
          

          SUMMARY
            DESCRIPTION OF BENEFITS

        

        
          

          A.       Covered
            Services included in the Capitation Payment

        

        
          

          
            	
                    1.

                  	
                    Hospital
                      Inpatient Care (acute care hospitals) - Medically necessary
                      and medically appropriate hospital inpatient acute care, procedures,
                      and services, as authorized by the responsible physician(s) or
                      dentist, and covered under Department of Social Services (DSS)
                      policies and regulations. The responsibilities of the MCO and the BHP
                      for inpatient care are outlined in detail in Appendix N. In general,
                      the MCO is responsible for inpatient hospital care when the medical
                      diagnosis is primary.

                  

          

        

        
          

          
            	
                    a.

                  	
                    Administratively
                      Necessary Days (AMDs) are covered when a nursing home placement delay
                      is due to unavailability of beds. However, a patient is required to
                      accept the first available, medically
                      appropriate bed.

                  

          

        

        
          

          
            	
                    b.

                  	
                    Organ
                      transplants are covered if they are of demonstrated
                      therapeutic value, medically necessary and medically appropriate, and
                      likely to result in the prolongation and the improvement in the
                      quality of life of the applicant. The DEPARTMENT has developed, and
                      continues to develop, medical criteria relating to particular organ
                      transplant procedures. These criteria are available for use by health
                      plans. The criteria are guidelines. However, a final decision to deny
                      a transplant request is not to be rendered without considering the
                      medical opinion of a qualified organ transplantation expert(s) in the
                      community.

                  

          

        

        
          

          
            	
                    2.

                  	
                    Chronic
                      Disease Hospital Inpatient Care - Such medically necessary
                      care, procedures, and services as covered under DSS policy and
                      regulation.

                  

          

        

        
          

          
            	
                    3.

                  	
                    Nursing
                      Facility (Skilled Nursing and Intermediate Care) Inpatient
                      Care
                      - Such medically necessary care is covered while the patient
                      remains
                      in a managed care coverage
                      group.

                  

          

        

        
          

          
            	
                    4.

                  	
                    Intermediate
                      Care Facility (Mentally Retarded) Inpatient Care - Such medically
                      necessary care is covered while the patient remains in a managed care
                      coverage group.

                  

          

        

        
          

          
            	
                    5.

                  	
                    Christian
                      Science Sanitoria Service - Such medically necessary care is covered
                      while the patient remains in a managed care coverage
                      group.

                  

          

        

        
          

          
            	
                     

                  	
                    .

                  

          

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            A- MCO Contract

        

        
          
            	
                     

                  	
                    05/07

                  

          

        

        
           

        

        
          
            	
                    6.

                  	
                    Hospital
                      Outpatient Care (General Hospital,, and Chronic Disease Hospital and
                      freestanding Medical/Primary Care Clinics) - Preventive, diagnostic,
                      therapeutic, rehabilitative, or palliative medical services provided
                      to an outpatient by or under the direction of a physician or
                      dentist in a licensed hospital facility. Section 3.17 and Appendix
                      N
                      outline the responsibilities of the MCO and the CT BHP. The MCO is
                      responsible for coverage for all primary care and other medical
                      services at hospital outpatient clinics, regardless of diagnosis and
                      including all medical specialty and ancillary services. The MCO will
                      maintain responsibility for primary care and other medical services
                      provided by freestanding clinics, regardless of
                      diagnosis.

                  

          

        

        
          

          
            	
                    7.

                  	
                    Physician
                      Services - Primary and specialty services provided by a licensed
                      physician or doctor of osteopathy and performed within the
                      scope of
                      practice of medicine or osteopathy as defined by State law.
                      As
                      outlined in Section 3.17 and Appendix N, the MCO retains
                      responsibility for all primary care services and charges regardless
                      of diagnosis.

                  

          

        

        
          

          
            	
                    8.

                  	
                    Nurse-Midwifery
                      Services - Services provided by a licensed, certified nurse-midwife
                      that are related to the care, and to the management of the care, of
                      essentially normal mothers and newborns (only throughout
                      the maternity cycle) and well woman gynecological care, including
                      family planning
                      services.

                  

          

        

        
          

          
            	
                    9.

                  	
                    Nurse
                      Practitioner Services - Services that are provided by a
                      licensed Advanced Practice Registered Nurse (APRN) and that are
                      within his or her scope of practice as defined by State
                      law.

                  

          

        

        
          

          
            	
                    10.

                  	
                    Chiropractor
                      Services - Manual manipulation of the spine performed by a licensed
                      chiropractor within the scope of chiropractic practice.
                      Noncovered services:

                  

          

        

        
          

          
            	
                    a.

                  	
                    Prescription
                      or administration of any medicine or drug or the performance of any
                      surgery;

                  

          

        

        
          

          b.      X-rays
            furnished by a chiropractor.

        

        
          

          
            	
                    c.

                  	
                    Manipulation
                      of other parts of the body (e.g., shoulder, arm, knee, etc.) even
                      when for subluxation of the spine;
                      and

                  

          

        

        
          

          d.      Lab
            work ordered by a chiropractor.

        

        
          

          
            	
                    e.

                  	
                    Chiropractor
                      services provided by independently enrolled chiropractors for
                      individuals who are 21 years of age or
                      older.

                  

          

        

        
          
             

            
              	
                      11.

                    	
                       

                    	
                      Naturopathic
                        Services - Services provided by a licensed naturopath that conform to
                        accepted methods of diagnosis and treatment and that are within the
                        scope of naturopathic
                        practice.

                    

            

          

        

        
           

          Naturopathic
            services provided by independently enrolled naturopaths are not covered
            for
            individuals who are 21 years of age or older.

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            A - MCO Contract

        

        
          05/07

        

        
          

          
            	
                    12.

                  	
                    Podiatrist
                      Services - Services provided by a licensed podiatrist that conform to
                      accepted methods of diagnosis and treatment and that are within the
                      scope of podiatric practice.

                  

          

        

        
          

          a.      Limitations
            of Coverage

        

        
          

          
            	
                     

                  	
                    i.    Orthotic
                      and/or corrective arch supports for recipients under five years
                      of age;
                      and

                  

          

        

        
          

          
            	
                     

                  	
                    ii.   Orthotic
                      and/or corrective arch supports only once every two (2)
                      years.

                  

          

        

        
          

          b.      Noncovered
            Services

        

        
          

          i.   Services
            of assistants at surgery;

        

        
          

          
            	
                     

                  	
                    ii.   Simplified
                      tests requiring minimal time or equipment and employing materials
                      nominal
                      in cost such as Clinitest, testape, Hematest, Bumintest, Dextrostix,
                      nonphotolitric hemogloblin,
                      etc.;

                  

          

        

        
          

          
            	
                  	
                    iii.

                  	
                    Simple
                      foot hygiene; and

                  

          

        

        
          

          
            	
                     

                  	
                    iv.
                      Repairs to devices judged to be necessitated by willful or
                      malicious abuse
                      on the part of the patient.

                  

          

        

        
          

          
            	
                     

                  	
                    v.   Podiatrist
                      services provided by independently enrolled podiatrists are
                      not covered
                      for individuals who are 21 years of age or
                      older.

                  

          

        

        
          

          
            	
                    13.

                  	
                    Laboratory
                      Services - Laboratory services: a) ordered by a duly
                      licensed physician or other licensed practitioner of the healing
                      arts; and b) performed in a laboratory that is certified according to
                      the applicable provisions of the Clinical Laboratory Improvement
                      Amendments of 1988 (CLIA) and meets all applicable licensing,
                      accreditation and certification requirements for the specific
                      services and procedures it provides. The MCO maintains coverage
                      responsibilities for ancillary services such as laboratory,
                      regardless of diagnosis.

                  

          

        

        
          

          
            	
                    14.

                  	
                    Outpatient
                      Medical Rehabilitation Services - Medically necessary and medically
                      appropriate outpatient rehabilitation services provided by
                      a licensed
                      or certified practitioner. Such services include: physical
                      therapy, occupational therapy, speech therapy, audiology, inhalation
                      therapy, social services, psychological services, traumatic brain
                      injury (T.B.I.) day treatment, neuropsychological evaluation,
                      electronystagmography, and early childhood intervention
                      services.

                  

          

        

        
          

          a.  Limitations
            include:

        

        
          

          
            	
                     

                  	
                    i.   Sheltered
                      workshop services for individuals who are primarily developmentally
                      disabled are covered only if their need for this type of program
                      stems
                      from an etiology readily identifiable as medical or psychological
                      in
                      origin;

                  

          

        

        
          

          
            	
                     

                  	
                    ii.   T.B.I,
                      treatment programs are limited to individuals who have sustained
                      injury
                      from interaction of any external forces resulting
                      in

                  

          

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            A - MCO Contract

          05/07

        

        
          

          the
            central nervous system (brain) dysfunctions. Developmental impairment
            primarily
            contributing to brain dysfunction is not included. The impairment must
            be
            readily identifiable as having been sustained through injury;

        

        
          

          
            	
                     

                  	
                    iii.
                      The T.B.I, program is primarily a medical rehabilitation program,
                      however,
                      vocational, social, and educational services may be covered
                      only when
                      these services are: a) related to the individual's injury,
                      b) are
                      reasonable and necessary for the diagnosis or treatment of
                      the injury, and
                      c) are a part of the recipient's written individual plan of
                      care;
                      and

                  

          

        

        
          

          
            	
                     

                  	
                    iv.
                      Programs relating to the learning of basic living skills, or
                      other
                      activities of daily living, are limited to individuals who
                      have lost or
                      had impaired functions of daily living and require retraining
                      to maximize
                      restoration of these skills.

                  

          

        

        
          

          b.  Noncovered
            Services include:

        

        
          

          i.   Services
            that are related solely to specific employment opportunities,
            work skills, work settings, and/or academic skills and are not reasonable
            or
            necessary for the diagnosis or treatment of an illness or
            injury;

        

        
          

          
            	
                     

                  	
                    ii.   Speech
                      services involving nondiagnostic, nontherapeutic, routine,
                      repetitive, and
                      reinforced procedures or services for the patient's general
                      good and
                      welfare; and

                  

          

        

        
          

          
            	
                     

                  	
                    iii.
                      Services ordinarily covered are not covered if an individual's
                      expected
                      restoration potential would be insignificant in relation to
                      the extent and
                      duration of rehabilitation services required to achieve such
                      potential.

                  

          

        

        
          

          
            	
                     

                  	
                    iv.
                      Services provided by independently enrolled physical therapists,
                      audiologists and speech pathologists for individuals who are
                      21 years of
                      age or older.

                  

          

        

        
          

          15.      Vision
            Care - Services performed by a licensed ophthalmologist, optometrist,
            or optician that conform to accepted methods of diagnosis and
            treatment.

        

        
          

          a.  Limitations
            of Coverage

        

        
          

          
            	
                     

                  	
                    i.    Contact
                      lenses are covered when such lenses provide better management
                      of a
                      visual or ocular condition than can be achieved with spectacle
                      lenses, including, but not limited to the diagnosis of Unilateral
                      Aphakia,
                      Keratoconus, Corneal Transplant, and High
                      Anisometropia;

                  

          

        

        
          

          
            	
                     

                  	
                    ii.   Prescription
                      sunglasses are covered when light sensitivity that will hinder
                      driving or
                      seriously handicap the outdoor activity of a patient is
                      evident;

                  

          

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            A- MCO Contract 05/07

        

        
          

          
            	
                     

                  	
                    iii.
                      Trifocals are covered when the patient has a special need due
                      to job
                      training program or extenuating
                      circumstances;

                  

          

        

        
          

          
            	
                     

                  	
                    iv.
                      Extended wear contact lenses are covered for aphakia and for
                      members whose
                      coordination or physical condition make daily usage of contact
                      lenses
                      impossible;

                  

          

        

        
          

          
            	
                     

                  	
                    v.
                      Oversize lens are covered only when needed for physiological
                      reasons, and
                      not for cosmetic reasons; and

                  

          

        

        
          

          
            	
                  	
                    vi.

                  	
                     A
                      spare pair of eyeglasses is not
                      covered.

                  

          

        

        
          

          
            	
                    16. 

                  	
                    Dental
                      Care - Services performed by a licensed dentist or dental hygienist
                      that
                      conform to accepted methods of diagnosis and
                      treatment.

                  

          

        

        
          

          a.
            The
            categories of covered services are as follows:

        

        
          

          
            	
                     

                  	
                    1).
                      Diagnostic Services are the procedures needed to diagnose the
                      oral
                      condition.

                  

          

        

        
          

                a).
            Radiographs:

          i     Full
            mouth series or panoramic radiograph;

        

        
          ii    Bitewing
            films and

          iii   Periapical
            films, 

           

          b)
Oral
            examinations:

          i.   Initial
            comprehensive oral examination, which includes a complete evaluation
            including
            medical history;

          ii.   Periodic
            oral exams and

        

        
          iii.
            Emergency oral examination.

        

        
          

          
            	
                     

                  	
                    2).
                      Preventive Services are the procedures used to help avoid oral
                      disease.

                  

          

        

        
          

          a) 
             Prophylaxis;

        

        
          b)  
            Fluoride treatment for children under 21;

        

        
          c) 
             Sealants for adult (secondary) teeth;

        

        
          d) 
             Space maintainers and

          e) 
             Night guards.

        

        
          

          
            	
                     

                  	
                    3).
                      Restorative Services are the procedures performed to remove
                      disease or
                      repair broken teeth.

                  

          

        

        
          

          a)      Amalgam
            (silver) fillings;

        

        
          b)      Composite
            (white) fillings and

        

        
          c)      Crowns.

        

        
          

          
            	
                     

                  	
                    4).
                      Endodontic Services are the procedures used to treat infections
                      or repair
                      trauma that has reached deep into the tooth
                      structure.

                  

          

        

        
          

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            A - MCO Contract 

          05/07

           

        

        
          a)      Pulpotomy
            in primary teeth;

        

        
          b)      Root
            canal therapy in adult teeth;

        

        
          c)      Apicoectomy
            in adult teeth and

        

        
          d)      Apexification
            in adult teeth

        

        
          

          
            	
                     

                  	
                    5).
                      Periodontal Services are those procedures used to treat diseases
                      of he
                      gingival (gum) and supporting structures (periodontal ligament
                      and bone)
                      of the teeth.

                  

          

        

        
          

          a)      Gingivectomy
            and

        

        
          b)      Gingivoplasty.

        

        
          

          
            	
                     

                  	
                    6).
                      Prosthodontic Services are the procedures used to repair teeth
                      when a
                      great deal of tooth structure is lost due to disease or trauma
                      or
                      and/replaces missing teeth.

                  

          

        

        
          

          a)      Crowns;

        

        
          b)      Removable
            complete upper and/or lower dentures and

        

        
          c)      Removable
            partial upper and or lower dentures.

        

        
          

          
            	
                     

                  	
                    7).
                      Oral Surgery is the surgical and non surgical procedures used
                      to restore
                      the health of the mouth and surrounding
                      structures.

                  

          

        

        
          

          a)      Edxoodontia
            (extractions);

        

        
          b)      Biopsy;

        

        
          c)      Lesion
            and tissue removal

        

        
          d)      Surgery
            for trauma, and e.Fracture reduction

        

        
          

          
            	
                     

                  	
                    8).
                      Orthodontics are the procedures used to realign teeth in the
                      proper
                      position when the teeth are determined to be in a severe handicapping
                      malocclusion.

                  

          

        

        
          

          
            	
                     

                  	
                    a)
                      Active treatment may extend up to but not exceeding thirty
                      months per
                      recipient.

                  

          

        

        
          

          
            	
                     

                  	
                    9).
                      Miscellaneous Services are procedures required for oral care
                      utilized in
                      conjunction with dental
                      services.

                  

          

        

        
          

          
            	
                    a)

                  	
                    Patient
                      Management - in connection with dental services to individuals with
                      cognitive disabilities as determined by the Department of Mental
                      Retardation.

                  

          

        

        
          b)      General
            Surgical Anesthesia;

        

        
          c)      Home
            visits.

           

        

        
          
            	
                    b.
                      

                  	
                    The
                      categories of Program Limitations are as follows: 

                     

                    1).
                      Diagnostic Services:

                  

          

        

        
          

        

        
          
            	
                     

                  	
                     

                  

          

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            A - MCO Contract 05/07

        

        
          

          a).
            Radiographs:

        

        
          

          
            	
                    i. 

                  	
                    Full
                      mouth series or panoramic radiograph once every three
                      years;

                  

          

        

        
          

          ii.   Bitewing
            films once every six months;

        

        
          

          
            	
                    iii.

                  	
                    Periapical
                      films the single first film is not    covered on the
                      same date of service as bitewings, panoramic, or lateral jaw
                      films.

                  

          

        

        
          

          b).
            Oral
            examinations:

        

        
          

          
            	
                    i. 

                  	
                    Initial
                      oral complete examination includes a complete history workup
                      and is
                      limited to one time per patient per three year (3)
                      period;

                  

          

        

        
          

          
            	
                    ii.

                  	
                    Periodic
                      oral exams once six months after the initial oral exam and
                      every six
                      months thereafter;

                  

          

        

        
           

          iii.
            Emergency oral examination. 

           

          2).
            Preventive Services:

        

        
           

          a)      Prophylaxis
            once every six months;

        

        
          

          
            	
                     

                  	
                    i.     Prophylaxis
                      includes supra and sub gingival scaling and polishing by rotary,
                      ultrasonic or other mechanical means as described as standard
                      procedure by
                      the American Dental
                      Association.

                  

          

        

        
          

          
            	
                     

                  	
                    ii.   "Toothbrush"
                      prophylaxis is not a Medicaid covered procedure in children
                      over 48 months
                      of age.

                  

          

        

        
          

          
            	
                    b)

                  	
                    Fluoride
                      treatment for children under 21 every six months (prior authorization
                      is required for members over 21 years of
                      age);

                  

          

        

        
          

          
            	
                    c)

                  	
                    Sealants
                      for adult (secondary) teeth for all molar teeth and for premolar
                      teeth on children who are at moderate or severe risk for caries as
                      assessed by the Caries Assesment Tool. A sealant may be placed from
                      ages 5 through 16, only one time in a five year period per
                      tooth.

                  

          

        

        
          

          d)      Space
            maintainers cannot be unilateral and removable in form.

           

          e)      Occlusal
            guards. 

           

          3).
            Restorative Services:

        

        
          

          
            	
                    a)

                  	
                    Amalgam
                      and composite fillings are limited to one per year to the same
                      surface per tooth by the same provider unless prior authorization is
                      obtained.

                  

          

        

        
          

          
            	
                    b)

                  	
                    More
                      than one amalgam filling on a single surface will be considered a
                      single filling. Anterior or composite fillings involving more than
                      one surface will be considered as a
                      single

                  

          

        

        
          

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            A - MCO Contract 05/07

        

        
          

          filling.
            Only those fillings involving the incisal corner will be considered a
            two
            filling procedure.

        

        
          

          
            	
                    c) 

                  	
                    Crowns
                      may be used only in those cases where the breakdown of tooth
                      structure is
                      excessive or root canal therapy has been performed. Suitable
                      types of
                      crowns include:

                  

          

        

        
          

          
            	
                     

                  	
                    i.   Stainless
                      steel, may be used for deciduous or permanent, anterior or
                      posterior
                      teeth.

                  

          

        

        
          

          
            	
                     

                  	
                    ii.   Preformed
                      plastic may be used on anterior deciduous or permanent
                      teeth.

                  

          

        

        
          

          iii.
            Acrylic or porcelain veneer, permanent anterior teeth only

        

        
          

          iv.
            Porcelin fused to metal on permanent teeth only.

        

        
          

          4).
            Endodontic Services:

        

        
          

          
            	
                    a)

                  	
                    Performed
                      in anterior upper and lower six teeth only when the retention of the
                      tooth in site is necessary to maintain the integrity of the dentition
                      and when the prognosis is
                      favorable.

                  

          

        

        
          

          
            	
                    b)

                  	
                    Performed
                      in the eight posterior teeth only in cases where there is a full
                      dentition or when the tooth is the only source for an abutment tooth
                      or the integrity of the bite would be
                      seriously affected.

                  

          

        

        
          

          
            	
                    c)

                  	
                    Apexification
                      does not include root canal treatment but includes all visits to
                      complete the service.

                  

          

        

        
          

          5).
            Periodontal Services:

           

        

        
          a)      Limited
            to givoplasty and

          b)      Limited
            to givectomy. 

           

          6).
            Prosthodontic Services:

           

        

        
          a)      Crowns
            (refer to Section 3b Restorative, Crowns);

        

        
          

          
            	
                    b)

                  	
                    Removable
                      complete upper and/or lower dentures will be approved if the patient
                      can tolerate and is expected to use them on a daily
                      basis.

                  

          

        

        
          

          
            	
                    c)

                  	
                    Removable
                      partial upper and/or lower dentures will be approved if the patient
                      can tolerate them and is expected to use them on a daily basis. There
                      must less than eight posterior teeth in occlusion with missing
                      anterior teeth.

                  

          

        

        
          

          
            	
                    d)

                  	
                    Replacement
                      of existing complete or partial dentures, may be reconstructed in any
                      five (5) year period. Prior authorization must be requested with a
                      documented need of medical necessity if the removable complete or
                      partial denture(s) must be remade or replaced for any reason within
                      the date of delivery of the initial
                      prosthesis.

                  

          

        

        
          

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            A - MCO Contract 05/07

        

        
          

          
            	
                    e)

                  	
                    Relining
                      or rebasing of existing complete or partial dentures may be performed
                      one time in a two year
                      period.

                  

          

        

        
          

          
            	
                    f)

                  	
                    Denture
                      labeling may be performed for patients residing in long term care
                      facilities.

                  

          

        

        
          

          7). 
            Oral Surgery:

        

        
          

          
            	
                    a)

                  	
                    Suturing
                      of lacerations of the mouth is covered in accident cases only and not
                      cases incidental to and connected with dental
                      surgery.

                  

          

        

        
          

          
            	
                    b)

                  	
                    The
                      following services are not covered unless the procedure is used in
                      conjunction with orthodontic
                      therapy:

                  

          

        

        
          

          
            	
                     

                  	
                    i.    Uncovering
                      of impacted or un-erupted teeth for orthodontic
                      reasons;

                  

          

        

        
          

          
            	
                     

                  	
                    ii.   Ostoplasty/osteotomy
                      of facial bones for midface hypoplasia or mandibular progngaathism
                      without
                      bone graft.

                  

          

        

        
          

          
            	
                    c)

                  	
                    Reimplantation
                      of an avulsed anterior tooth may not be billed in conjunction with
                      root canal therapy on the same
                      tooth.

                  

          

        

        
          

          
            	
                    d)

                  	
                    Bone
                      grafts of the mandible are restricted to the replacement of bone
                      previously removed by a radical surgical
                      procedure.

                  

          

        

        
          

          8).
            Orthodontics:

        

        
          

          
            	
                    a)

                  	
                    In
                      cases where a severe handicapping malocclussion exists under the
                      Early Periodic Screening, Diagnosis and Treatment (EPSDT) and is
                      limited to recipients under the age of
                      21.

                  

          

        

        
          

          
            	
                     

                  	
                    i.    Services
                      must be rendered by providers who are qualified by Section
                      184.B in
                      regulations.

                  

          

        

        
          

          
            	
                    b)

                  	
                    Screening
                      may be performed one time per provider for the
                      same recipient

                  

          

        

        
          

          
            	
                    c)

                  	
                    Consultation
                      may be performed one time per provider for the same
                      recipient;

                  

          

        

        
          

          d)      Diagnostic
            Assessment:

        

        
          

          
            	
                     

                  	
                    i.    Preliminary
                      casts/study models one time per provider per
                      recipient;

                  

          

        

        
          

          
            	
                     

                  	
                    ii.   Comprehensive
                      casts/study models one time per provider per
                      recipient.

                  

          

        

        
          

          e)      Appliance:

        

        
          

          i.    Initial
            appliance is limited to one per provider per recipient;

        

        
          

          
            	
                     

                  	
                    ii.   Retainer
                      appliance is limited to one replacement per dental arch for
                      each recipient
                      regardless of the reason.

                  

          

        

        
          

          9).
            Miscellaneous Services

        

        

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

         

        
          Appendix
            A - MCO Contract 05/07

        

        
          

          
            	
                    a)

                  	
                    Services
                      covered under Husky are limited to the Department's fee schedule,
                      which can be found
                      on www.ctmedicalprogram.com;

                  

          

        

        
          

          
            	
                    b)

                  	
                    Patient
                      management - in conjunction with dental services when the provider
                      has documented the specific diagnosis in the patient's chart. A
                      diagnosis of moderate, severe, or profound mental retardation will
                      satisfy the diagnosis
                      requirement.

                  

          

        

        
          

          i.   The
            provider's record of the patient must contain the

        

        
          signature
            of the physician or a professional staff member of the Department of
            Mental
            Retardation attesting to the authority of the diagnosis.

        

        
          

          
            	
                    c. 

                  	
                     The
                      categories of dental services that have noncovered procedures
                      are as
                      follows:

                  

          

        

        
           

          1)      Preventive
            Services:

        

        
          i.    Unilateral
            Removable Appliances.

        

        
          2)      Restorative
            Services:

        

        
          i.    Cosmetic
            dentistry;

        

        
          ii.   Unilateral
            Removable Appliances;

        

        
          iii.
            Procedures to teeth nearing exfoliation (ready to fall out).

        

        
          3)      Periodontal
            Services:

        

        
          i.   Any
            surgical periodontal procedure; ii.   Any non surgical
            periodontal therapies; iii. Scaling and root planning.

           

        

        
          
            	
                    4)

                  	
                    Prosthodontic
                      Services: 

                  

          

        

        
          i.   Cosmetic
            dentistry;

          ii.Dentures
            (partial) where there are more than 8
            posterior teeth in occlusion and no missing anterior teeth;

        

        
          iii.
            Fixed Partial Dentures (Bridges);

        

        
          iv.
            Implants and associated abutments and /or attachments;

        

        
          iv.
            Implant sustained crowns;

        

        
          v.
            Office visits to obtain a prescription where the need
            for such prescription has already been ascertained and

          vi.
            Unilateral removable appliances. 

          5)      Oral
            Surgical Services:

        

        
          i.   Alveoplasty
            in conjunction with extraction (s);

        

        
          ii.   Cosmetic
            surgery;

        

        
          

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            A - MCO Contract 05/07

        

        
          iii.
            I.V.
            Sedation (conscious sedation);

        

        
          iv.
            Implant placement;

        

        
          v.   Nitrous
            Oxide (inhalation conscious sedation);

        

        
          vi.
            Vestibuloplasty.

        

        
           

          6)
            Miscellaneous:

           

          i.    Broken
            or cancelled appointments;

           

        

        
          
            	
                    17.

                  	
                    Durable
                      Medical Equipment - equipment
                      that: 

                  

          

          a   Can
            stand repeated
            use;

        

        
          b   Is
            primarily and customarily used to serve a medical purpose;

        

        
          
            c   Is
              generally not useful to a person in the absence of an illness or injury;
              and

          

        

        
          d   Excludes
            items that are disposable.

        

        
          

          Equipment
            covered includes: wheelchairs and accessories, walking aids, bathroom
            equipment
            (e.g., commode and safety equipment), hospital beds and accessories,
            inhalation
            therapy equipment (e.g., IPPR machines, suction machines, nebulizers,
            and
            related equipment), enteral/parenteral therapy equipment, and the repair
            and
            replacement of durable medical equipment (DME) and related
            equipment.

        

        
          

          
            	
                    18.

                  	
                    Orthotic
                      and Prosthetic Devices - Mechanical appliances and devices
                      for the
                      purpose of providing artificial replacement of missing parts,
                      and/or prevention or correction of disorders in involving physical
                      deformities
                      and impairments.

                  

          

        

        
          

          
            	
                    a.

                  	
                    Devices
                      covered include: braces, corsets, collars, arch supports, footplates,
                      orthopedic shoes, orthopedic prostheses, hearing aids (including
                      batteries, earmolds, and
                      cords).

                  

          

        

        
          

          
            	
                    b.

                  	
                    Limitations:
                      i) orthotic and/or corrective arch supports are not provided for
                      recipients under five years of age; ii) Metatarsus Adductus
                      Shoes are
                      limited to a congenital metatarsus adductus condition and are limited
                      to children through age four as medically
                      necessary.

                  

          

        

        
          

          
            	
                    19.

                  	
                    Oxygen
                      Therapy - oxygen, equipment, supplies, and services related
                      to the
                      delivery of oxygen.

                  

          

        

        
          

          
            	
                    20.

                  	
                    Respiratory
                      Therapy - services include: intermittent positive pressure breathing,
                      ultrasonography, aerosol, sputum induction, percussion and postural
                      drainage, arterial puncture, and withdrawal of blood for
                      diagnosis.

                  

          

        

        
          

          
            	
                    21.

                  	
                    Dialysis
                      - hemodialysis and peritoneal dialysis services are
                      covered, including the treatment of end stage renal
                      disease.

                  

          

        

        
          

          
            	
                    22.

                  	
                    School-Based
                      Clinics - services provided at a facility: a) located on the grounds
                      of a public school; b) serving enrolled recipients on a
                      scheduled

                  

          

        

        
          

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

        

        
          Appendix
            A - MCO Contract 05/07

        

        
          

          basis
            or
            for an emergency situation; and c) licensed as an outpatient medical
            facility to
            provide comprehensive care.

        

        
          

          
            	
                    a.

                  	
                    Covered
                      services include: health assessments; family planning services;
                      diagnosis and/or treatment of illness or injuries; laboratory testing
                      (performed by the School-Based Health Clinic); follow-up
                      visits; EPSDT services; one-on- one health education, medical social
                      work services, and nutritional counseling;. The MCO is responsible
                      for primary care services provided by school-based clinics,
                      regardless of diagnosis, except for services described in Appendix
                      N.

                  

          

        

        
          

          
            	
                    b.

                  	
                    Noncovered
                      services include: mandated school health screenings, simple
                      intervention of a health problem such as nonmedical personnel could
                      render, visits where the presenting health problem does not require a
                      health or mental health assessment/evaluation, visits for the sole
                      purpose of administering or monitoring medications, services
                      that are
                      not part of the written individual plan of
                      care.

                  

          

        

        
          

          
            	
                    23.

                  	
                    Family
                      Planning and Abortion - medically approved diagnostic
                      procedures, treatment, counseling, drugs, supplies, or devices that
                      are prescribed or furnished by a provider to individuals of child
                      bearing age for the purpose of enabling such individuals to freely
                      determine the number and spacing of their children.

                     

                    Noncovered
                      services include: a) sterilizations for patients who are under
                      age
                      twenty-one (21), mentally incompetent, or institutionalized;
                      and b)
                      hysterectomies performed solely for the purpose of rendering
                      an individual
                      permanently incapable of
                      reproducing.

                  

          

        

        
           

        

        
          
            	
                    24.

                  	
                    Ambulatory
                      Surgery - Services include preoperative examinations, operating and
                      recovery room services, and all required drugs
                      and medicine.

                  

          

        

        
          

          
            	
                    25.

                  	
                    Early
                      and Periodic Screening, Diagnostic and Treatment (EPSDT) Services
                      (HealthTrack Services)- Comprehensive child health care services to
                      recipients under twenty-one (21) years of age, including
                      all medically necessary prevention, screening, diagnosis, and
                      treatment services listed in Section 1905(r) of the Social Security
                      Act.

                  

          

        

        
          

          EPSDT
            Covered Services are described below:

        

        
          

          
            	
                    a.  

                  	
                    Initial
                      and Periodic Comprehensive Health Screenings - includes the
                      following
                      services provided at the intervals recommended in the Periodicity
                      Schedule
                      consistent with the standards of the American Academy of Pediatrics
                      and
                      Center for Disease Control:

                  

          

        

        
          

          
            	
                     

                  	
                    i.   A
                      comprehensive health and developmental history, including physical
                      and
                      nutritional assessments and mental health development
                      screening;

                  

          

        

        
          

          ii.   A
            comprehensive unclothed physical examination;

        

        

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        
          Appendix
            A - MCO Contract 05/07

        

        
          

          
            	
                     

                  	
                    iii.
                      Appropriate immunizations according to age and health history,
                      unless
                      medically contraindicated at the
                      time;

                  

          

        

        
          

          
            	
                     

                  	
                    iv.
                      Appropriate laboratory tests (including blood lead level assessments
                      appropriate for age and risk
                      factors);

                  

          

        

        
          

          
            	
                     

                  	
                    v.   Health
                      education (including anticipatory guidance and risk
                      assessment);

                  

          

        

        
          

          vi.
            Diagnosis and treatment of problems found during the
            screening;

        

        
          

          vii.
            Vision screenings - an objective vision screening is indicated beginning
            at three years of age as indicated in accordance with the Periodicity
            Schedule;

        

        
          

          
            	
                     

                  	
                    viii.
                      Hearing screenings - an objective hearing screening is indicated
                      beginning
                      at four years of age according to the Periodicity Schedule;
                      and

                  

          

        

        
          

          
            	
                     

                  	
                    ix.
                      Dental screenings are recommended in the Periodicity Schedule,
                      for
                      example, an initial direct referral to a dentist beginning
                      at age
                      two.

                  

          

        

        
          

          
            	
                    b.

                  	
                    Dental
                      Services - includes those dental services provided by or under the
                      direction of a dentist, in addition to the dental screening,
                      that
                      are recommended in the Periodicity Schedule. Dental services also
                      include relief of pain and infections, restoration of teeth, and
                      maintenance of dental
                      health.

                  

          

        

        
          

          
            	
                    c.

                  	
                    Administration
                      and Medical Interpretation of Developmental Tests - objective
                      standardized tests, recognized by the Connecticut Birth-To- Three
                      Council, for further diagnosis and treatment of problems found during
                      a periodic comprehensive health screen or interperiodic encounter.
                      Such tests include, but are not limited to, the Battelle, the Mullen,
                      and the Bayley.

                  

          

        

        
          

          
            	
                    d.

                  	
                    Case
                      Management Services - The following services are determined
                      to be
                      necessary when a child evidences a need for such services as
                      a result
                      of a periodic comprehensive health screening or
                      interperiodic encounter:

                  

          

        

        
          

          
            	
                     

                  	
                    i.    Initial
                      case management assessment and periodic reassessment, including
                      development of the plan of services and revision as
                      necessary.

                  

          

        

        
          

          ii.   Ongoing
            case management, including, at a minimum:

        

        
          

          
            	
                     

                  	
                    A)
                      Assistance in implementing the plan of services, which includes:
                      facilitating referrals, providing assistance in scheduling
                      needed health
                      or health-related services, and helping to identify and link
                      with the
                      child's health and social service providers. Particularly,
                      the case
                      management provider shall identify the child's
                      health

                  

          

        

        
           

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            A - MCO Contract 05/07

        

        
          

          home
            or,
            if necessary, participate in linking the child with a quality health
            home, and
            encourage continuity of care;

        

        
          

          
            	
                    B)

                  	
                    Monitoring
                      the delivery of and facilitating access to a periodic comprehensive
                      health screening at the intervals recommended in the Periodicity
                      Schedule, and other screening, diagnosis, and treatment services.
                      Such activities also include follow-up on missed appointments, and,
                      if necessary, assistance with arranging medical transportation, child
                      care, and
                      interpreter services;

                  

          

        

        
          

          
            	
                    C)

                  	
                    Coordinating
                      and integrating the plan of services, as necessary, through direct or
                      collateral contacts with the family and members of their team of
                      direct service providers,
                      as appropriate;

                  

          

        

        
          

          
            	
                    D)

                  	
                    Monitoring
                      the quality and quantity of needed services that are being provided,
                      and evaluating outcomes and assessing future needs which might
                      support changes in the plan of services, including completing a
                      quarterly progress note;

                  

          

        

        
          

          
            	
                    E)

                  	
                    Providing
                      health education, as needed, and in coordinating with a direct
                      service provider, interpreting and reinforcing the service provider's
                      recommendations for the health of the child;
                      and

                  

          

        

        
          

          
            	
                    F)

                  	
                    Providing
                      client advocacy to ensure the smooth flow of information between the
                      child, the child's representative, providers, and agencies, to
                      minimize conflict between service providers, and to mobilize
                      resources to obtain needed
                      services.

                  

          

        

        
          

          e.  Interperiodic
            Encounters

        

        
          

          
            	
                     

                  	
                    i.   An
                      encounter or visit to determine if there is a problem, or to
                      treat a
                      problem that was not evident at the time of the regularly scheduled
                      periodic comprehensive screening but needs to be addressed
                      before the next
                      periodic comprehensive
                      screening;

                  

          

        

        
          

          
            	
                     

                  	
                    ii.   Any
                      screening, in addition to the screenings recommended in the
                      Periodicity
                      Schedule, to determine the existence of suspected physical,
                      mental, or
                      developmental conditions;

                  

          

        

        
          

          
            	
                  	
                    iii.

                  	
                    An
                      encounter or follow-up visit in the case of a child whose physical,
                      mental, or developmental illness or condition has already been
                      diagnosed
                      prior to the child being Medicaid eligible (e.g., a pre- existing
                      condition), but needs to be addressed before the next scheduled
                      screening
                      interval recommended in the Periodicity Schedule, if there
                      are indications
                      that the illness or condition may have become more severe or
                      changed
                      sufficiently so that further examination is medically necessary;
                      and

                  

          

        

        
          

          
            	
                     

                  	
                    iv. 
                      An encounter necessary to provide immunizations, vision, and/or
                      hearing
                      screenings (e.g., which had been deemed
                      medically

                  

          

        

        
          

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

           

        

        
          Appendix
            A - MCO Contract 05/07

        

        
          

          contraindicated
            at the time of the periodic comprehensive health screening).

        

        
          

          
            	
                    f.

                  	
                    Personal
                      Care Services - services for a child who has a diagnosed disability
                      and is judged to be able to benefit from one (1) or more personal
                      care service activities as the result of a periodic comprehensive
                      health screen or interperiodic encounter performed by a primary care
                      provider.

                  

          

        

        
          

          
            	
                     

                  	
                    i.
                      Covered personal care services include all tasks to assist
                      a child with
                      major life activities of self-care and instrumental activities
                      as
                      identified in the personal care services plan of
                      care:

                  

          

        

        
          

          
            	
                    A)

                  	
                    Covered
                      major life activities include, but are not limited to, dressing,
                      bathing, eating, and personal health care maintenance;
                      and

                  

          

        

        
          

          
            	
                    B)

                  	
                    Covered
                      instrumental activities include, but are not limited to, cooking,
                      cleaning, travel, and
                      shopping.

                  

          

        

        
          

          ii.   The
            following services are not covered:

        

        
          

          
            	
                    A)

                  	
                    Personal
                      care services provided to an individual who does not reside at
                      home;

                  

          

        

        
          

          B)           Personal
            care services provided by a family member;

        

        
          

          
            	
                    C)

                  	
                    Home
                      health services which duplicate personal care services (e.g., home
                      health aide services are not covered when personal care services are
                      appropriate);

                  

          

        

        
          

          
            	
                    D)

                  	
                    Transportation
                      of the personal attendant to and from the child's home to provide
                      services;

                  

          

        

        
          

          
            	
                    E)

                  	
                    Acute
                      health care services that are covered under other
                      DSS regulations;

                  

          

        

        
          

          
            	
                    F)

                  	
                    Personal
                      care services when the child is eligible for or receiving comparable
                      services from another agency or program;
                      and

                  

          

        

        
          

          
            	
                    G)

                  	
                    Personal
                      care services for the care or assistance that would routinely be
                      given to a child in the absence of a
                      disability.

                  

          

        

        
          

          
            	
                    g.

                  	
                    EPSDT
                      Special Services - other medically necessary and
                      medically appropriate health care, diagnostic services, treatment, or
                      other measures necessary to correct or ameliorate disabilities and
                      physical and mental illnesses and conditions discovered as a result
                      of a periodic comprehensive health screening or interperiodic
                      encounter, whether or not the good or service is included in the
                      Connecticut Medicaid Program State Plan as a good or service
                      available to all other Medicaid recipients. Such services include,
                      but are not limited to, medically necessary and medically appropriate
                      over-the-counter drugs and personal care
                      services.

                  

          

        

        
          

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            A - MCO Contract 05/07

        

        
          

          
            	
                    h.
                      

                  	
                    All
                      medically necessary diagnosis and treatment services available
                      to all
                      Medicaid recipients under the Connecticut Medical Assistance
                      Program.

                  

          

        

        
          

          
            	
                    26.

                  	
                    Diagnostic
                      Services - Medical procedures (e.g., radiology, cardiology,
                      EEC, and
                      ultrasound procedures) or supplies recommended by a physician
                      or
                      other licensed practitioner of the healing arts, within the scope
                      of
                      his/her practice under State law, to enable the identification of the
                      existence, nature, or extent of illness, injury, or other health
                      deviation. The MCO retains the responsibility for ancillary services
                      such as radiology, regardless of
                      diagnosis

                  

          

        

        
          

          
            	
                    27.

                  	
                    Home
                      Health Care - Medically necessary home health services ordered
                      by the
                      licensed practitioner and provided by a licensed home health
                      agency on
                      a part-time or intermittent basis to members who reside at home,
                      as
                      defined by Departmental policy, for the purpose of enabling the
                      patient to remain at home or to provide a less costly alternative to
                      institutional care. The MCO and BHP share responsibilities for home
                      health services, as outlined in Section 3.17 and Appendix N. In
                      general, the MCO must provide home health services for the treatment
                      of medical diagnoses alone, and when a client has both medical and
                      behavioral diagnosis, but the medical diagnosis is
                      primary.

                  

          

        

        
          

          
            	
                    28
                      

                  	
                     

                  	
                    Mental
                      Health/Substance Abuse Services - As outlined in Section 3.17
                      and Appendix
                      N, the BHP assumes coverage responsibility for most behavioral
                      health
                      services. The MCO retains responsibility for all primary care
                      services and
                      associated changes, regardless of diagnosis. This includes,
                      but is not
                      limited to behavioral health prevention and
                      screening.

                  

          

        

        
          

          29.      Medical
            Transportation Services

           

        

        
          
            	
                    a.

                  	
                    Emergency
                      and Nonemergency Ambulance Service is covered when: 

                     

                    i    The
                      patient's condition requires medical attention during transit;
                      or

                  

          

        

        
          

          
            	
                     

                  	
                    ii
                      The patient's diagnosis indicates that the patient's condition
                      might
                      deteriorate in transit to the point where medical attention
                      would be
                      needed; or

                  

          

        

        
          

          iii   The
            patient's condition requires hand and/or feet restraints; or iv  The
            ambulance is responding to an emergency; or

        

        
          

          
            	
                     

                  	
                    v .  No
                      alternative less expensive means of transportation is available.
                      Ambulance
                      trips to an emergency room, regardless of the outcome, nor
                      ambulance trips
                      in response to a 911 call, cannot be subject to prior authorization.
                      The
                      MCO is responsible for emergency medical transportation regardless
                      of
                      diagnosis. Hospital to hospital transportation of members with
                      a medical
                      condition is also covered.

                  

          

        

        
          

          
            	
                    b.

                  	
                    Air
                      Transportation - when a medical condition or time constraint dictates
                      its use.

                  

          

        

        
          

          
            	
                    c.

                  	
                    Critical
                      Care Helicopter - when a medical condition or time
                      constraint dictates its
                      use.

                  

          

        

         

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            A - MCO Contract 05/07

        

        
          

          
            	
                    d.

                  	
                    Other
                      Nonambulance Transportation [Livery, Wheelchair van, Commercial
                      Carrier, Taxi, Private Transportation, Service bus - when needed to
                      obtain necessary medical services covered by Medicaid including
                      behavioral health services, and when it is not available
                      from volunteer organizations, other agencies, personal resources,
                      etc. To administer this benefit, DSS currently employs the following
                      limitations on services:

                  

          

        

        
          

          i.    Requirement
            of prior authorization;

        

        
          

          
            	
                     

                  	
                     ii.  
                      Requirement of the use of the nearest appropriate provider
                      of medical
                      services when a determination has been made that traveling
                      further
                      distances provides no medical benefit to the patient;
                      and

                  

          

        

        
          

          
            	
                    .
                      

                  	
                    iii.  
                      Requirement of the use of the least expensive appropriate method
                      of
                      transportation, depending on the availability of the service
                      and the
                      physical and medical circumstances of the
                      patient.

                  

          

        

        
          

          
            	
                    e.

                  	
                    Transportation
                      for relatives, guardians, or foster parents of a Medicaid recipient -
                      only under the following
                      circumstances:

                  

          

        

        
          

          
            	
                     

                  	
                    i.   The
                      person needs to be present at and during the medical service
                      being
                      provided to the patient (for example, in parent/child situations);
                      and

                  

          

        

        
          

          
            	
                     

                  	
                    ii.
                      The person needs to be trained by hospital staff to provide
                      unpaid health
                      care in the home to the patient, and without this health care
                      being
                      provided the patient would not be able to return
                      home.

                  

          

        

        
          

          
            	
                     

                  	
                    iii.
                      Children under twelve (12) years of age shall be escorted to
                      medical
                      appointments. Either the child's parent, foster parent, caretaker,
                      legal
                      guardian or the Department of Children and Families (DCF),
                      as appropriate,
                      shall be responsible for providing the
                      escort.

                  

          

        

        
          

          
            	
                     

                  	
                    iv.
                      For children between the ages of twelve (12) to fifteen (15)
                      years, a
                      consent form signed by a parent, caretaker or guardian shall
                      be required
                      in order for a child to be transported without parental consent
                      as
                      specified by state statute (i.e., for family planning and mental
                      health
                      treatment).

                  

          

        

        
          

          For
            children sixteen (16) years or older, no consent form shall be
            required.

        

        
          

          
            	
                    f.

                  	
                    The
                      MCO is not responsible for transportation to non-Medicaid services
                      such as respite or DCF services that are designed to be provided at
                      the client's location, such as
                      home.

                  

          

        

        
          

          
            	
                    g.

                  	
                    Out-of-State
                      Transportation Services - when out-of-state- medical services are
                      needed because of the
                      following:

                  

          

        

        
          

          i.   A
            medical emergency;

        

         

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            A - MCO Contract 05/07

        

        
          

          
            	
                     

                  	
                    ii.  The
                      patient's health would be endangered if required to travel
                      to Connecticut;
                      and

                  

          

        

        
          

          iii.
            Needed medical services are not available in Connecticut.

        

        
          

          
            	
                     

                  	
                    30.      Medical
                      Surgical Supplies - those items that are prescribed by a physician
                      to meet
                      the needs or requirements of a specific medical and/or surgical
                      treatment.
                      They are generally disposable and not
                      reusable.

                  

          

        

        
          

          
            	
                     

                  	
                    
                      a. 
                        Covered services include: gauze pads, surgical dressing
                        material, splints, tracheotomy tube, diabetic supplies, elastic
                        hosiery, sterile gloves, incontinence supplies, thermometers, blood
                        pressure kit (aneroid type including stethoscope, but limited to use
                        in the home for patient's diagnosed to have complicated cardiac
                        conditions and labile hypertension), enteral/parenteral feeding
                        therapy supplies including solutions and manufacturing
                        materials,

                    

                  

          

        

        
          

          
            	
                  	
                    b.
                      Items considered first aid supplies such as, bandages,
                      solutions, vaseline, etc., are not covered
                      services.

                  

          

        

        
          

          34.      Pharmacy
            Services

        

        
           

          a.      Covered
            services

        

        
          

          
            	
                     

                  	
                    i.    Drugs
                      prescribed by a licensed authorized practitioner. The MCO maintains
                      responsibility for all pharmacy services and associated charges,
                      regardless of diagnosis The MCO may use a prescription drug
                      formulary as
                      is described in Section 3.15, Pharmacy Access of the contract.
                      CT BMP
                      providers are required to follow the MCO's pharmacy program
                      requirements

                  

          

        

        
          

          
            	
                     

                  	
                    ii.
                      Over-The-Counter (OTC) Drugs on the State of Connecticut's
                      OTC Formulary,
                      including liquid generic antacids, birth control products,
                      calcium
                      preparations, diabetic-related products, electrolyte replacement
                      products,
                      heratinics, nutritional supplements and vitamins (prenatal,
                      pediatric,
                      high potency).

                  

          

        

        
          

          b.      Noncovered
            Services

        

        
          

          
            	
                     

                  	
                    i.
                      Drugs included in the Food and Drug Administration's Drug Efficacy
                      Study
                      Implementation Program;

                  

          

        

        
          ii.   Alcoholic
            liquors;

        

        
          iii.
            Items used for personal care and hygiene or cosmetic
            purposes;

        

        
          iv.
            Drugs
            solely used to promote fertility;

        

        
          
            	
                     

                  	
                    v.
                      Drugs not directly related to the patient's diagnosis, when
                      diagnosis is
                      required by the DEPARTMENT to be written on the
                      prescription;

                  

          

        

        
          
            	
                     

                  	
                    vi.
                      Any vaccines and/or biologicals which can be obtained free
                      of charge
                      from   the CT. State Department of Health Services. The
                      DEPARTMENT will notify pharmacists of such vaccines or
                      biologicals;

                  

          

        

        
          

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

        

        
          Appendix
            A - MCO Contract 05/07

        

        
          

          
            	
                     

                  	
                    vii.
                      Any drugs used in the treatment of obesity unless caused by
                      a medical
                      condition;

                  

          

        

        
          

          
            	
                     

                  	
                    viii.
                      Controlled substances dispensed to HUSKY members that are in
                      excess of the
                      product manufacturer's recommendation for safe and effective
                      use for which
                      there is no documentation of medical justification in the pharmacy's
                      file;
                      and,

                  

          

        

        
          

          ix.
            Drugs
            used to promote smoking cessation.

        

        
          

          x.   Drugs
            used to treat sexual or erectile dysfunction,

        

        
          

          
            	
                    35.

                  	
                    Emergency
                      Services - such inpatient and outpatient services in and out
                      of the
                      health plan's service area are covered services. As described
                      in Section 3.05 and Appendix N, in general, the MCO maintains
                      coverage responsibility for emergency department services, including
                      emergent and urgent visits and al associated charges, regardless of
                      diagnosis.

                  

          

        

        
          

          
            	
                    36.

                  	
                    Dental
                      Hygienist Services - Services that are provided by a licensed dental
                      hygienist and that are within his or her scope of practice
                      as
                      defined by State Law.

                  

          

        

        
          

          B.           Covered
            Services Not Included In the Capitation Payment

        

        
          

          
            	
                    1.

                  	
                    School-Based
                      Child Health Services - Medically necessary special education related
                      diagnostic and treatment services provided to children by or on
                      behalf of school districts pursuant to the Individuals
                      with Disabilities Education Act (IDEA) and Connecticut General
                      Statutes (CGS). Diagnostic services must be ordered by a Planning and
                      Placement Team and treatment services must be prescribed in a child's
                      Individualized Education Program (lEP)--and verified by a physician's
                      signature.

                  

          

        

        
          

          
            	
                    2.

                  	
                    Connecticut
                      Birth to Three Program Services - The Connecticut Birth to Three
                      Program, pursuant to the Individuals with Disabilities Education
                      Act (IDEA ) and Connecticut General Statutes (CGS), provides a
                      range
                      of early intervention services for eligible children from birth
                      to
                      three years of age with developmental delays and disabilities.
                      Eligibility of children is determined by Department of Mental
                      Retardation (DMR) staff or entities with which DMR contracts.
                      Services are authorized in an Individualized Family Service Plan
                      (IFSP) and verified by a physician's
                      signature.

                  

          

        

        
          

          
            	
                    3.

                  	
                    All
                      Medicaid covered behavioral health and behavioral health
                      related services described, Appendix N, and the HUSKY contract, are
                      the responsibility of the
                      BHP.

                  

          

        

        
          

          C.           Noncovered
            Services

        

        
          

          
            	
                     

                  	
                    1.        Institutions
                      for Mental Disease (IMD) - The federal definition of an IMD
                      is a hospital,
                      nursing facility, freestanding alcohol treatment center, or
                      other
                      institution of more than sixteen (16) beds that is primarily
                      engaged in
                      providing diagnosis, treatment, or care of persons with mental
                      diseases.

                  

          

        

        

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

         

        
          Appendix
            A - MCO Contract 05/07

        

        
          

          
            	
                    a.

                  	
                    IMD
                      Exclusion - Medicaid does not cover IMD services (i.e.,
                      these services are excluded). States, rather than the Federal
                      Government, have principle responsibility for funding inpatient
                      psychiatric services; therefore, State funding of IMD)s is not
                      through the Medicaid program.

                  

          

        

        
          

          
            	
                    b.

                  	
                    Exceptions
                      - certain individuals are not part of the IMD exclusion (i.e.,
                      they are covered by Medicaid for services in
                      IMDs):

                  

          

        

        
          

          i.    inpatient
            psychiatric services for individuals under age 21;

        

        
          

          
            	
                     

                  	
                    ii.   individuals
                      65 years of age or older who are in hospitals or nursing facilities
                      that
                      are IMDs.

                  

          

        

        
          

          
            	
                    2.

                  	
                    Services
                      and/or procedures considered to be of an unproven, experimental, or
                      research nature or cosmetic, social, habilitative, vocational,
                      recreational, or educational.

                  

          

        

        
          

          
            	
                    3.

                  	
                    Services
                      in excess of those deemed medically necessary to treat the patient's
                      condition.

                  

          

        

        
          

          
            	
                    4.

                  	
                    Services
                      not directly related to the patient's diagnosis, symptoms,
                      or medical
                      history.

                  

          

        

        
          

          
            	
                    5.

                  	
                    Any
                      services or items furnished for which the provider does not
                      usually charge.

                  

          

        

        
          

          
            	
                    6.

                  	
                    Medical
                      services or procedures in the treatment of obesity, including gastric
                      stapling. When obesity is caused by an illness
                      (hypothyroidism, Cushing's disease, hypothalamic lesions) or
                      aggravates an illness (cardiac and respiratory diseases, diabetes,
                      hypertension) services in connection with the treatment of obesity
                      could be covered services.

                  

          

        

        
          

          
            	
                    7.

                  	
                    Services
                      related to transsexual surgery or for a procedure which is performed
                      as part of the process of preparing an individual for
                      transsexual surgery, such as hormone therapy and
                      electrolysis.

                  

          

        

        
          

          8.           Services
            for a condition that is not medical in nature.

        

        
          

          
            	
                    9.

                  	
                    Routine
                      physical examinations requested by third parties, such as employers
                      or insurance companies.

                  

          

        

        
          

          
            	
                    10.

                  	
                    Drugs
                      that the Food and Drug Administration (FDA) has proposed to withdraw
                      from the market in a notice of opportunity for
                      hearing.

                  

          

        

        
          

          11.           Tattooing
            or tattoo removal.

           

        

        
          12.           Punch
            graft hair transplants.

           

        

        
          13.           Tuboplasty
            and sterilization reversal.

           

        

        
          14.           Implantation
            of nuclear-powered pacemaker.

           

        

        
          15.           Nuclear
            powered pacemakers.

           

        

        
          16.           Inpatient
            charges related to autopsy.

        

        

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        
          Appendix
            A - MCO Contract 05/07

        

        
          

          
            	
                    17.

                  	
                    All
                      services or procedures of a plastic or cosmetic nature performed
                      for reconstructive purposes, including but not limited to lipectomy,
                      hair transplant, rhinoplasty, dermabrasion, and
                      chernabrasion.

                  

          

        

        
          

          18.           Drugs
            solely used to promote fertility.

        

        
          

          19.           Drugs
            used to promote smoking cessation.

        

        
          

          
            	
                    20.

                  	
                    Services
                      that are not within the scope of a practitioner's practice
                      under state law.

                  

          

        

        
          

          21.           Drugs
            used to treat sexual or erectile dysfunction,

        

        
           

        

         

        
          
            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

            
              Appendix
                A - MCO Contract

            

            

            
              

              MEDICAL
                ASSISTANCE PROGRAM POLICIES AND REGULATIONS BY PROVIDER
                AREA

               

            

            
              	
                      
                        Provider
                          Area

                      

                    	
                      
                        Policy
                          or Regulation Sections

                      

                    
	
                      
                        Birth
                          to Three

                      

                    	
                      
                        Sections
                          1 7b-262-597 through 17b-262-605 of the Regulations of
                          Connecticut State
                          Agencies

                      

                    
	
                      
                        Case
                          Management Services to Persons Under 21

                      

                    	
                      
                        Proposed
                          Regulations

                      

                    
	
                      
                        Chiropractic
                          Services

                      

                    	
                      
                        Sections
                          1 7b-262-535 through 17b-262-545 of the Regulations of
                          Connecticut State
                          Agencies

                      

                    
	
                      
                        Clinics

                      

                    	
                      
                        Sections
                          171 through 171 B. XI of Medical Services Policy and Sections
                          1 7-1 34d-7
                          through 17-134d-8, 17-134d-56 and 17-134d-70 through 17-134d-78
                          of the
                          Regulations of Connecticut State Agencies

                      

                    
	
                      
                        Rehabilitation
                          Clinics

                      

                    	
                      
                        Sections
                          171.2 through 171.2l.lll.k.of Medical Services
                          Policy

                      

                    
	
                      
                        Dental
                          Clinics

                      

                    	
                      
                        Sections
                          171 .3 through 171.3l.lll.f. of Medical Services
                          Policy

                      

                    
	
                      
                        Medical
                          Clinics

                      

                    	
                      
                        Sections
                          171 .4 through 171.4I.IIU. of Medical Services
                          Policy

                      

                    
	
                      
                        Dental
                          Services

                      

                    	
                      
                        Sections
                          184 through 184l.lll.h. of Medical Services Policy and
                          Section 1 7-1
                          34d-35 of the Regulations of Connecticut State
                          Agencies

                      

                    
	
                      
                        Dialysis

                      

                    	
                      
                        Sections
                          17b-262-651 through 17b-262-660 of the Regulations of Connecticut
                          State
                          Agencies

                      

                    
	
                      
                        Early
                          and Periodic Screening, Diagnostic and Treatment Services
                          (Health Track
                          Services)

                      

                    	
                      
                        Included
                          in Regulations with Other Providers

                      

                    
	
                      
                        Family
                          Planning, Abortions and Hysterectomies

                      

                    	
                      
                        Sections
                          173 through 1731. of Medical Services Policy

                      

                    
	
                      
                        Home
                          Health Services

                      

                    	
                      
                        Sections
                          185 through 1851. III. b.4. of Medical Services Policy
                          and Sections
                          17-134d-37, 17»134d-48, 17-134d-60, 17-134d-62 and 17b-262-1 through
                          17b-262-9 of the Regulations of Connecticut
                          State Agencies

                      

                    

            

            
              

                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

            

            
              

              05/07

            

            
              

              Appendix
                A - MCO Contract

            

            

            
              	
                      
                        Hospital
                          Inpatient Services

                      

                    	
                      
                        Sections
                          150.1 through 150.1I.VI.d of Medical Services Policy and
                          Sections 19a-630,
                          17b-225, 1 7b-238 through 17b-247, 17b-262, 19-1 3D, 19a-490
                          through
                          19a-493, 19a-495 of the Regulations of Connecticut State
                          Agencies

                      

                    
	
                      
                        Hospital
                          Outpatient Services

                      

                    	
                      
                        Sections
                          150.2 through 150.2J.V.n of Medical Services Policy and
                          Sections
                          4-67c(fees), 17-311 (payments), 17-312 (payments), 19a-490
                          (licensing),
                          19a-493 (licensing) of the Connecticut General Statutes
                          and Sections 19-1
                          3D, 17-134d-2 (Medical Care), 17-134d-40 (payments - clinic),
                          17-134d-63
                          (out-of-state hospitals), 17-134d-86 (emergency room) of
                          the Regulations
                          of Connecticut State Agencies.

                      

                    
	
                      
                        Intermediate
                          Care Facility

                      

                    	
                      
                        Sections
                          156 through 156l.l.b.6. of Medical Services Policy and
                          Section 17-134d-47
                          of the Regulations of Connecticut State Agencies.

                      

                    
	
                      
                        Independent
                          Radiology and Ultrasound Centers

                      

                    	
                      
                        Sections
                          17b-262-51 2 through 17b-262-520 of the Regulations of
                          Connecticut State
                          Agencies.

                      

                    
	
                      
                        Independent
                          Therapy Services

                      

                    	
                      
                        Sections
                          17b-262-630 through 17b-262-640 of the Regulations of Connecticut
                          State
                          Agencies.

                      

                    
	
                      
                        Laboratory
                          Services

                      

                    	
                      
                        Sections
                          1 7b-262=641 through 17b-262-650 of the Regulations of
                          Connecticut State
                          Agencies.

                      

                    
	
                      
                        Medical
                          Equipment, Devices and Supplies (MEDS)

                      

                    	
                      
                        See
                          Below.

                      

                    
	
                      
                        Medical
                          Surgical Supplies

                      

                    	
                      
                        Sections
                          188 through 188J. of Medical Services Policy

                      

                    
	
                      
                        Durable
                          Medical Equipment

                      

                    	
                      
                        Sections
                          17b-262-672 through 17b-262-682 of Medical Services
                          Policy

                      

                    
	
                      
                        Orthotic
                          and Prosthetic Devices

                      

                    	
                      
                        Sections
                          190 through 190l.iii.k. of Medical Services
                          Policy

                      

                    
	
                      
                        Oxygen
                          Therapy

                      

                    	
                      
                        Section
                          196 of Medical Services Policy and
                          17-134d-83through 17-134d-85 of the Regulations of Connecticut
                          State Agencies

                      

                    

            

             

             

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

            
               

              Appendix
                A - MCO Contract

            

            
              05/07

               

            

            
              	
                      
                        Natureopathic
                          Services

                      

                    	
                      Sections
                        17b-262-547 through 17b- 262-557 of the Regulations
                        of Connecticut State Agencies

                    
	
                      
                        Nurse-Midwifery
                          Services

                      

                    	
                      Sections
                        17t>262-573 through 17b- 262-585 of the Regulations
                        of Connecticut State Agencies

                    
	
                      
                        Nurse
                          Practitioner Services

                      

                    	
                      Sections
                        17b-262-607 through 17b- 262-618 of the Regulations
                        of Connecticut State Agencies

                    
	
                      
                        Pharmacy

                      

                    	
                      Sections
                        174 through 174H.IV.a.4. of Medical Services Policy and
                        Section 17-134d-81 of the Regulations of Connecticut State
                        Agencies

                    
	
                      
                        Physician's
                          Services

                      

                    	
                      Sections
                        17b-262-337 through 17b- 262-449 of the Regulations
                        of Connecticut State Agencies

                    
	
                      
                        Podiatric
                          Services

                      

                    	
                      Sections
                        179 through 1791.II.b. of Medical Services Policy

                    
	
                      
                        Provider
                          Participation

                      

                    	
                      Sections
                        17b-262-522 through 17b- 262-533 of the Regulations
                        of Connecticut State Agencies

                    
	
                      
                        School
                          Based Child Health Services

                      

                    	
                      Sections
                        17b-262-213 through 17b- 262-224 of the Regulations
                        of Connecticut State Agencies

                    
	
                      
                        Skilled
                          Nursing Facility

                      

                       

                    	
                      Sections
                        154 through 1541.1.b.6. of Medical Services Policy and
                        Sections 17-134d-46, 17-134d-68and 117- 134d-79 of the
                        Regulations of Connecticut State Agencies

                    
	
                      
                        Transportation
                          Services

                      

                    	
                      Section
                        17b-134d-33 of the Regulations of Connecticut
                        State Agencies

                    
	
                      
                        Vision
                          Care Services

                      

                       

                    	
                      Sections
                        17b-262-559 through 17b- 262-571 of the Regulations
                        of Connecticut State Agencies, DSS Policy Transmittal MS 93-18
                        and DSS Policy Bulletin 98-19.

                    

            

            

            

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

          

           

           

          APPENDIX
            B

        

        
          Provider
            Credentialing and Enrollment Requirements

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

         

        Appendix
          B

        

        
          05/07                                                      

        

        
          

          HUSKY
            PROVIDER CREDENTIALING AND ENROLLMENT REQUIREMENTS

        

        
          

          1.           Provider
            Credentialing, and Enrollment Distinction

        

        
          

          Provider
            Credentialing and provider enrollment are separate and distinct processes
            in the
            HUSKY Programs. However, Credentialing and enrollment are linked in that
            these
            requirements affect direct service providers as well as the manner in
            which MCOs
            submit provider network information to the Department of Social
            Services.

        

        
          

          2.           Credentialing
            Definition

        

        
          

          For
            the
            purpose of the HUSKY programs, the term Credentialing means the requirements
            for
            provider participation specified in the contracts between the Department
            of
            Social Services (DSS or the Department) and the MCO (Part II, 3.11, Provider
            Credentialing and Enrollment). In this section of the contract, the Department
            specifies the minimum criteria that the MCOs must require for provider
            participation in a health plan. The MCOs must ensure that their providers
            meet
            the Department's Credentialing requirements.

        

        
          

          3.           Other
            Sources Credentialing

        

        
          

          Credenting
            is sometimes used to refer to a variety of requirements or entities,
            which issue
            Credentialing standards. Examples include: the MCO's individual Credentialing
            requirements; the managed care subcontractor's Credentialing requirements;
            an
            accreditation organization requirements, such as the National Committee
            on
            Quality Assurance (NCQA); the licensure process; a trade organization
            or
            association such as the Joint Commission on Accreditation of Health
            Organizations (JCAHO).

        

        
          

          4.           DSS
            Requirements and Other Credentialing Sources

        

        
          

          DSS
            Credentialing requirements represent the minimum criteria for provider
            participation in a health plan. The Department will allow flexibility
            to the
            MCOs to use more stringent criteria, particularly as it concerns quality
            level
            of care for clients. While the MCOs may require additional, more stringent
            criteria, the Department is concerned with the impact on access to care.
            Therefore, DSS expects the MCOs to balance the need for stringent Credentialing
            standards with the need to assure accessibility and continuity of
            care.

        

        
          

          5.           Delegated
            Credentialing

        

        
          

          The
            contract between the Department and the MCOs permits the plan to delegate
            Credentialing of individual providers to a facility. However, the MCO
            is
            ultimately responsible and accountable to DSS for compliance with the
            Department's Credentialing requirements.

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        Appendix
          B

        
          05/07                                                      

        

        
          

        

        
          HUSKY
            PROVIDER CREDENTIALING AND ENROLLMENT REQUIREMENTS

        

        
          

          For
            the
            purpose of HUSKY, delegated credentialing means that the MCO entrusts
            the
            Department's credentialing requirements to another entity. MCOs delegate
            credentialing to a variety of entities depending on the nature of the
            services
            and the type of provider.

        

        
          

          In
            delegated credentialing, the MCO remains responsible to DSS to verify
            and
            monitor compliance with the Department's credentialing requirements.
            The
            Department views delegated credentialing as a form of subcontract, therefore,
            similar oversight issues arise in the performance of the credentialing
            requirements. The Department requires the plans to demonstrate and document
            to
            DSS the plan's strong oversight of its delegated credentialing facilities.
            (Part
            II, Section 3.41 in B 3.44 in A, Subcontracting for
            Services).

        

        
          

          6.           Implications
            of Delegated Credentialing

        

        
          

          In
            some
            instances, the MCO credentials the individual provider directly or delegates
            credentialing of the providers to the following entities:

        

        
          

          •      A
            subcontractor providing specific services (e.g., dental
            care);

        

        
          •      A
            credentialing subcontractor; or

        

        
          •      A
            facility (e.g., a freestanding clinic or hospital)

        

        
          

          The
            relationship between the MCO and the delegated entity as well as the
            interplay
            with various credentialing requirements may take any number of configurations.
            Currently, the Department reiterates that the MCO may delegate credentialing
            of
            individual providers to a facility (e.g., a school based health center,
            freestanding clinic or hospital). However, the Department emphasizes
            that the
            MCO is ultimately responsible and accountable to DSS for compliance with
            all of
            the Department's credentialing requirements.

        

        
          

          7.           Oversight
            of Delegated Credentialing

        

        
          

          The
            Department requires the MCO to demonstrate strong oversight of their
            delegated
            credentialing facilities, as with any subcontract. - Therefore, the Department
            reiterates that these arrangements are subject to the Department's review
            and
            approval. For the purpose of delegated credentialing, the MCOs must provide
            assurances to DSS at a minimum of the following:

        

        
          

          
            	
                    •

                  	
                    The
                      MCO and the delegated entity should clearly identify in detail
                      each
                      party's responsibility for credentialing of
                      providers.

                  

          

        

        
          

          
            	
                    • 

                  	
                     The
                      Department's credentialing requirements should be clearly identified
                      as
                      well as each party's role in adhering to these
                      requirements.

                  

          

        

        
          

          
            	
                    •

                  	
                    The
                      *credentialing files must be available to the plan in order
                      to perform
                      its oversight of the credentialing requirements. The Department
                      must
                      also have adequate access to credentialing files for the purposes of
                      administering the managed care
                      contracts.

                  

          

        

        
          

          (DSS/MCO
            HUSKY A Contract, Part II, Section 3.45 "Subcontracting for Services;
            HUSKY B 3
            .42 "Subcontracting for Services".)

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        Appendix
          B

        
          05/07                                                      

        

        
          

          8.       Provider
            Enrollment Clarifications

        

        
          

          For
            the
            purpose of HUSKY, the Department refers to provider enrollment as the
            process of capturing information on providers participating with MCOs
            contracted
            by DSS to provide services to clients. This process results in a profile
            of an
            MCO's provider network.    The MCOs submit the provider
            network information to DSS via the Department's agent on a continuous
            basis. The
            Department utilizes the provider network information to facilitate the
            administration of managed care contracts and- the Medicaid
            program.

        

        
          

          Provider
            enrollment information serves the following purposes:

        

        
          

          
            	
                    a)

                  	
                    to
                      evaluate each MCO's service area and access to services which
                      are
                      used to establish enrollment ceiling or cap (currently summarized
                      by
                      plan submittals of provider
                      tables);

                  

          

        

        
          

          
            	
                    b)

                  	
                    to
                      provide accurate information to clients for the purpose of
                      client
                      enrollment in an MCO;
                      and

                  

          

        

        
          

          
            	
                    c)

                  	
                    to
                      maintain each plan's provider network information consistent
                      with
                      the provider directory.

                  

          

        

        
          

          Based
            on
            the previous discussion of credentialing, the Department clarifies the
            relationship between credentialing or delegated credentialing and provider
            enrollment as follows:

        

        
          

          a)      Enrollment
            for purposes of cap determination.

        

        
          

          
            	
                    -

                  	
                    The
                      MCO must credential and enroll individual providers when the
                      providers are
                      counted towards the member enrollment
                      ceiling.

                  

          

        

        
          

          
            	
                    -

                  	
                    DSS
                      credentialing requirements and provider enrollment processes
                      also apply to
                      individual providers in a facility when the individual provider
                      is
                      included in the count for cap
                      determination.

                  

          

        

        
          

          
            	
                    -

                  	
                    The
                      MCO may delegate credentialing of individual providers to a
                      facility
                      (e.g., a clinic or hospital) and enroll the facility as such.
                      In this
                      case, -neither the facility nor the individual providers are
                      provided in
                      the count for cap
                      determination.

                  

          

        

        
          

          b)           Enrollment
            for purposes of accurate information to clients

        

        
          

          
            	
                    -

                  	
                    The
                      MCO must enroll and credential individual providers as well
                      as facilities
                      in order to maintain accurate and updated information on the
                      providers
                      participating with a health plan. The provider network information
                      is used
                      by the Department's enrollment broker during
                      enrollment.

                  

          

        

        
          

          
            	
                    -

                  	
                    The
                      Department stresses the importance of maintaining provider
                      network
                      information accurate and up-to-date. It is crucial that clients
                      should
                      have access to provider network information during the MCO
                      select-ion
                      process.

                  

          

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

          Appendix
          B

        
          05/07                                                    

        

        
          

          c)       Enrollment
            for purposes of inclusion in the provider network directory.

        

        
          

          
            	
                    -

                  	
                    The
                      MCO must credential and enroll individual providers when the
                      providers are
                      included and listed as individual providers in the health plan's
                      provider
                      directory.

                  

          

        

        
          

          
            	
                    -

                  	
                    DSS
                      credentialing requirements and provider enrollment processes
                      also apply to
                      individual providers in a facility when the individual provider
                      is
                      included and listed in the provider
                      directory.

                  

          

        

        
          

          
            	
                    -

                  	
                    If
                      the 14CO delegates credeintialing of individual providers to
                      a      facility and enrolls the facility,
                      the facility is included and listed in the provider directory.
                      The
                      facility's individual providers are listed in the provider
                      directory. The
                      facility's providers are not listed in the provider
                      directory.

                  

          

        

        
          

          9.        Specific
            Issues and DSS Credentialing Requirements

        

        
          

          a)      Medicaid
            participation

        

        
          

          The
            MCO
            or the delegated credentialing entity is responsible for the determination
            and
            verification that the provider meets the minimum requirements for Medicaid
            participation. The MCO or its -subcontractors may not delegate this provision
            to
            the Department nor require providers to enroll or participate in fee-for-service
            Medicaid to fulfill the requirement. While the Department encourages
            the MCO to
            contract with traditional and existing Medicaid providers, Medicaid
            participation in itself is not a requirement of the HUSKY
            contracts.

        

        
          

          b)      Allied
            Health Professional Licensed Clinics or Hospitals

        

        
          

          The
            Department pays freestanding clinics participating in the Medicaid program
            for a
            variety of services. In Connecticut, clinic services include for example,
            medical services, well-child care, dental care, mental health and substance
            abuse services, rehabilitation services and other services. Clinic providers
            must meet federal and state requirements for participation in the Medicaid
            program. In accordance with Title 42 of the Code of Federal Regulations,
            Part
            440.90 and Section 171 of the Medical Services Policy of the Connecticut
            Medical
            Assistance Program, clinic services are provided by or under the direction
            or a
            physician, dentist or psychiatrist.

        

        
          

          The
            physician direction requirement means that the free-standing clinic's
            services
            may be provided by the clinic's allied health professionals whether or
            not the
            physician is physically present at the time that the services are provided.
            An
            allied health professional

        

        
          

          is
            further defined as an individual, employed in a clinic, who is qualified
            by
            special education and training, skills, and experience in providing care
            and
            treatment. The clinic is staffed by physicians and allied health professionals
            who are directly involved in the facility's programs. The allied health
            professionals provide services under the direction of a physician who
            is a
            licensed practitioner performing within the scope of his/her
            practice.

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        Appendix
          B

        
          05/07                                                      

        

        
          Based
            on
            the Department's definition of clinic services, the services provided
            by allied
            health professionals are included under the terms of the contracts between
            the
            Department and the MCOs.

        

        
          

          As
            with
            all services, clinic services must be properly credentialed according
            to the
            Department's requirements, including licensure and certification standards.
            Allied health professionals may have licensure or certification requirements,
            such as Certified Addition Counselors or Licensed Social Workers. In
            accordance
            with the Department's definition, other allied health professions may
            qualify by
            virtue of their skills or experience and must function under the direction
            of a
            physician. In this case- the directing physician, as opposed to the allied
            health professional, is subject to the credentialing requirements as
            well as
            provider enrollment. The MCO may credential the physician directly or
            may
            delegate credentialing.

        

        
          

          The
            Department's provisions for credentialing, delegated and provider enrollment
            would remain in effect for the directing physician (please refer to Section
            8,
            Provider Enrollment Clarifications).

        

        
          

          c)  NCQA
            Standards and DSS requirements

        

        
          

          While
            NCQA standards do not address credentialing of allied health professionals,
            services provided by allied health professionals may qualify for reimbursement
            by virtue of their skills or experience, however, the allied health
            professionals must function under the direction of a physician. In this
            case,
            the directing physician is subject to the credentialing
            requirements.

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        APPENDIX
          C

        
          
            
              

              

            

            
              

              EPSDT
                Periodicity & Immunization Schedules

            

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

            

            
              
                	
                         

                      	
                        Appendix
                          C - MCO Contract (document 1 of
                          3)

                      

              

            

            
              

              HEALTHRACK/EPSDT
                PERIODICITY SCHEDULE OF PREVENTIVE HEALTH SERVICES Department of
                Social Services05/07

            

            
              	 	
                      
                        INFANCY

                      

                    	
                      
                        EARLY
                          CHILDHOOD

                      

                    
	
                      
                        AGE

                      

                    	
                      
                        NB

                      

                    	
                      
                        2-4
                          DAYS

                      

                      
                         (1)

                      

                    	
                      
                        2
                          Weeks

                      

                    	
                      
                        2
                          mo.

                      

                    	
                      
                        4
                          mo.

                      

                    	
                      
                        6
                          mo.

                      

                    	
                      
                        9
                          mo.

                      

                    	
                      
                        12
                          mo.

                      

                    	
                      
                        15
                          mo.

                      

                    	
                      
                        18
                          mo.

                      

                    	
                      
                        24
                          mo.

                      

                    	
                      
                        3yr.

                      

                    	
                      
                        4yr.

                      

                    	
                      
                        '5yr.

                      

                    
	
                      
                        Screening
                          Components

                      

                    	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                      
                        History:
                          Initial/Interval

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    
	
                      
                        Physical
                          Examination (2)

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    
	
                      
                        Height/Weight

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    
	
                      
                        Head
                          Circumference

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                       

                    	 	 
	
                      
                        Blood
                          Pressure

                      

                    	 	 	 	 	 	 	 	 	 	 	 	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    
	
                      
                        Health
                          Education (3) Anticipatory Guidance

                      

                    	
                      
                        SEE
                          ATTACHED RECOMMENDATIONS

                      

                    
	
                      
                        Developmental
                          / Beh. Assessment (4)

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    
	
                      
                        Immunizations
                          (5)

                      

                    	
                      
                        SEE
                          ATTACHED IMMUNIZATION SCHEDULE

                      

                    
	
                      
                        Hereditary
                          Metabolic Screening (6)

                      

                    	
                      
                        X
                          →

                      

                    	 	 	 	 	 	 	 	 	 	 	 
	
                      
                        Lead
                          Screening (7)

                      

                    	 	 	 	 	 	 	
                      
                        X
                          →

                      

                    	 	
                       

                    	
                      
                        X

                      

                    	 	 	 
	
                      
                        Hematocrit/
                          Hemoglobin

                      

                    	 	 	 	 	 	 	
                      
                        X
                          →

                      

                    	
                      
                        W-HR

                      

                    	
                      
                        W-HR

                      

                    	
                      
                        X

                      

                    	
                      
                        W-HR

                      

                    	
                      
                        W-HR

                      

                    	
                      
                        W-HR

                      

                    
	
                      
                        Cholesterol
                          Screening

                      

                    	 	 	 	 	 	 	 	 	 	 	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    
	
                      
                        Tuberculin
                          Test

                      

                    	 	 	 	 	 	 	 	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    
	
                      
                        Hearing
                          Screening

                      

                    	
                      
                        O

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        O*

                      

                    	
                      
                        O

                      

                    
	
                      
                        Vision
                          Screening

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        O*

                      

                    	
                      
                        O

                      

                    	
                      
                        O

                      

                    
	
                      
                        Initial
                          Dental Referral (9)

                      

                    	 	 	 	 	 	 	 	 	 	 	
                      
                        X
                          →

                      

                    	 	 
	
                      
                        Evaluate
                          Dental Fluoride Access

                      

                    	 	 	 	 	 	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    

            

            
              

              Key:   X
                = To be performed; HR = To be performed for patients at risk; S =
                Subjective, by
                history; O = By Objective Standardized Test (SNELLEN; AUDIOMETRIC);
←
→ = The range during which a service may be provided, * If
                child
                uncooperative, re-screen within 6 months. W-HR= Required by WIC.
                Covered for WIC
                clients or high risk clients. Footnotes:   (1) For
                Newborns discharged less than 48 hours after delivery; (2) At each
                visit, a
                complete physical examination is essential, with infant totally unclothed,
                older
                child undressed and suitably draped; (3) Age appropriate/patient
                specific health
                education and counseling should be part of every visit; (4) By history
                and
                appropriate physical examination; if suspicious, by specific objective
                developmental testing; (5) Childhood immunizations are based on age
                and health
                history, and should be screened each visit. (6) Metabolic Screening
                (e.g.,
                thyroid, hemoglobinopathies, PKU,

              

            

            

            
              

              EPSDT2001.DOC

            

            
              

              1

            

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

            

            
              Appendix
                C - MCO Contract (document 1 of 3)

            

            
              HEALTHTRACK/EPSDT
                PERIODICITY SCHEDULE OF PREVENTIVE HEALTH SERVICES

            

            
              Department
                of Social Services05/07

            

            
              

              galactosemia)
                should be done according to State law. Sickle Cell Screening if appropriate;
                (7)
                Further venous blood level measurement is required for children showing
                elevated
                lead level (greater than or equal to 10 ug/deciliter of whole blood);
                Children
                aged 2-5 should be screened at annual exam if there is no record
                of a negative
                lead screen. (9)Earlier referral should be made if problem
                indicated.

               

            

            
              	 	
                      
                        MIDDLE
                          CHILDHOOD

                      

                    	
                      
                        ADOLESCENCE

                      

                    
	
                      
                        Age:

                      

                    	
                      
                        6
                          yr.

                      

                    	
                      
                        7-8
                          yr. (b)

                      

                    	
                      
                        9-10
                          yr. (b)

                      

                    	
                      
                        11
                          yr.

                      

                    	
                      
                        12
                          yr.

                      

                    	
                      
                        13
                          yr.

                      

                    	
                      
                        14
                          yr.

                      

                    	
                      
                        15
                          yr.

                      

                    	
                      
                        16
                          yr.

                      

                    	
                      
                        17
                          yr.

                      

                    	
                      
                        18
                          yr.

                      

                    	
                      
                        19
                          yr.

                      

                    	
                      
                        20
                          yr.

                      

                    	
                      
                        21
                          yr.

                      

                      
                        *

                      

                    
	
                      
                        Screening
                          Components

                      

                    	 	
                       

                    	
                       

                    	 	 	 	 	 	 	 	 	 	 	 
	
                      
                        History:
                          Initial/Interval

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    
	
                      
                        Physical
                          Examination (2)

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    
	
                      
                        Height/Weight

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    
	
                      
                        Blood
                          .iPressure

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    
	
                      
                        Health
                          Education    (3) Anticipatory
                          Guidance

                      

                    	
                      
                        SEE
                          ATTACHED RECOMMENDATIONS

                      

                    
	
                      
                        Developmental
                          / Ben. Assessment (4)

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    
	
                      
                        Immunizations
                          (5)

                      

                    	
                      
                        SEE
                          ATTACHED IMMUNIZATION SCHEDULE

                      

                    
	
                      
                        Hematocrit
                          / Hemoglobin

                      

                    	 	 	 	
                      
                        ←
                          (9) →

                      

                    	 	
                       

                    	 
	
                      
                        Urinalysis

                      

                    	 	 	 	
                      
                        ←
                          (10) →

                      

                    
	
                      
                        Cholesterol
                          Screening

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    
	
                      
                        Tuberculin
                          Test

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    	
                      
                        HR

                      

                    
	
                      
                        Pelvic
                          'Exam/PAP Smear

                      

                    	 	 	 	
                      
                        ←
                          (11)

                      

                    
	
                      
                        STD
                          Screenings

                      

                    	 	 	 	 	
                      
                        ←
                          (12)

                      

                    
	
                      
                        Healing
                          Screening

                      

                    	
                      
                        0(8)

                      

                    	
                      
                        0(8)

                      

                    	
                      
                        O

                      

                    	
                      
                        S

                      

                    	
                      
                        O

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        O

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        O

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    
	
                      
                        Vision
                          Screening

                      

                    	
                      
                        0(8)

                      

                    	
                      
                        0(8)

                      

                    	
                      
                        O

                      

                    	
                      
                        S

                      

                    	
                      
                        O

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        O

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        O

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    	
                      
                        S

                      

                    
	
                      
                        Evaluate
                          Dental Fluoride Access

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	
                      
                        X

                      

                    	 	 	 	 	 	 	 	 	
                       

                    	 

            

             

            Key:   X
              = To be performed; HR = To be performed for patients at risk; S = Subjective,
              by
              history; O = By Objective Standardized Test; <—» = The range during at which
              a service may be provided; * Appropriate provision of EPSDT services is
              required through age 20, up to, but not including, the 21st birthday,
              (b)
              Biannually, at 2 year intervals. Footnotes:(2) At each visit, a complete
              physical examination is essential with infant totally undressed and
              older child
              undressed and suitably draped; (3) Age appropriate and patient specific
              health education and counseling should be a part of every visit; (4) By
              history and appropriate physical examination, if suspicious, by specific
              objective developmental testing; (5) Childhood Immunizations are based on
              age and health history and should be screened each visit. (8) State
              law requires
              screening at school. Screening should be done if there is evidence
              it was not
              done at school. (9) Hemoglobin or Hematocrit to be administered xl during
              adolescence, annually for menstruating females that are at risk for
              anemia; (10)
              Urinalysis to be administered xl during adolescence, annually for
              sexually active clients at risk for STD's (i.e. gonorrhea,
              syphilis/serology, chlamydia, HIV, etc.); (11) All sexually active
              females
              should have a pelvic examination and a routine pap smear annually.
              A
              pelvic examination and routine pap smear should be offered as part of
              preventive health maintenance between 18-21 years. (12) All sexually
              active
              patients should be screened for sexually transmitted
              diseases (STD's) EPSDT2001.DOC

          

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        

        
          Appendix
            C - MCO Contract 

          Document
            2 of 3

          05/07

        

        

        

        

        
          State
            of
            Connecticut

        

        
          Department
            of Social Services

        

        
          Health
            Care Financing Division

        

        
          25
            Sigourney Street

        

        
          Hartford,
            CT 06106-5033

        

        

        
          

          PB
            2001-18   Policy Transmittal 2001-07 March
            20,2001

        

         

        
          Michael
            P. Starkowski Deputy Commissioner 
            Contact:
              James Linnane (860) 424-5111

          

        

        
          Effective
            Date:  July 1. 2001 

          
TO:  
            Physicians,
            Clinics, Hospitals, Managed Care Plans, Nurse Practitioners, Home Health
            Agencies, Nurse Midwives, Dentists and Dental
            Hygienists

        

        

        
          

          
            	
                     

                  	
                    SUBJECT:     New
                      EPSDT (Early, and Periodic Screening. Diagnosis and Treatment
                      Services)PeriodicityScheduleand Immunization
                      Schedule

                  

          

        

        
          

          The
            Department of Social Services is revising the EPSDT Periodicity Schedule
            to
            follow the recently
            issued American Academy of Pediatrics (AAP) guidelines. This Policy Transmittal
            contains
            the EPSDT Periodicity Schedule that is to be effective as of 7/1/2001
            and a
            revised immunization
            schedule.   Please replace the enclosed pages in Chapter 8 of
            your Connecticut Medical
            Assistance Provider Manual. Changes to the periodicity schedule include
            the
            following:

           

        

        
          
            	
                    -

                  	
                    A   newborn   hearing   screening   is   now   required  by   Connecticut   law   and   is
                      recommended by the AAP.    Therefore, this screening
                      is being changed from a subjective to objective screen on the
                      periodicity
                      schedule.

                  

          

        

        
          
            	
                    -

                  	
                    Infants
                      at high risk for tuberculosis should receive a tuberculin test
                      at 12
                      months, 15

                  

          

        

        
          
            	
                    -

                  	
                    months
                      and 18 months.

                  

          

        

        
          
            	
                    -

                  	
                    Infants
                      who have anemia at 1 year should be retested for it at 15 and
                      18 months.
                      a   A hematocrit/hemoglobin test has been added at age 2 in
                      accordance with AAP guidelines. The hematocrit/hemoglobin test
                      should be
                      repeated for high-risk clients and WIC clients at age 3, 4,
                      and
                      5.

                  

          

        

        
          
            	
                    -

                  	
                    The
                      3-year-old vision screening has been changed from subjective
                      to objective.
                      An asterisk has been added indicating that if the child is
                      uncooperative,
                      he or she should be rescreened within six
                      months.

                  

          

        

        
           

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

         

        
          Appendix
            C - MCO Contract

        

        
          Document
            2 of 3 

          05/07

        

        
          
            	
                    -

                  	
                    Objective
                      hearing and vision screenings have been added to the periodicity
                      schedule
                      for ages 6 and 8. Section 10-214 of the Connecticut General
                      Statutes
                      requires local or regional boards of education in Connecticut
                      to provide
                      these screenings in kindergarten through sixth grade. Objective
                      hearing
                      and vision screenings should be done by the Primary Care Provider
                      (PCP) at
                      age 6 and 8 if there is reason to believe that the screenings
                      were not
                      done at school.

                  

          

        

        
          
            	
                    -

                  	
                    A
                      note has been added that the screenings given at age 7-8 and
                      age 9-10
                      should be performed at two-year
                      intervals.

                  

          

        

        
          

          The
            American Academy of Pediatrics recommends a prenatal visit to a pediatrician
            for
            high-risk parents. Such a visit is medically necessary for the well-being
            of a
            yet-to-be-born child and is a covered EPSDT service under Connecticut
            Medicaid.

        

        
          

          The
            new
            Recommended Childhood Immunization Schedule recommends administering
            four doses
            of pneumococcal conjugate vaccine at age 2 months, 4 months, 6 months
            and 12-15
            months The immunization schedule recommends administration of "DTaP"
            not "DTP"
            at age 2 months, 4 months, 6 months, 15-18 months and 4-6 years. Hepatitis
            A
            appears on the immunization schedule as recommended in some parts of
            the United
            States, but is not a recommended vaccine in Connecticut.

        

        
          

          A
            new
            Women, Infants and Children (WIC) Coordinators contact sheet is also
            included.

        

        
          

          Posting
            Instructions: Holders of the Connecticut
            Medical Assistance Program Provider Manual should replace the current
            EPSDT
            Periodicity Schedule, Immunization Schedule and WIC Coordinators contact
            sheet
            with the attached schedules and contact sheet for use effective 7/1/2001.
            Policy
            transmittals can also be downloaded from EDS' Web site at
            www.ctmedicalprogram.com.

        

        
          

          Distribution: This
            policy transmittal is being distributed to holders of the Medical Services
            Policy Manual by EDS, and the Medicaid Mailing List by the Department
            of Social
            Services. Managed Care Organizations are requested to send this information
            to
            their network providers and subcontractors.

        

        
          

          Responsible
            Unit: DSS, HUSKY, James Linnane, Manager, Program Analysis
            and Enrollment at (860) 424-5111.

        

        
          

          Date
            Issued: March 20, 2001

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        

        
          Connecticut
            Department of Social Services 

          Medical
            Assistance Program 

          Provider
            Bulletin

        

        
          

          PB
            2005-59                                                            November
            2005

        

        
          

        

        
          

          TO:                     Physicians,
            Nurse Practitioners, Freestanding Clinics, Hospitals and Managed
            Care Organizations (MCOs)

        

        
          

          SUBJECT:    Revised
            Immunization Schedule

        

        
          

          This
            bulletin is being sent to inform you that the Department of Social Services
            has
            revised the Childhood Immunization Schedule in the Provider Manual for
            Providers
            listed above to be consistent with the latest immunization schedule of
            the
            American Academy of Pediatrics, the American Academy of Family Physicians
            and
            the Centers for Disease Control.

        

        
          

          Changes
            to the Immunization Schedule include:

        

        
          

          
            	
                    1)

                  	
                    Influenza
                      immunizations are now recommended for all children age 6-23
                      months,
                      and all older children who are in households with children age
                      0-23
                      months or at risk for complications from
                      influenza.

                  

          

        

        
          

          2)         The
            recommendations for the timing of the Hepatitis B Series have
            changed.

        

        
          

          
            	
                    3)

                  	
                    Administration
                      of PPV (pneumococcal polysaccharide vaccine) is now recommended in
                      addition to PCV (pneumococcal conjugate vaccine) for certain
                      high risk
                      groups.

                  

          

        

        
          

          Further
            information about these changed recommendations is available at
            http://www.cispimmunize.org.

        

        
          

          MCOs
            are
            requested to send this information to their network providers and
            subcontractors.

        

        
          

          This
            bulletin and other program information can be found at
www.ctmedicalprogram.com.  Questions
            regarding this bulletin may be directed to the EDS Provider Assistance
            Center - Monday
            through Friday from 8:30 a.m. to 5:00 p.m. at: In-state
            toll free 800-842-8440 or Out-of-state
            or in the local New Britain, CT area 860-832-9259. 
EDS Hartford, PO Box 299 CT 06104

        

        
                                                                                             

        

         

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        

        
          DEPARTMENT
            OF HEALTH AND HUMAN SERVICES 

          CENTERS
            FOR DISEASE CONTROL AND PREVENTION
            (CDC)

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

           

          Appendix
            D

        

        
          

          Detailed
            Marketing Guidelines

        

        
          1)           General
            HUSKY marketing materials

        

        
          

          Marketing
            materials are defined as all media, including brochures and leaflets;
            newspaper,
            magazine, radio, television, billboard and yellow pages advertisements;
            and
            presentation materials used by MCO representatives.

        

        
          

          The
            DEPARTMENT will not restrict the MCO's general communications to the
            public.
            However, the MCO must obtain prior approval from the DEPARTMENT prior
            to any
            written material or advertisement that is mailed to, distributed to,
            or aimed at
            HUSKY recipients or individuals potentially eligible for HUSKY, specifically,
            material that mentions Medicaid, Medical Assistance, Title XIX, Title
            XXI State
            Children's Health Insurance Program (SCHIP) or HUSKY. Examples of HUSKY-specific
            materials would be those which are in any way targeted to HUSKY populations
            (such as billboards or bus posters disproportionately located in low-income
            neighborhoods); those that mention the MCO's HUSKY product name; or those
            that
            contain language or information specifically designed to attract HUSKY
            enrollment.

        

        
          

          2)           General
            MCO marketing/advertising

        

        
          

          All
            MCO-specific marketing activities for the HUSKY population, as defined
            above,
            and all marketing materials /advertising put forth by HUSKY-only MCO
            require
            DEPARTMENT prior approval.

        

        
          

          In
            determining whether to approve a particular marketing activity, the DEPARTMENT
            will apply a variety of criteria, including, but not limited
            to:

        

        
          

          
            	
                    a)

                  	
                    Accuracy:
                      The content of the material must be accurate. Any information
                      that
                      is deemed inaccurate will be
                      disallowed.

                  

          

        

        
          

          
            	
                    b)

                  	
                    Misleading
                      references to the MCO's positive attributes: Misleading
                      information will be disallowed even if it is accurate. For example,
                      the MCO may seek to advertise that its health care services are free
                      to its' Medicaid (HUSKY A) Members. In this situation, DEPARTMENT
                      would disallow the language since this could be construed by Members
                      as being a particular advantage of the plan (e.g. they might believe
                      they would have to pay for health services if they chose another MCO
                      or remained in
                      fee-for-service).

                  

          

        

        
          

          
            	
                    c)

                  	
                    Threatening
                      Messages: MCOs shall not imply that the managed care program
                      or the
                      failure to join a particular MCO would endanger the Member's
                      health
                      status, personal dignity, or the opportunity to succeed in various
                      aspects of their lives. MCOs are strictly prohibited from creating
                      threatening implications about the State's mandatory assignment
                      process for HUSKY A Members or other aspects of the HUSKY A or HUSKY
                      B programs.

                  

          

        

        
          

          
            	
                    d)

                  	
                    MCO's
                      Legitimate Strengths: MCOs may differentiate themselves by
                      promoting their legitimate positive
                      attributes.

                  

          

        

        
          

          3)           MCO advertising
            at provider care sites

        

        
          

          Promotional
            and health education materials at care delivery sites (including patient
            waiting
            areas) are permitted, subject to prior DEPARTMENT content approval. MCO
            member
            services staff may provide member services (e.g. face-to-face
            member

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        

        
          05/07

        

        
          

          education)
            at provider care sites, however, face-to-face meetings, for purposes
            of
            marketing, at care delivery sites between individual Members and MCO
            staff are
            not permitted.

        

        
          

          4)            MCO
            advertising in DEPARTMENT eligibility offices

        

        
          

          MCOs
            may
            make their materials available at DEPARTMENT offices only through the
            DEPARTMENT
            or its agent. This restriction applies to all eligibility offices, including
            those based in hospitals. MCO marketing staff and provider staff are
            not
            permitted to solicit Member enrollment by positioning themselves at or
            near
            eligibility offices. Note that the only face-to-face marketing activities
            allowed are those directly permitted under items #5, #7, #11 and #12
            of these
            guidelines. All other face-to-face marketing activities are
            prohibited.

        

        
          

          5)            Provider
            communications with HUSKY patients about
            MCOoptions

        

        
          

          DEPARTMENT
            marketing restrictions apply to the MCO's participating providers as
            well as to
            the MCOs. MCOs must notify all of their participating providers of the
            DEPARTMENT marketing restrictions and provide them with a copy of this
            document.

        

        
          

          Each
            provider entity is allowed to notify its patients of the HUSKY-certified
            MCOs it
            participates in, and to explain that the patients must enroll in one
            of these
            MCOs if they wish to preserve their existing relationship. This must
            be done
            through written materials prior-approved by DEPARTMENT, and must be distributed
            to HUSKY patients without regard to health status. Providers must not
            indicate a
            preference between the MCOs in which they participate.

        

        
          

          6)            Member-initiated
            telephone conversations with MCOS and providers

        

        
          

          These
            conversations are permitted and do not require prior approval by the
            DEPARTMENT,
            but information given to potential Members, during such telephone conversation
            must be in accordance with the DEPARTMENT'S marketing guidelines. However,
            telephone conversations must be initiated by the potential Member, not
            by the
            MCO staff (or provider staff). MCOs and providers may return calls to
            Members
            and potential Members when Members and potential Members leave a message
            requesting that this occur.

        

        
          

          7)            Member-initiated
            one-on-one meetings with MCO staff prior to
            enrollment

        

        
          

          Such
            meetings, when requested by the Member, are permitted but may not occur
            at a
            participating provider's care delivery site or at the Member's residence.
            These
            meetings must occur at the MCO's offices or another mutually-agreed upon
            public
            location. All verbal interaction with the Member must be in compliance
            with the
            DEPARTMENT'S marketing guidelines.

        

        
          

          8)            Mailings
            by MCO in response to Member requests

        

        
          

          MCO
            mailings are permitted in response to Member verbal or written requests
            for
            information. The content of such mailings must be prior-approved by the
            DEPARTMENT. MCOs may include gifts of nominal value (unit cost less than
            $2,
            e.g. magnets, pens, bags, jar grippers, etc.) in these
            mailings.

        

        
          

          9)            Unsolicited
            MCO mailings

        

        
          

          MCOs
            are
            permitted to send unsolicited mailings. The content of such mailings
            must be
            prior-approved by DEPARTMENT. In addition, the target audiences must
            be
            prior-approved by DEPARTMENT, and the MCOs must explain how they obtained
            the
            list of names, addresses and phone numbers.

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        

        
          05/07

        

        
          

          10)           Telemarketing

           

        

        
          Telemarketing
            is not a permitted marketing activity

           

        

        
          11)           MCO
            group meetings held at MCO

        

        
          

          These
            meetings must be prior approved by the DEPARTMENT. The MCO may not notify
            prospective Members until DEPARTMENT prior approval has been
            obtained

        

        
          

          
            	
                    12)

                  	
                    MCO group
                      meetings held in public facilities, churches, health fairs,
                      or other community
                      sites

                  

          

        

        
          

          These
            are
            permitted activities as long as DEPARTMENT approved materials are utilized
            in
            the presentations and the DEPARTMENT'S marketing guidelines are followed.
            The
            DEPARTMENT reserves the right to monitor such meetings on an ad hoc basis.
            MCOs
            are required to notify the DEPARTMENT sufficiently in advance to allow
            DEPARTMENT representatives to attend such meetings in order to monitor
            MCO
            activities if desired. As soon as the MCO has scheduled these activities,
            the
            DEPARTMENT should be notified.

        

        
          

          13)           MCO group
            meetings held in private clubs or homes

        

        
          

          These
            activities are prohibited. The only permitted group meetings are those
            described
            under items #11 and #12.

        

        
          

          14)           Individual
            solicitation, residences

        

        
          

          MCO
            (and
            provider) staff are not permitted to visit potential Members at their
            places of
            residence for purposes of explaining MCO features and promoting enrollment.
            This
            prohibition is absolute, and applies even in situations where the potential
            Member desires and/or requests a home visit. MCO staff can visit Member
            homes
            after enrollment becomes effective, as part of their orientation/education
            efforts.

        

        
          

          15)           Gifts,
            cash incentives, or rebates to potential Members and
            members.

        

        
          

          MCOs
            (and
            their providers) are prohibited from disseminating gift items, except
            those of a
            nominal value (pens, key chains, magnets, etc.), to potential Members.
            DEPARTMENT-approved written materials may also be disseminated to prospective
            Members along with similar nominal value gifts. MCOs may give items of
            nominal
            value (unit cost less than $2), with their logo on it, to persons (potential
            Members and others) attending health fairs, presentations at community
            forums
            organized through or other sanctioned events, with DEPARTMENT approval.
            Such
            items would include magnets, pens, bags, plastic band-aid dispensers,
            etc.
            Pre-approved nominal value items may also be included with new Member
            information packets.

        

        
          

          16)           Gifts
            to Members for specific health-related events

        

        
          

          Gifts
            to
            Members are allowed for medically "good" behavior (e.g. baby T-shirt
            showing
            immunization schedule once a woman completes targeted series of prenatal
            visits). All such gifts, including any written materials included with
            them (or
            on them), must be prior-approved by the DEPARTMENT. The criteria for
            providing
            such gifts must also be prior-approved by DEPARTMENT. MCOs must not provide
            gifts in any situations other than those that have been prior-approved
            by
            DEPARTMENT. Additional DEPARTMENT prior approval is required for all
            additional
            uses of the gift items or for new gifts.

        

        
          

          The
            DEPARTMENT may approve magnets, phone labels, and other nominal items
            that
            reinforce a MCO's care coordination programs (e.g. through advertising
            the
            Member Services hotline and/or the PCP office phone number). All such
            items must
            be prior-approved by the DEPARTMENT. The criteria for disseminating this
            information must

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        

        
          05/07

        

        
          

          also
            be
            prior-approved, although the DEPARTMENT is likely to be amenable to the
            MCOs
            inclusion of this information in "welcome" packets sent to new
            Members.

        

        
          

          Health
            education videos are also allowed, but must be prior-approved by
            DEPARTMENT.

        

        
          

          17)            Phoning
            by Members from health care provider locations

        

        
          

          Providers
            may provide the use of a phone to potential HUSKY Members or HUSKY Members
            subject to the following restrictions:

        

        
          

          a)      MCO
            or provider staff may not coach or instruct the caller;

        

        
          

          
            	
                    b)

                  	
                    Privacy
                      must be given to the MEMBER during their phone conversation
                      with
                      the HUSKY application and enrollment
                      center.

                  

          

        

        
          

          
            	
                    18)

                  	
                    Non-alcoholic
                      beverages and light refreshments for potential Members
                      at meetings

                  

          

        

        
          

          Non-alcoholic
            beverages and light refreshments are permitted at DEPARTMENT approved
            group
            meetings.

        

        
          

          
            	
                    19.)

                  	
                          Use
                      of HUSKY Name; HUSKY Logo and Mandatory Language
                      Requirements

                  

          

        

        
          

          MCOs
            will
            be allowed use of the HUSKY logo and name for use in their marketing
            materials,
            subject to the following:

        

        
          

          
            	
                    a)

                  	
                    must
                      be used in conjunction with the following language unless
                      alternative language has been prior approved by the
                      DEPARTMENT.

                  

          

        

        
          

          HUSKY
            gives families the freedom of choice to enroll in one of several participating
            health plans. Toll-free information:
            1-877-CT-HUSKY;

        

        
          

          
            	
                    b)

                  	
                    the
                      above mandatory language must be placed in the vicinity of
                      the HUSKY
                      logo; and

                  

          

        

        
          

          
            	
                    c)

                  	
                    the
                      font size for the HUSKY phone number cannot be smaller than
                      the
                      MCOs member services phone
                      number.

                  

          

        

        

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

          
            	 	
                    
                      Type
                        of Marketing Activity

                    

                  	
                    
                      Permitted

                    

                  	
                    
                      Not
                        Permitted

                    

                  	
                    
                      Permitted
                        With DEPARTMENT Approval

                    

                  
	
                    
                      1

                    

                  	
                    
                      General
                        HUSKY marketing materials

                    

                  	 	 	
                    
                      X

                    

                  
	
                    
                      2

                    

                  	
                    
                      General,
                        MCO advertising/marketing

                    

                  	 	 	
                    
                      X

                    

                  
	
                    
                      3

                    

                  	
                    
                      MCO
                        advertising in provider care sites

                    

                  	 	 	
                    
                      X

                    

                  
	
                    
                      4

                    

                  	
                    
                      MCO
                        advertising in all DEPARTMENT- eligibility offices, including
                        hospital-based (Must be made available only through the DEPARTMENT
                        or its
                        agent)

                    

                  	 	 	
                    
                      X

                    

                  
	
                    
                      5

                    

                  	
                    
                      Provider
                        communications with Medicaid patients about MCO
                        options

                    

                  	 	 	
                    
                      X

                    

                  
	
                    
                      6

                    

                  	
                    
                      Member-initiated
                        telephone conversations with MCO and Provider staff

                    

                  	
                    
                      X

                    

                  	 	
                     

                  

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

          
            05/07

          

          

          
            	
                    
                      7

                    

                  	
                    
                      Member-initiated
                        one-on-one meetings with MCO staff prior to
                        enrollment

                    

                  	
                    
                      X

                    

                  	 	 
	
                    
                      8

                    

                  	
                    
                      Mailings
                        by MCO in response to Member requests

                    

                  	 	 	
                    
                      X

                    

                  
	
                    
                      9

                    

                  	
                    
                      Unsolicited
                        MCO mailings to Members

                    

                  	 	 	
                    
                      X

                    

                  
	
                    
                      10

                    

                  	
                    
                      Telemarketing

                    

                  	 	
                    
                      X

                    

                  	 
	
                    
                      11

                    

                  	
                    
                      MCO
                        group meetings, held at MCO

                    

                  	 	 	
                    
                      X

                    

                  
	
                    
                      12

                    

                  	
                    
                      MCO
                        group meetings held in public facilities such as churches,
                        health fairs,
                        WIC program or other community sites

                    

                  	 	 	
                    
                      X

                    

                  
	
                    
                      13

                    

                  	
                    
                      MCO
                        group meetings held in private clubs or homes

                    

                  	 	
                    
                      X

                    

                  	 
	
                    
                      14

                    

                  	
                    
                      Individual
                        solicitation at residences

                    

                  	 	
                    
                      X

                    

                  	 
	
                    
                      15

                    

                  	
                    
                      Items
                        of nominal value along with written information about the
                        MCO or general
                        health education information to potential Members (given
                        at such places as
                        health fairs, community forums or other events approved by
                        the Department)
                        or included in new Member information packets.

                    

                  	 	 	
                    
                      X

                    

                  
	
                    
                      16

                    

                  	
                    
                      Gifts
                        to Members (e.g. baby T-shirt showing immunization schedule)
                        based on
                        specific health events unrelated to enrollment

                    

                  	 	 	
                    
                      X

                    

                  
	
                    
                      17

                    

                  	
                    
                      Phoning
                        by Members from health care provider locations

                    

                  	
                    
                      X

                    

                  	 	 
	
                    
                      18

                    

                  	
                    
                      Non-alcoholic
                        beverages and light refreshments (e.g. fruit, cookies) for
                        potential
                        Members at meetings (may not mention refreshments in advertisements
                        for
                        meetings)

                    

                  	
                    
                      X

                    

                  	 	 

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        
          APPENDIX
            E

        

        
          Standards
            for Internal Quality Assurance Programs

        

        
          For
            Health Plans

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            E - MCO Contract 05/07

        

        
          

        

        
          STANDARDS
            FOR INTERVAL QUALITY ASSURANCE PROGRAMS FOR HEALTH
            PLANS

        

        
          

          Standard
            I: Written QAP Description

        

        
          

          The
            organization has a written description of its Quality Assurance Program
            (QAP).
            This written description meets the following criteria:

        

        
          

          
            	
                    A.

                  	
                    Goals
                      and objectives - There is a written description of the QA program
                      with detailed goals and annually developed objectives that outline
                      the program structure and design and include a timetable for
                      implementation
                      and accomplishment.

                  

          

        

        
          

          B.           Scope
            -

        

        
          

          
            	
                    1.

                  	
                    The
                      scope of the QAP is comprehensive, addressing both the quality
                      of clinical care and quality of non-clinical aspects of services,
                      such as and including: availability, accessibility, coordination, and
                      continuity of care.

                  

          

        

        
          

          
            	
                    2.

                  	
                    The
                      QAP methodology provides for review of the entire range of
                      care provided by the organization, by assuring that all demographic
                      groups, care settings (e.g. inpatient, ambulatory, [including care
                      provided in private practice offices] and home care), and types of
                      services (e.g. preventive, primary, specialty care and ancillary) are
                      included in the scope of the review. This review should be carried
                      out over multiple review periods and not on just a concurrent
                      basis.

                  

          

        

        
          

          
            	
                    C.

                  	
                    Specific
                      activities - The written description specifies quality of care
                      studies and other activities to be undertaken over a prescribed
                      period of time, and methodologies and organizational arrangements to
                      be used to accomplish them. Individuals responsible for the studies
                      and other activities are clearly identified and are
                      appropriate.

                  

          

        

        
          

          
            	
                    D.

                  	
                    Continuous
                      activity - The written description provides for
                      continuous performance of the activities, including tracking of
                      issues overtime.

                  

          

        

        
          

          E.     Provider
            review - The QAP provides:

        

        
          

          
            	
                    1.

                  	
                    Review
                      by physicians and other health professionals of the process followed
                      in the provision of health
                      services;

                  

          

        

        
          

          
            	
                    2.

                  	
                    Feedback
                      to health professionals and health plan staff regarding performance
                      and patient results.

                  

          

        

        
          

          
            	
                    F.

                  	
                    Focus
                      on health outcomes - The QAP methodology addresses
                      health outcomes to the extent consistent with existing
                      technology.

                  

          

        

        
          

          Page
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            13(9/06)

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            E - MCO Contract 

          05/07

        

        
          

          Standard
            II: Systematic Process of Quality Assessment and Improvement

        

        
          

          The
            QAP
            objectively and systematically monitors and evaluates the quality and
            appropriateness of care and service provided members, through quality
            of care
            studies and related activities, and pursues opportunities for improvement
            on an
            ongoing basis.

        

        
          

          A.            Specification
            of clinical or health services delivery areas to be
            monitored

        

        
          

          
            	
                    1.

                  	
                    Monitoring
                      and evaluation of clinical issues reflects the population served by
                      the health plan, in terms of age groups, disease categories, and
                      special risk status.

                  

          

        

        
          

          
            	
                    2.

                  	
                    For
                      the Medicaid population, the QAP monitors and evaluates at
                      a minimum,
                      care and services in certain priority areas of concern selected by
                      the State. It is recommended that these be taken from among
                      those identified by the Health Care Financing Administration's
                      (HCFA's) Medicaid Bureau and jointly determined by the State and the
                      Managed Care Organization
                      (MCO).

                  

          

        

        
          

          
            	
                    3.

                  	
                    At
                      its discretion and/or as required by the State Medicaid agency,
                      the MCO's QAP also monitors and evaluates other aspects of care
                      and service.

                  

          

        

        
          

          B.            Use
            of quality indicators

        

        
          

          Quality
            indicators are measurable variables relating to a specified clinical
            or health
            services delivery area, which are reviewed over a period of time to monitor
            the
            process of outcomes of care delivered in that area.

        

        
          

          
            	
                    1.

                  	
                    The
                      MCO identifies and uses quality indicators that are
                      measurable, objective, and based on current knowledge and clinical
                      experiences.

                  

          

        

        
          

          
            	
                    2.

                  	
                    For
                      the priority area selected by the State from the HCFA
                      Medicaid Bureau's list of priority clinical and health service
                      delivery areas of concern, the MCO monitors and evaluates quality of
                      care through studies, which include, but are not limited to, the
                      quality indicators also specified by the HCFA Medicaid
                      Bureau.

                  

          

        

        
          

          
            	
                    3.

                  	
                    Methods
                      and frequency of data collection are appropriate and sufficient to
                      detect need for program
                      change.

                  

          

        

        
          

          C.            Use
            of clinical care standards/practice guidelines

        

        
          

          
            	
                    1.

                  	
                    The
                      QAP studies and other activities monitor quality of care
                      against clinical care or health services delivery standards or
                      practice guidelines specified for each area
                      identified.

                  

          

        

        
          

          
            	
                    2.

                  	
                    The
                      clinical standards/practice guidelines are based on
                      reasonable scientific evidence and are developed or reviewed by plan
                      providers.

                  

          

        

        
          

          Page
            2 of
            13(9/06)

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            E - MCO Contract

           

        

        
          
            	
                     

                  	
                    05/07

                  

          

        

        
          

          
            	
                    3.

                  	
                    The
                      clinical standards/practice guidelines focus on the process
                      and outcomes of health care delivery, as well as access to
                      care.

                  

          

        

        
          

          
            	
                    4.

                  	
                    A
                      mechanism is in place for continuously updating
                      the standards/practice
                      guidelines.

                  

          

        

        
          

          
            	
                    5.

                  	
                    The
                      clinical standards/practice guidelines shall be included in
                      provider manuals developed for use by HMO providers or
                      otherwise disseminated to the providers as they are
                      adopted.

                  

          

        

        
          

          
            	
                    6.

                  	
                    The
                      clinical standards/practice guidelines address preventive
                      health services.

                  

          

        

        
          

          
            	
                    7.

                  	
                    The
                      clinical standards/practice guidelines are developed for the
                      full spectrum of populations enrolled in the
                      plan.

                  

          

        

        
          

          
            	
                    8.

                  	
                    The
                      QAP shall use these clinical standards/practice guidelines
                      to evaluate the quality of care provided by the MCO's providers,
                      whether the providers are organized in groups, as individuals, as
                      IPAs, or in a combination
                      thereof.

                  

          

        

        
          

          D.           Analysis
            of clinical care and related services

        

        
          

          
            	
                    1.

                  	
                    Appropriate
                      clinicians monitor and evaluate quality through review of individual
                      cases where there are questions about care and through studies
                      analyzing patterns of clinical care and related service. For quality
                      issues identified in the QAP's targeted clinical areas, the
                      analysis includes the identified quality indicators and uses clinical
                      care standards or practice
                      guidelines.

                  

          

        

        
          

          
            	
                    2.

                  	
                    Mulitdisciplinary
                      teams are used, where indicated, to analyze and address system
                      issues.

                  

          

        

        
          

          
            	
                    3.

                  	
                    For
                      the D.1. and D.2. above, clinical and related services
                      requiring improvement are
                      identified.

                  

          

        

        
          

          E.           Implementation
            of remedial/corrective actions

        

        
          

          The
            QAP
            includes written procedures for taking appropriate remedial action whenever,
            as
            determined under the QAP, inappropriate or substandard services are furnished,
            or services that should have been furnished were not.

        

        
          

          These
            written remedial/corrective action procedures include:

        

        
          

          
            	
                    1.

                  	
                    Specification
                      of the types of problems requiring
                      remedial/corrective action.

                  

          

        

        
          

          
            	
                    2.

                  	
                    Specification
                      of the person(s) or body responsible for making the
                      final determinations regarding quality
                      problems.

                  

          

        

        
          

          3.      Specific
            actions to be taken.

        

        
          

          
            	
                    4.

                  	
                    Provision
                      of feedback to appropriate health professionals, providers
                      and staff.

                  

          

        

        
          

          5.      The
            schedule and accountability for implementing corrective
            actions.

        

        
          

          Page
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            13(9/06)

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            E - MCO Contract 

          05/07

        

        
          

          
            	
                    6.

                  	
                    The
                      approach to modify the corrective action if improvements do
                      not occur.

                  

          

        

        
          

          
            	
                    7.

                  	
                    Procedures
                      for terminating the affiliation with the physician, or other health
                      professional or provider.

                  

          

        

        
          

          F.           Assessment
            of effectiveness of corrective actions

        

        
          

          
            	
                    1.

                  	
                    As
                      actions are taken to improve care, there is monitoring and
                      evaluation of corrective actions to assure that appropriate changes
                      have been made. In addition, changes in practice patterns are
                      tracked.

                  

          

        

        
          

          
            	
                    2.

                  	
                    The
                      MCO assures follow-up on identified issues to ensure that actions for
                      improvement have been
                      effective.

                  

          

        

        
          

          G.           Evaluation
            of continuity and effectiveness of the QAP

        

        
          

          1.      The
            MCO conducts a regular and periodic examination of the scope
            and

        

        
          content
            of the QAP to ensure that it covers all types of services in all settings,
            as
            specified in standard l-B-2.

        

        
          

          
            	
                    2.

                  	
                    At
                      the end of each year, a written report on the QAP is prepared
                      which addresses: QA studies and other activities completed, trending
                      of clinical and services indicators and other performance
                      data; demonstrated improvements in quality; areas of deficiency
                      and recommendations for corrective action; and an evaluation of
                      the
                      overall effectiveness of the
                      QAP

                  

          

        

        
          

          
            	
                    3.

                  	
                    There
                      is evidence that QA activities have contributed to
                      significant improvements in the care and services delivered to
                      members.

                  

          

        

        
          

          Standard
            III:  Accountability to the Governing
            Body

        

        
          

          The
            QA
            committee is accountable to the governing body of the managed care organization.
            The governing body should be the board of directors, or a committee of
            senior
            management may be designated in instances in which the board's participation
            with QA issues is not direct. There is evidence of a formally designated
            structure, accountability at the highest levels of the organization,
            and ongoing
            and/or continuous oversight of the QA program. Responsibilities of the
            Governing
            Board for monitoring, evaluating, and making improvements to care
            include:

        

        
          

          
            	
                    A.

                  	
                    Oversight
                      of the QAP - There is documentation that the governing body has
                      approved the overall QAP and the annual
                      QAP.

                  

          

        

        
          

          
            	
                    B.

                  	
                    Oversight
                      of entity - The Governing Body has formally designated
                      an accountable entity or entities within the organization to provide
                      oversight of QA, or has formally decided to provide such oversight as
                      a committee of
                      the whole.

                  

          

        

        
          

          
            	
                    C.

                  	
                    QAP
                      progress reports - The Governing body routinely receives
                      written reports from the QAP describing actions taken, progress in
                      meeting QA objectives, and improvements
                      made.

                  

          

        

        
          

          Page
            4 of
            13(9/06)

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            E - MCO Contract 

          05/07

        

        
          

          
            	
                    D.

                  	
                    Annual
                      QAP review - The Governing Body formally reviews on a
                      periodic basis (but no less frequently than annually) a written
                      report on the QAP which includes: studies undertaken, results,
                      subsequent actions, and aggregate data on utilization and quality of
                      services rendered, to assess the QAP's continuity, effectiveness and
                      current acceptability.

                  

          

        

        
          

          
            	
                    E.

                  	
                    Program
                      modification - Upon receipt of regular written reports from the
                      QAP delineating actions taken and improvements made, the Governing
                      Body takes actions when appropriate and directs that the operational
                      QAP be modified on an ongoing basis to accommodate review findings
                      and issues of concern within the MCO. Minutes of the meetings of the
                      Governing Board demonstrate that the Board has directed and followed
                      up on necessary actions pertaining to
                      QA.

                  

          

        

        
          

          Standard
            IV: Active QA Committee

        

        
          

          The
            QAP
            delineates an identifiable structure responsible for performing QA functions
            within the MCO. The committee or other structure has:

        

        
          

          
            	
                    A.

                  	
                    Regular
                      meetings - The structure/committee meets on a regular basis
                      with specified frequency to oversee QAP activities. This frequency
                      is
                      sufficient to demonstrate that the structure/committee is following
                      up on all findings and required actions, but in no case are such
                      meetings less frequent
                      than quarterly.

                  

          

        

        
          

          
            	
                    B.

                  	
                    Established
                      parameters for operating -The role, structure and function
                      of the structure/committee are
                      specified.

                  

          

        

        
          

          
            	
                    C.

                  	
                    Documentation
                      - There are contemporaneous records documenting
                      the structure's/committee's activities, findings, recommendations
                      and
                      actions.

                  

          

        

        
          

          
            	
                    D.

                  	
                    Accountability
                      - The QAP committee is accountable to the Governing Body and
                      reports to it (or its designee) on a scheduled basis on
                      activities, findings, recommendations and
                      actions.

                  

          

        

        
          

          
            	
                    E.

                  	
                    Membership
                      - There is active participation in the QA committee from
                      health plan providers, who are representative of the composition of
                      the health plan's
                      providers.

                  

          

        

        
          

          Standard
            V: QAP Supervision

        

        
          

          There
            is
            a designated senior executive who is responsible for program implementation.
            The
            organization's Medical Director has substantial involvement in QA
            activities.

        

        
          

          Standard
            VI:  Adequate Resources

        

        
          

          The
            QAP
            has sufficient material resources, and staff with the necessary education,
            experience, or training; to effectively carry out its specified
            activities.

        

        
          

          Page
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          Appendix
            E - MCO Contract 

          05/07

        

        
          

          Standard
            VII: Provider Participation in the QAP

        

        
          

          
            	
                    A.

                  	
                    Participating
                      physicians and other providers are kept informed about the written QA
                      plan.

                  

          

        

        
          

          
            	
                    B.

                  	
                    The
                      MCO includes in all its provider contracts and employment agreements,
                      for both physicians and nonphysician providers, a
                      requirement securing cooperation with the
                      QAP.

                  

          

        

        
          

          
            	
                    C.

                  	
                    Contracts
                      specify that hospitals, physicians, and other contractors will
                      allow the MCO access to the medical records of their
                      members.

                  

          

        

        
          

          Standard
            VIII: Delegation of QAP Activities

        

        
          

          The
            MCO
            remains accountable for all QAP functions, even if certain functions
            are
            delegated to other entities. If the MCO delegates any QA activities to
            contractors.

        

        
          

          
            	
                    A.

                  	
                    There
                      is a written description of delegated activities; the
                      delegate's accountability for these activities; and the frequency of
                      reporting to the MCO.

                  

          

        

        
          

          
            	
                    B.

                  	
                    The
                      MCO has written procedures for monitoring the implementation
                      of
                      the delegated functions and for verifying the actual quality of
                      care
                      being provided.

                  

          

        

        
          

          
            	
                    C.

                  	
                    There
                      is evidence of continuous and ongoing evaluation of
                      delegated activities, including approval of quality improvement plans
                      and regular specified
                      reports.

                  

          

        

        
          

          Standard
            IX: Enrollee Rights and Responsibilities

        

        
          

          The
            MCO
            demonstrates a commitment to treating members in a manner that acknowledges
            their rights and responsibilities.

        

        
          

          A.        Written
            policy on enrollee rights

        

        
          

          The
            MCO
            has a written policy that recognizes the following rights of
            members:

        

        
          

          
            	
                    1.

                  	
                    To
                      be treated with respect, and recognition of their dignity and
                      need
                      for privacy;

                  

          

        

        
          
            	
                    2.

                  	
                    To
                      be provided with information about the MCO, its services,
                      the practitioners providing care, and members' rights and
                      responsibilities;

                  

          

        

        
          
            	
                    3.

                  	
                    To
                      be able to choose primary care practitioners, within the limits
                      of
                      the plan network, including the right to refuse care from
                      specific practitioners;

                  

          

        

        
          4.      To
            participate in decision-making regarding their health care;

        

        
          5.      To
            voice grievances about the MCO or care provided;

        

        
          6.      To
            formulate advance directives; and

        

        
          

          Page
            6 of
            13 (9/06)

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix E
            - MCO Contract 

          05/07

        

        
          

          
            	
                     

                  	
                    7.
                      To have access to his/her medical records on accordance with
                      applicable
                      Federal and State laws.

                  

          

        

        
          

          
            	
                    B.

                  	
                    Written
                      policy enrollee responsibilities - The MCO has a written policy
                      that addresses members' responsibility for cooperating with those
                      providing health care services. This written policy addresses
                      members'
                      responsibility for:

                  

          

        

        
          

          
            	
                    1.

                  	
                    Providing,
                      to the extent possible, information needed by professional staff in
                      caring for the member; and

                  

          

        

        
          

          
            	
                    2.

                  	
                    Following
                      instructions and guidelines given by those providing health care
                      services.

                  

          

        

        
          

          
            	
                    C.

                  	
                    Communication
                      of policies to providers - A copy of the organization's policies
                      on members' rights and responsibilities is provided to
                      all participating
                      providers.

                  

          

        

        
          

          
            	
                    D.

                  	
                    Communication
                      of policies to enrollees/members - Upon enrollment, members are
                      provided a written statement that includes information on
                      the following:

                  

          

        

        
          

          1.      Rights
            and responsibilities of members;

        

        
          

          
            	
                    2.

                  	
                    Benefits
                      and services included and excluded as a condition of memberships, and
                      how to obtain them, including a description
                      of:

                  

          

        

        
          

          
            	
                    a.

                  	
                    Any
                      special benefit provisions (example, co-payment, higher deductibles,
                      rejection of claim) that may apply to service obtained outside the
                      system; and

                  

          

           

        

        
          b.      The
            procedures for obtaining out-of-area coverage;

        

        
           

          3.      Provisions
            for after-hours and emergency coverage;

        

        
           

          4.      The
            organization's policy on referrals for specialty care;

        

        
           

          5.      Charges
            to members, if applicable, including:

        

        
           

          a.      Policy
            on payment of charges; and

        

        
           

          b.      Co-payment
            and fees for which the member is responsible.

        

        
          

          
            	
                    6.

                  	
                    Procedures
                      for notifying those members affected by the termination or change in
                      any benefit services, or service delivery
                      office/site;

                  

          

        

        
          

          
            	
                    7.

                  	
                    Procedures
                      for appealing decisions adversely affecting the members' coverage,
                      benefits, or relationship with the
                      organization;

                  

          

        

        
          

          8.      Procedures
            for changing practitioners;

        

        
          

          9.      Procedures
            for disenrollment; and

        

        
          

          
            	
                    10.

                  	
                    Procedures
                      for voicing complaints and/or grievances and for recommending changes
                      in policies and services.

                  

          

        

        
          

          Page
            7 of
            13(9/06)

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            E - MCO Contract 

           

          05/07

        

        
          

          
            	
                    E.

                  	
                    Enrollee/member
                      grievance procedures - The organization has a system(s) linked
                      to the QAP, for resolving members' complaints and formal grievances.
                      This system includes:

                  

          

        

        
          

          
            	
                    1.

                  	
                    Procedures
                      for registering and responding to complaints and
                      grievances in  a timely fashion (organizations should
                      establish and monitor standards for
                      timeliness);

                  

          

        

        
          

          
            	
                    2.

                  	
                    Documentation
                      of the substance of the complaint or grievances, and actions
                      taken;

                  

          

        

        
          

          3.      Procedures
            to ensure a resolution of the compliant or grievance;

        

        
          

          
            	
                    4.

                  	
                    Aggregation
                      and analysis of complaint and grievance data and use of the data for
                      quality improvement; and

                  

          

        

        
          

          5.      An
            appeal process for grievances.

        

        
          

          
            	
                    F.

                  	
                    Enrollee/member
                      suggestions - Opportunity is provided for members to offer
                      suggestions for changes in policies and
                      procedures.

                  

          

        

        
          

          
            	
                    G.

                  	
                    Steps
                      to assure accessibility of services - The MCO takes steps to
                      promote accessibility of services offered to members. These steps
                      include:

                  

          

        

        
          

          
            	
                    1.

                  	
                    The
                      points of access to primary care, specialty care and
                      hospital services are identified for
                      members;

                  

          

        

        
          

          2.    At
            a minimum, members are given information about:

        

        
          a.    How
            to obtain services during regularly hours of operation

        

        
          b.    How
            to obtain emergency and after-hours care; and

        

        
          
            	
                    c.

                  	
                    How
                      to obtain the names, qualifications, and titles of the professionals
                      providing and/or responsible for their
                      care.

                  

          

        

        
          

          H.       Written
            information for members

        

        
          

          
            	
                    1.

                  	
                    Member
                      information is written in prose that is readable and
                      easily understood; and

                  

          

        

        
          

          
            	
                    2.

                  	
                    Written
                      information is available, as needed, in the languages of the major
                      population groups served. A "major" population group is one which
                      represents at least 10% of plan's
                      membership.

                  

          

        

        
          

          /.         Confidentiality
            of patient information - The MCO acts to ensure that the confidentiality
            of the specified patient information and records is
            protected.

        

        
          

          
            	
                    1.

                  	
                    The
                      MCO has established in writing, and enforced, policies and procedures
                      on confidentiality of medical
                      records.

                  

          

        

        
          

          
            	
                    2.

                  	
                    The
                      MCO ensures that patient care offices/sites have
                      implemented mechanisms that guard against the unauthorized or
                      inadvertent disclosure of confidential information to persons outside
                      of the medical care
                      organization.

                  

          

        

        
          

          Page
            8 of
            13 (9/06)

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            E - MCO Contract 

          05/07

        

        
          

          
            	
                    3.

                  	
                    The
                      MCO shall hold confidential information obtained by its
                      personnel about enrollees related to their examination, care and
                      treatment and shall not divulge it without the enrollee's
                      authorization, unless:

                  

          

        

        
          

          a.      it
            is required by law;

        

        
          

          
            	
                    b.

                  	
                    it
                      is necessary to coordinate the patient's care with
                      physicians, hospitals, or other health care entities, or to
                      coordinate insurance or other matters pertaining to payment;
                      or

                  

          

        

        
          

          
            	
                    c.

                  	
                    it
                      is necessary in compelling circumstances to protect the health
                      or safety of an
                      individual.

                  

          

        

        
          

          
            	
                    4.

                  	
                    Any
                      release of information in response to a court order is reported
                      to
                      the patient in a timely manner;
                      and

                  

          

        

        
          

          
            	
                    5.

                  	
                    Enrollee
                      records may be disclosed, whether or not authorized by the enrollee,
                      to qualified personnel for the purpose of conducting
                      scientific research, but these personnel may not identify, directly
                      or indirectly, any individual enrollee in any report of the research
                      or otherwise disclose participant identity in any
                      manner.

                  

          

        

        
          

          
            	
                     

                  	
                    J.        Treatment
                      of minors - The MCO has written policies regarding the appropriate
                      treatment of minors.

                  

          

        

        
          

          
            	
                     

                  	
                    K.       Assessment
                      of member satisfaction - The MCO conducts periodic surveys of member
                      satisfaction with its
                      services.

                  

          

        

        
          

          
            	
                    1.

                  	
                    The
                      surveys include content on perceived problems in the
                      quality, accessibility and availability of
                      care.

                  

          

        

        
          

          2.      The
            surveys assess at least a sample of:

        

        
          

          a.      All
            Medicaid members;

           

        

        
          
            	
                    b.

                  	
                    Medicaid
                      member requests to change practitioners and/or
                      facilities; and

                  

          

           

        

        
          c.      Disenrollment
            by Medicaid members.

           

        

        
          3.      As
            a results of the surveys, the organization:

           

        

        
          a.      Identifies
            and investigates sources of dissatisfaction;

           

        

        
          b.      Outlines
            action steps to follow-up on the findings; and

           

        

        
          c.      Informs
            practitioners and providers of assessment results.

           

        

        
          4.      The
            MCO reevaluates the effects of the above activities.

        

        
          

          Standard
            X:  Standards for Availability and
            Accessibility

        

        
          

          The
            MCO
            has established standards for access (e.g. to routine, urgent and emergency
            care; telephone appointments; advice; and member service lines). Performance
            on
            these on these dimensions of access are assessed against the
            standards.

        

        
          

          Page
            9 of
            13(9/06)

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            E - MCO Contract 

          05/07

        

        
          

          Standard
            XI: Medical Records Standards

        

        
          

          
            	
                    A.

                  	
                    Accessibility
                      and availability of medical records - The MCO shall
                      include provision in provider contracts for appropriate access to the
                      medical records of its enrollees for purposes of quality reviews
                      conducted by the Secretary, State Medicaid agencies, or agents
                      thereof.

                  

          

        

        
          

          
            	
                    B.

                  	
                    Record
                      keeping - Medical records may be on paper or electronic. The
                      plan takes steps to promote maintenance of medical records in a
                      legible, current, detailed, organized and comprehensive manner that
                      permits effective patient care and quality review as
                      follows:

                  

          

        

        
          

          
            	
                     

                  	
                    1.  Medical
                      records standards- The MCO sets standards for medical records.
                      The records
                      reflect all aspects of patient care, including ancillary services.
                      These
                      standards shall at a minimum, include requirements
                      for:

                  

          

        

        
          

          
            	
                    a.

                  	
                    Patient
                      identification information - Each page or electronic file in
                      the record contains the patient's name or patient ID
                      number.

                  

          

        

        
          

          
            	
                    b.

                  	
                    Personal/biographical
                      data - Personal/biographical data includes: age, sex, address;
                      employer; home and work telephone numbers; and martial
                      status.

                  

          

        

        
          

          c.      Entry
            date - All entries are dated.

        

        
          

          d.      Provider
            identification - All entries are identified as to author.

        

        
          

          
            	
                    e.

                  	
                    Legibility
                      - The record is legible to someone other than the writer. Any record
                      judged illegible by one physician reviewer should be evaluated by a
                      second reviewer.

                  

          

        

        
          

          
            	
                    f.

                  	
                    Allergies
                      - Medication allergies and adverse reactions are prominently noted on
                      the record. Absence of allergies (no known allergies-NKA) is noted in
                      an easily recognizable
                      location.

                  

          

        

        
          

          
            	
                    g.

                  	
                    Past
                      medical history - (for patients seen 3 or more times) Past medical
                      history is easily identified including serious accidents, operations,
                      illnesses. For children, past medical history relates to prenatal
                      care and birth.

                  

          

        

        
          

          
            	
                    h. 

                  	
                    Immunizations-
                      For pediatric records (ages 12 and under) there is a completed
                      immunization record or a notation that immunizations are
                      up-to-date.

                  

          

        

        
          

          i.    Diagnostic
            information j     Medication
            information

        

        
          

          
            	
                    k.  

                  	
                     Identification
                      of current problems - Significant illness, medical conditions
                      and health
                      maintenance concerns are identified in the medical
                      record.

                  

          

        

        
          

          
            	
                    l.  

                  	
                     Smoking/ETOH/substance
                      abuse - Notation concerning cigarettes and alcohol use and
                      substance abuse
                      is present (for patients 12

                  

          

        

        
          

          Page
            10
            of 13 (9/06)

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            E - MCO Contract 

          05/07

        

        
          

          years
            and
            over and seen three or more times). Abbreviations and symbols may be
            appropriate.

        

        
          

          
            	
                    m.

                  	
                     

                  	
                    Consultations,
                      referral and specialist reports - Notes from consultations
                      are in the record. Consultation, lab, and x-ray reports filed
                      in the chart
                      have the ordering physicians initials or other documentation
                      signifying
                      review. Consultation and significantly abnormal lab and imaging
                      study
                      results have an explicit notation in the record and follow-up
                      plans.

                  

          

        

        
          

          n.  Emergency
            care

        

        
          

          
            	
                    o.

                  	
                    Hospital
                      discharge summaries - Discharge summaries are included as part of the
                      medical record for (1) all hospital admissions which occur while the
                      patient is enrolled in the MCO and (2) prior admissions as
                      necessary.

                  

          

        

        
          

          
            	
                    p.

                  	
                     Advance
                      directives - For medical records of adults, the medical record
                      documents
                      whether or not the individual has executed an advance directive.
                      An
                      advance directive is a written instruction such as a living
                      will or
                      durable power of attorney for health care relating to the provision
                      of
                      health care when the individual is
                      incapacitated.

                  

          

        

        
          

          
            	
                    2.

                  	
                    Patient
                      visit data - Documentation of individual encounters must
                      provide adequate evidence of, at a
                      minimum;

                  

          

        

        
          

          
            	
                    a.

                  	
                    History
                      and physical examination - Appropriate subjective and objective
                      information is obtained for the presenting
                      complaints.

                  

            	 b. 	 Plan
                    of treatment

            	 c.  	Diagnostic
                    tests

            	d. 	Therapies
                    and other prescribed regimens; andherapies and other prescribed
                    regimens;
                    and

            	 
                    
                    e.

                  	Follow-up
                    - Encounter forms or notes have a notation, when indicated,
                    concerning follow-up care, call, or visit. Specific time to return is
                    noted in weeks, months, or PRN. Unresolved problems from previous
                    visits are addressed in subsequent
                    visits.

            	 f.	 Referrals
                    and results thereof; and

            	g.	 All
                    other aspects of patient care, including ancillary
                    services.

          

        

        
            

          3.      Record
            review process-

        

        
          

          
            	
                    1.

                  	
                    The
                      MCO has a system (record review process) to assess the content of
                      medical records for legibility, organization, completion
                      and conformance to its
                      standards.

                  

          

        

        
          

          
            	
                    2.

                  	
                    The
                      record assessment system addresses documentation of the items listed
                      in B, above.

                  

          

        

        
          

          Page
            11
            of 13(9/06)

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            E - MCO Contract 

          05/07

        

        
          

          Standard
            XII:  Utilization Review

        

        
          

          
            	
                    A.

                  	
                    Written
                      program description- The MCO has a written utilization management
                      program description which includes, at a minimum, procedures to
                      evaluate medical necessity, criteria used, information sources and
                      the process used to review and approve the provision of medical
                      services.

                  

          

        

        
          

          
            	
                    B.

                  	
                    Scope
                      - The program has mechanisms to detect underutilization as
                      well
                      as overutilization.

                  

          

        

        
          

          
            	
                    C.

                  	
                    Preauthorization
                      and concurrent review - For MCO with preauthorization or concurrent
                      review programs:

                  

          

        

        
          

          
            	
                    1.

                  	
                    Preauthorization
                      and concurrent review decisions are supervised by qualified medical
                      professionals;

                  

          

        

        
          

          
            	
                    2.

                  	
                    Efforts
                      are made to obtain all necessary information, including
                      pertinent clinical information, and consult with the treating
                      physician
                      as appropriate;

                  

          

        

        
          

          
            	
                    3.

                  	
                    The
                      reasons for decisions are clearly documented and available
                      to
                      the member.

                  

          

        

        
          

          
            	
                    4.

                  	
                    There
                      are well-publicized and readily available appeals mechanisms
                      for both
                      providers and patients. Notification of a denial includes
                      a description of how file an
                      appeal;

                  

          

        

        
          

          
            	
                    5.

                  	
                    Decisions
                      and appeals are made in a timely manner as required by the exigencies
                      of the situation;

                  

          

        

        
          

          
            	
                    6.

                  	
                    There
                      are mechanisms to evaluate the effects of the program using
                      data on
                      member satisfaction, provider satisfaction or other appropriate;
                      and

                  

          

        

        
          

          
            	
                    7.

                  	
                    If
                      the MCO delegates responsibilities for utilization management,
                      it
                      has mechanisms to ensure that these standards are met by the
                      delegate.

                  

          

        

        
          

          Standard
            XIII: Continuity of
            Care System

        

        
          

          The
            MCO
            has put a basic system in place which promotes continuity of care and
            case
            management.

        

        
          

          Standard
            XIV: QAP Documentation

        

        
          

          
            	
                    A.

                  	
                    Scope
                      - The MCO shall document that it is monitoring the quality
                      of
                      care across all services and all treatment modalities, according
                      to
                      its written QAP.

                  

          

        

        
          

          
            	
                    B.

                  	
                    Maintenance
                      and availability of documentation - The MCO must maintain and
                      make available to the State, and upon request to the Secretary
                      of
                      HHS, studies, reports, appropriate, concerning the activities and
                      corrective actions.

                  

          

        

        
          

          Page
            12
            of 13(9/06)

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            E - MCO Contract 

          05/07

           

        

        
          Standard
            XV: Coordination of QA
            Activity with other Management Activity

           

        

        
          The
            findings, conclusions, recommendations, actions taken, and results of
            actions
            taken as a result of QA activity, are documented and reported to appropriate
            individuals within the MCO and through established QA
            channels.

        

        
          

          
            	
                    A.

                  	
                    QA
                      information is used in recredentialing, recontracting, and/or
                      annual performance
                      evaluations.

                  

          

        

        
          

          
            	
                    B.

                  	
                    QA
                      activities are coordinated with other performance monitoring
                      activities, including utilization management, risk management, and
                      resolution and monitoring of member complaints and
                      grievances.

                  

          

        

        
          

          
            	
                    C.

                  	
                    There
                      is a linkage between QA and other management functions of the MCO,
                      such as: network changes, benefit redesign, medical
                      management systems, practice feedback to providers, patient education
                      and member services.

                  

          

        

        
          

          Page
            13
            of 13 (9/06)

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          APPENDIX
            F

        

        
          

        

        
          Claims
            Inventory, Aging and Unaudited Quarterly

        

        
          Financial
            Reports

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Appendix
            F - MCO Contract

        

        
          0507

        

        
          (document
            1 of 5)

        

        
          Report
            #1

        

        
          HUSKY
            A & B Unprocessed Claims in Dollars

        

        
          Plan Name

        

        
          Qtr.
            Ending:

        

        

        
          	 	
                  
                    Claims
                      In Process During Qtr. (In Dollars) (1)

                  

                
	
                  Claims
                    Type

                	
                  
                    1-30
                      Days

                  

                	
                  
                    31-45
                      Days

                  

                	
                  
                    46-60
                      Days

                  

                	
                  
                    61-90
                      Days

                  

                	
                  
                    91-120
                      Days

                  

                	
                  
                    >120
                      Days

                  

                	
                  
                    Total
                      Claims Outstanding At The End Of The
                      Qtr.

                  

                
	
                  UB92
                    Claims

                  HCFA
                    1500 Claims

                  Subtotal
                    MCO Claims

                  Pharmacy

                  Dental

                  Vision

                  Mental
                    Health

                  Subtotal
                    Vendor Claims

                  Total

                	 	 	 	 	 	 	 
	 	 	 	 	 	 	 
	 	 	 	 	 	 	 

        

        

        
          	
                  
                    Claim
                      Type

                  

                	
                  
                    Unpaid
                      Adjudicated Claims (In Dollars) (2)

                  

                
	 	
                  
                    1-30
                      Days

                  

                	
                  
                    31-45
                      Days

                  

                	
                  
                    46-60
                      Days

                  

                	
                  
                    61-90
                      Days

                  

                	
                  
                    91-120
                      Days

                  

                	
                  
                    >120
                      Days

                  

                	
                  
                    Total
                      Unpaid Adjudicated Claims (In Dollars) At The End Of The
                      Qtr.

                  

                
	
                  
                    UB92
                      Claims

                  

                  
                    HCFA
                      1500 Claims Subtotal MCO Claims
                      Pharmacy

                  

                  
                    Dental

                  

                  
                    Vision

                  

                  
                    Subtotal
                      Vendor Claims

                  

                  
                    Total

                  

                	 	 	 	 	 	 	 
	 	 	 	 	 	 	 
	 	 	 	 	 	 	 

        

        
          

          1.  Claims
            in process-all claims that are in a pending status (data, medical, COB
            edits)
            and require review by a claim examiner prior to being released for
            adjudication. Because the final pay amount is unknown, the amounts are
            recorded
            at the billed amount

        

        
          

          2.  Unpaid
            adjudicated claims-claims which have been adjudicated and have a known
            pay
            amount, however, a check has not been issued for these claims. Because the
            final pay amount is known, the amounts are recorded using net amount
            +
            withhold.

        

        
          

          UB92
            - In
            general these claim forms represent hospital based claims (inpatient
            and
            outpatient). HCFA 1500 - These claim forms are used for outpatient services
            provided by non-hospital facilities.

        

        
          

          Other
            items to note about report #1 and #2:

        

        
          *   If
            a claim does not include the information specified in Bulletin HC-56
            it is
            rejected. This claim would not appear in the inventory after
            it
            was rejected.

        

        
          * 
A
            claim could contain all of the infonnation specified by Bulletin HC-56,
            but it
            is incorrect. In this instance it could have been included in the
            pending claims prior to identifying it as a claim with incorrect data.
            Examples of incorrect data would be using a discontinued code.

          
            *
              If a
              claim is submitted for a service which requires prior authorization,
              but none if
              found by the MCO, it is denied. At the point of denial the claim would be
              excluded from the report.

          

        

        
          * The
            pending claims could include duplicates which have not been identified
            by the
            MCO. If a duplicate is identified, one is paid and all of the duplicates
            are rejected.

        

        
          * The
            pending category may include claims which have been pended for a medical
            records
            review. As per the guidelines in Bulleting HC-56, if
            additional information is needed from the provider, the MCO has 30 days
            to
            request additional information. After the information is received, the
            MCO has
            30 days to pay the claim without interest.

        

        
          * If
            a claim is denied and subsequently reversed on appeal, the clock would
            start on
            the date of the appeal determination.

        

        
          * If
            a credit balance exists for a provider, the time to process the claim
            is still
            measured. To the extent that processing exceeds 45 days it would accrue
            interest as any other claim would.

        

        
          If
            a
            rejected or denied claim is subsequently resubmitted, it would take on
            a new
            claim number. The clock would begin from the date of
            re-submissions.

        

        
          

          The
            only
            time a processed claim is re-opened is for an adjustment to amount
            paid.

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        
Appendix
          F - MCO Contract 

        (document
          2 of 5)

        
          
            Report
              #2 

            HUSKY
              A & B Volume of Unprocessed Claims

          

          
            Plan
              Name

          

          
            Qtr.
              Ending:

          

          
            

          

          
            	 	
                    
                      Claims
                        In Process During Qtr. (# of claims) (1)

                    

                  
	
                    Claims
                      Type

                  	
                    
                      1-30
                        Days

                    

                  	
                    
                      31-45
                        Days

                    

                  	
                    
                      46-60
                        Days

                    

                  	
                    
                      61-90
                        Days

                    

                  	
                    
                      91-120
                        Days

                    

                  	
                    
                      >120
                        Days

                    

                  	
                    
                      Total
                        Claims in Process During Qtr.

                    

                  
	
                    UB92
                      Claims

                    HCFA
                      1500 Claims

                    Subtotal
                      MCO Claims

                    Pharmacy

                    Dental

                    Vision

                    Mental
                      Health

                    Subtotal
                      Vendor Claims

                    Total

                  	 	 	 	 	 	 	 
	 	 	 	 	 	 	 
	 	 	 	 	 	 	
                    
                      323

                    

                  
	 	 	 	 	 	 	 

          

          

          
            	 	
                    
                      Unpaid
                        adjudicated (# of claims) (2)

                    

                  
	
                    Claims
                      Type

                  	
                    
                      1-30
                        Days

                    

                  	
                    
                      31-45
                        Days

                    

                  	
                    
                      46-60
                        Days

                    

                  	
                    
                      61-90
                        Days

                    

                  	
                    
                      91-120
                        Days

                    

                  	
                    
                      >120
                        Days

                    

                  	
                    
                      Total
                        Unpaid Adjudicated Claims (# of claims) At the End of The
                        Qtr.

                    

                  
	
                    UB92
                      Claims

                    HCFA
                      1500 Claims

                    Subtotal
                      MCO Claims

                    Pharmacy

                    Dental

                    Vision

                    Mental
                      Health

                    Subtotal
                      Vendor Claims

                    Total

                  	 	 	 	 	 	 	 
	 	 	 	 	 	 	
                    
                      0

                    

                  
	 	 	 	 	 	 	 
	 	 	 	 	 	 	 

          

          

          
            	
                    Claims
                      Inventory

                  	
                    EQUAL
                      TO OR  less than 45 days

                  	
                    Greater
                      than 45 Days

                  
	 	 	 
	
                    MCO
                      Claims

                  	 	 
	
                    Pharmacy

                  	 	 
	
                    Dental

                  	 	 
	
                    Vision

                  	 	 
	
                    Mental
                      Health

                  	 	 
	
                    Total

                  	 	 

          

          

          

          
            	 	
                    
                      Estimated
                        Claims Received but not in system (# of claims)
                        (4)

                    

                  
	
                    Claims
                      Type

                  	
                    
                      1-30
                        Days

                    

                  	
                    
                      31-45
                        Days

                    

                  	
                    
                      46-60
                        Days

                    

                  	
                    
                      61-90
                        Days

                    

                  	
                    
                      91-120
                        Days

                    

                  	
                    
                      >120
                        Days

                    

                  	
                    
                      Estimated
                        Claims Received but not in system

                    

                  
	
                    UB92
                      Claims

                    HCFA
                      1500 Claims

                    Subtotal
                      MCO Claims

                    Pharmacy

                    Dental

                    Vision

                    Mental
                      Health

                    Subtotal
                      Vendor Claims

                    Total

                  	 	 	 	 	 	 	 
	 	 	 	 	 	 	
                    
                      0

                    

                  
	 	 	 	 	 	 	 
	 	 	 	 	 	 	 

          

          
            

          

          
            Tick
              Mark Legend:

          

          
            1.
              Claims in process-all claims that are in a pending
              status (data, medical, COB edits) and require review by a claim examiner
              prior to being released for adjudication.

          

          
            2.  Unpaid
              adjudicated claims- claims which have been adjudicated and have a known
              pay amount, however, a check has not been issued for these
              claims.

          

          
            3.  Total
              of estimated claims in process, and unpaid adjudicated
              claims.

          

          
            4.   Estimated
              claims received but not in system-includes any claim that has been
              received and
              not input in the system (I.e. claims in the mailroom).

          

          
            

          

          
            05/07

          

          
            

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

             

            Appendix
              F - MCO Contract

          

          
            (document
              3 of 5)

          

          
            Report
              #3

          

          
            HUSKY
              A & B Turn Around Time - Claims Processed

            Plan
              Name 

            Qtr.
              Ending:

          

          

          
            	
                    
                      Claim
                        Type

                    

                  	
                    
                      Paper
                        Claims Processed During Qtr.

                    

                  
	
                    
                      01-30
                        Days

                    

                  	
                    
                      31-45
                        Days

                    

                  	
                    
                      46-60
                        Days

                    

                  	
                    
                      61-90
                        Days

                    

                  	
                    
                      91-120
                        Days

                    

                  	
                    
                      >120
                        Days

                    

                  	
                    
                      Total
                        Paper Claims Processed During Qtr.

                    

                  
	
                    
                      UB92
                        Claims

                    

                    
                      HCFA
                        1500 Claims Subtotal MCO Claims

                    

                    
                      Pharmacy

                    

                    
                      Dental

                    

                    
                      Vision

                    

                    
                      Mental
                        Health

                    

                    
                      Subtotal
                        Vendor Claims Total

                    

                  	 	 	 	 	 	 	 
	 	 	 	 	 	 	 
	 	 	 	 	 	 
	 	 	 	 	 	 	 

          

          

          
            	
                    Claim
                      Type

                  	
                    
                      Electronic
                        Claims Processed During Qtr.

                    

                  
	
                    
                      01-30
                        Days

                    

                  	
                    
                      31-45
                        Days

                    

                  	
                    
                      46-60
                        Days

                    

                  	
                    
                      61-90
                        Days

                    

                  	
                    
                      91-120
                        Days

                    

                  	
                    
                      >120
                        Days

                    

                  	
                    
                      Total
                        Electronic Claims Processed During Qtr.

                    

                  
	
                    
                      UB92
                        Claims

                    

                    
                      HCFA
                        1500 Claims Subtotal MCO Claims

                    

                    
                      Pharmacy

                    

                    
                      Dental

                    

                    
                      Vision

                    

                    
                      Mental
                        Health

                    

                    
                      Subtotal
                        Vendor Claims Total

                    

                  	 	 	 	 	 	 	 
	 	 	 	 	 	 	 
	 	 	 	 	 	 	 
	 	 	 	 	 	 	 

          

          

          
            	
                    Claim
                      Type

                  	
                    
                      Total
                        Paper and Electronic Claims Processed During Qtr.

                    

                  
	
                    
                      01-30
                        Days

                    

                  	
                    
                      31-45
                        Days

                    

                  	
                    
                      46-60
                        Days

                    

                  	
                    
                      61-90
                        Days

                    

                  	
                    
                      91-120
                        Days

                    

                  	
                    
                      >120
                        Days

                    

                  	
                    
                      Total
                        Paper & Electronic Claims Processed During
                        Qtr.

                    

                  
	
                    
                      UB92
                        Claims

                    

                    
                      HCFA
                        1500 Claims Subtotal MCO Claims

                    

                    
                      Pharmacy

                    

                    
                      Dental

                    

                    
                      Vision

                    

                    
                      Mental
                        Health

                    

                    
                      Subtotal
                        Vendor Claims Total

                    

                  	 	 	 	 	 	 	 
	 	 	 	 	 	 	 
	 	 	 	 	 	 	 
	 	 	 	 	 	 	 

          

           

          
            	
                    Turn
                      Around Statistics

                  	
                    Equal
                      or Less than 45 Days

                  	
                    Greater
                      than 45 Days

                  
	
                    MCO
                      Claims

                  	
                    %

                  	
                    %

                  
	
                    Pharmacy

                  	
                    %

                  	
                    %

                  
	
                    Dental

                  	
                    %

                  	
                    %

                  
	
                    Vision

                  	
                    %

                  	
                    %

                  
	
                    
                      Mental
                        Health

                    

                  	
                    %

                  	
                    %

                  
	
                    Total

                  	
                    %

                  	
                    %

                  

          

          
            

            This
              report includes only paid claims, therefore it excludes denied
              claims.

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            05/07

          

          
            Appendix
              F - MCO Contract

          

          
            (document
              4 of 5)

          

          
            Report
              #4

          

          
            HUSKY
              A & B - Claims paid in excess of 45 Days

          

          
            

            Plan
              Name Qtr. Ending:

          

          

          
            	 	
                    
                      Claims
                        older than 45 days paid during the Qtr.

                    

                  
	
                    
                      Vendor(Pay
                        To)

                    

                  	
                    
                      Claim
                        #

                    

                  	
                    
                      Pay
                        Amount

                    

                  	
                    
                      Allowed
                        Amount*

                    

                  	
                    
                      Interest

                    

                  	
                    
                      Age
                        of Claim (in Days)

                    

                  
	 	 

          

          
            Claim
              Count                                Pay
              Amount

          

          
            

            Interest
              < 1.00

          

          

          
            

            The
              following should be noted about this report:

          

          
            It
              includes only paid claims and excludes denied or rejected
              claims.

          

          
            It
              is
              sorted by provider, alphabetically

          

          
            If
              an
              amount is used other than

          

          
            *
              Allowed
              amount column has been Included in the report as a column, only if
              it used to
              calculate interest.

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          
05/07   

          
            	
                    
                      Appendix
                        F - MCO Contract

                    

                    
                      (document
                        5 of 6)

                    

                    
                      Unaudited
                        Quarterly Financial Reports

                    

                  
	
                     

                  	
                    
                      Current
                        Assets:

                    

                  	
                    
                      Current
                        Year

                    

                  	
                    
                      Previous
                        Year

                    

                  
	
                    
                      1

                    

                  	
                    
                      Cash
                        and Cash Equivalents

                    

                  	 	 
	
                    
                      2

                    

                  	
                    
                      Short-Term
                        Investments

                    

                  	 	 
	
                    
                      3

                    

                  	
                    
                      Premiums
                        Receivable

                    

                  	 	 
	
                    
                      4

                    

                  	
                    
                      Investment
                        Income Receivables

                    

                  	 	 
	
                    
                      5

                    

                  	
                    
                      Health
                        Care receivables

                    

                  	 	 
	
                    
                      6

                    

                  	
                    
                      Amounts
                        Due from Affiliates

                    

                  	 	 
	
                    
                      7

                    

                  	
                    
                      Aggregate
                        Write-ins for Current Assets

                    

                  	 	 
	
                    
                      8

                    

                  	
                    
                      TOTAL
                        CURRENT ASSETS (items 1-7)

                    

                  	 	 
	
                     

                  	 	 	 
	
                     

                  	
                    
                      Other
                        Assets

                    

                  	 	 
	
                    
                      9

                    

                  	
                    
                      Restricted
                        Cash and Other Assets

                    

                  	 	 
	
                    
                      10

                    

                  	
                    
                      Long
                        Term Investments

                    

                  	 	 
	
                    
                      11

                    

                  	
                    
                      Amounts
                        Due from Affiliates

                    

                  	 	 
	
                    
                      12

                    

                  	
                    
                      Aggregate
                        Write-ins for Other Assets

                    

                  	 	 
	
                    
                      13

                    

                  	
                    
                      TOTAL
                        OTHER ASSETS (items 9-12)

                    

                  	 	 
	
                     

                  	 	 	 
	
                     

                  	
                    
                      Property
                        and Equipment

                    

                  	 	 
	
                    
                      14

                    

                  	
                    
                      Land,
                        building and Improvements

                    

                  	 	 
	
                    
                      15

                    

                  	
                    
                      Furniture
                        and Equipment

                    

                  	 	 
	
                    
                      16

                    

                  	
                    
                      Leasehold
                        Improvements

                    

                  	 	 
	
                    
                      17

                    

                  	
                    
                      Aggreate
                        Write-ins for Other Equipment

                    

                  	 	 
	
                    
                      18

                    

                  	
                    
                      TOTAL
                        PROPERTY (items 7-14)

                    

                  	 	 
	
                    
                      19

                    

                  	
                    
                      TOTAL
                        ASSETS 9items 8, 13, and 18)

                    

                  	 	 
	
                     

                  	 	 	 
	
                     

                  	
                    
                      Details
                        of Write-ins Aggregated at item 7 for Current Assets

                    

                  	 	 
	
                    
                      701

                    

                  	 	 	 
	
                    
                      702

                    

                  	 	 	 
	
                    
                      703

                    

                  	 	 	 
	
                    
                      704

                    

                  	 	 	 
	
                    
                      705

                    

                  	 	 	 
	
                    
                      798

                    

                  	
                    
                      Summary
                        of remaining write-ins for item 7 from overflow page

                    

                  	 	 
	
                    
                      799

                    

                  	
                    
                      TOTALS:
                        (items 701 through 705 plus 798 page 2, item 7)

                    

                  	 	 
	
                     

                  	 	 	 
	
                     

                  	
                    
                      Details
                        of Write-ins Aggregated at item 1 2 for Other Assets

                    

                  	 	 
	
                    
                      1201

                    

                  	 	 	 
	
                    
                      1202

                    

                  	 	 	 
	
                    
                      1203

                    

                  	 	 	 
	
                    
                      1204

                    

                  	 	 	 
	
                    
                      1205

                    

                  	 	 	 
	
                    
                      1298

                    

                  	
                    
                      Summary
                        of remaining write-ins for item 12 from overflow
                        page

                    

                  	 
	
                    
                      1299

                    

                  	
                    
                      TOTALS:
                        (items 1201 through 1205 plus 1298 page 2, item 12)

                    

                  	 
	
                     

                  	 	 	 
	 	
                    
                      Details
                        of Write-ins Aggregated at item 17 for Other
                        Equipment

                    

                  	 
	
                    
                      1701

                    

                  	 	 	 
	
                    
                      1702

                    

                  	 	 	 
	
                    
                      1703

                    

                  	 	 	 
	
                    
                      1704

                    

                  	 	 	 
	
                    
                      1705

                    

                  	 	 	 

          

          
            

            page
              1 of
              4

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          
05/07  

          
            	
                    
                      Appendix
                        F - MCO Contract

                    

                    
                      (document
                        5 of 6)

                    

                    
                      Unaudited
                        Quarterly. Financial Reports

                    

                  
	
                    
                      1798

                    

                  	
                    
                      Summary
                        of remaining write-ins for item 17 from overflow
                        page

                    

                  	 
	
                    
                      1799

                    

                  	
                    
                      TOTALS:
                        (items 1701 through 1705 plus 1798 page 2, item 17)

                    

                  	 
	
                     

                  	 	 	 
	
                     

                  	
                    
                      Current
                        Liabilities

                    

                  	 	 
	
                    
                      1

                    

                  	
                    
                      Accounts
                        Payable (Schedule G)

                    

                  	 	 
	
                    
                      2

                    

                  	
                    
                      Claims
                        Payable (Reported and Unreported) (Schedule H)

                    

                  	 	 
	
                    
                      3

                    

                  	
                    
                      Accrued
                        Medical Incentive Pool (Schedule H)

                    

                  	 	 
	
                    
                      4

                    

                  	
                    
                      Unearned
                        Premiums

                    

                  	 	 
	
                    
                      5

                    

                  	
                    
                      Amounts
                        Due to Affiliates (Schedule J)

                    

                  	 	 
	
                    
                      6

                    

                  	 	 	 
	
                    
                      7

                    

                  	
                    
                      Aggregate
                        Write-ins for Current Liabilities

                    

                  	 	 
	
                    
                      8

                    

                  	
                    
                      TOTAL
                        CURRENT LIABILITIES (items 1-7)

                    

                  	 	 
	
                     

                  	 	 	 
	
                     

                  	
                    
                      Other
                        Liabilities

                    

                  	 	 
	
                    
                      9

                    

                  	
                    
                      Loans
                        and Notes Payable (Schedule I)

                    

                  	 	 
	
                    
                      10

                    

                  	
                    
                      Amounts
                        Due to Affiliates (Schedule J)

                    

                  	 	 
	
                    
                      11

                    

                  	
                    
                      Aggregate
                        Write-ins for Other Liabilities

                    

                  	 	 
	
                    
                      12

                    

                  	
                    
                      TOTAL
                        OTHER LIABILITIES (items 9-11)

                    

                  	 	 
	
                    
                      13

                    

                  	
                    
                      TOTAL
                        LIABILITIES (items 8 and 12)

                    

                  	 	 
	
                     

                  	 	 	 
	
                     

                  	
                    
                      Net
                        Worth

                    

                  	 	 
	
                    
                      14

                    

                  	
                    
                      Common
                        Stock

                    

                  	 	 
	
                    
                      15

                    

                  	
                    
                      Preferred
                        Stock

                    

                  	 	 
	
                    
                      16

                    

                  	
                    
                      Paid
                        in Surplus

                    

                  	 	 
	
                    
                      17

                    

                  	
                    
                      Contributed
                        Capital

                    

                  	 	 
	
                    
                      18

                    

                  	
                    
                      Surplus
                        Notes (Schedule K)

                    

                  	 	 
	
                    
                      19

                    

                  	
                    
                      Contingency
                        Reserves

                    

                  	 	 
	
                    
                      20

                    

                  	
                    
                      Retained
                        Earnings/Fund Balance

                    

                  	 	 
	
                    
                      21

                    

                  	
                    
                      Aggregate
                        Write-ins for Other Net Worth Items

                    

                  	 	 
	
                    
                      22

                    

                  	
                    
                      TOTAL
                        NET WORTH (items 13 and 22)

                    

                  	 	 
	
                    
                      23

                    

                  	
                    
                      TOTAL
                        LIABILITIES AND NET WORTH (items 13 and 22)

                    

                  	 	 
	
                     

                  	 	 	 
	
                     

                  	
                    
                      Details
                        of Write-ins Aggregated at item 7 for Current
                        Liabilities

                    

                  	 	 
	
                    
                      701

                    

                  	
                    
                      Payroll
                        and Related Liabilities

                    

                  	 	 
	
                    
                      702

                    

                  	
                    
                      Accrued
                        Audit and Actuarial Fees

                    

                  	 	 
	
                    
                      703

                    

                  	 	 	 
	
                    
                      704

                    

                  	 	 	 
	
                    
                      705

                    

                  	 	 	 
	
                    
                      798

                    

                  	
                    
                      Summary
                        of Remaining Write-ins for item 7 from overflow page

                    

                  	 
	
                    
                      799

                    

                  	
                    
                      TOTALS
                        (items 0701 through 0705 plus 0798 Page 3, item 7)

                    

                  	 	 
	
                     

                  	 	 	 
	 	
                    
                      Details
                        of Write-ins Aggregated at item 11 for Other
                        Liabilities

                    

                  	 	 
	
                    
                      1101

                    

                  	 	 	 
	
                    
                      1102

                    

                  	 	 	 
	
                    
                      1103

                    

                  	 	 	 
	
                    
                      1104

                    

                  	 	 	 
	
                    
                      1105

                    

                  	 	 	 
	
                    
                      1198

                    

                  	
                    
                      Summary
                        of remaining write-ins for item 1 1 from overflow
                        page

                    

                  	 
	
                    
                      1199

                    

                  	
                    
                      TOTALS:
                        (items 1101 through 1 1 05 plus 1 1 98 page 3, item 1 1
                        )

                    

                  	 
	
                     

                  	 	 
	
                     

                  	
                    
                      Details
                        of Write-ins Aggregated at item 21 for Other Net Worth
                        Items

                    

                  	 
	
                    
                      2101

                    

                  	 	 

          

          
            

            page
              2 of
              4

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          
05/07 

          
            	
                    
                      Appendix
                        F - MCO Contract

                      (document
                        5 of 6)

                      Unaudited
                        Quarterly Financial Reports

                    

                  
	
                    
                      2102

                    

                  	 	 	 
	
                    
                      2103

                    

                  	 	 	 
	
                    
                      2104

                    

                  	 	 	 
	
                    
                      2105

                    

                  	 	 	 
	
                    
                      2198

                    

                  	
                    
                      Summary
                        of remaining write-ins for item 21 from overflow
                        page

                    

                  	 
	
                    
                      2199

                    

                  	
                    
                      TOTALS:
                        (items 2101 through 2105 plus 2198 page 3, item 21)

                    

                  	 
	
                     

                  	 	 	 
	
                     

                  	
                    
                      Member
                        months

                    

                  	 	 
	
                     

                  	
                    
                      Revenues

                    

                  	 	 
	
                    
                      1

                    

                  	
                    
                      Premium

                    

                  	 	 
	
                    
                      2

                    

                  	
                    
                      Fee-For-Service

                    

                  	 	 
	
                    
                      3

                    

                  	
                    
                      Title
                        XVIII - Medicare

                    

                  	 	 
	
                    
                      4

                    

                  	
                    
                      Title
                        XIX -
                        Medicaid                                                           

                    

                  	 
	
                    
                      5

                    

                  	
                    
                      Investment

                    

                  	 	 
	
                    
                      6

                    

                  	
                    
                      Aggregate
                        Write-ins for Other Revenues

                    

                  	 	 
	
                    
                      7

                    

                  	
                    
                      TOTAL
                        REVENUES (items 1-6)

                    

                  	 	 
	
                     

                  	 	 	 
	
                     

                  	
                    
                      Expenses

                    

                  	 	 
	
                    
                      8

                    

                  	
                    
                      Medical
                        and Hospital

                    

                  	 	 
	
                    
                      9

                    

                  	
                    
                      Other
                        Professional Services

                    

                  	 	 
	
                    
                      10

                    

                  	
                    
                      Outside
                        Referrals

                    

                  	 	 
	
                    
                      11

                    

                  	
                    
                      Emergency
                        Room and Out-of-Area

                    

                  	 	 
	
                    
                      12

                    

                  	
                    
                      Occupancy,
                        Depreciation and Amortization

                    

                  	 	 
	
                    
                      13

                    

                  	
                    
                      Inpatient

                    

                  	 	 
	
                    
                      14

                    

                  	
                    
                      Incentive
                        Pool and Withhold Adjustments

                    

                  	 	 
	
                    
                      15

                    

                  	
                    
                      Aggregate
                        Write-ins for other Medical and Hospital Expenses

                    

                  	 	 
	
                    
                      16

                    

                  	
                    
                      Subtotal
                        (items 8-1 5)

                    

                  	 	 
	
                    
                      17

                    

                  	
                    
                      Reinsurance
                        Expenses of Net of Recoveries

                    

                  	 	 
	
                     

                  	 	 	 
	
                     

                  	
                    
                      Less

                    

                  	 	 
	
                    
                      18

                    

                  	
                    
                      Copayments

                    

                  	 	 
	
                    
                      19

                    

                  	
                    
                      COB
                        and Subrogation

                    

                  	 	 
	
                    
                      20

                    

                  	
                    
                      Subtotal
                        (items 18 and 19)

                    

                  	 	 
	
                    
                      21

                    

                  	
                    
                      Total
                        Medical and Hospital (items 16 and 17 less 20)

                    

                  	 	 
	
                     

                  	 	 	 
	 	
                    
                      Administration

                    

                  	 	 
	
                    
                      22

                    

                  	
                    
                      Compensation

                    

                  	 	 
	
                    
                      23

                    

                  	
                    
                      Interest
                        Expense

                    

                  	 	 
	
                    
                      24

                    

                  	
                    
                      Occupancy,
                        Depreciation and Amortization

                    

                  	 	 
	
                    
                      25

                    

                  	
                    
                      Marketing

                    

                  	 	 
	
                    
                      26

                    

                  	
                    
                      Aggregate
                        Write-ins for Other Administration Expenses

                    

                  	 	 
	
                    
                      27

                    

                  	
                    
                      TOTAL
                        ADMINISTRATION (items 22-26)

                    

                  	 	 
	
                    
                      28

                    

                  	
                    
                      TOTAL
                        EXPENSES (items 21 and 27)

                    

                  	 	 
	
                    
                      29

                    

                  	
                    
                      Income
                        (LOSS) (item 21 and 27)

                    

                  	 	 
	
                    
                      30

                    

                  	
                    
                      Cumulative
                        Effect of Accountin Change)

                    

                  	 	 
	
                    
                      31

                    

                  	
                    
                      Provision
                        for Federal Income Taxes

                    

                  	 	 
	
                    
                      32

                    

                  	
                    
                      NET
                        INCOME (item 29, less items 30 and 31)

                    

                  	 	 
	
                     

                  	 	 	 
	
                     

                  	
                    
                      Details
                        or Write-ins Aggregated at item 6 for other Revenues

                    

                  	 	 
	
                    
                      601

                    

                  	
                    
                      Other
                        Income

                    

                  	 	 
	
                    
                      602

                    

                  	 	 	 
	
                    
                      603

                    

                  	 	 	 

          

          
            

            page
              3 of
              4

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          
05/07  

          
            	
                    
                      Appendix
                        F - MCO Contract

                    

                    
                      (document
                        5 of 6)

                    

                    
                      Unaudited
                        Quarterly Financial Reports

                    

                  
	
                    
                      604

                    

                  	 	 	 
	
                    
                      605

                    

                  	 	 	 
	
                    
                      698

                    

                  	
                    
                      Summary
                        of remaining write-ins for item 6 from overflow page

                    

                  	 	 
	
                    
                      699

                    

                  	
                    
                      TOTALS:
                        (items 601 through 605 plus 698 page 4, item 6)

                    

                  	 	 
	
                     

                  	 	 	 
	
                     

                  	
                    
                      Member
                        months

                    

                  	 	 
	 	
                    
                      Details
                        of Write-ins Aggregated at Item 6 for Other Revenues

                    

                  	 	 
	
                    
                      1501

                    

                  	
                    
                      Drugs

                    

                  	 	 
	
                    
                      1502

                    

                  	
                    
                      Outpatient

                    

                  	 	 
	
                    
                      1503

                    

                  	 	 	 
	
                    
                      1504

                    

                  	 	 	 
	
                    
                      1505

                    

                  	 	 	 
	
                    
                      1598

                    

                  	
                    
                      Summary
                        of remaining write-ins for item 15 from overflow
                        page

                    

                  	 
	
                     

                  	 	 	 
	
                     

                  	
                    
                      Details
                        of Write-ins Aggregated at Item 26 for Other Administration
                        Expenses

                    

                  	 
	
                    
                      2601

                    

                  	
                    
                      MGMT
                        Fee Income - SWWA

                    

                  	 	 
	
                    
                      2602

                    

                  	
                    
                      MGMTFee
                        Expense GOHS

                    

                  	 	 
	
                    
                      2603

                    

                  	
                    
                      Other
                        Administration Expense

                    

                  	 	 
	
                    
                      2604

                    

                  	
                    
                      MGMT
                        Fee Expense Corp.

                    

                  	 	 
	
                    
                      2605

                    

                  	
                    
                      Accrued
                        Audit and Actuarial Expense

                    

                  	 	 
	
                    
                      2698

                    

                  	
                    
                      Summary
                        of remaining write-ins for item 26 from ovrflow page

                    

                  	 	 
	
                    
                      2699

                    

                  	
                    
                      TOTALS
                        (items 2601 through 2605 plus 2698) (page 4, item
                        26)

                    

                  	 

          

          
            

            page
              4 of
              4

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            APPENDIX
              G

          

          
            HUSKY
              A MEDICAID COVERAGE GROUPS

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            05/07

          

          
            

            Appendix
              G - MCO Contract

          

          
            

            HUSKY
              A Medicaid Coverage Groups

          

          

          
            	
                    
                      Eligibility
                        Code

                    

                  	
                    
                      Description

                    

                  
	
                    
                      F01

                    

                  	
                    
                      Temporary
                        Assistance to Needy Families (TANF)

                    

                  
	
                    
                      F03

                    

                  	
                    
                      Transitional
                        Work Extension

                    

                  
	
                    
                      F04

                    

                  	
                    
                      Child
                        Support Extension

                    

                  
	
                    
                      F05

                    

                  	
                    
                      Work
                        Supplementation

                    

                  
	
                    
                      F07

                    

                  	
                    
                      Family
                        Coverage (150 % FPL)

                    

                  
	
                    
                      F08

                    

                  	
                    
                      Special
                        Child Care Deduction

                    

                  
	
                    
                      F09

                    

                  	
                    
                      Eligible
                        for TANF except for Non-Medicaid Requirements

                    

                  
	
                    
                      F10

                    

                  	
                    
                      Newborn
                        Coverage

                    

                  
	
                    
                      F11

                    

                  	
                    
                      Newborn
                        Children

                    

                  
	
                    
                      F12

                    

                  	
                    
                      CN
                        Ribicoff Children

                    

                  
	
                    
                      F13*

                    

                  	
                    
                      Children
                        < 1, under 185 9 of the Federal Poverty Level
                        (FPL)

                    

                  
	
                    
                      F20*

                    

                  	
                    
                      Children
                        1-6, under 185 % of the Federal Poverty Level
                        (FPL)

                    

                  
	
                    
                      F25

                    

                  	
                    
                      Children
                        under 185 % of the Federal Poverty Level (FPL)

                    

                  
	 	 
	
                    
                      F95

                    

                  	
                    
                      Children
                        under 18, 18-21, and caretaker Relatives

                    

                  
	
                    
                      P01

                    

                  	
                    
                      Pregnant
                        Women -who meet TANF Financial Requirements

                    

                  
	
                    
                      P02

                    

                  	
                    
                      Pregnant
                        Women under 185 % of the Federal Poverty Level
                        (FPL)

                    

                  
	
                    
                      P95

                    

                  	
                    
                      Pregnant
                        Women Coverage

                    

                  
	
                    
                      M
                        01/M 02

                    

                  	
                    
                      Pregnant
                        Women Extension (Post-Partum)

                    

                  
	
                    
                      D01,
                        D02, D 03, D 04

                    

                  	
                    
                      DCF
                        Children

                    

                  

          

          
            

            MCO
              Contract 1/06

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

          
            APPENDIX
              H

          

          
            BLANK

          

          
            Reserved
              for Possible Future Use

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

          APPENDIX
            I

          CAPITATION
            PAYMENT AMOUNT

          

          

          Table
            1 – HUSKY A Capitation Rates Effective 010106-063006

          

          Table
            2 – HUSKY A capitation Rates effective 070106-063007

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

          
            

            State
              of
              Connecticut   WellCare  
              Confidential

          

          

          
            	 	
                    
                      HUSKY
                        A Capitation Rates (1/01/06 - 6/30/06)

                    

                  
	
                    
                      Fairfield

                    

                  	
                    
                      Hartford

                    

                  	
                    
                      Litchfield

                    

                  	
                    
                      Middlesex

                    

                  	
                    
                      New
                        Haven

                    

                  	
                    
                      New
                        London

                    

                  	
                    
                      Tolland

                    

                  	
                    
                      Windham

                    

                  	
                    
                      All
                        Counties

                    

                  
	
                    
                      WellCare

                    

                  	
                    
                      <1
                        Male and Female

                    

                  	
                    
                      $         574.44

                    

                  	
                    
                      $        652.05

                    

                  	
                    
                      $        650.10

                    

                  	
                    
                      $        773.55

                    

                  	
                    
                      $           647.74

                    

                  	
                    
                      $              644.47

                    

                  	
                    
                      $        781.92

                    

                  	
                    
                      $        624.10

                    

                  	
                    
                      $         630.87

                    

                  
	
                    
                      1-14
                        Male and Female

                    

                  	
                    
                      $           96.22

                    

                  	
                    
                      $         105.18

                    

                  	
                    
                      $         104.84

                    

                  	
                    
                      $         126.82

                    

                  	
                    
                      $           104.44

                    

                  	
                    
                      $              103.83

                    

                  	
                    
                      $         128.32

                    

                  	
                    
                      $         102.15

                    

                  	
                    
                      $         102.68

                    

                  
	
                    
                      15-39
                        Male

                    

                  	
                    
                      $         123.65

                    

                  	
                    
                      $         135.99

                    

                  	
                    
                      $         135.56

                    

                  	
                    
                      $         162.53

                    

                  	
                    
                      $           135.08

                    

                  	
                    
                      $              134.35

                    

                  	
                    
                      $         164.36

                    

                  	
                    
                      $         132.42

                    

                  	
                    
                      $         132.95

                    

                  
	
                    
                      1
                        5-39 Female

                    

                  	
                    
                      $        212.38

                    

                  	
                    
                      $        238.50

                    

                  	
                    
                      $        237.76

                    

                  	
                    
                      $        285.08

                    

                  	
                    
                      $           236.86

                    

                  	
                    
                      $              235.59

                    

                  	
                    
                      $        288.32

                    

                  	
                    
                      $        229.24

                    

                  	
                    
                      $         231.87

                    

                  
	
                    
                      40+
                        Male

                    

                  	
                    
                      $        233.93

                    

                  	
                    
                      $        263.57

                    

                  	
                    
                      $        262.74

                    

                  	
                    
                      $        315.28

                    

                  	
                    
                      $           261.75

                    

                  	
                    
                      $              260.35

                    

                  	
                    
                      $        318.84

                    

                  	
                    
                      $        253.04

                    

                  	
                    
                      $         256.84

                    

                  
	
                    
                      40+
                        Female

                    

                  	
                    
                      $        224.22

                    

                  	
                    
                      $         252.45

                    

                  	
                    
                      $        251.65

                    

                  	
                    
                      $        302.09

                    

                  	
                    
                      $           250.70

                    

                  	
                    
                      $              249.34

                    

                  	
                    
                      $        305.53

                    

                  	
                    
                      $        242.42

                    

                  	
                    
                      $         245.16

                    

                  
	 	
                    
                      Total
                        *

                    

                  	
                    
                      $          157.99

                    

                  	
                    
                      $         176.42

                    

                  	
                    
                      $        170.86

                    

                  	
                    
                      $         219.74

                    

                  	
                    
                      $           179.60

                    

                  	
                    
                      $             173.06

                    

                  	
                    
                      $        215.20

                    

                  	
                    
                      $        173.10

                    

                  	
                    
                      $         173.49

                    

                  

          

          
            

            *Totals
              weighted on January 2006 through June 2006 member months

          

          
            

            APPENDIX
              I

          

          
            TABLE
              1

            HUSKY
              A
              Capitation Rates effective 010106 - 063006

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

          
            State
              of
              Connecticut WellCare  
              Confidential

          

          

          
            	
                    
                      WELLCARE

                    

                  	
                    
                      Husky
                        A Capitation Rates for SPY 2007 ( 7/01/2006 -
                        6/30/2007]

                    

                  	 
	 	
                    
                      Fairfield

                    

                  	
                    
                      Hartford

                    

                  	
                    
                      Litchfield

                    

                  	
                    
                      Middlesex

                    

                  	
                    
                      New
                        Haven

                    

                  	
                    
                      New
                        London

                    

                  	
                    
                      Tolland

                    

                  	
                    
                      Windham

                    

                  
	
                    
                      Under
                        One

                    

                  	
                    
                      $         598.53

                    

                  	
                    
                      $         679.15

                    

                  	
                    
                      $         677.13

                    

                  	
                    
                      $         805.36

                    

                  	
                    
                      $         674.67

                    

                  	
                    
                      $         671.27

                    

                  	
                    
                      $         814.07

                    

                  	
                    
                      $         650.12

                    

                  
	
                    
                      Ages
                        1 to 14

                    

                  	
                    
                      $          101.92

                    

                  	
                    
                      $         111.23

                    

                  	
                    
                      $         110.88

                    

                  	
                    
                      $          133.70

                    

                  	
                    
                      $         110.46

                    

                  	
                    
                      $         109.82

                    

                  	
                    
                      $         135.27

                    

                  	
                    
                      $         108.08

                    

                  
	
                    
                      Male
                        – Ages 15 to 39

                    

                  	
                    
                      $          130.17

                    

                  	
                    
                      $         142.99

                    

                  	
                    
                      $         142.54

                    

                  	
                    
                      $          170.56

                    

                  	
                    
                      $          142.05

                    

                  	
                    
                      $         141.29

                    

                  	
                    
                      $         172.46

                    

                  	
                    
                      $         139.29

                    

                  
	
                    
                      Female
                        – Ages 15 to 39

                    

                  	
                    
                      $         222.35

                    

                  	
                    
                      $         249.48

                    

                  	
                    
                      $         248.71

                    

                  	
                    
                      $         297.87

                    

                  	
                    
                      $         247.78

                    

                  	
                    
                      $         246.46

                    

                  	
                    
                      $         301.23

                    

                  	
                    
                      $         239.86

                    

                  
	
                    
                      Male
                        – Ages 40 and over

                    

                  	
                    
                      $         244.64

                    

                  	
                    
                      $         275.43

                    

                  	
                    
                      $         274.56

                    

                  	
                    
                      $         329.14

                    

                  	
                    
                      $         273.54

                    

                  	
                    
                      $         272.08

                    

                  	
                    
                      $         332.84

                    

                  	
                    
                      $         264.49

                    

                  
	
                    
                      Female
                        – Ages 40 and over

                    

                  	
                    
                      $         234.55

                    

                  	
                    
                      $         263.88

                    

                  	
                    
                      $         263.04

                    

                  	
                    
                      $         315.44

                    

                  	
                    
                      $         262.06

                    

                  	
                    
                      $         260.64

                    

                  	
                    
                      $         319.01

                    

                  	
                    
                      $         253.46

                    

                  

          

          
            

            APPENDIX
              I

          

          
            TABLE
              2

            HUSKY
              A
              Capitation Rates effective 070106 - 063007

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

          
            APPENDIX
              J

          

          
            

          

          
            BLANK

          

          
            

          

          
            Reserved
              for Possible Future Use

          

          
            

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

          
            APPENDIX
              K

          

          
            

          

          
            INPATIENT/ELIGIBILITY
              RECATEGORIZATION CHART

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

          
            0507

          

          
            Appendix
              K - MCO Contract

          

          
            HUSKY
              A&B

            

          

          
            Inpatient/Eligibility
              Recategorization Changes

          

          

          
            	
                    
                      Description

                    

                  	
                    
                      Admitting
                        MCO

                    

                  	
                    
                      New/Continued
                        MCO

                    

                  	
                    
                      Responsible
                        Entity

                    

                  
	
                    
                      HUSKY
                        A, different MCO

                    

                  	
                    
                      A1

                    

                  	
                    
                      A2

                    

                  	
                    
                      A1

                    

                  
	
                    
                      HUSKY
                        A to FFS

                    

                  	
                    
                      A1

                    

                  	
                    
                      FFS

                    

                  	
                    
                      FFS

                    

                  
	
                    
                      HUSKY
                        A to HUSKY B, same MCO

                    

                  	
                    
                      A1

                    

                  	
                    
                      B1

                    

                  	
                    
                      A1

                    

                  
	
                    
                      HUSKY
                        A to HUSKY B, different MCO

                    

                  	
                    
                      A1

                    

                  	
                    
                      B2

                    

                  	
                    
                      A1

                    

                  
	
                    
                      HUSKY
                        B, different MCO

                    

                  	
                    
                      B1

                    

                  	
                    
                      B2

                    

                  	
                    
                      B1

                    

                  
	
                    
                      HUSKY
                        A to disenrolled due to loss of eligibility (Out of
                        Program)

                    

                  	
                    
                      A1

                    

                  	
                    
                      Θ

                    

                  	
                    
                      A1

                    

                  
	
                    
                      HUSKY
                        B to disenrolled due to loss of eligibility (Out of
                        Program)

                    

                  	
                    
                      B1

                    

                  	
                    
                      Θ

                    

                  	
                    
                      B1

                    

                  
	
                    
                      HUSKY
                        B to A (Same MCO, different coverage)

                    

                  	
                    
                      B1

                    

                  	
                    
                      A1

                    

                  	
                    
                      A1

                    

                  
	
                    
                      HUSKY
                        B to A (different MCO, different coverage)

                    

                  	
                    
                      B1

                    

                  	
                    
                      A2

                    

                  	
                    
                      A2

                    

                  
	
                    
                      HUSKY
                        B to FFS

                    

                  	
                    
                      B1

                    

                  	
                    
                      FFS

                    

                  	
                    
                      FFS

                    

                  

          

          
            Code

          

          
            A1
              =
              HUSKY A, MCO #1 

            A2
              =
              HUSKY A, MCO #2 

            B1
              =
              HUSKY B, MCO #1 

            B2
              =
              HUSKY B, MCO #2 

            FFS
              =
              Fee-for-service

          

          
            Θ
              =
              Disenrolled due to loss of eligibility

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

          APPENDIX
            L

          

          PHARMACY
            REPORTS

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

          
            05/07

          

          

          
            	 	
                    
                      Appendix
                        L - MCO Contract (document 1 of 2)

                    

                  	 
	
                    Column
                      1

                  	
                    
                      Column
                        2

                    

                  	
                    
                      Column
                        3

                    

                  	
                    
                      Column
                        4

                    

                  	
                    
                      Column
                        5

                    

                  	
                    
                      Column
                        6

                    

                  	
                    
                      Column
                        7

                    

                  	
                    
                      Column
                        8 (cell description col 3)

                    

                  
	 	
                    
                      Pharmacy
                        Report #1

                    

                    
                      Prescription
                        Request Process (Revision 10/05)

                    

                  	 
	 	
                    
                      Name
                        of MCO

                    

                  	
                    
                      Quarter
                        Ending:

                    

                  
	
                    
                      1.0

                    

                  	
                    
                      Total
                        Prescriptions Filled by the MCO this
                        Quarter

                    

                  	
                    
                      #

                    

                  	 
	
                    
                      2.0

                    

                  	
                    
                      Total
                        Member Months This Quarter

                    

                  	
                    
                      #

                    

                  
	
                    
                      3.0

                    

                  	
                    
                      Number
                        of Prescriptions filled Per Member Per
                        Month

                    

                  	
                    
                      #VALUE!

                    

                  	 	
                    
                      Calc.
                        field=total scripts/mm1.0/2.02

                    

                  
	 
	
                    
                      4.0

                    

                  	
                    
                      Requests
                        for Prior Authorization

                    

                  	 	
                    
                      %
                        of total prescription filled

                    

                  	 	 
	
                    
                      4.1.

                    

                  	
                    
                      Total
                        requests for Prior Authorization

                    

                  	
                    
                      #VALUE!

                    

                  	
                    
                      #VALUE!

                    

                  	
                    
                      Calc
                        field: = 4.2+4.3+4.5.

                    

                  
	
                    
                      4.2.

                    

                  	
                    
                      No
                        Temporary Supply Dispensed

                    

                  	
                    
                      #VALUE!

                    

                  	
                    
                      #VALUE!

                    

                  	
                    
                      Calc
                        field: = 4.2.2+4.2.3.

                    

                  
	
                    
                      4.2.2.

                    

                  	
                    
                      No
                        Temporary Supply - PA Approved

                    

                  	
                    
                      #!

                    

                  	
                    
                      #VALUE!

                    

                  	 
	
                    
                      4.2.3.

                    

                  	
                    
                      No
                        Temporary Supply - PA Denied

                    

                  	
                    
                      #

                    

                  	
                    
                      #VALUE!

                    

                  
	
                    
                      4.3.

                    

                  	
                    
                      Temporary
                        Supply Dispensed

                    

                  	
                    
                      #VALUE!

                    

                  	
                    
                      #VALUE!

                    

                  	
                    
                      Calc
                        field 4.3.1+ 4.3.2.

                    

                  
	
                    4.3.1

                  	
                    Temporary
                      Supply dispensed for PA of script with refill

                  	
                    
                      #VALUE!

                    

                  	
                    
                      #VALUE!

                    

                  	
                    
                      Calc
                        field: 4.3.1.1. + 4.3.1.2.

                    

                  
	
                    
                      4.3.1.1.

                    

                  	
                    
                      TS
                        for PA of script with refill - PA approved

                    

                  	
                    
                      #

                    

                  	
                    
                      #VALUE!

                    

                  	 
	
                    
                      4.3.1.2.

                    

                  	
                    
                      TS
                        for PA of script with refill - PA denied

                    

                  	
                    
                      #

                    

                  	
                    
                      #VALUE!

                    

                  
	
                    
                      4.3.2.

                    

                  	
                    
                      Temporary
                        Supply Dispensed for PA of script without refill

                    

                  	
                    
                      #

                    

                  	
                    
                      #VALUE!

                    

                  	
                    
                      Subset
                        of 4.3

                    

                  
	
                    
                      4.4.

                    

                  	
                    
                      Total
                        requests for Prior Authorization that REQUIRE PA

                    

                  	
                    
                      #VALUE!

                    

                  	
                    
                      #VALUE!

                    

                  	
                    
                      Calc
                        field:= total requests minus temp

                    

                    
                      Supply
                        dispensed without refill; =4.1-4.3.2

                    

                  
	
                    
                      4.5.

                    

                  	
                    
                      Other
                        (refers to Prior Authorization disruption where "approve"
                        or "deny" are
                        not applicable, i.e. prescriber provides a member a replacement
                        script and
                        the original script remains unfilled, the member changes
                        his or her plan
                        membership.

                    

                  	
                    
                      #

                    

                  	
                    
                      #VALUE!

                    

                  	 
	 
	
                    
                      5.0.

                    

                  	
                    
                      Turn
                        Around Time to Approve or Deny PA Request

                    

                  	 	 	 	 	 	 
	
                    
                      5.1.

                    

                  	
                    
                      No
                        Temporary Supply Dispensed

                    

                  	
                    
                      Less
                        than 4 days

                    

                  	
                    
                      4-7
                        days

                    

                  	
                    
                      8-14
                        days

                    

                  	
                    
                      14+
                        days

                    

                  
	
                    
                      5.1.1.

                    

                  	
                    
                      Approved
                        PA request without Temporary Supply

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  
	
                    
                      5.1.2.

                    

                  	
                    
                      Denied
                        PA Request without Temporary Supply

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  
	
                    
                      5.2.

                    

                  	
                    
                      Temporary
                        Supply

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  
	
                    
                      5.2.1.

                    

                  	
                    
                      Approved
                        PA request with Temporary Supply

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  
	
                    
                      5.2.2.

                    

                  	
                    
                      Denied
                        PA request with Temporary Supply

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  
	 	 
	
                    
                      6.0.

                    

                  	
                    
                      Turn
                        around Time to approve Temporary Supply

                    

                  	
                    
                      Same
                        Day

                    

                  	
                    
                      Next
                        Day

                    

                  	
                    
                      More
                        than the Next Day

                    

                  	 
	
                    
                      6.1.

                    

                  	
                    
                      Urgent
                        / emergent

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  
	
                    
                      6.2.

                    

                  	
                    
                      Unable
                        to reach the provider within time limit

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  	
                    
                      #

                    

                  
	 	
                    
                      Directions
                        - Definitions

                    

                  	 
	 	
                    
                      This
                        report is formatted in Excel. Enter amounts for each cell
                        identified with
                        "#." The spreadsheet will calculate values
                        in shaded cells.

                    

                  	 
	
                    
                      Prior
                        Authorization

                    

                  	
                    
                      Refers
                        to those instances where an MCO requires a prescriber to
                        obtain
                        authorization for reimbursing the cost of the drug when the drug is
                        not on  the MCO's formulary or the MCO requires prior
                        authorization for a particular drug on the MCO's
                        formulary.

                    

                  
	
                    
                      Temporary
                        Supply

                    

                  	
                    
                      Refers
                        to those drugs that require prior authorization that a pharmacist
                        provides
                        a member when the pharmacist is unable to contact the prescriber
                        for
                        justification or the prescriber claims the drug is urgent
                        when the
                        pharmacist contacts the prescriber. Temporary Supply anticipates a PA
                        decision on a script. "With Refill" means the script has
                        a refill. "With
                        Refill" does not apply to the temporary supply. "Without
                        refill" applies
                        to the script and not the temporary supply.

                    

                  
	
                    
                      Turn
                        Around Time (TAT)

                    

                  	
                    
                      For
                        PA - refers to the time between the time when the Pharmacist
                        enters the
                        script in the system and the time when the PBM authorizes the
                        script.

                      For
                        Temporary Supply - refers to the time between the time when
                        the Pharmacist
                        enters the script in the system and the time when the Pharmacist
                        dispenses the temporary
                        supply.

                    

                  

          

           

           

          

          
            

            Appendix
              L - MCO Contract - document 2 of 2 05/07

          

          
            Pharmacy
              Report # 2

          

          
            Top
              30 Drugs - by Number of PA Requests Denied Revision
              10/05

          

          

          
            	
                    
                      Name
                        of MCO:

                    

                  	
                    
                      Quarter
                        Ending:

                    

                  	 	 	 
	
                    
                      Directions:
                        This report is formatted in Excel. Enter the MCO name, quarter
                        ending and
                        blank cells, as appropriate for each drug listed. The spreadsheet
                        will
                        calculate the shaded cells.

                    

                  	
                    
                      Number
                        of Authorization Reviews Completed this Quarter

                    

                  	
                    
                      Percent
                        of Authorization Reviews Completed this Quarter

                    

                  	 	
                    
                      Reason
                        for Denial

                    

                  
	
                    
                      (1)

                    

                  	
                    
                      (2)

                    

                  	
                    
                      (3)

                    

                  	
                    
                      (4)

                    

                  	
                    
                      (5)

                    

                  	
                    
                      (6)

                    

                  	
                    
                      (7)

                    

                  	
                    
                      (8)

                    

                  	
                    
                      (9)

                    

                  	
                    
                      (10)

                    

                  	
                    
                      (11)

                    

                  	
                    
                      (12)

                    

                  	
                    
                      (13)

                    

                  	
                    
                      (14)

                    

                  
	
                    Rank

                  	
                    Name
                      of Drug

                  	
                    Therapeutic
                      Class

                  	
                    Total

                  	
                    Number
                      Approved

                  	
                    Number
                      Denied

                  	
                    Percent
                      Approved

                  	
                    Percent
                      Denied

                  	
                    Number
                      of Temporary Supply

                  	
                    Inappropriate
                      Diagnosis

                  	
                    Equally
                      Effective Alternative on Formulary

                  	
                    Medical
                      Necessity not Established

                  	
                    Lack
                      of Information

                  	
                    Other

                  
	
                    
                      1

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #D!V/0!

                    

                  	 	 	 	 	 	 
	
                    
                      2

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      3

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/O!

                    

                  	 	 	 	 	 	 
	
                    
                      4

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      5

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      6

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DlV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      7

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      8

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      9

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      10

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      11

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      12

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      13

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      14

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      15

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      16

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      17

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      18

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      19

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      20

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      21

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      22

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      23

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      24

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!
                        .

                    

                  	 	 	 	 	 	 
	
                    
                      25

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      26

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      27

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      28

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      ,.#DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      29

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                       #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      30

                    

                  	 	 	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	 	
                    
                      Subtotal

                    

                  	
                    
                      0

                    

                  	
                    
                      0

                    

                  	
                    
                      0

                    

                  	
                    
                      #DiV/0!

                    

                  	
                    
                      WDIV/0!

                    

                  	
                    
                      0

                    

                  	
                    
                      0

                    

                  	
                    
                      0

                    

                  	
                    
                      0

                    

                  	
                    
                      0

                    

                  	
                    
                      0

                    

                  
	
                    
                      All
                        other requests for PA

                    

                  	 	 	 	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	 	 	 	 	 	 
	
                    
                      Total
                        of all requests for PA

                    

                  	
                    
                      0

                    

                  	
                    
                      0

                    

                  	
                    
                      0

                    

                  	
                    
                      #DIV/0!

                    

                  	
                    
                      #DIV/0!

                    

                  	
                    
                      0

                    

                  	
                    
                      0

                    

                  	
                    
                      0

                    

                  	
                    
                      0

                    

                  	
                    
                      0

                    

                  	
                    
                      0

                    

                  

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

          
            APPENDIX
              M

          

          
            

          

          RATE
            CERTIFICATION

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        APPENDIX
          N

        

        HUSKY
          BEHAVIORAL HEALTH CARE-OUT COVERAGE

        AND
          COORDINATION OF MEDICAL AND BEHAVIORAL SERVICES

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        

        
          HUSKY
            A -
            05/07 - Appendix N

        

        
          

        

        
          

        

        
          

        

        
          HUSKY
            BEHAVIORAL

        

        
          

        

        
          

        

        
          Health
            Carve-Out

        

        
          

        

        
          

        

        
          Coverage
            and Coordination of Medical and Behavioral
            Services

        

        
          

        

        
          

        

        
          

        

        
          

        

        
          DEPARTMENT
            OF SOCIAL SERVICES DEPARTMENT OF CHILDREN AND FAMILIES

        

        
          

          Updated
            January 26, 2006

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Contents

        

        
          

        

        
          	
                  
                    Introduction

                  

                	
                  
                    3

                  

                
	
                  
                    Ancillary
                      Services

                  

                	
                  
                    3

                  

                
	
                  
                    Co-Occurring
                      Medical and Behavioral Health Conditions - Screening, Referral,
                      and
                      Coordination

                  

                	
                  
                    4

                  

                
	
                  
                    Freestanding
                      Medical/Primary Care Clinics

                  

                	
                  
                    5

                  

                
	
                  
                    Home
                      Health Services

                  

                	
                  
                    5

                  

                
	
                  
                    Hospital
                      Emergency Department

                  

                	
                  
                    7

                  

                
	
                  
                    Hospital
                      Inpatient Services

                  

                	
                  
                    8

                  

                
	
                  
                    Hospital
                      Outpatient Clinic Services

                  

                	
                  
                    9

                  

                
	
                  
                    HUSKY
                      Plus Behavioral

                  

                	
                  
                    9

                  

                
	
                  
                    Long
                      Term Care

                  

                	
                  
                    9

                  

                
	
                  
                    Member
                      Services

                  

                	
                  
                    10

                  

                
	
                  
                    Mental
                      Health Clinics

                  

                	
                  
                    10

                  

                
	
                  
                    Methadone
                      Maintenance

                  

                	
                  
                    11

                  

                
	
                  
                    Multi-Disciplinary
                      Examinations

                  

                	
                  
                    11

                  

                
	
                  
                    Notice
                      of Action

                  

                	
                  
                    11

                  

                
	
                  
                    Operations

                  

                	
                  
                    12

                  

                
	
                  
                    Outreach

                  

                	
                  
                    12

                  

                
	
                  
                    Pharmacy

                  

                	
                  
                    12

                  

                
	
                  
                    Primary
                      Care Behavioral Health Services

                  

                	
                  
                    13

                  

                
	
                  
                    Quality
                      Management

                  

                	
                  
                    14

                  

                
	
                  
                    Reports

                  

                	
                  
                    14

                  

                
	
                  
                    School-Based
                      Health Center Services

                  

                	
                  
                    15

                  

                
	
                  
                    Transportation

                  

                	
                  
                    16

                  

                

        

         

        State
          of
          Connecticut                                                             Page
          2                                                           01/26/06

        
 

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Introduction

        

        
          

          The
            purpose of this document is to outline the policies according to which
            the HUSKY
            MCOs and the Behavioral Health Partnership (BHP) will share responsibility
            for
            providing covered services to HUSKY A and B enrollees after HUSKY behavioral
            health benefits are carved out and administered under a contract with
            the BHP
            Administrative Service Organization ("BHP ASO"). After the carve-out,
            the
            Managed Care Organizations that participate in HUSKY A and B ("HUSKY
            MCOs") will
            be responsible for providing services for medical conditions and BHP
            will be
            responsible for providing services for behavioral health conditions.
            The BHP ASO
            will provide member services, provider relations services, utilization
            management, intensive care management, quality management and other management
            services to facilitate the provision of timely, effective, and coordinated
            services under the BHP. The BHP ASO will not be responsible for contracting
            with
            providers or maintaining a provider network. Behavioral health providers
            will be
            required to enroll in the Department of Social Services' Connecticut
            Medical
            Assistance Program Network (CMAP). With the exception of DCF funded residential
            services, claims will be processed by the Department of Social Services'
            Medicaid vendor, Electronic Data Systems (EDS).

        

        
          This
            document is intended to summarize the coverage responsibilities and coordination
            responsibilities for each of the major service areas as established by
            the HUSKY
            BH carve-out transition planning workgroup. In addition to this document,
            which
            is intended for use as an amendment or attachment to the ASO and MCO
            contracts,
            each of the HUSKY MCOs will develop a coordination agreement with the
            BHP ASO.
            The coordination agreements will further elaborate the coordination protocols
            with special attention to the areas noted below and to the key contacts
            and
            workflows particular to each MCO.

        

        
          

          Ancillary
            Services

        

        
          

          HUSKY
            MCOs will retain responsibility for all ancillary services such as laboratory,
            radiology, and medical equipment, devices and supplies regardless of
            diagnosis.
            However, laboratory costs for methadone chemistry (quantitative analysis)
            will
            be covered under the BHP when they are part of the bundled reimbursement
            for
            methadone maintenance providers. The HUSKY MCOs may track and trend laboratory
            utilization as part of coordination with the BHP ASO. In addition, the
            MCOs will
            address any increases in the utilization trend with The Department of
            Social
            Services.

        

        
          

          State
            of
            Connecticut                                                              Page
            3                                                           01/26/06

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Co-Occurring
            Medical and Behavioral Health Conditions - Screening, Referral, and
            Coordination

        

        
          

          The
            HUSKY
            MCOs currently have programs and procedures designed to support the
            identification of untreated behavioral health disorders in medical patients
            at
            risk for such disorders. Such procedures may be carried out by medical
            service
            providers or by the MCO through the utilization management, case management
            and
            quality management processes. The MCOs will be expected to continue such
            activities in order to foster early and effective treatment of behavioral
            health
            disorders, including those disorders that could affect compliance with
            and the
            effectiveness of medical interventions.

        

        
          

          Both
            the
            HUSKY MCOs and the BHP ASO will be required to communicate and coordinate
            as
            necessary to ensure the effective coordination of medical and behavioral
            health
            benefits. The HUSKY MCOs will contact the BHP ASO when co-management
            is
            indicated (including BH hospital emergency department visits), such as
            for
            persons with special physical health and behavioral health needs; will
            respond
            to inquiries by the BHP ASO regarding the presence of medical co-morbidities;
            and will coordinate with the BHP ASO when invited to do so. Conversely,
            the BHP
            ASO will contact the HUSKY MCOs when co-management is indicated; will
            respond to
            inquiries by the HUSKY MCOs regarding the presence of behavioral co-morbidities;
            and will coordinate with the HUSKY MCOs when invited to do
            so.

        

        
          

          Both
            the
            BHP ASO and the MCOs will assign key contacts in order to facilitate
            timely
            coordination. In addition, it is anticipated that the BHP ASO's intensive
            care
            management department will be able to accept warm-line transfers as necessary
            from the HUSKY MCO case management departments to facilitate timely
            co-management.

        

        
          

          The
            BHP
            ASO will convene Medical/Behavioral Co-Management meetings at least once
            a month
            with each HUSKY MCO. The frequency of the meetings will be by agreement
            between
            the BHP ASO and each HUSKY MCO. The purpose of the meeting will be to
            ensure
            appropriate management of clients with co-occurring medical and behavioral
            health conditions. Cases discussed between the BHP ASO and the MCO will
            include
            all levels of behavioral health and medical care. Furthermore, the BHP
            ASO and
            the HUSKY MCOs shall provide reports in advance of the meetings on the
            cases to
            be reviewed.

        

        
          

          The
            HUSKY
            MCOs and the BHP ASO will from time to time make a determination as to
            whether a
            client's medical or behavioral health condition is primary. If there
            is a
            conflicting determination as to whether medical or behavioral health
            is primary,
            the respective medical directors will work together toward a timely and
            mutually
            agreeable resolution. At the request of either party, the Department
            of Social
            Services will make a determination as to the whether medical or behavioral
            health is primary and that determination shall be binding.

        

        
          

          State
            of
            Connecticut                                                             Page
            4                                                           01/26/06

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          Freestanding
            Medical/Primary Care Clinics

        

        
          

          The
            HUSKY
            MCOs will be responsible for primary care and other medical services
            provided by
            freestanding primary care/medical clinics regardless of diagnosis except
            for
            behavioral health evaluation and treatment services billed under CPT
            codes
            90801-90806, 90853, 90846, 90847, and 90862 with a primary behavioral
            health
            diagnosis and only when provided by a licensed behavioral health
            professional.

        

        
          

          Home
            Health Services

        

        
          

          HUSKY
            MCOs and BHP will share responsibility for covering home health services.
            The
            coordination agreements will include language that details procedures
            for
            resolving coverage responsibility issues. Home health coordination will
            be based
            on the following guidelines:

        

        
          

          The
            HUSKY
            MCOs will be responsible for management and payment of claims when home
            health
            services are required for the treatment of medical diagnoses alone and
            when home
            health services are required to treat both medical and behavioral diagnoses,
            but
            the medical diagnosis is primary. If the individual's behavioral health
            treatment needs cannot be safely and effectively managed by the medical
            nurse
            and/or aide, the home care agency will be required to provide psychiatric
            nursing and/or aide services separately authorized and paid for under
            the
            BHP.

        

        
          

          BHP
            will
            be responsible for management and payment of claims when home health
            services
            are required for the treatment of behavioral diagnoses alone (ICD 9:
            291-316)
            and when home health services are required to treat both medical and
            behavioral
            diagnoses, but the behavioral diagnosis is primary. If the individual's
            medical
            treatment needs cannot be safely and effectively managed by the psychiatric
            nurse and/or aide, then the home care agency will be required to provide
            medical
            nursing and/or aide services separately authorized and paid for by the
            HUSKY
            MCOs.

        

        
          

          The
            following table summarizes this policy:

        

        

        
          	
                  
                    HUSKY
                      MCOs

                  

                	
                  
                    BHP
                      ASO

                  

                
	
                  
                    Medical
                      diagnosis only

                  

                	
                  
                    Behavioral
                      diagnosis only

                  

                
	
                  
                    Medical
                      and behavioral diagnoses, Med primary

                  

                	
                  
                    Behavioral
                      and medical diagnoses, Behavioral primary

                  

                
	
                  
                    Medical
                      component only, when medical and behavioral diagnoses are present
                      and
                      behavioral health needs cannot be effectively managed by the
                      medical nurse
                      and/or aide.

                  

                	
                  
                    Behavioral
                      component only, when behavioral and medical diagnoses are present
                      and
                      medical needs cannot be effectively managed by the medical
                      nurse and/or
                      aide.

                  

                

        

        
          

          In
            addition, HUSKY MCOs will manage and pay claims for home health physical
            therapy, occupational therapy, and speech therapy services regardless
            of
            diagnosis.

        

        
          

          State
            of
            Connecticut                                          
Page
            5             
                  
01/26/06

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          When
            physical therapy, occupational therapy, and speech therapy services occur
            alongside home health behavioral health services, the home health care
            agency
            will be required to get authorization from and submit claims to the both
            the
            HUSKY MCO and to Electronic Data Systems (EDS), the claims vendor for
            the
            BHP.

        

        
          

          The
            above
            policy will require that providers and management entities make decisions
            as to
            whether a medical or behavioral diagnosis is primary. This determination
            will be
            made at the time the service is presented for authorization. The determination
            will be based on the diagnosis that is the principal focus of the services
—
typically the one that requires the most time and/or expertise. A rebuttable
            presumption shall be made that the primary diagnosis is psychiatric if
            a
            psychiatrist makes the referral. The following examples should help in
            determining the issue of primary diagnosis:

        

        
          

          
            	
                    • 

                  	
                    In
                      general, if a recipient is receiving home health behavioral
                      health
                      services and at some point requires home health services for
                      a medical
                      condition, the behavioral health diagnosis remains primary
                      if the medical
                      treatment needs can be safely and effectively managed by the
                      nurse that is
                      providing the behavioral health services. If the medical condition
                      requires treatment by a medical nurse, and the medical nurse
                      is able to
                      safely assume responsibility for the behavioral condition,
                      then the
                      medical diagnosis becomes
                      primary.

                  

          

        

        
          

          
            	
                    •  

                  	
                    Similarly,
                      if a recipient is receiving home health medical services and
                      at some point
                      requires home health behavioral services for a behavioral condition,
                      the
                      medical diagnosis remains primary if the behavioral health
                      treatment needs
                      can be safely and effectively managed by the nurse that is
                      providing the
                      medical services. If the behavioral condition requires treatment
                      by a
                      psychiatric nurse, and the psychiatric nurse is able to safely
                      assume
                      responsibility for the medical condition, then the behavioral
                      diagnosis
                      becomes primary.

                  

          

        

        
          

          If,
            at
            some point, separate nurses or aides are required to provide the behavioral
            and
            medical services, then the nurse and/or aide treating the medical condition
            must
            obtain authorization and payment from the HUSKY MCO and the nurse and/or
            aide
            treating the behavioral health condition must obtain authorization and
            payment
            under the BHP.

        

        
          

          In
            some
            cases, a recipient will not require treatment for both a medical and
            behavioral
            condition at every visit. For example, a recipient may require two visits
            per
            day for his or her medical condition, but only one visit per day for
            the
            behavioral health condition, hi this case, the medical condition ought
            to be
            billed as primary for both visits. Conversely, if a recipient requires
            two
            visits per day for his or her behavioral condition, but only one visit
            per day
            for the medical condition, the behavioral condition ought to be billed
            as
            primary for both visits.

        

        
          

          Finally,
            the primary reason for a visit may change from medical to behavioral
            or visa
            versa in the course of home health treatment. If this change occurs at
            the time
            of re-authorization, the home health care agency should pursue a new
            authorization from the entity with responsibility for the new condition
            for
            which home health care is required. If

        

        
          

          State
            of
            Connecticut                                                             Page
            6                                                           01/26/06

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          the
            change in primary diagnosis occurs during an authorized episode of care,
            the
            home health care agency should discontinue services under the preceding
            authorization and pursue a new authorization from the entity with responsibility
            for the services going forward. If the HUSKY MCO reviews a request for
            authorization and believes that the primary has changed from medical
            to
            behavioral health, the MCO should direct the home care agency to pursue
            authorization through the BHP ASO.   The converse is also true.
            If the primary is not apparent, the clinical reviewers from the BHP ASO
            and the
            MCO should confer and come to agreement.

        

        
          

          Data
            provided by the HUSKY MCOs suggests that there are a modest number of
            clients
            with diagnoses of autism or mental retardation receiving home health
            services
            and that more than half of these clients have mixed diagnoses that could
            complicate management and billing. BHP will be responsible for the management
            and payment of claims when home health services are required for the
            treatment
            of autism, whether on its own or co-morbid with mental retardation. For
            those
            members with these dual diagnoses, providers will be directed to obtain
            authorization from the BHP ASO and to bill EDS with autism primary. The
            HUSKY
            MCOs will retain responsibility for mental retardation alone. BHP will
            also be
            responsible for management and payment of claims when home health services
            are
            required for the treatment of both autism and medical disorders, when
            the
            medical disorder can be safely and effectively managed by the psychiatric
            nurse
            and/or aide. If the individual's medical treatment needs are so significant
            that
            they cannot be safely and effectively managed by the psychiatric nurse
            and/or
            aide, then the home care agency will be required to provide medical nursing
            and/or aide services separately authorized and paid for by the HUSKY
            MCOs.

        

        
          

          All
            home
            health care agencies operating in Connecticut are enrolled in the Connecticut
            Medical Assistance Program (CMAP) network and may, at their discretion,
            provide
            behavioral health home health services to HUSKY recipients. In contrast,
            the
            HUSKY MCOs may contract with only a subset of the CMAP providers. This
            means
            that there may be times when a client is in treatment for a behavioral
            health
            condition with a CMAP provider that is not participating with a HUSKY
            MCO. If
            this client develops a co-occurring medical disorder that is secondary
            and can
            be managed by the psychiatric home care nurse, BHP will continue to be
            responsible for management and payment of claims. If, however, the patient's
            medical disorder becomes primary and thus the responsibility of the HUSKY
            MCO,
            the HUSKY MCO can elect to continue to use the home care provider as
            an out of
            network provider, or the HUSKY MCO can, at its discretion, transition
            the care
            to a participating home care provider. The client's best interest will
            be a
            factor in this determination. The MCOs and BHP ASO will be expected to
            create
            coordination agreements to expedite the proper handling of such
            cases.

        

        
          

          Hospital
            Emergency Department

        

        
          

          The
            HUSKY
            MCOs will assume responsibility for emergency department services, including
            emergent and urgent visits and all associated charges billed by the facility,
            regardless of diagnosis. Professional psychiatric services rendered in
            an
            emergency department by a community psychiatrist will be reimbursed by
            the BHP
            if the psychiatrist

        

        
          

          State
            of
            Connecticut                                                             Page
            7                                                           01/26/06

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          is
            enrolled in CMAP as an independent solo or group practitioner and bills
            under
            the solo or group practice ID. The BHP will be responsible for observation
            stays
            of 23 hours or less (RCC 762) with a primary behavioral health diagnosis.
            The
            HUSKY MCOs and the Department will implement audit procedures to ensure
            that
            hospitals do not bill HUSKY MCOs for emergency department services when
            patients
            are admitted to the hospital and behavioral health is primary. The HUSKY
            MCOs
            may track and trend Emergency Department utilization for behavioral health.
            The
            MCOs will address any increase in the utilization trend with the
            Departments.

        

        
          

          Hospital
            Inpatient Services

        

        
          

          In
            order
            to assure appropriate coordination and communication, the coordination
            agreements will include specific language detailing processes and procedures
            for
            concurrent communication and the process for handling co-occurring medical
            and
            behavioral health hospital inpatient conditions. In addition, the agreements
            will include specific language on the procedures for resolving coverage
            related
            issues when the ASO and MCOs disagree. Coordination will be based on
            the
            following guidelines:

        

        
          

          Psychiatric
            Hospitals

        

        
          

          BHP
            will
            be responsible for all psychiatric hospital services and all associated
            charges
            billed by a psychiatric hospital, regardless of diagnosis. The rate is
            all-inclusive so there will be no reimbursement for professional services
            rendered by community-based consulting physicians.

        

        
          

          General
            Hospitals

        

        
          

          HUSKY
            MCOs and BHP will share responsibility for covering inpatient general
            hospital
            services. The HUSKY MCOs will be responsible for management and payment
            of
            claims for inpatient general hospital services when the medical diagnosis
            is
            primary. Medical would be considered primary when the billed RCC and
            the primary
            diagnosis are both medical.

        

        
          

          During
            a
            medical stay, BHP will be responsible for professional services associated
            with
            behavioral health diagnoses. The admitting physician will be responsible
            for
            coordinating medical orders for any necessary behavioral health services
            with
            the BHP ASO. Other ancillary charges associated with non-primary behavioral
            health diagnoses shall remain the responsibility of the HUSKY MCOs, as
            described
            in the ancillary services section of this document.

        

        
          

          BHP
            will
            be responsible for management and payment of claims for inpatient general
            hospital services when the behavioral diagnosis is primary. The behavioral
            diagnosis will be considered primary when the billed RCC and the primary
            diagnosis are both behavioral or when the billed RCC is medical, but
            the primary
            diagnosis on the claim form is behavioral. During a behavioral stay,
            the HUSKY
            MCOs will be responsible for professional services and other charges
            associated
            with primary medical diagnoses.

        

        
          

          State
            of
            Connecticut                                                             Page
            8                                                           01/26/06

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        
          
            	
                     

                  	
                    o   When
                      an admission to a general hospital is initially medical, but
                      the reason
                      for continued admission becomes behavioral, responsibility
                      for management
                      and payment of claims will transition to BHP. When the hospital
                      admission
                      is no longer medically necessary for the medical diagnosis,
                      the HUSKY MCO
                      ceases to be responsible for management and payment. The BHP
                      ASO will
                      monitor the timeliness of transfer from a medical unit to a
                      psychiatric
                      unit when the primary diagnosis changes from medical to behavioral
                      health.

                  

          

        

        
          

          The
            following table summarizes this policy:

        

        

        
          	
                  
                    Inpatient
                      Payment for Primary Diagnosis

                  

                	 	
                  
                    Professional
                      Services Paid for Secondary Diagnosis

                  

                
	
                  
                    Inpatient
                      Type

                  

                	
                  
                    Revenue
                      Codes

                  

                	
                  
                    Diagnosis

                  

                	
                  
                    Assignment

                  

                	 	
                  
                    HCPCS

                  

                	
                  
                    Diagnosis

                  

                	
                  
                    Assignment

                  

                
	
                  
                    General
                      Hospital

                  

                	
                  
                    BH

                  

                	
                  
                    BH

                  

                	
                  
                    BHP

                  

                	 	
                  
                    BH

                  

                	
                  
                    BH

                  

                	
                  
                    BHP

                  

                
	
                  
                    General
                      Hospital

                  

                	
                  
                    BH

                  

                	
                  
                    BH

                  

                	
                  
                    BHP

                  

                	 	
                  
                    Med

                  

                	
                  
                    Med

                  

                	
                  
                    MCO

                  

                
	
                  
                    General
                      Hospital

                  

                	
                  
                    Med

                  

                	
                  
                    BH

                  

                	
                  
                    BHP

                  

                	 	
                  
                    BH

                  

                	
                  
                    BH

                  

                	
                  
                    BHP

                  

                
	
                  
                    General
                      Hospital

                  

                	
                  
                    Med

                  

                	
                  
                    BH

                  

                	
                  
                    BHP

                  

                	 	
                  
                    Med

                  

                	
                  
                    Med

                  

                	
                  
                    MCO

                  

                
	
                  
                    General
                      Hospital

                  

                	
                  
                    Med

                  

                	
                  
                    Med

                  

                	
                  
                    MCO

                  

                	 	
                  
                    Med

                  

                	
                  
                    Med

                  

                	
                  
                    MCO

                  

                
	
                  
                    General
                      Hospital

                  

                	
                  
                    Med

                  

                	
                  
                    Med

                  

                	
                  
                    MCO

                  

                	 	
                  
                    BH

                  

                	
                  
                    BH

                  

                	
                  
                    BHP

                  

                

        

        
          

          Hospital
            Outpatient Clinic Services

        

        
          

          BHP
            will
            be responsible for all outpatient psychiatric clinic, intensive outpatient,
            extended day treatment, and partial hospitalization services provided
            by general
            and psychiatric hospitals for the evaluation and treatment of behavioral
            health
            disorders. BHP will also cover evaluation and treatment services related
            to a
            non-behavioral health diagnosis if the billing code is psychiatric as
            outlined
            in the covered services grid.

        

        
          

          The
            HUSKY
            MCOs will be responsible for all primary care and other medical services
            provided by hospital medical clinics regardless of diagnosis including
            all
            medical specialty services and all ancillary services.

        

        
          

          HUSKY
            Plus Behavioral

        

        
          

          HUSKY
            Plus Behavioral services (intensive in-home psychiatric services) will
            be
            included in the HUSKY B benefit package. The ASO will manage access to
            these
            services under the carve-out.

        

        
          

          Long
            Term
            Care

        

        
          

          The
            HUSKY
            MCOs will be responsible for all long term care services (i.e., nursing
            homes,
            chronic disease hospitals) regardless of diagnosis. These services are
            seldom

          

        

        
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          required
            for the treatment of clients with primary behavioral health disorders
            under the
            HUSKY program. The admission of a client with a primary behavioral health
            disorder must be by mutual agreement of the BHP ASO and the HUSKY MCO
            in which
            the client is enrolled.

        

        
          

          DSS
            currently exempts any long-term care client from managed care the first
            of the
            month in which the client's stay exceeds 90 days. DSS will consider early
            exemption for clients with a primary behavioral health diagnosis if DSS
            were
            provided with adequate notice when such clients are admitted to long-term
            care.

        

        
          

          Member
            Services

        

        
          

          The
            BHP
            ASO will have its own member services department with a dedicated toll
            free
            phone number. The member services staff will provide non-clinical information
            to
            recipients and when appropriate provide immediate access to clinical
            staff for
            care related assistance. The member services staff will respond to all
            calls
            directed to the member services line and it is expected will have the
            ability to
            accept warm-line transfers from the HUSKY MCOs. The HUSKY MCOs will replace
            references to existing BH subcontractors on member materials with the
            new BHP
            ASO name and member services phone number, wherever such references occur.
            Branch logic for the DSS' 1-877-CTHUSKY number will be modified to incorporate
            the ASO member services line as an option for callers that require BHP
            related
            assistance.

        

        
          

          The
            MCOs
            will continue to conduct welcome calls to new members. At the time of
            the
            welcome call, the HUSKY MCO member services representative will provide
            the
            member with information on how to access the BHP ASO.

        

        
          

          HUSKY
            MCO
            member services departments will occasionally receive calls from members
            who are
            requesting BH services. In addition, BH issues may emerge in the course
            of a
            welcoming call. The member may screen positive for behavioral health
            issues and
            express an interest in discussing further or have clear behavioral health
            issues
            and need a referral. In either case, the member service representative
            can
            affect a warm-line transfer to the ASO member services department, take
            the
            member's information and fax this information to the ASO for follow-up,
            or
            provide the member with the telephone number for the BHP ASO.

        

        
          

          If
            the
            client is in crisis, the MCO member services representative should follow
            the
            MCO's protocols for handling crisis calls. The BHP ASO will have the
            capacity to
            accept warm-line transfer of such crisis calls when, at the discretion
            of the
            MCO, such transfer is appropriate.

        

        
          

          Mental
            Health Clinics

        

        
          

          BHP
            will
            be responsible for all Mental Health Clinic Services regardless of diagnosis
            including routine outpatient services and all diagnostic and treatment
            services
            billed as intensive outpatient treatment, extended day treatment, and
            partial
            hospitalization

        

        
          

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          treatment.
            BHP will also cover evaluation and treatment services related to a medical
            diagnosis such as psychological testing for a client with traumatic brain
            injury.

        

        
          

          Methadone
            Maintenance

        

        
          

          BHP
            will
            be responsible for reimbursing methadone clinics for methadone maintenance
            services provided to HUSKY enrollees. All methadone maintenance services
            for
            which the source of service is the methadone maintenance clinic are included
            in
            the Department's bundled rate with methadone maintenance
            clinics.   The MCOs will cover all methadone maintenance
            laboratory services when billed by an independent laboratory

        

        
          

          Multi-Disciplinary
            Examinations

        

        
          

          The
            MCOs
            will be responsible for contracting with DCF certified Multi-Disciplinary
            Examination providers and for covering all components of the DCF
            Multi-Disciplinary Examinations including behavioral health evaluation
            services
            (e.g., 90801, 96110). .

        

        
          

          Notice
            of
            Action

        

        
          

          The
            HUSKY
            MCOs will be responsible for issuing notices of action for medical review
            decisions and the BHP ASO will be responsible for issuing notices of
            action for
            behavioral health review decisions. The HUSKY MCOs will issue notices
            of action
            to the client and the provider, but will not issue a notice to the BHP
            ASO.
            Similarly, the BHP ASO will issue notices of action to the client and
            the
            provider, but will not issue a notice to the HUSKY MCO.

        

        
          

          In
            preparation for a fair hearing, the Department of Social Services will
            work with
            the Department's contractor that issued the notice to prepare the Department's
            case. Typically, the ASO will not be involved in an MCO related fair
            hearing and
            the MCO will not be involved in an ASO related fair hearing. However,
            when a
            client has co-morbid medical and behavioral health conditions and the
            action
            affects both conditions, then both the MCO and the ASO may be involved
            in
            preparation for the fair hearing.

        

        
          

          If
            a
            HUSKY MCO or one of its providers disagrees with a clinical management
            decision
            made by the BHP ASO, the HUSKY MCO is encouraged to raise the issue with
            the ASO
            on behalf of the client and to resolve the issue informally prior to
            the
            scheduled fair hearing. The converse is also true. If the issue remains
            unresolved, DSS will review the issue with the HUSKY MCO and the ASO
            and make a
            determination as to whether DSS supports the decision of the contractor
            that
            issued the notice. If DSS supports the contractor that issued the notice,
            the
            matter will proceed to fair hearing.

        

        
          

          The
            HUSKY
            MCOs may at times refer a client or provider to the BHP ASO because the
            primary
            presenting condition is behavioral health rather than medical. The HUSKY
            MCO's
            determination that a condition is behavioral health rather than medical
            shall
            not constitute grounds for issuing a notice of action. The converse is
            true for
            the BHP ASO.

        

        
          

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          The
            HUSKY
            MCO may at times issue a notice of action for a prescription written
            by a CMAP
            enrolled behavioral health prescribing provider. In such instances, the
            HUSKY
            MCO will be expected to send notice of action to the client and to the
            prescribing provider.

        

        
          

          Operations

        

        
          

          In
            order
            to support coordination and communication regarding operational issues
            such as
            claims payment, the Departments will host a monthly meeting with the
            BHP ASO and
            the HUSKY MCOs.

        

        
          

          Outreach

        

        
          

          The
            HUSKY
            MCOs currently provide outreach to members to assist them with accessing
            necessary services. The MCOs will continue to provide outreach to members
            to
            assist them with accessing medical services. For example, they may reach
            out to
            members to connect them to a primary care provider or to ensure necessary
            follow-up after a medical hospitalization. If an MCO's outreach worker
            identifies a member with a behavioral health issue, the worker may, at
            the MCO's
            discretion, provide information to the member on how to access behavioral
            health
            services via the ASO or facilitate a direct referral.

        

        
          

          The
            BHP
            ASO will conduct extensive outreach focused on connecting clients to
            behavioral
            health care when clients are experiencing barriers to care. They will
            also make
            efforts to ensure a connection to care after discharge from a hospital
            or
            residential treatment center. If in the course of outreach the BHP ASO
            identifies a member with a significant medical issue, the ASO may provide
            information to the member on how to access necessary medical services
            through
            the MCO or the member's primary care provider or facilitate a direct
            referral.

        

        
          

          Pharmacy

        

        
          

          The
            HUSKY
            MCOs will assume responsibility for all pharmacy services and all associated
            charges, regardless of diagnosis. However, methadone costs that are part
            of the
            bundled reimbursement for methadone maintenance and ambulatory detox
            providers
            will be covered under BHP. Methadone maintenance providers and ambulatory
            detox
            providers are responsible for supplying and dispensing methadone and
            these costs
            are covered by the BHP as part of an all-inclusive rate.

        

        
          

          Each
            HUSKY MCO maintains its own pharmacy program with distinct formularies,
            drug
            utilization review requirements, and prior authorization requirements.
            Under
            BHP, the Departments will have contracts with prescribing behavioral
            health
            providers and these providers will be required to follow the pharmacy
            program
            requirements of the HUSKY MCO in which the member is enrolled as well
            as other
            applicable Medicaid program

        

        
          

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          requirements.
            BHP prescribing providers include psychiatrists, psychiatric nurses,
            freestanding behavioral health clinics, and hospitals.

        

        
          

          DSS
            disseminates all policy transmittals and provider bulletins for CMAP
            providers
            through EDS. The ASO will not have a role in communications of this type.
            DSS
            will issue a provider bulletin to all enrolled prescribing providers
            prior to
            the carve-out date in order to apprise the providers of the pharmacy
            program
            requirements of each MCO and remind providers of the HUSKY program's
            temporary
            supply rules. DSS will require that providers adhere to each MCOs pharmacy
            program requirements and provide MCOs with any clinical information necessary
            to
            support requests for authorization or the preparation of clinical summaries
            for
            the purpose of fair hearings.

        

        
          

          Subsequently,
            the MCOs must notify DSS of changes to its pharmacy program requirements.
            DSS
            will in turn use the provider bulletin process to notify CMAP providers
            of such
            changes within 30 days of the effective date. The Departments prefer
            that DSS
            manage such pharmacy program communications since it will have a complete
            and
            up-to-date file of enrolled prescribing providers. This new communication
            process should resolve some of the pharmacy program communication issues
            that
            currently exist in the HUSKY program. Specifically, among some HUSKY
            MCOs,
            certain providers such as freestanding behavioral health clinics are
            not
            included in routine pharmacy program communications issued by the MCO.
            Under the
            carve-out, all providers will be apprised of the requirements of all
            HUSKY MCOs.
            The initial provider bulletin pertaining to pharmacy will provide each
            MCO's web
            address where pharmacy program requirements are available.

        

        
          The
            BHP
            ASO will fully cooperate with the MCOs and work closely with the MCOs
            to ensure
            compliance with the pharmacy programs of the individual MCOs. The BHP
            ASO will
            work closely with the MCOs to monitor pharmacy utilization and, if necessary,
            cooperate with the MCOs in conducting targeted provider education or
            training
            related to prescribing. DSS will require that its prescribing providers
            participate in quality initiatives and targeted pharmacy education and
            training
            conducted by the HUSKY MCOs for the purpose of improving prescribing
            practices
            and/or adherence to pharmacy program requirements. If the HUSKY MCOs
            encounter a
            behavioral health provider who engages in persistent misconduct related
            to
            psychiatric prescribing, the matter should be referred to DSS for
            investigation.

        

        
          

          The
            HUSKY
            MCOs may track and trend behavioral health pharmacy utilization and address
            any
            increase in the utilization trend with the Departments. DSS will continue
            to
            review each MCO's compliance with pharmacy contract provisions and new
            DSS staff
            will meet with each MCO to familiarize themselves with each MCO
            formulary/pharmacy process and available data in order to be prepared
            to work
            with the MCOs on reporting specs.

        

        
          

          Primary
            Care Behavioral Health Services

        

        
          

          The
            HUSKY
            MCOs will retain responsibility for all primary care services and all
            associated
            charges, regardless of diagnosis. These responsibilities
            include:

        

        
          

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          1.      behavioral
            health related prevention and anticipatory guidance;

        

        
          2.      screening
            for behavioral health disorders;

        

        
          
            	
                    3.

                  	
                    treatment
                      of behavioral health disorders that the primary care
                      physician concludes can be safely and appropriately treated in a
                      primary care setting;

                  

          

        

        
          
            	
                    4.

                  	
                    management
                      of psychotropic medications, when the primary care
                      physician concludes it is safe and appropriate to do so, in
                      conjunction with treatment by a BHP non-medical behavioral health
                      specialist when necessary;
                      and

                  

          

        

        
          
            	
                    5.

                  	
                    referral
                      to a behavioral health specialist when the primary care
                      physician concludes that it is safe and appropriate to do
                      so.

                  

          

        

        
          

          The
            BHP
            ASO will develop education and guidance for primary care physicians related
            to
            the provision of behavioral health services in primary care settings.
            At their
            discretion, the HUSKY MCOs can collaborate with the ASO in the development
            of
            education and guidance or they will be provided the opportunity to review
            and
            comment. The education and guidance will address PCP prescribing with
            support
            and guidance from the ASO or referring clinic, in circumstances when
            the PCP is
            comfortable with this responsibility. The BHP ASO will make telephonic
            psychiatric consultation services available to primary care providers.
            Consultation may be initiated by any primary care provider that is seeking
            guidance on psychotropic prescribing for a HUSKY A, HUSKY B, or Voluntary
            Services enrollee.

        

        
          

          To
            promote effective coordination and collaboration, the BHP ASO will work
            with
            interested HUSKY MCOs and provider organizations to sponsor opportunities
            for
            joint training. HUSKY MCO policies and provider contracts must permit
            the
            provision of behavioral health services by primary care providers; however,
            the
            MCOs will not be expected to provide education and training to improve
            ability
            of primary care providers to provide these services.

        

        
          

          The
            HUSKY
            MCOs may track and trend primary care behavioral health utilization.
            The MCOs
            will address any increase in the utilization trend with the
            Departments.

        

        
          

          Quality
            Management

        

        
          

          The
            BHP
            ASO will be required to conduct at least three quality improvement initiatives
            each year. For the second year of the contract, the ASO will invite the
            HUSKY
            MCOs to participate in a joint quality improvement initiative focused
            on an area
            of mutual concern. Each MCO may participate at its discretion. The Departments
            will determine during the second year of the project whether to ask the
            BHP ASO
            to propose an additional joint quality improvement initiative with the
            MCOs
            during the third year of its contract.

        

        
          

          Reports

        

        
          

          The
            BHP
            ASO will provide a weekly census report on all behavioral health inpatient
            stays
            identifying those with co-occurring medical and behavioral health conditions.
            In

        

        
          

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          addition,
            the reports in Exhibit E of the BHP ASO contract will also be made available
            to
            the MCOs upon request.

        

        
          

          The
            MCOs
            will provide daily and monthly reports and/or data as mutually agreed
            upon to
            the BHP ASO regarding i) behavioral health emergency department visits,
            ii)
            behavioral health emergency room recidivism, iii) substance abuse & neonatal
            withdrawal, iv) child/adolescent obesity and/or type II diabetes, v)
            sickle cell
            report, vi) eating disorders report, and vii) medical detox.

        

        
          

          The
            Departments will also make MCO specific behavioral health encounter data
            available to the MCOs upon request to support quality management activities
            and
            coordination. The format of the data extract will be consistent with
            the
            encounter data reporting format, or other format mutually agreed upon
            by the
            Departments and the MCO.

        

        
          

          The
            HUSKY
            MCOs will identify BH NEMT data versus medical NEMT data in their NEMT
            reporting
            to DSS. In addition, the HUSKY MCOs will track and trend NEMT complaints
            related
            to BH visits separately from NEMT complaints related to medical visits.
            The BHP
            ASO will also compile NEMT related complaints, although these complaints
            will be
            forwarded to the HUSKY MCOs for resolution.

        

        
          

          The
            MCOs
            will continue to include behavioral health access in their CAHPS survey
            and
            report this information to the Departments.

        

        
          

          School-Based
            Health Center Services

        

        
          

          In
            general, BHP will be responsible for reimbursing school-based health
            centers for
            behavioral health diagnostic and treatment services (CPT 90801-90807,
            90853,
            90846, and 90847) provided to students with a behavioral health diagnosis.
            The
            HUSKY MCOs will be responsible for primary care services provided by
            school-based health centers, regardless of diagnosis, but they will not
            be
            responsible for behavioral health assessment and treatment services billed
            under
            CPT codes 90801-90807, 90853, 90846, and 90847. The following narrative
            provides
            additional background and a rationale for this arrangement.

        

        
          

          School-based
            health centers currently provide a range of general health and behavioral
            health
            services that are reimbursable under the HUSKY program. All of these
            school-based health centers are licensed by the Department of Public
            Health,
            either as freestanding outpatient clinics or as satellites under a hospital
            license. Under these licenses, clinics can provide general medical services
            as
            well as behavioral health services.

        

        
          

          School-based
            health centers vary in their degree of expertise in the provision of
            behavioral
            health services. Some school-based health centers provide prevention
            and
            counseling for students with emotional or behavioral issues and bill
            for those
            services using general primary care prevention and counseling codes,
            often
            without a behavioral

        

        
          

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          health
            diagnosis. Those primary care and preventive counseling services that
            are
            currently covered under the MCO contracts with individual School-Based
            Health
            Centers will continue to be the responsibility of the HUSKY
            MCOs.

        

        
          

          Other
            school-based health centers have taken steps to develop their behavioral
            health
            services including relying on licensed behavioral health practitioners
            and/or
            affiliation agreements with local outpatient child psychiatric clinic
            that
            provide clinical staff, consultation, or oversight. If the school-based
            health
            center provides behavioral health diagnostic and treatment services,
            these
            services will be the responsibility of the BHP ASO. The school-based
            health
            center must enroll as a CMAP provider in order to be reimbursed for those
            services under BHP.

        

        
          

          In
            some
            cases, the behavioral health component of the school-based health center's
            services is provided under the license of an outpatient child psychiatric
            clinic. In this case, the outpatient child psychiatric clinic will be
            enrolled
            as a CMAP provider and the services provided will be reimbursable as
            behavioral
            health clinic services under BHP.

        

        
          

          Transportation

        

        
          

          All
            of
            the HUSKY MCOs will continue to provide transportation for HUSKY A enrollees
            with behavioral health disorders for behavioral health services that
            are covered
            under Medicaid. Specifically, the MCOs will continue to be responsible
            for
            transportation to hospitals, clinics, and independent professionals for
            routine
            outpatient, extended day treatment, intensive outpatient, partial
            hospitalization, detoxification, methadone maintenance, and inpatient
            psychiatric services. The MCOs will also be responsible for services
            that might
            be covered under EPSDT. For example, case management services are not
            included
            in the Connecticut Medicaid state plan, but they are covered under EPSDT
            when
            medically necessary. Although case management does not necessarily require
            transportation to a facility, if transportation to a facility were necessary
            for
            a case management encounter, the MCOs would be responsible for providing
            it.
            These policies under BHP are simply a continuation of current HUSKY A
            program
            policies.

        

        
          

          The
            MCOs
            will not be responsible for transportation for non-Medicaid services
            such as
            respite, or DCF funded services that are designed to come to the client
            including care coordination, emergency mobile psychiatric services, home-based
            services, and therapeutic mentoring.

        

        
          

          The
            transportation benefit for behavioral health visits will continue to
            be subject
            to the same policies and procedures applicable to other HUSKY A covered
            services. The Departments will issue a member services handbook that
            indicates
            that transportation services are covered for HUSKY A enrollees and that
            such
            services will be covered by the HUSKY MCO with which the member is enrolled.
            The
            handbook will indicate that the MCO specific transportation policies
            apply, that
            HUSKY MCO recipients should refer to their HUSKY member handbook for
            details,
            and arrange for transportation directly with their HUSKY MCO transportation
            broker.

        

        
          

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          The
            ASO
            will make referrals to the closest appropriate providers (typically 3
            names will
            be given upon request) and avoid referrals to facilities and offices
            outside of
            a 25-30 mile radius unless circumstances require otherwise. The ASO is
            not
            required to review provider distance from the member when responding
            to requests
            for authorization. The transportation brokers will assess all requests
            for
            transportation when contacted by the member and it will be up to the
            transportation broker and the MCO to apply coverage limitations as appropriate
            when contacted by the member. In most cases, the transportation broker
            and/or
            the MCO will be able to make decisions about whether to authorize transportation
            to the non-closest provider or to a provider that is outside of the 25-30
            mile
            radius by working directly with the member.   However, the ASO
            will be required to respond to inquiries from the MCO or transportation
            broker
            if additional information is needed to support authorization of a transportation
            request.

        

        
          

          The
            HUSKY
            MCOs will also retain responsibility for all Emergency Medical Transportation
            and associated charges, regardless of diagnosis, and hospital-to-hospital
            ambulance transportation of members with a behavioral health
            condition.

        

        
          

          The
            BHP
            ASO is expected to work closely with the MCOs to monitor transportation
            utilization and, if necessary, cooperate with the MCOs in conducting
            targeted
            provider education or training related to the appropriate use of transportation
            services. The HUSKY MCOs may track and trend utilization of transportation
            to
            behavioral health facilities. Any increases in the utilization trend
            will be
            addressed with the Departments.

        

        
          

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            of
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          APPENDIX
            O

        

        
          

        

        
          CTBHP
            Master Covered Services Table

        

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

         

        
          
            
              	
                       

                    	
                      CTBHP
                        Covered Services Table Revised July
                        31,2006

                    

            

          

          
            

            0507

          

          

          
            	
                    
                      HUSKY
                        A and B Appendix O - CT BHP Master Covered Services Table
                        - September
                        2006

                    

                  
	
                    
                      Coverage

                    

                  	
                    
                      1
                        =
                        HUSKY MCO - All diagnoses

                    

                  
	
                    
                      Responsibility

                    

                  	
                    
                      2=
                        BHP -All diagnoses

                    

                  
	
                    
                      Legend:

                    

                  	
                    
                      3=
                        BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                        diagnoses

                    

                  
	 	
                    
                      4=
                        Not covered

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      General
                        Hospital Inpatient

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      110

                    

                  	
                    
                      Room
                        & Board- Private

                    

                  	
                    
                      3

                    

                  
	
                    
                      111

                    

                  	
                    
                      Room
                        & Board- Private -Med/Surg/Gyn

                    

                  	
                    
                      3

                    

                  
	
                    
                      112

                    

                  	
                    
                      Room
                        & Board- Private -OB

                    

                  	
                    
                      3

                    

                  
	
                    
                      113

                    

                  	
                    
                      Room
                        & Board- Private -Pediatric

                    

                  	
                    
                      3

                    

                  
	
                    
                      114

                    

                  	
                    
                      Room
                        & Board - Private - Psychiatric

                    

                  	
                    
                      2

                    

                  
	
                    
                      115

                    

                  	
                    
                      Room
                        & Board- Private -Hospice

                    

                  	
                    
                      3

                    

                  
	
                    
                      116

                    

                  	
                    
                      Room
                        & Board - Private - Detox

                    

                  	
                    
                      2

                    

                  
	
                    
                      117

                    

                  	
                    
                      Room
                        & Board- Private -Oncology

                    

                  	
                    
                      3

                    

                  
	
                    
                      118

                    

                  	
                    
                      Room
                        & Board- Private -Rehab

                    

                  	
                    
                      3

                    

                  
	
                    
                      119

                    

                  	
                    
                      Room
                        & Board- Private -Other

                    

                  	
                    
                      3

                    

                  
	
                    
                      120

                    

                  	
                    
                      Room
                        & Board-Semi-Private/2 Bed

                    

                  	
                    
                      3

                    

                  
	
                    
                      121

                    

                  	
                    
                      Room
                        & Board-Semi-Private/ 2 Bed- Med/Surg/Gyn

                    

                  	
                    
                      3

                    

                  
	
                    
                      122

                    

                  	
                    
                      Room
                        & Board-Semi-Private/ 2 Bed -OB

                    

                  	
                    
                      3

                    

                  
	
                    
                      123

                    

                  	
                    
                      Room
                        & Board-Semi-Private/ 2 Bed-Pediatric

                    

                  	
                    
                      3

                    

                  
	
                    
                      124

                    

                  	
                    
                      Room
                        & Board - Semi-Private/2 Bed - Psychiatric

                    

                  	
                    
                      2

                    

                  
	
                    
                      125

                    

                  	
                    
                      Room
                        & Board-Semi-Private/ 2 Bed-Hospice

                    

                  	
                    
                      3

                    

                  
	
                    
                      126

                    

                  	
                    
                      Room
                        & Board - Semi-Private/2 Bed - Detox

                    

                  	
                    
                      2

                    

                  
	
                    
                      127

                    

                  	
                    
                      Room
                        & Board-Semi-Private/ 2 Bed-Oncology

                    

                  	
                    
                      3

                    

                  
	
                    
                      128

                    

                  	
                    
                      Room
                        & Board-Semi-Private/ 2 Bed-Rehab

                    

                  	
                    
                      3

                    

                  
	
                    
                      129

                    

                  	
                    
                      Room
                        & Board-Semi-Private/ 2 Bed-Other

                    

                  	
                    
                      3

                    

                  
	
                    
                      130

                    

                  	
                    
                      Room
                        & Board-Semi-Private/3-4 Bed

                    

                  	
                    
                      3

                    

                  
	
                    
                      131

                    

                  	
                    
                      Room
                        & Board-Semi-Private/3-4 Bed- Med/Surg/Gyn

                    

                  	
                    
                      3

                    

                  
	
                    
                      132

                    

                  	
                    
                      Room
                        & Board-Semi-Private/3-4 Bed-OB

                    

                  	
                    
                      3

                    

                  
	
                    
                      133

                    

                  	
                    
                      Room
                        & Board-Semi-Private/3-4 Bed-Pediatric

                    

                  	
                    
                      3

                    

                  
	
                    
                      134

                    

                  	
                    
                      Room
                        & Board - Semi-Private/3-4 Bed - Psychiatric

                    

                  	
                    
                      2

                    

                  
	
                    
                      135

                    

                  	
                    
                      Room
                        & Board-Semi-Private/3-4 Bed-Hospice

                    

                  	
                    
                      3

                    

                  
	
                    
                      136

                    

                  	
                    
                      Room
                        & Board - Semi-Private/3-4 Bed - Detox

                    

                  	
                    
                      2

                    

                  
	
                    
                      137

                    

                  	
                    
                      Room
                        & Board-Semi-Private/3-4 Bed-Oncology

                    

                  	
                    
                      3

                    

                  
	
                    
                      138

                    

                  	
                    
                      Room
                        & Board-Semi-Private/3-4 Bed-Rehab

                    

                  	
                    
                      3

                    

                  
	
                    
                      139

                    

                  	
                    
                      Room
                        & Board-Semi-Private/3-4 Bed-Other

                    

                  	
                    
                      3

                    

                  
	
                    
                      140

                    

                  	
                    
                      Room
                        & Board-Private-Deluxe

                    

                  	
                    
                      3

                    

                  
	
                    
                      141

                    

                  	
                    
                      Room
                        & Board-Private-Deluxe- Med/Surg/Gyn

                    

                  	
                    
                      3

                    

                  
	
                    
                      142

                    

                  	
                    
                      Room
                        & Board-Private - Deluxe-OB

                    

                  	
                    
                      3

                    

                  
	
                    
                      143

                    

                  	
                    
                      Room
                        & Board-Private - Deluxe-Pediatric

                    

                  	
                    
                      3

                    

                  
	
                    
                      144

                    

                  	
                    
                      Room
                        & Board - Private - Deluxe - Psychiatric

                    

                  	
                    
                      2

                    

                  
	
                    
                      145

                    

                  	
                    
                      Room
                        & Board-Private - Deluxe-Hospice

                    

                  	
                    
                      3

                    

                  
	
                    
                      146

                    

                  	
                    
                      Room
                        & Board - Private - Deluxe - Detox

                    

                  	
                    
                      2

                    

                  
	
                    
                      147

                    

                  	
                    
                      Room
                        & Board-Private - Deluxe-Oncology

                    

                  	
                    
                      3

                    

                  
	
                    
                      148

                    

                  	
                    
                      Room
                        & Board-Private - Deluxe-Rehab

                    

                  	
                    
                      3

                    

                  
	
                    
                      149

                    

                  	
                    
                      Room
                        & Board-Private - Deluxe-Other

                    

                  	
                    
                      3

                    

                  
	
                    
                      150

                    

                  	
                    
                      Room
                        & Board - Ward

                    

                  	
                    
                      3

                    

                  
	
                    
                      151

                    

                  	
                    
                      Room
                        & Board - Ward - Med/Surg/ Gyn

                    

                  	
                    
                      3

                    

                  
	
                    
                      152

                    

                  	
                    
                      Room
                        & Board - Ward - OB

                    

                  	
                    
                      3

                    

                  
	
                    
                      153

                    

                  	
                    
                      Room
                        & Board - Ward - Pediatric

                    

                  	
                    
                      3

                    

                  
	
                    
                      154

                    

                  	
                    
                      Room
                        & Board - Ward - Psychiatric

                    

                  	
                    
                      2

                    

                  
	
                    
                      155

                    

                  	
                    
                      Room
                        & Board - Ward - Hospice

                    

                  	
                    
                      3

                    

                  
	
                    
                      156

                    

                  	
                    
                      Room
                        & Board - Ward - Detox

                    

                  	
                    
                      2

                    

                  
	
                    
                      157

                    

                  	
                    
                      Room
                        & Board - Ward - Oncology

                    

                  	
                    
                      3

                    

                  
	
                    
                      158

                    

                  	
                    
                      Room
                        & Board - Ward - Rehab

                    

                  	
                    
                      3

                    

                  
	
                    
                      159

                    

                  	
                    
                      Room
                        & Board - Ward - Other

                    

                  	
                    
                      3

                    

                  
	
                    
                      160

                    

                  	
                    
                      Other
                        Room & Board

                    

                  	
                    
                      3

                    

                  
	
                    
                      164

                    

                  	
                    
                      Other
                        Room & Board - Sterile Environment

                    

                  	
                    
                      3

                    

                  
	
                    
                      167

                    

                  	
                    
                      Other
                        Room & Board - Self Care

                    

                  	
                    
                      3

                    

                  
	
                    
                      169

                    

                  	
                    
                      Other
                        Room & Board - Other

                    

                  	
                    
                      3

                    

                  
	
                    
                      170

                    

                  	
                    
                      Room
                        & Board- Nursery

                    

                  	
                    
                      3

                    

                  
	
                    
                      171

                    

                  	
                    
                      Room
                        & Board- Nursery - Newborn

                    

                  	
                    
                      3

                    

                  
	
                    
                      172

                    

                  	
                    
                      Room
                        & Board- Nursery - Premature

                    

                  	
                    
                      3

                    

                  
	
                    
                      175

                    

                  	
                    
                      Room
                        & Board- Nursery - Neonatal ICU

                    

                  	
                    
                      3

                    

                  
	
                    
                      179

                    

                  	
                    
                      Room
                        & Board- Nursery - Other

                    

                  	
                    
                      3

                    

                  

          

          

          
            

            5/1/2007

          

          
            

            1
              of 11
              HUSKY A B Appendix O - BHP Master Covered Services Table
              05/01/07]

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            
              	
                       

                    	
                      CTBHP
                        Covered Services Table Revised July 31,
                        2006

                    

            

          

          
            

            0507

          

          

          
            	 	
                    
                      HUSKY
                        A and B Appendix 0 - CT BHP Master Covered Services Table
                        - September
                        2006

                    

                  	 
	
                    
                      Coverage

                    

                  	
                    
                      1=
                        HUSKY MCO - All diagnoses

                    

                  	 
	
                    
                      Responsibility

                    

                  	
                    
                      2=
                        BHP - All diagnoses

                    

                  	 
	
                    
                      Legend:

                    

                  	
                    
                      3=
                        BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                        diagnoses

                    

                  	 
	 	
                    
                      4=
                        Not covered

                    

                  	 
	
                    
                      190

                    

                  	
                    
                      Subacute
                        Care

                    

                  	
                    
                      3

                    

                  
	
                    
                      200

                    

                  	
                    
                      Intensive
                        Care

                    

                  	
                    
                      3

                    

                  
	
                    
                      201

                    

                  	
                    
                      Intensive
                        Care - Surgical

                    

                  	
                    
                      3

                    

                  
	
                    
                      202

                    

                  	
                    
                      Intensive
                        Care - Medical

                    

                  	
                    
                      3

                    

                  
	
                    
                      203

                    

                  	
                    
                      Intensive
                        Care - Pediatric

                    

                  	
                    
                      3

                    

                  
	
                    
                      204

                    

                  	
                    
                      Intensive
                        Care - Psychiatric

                    

                  	
                    
                      2

                    

                  
	
                    
                      205

                    

                  	
                    
                      Intensive
                        Care - Post ICU

                    

                  	
                    
                      3

                    

                  
	
                    
                      207

                    

                  	
                    
                      Intensive
                        Care - Burn Treatment

                    

                  	
                    
                      3

                    

                  
	
                    
                      208

                    

                  	
                    
                      Intensive
                        Care - Trauma

                    

                  	
                    
                      3

                    

                  
	
                    
                      209

                    

                  	
                    
                      Intensive
                        Care - Other

                    

                  	
                    
                      3

                    

                  
	
                    
                      210

                    

                  	
                    
                      Coronary
                        Care

                    

                  	
                    
                      3

                    

                  
	
                    
                      211

                    

                  	
                    
                      Coronary
                        Care - Myocardial Infarction

                    

                  	
                    
                      3

                    

                  
	
                    
                      212

                    

                  	
                    
                      Coronary
                        Care - Pulmonary

                    

                  	
                    
                      3

                    

                  
	
                    
                      213

                    

                  	
                    
                      Coronary
                        Care - Heart Transplant

                    

                  	
                    
                      3

                    

                  
	
                    
                      214

                    

                  	
                    
                      Coronary
                        Care - Post CCU

                    

                  	
                    
                      3

                    

                  
	
                    
                      219

                    

                  	
                    
                      Coronary
                        Care - Other

                    

                  	
                    
                      3

                    

                  
	
                    
                      224

                    

                  	
                    
                      Late
                        discharge/Medically necessary

                    

                  	
                    
                      4

                    

                  
	 	
                    
                      Note:
                        MCOs cover alcohol detoxification on a medical
                        floor.

                    

                  	 
	
                    
                      Code

                    

                  	
                    
                      General
                        Hospital Emergency Department

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      450

                    

                  	
                    
                      Emergency
                        Room General Classification

                    

                  	
                    
                      1

                    

                  
	
                    
                      451

                    

                  	
                    
                      EMTALA
                        Emergency Medical Screening Services

                    

                  	
                    
                      1

                    

                  
	
                    
                      452

                    

                  	
                    
                      Emergency
                        Room Beyond EMTALA Screening

                    

                  	
                    
                      1

                    

                  
	
                    
                      456

                    

                  	
                    
                      Urgent
                        Care

                    

                  	
                    
                      1

                    

                  
	
                    
                      459

                    

                  	
                    
                      Other
                        Emergency Room

                    

                  	
                    
                      1

                    

                  
	
                    
                      762

                    

                  	
                    
                      Observation
                        room

                    

                  	
                    
                      3

                    

                  
	
                    
                      981

                    

                  	
                    
                      Professional
                        Fee - Emergency Department

                    

                  	
                    
                      1

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      General
                        Hospital Outpatient

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      490

                    

                  	
                    
                      Ambulatory
                        Surgery**

                    

                  	
                    
                      3

                    

                  
	
                    
                      762

                    

                  	
                    
                      Observation
                        room

                    

                  	
                    
                      3

                    

                  
	
                    
                      900

                    

                  	
                    
                      Psychiatric
                        Services General (Evaluation)

                    

                  	
                    
                      2

                    

                  
	
                    
                      901

                    

                  	
                    
                      Electroconvulsive
                        Therapy**

                    

                  	
                    
                      2

                    

                  
	
                    
                      905

                    

                  	
                    
                      Intensive
                        Outpatient Services - Psychiatric

                    

                  	
                    
                      2

                    

                  
	
                    
                      906

                    

                  	
                    
                      Intensive
                        Outpatient Services - Chemical Dependency

                    

                  	
                    
                      2

                    

                  
	
                    
                      907

                    

                  	
                    
                      Community
                        Behavioral Health Program (Day Treatment)

                    

                  	
                    
                      2

                    

                  
	
                    
                      913

                    

                  	
                    
                      Partial
                        Hospital

                    

                  	
                    
                      2

                    

                  
	
                    
                      914

                    

                  	
                    
                      Individual
                        Therapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      915

                    

                  	
                    
                      Group
                        Therapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      916

                    

                  	
                    
                      Family
                        Therapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      918

                    

                  	
                    
                      Psychiatric
                        Service - Testing

                    

                  	
                    
                      3

                    

                  
	
                    
                      919

                    

                  	
                    
                      Other
                        - Med Admin

                    

                  	
                    
                      2

                    

                  
	
                    
                      961

                    

                  	
                    
                      Professional
                        Fees-Psychiatric

                    

                  	
                    
                      4

                    

                  
	
                    
                      All
                        others

                    

                  	 	
                    
                      1

                    

                  
	 	
                    
                      Note:
                        Includes outpatient provided by special care hospitals (e.g.,
                        Gaylord)

                    

                  	 
	 	
                    
                      "MCOs
                        pay for all professional services charges (e.g., anesthesiologist)
                        regardless of diagnosis, except psychiatrist
                        charges.

                    

                  	 
	
                    
                      Code

                    

                  	
                    
                      Psychiatric
                        Hospital Inpatient (includes Riverview, CVH)

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      100

                    

                  	
                    
                      All
                        inclusive room and board plus ancillary

                    

                  	
                    
                      4

                    

                  
	
                    
                      124

                    

                  	
                    
                      Room
                        and Board-Psychiatric

                    

                  	
                    
                      2

                    

                  
	
                    
                      126

                    

                  	
                    
                      Room
                        & Board - Semi-Private/2 Bed - Detox

                    

                  	
                    
                      2

                    

                  
	
                    
                      128

                    

                  	
                    
                      Room
                        & Board-Semi-Private/ 2 Bed-Rehab

                    

                  	
                    
                      4

                    

                  
	
                    
                      190

                    

                  	
                    
                      Subacute
                        Care

                    

                  	
                    
                      2

                    

                  
	
                    
                      224

                    

                  	
                    
                      Late
                        discharge/Medically necessary

                    

                  	
                    
                      4

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Psychiatric
                        Hospital Outpatient

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      490

                    

                  	
                    
                      Ambulatory
                        Surgery**

                    

                  	
                    
                      3

                    

                  
	
                    
                      762

                    

                  	
                    
                      Observation
                        room

                    

                  	
                    
                      2

                    

                  
	
                    
                      900

                    

                  	
                    
                      Psychiatric
                        Services General (Evaluation)

                    

                  	
                    
                      2

                    

                  
	
                    
                      901

                    

                  	
                    
                      Electroconvulsive
                        Therapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      905

                    

                  	
                    
                      Intensive
                        Outpatient Services ^psychiatric

                    

                  	
                    
                      2

                    

                  
	
                    
                      906

                    

                  	
                    
                      Intensive
                        Outpatient Services - Chemical Dependency

                    

                  	
                    
                      2

                    

                  

          

          
            5/1/2007

          

          
            

            2
              of 11
              HUSKY A B Appendix 0 - BHP Master Covered Services Table
              05/01/07]

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            
              	
                       

                    	
                      CTBHP
                        Covered Services Table Revised July 31,
                        2006

                    

            

          

          
            

            0507

          

          

          
            	
                    
                      HUSKY
                        A and B Appendix O - CT BHP Master Covered Services Table
                        - September
                        2006

                    

                  
	
                    
                      Coverage

                    

                  	
                    
                      1=
                        HUSKY MCO -All diagnoses

                    

                  
	
                    
                      Responsibility

                    

                  	
                    
                      2=
                        BHP -All diagnoses

                    

                  
	
                    
                      Legend:

                    

                  	
                    
                      3=
                        BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                        diagnoses

                    

                  
	 	
                    
                      4=
                        Not covered

                    

                  
	
                    
                      907

                    

                  	
                    
                      Community
                        Behavioral Health Program (Day Treatment)

                    

                  	
                    
                      2

                    

                  
	
                    
                      913

                    

                  	
                    
                      Partial
                        Hospital-More Intensive

                    

                  	
                    
                      2

                    

                  
	
                    
                      914

                    

                  	
                    
                      Psychiatric
                        Service-Individual Therapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      915

                    

                  	
                    
                      Psychiatric
                        Service-Group Therapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      916

                    

                  	
                    
                      Psychiatric
                        Service-Family Therapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      918

                    

                  	
                    
                      Psychiatric
                        Service-Testing

                    

                  	
                    
                      2

                    

                  
	
                    
                      919

                    

                  	
                    
                      Other-
                        Med Admin

                    

                  	
                    
                      2

                    

                  
	 	
                    
                      "MCOs
                        pay for all professional services charges (e.g., anesthesiologist)
                        regardless of diagnosis, except psychiatrist
                        charges.

                    

                  	 
	
                    
                      Code

                    

                  	
                    
                      Alcohol
                        and Drug Abuse Center (Non-hospital Inpatient Detox)

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      H0011

                    

                  	
                    
                      Acute
                        Detoxification (residential program inpatient)

                    

                  	
                    
                      2

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Alcohol
                        and Drug Abuse Center (Ambulatory Detoxification)

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      H0014

                    

                  	
                    
                      Ambulatory
                        Detoxification

                    

                  	
                    
                      2

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      PRTF

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      T2048

                    

                  	
                    
                      Psychiatric
                        health facility service, per diem

                    

                  	
                    
                      2

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      DCF
                        Residential

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      N/A

                    

                  	
                    
                      DCF
                        Funded residential facility

                    

                  	
                    
                      2

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Long
                        Term Care Facility

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      100

                    

                  	
                    
                      Per
                        diem rate

                    

                  	
                    
                      1

                    

                  
	
                    
                      183

                    

                  	
                    
                      Home
                        reserve

                    

                  	
                    
                      1

                    

                  
	
                    
                      185

                    

                  	
                    
                      Inpatient
                        hospital reserve

                    

                  	
                    
                      1

                    

                  
	
                    
                      189

                    

                  	
                    
                      Non-covered
                        reserve

                    

                  	
                    
                      4

                    

                  
	 	
                    
                      Note:
                        Includes inpatient at special care hospitals.

                    

                  	 
	
                    
                      Code

                    

                  	
                    
                      MH
                        Clinic

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      90801

                    

                  	
                    
                      Psychiatric
                        Diagnostic Interview

                    

                  	
                    
                      2

                    

                  
	
                    
                      90802

                    

                  	
                    
                      Interactive
                        Psychiatric Diagnostic Interview

                    

                  	
                    
                      2

                    

                  
	
                    
                      90804

                    

                  	
                    
                      Individual
                        Psychotherapy- Office or other Outpatient (20-30
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90805

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (20-30 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90806

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (45-50 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90807

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (45-50 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90808

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (75-80 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90809

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (75-80 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90810

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (20-30
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90811

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (20-30
                        min) with
                        medical evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90812

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (45-50
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90813

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (45-50
                        min) with
                        medical evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90814

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (75-80
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90815

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (75-80
                        min) with
                        medical evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90846

                    

                  	
                    
                      Family
                        Psychotherapy (without the patient present)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90847

                    

                  	
                    
                      Family
                        Psychotherapy (conjoint psychotherapy) (with the patient
                        present)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90849

                    

                  	
                    
                      Multi-group
                        family psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90853

                    

                  	
                    
                      Group
                        psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90857

                    

                  	
                    
                      Interactive
                        group psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90862

                    

                  	
                    
                      Pharmacologic
                        management

                    

                  	
                    
                      2

                    

                  
	
                    
                      90887

                    

                  	
                    
                      Interpretation
                        or explanation of results of psychiatric or other medical
                        examinations and
                        procedures or other accumulated data to family or other responsible
                        persons.

                    

                  	
                    
                      2

                    

                  
	
                    
                      96101

                    

                  	
                    
                      Psychological
                        testing, per hour

                    

                  	
                    
                      2

                    

                  
	
                    
                      96110

                    

                  	
                    
                      Developmental
                        testing and report, limited

                    

                  	
                    
                      2

                    

                  
	
                    
                      96111

                    

                  	
                    
                      Developmental
                        testing and report, extended

                    

                  	
                    
                      2

                    

                  
	
                    
                      96118

                    

                  	
                    
                      Neuropsychological
                        testing battery, per hour

                    

                  	
                    
                      2

                    

                  
	
                    
                      H0015

                    

                  	
                    
                      Intensive
                        Outpatient-Substance Dependence*

                    

                  	
                    
                      2

                    

                  
	
                    
                      H0035

                    

                  	
                    
                      Mental
                        health partial hospitalization, treatment, less than 24 hours
                        (CMHC)*

                    

                  	
                    
                      2

                    

                  
	
                    
                      H2012

                    

                  	
                    
                      Extended
                        Day Treatment

                    

                  	
                    
                      p*ft**

                    

                  
	
                    
                      H2013

                    

                  	
                    
                      Partial
                        Hospitalization (non-CMHC)*

                    

                  	
                    
                      2*

                    

                  

          

          

          
            

            5/1/2007

          

          
            

            3
              of 11
              HUSKY A B Appendix O - BHP Master Covered Services Table
              05/01/07]

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            
              	
                       

                    	
                      CTBHP
                        Covered Services Table Revised July
                        31,2006

                    

            

          

          
            

            0507

          

          

          
            	
                    
                      HUSKY
                        A and B Appendix O - CT BMP Master Covered Services Table
                        - September
                        2006

                    

                  
	
                    
                      Coverage

                    

                  	
                    
                      1=
                        HUSKY MCO - All diagnoses

                    

                  
	
                    
                      Responsibility

                    

                  	
                    
                      2=
                        BMP -All diagnoses

                    

                  
	
                    
                      Legend:

                    

                  	
                    
                      3=
                        BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                        diagnoses

                    

                  
	 	
                    
                      4=
                        Not covered

                    

                  
	
                    
                      H2019

                    

                  	
                    
                      Therapeutic
                        Behavioral Services, per 15 minutes (IICAPS, MST, MDFT, FFT,
                        FST, HVS)
                        (Clients under 21 only)

                    

                  	
                    
                      2***

                    

                  
	
                    
                      T1017

                    

                  	
                    
                      Targeted
                        case management, each 15 minutes (part of home-based services
                        only -
                        IICAPS, MST, MDFT, FFT, FST, HVS) (Clients under 21
                        only)

                    

                  	
                    
                      2

                    

                  
	
                    
                      J1630

                    

                  	
                    
                      Jnjection,
                        Haloperidol, up to 5 mg

                    

                  	
                    
                      2

                    

                  
	
                    
                      J1631

                    

                  	
                    
                      Injection,
                        Haloperidol decanoate, per 50 mg^

                    

                  	
                    
                      2

                    

                  
	
                    
                      J2680

                    

                  	
                    
                      Injection,
                        Fluphenazine decanoate, up to 25 mg

                    

                  	
                    
                      2

                    

                  
	
                    
                      M0064

                    

                  	
                    
                      Brief
                        office visit for the sole purpose of monitoring or changing
                        drug
                        prescriptions used in the treatment of mental psychoneurotic
                        and
                        personality disorders

                    

                  	
                    
                      2

                    

                  
	
                    
                      S9480

                    

                  	
                    
                      Intensive
                        Outpatient-Mental Health

                    

                  	
                    
                      2

                    

                  
	
                    
                      S9484

                    

                  	
                    
                      Emergency
                        mobile mental health service, follow-up (Clients under 21
                        only)

                    

                  	
                    
                      o***

                    

                  
	
                    
                      S9485

                    

                  	
                    
                      Emergency
                        mobile mental health service, initial evaluation (Clients
                        under 21
                        only)

                    

                  	
                    
                      Oft**

                    

                  
	
                    
                      T1016

                    

                  	
                    
                      Case
                        Management - Coordination of health care services - each
                        15
                        min.

                    

                  	
                    
                      2

                    

                  
	
                    
                      H0037

                    

                  	
                    
                      Community_psychiatric
                        supportive treatment program, per diem

                    

                  	
                    
                      4

                    

                  
	
                    
                      S9475

                    

                  	
                    
                      Ambulatory
                        setting, substance abuse treatment or detoxification
                        services

                    

                  	
                    
                      4

                    

                  
	 	
                    
                      'Coverage
                        restricted to providers approved by DSS to provide this
                        service

                    

                  	 
	 	
                    
                      ***
                        Coverage restricted to providers certified by DCF to provide
                        this
                        service

                    

                  	 
	 	
                    
                      ""Coverage
                        restricted to providers licensed by DCF to provide this
                        service

                    

                  	 
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      FQHC
                        Mental Health Clinic

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      90801

                    

                  	
                    
                      Psychiatric
                        Diagnostic Interview

                    

                  	
                    
                      2

                    

                  
	
                    
                      90802

                    

                  	
                    
                      Interactive
                        Psychiatric Diagnostic Interview

                    

                  	
                    
                      2

                    

                  
	
                    
                      90804

                    

                  	
                    
                      Individual
                        Psychotherapy- Office or other Outpatient (20-30
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90805

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (20-30 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90806

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (45-50 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90807

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (45-50 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90808

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (75-80 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90809

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (75-80 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90810

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (20-30
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90811

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (20-30
                        min) with
                        medical evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90812

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (45-50
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90813

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (45-50
                        min) with
                        medical evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90814

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (75-80
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90815

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (75-80
                        min) with
                        medical evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90846

                    

                  	
                    
                      Family
                        Psychotherapy (without the patient present)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90847

                    

                  	
                    
                      Family
                        Psychotherapy (conjoint psychotherapy) (with the patient
                        present)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90849

                    

                  	
                    
                      Multi-group
                        family psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90853

                    

                  	
                    
                      Group
                        psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90857

                    

                  	
                    
                      Interactive
                        group psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90862

                    

                  	
                    
                      Pharmacologic
                        management

                    

                  	
                    
                      2

                    

                  
	
                    
                      90887

                    

                  	
                    
                      Interpretation
                        or explanation of results of psychiatric or other medical
                        examinations and
                        procedures or other accumulated data to family or other responsible
                        persons.

                    

                  	
                    
                      2

                    

                  
	
                    
                      96101

                    

                  	
                    
                      Psychological
                        testing, per hour

                    

                  	
                    
                      2

                    

                  
	
                    
                      96110

                    

                  	
                    
                      Developmental
                        testing and report, limited

                    

                  	
                    
                      2

                    

                  
	
                    
                      96111

                    

                  	
                    
                      Developmental
                        testing and report, extended

                    

                  	
                    
                      2

                    

                  
	
                    
                      96118

                    

                  	
                    
                      Neuropsychological
                        testing battery, per hour

                    

                  	
                    
                      2

                    

                  
	
                    
                      H0015

                    

                  	
                    
                      Intensive
                        Outpatient-Substance Dependence*

                    

                  	
                    
                      2

                    

                  
	
                    
                      H2012

                    

                  	
                    
                      Extended
                        Day Treatment

                    

                  	
                    
                      n****

                    

                  
	
                    
                      H2013

                    

                  	
                    
                      Partial
                        Hospitalization (non-CMHC)*

                    

                  	
                    
                      2*

                    

                  
	
                    
                      J1630

                    

                  	
                    
                      Injection,
                        Haloperidol, up to 5 mg

                    

                  	
                    
                      2

                    

                  
	
                    
                      J1631

                    

                  	
                    
                      Injection,
                        Haloperidol decanoate, per 50 mg

                    

                  	
                    
                      2

                    

                  
	
                    
                      J2680

                    

                  	
                    
                      Injection,
                        Fluphenazine decanoate, up to 25 mg

                    

                  	
                    
                      2

                    

                  
	
                    
                      M0064

                    

                  	
                    
                      Brief
                        office visit for the sole purpose of monitoring or changing
                        drug
                        prescriptions used in the treatment of mental psychoneurotic
                        and
                        personality disorders

                    

                  	
                    
                      2

                    

                  
	
                    
                      S9480

                    

                  	
                    
                      Intensive
                        Outpatient-Mental Health

                    

                  	
                    
                      2

                    

                  
	
                    
                      S9484

                    

                  	
                    
                      Emergency
                        mobile mental health service, follow-up (Clients under 21
                        only)

                    

                  	
                    
                      2***

                    

                  
	
                    
                      S9485

                    

                  	
                    
                      Emergency
                        mobile mental health service, initial evaluation (Clients
                        under 21
                        only)

                    

                  	
                    
                      o***

                    

                  
	
                    
                      T1015

                    

                  	
                    
                      Clinic
                        visit/encounter all-inclusive (For use by FQHC MH
                        Clinics)

                    

                  	
                    
                      2

                    

                  

          

          
            5/1/2007

          

          
            

            4
              of 11
              HUSKY A B Appendix O - BHP Master Covered Services Table
              05/01/07]

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            
              	
                       

                    	
                      CTBHP
                        Covered Services Table Revised July 31,
                        2006

                    

            

          

          
            

            0507

          

          

          
            	 	
                    
                      HUSKY
                        A and B Appendix O - CT BHP Master Covered Services Table
                        - September
                        2006

                    

                  	 
	
                    
                      Coverage

                    

                  	
                    
                      1=
                        HUSKY MCO - All diagnoses

                    

                  	 
	
                    
                      Responsibility

                    

                  	
                    
                      2=
                        BHP - All diagnoses

                    

                  	 
	
                    
                      Legend:

                    

                  	
                    
                      3=
                        BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                        diagnoses

                    

                  	 
	 	
                    
                      4=
                        Not covered

                    

                  	 
	
                    
                      H0037

                    

                  	
                    
                      Community
                        psychiatric supportive treatment program, per diem

                    

                  	
                    
                      4

                    

                  
	
                    
                      S9475

                    

                  	
                    
                      Ambulatory
                        setting, substance abuse treatment or detoxification
                        services

                    

                  	
                    
                      4

                    

                  
	 	
                    
                      'Coverage
                        restricted to providers approved by DSS to provide this
                        service

                    

                  	 
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Rehabilitation
                        Clinic

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      90801

                    

                  	
                    
                      Psychiatric
                        Diagnostic Interview

                    

                  	
                    
                      3

                    

                  
	
                    
                      90804

                    

                  	
                    
                      Individual
                        Psychotherapy- Office or other Outpatient (20-30
                        min)

                    

                  	
                    
                      3

                    

                  
	
                    
                      90805

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (20-30 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      3

                    

                  
	
                    
                      90806

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (45-50 min)

                    

                  	
                    
                      3

                    

                  
	
                    
                      90807

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (45-50 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      3

                    

                  
	
                    
                      90808

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (75-80 min)

                    

                  	
                    
                      3

                    

                  
	
                    
                      90809

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (75-80 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      3

                    

                  
	
                    
                      90846

                    

                  	
                    
                      Family
                        psychotherapy (without the patient present)

                    

                  	
                    
                      3

                    

                  
	
                    
                      90847

                    

                  	
                    
                      Family
                        psychotherapy (conjoint)

                    

                  	
                    
                      3

                    

                  
	
                    
                      90853

                    

                  	
                    
                      Group
                        psychotherapy

                    

                  	
                    
                      3

                    

                  
	
                    
                      90857

                    

                  	
                    
                      Interactive
                        Group therapy

                    

                  	
                    
                      3

                    

                  
	
                    
                      96118

                    

                  	
                    
                      Neuropsychological
                        testing battery, per hour

                    

                  	
                    
                      3

                    

                  
	
                    
                      All
                        others

                    

                  	 	
                    
                      1

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      School-Based
                        Health Centers (Freestanding Medical Clinic)

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      90782

                    

                  	
                    
                      Therapeutic
                        or diagnostic injection; subcutaneous or
                        intramuscular

                    

                  	
                    
                      1

                    

                  
	
                    
                      90783

                    

                  	
                    
                      Therapeutic
                        or diagnostic injection; intra-arterial

                    

                  	
                    
                      1

                    

                  
	
                    
                      90784

                    

                  	
                    
                      Therapeutic
                        or diagnostic injection; intravenous

                    

                  	
                    
                      1

                    

                  
	
                    
                      90801

                    

                  	
                    
                      Psychiatric
                        Diagnostic Interview

                    

                  	
                    
                      3

                    

                  
	
                    
                      90804

                    

                  	
                    
                      Individual
                        psychotherapy (20-30 min)

                    

                  	
                    
                      3

                    

                  
	
                    
                      90806

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (45-50 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90846

                    

                  	
                    
                      Family
                        psychotherapy (without the patient present)

                    

                  	
                    
                      3

                    

                  
	
                    
                      90847

                    

                  	
                    
                      Family
                        psychotherapy (conjoint psychotherapy w/patient
                        present)

                    

                  	
                    
                      3

                    

                  
	
                    
                      90853

                    

                  	
                    
                      Group
                        psychotherapy (other than of a multiple-family
                        group)

                    

                  	
                    
                      3

                    

                  
	
                    
                      99211

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, that may not require the presence of
                        a physician.
                        (Typically 5 minutes)

                    

                  	
                    
                      1

                    

                  
	
                    
                      99212

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, which requires at least two of these
                        three
                        components: problem focused history; problem focused examination;
                        straightforward medical decision-making. (Typically 10 minutes
                        face-to-face)

                    

                  	
                    
                      1

                    

                  
	
                    
                      99213

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, which requires at least two of these
                        three
                        components: expanded problem focused history; expanded problem
                        focused
                        examination; medical decision making of low complexity. (Typically
                        15
                        minutes face-to-face)

                    

                  	
                    
                      1

                    

                  
	
                    
                      99214

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, which requires at least two of these
                        three
                        components: detailed history; detailed examination; medical
                        decision
                        making of moderate complexity (Typically 25 minutes
                        face-to-face)

                    

                  	
                    
                      1

                    

                  
	
                    
                      99215

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, which requires at least two of these
                        three
                        components: comprehensive history; comprehensive examination;
                        medical
                        decision making of high complexity (Typically 40 minutes
                        face-to-face)

                    

                  	
                    
                      1

                    

                  
	
                    
                      All
                        others

                    

                  	 	
                    
                      1

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      School-Based
                        Health Centers (FQHC Medical Clinic)

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      90782

                    

                  	
                    
                      Therapeutic
                        or diagnostic injection; subcutaneous or
                        intramuscular

                    

                  	
                    
                      1

                    

                  
	
                    
                      90783

                    

                  	
                    
                      Therapeutic
                        or diagnostic injection; intra-arterial

                    

                  	
                    
                      1

                    

                  
	
                    
                      90784

                    

                  	
                    
                      Therapeutic
                        or diagnostic injection; intravenous

                    

                  	
                    
                      1

                    

                  
	
                    
                      90801

                    

                  	
                    
                      Psychiatric
                        Diagnostic Interview

                    

                  	
                    
                      3

                    

                  
	
                    
                      90804

                    

                  	
                    
                      Individual
                        psychotherapy (20-30 min)

                    

                  	
                    
                      3

                    

                  
	
                    
                      90806

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (45-50 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90846

                    

                  	
                    
                      Family
                        psychotherapy (without the patient present)

                    

                  	
                    
                      3

                    

                  
	
                    
                      90847

                    

                  	
                    
                      Family
                        psychotherapy (conjoint psychotherapy w/patient
                        present)

                    

                  	
                    
                      3

                    

                  
	
                    
                      90853

                    

                  	
                    
                      Group
                        psychotherapy (other than of a multiple-family
                        group)

                    

                  	
                    
                      3

                    

                  
	
                    
                      T1015

                    

                  	
                    
                      Clinic
                        visit/encounter all-inclusive (For use by FQHC
                        Clinics)

                    

                  	
                    
                      2

                    

                  
	
                    
                      99211

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, that may not require the presence of
                        a physician.
                        (Typically 5 minutes)

                    

                  	
                    
                      1

                    

                  

          

          
            5/1/2007

          

          
            

            5
              of 11
              HUSKY A B Appendix O - BHP Master Covered Services Table
              05/01/07]

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            
              	
                       

                    	
                      CTBHP
                        Covered Services Table Revised July 31,
                        2006

                    

            

          

          
            

            0507

          

          

          
            	
                    
                      HUSKY
                        A and B Appendix O - CT BHP Master Covered Services Table
                        - September
                        2006

                    

                  
	
                    
                      Coverage

                    

                  	
                    
                      1
                        =
                        HUSKY MCO - All diagnoses

                    

                  
	
                    
                      Responsibility

                    

                  	
                    
                      2=
                        BHP - All diagnoses

                    

                  
	
                    
                      Legend:

                    

                  	
                    
                      3=
                        BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                        diagnoses

                    

                  
	 	
                    
                      4=
                        Not covered

                    

                  
	
                    
                      99212

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, which requires at least two of these
                        three
                        components: problem focused history; problem focused examination;
                        straightforward medical decision-making. (Typically 10 minutes
                        face-to-face)

                    

                  	
                    
                      1

                    

                  
	
                    
                      99213

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, which requires at least two of these
                        three
                        components: expanded problem focused history; expanded problem
                        focused
                        examination; medical decision making of low complexity. (Typically
                        15
                        minutes face-to-face)

                    

                  	
                    
                      1

                    

                  
	
                    
                      99214

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, which requires at least two of these three
                        components: detailed history; detailed examination; medical
                        decision
                        making of moderate complexity (Typically 25 minutes
                        face-to-face)

                    

                  	
                    
                      1

                    

                  
	
                    
                      99215

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, which requires at least two of these
                        three
                        components: comprehensive history; comprehensive examination;
                        medical
                        decision making of high complexity (Typically 40 minutes
                        face-to-face)

                    

                  	
                    
                      1

                    

                  
	
                    
                      All
                        others

                    

                  	 	
                    
                      1

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Methadone
                        Clinic

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      H0020

                    

                  	
                    
                      Methadone
                        service; rate includes all services for which the source
                        of service is the
                        methadone maintenance clinic.

                    

                  	
                    
                      2

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      MD,
                        DO and APRN other than Psychiatrist or Psychiatric
                        APRN

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      00104

                    

                  	
                    
                      Anesthesia
                        for electroconvulsive therapy

                    

                  	
                    
                      1

                    

                  
	
                    
                      80100

                    

                  	
                    
                      Drug
                        screen, qualitative, chromatographic method, each
                        procedure

                    

                  	
                    
                      1

                    

                  
	
                    
                      81000

                    

                  	
                    
                      Urinalysis,
                        by dip stick or tablet reagent, non-automated, with
                        microscopy

                    

                  	
                    
                      1

                    

                  
	
                    
                      83840

                    

                  	
                    
                      Methadone
                        chemistry (quantitative analysis)

                    

                  	
                    
                      1

                    

                  
	
                    
                      90782

                    

                  	
                    
                      Therapeutic
                        or diagnostic injection; subcutaneous or
                        intramuscular

                    

                  	
                    
                      1

                    

                  
	
                    
                      90783

                    

                  	
                    
                      Therapeutic
                        or diagnostic injection; intra-arterial

                    

                  	
                    
                      1

                    

                  
	
                    
                      90784

                    

                  	
                    
                      Therapeutic
                        or diagnostic injection; intravenous

                    

                  	
                    
                      1

                    

                  
	
                    
                      908XX

                    

                  	
                    
                      Psychotherapy
                        codes

                    

                  	
                    
                      4

                    

                  
	
                    
                      99211

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, that may not require the presence of
                        a physician.
                        (Typically 5 minutes)

                    

                  	
                    
                      1

                    

                  
	
                    
                      99212

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, which requires at least two of these
                        three
                        components: problem focused history; problem focused examination;
                        straightforward medical decision making (Typically 10 minutes
                        face-to-face)

                    

                  	
                    
                      1

                    

                  
	
                    
                      99213

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, which requires at least two of these
                        three
                        components: expanded problem focused history; expanded problem
                        focused
                        examination; medical decision making of low complexity. (Typically
                        15
                        minutes face-to-face)

                    

                  	
                    
                      1

                    

                  
	
                    
                      99214

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, which requires at least two of these
                        three
                        components: detailed history; detailed examination; medical
                        decision
                        making of moderate complexity (Typically 25 minutes
                        face-to-face)

                    

                  	
                    
                      1

                    

                  
	
                    
                      99215

                    

                  	
                    
                      Office
                        or other outpatient visit for the evaluation and management
                        of an
                        established patient, which requires at least two of these
                        three
                        components: comprehensive history; comprehensive examination;
                        medical
                        decision making of high complexity (Typically 40 minutes
                        face-to-face)

                    

                  	
                    
                      1

                    

                  
	
                    
                      All
                        others

                    

                  	 	
                    
                      1

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Psychiatrist
                        (MD or DO)

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      90801

                    

                  	
                    
                      Diagnostic
                        Interview

                    

                  	
                    
                      2

                    

                  
	
                    
                      90802

                    

                  	
                    
                      Interactive
                        Diagnostic Interview

                    

                  	
                    
                      2

                    

                  
	
                    
                      90804

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (20-30 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90805

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (20-30 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90806

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (45-50 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90807

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (45-50 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90808

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (75-80 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90809

                    

                  	
                    
                      Individual
                        PsychotherapyjOffice or other Outpatient (75-80 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90810

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (20-30
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90811

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (20-30
                        min) with
                        medical evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90812

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (45-50
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90813

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (45-50
                        min) with
                        medical evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90814

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (75-80
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90815

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (75-80
                        min) with
                        medical evaluation and management services

                    

                  	
                    
                      2

                    

                  

          

          
            5/1/2007

          

          
            

            6
              of 11
              HUSKY A B Appendix O - BHP Master Covered Services Table
              05/01/07]

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            
              	
                       

                    	
                      CTBHP
                        Covered Services Table Revised July 31,
                        2006

                    

            

          

          
            

            0507

          

          

          
            	 	
                    
                      HUSKY
                        A and B Apjoejrdixjg^CT BMP Master Covered Services Table
                        - September
                        2006

                    

                  	 
	
                    
                      Coverage

                    

                  	
                    
                      1
                        =
                        HUSKY MCO - All diagnoses

                    

                  	 
	
                    
                      Responsibility

                    

                  	
                    
                      2=
                        BHP- All diagnoses

                    

                  	 
	
                    
                      Legend:

                    

                  	
                    
                      3=
                        BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                        diagnoses

                    

                  	 
	 	
                    
                      4=
                        Not covered

                    

                  	 
	
                    
                      90816

                    

                  	
                    
                      Individual
                        Psychotherapy-Facility Based (20-30 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90817

                    

                  	
                    
                      90816
                        with medical evaluation and management

                    

                  	
                    
                      2

                    

                  
	
                    
                      90818

                    

                  	
                    
                      Individual
                        psychotherapy, insight oriented 45-50 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      90819

                    

                  	
                    
                      90818
                        with medical evaluation and management

                    

                  	
                    
                      2

                    

                  
	
                    
                      90821

                    

                  	
                    
                      Individual
                        Psychotherapy-Facility Based (75-80 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90822

                    

                  	
                    
                      Individual
                        Psychotherapy-Facility Based (75-80 min) with med
                        management

                    

                  	
                    
                      2

                    

                  
	
                    
                      90823

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (20-30 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90824

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (20-30 min) med
                        management

                    

                  	
                    
                      2

                    

                  
	
                    
                      90826

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (45-50 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90827

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (45-50 min) med
                        management

                    

                  	
                    
                      2

                    

                  
	
                    
                      90828

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (75-80 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90829

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (75-80 min) med
                        management

                    

                  	
                    
                      2

                    

                  
	
                    
                      90846

                    

                  	
                    
                      Family
                        Psychotherapy (without the patient present)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90847

                    

                  	
                    
                      Family
                        Psychotherapy (conjoint)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90849

                    

                  	
                    
                      Multi-group
                        family psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90853

                    

                  	
                    
                      Group
                        Psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90857

                    

                  	
                    
                      Interactive
                        Group psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90862

                    

                  	
                    
                      Pharmacological
                        management, including prescription, use, and review of medication
                        with no
                        more than minimal medical psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90865

                    

                  	
                    
                      Narcosynthesis
                        for Psychiatric Diagnostic and Therapeutic purposes

                    

                  	
                    
                      2

                    

                  
	
                    
                      90870

                    

                  	
                    
                      Electroconvulsive
                        therapy (including necessary monitoring); single
                        seizure

                    

                  	
                    
                      2

                    

                  
	
                    
                      90875

                    

                  	
                    
                      Individual
                        psychophysiological therapy incorporating biofeedback training
                        (20-30
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90876

                    

                  	
                    
                      Individual
                        psychophysiological therapy incorporating biofeedback training
                        (45-50
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90880

                    

                  	
                    
                      Hypnotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90887

                    

                  	
                    
                      Interpretation
                        or explanation of results of psychiatric or other medical
                        examinations and
                        procedures or other accumulated data to family or other responsible
                        persons.

                    

                  	
                    
                      2

                    

                  
	
                    
                      96101

                    

                  	
                    
                      Psychological
                        testing, per hour

                    

                  	
                    
                      2

                    

                  
	
                    
                      96110

                    

                  	
                    
                      Developmental
                        testing with report

                    

                  	
                    
                      2

                    

                  
	
                    
                      96111

                    

                  	
                    
                      Developmental
                        testing, extended

                    

                  	
                    
                      2

                    

                  
	
                    
                      96118

                    

                  	
                    
                      Neuropsychological
                        testing battery, per hour

                    

                  	
                    
                      2

                    

                  
	
                    
                      99201

                    

                  	
                    
                      Office
                        or other outpatient visit, 10 minutes, new patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99202

                    

                  	
                    
                      Office
                        or other outpatient visit, 20 minutes, new patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99203

                    

                  	
                    
                      Office
                        or other outpatient visit, 30 minutes, new patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99204

                    

                  	
                    
                      Office
                        or other outpatient visit, 45 minutes, new patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99205

                    

                  	
                    
                      Office
                        or other outpatient visit, 60 minutes, new patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99211

                    

                  	
                    
                      Office
                        or other outpatient visit, 5 minutes, established
                        patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99212

                    

                  	
                    
                      Office
                        or other outpatient visit, 10 minutes, established
                        patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99213

                    

                  	
                    
                      Office
                        or other outpatient visit, 15 minutes, established
                        patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99214

                    

                  	
                    
                      Office
                        or other outpatient visit, 25 minutes, established
                        patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99215

                    

                  	
                    
                      Office
                        or other outpatient visit, 40 minutes, established
                        patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99217

                    

                  	
                    
                      Observation
                        care discharge

                    

                  	
                    
                      2

                    

                  
	
                    
                      99218

                    

                  	
                    
                      Initial
                        observation care, low severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99219

                    

                  	
                    
                      Initial
                        observation care, moderate severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99220

                    

                  	
                    
                      Initial
                        observation care, high severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99221

                    

                  	
                    
                      Inpatient
                        hospital care, 30 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99222

                    

                  	
                    
                      Inpatient
                        hospital care, 50 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99223

                    

                  	
                    
                      Inpatient
                        hospital care, 70 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99231

                    

                  	
                    
                      Subsequent
                        hospital care, 15 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99232

                    

                  	
                    
                      Subsequent
                        hospital care, 25 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99233

                    

                  	
                    
                      Subsequent
                        hospital care, 35 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99234

                    

                  	
                    
                      Observation
                        of inpatient hospital care, low severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99235

                    

                  	
                    
                      Observation
                        of inpatient hospital care, moderate severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99236

                    

                  	
                    
                      Observation
                        of inpatient hospital care, high severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99238

                    

                  	
                    
                      Hospital
                        discharge day management 30 minutes or less

                    

                  	
                    
                      2

                    

                  
	
                    
                      99239

                    

                  	
                    
                      Hospital
                        discharge day management more than 30 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99241

                    

                  	
                    
                      Office
                        consultation for a new or established patient, approximately
                        15
                        minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99242

                    

                  	
                    
                      Office
                        consultation for a new or established patient, approximately
                        30
                        minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99243

                    

                  	
                    
                      Office
                        consultation for a new or established patient, approximately
                        40
                        minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99244

                    

                  	
                    
                      Office
                        consultation for a new or established patient, approximately
                        60
                        minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99245

                    

                  	
                    
                      Office
                        consultation for a new or established patient, approximately
                        80
                        minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99251

                    

                  	
                    
                      Initial
                        inpatient consultation, 20 minutes

                    

                  	
                    
                      2

                    

                  

          

          

          
            

            5/1/2007

          

          
            

            7
              of 11
              HUSKY A B Appendix O - BHP Master Covered Services Table
              05/01/07]

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            
              	
                       

                    	
                      CTBHP
                        Covered Services Table Revised July 31,
                        2006

                    

            

          

          
            

            0507

          

          

          
            	 	
                    
                      HUSKY
                        A and B Appendix 0 - CT BHP Master Covered Services Table
                        - September
                        2006

                    

                  	 
	
                    
                      Coverage

                    

                  	
                    
                      1=
                        HUSKY MCO - All diagnoses

                    

                  	 
	
                    
                      Responsibility

                    

                  	
                    
                      2=
                        BHP - All diagnoses

                    

                  	 
	
                    
                      Legend:

                    

                  	
                    
                      3=
                        BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                        diagnoses

                    

                  	 
	 	
                    
                      4=
                        Not covered

                    

                  	 
	
                    
                      99252

                    

                  	
                    
                      Initial
                        inpatient consultation, 40 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99253

                    

                  	
                    
                      Initial
                        inpatient consultation, 55 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99254

                    

                  	
                    
                      Initial
                        inpatient consultation, 80 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99255

                    

                  	
                    
                      Initial
                        inpatient consultation, 110 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99271

                    

                  	
                    
                      Confirmatory
                        consultation, limited or minor

                    

                  	
                    
                      2

                    

                  
	
                    
                      99272

                    

                  	
                    
                      Confirmatory
                        consultation, low severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99273

                    

                  	
                    
                      Confirmatory
                        consultation, moderate severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99274

                    

                  	
                    
                      Confirmatoryjjonsultation,
                        moderate to high severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99275

                    

                  	
                    
                      Confirmatory
                        consultation, high severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99281

                    

                  	
                    
                      Emergency
                        department visit, minor severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99282

                    

                  	
                    
                      Emergency
                        department visit, low to moderate severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99283

                    

                  	
                    
                      Emergency
                        department visit, moderate severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99284

                    

                  	
                    
                      Emergency
                        department visit, high severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99285

                    

                  	
                    
                      Emergency
                        department visit, high severity with significant
                        threat

                    

                  	
                    
                      2

                    

                  
	
                    
                      J1630

                    

                  	
                    
                      Injection,
                        Haloperidol, up to 5 mg

                    

                  	
                    
                      2

                    

                  
	
                    
                      J1631

                    

                  	
                    
                      Injection,
                        Haloperidol decanoate, per 50 mg

                    

                  	
                    
                      2

                    

                  
	
                    
                      J2680

                    

                  	
                    
                      Injection,
                        Fluphenazine decanoate, up to 25 mg

                    

                  	
                    
                      2

                    

                  
	
                    
                      M0064

                    

                  	
                    
                      Brief
                        office visit for the sole purpose of monitoring or changing
                        prescriptions
                        used in the treatment of mental psychoneurotic or personality
                        disorders

                    

                  	
                    
                      2

                    

                  
	
                    
                      T1016

                    

                  	
                    
                      Case
                        Management - Coordination of health care services - each
                        15
                        min.

                    

                  	
                    
                      2

                    

                  
	
                    
                      All
                        others

                    

                  	 	
                    
                      4

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Psychiatric
                        APRN

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      90801

                    

                  	
                    
                      Diagnostic
                        Interview

                    

                  	
                    
                      2

                    

                  
	
                    
                      90802

                    

                  	
                    
                      Interactive
                        Diagnostic Interview

                    

                  	
                    
                      2

                    

                  
	
                    
                      90804

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (20-30 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90805

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (20-30 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90806

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (45-50 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90807

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (45-50 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90808

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (75-80 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90809

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (75-80 min) with
                        medical
                        evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90810

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (20-30
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90811

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (20-30
                        min) with
                        medical evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90812

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (45-50
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90813

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (45-50
                        min) with
                        medical evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90814

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (75-80
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90815

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (75-80
                        min) with
                        medical evaluation and management services

                    

                  	
                    
                      2

                    

                  
	
                    
                      90816

                    

                  	
                    
                      Individual
                        Psychotherapy-Facility Based (20-30 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90817

                    

                  	
                    
                      90816
                        with medical evaluation and management

                    

                  	
                    
                      2

                    

                  
	
                    
                      90818

                    

                  	
                    
                      Individual
                        psychotherapy, insight oriented 45-50 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      90819

                    

                  	
                    
                      90818
                        with medical evaluation and management

                    

                  	
                    
                      2

                    

                  
	
                    
                      90821

                    

                  	
                    
                      Individual
                        Psychotherapy-Facility Based (75-80 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90822

                    

                  	
                    
                      Individual
                        Psychotherapy-Facility Based (75-80 min) with med
                        management

                    

                  	
                    
                      2

                    

                  
	
                    
                      90823

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (20-30 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90824

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (20-30 min) med
                        management

                    

                  	
                    
                      2

                    

                  
	
                    
                      90826

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (45-50 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90827

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (45-50 min) med
                        management

                    

                  	
                    
                      2

                    

                  
	
                    
                      90828

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (75-80 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90829

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (75-80 min) med
                        management

                    

                  	
                    
                      2

                    

                  
	
                    
                      90846

                    

                  	
                    
                      Family
                        Psychotherapy (without the patient present)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90847

                    

                  	
                    
                      Family
                        Psychotherapy (conjoint)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90849

                    

                  	
                    
                      Multi-group
                        family psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90853

                    

                  	
                    
                      Group
                        Psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90857

                    

                  	
                    
                      Interactive
                        Group psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90862

                    

                  	
                    
                      Pharmacological
                        management, including prescription, use, and review of medication
                        with no
                        more than minimal medical psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90865

                    

                  	
                    
                      Narcosynthesis
                        for Psychiatric Diagnostic and Therapeutic purposes

                    

                  	
                    
                      2

                    

                  

          

          
            5/1/2007

          

          
            

            8
              of 11
              HUSKY A B Appendix 0 - BHP Master Covered Services Table
              05/01/07]

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            
              	
                       

                    	
                      CTBHP
                        Covered Services Table Revised July
                        31,2006

                    

            

          

          
            

            0507

          

          

          
            	 	
                    
                      HUSKY
                        A and B Appendix O - CT BHP Master Covered Services Table
                        - September
                        2006

                    

                  	 
	
                    
                      Coverage

                    

                  	
                    
                      1=
                        HUSKY MCO - All diagnoses

                    

                  	 
	
                    
                      Responsibility

                    

                  	
                    
                      2=
                        BHP - All diagnoses

                    

                  	 
	
                    
                      Legend:

                    

                  	
                    
                      3=
                        BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                        diagnoses

                    

                  	 
	 	
                    
                      4=
                        Not covered

                    

                  	 
	
                    
                      90870

                    

                  	
                    
                      Electroconvulsive
                        therapy (including necessary monitoring); single
                        seizure

                    

                  	
                    
                      2

                    

                  
	
                    
                      90875

                    

                  	
                    
                      Individual
                        psychophysiological therapy incorporating biofeedback training
                        (20-30
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90876

                    

                  	
                    
                      Individual
                        psychophysiological therapy incorporating biofeedback training
                        (45-50
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90880

                    

                  	
                    
                      Hypnotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90887

                    

                  	
                    
                      Interpretation
                        or explanation of results of psychiatric or other medical
                        examinations and
                        procedures or other accumulated data to family or other responsible
                        persons.

                    

                  	
                    
                      2

                    

                  
	
                    
                      96101

                    

                  	
                    
                      Psychological
                        testing, per hour

                    

                  	
                    
                      2

                    

                  
	
                    
                      96110

                    

                  	
                    
                      Developmental
                        testing with report

                    

                  	
                    
                      2

                    

                  
	
                    
                      96111

                    

                  	
                    
                      Developmental
                        testing, extended

                    

                  	
                    
                      2

                    

                  
	
                    
                      96118

                    

                  	
                    
                      Neuropsychological
                        testing battery, per hour

                    

                  	
                    
                      2

                    

                  
	
                    
                      99201

                    

                  	
                    
                      Office
                        or other outpatient visit, 10 minutes, new patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99202

                    

                  	
                    
                      Office
                        or other outpatient visit, 20 minutes, new patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99203

                    

                  	
                    
                      Office
                        or other outpatient visit, 30 minutes, new patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99204

                    

                  	
                    
                      Office
                        or other outpatient visit, 45 minutes, new patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99205

                    

                  	
                    
                      Office
                        or other outpatient visit, 60 minutes, new patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99211

                    

                  	
                    
                      Office
                        or other outpatient visit, 5 minutes, established
                        patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99212

                    

                  	
                    
                      Office
                        or other outpatient visit, 10 minutes, established
                        patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99213

                    

                  	
                    
                      Office
                        or other outpatient visit, 15 minutes, established
                        patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99214

                    

                  	
                    
                      Office
                        or other outpatient visit, 25 minutes, established
                        patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99215

                    

                  	
                    
                      Office
                        or other outpatient visit, 40 minutes, established
                        patient

                    

                  	
                    
                      2

                    

                  
	
                    
                      99217

                    

                  	
                    
                      Observation
                        care discharge

                    

                  	
                    
                      2

                    

                  
	
                    
                      99218

                    

                  	
                    
                      Initial
                        observation care, low severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99219

                    

                  	
                    
                      Initial
                        observation care, moderate severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99220

                    

                  	
                    
                      Initial
                        observation care, high severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99221

                    

                  	
                    
                      Inpatient
                        hospital care, 30 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99222

                    

                  	
                    
                      Inpatient
                        hospital care, 50 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99223

                    

                  	
                    
                      Inpatient
                        hospital care, 70 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99231

                    

                  	
                    
                      Subsequent
                        hospital care, 15 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99232

                    

                  	
                    
                      Subsequent
                        hospital care, 25 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99233

                    

                  	
                    
                      Subsequent
                        hospital care, 35 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99234

                    

                  	
                    
                      Observation
                        of inpatient hospital care, low severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99235

                    

                  	
                    
                      Observation
                        of inpatient hospital care, moderate severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99236

                    

                  	
                    
                      Observation
                        of inpatient hospital care, high severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99238

                    

                  	
                    
                      Hospital
                        discharge day management 30 minutes or less

                    

                  	
                    
                      2

                    

                  
	
                    
                      99239

                    

                  	
                    
                      Hospital
                        discharge day management more than 30 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99241

                    

                  	
                    
                      Office
                        consultation for a new or established patient, approximately
                        15
                        minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99242

                    

                  	
                    
                      Office
                        consultation for a new or established patient, approximately
                        30
                        minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99243

                    

                  	
                    
                      Office
                        consultation for a new or established patient, approximately
                        40
                        minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99244

                    

                  	
                    
                      Office
                        consultation for a new or established patient, approximately
                        60
                        minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99245

                    

                  	
                    
                      Office
                        consultation for a new or established patient, approximately
                        80
                        minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99251

                    

                  	
                    
                      Initial
                        inpatient consultation, 20 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99252

                    

                  	
                    
                      Initial
                        inpatient consultation, 40 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99253

                    

                  	
                    
                      Initial
                        inpatient consultation, 55 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99254

                    

                  	
                    
                      Initial
                        inpatient consultation, 80 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99255

                    

                  	
                    
                      Initial
                        inpatient consultation, 110 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      99271

                    

                  	
                    
                      Confirmatory
                        consultation, limited or minor

                    

                  	
                    
                      2

                    

                  
	
                    
                      99272

                    

                  	
                    
                      Confirmatory
                        consultation, low severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99273

                    

                  	
                    
                      Confirmatory
                        consultation, moderate severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99274

                    

                  	
                    
                      Confirmatory
                        consultation, moderate to high severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99275

                    

                  	
                    
                      Confirmatory
                        consultation, high severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99281

                    

                  	
                    
                      Emergency
                        department visit, minor severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99282

                    

                  	
                    
                      Emergency
                        department visit, low to moderate severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99283

                    

                  	
                    
                      Emergency
                        department visit, moderate severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99284

                    

                  	
                    
                      Emergency
                        department visit, high severity

                    

                  	
                    
                      2

                    

                  
	
                    
                      99285

                    

                  	
                    
                      Emergency
                        department visit, high severity with significant
                        threat

                    

                  	
                    
                      2

                    

                  
	
                    
                      J1630

                    

                  	
                    
                      Injection,
                        Haloperidol, up to 5 mg

                    

                  	
                    
                      2

                    

                  
	
                    
                      J1631

                    

                  	
                    
                      Injection,
                        Haloperidol decanoate, per 50 mg

                    

                  	
                    
                      2

                    

                  
	
                    
                      J2680

                    

                  	
                    
                      Injection,
                        Fluphenazine decanoate, up to 25 mg

                    

                  	
                    
                      2

                    

                  
	
                    
                      M0064

                    

                  	
                    
                      Brief
                        office visit for the sole purpose of monitoring or changing
                        prescriptions
                        used in the treatment of mental psychoneurotic or personality
                        disorders

                    

                  	
                    
                      2

                    

                  
	
                    
                      T1016

                    

                  	
                    
                      Case
                        Management - Coordination of health care services - each
                        15
                        min.

                    

                  	
                    
                      2

                    

                  

          

          
            5/1/2007

          

          
            

            9
              of 11
              HUSKY A B Appendix O - BHP Master Covered Services Table
              05/01/07]

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            
              	
                       

                    	
                      CTBHP
                        Covered Services Table Revised July 31,
                        2006

                    

            

          

          
            

            0507

          

          

          
            	
                    
                      HUSKY
                        A and B Appendix O;- CT BMP Master Covered Services
                        Table

                    

                  	
                    
                      -
                        September 2006

                    

                  
	
                    
                      Coverage

                    

                  	
                    
                      1=
                        HUSKY MCO - All diagnoses

                    

                  
	
                    
                      Responsibility

                    

                  	
                    
                      2=
                        BMP - All diagnoses

                    

                  
	
                    
                      Legend:

                    

                  	
                    
                      3=
                        BMP for Primary Diagnoses 291-316, HUSKY MCO all other
                        diagnoses

                    

                  	 
	 	
                    
                      4=
                        Not covered

                    

                  	 
	
                    
                      All
                        others

                    

                  	 	
                    
                      4

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Psychologist
                        and Psychologist Group

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      90801

                    

                  	
                    
                      Diagnostic
                        Interview

                    

                  	
                    
                      2

                    

                  
	
                    
                      90802

                    

                  	
                    
                      Interactive
                        Diagnostic Interview

                    

                  	
                    
                      2

                    

                  
	
                    
                      90804

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (20-30 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90806

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (45-50 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90808

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (75-80 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90810

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (20-30
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90812

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (45-50
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90814

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (75-80
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90816

                    

                  	
                    
                      Individual
                        Psychotherapy-Facility Based (20-30 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90818

                    

                  	
                    
                      Individual
                        psychotherapy, insight oriented 45-50 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      90821

                    

                  	
                    
                      Individual
                        Psychotherapy-Facility Based (75-80 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90823

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (20-30 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90826

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (45-50 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90828

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (75-80 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90846

                    

                  	
                    
                      Family
                        Psychotherapy (without the patient present)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90847

                    

                  	
                    
                      Family
                        Psychotherapy (conjoint)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90849

                    

                  	
                    
                      Multi-group
                        family psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90853

                    

                  	
                    
                      Group
                        Psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90857

                    

                  	
                    
                      Interactive
                        Group psychotherapy

                    

                  	 	
                    
                      2

                    

                  
	
                    
                      90875

                    

                  	
                    
                      Individual
                        psychophysiological therapy incorporating biofeedback training
                        (20-30

                    

                  	
                    
                      min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90876

                    

                  	
                    
                      Individual
                        psychophysiological therapy incorporating biofeedback training
                        (45-50

                    

                  	
                    
                      min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90880

                    

                  	
                    
                      Hypnotherapy

                    

                  	 	
                    
                      2

                    

                  
	
                    
                      90887

                    

                  	
                    
                      Interpretation
                        or explanation of results of psychiatric or other medical
                        examinations and
                        procedures or other accumulated data to family or other responsible
                        persons. .

                    

                  	
                    
                      2

                    

                  
	
                    
                      96101

                    

                  	
                    
                      Psychological
                        testing, per hour

                    

                  	
                    
                      2

                    

                  
	
                    
                      96110

                    

                  	
                    
                      Developmental
                        testing with report

                    

                  	
                    
                      2

                    

                  
	
                    
                      96111

                    

                  	
                    
                      Developmental
                        testing, extended

                    

                  	
                    
                      2

                    

                  
	
                    
                      96118

                    

                  	
                    
                      Neuropsychological
                        testing battery, per hour

                    

                  	
                    
                      2

                    

                  
	
                    
                      T1016

                    

                  	
                    
                      Case
                        Management - Coordination of health care services - each
                        15
                        min.

                    

                  	
                    
                      2

                    

                  
	 	 	 
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Independent
                        Practice Behavioral Health Professional (LCSW, LMFT, LPC,
                        LADC)

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      90801

                    

                  	
                    
                      Diagnostic
                        Interview

                    

                  	
                    
                      2

                    

                  
	
                    
                      90802

                    

                  	
                    
                      Interactive
                        Diagnostic Interview

                    

                  	
                    
                      2

                    

                  
	
                    
                      90804

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (20-30 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90806

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (45-50 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90808

                    

                  	
                    
                      Individual
                        Psychotherapy-Office or other Outpatient (75-80 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90810

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (20-30
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90812

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (45-50
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90814

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Office or other Outpatient (75-80
                        min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90816

                    

                  	
                    
                      Individual
                        Psychotherapy-Facility Based (20-30 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90818

                    

                  	
                    
                      Individual
                        psychotherapy, insight oriented 45-50 minutes

                    

                  	
                    
                      2

                    

                  
	
                    
                      90821

                    

                  	
                    
                      Individual
                        Psychotherapy-Facility Based (75-80 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90823

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (20-30 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90826

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (45-50 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90828

                    

                  	
                    
                      Interactive
                        Individual Psychotherapy-Facility Based (75-80 min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90846

                    

                  	
                    
                      Family
                        Psychotherapy (without the patient present)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90847

                    

                  	
                    
                      Family
                        Psychotherapy (conjoint)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90849

                    

                  	
                    
                      Multi-group
                        family psychotherapy

                    

                  	 	
                    
                      2

                    

                  
	
                    
                      90853

                    

                  	
                    
                      Group
                        Psychotherapy

                    

                  	 	
                    
                      2

                    

                  
	
                    
                      90857

                    

                  	
                    
                      Interactive
                        Group psychotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90875

                    

                  	
                    
                      Individual
                        psychophysiological therapy incorporating biofeedback training
                        (20-30

                    

                  	
                    
                      min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90876

                    

                  	
                    
                      Individual
                        psychophysiological therapy incorporating biofeedback training
                        (45-50

                    

                  	
                    
                      min)

                    

                  	
                    
                      2

                    

                  
	
                    
                      90880

                    

                  	
                    
                      Hypnotherapy

                    

                  	
                    
                      2

                    

                  
	
                    
                      90887

                    

                  	
                    
                      Interpretation
                        or explanation of results of psychiatric or other medical
                        examinations and
                        procedures or other accumulated data to family or other responsible
                        persons.

                    

                  	
                    
                      2

                    

                  
	
                    
                      96110

                    

                  	
                    
                      Developmental
                        testing with report

                    

                  	
                    
                      2

                    

                  

          

          
            5/1/2007

          

          
            

            10
              of
              11HUSKY A B Appendix O - BMP Master Covered Services Table
              05/01/07]

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

          
            

            
              	
                       

                    	
                      CTBHP
                        Covered Services Table Revised July 31,
                        2006

                    

            

          

          
            

            0507

          

          

          
            	 	
                    
                      HUSKY
                        A and B Appendix O - CT BMP Master Covered Services Table
                        - September
                        2006

                    

                  	 
	
                    
                      Coverage

                    

                  	
                    
                      1=
                        HUSKY MCO - All diagnoses

                    

                  	 
	
                    
                      Responsibility

                    

                  	
                    
                      2=
                        BMP - All diagnoses

                    

                  	 
	
                    
                      Legend:

                    

                  	
                    
                      3=
                        BMP for Primary Diagnoses 291-316, HUSKY MCO all other
                        diagnoses

                    

                  	 
	 	
                    
                      4=
                        Not covered

                    

                  	 
	
                    
                      96111

                    

                  	
                    
                      Developmental
                        testing, extended

                    

                  	
                    
                      2

                    

                  
	
                    
                      T1016

                    

                  	
                    
                      Case
                        Management - Coordination of health care services - each
                        15
                        min.

                    

                  	
                    
                      2

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Home
                        Health Care Agencies

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      RCC/HCPC

                    

                  	 	 
	
                    
                      421

                    

                  	
                    
                      Physical
                        Therapy

                    

                  	
                    
                      1

                    

                  
	
                    
                      424

                    

                  	
                    
                      Physical
                        Therapy Evaluation

                    

                  	
                    
                      1

                    

                  
	
                    
                      431

                    

                  	
                    
                      Occupational
                        Therapy

                    

                  	
                    
                      1

                    

                  
	
                    
                      434

                    

                  	
                    
                      Occupational
                        Therapy Evaluation

                    

                  	
                    
                      1

                    

                  
	
                    
                      441

                    

                  	
                    
                      Speech
                        Therapy

                    

                  	
                    
                      1

                    

                  
	
                    
                      444

                    

                  	
                    
                      Speech
                        Therapy Evaluation

                    

                  	
                    
                      1

                    

                  
	
                    
                      570/T1004

                    

                  	
                    
                      Services
                        of a qualified nursing aide, up to 15 minutes

                    

                  	
                    
                      3

                    

                  
	
                    
                      580/S9123

                    

                  	
                    
                      Nursing
                        care, in the home by an RN, per hour

                    

                  	
                    
                      3

                    

                  
	
                    
                      580/S9124

                    

                  	
                    
                      Nursing
                        Care, in the home by an LPN, per hour

                    

                  	
                    
                      3

                    

                  
	
                    
                      580/T1001

                    

                  	
                    
                      Nursing
                        Assessment/Evaluation

                    

                  	
                    
                      3

                    

                  
	
                    
                      580/T1002

                    

                  	
                    
                      RN
                        Services, up to 15 minutes

                    

                  	
                    
                      3

                    

                  
	
                    
                      580/T1003

                    

                  	
                    
                      LPN/LVN
                        services, up to 15 minutes

                    

                  	
                    
                      3

                    

                  
	
                    
                      580/T1502

                    

                  	
                    
                      Administration
                        of oral, intramuscular and/or subcutaneous medication by
                        health care
                        agency/professional, per visit

                    

                  	
                    
                      3

                    

                  
	 	
                    
                      *BHP
                        covers home health services for children with autism including
                        when autism
                        is co-morbid with mental retardation.

                    

                  	 
	
                    
                      Code

                    

                  	
                    
                      Independent
                        Occupational Therapist

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      All
                        codes

                    

                  	 	
                    
                      1

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Independent
                        Physical Therapist

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      All
                        codes

                    

                  	 	
                    
                      1

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Medical
                        Transportation

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      All
                        codes

                    

                  	 	
                    
                      1

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Emergency
                        Medical Transportation

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      All
                        codes

                    

                  	 	
                    
                      1

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Independent
                        Laboratory Services

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      80100

                    

                  	
                    
                      Drug
                        screen, qualitative, chromatographic method, each
                        procedure

                    

                  	
                    
                      1

                    

                  
	
                    
                      81000

                    

                  	
                    
                      Urinalysis,
                        by dip stick or tablet reagent, non-automated, with
                        microscopy

                    

                  	
                    
                      1

                    

                  
	
                    
                      83840

                    

                  	
                    
                      Methadone
                        chemistry (quantitative analysis)

                    

                  	
                    
                      1

                    

                  
	
                    
                      All
                        other codes

                    

                  	 	
                    
                      1

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Pharmacy

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      All
                        codes

                    

                  	 	
                    
                      1

                    

                  
	 	 	 
	
                    
                      Code

                    

                  	
                    
                      Other
                        Community Services

                    

                  	
                    
                      Coverage

                    

                  
	
                    
                      H2017

                    

                  	
                    
                      Psychosocial
                        Rehabilitation services, per 15 minutes

                    

                  	 
	
                    
                      H2019

                    

                  	
                    
                      Therapeutic
                        Behavioral Services, per 15 minutes (IICAPS, MST, MDFT, FFT,
                        FST, HBV)
                        (Clients under 21 only)

                    

                  	
                    
                      2

                    

                  
	
                    
                      T1017

                    

                  	
                    
                      Targeted
                        case management, each 15 minutes (part of home-based services
                        only -
                        IICAPS, MST, MDFT, FFT, FST, HBV) (Clients under 21
                        only)

                    

                  	
                    
                      2***

                    

                  
	
                    
                      H2032

                    

                  	
                    
                      Activity
                        Therapy, per 15 minutes (Therapeutic Mentoring/Behavioral
                        Management
                        Service) (Clients under 21 only)

                    

                  	
                    
                      2***

                    

                  
	 	
                    
                      "'Coverage
                        restricted to providers certified by DCF to provide this
                        service

                    

                  	 
	 	
                    
                      ""Coverage
                        restricted to providers licensed by DCF to provide this
                        service

                    

                  	 

          

          
            5/1/2007

          

          
            

            11
              of
              11HUSKY A B Appendix 0 - BHP Master Covered Services Table
              05/01/07]exhibit10-7.htm

    
      

    

    
      
        Back
          to Form 10-Q

      

      
        Exhibit
          10.7

      

      
        

      

      
        STATE
          OF CONNECTICUT

      

      
        DEPARTMENT
          OF SOCIAL SERVICES

      

      
        

      

      
        	
                Amendment
                  Number:

              	
                1

              
	
                Contract
                  #:

              	
                093-HUS-WCC-2

              
	
                Contract
                  Period:

              	
                07/01/2005
                  - 06/30/2007

              
	
                Contractor
                  Name:

              	
                WELLCARE
                  OF CONNECTICUT, INC.

              
	
                Contractor
                  Address:

              	
                127
                  Washington Avenue, North Haven, CT
                  06473

              

      

      
        

      

      
        Contract
          number 093-HUS-WCC-2 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 is hereby amended as
          follows:

      

      
         

        
          	
                  1.

                	
                  Part
                    II "GENERAL CONTRACT TERMS FOR MCOs" dated December 12, 2003
                    are deleted
                    in their entirety and replaced with Part II "GENERAL CONTRACT TERMS
                    FOR MCOs" pages 1 through 108 dated 05/01/07 attached
                    hereto.

                

        

      

      
         

        
          	
                  2.

                	
                  Appendices
                    A through J are deleted in their entirety and replaced with the
                    following
                    appendices
                    attached hereto;

                

        

      

      
        

         

        A. HUSKY
          B Covered Services

      

      
        B. DELETED

      

      
        C. HUSKY
          Plus

      

      
        D. Provider
          Credentialing and Enrollment Requirements

      

      
        E.  American
          Academy of Pediatrics - Recommendations for Preventative Pediatric Health
          Care

      

      
        F.  DSS
          Marketing Guidelines

      

      
        G. 
          Standards for Internal Quality Assurance Programs for Health
          Plans

      

      
        H. 
          Claims Inventory, Aging and Unaudited Quarterly Financial
          Reports

      

      
        I.   Capitation
          Payment Amount

      

      
        J.   Inpatient/Eligibility
          Recategorization Chart

      

      
        K. Abortion
          Reporting

      

      
        L.
           BLANK - RESERVED FOR POSSIBLE FUTURE USE

      

      
        M.BLANK
          -
          RESERVED FOR POSSIBLE FUTURE USE

      

      
        
          N.  HUSKY
            Behavioral Health Carve-Out Coverage and Coordination of Medical and
            Behavioral
            Services

        

        O.  CTBHP
          Master Covered Services Table

      

      
         

        
          	
                  3.

                	
                  Appendices
                    A through H and J through O shall become effective upon the proper
                    execution of this amendment by the Department and the
                    Contractor.

                

        

      

      
        

         

        Page
          1 of
          2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  4.

                	
                  Appendix
                    I Capitation Payment Amount HUSKY B Capitation Rate shall be
                    effective for
                    the 07/01/06 - 06/30/07.

                

        

      

      
         

        
          	
                  5.

                	
                  Pursuant
                    to Public Act 07-1, An Act Concerning the State Contractor Contribution
                    Ban and Gifts to State and Quasi-Public Agencies the Department must
                    provide and each Contractor must acknowledge receipt of the State
                    Elections Enforcement Commission's notice advising state contractors
                    of
                    state campaign contribution and solicitation prohibitions. Through
                    the execution of this amendment the Department certifies that
                    SEEC FORM 11 - NOTICE TO EXECUTIVE BRANCH STATE CONTRACTORS
                    AND PROSPECTIVE STATE CONTRACTORS OF CAMPAIGN
                    CONTRIBUTION AND SOLICITATION BAN has been
                    provided to the Contractor and the Contractor acknowledges receipt
                    of the
                    same.

                

        

      

      
        

         

        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.

      

      
        

      

      
        	
                WELLCARE
                  of CONNECTICUT, Inc.

                 

              	
                Department
                  of Social Services

              
	
                /s/  Todd
                  Farha

              	
                5/30/2007

              	
                /s/  Michael
                  P. Starkowski

              	
                5/31/2007

              
	
                Signature
                  (Authorized Official)

              	
                Date

              	
                Signature
                  (Authorized Official)

              	
                Date

                 

              
	
                Todd
                  Farha

              	
                President
                  & CEO

              	
                Michael
                  P. Starkowski

              	
                Commissioner

              
	
                Typed
                  Name (Authorized Official)

              	
                Title

              	
                Typed
                  Name (Authorized Official)

              	
                Title

              

      

      
        

      

      
        

      

      
        Attorney
          General (as to
          form)                                                                                                                        Date

      

      
        

         

        (   )
          This contract does not require the signature of the Attorney General pursuant
          to
          an agreement between the Department and the Office of the Attorney General
          dated: __________

      

      
         

      

      
         

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          2 of
          2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
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        PART
          I:   STANDARD CONNECTICUT
          CONTRACT TERMS

      

      
        PART  II: GENERAL
          CONTRACT TERMS FOR MCOS

      

      
         

        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
          and Specialist 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 Physical

      

      
        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

      

      
        

         

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        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

      

      
         

        4.  MCO
          Responsibility Concerning Payments Made On Behalf Of The
          Member

      

      
         

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

      

      
        4.2     Payments
          for Noncovered Services

      

      
        4.3     Cost-Sharing
          Exemption for American Indian/Native American Children

      

      
        4.4     Copayments

      

      
        4.5     Copayments
          Prohibited

      

      
        4.6     Maximum
          Annual Limits for Copayments

      

      
        4.7     Tracking
          Copayments

      

      
        4.8     Amount
          of Premium Paid

      

      
        4.9     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

      

      
        4.17   Behavioral
          Health Payment Adjustment

      

      
         

        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

      

      
        6.1    Eligibility
          Determinations

      

      
        6.2    Ineligibility
          Determinations

      

      
        6.3    Enrollment
          / Disenrollment

      

      
        6.4    Lock-In
          / Open Enrollment

      

      
        6.5    Capitation
          Payments to the MCO

      

      
        6.6    Newborn
          Retroactive Adjustments

      

      
        6.7    Information

      

      
         

        7.      DECLARATIONS
          AND MISCELLANEOUS PROVISIONS

      

      
        7.01  Competition
          not Restricted

      

      
        7.02  Nonsegregated
          Facilities

      

      
        

         

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        7.03   Offer
          of Gratuities

      

      
        7.04   Employment/Affirmative
          Action Clause

      

      
        7.05   Confidentiality

      

      
        7.06   Independent
          Capacity

      

      
        7.07   Liaison

      

      
        7.08   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

      

      
        7.20   Hold
          Harmless

      

      
        7.21   Executive
          Order Number 16

      

      
         

        8.      MCO
          RESPONSIBILITIES CONCERNING INTERNAL AND
          EXTERNAL APPEALS

      

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

      

      
        8.2    Internal
          Appeal Process Required

      

      
        8.3    Denial
          Notice

      

      
        8.4    Internal
          Appeal Process

      

      
        8.5    Written
          Appeal Decision

      

      
        8.6    Expedited
          Review

      

      
        8.7    External
          Appeal Process through the DOI

      

      
        8.8    Provider
          Appeal Process

      

      
         

        9.      CORRECTION
          ACTION AND CONTRACT TERMINATION

      

      
        9.1     Performance
          Review

      

      
        9.2     Settlement
          of Disputes

      

      
        9.3     Administrative
          Errors

      

      
        9.4     Suspension
          of New Enrollment

      

      
        9.5     Sanctions

      

      
        9.6     Payment
          Withhold, Class C Sanctions

      

      
        9.7     Emergency
          Services Denials

      

      
        9.8     Termination
          for Default

      

      
        9.9     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

         

        12

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
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        10.     OTHER
          PROVISIONS

      

      
        10.1    Severability

      

      
        10.2    Effective
          Date

      

      
        10.3    Order
          of Precedence

      

      
        10.4    Correction
          of Deficiencies

      

      
        10.5    This
          is not a Public Works Contract

      

      
         

        11.        APPENDICES

      

      
        
          	
                  
                    Appendix
                      A  HUSKY B Covered Services

                  

                	
                   

                

        

      

      
        
          	
                  
                    Appendix
                      B   HUSKY Plus-Behavioral Deleted

                  

                	
                   

                

        

      

      
        
          	
                  
                    Appendix
                      C  HUSKY Plus

                  

                	
                   

                

        

      

      
        
          	
                  
                    Appendix
                      D  Provider Credentialing and Enrollment Requirements; (same as
                      HUSKY A)

                  

                	
                   

                

        

      

      
        
          	
                  
                    Appendix
                      E  American Academy of Pediatrics - Recommendations for
                      Preventive Pediatric Health Care

                  

                	
                   

                

        

      

      
        
          	
                  
                    Appendix
                      F  DSS Marketing Guidelines; (same as HUSKY
                      A)

                  

                	
                   

                

        

      

      
        
          	
                  
                    Appendix
                      G Standards for Internal Quality Assurance Programs for Health
                      Plans;
                      (same as HUSKY A)

                  

                	
                   

                

        

      

      
        
          	
                  
                    Appendix
                      H Claims Inventory, Aging and Unaudited Quarterly Financial
                      Reports; (same
                      as HUSKY A)

                  

                	
                   

                

        

      

      
        
          	
                  
                    Appendix
                      I  Capitation Payment Amount

                  

                	
                   

                

        

      

      
        
          	
                  
                    Appendix
                      J  Inpatient/Eligibility Recategorization Chart, (same as HUSKY
                      A)

                  

                	
                   

                

        

      

      
        
          	
                  
                    Appendix
                      K Abortion Reporting.

                  

                	
                   

                

        

      

      
        
          	
                  
                    Appendix
                      N HUSKY (Behavioral Health Carve-Out Coverage and Coordination of
                      Medical and Behavioral Services) (same as HUSKY A)

                  

                	
                   

                

        

      

      
        
          	
                  
                    Appendix
                      O CTBHP Master Covered Services Table (same as HUSKY
                      A)

                  

                	
                   

                

        

      

      
        

        12.        SIGNATURES

      

      
        

        
 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      
        
          
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            PART
              II:
              GENERAL CONTRACT TERMS  FOR MCOs

          

          
            

            1.        DEFINITIONS

          

          
            

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

          

          
            

            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.

          

          
            

            Administrative
              Services Organization (ASO):

          

          
            

            An
              organization providing utilization management, benefit information
              and intensive
              care management services within a centralized information system
              framework

          

          
            

            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 (Al):

          

          
             

          

          
            
              	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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            Behavioral
              Health Partnership ("Partnership" or "BHP"):

          

          
            

            An
              integrated behavioral health service system for HUSKY Part A and HUSKY
              Part B
              members, children enrolled in the Voluntary Services Program operated
              by the
              Department of Children and Families and may, at the discretion of the
              Commissioners of Children and Families and Social Services, include
              other
              children, adolescents, and families served by the Department of Children
              and
              Families

          

          
            

            Behavioral
              Health Services:

          

          
            

            Services
              that are necessary to diagnose, correct or diminish the adverse effects
              of a
              psychiatric or substance use disorder.

          

          
            

            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 that 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.

          

          
            

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            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.

          

          
            

            Contract
              Services:

          

          
            

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

          

          
            

            Co-payment:

          

          
            

            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
              co-payments, premiums, deductibles and coinsurance, as defined in Section
              17b-290 of the Connecticut General Statutes.

          

          
            

            CPT
              Codes or Current Procedure Terminology:

          

          
            

            A
              listing
              of descriptive terms and identifying codes for reporting medical services
              and
              procedures for a variety of uses, including billing of public and private
              health
              insurance programs. The codes are developed and published by the American
              Medical Association.

          

          
            

            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.

          

          
            

            16

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
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            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.

          

          
            

            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.

          

          
            

            Such
              services shall include, but not be limited to, behavioral health and
              detoxification needed to evaluate or stabilize an emergency medical
              condition
              that is found to exist using the prudent layperson standard.

          

          
            

            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.

          

          
            

          

          
            

            17

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
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              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.

          

          
            

            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.

          

          
            

            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.

          

          
            

            Global
              Plan of Care:

          

          
            

            The
              treatment plan that integrates the needed services from the benefit
              packages of
              the HUSKY B and the HUSKY Plus Physical programs when a medically eligible
              Member is concurrently receiving services from HUSKY B and the HUSKY
              Plus
              Physical programs.

          

          
            

            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.

          

          
            

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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 Physical Programs:

          

          
            

            A
              supplemental physical 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 intensive physical health needs
              cannot be
              accommodated within the HUSKY Plan, Part B.

          

          
            

            ICD9-CM:

          

          
            

            The
              International Classification of Disease, 9th
              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 300% of
              the

          

          
            
 

            federal
              poverty level.

          

          
            

            Income
              Band 3:

          

          
            

            Families
              with household incomes over 300% of the federal poverty
              level.

          

          
            

            In-network
              providers or network providers:

          

          
            

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            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 co-payments 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(11) 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.

          

          
            

            Post-Stabilization
              Services:

          

          
            

            Covered
              services related to an emergency medical condition that are provided
              after a
              Member is stabilized in order to maintain the stabilized condition,
              or under the
              circumstances described in 42 CFR 422.114(3), to improve or resolve
              the Member's
              condition.

          

          
            

            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:

          

          
            

            
              	
                      1)

                    	
                      Child
                        preventive care, including periodic and interperiodic well-child
                        visits,
                        routine immunizations, health screenings and routine laboratory
                        tests;

                    

              	2) 	Prenatal
                      care, including care of all complications of
                      pregnancy;

              	
                      3)

                    	
                      Dare
                        of newborn infants, including attendance at high-risk deliveries
                        and normal newborn care;

                    

              	4) 	WIC
                      evaluations as applicable

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

                    

              	6)	 Preventive
                      dental care for children; and

              	7)	
                      Periodicity
                        schedules and reporting based on the standards specified
                        by the American
                        Academy of Pediatrics.

                    

            

          

          
             

          

          
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            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.

          

          
            

            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.

          

          
            

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            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 seg.,
              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.

          

          
            

            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.

          

          
            

            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 II 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

                    

            

          

          
            

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            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.

          

          
            

            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, 31-51d, 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

          

          
            

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            0501
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              HUSKY B Final

          

          
            

            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 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 to Members 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 of HUSKY 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.

                    

            

          

          
            

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                      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.

                    

            

          

          
            

            
              	
                      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 Pius 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.

                    

            

          

          
            

            
              	
                      8.

                    	
                      The
                        MCO shall coordinate Members' care with the Behavioral Health
                        Partnership, as outlined in this Contract, including but
                        not limited
                        to section 3.16, and Appendix
                        N.

                    

            

          

          
            

            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 be responsible for payment for emergency department visits,
                        including emergent and urgent visits and all associated
                        charges billed by the facility, regardless of the Member's diagnosis.
                        The Department and MCO will jointly develop audit procedures
                        related
                        to emergency department services when Members are admitted to
                        the hospital and the primary diagnosis is behavioral. The Partnership
                        shall be responsible for payment for the
                        following:

                    

            

          

          
            

            
              	
                      1.

                    	
                      Professional
                        psychiatric services rendered in an emergency department by a
                        community psychiatrist, if the psychiatrist is enrolled in the
                        Medicaid program under either an individual provider or
                        group provider number and bills the emergency facility under that
                        provider number; and

                    

            

          

          
            

            
              	
                      2.

                    	
                       Observation
                        stays of 23 hours or less, billed as Revenue Center Code 762, with a
                        primary behavioral health
                        diagnosis.

                    

            

          

          
            

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

          

          
            

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                      e.

                    	
                      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.

                    

            

          

          
            

            
              	
                      f.

                    	
                      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.

                    

            

          

          
            

            
              	
                      g.

                    	
                      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.

                    

            

          

          
            

            
              	
                      h.

                    	
                      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.

                    

            

          

          
            

            
              	
                      i.

                    	
                      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.

                    

            

          

          
            

            
              	
                      j.

                    	
                      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.

                    

            

          

          
            

            
              	
                      k.

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

                    

            

          

          
            

            
              	
                      I.

                    	
                      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.

                    

            

          

          
            

            
              	
                      m.

                    	
                      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.

                    

            

          

          
            

            
              	
                      n.

                    	
                      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

                    

            

          

          
            

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            medically
              necessary emergency services, without regard to whether the patient
              meets the
              prudent layperson standard described above.

          

          
            

            
              	
                      o.

                    	
                      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.

                    

            

          

          
            

            
              	
                      p.

                    	
                      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 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.

                    

            

          

          
            

            
              	
                      q.

                    	
                      The
                        MCO shall retain responsibility for payment for emergency
                        medical transportation and associated charges, regardless of
                        diagnosis. The MCO shall also retain responsibility for
                        hospital-to-hospital ambulance transportation of members
                        with a behavioral
                        health condition.

                    

            

          

          
            

            
              	
                      r.

                    	
                      Effective
                        January 1, 2007, when the MCO reimburses emergency services
                        provided by an
                        out-of-network provider whether within or outside Connecticut,
                        the rate of
                        reimbursement shall be limited to the fees established by
                        the DEPARTMENT
                        for the Medicaid fee-for-service
                        program.

                    

            

          

          
            

            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.

          

          
            

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            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.

                    

            

          

          
            

            3.09            Network
              Adequacy and Maximum Enrollment Levels

          

          
            

            Primary
              Care Providers and Dentists

          

          
            

            
              	
                      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 33.1%, nurse
                        practitioners of the appropriate specialties, and physician
                        assistants, 301 Members per
                        provider;

                    

            

          

          
            

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                      3.

                    	
                      Women's
                        PCPs, including obstetrics and gynecology specialists, nurse
                        midwives, and nurse practitioners of the appropriate specialty, 835
                        Members per provider;

                    

            

          

          
            

            
              	
                      4.

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

                    

            

          

          
            

            
              	
                      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.

                    

            

          

          
            

            
              	
                      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.

                    

            

          

          
            

            Specialists

          

          
            

            
              	
                      e.

                    	
                      In
                        addition to the network adequacy measures described in
                        subsections (a) through (d) above, the DEPARTMENT shall measure
                        access to specialists by examining and reviewing confirmed complaints
                        received by the MCO, the Enrollment Broker, the DEPARTMENT and HUSKY
                        Infoline and taking other steps as more fully described
                        below:

                    

            

          

          
            

            
              	
                      1.

                    	
                      For
                        purposes of this section, a "complaint" shall be defined
                        as
                        dissatisfaction expressed by a Member, or their authorized
                        representative,
                        with the Member's ability to obtain an appointment with a
                        specialist that
                        will accommodate the member's medical needs within a reasonable
                        timeframe
                        or within a reasonable
                        distance.

                    

            

          

          
            

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                      a)

                    	
                      Member
                        requests for information or referrals to specialists within the MCO's
                        network shall not constitute a
                        complaint.

                    

            

          

          
            

            
              	
                      b)

                    	
                      The
                        DEPARTMENT will count more than one complaint to different entities
                        about a Member's inability to access a particular specialist, within
                        the same timeframe, as
                        one complaint.

                    

            

          

          
            

            
              	
                      c)

                    	
                      The
                        DEPARTMENT will count as separate complaints when a Member complains
                        about being unable to make appointments with more than one
                        specialist.

                    

            

          

           

          
            
              	
                      2.

                    	
                      The
                        DEPARTMENT will refer to the MCO all complaints
                        for resolution.

                    

            

          

          
            

            
              	
                      3.

                    	
                      The
                        DEPARTMENT will send the MCO a "Complaint Report" when it receives a
                        certain number of confirmed access complaints from HUSKY A and HUSKY
                        B members during a quarter regarding a particular
                        specialty.

                    

            

          

           

          
            
              	
                      a)

                    	
                      The
                        number of confirmed complaints that will initiate the DEPARTMENT'S
                        sending a "Complaint Report" will be based on the MCOs HUSKY A
                        membership factored by the ratio of one complaint per 10,000
                        members.

                    

            

          

          
            

            
              	
                      b)

                    	
                      For
                        purposes of this section, a "confirmed complaint" means that the
                        DEPARTMENT or another entity has received a complaint and the
                        DEPARTMENT has confirmed that the MCO has not provided a specialist
                        or dentist within a reasonable timeframe or within a reasonable
                        distance from the Member's home, or
                        both.

                    

            

          

          
            

            
              	
                      c)

                    	
                      In
                        determining whether a complaint will be confirmed, the DEPARTMENT
                        will consider a number of factors, including but not limited
                        to:

                    

            

          

           

          
            
              	
                      1)

                    	
                      The
                        Member's PCP or other referring provider's medical opinion regarding
                        how soon the Member should be seen by the specialist;

                       

                    

              	2) 	The
                      severity of the Member's condition;

            

          

          
             

          

          
            
              	
                      3)

                    	
                      Nationally
                        recognized standards of access, if any, with respect to the
                        particular specialty;

                    

            

          

          
            

            
              	
                      4)

                    	
                      Whether
                        the access problem is related to a broader access or provider
                        availability problem that is not within the
                        MCO's control;

                    

            

          

          
            

            
              	
                      5)

                    	
                      The
                        MCO's diligence in attempting to address the
                        Member's complaint;

                    

            

          

          
            

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                      6)
                        Whether both the Member and the MCO have reasonably attempted
                        to obtain an
                        appointment that will meet his or her medical
                        needs.

                    

            

          

          
            

            Sanctions:

          

          
            

            
              	
                      1.

                    	
                      In
                        the event the DEPARTMENT deems that the MCO's provider network is not
                        capable of accepting additional enrollments and lacks adequate access
                        to providers as described in (a) through (d) above, the DEPARTMENT
                        may exercise its rights under Section 7 of this contract, including
                        but not limited to the rights under Section 7.04, Suspension of New
                        Enrollments.

                    

            

          

          
            

            
              	
                      2.

                    	
                      In
                        the event the DEPARTMENT determines that it has received sufficient
                        confirmed complaints regarding specialist access problems to initiate
                        a statewide default enrollment freeze, The DEPARTMENT shall advise
                        the MCO in the Complaint Report that it has received confirmed
                        complaints and that it will impose a default enrollment freeze on the
                        MCO in 30 days unless the MCO submits a satisfactory resolution of
                        the access issue in a corrective action
                        plan.

                    

            

          

           

          
            
              	
                      a)

                    	
                      The
                        MCO, at its request, will have an opportunity to meet with the
                        DEPARTMENT prior to the imposition of the default enrollment
                        freeze;

                    

            

          

          
            

            
              	
                      b)

                    	
                      The
                        DEPARTMENT will impose a default enrollment freeze statewide, for a
                        minimum of three months. The default enrollment freeze will remain in
                        effect until the DEPARTMENT determines that the access problem
                        has been resolved to the DEPARTMENT'S
                        satisfaction.

                    

            

          

           

          
            
              	
                      3.

                    	
                      The
                        MCO shall submit a corrective action plan to the DEPARTMENT when the
                        DEPARTMENT formally notifies the MCO that the number of confirmed
                        specialist complaints has passed the report threshold for that MCO
                        during the reporting period.

                    

            

          

          
            

            
              	
                      4.

                    	
                      If,
                        subsequent to the DEPARTMENT'S approval of the corrective action
                        plan, the network deficiency is not remedied within the
                        time specified in the corrective action plan, or if the MCO does
                        not develop a corrective action plan satisfactory to the
                        DEPARTMENT, the DEPARTMENT may impose a strike towards a Class
                        A sanction for each month the MCO fails to correct the deficiency,
                        in accordance with Section 7.05. This sanction shall be in addition
                        to any enrollment freeze imposed in accordance with (2)
                        above.

                    

            

          

          
            

            3.10    Provider
              Contracts

          

          
            

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

          

          
            

            33

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
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                      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.

                    

            

          

          
            

            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 (DEA) 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;

            

          

           

          
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            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 seg. 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;

                    

            

          

          
            

            
              	
                      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 DEA 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

                    

            

          

          
            

            35

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
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            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.

                    

            

          

          
            

            
              	
                      b.

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

                    

            

          

          
            

            3.13            PCP
              and Specialist 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;

                    

            

          

          
            

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                      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 Practices (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.

                    

            

          

          
            

            Performance Measure:
              PCP Appointment Availability. The DEPARTMENT or its agent
              will
              routinely monitor appointment availability as measured by b(1) 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)(1) 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.

                    

            

          

          
            

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                      d.

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

                    

            

          

          
            

            The
              MCO
              shall not charge co-payments 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.

                    	
                      The
                        MCO shall be responsible for payment for pharmacy services
                        and all
                        associated charges, regardless of a Member's diagnosis. The
                        only exception
                        is that the Partnership shall be responsible for methadone
                        costs that are
                        part of the bundled reimbursement for methadone maintenance
                        and ambulatory
                        detox providers. Prescribing behavioral health providers
                        participating in
                        the Partnership will follow the applicable pharmacy program
                        requirements,
                        including the formulary, of the MCO. These providers will
                        provide the MCO
                        with any clinical information needed to support requests
                        for authorization
                        or the preparation of summaries for administrative hearings.
                        The MCO shall
                        promptly inform the Department of any changes to its pharmacy
                        program
                        requirements.

                    

            

          

          
            

            
              	
                      b.

                    	
                      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;

                    

            

          

          
            

            
              	
                      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

                    

            

          

          
            

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            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.

                    

            

          

          
            

            3.16    Mental
              Health and Substance Abuse Access

          

          
            

            
              	
                      a.

                    	
                      Except
                        as otherwise identified in this section and this Contract,
                        mental health and substance abuse services, for HUSKY A Members
                        will
                        be managed by the Connecticut Behavioral Health Partnership
                        (CT-BHP)
                        and paid for by the Department. The MCO shall coordinate services
                        covered under this contract with the behavioral health services
                        managed by the Partnership as outlined in Appendix
                        X.

                    

            

          

          
            

            
              	
                      b.

                    	
                      The
                        MCO may track utilization, including, but not limited to,
                        primary
                        care behavioral health, laboratory, behavioral health pharmacy,
                        and transportation. The MCO shall bring any increases in the
                        utilization trend for any of these services to the attention of the
                        Department.

                    

            

          

          
            

            
              	
                      c.

                    	
                      If
                        there is a conflict between the MCO and the BHP as to whether
                        a Member's medical or behavioral health condition is primary,
                        the
                        MCO's

                    

            

          

          
            

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            0501
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              HUSKY B Final

          

          
            

            medical
              director shall work with the BHP's medical director to reach a timely
              and
              mutually agreeable resolution.   If the MCO and BMP are not able
              to reach a resolution, the Department will make a determination and
              the
              Department's determination shall be binding. Issues related to whether
              a
              Member's medical or behavioral health condition is primary must not
              delay timely
              medical necessity determinations. In these circumstances, the MCO must
              render a
              determination within the standard timeframe required under this contract
              or its
              policies and procedures.

          

          
             

          

          
            
              	d.	
                      Ancillary
                        Services

                       

                    

              	
                      1.

                    	
                      The
                        MCO shall retain responsibility for all ancillary services
                        such
                        as laboratory, radiology, and medical equipment, devices and
                        supplies regardless of
                        diagnosis.

                    

            

          

          
            

            
              	
                      2.

                    	
                      The
                        MCO is not responsible for ancillary services that are part
                        of the
                        Department's all-inclusive rate for inpatient behavioral
                        health services.

                    

              	
                       

                      e.

                    	
                       

                      Co-Occuring
                        Medical and Behavioral Health
                        Conditions

                    

            

          

          
             

          

          
            The
              MCO
              shall continue programs and procedures designed to support the identification
              of
              untreated behavioral health disorders in medical patients at risk for
              such
              disorders.   The MCO shall:

          

          
            

            
              	
                      1.

                    	
                      Contact
                        the BMP ASO when co-management of a Member's care by the MCO and the
                        BMP ASO is indicated, such as for persons with special physical
                        health and behavioral health
                        needs;

                    

            

          

          
            

            
              	
                      2.

                    	
                      Respond
                        to inquiries by the BMP ASO regarding the presence of medical co-
                        morbidities; and

                       

                    

              	3.	Coordinate
                      with the BMP ASO, upon request.

            

          

          
             

          

          
            
              	
                      4.

                    	
                      Assign
                        a key contact person in order to facilitate timely coordination with
                        the ASO; and

                    

            

          

          
            

            
              	
                      5.

                    	
                      Participate
                        in medical/behavioral co-management meetings at least once a month,
                        with the specific frequency to be determined by agreement between the
                        MCO and the ASO.

                    

              	 	 

            

          

          
            

            f.            Freestanding
              Primary Care Clinics

          

          
            

            The
              MCO
              shall be responsible for primary care and other services providing
              by primary
              care and medical clinics not affiliated with a hospital, regardless
              of
              diagnosis. The only exception is that the MCO shall not be responsible
              for
              behavioral health evaluation and treatment services billed un CPT codes
              90801-90806, 90853, 90846, 90847 and 90862, when the Member has a primary
              behavioral health diagnosis and the services are provided by a licensed
              behavioral health professional.

          

          
            

            g.            Home
              Health Services

          

          
            

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            05
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                      1.

                    	
                      The
                        MCO shall be responsible for management and payment of claims when
                        home health services are required for the treatment of medical
                        diagnoses alone and when home health services are required to treat
                        both medical and behavioral diagnoses, but the medical diagnosis is
                        primary.

                    

            

          

          
            

            
              	
                      2.

                    	
                      The
                        MCO shall also be responsible for authorization and payment of the
                        medical component of claims if a Member has both medical and
                        behavioral diagnoses, and the Member's medical treatment needs cannot
                        be safely and effectively managed by the psychiatric nurse or
                        aide.

                    

            

          

          
            

            
              	
                      3.

                    	
                      the
                        MCO shall manage and pay claims for home health physical therapy,
                        occupational therapy, and speech therapy, regardless of diagnosis to
                        the extent such services are otherwise covered under this
                        contract.

                    

            

          

          
            

            
              	
                      4.

                    	
                      The
                        MCO shall be responsible for the management and payment of claims for
                        home health services for Members with mental retardation when the
                        Member does not also have a diagnosis
                        of autism.

                    

              	
                       

                      h.

                    	
                       

                      Hospital
                        Inpatient Services.

                    

            

          

          
             

          

          
            
              	
                      1.

                    	
                      The
                        MCO will share responsibility for inpatient general hospital services
                        with the BHP.

                    

            

          

          
            

            
              	
                      2.

                    	
                      The
                        MCO shall be responsible for management and payment of claims for
                        inpatient general hospital services when the medical diagnosis is
                        primary. The medical diagnosis is primary if both the Revenue Center
                        Code and primary diagnosis are both
                        medical.

                    

            

          

          
            

            
              	
                      3.

                    	
                      The
                        MCO shall also be responsible for professional services and other
                        charges associated with primary medical diagnoses during
                        a behavioral
                        stay.

                    

            

          

          
            

            
              	
                      4.

                    	
                      The
                        MCO shall also be responsible for ancillary services associated with
                        non-primary behavioral health diagnoses during a medical stay, as
                        described in subsection a. of this
                        section.

                    

            

          

          
            

            
              	
                      5.

                    	
                      The
                        MCO shall not be responsible for ancillary services that
                        are included
                        in the hospital's per diem inpatient behavioral health rate.

                       

                    

              	i.	
                      Hospital
                        Outpatient Clinic Services

                       

                      The
                        MCO shall be responsible for all primary care and other medical
                        services
                        provided by hospital outpatient clinics, regardless of diagnosis,
                        including all medical specialty services and all ancillary
                        services.

                    

              	j.  	
                      Long
                        Term Care

                       

                      The
                        MCO shall be responsible for all long term care services
                        such as nursing
                        homes and chronic disease hospitals, regardless of a Member's
                        diagnosis.

                    

            

          

           

          
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            k.           Primary
              Care Behavioral Health Services

          

          
            

            
              	
                      1.

                    	
                      The
                        MCO shall be responsible for all primary care services and
                        all associated charges, regardless of diagnosis. Such
                        responsibilities include:

                    

            

          

          
             

          

          
            
              	a)	Behavioral
                      health related prevention and anticipatory
                      guidance;

              	b) 	Screening
                      for behavioral health disorders;

              	
                      c)

                    	
                      Treatment
                        of behavioral health disorders that the primary care physician
                        concludes can be safely and appropriately treated in a primary care
                        setting;

                    

            

          

          
            
              	
                      d)

                    	
                      Management
                        of psychotropic medications, when the PCP determines it is safe and
                        appropriate to do so, and in conjunction with treatment by a BMP
                        non-medical behavioral health specialist when necessary;
                        and

                    

            

          

          
            
              	
                      e)

                    	
                      Referral
                        to a behavioral health specialist when the PCP concludes it is safe
                        and appropriate to do so.

                    

            

          

          
            

            
              	
                      2.

                    	
                      The
                        BMP ASO will develop education and guidance for primary care
                        physicians related to the provision of behavioral health services in
                        primary care settings. The MCOs may participate with the ASO in the
                        development of education and guidance or they will be provided the
                        opportunity for review and comment. The education and guidance will
                        address PCP prescribing with support and guidance from the ASO or
                        referring clinic. The BMP ASO will make telephonic psychiatric
                        consultation services available to primary care providers.
                        Consultation may be initiated by any primary care provider that is
                        seeking guidance on psychotropic prescribing for a HUSKY A or HUSKY B
                        member.

                    

            

          

          
            

            
              	
                      3.

                    	
                      The
                        BHP ASO will work with the MCO and provider organizations to sponsor
                        opportunities for joint training to promote effective coordination
                        and collaboration. MCO policies and provider contracts must support
                        the provision of behavioral health services by primary care providers
                        and entry into coordination agreements with Enhanced Care Clinics
                        established by the
                        Department.

                    

            

          

          
            

            I.           
              School Based Health Center Services

          

          
            

            The
              HUSKY
              MCOs will be responsible for primary care services provided by school-based
              health centers, regardless of diagnosis, but they will not be responsible
              for
              behavioral health assessment and treatment services billed under CPT
              codes 90801
              - 90807, 90853, 90846 and 90847.

          

          
            

            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:

          

          
            

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            05
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                      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:

                    

            

          

          
            

            43

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            05
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                      1.

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

                       

                    

              	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.

          

          
            

            44

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            05
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            3.19           HUSKY
              PLUS: Physical

          

          
            

            a.           Overview

          

          
            

            
              	
                      1.

                    	
                      HUSKY
                        Plus Physical is a supplemental health insurance program that
                        provides services to children whose intensive physical health care
                        needs cannot be accommodated within the benefit package offered under
                        HUSKY B.

                    

            

          

          
            

            
              	
                      2.

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

                    

            

          

          
            

            
              	
                      3.

                    	
                      HUSKY
                        Plus Physical is available for children with intensive physical
                        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
                        Physical 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 Physical
              case
              manager, and the Member or his/her representative.

          

          
            

            c.           HUSKY
              B MCO Case Management Responsibilities

          

          
            

            
              	
                      1.

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

                    

            

          

          
            

            
              	
                      2.

                    	
                      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 Physical programs providing services to the
                        Member.

                    

            

          

          
            

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                      3.

                    	
                      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. The
                        MCO shall be responsible for managing the utilization of HUSKY B
                        services contained in the global plan of
                        care.

                    

            

          

          
            

            
              	
                      4.

                    	
                      The
                        MCO case manager shall actively participate with the HUSKY Plus
                        Physical case management team to ensure that all medically necessary
                        HUSKY Plus Physical 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 Physical programs.

          

          
            

            e.            Quality
              Assurance

          

          
            

            
              	
                      1.

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

                    

            

          

          
            

            
              	
                      2.

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

                    

            

          

          
            

            f.            Payment

          

          
            

            Sanction:
              If the MCO fails to have a procedure to identify potential
              HUSKY Plus
              Physical 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;

                       

                    

              	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;

                    

            

          

          
            

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                      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 the
                        CT BMP ASO; 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 and
                        treatment;

                    

            

          

          
            

            
              	
                      3.

                    	
                      Implement
                        a 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;

                    

            

          

          
            

            
              	
                      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

                    

            

          

          
            

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            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

          

          
            

            a.           There
              is no exclusion for pre-existing conditions.

          

          
            

            
              	
                      b.

                    	
                      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

          

          
            

            
              	
                      a.

                    	
                      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;

          

          
            

            
              	
                      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

                    

            

          

          
            

            f)      Emergency
              ambulance services or emergency care.

          

          
            

            
              	
                      b.

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

                    

            

          

          
            

            3.24        Newborn
              Enrollment and Minimum Hospital Stays

          

          
            

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                      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, Nursing Home or Chronic Disease Hospital
                        Stay 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.

                    

            

          

          
            

            
              	
                      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

                    

            

          

          
            

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            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.

                    

            

          

          
            

            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;

          

          
            

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            3.           The
              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.

                    

            

          

          
            

            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:

                    

            

          

          
            

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              	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;

                    

            

          

          
            
              	
                      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 DOI appeal
                      process);

              	24.	Preventive
                      health guidelines; and

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

              	26.	Information
                      on how to access services from the
                      Partnership.

          

          
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                      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.

                    

            

          

          
            

            
              	
                      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.

                    

            

          

          
            

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            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.

                    

            

          

          
            

            
              	
                      l.

                    	
                      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.

                       

                      The
                        MCO's CAHPS survey shall continue to include behavioral health
                        questions.

                    

            

          

          
             

          

          
            
              	
                      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.

                    

            

          

          
            

            
              	
                      n.

                    	
                      The
                        MCO shall make appropriate referrals of Members who express
                        the need for
                        or may require behavioral health services to the Partnership.
                        If a Member
                        is in crisis, the MCO shall stay on the line with the member
                        while
                        connecting the Member with the
                        Partnership.

                    

            

          

          
            

            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

          

          
            

            The
              MCO
              may, at its option, market or promote their plan to potential members.
              All
              marketing and marketing related activities must be in compliance with
              the
              guidelines and restrictions as set forth in this section and Appendix
              D. 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 D.

          

          
            

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              	 a. 	
                       Prohibited
                        Marketing Activities:

                      Appendix
                        D describes permitted and prohibited marketing activities
                        that apply to
                        all forms of communication, regardless of whether they are
                        performed by
                        the MCO directly, by its contracted providers, or its
                        subcontractors:

                       

                    

              	
                      b.

                    	
                      Any
                        type of marketing activity that has not been clearly specified
                        as permissible under the guidelines in Appendix D 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 submit its annual marketing plan, revisions to
                        the marketing plan and all marketing materials to the DEPARTMENT
                        for approval.   The DEPARTMENT will provide comments
                        on the marketing materials to the MCO within thirty (30) days of
                        receipt of the materials. MCOs, subcontractors and their providers
                        must wait until receiving DSS written approval or 31 days from
                        submission to the Department, if the Department has not responded by
                        the 30th
                        day before disseminating any such information to potential Members.
                        DSS reserves the right to request revisions or changes in marketing
                        materials at any time

                       

                    

              	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.

          

          
            

            Sanction:
              If the MCO engages in non-compliant marketing practices within
              one year
              of a marketing related sanction, the Department shall impose a Class
              C sanction
              of $25,000 for each determination of a marketing violation following
              the initial
              sanction episode.

          

          
            

            Sanction:
              Each marketing sanction episode shall include a mandatory
              enrollment
              freeze of no less than three months in duration.

          

          
            

            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

                    

            

          

          
            

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            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.

                    

            

          

          
            

            
              	
                      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

                    

            

          

          
            

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            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:

          

          
            

            
              	
                      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.

                    

            

          

          
            

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                      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.

                    

            

          

          
            

            
              	
                      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

          

          
            

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                      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.

                    

            

          

           

          
            
              	
                      16.

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

                    

            

          

          
            

            
              	
                      17.

                    	
                      At
                        the invitation of the Partnership, the MCO may, at its
                        discretion, participate in a joint quality improvement initiative on
                        an area of mutual
                        concern.

                    

            

          

          
            

            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

                    

            

          

          
            

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            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 II 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 II
                        3.35.

                    

            

          

          
            

            
              	
                      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 secj. 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.

                    

            

          

          
            

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                      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
                        seq.. 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.

                    

            

          

          
            

            
              	
                      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.

                    

            

          

          
            

            
              	
                      c.

                    	
                      The
                        MCO shall share information and provide copies of documents,
                        files and records pertaining to a Member to the CT BHP ASO and
                        any subcontractor upon the request of the Member, Department
                        or
                        ASO.

                    

            

          

          
            

            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

          

          
            

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            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.           HEDIS/CAHPS;
              and

          

          
            8.           Other
              services.

          

          
            

            
              	
                      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.

                    

            

          

          
            

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            g.           Daily
              and Monthly Reports

          

          
            

            
              	
                      1.

                    	
                      The
                        MCO shall provide to the BHP ASO daily and monthly reports and/or
                        data as mutually agreed upon with the ASO regarding
                        the following:

                    

            

          

          
            

            a)      Behavioral
              health emergency department visits;

          

          
            b)      Behavioral
              health emergency room recidivism;

          

          
            c)      Substance
              abuse and neonatal withdrawal;

          

          
            d)      Child
              and adolescent obesity and/or type II diabetes;

          

          
            e)      Sickle
              cell;

          

          
            f)      Eating
              disorders; and

          

          
            g)      Medical
              detox.

          

          
            

            
              	
                      2.

                    	
                      The
                        Department shall provide-specific behavioral health encounter data to
                        the MCO upon request to support quality management activities and
                        coordination. The format of the data extract will be consistent with
                        the encounter data reporting format, or other format mutually agreed
                        upon by the Department and the
                        MCO.

                    

            

          

          
            

            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.

                    

            

          

          
            

            
              	
                      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.

                    

            

          

          
            

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                      c.

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

                    

            

          

          
            

            
              	
                      d.

                    	
                      If
                        the MCO disagrees with a clinical management decision made
                        by the BMP
                        ASO, the MCO may raise the issue with the ASO on behalf of
                        the Member
                        and seek to resolve the issue informally prior to a
                        scheduled administrative
                        hearing.

                    

            

          

          
            

            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)(1) 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.

                    

            

          

          
            

            
              	
                      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.

                    

            

          

          
            

             

          

          
            

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            3.41           Insurance

             

            
              	
                      a.

                    	
                      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.

            

          

          
             

          

          
            
              	
                      b.

                    	
                      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 II, 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
                        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 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 dental subcontractor. Such plan shall meet
                        the requirements described in subsection (h)
                        below.

                    

            

          

          
            

            
              	
                      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.

                    

            

          

          
            

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                      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 in preventing and prosecuting fraud and
                        abuse in the HUSKY B
                        program.

                    

            

          

          
            

            
              	
                      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.

                    

            

          

          
            

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                      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

                    

            

          

          
            

            
              	
                      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

                    

            

          

          
            

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            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 Non-covered Services

          

          
            

            
              	
                      a.

                    	
                      The
                        MCO may allow a provider to charge for non-covered 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, non-covered 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.

                    

            

          

          
            

            
              	
                      b.

                    	
                      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

                    

            

          

          
            

            
              	
                      a.

                    	
                      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 any cost sharing for HUSKY
                        B.

                    

            

          

          
            

            
              	
                      b.

                    	
                      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 co-payments for
                        qualified AI/AN children as of the date the DEPARTMENT or its agent
                        makes
                        that determination.

                    

            

          

          
            

            
              	
                      c.

                    	
                      The
                        MCO shall notify its providers and subcontractors of the
                        AI/AN exemption from cost sharing. Member handbooks and
                        information handouts developed by the MCO shall include information
                        about the AI/AN exclusion from cost sharing. The MCO shall refer any
                        Members who

                    

            

          

          
            

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            believe
              they qualify for the AI/AN exemption to the DEPARTMENT or its agent
              for a
              determination of their qualification.

          

          
            

            
              	
                      d.

                    	
                      The
                        MCO shall provide all qualified AI/AN children in Income
                        Bands 1
                        and 2 with Membership identification cards stating "no cost sharing"
                        and the MCO shall inform their HUSKY B providers and subcontractors
                        that children with Membership cards so noted shall not be charged
                        any
                        cost sharing.

                    

            

          

          
            

            
              	
                      e.

                    	
                      If
                        the family has paid premiums and, co-payments or any other
                        type
                        of cost sharing for qualified AI/AN children, it is the
                        responsibility of the MCO to repay their payments 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 co-payments or any other cost sharing 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 cost sharing payment liability
              has been
              reached or if the MCO fails to exempt AI/AN children from cost sharing,
              the
              DEPARTMENT may impose a sanction up to and including a Class B sanction
              pursuant
              to Section 9.05.

          

          
            

            4.04         Co-payments

          

          
            

            
              	
                      a.

                    	
                      The
                        MCO shall allow providers to collect co-payments for the
                        following goods
                        and services only:

                    

            

          

          
            

            1.  Outpatient
              physician visits, except for well child visits;

          

          
            2.  Powered
              wheelchairs;

          

          
            3.  Hearing
              examinations;

          

          
            4.  Nurse
              midwife visits;

          

          
            5.  Nurse
              practitioner visits;

          

          
            6.  Podiatrist
              visits;

          

          
            7.  Chiropractor
              visits;

          

          
            8.  Naturopathic
              visits;

          

          
            9.  Eye
              care exams;

          

          
            10. Oral
              contraceptives;

          

          
            11. Generic
              and brand name prescriptions; and

            
              12.
Non-emergency
                care provided in a hospital emergency department or urgent care facility,
                except for a condition such that a prudent

            

          

          
             

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            layperson,
              acting reasonably, would have believed that emergency medical treatment
              is
              needed.

          

          
            

            b.  The
              amounts of these co-payments are detailed in Appendix A.

          

          
            

            4.05      Co-payments
              Prohibited No co-payment shall be charged
              for:

          

          
            1. Ambulance
              for emergency medical conditions;

          

          
            2. Durable
              medical equipment other than powered wheelchairs;

          

          
            3. Emergency
              medical conditions; and

          

          
            4.  Family
              planning services, excluding oral contraceptives;

          

          
            5.  Home
              health services;

          

          
            6.  Hospice
              and short-term rehabilitation;

          

          
            7.  Inpatient
              hospital services;

          

          
            8.  Inpatient
              physician services;

            
              9. 
                Laboratory
                and x-ray services, including diagnostic and treatment radiology and
                ultrasound treatment;
10. Occupational
              therapy;

          

          
            11. Outpatient
              surgical visits;

          

          
            12. Physical
              therapy,

          

          
            13. Preadmission
              testing;

            
              14.
Preventive
                care and services, including all well-baby and well-child services as
                described in 42 CFR 457.520;
15.  Prosthetic
              devices;

          

          
            16.  Skilled
              nursing;

          

          
            17.  Speech
              therapy;

          

          
            
              18. 
                The
                following dental services: oral exams, prophylaxis, x-rays, fillings,
                fluoride treatments, sealants, and oral surgery.

            

          

          
             

            4.06            Maximum
              Annual Limits for Co-payments

          

          
            

            
              	
                      a.

                    	
                      The
                        maximum annual limit for co-payments is $760 for families
                        in
                        Income Bands 1 and 2.

                    

            

          

          
            

            
              	
                      b.

                    	
                      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 co-payments to
                        be
                        charged once the family has reached its maximum annual limit for
                        co-payments.

                    

            

          

          
            

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                      c.

                    	
                      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.

                    

            

          

          
            

            
              	
                      d.

                    	
                      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.

                    

            

          

          
            

            
              	
                      e.

                    	
                      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 co-payments. 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.

                    

            

          

          
            

            
              	
                      f.

                    	
                      If
                        the family has paid more than the allowed limits for co-payments,
                        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 co-payments had been
                        met.

                    

            

          

          
            

            
              	
                      g.

                    	
                      There
                        is no maximum annual limit for co-payments 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
              Co-payments

          

          
            

            
              	
                      a.

                    	
                      The
                        MCO shall establish and maintain a system to track the
                        co-payments 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 co- payments. The MCO shall require their
                        providers and subcontractors to verify whether a family has reached
                        the maximum annual limit for co-payments before charging
                        a
                        co-payment.

                    

            

          

          
            

            
              	
                      b.

                    	
                      The
                        MCO shall carry over the tracking of the co-payment 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.

                    

            

          

          
            

            
              	
                      c.

                    	
                      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 co-payments paid by the family throughout the
                        remainder of the annual
                        period.

                    

            

          

          
            

            
              	
                      d.

                    	
                      Families
                        in Income Bands 1 and 2 shall not be charged co-payments
                        once the
                        maximum annual limits have been met. When a family in
                        Income

                    

            

          

          
            

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            Bands
              1
              or 2 reaches the maximum annual limits for co-payments, the MCO shall
              inform the
              providers and subcontractors that the co-payment limit has been met,
              that the
              providers and subcontractors cannot charge further co-payments 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.

          

          
            

            
              	
                      e.

                    	
                      The
                        MCO shall send a monthly file to the DEPARTMENT or its agent showing
                        the premiums and co-payments paid by the family. The DEPARTMENT or
                        its agent will keep information regarding the amount of co-payments
                        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
                        co-payment totals for the annual period to the new
                        MCO.

                    

            

          

          
            

            
              	
                      f.

                    	
                      If
                        a family believes it has reached the maximum annual limit
                        for
                        co- payments, it may request, in writing, that the MCO review
                        the
                        co- payments that have been paid by the family. The MCO shall
                        then
                        review the co-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 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.

                    

            

          

          
            

            
              	
                      g.

                    	
                      If
                        the family has paid more than the allowed limits for co-payments,
                        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 toward
              a Class A
              Sanction pursuant to Section 9.05:

          

          
            

            
              	
                      a.

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

                    

            

          

          
            

            
              	
                      b.

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

                    

            

          

          
            

            
              	
                      c.

                    	
                      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

          

          
            

            
              	
                      a.

                    	
                      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.

                    

            

          

          
            

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                      b.

                    	
                      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.

                    

            

          

          
            

            
              	
                      c.

                    	
                      The
                        premium charged and collected for families in Income Bands
                        1, 2 and 3
                        will be the rate negotiated with the DEPARTMENT per month,
                        per
                        child

                    

            

          

          
            

            
              	
                      1.

                    	
                      The
                        premium for families in Income Bands 1 and 2 will be based
                        on Medical
                        coverage only

                    

            

          

          
            

            
              	
                      2.

                    	
                      The
                        premium for families in Income Bands 3 will be based on both Medical
                        and Behavioral Health
                        coverage.

                    

            

          

          
            

            
              	
                      d. 
                        

                    	
                      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

          

          
            

            
              	
                      a.

                    	
                      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

          

          
            

            
              	
                      a.

                    	
                      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.

                    

            

          

          
            

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            b. The
              notice shall contain:

          

          
            1.  The
              amount of the premium that is due;

          

          
            2.  The
              date the premium was due;

          

          
            3.  The
              effective date of disenrollment for failure to pay the
              premium;

          

          
            4.  Information
              concerning lock-out;

          

          
            
              5. 
                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 other change in family circumstances;
                and

            

          

          
            
              6.
Any
                additional information required to be included in the notice by the
                DEPARTMENT.

               

            

          

          
            
              	
                      b.

                    	
                      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

          

          
            

            
              	
                      a.

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

                    

            

          

          
            

            
              	
                      b.

                    	
                      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.

                    

            

          

          
            

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            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 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

          

          
            

            
              	
                      a.

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

                    

            

          

          
            

            
              	
                      b.

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

                    

            

          

          
            

            
              	
                      c.

                    	
                      The
                        MCO shall send a monthly file to the DEPARTMENT or its agent showing
                        the premiums and co-payments 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.

                    

            

          

          
            

            
              	
                      d.

                    	
                      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.

                    

            

          

          
            

            
              	
                      e.

                    	
                      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

                    

            

          

          
            

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            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.

          

          
            

            4.17       Behavioral
              Health Payment Adjustment

          

           

          
            
              	a. 	
                      placeholder
                        for the amount.

                       

                    

              	
                      b.

                    	
                      The
                        MCO shall serve as the single point of premium collection
                        for Band
                        3 members by:

                    

            

          

          
            

            
              	
                      1)

                    	
                      Collecting
                        a single premium for both Medical and Behavioral Health coverage,
                        and

                    

            

          

          
            

            
              	
                      2)

                    	
                      Transferring
                        to the Department on a quarterly basis the pro-rated Behavioral
                        Health portion of the premium collected commencing with those
                        Behavioral Health premiums collected on or after January
                        1, 2006.

                    

            

          

          
            

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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/Disenrollment

          

          
            

            
              	
                      a.

                    	
                      Enrollment,
                        disenrollment and initial selection of PGP's Members will
                        be handled
                        by the DEPARTMENT through a contract with a central enrollment
                        broker.

                    

            

          

          
             

          

          
            
              	     
                      1. 	
                      Coverage
                        for new Members will be effective the first of the month

                       

                    

              	
                      2.

                    	
                      Coverage
                        for disenrolled Members will terminate on the last day of the
                        month.

                    

            

          

          
            

            
              	
                      3.

                    	
                      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.

                    

            

          

          
            

            
              	
                      4.

                    	
                      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.

                    

            

          

          
            

            
              	
                      5.

                    	
                      The
                        DEPARTMENT or its agent will notify the MCO of enrollments and
                        disenrollments specific to the MCO via a daily data
                        file.

                    

            

          

          
            

            
              	
                      6.

                    	
                      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 full file can be accessed by the MCO electronically via
                        dial-up.

                    

            

          

          
            

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            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:

                    

            

          

          
            

            
              	
                      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:

                    

            

          

          
            

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                      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

                    

            

          

          
            

            
              	
                      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 rates specified in Appendix I. The DEPARTMENT
                        will
                        make the payments in the month following the month to which the
                        capitation applies.

                    

            

          

          
            

            
              	
                      b.

                    	
                      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.

                    

            

          

          
            

            
              	
                      c.

                    	
                      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.

                    

            

          

          
            

            
              	
                      d.

                    	
                      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.

                    

            

          

          
            

            
              	
                      e.

                    	
                      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 c, noted
                        above.

                    

            

          

          
            

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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       Non-segregated
              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.

          

          
            

            7.04            Employment/Affirmative
              Action Clause

          

          
            

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            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         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 interpretations resulting there from. 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

          

          
            

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            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 hereunderfor 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.

          

          
            

            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.

                    

            

          

          
            

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                      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 sequestere'd 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:

          

          
             

          

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

                       

                    

              	
                      b.

                    	
                      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

                    

            

          

          
            

            
              	
                      c.

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

                    

            

          

          
            

            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

          

          
            

            a.           
              General

          

          
            

            
              	
                      1.

                    	
                      The
                        MCO shall comply with those federal requirements and assurances
                        for
                        recipients of federal grants provided in OMB Standard Form
                        424B (4-88)
                        which are applicable to the MCO. The MCO is responsible for
                        determining
                        which requirements and

                    

            

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
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            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.

          

          
            

            
              	
                      2.

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

                    

            

          

          
            

            b.           Lobbying

          

          
            

            
              	
                      1. 

                    	
                      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.

                    

            

          

          
            

            
              	
                      2. 

                    	
                      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.

                    

            

          

          
            

            c.           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

          

          
            

            d.           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.

          

          
            

            e.           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,

          

          
            

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            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 - ILL, "Disclosure Form to Report Lobbying," in accordance
              with
              its instructions.

          

          
            

            f.           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

          

          
            

            a.           Federal
              Authority

          

          
            

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

          

          
            

            b.           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.

          

          
            

            c.           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.

          

          
            

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            d.           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.

                    

            

          

          
            

            
              	
                      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.

                    

            

          

          
            

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                      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
                        II
                        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

          

          
            

            
              	
                      a.

                    	
                      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.

                    

            

          

          
            

            
              	
                      b.

                    	
                      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.

                    

            

          

          
            

            
              	
                      c.

                    	
                      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
              Order Number 16

          

          
            

            This
              contract is subject to Executive Order No. 16 of Governor John G. Rowland
              promulgated August 4, 1999 and, as such, this contract may be cancelled,
              terminated or suspended by the State for violation of or noncompliance
              with said
              Executive Order No. 16. The parties to this contract, as part of the
              consideration hereof, agree that:

          

          
            

            
              	
                      a.

                    	
                      The
                        MCO 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
                        b.

                    

            

          

          
            

            
              	
                      b.

                    	
                      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

                    

            

          

          
            

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            electronic
              defense weapon. Dangerous instrument means any instrument, article
              or substance
              that, under the circumstances, is capable of causing death or serious
              physical
              injury.

          

          
            

            
              	
                      c.

                    	
                      The
                        MCO shall prohibit employees from using, attempting to use
                        or threatening 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.

                    

            

          

          
            

            
              	
                      d.

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

                    

            

          

          
            

            
              	
                      e.

                    	
                      The
                        MCO agrees that any subcontract it enters into in furtherance
                        of
                        the work to be performed hereunder shall contain the provisions
                        (a)
                        through (d).

                    

            

          

          
            

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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. In 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;

                    

            

          

          
            

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                      5.

                    	
                      The
                        Member's right to challenge the denial by filing an internal appeal
                        with the MCO;

                    

            

          

          
            

            
              	
                      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.

                    	
                      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.

                    

            

          

          
            

            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.

                    

            

          

          
            

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                      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.

                    

            

          

          
            

            
              	
                      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 mailed to the
                        Member. 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

                    

            

          

          
            

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            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.

          

          
            

            
              	
                      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.

                    

            

          

          
            

            
              	
                      d.

                    	
                      The
                        MCO shall include a copy of the HUSKY B Program - State
                        of Connecticut - Insurance Department Request
                        for
                        External Appeal form approved by the DEPARTMENT with
                        each written decision.

                    

            

          

          
            

            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

                    

            

          

          
            

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            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;

          

          
            

            
              	
                      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 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 that 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.

          

          
            

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            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
              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:

          

          
            

            
              	
                      a)

                    	
                      Each
                        time the MCO fails to comply with the contract on an issue warranting
                        a Class A sanction, the MCO receives a
                        strike.

                    

            

          

          
            

            
              	
                      b)

                    	
                      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.

                    

            

          

          
            

            
              	
                      c)

                    	
                      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

                    

            

          

          
            

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            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.

          

          
            

            
              	
                      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:

          

          
            

            a)
              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

                    

            

          

          
            

            
              	
                      1.

                    	
                      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:

                    

            

          

          
            

            
              	
                      a)

                    	
                      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;

                    

            

          

          
            

            
              	
                      b)

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

                    

            

          

          
            

            
              	
                      c)

                    	
                      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;

                    

            

          

          
            

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                      d)

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

                    

            

          

          
            

            
              	
                      e)

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

                    

            

          

          
            

            
              	
                      2.

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

                    

            

          

          
            

            
              	
                      a)

                    	
                      Withholding
                        the next month's capitation payment to the MCO in full or in
                        part;

                       

                    

              	          
                      b)	Assessment
                      of liquidated damages:

            

          

          
             

          

          
            
              	
                      1)

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

                    

            

          

          
            

            
              	
                      2)

                    	
                      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;

                    

            

          

          
            

            
              	
                      3)

                    	
                      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 co-payments on Members in excess of the premiums
                        or co- payments 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;

                    

            

          

           

          
            
              	
                      c)

                    	
                      Freeze
                        on new enrollment and/or alter the current enrollment;
                        or

                    

            

          

          
            

            
              	
                      d)

                    	
                      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

                    

            

          

          
            

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            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.

          

          
            

            
              	
                      3.

                    	
                      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 the
                        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

                    

            

          

          
            

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            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.

          

          
            

            
              	
                      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 II, 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 the 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

                    

            

          

          
            

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            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.

          

          
            

            
              	
                      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 I Section 8,
                        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 II Section 6.05 and Part III 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

                    

            

          

          
            

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            contract.
              Whenever possible, the MCO will be given thirty (30) days notification
              of
              termination.

          

          
            

            
              	
                      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

                    

            

          

          
            

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            DEPARTMENT
              may notify Members of the MCO and permit such Members to disenroll
              immediately
              without cause during the hearing process.

          

          
            

            
              	
                      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 II 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.

          

          
            

            108

          

        

      

    

     

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

    

    

    HUSKY
      B - APPENDIX A: Covered Benefits

     

    
      	
              Benefit
                Features

            	
              HUSKY
                Coverage

            	 
	
              Outpatient
                Physician Visits

            	
              $5
                co-pay

            	
              *

            
	
              Preventive
                Care

            	
              No
                co-pay

              Periodic
                and well child visits, immunizations, WIC evaluations as applicable,
                and
                prenatal care covered in full with $5 co-pay on other visits.

              Periodicity
                schedule and reporting based on the American Academy of
                Pediatrics (AAP) as amended from time to time:

              Age
                Category  # of Exams

              Birth
                to Age 1  6 exams

              Ages
                1-5           6
                exams

              Ages
                6-10         1 exam every 2
                years

              Ages
                11-19       1 exam every
                year.

              Immunization
                schedule per the Advisory Committee on Immunization Practices
                (ACIP), as amended from time to time. As of January 1, 2001, the
                schedule
                is as follows:

              Age
                CategoryVaccine Type

              BirthHepatitis
                B-1st
                dose

              1-4
                monthsHepatitis B-2nd
                dose

              2
                monthsDiphtheria, Tetanus, Pertussis (DTP) 1st
                dose;
                Haemophilus Influenza Type B (hib)-1st
                dose; Polio
                (OVP)-1st
                dose

              4
                monthsDiphtheria, Tetanus, Pertussis (DTP) 2nd
                dose;
                Haemophilus Influenza Type B (hib)- 2nd
                dose; Polio
                (OVP)- 2nd
                dose

              6
                monthsDiphtheria, Tetanus, Pertussis (DTP) 3rd
                dose;
                Haemophilus Influenza Type B (hib)-3rd
                dose

              6-12
                monthsHepatitis B-3rd
                dose; Polio
                (OVP)-3rd
                dose

              12-15
                monthsHaemophilus Influenza Type B (hib)-3rd
                dose;
                Measles, Mumps, Rubella (MMR)-1st
                dose

              12-18
                monthsChicken Pox (Var)-single dose; Diphtheria, Tetanus, Pertussis
                (DTP)
                4th
                dose

              4-6
                yearsDiphtheria, Tetanus, Pertussis (DTP) 5th
                dose;
                Measles, Mumps, Rubella (MMR)-2nd
                dose; Polio
                (OVP)-4th
                dose

              11-12
                yearsTetanus Diphtheria (Td)

              Influenza:
                Every year beginning at 6 months for children who have serious long-term
                health problems such as heart disease, lung disease, kidney disease,
                metabolic disease, diabetes, asthma, anemia, and/or are on long term
                aspirin treatment

              Pneumococcal:
                Vaccinate children 2 years and older who are at risk of pneumococcal
                disease or its complications

            	
              *

            
	
              Family
                Planning

            	
              100%

              Family
                Planning Services include:

              Reproductive
                health exams;

              Patient
                Counseling;

              Patient
                Education;

              Lab
                tests to detect the presence of conditions affecting reproductive
                health;

              Screening,
                testing and treatment;

              Pre
                and post-test counseling for sexually transmitted diseases and
                HIV;

              Abortions
                that are necessary to save the life of the mother or if the pregnancy
                resulted from rape or incest or if pregnancy resulted from rape or
                incest
                and other medically necessary abortions as defined in Section 3.14
                of the
                contract.

            	 
	
              Preventative
                Family Planning Services

            	
              100%

            	
              *

            
	
              Oral
                Contraceptives

            	
              $5
                co-pay (included in prescription drugs)

            	
              *

            
	
              Inpatient
                Physician

            	
              100%

            	
              *

            
	
              Inpatient
                Hospital

            	
              100%

            	 
	
              Outpatient
                Surgical Facility

            	
              100%

            	 
	
              Ambulance

            	
              100%
                if determined to be an emergency in accordance with state
                law

            	 
	
              Pre-Admission
                /Continued Stay

            	
              Arranged
                through provider.

            	 
	
              Prescription
                Drug

            	
              $3
                co-pay on generics

              $5
                co-pay on oral contraceptives

              $6
                co-pay on brand-name formularies

            	
              *

            
	
              Short
                Term Rehabilitation

            	
              100%

              For
                conditions where significant improvement is expected within 60 days
                including:

              Physical
                Therapy;

              Speech
                Therapy;

              Occupational
                Therapy; and

              Skilled
                Nursing Care (excludes private duty nursing)

            	 
	
              Home
                Health Care

            	
              100%

              Includes                    Disposable
                medical supplies for homebound members

              Excludes:                      Custodial
                care, homemaker care or care that may be provided in a medical office,
                hospital or skilled nursing facility and offered to the member is
                such
                setting.

            	 
	
              Hospice

            	
              100%
                provided to members who are diagnosed as having a terminal illness
                with a
                life expectancy of six months or less.  Covered care
                includes

              Nursing
                care;

              Physical
                therapy, Speech therapy, and Occupational therapy;

              Medical
                social services;

              Home
                health aides and homemakers;

              Medical
                supplies;

              Drugs;

              Appliances;

              DME;

              Physician
                services;

              Short-term
                inpatient care, including respite care and care for pain control
                and acute
                and chronic symptom management; services of volunteers and other
                benefits
                when ordered by a physician.

              Limitations
                on short-term therapies do not apply.

            	 
	
              Long
                Term: Rehabilitation; Physical Therapy; Skilled Nursing
                Care

            	
              Not
                covered under HUSKY B.

              Supplemental
                coverage available under HUSKY Plus Physical for medically eligible
                children.

            	 
	
              Lab
                and X-Ray

            	
              100%

            	 
	
              Pre-Admission
                Testing

            	
              100%

            	 
	
              Emergency
                Care

            	
              100%
                if determined to be an emergency in accordance with state
                law.  $25 co-pay if determined a non-emergency. $25 co-pay
                waived if the patient is admitted.

            	
              *

            
	
              Durable
                Medical Equipment (DME)

            	
              DME
                means equipment that is furnished by a supplier or home health agency
                that:

              1.can
                withstand repeated use;

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

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

              4.is
                appropriate for use in the home

              100
                % covered except DME does not include:

              ·
Power
                wheelchairs for members who are eligible for HUSKY Plus
                Physical;

              ·
Devices
                not
                medical in natures such as:

              ·
                whirlpools,

              ·
                saunas,

              ·
                elevators,

              ·
                vans,

              ·
van
                lifts,

              ·
home
                convenience items (e.g., air cleaners, filtration units and related
                apparatus, exercise bicycles and other types of exercise
                equipment),

              ·
insulin
                injectors,

              ·
non-rigid
                appliances and supplies, such as, sheets, self-help devices, experimental
                or investigational research equipment, and

              ·
items
                for
                personal comfort and or usefulness to the member’s household.

              Supplemental
                coverage available under HUSKY Plus Physical for medically eligible
                children.

            	 
	
              Hearing
                Aids

               

            	
              Hearing
                aids for children twelve years of age or younger, limited to $1,000.00
                within a 24-month period.

              Supplemental
                coverage available under HUSKY Plus for medically eligible
                children

            	 
	
              Prosthetics

            	
              100%

              Includes:                      Devices
                whether worn anatomically or surgically implanted, which replace
                all or
                part of a body organ or structure and which correct, strengthen or
                provide
                necessary support to the body will be covered when medically
                necessary.

              Excludes:                      Orthopedic
                shoes, foot orthotics, wigs or hairpieces.

              Supplemental
                coverage available under HUSKY Plus Physical for medically eligible
                children

            	 
	
              Eye
                Care

              Eye
                Exams

            	
               

              5$
                co-pay

            	
              *

            
	
              Hearing
                Exam

            	
              $5
                co-pay

            	
              *

            
	
              Nurse
                Midwives

            	
              $5
                co-pay (except for preventative services)

            	
              *

            
	
              Nurse
                Practitioners

            	
              $5
                co-pay (except for preventative services)

            	
              *

            
	
              Podiatrists

            	
              $5
                co-pay

            	
              *

            
	
              Chiropractors

            	
              $5
                co-pay

            	
              *

            
	
              Naturopaths

            	
              $5
                co-pay

            	
              *

            
	
              Dental

            	
              100%

              Dental
                Services include:

              Exams,
                1 every 6 months;

              X-rays,

              Fillings;

              Fluoride
                Treatments;

              Oral
                Surgery

            	
              *

            

    

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
                  

          

        

      

    

    

    Limited
      Benefits

    
      	
              Benefit
                Features

            	
              HUSKY
                Coverage

            	 
	
              Eye
                Care

              Eyeglass
                frames and lenses or contact lenses

            	
              Once
                every 2 consecutive eligibility periods with an allowance of $100
                toward
                the purchase of these goods.  The optical hardware must be
                provided without charge under the following conditions:

              (i)One
                pair of contact lenses every 2 consecutive eligibility periods when
                such
                lenses are determined to be the primary and the best method for aiding
                the
                member vision and the lenses are not needed solely for the correction
                of
                vision;

              (ii)Eyeglass
                frames and lenses and contact lenses that are determined to be medically
                necessary after eye surgery, the initial pair only; and

              (iii)Contact
                lenses, as needed, for the treatment of Keratonconus.

            	 
	
              Dental

              Orthodontia

            	
               

              $725
                allowance per orthodontia case.

            	 
	
              Bridges
                or crowns; root canals; full or partial dentures; or
                extractions

            	
              $50
                allowance per procedure, per member but no more than an aggregate
                allowance for all such procedures of $250 per eligibility
                period.

            	 
	
              Contraceptives

              Intruterine
                Devices (IUD) and insertion of the IUD

            	
               

              $50
                allowance per member

            	
               

              *

            
	
              Internally
                implantable time-release devices and their insertion

            	
              $50
                allowance per member

            	
              *

            
	
              Time-released
                contraceptive injections

            	
              $15
                allowance per member per injection

            	
              *

            
	
              Nutritional
                Formulas

            	
              100%

              Limited
                to medically necessary amino acid modified preparations and low protein
                modified food products for the treatment of inherited metabolic diseases
                when ordered by a participating physician

            	
              *

            

    

    

    Annual
      co-payments cannot exceed $760/$1350 (Income Band 1/Income Band 2) including
      premiums, per year.

    

    
      
        
          `Note:
            Prior authorization may be required by the MCO unless otherwise noted
            by an
            asterisk (*).  Co-payment not required for preventive
            services.           

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    EXCLUSIONS
      AND LIMITATIONS

    
      	
              1.

            	
              Services
                and/or procedures considered to be of an unproven, experimental,
                or
                research nature or cosmetic, social, habilitative, vocational,
                recreational, or educational.

            

    

    
      	
              2.

            	
              Services
                in excess of those deemed medically necessary to treat the patient’s
                condition.

            

    

    
      	
              3.

            	
              Services
                for a condition that is not medical in
                nature.

            

    

    
      	
              4.

            	
              Devices
                required by third parties, such as school or employment physicals,
                physicals for summer camp, enrollment in health, athletic, or similar
                clubs, premarital blood work or physicals, or physicals required
                by
                insurance companies or court ordered alcohol or drug abuse
                course.

            

    

    
      	
              5.

            	
              Cosmetic
                and reconstructive surgery is excluded, except when surgery is required
                for:

            

    

    
      	
              a) 
                

            	
              reconstructive
                surgery in connection with the treatment of malignant tumors or other
                destructive pathology that causes
                dysfunction;

            

    

    
      	
              b) 
                

            	
              reduction
                mammoplasty in females when Medically Necessary and breast surgery
                in
                males only in cases of suspected malignancy. Surgery must be necessary
                to
                achieve normal physical or bodily
                function.

            

    

    
      	
              6.

            	
              Routine
                foot care rendered:

            

    

    
      	
              a)  

            	
              in
                the examination, treatment or removal of all or part of corns,
                callosities, hypertrophy or hyperplasia of the skin or subcutaneous
                tissues of the foot.

            

    

    
      	
              b) 
                

            	
              in
                the cutting, trimming or other non-operative partial removal of toenails,
                except when Medically Necessary in the treatment of neuro-circulatory
                conditions.

            

    

    
      	
              7.

            	
              Evaluation,
                treatment and procedures related to, and performance of, sex-change
                operations.

            

    

    
      	
              8.

            	
              Surgical
                treatment or hospitalization for the treatment of morbid obesity
                except
                where prior authorized Medically
                Necessary.

            

    

    
      	
              9.

            	
              Care,
                treatment, procedures, services or supplies that are primarily for
                dietary
                control including, but not limited to, any exercise weight reduction
                programs, whether formal or informal, and whether or not recommended
                by an
                In-network Physician or Out-of-Network
                Physician.

            

    

    
      	
              10.

            	
              Acupuncture,
                biofeedback, or hypnosis.

            

    

    
      	
              11.

            	
              Treatment
                at pain clinics unless determined to be Medically
                Necessary.

            

    

    
      	
              12.

            	
              Ambulatory
                blood pressure monitoring.

            

    

    
      	
              13.

            	
              Any
                court order for testing, diagnosis, care, or treatment deemed not
                Medically Necessary.

            

    

    

    
      
        
          `Note:
            Prior authorization may be required by the MCO unless otherwise noted
            by an
            asterisk (*).  Co-payment not required for preventive
            services.           

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
Appendix
      B

    Husky
      Plus Behavioral - Deleted

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

    Appendix
      C

    HUSKY
      Plus

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

        
             

        

      

    

    HUSKY
      PLUS

    SUPPLEMENTAL
      INSURANCE COVERAGE

     

    On
      October 29, 1997, the Connecticut legislature authorized the establishment
      of
      the HUSKY, Part B and HUSKY Plus insurance programs to provide health care
      coverage for uninsured children pursuant to Title XXI of the Social Security
      Act. HUSKY, Part A is the program for children’s coverage under Title XIX of the
      Social Security Act. The HUSKY Plus program was originally comprised of two
      supplemental health insurance programs to provide services to children whose
      intensive medical and/or behavioral health needs cannot be accommodated within
      the basic benefit package offered under HUSKY, Part B.  Effective
      January 1, 2006 the supplemental health insurance program that covered children
      with intensive behavioral health needs, HUSKY Plus Behavioral (HPB) was
      eliminated. Emergency mobile, case management, and rehabilitative services
      previously covered under HPB are now covered under the core HUSKY B benefit
      package (see Sec. 6.2 and Appendix 6.1). This appendix only addresses the HUSKY
      Plus Physical program, the program designed to provide coverage to children
      with
      intensive physical health needs.  General Features of the HUSKY Plus
      Physical Program

     

    The
      HUSKY
      Plus Physical (HPP) Plan is a supplemental benefit package for children who
      are
      eligible for and enrolled in HUSKY, Part B, with household incomes under 300%
      of
      the federal poverty limit (Income bands 1 and 2 only). Children may not apply
      for coverage under HUSKY Plus unless they have already been determined to be
      eligible under HUSKY, Part B, and have enrolled in HUSKY, Part B.

    Children
      who are eligible under HPP will be dually eligible. That
      is, children who are determined to be eligible under HPP will continue to
      receive benefits under HUSKY, Part B, including those physical health services
      for their special needs diagnoses or conditions that are covered under Part
      B.

     

    As
      described below, these services will be coordinated by a case
      management/treatment team composed of case managers from both HUSKY, Part B
      and
      one or both of the HUSKY Plus Physical plan, which will maximize the
      coordination of benefits under both plans and other sources of coverage through
      federal, state and private support. The case management/treatment team will
      need
      to coordinate the development of the Global Plan of Care (GPC) so that services
      included do not replicate special education services authorized under an
      Individual Education Plan (I.E.P.) or Individualized Family Service Plan
      (I.F.S.P.).

    In
      the
      event that the child is eligible for HUSKY, Part B and HPP, the case management
      team leader of HPP will need to coordinate with the HUSKY, Part B case manager
      to assure that the HPP GPC’s complements services provided under HUSKY, Part
      B.

     

    However,
      ultimate utilization management decisions will rest with the utilization
      managers of the plan that is financially at risk; i.e., HUSKY, Part B
      utilization managers will have final decision making authority for those
      services for which they are at risk and HPP utilization managers will have
      the
      decision making authority for those supplemental services included in their
      benefit package.

    In
      the
      event there is a dispute between the participating HUSKY, Part B managed care
      plan and the HPP concerning the responsibility for reimbursement of a service
      authorized under the treatment plan, the dispute will be referred to the
      Commissioner (or his/her designee) for resolution.

     

    Eligible
      children will be able to receive services under both the basic and one or both
      supplemental benefit package simultaneously in order to allow both plans to
      provide services to the child to the fullest extent possible in the least
      restrictive setting.

     

    HPP
      services may supplement HUSKY, Part B services once a child has exhausted his
      or
      her annual benefit limits under Part B. However, HPP will always be the payer
      of
      last resort. The case management/treatment team will always look to exhaust
      all
      medically necessary coverage benefits under HUSKY, Part B, including conversion
      options when appropriate, before these services are supplanted or replaced
      by
      services available under HPP .

     

    II.  HUSKY
      Plus Plan for Children with Special Physical Health Care
      Needs

     

    Program
      Administration

    The
      HUSKY
      Plus Plan for Children with Special Physical Health Care Needs (HPP) will be
      administered by the Connecticut Children’s Medical Center. The advisory
      committee established by the Department of Public Health for Title V of the
      Social Security Act will be the Steering Committee for the HPP plan along with
      representatives from the Departments of Social Services (DSS) and Children
      and
      Families (DCF). The Steering Committee shall be named the Steering and Advisory
      Committee for Children with Special Health Care Needs and HUSKY Plus Physical
      (SASH).

     

    Eligibility

    Children
      enrolled in HUSKY, Part B, Income Bands 1 and 2, who have intensive physical
      health needs that cannot be met within the Part B benefit package will be
      eligible for supplemental services under the HPP plan if they meet the clinical
      eligibility standard. The clinical eligibility standard is based on diagnostic
      and/or acuity criteria and shall be the same as those for the Title V program
      currently operating in the state.

    Clinical
      eligibility will be determined:

     

    
      	
              1.  

            	
              By
                documentation of clinical information which meets the “Medical Eligibility
                Criteria” of the Department of Public Health Title V Program;
                or

            

    

     

    
      	
              2.  

            	
              By
                meeting the approved definition of Children with Special Health Needs
                with
                documentation of clinical evidence. The definition adopted by the
                Steering
                Committee but subject to change is as
                follows:

            

    

     

     “Children
      with Special Health Care Needs are those who have or are at elevated risk for
      (biologic or acquired) chronic physical or developmental conditions and who
      also
      require health and related (not educational and not recreational) services
      of a
      type and amount not usually required by children of the same age (beyond
      Connecticut’s EPSDT periodicity schedule). The age of eligibility is birth to 18
      years, but may include those to age 21 (for those determined eligible before
      age
      18) for purposes of transition to adult services.” . In addition, eligibility
      for HPP will end at age 19, when eligibility for HUSKY, Part B also
      ends.

    For
      the
      purposes of determining acuity of a child who meets the Medical Eligibility
      Criteria or who may qualify as a Child with Special Health Care Needs, the
      HPP
      Center will use the Children with Special Health Care Needs Screening Tool,
      or
      others as approved by the Department (See attached).

     

    Referral
      and Application Process

    Children
      who may be at risk may be identified by their parents, their primary care
      provider, or another provider in the HUSKY, Part B Plan in which the child
      is
      enrolled. Referral made by made in writing or by telephone by any of the above
      parties. However, the application process for HPP will be coordinated by the
      HUSKY, Part B Plan.

    Children
      will be assessed for eligibility consistent with the practices and procedures
      currently in place under the Title V Program.

     

    Covered
      Services

    All
      children determined eligible for HPP will receive care coordination, advocacy,
      family support and case management services as well as comprehensive
      multidisciplinary evaluation once a year and up to 3 follow-up visits per year
      with members of the multidisciplinary group as needed. In addition, the range
      of
      services will include the following to the extent that they are not covered
      under the HUSKY, Part B benefit package:

     

    
      	
              ·  

            	
              Adaptive
                Seating,
                Specialized:   One
                evaluation, fabrication and completion per year. Fees are inclusive
                of one
                adjustment every 2 weeks until family is
                satisfied.

            

    

     

    
      	
              ·  

            	
              Audiometry:
                 Includes BAER, OAE; two per
                year.

            

    

     

    
      	
              ·  

            	
              Cast
                Room:  Cast room visits
                as necessary to maintain integrity of cast or to implement treatment
                plan.

            

    

     

    
      	
              ·  

            	
              Diagnostic
                Imaging (i.e., MRI,
                CT):

            

    

     

    
      	
              ·  

            	
              Durable
                Medical Equipment:   Exclusive of the basic
                HUSKY B plan and include items that assist in the activities of daily
                living

            

    

     

    
      	
              ·  

            	
              EEG/telemetry: Two
                per year.

            

    

     

    
      	
              ·  

            	
              EKG/Holter:  Two
                per year.

            

    

     

    
      	
              ·  

            	
              Emergency
                Care: Exclusive of the
                basic plan; directly related to condition that qualifies child for
                HPP.

            

    

     

    
      	
              ·  

            	
              Gait
                Analysis: One per
                year.

            

    

     

    
      	
              ·  

            	
              General
                Dental, Orthodontic: Only for children who have
                malocclusive disorders or periodontal disease resulting from their
                underlying qualifying condition or related
                treatment.

            

    

     

    
      	
              ·  

            	
              Hearing
                Aids:  One (or one pair) analog hearing aid(s)
                as prescribed per year; One (or one pair) digital hearing aid(s)
                as
                prescribed every 5 years

            

    

     

    
      	
              ·  

            	
              Home
                Health
                Aide:   Total
                of ten hours/week

            

    

     

    
      	
              ·  

            	
              Laboratory

            

    

     

    
      	
              ·  

            	
              Medical
                and Surgical
                Supplies

            

    

     

    
      	
              ·  

            	
              Medical
                Nutrition
                Services

            

    

     

    
      	
              ·  

            	
              Medical
                23 Hour and Day
                Surgery

            

    

     

    
      	
              ·  

            	
              Occupational,
                Physical and Speech
                Therapies

            

    

     

    
      	
              ·  

            	
              Orthotic
                Devices:   No more
                than one a year or one pair per year per prescribed type, including
                all
                delivery fees, fittings and
                adjustments.

            

    

     

    
      	
              ·  

            	
              Pharmacy: Over
                the Counter medications will be covered if medically necessary and
                directly related to the condition that qualifies the child for the
                program. Prior authorization by DSS
                required.

            

    

     

    
      	
              ·  

            	
              Physician
                Fees for Inpatient
                Care: Visits must be
                requested as consultations by the admitting physician and be specifically
                related to the qualifying
                condition.

            

    

     

    
      	
              ·  

            	
              Physician
                Fees for Outpatient
                Care: Covered as per care
                plan.

            

    

     

    
      	
              ·  

            	
              Prosthetics/Prosthetic
                Devices: No more than one
                per year including all delivery fees, fittings and adjustments/repairs.
                Excludes myoelectric devices.

            

    

     

    
      	
              ·  

            	
              Pulmonary
                Function Testing:  One per
                year.

            

    

     

    
      	
              ·  

            	
              Radiology

            

    

     

    
      	
              ·  

            	
              Skilled
                Intermittent Nursing:  One visit per day for
                evaluation, treatment, and education. Must be provided by a licensed
                home
                health
                agency.

            

    

     

    
      	
              ·  

            	
              Sleep
                Study/Polysomography:  One per
                year.

            

    

     

    
      	
              ·  

            	
              Special
                Nutritional Formulas or Supplements/ PKU
                Foods: Nutritional habilitative and/or
                rehabilitative sustenance of a type or amount not usually required
                by
                children. Prescribed by an authorized professional within acceptable
                standards of the American Dietetic
                Association.

            

    

     

    
      	
              · 

            	
              Transportation:  2
                round trips per year to any health care appointment by ambulance,
                chair-vans and/or other licensed medical transportation for non-emergent
                visits.

            

    

     

    
      	
              ·  

            	
              Wheelchairs:  One
                new manual wheelchair no more than every three years. One new motorized
                wheelchair no more than every five
                years.

            

    

     

    This
      list
      may be revised from time to time as recommended by the Steering Committee and
      approved by the Department.

     

    Service
      Providers

    The
      Connecticut Children’s Medical Center will serve as the coordinating
      organization. but services will be provided by the entities under contract
      to
      provide Title V services.

     

    Service
      Utilization Management

    Service
      utilization will be managed through a clear definition of medical necessity.
      “Medical Necessity” or “medically necessary” is defined as 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.

    All
      services will be subject to prior authorization by the utilization management
      staff at the Connecticut Children’s Medical Center. These decisions will be
      subject to the process for Grievances and Appeals (see below).

     

    Coordination
      of HPP Services with HUSKY, Part B

    In
      order
      to ensure that HPP will be the documented payer of last resort, the HPP Center
      shall assign each enrollee with a case manager and provide care coordination
      services. The HPP case manager shall coordinate with the HUSKY, Part B case
      manager to ensure that all medically necessary HPP covered services identified
      in the global plan of care (GPC), which are also covered in the HUSKY, Part
      B
      basic benefit package, are exhausted first under HUSKY, Part B.

    The
      HPP
      Center shall designate a Lead Case Manager who will be responsible for convening
      a case management/treatment team that will develop an individualized
      GPC for each enrollee. The case
      management/treatment team may be composed of, but not limited to, the enrollee
      or enrollee’s parent(s), treating clinicians and/or providers, the HUSKY, Part B
      Case Manager, and the Lead Case Manager. The case management/treatment team
      will
      coordinate the development of the GPC so that covered services included in
      the
      GPC do not replicate special education services authorized under an I.E.P.
      or
      I.F.S.P.

    In
      the
      event that the enrollee is also eligible for HPB, the case management/treatment
      team shall include the case manager from HPB. The case management/treatment
      team
      shall develop a GPC that integrates services from HUSKY, Part B, HPP and HPB
      as
      appropriate.

     

    Global
      Plan of Care (GPC)

    HPP
      will
      ensure that the case management/treatment team completes the GPC for each
      enrollee within 30 days of the date of eligibility determination. The case
      management/treatment team on at least a semi-annual basis will reassess the
      GPC.
      The GPC will be based on the comprehensive need assessment, periodic
      reassessments, and treatment plans from the HUSKY, Part B Plan and HPP
      Contractor providing services to the child. The GPC will include medical
      management recommendations reflecting the level of involvement of the HPP staff
      and the scope of clinical practice of the clinical staff, estimates of the
      need
      and frequency of specific clinical services and a designation of who is
      responsible for the specific elements of the GPC.

     

    The
      GPC
      will be mailed or faxed to the enrollee’s HUSKY, Part B Plan and to the child’s
      primary care physician.  A written copy of the GPC will be kept on
      file at HPP, as part of the child’s case file.

     

    Program
      Quality

    Both
      HPP
      will be reviewed annually by an external quality review organization (EQRO)
      pursuant to the goals identified in the Title XXI State Plan. Pursuant to this
      review, the Commissioner will submit a report to the Governor and the General
      Assembly on the HUSKY Plus Programs which will include an evaluation of the
      special health outcome and access measures identified for HUSKY Plus
      enrollees.

    In
      addition, the Department will review the HPP Center at least annually. Based
      on
      the EQRO report and the Department review, recommendations for program quality
      improvement will be identified. Corrective action plans and quality improvement
      projects will be initiated by the Centers in conjunction with the
      Department.

     

    Grievance
      and Appeals Process

    In
      accordance with 42 CFR 457 part(s) 1120 – 1180, a HUSKY Plus applicant has the
      right to request an administrative review regarding a decision made on their
      HUSKY Plus application. Whenever possible, HPP will attempt to resolve
      grievances informally. However, parents and providers will be encouraged and
      supported in the filing of appeals without fear of compromised service. A copy
      of the appeals procedure, written in a manner easily understood by the lay
      public, will be distributed to every family at the time of their application
      to
      HPP.

     

    The
      state
      ensures that all enrollees and applicants receive timely written notice of
      any
      determinations required to be subject to review, as outlined
      below.  Written notices at each level include the reasons for the
      determination, an explanation of applicable rights to review of that
      determination, the standard and expedited time frames for review, the manner
      in
      which a review can be requested, and the circumstances under which enrollment
      may continue pending review.  However, the State will not provide
      an opportunity for review of a matter if the sole basis for the decision is
      a
      provision in this plan or in federal or State law requiring automatic change
      in
      eligibility, enrollment, or a change in coverage under the health benefits
      package that affects all applicants or enrollees or a group of applicants or
      enrollees without regard to their individual circumstances.

    The
      following decisions can be appealed through the grievance process:

     

    
      	
              ·  

            	
              Denial
                of eligibility for Income Bands One and Two
                only;

            

    

     

    
      	
              ·  

            	
              Failure
                to make a determination of eligibility within 21 days of
                application;

            

    

     

    
      	
              ·  

            	
              Suspension
                or termination of enrollment in HPP for enrollees enrolled in Income
                Band
                One or Income Band Two of HUSKY B;

            

    

     

    
      	
              ·  

            	
              Delay,
                denial, reduction, suspension or termination of goods or services,
                including determination regarding level of
                services;

            

    

     

    
      	
              ·  

            	
              Failure
                to approve, furnish or provide payment for services in a timely
                manner;

            

    

     

    
      	
              ·  

            	
              Medical
                necessity of a type of service or setting;
                and

            

    

     

    
      	
              ·  

            	
              Choice
                of provider

            

    

     

    While
      an
      appeal regarding suspension or termination of eligibility or enrollment is
      being
      considered, the enrollee will remain eligible for HPP and their goods and/or
      services will be continued until the grievance is decided, so long as the
      enrollee remains in Income Band 1 and 2. An enrollee who has been enrolled
      in
      Income Band 3 of the HUSKY B program shall be disenrolled from HPP.

    While
      an
      appeal regarding delay, denial, reduction, suspension or termination of goods
      and/or services is being considered, the enrollee will continue to receive
      such
      goods and/or services until the appeal is decided, so long as the child remains
      in Income Band 1 or 2.

     

    Applicants
      or enrollees requesting to review their files or other information relevant
      to
      the appeal review will be provided access to their files at a mutually
      convenient date and time, but no later than four days prior to the decision
      being issued. Additionally, the State will ensure that applicants or
      enrollees have opportunities to represent themselves or have representatives
      of
      their choosing in the review process, and to fully participate in the review
      process.

    The
      grievance and appeals process will have three levels of appeal: the first to
      HPP’s medical director (who was not involved in the prior decision), the second
      to a sub-group of the Steering Committee, and the third to the
      Commissioner.

     

    Whenever
      a decision is made regarding an enrollee’s eligibility, enrollment or goods
      and/or services, a letter is sent from the HPP Center to the parent describing
      the decision. Letters, which deny, reduce, suspend or terminate eligibility
      or
      enrollment, or goods and/or services (as listed above), will also include a
      one
      page Appeal Form and a copy of the Appeals Procedure Summary. To begin the
      appeals process, the parent or provider should complete the Appeals Form. The
      form should be mailed or delivered to the HPP Center but must be received by
      the
      Center within 45 days of the date of the letter describing the decision that
      is
      being appealed.

     

    Level
      One Appeal:

    The
      HPP
      Center will send a letter that acknowledges receipt of the appeal form to the
      parent or provider. The letter will identify a HPP staff member as the Appeals
      Manager. The Appeals Manager will track the appeal, act as the contact person
      for questions and updates, and will attempt to resolve the appeal within ten
      days. If the appeal is resolved to the satisfaction of the parent or provider
      by
      the Appeals Manager, a letter will be sent describing the resolution, and there
      will be no further action. If the appeal cannot be resolved at this level,
      the
      Appeals Subcommittee will review the appeal.

     

    Level
      Two Appeal:

    The
      Appeals Subcommittee of the Steering and Advisory Committee for Children with
      Special Health Care Needs and HUSKY Plus Physical (SASH) for HPP has three
      members, one each from:

     

    
      	
              ·  

            	
              The
                Department of Social Services (DSS)

            

    

     

    
      	
              ·  

            	
              The
                Department of Public Health (DPH)
                and

            

    

     

    
      	
              ·  

            	
              The
                Connecticut Children’s Medical
                Center

            

    

     

    No
      one
      directly involved in the decision being appealed will be a member of this
      subcommittee. The Appeals Manager is not a member of this subcommittee but
      will
      attend to provide needed information.

    A
      letter
      will be sent to the parent or provider that gives the time and date of the
      Appeals Subcommittee meeting. The meeting will be scheduled to occur within
      ten
      business days of receipt of the written appeal. The parent or provider may
      reschedule this meeting, for any reason, once. However, the Appeals Committee
      meeting must occur within 25 business days of the receipt of the
      appeal.

    The
      parent or provider may bring support persons to the Appeals Subcommittee
      meeting, including legal counsel, a person with special knowledge or training
      with respect to the problems of the enrollee, and one or two individuals for
      support.

     

    In
      the
      Appeals Subcommittee, the Appeals Manager will present the appeal; along with
      any documents involved in the initial decision. The Appeals Manager will also
      present a summary of the efforts to this point to resolve the appeal. The
      parent, provider or accompanying support persons may also present arguments
      and
      documents, which support the appeal. Once all appeal arguments are completed,
      the Appeals Subcommittee will either make a decision regarding the appeal,
      or if
      necessary, continue the case until more information is obtained or until
      documents are reviewed. The Appeals Subcommittee must render a final decision
      no
      later than 30 days from the date of the Appeals Subcommittee meeting. The
      Appeals Subcommittee chairperson will send the parent or provider a letter
      describing the Appeal Committee’s decision no later than 30 days from the date
      of the Appeals Subcommittee meeting.

     

    Level
      Three Appeal:

    If
      the
      parent or provider does not agree with the Appeal Subcommittee’s decision,
      he/she may continue the appeal process by writing a letter to the Commissioner
      of the Department of Social Services (DSS) or designee. In this case, the parent
      or provider must send a copy of the original Appeal Form, the Appeals
      Subcommittee letter and any other pertinent documents to the Commissioner or
      designee within ten business days of the date of the Appeals Subcommittee
      letter. The Appeals Manager will continue to help the parent or provider with
      this next step. The DSS Commissioner or designee shall make a determination
      and
      provide a written decision to the parent no later than 90 days from the initial
      request date.

    If
      the
      enrollee has been enrolled in the HPP program and is found to be ineligible
      for
      HPP, and this decision is appealed, the enrollee will continue to be eligible
      for HPP services so long as the child remains eligible for and enrolled in
      HUSKY, Part B, Income Bands 1 and 2, until the appeal process is completed.
      Enrollees of HUSKY, Part B who are in Income Band 3 are not eligible for the
      HUSKY Plus Program and shall be immediately disenrolled from HPP

     

    Expedited
      Appeal:

    Pursuant
      to 42 CFR 457.1160, the appeal process for HPP must allow for expedited review.
      This process applies to both eligibility and enrollment matters as well as
      for
      goods and/or services. If an enrollee requests an expedited review, HPP 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. The review may be expedited if the Medical Director of HPP
      determines that the standard time frame could seriously jeopardize life or
      health or ability to attain, maintain or regain maximum function. If the Medical
      Director of HPP determines that the appeal should be expedited, the Level One
      review must be completed within 72 hours of receipt of the appeal request by
      HPP. A Level Two review of an expedited appeal must be completed within 72
      hours
      after completion of the Level One review. An expedited Level Three review must
      be completed within 72 hours after completion of the Level Two expedited review.
      The above timeframe may be extended upon request of the parent up to a maximum
      of 14 days.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Appenndix
      D

     

    Provider
      Credentialing and Enrollment
      Requirements

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

                

      

    

    

    HUSKY
      B

    PROVIDER
      CREDENTIALING AND ENROLLMENT REQUIREMENTS

    1. Provider
      Credentialing, and Enrollment Distinction

    Provider
      Credentialing and provider enrollment are separate and distinct processes in
      the
      HUSKY Programs. However, credentialing and enrollment are linked in that these
      requirements affect direct service providers as well as the manner in which
      MCOs
      submit provider network information to the Department of Social
      Services.

     

    2. Credentialing
      Definition

    For
      the
      purpose of the HUSKY programs, the term credentialing means the requirements
      for
      provider participation specified in the contracts between the Department of
      Social Services (DSS or the Department) and the MCO (Part II, 3.11, Provider
      Credentialing and Enrollment). In this section of the contract, the Department
      specifies the minimum criteria that the MCOs must require for provider
      participation in a health plan. The MCOs must ensure that their providers
      meet the Department's credentialing requirements.

     

    3. Other
      Sources Credentialing

    Credentialing
      is sometimes used to refer to a variety of requirements or entities, which
      issue
      credentialing standards. Examples include: the MCO's individual credentialing
      requirements; the managed care subcontractor's credentialing requirements;
      an
      accreditation organization requirements, such as the National Committee on
      Quality Assurance (NCQA); the licensure process; a trade organization or
      association such as the Joint Commission on Accreditation of Health
      Organizations (JCAHO).

     

    4. DSS
      Requirements and Other Credentialing Sources

    DSS
      credentialing requirements represent the minimum criteria for provider
      participation in a health plan. The Department will allow flexibility to the
      MCOs to use more stringent criteria, particularly as it concerns quality level
      of care for clients. While the MCOs may require additional, more stringent
      criteria, the Department is concerned with the impact on access to care.
      Therefore, DSS expects the MCOs to balance the need for stringent credentialing
      standards with the need to assure accessibility and continuity of
      care.

     

    5. Delegated
      Credentialing

    The
      contract between the Department and the MCOs permits the plan to delegate
      credentialing of individual providers to a facility. However, the MCO is
      ultimately responsible and accountable to DSS for compliance with the
      Department's credentialing requirements.

    For
      the
      purpose of HUSKY, delegated credentialing means that the MCO entrusts the
      Department's credentialing requirements to another entity. MCOs delegate
      credentialing to a variety of entities depending on the nature of the services
      and the type of provider.

    In
      delegated credentialing, the MCO remains responsible to DSS to verify and
      monitor compliance with the Department's credentialing requirements. The
      Department views delegated credentialing as a form of subcontract, therefore,
      similar oversight issues arise in the performance of the credentialing
      requirements. The Department requires the plans to demonstrate and document
      to
      DSS the plan's strong oversight of its delegated credentialing facilities.
      (Part
      II, Section 3.41 in B 3.44 in A, Subcontracting for Services).

     

    6. Implications
      of Delegated Credentialing

    In
      some
      instances, the MCO credentials the individual provider directly or delegates
      credentialing of the providers to the following entities:

     

    
      	
              ·  

            	
              A
                subcontractor providing specific services (e.g., dental
                care);

            

    

     

    
      	
              ·  

            	
              A
                credentialing subcontractor; or

            

    

     

    
      	
              ·  

            	
              A
                facility (e.g., a freestanding clinic or
                hospital)

            

    

    The
      relationship between the MCO and the delegated entity as well as the interplay
      with various credentialing requirements may take any number of configurations.
      Currently, the Department reiterates that the MCO may delegate credentialing
      of
      individual providers to a facility (e.g., a school based health center,
      freestanding clinic or hospital). However, the Department emphasizes that the
      MCO is ultimately responsible and accountable to DSS for compliance with all
      of
      the Department's credentialing requirements.

     

    7.  Oversight
      of Delegated Credentialing

    The
      Department requires the MCO to demonstrate strong oversight of their delegated
      credentialing facilities, as with any subcontract. - Therefore, the Department
      reiterates that these arrangements are subject to the Department's review and
      approval. For the purpose of delegated credentialing, the MCOs must provide
      assurances to DSS at a minimum of the following:

     

    
      	
              •

            	
              The
                MCO and the delegated entity should clearly identify in detail each
                party's responsibility for credentialing of
                providers.

            

    

    
      	
              •

            	
              The
                Department's credentialing requirements should be clearly identified
                as
                well as each party's role in adhering to these
                requirements.

            

    

    
      	
              •

            	
              The
                *credentialing files must be available to the plan in order to perform
                its
                oversight of the credentialing requirements. The Department must
                also have
                adequate access to credentialing files for the purposes of administering
                the managed care contracts.

            

    

    (DSS/MCO
      HUSKY A Contract, Part II, Section 3.45 “Subcontracting for Services” and in
      HUSKY B Section 3.42 “Subcontracting for Services”.)

     

    8.  Provider
      Enrollment Clarifications

    For
      the
      purpose of HUSKY, the Department refers to provider enrollment as the process
      of
      capturing information on providers participating with MCOs contracted by DSS
      to
      provide services to clients. This process results in a profile of an MCO's
      provider network.    The MCOs submit the provider network
      information to DSS via the Department's agent on a continuous basis. The
      Department utilizes the provider network information to facilitate the
      administration of managed care contracts and- the Medicaid program.

     

    Provider
      enrollment information serves the following purposes:

     

    
      	
              a)

            	
              To
                evaluate each MCO's service area and access to services which areused
                to
                establish enrollment ceiling or cap (currently summarized by plan
                submittals of provider tables);

            

    

    
      	
              b)

            	
              To
                provide accurate infori-nation to clients for the purpose of client
                enrollment in an MCO; and

            

    

    
      	
              c)

            	
              To
                maintain each plan's provider network information consistent with
                the
                provider directory.

            

    

     

    Based
      on
      the previous discussion of credentialing, the Department clarifies the
      relationship between credentialing or delegated credentialing and provider
      enrollment as follows:

    
      	
              a)

            	
              Enrollment
                for purposes of cap determination.

            

    

    
      	
               

            	
              •

            	
              The
                MCO must credential and enroll individual providers when the providers
                are
                counted towards the member enrollment
                ceiling.

            

    

    
      	
               

            	
              •

            	
              DSS
                credentialing requirements and provider enrollment processes also
                apply to
                individual providers in a facility when the individual provider is
                included in the count for cap
                determination.

            

    

    
      	
               

            	
              •

            	
              The
                MCO may delegate credentialing of individual providers to a facility
                (e.g., a clinic or hospital) and enroll the facility as such. In
                this
                case, -neither the facility nor the individual providers are provided
                in
                the count for cap determination.

            

    

    b)           Enrollment
      for purposes of accurate information to clients

    
      	
              ·  

            	
              The
                MCO must enroll and credential individual providers as well as facilities
                in order to maintain accurate and updated information on the providers
                participating with a health plan. The provider network information
                is used
                by the Department's enrollment broker during
                enrollment.

            

    

    
      	
              ·  

            	
              The
                Department stresses the importance of maintaining provider network
                information accurate and up-to-date. It is crucial that clients should
                have access to provider network information during the MCO select-ion
                process.

            

    

    c)           Enrollment
      for purposes of inclusion in the provider network directory.

    
      	
               

            	
              •

            	
              The
                MCO must credential and enroll individual providers when the providers
                are
                included and listed as individual providers in the health plan's
                provider
                directory.

            

    

    
      	
               

            	
              •

            	
              DSS
                credentialing requirements and provider enrollment processes also
                apply to
                individual providers in a facility when the individual provider is
                included and listed in the provider
                directory.

            

    

    
      	
               

            	
              •

            	
              If
                the 14CO delegates credeintialing of individual providers to
                a       facility and enrolls the
                facility, the facility is included and listed in the provider directory.
                The facility's individual providers are listed in the provider directory.
                The facility's providers are not listed in the provider
                directory.

            

    

     

    
      	
              9.  

            	
              Specific
                Issues and DSS Credentialing
                Requirements

            

    

     

    
      	
              a)

            	
              Medicaid
                participation

            

    

    The
      MCO
      or the delegated credentialing entity is responsible for the determination
      and
      verification that the provider meets the minimum requirements for Medicaid
      participation. The MCO or its -subcontractors may not delegate this provision
      to
      the Department nor require providers to enroll or participate in fee-for-service
      Medicaid to fulfill the requirement. While the Department encourages the MCO
      to
      contract with traditional and existing Medicaid providers, Medicaid
      participation in itself is not a requirement of the HUSKY
      contracts.

     

    
      	
              b)

            	
              Allied
                Health Professional Licensed Clinics or
                Hospitals

            

    

    The
      Department pays freestanding clinics participating in the Medicaid program
      for a
      variety of services. In Connecticut, clinic services include for example,
      medical services, well-child care, dental care, mental health and substance
      abuse services, rehabilitation services and other services. Clinic providers
      must meet federal and state requirements for participation in the Medicaid
      program. In accordance with Title 42 of the Code of Federal Regulations, Part
      440.90 and Section 171 of the Medical Services Policy of the Connecticut Medical
      Assistance Program, clinic services are provided by or under the direction
      or a
      physician, dentist or psychiatrist.

     

    The
      physician direction requirement means that the free-standing clinic's services
      may be provided by the clinic's allied health professionals whether or not
      the
      physician is physically present at the time that the services are provided.
      An
      allied health professional is further defined as an individual, employed in
      a
      clinic, who is qualified by special education and training, skills, and
      experience in providing care and treatment. The clinic is staffed by physicians
      and allied health professionals who are directly involved in the facility's
      programs. The allied health professionals provide services under the direction
      of a physician who is a licensed practitioner performing within the scope of
      his/her practice.

     

    Based
      on
      the Department's definition of clinic services, the services provided by allied
      health professionals are included under the terms of the contracts between
      the
      Department and the MCOs.

    As
      with
      all services, clinic services must be properly credentialed according to the
      Department's requirements, including licensure and certification standards.
      Allied health professionals may have licensure or certification requirements,
      such as Certified Addition Counselors or Licensed Social Workers. In accordance
      with the Department's definition, other allied health professions may qualify
      by
      virtue of their skills or experience and must function under the direction
      of a
      physician. In this case- the directing physician, as opposed to the allied
      health professional, is subject to the credentialing requirements as well as
      provider enrollment. The MCO may credential the physician directly or may
      delegate credentialing.

     

    The
      Department's provisions for credentialing, delegated and provider enrollment
      would remain in effect for the directing physician (please refer to Section
      8,
      Provider Enrollment Clarifications).

     

    
      	
              c)

            	
              NCQA
                Standards and DSS requirements

            

    

     

    While
      NCQA standards do not address credentialing of allied health professionals,
      services provided by allied health professionals may qualify for reimbursement
      by virtue of their skills or experience, however, the allied health
      professionals must function under the direction of a physician. In this case,
      the directing physician is subject to the credentialing
      requirements.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Appendix
      E

     

    American
      Academy of Pediatrics - Recommendations for
      Preventive Pediatric Health Care

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

            

      

    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
Appendix
      F

     

    DSS
      Marketing Guidelines

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

                

        

      

    

    

    Appendix
      F

     

    Detailed
      Marketing Guidelines

    1)  General
      HUSKY marketing materials

     

    Marketing
      materials are defined as all media, including brochures and leaflets; newspaper,
      magazine, radio, television, billboard and yellow pages advertisements; and
      presentation materials used by MCO representatives.

    The
      DEPARTMENT will not restrict the MCO's general communications to the public.
      However, the MCO must obtain prior approval from the DEPARTMENT prior to any
      written material or advertisement that is mailed to, distributed to, or aimed
      at
      HUSKY recipients or individuals potentially eligible for HUSKY, specifically,
      material that mentions Medicaid, Medical Assistance, Title XIX, Title XXI State
      Children's Health Insurance Program (SCHIP) or HUSKY. Examples of HUSKY-specific
      materials would be those which are in any way targeted to HUSKY populations
      (such as billboards or bus posters disproportionately located in low-income
      neighborhoods); those that mention the MCO's HUSKY product name; or those that
      contain language or information specifically designed to attract HUSKY
      enrollment.

     

    2)  General
      MCO marketing/advertising

    All
      MCO-specific marketing activities for the HUSKY population, as defined above,
      and all marketing materials /advertising put forth by HUSKY-only MCO require
      DEPARTMENT prior approval.

    In
      determining whether to approve a particular marketing activity, the DEPARTMENT
      will apply a variety of criteria, including, but not limited to:

     

    
      	
              a)

            	
              Accuracy:
                The content of the material must be accurate. Any information that
                is
                deemed inaccurate will be
                disallowed.

            

    

    
      	
              b)

            	
              Misleading
                references to the MCO's positive attributes: Misleading information
                will
                be disallowed even if it is accurate. For example, the MCO may seek
                to
                advertise that its health care services are free to its Medicaid
                (HUSKY A)
                Members. In this situation, DEPARTMENT would disallow the language
                since
                this could be construed by Members as being a particular advantage
                of the
                plan (e.g. they might believe they would have to pay for health services
                if they chose another MCO or remained in
                fee-for-service).

            

    

    
      	
              c)

            	
              Threatening
                Messages: MCOs shall not imply that the managed care program or the
                failure to join a particular MCO would endanger the Member's health
                status, personal dignity, or the opportunity to succeed in various
                aspects
                of their lives. MCOs are strictly prohibited from creating threatening
                implications about the State's mandatory assignment process for HUSKY
                A
                Members or other aspects of the HUSKY A or HUSKY B
                programs.

            

    

    
      	
              d)

            	
              MCO's
                Legitimate Strengths: MCOs may differentiate themselves by promoting
                their
                legitimate positive attributes.

            

    

     

    3) MCO
      advertising at provider care sites

    Promotional
      and health education materials at care delivery sites (including patient waiting
      areas) are permitted, subject to prior DEPARTMENT content approval. MCO member
      services staff may provide member services (e.g. face-to-face member education)
      at provider care sites, however, face-to-face meetings, for purposes of
      marketing, at care delivery sites between individual Members and MCO staff
      are
      not permitted.

     

    4)  MCO
      advertising in DEPARTMENT eligibility offices

     

    MCOs
      may
      make their materials available at DEPARTMENT offices only through the DEPARTMENT
      or its agent. This restriction applies to all eligibility offices, including
      those based in hospitals. MCO marketing staff and provider staff are not
      permitted to solicit Member enrollment by positioning themselves at or near
      eligibility offices. Note that the only face-to-face marketing activities
      allowed are those directly permitted under items #5, #7, #11 and #12 of these
      guidelines. All other face-to-face marketing activities are
      prohibited.

     

    5) Provider
      communications with HUSKY patients about MCO options

     

    DEPARTMENT
      marketing restrictions apply to the MCO's participating providers as well as
      to
      the MCOs. MCOs must notify all of their participating providers of the
      DEPARTMENT marketing restrictions and provide them with a copy of this
      document.

     

    Each
      provider entity is allowed to notify its patients of the HUSKY-certified MCOs
      it
      participates in, and to explain that the patients must enroll in one of these
      MCOs if they wish to preserve their existing relationship. This must be done
      through written materials prior-approved by DEPARTMENT, and must be distributed
      to HUSKY patients without regard to health status. Providers must not indicate
      a
      preference between the MCOs in which they participate.

     

    6) Member-initiated
      telephone conversations with MCOS and providers

     

    These
      conversations are permitted and do not require prior approval by the DEPARTMENT,
      but information given to potential Members, during such telephone conversation
      must be in accordance with the DEPARTMENT's marketing guidelines. However,
      telephone conversations must be initiated by the potential Member, not by the
      MCO staff (or provider staff). MCOs and providers may return calls to Members
      and potential Members when Members and potential Members leave a message
      requesting that this occur.

     

    7)  Member-initiated
      one-on-one meetings with MCO staff prior to enrollment

    Such
      meetings, when requested by the Member, are permitted but may not occur at
      a
      participating provider's care delivery site or at the Member's residence. These
      meetings must occur at the MCO's offices or another mutually-agreed upon public
      location. All verbal interaction with the Member must be in compliance with
      the
      DEPARTMENT's marketing guidelines.

     

    8) Mailings
      by MCO in response to Member requests

     

    MCO
      mailings are permitted in response to Member verbal or written requests for
      information. The content of such mailings must be prior-approved by the
      DEPARTMENT. MCOs may include gifts of nominal value (unit cost less than $2,
      e.g. magnets, pens, bags, jar grippers, etc.) in these mailings.

     

    9) Unsolicited
      MCO mailings

     

    MCOs
      are
      permitted to send unsolicited mailings. The content of such mailings must be
      prior-approved by DEPARTMENT. In addition, the target audiences must be
      prior-approved by DEPARTMENT, and the MCOs must explain how they obtained the
      list of names, addresses and phone numbers.

     

    10) 
      Telemarketing

     

    Telemarketing
      is not a permitted marketing activity

     

    11) MCO
      group meetings held at MCO

     

    These
      meetings must be prior approved by the DEPARTMENT. The MCO may not notify
      prospective Members until DEPARTMENT prior approval has been
      obtained

    
       

      12)
        MCO
        group meetings held in public facilities, churches, health fairs, or other
        community sites

    

     

    These
      are
      permitted activities as long as DEPARTMENT approved materials are utilized
      in
      the presentations and the DEPARTMENT's marketing guidelines are followed. The
      DEPARTMENT reserves the right to monitor such meetings on an ad hoc basis.
      MCOs
      are required to notify the DEPARTMENT sufficiently in advance to allow
      DEPARTMENT representatives to attend such meetings in order to monitor MCO
      activities if desired. As soon as the MCO has scheduled these activities, the
      DEPARTMENT should be notified.

     

    13)  MCO
      group meetings held in private clubs or homes

     

    These
      activities are prohibited. The only permitted group meetings are those described
      under items #11 and #12.

     

    14)   Individual
      solicitation, residences

     

    MCO
      (and
      provider) staff are not permitted to visit potential Members at their places
      of
      residence for purposes of explaining MCO features and promoting enrollment.
      This
      prohibition is absolute, and applies even in situations where 

    the
      potential Member desires and/or requests a home visit. MCO staff can visit
      Member homes after enrollment becomes effective, as part of their
      orientation/education efforts.

     

    15) Gifts,
      cash incentives, or rebates to potential Members and
      members.

     

    MCOs
      (and
      their providers) are prohibited from disseminating gift items, except those
      of a
      nominal value (pens, key chains, magnets, etc.), to potential Members.
      DEPARTMENT-approved written materials may also be disseminated to prospective
      Members along with similar nominal value gifts. MCOs may give items of nominal
      value (unit cost less than $2), with their logo on it, to persons (potential
      Members and others) attending health fairs, presentations at community forums
      organized through or other sanctioned events, with DEPARTMENT approval. Such
      items would include magnets, pens, bags, plastic band-aid dispensers, etc.
      Pre-approved nominal value items may also be included with new Member
      information packets.

     

    16)  Gifts
      to Members for specific health-related events

     

    Gifts
      to
      Members are allowed for medically "good" behavior (e.g. baby T-shirt showing
      immunization schedule once a woman completes targeted series of prenatal
      visits). All such gifts, including any written materials included with them
      (or
      on them), must be prior-approved by the DEPARTMENT. The criteria for providing
      such gifts must also be prior-approved by DEPARTMENT. MCOs must not provide
      gifts in any situations other than those that have been prior-approved by
      DEPARTMENT. Additional DEPARTMENT prior approval is required for all additional
      uses of the gift items or for new gifts.

     

    The
      DEPARTMENT may approve magnets, phone labels, and other nominal items that
      reinforce a MCO's care coordination programs (e.g. through advertising the
      Member Services hotline and/or the PCP office phone number). All such items
      must
      be prior-approved by the DEPARTMENT. The criteria for disseminating this
      information must also be prior-approved, although the DEPARTMENT is likely
      to be
      amenable to the MCOs' inclusion of this information in "welcome" packets sent
      to
      new Members.

     

    Health
      education videos are also allowed, but must be prior-approved by
      DEPARTMENT.

     

    17)           Phoning
      by Members from health care provider locations

     

    Providers
      may provide the use of a phone to potential HUSKY Members or HUSKY Members
      subject to the following restrictions:

     

    
      	
              a)

            	
              MCO
                or provider staff may not coach or instruct the
                caller;

            

    

    
      	
              b)

            	
              Privacy
                must be given to the MEMBER during their phone conversation with
                the HUSKY
                application and enrollment center.

            

    

     

    
      	
              18)

            	
              Non-alcoholic
                beverages and light refreshments for potential Members at
                meetings

            

    

    Non-alcoholic
      beverages and light refreshments are permitted at DEPARTMENT approved group
      meetings.

     

    
      	
              19.

            	
              Use
                of HUSKY Name; HUSKY Logo and Mandatory Language
                Requirements

            

    

     

    MCOs
      will
      be allowed use of the HUSKY logo and name for use in their marketing materials,
      subject to the following:

    
      	
              a)

            	
              must
                be used in conjunction with the following language unless alternative
                language has been prior approved by the DEPARTMENT.

               

              HUSKY
                gives families the freedom of choice to enroll in one of several
                participating health plans. Toll-free information:
                1-877-CT-HUSKY;

            

    

    
      	
              b)

            	
              the
                above mandatory language must be placed in the vicinity of the HUSKY
                logo;
                and

            

    

    
      	
              c)

            	
              the
                font size for the HUSKY phone number cannot be smaller than the MCOs
                member services phone number.

            

    

    

    
      	 	
              Type
                of Marketing Activity

            	
              Permitted

            	
              Not
                Permitted

            	
              Permitted
                With DEPARTMENT Approval

            
	
              1

            	
              General
                HUSKY marketing materials

            	 	 	
              X

            
	
              2

            	
              General,
                MCO advertising/marketing

            	 	 	
              X

            
	
              3

            	
              MCO
                advertising in provider care sites

            	 	 	
              X

            
	
              4

            	
              MCO
                advertising in all DEPARTMENT- eligibility offices, including
                hospital-based (Must be made available only through the DEPARTMENT
                or its
                agent)

            	 	 	
              X

            
	
              5

            	
              Provider
                communications with Medicaid patients about MCO options

            	 	 	
              X

            
	
              6

            	
              Member-initiated
                telephone conversations with MCO and Provider staff

            	
              X

            	 	 
	
              7

            	
              Member-initiated
                one-on-one meetings with MCO staff prior to enrollment

            	
              X

            	 	 
	
              8

            	
              Mailings
                by MCO in response to Member requests

            	 	 	
              X

            
	
              9

            	
              Unsolicited
                MCO mailings to Members

            	 	 	
              X

            
	
              10

            	
              Telemarketing

            	 	
              X

            	 
	
              11

            	
              MCO
                group meetings, held at MCO

            	 	 	
              X

            
	
              12

            	
              MCO
                group meetings held in public facilities such as churches, health
                fairs,
                WIC program or other community sites

            	 	 	
              X

            
	
              13

            	
              MCO
                group meetings held in private clubs or homes

            	 	
              X

            	 
	
              14

            	
              Individual
                solicitation at residences

            	 	
              X

            	 
	
              15

            	
              Items
                of nominal value along with written information about the MCO or
                general
                health education information to potential Members (given at such
                places as
                health fairs, community forums or other events approved by the Department)
                or included in new Member information packets.

            	 	 	
              X

            
	
              16

            	
              Gifts
                to Members (e.g. baby T-shirt showing immunization schedule) based
                on
                specific health events unrelated to enrollment

            	 	 	
              X

            
	
              17

            	
              Phoning
                by Members from health care provider locations

            	
              X

            	 	 
	
              18

            	
              Non-alcoholic
                beverages and light refreshments (e.g. fruit, cookies) for potential
                Members at meetings (may not mention refreshments in advertisements
                for
                meetings)

            	
              X

            	 	 

    

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

Appendix
      G

     

    Standards
      for Internal Quality Assurance Programs for
      Health Plans

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

       

      STANDARDS
        FOR INTERNAL QUALITY ASSURANCE PROGRAMS FOR HEALTH PLANS

       

      
        	
                Standard
                  I:

              	
                Written
                  QAP Description

              

      

       

      The
        organization has a written description of its Quality Assurance Program
        (QAP).  This written description meets the following
        criteria:

      
        	
                A.

              	
                Goals
                  and objectives - There is a written description of the QA program
                  with detailed goals and annually developed objectives that outline
                  the
                  program structure and design and include a timetable for implementation
                  and accomplishment.

              

      

      B.           Scope

      
        	
                 

              	
                1.

              	
                The
                  scope of the QAP is comprehensive, addressing both the quality
                  of clinical
                  care and quality of non-clinical aspects of services, such as and
                  including: availability, accessibility, coordination, and continuity
                  of
                  care.

              

      

      
        	
                 

              	
                2.

              	
                The
                  QAP methodology provides for review of the entire range of care
                  provided
                  by the organization, by assuring that all demographic groups, care
                  settings (e.g. inpatient, ambulatory, [including care provided
                  in private
                  practice offices] and home care), and types of services (e.g. preventive,
                  primary, specialty care and ancillary) are included in the scope
                  of the
                  review.  This review should be carried out over multiple review
                  periods and not on just a concurrent
                  basis.

              

      

      
        	
                C.

              	
                Specific
                  activities - The written description specifies quality of care
                  studies and other activities to be undertaken over a prescribed
                  period of
                  time, and methodologies and organizational arrangements to be used
                  to
                  accomplish them.  Individuals responsible for the studies and
                  other activities are clearly identified and are
                  appropriate.

              

      

      
        	
                D.

              	
                Continuous
                  activity - The written description provides for continuous
                  performance of the activities, including tracking of issues over
                  time.

              

        	E. 	 Provider
                review - The QAP provides:

        

      
        	
                 

              	
                1.

              	
                Review
                  by physicians and other health professionals of the process followed
                  in
                  the provision of health services;

              

      

      
        	
                 

              	
                2.

              	
                Feedback
                  to health professionals and health plan staff regarding performance
                  and
                  patient results.

              

      

      
        	
                F.

              	
                Focus
                  on health outcomes - The QAP methodology addresses health outcomes to
                  the extent consistent with existing
                  technology.

              

      

      

      
        	
                Standard
                  II:

              	
                Systematic
                  Process of Quality Assessment and
                  Improvement

              

      

       

      The
        QAP
        objectively and systematically monitors and evaluates the quality and
        appropriateness of care and service provided members, through quality of
        care
        studies and related activities, and pursues opportunities for improvement
        on an
        ongoing basis.

       

      
        	
                A.

              	
                Specification
                  of clinical or health services delivery areas to be
                  monitored

              

      

      
        	
                 

              	
                1.

              	
                Monitoring
                  and evaluation of clinical issues reflects the population served
                  by the
                  health plan, in terms of age groups, disease categories, and special
                  risk
                  status.

              

      

      
        	
                 

              	
                2.

              	
                For
                  the Medicaid population, the QAP monitors and evaluates at a minimum,
                  care
                  and services in certain priority areas of concern selected by the
                  State.  It is recommended that these be taken from among those
                  identified by the Health

              	
                Care
                  Financing Administration's (HCFA's) Medicaid Bureau and jointly
                  determined
                  by the State and the Managed Care Organization
                  (MCO).

              

      

      
        	
                 

              	
                3.

              	
                At
                  its discretion and/or as required by the State Medicaid agency,
                  the MCO's
                  QAP also monitors and evaluates other aspects of care and
                  service.

              

      

       

      B.           Use
        of quality indicators 

      Quality
        indicators are measurable variables relating to a specified clinical or health
        services delivery area, which are reviewed over a period of time to monitor
        the
        process of outcomes of care delivered in that area.

      
        	
                 

              	
                1.

              	
                The
                  MCO identifies and uses quality indicators that are measurable,
                  objective,
                  and based on current knowledge and clinical
                  experiences.

              

      

      
        	
                 

              	
                2.

              	
                For
                  the priority area selected by the State from the HCFA Medicaid
                  Bureau's
                  list of priority clinical and health service delivery areas of
                  concern,
                  the MCO monitors and evaluates quality of care through studies,
                  which
                  include, but are not limited to, the quality indicators also specified
                  by
                  the HCFA Medicaid Bureau.

              

      

      
        	
                 

              	
                3.

              	
                Methods
                  and frequency of data collection are appropriate and sufficient
                  to detect
                  need for program change.

              

      

       

      C.           Use
        of clinical care standards/practice guidelines

      
        	
                 

              	
                1.

              	
                The
                  QAP studies and other activities monitor quality of care against
                  clinical
                  care or health services delivery standards or practice guidelines
                  specified for each area identified.

              

      

      
        	
                 

              	
                2.

              	
                The
                  clinical standards/practice guidelines are based on reasonable
                  scientific
                  evidence and are developed or reviewed by plan
                  providers.

              

      

      
        	
                 

              	
                3.

              	
                The
                  clinical standards/practice guidelines focus on the process and
                  outcomes
                  of health care delivery, as well as access to
                  care.

              

      

      
        	
                 

              	
                4.

              	
                A
                  mechanism is in place for continuously updating the standards/practice
                  guidelines.

              

      

      
        	
                 

              	
                5.

              	
                The
                  clinical standards/practice guidelines shall be included in provider
                  manuals developed for use by  HMO providers or otherwise
                  disseminated to the providers as they are
                  adopted.

              

      

      
        	
                 

              	
                6.

              	
                The
                  clinical standards/practice guidelines address preventive health
                  services.

              

      

      
        	
                 

              	
                7.

              	
                The
                  clinical standards/practice guidelines are developed for the full
                  spectrum
                  of populations enrolled in the
                  plan.

              

      

      
        	
                 

              	
                8.

              	
                The
                  QAP shall use these clinical standards/practice guidelines to evaluate
                  the
                  quality of care provided by the MCO's providers, whether the providers
                  are
                  organized in groups, as individuals, as IPAs, or in a combination
                  thereof.

              

      

      
        	
                 

                D.

              	
                 

                Analysis
                  of clinical care and related
                  services

              

      

      
        	
                 

              	
                1.

              	
                Appropriate
                  clinicians monitor and evaluate quality through review of individual
                  cases
                  where there are questions about care and through studies analyzing
                  patterns of clinical care and related service.  For quality
                  issues identified in the QAP's targeted clinical areas, the analysis
                  includes the identified quality indicators and uses clinical care
                  standards or practice guidelines.

              

      

      
        	
                 

              	
                2.

              	
                Mulitdisciplinary
                  teams are used, where indicated, to analyze and address system
                  issues.

              

      

      
        	
                 

              	
                3.

              	
                For
                  the D.1. and D.2. above, clinical and related services requiring
                  improvement are identified.

                 

              

        	 E.  	 	Implementation
                of remedial/corrective actions

        	 	 	The
                QAP includes written procedures for taking appropriate remedial action
                whenever, as determined under the QAP, inappropriate or substandard
                services are furnished, or services that should have been furnished
                were
                not. 
                These
                  written remedial/corrective action procedures
                  include:

              

      

               

      
        	
                 

              	
                1.

              	
                Specification
                  of the types of problems requiring remedial/corrective
                  action.

              

      

      
        	
                 

              	
                2.

              	
                Specification
                  of the person(s) or body responsible for making the final determinations
                  regarding quality problems.

              

      

      
        	
                 

              	
                3.

              	
                Specific
                  actions to be taken.

              

      

      
        	
                 

              	
                4.

              	
                Provision
                  of feedback to appropriate health professionals, providers
                  and  staff.

              

      

      
        	
                 

              	
                5.

              	
                The
                  schedule and accountability for implementing corrective
                  actions.

              

      

      
        	
                 

              	
                6.

              	
                The
                  approach to modify the corrective action if improvements do not
                  occur.

              

      

      
        	
                 

              	
                7.

              	
                Procedures
                  for terminating the affiliation with the physician, or other health
                  professional or provider.

                 

              

      

      
        	
                F.

              	
                Assessment
                  of effectiveness of corrective
                  actions

              

      

      
        	
                 

              	
                1.

              	
                As
                  actions are taken to improve care, there is monitoring and evaluation
                  of
                  corrective actions to assure that appropriate changes have been
                  made.  In addition,
                  changes in practice patterns are tracked.

              	
                 

              

      

      
        	
                 

              	
                2.

              	
                The
                  MCO assures follow-up on identified issues to ensure that actions
                  for
                  improvement
                  have been effective.

                 

              	
                 

              

      

      
        	
                G.

              	
                Evaluation
                  of continuity and effectiveness of the
                  QAP

              

      

      
        	
                 

              	
                1.

              	
                The
                  MCO conducts a regular and periodic examination of the scope and
content
                  of the QAP to ensure that it covers all types of services in all
settings,
                  as specified in standard I-B-2.

              	
                 

              	
                 

              

      

      
        	
                 

              	
                2.

              	
                At
                  the end of each year, a written report on the QAP is prepared which
                  addresses: QA studies and other activities completed, trending
                  of clinical
                  and services indicators and other performance data; demonstrated
                  improvements in quality; areas of deficiency and recommendations
                  for
                  corrective action; and an evaluation of the overall effectiveness
                  of the
                  QAP

              

      

      
        	
                 

              	
                3.

              	
                There
                  is evidence that QA activities have contributed to significant
                  improvements in the care and services delivered to
                  members.

              

      

       

      
        	
                Standard
                  III:

              	
                Accountability
                  to the Governing Body

              

      

       

      The
        QA
        committee is accountable to the governing body of the managed care
        organization.  The governing body should be the board of directors, or
        a committee of senior management may be designated in instances in which
        the
        board's participation with QA issues is not direct.  There is evidence
        of a formally designated structure, accountability at the highest levels
        of the
        organization, and ongoing and/or continuous oversight of the QA
        program.  Responsibilities of the Governing Board for monitoring,
        evaluating, and making improvements to care include:

       

      
        	
                A.

              	
                Oversight
                  of the  QAP - There is documentation that the governing
                  body has approved the overall QAP and  the annual
                  QAP.

              

      

      
        	
                B.

              	
                Oversight
                  of entity - The Governing Body has formally designated an accountable
                  entity or entities within the organization to provide oversight
                  of QA, or
                  has formally decided to provide such oversight as a committee of
                  the
                  whole.

              

      

      
        	
                C.

              	
                QAP
                  progress reports - The Governing body routinely receives written
                  reports from the QAP describing actions taken, progress in meeting
                  QA
                  objectives, and improvements made.

              

      

      
        	
                D.

              	
                Annual
                  QAP review - The Governing Body formally reviews on a periodic basis
                  (but no less frequently than annually) a written report on the
                  QAP which
                  includes: studies undertaken, results, subsequent actions, and
                  aggregate
                  data on utilization and quality of services rendered, to assess
                  the QAP's
                  continuity, effectiveness and current
                  acceptability.

              

      

      
        	
                E.

              	
                Program
                  modification - Upon receipt of regular written reports from the QAP
                  delineating actions taken and improvements made, the Governing
                  Body takes
                  actions when appropriate and directs that the operational QAP be
                  modified
                  on an ongoing basis to accommodate review findings and issues of
                  concern
                  within the MCO.  Minutes of the meetings of the Governing Board
                  demonstrate that the Board has directed and followed up on necessary
                  actions pertaining to QA.

              

      

       

      
        	
                Standard
                  IV:

              	
                Active
                  QA Committee

              

      

       

      The
        QAP
        delineates an identifiable structure responsible for performing QA functions
        within the MCO.  The committee or other structure has:

       

      
        	
                A.

              	
                Regular
                  meetings - The structure/committee meets on a regular basis with
                  specified frequency to oversee QAP activities.  This frequency
                  is sufficient to demonstrate that the structure/committee is following
                  up
                  on all findings and required actions, but in no case are such meetings
                  less frequent than quarterly.

              

      

      
        	
                B.

              	
                Established
                  parameters for operating -The role, structure and function of the
                  structure/committee are specified.

              

      

      
        	
                C.

              	
                Documentation
                  - There are contemporaneous records documenting the
                  structure's/committee's activities, findings, recommendations and
                  actions.

              

      

      
        	
                D.

              	
                Accountability
                  - The QAP committee is accountable to the Governing Body and
                  reports
                  to it (or its designee) on a scheduled basis on activities, findings,
                  recommendations and actions.

              

      

      
        	
                E.

              	
                Membership
                  - There is active participation in the QA committee from health
                  plan
                  providers, who are representative of the composition of the health
                  plan's
                  providers.

              

      

       

      
        	
                Standard
                  V:

              	
                QAP
                  Supervision

              

      

       

      There
        is
        a designated senior executive who is responsible for program implementation.
        The
        organization's Medical Director has substantial involvement in QA
        activities.

       

      
        	
                Standard
                  VI:

              	
                Adequate
                  Resources

              

      

       

      The
        QAP
        has sufficient material resources, and staff with the necessary education,
        experience, or training; to effectively carry out its specified
        activities.

       

      
        	
                Standard
                  VII:

              	
                Provider
                  Participation in the
                  QAP

              

      

      
        	
                A.

              	
                Participating
                  physicians and other providers are kept informed about the written
                  QA
                  plan.

              

      

      
        	
                B.

              	
                The
                  MCO includes in all its provider contracts and employment agreements,
                  for
                  both physicians and nonphysician providers, a requirement securing
                  cooperation with the QAP.

              

      

      
        	
                C.

              	
                Contracts
                  specify that hospitals, physicians, and other contractors will
                  allow the
                  MCO access to the medical records of their
                  members.

              

      

       

      
        	
                Standard
                  VIII:

              	
                Delegation
                  of QAP Activities

              

      

      The
        MCO
        remains accountable for all QAP functions, even if certain functions are
        delegated to other entities.  If the MCO delegates any QA activities
        to contractors.

      
        	
                A.

              	
                There
                  is a written description of delegated activities; the delegate's
                  accountability for these activities; and the frequency of reporting
                  to the
                  MCO.

              

      

      
        	
                B.

              	
                The
                  MCO has written procedures for monitoring the implementation of
                  the
                  delegated functions and for verifying the actual quality of care
                  being
                  provided.

              

      

      
        	
                C.

              	
                There
                  is evidence of continuous and ongoing evaluation of delegated activities,
                  including approval of quality improvement plans and regular specified
                  reports.

              

      

       

      
        	
                Standard
                  IX:

              	
                Enrollee
                  Rights and
                  Responsibilities

              

      

      The
        MCO
        demonstrates a commitment to treating members in a manner that acknowledges
        their rights and responsibilities.

       

                 

      
        	 A.	 	 Written
                policy on enrollee rights

        	 	 	The
                MCO has a written policy that recognizes the following rights of
                members:
                 

              

        	
                 

              	
                1.

              	
                To
                  be treated with respect, and recognition of their dignity and need
                  for
                  privacy;

              

      

      
        	
                 

              	
                2.

              	
                To
                  be provided with information about the MCO, its services, the
                  practitioners providing care, and members' rights and
                  responsibilities;

              

      

      
        	
                 

              	
                3.

              	
                To
                  be able to choose primary care practitioners, within the limits
                  of the
                  plan network, including the right to refuse care from specific
                  practitioners;

              

      

      
        	
                 

              	
                4.

              	
                To
                  participate in decision-making regarding their health
                  care;

              

      

      
        	
                 

              	
                5.

              	
                To
                  voice grievances about the MCO or care
                  provided;

              

      

      
        	
                 

              	
                6.

              	
                To
                  formulate advance directives; and

              

      

      
        	
                 

              	
                7.

              	
                To
                  have access to his/her medical records on accordance with applicable
                  Federal and State laws.

                 

              

      

      
        	
                B.

              	
                Written
                  policy enrollee responsibilities - The MCO has a written policy that
                  addresses members' responsibility for cooperating with those providing
                  health care services. This written policy addresses members'
                  responsibility for:

              

      

      
        	
                 

              	
                1.

              	
                Providing,
                  to the extent possible, information needed by professional staff
                  in caring
                  for the member; and

              

      

      
        	
                 

              	
                2.

              	
                Following
                  instructions and guidelines given by those providing health care
                  services.

                 

              

      

      
        	
                C.

              	
                Communication
                  of policies to providers - A copy of the organization's policies on
                  members' rights and responsibilities is provided to all participating
                  providers.

                 

              

      

      
        	
                D.

              	
                Communication
                  of policies to enrollees/members - Upon enrollment, members are
                  provided a written statement that includes information on the
                  following:

              

      

      
        	
                 

              	
                1.

              	
                Rights
                  and responsibilities of members;

              

      

      
        	
                 

              	
                2.

              	
                Benefits
                  and services included and excluded as a condition of memberships,
                  and how
                  to obtain them, including a description
                  of:

              

      

      
        	
                 

              	
                a.

              	
                Any
                  special benefit provisions (example, co-payment, higher deductibles,
                  rejection of claim) that may apply to service obtained outside
                  the system;
                  and

              

      

      
        	
                 

              	
                b.

              	
                The
                  procedures for obtaining out-of-area
                  coverage;

              

      

      
        	
                 

              	
                3.

              	
                Provisions
                  for after-hours and emergency
                  coverage;

              

      

      
        	
                 

              	
                4.

              	
                The
                  organization's policy on referrals for specialty
                  care;

              

      

      
        	
                 

              	
                5.

              	
                Charges
                  to members, if applicable,
                  including:

              

      

      
        	
                 

              	
                a.

              	
                Policy
                  on payment of charges; and

              

      

      
        	
                 

              	
                b.

              	
                Co-payment
                  and fees for which the member is
                  responsible.

              

      

      
        	
                 

              	
                6.

              	
                Procedures
                  for notifying those members affected by the termination or change
                  in any
                  benefit services, or service delivery
                  office/site;

              

      

      
        	
                 

              	
                7.

              	
                Procedures
                  for appealing decisions adversely affecting the members' coverage,
                  benefits, or relationship with the
                  organization;

              

      

      
        	
                 

              	
                8.

              	
                Procedures
                  for changing practitioners;

              

      

      
        	
                 

              	
                9.

              	
                Procedures
                  for disenrollment; and

              

      

      
        	
                 

              	
                10.

              	
                Procedures
                  for voicing complaints and/or grievances and for recommending changes
                  in
                  policies and services.

                 

              

      

      
        	
                E.

              	
                Enrollee/member
                  grievance procedures - The organization has a system(s) linked to the
                  QAP, for resolving members' complaints and formal grievances. This
                  system
                  includes:

              

      

      
        	
                 

              	
                1.

              	
                Procedures
                  for registering and responding to complaints and grievances in
a
                  timely fashion (organizations should establish and monitor standards
                  for
                  timeliness);

              	
                 

              

      

      
        	
                 

              	
                2.

              	
                Documentation
                  of the substance of the complaint or grievances, and actions
                  taken;

              

      

      
        	
                 

              	
                3.

              	
                Procedures
                  to ensure a resolution of the compliant or
                  grievance;

              

      

      
        	
                 

              	
                4.

              	
                Aggregation
                  and analysis of complaint and grievance data and use of the data
                  for
                  quality improvement; and

              

      

      
        	
                 

              	
                5.

              	
                An
                  appeal process for grievances.

                 

              

      

      
        	
                F.

              	
                Enrollee/member
                  suggestions - Opportunity is provided for members to offer
                  suggestions for changes in policies and procedures.

                 

              

      

      
        	
                G.

              	
                Steps
                  to assure accessibility of services - The MCO takes steps to promote
                  accessibility of services offered to members. These steps
                  include:

              

      

      
        	
                 

              	
                1.

              	
                The
                  points of access to primary care, specialty care and hospital services
                  are
                  identified for members;

              

      

      
        	
                 

              	
                2.

              	
                At
                  a minimum, members are given information
                  about:

              

      

      
        	
                 

              	
                a.

              	
                How
                  to obtain services during regularly hours of
                  operation

              

      

      
        	
                 

              	
                b.

              	
                How
                  to obtain emergency and after-hours care;
                  and

              

      

      
        	
                 

              	
                c.

              	
                How
                  to obtain the names, qualifications, and titles of the professionals
                  providing and/or responsible for their care.

                 

              

      

      
        	
                H.

              	
                Written
                  information for members

              

      

      
        	
                 

              	
                1.

              	
                Member
                  information is written in prose that is readable and easily understood;
                  and

              

      

      
        	
                 

              	
                2.

              	
                Written
                  information is available, as needed, in the languages of the major
                  population groups served.  A "major" population group is one
                  which represents at least 10% of plan's membership.

                 

              

      

      
        	
                I.

              	
                Confidentiality
                  of patient information - The MCO acts to ensure that the
                  confidentiality of the specified patient information and records
                  is
                  protected.

              

      

      
        	
                 

              	
                1.

              	
                The
                  MCO has established in writing, and enforced, policies and procedures
                  on
                  confidentiality of medical records.

              

      

      
        	
                 

              	
                2.

              	
                The
                  MCO ensures that patient care offices/sites have implemented mechanisms
                  that guard against the unauthorized or inadvertent disclosure of
                  confidential information to persons outside of the medical care
                  organization.

              

      

      
        	
                 

              	
                3.

              	
                The
                  MCO shall hold confidential information obtained by its personnel
                  about
                  enrollees related to their examination, care and treatment and
                  shall not
                  divulge it without the enrollee's authorization,
                  unless:

              

      

      
        	
                 

              	
                a.

              	
                it
                  is required by law;

              

      

      
        	
                 

              	
                b.

              	
                it
                  is necessary to coordinate the patient's care with physicians,
                  hospitals,
                  or other health care entities, or to coordinate insurance or other
                  matters
                  pertaining to payment; or

              

      

      
        	
                 

              	
                c.

              	
                it
                  is necessary in compelling circumstances to protect the health
                  or safety
                  of an individual.

              

      

      
        	
                 

              	
                4.

              	
                Any
                  release of information in response to a court order is reported
                  to the
                  patient in a timely manner; and

              

      

      
        	
                 

              	
                5.

              	
                Enrollee
                  records may be disclosed, whether or not authorized by the enrollee,
                  to
                  qualified personnel for the purpose of conducting scientific research,
                  but
                  these personnel may not identify, directly or indirectly, any individual
                  enrollee in any report of the research or otherwise disclose participant
                  identity in any manner.

                 

              

      

      
        	
                J.

              	
                Treatment
                  of minors - The MCO has written policies regarding the appropriate
                  treatment of minors.

                 

              

      

      
        	
                K.

              	
                Assessment
                  of member satisfaction - The MCO conducts periodic surveys of member
                  satisfaction with its services.

              

      

      
        	
                 

              	
                1.

              	
                The
                  surveys include content on perceived problems in the quality,
                  accessibility and availability of
                  care.

              

      

      
        	
                 

              	
                2.

              	
                The
                  surveys assess at least a sample
                  of:

              

      

      
        	
                 

              	
                a.

              	
                All
                  Medicaid members;

              

      

      
        	
                 

              	
                b.

              	
                Medicaid
                  member requests to change practitioners and/or facilities;
                  and

              

      

      
        	
                 

              	
                c.

              	
                Disenrollment
                  by Medicaid members.

              

      

      
        	
                 

              	
                3.

              	
                As
                  a results of the surveys, the
                  organization:

              

      

      
        	
                 

              	
                a.

              	
                Identifies
                  and investigates sources of
                  dissatisfaction;

              

      

      
        	
                 

              	
                b.

              	
                Outlines
                  action steps to follow-up on the findings;
                  and

              

      

      
        	
                 

              	
                c.

              	
                Informs
                  practitioners and providers of assessment
                  results.

              

      

      
        	
                 

              	
                4.

              	
                The
                  MCO reevaluates the effects of the above
                  activities.

              

      

       

      
        	
                Standard
                  X:

              	
                Standards
                  for Availability and
                  Accessibility

              

      

      The
        MCO
        has established standards for access (e.g. to routine, urgent and emergency
        care; telephone appointments; advice; and member service
        lines).  Performance on these on these dimensions of access are
        assessed against the standards.

       

      
        	
                Standard
                  XI:

              	
                Medical
                  Records Standards

              

      

      
        	
                A.

              	
                Accessibility
                  and availability of medical records - The MCO shall include provision
                  in provider contracts for appropriate access to the medical records
                  of its
                  enrollees for purposes of quality reviews conducted by the Secretary,
                  State Medicaid agencies, or agents thereof.

                 

              

      

      
        	
                B.

              	
                Record
                  keeping - Medical records may be on paper or electronic. The plan
                  takes steps to promote maintenance of medical records in a legible,
                  current, detailed, organized and comprehensive manner that permits
                  effective patient care and quality review as follows:

                 

              

      

      
        	
                 

              	
                1.

              	
                Medical
                  records standards- The MCO sets standards for medical records.
                  The records
                  reflect all aspects of patient care, including ancillary services.
                  These
                  standards shall at a minimum, include requirements
                  for:

              

      

      
        	
                 

              	
                a.

              	
                Patient
                  identification information - Each page or electronic file in the
                  record
                  contains the patient's name or patient ID
                  number.

              

      

      
        	
                 

              	
                b.

              	
                Personal/biographical
                  data - Personal/biographical data includes: age, sex, address;
                  employer;
                  home and work telephone numbers; and martial
                  status.

              

      

      
        	
                 

              	
                c.

              	
                Entry
                  date - All entries are dated.

              

      

      
        	
                 

              	
                d.

              	
                Provider
                  identification - All entries are identified as to
                  author.

              

      

      
        	
                 

              	
                e.

              	
                Legibility
                  - The record is legible to someone other than the writer.  Any
                  record judged illegible by one physician reviewer should be evaluated
                  by a
                  second reviewer.

              

      

      
        	
                 

              	
                f.

              	
                Allergies
                  - Medication allergies and adverse reactions are prominently noted
                  on the
                  record.  Absence of allergies (no known allergies-NKA) is noted
                  in an easily recognizable location.

              

      

      
        	
                 

              	
                g.

              	
                Past
                  medical history - (for patients seen 3 or more times) Past medical
                  history
                  is easily identified including serious accidents, operations,
                  illnesses.  For children, past medical history relates to
                  prenatal care and birth.

              

      

      
        	
                 

              	
                h.

              	
                Immunizations-
                  For pediatric records (ages 12 and under) there is a completed
                  immunization record or a notation that immunizations are
                  up-to-date.

              

      

      
        	
                 

              	
                i.

              	
                Diagnostic
                  information

              

      

      
        	
                 

              	
                j

              	
                Medication
                  information

              

      

      
        	
                 

              	
                k.

              	
                Identification
                  of current problems - Significant illness, medical conditions and
                  health
                  maintenance concerns are identified in the medical
                  record.

              

      

      
        	
                 

              	
                l.

              	
                Smoking/ETOH/substance
                  abuse - Notation concerning cigarettes and alcohol use and substance
                  abuse
                  is present (for patients 12 years and over and seen three or more
                  times).  Abbreviations and symbols may be
                  appropriate.

              

      

      
        	
                 

              	
                m.

              	
                Consultations,
                  referral and specialist reports - Notes from consultations are
                  in the
                  record. Consultation, lab, and x-ray reports filed in the chart
                  have the
                  ordering physicians initials or other documentation signifying
                  review.  Consultation and significantly abnormal lab and imaging
                  study results have an explicit notation in the record and follow-up
                  plans.

              

      

      
        	
                 

              	
                n.

              	
                Emergency
                  care

              

      

      
        	
                 

              	
                o.

              	
                Hospital
                  discharge summaries - Discharge summaries are included as part
                  of the
                  medical record for (1) all hospital admissions which occur while
                  the
                  patient is enrolled in the MCO and (2) prior admissions as
                  necessary.

              

      

      
        	
                 

              	
                p.

              	
                Advance
                  directives - For medical records of adults, the medical record
                  documents
                  whether or not the individual has executed an advance
                  directive.  An advance directive is a written instruction such
                  as a living will or durable power of attorney for health care relating
                  to
                  the provision of health care when the individual is
                  incapacitated.

              

      

      
        	
                 

              	
                2.

              	
                Patient
                  visit data - Documentation of individual encounters must provide
                  adequate
                  evidence of, at a minimum;

              

      

      
        	
                 

              	
                a.

              	
                History
                  and physical examination - Appropriate subjective and objective
                  information is obtained for the presenting
                  complaints.

              

      

      
        	
                 

              	
                b.

              	
                Plan
                  of treatment

              

      

      
        	
                 

              	
                c.

              	
                Diagnostic
                  tests

              

      

      
        	
                 

              	
                d.

              	
                Therapies
                  and other prescribed regimens; and

              

      

      
        	
                 

              	
                e.

              	
                Follow-up
                  - Encounter forms or notes have a notation, when indicated, concerning
                  follow-up care, call, or visit.  Specific time to return is
                  noted in weeks, months, or PRN. Unresolved problems from previous
                  visits
                  are addressed in subsequent visits.

              

      

      
        	
                 

              	
                f.

              	
                Referrals
                  and results thereof; and

              

      

      
        	
                 

              	
                g.

              	
                All
                  other aspects of patient care, including ancillary
                  services.

              

      

      
        	
                 

              	
                3.

              	
                Record
                  review process-

              

      

      
        	
                 

              	
                1.

              	
                The
                  MCO has a system (record review process) to assess the content
                  of medical
                  records for legibility, organization, completion and conformance
                  to its
                  standards.

              

      

      
        	
                 

              	
                2.

              	
                The
                  record assessment system addresses documentation of the items listed
                  in B,
                  above.

              

      

      

      
        	
                Standard
                  XII:

              	
                Utilization
                  Review

                 

              

      

      
        	
                A.

              	
                Written
                  program description- The MCO has a written utilization management
                  program
                  description which includes, at a minimum, procedures to evaluate
                  medical
                  necessity, criteria used, and approve the provision of medical
                  information
                  sources and the process used to review services

              	
                .

              

      

      
        	
                B.

              	
                Scope
                  - The program has mechanisms to detect underutilization as well
                  as
                  overutilization.

              

      

      
        	
                C.

              	
                Preauthorization
                  and concurrent review - For MCO with preauthorization or concurrent
                  review
                  programs:

              

      

      
        	
                 

              	
                1.

              	
                Preauthorization
                  and concurrent review decisions are supervised by qualified medical
                  professionals;

              

      

      
        	
                 

              	
                2.

              	
                Efforts
                  are made to obtain all necessary information, including pertinent
                  clinical
                  information, and consult with the treating physician as
                  appropriate;

              

      

      
        	
                 

              	
                3.

              	
                The
                  reasons for decisions are clearly documented and available to the
                  member.

              

      

      
        	
                 

              	
                4.

              	
                There
                  are well-publicized and readily available appeals mechanisms for
                  both
                  providers and patients. Notification of a denial includes a description
                  of
                  how file an appeal;

              

      

      
        	
                 

              	
                5.

              	
                Decisions
                  and appeals are made in a timely manner as required by the exigencies
                  of
                  the situation;

              

      

      
        	
                 

              	
                6.

              	
                There
                  are mechanisms to evaluate the effects of the program using data
                  on member
                  satisfaction, provider satisfaction or other appropriate;
                  and

              

      

      
        	
                 

              	
                7.

              	
                If
                  the MCO delegates responsibilities for utilization management,
                  it has
                  mechanisms to ensure that these standards are met by the
                  delegate.

              

      

       

      
        	
                Standard
                  XIII:

              	
                Continuity
                  of Care System

                 

              

      

      The
        MCO
        has put a basic system in place which promotes continuity of care and case
        management.

       

      
        	
                Standard
                  XIV:

              	
                QAP
                  Documentation

                 

              

      

      
        	
                A.

              	
                Scope
                  - The MCO shall document that it is monitoring the quality
                  of care
                  across all services and all treatment modalities, according to
                  its written
                  QAP.

              

      

      
        	
                B.

              	
                Maintenance
                  and availability of documentation - The MCO must maintain and make
                  available to the State, and upon request to the Secretary of HHS,
                  studies,
                  reports, appropriate, concerning the activities and corrective
                  actions.

              

      

       

      
        	
                Standard
                  XV:

              	
                Coordination
                  of QA Activity with other Management Activity

                 

              

      

      The
        findings, conclusions, recommendations, actions taken, and results of actions
        taken as a result of QA activity, are documented and reported to appropriate
        individuals within the MCO and through established QA channels.

      
        	
                A.

              	
                QA
                  information is used in recredentialing, recontracting, and/or annual
                  performance evaluations.

              	
                 

              

      

      
        	
                B.

              	
                QA
                  activities are coordinated with other performance monitoring activities,
                  including utilization management, risk management, and resolution
                  and
                  monitoring of member complaints and
                  grievances.

              

      

      
        	
                C.

              	
                There
                  is a linkage between QA and other management functions of the MCO,
                  such
                  as: network changes, benefit redesign, medical management systems,
                  practice feedback to providers, patient education and member
                  services.

              

      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
Appendix
        H

       

      Claims
        Inventory, Aging and Unaudited Quarterly Financial
        Reports

       

    

    

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      HUSKY
        B
        Appendix H

      (document
        1 of 5)

      Report
        #1

      HUSKY
        A & B Unprocessed Claims in Dollars

       

      
        	
                Plan
                  Name

              	 	 	 	 	 	 	 
	
                Qtr.
                  Ending:

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Claims
                  In Process During Qtr. (In Dollars) (1)

              	 	 	 
	 	
                1-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	
                Total
                  Claims Outstanding At The End Of The Qtr.

              
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Unpaid
                  Adjudicated Claims (In Dollars) (2)

              	 	 	 	 
	 	
                1-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	
                Total
                  Unpaid Adjudicated Claims (In Dollars) At The End Of The
                  Qtr.

              
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                1.   Claims
                  in process-all claims that are in a pending status (data,
                  medical, COB edits) and require review by a claim examiner prior
                  to being
                  released for adjudication.  Because the final pay amount is
                  unknown, the amounts are recorded at the billed amount

              
	
                2.  Unpaid
                  adjudicated claims-claims which have been adjudicated and have a
                  known pay amount, however, a check has not been issued for these
                  claims.  Because the final pay amount is known, the amounts are
                  recorded using net amount + withhold.

              
	 	 	 	 	 	 	 	 
	
                UB92
                  - In general these claim forms represent hospital based claims
                  (inpatient
                  and outpatient).

              	 	 	 
	
                HCFA
                  1500 - These claim forms are used for outpatient services provided
                  by
                  non-hospital facilities.

              	 	 	 
	 	 	 	 	 	 	 	 
	
                Other
                  items to note about report #1 and #2:

              	 	 	 	 	 	 
	
                *  If
                  a claim does not include the information specified in Bulletin
                  HC-56 it is
                  rejected.  This claim would not appear in the
                  inventory

                after
                  it was rejected.

              
	
                *   A
                  claim could contain all of the information specified by Bulletin
                  HC-56,
                  but it is incorrect.  In this instance it could have been
                  included in the pending claims prior to identifying it as a claim
                  with
                  incorrect data.  Examples of incorrect data would be using a
                  discontinued code.

              
	
                *  If
                  a claim is submitted for a service which requires prior authorization,
                  but
                  none if found by the MCO, it is denied.

              	 	 
	
                    At
                  the point of denial the claim would be excluded from the
                  report.

              	 	 	 	 	 
	
                *  The
                  pending claims could include duplicates which have not been identified
                  by
                  the MCO.  If a duplicate is identified, one is paid
                  and

              	 
	
                     all
                  of the duplicates are rejected.

              	 	 	 	 	 	 	 
	
                *   The
                  pending category may include claims which have been pended for
                  a medical
                  records review.  As per the guidelines in Bulleting
                  HC-56,

                if
                  additional information is needed from the provider, the MCO has
                  30 days to
                  request additional information. After the information is received,
                  the MCO
                  has 30 days to pay the claim without interest.

              
	
                *   If
                  a claim is denied and subsequently reversed on appeal,
                  the  clock would start on the date of the appeal
                  determination.

              	 	 
	
                *  If
                  a credit balance exists for a provider, the time to process the
                  claim is
                  still measured.  To the extent that processing exceeds 45
                  days

                it
                  would accrue interest as any other claim would.

              
	
                If
                  a rejected or denied claim is subsequently resubmitted, it would
                  take on a
                  new claim number.  The clock would begin from the date of
                  re-submissions.

              	 
	
                The
                  only time a processed claim is re-opened is for an adjustment to
                  amount
                  paid.

              	 	 	 	 	 

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      HUSKY
        B Appendix H

      document
        2 of 5)

      Report
        #2

      HUSKY
        A & B Volume of Unprocessed Claims

      
        	
                Plan
                  Name

              	 	 	 	 	 	 	 
	
                Qtr.  Ending:

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Claims
                  In Process During Qtr. (# of claims) (1)

              	 	 	
                Total
                  Claims In Process During Qtr.

              
	 	
                01-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	 
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Unpaid
                  Adjudicated Claims (# of claims) (2)

              	 	 	
                Total
                  Unpaid Adjudicated Claims (# of claims) At The End Of The
                  Qtr.

              
	 	
                01-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	 
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Total
                  Unprocessed And Unpaid Adjudicated Claims (3)

              	 	 	
                Total
                  Unprocessed & Unpaid Adjudicated Claims

              
	 	
                01-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	 
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 

      

       

      
        
          	
                  
                    Claims
                      Inventory

                  

                	
                  EQUAL
                    OR Less than 45 Days

                	
                  Greater
                    than 45 Days

                
	 	 	 
	
                  MCO
                    Claims

                	
                  %

                	
                  %

                
	
                  Pharmacy

                	
                  %

                	
                  %

                
	
                  Dental

                	
                  %

                	
                  %

                
	
                  Vision

                	
                  %

                	
                  %

                
	
                  Mental
                    Health

                	
                  %

                	
                  %

                
	
                  Total

                	
                  %

                	
                  %

                

        

         

      

      
        	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Estimated
                  Claims Received but not in system (# of claims)
                  (4)

              	 	 
	 	
                01-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	
                Total
                  Claims Received But Not In System

              
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Mental
                  Health

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Tick
                  Mark Legend:

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                1.   Claims
                  in process-all claims that are in a pending status (data,
                  medical, COB edits) and require review by a claim examiner
                  prior to being released for adjudication.

              
	
                 

              	 	 	 	 	 
	
                2.
                  Unpaid adjudicated claims-claims which have been
                  adjudicated and have a known pay amount, however, a
                  check has not been issued for these claims.

              	 
	
                 

              	 	 	 	 	 
	
                3.  Total
                  of estimated claims in process, and unpaid adjudicated
                  claims.

                 

              	 	 	 
	
                4.  Estimated
                  claims received but not in system-includes any claim that has been
                  received and not input in the system(I.e.
                  claims in the mailroom).

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      HUSKY
        B Appendix H

      (document
        3 of 5)

      Report
        #3

      HUSKY
        A & B Turn Around Time - Claims Processed

      
        	
                Plan
                  Name

              	 	 	 	 	 	 	 
	
                Qtr.
                  Ending:

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Paper
                  Claims Processed During Qtr.

              	 	 	 	 	 
	 	
                01-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	
                Total
                  Paper Claims Processed During Qtr.

              
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Electronic
                  Claims Processed During Qtr.

              	 	 	 	 	 
	 	
                01-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	
                Total
                  Electronic Claims Processed During Qtr.

              
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Total
                  Paper and Electronic Claims Processed During Qtr.

              	 	 	 	 
	 	
                01-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	
                Total
                  Paper & Electronic Claims Processed During
                  Qtr.

              
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 

      

       

      
        	
                Turn
                  Around Statistics

              	
                EQUAL
                  OR Less than 45 Days

              	
                Greater
                  than 45 Days

              
	 	 	 
	
                MCO
                  Claims

              	
                %

              	
                %

              
	
                Pharmacy

              	
                %

              	
                %

              
	
                Dental

              	
                %

              	
                %

              
	
                Vision

              	
                %

              	
                %

              
	
                Mental
                  Health

              	
                %

              	
                %

              
	
                Total

              	
                %

              	
                %

              

      

       

      Note:  This
        report includes only paid claims,
        therefore it excludes denied claims.

      
 

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

       

      (document
        5 of 6)

      Appendix
        H

      Unaudited
        Quarterly Financial Reports

    

    
      	 	
              Current
                Assets:

            	
              Current
                Year

            	
              Previous
                Year

            
	
              1

            	
              Cash
                and Cash Equivalents

            	 	 
	
              2

            	
              Short-Term
                Investments

            	 	 
	
              3

            	
              Premiums
                Receivable

            	 	 
	
              4

            	
              Investment
                Income Receivables

            	 	 
	
              5

            	
              Health
                Care receivables

            	 	 
	
              6

            	
              Amounts
                Due from Affiliates

            	 	 
	
              7

            	
              Aggregate
                Write-Ins for Current Assets

            	 	 
	
              8

            	
              TOTAL
                CURRENT ASSETS (items 1-7)

            	 	 
	 	 	 	 
	 	
              Other
                Assets

            	 	 
	
              9

            	
              Restricted
                Cash and Other Assets

            	 	 
	
              10

            	
              Long
                Term Investments

            	 	 
	
              11

            	
              Amounts
                Due from Affiliates

            	 	 
	
              12

            	
              Aggregate
                Write-Ins for Other Assets

            	 	 
	
              13

            	
              TOTAL
                OTHER ASSETS (items 9-12)

            	 	 
	 	 	 	 
	 	
              Property
                and Equipment

            	 	 
	
              14

            	
              Land,
                building and Improvements

            	 	 
	
              15

            	
              Furniture
                and Equipment

            	 	 
	
              16

            	
              Leasehold
                Improvements

            	 	 
	
              17

            	
              Aggreate
                Write-Ins for Other Equipment

            	 	 
	
              18

            	
              TOTAL
                PROPERTY (items 7-14)

            	 	 
	
              19

            	
              TOTAL
                ASSETS 9items 8, 13, and 18)

            	 	 
	 	 	 	 
	 	
              Details
                of Write-Ins Aggregated at item 7 for Current Assets

            	 	 
	
              701

            	 	 	 
	
              702

            	 	 	 
	
              703

            	 	 	 
	
              704

            	 	 	 
	
              705

            	 	 	 
	
              798

            	
              Summary
                of remaining write-ins for item 7 from overflow page

            	 	 
	
              799

            	
              TOTALS:
                (items 701 through 705 plus 798 page 2, item 7)

            	 	 
	 	 	 	 
	 	
              Details
                of Write-Ins Aggregated at item 12 for Other Assets

            	 	 
	
              1201

            	 	 	 
	
              1202

            	 	 	 
	
              1203

            	 	 	 
	
              1204

            	 	 	 
	
              1205

            	 	 	 
	
              1298

            	
              Summary
                of remaining write-ins for item 12 from overflow page

            	 
	
              1299

            	
              TOTALS:
                (items 1201 through 1205 plus 1298 page 2, item 12)

            	 
	 	 	 	 
	 	
              Details
                of Write-Ins Aggregated at item 17 for Other Equipment

            	 
	
              1701

            	 	 	 
	
              1702

            	 	 	 
	
              1703

            	 	 	 
	
              1704

            	 	 	 
	
              1705

            	 	 	 

    

     

     

    
      (document
        5 of 6)

      Appendix
        H

      Unaudited
        Quarterly Financial Reports

       

    

    
      	
              1798

            	
              Summary
                of remaining write-ins for item 17 from overflow page

            	 
	
              1799

            	
              TOTALS:
                (items 1701 through 1705 plus 1798 page 2, item 17)

            	 
	 	 	 	 
	 	
              Current
                Liabilities

            	 	 
	
              1

            	
              Accounts
                Payable (Schedule G)

            	 	 
	
              2

            	
              Claims
                Payable (Reported and Unreported) (Schedule H)

            	 	 
	
              3

            	
              Accrued
                Medical Incentive Pool (Schedule H)

            	 	 
	
              4

            	
              Unearned
                Premiums

            	 	 
	
              5

            	
              Amounts
                Due to Affiliates (Schedule J)

            	 	 
	
              6

            	 	 	 
	
              7

            	
              Aggregate
                Write-Ins for Current Liabilities

            	 	 
	
              8

            	
              TOTAL
                CURRENT LIABILITIES (items 1-7)

            	 	 
	 	 	 	 
	 	
              Other
                Liabilities

            	 	 
	
              9

            	
              Loans
                and Notes Payable (Schedule I)

            	 	 
	
              10

            	
              Amounts
                Due to Affiliates (Schedule J)

            	 	 
	
              11

            	
              Aggregate
                Write-Ins for Other Liabilities

            	 	 
	
              12

            	
              TOTAL
                OTHER LIABILITIES (items 9-11)

            	 	 
	
              13

            	
              TOTAL
                LIABILITIES (items 8 and 12)

            	 	 
	 	 	 	 
	 	
              Net
                Worth

            	 	 
	
              14

            	
              Common
                Stock

            	 	 
	
              15

            	
              Preferred
                Stock

            	 	 
	
              16

            	
              Paid
                in Surplus

            	 	 
	
              17

            	
              Contributed
                Capital

            	 	 
	
              18

            	
              Surplus
                Notes (Schedule K)

            	 	 
	
              19

            	
              Contingency
                Reserves

            	 	 
	
              20

            	
              Retained
                Earnings/Fund Balance

            	 	 
	
              21

            	
              Aggregate
                Write-Ins for Other Net Worth Items

            	 	 
	
              22

            	
              TOTAL
                NET WORTH (items 13 and 22)

            	 	 
	
              23

            	
              TOTAL
                LIABILITIES AND NET WORTH (items 13 and 22)

            	 	 
	 	 	 	 
	 	
              Details
                of Write-Ins Aggregated at item 7 for Current Liabilities

            	 
	
              701

            	
              Payroll
                and Related Liabilities

            	 	 
	
              702

            	
              Accrued
                Audit and Actuarial Fees

            	 	 
	
              703

            	 	 	 
	
              704

            	 	 	 
	
              705

            	 	 	 
	
              798

            	
              Summary
                of Remaining Write-Ins for item 7 from overflow page

            	 
	
              799

            	
              TOTALS
                (items 0701 through 0705 plus 0798 Page 3, item 7)

            	 	 
	 	 	 	 
	 	
              Details
                of Write-Ins Aggregated at item 11 for Other Liabilities

            	 	 
	
              1101

            	 	 	 
	
              1102

            	 	 	 
	
              1103

            	 	 	 
	
              1104

            	 	 	 
	
              1105

            	 	 	 
	
              1198

            	
              Summary
                of remaining write-ins for item 11 from overflow page

            	 
	
              1199

            	
              TOTALS:
                (items 1101 through 1105 plus 1198 page 3, item 11)

            	 
	 	 	 	 
	 	
              Details
                of Write-Ins Aggregated at item 21 for Other Net Worth
                Items

            	 
	
              2101

            	 	 	 

    

     

     

    
      (document
        5 of 6)

      Appendix
        H

      Unaudited
        Quarterly Financial Reports

       

    

    
      	
              2102

            	 	 	 
	
              2103

            	 	 	 
	
              2104

            	 	 	 
	
              2105

            	 	 	 
	
              2198

            	
              Summary
                of remaining write-ins for item 21 from overflow page

            	 
	
              2199

            	
              TOTALS:
                (items 2101 through 2105 plus 2198 page 3, item 21)

            	 
	 	 	 	 
	 	
              Member
                months

            	 	 
	 	
              Revenues

            	 	 
	
              1

            	
              Premium

            	 	 
	
              2

            	
              Fee-For-Service

            	 	 
	
              3

            	
              Title
                XVIII - Medicare

            	 	 
	
              4

            	
              Title
                XIX - Medicaid

            	 	 
	
              5

            	
              Investment

            	 	 
	
              6

            	
              Aggregate
                Write-Ins for Other Revenues

            	 	 
	
              7

            	
              TOTAL
                REVENUES (items 1-6)

            	 	 
	 	 	 	 
	 	
              Expenses

            	 	 
	
              8

            	
              Medical
                and Hospital

            	 	 
	
              9

            	
              Other
                Professional Services

            	 	 
	
              10

            	
              Outside
                Referrals

            	 	 
	
              11

            	
              Emergency
                Room and Out-of-Area

            	 	 
	
              12

            	
              Occupancy,
                Depreciation and Amortization

            	 	 
	
              13

            	
              Inpatient

            	 	 
	
              14

            	
              Incentive
                Pool and Withhold Adjustments

            	 	 
	
              15

            	
              Aggregate
                Write-Ins for other Medical and Hospital Expenses

            	 	 
	
              16

            	
              Subtotal
                (items 8-15)

            	 	 
	
              17

            	
              Reinsurance
                Expenses of Net of Recoveries

            	 	 
	 	 	 	 
	 	
              Less

            	 	 
	
              18

            	
              Copayments

            	 	 
	
              19

            	
              COB
                and Subrogation

            	 	 
	
              20

            	
              Subtotal
                (items 18 and 19)

            	 	 
	
              21

            	
              Total
                Medical and Hospital (items 16 and 17 less 20)

            	 	 
	 	 	 	 
	 	
              Administration

            	 	 
	
              22

            	
              Compensation

            	 	 
	
              23

            	
              Interest
                Expense

            	 	 
	
              24

            	
              Occupancy,
                Depreciation and Amortization

            	 	 
	
              25

            	
              Marketing

            	 	 
	
              26

            	
              Aggregate
                Write-Ins for Other Administration Expenses

            	 	 
	
              27

            	
              TOTAL
                ADMINISTRATION (items 22-26)

            	 	 
	
              28

            	
              TOTAL
                EXPENSES (items 21 and 27)

            	 	 
	
              29

            	
              Income
                (LOSS) (item 21 and 27)

            	 	 
	
              30

            	
              Cumulative
                Effect of Accountin Change)

            	 	 
	
              31

            	
              Provision
                for Federal Income Taxes

            	 	 
	
              32

            	
              NET
                INCOME (item 29, less items 30 and 31)

            	 	 
	 	 	 	 
	 	
              Details
                or Write-Ins Aggregated at item 6 for other Revenues

            	 	 
	
              601

            	
              Other
                Income

            	 	 
	
              602

            	 	 	 
	
              603

            	 	 	 

    

    
       

      (document
        5 of 6)

      Appendix
        H

      Unaudited
        Quarterly Financial Reports

       

      
        	 

    

    
      	
              604

            	 	 	 
	
              605

            	 	 	 
	
              698

            	
              Summary
                of remaining write-ins for item 6 from overflow page

            	 	 
	
              699

            	
              TOTALS:
                (items 601 through 605 plus 698 page 4, item 6)

            	 	 
	 	 	 	 
	 	
              Member
                months

            	 	 
	 	
              Details
                of Write-Ins Aggregated at Item 6 for Other Revenues

            	 	 
	
              1501

            	
              Drugs

            	 	 
	
              1502

            	
              Outpatient

            	 	 
	
              1503

            	 	 	 
	
              1504

            	 	 	 
	
              1505

            	 	 	 
	
              1598

            	
              Summary
                of remaining write-ins for item 15 from overflow page

            	 
	 	 	 	 
	 	
              Details
                of Write-Ins Aggregated at Item 26 for Other Administration
                Expenses

            	 
	
              2601

            	
              MGMT
                Fee Income - SWWA

            	 	 
	
              2602

            	
              MGMTFee
                Expense GOHS

            	 	 
	
              2603

            	
              Other
                Administration Expense

            	 	 
	
              2604

            	
              MGMT
                Fee Expense Corp.

            	 	 
	
              2605

            	
              Accrued
                Audit and Actuarial Expense

            	 	 
	
              2698

            	
              Summary
                of remaining write-Ins for item 26 from ovrflow page

            	 	 
	
              2699

            	
              TOTALS
                (items 2601 through 2605 plus 2698) (page 4, item 26)

            	 

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
Appendix
      I

     

    Capitation
      Payment Amount

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    SFY
      2007 Rates for Husky B Band 1 & 2

     

    Includes
      BHP Carve out, 3.88% Rate Increase, Hosp Adjustment and Dental
      Adjustment

     

     

    
      	 	
               (Hardcoded)

              SFY
                2007
                Rate

            
	
               FirstChoice

            	
               $155.73

            

    

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Appendix
      J

     

    Inpatient
      / Eligibility Recategorization
      Chart

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      	
              HUSKY
                B - Appendix J

              HUSKY
                A & B

              Medical
                Acute Care Primary Inpatient/Eligibility Recategorization
                Changes

            
	 	 	 	 	 
	
              Description

            	
              Admitting
                MCO

            	
              New/Continued
                MCO

            	
              Responsible
                Entity

            
	
              HUSKY
                A, different MCO

            	
              A1

            	
              A2

            	
              A1

            	 
	
              HUSKY
                A to FFS

            	
              A1

            	
              FFS

            	
              FFS

            	 
	
              HUSKY
                A to HUSKY B, same MCO

            	
              A1

            	
              B1

            	
              A1

            	 
	
              HUSKY
                A to HUSKY B, different MCO

            	
              A1

            	
              B2

            	
              A1

            	 
	
              HUSKY
                B, different MCO

            	
              B1

            	
              B2

            	
              B1

            	 
	
              HUSKY
                A to disenrolled due to loss

              of
                eligibility (Out of Program)

            	
              A1

            	
              x

            	
              A1

            	 
	
              HUSKY
                B to disenrolled due to loss

              of
                eligibility (Out of Program)

            	
              B1

            	
              x

            	
              B1

            	 
	
              HUSKY
                B to A (Same MCO,

              different
                coverage)

            	
              B1

            	
              A1

            	
              A1

            	 
	
              HUSKY
                B to A (different MCO,

              different
                coverage)

            	
              B1

            	
              A2

            	
              A2

            	 
	
              HUSKY
                B to FFS

            	
              B1

            	
              FFS

            	
              FFS

            	 

    

     

    
      	
              Code

            	 	 	 	 
	
              A1
                = HUSKY A, MCO #1

            	 	 	 	 
	
              A2
                = HUSKY A, MCO #2

            	 	 	 	 
	
              B1
                = HUSKY B, MCO #1

            	 	 	 	 
	
              B2
                = HUSKY B, MCO #2

            	 	 	 	 
	
              FFS
                = Fee-for-service

            	 	 	 	 
	
              x=
                Disenrolled due to loss of eligibility

            	 	 	 	 

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
Appendix
      K

     

    Abortion
      Reporting

     

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

    HUSKY
      B Non-Hyde Amendment Abortions

     

    Name
      of
      MCO: ___________________________

    Quarter
      Ended: ___________________________ 

                                                                                     

    This
      report shall include all abortions that do not meet the HYDE Amendment criteria,
      and that are paid by the MCO during the quarter (e.g. July 1 - September 30).
      These reports shall be submitted by the 15th of the month following the end
      of
      the quarter (e.g. October 15). The reports shall be submitted in hard copy,
      as
      well as electronically to Lee Voghel, Division of Fiscal Analysis.

    

    
      	
              Date
                of Service

            	
              CPT
                Code

            	
              Medicaid
                Recipient ID#

            	
              Provider
                ID#

            	
              Provider
                Name

            	
              Date
                Paid

            	
              Amount
                Paid

            
	 	 	 	
               

               

              Total

            	 	 	 

    

    

    

    I
      hereby
      certify that to the best of my knowledge the information contained herein is
      true and accurate.

     

    Signature:                                                                                     

    Printed
      Name:                                                                                     

    Title:                                                                                     

    Date:                                                                                     

     

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    Appendix
      L

     

    Blank

     

    Reserved
      for Possible Future Use

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
Appendix
      M

     

    Blank

     

    Reserved
      for Possible Future Use

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      

      APPENDIX
        N

      

      HUSKY
        BEHAVIORAL HEALTH CARE-OUT COVERAGE

      AND
        COORDINATION OF MEDICAL AND BEHAVIORAL SERVICES

      

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      

      

      
        HUSKY
          A -
          05/07 - Appendix N

      

      
        

      

      
        

      

      
        

      

      
        HUSKY
          BEHAVIORAL

      

      
        

      

      
        

      

      
        Health
          Carve-Out

      

      
        

      

      
        

      

      
        Coverage
          and Coordination of Medical and Behavioral
          Services

      

      
        

      

      
        

      

      
        

      

      
        

      

      
        DEPARTMENT
          OF SOCIAL SERVICES DEPARTMENT OF CHILDREN AND FAMILIES

      

      
        

        Updated
          January 26, 2006

      

      

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      

      

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      

      
        Contents

      

      
        

      

      
        	
                
                  Introduction

                

              	
                
                  3

                

              
	
                
                  Ancillary
                    Services

                

              	
                
                  3

                

              
	
                
                  Co-Occurring
                    Medical and Behavioral Health Conditions - Screening, Referral,
                    and
                    Coordination

                

              	
                
                  4

                

              
	
                
                  Freestanding
                    Medical/Primary Care Clinics

                

              	
                
                  5

                

              
	
                
                  Home
                    Health Services

                

              	
                
                  5

                

              
	
                
                  Hospital
                    Emergency Department

                

              	
                
                  7

                

              
	
                
                  Hospital
                    Inpatient Services

                

              	
                
                  8

                

              
	
                
                  Hospital
                    Outpatient Clinic Services

                

              	
                
                  9

                

              
	
                
                  HUSKY
                    Plus Behavioral

                

              	
                
                  9

                

              
	
                
                  Long
                    Term Care

                

              	
                
                  9

                

              
	
                
                  Member
                    Services

                

              	
                
                  10

                

              
	
                
                  Mental
                    Health Clinics

                

              	
                
                  10

                

              
	
                
                  Methadone
                    Maintenance

                

              	
                
                  11

                

              
	
                
                  Multi-Disciplinary
                    Examinations

                

              	
                
                  11

                

              
	
                
                  Notice
                    of Action

                

              	
                
                  11

                

              
	
                
                  Operations

                

              	
                
                  12

                

              
	
                
                  Outreach

                

              	
                
                  12

                

              
	
                
                  Pharmacy

                

              	
                
                  12

                

              
	
                
                  Primary
                    Care Behavioral Health Services

                

              	
                
                  13

                

              
	
                
                  Quality
                    Management

                

              	
                
                  14

                

              
	
                
                  Reports

                

              	
                
                  14

                

              
	
                
                  School-Based
                    Health Center Services

                

              	
                
                  15

                

              
	
                
                  Transportation

                

              	
                
                  16

                

              

      

       

      State
        of
        Connecticut                                                             Page
        2                                                           01/26/06

      
 

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      

      
        Introduction

      

      
        

        The
          purpose of this document is to outline the policies according to which
          the HUSKY
          MCOs and the Behavioral Health Partnership (BHP) will share responsibility
          for
          providing covered services to HUSKY A and B enrollees after HUSKY behavioral
          health benefits are carved out and administered under a contract with the
          BHP
          Administrative Service Organization ("BHP ASO"). After the carve-out, the
          Managed Care Organizations that participate in HUSKY A and B ("HUSKY MCOs")
          will
          be responsible for providing services for medical conditions and BHP will
          be
          responsible for providing services for behavioral health conditions. The
          BHP ASO
          will provide member services, provider relations services, utilization
          management, intensive care management, quality management and other management
          services to facilitate the provision of timely, effective, and coordinated
          services under the BHP. The BHP ASO will not be responsible for contracting
          with
          providers or maintaining a provider network. Behavioral health providers
          will be
          required to enroll in the Department of Social Services' Connecticut Medical
          Assistance Program Network (CMAP). With the exception of DCF funded residential
          services, claims will be processed by the Department of Social Services'
          Medicaid vendor, Electronic Data Systems (EDS).

      

      
        This
          document is intended to summarize the coverage responsibilities and coordination
          responsibilities for each of the major service areas as established by
          the HUSKY
          BH carve-out transition planning workgroup. In addition to this document,
          which
          is intended for use as an amendment or attachment to the ASO and MCO contracts,
          each of the HUSKY MCOs will develop a coordination agreement with the BHP
          ASO.
          The coordination agreements will further elaborate the coordination protocols
          with special attention to the areas noted below and to the key contacts
          and
          workflows particular to each MCO.

      

      
        

        Ancillary
          Services

      

      
        

        HUSKY
          MCOs will retain responsibility for all ancillary services such as laboratory,
          radiology, and medical equipment, devices and supplies regardless of diagnosis.
          However, laboratory costs for methadone chemistry (quantitative analysis)
          will
          be covered under the BHP when they are part of the bundled reimbursement
          for
          methadone maintenance providers. The HUSKY MCOs may track and trend laboratory
          utilization as part of coordination with the BHP ASO. In addition, the
          MCOs will
          address any increases in the utilization trend with The Department of Social
          Services.

      

      
        

        State
          of
          Connecticut                                                              Page
          3                                                           01/26/06

      

      

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      

      
        Co-Occurring
          Medical and Behavioral Health Conditions - Screening, Referral, and
          Coordination

      

      
        

        The
          HUSKY
          MCOs currently have programs and procedures designed to support the
          identification of untreated behavioral health disorders in medical patients
          at
          risk for such disorders. Such procedures may be carried out by medical
          service
          providers or by the MCO through the utilization management, case management
          and
          quality management processes. The MCOs will be expected to continue such
          activities in order to foster early and effective treatment of behavioral
          health
          disorders, including those disorders that could affect compliance with
          and the
          effectiveness of medical interventions.

      

      
        

        Both
          the
          HUSKY MCOs and the BHP ASO will be required to communicate and coordinate
          as
          necessary to ensure the effective coordination of medical and behavioral
          health
          benefits. The HUSKY MCOs will contact the BHP ASO when co-management is
          indicated (including BH hospital emergency department visits), such as
          for
          persons with special physical health and behavioral health needs; will
          respond
          to inquiries by the BHP ASO regarding the presence of medical co-morbidities;
          and will coordinate with the BHP ASO when invited to do so. Conversely,
          the BHP
          ASO will contact the HUSKY MCOs when co-management is indicated; will respond
          to
          inquiries by the HUSKY MCOs regarding the presence of behavioral co-morbidities;
          and will coordinate with the HUSKY MCOs when invited to do
          so.

      

      
        

        Both
          the
          BHP ASO and the MCOs will assign key contacts in order to facilitate timely
          coordination. In addition, it is anticipated that the BHP ASO's intensive
          care
          management department will be able to accept warm-line transfers as necessary
          from the HUSKY MCO case management departments to facilitate timely
          co-management.

      

      
        

        The
          BHP
          ASO will convene Medical/Behavioral Co-Management meetings at least once
          a month
          with each HUSKY MCO. The frequency of the meetings will be by agreement
          between
          the BHP ASO and each HUSKY MCO. The purpose of the meeting will be to ensure
          appropriate management of clients with co-occurring medical and behavioral
          health conditions. Cases discussed between the BHP ASO and the MCO will
          include
          all levels of behavioral health and medical care. Furthermore, the BHP
          ASO and
          the HUSKY MCOs shall provide reports in advance of the meetings on the
          cases to
          be reviewed.

      

      
        

        The
          HUSKY
          MCOs and the BHP ASO will from time to time make a determination as to
          whether a
          client's medical or behavioral health condition is primary. If there is
          a
          conflicting determination as to whether medical or behavioral health is
          primary,
          the respective medical directors will work together toward a timely and
          mutually
          agreeable resolution. At the request of either party, the Department of
          Social
          Services will make a determination as to the whether medical or behavioral
          health is primary and that determination shall be binding.

      

      
        

        State
          of
          Connecticut                                                             Page
          4                                                           01/26/06

      

      

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      

      
        Freestanding
          Medical/Primary Care Clinics

      

      
        

        The
          HUSKY
          MCOs will be responsible for primary care and other medical services provided
          by
          freestanding primary care/medical clinics regardless of diagnosis except
          for
          behavioral health evaluation and treatment services billed under CPT codes
          90801-90806, 90853, 90846, 90847, and 90862 with a primary behavioral health
          diagnosis and only when provided by a licensed behavioral health
          professional.

      

      
        

        Home
          Health Services

      

      
        

        HUSKY
          MCOs and BHP will share responsibility for covering home health services.
          The
          coordination agreements will include language that details procedures for
          resolving coverage responsibility issues. Home health coordination will
          be based
          on the following guidelines:

      

      
        

        The
          HUSKY
          MCOs will be responsible for management and payment of claims when home
          health
          services are required for the treatment of medical diagnoses alone and
          when home
          health services are required to treat both medical and behavioral diagnoses,
          but
          the medical diagnosis is primary. If the individual's behavioral health
          treatment needs cannot be safely and effectively managed by the medical
          nurse
          and/or aide, the home care agency will be required to provide psychiatric
          nursing and/or aide services separately authorized and paid for under the
          BHP.

      

      
        

        BHP
          will
          be responsible for management and payment of claims when home health services
          are required for the treatment of behavioral diagnoses alone (ICD 9: 291-316)
          and when home health services are required to treat both medical and behavioral
          diagnoses, but the behavioral diagnosis is primary. If the individual's
          medical
          treatment needs cannot be safely and effectively managed by the psychiatric
          nurse and/or aide, then the home care agency will be required to provide
          medical
          nursing and/or aide services separately authorized and paid for by the
          HUSKY
          MCOs.

      

      
        

        The
          following table summarizes this policy:

      

      

      
        	
                
                  HUSKY
                    MCOs

                

              	
                
                  BHP
                    ASO

                

              
	
                
                  Medical
                    diagnosis only

                

              	
                
                  Behavioral
                    diagnosis only

                

              
	
                
                  Medical
                    and behavioral diagnoses, Med primary

                

              	
                
                  Behavioral
                    and medical diagnoses, Behavioral primary

                

              
	
                
                  Medical
                    component only, when medical and behavioral diagnoses are present
                    and
                    behavioral health needs cannot be effectively managed by the
                    medical nurse
                    and/or aide.

                

              	
                
                  Behavioral
                    component only, when behavioral and medical diagnoses are present
                    and
                    medical needs cannot be effectively managed by the medical nurse
                    and/or
                    aide.

                

              

      

      
        

        In
          addition, HUSKY MCOs will manage and pay claims for home health physical
          therapy, occupational therapy, and speech therapy services regardless of
          diagnosis.

      

      
        

        State
          of
          Connecticut                                          
Page
          5             
                  
01/26/06

      

      

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      

      
        When
          physical therapy, occupational therapy, and speech therapy services occur
          alongside home health behavioral health services, the home health care
          agency
          will be required to get authorization from and submit claims to the both
          the
          HUSKY MCO and to Electronic Data Systems (EDS), the claims vendor for the
          BHP.

      

      
        

        The
          above
          policy will require that providers and management entities make decisions
          as to
          whether a medical or behavioral diagnosis is primary. This determination
          will be
          made at the time the service is presented for authorization. The determination
          will be based on the diagnosis that is the principal focus of the services
—
typically the one that requires the most time and/or expertise. A rebuttable
          presumption shall be made that the primary diagnosis is psychiatric if
          a
          psychiatrist makes the referral. The following examples should help in
          determining the issue of primary diagnosis:

      

      
        

        
          	
                  • 

                	
                  In
                    general, if a recipient is receiving home health behavioral health
                    services and at some point requires home health services for
                    a medical
                    condition, the behavioral health diagnosis remains primary if
                    the medical
                    treatment needs can be safely and effectively managed by the
                    nurse that is
                    providing the behavioral health services. If the medical condition
                    requires treatment by a medical nurse, and the medical nurse
                    is able to
                    safely assume responsibility for the behavioral condition, then
                    the
                    medical diagnosis becomes
                    primary.

                

        

      

      
        

        
          	
                  •  

                	
                  Similarly,
                    if a recipient is receiving home health medical services and
                    at some point
                    requires home health behavioral services for a behavioral condition,
                    the
                    medical diagnosis remains primary if the behavioral health treatment
                    needs
                    can be safely and effectively managed by the nurse that is providing
                    the
                    medical services. If the behavioral condition requires treatment
                    by a
                    psychiatric nurse, and the psychiatric nurse is able to safely
                    assume
                    responsibility for the medical condition, then the behavioral
                    diagnosis
                    becomes primary.

                

        

      

      
        

        If,
          at
          some point, separate nurses or aides are required to provide the behavioral
          and
          medical services, then the nurse and/or aide treating the medical condition
          must
          obtain authorization and payment from the HUSKY MCO and the nurse and/or
          aide
          treating the behavioral health condition must obtain authorization and
          payment
          under the BHP.

      

      
        

        In
          some
          cases, a recipient will not require treatment for both a medical and behavioral
          condition at every visit. For example, a recipient may require two visits
          per
          day for his or her medical condition, but only one visit per day for the
          behavioral health condition, hi this case, the medical condition ought
          to be
          billed as primary for both visits. Conversely, if a recipient requires
          two
          visits per day for his or her behavioral condition, but only one visit
          per day
          for the medical condition, the behavioral condition ought to be billed
          as
          primary for both visits.

      

      
        

        Finally,
          the primary reason for a visit may change from medical to behavioral or
          visa
          versa in the course of home health treatment. If this change occurs at
          the time
          of re-authorization, the home health care agency should pursue a new
          authorization from the entity with responsibility for the new condition
          for
          which home health care is required. If

      

      
        

        State
          of
          Connecticut                                                             Page
          6                                                           01/26/06

      

      

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      

      
        the
          change in primary diagnosis occurs during an authorized episode of care,
          the
          home health care agency should discontinue services under the preceding
          authorization and pursue a new authorization from the entity with responsibility
          for the services going forward. If the HUSKY MCO reviews a request for
          authorization and believes that the primary has changed from medical to
          behavioral health, the MCO should direct the home care agency to pursue
          authorization through the BHP ASO.   The converse is also true.
          If the primary is not apparent, the clinical reviewers from the BHP ASO
          and the
          MCO should confer and come to agreement.

      

      
        

        Data
          provided by the HUSKY MCOs suggests that there are a modest number of clients
          with diagnoses of autism or mental retardation receiving home health services
          and that more than half of these clients have mixed diagnoses that could
          complicate management and billing. BHP will be responsible for the management
          and payment of claims when home health services are required for the treatment
          of autism, whether on its own or co-morbid with mental retardation. For
          those
          members with these dual diagnoses, providers will be directed to obtain
          authorization from the BHP ASO and to bill EDS with autism primary. The
          HUSKY
          MCOs will retain responsibility for mental retardation alone. BHP will
          also be
          responsible for management and payment of claims when home health services
          are
          required for the treatment of both autism and medical disorders, when the
          medical disorder can be safely and effectively managed by the psychiatric
          nurse
          and/or aide. If the individual's medical treatment needs are so significant
          that
          they cannot be safely and effectively managed by the psychiatric nurse
          and/or
          aide, then the home care agency will be required to provide medical nursing
          and/or aide services separately authorized and paid for by the HUSKY
          MCOs.

      

      
        

        All
          home
          health care agencies operating in Connecticut are enrolled in the Connecticut
          Medical Assistance Program (CMAP) network and may, at their discretion,
          provide
          behavioral health home health services to HUSKY recipients. In contrast,
          the
          HUSKY MCOs may contract with only a subset of the CMAP providers. This
          means
          that there may be times when a client is in treatment for a behavioral
          health
          condition with a CMAP provider that is not participating with a HUSKY MCO.
          If
          this client develops a co-occurring medical disorder that is secondary
          and can
          be managed by the psychiatric home care nurse, BHP will continue to be
          responsible for management and payment of claims. If, however, the patient's
          medical disorder becomes primary and thus the responsibility of the HUSKY
          MCO,
          the HUSKY MCO can elect to continue to use the home care provider as an
          out of
          network provider, or the HUSKY MCO can, at its discretion, transition the
          care
          to a participating home care provider. The client's best interest will
          be a
          factor in this determination. The MCOs and BHP ASO will be expected to
          create
          coordination agreements to expedite the proper handling of such
          cases.

      

      
        

        Hospital
          Emergency Department

      

      
        

        The
          HUSKY
          MCOs will assume responsibility for emergency department services, including
          emergent and urgent visits and all associated charges billed by the facility,
          regardless of diagnosis. Professional psychiatric services rendered in
          an
          emergency department by a community psychiatrist will be reimbursed by
          the BHP
          if the psychiatrist

      

      
        

        State
          of
          Connecticut                                                             Page
          7                                                           01/26/06

      

      

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      

      
        is
          enrolled in CMAP as an independent solo or group practitioner and bills
          under
          the solo or group practice ID. The BHP will be responsible for observation
          stays
          of 23 hours or less (RCC 762) with a primary behavioral health diagnosis.
          The
          HUSKY MCOs and the Department will implement audit procedures to ensure
          that
          hospitals do not bill HUSKY MCOs for emergency department services when
          patients
          are admitted to the hospital and behavioral health is primary. The HUSKY
          MCOs
          may track and trend Emergency Department utilization for behavioral health.
          The
          MCOs will address any increase in the utilization trend with the
          Departments.

      

      
        

        Hospital
          Inpatient Services

      

      
        

        In
          order
          to assure appropriate coordination and communication, the coordination
          agreements will include specific language detailing processes and procedures
          for
          concurrent communication and the process for handling co-occurring medical
          and
          behavioral health hospital inpatient conditions. In addition, the agreements
          will include specific language on the procedures for resolving coverage
          related
          issues when the ASO and MCOs disagree. Coordination will be based on the
          following guidelines:

      

      
        

        Psychiatric
          Hospitals

      

      
        

        BHP
          will
          be responsible for all psychiatric hospital services and all associated
          charges
          billed by a psychiatric hospital, regardless of diagnosis. The rate is
          all-inclusive so there will be no reimbursement for professional services
          rendered by community-based consulting physicians.

      

      
        

        General
          Hospitals

      

      
        

        HUSKY
          MCOs and BHP will share responsibility for covering inpatient general hospital
          services. The HUSKY MCOs will be responsible for management and payment
          of
          claims for inpatient general hospital services when the medical diagnosis
          is
          primary. Medical would be considered primary when the billed RCC and the
          primary
          diagnosis are both medical.

      

      
        

        During
          a
          medical stay, BHP will be responsible for professional services associated
          with
          behavioral health diagnoses. The admitting physician will be responsible
          for
          coordinating medical orders for any necessary behavioral health services
          with
          the BHP ASO. Other ancillary charges associated with non-primary behavioral
          health diagnoses shall remain the responsibility of the HUSKY MCOs, as
          described
          in the ancillary services section of this document.

      

      
        

        BHP
          will
          be responsible for management and payment of claims for inpatient general
          hospital services when the behavioral diagnosis is primary. The behavioral
          diagnosis will be considered primary when the billed RCC and the primary
          diagnosis are both behavioral or when the billed RCC is medical, but the
          primary
          diagnosis on the claim form is behavioral. During a behavioral stay, the
          HUSKY
          MCOs will be responsible for professional services and other charges associated
          with primary medical diagnoses.

      

      
        

        State
          of
          Connecticut                                                             Page
          8                                                           01/26/06

      

      

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      

      
        
          	
                   

                	
                  o   When
                    an admission to a general hospital is initially medical, but
                    the reason
                    for continued admission becomes behavioral, responsibility for
                    management
                    and payment of claims will transition to BHP. When the hospital
                    admission
                    is no longer medically necessary for the medical diagnosis, the
                    HUSKY MCO
                    ceases to be responsible for management and payment. The BHP
                    ASO will
                    monitor the timeliness of transfer from a medical unit to a psychiatric
                    unit when the primary diagnosis changes from medical to behavioral
                    health.

                

        

      

      
        

        The
          following table summarizes this policy:

      

      

      
        	
                
                  Inpatient
                    Payment for Primary Diagnosis

                

              	 	
                
                  Professional
                    Services Paid for Secondary Diagnosis

                

              
	
                
                  Inpatient
                    Type

                

              	
                
                  Revenue
                    Codes

                

              	
                
                  Diagnosis

                

              	
                
                  Assignment

                

              	 	
                
                  HCPCS

                

              	
                
                  Diagnosis

                

              	
                
                  Assignment

                

              
	
                
                  General
                    Hospital

                

              	
                
                  BH

                

              	
                
                  BH

                

              	
                
                  BHP

                

              	 	
                
                  BH

                

              	
                
                  BH

                

              	
                
                  BHP

                

              
	
                
                  General
                    Hospital

                

              	
                
                  BH

                

              	
                
                  BH

                

              	
                
                  BHP

                

              	 	
                
                  Med

                

              	
                
                  Med

                

              	
                
                  MCO

                

              
	
                
                  General
                    Hospital

                

              	
                
                  Med

                

              	
                
                  BH

                

              	
                
                  BHP

                

              	 	
                
                  BH

                

              	
                
                  BH

                

              	
                
                  BHP

                

              
	
                
                  General
                    Hospital

                

              	
                
                  Med

                

              	
                
                  BH

                

              	
                
                  BHP

                

              	 	
                
                  Med

                

              	
                
                  Med

                

              	
                
                  MCO

                

              
	
                
                  General
                    Hospital

                

              	
                
                  Med

                

              	
                
                  Med

                

              	
                
                  MCO

                

              	 	
                
                  Med

                

              	
                
                  Med

                

              	
                
                  MCO

                

              
	
                
                  General
                    Hospital

                

              	
                
                  Med

                

              	
                
                  Med

                

              	
                
                  MCO

                

              	 	
                
                  BH

                

              	
                
                  BH

                

              	
                
                  BHP

                

              

      

      
        

        Hospital
          Outpatient Clinic Services

      

      
        

        BHP
          will
          be responsible for all outpatient psychiatric clinic, intensive outpatient,
          extended day treatment, and partial hospitalization services provided by
          general
          and psychiatric hospitals for the evaluation and treatment of behavioral
          health
          disorders. BHP will also cover evaluation and treatment services related
          to a
          non-behavioral health diagnosis if the billing code is psychiatric as outlined
          in the covered services grid.

      

      
        

        The
          HUSKY
          MCOs will be responsible for all primary care and other medical services
          provided by hospital medical clinics regardless of diagnosis including
          all
          medical specialty services and all ancillary services.

      

      
        

        HUSKY
          Plus Behavioral

      

      
        

        HUSKY
          Plus Behavioral services (intensive in-home psychiatric services) will
          be
          included in the HUSKY B benefit package. The ASO will manage access to
          these
          services under the carve-out.

      

      
        

        Long
          Term
          Care

      

      
        

        The
          HUSKY
          MCOs will be responsible for all long term care services (i.e., nursing
          homes,
          chronic disease hospitals) regardless of diagnosis. These services are
          seldom

        

      

      
        State
          of
          Connecticut                       
Page
          9                    
01/26/06

      

      

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      

      
        required
          for the treatment of clients with primary behavioral health disorders under
          the
          HUSKY program. The admission of a client with a primary behavioral health
          disorder must be by mutual agreement of the BHP ASO and the HUSKY MCO in
          which
          the client is enrolled.

      

      
        

        DSS
          currently exempts any long-term care client from managed care the first
          of the
          month in which the client's stay exceeds 90 days. DSS will consider early
          exemption for clients with a primary behavioral health diagnosis if DSS
          were
          provided with adequate notice when such clients are admitted to long-term
          care.

      

      
        

        Member
          Services

      

      
        

        The
          BHP
          ASO will have its own member services department with a dedicated toll
          free
          phone number. The member services staff will provide non-clinical information
          to
          recipients and when appropriate provide immediate access to clinical staff
          for
          care related assistance. The member services staff will respond to all
          calls
          directed to the member services line and it is expected will have the ability
          to
          accept warm-line transfers from the HUSKY MCOs. The HUSKY MCOs will replace
          references to existing BH subcontractors on member materials with the new
          BHP
          ASO name and member services phone number, wherever such references occur.
          Branch logic for the DSS' 1-877-CTHUSKY number will be modified to incorporate
          the ASO member services line as an option for callers that require BHP
          related
          assistance.

      

      
        

        The
          MCOs
          will continue to conduct welcome calls to new members. At the time of the
          welcome call, the HUSKY MCO member services representative will provide
          the
          member with information on how to access the BHP ASO.

      

      
        

        HUSKY
          MCO
          member services departments will occasionally receive calls from members
          who are
          requesting BH services. In addition, BH issues may emerge in the course
          of a
          welcoming call. The member may screen positive for behavioral health issues
          and
          express an interest in discussing further or have clear behavioral health
          issues
          and need a referral. In either case, the member service representative
          can
          affect a warm-line transfer to the ASO member services department, take
          the
          member's information and fax this information to the ASO for follow-up,
          or
          provide the member with the telephone number for the BHP ASO.

      

      
        

        If
          the
          client is in crisis, the MCO member services representative should follow
          the
          MCO's protocols for handling crisis calls. The BHP ASO will have the capacity
          to
          accept warm-line transfer of such crisis calls when, at the discretion
          of the
          MCO, such transfer is appropriate.

      

      
        

        Mental
          Health Clinics

      

      
        

        BHP
          will
          be responsible for all Mental Health Clinic Services regardless of diagnosis
          including routine outpatient services and all diagnostic and treatment
          services
          billed as intensive outpatient treatment, extended day treatment, and partial
          hospitalization

      

      
        

        State
          of
          Connecticut                                                             Page
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        treatment.
          BHP will also cover evaluation and treatment services related to a medical
          diagnosis such as psychological testing for a client with traumatic brain
          injury.

      

      
        

        Methadone
          Maintenance

      

      
        

        BHP
          will
          be responsible for reimbursing methadone clinics for methadone maintenance
          services provided to HUSKY enrollees. All methadone maintenance services
          for
          which the source of service is the methadone maintenance clinic are included
          in
          the Department's bundled rate with methadone maintenance
          clinics.   The MCOs will cover all methadone maintenance
          laboratory services when billed by an independent laboratory

      

      
        

        Multi-Disciplinary
          Examinations

      

      
        

        The
          MCOs
          will be responsible for contracting with DCF certified Multi-Disciplinary
          Examination providers and for covering all components of the DCF
          Multi-Disciplinary Examinations including behavioral health evaluation
          services
          (e.g., 90801, 96110). .

      

      
        

        Notice
          of
          Action

      

      
        

        The
          HUSKY
          MCOs will be responsible for issuing notices of action for medical review
          decisions and the BHP ASO will be responsible for issuing notices of action
          for
          behavioral health review decisions. The HUSKY MCOs will issue notices of
          action
          to the client and the provider, but will not issue a notice to the BHP
          ASO.
          Similarly, the BHP ASO will issue notices of action to the client and the
          provider, but will not issue a notice to the HUSKY MCO.

      

      
        

        In
          preparation for a fair hearing, the Department of Social Services will
          work with
          the Department's contractor that issued the notice to prepare the Department's
          case. Typically, the ASO will not be involved in an MCO related fair hearing
          and
          the MCO will not be involved in an ASO related fair hearing. However, when
          a
          client has co-morbid medical and behavioral health conditions and the action
          affects both conditions, then both the MCO and the ASO may be involved
          in
          preparation for the fair hearing.

      

      
        

        If
          a
          HUSKY MCO or one of its providers disagrees with a clinical management
          decision
          made by the BHP ASO, the HUSKY MCO is encouraged to raise the issue with
          the ASO
          on behalf of the client and to resolve the issue informally prior to the
          scheduled fair hearing. The converse is also true. If the issue remains
          unresolved, DSS will review the issue with the HUSKY MCO and the ASO and
          make a
          determination as to whether DSS supports the decision of the contractor
          that
          issued the notice. If DSS supports the contractor that issued the notice,
          the
          matter will proceed to fair hearing.

      

      
        

        The
          HUSKY
          MCOs may at times refer a client or provider to the BHP ASO because the
          primary
          presenting condition is behavioral health rather than medical. The HUSKY
          MCO's
          determination that a condition is behavioral health rather than medical
          shall
          not constitute grounds for issuing a notice of action. The converse is
          true for
          the BHP ASO.

      

      
        

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        The
          HUSKY
          MCO may at times issue a notice of action for a prescription written by
          a CMAP
          enrolled behavioral health prescribing provider. In such instances, the
          HUSKY
          MCO will be expected to send notice of action to the client and to the
          prescribing provider.

      

      
        

        Operations

      

      
        

        In
          order
          to support coordination and communication regarding operational issues
          such as
          claims payment, the Departments will host a monthly meeting with the BHP
          ASO and
          the HUSKY MCOs.

      

      
        

        Outreach

      

      
        

        The
          HUSKY
          MCOs currently provide outreach to members to assist them with accessing
          necessary services. The MCOs will continue to provide outreach to members
          to
          assist them with accessing medical services. For example, they may reach
          out to
          members to connect them to a primary care provider or to ensure necessary
          follow-up after a medical hospitalization. If an MCO's outreach worker
          identifies a member with a behavioral health issue, the worker may, at
          the MCO's
          discretion, provide information to the member on how to access behavioral
          health
          services via the ASO or facilitate a direct referral.

      

      
        

        The
          BHP
          ASO will conduct extensive outreach focused on connecting clients to behavioral
          health care when clients are experiencing barriers to care. They will also
          make
          efforts to ensure a connection to care after discharge from a hospital
          or
          residential treatment center. If in the course of outreach the BHP ASO
          identifies a member with a significant medical issue, the ASO may provide
          information to the member on how to access necessary medical services through
          the MCO or the member's primary care provider or facilitate a direct
          referral.

      

      
        

        Pharmacy

      

      
        

        The
          HUSKY
          MCOs will assume responsibility for all pharmacy services and all associated
          charges, regardless of diagnosis. However, methadone costs that are part
          of the
          bundled reimbursement for methadone maintenance and ambulatory detox providers
          will be covered under BHP. Methadone maintenance providers and ambulatory
          detox
          providers are responsible for supplying and dispensing methadone and these
          costs
          are covered by the BHP as part of an all-inclusive rate.

      

      
        

        Each
          HUSKY MCO maintains its own pharmacy program with distinct formularies,
          drug
          utilization review requirements, and prior authorization requirements.
          Under
          BHP, the Departments will have contracts with prescribing behavioral health
          providers and these providers will be required to follow the pharmacy program
          requirements of the HUSKY MCO in which the member is enrolled as well as
          other
          applicable Medicaid program

      

      
        

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        requirements.
          BHP prescribing providers include psychiatrists, psychiatric nurses,
          freestanding behavioral health clinics, and hospitals.

      

      
        

        DSS
          disseminates all policy transmittals and provider bulletins for CMAP providers
          through EDS. The ASO will not have a role in communications of this type.
          DSS
          will issue a provider bulletin to all enrolled prescribing providers prior
          to
          the carve-out date in order to apprise the providers of the pharmacy program
          requirements of each MCO and remind providers of the HUSKY program's temporary
          supply rules. DSS will require that providers adhere to each MCOs pharmacy
          program requirements and provide MCOs with any clinical information necessary
          to
          support requests for authorization or the preparation of clinical summaries
          for
          the purpose of fair hearings.

      

      
        

        Subsequently,
          the MCOs must notify DSS of changes to its pharmacy program requirements.
          DSS
          will in turn use the provider bulletin process to notify CMAP providers
          of such
          changes within 30 days of the effective date. The Departments prefer that
          DSS
          manage such pharmacy program communications since it will have a complete
          and
          up-to-date file of enrolled prescribing providers. This new communication
          process should resolve some of the pharmacy program communication issues
          that
          currently exist in the HUSKY program. Specifically, among some HUSKY MCOs,
          certain providers such as freestanding behavioral health clinics are not
          included in routine pharmacy program communications issued by the MCO.
          Under the
          carve-out, all providers will be apprised of the requirements of all HUSKY
          MCOs.
          The initial provider bulletin pertaining to pharmacy will provide each
          MCO's web
          address where pharmacy program requirements are available.

      

      
        The
          BHP
          ASO will fully cooperate with the MCOs and work closely with the MCOs to
          ensure
          compliance with the pharmacy programs of the individual MCOs. The BHP ASO
          will
          work closely with the MCOs to monitor pharmacy utilization and, if necessary,
          cooperate with the MCOs in conducting targeted provider education or training
          related to prescribing. DSS will require that its prescribing providers
          participate in quality initiatives and targeted pharmacy education and
          training
          conducted by the HUSKY MCOs for the purpose of improving prescribing practices
          and/or adherence to pharmacy program requirements. If the HUSKY MCOs encounter
          a
          behavioral health provider who engages in persistent misconduct related
          to
          psychiatric prescribing, the matter should be referred to DSS for
          investigation.

      

      
        

        The
          HUSKY
          MCOs may track and trend behavioral health pharmacy utilization and address
          any
          increase in the utilization trend with the Departments. DSS will continue
          to
          review each MCO's compliance with pharmacy contract provisions and new
          DSS staff
          will meet with each MCO to familiarize themselves with each MCO
          formulary/pharmacy process and available data in order to be prepared to
          work
          with the MCOs on reporting specs.

      

      
        

        Primary
          Care Behavioral Health Services

      

      
        

        The
          HUSKY
          MCOs will retain responsibility for all primary care services and all associated
          charges, regardless of diagnosis. These responsibilities
          include:

      

      
        

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        1.      behavioral
          health related prevention and anticipatory guidance;

      

      
        2.      screening
          for behavioral health disorders;

      

      
        
          	
                  3.

                	
                  treatment
                    of behavioral health disorders that the primary care
                    physician concludes can be safely and appropriately treated in a
                    primary care setting;

                

        

      

      
        
          	
                  4.

                	
                  management
                    of psychotropic medications, when the primary care
                    physician concludes it is safe and appropriate to do so, in
                    conjunction with treatment by a BHP non-medical behavioral health
                    specialist when necessary;
                    and

                

        

      

      
        
          	
                  5.

                	
                  referral
                    to a behavioral health specialist when the primary care
                    physician concludes that it is safe and appropriate to do
                    so.

                

        

      

      
        

        The
          BHP
          ASO will develop education and guidance for primary care physicians related
          to
          the provision of behavioral health services in primary care settings. At
          their
          discretion, the HUSKY MCOs can collaborate with the ASO in the development
          of
          education and guidance or they will be provided the opportunity to review
          and
          comment. The education and guidance will address PCP prescribing with support
          and guidance from the ASO or referring clinic, in circumstances when the
          PCP is
          comfortable with this responsibility. The BHP ASO will make telephonic
          psychiatric consultation services available to primary care providers.
          Consultation may be initiated by any primary care provider that is seeking
          guidance on psychotropic prescribing for a HUSKY A, HUSKY B, or Voluntary
          Services enrollee.

      

      
        

        To
          promote effective coordination and collaboration, the BHP ASO will work
          with
          interested HUSKY MCOs and provider organizations to sponsor opportunities
          for
          joint training. HUSKY MCO policies and provider contracts must permit the
          provision of behavioral health services by primary care providers; however,
          the
          MCOs will not be expected to provide education and training to improve
          ability
          of primary care providers to provide these services.

      

      
        

        The
          HUSKY
          MCOs may track and trend primary care behavioral health utilization. The
          MCOs
          will address any increase in the utilization trend with the
          Departments.

      

      
        

        Quality
          Management

      

      
        

        The
          BHP
          ASO will be required to conduct at least three quality improvement initiatives
          each year. For the second year of the contract, the ASO will invite the
          HUSKY
          MCOs to participate in a joint quality improvement initiative focused on
          an area
          of mutual concern. Each MCO may participate at its discretion. The Departments
          will determine during the second year of the project whether to ask the
          BHP ASO
          to propose an additional joint quality improvement initiative with the
          MCOs
          during the third year of its contract.

      

      
        

        Reports

      

      
        

        The
          BHP
          ASO will provide a weekly census report on all behavioral health inpatient
          stays
          identifying those with co-occurring medical and behavioral health conditions.
          In

      

      
        

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        addition,
          the reports in Exhibit E of the BHP ASO contract will also be made available
          to
          the MCOs upon request.

      

      
        

        The
          MCOs
          will provide daily and monthly reports and/or data as mutually agreed upon
          to
          the BHP ASO regarding i) behavioral health emergency department visits,
          ii)
          behavioral health emergency room recidivism, iii) substance abuse & neonatal
          withdrawal, iv) child/adolescent obesity and/or type II diabetes, v) sickle
          cell
          report, vi) eating disorders report, and vii) medical detox.

      

      
        

        The
          Departments will also make MCO specific behavioral health encounter data
          available to the MCOs upon request to support quality management activities
          and
          coordination. The format of the data extract will be consistent with the
          encounter data reporting format, or other format mutually agreed upon by
          the
          Departments and the MCO.

      

      
        

        The
          HUSKY
          MCOs will identify BH NEMT data versus medical NEMT data in their NEMT
          reporting
          to DSS. In addition, the HUSKY MCOs will track and trend NEMT complaints
          related
          to BH visits separately from NEMT complaints related to medical visits.
          The BHP
          ASO will also compile NEMT related complaints, although these complaints
          will be
          forwarded to the HUSKY MCOs for resolution.

      

      
        

        The
          MCOs
          will continue to include behavioral health access in their CAHPS survey
          and
          report this information to the Departments.

      

      
        

        School-Based
          Health Center Services

      

      
        

        In
          general, BHP will be responsible for reimbursing school-based health centers
          for
          behavioral health diagnostic and treatment services (CPT 90801-90807, 90853,
          90846, and 90847) provided to students with a behavioral health diagnosis.
          The
          HUSKY MCOs will be responsible for primary care services provided by
          school-based health centers, regardless of diagnosis, but they will not
          be
          responsible for behavioral health assessment and treatment services billed
          under
          CPT codes 90801-90807, 90853, 90846, and 90847. The following narrative
          provides
          additional background and a rationale for this arrangement.

      

      
        

        School-based
          health centers currently provide a range of general health and behavioral
          health
          services that are reimbursable under the HUSKY program. All of these
          school-based health centers are licensed by the Department of Public Health,
          either as freestanding outpatient clinics or as satellites under a hospital
          license. Under these licenses, clinics can provide general medical services
          as
          well as behavioral health services.

      

      
        

        School-based
          health centers vary in their degree of expertise in the provision of behavioral
          health services. Some school-based health centers provide prevention and
          counseling for students with emotional or behavioral issues and bill for
          those
          services using general primary care prevention and counseling codes, often
          without a behavioral

      

      
        

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        health
          diagnosis. Those primary care and preventive counseling services that are
          currently covered under the MCO contracts with individual School-Based
          Health
          Centers will continue to be the responsibility of the HUSKY
          MCOs.

      

      
        

        Other
          school-based health centers have taken steps to develop their behavioral
          health
          services including relying on licensed behavioral health practitioners
          and/or
          affiliation agreements with local outpatient child psychiatric clinic that
          provide clinical staff, consultation, or oversight. If the school-based
          health
          center provides behavioral health diagnostic and treatment services, these
          services will be the responsibility of the BHP ASO. The school-based health
          center must enroll as a CMAP provider in order to be reimbursed for those
          services under BHP.

      

      
        

        In
          some
          cases, the behavioral health component of the school-based health center's
          services is provided under the license of an outpatient child psychiatric
          clinic. In this case, the outpatient child psychiatric clinic will be enrolled
          as a CMAP provider and the services provided will be reimbursable as behavioral
          health clinic services under BHP.

      

      
        

        Transportation

      

      
        

        All
          of
          the HUSKY MCOs will continue to provide transportation for HUSKY A enrollees
          with behavioral health disorders for behavioral health services that are
          covered
          under Medicaid. Specifically, the MCOs will continue to be responsible
          for
          transportation to hospitals, clinics, and independent professionals for
          routine
          outpatient, extended day treatment, intensive outpatient, partial
          hospitalization, detoxification, methadone maintenance, and inpatient
          psychiatric services. The MCOs will also be responsible for services that
          might
          be covered under EPSDT. For example, case management services are not included
          in the Connecticut Medicaid state plan, but they are covered under EPSDT
          when
          medically necessary. Although case management does not necessarily require
          transportation to a facility, if transportation to a facility were necessary
          for
          a case management encounter, the MCOs would be responsible for providing
          it.
          These policies under BHP are simply a continuation of current HUSKY A program
          policies.

      

      
        

        The
          MCOs
          will not be responsible for transportation for non-Medicaid services such
          as
          respite, or DCF funded services that are designed to come to the client
          including care coordination, emergency mobile psychiatric services, home-based
          services, and therapeutic mentoring.

      

      
        

        The
          transportation benefit for behavioral health visits will continue to be
          subject
          to the same policies and procedures applicable to other HUSKY A covered
          services. The Departments will issue a member services handbook that indicates
          that transportation services are covered for HUSKY A enrollees and that
          such
          services will be covered by the HUSKY MCO with which the member is enrolled.
          The
          handbook will indicate that the MCO specific transportation policies apply,
          that
          HUSKY MCO recipients should refer to their HUSKY member handbook for details,
          and arrange for transportation directly with their HUSKY MCO transportation
          broker.

      

      
        

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        The
          ASO
          will make referrals to the closest appropriate providers (typically 3 names
          will
          be given upon request) and avoid referrals to facilities and offices outside
          of
          a 25-30 mile radius unless circumstances require otherwise. The ASO is
          not
          required to review provider distance from the member when responding to
          requests
          for authorization. The transportation brokers will assess all requests
          for
          transportation when contacted by the member and it will be up to the
          transportation broker and the MCO to apply coverage limitations as appropriate
          when contacted by the member. In most cases, the transportation broker
          and/or
          the MCO will be able to make decisions about whether to authorize transportation
          to the non-closest provider or to a provider that is outside of the 25-30
          mile
          radius by working directly with the member.   However, the ASO
          will be required to respond to inquiries from the MCO or transportation
          broker
          if additional information is needed to support authorization of a transportation
          request.

      

      
        

        The
          HUSKY
          MCOs will also retain responsibility for all Emergency Medical Transportation
          and associated charges, regardless of diagnosis, and hospital-to-hospital
          ambulance transportation of members with a behavioral health
          condition.

      

      
        

        The
          BHP
          ASO is expected to work closely with the MCOs to monitor transportation
          utilization and, if necessary, cooperate with the MCOs in conducting targeted
          provider education or training related to the appropriate use of transportation
          services. The HUSKY MCOs may track and trend utilization of transportation
          to
          behavioral health facilities. Any increases in the utilization trend will
          be
          addressed with the Departments.

      

      
        

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        APPENDIX
          O

      

      
        

      

      
        CTBHP
          Master Covered Services Table

      

      

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

       

      
        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July
                      31,2006

                  

          

        

        
          

          0507

        

        

        
          	
                  
                    HUSKY
                      A and B Appendix O - CT BHP Master Covered Services Table -
                      September
                      2006

                  

                
	
                  
                    Coverage

                  

                	
                  
                    1
                      =
                      HUSKY MCO - All diagnoses

                  

                
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP -All diagnoses

                  

                
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                
	 	
                  
                    4=
                      Not covered

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    General
                      Hospital Inpatient

                  

                	
                  
                    Coverage

                  

                
	
                  
                    110

                  

                	
                  
                    Room
                      & Board- Private

                  

                	
                  
                    3

                  

                
	
                  
                    111

                  

                	
                  
                    Room
                      & Board- Private -Med/Surg/Gyn

                  

                	
                  
                    3

                  

                
	
                  
                    112

                  

                	
                  
                    Room
                      & Board- Private -OB

                  

                	
                  
                    3

                  

                
	
                  
                    113

                  

                	
                  
                    Room
                      & Board- Private -Pediatric

                  

                	
                  
                    3

                  

                
	
                  
                    114

                  

                	
                  
                    Room
                      & Board - Private - Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    115

                  

                	
                  
                    Room
                      & Board- Private -Hospice

                  

                	
                  
                    3

                  

                
	
                  
                    116

                  

                	
                  
                    Room
                      & Board - Private - Detox

                  

                	
                  
                    2

                  

                
	
                  
                    117

                  

                	
                  
                    Room
                      & Board- Private -Oncology

                  

                	
                  
                    3

                  

                
	
                  
                    118

                  

                	
                  
                    Room
                      & Board- Private -Rehab

                  

                	
                  
                    3

                  

                
	
                  
                    119

                  

                	
                  
                    Room
                      & Board- Private -Other

                  

                	
                  
                    3

                  

                
	
                  
                    120

                  

                	
                  
                    Room
                      & Board-Semi-Private/2 Bed

                  

                	
                  
                    3

                  

                
	
                  
                    121

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed- Med/Surg/Gyn

                  

                	
                  
                    3

                  

                
	
                  
                    122

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed -OB

                  

                	
                  
                    3

                  

                
	
                  
                    123

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed-Pediatric

                  

                	
                  
                    3

                  

                
	
                  
                    124

                  

                	
                  
                    Room
                      & Board - Semi-Private/2 Bed - Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    125

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed-Hospice

                  

                	
                  
                    3

                  

                
	
                  
                    126

                  

                	
                  
                    Room
                      & Board - Semi-Private/2 Bed - Detox

                  

                	
                  
                    2

                  

                
	
                  
                    127

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed-Oncology

                  

                	
                  
                    3

                  

                
	
                  
                    128

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed-Rehab

                  

                	
                  
                    3

                  

                
	
                  
                    129

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed-Other

                  

                	
                  
                    3

                  

                
	
                  
                    130

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed

                  

                	
                  
                    3

                  

                
	
                  
                    131

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed- Med/Surg/Gyn

                  

                	
                  
                    3

                  

                
	
                  
                    132

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed-OB

                  

                	
                  
                    3

                  

                
	
                  
                    133

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed-Pediatric

                  

                	
                  
                    3

                  

                
	
                  
                    134

                  

                	
                  
                    Room
                      & Board - Semi-Private/3-4 Bed - Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    135

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed-Hospice

                  

                	
                  
                    3

                  

                
	
                  
                    136

                  

                	
                  
                    Room
                      & Board - Semi-Private/3-4 Bed - Detox

                  

                	
                  
                    2

                  

                
	
                  
                    137

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed-Oncology

                  

                	
                  
                    3

                  

                
	
                  
                    138

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed-Rehab

                  

                	
                  
                    3

                  

                
	
                  
                    139

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed-Other

                  

                	
                  
                    3

                  

                
	
                  
                    140

                  

                	
                  
                    Room
                      & Board-Private-Deluxe

                  

                	
                  
                    3

                  

                
	
                  
                    141

                  

                	
                  
                    Room
                      & Board-Private-Deluxe- Med/Surg/Gyn

                  

                	
                  
                    3

                  

                
	
                  
                    142

                  

                	
                  
                    Room
                      & Board-Private - Deluxe-OB

                  

                	
                  
                    3

                  

                
	
                  
                    143

                  

                	
                  
                    Room
                      & Board-Private - Deluxe-Pediatric

                  

                	
                  
                    3

                  

                
	
                  
                    144

                  

                	
                  
                    Room
                      & Board - Private - Deluxe - Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    145

                  

                	
                  
                    Room
                      & Board-Private - Deluxe-Hospice

                  

                	
                  
                    3

                  

                
	
                  
                    146

                  

                	
                  
                    Room
                      & Board - Private - Deluxe - Detox

                  

                	
                  
                    2

                  

                
	
                  
                    147

                  

                	
                  
                    Room
                      & Board-Private - Deluxe-Oncology

                  

                	
                  
                    3

                  

                
	
                  
                    148

                  

                	
                  
                    Room
                      & Board-Private - Deluxe-Rehab

                  

                	
                  
                    3

                  

                
	
                  
                    149

                  

                	
                  
                    Room
                      & Board-Private - Deluxe-Other

                  

                	
                  
                    3

                  

                
	
                  
                    150

                  

                	
                  
                    Room
                      & Board - Ward

                  

                	
                  
                    3

                  

                
	
                  
                    151

                  

                	
                  
                    Room
                      & Board - Ward - Med/Surg/ Gyn

                  

                	
                  
                    3

                  

                
	
                  
                    152

                  

                	
                  
                    Room
                      & Board - Ward - OB

                  

                	
                  
                    3

                  

                
	
                  
                    153

                  

                	
                  
                    Room
                      & Board - Ward - Pediatric

                  

                	
                  
                    3

                  

                
	
                  
                    154

                  

                	
                  
                    Room
                      & Board - Ward - Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    155

                  

                	
                  
                    Room
                      & Board - Ward - Hospice

                  

                	
                  
                    3

                  

                
	
                  
                    156

                  

                	
                  
                    Room
                      & Board - Ward - Detox

                  

                	
                  
                    2

                  

                
	
                  
                    157

                  

                	
                  
                    Room
                      & Board - Ward - Oncology

                  

                	
                  
                    3

                  

                
	
                  
                    158

                  

                	
                  
                    Room
                      & Board - Ward - Rehab

                  

                	
                  
                    3

                  

                
	
                  
                    159

                  

                	
                  
                    Room
                      & Board - Ward - Other

                  

                	
                  
                    3

                  

                
	
                  
                    160

                  

                	
                  
                    Other
                      Room & Board

                  

                	
                  
                    3

                  

                
	
                  
                    164

                  

                	
                  
                    Other
                      Room & Board - Sterile Environment

                  

                	
                  
                    3

                  

                
	
                  
                    167

                  

                	
                  
                    Other
                      Room & Board - Self Care

                  

                	
                  
                    3

                  

                
	
                  
                    169

                  

                	
                  
                    Other
                      Room & Board - Other

                  

                	
                  
                    3

                  

                
	
                  
                    170

                  

                	
                  
                    Room
                      & Board- Nursery

                  

                	
                  
                    3

                  

                
	
                  
                    171

                  

                	
                  
                    Room
                      & Board- Nursery - Newborn

                  

                	
                  
                    3

                  

                
	
                  
                    172

                  

                	
                  
                    Room
                      & Board- Nursery - Premature

                  

                	
                  
                    3

                  

                
	
                  
                    175

                  

                	
                  
                    Room
                      & Board- Nursery - Neonatal ICU

                  

                	
                  
                    3

                  

                
	
                  
                    179

                  

                	
                  
                    Room
                      & Board- Nursery - Other

                  

                	
                  
                    3

                  

                

        

         

        
          5/1/2007

        

        
          1
            of 11
            HUSKY A B Appendix O - BHP Master Covered Services Table
            05/01/07]

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  

          

        

        
          

          0507

        

        

        
          	 	
                  
                    HUSKY
                      A and B Appendix 0 - CT BHP Master Covered Services Table -
                      September
                      2006

                  

                	 
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO - All diagnoses

                  

                	 
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP - All diagnoses

                  

                	 
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                	 
	 	
                  
                    4=
                      Not covered

                  

                	 
	
                  
                    190

                  

                	
                  
                    Subacute
                      Care

                  

                	
                  
                    3

                  

                
	
                  
                    200

                  

                	
                  
                    Intensive
                      Care

                  

                	
                  
                    3

                  

                
	
                  
                    201

                  

                	
                  
                    Intensive
                      Care - Surgical

                  

                	
                  
                    3

                  

                
	
                  
                    202

                  

                	
                  
                    Intensive
                      Care - Medical

                  

                	
                  
                    3

                  

                
	
                  
                    203

                  

                	
                  
                    Intensive
                      Care - Pediatric

                  

                	
                  
                    3

                  

                
	
                  
                    204

                  

                	
                  
                    Intensive
                      Care - Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    205

                  

                	
                  
                    Intensive
                      Care - Post ICU

                  

                	
                  
                    3

                  

                
	
                  
                    207

                  

                	
                  
                    Intensive
                      Care - Burn Treatment

                  

                	
                  
                    3

                  

                
	
                  
                    208

                  

                	
                  
                    Intensive
                      Care - Trauma

                  

                	
                  
                    3

                  

                
	
                  
                    209

                  

                	
                  
                    Intensive
                      Care - Other

                  

                	
                  
                    3

                  

                
	
                  
                    210

                  

                	
                  
                    Coronary
                      Care

                  

                	
                  
                    3

                  

                
	
                  
                    211

                  

                	
                  
                    Coronary
                      Care - Myocardial Infarction

                  

                	
                  
                    3

                  

                
	
                  
                    212

                  

                	
                  
                    Coronary
                      Care - Pulmonary

                  

                	
                  
                    3

                  

                
	
                  
                    213

                  

                	
                  
                    Coronary
                      Care - Heart Transplant

                  

                	
                  
                    3

                  

                
	
                  
                    214

                  

                	
                  
                    Coronary
                      Care - Post CCU

                  

                	
                  
                    3

                  

                
	
                  
                    219

                  

                	
                  
                    Coronary
                      Care - Other

                  

                	
                  
                    3

                  

                
	
                  
                    224

                  

                	
                  
                    Late
                      discharge/Medically necessary

                  

                	
                  
                    4

                  

                
	 	
                  
                    Note:
                      MCOs cover alcohol detoxification on a medical
                      floor.

                  

                	 
	
                  
                    Code

                  

                	
                  
                    General
                      Hospital Emergency Department

                  

                	
                  
                    Coverage

                  

                
	
                  
                    450

                  

                	
                  
                    Emergency
                      Room General Classification

                  

                	
                  
                    1

                  

                
	
                  
                    451

                  

                	
                  
                    EMTALA
                      Emergency Medical Screening Services

                  

                	
                  
                    1

                  

                
	
                  
                    452

                  

                	
                  
                    Emergency
                      Room Beyond EMTALA Screening

                  

                	
                  
                    1

                  

                
	
                  
                    456

                  

                	
                  
                    Urgent
                      Care

                  

                	
                  
                    1

                  

                
	
                  
                    459

                  

                	
                  
                    Other
                      Emergency Room

                  

                	
                  
                    1

                  

                
	
                  
                    762

                  

                	
                  
                    Observation
                      room

                  

                	
                  
                    3

                  

                
	
                  
                    981

                  

                	
                  
                    Professional
                      Fee - Emergency Department

                  

                	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    General
                      Hospital Outpatient

                  

                	
                  
                    Coverage

                  

                
	
                  
                    490

                  

                	
                  
                    Ambulatory
                      Surgery**

                  

                	
                  
                    3

                  

                
	
                  
                    762

                  

                	
                  
                    Observation
                      room

                  

                	
                  
                    3

                  

                
	
                  
                    900

                  

                	
                  
                    Psychiatric
                      Services General (Evaluation)

                  

                	
                  
                    2

                  

                
	
                  
                    901

                  

                	
                  
                    Electroconvulsive
                      Therapy**

                  

                	
                  
                    2

                  

                
	
                  
                    905

                  

                	
                  
                    Intensive
                      Outpatient Services - Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    906

                  

                	
                  
                    Intensive
                      Outpatient Services - Chemical Dependency

                  

                	
                  
                    2

                  

                
	
                  
                    907

                  

                	
                  
                    Community
                      Behavioral Health Program (Day Treatment)

                  

                	
                  
                    2

                  

                
	
                  
                    913

                  

                	
                  
                    Partial
                      Hospital

                  

                	
                  
                    2

                  

                
	
                  
                    914

                  

                	
                  
                    Individual
                      Therapy

                  

                	
                  
                    2

                  

                
	
                  
                    915

                  

                	
                  
                    Group
                      Therapy

                  

                	
                  
                    2

                  

                
	
                  
                    916

                  

                	
                  
                    Family
                      Therapy

                  

                	
                  
                    2

                  

                
	
                  
                    918

                  

                	
                  
                    Psychiatric
                      Service - Testing

                  

                	
                  
                    3

                  

                
	
                  
                    919

                  

                	
                  
                    Other
                      - Med Admin

                  

                	
                  
                    2

                  

                
	
                  
                    961

                  

                	
                  
                    Professional
                      Fees-Psychiatric

                  

                	
                  
                    4

                  

                
	
                  
                    All
                      others

                  

                	 	
                  
                    1

                  

                
	 	
                  
                    Note:
                      Includes outpatient provided by special care hospitals (e.g.,
                      Gaylord)

                  

                	 
	 	
                  
                    "MCOs
                      pay for all professional services charges (e.g., anesthesiologist)
                      regardless of diagnosis, except psychiatrist
                      charges.

                  

                	 
	
                  
                    Code

                  

                	
                  
                    Psychiatric
                      Hospital Inpatient (includes Riverview, CVH)

                  

                	
                  
                    Coverage

                  

                
	
                  
                    100

                  

                	
                  
                    All
                      inclusive room and board plus ancillary

                  

                	
                  
                    4

                  

                
	
                  
                    124

                  

                	
                  
                    Room
                      and Board-Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    126

                  

                	
                  
                    Room
                      & Board - Semi-Private/2 Bed - Detox

                  

                	
                  
                    2

                  

                
	
                  
                    128

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed-Rehab

                  

                	
                  
                    4

                  

                
	
                  
                    190

                  

                	
                  
                    Subacute
                      Care

                  

                	
                  
                    2

                  

                
	
                  
                    224

                  

                	
                  
                    Late
                      discharge/Medically necessary

                  

                	
                  
                    4

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Psychiatric
                      Hospital Outpatient

                  

                	
                  
                    Coverage

                  

                
	
                  
                    490

                  

                	
                  
                    Ambulatory
                      Surgery**

                  

                	
                  
                    3

                  

                
	
                  
                    762

                  

                	
                  
                    Observation
                      room

                  

                	
                  
                    2

                  

                
	
                  
                    900

                  

                	
                  
                    Psychiatric
                      Services General (Evaluation)

                  

                	
                  
                    2

                  

                
	
                  
                    901

                  

                	
                  
                    Electroconvulsive
                      Therapy

                  

                	
                  
                    2

                  

                
	
                  
                    905

                  

                	
                  
                    Intensive
                      Outpatient Services ^psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    906

                  

                	
                  
                    Intensive
                      Outpatient Services - Chemical Dependency

                  

                	
                  
                    2

                  

                

        

        
           

          5/1/2007

        

        
          2
            of 11
            HUSKY A B Appendix 0 - BHP Master Covered Services Table
            05/01/07]

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  

          

        

        
          

          0507

        

        

        
          	
                  
                    HUSKY
                      A and B Appendix O - CT BHP Master Covered Services Table -
                      September
                      2006

                  

                
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO -All diagnoses

                  

                
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP -All diagnoses

                  

                
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                
	 	
                  
                    4=
                      Not covered

                  

                
	
                  
                    907

                  

                	
                  
                    Community
                      Behavioral Health Program (Day Treatment)

                  

                	
                  
                    2

                  

                
	
                  
                    913

                  

                	
                  
                    Partial
                      Hospital-More Intensive

                  

                	
                  
                    2

                  

                
	
                  
                    914

                  

                	
                  
                    Psychiatric
                      Service-Individual Therapy

                  

                	
                  
                    2

                  

                
	
                  
                    915

                  

                	
                  
                    Psychiatric
                      Service-Group Therapy

                  

                	
                  
                    2

                  

                
	
                  
                    916

                  

                	
                  
                    Psychiatric
                      Service-Family Therapy

                  

                	
                  
                    2

                  

                
	
                  
                    918

                  

                	
                  
                    Psychiatric
                      Service-Testing

                  

                	
                  
                    2

                  

                
	
                  
                    919

                  

                	
                  
                    Other-
                      Med Admin

                  

                	
                  
                    2

                  

                
	 	
                  
                    "MCOs
                      pay for all professional services charges (e.g., anesthesiologist)
                      regardless of diagnosis, except psychiatrist
                      charges.

                  

                	 
	
                  
                    Code

                  

                	
                  
                    Alcohol
                      and Drug Abuse Center (Non-hospital Inpatient Detox)

                  

                	
                  
                    Coverage

                  

                
	
                  
                    H0011

                  

                	
                  
                    Acute
                      Detoxification (residential program inpatient)

                  

                	
                  
                    2

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Alcohol
                      and Drug Abuse Center (Ambulatory Detoxification)

                  

                	
                  
                    Coverage

                  

                
	
                  
                    H0014

                  

                	
                  
                    Ambulatory
                      Detoxification

                  

                	
                  
                    2

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    PRTF

                  

                	
                  
                    Coverage

                  

                
	
                  
                    T2048

                  

                	
                  
                    Psychiatric
                      health facility service, per diem

                  

                	
                  
                    2

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    DCF
                      Residential

                  

                	
                  
                    Coverage

                  

                
	
                  
                    N/A

                  

                	
                  
                    DCF
                      Funded residential facility

                  

                	
                  
                    2

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Long
                      Term Care Facility

                  

                	
                  
                    Coverage

                  

                
	
                  
                    100

                  

                	
                  
                    Per
                      diem rate

                  

                	
                  
                    1

                  

                
	
                  
                    183

                  

                	
                  
                    Home
                      reserve

                  

                	
                  
                    1

                  

                
	
                  
                    185

                  

                	
                  
                    Inpatient
                      hospital reserve

                  

                	
                  
                    1

                  

                
	
                  
                    189

                  

                	
                  
                    Non-covered
                      reserve

                  

                	
                  
                    4

                  

                
	 	
                  
                    Note:
                      Includes inpatient at special care hospitals.

                  

                	 
	
                  
                    Code

                  

                	
                  
                    MH
                      Clinic

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90801

                  

                	
                  
                    Psychiatric
                      Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90802

                  

                	
                  
                    Interactive
                      Psychiatric Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      Psychotherapy- Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90805

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90807

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90808

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90809

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90810

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90811

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90812

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90813

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90814

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90815

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      Psychotherapy (without the patient present)

                  

                	
                  
                    2

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      Psychotherapy (conjoint psychotherapy) (with the patient
                      present)

                  

                	
                  
                    2

                  

                
	
                  
                    90849

                  

                	
                  
                    Multi-group
                      family psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90857

                  

                	
                  
                    Interactive
                      group psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90862

                  

                	
                  
                    Pharmacologic
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90887

                  

                	
                  
                    Interpretation
                      or explanation of results of psychiatric or other medical examinations
                      and
                      procedures or other accumulated data to family or other responsible
                      persons.

                  

                	
                  
                    2

                  

                
	
                  
                    96101

                  

                	
                  
                    Psychological
                      testing, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    96110

                  

                	
                  
                    Developmental
                      testing and report, limited

                  

                	
                  
                    2

                  

                
	
                  
                    96111

                  

                	
                  
                    Developmental
                      testing and report, extended

                  

                	
                  
                    2

                  

                
	
                  
                    96118

                  

                	
                  
                    Neuropsychological
                      testing battery, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    H0015

                  

                	
                  
                    Intensive
                      Outpatient-Substance Dependence*

                  

                	
                  
                    2

                  

                
	
                  
                    H0035

                  

                	
                  
                    Mental
                      health partial hospitalization, treatment, less than 24 hours
                      (CMHC)*

                  

                	
                  
                    2

                  

                
	
                  
                    H2012

                  

                	
                  
                    Extended
                      Day Treatment

                  

                	
                  
                    p*ft**

                  

                
	
                  
                    H2013

                  

                	
                  
                    Partial
                      Hospitalization (non-CMHC)*

                  

                	
                  
                    2*

                  

                

        

         

        
          5/1/2007

        

        
          3
            of 11
            HUSKY A B Appendix O - BHP Master Covered Services Table
            05/01/07]

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July
                      31,2006

                  

          

        

        
          

          0507

        

        

        
          	
                  
                    HUSKY
                      A and B Appendix O - CT BMP Master Covered Services Table -
                      September
                      2006

                  

                
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO - All diagnoses

                  

                
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BMP -All diagnoses

                  

                
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                
	 	
                  
                    4=
                      Not covered

                  

                
	
                  
                    H2019

                  

                	
                  
                    Therapeutic
                      Behavioral Services, per 15 minutes (IICAPS, MST, MDFT, FFT,
                      FST, HVS)
                      (Clients under 21 only)

                  

                	
                  
                    2***

                  

                
	
                  
                    T1017

                  

                	
                  
                    Targeted
                      case management, each 15 minutes (part of home-based services
                      only -
                      IICAPS, MST, MDFT, FFT, FST, HVS) (Clients under 21
                      only)

                  

                	
                  
                    2

                  

                
	
                  
                    J1630

                  

                	
                  
                    Jnjection,
                      Haloperidol, up to 5 mg

                  

                	
                  
                    2

                  

                
	
                  
                    J1631

                  

                	
                  
                    Injection,
                      Haloperidol decanoate, per 50 mg^

                  

                	
                  
                    2

                  

                
	
                  
                    J2680

                  

                	
                  
                    Injection,
                      Fluphenazine decanoate, up to 25 mg

                  

                	
                  
                    2

                  

                
	
                  
                    M0064

                  

                	
                  
                    Brief
                      office visit for the sole purpose of monitoring or changing
                      drug
                      prescriptions used in the treatment of mental psychoneurotic
                      and
                      personality disorders

                  

                	
                  
                    2

                  

                
	
                  
                    S9480

                  

                	
                  
                    Intensive
                      Outpatient-Mental Health

                  

                	
                  
                    2

                  

                
	
                  
                    S9484

                  

                	
                  
                    Emergency
                      mobile mental health service, follow-up (Clients under 21
                      only)

                  

                	
                  
                    o***

                  

                
	
                  
                    S9485

                  

                	
                  
                    Emergency
                      mobile mental health service, initial evaluation (Clients under
                      21
                      only)

                  

                	
                  
                    Oft**

                  

                
	
                  
                    T1016

                  

                	
                  
                    Case
                      Management - Coordination of health care services - each 15
                      min.

                  

                	
                  
                    2

                  

                
	
                  
                    H0037

                  

                	
                  
                    Community_psychiatric
                      supportive treatment program, per diem

                  

                	
                  
                    4

                  

                
	
                  
                    S9475

                  

                	
                  
                    Ambulatory
                      setting, substance abuse treatment or detoxification
                      services

                  

                	
                  
                    4

                  

                
	 	
                  
                    'Coverage
                      restricted to providers approved by DSS to provide this
                      service

                  

                	 
	 	
                  
                    ***
                      Coverage restricted to providers certified by DCF to provide
                      this
                      service

                  

                	 
	 	
                  
                    ""Coverage
                      restricted to providers licensed by DCF to provide this
                      service

                  

                	 
	 	 	 
	
                  
                    Code

                  

                	
                  
                    FQHC
                      Mental Health Clinic

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90801

                  

                	
                  
                    Psychiatric
                      Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90802

                  

                	
                  
                    Interactive
                      Psychiatric Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      Psychotherapy- Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90805

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90807

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90808

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90809

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90810

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90811

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90812

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90813

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90814

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90815

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      Psychotherapy (without the patient present)

                  

                	
                  
                    2

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      Psychotherapy (conjoint psychotherapy) (with the patient
                      present)

                  

                	
                  
                    2

                  

                
	
                  
                    90849

                  

                	
                  
                    Multi-group
                      family psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90857

                  

                	
                  
                    Interactive
                      group psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90862

                  

                	
                  
                    Pharmacologic
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90887

                  

                	
                  
                    Interpretation
                      or explanation of results of psychiatric or other medical examinations
                      and
                      procedures or other accumulated data to family or other responsible
                      persons.

                  

                	
                  
                    2

                  

                
	
                  
                    96101

                  

                	
                  
                    Psychological
                      testing, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    96110

                  

                	
                  
                    Developmental
                      testing and report, limited

                  

                	
                  
                    2

                  

                
	
                  
                    96111

                  

                	
                  
                    Developmental
                      testing and report, extended

                  

                	
                  
                    2

                  

                
	
                  
                    96118

                  

                	
                  
                    Neuropsychological
                      testing battery, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    H0015

                  

                	
                  
                    Intensive
                      Outpatient-Substance Dependence*

                  

                	
                  
                    2

                  

                
	
                  
                    H2012

                  

                	
                  
                    Extended
                      Day Treatment

                  

                	
                  
                    n****

                  

                
	
                  
                    H2013

                  

                	
                  
                    Partial
                      Hospitalization (non-CMHC)*

                  

                	
                  
                    2*

                  

                
	
                  
                    J1630

                  

                	
                  
                    Injection,
                      Haloperidol, up to 5 mg

                  

                	
                  
                    2

                  

                
	
                  
                    J1631

                  

                	
                  
                    Injection,
                      Haloperidol decanoate, per 50 mg

                  

                	
                  
                    2

                  

                
	
                  
                    J2680

                  

                	
                  
                    Injection,
                      Fluphenazine decanoate, up to 25 mg

                  

                	
                  
                    2

                  

                
	
                  
                    M0064

                  

                	
                  
                    Brief
                      office visit for the sole purpose of monitoring or changing
                      drug
                      prescriptions used in the treatment of mental psychoneurotic
                      and
                      personality disorders

                  

                	
                  
                    2

                  

                
	
                  
                    S9480

                  

                	
                  
                    Intensive
                      Outpatient-Mental Health

                  

                	
                  
                    2

                  

                
	
                  
                    S9484

                  

                	
                  
                    Emergency
                      mobile mental health service, follow-up (Clients under 21
                      only)

                  

                	
                  
                    2***

                  

                
	
                  
                    S9485

                  

                	
                  
                    Emergency
                      mobile mental health service, initial evaluation (Clients under
                      21
                      only)

                  

                	
                  
                    o***

                  

                
	
                  
                    T1015

                  

                	
                  
                    Clinic
                      visit/encounter all-inclusive (For use by FQHC MH
                      Clinics)

                  

                	
                  
                    2

                  

                

        

        
           

          5/1/2007

        

        
          4
            of 11
            HUSKY A B Appendix O - BHP Master Covered Services Table
            05/01/07]

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  

          

        

        
          

          0507

        

        

        
          	 	
                  
                    HUSKY
                      A and B Appendix O - CT BHP Master Covered Services Table -
                      September
                      2006

                  

                	 
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO - All diagnoses

                  

                	 
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP - All diagnoses

                  

                	 
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                	 
	 	
                  
                    4=
                      Not covered

                  

                	 
	
                  
                    H0037

                  

                	
                  
                    Community
                      psychiatric supportive treatment program, per diem

                  

                	
                  
                    4

                  

                
	
                  
                    S9475

                  

                	
                  
                    Ambulatory
                      setting, substance abuse treatment or detoxification
                      services

                  

                	
                  
                    4

                  

                
	 	
                  
                    'Coverage
                      restricted to providers approved by DSS to provide this
                      service

                  

                	 
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Rehabilitation
                      Clinic

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90801

                  

                	
                  
                    Psychiatric
                      Diagnostic Interview

                  

                	
                  
                    3

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      Psychotherapy- Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    3

                  

                
	
                  
                    90805

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min) with medical
                      evaluation and management services

                  

                	
                  
                    3

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    3

                  

                
	
                  
                    90807

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min) with medical
                      evaluation and management services

                  

                	
                  
                    3

                  

                
	
                  
                    90808

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min)

                  

                	
                  
                    3

                  

                
	
                  
                    90809

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min) with medical
                      evaluation and management services

                  

                	
                  
                    3

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      psychotherapy (without the patient present)

                  

                	
                  
                    3

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      psychotherapy (conjoint)

                  

                	
                  
                    3

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      psychotherapy

                  

                	
                  
                    3

                  

                
	
                  
                    90857

                  

                	
                  
                    Interactive
                      Group therapy

                  

                	
                  
                    3

                  

                
	
                  
                    96118

                  

                	
                  
                    Neuropsychological
                      testing battery, per hour

                  

                	
                  
                    3

                  

                
	
                  
                    All
                      others

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    School-Based
                      Health Centers (Freestanding Medical Clinic)

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90782

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; subcutaneous or
                      intramuscular

                  

                	
                  
                    1

                  

                
	
                  
                    90783

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; intra-arterial

                  

                	
                  
                    1

                  

                
	
                  
                    90784

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; intravenous

                  

                	
                  
                    1

                  

                
	
                  
                    90801

                  

                	
                  
                    Psychiatric
                      Diagnostic Interview

                  

                	
                  
                    3

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      psychotherapy (20-30 min)

                  

                	
                  
                    3

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      psychotherapy (without the patient present)

                  

                	
                  
                    3

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      psychotherapy (conjoint psychotherapy w/patient
                      present)

                  

                	
                  
                    3

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      psychotherapy (other than of a multiple-family
                      group)

                  

                	
                  
                    3

                  

                
	
                  
                    99211

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, that may not require the presence of a
                      physician.
                      (Typically 5 minutes)

                  

                	
                  
                    1

                  

                
	
                  
                    99212

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: problem focused history; problem focused examination;
                      straightforward medical decision-making. (Typically 10 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99213

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: expanded problem focused history; expanded problem
                      focused
                      examination; medical decision making of low complexity. (Typically
                      15
                      minutes face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99214

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: detailed history; detailed examination; medical
                      decision
                      making of moderate complexity (Typically 25 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99215

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: comprehensive history; comprehensive examination;
                      medical
                      decision making of high complexity (Typically 40 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    All
                      others

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    School-Based
                      Health Centers (FQHC Medical Clinic)

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90782

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; subcutaneous or
                      intramuscular

                  

                	
                  
                    1

                  

                
	
                  
                    90783

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; intra-arterial

                  

                	
                  
                    1

                  

                
	
                  
                    90784

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; intravenous

                  

                	
                  
                    1

                  

                
	
                  
                    90801

                  

                	
                  
                    Psychiatric
                      Diagnostic Interview

                  

                	
                  
                    3

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      psychotherapy (20-30 min)

                  

                	
                  
                    3

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      psychotherapy (without the patient present)

                  

                	
                  
                    3

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      psychotherapy (conjoint psychotherapy w/patient
                      present)

                  

                	
                  
                    3

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      psychotherapy (other than of a multiple-family
                      group)

                  

                	
                  
                    3

                  

                
	
                  
                    T1015

                  

                	
                  
                    Clinic
                      visit/encounter all-inclusive (For use by FQHC
                      Clinics)

                  

                	
                  
                    2

                  

                
	
                  
                    99211

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, that may not require the presence of a
                      physician.
                      (Typically 5 minutes)

                  

                	
                  
                    1

                  

                

        

        
          5/1/2007

        

        
          

          5
            of 11
            HUSKY A B Appendix O - BHP Master Covered Services Table
            05/01/07]

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  

          

        

        
          

          0507

        

        

        
          	
                  
                    HUSKY
                      A and B Appendix O - CT BHP Master Covered Services Table -
                      September
                      2006

                  

                
	
                  
                    Coverage

                  

                	
                  
                    1
                      =
                      HUSKY MCO - All diagnoses

                  

                
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP - All diagnoses

                  

                
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                
	 	
                  
                    4=
                      Not covered

                  

                
	
                  
                    99212

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: problem focused history; problem focused examination;
                      straightforward medical decision-making. (Typically 10 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99213

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: expanded problem focused history; expanded problem
                      focused
                      examination; medical decision making of low complexity. (Typically
                      15
                      minutes face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99214

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: detailed history; detailed examination; medical
                      decision
                      making of moderate complexity (Typically 25 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99215

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: comprehensive history; comprehensive examination;
                      medical
                      decision making of high complexity (Typically 40 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    All
                      others

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Methadone
                      Clinic

                  

                	
                  
                    Coverage

                  

                
	
                  
                    H0020

                  

                	
                  
                    Methadone
                      service; rate includes all services for which the source of
                      service is the
                      methadone maintenance clinic.

                  

                	
                  
                    2

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    MD,
                      DO and APRN other than Psychiatrist or Psychiatric
                      APRN

                  

                	
                  
                    Coverage

                  

                
	
                  
                    00104

                  

                	
                  
                    Anesthesia
                      for electroconvulsive therapy

                  

                	
                  
                    1

                  

                
	
                  
                    80100

                  

                	
                  
                    Drug
                      screen, qualitative, chromatographic method, each
                      procedure

                  

                	
                  
                    1

                  

                
	
                  
                    81000

                  

                	
                  
                    Urinalysis,
                      by dip stick or tablet reagent, non-automated, with
                      microscopy

                  

                	
                  
                    1

                  

                
	
                  
                    83840

                  

                	
                  
                    Methadone
                      chemistry (quantitative analysis)

                  

                	
                  
                    1

                  

                
	
                  
                    90782

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; subcutaneous or
                      intramuscular

                  

                	
                  
                    1

                  

                
	
                  
                    90783

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; intra-arterial

                  

                	
                  
                    1

                  

                
	
                  
                    90784

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; intravenous

                  

                	
                  
                    1

                  

                
	
                  
                    908XX

                  

                	
                  
                    Psychotherapy
                      codes

                  

                	
                  
                    4

                  

                
	
                  
                    99211

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, that may not require the presence of a
                      physician.
                      (Typically 5 minutes)

                  

                	
                  
                    1

                  

                
	
                  
                    99212

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: problem focused history; problem focused examination;
                      straightforward medical decision making (Typically 10 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99213

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: expanded problem focused history; expanded problem
                      focused
                      examination; medical decision making of low complexity. (Typically
                      15
                      minutes face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99214

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: detailed history; detailed examination; medical
                      decision
                      making of moderate complexity (Typically 25 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99215

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: comprehensive history; comprehensive examination;
                      medical
                      decision making of high complexity (Typically 40 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    All
                      others

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Psychiatrist
                      (MD or DO)

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90801

                  

                	
                  
                    Diagnostic
                      Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90802

                  

                	
                  
                    Interactive
                      Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90805

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90807

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90808

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90809

                  

                	
                  
                    Individual
                      PsychotherapyjOffice or other Outpatient (75-80 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90810

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90811

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90812

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90813

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90814

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90815

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                

        

        
          5/1/2007

        

        
          

          6
            of 11
            HUSKY A B Appendix O - BHP Master Covered Services Table
            05/01/07]

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  

          

        

        
          

          0507

        

        

        
          	 	
                  
                    HUSKY
                      A and B Apjoejrdixjg^CT BMP Master Covered Services Table -
                      September
                      2006

                  

                	 
	
                  
                    Coverage

                  

                	
                  
                    1
                      =
                      HUSKY MCO - All diagnoses

                  

                	 
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP- All diagnoses

                  

                	 
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                	 
	 	
                  
                    4=
                      Not covered

                  

                	 
	
                  
                    90816

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90817

                  

                	
                  
                    90816
                      with medical evaluation and management

                  

                	
                  
                    2

                  

                
	
                  
                    90818

                  

                	
                  
                    Individual
                      psychotherapy, insight oriented 45-50 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    90819

                  

                	
                  
                    90818
                      with medical evaluation and management

                  

                	
                  
                    2

                  

                
	
                  
                    90821

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90822

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (75-80 min) with med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90823

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90824

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (20-30 min) med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90826

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90827

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (45-50 min) med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90828

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90829

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (75-80 min) med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      Psychotherapy (without the patient present)

                  

                	
                  
                    2

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      Psychotherapy (conjoint)

                  

                	
                  
                    2

                  

                
	
                  
                    90849

                  

                	
                  
                    Multi-group
                      family psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      Psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90857

                  

                	
                  
                    Interactive
                      Group psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90862

                  

                	
                  
                    Pharmacological
                      management, including prescription, use, and review of medication
                      with no
                      more than minimal medical psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90865

                  

                	
                  
                    Narcosynthesis
                      for Psychiatric Diagnostic and Therapeutic purposes

                  

                	
                  
                    2

                  

                
	
                  
                    90870

                  

                	
                  
                    Electroconvulsive
                      therapy (including necessary monitoring); single
                      seizure

                  

                	
                  
                    2

                  

                
	
                  
                    90875

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90876

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90880

                  

                	
                  
                    Hypnotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90887

                  

                	
                  
                    Interpretation
                      or explanation of results of psychiatric or other medical examinations
                      and
                      procedures or other accumulated data to family or other responsible
                      persons.

                  

                	
                  
                    2

                  

                
	
                  
                    96101

                  

                	
                  
                    Psychological
                      testing, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    96110

                  

                	
                  
                    Developmental
                      testing with report

                  

                	
                  
                    2

                  

                
	
                  
                    96111

                  

                	
                  
                    Developmental
                      testing, extended

                  

                	
                  
                    2

                  

                
	
                  
                    96118

                  

                	
                  
                    Neuropsychological
                      testing battery, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    99201

                  

                	
                  
                    Office
                      or other outpatient visit, 10 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99202

                  

                	
                  
                    Office
                      or other outpatient visit, 20 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99203

                  

                	
                  
                    Office
                      or other outpatient visit, 30 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99204

                  

                	
                  
                    Office
                      or other outpatient visit, 45 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99205

                  

                	
                  
                    Office
                      or other outpatient visit, 60 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99211

                  

                	
                  
                    Office
                      or other outpatient visit, 5 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99212

                  

                	
                  
                    Office
                      or other outpatient visit, 10 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99213

                  

                	
                  
                    Office
                      or other outpatient visit, 15 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99214

                  

                	
                  
                    Office
                      or other outpatient visit, 25 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99215

                  

                	
                  
                    Office
                      or other outpatient visit, 40 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99217

                  

                	
                  
                    Observation
                      care discharge

                  

                	
                  
                    2

                  

                
	
                  
                    99218

                  

                	
                  
                    Initial
                      observation care, low severity

                  

                	
                  
                    2

                  

                
	
                  
                    99219

                  

                	
                  
                    Initial
                      observation care, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99220

                  

                	
                  
                    Initial
                      observation care, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99221

                  

                	
                  
                    Inpatient
                      hospital care, 30 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99222

                  

                	
                  
                    Inpatient
                      hospital care, 50 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99223

                  

                	
                  
                    Inpatient
                      hospital care, 70 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99231

                  

                	
                  
                    Subsequent
                      hospital care, 15 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99232

                  

                	
                  
                    Subsequent
                      hospital care, 25 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99233

                  

                	
                  
                    Subsequent
                      hospital care, 35 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99234

                  

                	
                  
                    Observation
                      of inpatient hospital care, low severity

                  

                	
                  
                    2

                  

                
	
                  
                    99235

                  

                	
                  
                    Observation
                      of inpatient hospital care, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99236

                  

                	
                  
                    Observation
                      of inpatient hospital care, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99238

                  

                	
                  
                    Hospital
                      discharge day management 30 minutes or less

                  

                	
                  
                    2

                  

                
	
                  
                    99239

                  

                	
                  
                    Hospital
                      discharge day management more than 30 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99241

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      15
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99242

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      30
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99243

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      40
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99244

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      60
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99245

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      80
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99251

                  

                	
                  
                    Initial
                      inpatient consultation, 20 minutes

                  

                	
                  
                    2

                  

                

        

        

        
          

          5/1/2007

        

        
          

          7
            of 11
            HUSKY A B Appendix O - BHP Master Covered Services Table
            05/01/07]

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  

          

        

        
          

          0507

        

        

        
          	 	
                  
                    HUSKY
                      A and B Appendix 0 - CT BHP Master Covered Services Table -
                      September
                      2006

                  

                	 
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO - All diagnoses

                  

                	 
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP - All diagnoses

                  

                	 
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                	 
	 	
                  
                    4=
                      Not covered

                  

                	 
	
                  
                    99252

                  

                	
                  
                    Initial
                      inpatient consultation, 40 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99253

                  

                	
                  
                    Initial
                      inpatient consultation, 55 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99254

                  

                	
                  
                    Initial
                      inpatient consultation, 80 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99255

                  

                	
                  
                    Initial
                      inpatient consultation, 110 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99271

                  

                	
                  
                    Confirmatory
                      consultation, limited or minor

                  

                	
                  
                    2

                  

                
	
                  
                    99272

                  

                	
                  
                    Confirmatory
                      consultation, low severity

                  

                	
                  
                    2

                  

                
	
                  
                    99273

                  

                	
                  
                    Confirmatory
                      consultation, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99274

                  

                	
                  
                    Confirmatoryjjonsultation,
                      moderate to high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99275

                  

                	
                  
                    Confirmatory
                      consultation, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99281

                  

                	
                  
                    Emergency
                      department visit, minor severity

                  

                	
                  
                    2

                  

                
	
                  
                    99282

                  

                	
                  
                    Emergency
                      department visit, low to moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99283

                  

                	
                  
                    Emergency
                      department visit, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99284

                  

                	
                  
                    Emergency
                      department visit, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99285

                  

                	
                  
                    Emergency
                      department visit, high severity with significant
                      threat

                  

                	
                  
                    2

                  

                
	
                  
                    J1630

                  

                	
                  
                    Injection,
                      Haloperidol, up to 5 mg

                  

                	
                  
                    2

                  

                
	
                  
                    J1631

                  

                	
                  
                    Injection,
                      Haloperidol decanoate, per 50 mg

                  

                	
                  
                    2

                  

                
	
                  
                    J2680

                  

                	
                  
                    Injection,
                      Fluphenazine decanoate, up to 25 mg

                  

                	
                  
                    2

                  

                
	
                  
                    M0064

                  

                	
                  
                    Brief
                      office visit for the sole purpose of monitoring or changing
                      prescriptions
                      used in the treatment of mental psychoneurotic or personality
                      disorders

                  

                	
                  
                    2

                  

                
	
                  
                    T1016

                  

                	
                  
                    Case
                      Management - Coordination of health care services - each 15
                      min.

                  

                	
                  
                    2

                  

                
	
                  
                    All
                      others

                  

                	 	
                  
                    4

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Psychiatric
                      APRN

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90801

                  

                	
                  
                    Diagnostic
                      Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90802

                  

                	
                  
                    Interactive
                      Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90805

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90807

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90808

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90809

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90810

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90811

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90812

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90813

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90814

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90815

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90816

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90817

                  

                	
                  
                    90816
                      with medical evaluation and management

                  

                	
                  
                    2

                  

                
	
                  
                    90818

                  

                	
                  
                    Individual
                      psychotherapy, insight oriented 45-50 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    90819

                  

                	
                  
                    90818
                      with medical evaluation and management

                  

                	
                  
                    2

                  

                
	
                  
                    90821

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90822

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (75-80 min) with med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90823

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90824

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (20-30 min) med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90826

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90827

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (45-50 min) med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90828

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90829

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (75-80 min) med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      Psychotherapy (without the patient present)

                  

                	
                  
                    2

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      Psychotherapy (conjoint)

                  

                	
                  
                    2

                  

                
	
                  
                    90849

                  

                	
                  
                    Multi-group
                      family psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      Psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90857

                  

                	
                  
                    Interactive
                      Group psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90862

                  

                	
                  
                    Pharmacological
                      management, including prescription, use, and review of medication
                      with no
                      more than minimal medical psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90865

                  

                	
                  
                    Narcosynthesis
                      for Psychiatric Diagnostic and Therapeutic purposes

                  

                	
                  
                    2

                  

                

        

        
          5/1/2007

        

        
          

          8
            of 11
            HUSKY A B Appendix 0 - BHP Master Covered Services Table
            05/01/07]

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July
                      31,2006

                  

          

        

        
          

          0507

        

        

        
          	 	
                  
                    HUSKY
                      A and B Appendix O - CT BHP Master Covered Services Table -
                      September
                      2006

                  

                	 
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO - All diagnoses

                  

                	 
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP - All diagnoses

                  

                	 
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                	 
	 	
                  
                    4=
                      Not covered

                  

                	 
	
                  
                    90870

                  

                	
                  
                    Electroconvulsive
                      therapy (including necessary monitoring); single
                      seizure

                  

                	
                  
                    2

                  

                
	
                  
                    90875

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90876

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90880

                  

                	
                  
                    Hypnotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90887

                  

                	
                  
                    Interpretation
                      or explanation of results of psychiatric or other medical examinations
                      and
                      procedures or other accumulated data to family or other responsible
                      persons.

                  

                	
                  
                    2

                  

                
	
                  
                    96101

                  

                	
                  
                    Psychological
                      testing, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    96110

                  

                	
                  
                    Developmental
                      testing with report

                  

                	
                  
                    2

                  

                
	
                  
                    96111

                  

                	
                  
                    Developmental
                      testing, extended

                  

                	
                  
                    2

                  

                
	
                  
                    96118

                  

                	
                  
                    Neuropsychological
                      testing battery, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    99201

                  

                	
                  
                    Office
                      or other outpatient visit, 10 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99202

                  

                	
                  
                    Office
                      or other outpatient visit, 20 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99203

                  

                	
                  
                    Office
                      or other outpatient visit, 30 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99204

                  

                	
                  
                    Office
                      or other outpatient visit, 45 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99205

                  

                	
                  
                    Office
                      or other outpatient visit, 60 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99211

                  

                	
                  
                    Office
                      or other outpatient visit, 5 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99212

                  

                	
                  
                    Office
                      or other outpatient visit, 10 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99213

                  

                	
                  
                    Office
                      or other outpatient visit, 15 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99214

                  

                	
                  
                    Office
                      or other outpatient visit, 25 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99215

                  

                	
                  
                    Office
                      or other outpatient visit, 40 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99217

                  

                	
                  
                    Observation
                      care discharge

                  

                	
                  
                    2

                  

                
	
                  
                    99218

                  

                	
                  
                    Initial
                      observation care, low severity

                  

                	
                  
                    2

                  

                
	
                  
                    99219

                  

                	
                  
                    Initial
                      observation care, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99220

                  

                	
                  
                    Initial
                      observation care, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99221

                  

                	
                  
                    Inpatient
                      hospital care, 30 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99222

                  

                	
                  
                    Inpatient
                      hospital care, 50 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99223

                  

                	
                  
                    Inpatient
                      hospital care, 70 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99231

                  

                	
                  
                    Subsequent
                      hospital care, 15 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99232

                  

                	
                  
                    Subsequent
                      hospital care, 25 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99233

                  

                	
                  
                    Subsequent
                      hospital care, 35 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99234

                  

                	
                  
                    Observation
                      of inpatient hospital care, low severity

                  

                	
                  
                    2

                  

                
	
                  
                    99235

                  

                	
                  
                    Observation
                      of inpatient hospital care, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99236

                  

                	
                  
                    Observation
                      of inpatient hospital care, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99238

                  

                	
                  
                    Hospital
                      discharge day management 30 minutes or less

                  

                	
                  
                    2

                  

                
	
                  
                    99239

                  

                	
                  
                    Hospital
                      discharge day management more than 30 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99241

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      15
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99242

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      30
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99243

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      40
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99244

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      60
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99245

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      80
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99251

                  

                	
                  
                    Initial
                      inpatient consultation, 20 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99252

                  

                	
                  
                    Initial
                      inpatient consultation, 40 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99253

                  

                	
                  
                    Initial
                      inpatient consultation, 55 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99254

                  

                	
                  
                    Initial
                      inpatient consultation, 80 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99255

                  

                	
                  
                    Initial
                      inpatient consultation, 110 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99271

                  

                	
                  
                    Confirmatory
                      consultation, limited or minor

                  

                	
                  
                    2

                  

                
	
                  
                    99272

                  

                	
                  
                    Confirmatory
                      consultation, low severity

                  

                	
                  
                    2

                  

                
	
                  
                    99273

                  

                	
                  
                    Confirmatory
                      consultation, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99274

                  

                	
                  
                    Confirmatory
                      consultation, moderate to high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99275

                  

                	
                  
                    Confirmatory
                      consultation, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99281

                  

                	
                  
                    Emergency
                      department visit, minor severity

                  

                	
                  
                    2

                  

                
	
                  
                    99282

                  

                	
                  
                    Emergency
                      department visit, low to moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99283

                  

                	
                  
                    Emergency
                      department visit, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99284

                  

                	
                  
                    Emergency
                      department visit, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99285

                  

                	
                  
                    Emergency
                      department visit, high severity with significant
                      threat

                  

                	
                  
                    2

                  

                
	
                  
                    J1630

                  

                	
                  
                    Injection,
                      Haloperidol, up to 5 mg

                  

                	
                  
                    2

                  

                
	
                  
                    J1631

                  

                	
                  
                    Injection,
                      Haloperidol decanoate, per 50 mg

                  

                	
                  
                    2

                  

                
	
                  
                    J2680

                  

                	
                  
                    Injection,
                      Fluphenazine decanoate, up to 25 mg

                  

                	
                  
                    2

                  

                
	
                  
                    M0064

                  

                	
                  
                    Brief
                      office visit for the sole purpose of monitoring or changing
                      prescriptions
                      used in the treatment of mental psychoneurotic or personality
                      disorders

                  

                	
                  
                    2

                  

                
	
                  
                    T1016

                  

                	
                  
                    Case
                      Management - Coordination of health care services - each 15
                      min.

                  

                	
                  
                    2

                  

                

        

        
          5/1/2007

        

        
          

          9
            of 11
            HUSKY A B Appendix O - BHP Master Covered Services Table
            05/01/07]

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  

          

        

        
          

          0507

        

        

        
          	
                  
                    HUSKY
                      A and B Appendix O;- CT BMP Master Covered Services
                      Table

                  

                	
                  
                    -
                      September 2006

                  

                
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO - All diagnoses

                  

                
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BMP - All diagnoses

                  

                
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BMP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                	 
	 	
                  
                    4=
                      Not covered

                  

                	 
	
                  
                    All
                      others

                  

                	 	
                  
                    4

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Psychologist
                      and Psychologist Group

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90801

                  

                	
                  
                    Diagnostic
                      Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90802

                  

                	
                  
                    Interactive
                      Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90808

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90810

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90812

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90814

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90816

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90818

                  

                	
                  
                    Individual
                      psychotherapy, insight oriented 45-50 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    90821

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90823

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90826

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90828

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      Psychotherapy (without the patient present)

                  

                	
                  
                    2

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      Psychotherapy (conjoint)

                  

                	
                  
                    2

                  

                
	
                  
                    90849

                  

                	
                  
                    Multi-group
                      family psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      Psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90857

                  

                	
                  
                    Interactive
                      Group psychotherapy

                  

                	 	
                  
                    2

                  

                
	
                  
                    90875

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (20-30

                  

                	
                  
                    min)

                  

                	
                  
                    2

                  

                
	
                  
                    90876

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (45-50

                  

                	
                  
                    min)

                  

                	
                  
                    2

                  

                
	
                  
                    90880

                  

                	
                  
                    Hypnotherapy

                  

                	 	
                  
                    2

                  

                
	
                  
                    90887

                  

                	
                  
                    Interpretation
                      or explanation of results of psychiatric or other medical examinations
                      and
                      procedures or other accumulated data to family or other responsible
                      persons. .

                  

                	
                  
                    2

                  

                
	
                  
                    96101

                  

                	
                  
                    Psychological
                      testing, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    96110

                  

                	
                  
                    Developmental
                      testing with report

                  

                	
                  
                    2

                  

                
	
                  
                    96111

                  

                	
                  
                    Developmental
                      testing, extended

                  

                	
                  
                    2

                  

                
	
                  
                    96118

                  

                	
                  
                    Neuropsychological
                      testing battery, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    T1016

                  

                	
                  
                    Case
                      Management - Coordination of health care services - each 15
                      min.

                  

                	
                  
                    2

                  

                
	 	 	 
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Independent
                      Practice Behavioral Health Professional (LCSW, LMFT, LPC,
                      LADC)

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90801

                  

                	
                  
                    Diagnostic
                      Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90802

                  

                	
                  
                    Interactive
                      Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90808

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90810

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90812

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90814

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90816

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90818

                  

                	
                  
                    Individual
                      psychotherapy, insight oriented 45-50 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    90821

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90823

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90826

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90828

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      Psychotherapy (without the patient present)

                  

                	
                  
                    2

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      Psychotherapy (conjoint)

                  

                	
                  
                    2

                  

                
	
                  
                    90849

                  

                	
                  
                    Multi-group
                      family psychotherapy

                  

                	 	
                  
                    2

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      Psychotherapy

                  

                	 	
                  
                    2

                  

                
	
                  
                    90857

                  

                	
                  
                    Interactive
                      Group psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90875

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (20-30

                  

                	
                  
                    min)

                  

                	
                  
                    2

                  

                
	
                  
                    90876

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (45-50

                  

                	
                  
                    min)

                  

                	
                  
                    2

                  

                
	
                  
                    90880

                  

                	
                  
                    Hypnotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90887

                  

                	
                  
                    Interpretation
                      or explanation of results of psychiatric or other medical examinations
                      and
                      procedures or other accumulated data to family or other responsible
                      persons.

                  

                	
                  
                    2

                  

                
	
                  
                    96110

                  

                	
                  
                    Developmental
                      testing with report

                  

                	
                  
                    2

                  

                

        

        
          5/1/2007

        

        
          

          10
            of 11
            HUSKY A B Appendix O - BMP Master Covered Services Table
            05/01/07]

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        

        
          

          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  

          

        

        
          

          0507

        

        

        
          	 	
                  
                    HUSKY
                      A and B Appendix O - CT BMP Master Covered Services Table -
                      September
                      2006

                  

                	 
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO - All diagnoses

                  

                	 
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BMP - All diagnoses

                  

                	 
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BMP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                	 
	 	
                  
                    4=
                      Not covered

                  

                	 
	
                  
                    96111

                  

                	
                  
                    Developmental
                      testing, extended

                  

                	
                  
                    2

                  

                
	
                  
                    T1016

                  

                	
                  
                    Case
                      Management - Coordination of health care services - each 15
                      min.

                  

                	
                  
                    2

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Home
                      Health Care Agencies

                  

                	
                  
                    Coverage

                  

                
	
                  
                    RCC/HCPC

                  

                	 	 
	
                  
                    421

                  

                	
                  
                    Physical
                      Therapy

                  

                	
                  
                    1

                  

                
	
                  
                    424

                  

                	
                  
                    Physical
                      Therapy Evaluation

                  

                	
                  
                    1

                  

                
	
                  
                    431

                  

                	
                  
                    Occupational
                      Therapy

                  

                	
                  
                    1

                  

                
	
                  
                    434

                  

                	
                  
                    Occupational
                      Therapy Evaluation

                  

                	
                  
                    1

                  

                
	
                  
                    441

                  

                	
                  
                    Speech
                      Therapy

                  

                	
                  
                    1

                  

                
	
                  
                    444

                  

                	
                  
                    Speech
                      Therapy Evaluation

                  

                	
                  
                    1

                  

                
	
                  
                    570/T1004

                  

                	
                  
                    Services
                      of a qualified nursing aide, up to 15 minutes

                  

                	
                  
                    3

                  

                
	
                  
                    580/S9123

                  

                	
                  
                    Nursing
                      care, in the home by an RN, per hour

                  

                	
                  
                    3

                  

                
	
                  
                    580/S9124

                  

                	
                  
                    Nursing
                      Care, in the home by an LPN, per hour

                  

                	
                  
                    3

                  

                
	
                  
                    580/T1001

                  

                	
                  
                    Nursing
                      Assessment/Evaluation

                  

                	
                  
                    3

                  

                
	
                  
                    580/T1002

                  

                	
                  
                    RN
                      Services, up to 15 minutes

                  

                	
                  
                    3

                  

                
	
                  
                    580/T1003

                  

                	
                  
                    LPN/LVN
                      services, up to 15 minutes

                  

                	
                  
                    3

                  

                
	
                  
                    580/T1502

                  

                	
                  
                    Administration
                      of oral, intramuscular and/or subcutaneous medication by health
                      care
                      agency/professional, per visit

                  

                	
                  
                    3

                  

                
	 	
                  
                    *BHP
                      covers home health services for children with autism including
                      when autism
                      is co-morbid with mental retardation.

                  

                	 
	
                  
                    Code

                  

                	
                  
                    Independent
                      Occupational Therapist

                  

                	
                  
                    Coverage

                  

                
	
                  
                    All
                      codes

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Independent
                      Physical Therapist

                  

                	
                  
                    Coverage

                  

                
	
                  
                    All
                      codes

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Medical
                      Transportation

                  

                	
                  
                    Coverage

                  

                
	
                  
                    All
                      codes

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Emergency
                      Medical Transportation

                  

                	
                  
                    Coverage

                  

                
	
                  
                    All
                      codes

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Independent
                      Laboratory Services

                  

                	
                  
                    Coverage

                  

                
	
                  
                    80100

                  

                	
                  
                    Drug
                      screen, qualitative, chromatographic method, each
                      procedure

                  

                	
                  
                    1

                  

                
	
                  
                    81000

                  

                	
                  
                    Urinalysis,
                      by dip stick or tablet reagent, non-automated, with
                      microscopy

                  

                	
                  
                    1

                  

                
	
                  
                    83840

                  

                	
                  
                    Methadone
                      chemistry (quantitative analysis)

                  

                	
                  
                    1

                  

                
	
                  
                    All
                      other codes

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Pharmacy

                  

                	
                  
                    Coverage

                  

                
	
                  
                    All
                      codes

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Other
                      Community Services

                  

                	
                  
                    Coverage

                  

                
	
                  
                    H2017

                  

                	
                  
                    Psychosocial
                      Rehabilitation services, per 15 minutes

                  

                	 
	
                  
                    H2019

                  

                	
                  
                    Therapeutic
                      Behavioral Services, per 15 minutes (IICAPS, MST, MDFT, FFT,
                      FST, HBV)
                      (Clients under 21 only)

                  

                	
                  
                    2

                  

                
	
                  
                    T1017

                  

                	
                  
                    Targeted
                      case management, each 15 minutes (part of home-based services
                      only -
                      IICAPS, MST, MDFT, FFT, FST, HBV) (Clients under 21
                      only)

                  

                	
                  
                    2***

                  

                
	
                  
                    H2032

                  

                	
                  
                    Activity
                      Therapy, per 15 minutes (Therapeutic Mentoring/Behavioral Management
                      Service) (Clients under 21 only)

                  

                	
                  
                    2***

                  

                
	 	
                  
                    "'Coverage
                      restricted to providers certified by DCF to provide this
                      service

                  

                	 
	 	
                  
                    ""Coverage
                      restricted to providers licensed by DCF to provide this
                      service

                  

                	 

        

        
          5/1/2007

        

        
          

          11
            of 11
            HUSKY A B Appendix 0 - BHP Master Covered Services Table
            05/01/07]

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00127-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00127-of-00352.parquet"}]]