Enrollees’ right to be free from restraint or seclusion used as a means of coercion or retaliation; The provision of Culturally and Linguistically Appropriate Services; Practice guidelines in quality measurement and improvement activities; Compliance with Emergency Services and Poststabilization Care Services requirements as identified in 42 CFR 438.114; Procedures for tracking appeals when Enrollees become aware of the Adverse Action, in the event that no notice had been sent; Handling of complaints/Grievances sent directly to EOHHS; Process used to monitor Provider and subcontractor implementation of amendments and improvements; Retention of medical records; Engagement and coordination with BH CPs and LTSS CPs, as described in Sections 2.5.F and 2.5.G; and Compliance with all CBHI requirements as set forth in this Contract. Other Contract Management Requirements Customer Service Team (CST) Enrollment Vendor Education The Contractor shall participate in educational sessions, at the request of EOHHS, to update EOHHS staff and its designated CST Enrollment Vendor regarding information which would assist prospective Enrollees in evaluating the Contractor’s Plan. These educational activities may include multiple presentations per Contract Year at EOHHS, Plan sites and CST Enrollment Vendor offices. Material Subcontracts/Subcontractors Prior to contracting with a Material Subcontractor, the Contractor shall evaluate the prospective Material Subcontractor’s ability to perform the activities to be subcontracted. All Material Subcontracts must be prior approved by EOHHS. To obtain such approval, the Contractor shall make a request in writing and submit with that request a completed Material
Questions that specifically screen for care needs experienced by children, including evaluating characteristics of the Enrollees’ families and homes; As further directed by EOHHS, evaluate Enrollees’ needs for Behavioral Health-related services, including unmet needs. Contractor’s Care Needs Screening shall evaluate characteristics such as but not limited to: The Enrollee’s current use of BH Services, if any, including substance use disorder treatment services; The presence of mental health diagnoses or conditions, if any; The presence of any substance use disorders, if any; and The Enrollee’s affiliation with any state agency that provides BH-related care management or other activities, including the Department of Mental Health (DMH) and the Bureau of Substance Abuse Services (BSAS); As further directed by EOHHS, evaluate Enrollees’ needs for LTSS and LTSS-related services, including unmet needs. The Contractor’s Care Needs Screening shall evaluate characteristics such as, but not limited to: Current use of MassHealth services that could be reasonably viewed as LTSS, such as: Adult Day Health Services; Adult Foster Care Services; Continuous Skilled Nursing Services (post-100 day of services); Day Habilitation Services; Group Adult Foster Care Services; Nursing Facility Services (post-100 days of services)s; Inpatient and Outpatient Chronic Disease Rehabilitation Hospital Services (post-100 days of services); and
The Clinical Advice and Support Line shall be incorporated in the Contractor’s policies and procedures for care coordination and Care Management, such as policies and procedures for: The Clinical Advice and Support Line notifying Providers and Care Management staff involved in an Enrollee’s care of a phone call, particularly if the call indicates a need to modify the Enrollee’s documented Care Plan or course of treatment or a need for follow-up; The Clinical Advice and Support Line’s clinicians being able to access relevant information from an Enrollee’s Care Plan or medical record under certain circumstances to respond to an Enrollee’s questions and coordinate care; and The Clinical Advice and Support Line providing appropriate information and navigation to Enrollees to Providers who can support an Enrollee’s needs, including but not limited to Network Providers and providers involved in an Enrollee’s care; The Clinical Advice and Support Line shall otherwise coordinate with an Enrollee’s PCP, Care Coordinator, or Clinical Care Manager, as applicable, including through providing “warm handoffs” to such individuals through direct transfer protocols and processes and capabilities to share information with such individuals; Provide general health information to Enrollees and answer general health and wellness-related questions; Comprehensive Assessment and Member-Centered Care Planning The Contractor shall ensure that certain Enrollees, as described in this Section and further specified by EOHHS, receive a Comprehensive Assessment that informs a documented Care Plan. Such Comprehensive Assessment and documented Care Plan shall be member-centered and shall inform Enrollees’ care, including but not limited to any Care Management activities, as described in this Section and further specified by EOHHS. The Contractor shall provide certain Enrollees with Comprehensive Assessments as follows:
Increase the capabilities of PCPs to perform and participate in the Contractor’s Care Management activities, including providing additional supports to Enrollees; Include but be not limited to investments such as: Investment in Primary Care technological infrastructure, including: Health Information Technology (HIT) infrastructure deployed in the Primary Care setting; Clinical platforms for PCPs; Fixed cost investments to support telehealth and costs for related non-reimbursable activities; Data sharing across Primary Care and Behavioral Health Providers to support Behavioral Health integration in primary care practices; and Data analytics and informatics to support individual primary care practices; Investment in Primary Care workforce to support the Contractor’s activities under this Contract, including hiring practice extenders and other personnel, such as community health workers, licensed social workers, Providers of BH or Primary Care services, or other office personnel to work in primary care settings within their scope of practice under state law; and Training and technical assistance that directly supports PCPs to improve performance and increase participation in Contractor’s activities under this Contract, including assistance with analytics, executing plans for performance improvement, quality measurement and management, and care coordination and Care Management activities such as those described in Section 2.5.E; The Contractor shall ensure that PCPs utilize a Screening, Brief Intervention, and Referral to Treatment (SBIRT) model for Enrollees with substance use disorder treatment needs;
Non-24-Hour Diversionary Services – within two calendar days of discharge; Medication Management – within 14 calendar days of discharge; Other Outpatient Services – within seven calendar days of discharge; and Intensive Care Coordination Services – within the time frame directed by EOHHS. The Contractor shall ensure that Network Providers offer hours of operation that are no less than the hours of operation offered to commercial enrollees or MassHealth Fee-For-Service if the Provider serves only Enrollees or other Members. The Contractor may request an exception to the access standards set forth in this Section 2.9.B. by submitting a written request to EOHHS. Such request shall include alternative standards that are equal to, or better than, the usual and customary community standards for accessing care. Upon approval by EOHHS, the Contractor shall notify Enrollees in writing of such alternative access standards. The Contractor shall have a system in place to monitor and document access and appointment scheduling standards. The Contractor shall use statistically valid sampling methods for monitoring compliance with the appointment/access standards specified above in Section 2.9.B.1.and 2. and shall promptly address any access deficiencies, including but not limited to taking corrective action if there is a failure to comply by a Provider. Annually, in accordance with Appendix A, the Contractor shall evaluate and report to EOHHS Network-wide compliance with the access standards specified in Section 2.9.B.1. and 2. Availability The Contractor shall execute and maintain written contracts with Providers to ensure that Enrollees have access to ACO Covered Services within a reasonable distance and travel time from the Enrollee’s residence, as provided below. The Contractor shall take into account both walking and public transportation. Primary Care Providers The Contractor shall develop and maintain a of Primary Care Providers (PCP network) that ensures PCP coverage and availability throughout the Service Area 24 hours a day, seven days a week.
Materials provided to Enrollees as set forth in this Contract; Marketing plan and Marketing materials; Grievance policies and procedures; and Any other documentation and materials requested by EOHHS. Additional Clinical Data Upon request of EOHHS, the Contractor shall participate in the development of specifications for a data set on clinical data in the Contractor’s Systems that include member identifier, and data on participation in the Children’s Behavioral Health Initiative, Care Management programs and special populations; and At the discretion of EOHHS, a data set developed on member enrollment in special programs and populations shall be produced and submitted to EOHHS in the frequency and format to be determined by EOHHS. System Exchange of Encounter Data The Contractor’s Systems shall generate and transmit Encounter Data files according to the specifications outlined in Appendix E of this Contract, as updated from time-to-time: The Contractor shall maintain processes to ensure the validity, accuracy and completeness of the Encounter Data in accordance with the standards specified in Section 2.14.B; and The Contractor shall participate in any Workgroup activities as specified in Section 2.14.A. System Access Management and Information Accessibility Requirements The Contractor shall make all Systems and system information available to authorized EOHHS and other agency staff as determined by EOHHS to evaluate the quality and effectiveness of the Contractor’s data and Systems. The Contractor is prohibited from sharing or publishing EOHHS data and information without prior written consent from EOHHS. System Availability and Performance Requirements
Contractor’s approach to Comprehensive Assessments and care planning, as described in Section 2.5.D; Contractor’s Care Management activities, as described in Section 2.5.E; Contractor’s relationships with Network Providers, state agencies, and other entities involved in the care of Enrollees; Contractor’s relationships with CPs specifically, including how Contractor and CPs coordinate care, resolve potential conflicts, and delineate responsibilities for care coordination and Care Management activities, as described in Sections 2.5.F and 2.5.G; Contractor’s activities to ensure Contractor’s compliance with the contract management, reporting, and administrative requirements described in Section 2.3; and The Contractor’s activities pursuant to any other requirements of this Contract specified by EOHHS; and A plan to increase the Contractor’s capabilities to share information among providers involved in Enrollees’ care. Such plan shall include, at a minimum: The Contractor’s current event notification capabilities and procedures to ensure that the Contractor’s PCPs are aware of Enrollees’ inpatient admissions and emergency department visits; The Contractor’s self-assessed gaps in such capabilities and procedures, and how the Contractor plans to address such gaps; A description of the Contractor’s plans, if any, to increase the use of EHR technologies certified by the Office of the National Coordinator (ONC); A description of how Contractor plans to ensure Network Providers consistently use the HIWay to send or receive legally and clinically appropriate patient clinical information and support transitions of care; The Contractor shall modify, update, and resubmit to EOHHS for approval its DSRIP Participation Plan upon any significant changes in the
EOHHS may withhold the Contractor’s DSRIP payment until EOHHS approves the Contractor’s to-date Progress Reports; and EOHHS may reduce the Contractor’s future DSRIP payments or otherwise recoup payment from the Contractor if, upon review of the financial accountings contained in such Progress Reports, EOHHS determines that Contractor has not spent all the Contractor’s DSRIP payments in accordance with the Contractor’s DSRIP Participation Plan or with the requirements of this Contract; and Report to EOHHS on the Contractor’s total patient service revenue payer mix, as described in Section 5.2.A.3.b.1, in form and format specified by EOHHS, annually or at a frequency specified by EOHHS; Report information to EOHHS, as requested and further specified by EOHHS, on the Contractor’s CPs, including but not limited to the number of BH CP-eligible Enrollees assigned by the Contractor to each of the Contractor’s BH CPs for outreach and enrollment and the number of Enrollees receiving any care coordination support or Care Management activities in which an LTSS CP is involved; Ensure and demonstrate to EOHHS’ satisfaction that the Contractor’s DSRIP payments are spent as follows: The Contractor shall spend DSRIP payments in accordance with the Contractor’s EOHHS-approved DSRIP Participation Plan, Progress Reports, Budgets, and Budget Narratives; The Contractor shall pay each Participating Safety Net Hospital the full amount of DSTI Glide Path Payments the Contractor receives for such Participating Safety Net Hospital; The Contractor shall spend an amount of its Start-up and Ongoing DSRIP not less than the amount specified by EOHHS on investments and payments to PCPs, as described in Section 2.7.C.1.c and as approved and further directed by EOHHS; and The Contractor shall ensure that any reimbursement the Contractor requests from Contractor’s Flexible Services Allotment as described in Section 5.2.C is not duplicative of funding available through other publicly available programs. Payments under DSRIP EOHHS shall pay the Contractor three streams of DSRIP funding (Startup and Ongoing DSRIP payments, DSTI Glide Path DSRIP payments, and Flexible Services DSRIP payments), as follows: EOHHS shall pay the Contractor Startup and Ongoing DSRIP payments as follows: