3-13-2 Prevention 3-14 Grievances and Complaints 3-15 Indemnification 3-16 Insurance 3-17 Lobbying Disclosure 3-18 Medical Records Requirements 3-19 Membership and Marketing Materials 3-19-1 Use of FHKC and Florida KidCare Marketing Materials 3-19-2 Requirements for Member Materials 3-20 Notification Requirements 3-21 Premium Rate Provisions 3-21-1 Premium Rate 3-21-2 Additional Requirements for Premium 3-21-3 Experience Adjustment 3-21-4 Annual Experience Adjustment Reporting Requirements 3-21-5 Quarterly Medical Loss Ratio Reporting Requirements 3-22 Premium Rate Modifications 3-22-1 Annual Adjustment Request 3-22-2 Annual Premium Rate Adjustment Denials 3-22-3 Change in Benefit Schedule 3-22-4 Specialty Fee Arrangements 3-23 Program Integrity 3-23-1 Excluded Providers 3-23-2 Physician Identifiers – National Provider Identifier (NPI) 3-23-3 Conflict of Interest Safeguards 3-24 Quality Management 3-24-1 Quality Improvement Plans 3-24-2 Quality Improvement Plan Committee 3-24-3 External Quality Review 3-25 Records Retention and Accessibility 3-26 Refusal of Coverage 3-27 Regulatory Filings 3-28 Reporting Requirements 3-29 Subrogation Rights 3-30 Termination of Participation 3-31 Use of Subcontractors and Affiliates 3-32 Reimbursement Requirements 3-32-1 Out of Network Providers 3-32-2 Reimbursement to Federally Qualified Health Centers and Health Clinics 3-33 Performance Standards SECTION 4 TERMS AND CONDITIONS 4-1 Amendment 4-2 Assignment 4-3 Attachments 4-4 Attorney Fees 4-5 Bankruptcy 4-6 Change of Controlling Interest 4-7 Confidentiality 4-8 Conflicts of Interest; Non-Solicitation 4-8-1 Conflicts of Interest
Contact’s Email: Contact’s Telephone No: Business Associate hereby notifies FHKC that there has been a Breach of Unsecured (unencrypted) Protected Health Information that Business Associate has used or has had access to under the terms of the Business Associate Agreement, as described in detail below: Breach Detail Date of Breach Date of Discovery of Breach Information about the Breach Type of Breach: Lost or stolen laptop, computer, flash drive, disk, etc. Stolen password or credentials Unauthorized access by an employee or contractor Unauthorized access by an outsider Other (describe) Detailed Description of the Breach Types of Unsecured Protected Health Information involved in the breach (such as Full Name, SSN, Date of Birth, Address, Account Number, Disability Code, etc). Personal Information: Name Address Date of birth Social Security number Drivers license or identification card number Financial insurance information (credit card number, bank account number, etc) Health insurance information (insurance carrier, insurance card number, etc) Other Personal or Health Information (describe): Health Information: Basic information (age, sex, height, etc) Disease or medical conditions Medications Treatments or procedures Immunizations Allergies Information about children Test results Hereditary conditions Mental health information Information about diet, exercise, weight, etc) Correspondence between patient, or medical power of attorney
I. Home Health Services Includes prescribed home visits by both registered and licensed practical nurses to provide skilled nursing services on a part-time intermittent basis. Coverage is limited to skilled nursing services only. housekeeping and personal comfort items are excluded. Services must be provided directly by INSURER. Private duty nursing is limited to circumstances such care is medically appropriate. Five dollars ($5.00) per J. Hospice Services Covered services include reasonable and necessary services for palliation or management of an Enrollee’s terminal illness. Services required for conditions totally unrelated to the terminal condition are covered to the extent that such services are otherwise covered under this contract. Five dollars ($5.00) per visit. K. Nursing Facility Services Covered services include regular nursing services, rehabilitation services, drugs and biologicals, medical supplies, and the use of appliances and equipment furnished by the facility. All admissions must be authorized by INSURER and provided by an INSURER affiliated facility. Participant must require and receive skilled services on a daily basis as ordered by an INSURER physician. The length of the Enrollee’s stay shall be determined by the medical condition of the Enrollee in relation to the necessary and appropriate level of care, but may be no more than one hundred (100) days per contract year. Room and board is limited to semi-private accommodations unless a private room is considered medically necessary or semi-private accommodations are not available. Specialized treatment centers and independent kidney disease treatment centers are excluded. Private duty nurses, television, and custodial care are excluded .Admissions for rehabilitation and physical therapy are limited to fifteen (15) days per contract year. NONE L. Durable Medical Equipment and Prosthetic Devices Equipment and devices that are medically indicated to assist in the treatment of a medical condition and specifically prescribed as medically necessary by Enrollee’s INSURER physician. Equipment and devices must be provided by authorized INSURER supplier. Covered prosthetic devices include artificial eyes, braces and other artificial aids. Low vision and telescopic lenses are not included. Hearing aids are covered only when medically indicated to assist in the treatment of a medical condition. NONE
Fraud and Abuse Preventions (Section 3-13) Changes of Notice and Contract Contact (Section Listing of Subcontractors and affiliates (Section Quality Improvement Plan (Section 3-24) Changes to Conflicts of Interest Disclosure Form (Section 4-8) (Section 3-23-3) Attachment F Member materials (Section 3-19-2) Cultural Competency Plan (Section 3-19) Regulatory Filings (Section 3-27) Proof of insurance coverage (3-16) Grievance Process (Section 3-14) Fraud and Abuse Preventions (Section 3-13) List of Subcontractors and Affiliates (Section (3-31) Quality Improvement Plan (Section 3-24-1) Cultural Competency Plan (Section 3-19) Updated Conflict of Interest Form Attachment F (Section 3-23-3) (Section 4-8) ATTACHMENT F – DISCLOSURE FORM