T
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ANNUAL REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934
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£
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TRANSITION REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934
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Delaware
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42-1406317
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(State or other jurisdiction of
incorporation or organization)
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(I.R.S. Employer
Identification Number)
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7700 Forsyth Boulevard
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St. Louis, Missouri
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63105
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(Address of principal executive offices)
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(Zip Code)
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Common Stock, $0.001 Par Value
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New York Stock Exchange
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Title of Each Class
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Name of Each Exchange on Which Registered
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Part I
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Item 1.
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2
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Item 1A.
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11
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Item 1B.
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17
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Item 2.
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17
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Item 3.
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17
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Part II
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Item 5.
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17
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Item 6.
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19
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Item 7.
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20
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Item 7A.
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29
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Item 8.
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30
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Item 9.
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49
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Item 9A.
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49
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Item 9B.
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51
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Part III
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Item 10.
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51
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Item 11.
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51
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Item 12.
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51
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Item 13
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51
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Item 14.
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51
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Part IV
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Item 15.
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51
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54
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our ability to accurately predict and effectively manage health benefits and other operating expenses;
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competition;
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membership and revenue projections;
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timing of regulatory contract approval;
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changes in healthcare practices;
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changes in federal or state laws or regulations, including the Patient Protection and Affordable Care Act and the Health Care and Education Affordability Reconciliation Act and any regulations enacted thereunder;
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inflation;
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provider contract changes;
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new technologies;
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reduction in provider payments by governmental payors;
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major epidemics;
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disasters and numerous other factors affecting the delivery and cost of healthcare;
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the expiration, cancellation or suspension of our Medicaid managed care contracts by state governments;
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availability of debt and equity financing, on terms that are favorable to us; and
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general economic and market conditions.
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Strong Historic Operating Performance. We have increased revenues as we have grown in existing markets, expanded into new markets and broadened our product offerings. We entered the Wisconsin market in 1984 as a single health plan and have grown to 12 health plans with at-risk membership totaling 1.8 million in 2011. For the year ended December 31, 2011, we had premium and service revenues of $5.2 billion, representing a five year Compound Annual Growth Rate, of 23.7%, generated total cash flow from operations of $261.7 million and net earnings of $108.4 million.
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Innovative Technology and Scalable Systems. The ability to access data and translate it into meaningful information is essential to operating across a multi-state service area in a cost-effective manner. Our centralized information systems support our core processing functions under a set of integrated databases and are designed to be both replicable and scalable to accommodate organic growth and growth from acquisitions. We continue to enhance our systems in order to leverage the platform we have developed for our existing states for configuration into new states or health plan acquisitions. Our predictive modeling technology enables the medical management operations to proactively case and disease manage specific high risk members. It can recommend medical care opportunities using a mix of company defined algorithms and evidence based medical guidelines. Interventions are determined by the clinical indicators, the ability to improve health outcomes, and the risk profile of members. Our integrated approach helps to assure that consistent sources of claim and member information are provided across all of our health plans. Our membership and claims processing system is capable of expanding to support additional members in an efficient manner.
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Medicaid Expertise. For more than 25 years, we have developed a specialized Medicaid expertise that has helped us establish and maintain relationships with members, providers and state governments. We have implemented programs developed to achieve savings for state governments and improve medical outcomes for members by reducing inappropriate emergency room use, inpatient days and high cost interventions, as well as by managing care of chronic illnesses. We work with state agencies on redefining benefits and eligibility requirements in order to maximize the number of uninsured individuals covered through Medicaid, CHIP, Foster Care, ABD and other state sponsored programs and expand the types of benefits offered. Our approach is to accomplish this while maintaining adequate levels of provider compensation and protecting our profitability.
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Diversified Business Lines. We continue to broaden our service offerings to address areas that we believe have been traditionally underserved by Medicaid managed care organizations. In addition to our Medicaid and Medicaid-related managed care services, our service offerings include behavioral health, care management software, health insurance exchanges, individual health insurance, life and health management, long-term care programs, managed vision, telehealth services and pharmacy benefits management. Through the utilization of a multi-business line approach, we are able to improve the quality of care, improve outcomes, diversify our revenues and help control our medical costs.
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Localized Approach with Centralized Support Infrastructure. We take a localized approach to managing our subsidiaries, including provider and member services. This approach enables us to facilitate access by our members to high quality, culturally sensitive healthcare services. Our systems and procedures have been designed to address these community-specific challenges through outreach, education, transportation and other member support activities. For example, our community outreach programs work with our members and their communities to promote health and self-improvement through employment and education on how best to access care. We complement this localized approach with a centralized infrastructure of support functions such as finance, information systems and claims processing, which allows us to minimize general and administrative expenses and to integrate and realize synergies from acquisitions. We believe this combined approach allows us to efficiently integrate new business opportunities in both Medicaid and specialty services while maintaining our local accountability and improved access.
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Increase Penetration of Existing State Markets. We seek to continue to increase our Medicaid membership in states in which we currently operate through alliances with key providers, outreach efforts, development and implementation of community-specific products and acquisitions. For example, in 2010, we expanded our health plan in Florida into long-term care through the acquisition of Citrus Health Care, Inc. In 2011, we expanded our health plan in Texas under an additional STAR+PLUS ABD contract in the Dallas service area and will expand in 2012 under a new contract to serve additional members in several new service areas.
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Diversify Business Lines. We seek to broaden our business lines into areas that complement our existing business to enable us to grow and diversify our revenue. We are constantly evaluating new opportunities for expansion both domestically and abroad. For instance, in July 2008, we completed the acquisition of Celtic Insurance Company, a nationwide individual health insurance provider. In 2010, we acquired a controlling ownership interest in Casenet, LLC, or Casenet, a care management software provider. We employ a disciplined acquisition strategy that is based on defined criteria including internal rate of return, accretion to earnings per share, market leadership and compatibility with our information systems. We engage our executives in the relevant operational units or functional areas to ensure consistency between the diligence and integration process.
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Address Emerging State Needs. We work to assist the states in which we operate in addressing the operating challenges they face. We seek to assist the states in balancing premium rates, benefit levels, member eligibility, policies and practices, and provider compensation. For example, in 2008, we began operating under a new statewide program providing managed care services to participants in the Texas Foster Care program; in April 2010, we began offering an individual insurance product for residents of Massachusetts who do not qualify for other state funded insurance programs; in November 2010, we began operating under a new contract to provide affordable health plans for Texas small businesses under the new Healthy Texas initiative; and, in January 2011, we began operating under a new contract with the state of Indiana to provide affordable health plans for uninsured Indiana individuals under the new Healthy Indiana Plan. By helping states structure an appropriate level and range of Medicaid, CHIP and specialty services, we seek to ensure that we are able to continue to provide those services on terms that achieve targeted gross margins, provide an acceptable return and grow our business.
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Develop and Acquire Additional State Markets. We continue to leverage our experience to identify and develop new markets by seeking both to acquire existing business and to build our own operations. We expect to focus expansion in states where Medicaid recipients are mandated to enroll in managed care organizations because we believe member enrollment levels are more predictable in these states. In addition, we focus on states where managed care programs can help address states’ financial needs. For example, in 2011, we began managing care for ABD members in Mississippi, began providing managed care services to older adults and adults with disabilities in Illinois, and began managing care for Medicaid, ABD and Foster Care members in Kentucky.
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Leverage Established Infrastructure to Enhance Operating Efficiencies. We intend to continue to invest in infrastructure to further drive efficiencies in operations and to add functionality to improve the service provided to members and other organizations at a low cost. Information technology, or IT, investments complement our overall efficiency goals by increasing the automated processing of transactions and growing the base of decision-making analytical tools. Our centralized functions and common systems enable us to add members and markets quickly and economically.
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Maintain Operational Discipline. We seek to operate in markets that allow us to meet our internal metrics including membership growth, plan size, market leadership and operating efficiency. We use multiple techniques to monitor and reduce our medical costs, including on-site hospital review by staff nurses and involvement of medical management in significant cases. Our executive dashboard is utilized to quickly identify cost drivers and medical trends. Our management team regularly evaluates the financial impact of proposed changes in provider relationships, contracts, changes in membership and mix of members, potential state rate changes and cost reduction initiatives. We may divest contracts or health plans in markets where the state’s Medicaid environment, over a long-term basis, does not allow us to meet our targeted performance levels.
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State
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Local Health Plan Name
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First Year of Operations Under
the Company
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Counties Served at
December 31, 2011
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Market Share
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At-risk Managed Care
Membership at
December 31, 2011
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Arizona
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Bridgeway Health Solutions (1)
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2006
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10
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(2)
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23,700
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Florida
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Sunshine State Health Plan
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2009
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24
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17.1%(3)
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198,300
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Georgia
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Peach State Health Plan
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2006
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90
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26.5%
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298,200
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Illinois
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IlliniCare Health Plan
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2011
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7
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50.0%
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16,300
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Indiana
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Managed Health Services
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1995
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92
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28.2%
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206,900
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Kentucky
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Kentucky Spirit Health Plan
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2011
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104
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34.7%
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180,700
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Massachusetts
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CeltiCare Health Plan
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2009
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14
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(4)
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35,700
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Mississippi
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Magnolia Health Plan
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2011
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82
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33.3%
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31,600
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Ohio
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Buckeye Community Health Plan
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2004
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43
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9.7%
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159,900
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South Carolina
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Absolute Total Care
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2007
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39
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13.6%
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82,900
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Texas
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Superior HealthPlan
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1999
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254
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18.7%
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503,800
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Wisconsin
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Managed Health Services
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1984
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41
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11.1%
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78,000
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1,816,000
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(1)
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Represents the acute care, long-term care and Medicare businesses under Bridgeway Health Solutions.
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(2)
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Bridgeway acute care has a market share of 1.5% and long-term care has a market share of 9.8%.
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(3)
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Florida market share excludes long-term care.
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(4)
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CeltiCare Health Plan manages members under the state Commonwealth Care Bridge program and Commonwealth Care program with market share of 100% and approximately 13.0%, respectively.
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Significant cost savings and budget predictability compared to state paid reimbursement for services. We bring bottom-line management experience to our health plans. On the administrative and management side, we bring experience including quality of care improvement methods, utilization management procedures, an efficient claims payment system, and provider performance reporting, as well as managers and staff experienced in using these key elements to improve the quality of and access to care. We receive a contracted premium on a per member basis and are responsible for the medical costs and as a result, provide budget predictability.
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Data-driven approaches to balance cost and verify eligibility. We seek to ensure effective outreach procedures for new members, then educate them and ensure they receive needed services as quickly as possible. Our IT department has created mapping/translation programs for loading membership and linking membership eligibility status to all of Centene’s subsystems. We utilize predictive modeling technology to proactively case and disease manage specific high risk members. In addition, we have developed Centelligence, our enterprise data warehouse system provides a seamless flow of data across our organization, enabling providers and case managers to access information, apply analytical insight and make informed decisions.
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Establishment of realistic and meaningful expectations for quality deliverables. We have collaborated with state agencies in redefining benefits, eligibility requirements and provider fee schedules with the goal of maximizing the number of individuals covered through Medicaid, CHIP, Foster Care and ABD programs.
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Managed care expertise in government subsidized programs. Our expertise in Medicaid has helped us establish and maintain strong relationships with our constituent communities of members, providers and state governments. We provide access to services through local providers and staff that focus on the cultural norms of their individual communities. To that end, systems and procedures have been designed to address community-specific challenges through outreach, education, transportation and other member support activities.
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Improved medical outcomes. We have implemented programs developed to achieve savings for state governments and improve medical outcomes for members by reducing inappropriate emergency room use, inpatient days and high cost interventions, as well as by managing care of chronic illness.
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Timely payment of provider claims. We are committed to ensuring that our information systems and claims payment systems meet or exceed state requirements. We continuously endeavor to update our systems and processes to improve the timeliness of our provider payments.
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Provider outreach and programs. Our health plans have adopted a physician-driven approach where network providers are actively engaged in developing and implementing healthcare delivery policies and strategies. We prepare provider comparisons on a severity adjusted basis. This approach is designed to eliminate unnecessary costs, improve services to members and simplify the administrative burdens placed on providers.
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Responsible collection and dissemination of utilization data. We gather utilization data from multiple sources, allowing for an integrated view of our members’ utilization of services. These sources include medical, vision and behavioral health claims and encounter data, pharmacy data, dental vendor claims and authorization data from the authorization and case management system utilized by us to coordinate care.
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Timely and accurate reporting. Our information systems have reporting capabilities which have been instrumental in identifying the need for new and/or improved healthcare and specialty programs. For state agencies, our reporting capability is important in demonstrating an auditable program.
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Fraud and abuse prevention. We have several systems in place to help identify, detect and investigate potential waste, abuse and fraud including pre and post payment software. We collaborate with state and federal agencies and assist with investigation requests. We use nationally recognized standards to benchmark our processes.
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· primary and specialty physician care
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· transportation assistance
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· inpatient and outpatient hospital care
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· vision care
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· emergency and urgent care
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· dental care
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· prenatal care
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· immunizations
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· laboratory and x-ray services
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· prescriptions and limited over-the-counter drugs
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· home health and durable medical equipment
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· therapies
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· behavioral health and substance abuse services
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· social work services
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· 24-hour nurse advice line
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· care coordination
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Start Smart For Your Baby is our award winning prenatal and infant health program designed to increase the percentage of pregnant women receiving early prenatal care, reduce the incidence of low birth weight babies, identify high risk pregnancies, increase participation in the federal Women, Infant and Children program, prevent hospital admissions in the first year of life and increase well-child visits. The program includes risk assessments, education through face-to-face meetings and materials, behavior modification plans, assistance in selecting a physician for the infant and scheduling newborn follow-up visits. These initiatives are supported by a statistically proven reduction in Neonatal Intensive Care Unit (NICU) days as well as increased gestational birth weights. The program includes a proprietary Notification of Pregnancy process to identify pregnant women more quickly and enables us to help them gain access to prenatal medical care, give them education on their healthcare needs, assist with social needs and concerns, and coordinate referrals to appropriate specialists and the obstetrics (OB) case management program as needed. The Notification of Pregnancy also identifies women eligible for our high risk OB management program, or 17P Program, which aims to reduce the rate of recurrent preterm delivery and neonatal intensive care admissions through the use of Progesterone. In addition, Start Smart has also co-written a book for the first year of life with the American Academy of Pediatrics. The results of this program have also been published in several peer reviewed articles. In 2010, Start Smart won the Platinum Award for Consumer Empowerment at the URAC Quality Summit. Start Smart also was awarded the 2010 URAC / GKEN International Health Promotion Award. The “Your Pregnancy Guide” developed by Start Smart was a 2010 Silver Medalist of the National Health Information Award. In 2011, Start Smart was recognized in NCQA Quality Profiles: Focus on Patient Engagement as a featured program.
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Connections Plus is a cell phone program developed for high-risk members who have limited or no access to a safe, reliable telephone. The program puts free, preprogrammed cell phones into the hands of eligible members. This program seeks to eliminate lack of safe, reliable access to a telephone as a barrier to coordinating care, thus reducing avoidable adverse events such as inappropriate emergency room utilization, hospital admissions and premature birth. Members are identified through case management activities or through a referral. Connections Plus is available to high-risk members in all Centene health plans. Originally designed for pregnant women and ABD populations, this program has now been expanded to service members with mental health issues, and specific diseases, including sickle cell. Connections Plus was recognized as a URAC Best Practice 2009 Silver Medalist.
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AT&T / WellDoc Program is a pilot program introduced in Ohio in 2011 through a partnership with AT&T. This program provides smart phones to a limited group of high-risk members with diabetes, giving them access to DiabetesManager, the enterprise mHealth solution from AT&T and WellDoc. DiabetesManager enables patients to manage their diabetes by offering real-time tips and advice based on their individual data. It not only tracks food consumption and blood sugar levels, but also allows members to take better control of self-management of their Type 2 diabetes to support them in establishing long-term healthy habits and improved quality of life. This highly-secure technology also empowers our nurse case managers to monitor patients virtually, so they can more efficiently intervene when necessary.
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MemberConnections is a community face-to-face outreach and education program designed to create a link between the member and the provider and help identify potential challenges or risk elements to a member’s health, such as nutritional challenges and health education shortcomings. MemberConnections representatives contact new members by phone or mail to discuss managed care, the Medicaid program and our services. Our MemberConnections representatives make home visits, conduct educational programs and represent our health plans at community events such as health fairs.
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Health Initiatives for Children is aimed at educating child members on a variety of health topics. Our health plans are reaching out directly to children with newsletters, contests and a series of children’s books that have been sponsored by the Company. These books have focused on managing asthma, obesity prevention and healthy eating. Obesity rates for children doubled in the past two decades and tripled for adolescents during the same period. Preventive obesity focuses on the childhood obesity epidemic with educational information encouraging proper eating and exercise habits. The books educate children on the importance of living an active and healthy life. During 2010, one of the books received the National Health Information Award Silver Medal.
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Health Passport is a leading-edge, patient-centric electronic community health record for foster care children. Health Passport collects patient demographic data, clinician visit records, dispensed medications, vital sign history, lab results, allergy charts, and immunization data. Providers can directly input additional or updated patient data and documentation into the Passport. All information is accessible anywhere, anytime to all authorized users, including health plan staff, greatly facilitating coordinated care among providers. In 2010, we expanded the Health Passport to our behavioral health program in Arizona.
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The CentAccount Program encourages healthy behaviors by offering members financial incentives for performing certain healthy behaviors. The incentives are delivered through a restricted-use MasterCard redeemable for health-related items only. This incentive-based approach effectively increases the utilization of preventive services while strengthening the relationships between members and their primary care providers.
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The Asthma Management Program integrates a hands-on approach with a flexible outreach methodology that can be customized to suit the different age groups and populations it serves that are affected by asthma. Working closely with Nurtur Health, Inc., a wholly-owned subsidiary of Centene that provides life, health and wellness programs, we provide proactive identification of members, stratification into appropriate levels of intervention including home visits, culturally sensitive education, and robust outcome reporting. The program also includes aggressive care coordination to ensure patients have basic services such as transportation to the doctor, electricity to power the nebulizer, and a clean, safe home environment. During 2011, the Asthma Management Program was the recipient of the EPA National Environmental Leadership Award in Asthma Management.
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Fluvention is an outreach program aimed at educating members on preventing the transmission of the influenza virus by encouraging members to get the seasonal influenza vaccines and take everyday precautions to prevent illness. We use an integrated communications approach including direct mail, phone calls, providing information via health plan websites and posting information in provider offices. The health plans also conduct general community awareness through public service announcements on television and radio. Beginning in 2009, we targeted education efforts related to health hygiene, preventative care and the benefits of obtaining appropriate care for their condition, for groups that are at higher-risk for contracting the influenza viruses, including pregnant women, children from six months old up to 24-year-old adults, as well as adults with chronic health conditions.
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EPSDT Case Management is a preventive care program designed to educate our members on the benefits of Early and Periodic Screening, Diagnosis and Treatment, or EPSDT, services. We have a systematic program of communicating, tracking, outreach, reporting and follow-through that promotes state EPSDT programs.
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Life and Health Management Programs are designed to help members understand their disease and treatment plan and improve their wellness in a cost effective manner. These programs address medical conditions that are common within the Medicaid population such as asthma, diabetes and pregnancy. Our Specialty Services segment manages many of our life and health management programs. Our ABD program uses a proprietary assessment tool that effectively identifies barriers to care, unmet functional needs, available social supports and the existence of behavioral health conditions that impede a member’s ability to maintain a proper health status. Care coordinators develop individual care plans with the member and healthcare providers ensuring the full integration of behavioral, social and acute care services. These care plans, while specific to an ABD member, incorporate “Condition Specific” practices in collaboration with physician partners and community resources.
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Primary Care
Physicians
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Specialty Care
Physicians
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Hospitals
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Arizona
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957 | 3,028 | 26 | ||||
Florida
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1,410 | 8,967 | 92 | ||||
Georgia
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4,834 | 9,651 | 116 | ||||
Illinois
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1,754 | 3,874 | 54 | ||||
Indiana
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1,168 | 7,037 | 111 | ||||
Kentucky
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2,283 | 4,897 | 75 | ||||
Massachusetts
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2,212 | 7,918 | 37 | ||||
Mississippi
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1,365 | 2,920 | 74 | ||||
Ohio
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2,530 | 10,061 | 148 | ||||
South Carolina
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1,729 | 4,664 | 29 | ||||
Texas
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9,775 | 25,966 | 409 | ||||
Wisconsin
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2,807 | 8,441 | 87 | ||||
Total
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32,824 | 97,424 | 1,258 |
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Under our fee-for-service contracts with physicians, particularly specialty care physicians, we pay a negotiated fee for covered services. This model is characterized as having no financial risk for the physician. In addition, this model requires management oversight because our total cost may increase as the units of services increase or as more expensive services replace less expensive services. We have prior authorization procedures in place that are intended to make sure that certain high cost diagnostic and other services are medically appropriate.
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Under our capitated contracts, primary care physicians are paid a monthly fee for each of our members assigned to his or her practice for all ambulatory care. In return for this payment, these physicians provide all primary care and preventive services, including primary care office visits and EPSDT services, and are at risk for all costs associated with such services. If these physicians also provide non-capitated services to their assigned members, they may receive payment under fee-for-service arrangements at standard Medicaid rates.
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Under risk-sharing arrangements, physicians are paid under a capitated or fee-for-service arrangement. The arrangement, however, contains provisions for additional bonus to the physicians or reimbursement from the physicians based upon cost and quality factors.
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Customized Utilization Reports provide certain of our contracted physicians with information that enables them to run their practices more efficiently and focuses them on specific patient needs. For example, quarterly detail reports update physicians on their status within their risk pools. Equivalency reports provide physicians with financial comparisons of capitated versus fee-for-service arrangements.
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Case Management Support helps the physician coordinate specialty care and ancillary services for patients with complex conditions and direct members to appropriate community resources to address both their health and socio-economic needs.
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Web-based Claims and Eligibility Resources have been implemented to provide physicians with on-line access to perform claims and eligibility inquiries.
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appropriate leveling of care for neonatal intensive care unit hospital admissions, other inpatient hospital admissions, and observation admissions, in accordance with Interqual criteria
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tightening of our pre-authorization list and more stringent review of durable medical equipment and injectibles
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emergency department, or ED, program designed to collaboratively work with hospitals to steer non-emergency care away from the costly ED setting (through patient education, on-site alternative urgent care settings, etc.)
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increase emphasis on case management and clinical rounding where case managers are nurses or social workers who are employed by the health plan to assist selected patients with the coordination of healthcare services in order to meet a patient's specific healthcare needs
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incorporation of disease management, which is a comprehensive, multidisciplinary, collaborative approach to chronic illnesses such as asthma and diabetes
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Start Smart For Your Baby, a prenatal case management program aimed at helping women with high-risk pregnancies deliver full-term, healthy infants
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Behavioral Health. Cenpatico Behavioral Health, or Cenpatico, manages behavioral healthcare for members via a contracted network of providers. Cenpatico works with providers to determine the best services to help people overcome mental illness and lead productive lives. Our networks feature a full range of services and levels of care to help people with mental illness reach their recovery and wellness goals. In addition, we operate school-based programs in Arizona that focus on students with special needs and also provide speech and other therapy services.
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Individual and State Sponsored Health Insurance Exchanges. Celtic Insurance Company, or Celtic, is a nationwide healthcare provider licensed in 49 states offering high-quality, affordable health insurance to individual customers and their families. Sold online and through independent insurance agents nationwide, Celtic’s portfolio of major medical plans is designed to meet the diverse needs of the uninsured at all budget and benefit levels. Celtic also offers a standalone guaranteed-issue medical conversion program to self-funded employer groups, stop-loss and fully-insured group carriers, managed care plans, and HMO reinsurers.
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Life and Health Management. Nurtur Health, Inc., or Nurtur, specializes in implementing life and health management programs that encourage healthy behaviors, promote healthier workplaces, improve workforce and societal productivity and reduce healthcare costs. Health risk appraisals, biometric screenings, online and telephonic wellness programs, disease management and work-life/employee assistance services are areas of focus. Nurtur uses telephonic health and work/life balance coaching, in-home and online interaction and informatics processes to deliver effective clinical outcomes, enhanced patient-provider satisfaction and overall healthcare cost.
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Long-term Care and Acute Care. Bridgeway Health Solutions, or Bridgeway, provides long-term care services to the elderly and people with disabilities that meet income and resources requirements who are at risk of being or are institutionalized. Bridgeway participates with community groups to address situations that might be barriers to quality care and independent living. Acute care services include emergency and physician and hospitalization services, limited dental and rehabilitative services and other maternal and child health services.
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Managed Vision. OptiCare administers routine and medical surgical eye care benefits via its own contracted national network of eye care providers. OptiCare clients include Medicaid, Medicare, and commercial health plans, as well as employer groups. OptiCare has been providing vision network services for over 25 years and offers a variety of plan designs to meet the individual needs of its clients and members.
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Telehealth Services. NurseWise and Nurse Response provide a toll-free nurse triage line 24 hours per day, 7 days per week, 52 weeks per year. Our members call one number and reach bilingual customer service representatives and nursing staff who provide health education, triage advice and offer continuous access to health plan functions. Additionally, our representatives verify eligibility, confirm primary care provider assignments and provide benefit and network referral coordination for members and providers after business hours. Our staff can arrange for urgent pharmacy refills, transportation and qualified behavioral health professionals for crisis stabilization assessments. Call volume is based on membership levels and seasonal variation.
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Pharmacy Benefits Management. US Script offers progressive pharmacy benefits management services that are specifically designed to improve quality of care while containing costs. This is achieved through a lowest net cost strategy that helps optimize clients' pharmacy benefit. Services include claims processing, pharmacy network management, benefit design consultation, drug utilization review, formulary and rebate management, specialty and mail order pharmacy services, and patient and physician intervention.
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Care Management Software. Casenet is a software provider of innovative care management solutions that automate the clinical, administrative and technical components of care management programs. We maintain a controlling ownership interest in Casenet and are currently implementing this new software platform which is available for sale to third parties.
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·
|
written standards of conduct |
·
|
designation of a corporate compliance officer and compliance committee |
·
|
effective training and education |
·
|
effective lines for reporting and communication |
·
|
enforcement of standards through disciplinary guidelines and actions |
·
|
internal monitoring and auditing |
·
|
prompt response to detected offenses and development of corrective action plans |
·
|
Medicaid Managed Care Organizations focus on providing healthcare services to Medicaid recipients. These organizations consist of national and regional organizations, as well as smaller organizations that operate in one city or state and are owned by providers, primarily hospitals.
|
·
|
National and Regional Commercial Managed Care Organizations have Medicaid members in addition to members in private commercial plans. Some of these organizations offer a range of specialty services including pharmacy benefits management, behavioral health management, health management, and nurse triage call support centers.
|
·
|
Primary Care Case Management Programs are programs established by the states through contracts with primary care providers. Under these programs, physicians provide primary care services to Medicaid recipients, as well as limited medical management oversight.
|
·
|
premium taxes or similar assessments
|
·
|
stringent prompt-pay laws
|
·
|
disclosure requirements regarding provider fee schedules and coding procedures
|
·
|
programs to monitor and supervise the activities and financial solvency of provider groups
|
Ÿ eligibility, enrollment and disenrollment processes
|
Ÿ health education and wellness and prevention programs
|
Ÿ covered services
|
Ÿ timeliness of claims payment
|
Ÿ eligible providers
|
Ÿ financial standards
|
Ÿ subcontractors
|
Ÿ safeguarding of member information
|
Ÿ record-keeping and record retention
|
Ÿ fraud and abuse detection and reporting
|
Ÿ periodic financial and informational reporting
|
Ÿ grievance procedures
|
Ÿ quality assurance
|
Ÿ organization and administrative systems
|
Ÿ accreditation
|
State Contract
|
|
Expiration Date
|
|
Renewal or Extension by the State
|
Arizona – Acute Care
|
September 30, 2012
|
May be extended for up to one additional one-year term.
|
||
Arizona – Behavioral Health
|
June 30, 2013
|
Renewable for two additional one-year terms.
|
||
Arizona – Long-term Care
|
September 30, 2014
|
May be extended for up to two additional one-year terms.
|
||
Arizona – Special Needs Plan (Medicare)
|
December 31, 2012
|
Renewable annually for successive 12-month periods.
|
||
Florida – Medicaid & ABD
|
August 31, 2012
|
Renewable through the state’s recertification process.
|
||
Florida – Long-term Care
|
August 31, 2012
|
Renewable through the state’s recertification process.
|
||
Georgia – Medicaid & CHIP
|
June 30, 2012
|
Renewable for two additional one-year terms.
|
||
Georgia – Special Needs Plan (Medicare)
|
December 31, 2012
|
Renewable annually for successive 12-month periods.
|
||
Illinois – ABD
|
April 30, 2016
|
May be extended for up to five additional years.
|
||
Indiana – Medicaid, CHIP & Hybrid (Healthy Indiana Plan)
|
December 31, 2014
|
Renewable for two additional one-year terms.
|
||
Kansas – Behavioral Health
|
September 30, 2012
|
Renewable through the state’s reprocurement process.
|
||
Kentucky – Medicaid, Foster Care, & ABD
|
June 30, 2014
|
Renewable for four additional one-year terms.
|
||
Louisiana – Medicaid, CHIP & ABD
|
January 31, 2015
|
Renewable for an additional 2-year period through the state’s recertification process.
|
||
Massachusetts – Hybrid (Commonwealth Care)
|
June 30, 2012
|
Renewable through the state’s recertification process.
|
||
Massachusetts – Hybrid (Commonwealth Care Bridge)
|
February 29, 2012
|
Program ends February 29, 2012.
|
||
Mississippi – ABD & Foster Care
|
December 31, 2013
|
Renewable through the state’s recertification process.
|
||
Ohio – Medicaid, CHIP & ABD
|
June 30, 2012
|
Renewable annually for successive 12-month periods.
|
||
Ohio – Special Needs Plan (Medicare)
|
December 31, 2012
|
Renewable annually for successive 12-month periods.
|
||
South Carolina – Medicaid, CHIP & ABD
|
March 31, 2012
|
May be extended for up to one additional year and subsequently renewable through the state’s recertification process.
|
||
Texas – Medicaid, CHIP & ABD(1)
|
August 31, 2015
|
May be extended for up to four and a half additional years.
|
||
Texas – ABD Dallas Expansion
|
August 31, 2013
|
May be extended for up to five additional years.
|
||
Texas – CHIP Rural Service Area
|
August 31, 2013
|
May be extended for up to five additional years.
|
||
Texas – Foster Care
|
August 31, 2012
|
May be extended for up to three and a half additional years.
|
||
Texas – Hybrid (Healthy Texas)
|
August 31, 2013
|
Renewable for two additional two-year terms.
|
||
Texas – Special Needs Plan (Medicare)
|
December 31, 2012
|
Renewable annually for successive 12-month periods.
|
||
Wisconsin – Medicaid, CHIP & ABD
|
February 29, 2012
|
Renewable through the state’s recertification process.
|
||
Wisconsin – Network Health Plan Subcontract
|
December 31, 2016
|
Renews automatically for successive five-year terms.
|
||
Wisconsin – Special Needs Plan (Medicare)
|
December 31, 2012
|
Renewable annually for successive 12-month periods.
|
·
|
limit certain uses and disclosures of health information, and require individual authorizations for some uses and disclosures of protected health information
|
·
|
guarantee patients the right to access their health information and to know who else has accessed it
|
·
|
limit most disclosure of health information to the minimum needed for the intended purpose
|
·
|
establish procedures to ensure the protection of health information
|
·
|
authorize access to records by researchers and others under certain circumstances
|
·
|
establish requirements for breach notification
|
·
|
impose criminal and civil sanctions for improper uses or disclosures of health information
|
·
|
the state law is necessary to prevent fraud and abuse associated with the provision of and payment for healthcare
|
·
|
the state law is necessary to ensure appropriate state regulation of insurance and health plans
|
·
|
the state law is necessary for state reporting on healthcare delivery or costs
|
·
|
the state law addresses controlled substances
|
Name
|
|
Age
|
|
Position
|
Michael F. Neidorff
|
|
69
|
|
Chairman and Chief Executive Officer
|
Karen A. Bedell
|
52
|
Senior Vice President, New Business Integration & Development
|
||
Mark W. Eggert
|
50
|
Executive Vice President, Health Plan Business Unit
|
||
Carol E. Goldman
|
|
54
|
|
Executive Vice President and Chief Administrative Officer
|
Jason M. Harrold
|
42
|
Senior Vice President, Specialty Business Unit
|
||
Jesse N. Hunter
|
36
|
Executive Vice President, Corporate Development
|
||
Donald G. Imholz
|
59
|
Executive Vice President and Chief Information Officer
|
||
Edmund E. Kroll
|
52
|
Senior Vice President, Finance and Investor Relations
|
||
Mary V. Mason
|
43
|
Senior Vice President and Chief Medical Officer
|
||
William N. Scheffel
|
|
58
|
|
Executive Vice President, Chief Financial Officer and Treasurer
|
Jeffrey A. Schwaneke
|
36
|
Senior Vice President, Corporate Controller and Chief Accounting Officer
|
||
Keith H. Williamson
|
59
|
Senior Vice President, Secretary and General Counsel
|
2012 Stock Price
(through February 15, 2012)
|
2011 Stock Price
|
2010 Stock Price
|
||||||||||||||||
High
|
Low
|
High
|
Low
|
High
|
Low
|
|||||||||||||
First Quarter
|
$ | 50.00 | $ | 38.97 | $ | 32.99 | $ | 25.08 | $ | 25.03 | $ | 17.60 | ||||||
Second Quarter
|
39.25 | 31.34 | 25.95 | 20.51 | ||||||||||||||
Third Quarter
|
39.35 | 25.64 | 23.65 | 20.00 | ||||||||||||||
Fourth Quarter
|
40.81 | 25.28 | 26.43 | 21.19 |
Issuer Purchases of Equity Securities
Fourth Quarter 2011
|
|||||||||
Period
|
Total Number of
Shares
Purchased1
|
Average Price
Per Share
|
Total Number
of Shares
Purchased as
Part of Publicly
Announced Plans
or Programs
|
Maximum
Number of Shares
that May Yet Be
Purchased Under
the Plans or
Programs
|
|||||
October 1 – October 31, 2011
|
7,535
|
$
|
31.02
|
—
|
1,667,724
|
||||
November 1 – November 30, 2011
|
6,892
|
35.30
|
—
|
1,667,724
|
|||||
December 1 – December 31, 2011
|
164,200
|
36.86
|
—
|
1,667,724
|
|||||
TOTAL
|
178,627
|
$
|
36.55
|
|
—
|
1,667,724
|
12/31/2006
|
12/31/2007
|
12/31/2008
|
12/31/2009
|
12/31/2010
|
12/31/2011
|
||||||||||||
Centene Corporation
|
$ | 100.00 | $ | 111.68 | $ | 80.22 | $ | 86.16 | $ | 103.13 | $ | 161.13 | |||||
New York Stock Exchange Composite Index
|
$ | 100.00 | $ | 106.58 | $ | 62.99 | $ | 78.62 | $ | 87.14 | $ | 81.81 | |||||
MS Health Care Payor Index
|
$ | 100.00 | $ | 116.19 | $ | 52.51 | $ | 80.55 | $ | 92.53 | $ | 124.77 |
Year Ended December 31,
|
|||||||||||||||
2011
|
2010
|
2009
|
2008
|
2007
|
|||||||||||
(In thousands, except share data)
|
|||||||||||||||
Revenues:
|
|||||||||||||||
Premium
|
$
|
5,077,242
|
$
|
4,192,172
|
$
|
3,786,525
|
$
|
3,199,360
|
$
|
2,611,953
|
|||||
Service
|
103,765
|
91,661
|
91,758
|
74,953
|
80,508
|
||||||||||
Premium and service revenues
|
5,181,007
|
4,283,833
|
3,878,283
|
3,274,313
|
2,692,461
|
||||||||||
Premium tax
|
159,575
|
164,490
|
224,581
|
90,202
|
76,567
|
||||||||||
Total revenues
|
5,340,582
|
4,448,323
|
4,102,864
|
3,364,515
|
2,769,028
|
||||||||||
Expenses:
|
|||||||||||||||
Medical costs
|
4,324,746
|
3,584,452
|
3,230,131
|
2,704,647
|
2,242,982
|
||||||||||
Cost of services
|
78,114
|
63,919
|
60,789
|
56,920
|
61,348
|
||||||||||
General and administrative expenses
|
587,004
|
477,765
|
447,921
|
380,421
|
332,886
|
||||||||||
Premium tax expense
|
160,394
|
165,118
|
225,888
|
90,966
|
76,567
|
||||||||||
Total operating expenses
|
5,150,258
|
4,291,254
|
3,964,729
|
3,232,954
|
2,713,783
|
||||||||||
Earnings from operations
|
190,324
|
157,069
|
138,135
|
131,561
|
55,245
|
||||||||||
Other income (expense):
|
|||||||||||||||
Investment and other income
|
13,369
|
15,205
|
15,691
|
21,728
|
24,452
|
||||||||||
Debt extinguishment costs
|
(8,488
|
)
|
—
|
—
|
—
|
—
|
|||||||||
Interest expense
|
(20,320
|
)
|
(17,992
|
)
|
(16,318
|
)
|
(16,673
|
)
|
(15,626
|
)
|
|||||
Earnings from continuing operations, before income tax expense
|
174,885
|
154,282
|
137,508
|
136,616
|
64,071
|
||||||||||
Income tax expense
|
66,522
|
59,900
|
48,841
|
52,435
|
23,031
|
||||||||||
Earnings from continuing operations, net of income tax expense
|
108,363
|
94,382
|
88,667
|
84,181
|
41,040
|
||||||||||
Discontinued operations, net of income tax expense (benefit) of $0, $4,388, $(1,204), $(281), and $(31,563), respectively
|
—
|
3,889
|
(2,422
|
)
|
(684
|
)
|
32,362
|
||||||||
Net earnings
|
108,363
|
98,271
|
86,245
|
83,497
|
73,402
|
||||||||||
Noncontrolling interest
|
(2,855
|
)
|
3,435
|
2,574
|
—
|
—
|
|||||||||
Net earnings attributable to Centene Corporation
|
$
|
111,218
|
$
|
94,836
|
$
|
83,671
|
$
|
83,497
|
$
|
73,402
|
|||||
Amounts attributable to Centene Corporation common shareholders:
|
|||||||||||||||
Earnings from continuing operations, net of income tax expense
|
$
|
111,218
|
$
|
90,947
|
$
|
86,093
|
$
|
84,181
|
$
|
41,040
|
|||||
Discontinued operations, net of income tax expense (benefit)
|
—
|
3,889
|
(2,422
|
)
|
(684
|
)
|
32,362
|
||||||||
Net earnings
|
$
|
111,218
|
$
|
94,836
|
$
|
83,671
|
$
|
83,497
|
$
|
73,402
|
|||||
Net earnings (loss) per common share attributable to Centene Corporation:
|
|||||||||||||||
Basic:
|
|||||||||||||||
Continuing operations
|
$
|
2.22
|
$
|
1.87
|
$
|
2.00
|
$
|
1.95
|
$
|
0.95
|
|||||
Discontinued operations
|
—
|
0.08
|
(0.06
|
)
|
(0.02
|
)
|
0.74
|
||||||||
Basic earnings per common share
|
$
|
2.22
|
$
|
1.95
|
$
|
1.94
|
$
|
1.93
|
$
|
1.69
|
|||||
Diluted:
|
|||||||||||||||
Continuing operations
|
$
|
2.12
|
$
|
1.80
|
$
|
1.94
|
$
|
1.90
|
$
|
0.92
|
|||||
Discontinued operations
|
—
|
0.08
|
(0.05
|
)
|
(0.02
|
)
|
0.72
|
||||||||
Diluted earnings per common share
|
$
|
2.12
|
$
|
1.88
|
$
|
1.89
|
$
|
1.88
|
$
|
1.64
|
|||||
Weighted average number of common shares outstanding:
|
|||||||||||||||
Basic
|
50,198,954
|
48,754,947
|
43,034,791
|
43,275,187
|
43,539,950
|
||||||||||
Diluted
|
52,474,238
|
50,447,888
|
44,316,467
|
44,398,955
|
44,823,082
|
December 31,
|
||||||||||||||
2011
|
2010
|
2009
|
2008
|
2007
|
||||||||||
(In thousands)
|
||||||||||||||
Consolidated Balance Sheet Data:
|
||||||||||||||
Cash and cash equivalents
|
$
|
573,698
|
$
|
434,166
|
$
|
400,951
|
$
|
370,999
|
$
|
267,305
|
||||
Investments and restricted deposits
|
663,457
|
639,983
|
585,183
|
451,058
|
369,545
|
|||||||||
Total assets
|
2,190,336
|
1,943,882
|
1,702,364
|
1,451,152
|
1,121,824
|
|||||||||
Medical claims liability
|
607,985
|
456,765
|
470,932
|
384,360
|
323,741
|
|||||||||
Long-term debt
|
348,344
|
327,824
|
307,085
|
264,637
|
206,406
|
|||||||||
Total stockholders’ equity
|
936,419
|
797,055
|
619,427
|
501,272
|
415,047
|
·
|
Year-end at-risk managed care membership of 1,816,000, an increase of 282,500 members, or 18.4% year over year.
|
·
|
Premium and service revenues from continuing operations of $5.2 billion, representing 20.9% growth year over year.
|
·
|
Health Benefits Ratio from continuing operations of 85.2%, compared to 85.5% in 2010.
|
·
|
General and Administrative expense ratio of 11.3%, compared to 11.2% in 2010.
|
·
|
Diluted net earnings per share from continuing operations of $2.12, including $(0.10) of debt extinguishment costs.
|
·
|
Total operating cash flows of $261.7 million, or 2.4 times net earnings.
|
·
|
Arizona. In December 2010, Cenpatico Behavioral Health of Arizona began operating under an expanded contract to manage behavioral healthcare services for an additional four counties. In October 2011, Bridgeway Health Solutions, began operating under an expanded contract to deliver long-term care services in three geographic service areas of Arizona.
|
·
|
Florida. In December 2010, we completed the conversion of non-risk managed care membership from Access Health Solutions LLC to our subsidiary, Sunshine State Health Plan. Additionally, in December 2010, we completed the acquisition of Citrus Health Care, Inc., a Medicaid and long-term care health plan.
|
·
|
Illinois. In May 2011, our new subsidiary, IlliniCare Health Plan, began providing managed care services for older adults and adults with disabilities under the Integrated Care Program in six counties.
|
·
|
Kentucky. In November 2011, our subsidiary, Kentucky Spirit Health Plan, began providing managed care services under a three-year contract with the Kentucky Finance and Administration Cabinet to serve Medicaid beneficiaries.
|
·
|
Massachusetts. In April 2010, we began offering an individual insurance product, under the names of Commonwealth Choice and CeltiCare Direct, for residents who do not qualify for other state funded insurance programs.
|
·
|
Mississippi. In January 2011, we began operating through the Mississippi Coordinated Access Network program to serve Medicaid beneficiaries.
|
·
|
Ohio. In October 2011, Buckeye Community Health Plan began operating under an amended contract with the Ohio Department of Job and Family Services which includes the management of the pharmacy benefit for Buckeye’s members.
|
·
|
South Carolina. In June 2010, we completed the acquisition of Carolina Crescent Health Plan.
|
·
|
Texas. In February 2011, we began operating under an additional STAR+PLUS ABD contract in the Dallas service area and in September 2011, added additional membership through the contiguous county expansion.
|
·
|
In July 2011, Louisiana Healthcare Connections, our joint venture subsidiary, was selected to contract with the Louisiana Department of Health and Hospitals to provide healthcare services to Medicaid enrollees participating in the Bayou Health Program in all three of the state’s geographical services areas. Services for these members commenced in February 2012, with a three-phase membership roll-out ending in the second quarter of 2012.
|
·
|
In August 2011, we were awarded renewed and expanded contracts by the Texas Health and Human Services Commission. The contracts expand Superior’s STAR, STAR+PLUS and CHIP product offerings to include the new 10 county Hidalgo Service Area (STAR and STAR+PLUS), Medicaid RSA West Texas, Medicaid RSA Central Texas, Medicaid RSA North-East Texas and Lubbock (STAR+PLUS). All of the service areas and products will now include the management of the pharmacy benefit for Superior’s members. In addition, the state has added inpatient facility services to the managed care structure for the STAR+PLUS program. Operations in the expanded areas are expected to commence late in the first quarter of 2012.
|
·
|
In 2012, we expect to realize the full year benefit of business commenced during 2011 in Arizona, Illinois, Kentucky, Ohio and Texas, as discussed above.
|
·
|
In 2012, we announced that we were selected to contract with the Washington Health Care Authority to serve Medicaid beneficiaries in the state. Operations are expected to commence in the third quarter of 2012.
|
December 31,
|
|||||
2011
|
2010
|
2009
|
|||
Arizona
|
23,700 | 22,400 | 20,700 | ||
Florida
|
198,300 | 194,900 | 102,600 | ||
Georgia
|
298,200 | 305,800 | 309,700 | ||
Illinois
|
16,300 | — | — | ||
Indiana
|
206,900 | 215,800 | 208,100 | ||
Kentucky
|
180,700 | — | — | ||
Massachusetts
|
35,700 | 36,200 | 27,800 | ||
Mississippi
|
31,600 | — | — | ||
Ohio
|
159,900 | 160,100 | 150,800 | ||
South Carolina
|
82,900 | 90,300 | 48,600 | ||
Texas
|
503,800 | 433,100 | 455,100 | ||
Wisconsin
|
78,000 | 74,900 | 134,800 | ||
Total at-risk membership
|
1,816,000 | 1,533,500 | 1,458,200 | ||
Non-risk membership
|
4,900 | 4,200 | 63,700 | ||
Total
|
1,820,900 | 1,537,700 | 1,521,900 |
December 31,
|
|||||
2011
|
2010
|
2009
|
|||
Medicaid
|
1,336,800 | 1,177,100 | 1,081,400 | ||
CHIP & Foster Care
|
213,900 | 210,500 | 263,600 | ||
ABD & Medicare
|
218,000 | 104,600 | 82,800 | ||
Hybrid Programs
|
40,500 | 36,200 | 27,800 | ||
Long-term Care
|
6,800 | 5,100 | 2,600 | ||
Total at-risk membership
|
1,816,000 | 1,533,500 | 1,458,200 | ||
Non-risk membership
|
4,900 | 4,200 | 63,700 | ||
Total
|
1,820,900 | 1,537,700 | 1,521,900 |
December 31,
|
|||||
2011
|
2010
|
2009
|
|||
Cenpatico Behavioral Health:
|
|||||
Arizona
|
168,900 | 174,600 | 120,100 | ||
Kansas
|
46,200 | 39,200 | 41,400 |
·
|
operations commenced in Illinois, Kentucky and Mississippi
|
·
|
contract awards and geographic expansion in Texas
|
·
|
expanded contract awards in Arizona
|
·
|
acquisitions in Florida and South Carolina
|
·
|
continued conversion of non-risk membership from Access to at-risk under Sunshine State Health Plan in Florida
|
·
|
decreased membership in Texas and Wisconsin resulting from reprocurements
|
2011
|
2010
|
2009
|
% Change
2010 - 2011
|
% Change
2009 - 2010
|
||||||||||||||||
Premium
|
$ | 5,077.2 | $ | 4,192.2 | $ | 3,786.5 | 21.1 | % | 10.7 | % | ||||||||||
Service
|
103.8 | 91.6 | 91.8 | 13.2 | % | (0.1) | % | |||||||||||||
Premium and service revenues
|
5,181.0 | 4,283.8 | 3,878.3 | 20.9 | % | 10.5 | % | |||||||||||||
Premium tax
|
159.6 | 164.5 | 224.6 | (3.0) | % | (26.8) | % | |||||||||||||
Total revenues
|
5,340.6 | 4,448.3 | 4,102.9 | 20.1 | % | 8.4 | % | |||||||||||||
Medical costs
|
4,324.8 | 3,584.5 | 3,230.1 | 20.7 | % | 11.0 | % | |||||||||||||
Cost of services
|
78.1 | 63.9 | 60.8 | 22.2 | % | 5.1 | % | |||||||||||||
General and administrative expenses
|
587.0 | 477.7 | 448.0 | 22.9 | % | 6.7 | % | |||||||||||||
Premium tax expense
|
160.4 | 165.1 | 225.9 | (2.9) | % | (26.9) | % | |||||||||||||
Earnings from operations
|
190.3 | 157.1 | 138.1 | 21.2 | % | 13.7 | % | |||||||||||||
Investment and other income, net
|
(15.4 | ) | (2.8 | ) | (0.6 | ) | 454.0 | % | 344.5 | % | ||||||||||
Earnings from continuing operations, before income tax expense
|
174.9 | 154.3 | 137.5 | 13.4 | % | 12.2 | % | |||||||||||||
Income tax expense
|
66.5 | 59.9 | 48.8 | 11.1 | % | 22.6 | % | |||||||||||||
Earnings from continuing operations, net of income tax expense
|
108.4 | 94.4 | 88.7 | 14.8 | % | 6.4 | % | |||||||||||||
Discontinued operations, net of income tax expense (benefit) of $0, $4.4, and $(1.2) respectively
|
— | 3.9 | (2.4 | ) | (100.0) | % | (260.6) | % | ||||||||||||
Net earnings
|
108.4 | 98.3 | 86.3 | 10.3 | % | 13.9 | % | |||||||||||||
Noncontrolling interest
|
(2.8 | ) | 3.5 | 2.6 | (183.1) | % | 33.4 | % | ||||||||||||
Net earnings attributable to Centene Corporation
|
$ | 111.2 | $ | 94.8 | $ | 83.7 | 17.3 | % | 13.3 | % | ||||||||||
Amounts attributable to Centene Corporation common shareholders:
|
||||||||||||||||||||
Earnings from continuing operations, net of income tax expense
|
$ | 111.2 | $ | 90.9 | $ | 86.1 | 22.3 | % | 5.6 | % | ||||||||||
Discontinued operations, net of income tax expense (benefit)
|
— | 3.9 | (2.4 | ) | (100.0) | % | (260.6) | % | ||||||||||||
Net earnings
|
$ | 111.2 | $ | 94.8 | $ | 83.7 | 17.3 | % | 13.3 | % | ||||||||||
Diluted earnings (loss) per common share attributable to Centene Corporation:
|
||||||||||||||||||||
Continuing operations
|
$ | 2.12 | $ | 1.80 | $ | 1.94 | 17.8 | % | (7.2) | % | ||||||||||
Discontinued operations
|
— | 0.08 | (0.05 | ) | (100.0) | % | (260.0) | % | ||||||||||||
Total diluted earnings per common share
|
$ | 2.12 | $ | 1.88 | $ | 1.89 | 12.8 | % | (0.5) | % |
2011
|
2010
|
2009
|
||||||||||||||||||||||
Medical
Costs
|
HBR
|
Medical
Costs
|
HBR
|
Medical
Costs
|
HBR
|
|||||||||||||||||||
Historical
|
$ | 4,227,916 | 83.3 | % | $ | 3,514,394 | 83.8 | % | $ | 3,163,523 | 83.5 | % | ||||||||||||
Reclassification impact
|
96,830 | 1.9 | 70,058 | 1.7 | 66,608 | 1.8 | ||||||||||||||||||
Revised
|
$ | 4,324,746 | 85.2 | % | $ | 3,584,452 | 85.5 | % | $ | 3,230,131 | 85.3 | % |
2011
|
2010
|
2009
|
||||||||||||||||||||||
G&A Expense
|
G&A
Ratio
|
G&A Expense
|
G&A
Ratio
|
G&A Expense
|
G&A
Ratio
|
|||||||||||||||||||
Historical
|
$ | 683,834 | 13.2 | % | $ | 547,823 | 12.8 | % | $ | 514,529 | 13.3 | % | ||||||||||||
Reclassification impact
|
(96,830 | ) | (1.9 | ) | (70,058 | ) | (1.6 | ) | (66,608 | ) | (1.7 | ) | ||||||||||||
Revised
|
$ | 587,004 | 11.3 | % | $ | 477,765 | 11.2 | % | $ | 447,921 | 11.6 | % |
Year Ended December 31,
|
||||||
2011
|
2010
|
|||||
Medicaid and CHIP
|
82.4 | % | 85.0 | % | ||
ABD and Medicare
|
89.8 | 87.1 | ||||
Specialty Services
|
89.1 | 86.2 | ||||
Total
|
85.2 | 85.5 |
|
The following table summarizes the components of investment and other income, net ($ in millions):
|
Year Ended December 31,
|
||||||||
2011
|
2010
|
|||||||
Investment income
|
$ | 13.1 | $ | 14.9 | ||||
Net gain on sale of investments
|
0.3 | 2.5 | ||||||
Impairment of investment
|
― | (5.5 | ) | |||||
Gain on Reserve Primary Fund distributions
|
― | 3.3 | ||||||
Debt extinguishment costs
|
(8.5 | ) | ― | |||||
Interest expense
|
(20.3 | ) | (18.0 | ) | ||||
Investment and other income, net
|
$ | (15.4 | ) | $ | (2.8 | ) |
2011
|
2010
|
% Change
2010-2011
|
||||||||||
Premium and Service Revenues
|
||||||||||||
Medicaid Managed Care
|
$ | 4,515.5 | $ | 3,740.5 | 20.7 | % | ||||||
Specialty Services
|
1,484.3 | 1,112.1 | 33.5 | % | ||||||||
Eliminations
|
(818.8 | ) | (568.8 | ) | 44.0 | % | ||||||
Consolidated Total
|
$ | 5,181.0 | $ | 4,283.8 | 20.9 | % | ||||||
Earnings from Operations
|
||||||||||||
Medicaid Managed Care
|
$ | 153.0 | $ | 117.1 | 30.6 | % | ||||||
Specialty Services
|
37.3 | 40.0 | (6.6 | ) % | ||||||||
Consolidated Total
|
$ | 190.3 | $ | 157.1 | 21.1 | % |
Year Ended December 31,
|
||||||
2010
|
2009
|
|||||
Medicaid and CHIP
|
85.0 | % | 86.1 | % | ||
ABD and Medicare
|
87.1 | 83.5 | ||||
Specialty Services
|
86.2 | 83.1 | ||||
Total
|
85.5 | 85.3 |
|
The following table summarizes the components of investment and other income, net ($ in millions):
|
Year Ended December 31,
|
||||||||
2010
|
2009
|
|||||||
Investment income
|
$ | 14.9 | $ | 15.6 | ||||
Net gain on sale of investments
|
2.5 | 0.1 | ||||||
Impairment of investment
|
(5.5 | ) | — | |||||
Gain on Reserve Primary Fund distributions
|
3.3 | — | ||||||
Interest expense
|
(18.0 | ) | (16.3 | ) | ||||
Investment and other income, net
|
$ | (2.8 | ) | $ | (0.6 | ) |
2010
|
2009
|
% Change
2009-2010
|
||||||||||
Premium and Service Revenues
|
||||||||||||
Medicaid Managed Care
|
$ | 3,740.5 | $ | 3,464.8 | 8.0 | % | ||||||
Specialty Services
|
1,112.1 | 1,049.5 | 6.0 | % | ||||||||
Eliminations
|
(568.8 | ) | (636.0 | ) | (10.6 | ) % | ||||||
Consolidated Total
|
$ | 4,283.8 | $ | 3,878.3 | 10.5 | % | ||||||
Earnings from Operations
|
||||||||||||
Medicaid Managed Care
|
$ | 117.1 | $ | 99.3 | 17.9 | % | ||||||
Specialty Services
|
40.0 | 38.8 | 2.9 | % | ||||||||
Consolidated Total
|
$ | 157.1 | $ | 138.1 | 13.7 | % |
Year Ended December 31,
|
||||||||||||
2011
|
2010
|
2009
|
||||||||||
Net cash provided by operating activities
|
$
|
261.7
|
$
|
168.9
|
$
|
248.2
|
||||||
Net cash used in investing activities
|
(129.1
|
)
|
(210.6
|
)
|
(270.1
|
)
|
||||||
Net cash provided by financing activities
|
6.9
|
72.1
|
46.6
|
|||||||||
Net increase in cash and cash equivalents
|
$
|
139.5
|
$
|
30.4
|
$
|
24.7
|
Year Ended December 31,
|
||||||||||||
2011
|
2010
|
2009
|
||||||||||
Premium and related receivables
|
$
|
(11.3
|
)
|
$
|
(23.4
|
)
|
$
|
2.4
|
||||
Unearned revenue
|
(109.1
|
)
|
25.7
|
78.3
|
||||||||
Net (decrease) increase in operating cash flow
|
$
|
(120.4
|
)
|
$
|
2.3
|
$
|
80.7
|
2011
|
2010
|
|||||||
Cash, cash equivalents and short-term investments
|
$ | 704.2 | $ | 455.2 | ||||
Long-term investments
|
506.1 | 595.9 | ||||||
Restricted deposits
|
26.8 | 22.8 | ||||||
Total cash, investments and restricted deposits
|
$ | 1,237.1 | $ | 1,073.9 | ||||
Regulated cash, investments and restricted deposits
|
$ | 1,198.9 | $ | 1,043.0 | ||||
Unregulated cash and investments
|
38.2 | 30.9 | ||||||
Consolidated Total
|
$ | 1,237.1 | $ | 1,073.9 |
Payments Due by Period
|
||||||||||||||||||||
Total
|
Less Than
1 Year
|
1-3
Years
|
3-5
Years
|
More Than
5 Years
|
||||||||||||||||
Medical claims liability
|
$ | 607,985 | $ | 607,985 | $ | — | $ | — | $ | — | ||||||||||
Debt and interest
|
467,225 | 21,814 | 51,397 | 42,176 | 351,838 | |||||||||||||||
Operating lease obligations
|
96,002 | 21,187 | 33,307 | 24,504 | 17,004 | |||||||||||||||
Purchase obligations
|
36,271 | 17,086 | 15,546 | 3,439 | 200 | |||||||||||||||
Reserve for uncertain tax positions
|
9,601 | — | 8,034 | 1,567 | — | |||||||||||||||
Other long-term liabilities 1
|
58,359 | 3,651 | 10,810 | 8,614 | 35,284 | |||||||||||||||
Total
|
$ | 1,275,443 | $ | 671,723 | $ | 119,094 | $ | 80,300 | $ | 404,326 |
Completion Factors (1):
|
|
Cost Trend Factors (2):
|
||||||||||
(Decrease)
Increase
in Factors
|
Increase
(Decrease) in
Medical Claims
Liabilities
|
(Decrease)
Increase
in Factors
|
|
Increase
(Decrease) in
Medical Claims
Liabilities
|
||||||||
(in thousands)
|
|
(in thousands) | ||||||||||
(2.0 |
)%
|
$
|
67,000
|
(2.0
|
)%
|
$
|
(16,600
|
)
|
||||
(1.5 |
)
|
49,900
|
(1.5
|
)
|
(12,600
|
)
|
||||||
(1.0 |
)
|
33,000
|
(1.0
|
)
|
(8,400
|
)
|
||||||
(0.5 |
)
|
16,500
|
(0.5
|
)
|
(4,200
|
)
|
||||||
0.5 |
(16,400
|
)
|
0.5
|
4,200
|
||||||||
1.0 |
(32,400
|
)
|
1.0
|
8,500
|
||||||||
1.5 |
(48,500
|
)
|
1.5
|
12,700
|
||||||||
2.0 |
(64,300
|
)
|
2.0
|
17,000
|
||||||||
(1) |
Reflects estimated potential changes in medical claims liability caused by changes in completion factors.
|
|||||||||||
(2) |
Reflects estimated potential changes in medical claims liability caused by changes in cost trend factors for the most recent periods.
|
|
Year Ended December 31,
|
|||||||||||
|
2011
|
2010
|
2009
|
|||||||||
Balance, January 1
|
|
$
|
456,765
|
$
|
470,932
|
$
|
384,360
|
|||||
Incurred related to:
|
|
|||||||||||
Current year
|
|
4,390,123
|
3,652,521
|
3,283,141
|
||||||||
Prior years
|
|
(65,377
|
)
|
(68,069
|
)
|
(53,010
|
)
|
|||||
Total incurred
|
|
4,324,746
|
3,584,452
|
3,230,131
|
||||||||
Paid related to:
|
|
|||||||||||
Current year
|
|
3,788,808
|
3,203,585
|
2,819,591
|
||||||||
Prior years
|
|
384,718
|
395,034
|
323,968
|
||||||||
Total paid
|
|
4,173,526
|
3,598,619
|
3,143,559
|
||||||||
Balance, December 31
|
|
$
|
607,985
|
$
|
456,765
|
$
|
470,932
|
|||||
|
||||||||||||
Claims inventory, December 31
|
|
495,500
|
434,900
|
423,400
|
||||||||
Days in claims payable 1
|
|
45.3
|
44.7
|
49.1
|
·
|
Appropriate leveling of care for neonatal intensive care unit hospital admissions, other inpatient hospital admissions, and observation admissions, in accordance with Interqual criteria.
|
·
|
Tightening of our pre-authorization list and more stringent review of durable medical equipment and injectibles.
|
·
|
Emergency department, or ED, program designed to collaboratively work with hospitals to steer non-emergency care away from the costly ED setting (through patient education, on-site alternative urgent care settings, etc.)
|
·
|
Increase emphasis on case management and clinical rounding where case managers are nurses or social workers who are employed by the health plan to assist selected patients with the coordination of healthcare services in order to meet a patient's specific healthcare needs.
|
·
|
Incorporation of disease management which is a comprehensive, multidisciplinary, collaborative approach to chronic illnesses such as asthma.
|
Intangible Asset
|
Amortization Period
|
|
Purchased contract rights
|
5 – 15 years
|
|
Provider contracts
|
7 – 10 years
|
|
Customer relationships
|
5 – 15 years
|
|
Trade names
|
7 – 20 years
|
December 31,
2011
|
December 31,
2010
|
|||||||
ASSETS
|
||||||||
Current assets:
|
||||||||
Cash and cash equivalents
|
$ | 573,698 | $ | 434,166 | ||||
Premium and related receivables, net of allowance for uncollectible accounts of $639 and $17, respectively
|
157,450 | 136,243 | ||||||
Short-term investments, at fair value (amortized cost $129,232 and $21,141, respectively)
|
130,499 | 21,346 | ||||||
Other current assets
|
78,363 | 65,066 | ||||||
Total current assets
|
940,010 | 656,821 | ||||||
Long-term investments, at fair value (amortized cost $497,805 and $585,862, respectively)
|
506,140 | 595,879 | ||||||
Restricted deposits, at fair value (amortized cost $26,751 and $22,755, respectively)
|
26,818 | 22,758 | ||||||
Property, software and equipment, net of accumulated depreciation of $177,294 and $138,629, respectively
|
349,622 | 326,341 | ||||||
Goodwill
|
281,981 | 278,051 | ||||||
Intangible assets, net
|
27,430 | 29,109 | ||||||
Other long-term assets
|
58,335 | 34,923 | ||||||
Total assets
|
$ | 2,190,336 | $ | 1,943,882 | ||||
LIABILITIES AND STOCKHOLDERS’ EQUITY
|
||||||||
Current liabilities:
|
||||||||
Medical claims liability
|
$ | 607,985 | $ | 456,765 | ||||
Accounts payable and accrued expenses
|
216,504 | 188,320 | ||||||
Unearned revenue
|
9,890 | 117,344 | ||||||
Current portion of long-term debt
|
3,234 | 2,817 | ||||||
Total current liabilities
|
837,613 | 765,246 | ||||||
Long-term debt
|
348,344 | 327,824 | ||||||
Other long-term liabilities
|
67,960 | 53,757 | ||||||
Total liabilities
|
1,253,917 | 1,146,827 | ||||||
Commitments and contingencies
|
||||||||
Stockholders’ equity:
|
||||||||
Common stock, $.001 par value; authorized 100,000,000 shares; 53,586,726 issued and 50,864,618 outstanding at December 31, 2011, and 52,172,037 issued and 49,616,824 outstanding at December 31, 2010
|
54 | 52 | ||||||
Additional paid-in capital
|
421,981 | 384,206 | ||||||
Accumulated other comprehensive income:
|
||||||||
Unrealized gain on investments, net of tax
|
5,761 | 6,424 | ||||||
Retained earnings
|
564,961 | 453,743 | ||||||
Treasury stock, at cost (2,722,108 and 2,555,213 shares, respectively)
|
(57,123 | ) | (50,486 | ) | ||||
Total Centene stockholders’ equity
|
935,634 | 793,939 | ||||||
Noncontrolling interest
|
785 | 3,116 | ||||||
Total stockholders’ equity
|
936,419 | 797,055 | ||||||
Total liabilities and stockholders’ equity
|
$ | 2,190,336 | $ | 1,943,882 |
Year Ended December 31,
|
||||||||||||
|
2011
|
2010
|
2009
|
|||||||||
Revenues:
|
|
|||||||||||
Premium
|
|
$
|
5,077,242
|
$
|
4,192,172
|
$
|
3,786,525
|
|||||
Service
|
|
103,765
|
91,661
|
91,758
|
||||||||
Premium and service revenues
|
5,181,007
|
4,283,833
|
3,878,283
|
|||||||||
Premium tax
|
159,575
|
164,490
|
224,581
|
|||||||||
Total revenues
|
|
5,340,582
|
4,448,323
|
4,102,864
|
||||||||
Expenses:
|
|
|||||||||||
Medical costs
|
|
4,324,746
|
3,584,452
|
3,230,131
|
||||||||
Cost of services
|
|
78,114
|
63,919
|
60,789
|
||||||||
General and administrative expenses
|
|
587,004
|
477,765
|
447,921
|
||||||||
Premium tax expense
|
160,394
|
165,118
|
225,888
|
|||||||||
Total operating expenses
|
|
5,150,258
|
4,291,254
|
3,964,729
|
||||||||
Earnings from operations
|
|
190,324
|
157,069
|
138,135
|
||||||||
Other income (expense):
|
|
|||||||||||
Investment and other income
|
|
13,369
|
15,205
|
15,691
|
||||||||
Debt extinguishment costs
|
(8,488
|
)
|
—
|
—
|
||||||||
Interest expense
|
|
(20,320
|
)
|
(17,992
|
)
|
(16,318
|
)
|
|||||
Earnings from continuing operations, before income tax expense
|
|
174,885
|
154,282
|
137,508
|
||||||||
Income tax expense
|
|
66,522
|
59,900
|
48,841
|
||||||||
Earnings from continuing operations, net of income tax expense
|
108,363
|
94,382
|
88,667
|
|||||||||
Discontinued operations, net of income tax expense (benefit) of $0, $4,388 and $(1,204), respectively
|
—
|
3,889
|
(2,422
|
)
|
||||||||
Net earnings
|
108,363
|
98,271
|
86,245
|
|||||||||
Noncontrolling interest
|
(2,855
|
)
|
3,435
|
2,574
|
||||||||
Net earnings attributable to Centene Corporation
|
|
$
|
111,218
|
$
|
94,836
|
$
|
83,671
|
|||||
Amounts attributable to Centene Corporation common shareholders:
|
||||||||||||
Earnings from continuing operations, net of income tax expense
|
$
|
111,218
|
$
|
90,947
|
$
|
86,093
|
||||||
Discontinued operations, net of income tax expense (benefit)
|
—
|
3,889
|
(2,422
|
)
|
||||||||
Net earnings
|
$
|
111,218
|
$
|
94,836
|
$
|
83,671
|
||||||
Net earnings (loss) per common share attributable to Centene Corporation:
|
|
|||||||||||
Basic:
|
||||||||||||
Continuing operations
|
|
$
|
2.22
|
$
|
1.87
|
$
|
2.00
|
|||||
Discontinued operations
|
|
—
|
0.08
|
(0.06
|
)
|
|||||||
Basic earnings per common share
|
|
$
|
2.22
|
$
|
1.95
|
$
|
1.94
|
|||||
Diluted:
|
|
|||||||||||
Continuing operations
|
|
$
|
2.12
|
$
|
1.80
|
$
|
1.94
|
|||||
Discontinued operations
|
|
—
|
0.08
|
(0.05
|
)
|
|||||||
Diluted earnings per common share
|
|
$
|
2.12
|
$
|
1.88
|
$
|
1.89
|
|||||
Weighted average number of common shares outstanding:
|
|
|||||||||||
Basic
|
|
50,198,954
|
48,754,947
|
43,034,791
|
||||||||
Diluted
|
|
52,474,238
|
50,447,888
|
44,316,467
|
Centene Stockholders’ Equity
|
||||||||||||||||||||||||||
Common Stock
|
Treasury Stock
|
|||||||||||||||||||||||||
$.001 Par
Value
Shares
|
Amt
|
Additional
Paid-in
Capital
|
Accumulated
Other
Comprehensive
Income
|
Retained
Earnings
|
$.001 Par
Value
Shares
|
Amt
|
Non
controlling
Interest
|
Total
|
||||||||||||||||||
Balance, December 31, 2008
|
45,071,179
|
$
|
45
|
$
|
263,835
|
$
|
3,152
|
$
|
275,236
|
2,083,415
|
$
|
(40,996)
|
$
|
—
|
$
|
501,272
|
||||||||||
Consolidation of Access Health Solutions LLC
|
—
|
—
|
—
|
—
|
—
|
—
|
—
|
29,144
|
29,144
|
|||||||||||||||||
Consolidation of Centene Center LLC
|
—
|
—
|
—
|
—
|
—
|
—
|
—
|
17,400
|
17,400
|
|||||||||||||||||
Comprehensive Earnings:
|
||||||||||||||||||||||||||
Net earnings
|
—
|
—
|
—
|
—
|
83,671
|
—
|
—
|
2,574
|
86,245
|
|||||||||||||||||
Change in unrealized investment gains, net of $2,663 tax
|
—
|
—
|
—
|
4,196
|
—
|
—
|
—
|
—
|
4,196
|
|||||||||||||||||
Total comprehensive earnings
|
90,441
|
|||||||||||||||||||||||||
Common stock issued for employee benefit plans
|
522,204
|
1
|
3,284
|
—
|
—
|
—
|
—
|
3,285
|
||||||||||||||||||
Common stock repurchases
|
—
|
—
|
—
|
—
|
—
|
332,595
|
(6,304)
|
—
|
(6,304
|
)
|
||||||||||||||||
Treasury stock issued for compensation
|
—
|
—
|
—
|
—
|
—
|
(2,000)
|
38
|
—
|
38
|
|||||||||||||||||
Stock compensation expense
|
—
|
—
|
14,634
|
—
|
—
|
—
|
—
|
—
|
14,634
|
|||||||||||||||||
Excess tax benefits from stock compensation
|
—
|
—
|
53
|
—
|
—
|
—
|
—
|
—
|
53
|
|||||||||||||||||
Conversion fee1
|
—
|
—
|
—
|
—
|
—
|
—
|
—
|
(27,366)
|
(27,366
|
)
|
||||||||||||||||
Distributions to noncontrolling interest
|
—
|
—
|
—
|
—
|
—
|
—
|
—
|
(3,170)
|
(3,170
|
)
|
||||||||||||||||
Balance, December 31, 2009
|
45,593,383
|
$
|
46
|
$
|
281,806
|
$
|
7,348
|
$
|
358,907
|
2,414,010
|
$
|
(47,262)
|
$
|
18,582
|
$
|
619,427
|
||||||||||
Consolidation of noncontrolling interest
|
—
|
—
|
—
|
—
|
—
|
—
|
—
|
3,104
|
3,104
|
|||||||||||||||||
Comprehensive Earnings:
|
||||||||||||||||||||||||||
Net earnings
|
—
|
—
|
—
|
—
|
94,836
|
—
|
—
|
3,435
|
98,271
|
|||||||||||||||||
Change in unrealized investment gains, net of $(511) tax
|
—
|
—
|
—
|
(924
|
)
|
—
|
—
|
—
|
—
|
(924
|
)
|
|||||||||||||||
Total comprehensive earnings
|
97,347
|
|||||||||||||||||||||||||
Common stock issued for stock offering
|
5,750,000
|
6
|
104,528
|
—
|
—
|
—
|
—
|
—
|
104,534
|
|||||||||||||||||
Common stock issued for employee benefit plans
|
828,654
|
—
|
4,254
|
—
|
—
|
—
|
—
|
—
|
4,254
|
|||||||||||||||||
Issuance of stock warrants
|
—
|
—
|
296
|
—
|
—
|
—
|
—
|
—
|
296
|
|||||||||||||||||
Common stock repurchases
|
—
|
—
|
—
|
—
|
—
|
141,203
|
(3,224)
|
—
|
(3,224
|
)
|
||||||||||||||||
Stock compensation expense
|
—
|
—
|
13,874
|
—
|
—
|
—
|
—
|
—
|
13,874
|
|||||||||||||||||
Excess tax benefits from stock compensation
|
—
|
—
|
868
|
—
|
—
|
—
|
—
|
—
|
868
|
|||||||||||||||||
Redemption / purchase of noncontrolling interest
|
—
|
—
|
(21,420)
|
—
|
—
|
—
|
—
|
(14,056)
|
(35,476
|
)
|
||||||||||||||||
Distributions to noncontrolling interest
|
—
|
—
|
—
|
—
|
—
|
—
|
—
|
(7,949)
|
(7,949
|
)
|
||||||||||||||||
Balance, December 31, 2010
|
52,172,037
|
$
|
52
|
384,206
|
$
|
6,424
|
$
|
453,743
|
2,555,213
|
$
|
(50,486)
|
$
|
3,116
|
$
|
797,055
|
|||||||||||
Comprehensive Earnings:
|
||||||||||||||||||||||||||
Net earnings
|
—
|
—
|
—
|
—
|
111,218
|
—
|
—
|
(2,855)
|
108,363
|
|||||||||||||||||
Change in unrealized investment gain, net of $(334) tax
|
—
|
—
|
—
|
(663)
|
—
|
—
|
—
|
—
|
(663)
|
|||||||||||||||||
Total comprehensive earnings
|
107,700
|
|||||||||||||||||||||||||
Common stock issued for employee benefit plans
|
1,414,689
|
2
|
15,435
|
—
|
—
|
—
|
—
|
—
|
15,437
|
|||||||||||||||||
Exercise of stock warrants
|
—
|
—
|
—
|
—
|
—
|
(50,000)
|
1,172
|
—
|
1,172
|
|||||||||||||||||
Common stock repurchases
|
—
|
—
|
—
|
—
|
—
|
216,895
|
(7,809)
|
—
|
(7,809
|
)
|
||||||||||||||||
Stock compensation expense
|
—
|
—
|
18,171
|
—
|
—
|
—
|
—
|
—
|
18,171
|
|||||||||||||||||
Excess tax benefits from stock compensation
|
—
|
—
|
4,169
|
—
|
—
|
—
|
—
|
—
|
4,169
|
|||||||||||||||||
Contribution from Noncontrolling interest
|
—
|
—
|
—
|
—
|
—
|
—
|
—
|
813
|
813
|
|||||||||||||||||
Deconsolidation of Noncontrolling interest
|
—
|
—
|
—
|
—
|
—
|
—
|
—
|
(289)
|
(289
|
)
|
||||||||||||||||
Balance, December 31, 2011
|
53,586,726
|
$
|
54
|
$
|
421,981
|
$
|
5,761
|
$
|
564,961
|
2,722,108
|
$
|
(57,123)
|
$
|
785
|
$
|
936,419
|
1
|
Conversion fee represents additional purchase price to noncontrolling holders of Access Health Solutions LLC for the transfer of membership to the Company’s wholly-owned subsidiary, Sunshine State Health Plan, Inc.
|
Year Ended December 31,
|
||||||||||
2011
|
2010
|
2009
|
||||||||
Cash flows from operating activities:
|
||||||||||
Net earnings
|
$
|
108,363
|
$
|
98,271
|
$
|
86,245
|
||||
Adjustments to reconcile net earnings to net cash provided by operating activities:
|
||||||||||
Depreciation and amortization
|
58,327
|
52,000
|
44,004
|
|||||||
Stock compensation expense
|
18,171
|
13,874
|
14,634
|
|||||||
Gain on sale of investments, net
|
(287
|
)
|
(6,337
|
)
|
(141
|
)
|
||||
Debt extinguishment costs
|
8,488
|
—
|
—
|
|||||||
(Gain) on sale of UHP
|
—
|
(8,201
|
)
|
—
|
||||||
Impairment loss on Casenet, LLC
|
—
|
5,531
|
—
|
|||||||
Deferred income taxes
|
2,031
|
10,317
|
3,696
|
|||||||
Changes in assets and liabilities:
|
||||||||||
Premium and related receivables
|
(11,306
|
)
|
(23,359
|
)
|
2,379
|
|||||
Other current assets
|
(11,812
|
)
|
(3,240
|
)
|
(1,263
|
)
|
||||
Other assets
|
(2
|
)
|
(2,028
|
)
|
9
|
|||||
Medical claims liability
|
149,756
|
(30,421
|
)
|
79,000
|
||||||
Unearned revenue
|
(109,082
|
)
|
25,700
|
78,345
|
||||||
Accounts payable and accrued expenses
|
38,889
|
37,398
|
(60,915
|
)
|
||||||
Other operating activities
|
10,160
|
(573
|
)
|
2,202
|
||||||
Net cash provided by operating activities
|
261,696
|
168,932
|
248,195
|
|||||||
Cash flows from investing activities:
|
||||||||||
Capital expenditures
|
(68,993
|
)
|
(63,304
|
)
|
(23,721
|
)
|
||||
Capital expenditures of Centene Center LLC
|
(4,715
|
)
|
(55,252
|
)
|
(59,392
|
)
|
||||
Purchase of investments
|
(318,397
|
)
|
(615,506
|
)
|
(791,194
|
)
|
||||
Sales and maturities of investments
|
267,404
|
570,423
|
642,783
|
|||||||
Proceeds from asset sales
|
—
|
13,420
|
—
|
|||||||
Investments in acquisitions, net of cash acquired, and investment in equity method investee
|
(4,375
|
)
|
(60,388
|
)
|
(38,563
|
)
|
||||
Net cash used in investing activities
|
(129,076
|
)
|
(210,607
|
)
|
(270,087
|
)
|
||||
Cash flows from financing activities:
|
||||||||||
Proceeds from exercise of stock options
|
15,815
|
3,419
|
2,365
|
|||||||
Proceeds from borrowings
|
419,183
|
218,538
|
659,059
|
|||||||
Proceeds from stock offering
|
—
|
104,534
|
—
|
|||||||
Payment of long-term debt
|
(416,283
|
)
|
(195,728
|
)
|
(616,219
|
)
|
||||
Purchase of noncontrolling interest
|
—
|
(48,257
|
)
|
—
|
||||||
Distributions from (to) noncontrolling interest
|
813
|
(7,387
|
)
|
8,049
|
||||||
Excess tax benefits from stock compensation
|
4,435
|
963
|
53
|
|||||||
Common stock repurchases
|
(7,809
|
)
|
(3,224
|
)
|
(6,304
|
)
|
||||
Debt issue costs
|
(9,242
|
)
|
(769
|
)
|
(458
|
)
|
||||
Net cash provided by financing activities
|
6,912
|
72,089
|
46,545
|
|||||||
Net increase in cash and cash equivalents
|
139,532
|
30,414
|
24,653
|
|||||||
Cash and cash equivalents, beginning of period
|
434,166
|
403,752
|
379,099
|
|||||||
Cash and cash equivalents, end of period
|
$
|
573,698
|
$
|
434,166
|
$
|
403,752
|
||||
Supplemental disclosures of cash flow information:
|
||||||||||
Interest paid
|
$
|
27,383
|
$
|
17,296
|
$
|
15,428
|
||||
Income taxes paid
|
$
|
50,444
|
$
|
53,938
|
$
|
52,928
|
||||
Supplemental disclosure of non-cash investing and financing activities:
|
||||||||||
Contribution from noncontrolling interest
|
$
|
—
|
$
|
306
|
$
|
5,875
|
||||
Capital expenditures
|
$
|
6,591
|
$
|
8,720
|
$
|
(1,476
|
)
|
·
|
Available for sale investments and restricted deposits: The carrying amount is stated at fair value, based on quoted market prices, where available. For securities not actively traded, fair values were estimated using values obtained from independent pricing services or quoted market prices of comparable instruments.
|
·
|
Senior unsecured notes: Estimated based on third-party quoted market prices for the same or similar issues.
|
·
|
Variable rate debt: The carrying amount of our floating rate debt approximates fair value since the interest rates adjust based on market rate adjustments.
|
·
|
Interest rate swap: Estimated based on third-party market prices based on the forward 3-month LIBOR curve.
|
Fixed Asset
|
Depreciation Period
|
|
Buildings and land improvements
|
5 – 40 years
|
|
Computer hardware and software
|
3 – 10 years
|
|
Furniture and equipment
|
5 – 10 years
|
|
Leasehold improvements
|
1– 20 years
|
Intangible Asset
|
Amortization Period
|
|
Purchased contract rights
|
5 – 15 years
|
|
Provider contracts
|
7 – 10 years
|
|
Customer relationships
|
5 – 15 years
|
|
Trade names
|
7 – 20 years
|
|
2011
|
2010
|
2009
|
|||||||||
Allowances, beginning of year
|
|
$
|
17
|
$
|
1,338
|
$
|
1,304
|
|||||
Amounts charged to expense
|
865
|
(48
|
)
|
285
|
||||||||
Write-offs of uncollectible receivables
|
|
(243
|
)
|
(1,273
|
)
|
(251
|
)
|
|||||
Allowances, end of year
|
|
$
|
639
|
$
|
17
|
$
|
1,338
|
2011
|
2010
|
2009
|
|||||
Georgia
|
13%
|
Georgia
|
17%
|
Georgia
|
19%
|
||
Ohio
|
10%
|
Ohio
|
13%
|
Ohio
|
14%
|
||
Texas
|
26%
|
Texas
|
30%
|
Texas
|
30%
|
·
|
Case management, care coordination, medication & care compliance
|
·
|
Nurse line triage services
|
·
|
Disease management
|
·
|
Cost of health risk assessments
|
·
|
Carolina Crescent Health Plan. In June 2010, the Company acquired certain assets of Carolina Crescent Health Plan, a South Carolina Medicaid managed care organization for $17,993 in total consideration. The Company’s allocation of fair value resulted in goodwill of $16,543 and other identifiable intangible assets of $1,450. The acquisition is recorded in the Medicaid Managed Care segment. All of the goodwill is deductible for income tax purposes.
|
·
|
NovaSys Health, LLC. In July 2010, the Company acquired certain assets and liabilities of NovaSys Health, LLC, a third party administrator in Arkansas and paid $4,330 in cash. The Company’s allocation of fair value resulted in goodwill of $1,444 and other identifiable intangible assets of $3,050 that were recorded in the Specialty Services segment. All of the goodwill is deductible for income tax purposes.
|
·
|
Citrus Health Care, Inc. In December 2010, the Company acquired certain assets in non reform counties of Citrus Health Care, Inc., a Florida Medicaid and long-term care health plan for $28,689. The Company performed a preliminary allocation of fair value that resulted in goodwill of $22,951 and other identifiable intangible assets of $5,738 that were recorded in the Medicaid Managed Care segment. During 2011, the Company finalized the allocation of the fair value that resulted in goodwill of $19,069 and other identifiable intangible assets of $9,620. All of the goodwill is deductible for income tax purposes.
|
·
|
Access Health Solutions, LLC. In December 2010, the Company exercised its right to obtain the remaining assets and ownership interest in Access Health Solutions, LLC, or Access, for zero dollars. Subsequent to the acquisition of the remaining interest, Access continues to be consolidated in the Company’s Medicaid Managed Care segment results as a wholly owned subsidiary of the Company. During 2011, the Company made a conversion payment to the former owners of Access resulting in additional goodwill of $1,773. All of the goodwill is deductible for income tax purposes.
|
·
|
Centene Center LLC. In December 2010, the Company acquired the remaining ownership interest in Centene Center LLC for $48,250. The excess purchase price over the noncontrolling interest was recorded to additional paid in capital, net of the related deferred tax asset of $12,779. Centene Center LLC is a real estate development entity created for the construction of a real estate development that includes the Company’s corporate headquarters. The Company previously reported its investment in Centene Center as a consolidated VIE. Subsequent to the acquisition of the remaining interest, Centene Center LLC continues to be consolidated as a wholly owned subsidiary of the Company. The operating results of Centene Center LLC are included in general and administrative expense of the Company’s Medicaid Managed Care segment.
|
·
|
Casenet, LLC. In December 2010, the Company acquired an additional ownership interest in Casenet, LLC (Casenet) for total consideration of $6,619, bringing its ownership interest to 68%. Casenet is a provider of care management solutions that automate the clinical, administrative, and technical components of care management programs. The Company performed an initial allocation of total consideration to assets acquired and liabilities assumed based on its initial estimates of fair value using methodologies and assumptions that it believed were reasonable. The initial allocation resulted in goodwill of $1,752 and other identifiable intangible assets of $4,500 that were recorded in the Specialty Services segment. During 2011, the Company finalized the allocation of the fair value that resulted in goodwill of $8,975, other identifiable intangible assets of $3,561 and an increase in unearned revenue of $6,284. All of the goodwill is deductible for income tax purposes. During 2011, the Company increased its ownership interest in Casenet to 81%.
|
·
|
Access. In July 2007, the Company acquired a 49% ownership interest in Access, a Medicaid managed care entity in Florida. The Company accounted for its investment in Access using the equity method of accounting through December 31, 2008. During the quarter ended March 31, 2009, the Company began presenting its investment in Access as a consolidated subsidiary in its financial statements. The consolidation of Access resulted in goodwill of approximately $43,400, and other identified intangible assets of approximately $5,400. In 2009, the Company paid an additional $33,927 conversion fee for the transfer of membership from Access to the Company’s wholly-owned subsidiary, Sunshine State Health Plan, Inc.
|
·
|
Additional 2009 Acquisitions. The Company acquired assets of the following entities: Pediatric Associates LLC, effective February 2009, Amerigroup Community Care of South Carolina, Inc., effective March 2009 and InSpeech, Inc., effective July 2009. The Company paid a total of approximately $12,500 in cash for these acquisitions. Goodwill of approximately $9,500 and other identifiable intangible assets of approximately $1,500 were included in the Medicaid Managed Care segment and other identifiable intangible assets of $1,700 were included in the Specialty Services segment, all of which is deductible for income tax purposes.
|
5. Short-term and Long-term Investments and Restricted Deposits
|
December 31, 2011
|
December 31, 2010
|
|||||||||||||||||||||||||||||
Amortized
Cost
|
Gross
Unrealized
Gains
|
Gross
Unrealized
Losses
|
Fair
Value
|
Amortized
Cost
|
Gross
Unrealized
Gains
|
Gross
Unrealized Losses
|
Fair
Value
|
|||||||||||||||||||||||
U.S. Treasury securities and obligations of U.S. government corporations and agencies
|
$ | 29,014 | $ | 638 | $ | (13 | ) | $ | 29,639 | $ | 28,665 | $ | 510 | $ | (140 | ) | $ | 29,035 | ||||||||||||
Corporate securities
|
186,018 | 3,762 | (751 | ) | 189,029 | 197,577 | 3,124 | (586 | ) | 200,115 | ||||||||||||||||||||
Restricted certificates of deposit
|
5,890 | — | — | 5,890 | 6,814 | — | — | 6,814 | ||||||||||||||||||||||
Restricted cash equivalents
|
13,775 | — | — | 13,775 | 8,814 | — | — | 8,814 | ||||||||||||||||||||||
Municipal securities:
|
||||||||||||||||||||||||||||||
General obligation
|
126,806 | 2,828 | (26 | ) | 129,608 | 109,866 | 3,601 | (6 | ) | 113,461 | ||||||||||||||||||||
Pre-refunded
|
33,247 | 465 | — | 33,712 | 32,442 | 756 | — | 33,198 | ||||||||||||||||||||||
Revenue
|
118,507 | 2,387 | (34 | ) | 120,860 | 100,198 | 2,781 | (15 | ) | 102,964 | ||||||||||||||||||||
Variable rate demand notes
|
64,658 | — | — | 64,658 | 106,540 | — | — | 106,540 | ||||||||||||||||||||||
Asset backed securities
|
51,779 | 430 | (17 | ) | 52,192 | 17,391 | 243 | (43 | ) | 17,591 | ||||||||||||||||||||
Cost and equity method investments
|
9,395 | — | — | 9,395 | 7,060 | — | — | 7,060 | ||||||||||||||||||||||
Life insurance contracts
|
14,699 | — | — | 14,699 | 14,391 | — | — | 14,391 | ||||||||||||||||||||||
Total
|
$ | 653,788 | $ | 10,510 | $ | (841 | ) | $ | 663,457 | $ | 629,758 | $ | 11,015 | $ | (790 | ) | $ | 639,983 |
December 31, 2011
|
December 31, 2010
|
||||||||||||||||||||||||||||||
Less Than 12 Months
|
12 Months or More
|
Less Than 12 Months
|
12 Months or More
|
||||||||||||||||||||||||||||
Unrealized
Losses
|
Fair
Value
|
Unrealized
Losses
|
Fair
Value
|
Unrealized
Losses
|
Fair
Value
|
Unrealized
Losses
|
Fair
Value
|
||||||||||||||||||||||||
U.S. Treasury securities and obligations of U.S. government corporations and agencies
|
$ | (13 | ) | $ | 2,184 | $ | — | $ | — | $ | (140 | ) | $ | 9,246 | $ | — | $ | — | |||||||||||||
Corporate securities
|
(751 | ) | 23,040 | — | — | (586 | ) | 40,341 | — | — | |||||||||||||||||||||
Municipal securities:
|
|||||||||||||||||||||||||||||||
General obligation
|
(26 | ) | 3,710 | — | — | (6 | ) | 1,131 | — | — | |||||||||||||||||||||
Revenue
|
(34 | ) | 12,597 | — | — | (15 | ) | 2,419 | — | — | |||||||||||||||||||||
Asset backed securities
|
(17 | ) | 20,417 | — | — | (43 | ) | 5,276 | — | — | |||||||||||||||||||||
Total
|
$ | (841 | ) | $ | 61,948 | $ | — | $ | — | $ | (790 | ) | $ | 58,413 | $ | — | $ | — |
December 31, 2011
|
December 31, 2010
|
||||||||||||||||||||||
Investments
|
Restricted Deposits
|
Investments
|
Restricted Deposits
|
||||||||||||||||||||
Amortized
Cost
|
Fair
Value
|
Amortized
Cost
|
Fair
Value
|
Amortized
Cost
|
Fair
Value
|
Amortized
Cost
|
Fair
Value
|
||||||||||||||||
One year or less
|
$ | 129,232 | $ | 130,499 | $ | 19,666 | $ | 19,666 | $ | 21,141 | $ | 21,346 | $ | 17,387 | $ | 17,392 | |||||||
One year through five years
|
406,140 | 413,953 | 7,085 | 7,152 | 464,270 | 474,255 | 5,368 | 5,366 | |||||||||||||||
Five years through ten years
|
34,945 | 34,961 | — | — | 39,732 | 39,731 | — | — | |||||||||||||||
Greater than ten years
|
56,720 | 57,226 | — | — | 81,860 | 81,893 | — | — | |||||||||||||||
Total
|
$ | 627,037 | $ | 636,639 | $ | 26,751 | $ | 26,818 | $ | 607,003 | $ | 617,225 | $ | 22,755 | $ | 22,758 |
|
2011
|
2010
|
2009
|
|||||||
Gross realized gains
|
|
$
|
314
|
$ |
6,036
|
$
|
1,252
|
|||
Gross realized losses
|
|
(27
|
)
|
(270
|
)
|
(1,111
|
)
|
|||
Impairment of investment
|
—
|
(5,531
|
)
|
—
|
||||||
Net realized gains (losses)
|
|
$
|
287
|
$ |
235
|
$
|
141
|
Level Input:
|
|
Input Definition:
|
Level I
|
|
Inputs are unadjusted, quoted prices for identical assets or liabilities in active markets at the measurement date.
|
Level II
|
|
Inputs other than quoted prices included in Level I that are observable for the asset or liability through corroboration with market data at the measurement date.
|
Level III
|
|
Unobservable inputs that reflect management’s best estimate of what market participants would use in pricing the asset or liability at the measurement date.
|
Level I
|
Level II
|
Level III
|
Total
|
|||||||||||||
Assets
|
||||||||||||||||
Cash and cash equivalents
|
$ | 573,698 | $ | ― | $ | ― | $ | 573,698 | ||||||||
Investments available for sale:
|
||||||||||||||||
U.S. Treasury securities and obligations of U.S. government corporations and agencies
|
$ | 17,091 | $ | 5,395 | $ | ― | $ | 22,486 | ||||||||
Corporate securities
|
― | 189,029 | ― | 189,029 | ||||||||||||
Municipal securities:
|
||||||||||||||||
General obligation
|
― | 129,608 | ― | 129,608 | ||||||||||||
Pre-refunded
|
― | 33,712 | ― | 33,712 | ||||||||||||
Revenue
|
― | 120,860 | ― | 120,860 | ||||||||||||
Variable rate demand notes
|
― | 64,658 | ― | 64,658 | ||||||||||||
Asset backed securities
|
― | 52,192 | ― | 52,192 | ||||||||||||
Total investments
|
$ | 17,091 | $ | 595,454 | $ | ― | $ | 612,545 | ||||||||
Restricted deposits available for sale:
|
||||||||||||||||
Cash and cash equivalents
|
$ | 13,775 | $ | ― | $ | ― | $ | 13,775 | ||||||||
Certificates of deposit
|
5,890 | ― | ― | 5,890 | ||||||||||||
U.S. Treasury securities and obligations of U.S. government corporations and agencies
|
7,153 | ― | ― | 7,153 | ||||||||||||
Total restricted deposits
|
$ | 26,818 | $ | ― | $ | ― | $ | 26,818 | ||||||||
Interest rate swap contract
|
$ | ― | $ | 11,431 | $ | ― | $ | 11,431 | ||||||||
Total assets at fair value
|
$ | 617,607 | $ | 606,885 | $ | ― | $ | 1,224,492 |
Level I
|
Level II
|
Level III
|
Total
|
|||||||||||||
Assets
|
||||||||||||||||
Cash and cash equivalents
|
$ | 434,166 | $ | ― | $ | ― | $ | 434,166 | ||||||||
Investments available for sale:
|
||||||||||||||||
U.S. Treasury securities and obligations of U.S. government corporations and agencies
|
$ | 14,809 | $ | 7,096 | $ | ― | $ | 21,905 | ||||||||
Corporate securities
|
― | 200,115 | ― | 200,115 | ||||||||||||
Municipal securities:
|
||||||||||||||||
General obligation
|
― | 113,461 | ― | 113,461 | ||||||||||||
Pre-refunded
|
― | 33,198 | ― | 33,198 | ||||||||||||
Revenue
|
― | 102,964 | ― | 102,964 | ||||||||||||
Variable rate demand notes
|
― | 106,540 | ― | 106,540 | ||||||||||||
Asset backed securities
|
― | 17,591 | ― | 17,591 | ||||||||||||
Total investments
|
$ | 14,809 | $ | 580,965 | $ | ― | $ | 595,774 | ||||||||
Restricted deposits available for sale:
|
||||||||||||||||
Cash and cash equivalents
|
$ | 8,814 | $ | ― | $ | ― | $ | 8,814 | ||||||||
Certificates of deposit
|
6,814 | ― | ― | 6,814 | ||||||||||||
U.S. Treasury securities and obligations of U.S. government corporations and agencies
|
7,130 | ― | ― | 7,130 | ||||||||||||
Total restricted deposits
|
$ | 22,758 | $ | ― | $ | ― | $ | 22,758 | ||||||||
Total assets at fair value
|
$ | 471,733 | $ | 580,965 | $ | ― | $ | 1,052,698 |
2011
|
2010
|
|||||||
Computer software
|
$ | 158,672 | $ | 141,918 | ||||
Building
|
186,194 | 171,072 | ||||||
Land
|
47,614 | 44,282 | ||||||
Computer hardware
|
51,805 | 35,639 | ||||||
Furniture and office equipment
|
37,865 | 33,812 | ||||||
Leasehold improvements
|
44,766 | 38,247 | ||||||
526,916 | 464,970 | |||||||
Less accumulated depreciation
|
(177,294 | ) | (138,629 | ) | ||||
Property, software and equipment, net
|
$ | 349,622 | $ | 326,341 |
Medicaid Managed Care
|
Specialty
Services
|
Total
|
|||||||||
Balance as of December 31, 2009
|
$ | 111,063 | $ | 113,524 | $ | 224,587 | |||||
Acquisitions
|
43,633 | 9,831 | 53,464 | ||||||||
Balance as of December 31, 2010
|
$ | 154,696 | $ | 123,355 | $ | 278,051 | |||||
Acquisitions
|
1,773 | ― | 1,773 | ||||||||
Other adjustments
|
(5,067 | ) | 7,224 | 2,157 | |||||||
Balance as of December 31, 2011
|
$ | 151,402 | $ | 130,579 | $ | 281,981 |
|
Weighted
Average Life
in Years
|
||||||||||
|
2011
|
2010
|
2011
|
2010
|
|||||||
Purchased contract rights
|
|
$
|
21,988
|
$
|
20,185
|
7.5
|
6.9
|
||||
Provider contracts
|
|
2,737
|
2,578
|
9.8
|
10.0
|
||||||
Customer relationships
|
16,056
|
16,056
|
7.9
|
7.7
|
|||||||
Trade names
|
|
6,495
|
5,595
|
16.3
|
18.9
|
||||||
Intangible assets
|
|
47,276
|
44,414
|
9.0
|
8.9
|
||||||
Less accumulated amortization:
|
|
||||||||||
Purchased contract rights
|
|
(8,554
|
)
|
(7,053
|
)
|
||||||
Provider contracts
|
|
(931
|
)
|
(697
|
)
|
||||||
Customer relationships
|
(8,753
|
)
|
(6,278
|
)
|
|||||||
Trade names
|
|
(1,608
|
)
|
(1,277
|
)
|
||||||
Total accumulated amortization
|
|
(19,846
|
)
|
(15,305
|
)
|
||||||
Intangible assets, net
|
|
$
|
27,430
|
$
|
29,109
|
Year
|
Expense
|
||
2012
|
$ | 5,200 | |
2013
|
4,700 | ||
2014
|
4,300 | ||
2015
|
3,500 | ||
2016
|
3,000 |
2011
|
2010
|
2009
|
||||||||
Current provision:
|
||||||||||
Federal
|
$
|
59,641
|
$
|
46,259
|
$
|
41,310
|
||||
State and local
|
5,186
|
6,868
|
5,578
|
|||||||
Total current provision
|
64,827
|
53,127
|
46,888
|
|||||||
Deferred provision
|
1,695
|
6,773
|
1,953
|
|||||||
Total provision for income taxes
|
$
|
66,522
|
$
|
59,900
|
$
|
48,841
|
|
2011
|
2010
|
2009
|
||||||
Earnings from continuing operations, before income tax expense
|
|
$
|
174,885
|
$
|
154,282
|
$
|
137,508
|
||
Less noncontrolling interest
|
|
(2,855)
|
3,435
|
2,574
|
|||||
Earnings from continuing operations, less noncontrolling interest, before income tax expense
|
177,740
|
150,847
|
134,934
|
||||||
Tax provision at the U.S. federal statutory rate
|
62,209
|
52,797
|
47,227
|
||||||
State income taxes, net of federal income tax benefit
|
|
3,411
|
6,231
|
2,419
|
|||||
Other, net
|
902
|
872
|
(805)
|
||||||
Income tax expense
|
|
$
|
66,522
|
$
|
59,900
|
$
|
48,841
|
||
Effective tax rate
|
37.4%
|
39.7%
|
36.2%
|
2011
|
2010
|
|||||||
Deferred tax assets:
|
||||||||
Current:
|
||||||||
Medical claims liability and other accruals
|
$ | 39,864 | $ | 25,418 | ||||
Unearned premium and other deferred revenue
|
985 | 8,934 | ||||||
Other
|
640 | 1,999 | ||||||
Current deferred tax assets
|
41,489 | 36,351 | ||||||
Valuation allowance
|
(2,896 | ) | (741 | ) | ||||
Net current deferred tax assets
|
$ | 38,593 | $ | 35,610 | ||||
Non-current deferred tax assets:
|
||||||||
State net operating loss carry forward
|
$ | 8,761 | $ | 4,841 | ||||
Purchase of noncontrolling interest
|
― | 13,223 | ||||||
Stock compensation
|
13,234 | 13,676 | ||||||
Other
|
13,456 | 8,599 | ||||||
Non-current deferred tax assets
|
35,451 | 40,339 | ||||||
Valuation allowance
|
(5,625 | ) | (4,400 | ) | ||||
Net non-current deferred tax assets
|
$ | 29,826 | $ | 35,939 | ||||
Deferred tax liabilities:
|
||||||||
Current:
|
||||||||
Prepaid assets and other
|
$ | 5,788 | $ | 4,350 | ||||
Net current deferred tax liabilities
|
$ | 5,788 | $ | 4,350 | ||||
Non-current deferred tax liabilities:
|
||||||||
Intangible assets
|
$ | 10,756 | $ | 11,519 | ||||
Depreciation and amortization
|
31,398 | 34,743 | ||||||
Unrealized gain on investments
|
2,877 | 3,613 | ||||||
Other
|
2,620 | 2,777 | ||||||
Net non-current deferred tax liabilities
|
$ | 47,651 | $ | 52,652 | ||||
Net deferred tax assets
|
$ | 14,980 | $ | 14,547 |
2011
|
2010
|
|||||||
Balance as January 1
|
$ | 3,036 | $ | 5,465 | ||||
Increase based on tax positions during the current year
|
10,863 | 231 | ||||||
Decreases based on tax positions taken in a prior period
|
(347 | ) | (2,660 | ) | ||||
Balance as of December 31
|
$ | 13,552 | $ | 3,036 |
Year Ended December 31,
|
||||||||||||
2011
|
2010
|
2009
|
||||||||||
Balance, January 1,
|
$ | 456,765 | $ | 470,932 | $ | 384,360 | ||||||
Incurred related to:
|
||||||||||||
Current year
|
4,390,123 | 3,652,521 | 3,283,141 | |||||||||
Prior years
|
(65,377 | ) | (68,069 | ) | (53,010 | ) | ||||||
Total incurred
|
4,324,746 | 3,584,452 | 3,230,131 | |||||||||
Paid related to:
|
||||||||||||
Current year
|
3,788,808 | 3,203,585 | 2,819,591 | |||||||||
Prior years
|
384,718 | 395,034 | 323,968 | |||||||||
Total paid
|
4,173,526 | 3,598,619 | 3,143,559 | |||||||||
Balance, December 31,
|
$ | 607,985 | $ | 456,765 | $ | 470,932 |
2011
|
2010
|
|||||||
Senior notes, at par
|
$ | 250,000 | $ | 175,000 | ||||
Unamortized discount on Senior notes
|
(2,814 | ) | ― | |||||
Interest rate swap fair value
|
11,431 | ― | ||||||
Senior notes, net
|
258,617 | 175,000 | ||||||
Revolving credit agreement
|
― | 60,000 | ||||||
Mortgage notes payable
|
86,948 | 89,500 | ||||||
Capital leases and other
|
6,013 | 6,141 | ||||||
Total debt
|
351,578 | 330,641 | ||||||
Less current portion
|
(3,234 | ) | (2,817 | ) | ||||
Long-term debt
|
$ | 348,344 | $ | 327,824 |
2012
|
$ | 3,212 | |
2013
|
3,372 | ||
2014
|
11,343 | ||
2015
|
3,173 | ||
2016
|
3,337 | ||
Thereafter
|
318,524 | ||
Total
|
$ | 342,961 |
Shares
|
Weighted Average
Exercise Price
|
Aggregate Intrinsic Value
|
Weighted
Average Remaining
Contractual Term
|
|||||||
Outstanding as of December 31, 2010
|
3,138,521
|
$
|
20.71
|
|||||||
Granted
|
10,000
|
31.39
|
||||||||
Exercised
|
(914,859)
|
20.65
|
||||||||
Forfeited
|
(37,100)
|
23.73
|
||||||||
Outstanding as of December 31, 2011
|
2,196,562
|
$
|
20.75
|
$
|
41,393
|
3.9
|
||||
Exercisable as of December 31, 2011
|
2,000,662
|
$
|
20.68
|
$
|
37,837
|
3.6
|
Year Ended December 31,
|
|||||||||
2011
|
2010
|
2009
|
|||||||
Expected life (in years)
|
5.2 | 5.8 | 5.8 | ||||||
Risk-free interest rate
|
0.9 | % | 2.7 | % | 2.2 | % | |||
Expected volatility
|
49.9 | % | 48.2 | % | 50.9 | % | |||
Expected dividend yield
|
0 | % | 0 | % | 0 | % |
Year Ended December 31,
|
|||||||||||
2011
|
2010
|
2009
|
|||||||||
Weighted-average fair value of options granted
|
$ | 13.94 | $ | 11.60 | $ | 8.76 | |||||
Total intrinsic value of stock options exercised
|
$ | 11,744 | $ | 1,999 | $ | 2,192 |
Shares
|
Weighted
Average
Grant Date
Fair Value
|
||||||
Non-vested balance as of December 31, 2010
|
1,868,035
|
$
|
22.62
|
||||
Granted
|
982,363
|
35.32
|
|||||
Vested
|
(698,110
|
)
|
21.55
|
||||
Forfeited
|
(33,685
|
)
|
20.69
|
||||
Non-vested balance as of December 31, 2011
|
2,118,603
|
$
|
28.55
|
2012
|
$ | 21,187 | ||
2013
|
17,858 | |||
2014
|
15,449 | |||
2015
|
12,884 | |||
2016
|
11,620 | |||
Thereafter
|
17,004 | |||
$ | 96,002 |
2011
|
2010
|
2009
|
||||||||||
Earnings (loss) attributable to Centene Corporation common shareholders:
|
||||||||||||
Earnings from continuing operations, net of tax
|
$ | 111,218 | $ | 90,947 | $ | 86,093 | ||||||
Discontinued operations, net of tax
|
― | 3,889 | (2,422 | ) | ||||||||
Net earnings
|
$ | 111,218 | $ | 94,836 | $ | 83,671 | ||||||
Shares used in computing per share amounts:
|
||||||||||||
Weighted average number of common shares outstanding
|
50,198,954 | 48,754,947 | 43,034,791 | |||||||||
Common stock equivalents (as determined by applying the treasury stock method)
|
2,275,284 | 1,692,941 | 1,281,676 | |||||||||
Weighted average number of common shares and potential dilutive common shares outstanding
|
52,474,238 | 50,447,888 | 44,316,467 | |||||||||
Net earnings (loss) per share attributable to Centene Corporation:
|
||||||||||||
Basic:
|
||||||||||||
Continuing operations
|
$ | 2.22 | $ | 1.87 | $ | 2.00 | ||||||
Discontinued operations
|
― | 0.08 | (0.06 | ) | ||||||||
Earnings per common share
|
$ | 2.22 | $ | 1.95 | $ | 1.94 | ||||||
Diluted:
|
||||||||||||
Continuing operations
|
$ | 2.12 | $ | 1.80 | $ | 1.94 | ||||||
Discontinued operations
|
― | 0.08 | (0.05 | ) | ||||||||
Earnings per common share
|
$ | 2.12 | $ | 1.88 | $ | 1.89 |
Medicaid
Managed Care
|
Specialty
Services
|
Eliminations
|
Consolidated
Total
|
||||||||||||
Premium and service revenues from external customers
|
$ | 4,450,336 | $ | 730,671 | $ | — | $ | 5,181,007 | |||||||
Premium and service revenues from internal customers
|
65,215 | 753,596 | (818,811 | ) | — | ||||||||||
Total premium and service revenues
|
4,515,551 | 1,484,267 | (818,811 | ) | 5,181,007 | ||||||||||
Earnings from operations
|
152,995 | 37,329 | — | 190,324 | |||||||||||
Total assets
|
1,754,108 | 436,228 | — | 2,190,336 |
Medicaid
Managed Care
|
Specialty
Services
|
Eliminations
|
Consolidated
Total
|
||||||||||||
Premium and service revenues from external customers
|
$ | 3,679,807 | $ | 604,026 | $ | — | $ | 4,283,833 | |||||||
Premium and service revenues from internal customers
|
60,676 | 508,157 | (568,833 | ) | — | ||||||||||
Total premium and service revenues
|
3,740,483 | 1,112,183 | (568,833 | ) | 4,283,833 | ||||||||||
Earnings from operations
|
117,106 | 39,963 | — | 157,069 | |||||||||||
Total assets
|
1,552,886 | 390,996 | — | 1,943,882 |
Medicaid
Managed Care
|
Specialty
Services
|
Eliminations
|
Consolidated
Total
|
||||||||||||
Premium and service revenues from external customers
|
$ | 3,398,009 | $ | 480,274 | $ | — | $ | 3,878,283 | |||||||
Premium and service revenues from internal customers
|
66,763 | 569,191 | (635,954 | ) | — | ||||||||||
Total premium and service revenues
|
3,464,772 | 1,049,465 | (635,954 | ) | 3,878,283 | ||||||||||
Earnings from operations
|
99,307 | 38,828 | — | 138,135 | |||||||||||
Total assets
|
1,330,987 | 371,377 | — | 1,702,364 |
Year Ended December 31,
|
|||||||||||
2011
|
2010
|
2009
|
|||||||||
Net earnings
|
$ | 111,218 | $ | 94,836 | $ | 83,671 | |||||
Other comprehensive earnings, net of tax:
|
|||||||||||
Change in unrealized gains on investments available for sale securities
|
(114 | ) | 736 | 3,944 | |||||||
Reclassification adjustment
|
(549 | ) | (1,660 | ) | 252 | ||||||
Unrealized gain on available for sale securities
|
(663 | ) | (924 | ) | 4,196 | ||||||
Other Comprehensive earnings
|
110,555 | 93,912 | 87,867 | ||||||||
Less: Comprehensive earnings attributable to the noncontrolling interest
|
(2,855 | ) | 3,435 | 2,574 | |||||||
Comprehensive earnings attributable to Centene Corporation
|
$ | 113,410 | $ | 90,477 | $ | 85,293 |
For the Quarter Ended
|
||||||||||||||||
March 31,
2011
|
June 30,
2011
|
September 30,
2011
|
December 31,
2011
|
|||||||||||||
Total revenues
|
$ | 1,216,357 | $ | 1,315,014 | $ | 1,302,035 | $ | 1,507,176 | ||||||||
Amounts attributable to Centene Corporation common shareholders:
|
||||||||||||||||
Earnings from continuing operations, net of income tax expense
|
23,745 | 28,374 | 28,987 | 30,112 | ||||||||||||
Discontinued operations, net of income tax expense
|
— | — | — | — | ||||||||||||
Net earnings
|
$ | 23,745 | $ | 28,374 | $ | 28,987 | $ | 30,112 | ||||||||
Net earnings per share attributable to Centene Corporation:
|
||||||||||||||||
Basic:
|
||||||||||||||||
Continued operations
|
$ | 0.48 | $ | 0.57 | $ | 0.58 | $ | 0.60 | ||||||||
Discontinued operations
|
— | — | — | — | ||||||||||||
Basic earnings per common share
|
$ | 0.48 | $ | 0.57 | $ | 0.58 | $ | 0.60 | ||||||||
Diluted:
|
||||||||||||||||
Continued operations
|
$ | 0.46 | $ | 0.54 | $ | 0.55 | $ | 0.57 | ||||||||
Discontinued operations
|
— | — | — | — | ||||||||||||
Diluted earnings per common share
|
$ | 0.46 | $ | 0.54 | $ | 0.55 | $ | 0.57 | ||||||||
Health Benefits Ratio
|
84.9 | % | 84.8 | % | 85.0 | % | 85.9 | % | ||||||||
General & Administrative Expense Ratio
|
12.0 | % | 11.2 | % | 11.3 | % | 11.0 | % | ||||||||
Period end at-risk membership
|
1,542,500 | 1,580,500 | 1,615,700 | 1,816,000 |
For the Quarter Ended
|
||||||||||||||||
March 31,
2010
|
June 30,
2010
|
September 30,
2010
|
December 31,
2010
|
|||||||||||||
Total revenues
|
$ | 1,068,721 | $ | 1,076,772 | $ | 1,121,861 | $ | 1,180,969 | ||||||||
Amounts attributable to Centene Corporation common shareholders:
|
||||||||||||||||
Earnings from continuing operations, net of income tax expense
|
20,082 | 22,999 | 22,402 | 25,464 | ||||||||||||
Discontinued operations, net of income tax expense (benefit)
|
3,920 | (226 | ) | 260 | (65 | ) | ||||||||||
Net earnings
|
$ | 24,002 | $ | 22,773 | $ | 22,662 | $ | 25,399 | ||||||||
Net earnings per share attributable to Centene Corporation:
|
||||||||||||||||
Basic:
|
||||||||||||||||
Continued operations
|
$ | 0.43 | $ | 0.46 | $ | 0.46 | $ | 0.52 | ||||||||
Discontinued operations
|
0.08 | — | — | — | ||||||||||||
Basic earnings per common share
|
$ | 0.51 | $ | 0.46 | $ | 0.46 | $ | 0.52 | ||||||||
Diluted:
|
||||||||||||||||
Continued operations
|
$ | 0.41 | $ | 0.45 | $ | 0.44 | $ | 0.50 | ||||||||
Discontinued operations
|
0.08 | — | — | — | ||||||||||||
Diluted earnings per common share
|
$ | 0.49 | $ | 0.45 | $ | 0.44 | $ | 0.50 | ||||||||
Health Benefits Ratio
|
85.7 | % | 85.4 | % | 85.9 | % | 85.0 | % | ||||||||
General & Administrative Expense Ratio
|
11.7 | % | 11.1 | % | 10.6 | % | 11.3 | % | ||||||||
Period end at-risk membership
|
1,471,300 | 1,534,600 | 1,473,800 | 1,533,500 |
December 31,
|
||||||||
2011
|
2010
|
|||||||
ASSETS
|
||||||||
Current assets:
|
||||||||
Cash and cash equivalents
|
$ | 28,527 | $ | 9,380 | ||||
Short-term investments, at fair value (amortized cost $0 and $560, respectively)
|
— | 568 | ||||||
Other current assets
|
36,354 | 102,754 | ||||||
Total current assets
|
64,881 | 112,702 | ||||||
Long-term investments, at fair value (amortized cost $4,164 and 10,848, respectively)
|
4,164 | 11,109 | ||||||
Investment in subsidiaries
|
1,105,491 | 898,601 | ||||||
Other long-term assets
|
32,105 | 17,134 | ||||||
Total assets
|
$ | 1,206,641 | $ | 1,039,546 | ||||
LIABILITIES AND STOCKHOLDERS’ EQUITY
|
||||||||
Current liabilities
|
$ | 3,100 | $ | 6,193 | ||||
Long-term debt
|
258,617 | 235,000 | ||||||
Other long-term liabilities
|
8,505 | 1,298 | ||||||
Total liabilities
|
270,222 | 242,491 | ||||||
Stockholders’ equity:
|
||||||||
Common stock, $.001 par value; authorized 100,000,000 shares; 53,586,726 issued and 50,864,618 outstanding at December 31, 2011, and 52,172,037 issued and 49,616,824 outstanding at December 31, 2010
|
54 | 52 | ||||||
Additional paid-in capital
|
421,981 | 384,206 | ||||||
Accumulated other comprehensive income:
|
||||||||
Unrealized gain on investments, net of tax
|
5,761 | 6,424 | ||||||
Retained earnings
|
564,961 | 453,743 | ||||||
Treasury stock, at cost (2,722,108 and 2,555,213 shares, respectively)
|
(57,123 | ) | (50,486 | ) | ||||
Total Centene stockholders’ equity
|
935,634 | 793,939 | ||||||
Noncontrolling interest
|
785 | 3,116 | ||||||
Total stockholders’ equity
|
936,419 | 797,055 | ||||||
Total liabilities and stockholders’ equity
|
$ | 1,206,641 | $ | 1,039,546 |
Year Ended December 31,
|
||||||||||||
2011
|
2010
|
2009
|
||||||||||
Expenses:
|
||||||||||||
General and administrative expenses
|
$
|
(4,488
|
)
|
$
|
(3,502
|
)
|
$
|
(2,906
|
)
|
|||
Other income (expense):
|
||||||||||||
Investment and other income
|
(8,790
|
)
|
(4,700
|
)
|
6
|
|||||||
Interest expense
|
(15,494
|
)
|
(14,844
|
)
|
(15,692
|
)
|
||||||
Loss before income taxes
|
(28,772
|
)
|
(23,046
|
)
|
(18,592
|
)
|
||||||
Income tax benefit
|
(12,825
|
)
|
(8,576
|
)
|
(6,004
|
)
|
||||||
Net earnings (loss) before equity in subsidiaries
|
(15,947
|
)
|
(14,470
|
)
|
(12,588
|
)
|
||||||
Equity in earnings from subsidiaries
|
127,165
|
109,306
|
96,259
|
|||||||||
Net earnings
|
$
|
111,218
|
$
|
94,836
|
$
|
83,671
|
||||||
Net earnings per share from continuing operations:
|
||||||||||||
Basic earnings per common share
|
$
|
2.22
|
$
|
1.87
|
$
|
2.00
|
||||||
Diluted earnings per common share
|
$
|
2.12
|
$
|
1.80
|
$
|
1.94
|
||||||
Weighted average number of shares outstanding:
|
||||||||||||
Basic
|
50,198,954
|
48,754,947
|
43,034,791
|
|||||||||
Diluted
|
52,474,238
|
50,447,888
|
44,316,467
|
Year Ended December 31,
|
||||||||||||
2011
|
2010
|
2009
|
||||||||||
Cash flows from operating activities:
|
||||||||||||
Cash provided by operating activities
|
$
|
72,754
|
$
|
23,504
|
$
|
92,711
|
||||||
Cash flows from investing activities:
|
||||||||||||
Net dividends from and capital contributions to subsidiaries
|
(50,581
|
)
|
(17,172
|
)
|
(67,328
|
)
|
||||||
Purchase of investments
|
(21,915
|
)
|
(86,549
|
)
|
(17,181
|
)
|
||||||
Sales and maturities of investments
|
11,111
|
90,121
|
9,189
|
|||||||||
Acquisitions, net of cash acquired
|
(1,773
|
)
|
(48,656
|
)
|
(38,563
|
)
|
||||||
Proceeds from asset sales
|
—
|
13,420
|
—
|
|||||||||
Net cash used in investing activities
|
(63,158
|
)
|
(48,836
|
)
|
(113,883
|
)
|
||||||
Cash flows from financing activities:
|
||||||||||||
Proceeds from borrowings
|
419,183
|
91,000
|
616,500
|
|||||||||
Payment of long-term debt and notes payable
|
(413,644
|
)
|
(115,000
|
)
|
(595,500
|
)
|
||||||
Proceeds from exercise of stock options
|
15,815
|
3,419
|
2,365
|
|||||||||
Common stock offering
|
—
|
104,534
|
—
|
|||||||||
Common stock repurchases
|
(7,809
|
)
|
(3,224
|
)
|
(6,304
|
)
|
||||||
Debt issue costs
|
(9,242
|
)
|
—
|
(368
|
)
|
|||||||
Distribution to noncontrolling interest
|
—
|
(8,158
|
)
|
(3,170
|
)
|
|||||||
Contributions from noncontrolling interest
|
813
|
771
|
11,219
|
|||||||||
Purchase of noncontrolling interest
|
—
|
(48,257
|
)
|
—
|
||||||||
Excess tax benefits from stock compensation
|
4,435
|
963
|
53
|
|||||||||
Net cash provided by financing activities
|
9,551
|
26,048
|
24,795
|
|||||||||
Net increase (decrease) in cash and cash equivalents
|
19,147
|
716
|
3,623
|
|||||||||
Cash and cash equivalents, beginning of period
|
9,380
|
8,664
|
5,041
|
|||||||||
Cash and cash equivalents, end of period
|
$
|
28,527
|
$
|
9,380
|
$
|
8,664
|
||||||
(a)
|
Financial Statements and Schedules
|
Report of Independent Registered Public Accounting Firm
|
Consolidated Balance Sheets as of December 31, 2011 and 2010
|
Consolidated Statements of Operations for the Years Ended December 31, 2011, 2010 and 2009
|
Consolidated Statements of Stockholders’ Equity for the Years Ended December 31, 2011, 2010 and 2009
|
Consolidated Statements of Cash Flows for the Years Ended December 31, 2011, 2010 and 2009
|
Notes to Consolidated Financial Statements
|
INCORPORATED BY REFERENCE 1
|
|||||||||||
EXHIBIT
NUMBER
|
DESCRIPTION
|
FILED WITH
THIS
FORM 10-K
|
FORM
|
FILING DATE
WITH SEC
|
EXHIBIT
NUMBER
|
||||||
3.1 |
Certificate of Incorporation of Centene Corporation
|
S-1 |
October 9, 2001
|
3.2 | |||||||
3.1a |
Certificate of Amendment to Certificate of Incorporation of Centene Corporation, dated November 8, 2001
|
S-1/A |
November 13, 2001
|
3.2 | a | ||||||
3.1b |
Certificate of Amendment to Certificate of Incorporation of Centene Corporation as filed with the Secretary of State of the State of Delaware
|
10-Q |
July 26, 2004
|
3.1 | b | ||||||
3.2 |
By-laws of Centene Corporation
|
S-1 |
October 9, 2001
|
3.4 | |||||||
4.1 |
Rights Agreement between Centene Corporation and Mellon Investor Services LLC, as Rights Agent, dated August 30, 2002
|
8-K |
August 30, 2002
|
4.1 | |||||||
4.1a |
Amendment No. 1 to Rights Agreement by and between Centene Corporation and Mellon Investor Services LLC, as Rights Agent, dated April 23, 2007
|
8-K |
April 26, 2007
|
4.1 | |||||||
4.2 |
Indenture, dated May 27, 2011, among the Company and The Bank of New York Mellon Trust Company, N.A., relating to the Company's 5.75% Senior Notes due 2017 (including Form of Global Note as Exhibit A thereto)
|
8-K |
May 27, 2011
|
4.1 | |||||||
10.1 |
Contract Between the Georgia Department of Community Health and Peach State Contract for provision of Services to Georgia Healthy Families
|
8-K |
July 22, 2005
|
10.1 | |||||||
10.1a |
Amendment #1 to the Contract No. 0653 Between Georgia Department of Community Health and Peach State
|
10-Q |
October 25, 2005
|
10.9 | |||||||
10.1b |
Amendment #2 to the Contract No. 0653 Between Georgia Department of Community Health and Peach State
|
10-K |
February 23, 2008
|
10.1 | b | ||||||
10.1c |
Amendment #3 to the Contract No. 0653 Between Georgia Department of Community Health and Peach State
|
10-K |
February 23, 2009
|
10.1 | c | ||||||
10.1d |
Amendment #4 to the Contract No. 0653 Between Georgia Department of Community Health and Peach State
|
10-K |
February 23, 2009
|
10.1 | d | ||||||
10.1e |
Amendment #6 to the Contract No. 0653 Between Georgia Department of Community Health and Peach State
|
10-K |
February 22, 2010
|
10.1 | e | ||||||
10.1f |
Amendment #7 to the Contract No. 0653 Between Georgia Department of Community Health and Peach State
|
10-K |
February 22, 2011
|
10.1 | f | ||||||
10.1g |
Amendment #8 to the Contract No. 0653 Between Georgia Department of Community Health and Peach State
|
10-K |
February 22, 2011
|
10.1 | g | ||||||
10.1h |
Amendment #10 to the Contract No. 0653 Between Georgia Department of Community Health and Peach State
|
10-Q/A |
October 28, 2011
|
10.1 | |||||||
10.1i ** |
Amendment #11 to the Contract No. 0653 Between Georgia Department of Community Health and Peach State
|
X | |||||||||
10.1j ** |
Amendment #12 to the Contract No. 0653 Between Georgia Department of Community Health and Peach State
|
X | |||||||||
10.2 |
Contract between the Texas Health and Human Services Commission and Superior HealthPlan, Inc.
|
10-K |
February 24, 2006
|
10.5 | |||||||
10.2a |
Amendment T (Version 1.19) to Contract between the Texas Health and Human Services Commission and Superior HealthPlan, Inc.
|
10-Q |
October 25, 2011
|
10.1 | |||||||
10.2b ** |
Amendment U (Version 1.20) to Contract between the Texas Health and Human Services Commission and Superior HealthPlan, Inc.
|
X | |||||||||
10.3 |
Contract between the Texas Health and Human Services Commission and Superior HealthPlan, Inc.
|
10-Q |
October 25, 2011
|
10.2 | |||||||
10.4 |
Contract between the Texas Health and Human Services Commission and Bankers Reserve Life Insurance Company of Wisconsin d.b.a. Superior HealthPlan Network.
|
10-Q |
October 25, 2011
|
10.3 | |||||||
10.5 * |
1996 Stock Plan of Centene Corporation, shares which are registered on Form S-8 – File Number 333-83190
|
S-1 |
October 9, 2001
|
10.9 | |||||||
10.6 * |
1998 Stock Plan of Centene Corporation, shares which are registered on Form S-8 – File number 333-83190
|
S-1 |
October 9, 2001
|
10.10 | |||||||
10.7 * |
1999 Stock Plan of Centene Corporation, shares which are registered on Form S-8 – File Number 333-83190
|
S-1 |
October 9, 2001
|
10.11 | |||||||
10.8 * |
2000 Stock Plan of Centene Corporation, shares which are registered on Form S-8 – File Number 333-83190
|
S-1 |
October 9, 2001
|
10.12 |
10.9 * |
2002 Employee Stock Purchase Plan of Centene Corporation, shares which are registered on Form S-8 – File Number 333-90976
|
10-Q |
April 29, 2002
|
10.5 |
10.9a * |
First Amendment to the 2002 Employee Stock Purchase Plan
|
10-K |
February 24, 2005
|
10.9 | a | ||||||
10.9b * |
Second Amendment to the 2002 Employee Stock Purchase Plan
|
10-K |
February 24, 2006
|
10.10 | b | ||||||
10.10 * |
Centene Corporation Amended and Restated 2003 Stock Incentive Plan, shares which are registered on Form S-8 – File Number 333-108467
|
8-K |
April 30, 2010
|
10.1 | |||||||
10.11 * |
Centene Corporation Non-Employee Directors Deferred Stock Compensation Plan
|
10-Q |
October 25, 2004
|
10.1 | |||||||
10.11a * |
First Amendment to the Non-Employee Directors Deferred Stock Compensation Plan
|
10-K |
February 24, 2006
|
10.12 | a | ||||||
10.12 * |
Centene Corporation Employee Deferred Compensation Plan
|
10-K |
February 22, 1010
|
10.10 | |||||||
10.13 * |
Centene Corporation 2007 Long-Term Incentive Plan
|
8-K |
April 26, 2007
|
10.2 | |||||||
10.14 * |
Centene Corporation Short-Term Executive Compensation Plan
|
10-K |
February 22, 2011
|
10.12 | |||||||
10.15 * |
Executive Employment Agreement between Centene Corporation and Michael F. Neidorff, dated November 8, 2004
|
8-K |
November 9, 2004
|
10.1 | |||||||
10.15a * |
Amendment No. 1 to Executive Employment Agreement between Centene Corporation and Michael F. Neidorff
|
10-Q |
October 28, 2008
|
10.2 | |||||||
10.15b * |
Amendment No. 2 to Executive Employment Agreement between Centene Corporation and Michael F. Neidorff
|
10-Q |
April 28, 2009
|
10.2 | |||||||
10.16 * |
Form of Executive Severance and Change in Control Agreement
|
10-Q |
October 28, 2008
|
10.3 | |||||||
10.17 * |
Form of Restricted Stock Unit Agreement
|
10-Q |
October 28, 2008
|
10.4 | |||||||
10.18 * |
Form of Non-statutory Stock Option Agreement (Non-Employees)
|
8-K |
July 28, 2005
|
10.3 | |||||||
10.19 * |
Form of Non-statutory Stock Option Agreement (Employees)
|
10-Q |
October 28, 2008
|
10.5 | |||||||
10.20 * |
Form of Non-statutory Stock Option Agreement (Directors)
|
10-K |
February 23, 2009
|
10.18 | |||||||
10.21 * |
Form of Incentive Stock Option Agreement
|
10-Q |
October 28, 2008
|
10.6 | |||||||
10.22 * |
Form of Stock Appreciation Right Agreement
|
8-K |
July 28, 2005
|
10.6 | |||||||
10.23 * |
Form of Restricted Stock Agreement
|
10-Q |
October 25, 2005
|
10.8 | |||||||
10.24 * |
Form of Performance Based Restricted Stock Unit Agreement #1
|
10-Q |
October 28, 2008
|
10.7 | |||||||
10.25 * |
Form of Performance Based Restricted Stock Unit Agreement #2
|
10-K |
February 23, 2009
|
10.23 | |||||||
10.26 * |
Form of Long Term Incentive Plan Agreement
|
8-K |
February 7, 2008
|
10.1 | |||||||
10.27 |
Credit Agreement dated as of January 31, 2011 among Centene Corporation, the various financial institutions party hereto and Barclays Bank PLC
|
10-K |
February 22, 2011
|
10.26 | |||||||
12.1 |
Computation of ratio of earnings to fixed charges
|
X | |||||||||
21 |
List of subsidiaries
|
X | |||||||||
23 |
Consent of Independent Registered Public Accounting Firm incorporated by reference in each prospectus constituting part of the Registration Statements on Form S-3 (File Numbers 333-164390 and 333-174164) and on Form S-8 (File Numbers 333-108467, 333-90976 and 333-83190)
|
X | |||||||||
31.1 |
Certification Pursuant to Rule 13a-14(a) and 15d-14(a) of the Exchange Act, as Adopted Pursuant to Section 302 of the Sarbanes-Oxley Act of 2002 (Chief Executive Officer)
|
X | |||||||||
31.2 |
Certification Pursuant to Rule 13a-14(a) and 15d-14(a) of the Exchange Act, as Adopted Pursuant to Section 302 of the Sarbanes-Oxley Act of 2002 (Chief Financial Officer)
|
X | |||||||||
32.1 |
Certification Pursuant to 18 U.S.C. Section 1350 (Chief Executive Officer)
|
X | |||||||||
32.2 |
Certification Pursuant to 18 U.S.C. Section 1350 (Chief Financial Officer)
|
X | |||||||||
101.12 |
XBRL Taxonomy Instance Document.
|
X | |||||||||
101.22 |
XBRL Taxonomy Extension Schema Document.
|
X | |||||||||
101.32 |
XBRL Taxonomy Extension Calculation Linkbase Document.
|
X |
|
||||||||
|
|||||||||||
101.42 |
XBRL Taxonomy Extension Definition Linkbase Document.
|
X |
|
||||||||
|
|||||||||||
101.52 |
XBRL Taxonomy Extension Label Linkbase Document.
|
X | |||||||||
101.62 |
XBRL Taxonomy Extension Presentation Linkbase Document.
|
X | |||||||||
1 SEC File No. 001-31826 (for filings prior to October 14, 2003, the Registrant’s SEC File No. was 000-33395).
2 XBRL (Extensible Business Reporting Language) information is furnished and not filed or a part of a registration statement or prospectus for purposes of sections 11 or 12 of the Securities Act of 1933, is deemed not filed for purposes of section 18 of the Securities Exchange Act of 1934, and otherwise is not subject to liability under these sections.
* Indicates a management contract or compensatory plan or arrangement.
** The Company has requested confidential treatment of the redacted portions of this exhibit pursuant to Rule 24b-2 under the Securities Exchange Act of 1934, as amended, and has separately filed a complete copy of this exhibit with the Securities and Exchange Commission.
|
CENTENE CORPORATION
|
||
By:
|
/s/ MICHAEL F. NEIDORFF | |
Michael F. Neidorff
Chairman and Chief Executive Officer
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Signature
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Title
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/s/ MICHAEL F. NEIDORFF
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Chairman and Chief Executive Officer (principal executive officer)
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Michael F. Neidorff | ||
/s/ WILLIAM N. SCHEFFEL
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Executive Vice President and Chief Financial Officer (principal financial officer)
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William N. Scheffel | ||
/s/ JEFFREY A. SCHWANEKE
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Senior Vice President, Corporate Controller and Chief Accounting Officer
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Jeffrey A. Schwaneke
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(principal accounting officer) | |
/s/ ORLANDO AYALA
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Director
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Orlando Ayala | ||
/s/ ROBERT K. DITMORE
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Director
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Robert K. Ditmore | ||
/s/ FRED H. EPPINGER
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Director
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Fred H. Eppinger | ||
/s/ RICHARD A. GEPHARDT
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Director
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Richard A. Gephardt | ||
/s/ PAMELA A. JOSEPH
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Director
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Pamela A. Joseph | ||
/s/ JOHN R. ROBERTS
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Director
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John R. Roberts | ||
/s/ DAVID L. STEWARD
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Director
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David L. Steward | ||
/s/ TOMMY G. THOMPSON
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Director
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Tommy G. Thompson |
1.0
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SCOPE OF SERVICE
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1.1
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BACKGROUND
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1.2
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ELIGIBILITY FOR GEORGIA FAMILIES
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1.2.1
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MEDICAID
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1.2.2
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PEACHCARE FOR KIDS®
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1.2.3
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EXCLUSIONS
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1.3
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SERVICE REGIONS
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1.4
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DEFINITIONS
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1.5
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ACRONYMS
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2.0
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DCH RESPONSIBILITIES
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2.1
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GENERAL PROVISIONS
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2.2
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LEGAL COMPLIANCE
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2.3
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ELIGIBILITY AND ENROLLMENT
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2.4
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DISENROLLMENT
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2.5
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MEMBER AND P4HB PARTICIPANT SERVICES AND MARKETING
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2.6
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COVERED SERVICES & SPECIAL COVERAGE PROVISIONS
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2.7
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NETWORK
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2.8
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QUALITY MONITORING
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2.9
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COORDINATION WITH CONTRACTOR’S KEY STAFF
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2.10
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FORMAT STANDARDS
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2.11
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FINANCIAL MANAGEMENT
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2.12
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INFORMATION SYSTEMS
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2.13
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READINESS OR ANNUAL REVIEW
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3.0
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GENERAL CONTRACTOR RESPONSIBILITIES
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4.0
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SPECIFIC CONTRACTOR RESPONSIBILITIES
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4.1
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ENROLLMENT
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4.1.1
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ENROLLMENT PROCEDURES
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4.1.2
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SELECTION OF A PRIMARY CARE PROVIDER (PCP)
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4.1.3
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NEWBORN ENROLLMENT
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4.1.4
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REPORTING REQUIREMENTS
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4.2
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DISENROLLMENT
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4.2.1
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DISENROLLMENT INITIATED BY THE MEMBER OR P4HB PARTICIPANT
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4.2.2
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DISENROLLMENT INITIATED BY THE CONTRACTOR
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4.2.3
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ACCEPTABLE REASONS FOR DISENROLLMENT REQUESTED BY CONTRACTOR[
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4.2.4
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UNACCEPTABLE REASONS FOR DISENROLLMENT REQUESTS BY CONTRACTOR
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4.3
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MEMBER AND P4HB PARTICIPANT SERVICES
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4.3.1
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GENERAL PROVISIONS
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4.3.2
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REQUIREMENTS FOR WRITTEN MATERIALS
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4.3.3
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MEMBER HANDBOOK AND P4HB PARTICIPANTS INFORMATION REQUIREMENTS
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4.3.4
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MEMBER AND P4HB PARTICIPANT RIGHTS
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4.3.5
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PROVIDER DIRECTORY
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4.3.6
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MEMBER AND P4HB PARTICIPANT IDENTIFICATION (ID) CARD
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4.3.7
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TOLL-FREE MEMBER AND P4HB PARTICIPANT SERVICES LINE
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4.3.8
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INTERNET PRESENCE/WEB SITE
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4.3.9
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CULTURAL COMPETENCY
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4.3.10
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TRANSLATION SERVICES
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4.3.11
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REPORTING REQUIREMENTS
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4.4
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MARKETING
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4.4.1
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PROHIBITED ACTIVITIES
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4.4.2
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ALLOWABLE ACTIVITIES
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4.4.3
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STATE APPROVAL OF MATERIALS
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4.4.4
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PROVIDER MARKETING MATERIALS
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4.5
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COVERED BENEFITS AND SERVICES
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4.5.1
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INCLUDED SERVICES
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4.5.2
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INDIVIDUALS W/DISABILITIES EDUCATION ACT (IDEA) SERVICES
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4.5.3
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ENHANCED SERVICES
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4.5.4
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MEDICAL NECESSITY
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4.5.5
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EXPERIMENTAL, INVESTIGATIONAL OR COSMETIC PROCEDURES, DRUGS, SERVICES, OR DEVICES
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4.5.6
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MORAL OR RELIGIOUS OBJECTIONS
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4.6
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SPECIAL COVERAGE PROVISIONS
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4.6.1
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EMERGENCY SERVICES
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4.6.2
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POST-STABILIZATION SERVICES
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4.6.3
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URGENT CARE SERVICES
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4.6.4
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FAMILY PLANNING SERVICES
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4.6.5
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STERILIZATIONS, HYSTERECTOMIES AND ABORTIONS
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4.6.6
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PHARMACY
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4.6.7
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IMMUNIZATIONS
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4.6.8
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TRANSPORTATION
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4.6.9
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PERINATAL SERVICES
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4.6.10
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PARENTING EDUCATION
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4.6.11
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MENTAL HEALTH AND SUBSTANCE ABUSE
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4.6.12
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ADVANCE DIRECTIVES
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4.6.13
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FOSTER CARE FORENSIC EXAM
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4.6.14
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LABORATORY SERVICES
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4.6.15
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MEMBER COST-SHARING
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4.7
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EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT(EPSDT) PROGRAM: HEALTH CHECK
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4.7.1
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GENERAL PROVISIONS
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4.7.2
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OUTREACH AND INFORMING
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4.7.3
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SCREENING
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4.7.4
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TRACKING
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4.7.5
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DIAGNOSTIC AND TREATMENT SERVICES
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4.7.6
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REPORTING REQUIREMENTS
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4.8
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PROVIDER NETWORK AND ACCESS
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4.8.1
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GENERAL PROVISIONS
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4.8.2
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PRIMARY CARE PROVIDERS (PCPS)
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4.8.3
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DIRECT ACCESS
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4.8.4
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PHARMACIES
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4.8.5
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HOSPITALS
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4.8.6
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LABORATORIES
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4.8.7
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MENTAL HEALTH/SUBSTANCE ABUSE
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4.8.8
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FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS)
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4.8.9
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RURAL HEALTH CLINICS (RHCS)
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4.8.10
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FAMILY PLANNING CLINICS
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4.8.11
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NURSE PRACTIONERS CERTIFIED (NP-CS) AND CERTIFIED NURSE MIDWIVES (CNMS)
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4.8.12
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DENTAL PRACTITIONERS
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4.8.13
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GEOGRAPHIC ACCESS REQUIREMENTS
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4.8.14
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WAITING MAXIMUMS AND APPOINTMENT REQUIREMENTS
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4.8.15
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CREDENTIALING
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4.8.16
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MAINSTREAMING
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4.8.17
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COORDINATION REQUIREMENTS
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4.8.18
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NETWORK CHANGES
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4.8.19
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OUT-OF-NETWORK PROVIDERS
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4.8.20
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SHRINERS HOSPITALS FOR CHILDREN
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4.8.21
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REPORTING REQUIREMENTS
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4.9
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PROVIDER SERVICES
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4.9.1
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GENERAL PROVISIONS
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4.9.2
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PROVIDER HANDBOOKS
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4.9.3
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EDUCATION AND TRAINING
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4.9.4
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PROVIDER RELATIONS
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4.9.5
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TOLL-FREE PROVIDER SERVICES TELEPHONE LINE
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4.9.6
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INTERNET PRESENCE/WEB SITE
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4.9.7
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PROVIDER COMPLAINT SYSTEM
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4.9.8
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REPORTING REQUIREMENTS
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4.10
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PROVIDER CONTRACTS AND PAYMENTS
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4.10.1
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PROVIDER CONTRACTS
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4.10.2
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PROVIDER TERMINATION
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4.10.3
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PROVIDER INSURANCE
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4.10.4
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PROVIDER PAYMENT
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4.10.5
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REPORTING REQUIREMENTS
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4.11
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UTILIZATION MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES
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4.11.1
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UTILIZATION MANAGEMENT
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4.11.2
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PRIOR AUTHORIZATION AND PRE-CERTIFICATION
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4.11.3
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REFERRAL REQUIREMENTS AND P4HB PARTICIPANTS
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4.11.4
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TRANSITION OF MEMBERS
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4.11.5
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BACK TRANSFERS
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4.11.6
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COURT-ORDERED EVALUATIONS AND SERVICES
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4.11.7
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SECOND OPINIONS
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4.11.8
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CARE COORDINATION RESPONSIBILITIES
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4.11.9
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CASE MANAGEMENT
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4.11.10
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DISEASE MANAGEMENT
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4.11.11
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DISCHARGE PLANNING
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4.11.12
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REPORTING REQUIREMENTS
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4.12
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QUALITY IMPROVEMENT
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4.12.1
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GENERAL PROVISIONS
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4.12.2
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QUALITY STRATEGIC PLAN REQUIREMENTS
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4.12.3
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PERFORMANCE MEASURES
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4.12.4
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REPORTING REQUIREMENTS
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4.12.5
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QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT (QAPI) PROGRAM
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4.12.6
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PERFORMANCE IMPROVEMENT PROJECTS
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4.12.7
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PRACTICE GUIDELINES
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4.12.8
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FOCUSED STUDIES
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4.12.9
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PATIENT SAFETY PLAN
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4.12.10
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RESERVED
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4.12.11
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EXTERNAL QUALITY REVIEW
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4.12.12
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REPORTING REQUIREMENTS
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4.13
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FRAUD AND ABUSE
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4.13.1
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PROGRAM INTEGRITY
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4.13.2
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COMPLIANCE PLAN
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4.13.3
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COORDINATION WITH DCH AND OTHER AGENCIES
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4.13.4
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REPORTING REQUIREMENTS
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4.14
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INTERNAL GRIEVANCE/APPEALS SYSTEM
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4.14.1
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GENERAL REQUIREMENTS
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4.14.2
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GRIEVANCE PROCESS
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4.14.3
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PROPOSED ACTION
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4.14.4
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ADMINISTRATIVE REVIEW PROCESS
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4.14.5
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NOTICE OF ADVERSE ACTION
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4.14.6
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ADMINISTRATIVE LAW HEARING
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4.14.7
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CONTINUATION OF BENEFITS WHILE THE CONTRACTOR APPEAL AND ADMINISTRATIVE LAW HEARING ARE PENDING
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4.14.8
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REPORTING REQUIREMENTS
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4.15
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ADMINISTRATION AND MANAGEMENT
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4.15.1
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GENERAL PROVISIONS
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4.15.2
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PLACE OF BUSINESS AND HOURS OF OPERATION
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4.15.3
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TRAINING
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4.15.4
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DATA AND REPORT CERTIFICATION
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4.16
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CLAIMS MANAGEMENT
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4.16.1
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GENERAL PROVISIONS
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4.16.2
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OTHER CONSIDERATIONS
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4.16.3
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ENCOUNTER DATA SUBMISSION REQUIREMENTS
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4.16.4
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REPORTING REQUIREMENTS
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4.16.5
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EMERGENCY HEALTH CARE SERVICES
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4.17
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INFORMATION MANAGEMENT AND SYSTEMS
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4.17.1
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GENERAL PROVISIONS
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4.17.2
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HEALTH INFORMATION TECHNOLOGY AND EXCHANGE
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4.17.3
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GLOBAL SYSTEM ARCHITECTURE AND DESIGN REQUIREMENTS
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4.17.4
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DATA AND DOCUMENT MANAGEMENT REQUIREMENTS BY MAJOR INFORMATION TYPE
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4.17.5
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SYSTEM AND DATA INTEGRATION REQUIREMENTS
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4.17.6
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SYSTEM ACCESS MANAGEMENT AND INFORMATION ACCESSIBILITY REQUIREMENTS
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4.17.7
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SYSTEMS AVAILABILITY AND PERFORMANCE REQUIREMENTS
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4.17.8
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SYSTEM USER AND TECHNICAL SUPPORT REQUIREMENTS
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4.17.9
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SYSTEM CHANGE MANAGEMENT REQUIREMENTS
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4.17.10
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SYSTEM SECURITY AND INFORMATION CONFIDENTIALITY AND PRIVACY REQUIREMENTS
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4.17.11
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INFORMATION MANAGEMENT PROCESS & INFORMATION SYSTEMS DOCUMENTATION REQUIREMENTS
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4.17.12
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REPORTING REQUIREMENTS
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4.18
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REPORTING REQUIREMENTS
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4.18.1
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GENERAL PROCEDURES
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4.18.2
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WEEKLY REPORTING
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4.18.3
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MONTHLY REPORTING
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4.18.4
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QUARTERLY REPORTING
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4.18.5
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ANNUAL REPORTS
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4.18.6
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AD HOC REPORTS
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5.0
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DELIVERABLES
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5.1
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CONFIDENTIALITY
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5.2
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NOTICE OF APPROVAL/DISAPPROVAL
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5.3
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RESUBMISSION WITH CORRECTIONS
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5.4
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NOTICE OF APPROVAL/DISAPPROVAL OF RESUBMISSION
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5.5
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DCH FAILS TO RESPOND
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5.6
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REPRESENTATIONS
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5.7
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CONTRACT DELIVERABLES
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5.8
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CONTRACT REPORTS
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6.0
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TERM OF CONTRACT
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7.0
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PAYMENT FOR SERVICES
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7.1
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GENERAL PROVISIONS
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7.2
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PERFORMANCE INCENTIVES
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8.0
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FINANCIAL MANAGEMENT
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8.1
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GENERAL PROVISIONS
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8.2
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SOLVENCY AND RESERVES STANDARDS
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8.3
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REINSURANCE
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8.4
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THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS
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8.4.2
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COST AVOIDANCE
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8.4.3
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COMPLIANCE
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8.5
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PHYSICIAN INCENTIVE PLAN
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8.6
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REPORTING REQUIREMENTS
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9.0
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PAYMENT OF TAXES
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10.0
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RELATIONSHIP OF PARTIES
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11.0
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INSPECTION OF WORK
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12.0
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STATE PROPERTY
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13.0
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OWNERSHIP AND USE OF DATA
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13.1
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SOFTWARE AND OTHER UPGRADES
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14.0
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CONTRACTOR: STAFFING ASSIGNMENTS & CREDENTIALS
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14.1
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STAFFING CHANGES
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14.2
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CONTRACTOR’S FAILURE TO COMPLY
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15.0
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CRIMINAL BACKGROUND CHECKS
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16.0
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SUBCONTRACTS
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16.1
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USE OF SUBCONTRACTORS
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16.2
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COST OR PRICING BY SUBCONTRACTORS
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17.0
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LICENSE, CERTIFICATE, PERMIT REQUIREMENT
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18.0
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RISK OF LOSS AND REPRESENTATIONS
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19.0
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PROHIBITION OF GRATUITIES AND LOBBYIST DISCLOSURES
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20.0
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RECORDS REQUIREMENTS
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20.1
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RECORDS RETENTION REQUIREMENTS
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20.2
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ACCESS TO RECORDS
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20.3
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MEDICAL RECORD REQUESTS
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21.0
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CONFIDENTIALITY REQUIREMENTS
|
21.1
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GENERAL CONFIDENTIALITY REQUIREMENTS
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21.2
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HIPAA COMPLIANCE
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22.0
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TERMINATION OF CONTRACT
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22.1
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GENERAL PROCEDURES
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22.2
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TERMINATION BY DEFAULT
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22.3
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TERMINATION FOR CONVENIENCE
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22.4
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TERMINATION FOR INSOLVENCY OR BANKRUPTCY
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22.5
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TERMINATION FOR INSUFFICIENT FUNDING
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22.6
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TERMINATION PROCEDURES
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22.7
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TERMINATION CLAIMS
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23.0
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LIQUIDATED DAMAGES
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23.1
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GENERAL PROVISIONS
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23.2
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CATEGORY 1
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23.3
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CATEGORY 2
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23.4
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CATEGORY 3
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23.5
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CATEGORY 4
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23.6
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OTHER REMEDIES
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23.7
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NOTICE OF REMEDIES
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24.0
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INDEMNIFICATION
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25.0
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INSURANCE
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26.0
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PAYMENT BOND & IRREVOCABLE LETTER OF CREDIT
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27.0
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COMPLIANCE WITH ALL LAWS
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27.1
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NON-DISCRIMINATION
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27.2
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DELIVERY OF SERVICE AND OTHER FEDERAL LAWS
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27.3
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COST OF COMPLIANCE WITH APPLICABLE LAWS
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27.4
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GENERAL COMPLIANCE
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28.0
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CONFLICT RESOLUTION
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29.0
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CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE
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30.0
|
NOTICE
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31.0
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MISCELLANEOUS
|
31.1
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CHOICE OF LAW OR VENUE
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31.2
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ATTORNEY’S FEES
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31.3
|
SURVIVABILITY
|
31.4
|
DRUG-FREE WORKPLACE
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31.5
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CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER MATTERS
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31.6
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WAIVER
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31.7
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FORCE MAJEURE
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31.8
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BINDING
|
31.9
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TIME IS OF THE ESSENCE
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31.10
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AUTHORITY
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31.11
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ETHICS IN PUBLIC CONTRACTING
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31.12
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CONTRACT LANGUAGE INTERPRETATION
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31.13
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ASSESSMENT OF FEES
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31.14
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COOPERATION WITH OTHER CONTRACTORS
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31.15
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SECTION TITLES NOT CONTROLLING
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31.16
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LIMITATION OF LIABILITY/EXCEPTIONS
|
31.17
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COOPERATION WITH AUDITS
|
31.18
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HOMELAND SECURITY CONSIDERATIONS
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31.19
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PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED
|
31.20
|
OWNERSHIP AND FINANCIAL DISCLOSURE
|
32.0
|
AMENDMENT IN WRITING
|
33.0
|
CONTRACT ASSIGNMENT
|
34.0
|
SEVERABILITY
|
35.0
|
COMPLIANCE WITH AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT ORGANIZATIONS (O.C.G.A §50-20-1 ET SEQ.)
|
36.0
|
ENTIRE AGREEMENT
|
|
ATTACHMENT A
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DRUG FREE WORKPLACE CERTIFICATE225
|
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ATTACHMENT B
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CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT, AND OTHER RESPONSIBILITY MATTERS
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ATTACHMENT C
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NONPROFIT ORGANIZATION DISCLOSURE FORM
|
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ATTACHMENT D
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CONFIDENTIALITY STATEMENT
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ATTACHMENT E
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BUSINESS ASSOCIATE AGREEMENT
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ATTACHMENT F
|
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VENDOR LOBBYIST DISCLOSURE & REGISTRATION CERTIFICATION FORM
|
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ATTACHMENT G
|
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RESERVED
|
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ATTACHMENT H
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CAPITATION PAYMENT
|
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ATTACHMENT I
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NOTICE OF YOUR RIGHT TO A HEARING
|
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ATTACHMENT J
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MAP OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS
|
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ATTACHMENT K
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APPLICABLE CO-PAYMENTS
|
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ATTACHMENT L
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INFORMATION MANAGEMENT AND SYSTEMS
|
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ATTACHMENT M
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PERFORMANCE MEASURES
|
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DEMONSTRATION COVERED SERVICES
|
1.0
|
SCOPE OF SERVICE
|
1.0.1
|
The State of Georgia is implementing reforms to the Medicaid and PeachCare for Kids® programs. These reforms will focus on system-wide improvements in performance and quality, will consolidate fragmented systems of care, and will prevent unsustainable trend rates in Medicaid and PeachCare for Kids® expenditures. The reforms will be implemented through a management of care approach to achieve the greatest value for the most efficient use of resources.
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1.0.2
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The Contractor shall assist the State of Georgia in this endeavor through the following tasks, obligations, and responsibilities.
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1.1
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BACKGROUND
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1.1.1
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In 2003, the Georgia Department of Community Health (DCH) identified unsustainable Medicaid growth and projected that without a change to the system, Medicaid would require 50 percent of all new State revenue by 2008. In addition, Medicaid utilization was driving more than 35 percent of total growth each year. For that reason, DCH decided to employ a management of care approach to organize its fragmented system of care, enhance access, achieve budget predictability, explore possible cost containment opportunities and focus on system-wide performance improvements. Furthermore, DCH believed that managed care could continuously and incrementally improve the quality of healthcare and services provided to patients and improve efficiency by utilizing both human and material resources more effectively and more efficiently. The DCH Division of Managed Care and Quality submitted a State Plan Amendment in 2004 to implement a full-risk mandatory Medicaid Managed Care program called Georgia Families.
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1.1.2
|
Effective June 1, 2006 the state of Georgia implemented Georgia Families (GF), a managed care program through which health care services are delivered to members of Medicaid and PeachCare for Kids®. The intent of this program is to:
|
·
|
Offer care coordination to members
|
·
|
Enhance access to health care services
|
·
|
Achieve budget predictability as well as cost containment
|
·
|
Create system-wide performance improvements
|
·
|
Continually and incrementally improve the quality of health care and services provided to members
|
·
|
Improve efficiency at all levels
|
·
|
Improve the Health Care status of the Member and Planning for Healthy Babies (P4HB) 1115 Demonstration Participant population;
|
·
|
Establish a Provider Home for the Member and P4HB Interpregnancy Care Participant through its use of assigned Primary Care Providers (PCPs);
|
·
|
Establish a climate of contractual accountability among the state, the care management organizations and the health care Providers;
|
·
|
Slow the rate of expenditure growth in the Medicaid program; and
|
·
|
Expand and strengthen a sense of the Member’s and P4HB Participant’s responsibility that leads to more appropriate utilization of health care services
|
1.2.1
|
Medicaid
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|
1.2.1.1
|
The following Medicaid eligibility categories are required to enroll in GF:
|
·
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Low Income Families – Adults and children who meet the standards of the old AFDC (Aid to Families with Dependent Children) program.
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·
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Transitional Medicaid – Former Low-Income Medicaid (LIM) families who are no longer eligible for LIM because their earned income exceeds the income limit.
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·
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Pregnant Women (Right from the Start Medicaid - RSM) – Pregnant women with family income at or below two hundred percent (200%) of the federal poverty level who receive Medicaid through the RSM program.
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·
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Children (Right from the Start Medicaid - RSM) – Children less than nineteen (19) years of age whose family income is at or below the appropriate percentage of the federal poverty level for their age and family.
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·
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Children (newborn) – A child born to a woman who is eligible for Medicaid on the day the child is born.
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·
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Women Eligible Due to Breast and Cervical Cancer Women less than sixty-five (65) years of age who have been screened through Title XV Center for Disease Control (CDC) screening and have been diagnosed with breast or cervical cancer.
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·
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Refugees – Those individuals who have the required INS documentation showing they meet a status in one of these groups: refugees, asylees, Cuban parolees/Haitian entrants, Amerasians or human trafficking victims.
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·
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Planning for Healthy Babies 1115 Demonstration Waiver Participants (otherwise known as P4HB Participants) – Women ages 18 through 44 who are otherwise uninsured with family income at or below two hundred percent (200%) of the Federal poverty level. This Demonstration includes two distinct groups: women eligible for Family Planning Services only and women eligible for Interpregnancy Care and Family Planning Services.
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1.2.1.2
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The following Medicaid eligibility categories are required to receive Resource Mothers Outreach through GF:
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·
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Women ages 18 through 44 who qualify under the Low Income Medicaid Class of Assistance under the Georgia Medicaid State Plan who are already enrolled in GF and who deliver a Very Low Birth Weight (VLBW) baby on or after January 1, 2011.
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·
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Women ages 18 through 44 who qualify under the Aged Blind and Disabled Classes of Assistance under the Georgia Medicaid State Plan and who deliver a VLBW baby on or after January 1, 2011.
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1.2.2
|
PeachCare for Kids®
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1.2.2.1
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PeachCare for Kids® – The State Children’s Health Insurance Program (SCHIP) in Georgia. Children less than nineteen (19) years of age who have family income that is less than two hundred thirty-five percent (235%) of the federal poverty level, who are not eligible for Medicaid, or any other health insurance program are eligible for services under PeachCare for Kids®. Effective January 1, 2012, employees of the State of Georgia may enroll their children in PeachCare for Kids® if the employee meets income and other eligibility requirements of the program.
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1.2.3
|
Exclusions
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1.2.3.1
|
The following recipients are excluded from Enrollment in GF, even if the recipient is otherwise eligible for GF per section 1.2.1 and section 1.2.2.
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·
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Recipients eligible for Medicare;
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·
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Recipients that are Members of a Federally Recognized Indian Tribe;
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·
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Recipients that are enrolled in fee-for-service Medicaid through Supplemental Security Income prior to enrollment in GF. Members that are already enrolled in a CMO through GF will remain in that CMO until the disenrollment is completed through the normal monthly process.
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·
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Children less than twenty-one (21) years of age who are in foster care or other out-of-home placement;
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·
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Children less than twenty-one (21) years of age who are receiving foster care or other adoption assistance under Title IV-E of the Social Security Act.
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·
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Medicaid children enrolled in the Children’s Medical Services program administered by the Georgia Department of Public Health;
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·
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Children less than twenty-one (21) years of age who are receiving foster care or other adoption assistance under Title IV-E of the Social Security Act (NOTE: Foster Children in “Relative” placement remain within the Georgia Families program);
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·
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Children enrolled in the Georgia Pediatric Program (GAPP);
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·
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Recipients enrolled under group health plans for which DCH provides payment for premiums, deductibles, coinsurance and other cost sharing, pursuant to Section 1906 of the Social Security Act.
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·
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Individuals enrolled in a Hospice category of aid.
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·
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Individuals enrolled in a Nursing Home category of aid.
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·
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Individuals enrolled in a Community Based Alternative for Youths (CBAY)
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1.2.3.2
|
The following recipients are excluded from the P4HB Demonstration (hereinafter
|
|
referred to as “the Demonstration”):
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·
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Women who become pregnant while enrolled in the Demonstration.
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·
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Women determined to be infertile (sterile) or who are sterilized while enrolled in the Demonstration.
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·
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Women who become eligible for any other Medicaid or commercial insurance program.
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·
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Women who no longer meet the Demonstration’s eligibility requirements
|
·
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Women who are or become incarcerated.
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1.3
|
SERVICE REGIONS
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1.3.1
|
For the purposes of coordination and planning, DCH has divided the State, by county, into six (6) Service Regions. See Attachment J for a listing of the counties in each Service Region.
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1.3.2
|
Members and P4HB Participants will choose or will be assigned to a Care Management Organization (CMO) plan that is operating in the Service Region in which they reside.
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1.3.3
|
Contractor has the option of operating in all six (6) Service Regions within the State. Should Contractor choose this option, Contractor shall seek DCH approval pursuant to Section 1.3.4. Once approval is obtained, Contractor shall provide health care services in no less than all six (6) Service Regions and must meet all requirements set forth in the Contract, including, but not limited to, the following Sections: 4.8.5.2, 4.8.7.1, 4.8.8.1, 4.8.9.1, 4.8.13, 4.8.14, 4.8.17.1, 4.11.1.2, 4.11.1.3, 4.15.2.1, and 26.1.
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1.3.4
|
Before DCH will approve the Contractor’s expansion into all six (6) Service Regions, the Contractor must demonstrate its ability to comply with all Contract requirements in these Service Regions by submitting the following to DCH no later than 5:00 pm EST on December 5, 2011: (a) an affidavit that the Contractor has met all applicable Contract requirements in these Service Regions; and (b) geographic access reports and supporting documentation regarding network access. If the Department approves the Contractor’s request, the effective date of the Service Region expansion will be January 1, 2012.
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1.3.5
|
DCH reserves the right to require that the Contractor’s expansion in a particular Service Region reach all areas of the Service Region in question.
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1.4
|
DEFINITIONS
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·
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Education and counseling necessary to make informed choices and understand contraceptive methods;
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·
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Initial and annual complete physical examinations;
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·
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Follow-up, brief and comprehensive visits;
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·
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Pregnancy testing;
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·
|
Contraceptive supplies and follow-up care;
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·
|
Diagnosis and treatment of sexually transmitted diseases; and
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·
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Infertility assessment
|
·
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Direct Cause: The cause that directly resulted in the event (the first cause in the chain).
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·
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Corrective Action: actions taken to correct the root cause generally a reactive process used to address problems after they have occurred
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·
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Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child;
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·
|
Serious impairment to bodily functions; or
|
·
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Serious dysfunction of any bodily organ or part.
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1.5
|
ACRONYMS
|
2.1
|
GENERAL PROVISIONS
|
2.1.1
|
DCH is responsible for administering the GF program. The agency will administer Contracts, monitor Contractor performance, and provide oversight in all aspects of the Contractor operations.
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2.1.2
|
DCH is responsible for providing training materials regarding the P4HB Demonstration including specific materials regarding the Resource Mothers Outreach component of the Demonstration.
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2.2
|
LEGAL COMPLIANCE
|
|
DCH will comply with, and will monitor the Contractor’s compliance with, all applicable State and federal laws and regulations. Notwithstanding the foregoing, the CMO remains responsible for compliance with all applicable State and federal laws and regulations.
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2.3
|
ELIGIBILITY AND ENROLLMENT
|
2.3.1
|
The State of Georgia has the sole authority for determining eligibility for the Medicaid program and whether Medicaid beneficiaries are eligible for Enrollment in GF. DCH or its Agent will determine eligibility for PeachCare for Kids® and will collect applicable premiums. DCH or its agent will continue responsibility for the electronic eligibility verification system (EVS).
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2.3.1.1
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The State of Georgia has the sole authority for determining eligibility for the P4HB Demonstration and whether P4HB Participants are eligible for enrollment in GF. DCH or its Agent will determine eligibility for the Demonstration and will continue responsibility for the electronic eligibility verification system (EVS).
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2.3.2
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DCH or its Agent will review the Medicaid Management Information System (MMIS) file daily and send written notification and information within two (2) Business Days to all Members who are determined eligible for GF. A Member shall have thirty (30) Calendar Days to select a CMO plan and a PCP. Each Family Head of Household shall have thirty (30) Calendar Days to select one (1) CMO plan for the entire Family and PCP for each member. DCH or its Agent will issue a monthly notice of all Enrollments to the CMO plan.
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2.3.2.1
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DCH or its Agent will review the Medicaid Management Information System (MMIS) file daily and send written notification and information within two (2) Business Days to all P4HB Participants who are determined eligible for GF. A P4HB Participant shall have thirty (30) Calendar Days to select a CMO and a Family Planning Provider. A P4HB Participant eligible for IPC services under GF will have thirty (30) Calendar Days to select a CMO plan, a Family Planning Provider and a PCP. The Family Planning Provider and the PCP may be the same provider.
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2.3.3
|
If the Member does not choose a CMO plan within thirty (30) Calendar Days of being deemed eligible for GF, DCH or its Agent will Auto-Assign the individual to a CMO plan using the following algorithm:
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·
|
If an immediate family member(s) of the Member is already enrolled in one CMO plan, the Member will be Auto-Assigned to that plan;
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·
|
If there are no immediate family members already enrolled and the Member has a Historical Provider Relationship with a Provider, the Member will be Auto-Assigned to the CMO plan where the Provider is contracted;
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·
|
If the Member does not have a Historical Provider Relationship with a Provider in any CMO plan, or the Provider contracts with all plans, the Member will be Auto-Assigned based on an algorithm determined by DCH that may include quality, cost, or other measures.
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2.3.3.1
|
If the Potential P4HB Participant does not choose a CMO Plan within thirty (30) Calendar Days of being deemed eligible for the Demonstration, DCH or its Agent will Auto-Assign the individual to a CMO plan using the algorithm described in Section 2.3.3 for Members.
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2.3.3.2
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Women already enrolled in GF due to pregnancy will have an expedited enrollment into the Demonstration upon termination of their pregnancy benefits. Members determined to be eligible for the Demonstration must be afforded the opportunity to choose a new CMO, if desired, for the delivery of Demonstration related Services. All P4HB Participants will have thirty (30) days from the date of eligibility notification to choose a CMO.
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2.3.3.3
|
The Contactor will notify its current pregnant Members at least thirty (30) Calendar Days prior to the expected date of delivery and prior to the date upon which the Member will end RSM, that they may be eligible to enroll in the Demonstration and may choose to switch to a different CMO plan for receipt of Demonstration services. Members who do not make a choice will be deemed to have chosen to remain in their current CMO plan for receipt of the Demonstration services they are eligible to receive.
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2.3.4
|
Enrollment, whether chosen or Auto-Assigned, will be effective at 12:01 a.m. on the first (1st) Calendar Day of the month following the Member or P4HB Participant’s selection or Auto-Assignment, for those Members or P4HB Participants assigned on or between the first (1st) and twenty-fourth (24th) Calendar Day of the month. For those Members or P4HB Participants assigned on or between the twenty-fifth (25th) and thirty-first (31st) Calendar Day of the month, Enrollment will be effective at 12:01 a.m. on the first (1st) Calendar Day of the second (2nd) month after assignment.
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2.3.5
|
DCH or its Agent may include quality measures in the Auto-Assignment algorithm. Members or P4HB Participants will be Auto-Assigned to those plans that have higher scores based on quality, cost, or other measures to be defined by DCH. This factor will be applied after determining that there are no Historical Provider Relationships.
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2.3.6
|
In any Service Region, DCH may, at its discretion, set a threshold percentage for the enrollment of members or P4HB Participants in a single plan and change this threshold percentage at its discretion. Members or P4HB Participants will not be Auto-Assigned to a CMO plan that exceeds this threshold unless a family member or P4HB Participant is enrolled in the CMO plan or a Historical Provider Relationship exists with a Provider that does not participate in any other CMO plan in the Service Region. When DCH changes the threshold percentage in any Service Region, DCH will provide the CMOs in the Service Region with a minimum of fourteen (14) days advance notice in writing.
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2.3.7
|
DCH or its Agent will have five (5) Business Days to notify Members or P4HB Participants and the CMO plan of the Auto-Assignment. Notice to the Member or P4HB Participant will be made in writing and sent via surface mail. Notice to the CMO plan will be made via file transfer.
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2.3.8
|
DCH or its Agent will be responsible for the consecutive Enrollment period and re-Enrollment functions.
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2.3.9
|
Conditioned on continued eligibility, all Members or P4HB Participants will be enrolled in a CMO plan for a period of twelve (12) consecutive months. This consecutive Enrollment period will commence on the first (1st) day of Enrollment or upon the date the notice is sent, whichever is later. If a Member or P4HB Participant disenrolls from one CMO plan and enrolls in a different CMO plan, consecutive Enrollment period will begin on the effective date of Enrollment in the second (2nd) CMO plan.
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2.3.10
|
DCH or its Agent will automatically enroll a Member or P4HB Participant into the CMO plan in which he or she was most recently enrolled if the Member or P4HB Participant has a temporary loss of eligibility, defined as less than sixty (60) Calendar Days. In this circumstance, the consecutive Enrollment period will continue as though there has been no break in eligibility, keeping the original twelve (12) month period.
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2.3.11
|
DCH or its Agent will notify Members or P4HB Participants at least once every twelve (12) months, and at least sixty (60) Calendar Days prior to the date upon which the consecutive Enrollment period ends (the annual Enrollment opportunity), that they have the opportunity to switch CMO plans. Members or P4HB Participants who do not make a choice will be deemed to have chosen to remain with their current CMO plan.
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2.3.12
|
In the event a temporary loss of eligibility has caused the Member or P4HB Participant to miss the annual Enrollment opportunity, DCH or its Agent will enroll the Member or P4HB Participant in the CMO plan in which he or she was enrolled prior to the loss of eligibility. The Member or P4HB Participant will receive a new 60-calendar day notification period beginning the first day of the next month.
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2.3.13
|
In accordance with current operations, the State will issue a Medicaid number to a newborn upon notification from the hospital, or other authorized Medicaid Provider.
|
2.3.14
|
Upon notification from a CMO plan that a Member is an expectant mother, DCH or its Agent shall mail a newborn enrollment packet to the expectant mother. This packet shall include information that the newborn will be Auto-Assigned to the mother’s CMO plan and that she may, if she wants, select a PCP for her newborn prior to the birth by contacting her CMO plan. The mother shall have ninety (90) Calendar Days from the day a Medicaid number was assigned to her newborn to choose a different CMO plan.
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2.3.15
|
DCH may, at its sole discretion, elect to modify this threshold and/or use quality based auto-assignments for reasons it deems necessary and proper.
|
2.4
|
DISENROLLMENT
|
2.4.1
|
DCH or its Agent will process all CMO plan Disenrollments. This includes Disenrollments due to non-payment of the PeachCare for Kids® premiums, loss of eligibility for GF due to other reasons, and all Disenrollment requests Members or P4HB Participants or CMO plans submit via telephone, surface mail, internet, facsimile, and in person.
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2.4.2
|
DCH or its Agent will make final determinations about granting Disenrollment requests and will notify the CMO plan via file transfer and the Member or P4HB Participant via surface mail of any Disenrollment decision within five (5) Calendar Days of making the final determination
|
·
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If the Disenrollment request is received by DCH or its agent on or before the managed care monthly process on the twenty-fourth (24th) Calendar Day of the month, the Disenrollment will be effective at midnight the first (1st) day of the month following the month in which the request was filed; and
|
·
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If the Disenrollment request is received by DCH or its agent after the managed care monthly process on the twenty-fourth (24th) Calendar Day of the month, the Disenrollment will be effective at midnight the first (1st) day of the second (2nd) month following the month in which the request was filed.
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2.4.3
|
If a Member is hospitalized in an acute inpatient facility on the first day of the month their Disenrollment is to be effective, the Member will remain enrolled until the month following their discharge from the inpatient facility. When Disenrollment is necessary due to a change in eligibility category, or eligibility for GF, the Member will be disenrolled according to the timeframes identified in Section 2.4.2.
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2.4.4
|
When disenrollment is necessary because a Member loses Medicaid or PeachCare for Kids® eligibility (for example, he or she has died, been incarcerated, or moved out-of-state) disenrollment shall be immediate.
|
2.4.4.1
|
When disenrollment is necessary because a P4HB Participant loses eligibility for the Demonstration (for example, she has died, been incarcerated, or moved out-of-state) disenrollment shall be immediate.
|
2.5
|
MEMBER AND P4HB PARTICIPANT SERVICES AND MARKETING
|
2.5.1
|
DCH will provide to the Contractor its methodology for identifying the prevalent non-English languages spoken. For the purposes of this Section, prevalent means a non-English language spoken by a significant number or percentage of Medicaid and PeachCare for Kids® eligible individuals in the State.
|
2.5.2
|
DCH will review and prior approve all marketing materials.
|
2.5.3
|
DCH will provide the Contractor with the Demonstration’s logo and design along with specific Demonstration language to be used in all written materials distributed to P4HB Participants and Potential P4HB Participants.
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2.6
|
COVERED SERVICES & SPECIAL COVERAGE PROVISIONS
|
|
DCH will use submitted Encounter Data, and other data sources, to determine Contractor compliance with federal requirements that eligible Members under the age of twenty-one (21) receive periodic screens and preventive/well child visits in accordance with the specified periodicity schedule. DCH will use the participant ratio as calculated using the CMS 416 methodology for measuring the Contractor’s performance.
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2.6.2
|
Specific services available under this Demonstration are outlined in Attachment N to this Contract.
|
2.7
|
NETWORK
|
2.7.1
|
DCH will provide to the Contractor up-to-date changes to the State’s list of excluded Providers, as well as any additional information that will affect the Contractor’s Provider network.
|
2.7.2
|
DCH will consider all Contractors’ requests to waive network geographic access requirements in rural areas. All such requests shall be submitted in writing.
|
2.7.3
|
DCH will provide the State’s Provider Credentialing policies to the Contractor upon execution of this Contract.
|
|
2.8
|
QUALITY MONITORING
|
2.8.1
|
DCH will have a written strategy for assessing and improving the quality of services provided by the Contractor. In accordance with 42 CFR 438.204, this strategy will, at a minimum, monitor:
|
·
|
The availability of services;
|
·
|
The adequacy of the Contractor’s capacity and services;
|
·
|
The Contractor’s coordination and continuity of care for Members;
|
·
|
The coverage and authorization of services;
|
·
|
The Contractor’s policies and procedures for selection and retention of Providers;
|
·
|
The Contractor’s compliance with Member information requirements in accordance with 42 CFR §438.10;
|
·
|
The Contractor’s compliance with State and federal privacy laws and regulations relative to Member’s confidentiality;
|
·
|
The Contractor’s compliance with Member Enrollment and Disenrollment requirements and limitations;
|
·
|
The Contractor’s Grievance System;
|
·
|
The Contractor’s oversight of all Subcontractor relationships and delegations;
|
·
|
The Contractor’s adoption of practice guidelines, including the dissemination of the guidelines to Providers and Providers’ application of them;
|
·
|
The Contractor’s quality assessment and performance improvement program; and
|
·
|
The Contractor’s health information systems.
|
·
|
The Contractor shall respond to requests for information within the stipulated time frame.
|
2.8.2
|
DCH will have a written strategy for assessing and improving the quality of services provided by the Contractor for the Demonstration and the outcomes resulting from those services. This strategy is incorporated in Attachment O.
|
2.9
|
COORDINATION WITH CONTRACTOR’S KEY STAFF
|
2.9.1
|
DCH will make diligent good faith efforts to facilitate effective and continuous communication and coordination with the Contractor in all areas of GF operations.
|
2.9.2
|
Specifically, DCH will designate individuals within the department who will serve as a liaison to the corresponding individual on the Contractor’s staff, including:
|
·
|
A program integrity staff Member;
|
·
|
A quality oversight staff Member;
|
·
|
A Grievance System staff Member who will also ensure that the State Administrative Law Hearing process is consistent with the Rules of the Office of the State Administrative Hearings Chapter 616-1-2 and with any other applicable rule, regulation, or procedure whether State or federal;
|
·
|
An information systems coordinator; and
|
·
|
A vendor management staff Member.
|
2.10
|
FORMAT STANDARDS
|
|
DCH will provide to the Contractor its standards for formatting all Reports requested of the Contractor. DCH will require that all Reports be submitted electronically.
|
|
DCH and Contractor agree that any change (new or revised standards) to Contractor’s Reports which is set forth in Amendment 11 to the Contract (new or revised standards) shall not become effective until January 1, 2012.
|
2.11
|
FINANCIAL MANAGEMENT
|
2.11.1
|
In order to facilitate the Contractor’s efforts in using Cost Avoidance processes to ensure that primary payments from the liable third party are identified and collected to offset medical expenses; DCH will include information about known Third Party Resources on the electronic Enrollment data given to the Contractor.
|
2.11.2
|
DCH will monitor Contractor compliance with federal and State physician incentive plan rules and regulations.
|
|
2.12
|
INFORMATION SYSTEMS
|
2.12.1
|
DCH will supply the following information to the Contractor:
|
·
|
Application and database design and development requirements (standards) that is specific to the State of Georgia.
|
·
|
Networking and data communications requirements (standards) that are specific to the State of Georgia.
|
·
|
Specific information for integrity controls and audit trail requirements.
|
·
|
State web portal (Georgia.gov) integration standards and design guidelines.
|
·
|
Specifications for data files to be transmitted by the Contractor to DCH and/or its agents.
|
·
|
Specifications for point-to-point, uni-directional or bi-directional interfaces between Contractor and DCH systems.
|
2.13
|
READINESS OR ANNUAL REVIEW
|
2.13.1
|
DCH will conduct a readiness review of each new CMO at least 30 days prior to Enrollment of Medicaid and/or PeachCare for Kids® recipients in the CMO plan and an annual review of each existing CMO plan. The readiness and financial review will include, at a minimum, one (1) or more as determined by DCH on-site review. DCH will conduct the reviews to provide assurances that the Contractor is able and prepared to perform all administrative functions and is providing for high quality of services to Members.
|
2.13.2
|
Specifically, DCH’s review will document the status of the Contractor with respect to meeting program standards set forth in this Contract, as well as any goals established by the Contractor. A multidisciplinary team appointed by DCH will conduct the readiness and annual review. The scope of the reviews will include, but not be limited to, review and/or verification of:
|
·
|
Network Provider composition and access;
|
·
|
Staff;
|
·
|
Marketing materials;
|
·
|
Content of Provider agreements;
|
·
|
EPSDT plan;
|
·
|
Member services capability;
|
·
|
Comprehensiveness of quality and Utilization Management strategies;
|
·
|
Policies and procedures for the Grievance System and Complaint System;
|
·
|
Financial solvency;
|
·
|
Contractor litigation history, current litigation, audits and other government investigations both in Georgia and in other states; and
|
·
|
Information systems’ Claims payment system performance and interfacing capabilities.
|
·
|
Change in business address, telephone number, facsimile number, and e-mail address;
|
·
|
Change in corporate status or nature;
|
·
|
Change in business location;
|
·
|
Change in solvency;
|
·
|
Change in corporate officers, executive employees, or corporate structure;
|
·
|
Change in ownership, including but not limited to the new owner’s legal name, business address, telephone number, facsimile number, and e-mail address;
|
·
|
Change in incorporation status; or
|
·
|
Change in federal employee identification number or federal tax identification number.
|
·
|
Change in CMO litigation history, current litigation, audits and other government investigations both in Georgia and in other states.
|
3.1
|
The Contractor shall not make any changes to any of the requirements herein, without explicit written approval from Commissioner of DCH, or his or her designee.
|
4.1
|
ENROLLMENT
|
4.1.1
|
Enrollment Procedures
|
4.1.1.1
|
DCH or its Agent is responsible for Enrollment, including auto-assignment of a CMO plan; Disenrollment; education; and outreach activities. The Contractor shall coordinate with DCH and its Agent as necessary for all Enrollment and Disenrollment functions.
|
4.1.1.2
|
DCH or its Agent will make every effort to ensure that recipients ineligible for Enrollment in GF are not enrolled in GF. However, to ensure that such recipients are not enrolled in GF, the Contractor shall assist DCH or its Agent in the identification of recipients that are ineligible for Enrollment in GF, as discussed in Section 1.2.3, should such recipients inadvertently become enrolled in GF.
|
|
4.1.1.2.1
|
DCH or its Agent will make every effort to ensure that individuals ineligible for Enrollment in the Demonstration are not enrolled in GF as P4HB Participants. However, to ensure that such individuals are not enrolled in the Demonstration, the Contractor shall assist DCH or its Agent in the identification of P4HB Participants that are ineligible for enrollment in the Demonstration, as discussed in Section 1.2.3, but have been inadvertently enrolled in GF as P4HB Participants
|
4.1.1.3
|
The Contractor shall assist DCH or its Agent in the identification of recipients that become ineligible for Medicaid (for example, those who have died, been incarcerated, or moved out-of-state).
|
4.1.1.4
|
The Contractor shall accept all individuals for enrollment without restrictions. The Contractor shall not discriminate against individuals on the basis of religion, gender, race, color, or national origin, and will not use any policy or practice that has the effect of discriminating on the basis of religion, gender, race, color, or national origin or on the basis of health, health status, pre-existing Condition, or need for Health Care services.
|
4.1.2
|
Selection of a Primary Care Provider (PCP)
|
4.1.2.1
|
At the time of plan selection, Members, with counseling and assistance from DCH or its Agent, will choose an In-Network PCP. If a Member fails to select a PCP, or if the Member has been Auto-Assigned to the CMO plan, the Contractor shall Auto-Assign Members to a PCP based on the following algorithm:
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Assignment shall be made to a Provider with whom, based on FFS Claims history, the Member has a Historical Provider Relationship, provided that the geographic access requirements in 4.8.13 are met;
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If there is no Historical Provider Relationship the Member shall be Auto-Assigned to a Provider who is the assigned PCP for an immediate family member enrolled in the CMO plan, if the Provider is an appropriate Provider based on the age and gender of the Member;
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If other immediate family members do not have an assigned PCP, Auto-Assignment shall be made to a Provider with whom a family member has a Historical Provider Relationship; if the Provider is an appropriate Provider based on the age and gender of the Member;
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If there is no Member or immediate family member historical usage Members shall be Auto-Assigned to a PCP, using an algorithm developed by the Contractor, based on the age and sex of the Member, and geographic proximity.
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4.1.2.1.1
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At the time of plan selection, Family Planning Only P4HB Participants, with counseling and assistance from DCH or its Agent, will be encouraged to choose a Primary Care Provider. Because primary care services are not covered services under the Demonstration for the Family Planning Only P4HB Participants, the Contractor is required to maintain an up-to-date list of available Providers affiliated with the Georgia Association for Primary Health Care and other primary care Providers serving the uninsured and underinsured populations who are available to provide primary care services. The Contractor must not use Demonstration funds to reimburse for primary care services delivered to Family Planning Only P4HB Participants.
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4.1.2.1.2
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At the time of plan selection, IPC P4HB Participants, with counseling and assistance from DCH or its Agent, will be encouraged to choose an In-Network PCP. If an IPC P4HB Participant fails to select a PCP, or if the IPC P4HB Participant has been Auto-Assigned to the CMO plan, the Contractor shall Auto-Assign the IPC P4HB Participant to a PCP based on the algorithm identified in 4.1.2.1. If there is no IPC P4HB Participant or immediate family member historical usage, IPC P4HB Participants shall be Auto-Assigned to a PCP, using an algorithm developed by the Contractor, based on geographic proximity.
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4.1.2.2
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PCP assignment shall be effective immediately. The Contractor shall notify the Member via surface mail of their Auto-Assigned PCP within ten (10) Calendar Days of Auto-Assignment.
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4.1.2.2.1
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For IPC P4HB Participants, PCP assignment shall be effective immediately. The Contractor shall notify the IPC P4HB Participant via surface mail of her Auto-Assigned PCP within ten (10) Calendar Days of Auto-Assignment.
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4.1.2.3
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The Contractor shall submit its PCP Auto-Assignment Policies and Procedures to DCH for review and approval as updated.
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4.1.3
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Newborn Enrollment
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4.1.3.1
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All newborns shall be Auto-Assigned by DCH or its Agent to the mother’s CMO plan.
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4.1.3.2
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The Contractor shall be responsible for notifying DCH or its Agent of any Members who are expectant mothers at least sixty (60) Calendar Days prior to the expected date of delivery. The Contractor shall be responsible for notifying DCH or its Agent of newborns born to enrolled members that do not appear on a monthly roster within 60 days after birth.
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4.1.3.3
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The Contractor shall provide assistance to any expectant mother who contacts them wishing to make a PCP selection for her newborn and record that selection.
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4.1.3.4
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Within twenty-four (24) hours of the birth, the Contractor shall ensure the submission of a newborn notification form to DCH or its agent. If the mother has made a PCP selection, this information shall be included in the newborn notification form. If the mother has not made a PCP selection, the Contractor shall Auto-Assign the newborn to a PCP within thirty (30) days of the birth. Auto-Assignment shall be made using the algorithm described in Section 4.1.2.1. Notice of the PCP Auto-Assignment shall be mailed to the mother within twenty-four (24) hours.
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4.1.4.1
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The Contractor shall submit to DCH monthly Member Data Conflict Report (formerly Member Information Reports) as described in Section 4.18.3.7.
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4.1.4.2
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The Contractor shall submit to DCH monthly Eligibility and Enrollment Reconciliation Reports as described in Section 4.18.3.2.
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4.2
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DISENROLLMENT
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4.2.1
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Disenrollment Initiated by the Member or P4HB Participant
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4.2.1.1
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A Member or P4HB Participant may request Disenrollment from a CMO plan without cause during the ninety (90) Calendar Days following the date of the Member’s or P4HB Participants initial Enrollment with the CMO plan or the date DCH or its Agent sends the Member or P4HB Participant notice of the Enrollment, whichever is later. A Member or P4HB Participant may request Disenrollment without cause every twelve (12) months thereafter.
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4.2.1.2
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A Member or P4HB Participant may request Disenrollment from a CMO plan for cause at any time. The following constitutes cause for Disenrollment by the Member or P4HB Participant:
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The Member or P4HB Participant moves out of the CMO plan’s Service Region;
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The CMO plan does not, because of moral or religious objections, provide the Covered Service the Member or P4HB Participant seeks;
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The Member or P4HB Participant needs related services to be performed at the same time and not all related services are available within the network. The Member’s or P4HB Participants Provider or another Provider have determined that receiving service separately would subject the Member or P4HB Participant to unnecessary risk;
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The Member or P4HB Participant requests to be assigned to the same CMO plan as family members or P4HB Participants; and
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The Member’s or P4HB Participants Medicaid eligibility category changes to a category ineligible for GF, and/or the Member or P4HB Participant otherwise becomes ineligible to participate in GF.
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Other reasons, per 42 CFR 438.56(d)(2), include, but are not limited to, poor quality of care, lack of access to services covered under the Contract, or lack of Providers experienced in dealing with the Member’s or P4HB Participants Health Care needs. (DCH or its Agent shall make determination of these reasons.)
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4.2.1.3
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The Contractor shall provide assistance to Members or P4HB Participants seeking to disenroll. This assistance shall consist of providing the forms to the Member or P4HB Participant and referring the Member or P4HB Participant to DCH or its Agent who will make Disenrollment determinations.
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4.2.1.4
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A P4HB Participant may request Disenrollment from a CMO plan for cause at any time during the ninety (90) Calendar Days following the date of the P4HB Participant’s initial enrollment with the CMO plan or the date DCH or its Agent sends the Participant notice of the enrollment into the Demonstration, whichever is later. The following constitutes cause for Disenrollment by the P4HB Participant:
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The P4HB Participant moves out of the CMO plan’s Service Region;
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The P4HB Participant requests to be assigned to the same CMO plan as family members; and
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The P4HB Participant otherwise becomes ineligible for participation in the Demonstration.
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Other reasons, per 42 CFR 438.56(d)(2), include, but are not limited to, poor quality of care, lack of access to services covered under the Demonstration amendment, or lack of Demonstration Providers experienced in dealing with the P4HB Participant’s health care needs. (DCH or its Agent shall make determination of these reasons.)
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4.2.2
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Disenrollment Initiated by the Contractor
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4.2.2.1
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The Contractor shall complete all Disenrollment paperwork for Members or P4HB Participants it is seeking to disenroll.
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4.2.2.1.1
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The Contractor shall complete all Disenrollment paperwork for any P4HB Participants it seeks to disenroll.
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4.2.2.2
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The Contractor shall notify DCH or its Agent upon identification of a Member or P4HB Participant who it knows or believes meets the criteria for Disenrollment, as defined in Section 4.2.3.
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4.2.2.2.1
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The Contractor shall notify DCH or its Agent upon identification of a P4HB Participant who it knows or believes meets the following criteria for disenrollment from the Demonstration:
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The P4HB Participant no longer meets the eligibility criteria for the Demonstration.
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The IPC P4HB Participant has reached the end of the twenty-four (24) months of eligibility for the IPC component of the Demonstration.
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The P4HB Participant becomes pregnant while enrolled in the Demonstration;
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The P4HB Participant becomes infertile through a sterilization procedure;
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The P4HB Participant moves out of the CMO plan’s Service Region;
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The P4HB Participant’s utilization of services is fraudulent or abusive;
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The Participant’s eligibility category changes to a category ineligible for participation in the P4HB program;
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The P4HB Participant has died, been incarcerated, or moved out of State, thereby making her ineligible for Medicaid.
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4.2.2.3
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Prior to requesting Disenrollment of a Member or P4HB Participant for reasons described in Sections 4.2.3, the Contractor shall document at least three (3) interventions over a period of ninety (90) Calendar Days that occurred through treatment, case management, and Care Coordination to resolve any difficulty leading to the request. The Contractor shall provide at least one (1) written warning to the Member or P4HB Participant, certified return receipt requested, regarding implications of his or her actions. DCH recommends that this notice be delivered within ten (10) Business Days of the Member’s or P4HB Participants action.
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4.2.2.4
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The Contractor shall cite to DCH or its Agent at least one (1) acceptable reason for Disenrollment outlined in Section 4.2.3 before requesting Disenrollment of the Member or P4HB Participant.
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4.2.2.5
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The Contractor shall submit Disenrollment requests to DCH or its Agent and the Contractor shall honor all Disenrollment determinations made by DCH or its Agent. DCH’s decision on the matter shall be final, conclusive and not subject to appeal.
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4.2.3
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Acceptable Reasons for Disenrollment Requested by Contractor
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The Contractor may request Disenrollment if:
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The Member’s Utilization of services is Fraudulent or abusive;
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The Member has moved out of the Service Region;
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The Member is placed in a long-term care nursing facility, State institution, or intermediate care facility for the mentally retarded;
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The Member’s Medicaid eligibility category changes to a category ineligible for GF, and/or the Member otherwise becomes ineligible to participate in GF. Disenrollments due to Member eligibility will follow the normal monthly process as described in Section 2.4.3. Disenrollments will be processed as of the date that the member eligibility category actually changes and will not be made retroactive, regardless of the effective date of the new eligibility category. Note exception when SSI members are hospitalized.
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The Member has any other condition as so defined by DCH; or
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The Member has died, been incarcerated, or moved out of State, thereby making them ineligible for Medicaid.
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4.2.4
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Unacceptable Reasons for Disenrollment Requests by Contractor
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4.2.4.1
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The Contractor shall not request Disenrollment of a Member or P4HB Participant for discriminating reasons, including:
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·
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Adverse changes in a Member’s or P4HB Participants health status;
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Missed appointments;
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Utilization of medical services;
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Diminished mental capacity;
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Pre-existing medical condition;
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Uncooperative or disruptive behavior resulting from his or her special needs; or
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Lack of compliance with the treating physician’s plan of care.
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4.2.4.2
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The Contractor shall not request Disenrollment because of the Member’s or P4HB Participants attempt to exercise his or her rights under the Grievance System.
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4.2.4.3
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The request of one PCP to have a Member or P4HB IPC Participant assigned to a different Provider shall not be sufficient cause for the Contractor to request that the Member or P4HB IPC Participant be disenrolled from the plan. Rather, the Contractor shall utilize its PCP assignment process to assign the Member or P4HB IPC Participant to a different and available PCP.
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4.3
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MEMBER AND P4HB PARTICIPANT SERVICES
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4.3.1
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General Provisions
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The Contractor shall ensure that Members are aware of their rights and responsibilities, the role of PCPs, how to obtain care, what to do in an emergency or urgent medical situation, how to request a Grievance, Appeal, or Administrative Law Hearings, and how to report suspected Fraud and Abuse. The Contractor shall convey this information via written materials and via telephone, internet, and face-to-face communications that allow the Members to submit questions and receive responses from the Contractor. The Contractor shall ensure that P4HB Participants are aware of their rights and responsibilities, the role of the Family Planning Provider and PCP (for IPC P4HB Participants only), how to obtain care, what to do in an emergency or urgent medical situation arising from the receipt of Demonstration related Services, how to submit a Grievance, request an Appeal, or Administrative Law Hearing, and how to report suspected Fraud and Abuse. The Contractor shall convey this information via written materials and via telephone, internet, and face-to-face communications that allow the P4HB Participant to submit questions and receive responses from the Contractor.
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4.3.2
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Requirements for Written Materials
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4.3.2.1
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The Contractor shall make all written materials available in alternative formats and in a manner that takes into consideration the Member’s or P4HB Participants special needs, including those who are visually impaired or have limited reading proficiency. The Contractor shall notify all Members or P4HB Participants and Potential Members that information is available in alternative formats and how to access those formats.
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4.3.2.2
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The Contractor shall make all written information available in English, Spanish and all other prevalent non-English languages, as defined by DCH. For the purposes of this Contract, prevalent means a non-English language spoken by a significant number or percentage of Medicaid and PeachCare for Kids® eligible individuals in the State.
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4.3.2.3
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All written materials distributed to Members or P4HB Participants shall include a language block, printed in Spanish and all other prevalent non-English languages, that informs the Member or P4HB Participant that the document contains important information and directs the Member to call the Contractor to request the document in an alternative language or to have it orally translated.
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4.3.2.4
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All written materials shall be worded such that they are understandable to a person who reads at the fifth (5th) grade level. Suggested reference materials to determine whether this requirement is being met are:
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Fry Readability Index;
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PROSE The Readability Analyst (software developed by Education Activities, Inc.);
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Gunning FOG Index;
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McLaughlin SMOG Index;
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The Flesch-Kincaid Index; or
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Other word processing software approved by DCH.
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4.3.2.5
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The Contractor shall provide written notice to DCH of any changes to any written materials provided to the Members or P4HB Participant. Written notice shall be provided at least thirty (30) Calendar Days before the effective date of the change.
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4.3.2.6
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The Contractor must submit all written materials, including information for the Web site, to DCH for approval prior to use or mailing. DCH will approve or identify any required changes to the member or P4HB Participant materials within 30 days of submission. DCH reserves the right to require the discontinuation of any member materials that violate the terms of this contract.
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4.3.3
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Member Handbook and P4HB Participants Information Requirements
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4.3.3.1
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The Contractor shall mail to all newly enrolled Members a Member Handbook within ten (10) Calendar Days of receiving the notice of enrollment from DCH or its Agent. The Contractor shall mail to all enrolled Member households a Member Handbook every other year thereafter unless requested sooner by the member.
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4.3.3.1.1
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The Contractor shall mail to all newly enrolled P4HB Participants an information packet including but not limited to the following:
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General information pertaining to the Demonstration (eligibility, enrollment and disenrollment criteria, and information pertaining to the Demonstration’s program components – family planning only, IPC, Resource Mothers Outreach).
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A list of benefits and services available under each Demonstration component
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A list of service exclusions or limitations under each Demonstration component
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Information about the role of the Family Planning Provider
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Information about the selection of a Primary Care Provider affiliated with the Georgia Association for Primary Health Care and whose services are not covered under the Demonstration
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Information on where and how P4HB Participants may access other benefits and services not available from or not covered by the Contractor under the Demonstration
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Information about the role of the PCP for the IPC P4HB Participant only
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Information about appointment procedures
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Information on how to access Demonstration services, including non-emergency transportation (NET) available to the IPC P4HB Participants only
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A notice stating that the Contractor shall be liable only for those Demonstration services authorized by CMS under the Demonstration
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A description of all pre-certification, prior authorization or other requirements for Demonstration related Services and treatments
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The geographic boundaries of the Service Regions
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Notice of all appropriate mailing addresses and telephone numbers to be utilized by P4HB Participants seeking information or authorization, including an inclusion of the Contractor’s toll-free telephone line and Web site
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A description of the P4HB Participant’s rights and responsibilities as described in Section 4.3.4
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The policies and procedures for Disenrollment from the Demonstration
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Information on Advance Directives
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A statement that additional information, including information on the structure and operation of the CMO plan and physician incentive plans, shall be made available upon request
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Information on the extent to which, and how, after hours and emergency coverage are provided, including the following:
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§
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What constitutes an Urgent and Emergency Demonstration related Medical Condition, Demonstration related Emergency Services, and Demonstration related Post Stabilization Services;
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§
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The fact that Prior Authorization is not required for Demonstration related Emergency Services;
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§
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The process and procedures for obtaining Demonstration related Emergency Services, including the use of the 911 telephone systems or its local equivalent;
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§
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The location of any emergency settings and other locations at which Demonstration Providers and hospitals furnish Demonstration related Emergency and Post Stabilization Services; and
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§
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The fact that a P4HB Participant has a right to use any hospital or other setting for Demonstration related Emergency Services
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Information on the Grievance Systems policies and procedures, as described in Section 4.14 of the Contract. This description must include the following:
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§
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The right to file a Grievance and Appeal with the Contractor;
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§
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The requirements and timeframes for filing a Grievance or Appeal with the Contractor;
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§
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The availability of assistance in filing a Grievance or Appeal with the Contractor;
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§
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The toll-free numbers P4HB Participants can use to file a Grievance or an Appeal with the Contractor by phone;
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§
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The right to a State Administrative Law hearing, the method for obtaining a hearing, and the rules that govern representation at the hearing;
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§
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Notice that if the P4HB Participant files an Appeal or a request for a State Administrative Law Hearing within the timeframes specified for filing, the P4HB Participant may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the P4HB Participant; and
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§
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Any Appeal rights that the State chooses to make available to Providers to challenge the failure of the Contractor to cover the Demonstration related Service.
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The Contractor shall submit to DCH for review and approval any changes and edits to the P4HB Participant Information Packet at least thirty (30) Calendar Days before the effective date of change.
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4.3.3.2
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Pursuant to the requirements set forth in 42 CFR 438.10, the Member Handbook shall include, but not be limited to:
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A table of contents;
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Information about the roles and responsibilities of the Member (this information to be supplied by DCH);
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Information about the role of the PCP;
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Information about choosing a PCP;
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Information about what to do when family size changes;
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Appointment procedures;
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Information on Benefits and services, including a description of all available GF Benefits and services;
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Information on how to access services, including Health Check services, non-emergency transportation (NET) services, and maternity and family planning services;
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An explanation of any service limitations or exclusions from coverage;
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A notice stating that the Contractor shall be liable only for those services authorized by the Contractor;
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Information on where and how Members may access Benefits not available from or not covered by the Contractor;
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The Medical Necessity definition used in determining whether services will be covered;
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A description of all pre-certification, prior authorization or other requirements for treatments and services;
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The policy on Referrals for specialty care and for other Covered Services not furnished by the Member’s PCP;
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Information on how to obtain services when the Member is out of the Service Region and for after-hours coverage;
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Cost-sharing;
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The geographic boundaries of the Service Regions;
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Notice of all appropriate mailing addresses and telephone numbers to be utilized by Members seeking information or authorization, including an inclusion of the Contractor’s toll-free telephone line and Web site;
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A description of Utilization Review policies and procedures used by the Contractor;
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A description of Member rights and responsibilities as described in Section 4.3.4;
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The policies and procedures for Disenrollment;
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Information on Advance Directives;
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A statement that additional information, including information on the structure and operation of the CMO plan and physician incentive plans, shall be made available upon request;
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4.3.3.3
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Information on the extent to which, and how, after-hours and emergency coverage are provided, including the following:
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i.
|
What constitutes an Urgent and Emergency Medical Condition, Emergency Services, and Post-Stabilization Services;
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ii.
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The fact that Prior Authorization is not required for Emergency Services;
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iii.
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The process and procedures for obtaining Emergency Services, including the use of the 911 telephone systems or its local equivalent;
|
iv.
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The locations of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Services covered herein; and
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v.
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The fact that a Member has a right to use any hospital or other setting for Emergency Services;
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4.3.3.4
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Information on the Grievance Systems policies and procedures, as described in Section 4.14 of this Contract. This description must include the following:
|
i.
|
The right to file a Grievance and Appeal with the Contractor;
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ii.
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The requirements and timeframes for filing a Grievance or Appeal with the Contractor;
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iii.
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The availability of assistance in filing a Grievance or Appeal with the Contractor;
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iv.
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The toll-free numbers that the Member can use to file a Grievance or an Appeal with the Contractor by phone;
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v.
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The right to a State Administrative Law Hearing, the method for obtaining a hearing, and the rules that govern representation at the hearing;
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vi.
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Notice that if the Member files an Appeal or a request for a State Administrative Law Hearing within the timeframes specified for filing, the Member may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Member; and
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vii.
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Any Appeal rights that the State chooses to make available to Providers to challenge the failure of the Contractor to cover a service.
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4.3.3.5
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The Contractor shall submit to DCH for review and approval any changes and edits to the Member Handbook at least thirty (30) Calendar Days before the effective date of change.
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4.3.4
|
Member and P4HB Participant Rights
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4.3.4.1
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The Contractor shall have written policies and procedures regarding the rights of Members and shall comply with any applicable federal and State laws and regulations that pertain to Member rights. These rights shall be included in the Member Handbook. At a minimum, said policies and procedures shall specify the Member’s right to:
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·
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Receive information pursuant to 42 CFR 438.10;
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·
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Be treated with respect and with due consideration for the Member’s dignity and privacy;
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Have all records and medical and personal information remain confidential;
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Receive information on available treatment options and alternatives, presented in a manner appropriate to the Member’s Condition and ability to understand;
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Participate in decisions regarding his or her Health Care, including the right to refuse treatment;
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Be free from any form of restraint or seclusion as a means of coercion, discipline, convenience or retaliation, as specified in other federal regulations on the use of restraints and seclusion;
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Request and receive a copy of his or her Medical Records pursuant to 45 CFR 160 and 164, subparts A and E, and request to amend or correct the record as specified in 45 CFR 164.524 and 164.526;
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Be furnished Health Care services in accordance with 42 CFR 438.206 through 438.210;
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·
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Freely exercise his or her rights, including those related to filing a Grievance or Appeal, and that the exercise of these rights will not adversely affect the way the Member is treated;
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·
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Not be held liable for the Contractor’s debts in the event of insolvency; not be held liable for the Covered Services provided to the Member for which DCH does not pay the Contractor; not be held liable for Covered Services provided to the Member for which DCH or the CMO plan does not pay the Health Care Provider that furnishes the services; and not be held liable for payments of Covered Services furnished under a contract, Referral, or other arrangement to the extent that those payments are in excess of amount the Member would owe if the Contractor provided the services directly; and
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·
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Only be responsible for cost sharing in accordance with 42 CFR 447.50 through 42 CFR 447.60 and Attachment K of this Contract.
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4.3.4.2
|
The Contractor shall have written policies and procedures regarding the rights of P4HB Participants and shall comply with any applicable federal and State laws and regulations that pertain to P4HB Participant rights. These rights shall be included in the P4HB Participant Information Packet. At a minimum, said policies and procedures shall specify the P4HB Participant’s right to:
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·
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Receive information pursuant to 42CFR 438.10;
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·
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Be treated with respect and with due consideration for the P4HB Participant’s dignity and privacy;
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·
|
Have all records and medical and personal information remain confidential;
|
·
|
Receive information on available Demonstration related treatment options and alternatives, presented in a manner appropriate to the P4HB Participant’s condition and ability to understand;
|
·
|
Participate in decisions regarding her Demonstration services;
|
·
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Request and receive a copy of her Medical Records pursuant to 45 CFR 160 and 164, subparts A and E, and request to amend or correct the record as specified in 45 CFR 164.524 and 164.526;
|
·
|
Be furnished Demonstration related Services in accordance with 42 CFR 438.206 through 438.210 as appropriate;
|
·
|
Freely exercise her rights, including those related to filing a Grievance or Appeal, and that the exercise of these rights will not adversely affect the way the P4HB Participant is treated;
|
·
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Not be held liable for the Contractor’s debts in the event of insolvency; not be held liable for the Demonstration related Services provided to the P4HB Participant for which DCH does not pay the Contractor; not be held liable for Demonstration related Services provided to the P4HB Participant for which neither DCH nor the CMO pays the Demonstration Provider that furnishes the Demonstration related Services; and not be held liable for payments of Demonstration related Services furnished under a contract, Referral, or other arrangement to the extent that those payments are in excess of the amount the P4HB Participant would owe if the Contractor provided the services directly; and
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·
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Only be responsible for cost sharing in accordance with 42 CFR 447.50 through 42 CFR 447.60 and Attachment K of this Contract.
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4.3.5
|
Provider Directory
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4.3.5.1
|
The Contractor shall mail via surface mail a Provider Directory to all new Members or P4HB Participants within ten (10) Calendar Days of receiving the notice of Enrollment from DCH or the State’s Agent.
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4.3.5.2
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The Provider Directory shall include names, locations, office hours, telephone numbers of and non-English language spoken by, current contracted Providers. This includes, at a minimum, information on PCPs, specialists, Family Planning Providers, dentists, pharmacists, FQHCs and RHCs, mental health and substance abuse Providers, and hospitals. The Provider Directory shall also identify Providers that are not accepting new patients.
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4.3.5.3
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The Contractor shall submit the Provider Directory to DCH for review and prior approval as updated.
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4.3.5.4
|
The Contractor shall up-date and amend the Provider Directory on its Web site within five (5) Business Days of any changes, produces and distributes quarterly up-dates to all Members or P4HB Participants, and re-print the Provider Directory and distribute to all Members at least once per year.
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4.3.5.5
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The Contractor shall post on its website a searchable list of all providers with which the care management organization has contracted. At a minimum, this list shall be searchable by provider name, specialty, and location.
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4.3.6
|
Member and P4HB Participant Identification (ID) Card
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4.3.6.1
|
The Contractor shall mail via surface mail a Member ID Card to all new Members according to the following timeframes:
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·
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Within ten (10) Calendar Days of receiving the notice of Enrollment from DCH or the Agent for Members who have selected a CMO plan and a PCP;
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·
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Within ten (10) Calendar Days of PCP assignment or selection for Members that are Auto-Assigned to the CMO plan.
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4.3.6.2
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The Member ID Card must, at a minimum, include the following information:
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·
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The Member’s name;
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The Member’s Medicaid or PeachCare for Kids® identification number;
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The PCP’s name, address, and telephone numbers (including after-hours number if different from business hours number);
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The name and telephone number(s) of the Contractor;
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The Contractor’s twenty-four (24) hour, seven (7) day a week toll-free Member services telephone number;
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Instructions for emergencies; and
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·
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Includes minimum or instructions to facilitate the submission of a claim by a Provider.
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4.3.6.3
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The Contractor shall reissue the Member ID Card within ten (10) Calendar Days of notice if a Member reports a lost card, there is a Member name change, the PCP changes, or for any other reason that results in a change to the information disclosed on the Member ID Card.
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4.3.6.4
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The Contractor shall submit a front and back sample Member ID Card to DCH for review and approval as updated.
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4.3.6.5
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The Contractor shall mail via surface mail a P4HB Participant ID Card to all new P4HB Participants in the Demonstration within ten (10) Calendar Days of receiving the notice of enrollment from DCH or its Agent. The P4HB Participant’s ID Card must meet all requirements as specified in Sections 4.3.6.2, 4.3.6.3 and 4.3.6.4. The P4HB Participant’s ID Card will identify the Demonstration component in which the P4HB Participant is enrolled:
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·
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A Pink color will signify the P4HB Participants as eligible for Family Planning Services Only.
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A Purple color will signify the P4HB Participants as eligible for Interpregnancy Care Services and Family Planning Services.
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A Yellow color will signify the P4HB Participant as eligible for Case Management - Resource Mothers Outreach Only.
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4.3.6.6
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At the time the P4HB Participant’s ID card is supplied to a P4HB Participant, the Contractor shall provide written materials that explain the meaning of the color coding of the ID card and its relevance to Demonstration benefits.
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4.3.7
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Toll-free Member and P4HB Participant Services Line
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4.3.7.1
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The Contractor shall operate a toll-free telephone line to respond to Member and P4HB Participant questions, comments and inquiries.
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4.3.7.2
|
The Contractor shall develop Telephone Line Policies and Procedures that address staffing, personnel, hours of operation, access and response standards, monitoring of calls via recording or other means, and compliance with standards.
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4.3.7.3
|
The Contractor shall submit these Telephone Line Policies and Procedures, including performance standards pursuant to Section 4.3.7.7, to DCH for review and approval as updated.
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4.3.7.4
|
The telephone line shall handle calls from non-English speaking callers, as well as calls from Members and P4HB Participants who are hearing impaired.
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4.3.7.5
|
The Contractor’s call center systems shall have the capability to track call management metrics identified in Attachment L.
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4.3.7.6
|
The telephone line shall be fully staffed between the hours of 7:00 a.m. and 7:00 p.m. EST, Monday through Friday, excluding State holidays. The telephone line staff shall be trained to accurately respond to Member and P4HB Participant questions in all areas, including, but not limited to, Covered Services, the provider network, and non-emergency transportation (NET).
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4.3.7.7
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The Contractor shall develop performance standards and monitor Telephone Line performance by recording calls and employing other monitoring activities. At a minimum, the standards shall require that, on a monthly basis, eighty percent (80%) of calls are answered by a person within thirty (30) seconds, the Blocked Call rate does not exceed one percent (1%), and the rate of Abandoned Calls does not exceed five percent (5%).
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4.3.7.8
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The Contractor shall have an automated system available between the hours of 7:00 p.m. and 7:00 a.m. EST Monday through Friday and at all hours on weekends and holidays. This automated system must provide callers with operating instructions on what to do in case of an emergency and shall include, at a minimum, a voice mailbox for callers to leave messages. The Contractor shall ensure that the voice mailbox has adequate capacity to receive all messages. A Contractor’s Representative shall return messages on the next Business Day.
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4.3.7.9
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The Contractor shall develop Call Center Quality Criteria and Protocols to measure and monitor the accuracy of responses and phone etiquette as it relates to the Toll-free Telephone Line. The Contractor shall submit the Call Center Quality Criteria and Protocols to DCH for review and approval annually.
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4.3.8
|
Internet Presence/Web Site
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4.3.8.1
|
The Contractor shall provide general and up-to-date information about the CMO plan’s program, its Provider network, its customer services, and its Grievance and Appeals Systems on its Web site.
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4.3.8.2
|
The Contractor shall maintain a Member and P4HB Participant portal that allows Members to access a searchable Provider Directory that shall be updated within five (5) Business Days upon changes to the Provider network.
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4.3.8.3
|
The Web site must have the capability for Members and P4HB Participants to submit questions and comments to the Contractor and for members to receive responses.
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4.3.8.4
|
The Web site must comply with the marketing policies and procedures and with requirements for written materials described in this Contract and must be consistent with applicable State and federal laws.
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4.3.8.5
|
In addition to the specific requirements above, the Contractor’s Web site shall be functionally equivalent, with respect to functions described in this Contract, to the Web site maintained by the State’s Medicaid fiscal agent. www.ghp.georgia.gov/wps/portal
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4.3.8.6
|
The Contractor shall submit Web site screenshots to DCH for review and approval as updated.
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4.3.8.7
|
The Contractor shall provide general and up to date information about the Demonstration on its website. This information must incorporate DCH’s messaging regarding the Demonstration.
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4.3.8.8
|
The Contractor shall provide links from its website to the DCH P4HB website.
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4.3.9
|
Cultural Competency
|
|
4.3.9.1
|
In accordance with 42 CFR 438.206, the Contractor shall have a comprehensive written Cultural Competency Plan describing how the Contractor will ensure that services are provided in a culturally competent manner to all Members and P4HB Participants, including those with limited English proficiency. The Cultural Competency Plan must describe how the Providers, individuals and systems within the CMO plan will effectively provide services to people of all cultures, races, ethnic backgrounds and religions in a manner that recognizes values, affirms and respects the worth of the individual Members and P4HB Participants and protects and preserves the dignity of each.
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4.3.9.2
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The Contractor shall submit the Cultural Competency Plan to DCH for review and approval as updated.
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4.3.9.3
|
The Contractor may distribute a summary of the Cultural Competency Plan to the In-Network Providers if the summary includes information on how the Provider may access the full Cultural Competency Plan on the Web site. This summary shall also detail how the Provider can request a hard copy from the CMO at no charge to the Provider.
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4.3.10
|
Translation Services
|
|
4.3.10.1
|
The Contractor is required to provide oral translation services of information to any Member or P4HB Participant who speaks any non-English language regardless of whether a Member or P4HB Participant speaks a language that meets the threshold of a Prevalent Non-English Language. The Contractor is required to notify its Members or P4HB Participants of the availability of oral interpretation services and to inform them of how to access oral interpretation services. There shall be no charge to the Member or P4HB Participant for translation services.
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4.3.11
|
Reporting Requirements
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4.3.11.1
|
The Contractor shall submit monthly Telephone and Internet Activity Reports to DCH as described in Section 4.18.3.1
|
4.3
|
MARKETING
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4.4.1
|
Prohibited Activities
|
4.4.1.1
|
The Contractor is prohibited from engaging in the following activities:
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·
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Directly or indirectly engaging in door-to-door, telephone, or other Cold-Call Marketing activities to Potential Members or P4HB Participants;
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Offering any favors, inducements or gifts, promotions, and/or other insurance products that are designed to induce Enrollment in the Contractor’s plan, and that are not health related and/or worth more than $10.00 cash;
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Distributing information plans and materials that contain statements that DCH determines are inaccurate, false, or misleading. Statements considered false or misleading include, but are not limited to, any assertion or statement (whether written or oral) that the recipient must enroll in the Contractor’s plan in order to obtain Benefits or in order to not lose Benefits or that the Contractor’s plan is endorsed by the federal or State government, or similar entity; and
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Distributing information or materials that, according to DCH, mislead or falsely describe the Contractor’s Provider network, the participation or availability of network Providers, the qualifications and skills of network Providers (including their bilingual skills); or the hours and location of network services.
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4.4.2
|
Allowable Activities
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4.4.2.1
|
The Contractor shall be permitted to perform the following marketing activities:
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·
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Distribute general information through mass media (i.e. newspapers, magazines and other periodicals, radio, television, the Internet, public transportation advertising, and other media outlets);
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Make telephone calls, mailings and home visits only to Members currently enrolled in the Contractor’s plan, for the sole purpose of educating them about services offered by or available through the Contractor;
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Distribute brochures and display posters at Provider offices and clinics that inform patients that the clinic or Provider is part of the CMO plan’s Provider network, provided that all CMO plans in which the Provider participates have an equal opportunity to be represented; and
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Attend activities that benefit the entire community such as health fairs or other health education and promotion activities.
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4.4.2.2
|
If the Contractor performs an allowable activity, the Contractor shall conduct these activities in the entire Service Region as defined by this Contract.
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4.4.2.3
|
All materials shall comply with the information requirements in 42 CFR 438.10 and detailed in Section 4.3.2 of this Contract.
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4.4.3
|
State Approval of Materials
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4.4.3.1
|
This requirement includes, but is not limited to posters, brochures, Web sites, and any materials that contain statements regarding the benefit package and Provider network-related materials. Neither the Contractor nor its Subcontractors shall distribute any marketing materials without prior, written approval from DCH.
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4.4.3.2
|
The Contractor shall submit any changes to previously approved marketing materials and receive approval from DCH of the changes before distribution.
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4.4.4
|
Provider Marketing Materials
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4.5.1
|
Included Services
|
4.5.1.1
|
The Contractor shall at a minimum provide Medically Necessary services and Benefits pursuant to the Georgia State Medicaid Plan, and the Georgia Medicaid Policies and Procedures Manuals. Such Medically Necessary services shall be furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to recipients under Fee-for-Service Medicaid. The Contractor may not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of the diagnosis, type of illness or Condition.
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4.5.1.2
|
The Contractor shall at a minimum provide to P4HB Participants Demonstration related Services and Benefits pursuant to the CMS SPECIAL TERMS AND CONDITIONS (STCs), NUMBER: 11-W-00249/4 Document pertaining to the Planning for Healthy Babies 1115 Demonstration Waiver Program. These STCs have been incorporated into this Contract as Attachment Q.
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4.5.2
|
Individuals with Disabilities Education Act (IDEA) Services
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4.5.2.1
|
For Members up to and including age two (2), the Contractor shall be responsible for Medically Necessary IDEA Part C services provided pursuant to an Individualized Family Service Plan (IFSP) or Individualized Education Plan (IEP).
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4.5.2.2
|
For Members age 3-21, the Contractor shall not be responsible for Medically Necessary IDEA Part B services provided pursuant to an IEP or IFSP. Such services shall remain in FFS Medicaid.
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4.5.2.2.1
|
The Contractor shall be responsible for all other Medically Necessary covered services.
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4.5.3
|
Enhanced Services
|
|
4.5.3.1
|
In addition to the Covered Services provided above, the Contractor shall do the following:
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·
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Place strong emphasis on programs to enhance the general health and well-being of Members;
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Make health promotion materials available to Members;
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Participate in community-sponsored health fairs; and
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Provide education to Members, families and other Health Care Providers about early intervention and management strategies for various illnesses.
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4.5.3.2
|
The Contractor shall not charge a Member for participating in health education services that are defined as either enhanced or Covered Services.
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4.5.4
|
Medical Necessity
|
|
4.5.4.1
|
Based upon generally accepted medical practices in light of Conditions at the time of treatment, Medically Necessary services are those that are:
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·
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Appropriate and consistent with the diagnosis of the treating Provider and the omission of which could adversely affect the eligible Member’s medical Condition;
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·
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Compatible with the standards of acceptable medical practice in the community;
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·
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Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms;
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Not provided solely for the convenience of the Member or the convenience of the Health Care Provider or hospital; and
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Not primarily custodial care unless custodial care is a covered service or benefit under the Members evidence of coverage.
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4.5.4.2
|
There must be no other effective and more conservative or substantially less costly treatment, service and setting available.
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4.5.4.3
|
For children under 21, the Contractor is required to provide medically necessary services to correct or ameliorate physical and behavioral health disorders, a defect, or a condition identified in an EPSDT (Health Check) screening, regardless whether those services are included in the State Plan, but are otherwise allowed pursuant to 1905 (a) of the Social Security Act. See Diagnostic and Treatment, Section 4.7.5.2.
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4.5.5
|
Experimental, Investigational or Cosmetic Procedures, Drugs, Services, or Devices
|
|
4.5.5.1
|
Pursuant to the Georgia State Medicaid Plan and the Georgia Medicaid Policies and Procedures Manuals, in no instance shall the Contractor cover experimental, investigational or cosmetic procedures, drugs, services or devices or those not recognized by the Federal Drug Administration, the United States Public Health Service, Medicaid and/or the Department’s contracted peer review organization as universally accepted treatment.
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4.5.6
|
Moral or Religious Objections
|
|
4.5.6.1
|
The Contractor is required to provide and reimburse for all Covered Services. If, during the course of the Contract period, pursuant to 42 CFR 438.102, the Contractor elects not to provide, reimburse for, or provide coverage of a counseling or Referral service because of an objection on moral or religious grounds, the Contractor shall notify:
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·
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DCH within one hundred and twenty (120) Calendar Days prior to adopting the policy with respect to any service;
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·
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Members within ninety (90) Calendar Days after adopting the policy with respect to any service; and
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·
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Members and Potential Members before and during Enrollment.
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|
4.5.6.2.
|
The Contractor acknowledges that such objection will be grounds for recalculation of rates paid to the Contractor.
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4.6.1
|
Emergency Services
|
4.6.1.1
|
Emergency Services shall be available twenty-four (24) hours a day, seven (7) Days a week to treat an Emergency Medical Condition.
|
4.6.1.2
|
An Emergency Medical Condition shall not be defined or limited based on a list of diagnoses or symptoms. An Emergency Medical Condition is a medical or mental health Condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:
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·
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Placing the physical or mental health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
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·
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Serious impairment to bodily functions;
|
·
|
Serious dysfunction of any bodily organ or part;
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·
|
Serious harm to self or others due to an alcohol or drug abuse emergency;
|
·
|
Injury to self or bodily harm to others; or
|
·
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With respect to a pregnant woman having contractions: (i) That there is inadequate time to affect a safe transfer to another hospital before delivery, or (ii) That transfer may pose a threat to the health or safety of the woman or the unborn child.
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4.6.1.3
|
The Contractor shall provide payment for Emergency Services when furnished by a qualified Provider, regardless of whether that Provider is in the Contractor’s network. These services shall not be subject to prior authorization requirements. The Contractor shall be required to pay for all Emergency Services that are Medically Necessary until the Member is stabilized. The Contractor shall also pay for any screening examination services conducted to determine whether an Emergency Medical Condition exists.
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4.6.1.3.1
|
The Contractor shall provide payment for Demonstration related Emergency Services when furnished by a qualified Provider, regardless of whether that Provider is in the Contractor’s network. These services shall not be subject to prior authorization requirements. The Contractor shall be required to pay all Demonstration related Emergency Services that are Medically Necessary until the P4HB Participant is stabilized. The Contractor shall also pay for any screening examination services conducted to determine whether a Demonstration related Emergency Medical Condition exists.
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4.6.1.4
|
The Contractor shall base coverage decisions for Emergency Services on the severity of the symptoms at the time of presentation and shall cover Emergency Services when the presenting symptoms are of sufficient severity to constitute an Emergency Medical Condition in the judgment of a prudent layperson.
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4.6.1.5
|
The attending emergency room physician, or the Provider actually treating the Member, is responsible for determining when the Member is sufficiently stabilized for transfer or discharge, and that determination is binding on the Contractor, who shall be responsible for coverage and payment. The Contractor, however, may establish arrangements with a hospital whereby the Contractor may send one of its own physicians with appropriate emergency room privileges to assume the attending physician’s responsibilities to stabilize, treat, and transfer the Member, provided that such arrangement does not delay the provision of Emergency Services.
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4.6.1.5.1
|
The attending emergency room physician, or the Provider actually treating the P4HB Participant, is responsible for determining when the P4HB Participant is sufficiently stabilized for transfer or discharge, and that determination is binding on the Contractor, who shall be responsible for coverage and payment. The Contractor, however, may establish arrangements with a hospital whereby the Contractor may send one of its own physicians with appropriate emergency room privileges to assume the attending physician’s responsibilities to stabilize, treat, and transfer the P4HB Participant; provided that such arrangement does not delay the provision of Demonstration related Emergency Services.
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4.6.1.6
|
The Contractor 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-emergency in nature. If an emergency screening examination leads to a clinical determination by the examining physician that an actual Emergency Medical Condition does not exist, then the determining factor for payment liability shall be whether the Member had acute symptoms of sufficient severity at the time of presentation. In this case, the Contractor shall pay for all screening and care services provided. Payment shall be at either the rate negotiated under the Provider Contract, or the rate paid by DCH under the Fee for Service Medicaid program.
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4.6.1.6.1
|
The Contractor shall not retroactively deny a Claim for a Demonstration related emergency screening examination because the Condition, which appeared to be a Demonstration related Emergency Medical Condition under the prudent layperson standard, turned out to be non-emergency in nature. If a Demonstration related emergency screening examination leads to a clinical determination by the examining physician that an actual Demonstration related Medical Condition does not exist, then the determining factor for payment liability shall be whether the P4HB Participant had acute symptoms of sufficient severity at the time of presentation. In this case, the Contractor shall pay for all Demonstration related emergency screening and care services provided. Payment shall be at either the rate negotiated under the Provider Contract, or the rate paid by DCH under the Fee for Service Medicaid Program.
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4.6.1.7
|
The Contractor may establish guidelines and timelines for submittal of notification regarding provision of emergency services, but, the Contractor shall not refuse to cover an Emergency Service based on the emergency room Provider, hospital, or fiscal agent’s failure to notify the Member’s PCP, CMO plan representative, or DCH of the Member’s screening and treatment within said timeframes.
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4.6.1.7.1
|
The Contractor may establish guidelines and timelines for submittal of notification regarding provision of Demonstration related Emergency Services, but, the Contractor shall not refuse to cover a Demonstration related Emergency Service based on the emergency room Provider, hospital, or fiscal agent’s failure to notify the P4HB Participant’s Family Planning Provider and/or PCP (in the case of the IPC P4HB Participant), CMO plan representative, or DCH of the P4HB Participant’s Demonstration related screening and treatment within said timeframes.
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4.6.1.8
|
When a representative of the Contractor instructs the Member to seek Emergency Services the Contractor shall be responsible for payment for the Medical Screening examination and for other Medically Necessary Emergency Services, without regard to whether the Condition meets the prudent layperson standard.
|
4.6.1.8.1
|
When a representative of the Contractor instructs the P4HB Participant to seek Emergency Services, the Contractor shall be responsible for payment for the Demonstration related Medical Screening examination without regard to whether the Condition meets the prudent layperson standard.
|
4.6.1.9
|
The Member who has an Emergency Medical Condition shall not be held liable for payment of subsequent screening and treatment needed to diagnose the specific Condition or stabilize the patient.
|
4.6.1.9.1
|
The P4HB Participant who has a Demonstration related Emergency Medical Condition shall not be held liable for payment of subsequent Demonstration related screening and treatment needed to diagnose the specific Condition or stabilize the P4HB Participant.
|
4.6.1.10
|
Once the Member’s Condition is stabilized, the Contractor may require Pre-Certification for hospital admission or Prior Authorization for follow-up care.
|
4.6.1.10.1
|
Once the P4HB Participant’s condition is stabilized, the Contractor may require Pre-Certification for hospital admission or prior authorization for follow up care.
|
4.6.2
|
Post-Stabilization Services
|
4.6.2.1
|
The Contractor shall be responsible for providing Post-Stabilization care services twenty-four (24) hours a day, seven (7) days a week, both inpatient and outpatient, related to an Emergency Medical Condition, that are provided after a Member is stabilized in order to maintain the stabilized Condition, or, pursuant to 42 CFR 438.114(e), to improve or resolve the Member’s Condition.
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4.6.2.2
|
The Contractor shall be responsible for payment for Post-Stabilization Services that are Prior Authorized or Pre-Certified by an In-Network Provider or organization representative, regardless of whether they are provided within or outside the Contractor’s network of Providers.
|
4.6.2.3
|
The Contractor is financially responsible for Post-Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network that are administered to maintain the Member’s stabilized Condition for one (1) hour while awaiting response on a Pre-Certification or Prior Authorization request.
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4.6.2.4
|
The Contractor is financially responsible for Post-Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network, that are not prior authorized by a CMO plan Provider or organization representative but are administered to maintain, improve or resolve the Member’s stabilized Condition if:
|
·
|
The Contractor does not respond to the Provider’s request for pre-certification or prior authorization within one (1) hour;
|
·
|
The Contractor cannot be contacted; or
|
·
|
The Contractor’s Representative and the attending physician cannot reach an agreement concerning the Member’s care and a CMO plan physician is not available for consultation. In this situation the Contractor shall give the treating physician the opportunity to consult with an In-Network physician and the treating physician may continue with care of the Member until a CMO plan physician is reached or one of the criteria in Section 4.6.2.5 are met.
|
4.6.2.5
|
The Contractor’s financial responsibility for Post-Stabilization Services it has not approved will end when:
|
·
|
An In-Network Provider with privileges at the treating hospital assumes responsibility for the Member’s care;
|
·
|
An In-Network Provider assumes responsibility for the Member’s care through transfer;
|
·
|
The Contractor’s Representative and the treating physician reach an agreement concerning the Member’s care; or
|
·
|
The Member is discharged.
|
4.6.2.6
|
In the event the Member receives Post-Stabilization Services from a Provider outside the Contractor’s network, the Contractor is prohibited from charging the Member more than he or she would be charged if he or she had obtained the services through an In-Network Provider.
|
4.6.2.7
|
The Contractor shall be responsible for providing Demonstration related Post Stabilization care services twenty-four (24) hours a day, seven (7) days a week, both inpatient and outpatient, related to a Demonstration related Emergency Medical Condition, that are provided after a P4HB participant is stabilized in order to maintain the stabilized Condition, or, pursuant to 42 CFR 438.114(e), to improve or resolve the P4HB Participant’s Condition.
|
4.6.2.8
|
The Contractor shall be responsible for payment for Demonstration related Post Stabilization Services that are Prior Authorized or Pre-Certified by an In-Network Provider or organization representative, regardless of whether they are provided within or outside the Contractor’s network of Providers.
|
4.6.2.9
|
The Contractor is financially responsible for Demonstration related Post Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network that are administered to maintain the P4HB participant’s stabilized Condition for one (1) hour while awaiting response on a Pre-Certification or Prior Authorization request.
|
4.6.2.10
|
The Contractor is financially responsible for Demonstration related Post Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network, that are not prior authorized by a CMO plan Provider or organization representative but are administered to maintain, improve or resolve the Member’s stabilized Condition if:
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·
|
The Contractor does not respond to the Provider’s request for pre-certification or prior authorization within one (1) hour;
|
·
|
The Contractor cannot be contacted; or
|
·
|
The Contractor’s Representative and the attending physician cannot reach an agreement concerning the P4HB Participant’s care and a CMO plan physician is not available for consultation. In this situation the Contractor shall give the treating physician the opportunity to consult with an In-Network physician and the treating physician may continue with care of the P4HB Participant until a CMO plan physician is reached or one of the criteria in Section 4.6.2.11 is met.
|
|
4.6.2.11
|
The Contractor’s financial responsibility for Demonstration related Post-Stabilization Services it has not approved will end when:
|
·
|
An In-Network Provider with privileges at the treating hospital assumes responsibility for the P4HB Participant’s care;
|
·
|
An In-Network Provider assumes responsibility for the P4HB Participant’s care through transfer;
|
·
|
The Contractor’s Representative and the treating physician reach an agreement concerning the P4HB Participant’s care; or
|
·
|
The P4HB Participant is discharged.
|
|
4.6.2.12
|
In the event the P4HB Participant received the Demonstration related Post-Stabilization Services from a Provider outside the Contractor’s network; the Contractor is prohibited from charging the P4HB Participant more than she would be charged if she had obtained services through an In-Network Provider.
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|
4.6.3
|
Urgent Care Services
|
4.6.4
|
Family Planning Services
|
4.6.4.1
|
The Contractor shall provide access to Family Planning Services within the network to Members and P4HB Participants. In meeting this obligation, the Contractor shall make a reasonable effort to contract with all family planning clinics, including those funded by Title X of the Public Health Services Act, for the provision of Family Planning Services. The Contractor shall verify its efforts to contract with Title X Clinics by maintaining records of communication. The Contractor shall not limit Members' or P4HB Participants freedom of choice for family planning services to In-Network Providers and the Contractor shall cover services provided by any qualified Provider regardless of whether the Provider is In-Network. The Contractor shall not require a Referral if a Member or P4HB Participant chooses to receive Family Planning services and supplies from outside of the network.
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4.6.4.2
|
The Contractor shall inform Members and P4HB Participants of the availability of family planning services and must provide services to Members and P4HB Participants wishing to prevent pregnancies, plan the number of pregnancies, plan the spacing between pregnancies, or obtain confirmation of pregnancy.
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4.6.4.3
|
Family Planning Services and supplies for Members and P4HB Participants include at a minimum:
|
·
|
Education and counseling necessary to make informed choices and understand contraceptive methods;
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·
|
Initial and annual complete physical examinations including a pelvic examination and Pap test;
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·
|
Follow-up, brief and comprehensive visits. P4HB Participants are allowed up to four (4) such visits per year of participation in the Demonstration;
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·
|
Pregnancy testing;
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·
|
Contraceptive supplies and follow-up care;
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·
|
Diagnosis of sexually transmitted infections;
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·
|
Treatment of sexually transmitted infections with the following exception – P4HB Participants are excluded from receiving drugs for the treatment of HIV/AIDS and hepatitis under the Demonstration;
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·
|
For P4HB Participants – Drugs, supplies, or devices related to the women’s health services described above that are prescribed by a health care provider who meets the State’s provider enrollment requirement; (subject to the national drug rebate program requirements).
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·
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Infertility assessments with the following exception – P4HB Participants are excluded from receiving this benefit.
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4.6.4.4
|
The Contractor shall furnish all services on a voluntary and confidential basis, even if the Member is less than eighteen (18) years of age.
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4.6.5
|
Sterilizations, Hysterectomies and Abortions
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4.6.5.1
|
In compliance with federal regulations, the Contractor shall cover sterilizations and hysterectomies, only if all of the following requirements are met:
|
·
|
The Member is at least twenty-one (21) years of age at the time consent is obtained;
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·
|
The Member is mentally competent;
|
·
|
The Member voluntarily gives informed consent in accordance with the State Policies and Procedures for Family Planning Clinic Services. This includes the completion of all applicable documentation;
|
·
|
At least thirty (30) Calendar Days, but not more than one hundred and eighty (180) Calendar Days, have passed between the date of informed consent and the date of sterilization, except in the case of premature delivery or emergency abdominal surgery. A Member may consent to be sterilized at the time of premature delivery or emergency abdominal surgery, if at least seventy-two (72) hours have passed since informed consent for sterilization was signed. In the case of premature delivery, the informed consent must have been given at least thirty (30) Calendar Days before the expected date of delivery (the expected date of delivery must be provided on the consent form);
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·
|
An interpreter is provided when language barriers exist. Arrangements are to be made to effectively communicate the required information to a Member who is visually impaired, hearing impaired or otherwise disabled; and
|
·
|
The Member is not institutionalized in a correctional facility, mental hospital or other rehabilitative facility.
|
4.6.5.1.1
|
In compliance with Federal regulations, the Contractor shall cover sterilizations for P4HB Participants only if all of the following requirements are met:
|
·
|
The P4HB Participant is at least twenty-one (21) years of age at the time consent is obtained;
|
·
|
The P4HB Participant is mentally competent;
|
·
|
The P4HB Participant voluntarily gives informed consent in accordance with the State Policies and Procedures for Family Planning Clinic Services. This includes the completion of all applicable documentation.
|
·
|
At least thirty (30) Calendar Days, but not more than one hundred and eight (180) Calendar Days, have passed between the date of informed consent and the date of sterilization.
|
·
|
An interpreter is provided when language barriers exist. Arrangements are to be made to effectively communicate the required information to a P4HB Participant who is visually impaired, hearing impaired or otherwise disabled; and
|
·
|
The P4HB Participant is not institutionalized in a correctional facility, mental hospital or other rehabilitative facility.
|
4.6.5.2
|
A hysterectomy shall be considered a Covered Service only if the following additional requirements are met:
|
·
|
The Member must be informed orally and in writing that the hysterectomy will render the individual permanently incapable of reproducing (this is not applicable if the individual was sterile prior to the hysterectomy or in the case of an emergency hysterectomy); and
|
·
|
The Member must sign and date the Georgia Families Sterilization Request Consent form prior to the Hysterectomy. Informed consent must be obtained regardless of diagnosis or age.
|
4.6.5.2.1
|
A hysterectomy shall not be considered a Covered Service for P4HB Participants.
|
4.6.5.3
|
Regardless of whether the requirements listed above are met, a hysterectomy shall not be covered under the following circumstances:
|
·
|
If it is performed solely for the purpose of rendering a Member permanently incapable of reproducing;
|
·
|
If there is more than one (1) purpose for performing the hysterectomy, but the primary purpose was to render the Member permanently incapable of reproducing; or
|
·
|
If it is performed for the purpose of cancer prophylaxis.
|
4.6.5.3.1
|
Abortions or abortion-related services performed for family planning purposes are not Covered Services. Abortions are Covered Services if a Provider certifies that the abortion is medically necessary to save the life of the mother or if pregnancy is the result of rape or incest. The Contractor shall cover treatment of medical complications occurring as a result of an elective abortion and treatments for spontaneous, incomplete, or threatened abortions and for ectopic pregnancies.
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4.6.5.3.2
|
Abortions or abortion-related services shall not be considered a Covered Service for P4HB Participants.
|
4.6.5.4
|
The Contractor shall maintain documentation of all sterilizations, hysterectomies and abortions and provide documentation to DCH upon the request of DCH.
|
4.6.6
|
Pharmacy
|
4.6.6.1
|
The Contractor shall provide pharmacy services either directly or through a Pharmacy Benefits Manager (PBM). The Contractor or its PBM may establish a drug formulary if the following minimum requirements are met:
|
·
|
Drugs from each specific therapeutic drug class are included and are sufficient in amount, duration, and scope to meet Members’ medical needs;
|
·
|
The only excluded drug categories are those permitted under section 1927(d) of the Social Security Act;
|
·
|
A Pharmacy & Therapeutics Committee that advises and/or recommends formulary decisions; and
|
·
|
Over-the-counter medications specified in the Georgia State Medicaid Plan are included in the formulary.
|
4.6.6.1.1
|
The Contractor shall provide covered pharmacy services either directly or through a Pharmacy Benefits Manager (PBM) to P4HB Participants.
|
4.6.6.1.2
|
The Contractor shall make available to P4HB Participants folic acid and/or a multivitamin with folic acid.
|
4.6.6.2
|
The Contractor shall provide the formulary to DCH upon the request of DCH.
|
4.6.6.3
|
If the Contractor chooses to implement a mail-order pharmacy program, any such program must be accordance with State and federal law.
|
4.6.7
|
Immunizations
|
4.6.7.1
|
The Contractor shall provide all Members less than twenty-one (21) years of age with all vaccines and immunizations in accordance with the Advisory Committee on Immunization Practices (ACIP) guidelines.
|
4.6.7.1.1
|
The Contractor shall provide P4HB Participants ages nineteen (19) and twenty (20) with Hepatitis B, Tetanus-Diphtheria (Td) and combined Tetanus, Diphtheria, Pertussis vaccinations according to the Advisory Committee on Immunization Practices (ACIP) guidelines as needed.
|
4.6.7.2
|
The Contractor shall ensure that all Providers use vaccines which have been made available, free of cost, under the Vaccine for Children (VFC) program for Medicaid children eighteen (18) years old and younger. Immunizations shall be given in conjunction with Well-Child/Health Check care.
|
4.6.7.2.1
|
The Contractor shall ensure that all Providers use vaccines which have been made available, free of cost, under the Vaccines for Children (VFC) program for P4HB Participants eighteen (18) years of age.
|
4.6.7.3
|
The Contractor shall ensure that all Providers administer appropriate vaccines to the PeachCare for Kids® children eighteen (18) years old and younger. Immunizations shall be given in conjunction with Well-Child/Health Check care.
|
4.6.7.4
|
The Contractor shall provide all adult immunizations specified in the Georgia Medicaid Policies and Procedures Manuals.
|
4.6.7.5
|
The Contractor shall report all immunizations to the Georgia Registry of Immunization Transactions and Services (GRITS) in a format to be determined by DCH.
|
4.6.8
|
Transportation
|
4.6.8.1
|
The Contractor shall provide emergency transportation and shall not retroactively deny a Claim for emergency transportation to an emergency Provider because the Condition, which appeared to be an Emergency Medical Condition under the prudent layperson standard, turned out to be non-emergency in nature.
|
4.6.8.2
|
The Contractor is not responsible for providing non-emergency transportation (NET) but the Contractor shall coordinate with the NET vendors for services required by Members. Non-Emergency Transportation is excluded for Peach Care for Kids™ members.
|
|
4.6.8.2.1
|
The Contractor shall coordinate with the NET vendors for services required by P4HB Participants in the IPC component of the Demonstration.
|
4.6.9
|
Perinatal Services
|
4.6.9.1
|
The Contractor shall ensure that appropriate perinatal care is provided to women and newborn Members. The Contractor shall have adequate capacity such that any new Member who is pregnant is able to have an initial visit with her Provider within fourteen (14) Calendar Days of Enrollment. The Contractor shall have in place a system that provides, at a minimum, the following services:
|
·
|
Pregnancy planning and perinatal health promotion and education for reproductive-age women;
|
·
|
Perinatal risk assessment of non-pregnant women, pregnant and post-partum women, and newborns and children up to five (5) months of age;
|
·
|
Childbirth education classes to all pregnant Members and their chosen partner. Through these classes, expectant parents shall be encouraged to prepare themselves physically, emotionally, and intellectually for the childbirth experience. The classes shall be offered at times convenient to the population served, in locations that are accessible, convenient and comfortable. Classes shall be offered in languages spoken by the Members.
|
·
|
Access to appropriate levels of care based on risk assessment, including emergency care;
|
·
|
Transfer and care of pregnant women, newborns, and infants to tertiary care facilities when necessary;
|
·
|
Availability and accessibility of OB/GYNs, anesthesiologists, and neonatologists capable of dealing with complicated perinatal problems; and
|
·
|
Availability and accessibility of appropriate outpatient and inpatient facilities capable of dealing with complicated perinatal problems.
|
4.6.9.2
|
The Contractor shall provide inpatient care and professional services relating to labor and delivery for its pregnant/delivering Members, and neonatal care for its newborn Members at the time of delivery and for up to forty-eight (48) hours following an uncomplicated vaginal delivery and ninety-six (96) hours following an uncomplicated Caesarean delivery.
|
4.6.10
|
Parenting Education
|
4.6.10.1
|
In addition to individual parent education and anticipatory guidance to parents and guardians at preventive pediatric visits and Health Check screens, the Contractor shall offer or arrange for parenting skills education to expectant and new parents, at no cost to the Member.
|
4.6.10.2
|
The Contractor agrees to create effective ways to deliver this education, whether through classes, as a component of post-partum home visiting, or other such means. The educational efforts shall include topics such as bathing, feeding (including breast feeding), injury prevention, sleeping, illness, when to call the doctor, when to use the emergency room, etc. The classes shall be offered at times convenient to the population served, and in locations that are accessible, convenient and comfortable. Convenience will be determined by DCH. Classes shall be offered in languages spoken by the Members.
|
4.6.11
|
Mental Health and Substance Abuse
|
4.6.11.1
|
The Contractor shall have written Mental Health and Substance Abuse Policies and Procedures that explain how they will arrange or provide for covered mental health and substance abuse services. Such policies and procedures shall include Advance Directives. The Contractor shall assure timely delivery of mental health and substance abuse services and coordination with other acute care services.
|
4.6.11.2
|
Mental Health and Substance Abuse Policies and Procedures shall be submitted to DCH for approval as updated.
|
4.6.11.3
|
The Contractor shall permit Members to self-refer to an In-Network Provider for an initial mental health or substance abuse visit but prior authorization may be required for subsequent visits.
|
4.6.11.4
|
The Contractor shall permit Participants in the IPC Component of the Demonstration to receive Detoxification and Intensive Outpatient Rehabilitation Services as specified in the Special Terms and Conditions. (See Attachment O.)
|
|
4.6.12
|
Advance Directives
|
4.6.12.1
|
In compliance with 42 CFR 438.6 (i) (1)-(2) and 42 CFR 422.128, the Contractor shall maintain written policies and procedures for Advance Directives, including mental health advance directives. Such Advance Directives shall be included in each Member’s and P4HB Participants medical record. The Contractor shall provide these policies to all Members and P4HB Participants eighteen (18) years of age and older and shall advise Members and P4HB Participants of:
|
4.6.12.1.1
|
Their rights under the law of the State of Georgia, including the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives; and
|
4.6.12.1.2
|
The Contractor’s written policies respecting the implementation of those rights, including a statement of any limitation regarding the implementation of Advance Directives as a matter of conscience.
|
4.6.12.2
|
The information must include a description of State law and must reflect changes in State laws as soon as possible, but no later than ninety (90) Calendar Days after the effective change.
|
4.6.12.3
|
The Contractor’s information must inform Members and P4HB Participants that complaints may be filed with the State’s Survey and Certification Agency.
|
4.6.12.4
|
The Contractor shall educate its staff about its policies and procedures on Advance Directives, situations in which Advance Directives may be of benefit to Members and P4HB Participants, and their responsibility to educate Members and P4HB Participants about this tool and assist them to make use of it.
|
4.6.12.5
|
The Contractor shall educate Members and P4HB Participants about their ability to direct their care using this mechanism and shall specifically designate which staff Members and P4HB Participants and/or network Providers are responsible for providing this education.
|
4.6.13
|
Foster Care Forensic Exam
|
4.6.13.1
|
The Contractor shall provide a forensic examination to a Member that is less than eighteen (18) years of age that is placed outside the home in State custody. Such exam shall be in accordance with State law and regulations.
|
4.6.14
|
Laboratory Services
|
4.6.14.1
|
The Contractor shall require all network laboratories to automatically report the Glomerular Filtration Rate (GFR) on any serum creatinine tests ordered by In-Network Providers.
|
4.6.15
|
Member Cost-Sharing
|
4.6.15.1
|
The Contractor shall ensure that Providers collect Member co-payments as specified in Attachment K.
|
4.7
|
EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM: HEALTH CHECK
|
4.7.1
|
General Provisions
|
4.7.1.1
|
The Contractor shall provide EPSDT services (called Health Check services) to Medicaid children less than twenty-one (21) years of age and PeachCare for Kids® children less than age nineteen (19) years of age (hereafter referred to as Health Check eligible children), in compliance with all requirements found below.
|
4.7.1.2
|
The Contractor shall comply with sections 1902(a)(43) and 1905(a)(4)(B) and 1905(r) of the Social Security Act and federal regulations at 42 CFR 441.50 that require EPSDT services to include outreach and informing, screening, tracking, and, diagnostic and treatment services. The Contractor shall comply with all Health Check requirements pursuant to the Georgia Medicaid Policies and Procedures Manuals.
|
4.7.1.3
|
The Contractor shall develop an EPSDT Plan that includes written policies and procedures for conducting outreach, informing, tracking, and follow-up to ensure compliance with the Health Check periodicity schedules. The EPSDT Plan shall emphasize outreach and compliance monitoring for children and adolescents (young adults), taking into account the multi-lingual, multi-cultural nature of the GF population, as well as other unique characteristics of this population. The plan shall include procedures for follow-up of missed appointments, including missed Referral appointments for problems identified through Health Check screens and exams. The plan shall also include procedures for referral, tracking and follow up for annual dental examinations and visits. The Contractor shall submit its EPSDT Plan to DCH for review and approval as updated.
|
4.7.1.4
|
The contractor shall ensure Providers perform a full EPSDT (Early and Periodic Screening Diagnostic and Treatment) visit according to the periodic schedule approved by DCH. The visit must include a comprehensive history, unclothed physical examination, appropriate immunizations, lead screening and testing per CMS requirements, and health education/anticipatory guidance. All five (5) components must be performed for the visit to be considered an EPSDT visit.
|
4.7.2
|
Outreach and Informing
|
4.7.2.1
|
The Contractor’s Health Check outreach and informing process shall include:
|
·
|
The importance of preventive care;
|
·
|
The periodicity schedule and the depth and breadth of services;
|
·
|
How and where to access services, including necessary transportation and scheduling services; and
|
·
|
A statement that services are provided without cost.
|
4.7.2.2
|
The Contractor shall inform its newly enrolled families with Health Check eligible children about the Health Check program within sixty (60) Calendar Days of Enrollment with the plan. This requirement includes informing pregnant women and new mothers, either before or within seven (7) days after the birth of their children, that Health Check services are available.
|
4.7.2.3
|
The Contractor shall provide written notification to its families with Health Check eligible children when appropriate periodic assessments or needed services are due.
|
4.7.2.4
|
The Contractor shall provide to each PCP, on a monthly basis, a list of the PCP’s Health Check eligible children that appear not to have had an encounter during the initial one hundred and twenty (120) Calendar Days of CMO plan Enrollment, and/or are not in compliance with the Health Check periodicity schedule. The Contractor and/or the PCP shall contact the Members’ parents or guardians to schedule an appointment for those screens and services that appear not to be in compliance with the Health Check periodicity schedule. If the PCP has medical record evidence that appropriate screens have occurred for the member, the Contractor must incorporate this information into its tracking system and remove the member from the PCP’s list of non compliant Health Check screenings.
|
4.7.2.5
|
Informing may be oral (on the telephone, face-to-face, or films/tapes) or written and may be done by Contractor personnel or Health Care Providers. All outreach and informing shall be documented and shall be conducted in non-technical language at or below a fifth (5th) grade reading level. The Contractor shall use accepted methods for informing persons who are blind or deaf, or cannot read or understand the English language, in accordance with Section 4.3.2 of this Contract.
|
4.7.2.6
|
The Contractor may provide incentives to Members and/or Providers to encourage compliance with periodicity schedules. Such incentives shall be established in accordance with all applicable State and Federal laws, rules and regulations. Additionally, Member incentives must be of nominal value ($10 or less per item or $50 in the aggregate on an annual basis) and may include gift cards so long as such gift cards are not redeemable for cash or Co-payments.
|
4.7.2.7
|
In accordance with 42 CFR 1003.101, the Nominal Value requirement stated herein is not applicable where the incentive is offered to promote the delivery of preventive care services, provided:
|
4.7.3
|
Screening
|
4.7.3.1
|
The Contractor is responsible for periodic screens in accordance with the State’s periodicity schedule. Such screens must include all of the following:
|
·
|
A comprehensive health and developmental history;
|
·
|
Developmental assessment, including mental, emotional, and behavioral health development;
|
·
|
Measurements (including head circumference for infants);
|
·
|
An assessment of nutritional status;
|
·
|
A comprehensive unclothed physical exam;
|
·
|
Immunizations according to the Advisory Committee of Immunization Practices (ACIP);
|
·
|
Certain laboratory tests (including the federally required blood lead screening);
|
·
|
Anticipatory guidance and health education;
|
·
|
Vision screening;
|
·
|
Tuberculosis and lead risk screening;
|
·
|
Hearing screening; and
|
·
|
Dental and oral health assessment.
|
|
4.7.3.2
|
The Contractor shall provide for a blood lead screening test for all Health Check eligible children at twelve (12) and twenty-four (24) months of age. Children between thirty-six (36) months of age and seventy-two (72) months of age should receive a blood lead screening test if there is no record of a previous test.
|
|
4.7.3.3
|
The Contractor shall have a lead case management program for Health Check eligibles and their households when there is a positive blood lead test equal to or greater than ten (10) micrograms per deciliter. The lead case management program shall include education, a written case management plan that includes all necessary referrals, coordination with other specific agencies, environmental lead assessments, and aggressive pursuit of non-compliance with follow-up tests and appointments. The contractor must ensure reporting of all blood lead levels to the Department of Public Health.
|
|
4.7.3.4
|
The Contractor shall have procedures for Referral to and follow up with oral health professionals, including annual dental examinations and services by an oral health professional.
|
|
4.7.3.5
|
The Contractor shall provide inter-periodic screens, which are screens that occur between the complete periodic screens and are Medically Necessary to determine the existence of suspected physical or mental illnesses or Conditions. This includes at a minimum vision and hearing services.
|
|
4.7.3.6
|
The Contractor shall allow Referrals for further diagnostic and/or treatment services to correct or ameliorate defects, and physical and mental illnesses and Conditions discovered by the Health Check screens. The PCP may make such Referrals and follow up pursuant to the PCP’s contract with the Contractor, as appropriate.
|
|
4.7.3.7
|
The Contractor shall ensure an initial health and screening visit is performed, as appropriate, for all newly enrolled GF Health Check eligible children within ninety (90) Calendar Days and within twenty-four (24) hours of birth to all newborns. If the member’s PCP provides medical record evidence to the Contractor that the initial health and screening visit have already taken place, this evidence will meet this contract requirement. The Contractor should incorporate this evidence for this member in its tracking system.
|
|
4.7.3.8
|
Minimum Contractor compliance with the Health Check screening requirements is an eighty percent (80%) screening rate, using the methodology prescribed by CMS to determine the screening rate. This requirement and screening percentage is related to the CMS-416 Report requirements.
|
|
4.7.4
|
Tracking
|
|
4.7.4.1
|
The Contractor shall establish a tracking system that provides information on compliance with Health Check requirements. This system shall track, at a minimum, the following areas:
|
·
|
Initial newborn Health Check visit occurring in the hospital;
|
·
|
Periodic and preventive/well child screens and visits as prescribed by the periodicity schedule;
|
·
|
Diagnostic and treatment services, including Referrals;
|
·
|
Immunizations, lead, tuberculosis and dental services; and
|
·
|
A reminder/notification system.
|
|
4.7.4.2
|
All information generated and maintained in the tracking system shall be consistent with Encounter Data requirements as specified elsewhere herein.
|
|
4.7.5
|
Diagnostic and Treatment Services
|
4.7.5.1
|
If a suspected problem is detected by a screening examination as described above, the child shall be evaluated as necessary for further diagnosis. This diagnosis is used to determine treatment needs.
|
|
4.7.5.2
|
Health Check requires coverage for all follow-up diagnostic and treatment services deemed Medically Necessary to ameliorate or correct a problem discovered during a Health Check screen. Such Medically Necessary diagnostic and treatment services must be provided regardless of whether such services are covered by the State Medicaid Plan, as long as they are Medicaid-Covered Services as defined in Title XIX of the Social Security Act. The Contractor shall provide Medically Necessary, Medicaid-covered diagnostic and treatment services.
|
4.7.6
|
Reporting Requirements
|
|
4.7.6.1
|
The Contractor shall submit all required Health Check Reports.
|
4.8.1
|
General Provisions
|
4.8.1.1
|
The Contractor is solely responsible for providing a network of physicians, pharmacies, hospitals, and other health care Providers through whom it provides the items and services included in Covered Services.
|
4.8.1.2
|
The Contractor shall ensure that its network of Providers is adequate to assure access to all Covered Services, and that all Providers are appropriately credentialed, maintain current licenses, and have appropriate locations to provide the Covered Services.
|
4.8.1.3
|
The Contractor shall notify DCH sixty (60) days in advance when a decision is made to close network enrollment for new provider contracts and also notify DCH when network enrollment is reopened. The Contractor must notify DCH sixty (60) days prior to closing a provider panel.
|
|
4.8.1.4
|
The Contractor shall not include any Providers who have been excluded from participation by the Department of Health and Human Services, Office of Inspector General, or who are on the State’s list of excluded Providers. The Contractor is responsible for routinely checking the exclusions list and shall immediately terminate any Provider found to be excluded and notify the Member per the requirements outlined in this Contract.
|
|
4.8.1.5
|
In accordance with 45 CFR 162.410, the Contractor shall require that each Provider have a National Provider Identifier (NPI).
|
4.8.1.6
|
The Contractor shall have written Selection and Retention Policies and Procedures. These policies shall be submitted to DCH for review and approval as updated. In selecting and retaining Providers in its network the Contractor shall consider the following:
|
·
|
The anticipated GF Enrollment;
|
·
|
The expected Utilization of services, taking into consideration the characteristics and Health Care needs of its Members;
|
·
|
The numbers and types (in terms of training, experience and specialization) of Providers required to furnish the Covered Services;
|
·
|
The numbers of network Providers who are not accepting new GF patients; and
|
·
|
The geographic location of Providers and Members, considering distance, travel time, the means of transportation ordinarily used by Members, and whether the location provides physical access for Members with disabilities.
|
4.8.1.7
|
If the Contractor declines to include individual Providers or groups of Providers in its network, the Contractor shall give the affected Providers written notice of the reason(s) for the decision. These provisions shall not be construed to:
|
·
|
Require the Contractor to contract with Providers beyond the number necessary to meet the needs of its Members;
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·
|
Preclude the Contractor from establishing measures that are designed to maintain quality of services and control costs and are consistent with its responsibilities to Members.
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4.8.1.8
|
The Contractor shall ensure that all network Providers have knowingly and willfully agreed to participate in the Contractor’s network. The Contractor shall be prohibited from acquiring established networks without contacting each individual Provider to ensure knowledge of the requirements of this Contract and the Provider’s complete understanding and agreement to fulfill all terms of the Provider Contract, as outlined in section 4.10. The Contractor shall send all newly contracted Providers a written network participation welcome letter that includes a contract effective date for which Providers are approved to begin providing medical services to Georgia Families members. DCH reserves the right to confirm and validate, through both the collection of information and documentation from the Contractor and on-site visits to network Providers, the existence of a direct relationship between the Contractor and the network Providers.
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4.8.1.8.1
|
The Contractor shall submit an up-dated version of the Provider Network Listing spreadsheet for all requested Provider types (as outlined under Required Attachments in 5.1.2.8 in the RFP). DCH may require the Contractor to include executed Signature Pages of Provider Contracts and written acknowledgements from all Providers part of a Preferred Health Organization ( PHO), IPA, or other network stating that they know they are in the CMO's network, know they are accepting Medicaid patients, and that they are accepting the terms and conditions.
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4.8.1.8.2
|
The Contractor shall identify in its Network Listing data that reports or indicates which providers are accepting new members; providers are not accepting new patients; providers that have full-time practice hour locations; and providers that have part-time practice hour locations.
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4.8.1.9
|
The Contractor shall at least quarterly validate provider demographic data to ensure that current, accurate, and clean data is on file for all contracted providers. Failure to do so may result in liquidation damages up to $5,000 per day against the Contractor.
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4.8.1.10
|
The Contractor shall ensure that all provider network data files are tested and validated for accuracy prior to deliverable submissions. The Contractor shall scrub data to identify inconsistencies such as addresses duplicates; mismatched cities, counties, and regions; and incorrect assigned specialties. The Contractor shall be responsible for submission of attestations for each network report. All reports are to be submitted in the established DCH format with all required data elements. Failure to do so may result in liquidated damages up to $5,000 per day against the Contractor.
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4.8.1.11
|
The Contractor shall ensure that all members have timely access to quality care.
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4.8.1.12
|
The Contractor shall instruct contracted Providers that the Georgia State Medicaid ID number is mandatory, and must be documented in record. The Contractor will emphasize to Providers the need for a unique GA Medicaid number for each practice location.
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4.8.2
|
Primary Care Providers (PCPs)
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|
4.8.2.1
|
The Contractor shall offer its Members freedom of choice in selecting a PCP. The Contractor shall have written PCP Selection Policies and Procedures describing how Members select their PCP.
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4.8.2.1.1
|
The Contractor shall offer its P4HB Participants in the IPC component of the Demonstration freedom of choice in selecting a PCP. The Contractor shall have written PCP selection policies and procedures describing how IPC P4HB Participants select their PCPs.
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4.8.2.2
|
The Contractor shall submit these PCP Selection Policies and Procedures policies to DCH for review and approval as updated.
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4.8.2.3
|
PCP assignment policies shall be in accordance with Section 4.1.2 of this Contract.
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4.8.2.4
|
The Contractor may require that Members and IPC P4HB Participants are assigned to the same PCP for a period of up to six (6) months. In the event the Contractor requires that Members and IPC P4HB Participants are assigned to the same PCP for a period of six (6) months or less, the following exceptions shall be made:
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4.8.2.4.1
|
Members and IPC P4HB Participants shall be allowed to change PCPs without cause during the first ninety (90) Calendar Days following PCP selection;
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4.8.2.4.2
|
Members and IPC P4HB Participants shall be allowed to change PCPs with cause at any time. The following constitute cause for change:
|
·
|
The PCP no longer meets the geographic access standards as defined in Section 4.8.14;
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·
|
The PCP does not, because of moral or religious objections, provide the Covered Service(s) the Member seeks; and
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·
|
The Member or IPC Participant requests to be assigned to the same PCP as other family members.
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4.8.2.4.3
|
Members and IPC P4HB Participants shall be allowed to change PCPs every six (6) months.
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4.8.2.5
|
The PCP is responsible for supervising, coordinating, and providing all Primary Care to each assigned Member. In addition, the PCP is responsible for coordinating and/or initiating Referrals for specialty care (both in and out of network), maintaining continuity of each Member’s Health Care and maintaining the Member’s Medical Record, which includes documentation of all services provided by the PCP as well as any specialty services. The Contractor shall require that PCPs fulfill these responsibilities for all Members.
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4.8.2.5.1
|
The PCP is responsible for supervising, coordinating, and providing all Primary Care to each assigned IPC P4HB Participant. In addition, the PCP is responsible for coordinating and/or initiating Referrals for non-CMO paid or provided specialty care, maintaining continuity of each IPC P4HB Participant’s Health Care and maintaining the IPC P4HB Participant’s Medical Record, which includes documentation of all services provided by the PCP as well as any specialty services. The Contractor shall require that PCPs fulfill these responsibilities for all IPC P4HB Participants.
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4.8.2.6
|
The Contractor shall include in its network as PCPs the following:
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|
4.8.2.6.1
|
Physicians who routinely provide Primary Care services in the areas of:
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·
|
Family Practice;
|
·
|
General Practice;
|
·
|
Pediatrics; or
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·
|
Internal Medicine.
|
4.8.2.6.2
|
Nurse Practitioners Certified (NP-C) specializing in:
|
·
|
Family Practice; or
|
·
|
Pediatrics.
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|
4.8.2.7
|
NP-Cs in independent practice must also have a current collaborative agreement with a licensed physician who has hospital admitting privileges.
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4.8.2.8
|
FQHCs and RHCs may be included as PCPs. The Contractor shall maintain an accurate list of all Providers rendering care at these facilities.
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4.8.2.9
|
Primary Care Public Health Department Clinics and Primary Care Hospital Outpatient Clinics may be included as PCPs if they agree to the requirements of the PCP role, including the following conditions:
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·
|
The practice must routinely deliver Primary Care as defined by the majority of the practice devoted to providing continuing comprehensive and coordinated medical care to a population undifferentiated by disease or organ system. If deemed necessary, a Medical Record audit of the practice will be performed. Any exceptions to this requirement will be considered on a case-by-case basis.
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·
|
Any Referrals for specialty care to other Providers of the same practice may be reviewed for appropriateness.
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4.8.2.10
|
Physician’s assistants (PAs) may participate as a PCP as a Member of a physician’s practice.
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4.8.2.11
|
The Contractor may allow female Members to select a gynecologist or obstetrician-gynecologist (OB-GYN) as their Primary Care Provider.
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|
4.8.2.12
|
The Contractor may allow Members with Chronic Conditions to select a specialist with whom he or she has an on-going relationship to serve as a PCP.
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4.8.3
|
Direct Access
|
4.8.3.1
|
The Contractor shall provide female Members with direct in-network access to a women’s health specialist for covered care necessary to provide her routine and preventive Health Care services. This is in addition to the Member’s designated source of Primary Care if that Provider is not a women’s health specialist.
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4.8.3.2
|
The Contractor shall have a process in place that ensures that Members determined to need a course of treatment or regular care monitoring have direct access to a specialist as appropriate for the Member’s condition and identified needs. The Medical Director shall be responsible for over-seeing this process.
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4.8.3.3
|
The Contractor shall ensure that Members who are determined to need a course of treatment or regular care monitoring have a treatment plan. This treatment plan shall be developed by the Member’s PCP with Member participation, and in consultation with any specialists caring for the Member. This treatment plan shall be approved in a timely manner by the Medical Director and in accord with any applicable State quality assurance and utilization review standards.
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4.8.4
|
Pharmacies
|
|
The Contractor shall maintain a comprehensive Provider network of pharmacies that ensures pharmacies are available and accessible to all Members or P4HB Participants.
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4.8.5
|
Hospitals
|
|
4.8.5.1
|
The Contractor shall have a comprehensive Provider network of hospitals such that they are available and accessible to all Members. This includes, but is not limited to tertiary care facilities and facilities with neo-natal, intensive care, burn, and trauma units.
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4.8.5.1.1
|
The Contractor shall maintain a comprehensive Provider network of hospitals such that they are available and accessible for Demonstration related Service and Benefit delivery to all P4HB Participants.
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4.8.5.2
|
The Contractor shall include in its network Critical Access Hospitals (CAHs) that are located in its Service Region.
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4.8.5.3
|
The Contractor shall maintain copies of all letters and other correspondence related to its efforts to include CAHs in its network. This documentation shall be provided to DCH upon request.
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|
4.8.5.4
|
A critical access hospital must provide notice to a care management organization and DCH of any alleged breaches in its contract by such care management organization (Title 33 of the Official Code of Georgia Annotated as amended pursuant to O.C.G.A. 33-21-1, et seq. known as the “Medicaid Care Management Organizations Act.” (HB1234)
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4.8.6
|
Laboratories
|
|
The Contractor shall maintain a comprehensive Provider network of laboratories that ensures laboratories are accessible to all Members. The Contractor shall ensure that all laboratory testing sites providing services under this contract have either a clinical laboratory (CLIA) certificate or a waiver of a certificate of registration, along with a CLIA number, pursuant to 42 CFR 493.3.
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|
4.8.6.1
|
The Contractor shall maintain a comprehensive Provider network of laboratories that ensures laboratories are accessible to all P4HB Participants for Demonstration related Services. The Contractor shall ensure that all laboratory testing sites providing services under this Contract have either a clinical laboratory (CLIA certificate or a waiver of a certificate of registration, along with a CLIA number, pursuant to 42 CFR 493.3.
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4.8.7
|
Mental Health/Substance Abuse
|
|
4.8.7.1
|
The Contractor shall include in its network Core Service Providers (CSP’s) that meet the requirements of the Department of Human Services and are located in its Service Region, provided they agree to the Contractor’s terms and conditions as well as rates; and presuming they meet the credentialing requirements established by the Contractor for that provider type.
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4.8.7.2
|
The Contractor shall maintain copies of all letters and other correspondence related to the inclusion of CSP’s in its network. This documentation shall be provided to DCH upon request.
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4.8.8
|
Federally Qualified Health Centers (FQHCs)
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|
4.8.8.1
|
The Contractor shall include in its Provider network all FQHCs in its Service Region based on PPS rates.
|
|
4.8.8.2
|
The Contractor shall maintain copies of all letters and other correspondence related to its efforts to include FQHCs in its network. This documentation shall be provided to DCH upon request.
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|
4.8.8.3
|
The FQHC must agree to provide those primary care services typically included as part of a physician’s medical practice, as described in §901 of State Medicaid Manual Part II for FQHC (the Manual). Services and supplies deemed necessary for the provision of a Core services as described in §901.2 of the Manual are considered part of the FQHC service. In addition, an FQHC can provide other ambulatory services of the following state Medicaid Program, once enrolled in the programs:
|
·
|
Health Check (COS 600),
|
·
|
Mental Health (COS 440),
|
·
|
Dental Services (COS 450 and 460),
|
·
|
Refractive Vision Care services (COS 470),
|
·
|
Podiatry (COS 550),
|
·
|
Pregnancy Related services (COS 730), and
|
|
4.8.9.1
|
The Contractor shall include in its Provider network all RHCs in its Service Region based on PPS rates.
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|
4.8.9.2
|
The Contractor shall maintain copies of all letters and other correspondence related to its efforts to include FQHCs and RHCs in its network. This documentation shall be provided to DCH upon request.
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|
4.8.9.3
|
The RHC must agree to provide those primary care services typically included as part of a physician’s medical practice, as described in §901 of State Medicaid Manual Part II for RHC (the Manual). Services and supplies deemed necessary for the provision of a Core services as described in §901.2 of the Manual are considered part of the RHC service. In addition, an RHC can provide other ambulatory services of the following state Medicaid Program, once enrolled in the programs:
|
·
|
Health Check (COS 600),
|
·
|
Mental Health (COS 440),
|
·
|
Dental Services (COS 450 and 460),
|
·
|
Refractive Vision Care services (COS 470),
|
·
|
Podiatry (COS 550),
|
·
|
Pregnancy Related services (COS 730), and
|
·
|
Perinatal Case Management (COS 761).
|
4.8.10
|
Family Planning Clinics
|
|
4.8.11.1
|
The Contractor shall make a reasonable effort to subcontract with all family planning clinics, including those funded by Title X of the Public Health Services Act.
|
|
4.8.11.2
|
The Contractor shall maintain copies of all letters and other correspondence related to its efforts to include Title X Clinics in its network. This documentation shall be provided to DCH upon request.
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4.8.11
|
Nurse Practitioners Certified (NP-Cs) and Certified Nurse Midwives (CNMs)
|
|
The Contractor shall ensure that Members have appropriate access to NP-Cs and CNMs, through either Provider contracts or Referrals. This provision shall in no way be interpreted as requiring the Contractor to provide any services that are not Covered Services.
|
|
4.8.12.1
|
The Contractor shall not deny any dentist from participating in the Medicaid and PeachCare for Kids® dental program administered by such care management organization if:
|
·
|
such dentist has obtained a license to practice in this state and is an enrolled Provider who has met all of the requirements of DCH for participation in the Medicaid and PeachCare for Kids® program; and
|
·
|
licensed dentist will provide dental services to members pursuant to a state or federally funded educational loan forgiveness program that requires such services; provided, however, each care management organization shall be required to offer dentists wishing to participate through such loan forgiveness programs the same contract terms offered to other dentists in the service region who participate in the care management organization’s Medicaid and PeachCare for Kids® dental programs;
|
·
|
the geographic area in which the dentist intends to practice has been designated as having a dental professional shortage as determined by DCH, which may be based on the designation of the Health Resources and Services Administration of the United States Department of Health and Human Services;
|
|
4.8.12.2
|
The Contractor must establish a sufficient number of general dentists and specialists as specified by 4.8.13 - Geographic Access Requirements to provide covered dental services to members in the geographic region.
|
|
4.8.12.2.1
|
The Contractor must establish a sufficient number of general dentists as specified by 4.8.13 – Geographic Access Requirements to provide covered dental services to IPC P4HB Participants in the Contractor’s Service Region.
|
|
4.8.12.3
|
The Contractor must report the total number of dental provider applications received, the number of applications pending a determination, and the total number of both approved and denied applications on a monthly basis.
|
|
4.8.12.4
|
The Contractor must process completed dental applications within 30 days from receipt.
|
|
4.8.12.5
|
The Contractor must include specific documentation that supports the decision to accept or decline a provider including a decision tool such as a checklist.
|
|
4.8.12.6
|
The Contractor’s denial letter of a provider’s application must include specific information regarding how to file an appeal.
|
|
4.8.12.7
|
The Contractor must report the number of dental application appeals, and appeal outcomes on a monthly basis.
|
|
4.8.13
|
Geographic Access Requirements
|
|
4.8.13.1
|
In addition to maintaining in its network a sufficient number of Providers to provide all services to its Members and P4HB Participants, the Contractor shall meet the following geographic access standards for all Members or P4HB Participants:
|
Urban
|
Rural
|
|
PCPs
|
Two (2) within eight (8) miles
|
Two (2) within fifteen (15) miles
|
Specialists
|
One (1) within thirty (30) minutes or thirty (30) miles
|
One within forty-five (45) minutes or forty-five (45) miles
|
General Dental Providers
|
One (1) within thirty (30) minutes or thirty (30) miles
|
One within forty-five (45) minutes or forty-five (45) miles
|
Dental Subspecialty Providers
|
One (1) within thirty (30) minutes or thirty (30) miles
|
One within forty-five (45) minutes or forty-five (45) miles
|
Hospitals
|
One (1) within thirty (30) minutes or thirty (30) miles
|
One within forty-five (45) minutes or forty-five (45) miles
|
Mental Health Providers
|
One (1) within thirty (30) minutes or thirty (30) miles
|
One within forty-five (45) minutes or forty-five (45) miles
|
Pharmacies
|
One (1) twenty-four (24) hours a day, seven (7) days a week within fifteen (15) minutes or fifteen (15) miles
|
One (1) twenty-four (24) hours a day (or has an after hours emergency phone number and pharmacist on call), seven (7) days a week within thirty (30) minutes or thirty (30) miles
|
|
4.8.13.2
|
All travel times are maximums for the amount of time it takes a Member or P4HB Participant, using usual travel means in a direct route to travel from their home to the Provider. DCH recognizes that transportation with NET vendors may not always follow direct routes due to multiple passengers.
|
|
4.8.13.3
|
The Contractor shall only include in its Geographic Access data reports those Providers that operate a full-time practice location. For purposes of this section, a full-time practice location is defined as a location operating for 16 or more hours in an office location each week. In addition to the Geographic Access data reports, the Contractor shall submit a separate report of those Providers and associated locations with closed panels (any Provider which the Contractor recognizes as no longer accepting new Members) and those Providers and associated locations with less than full-time practice hours. The separate reports must include a listing of the Providers by name and location, Provider type and an analysis of the total number of Providers with closed panels or less than full-time practice hours expressed as a percentage of the Contractor's total contracted Providers for the state and then for each Service Region. The Contractor must also provide any plans or corrective actions to enhance access of the Providers included in these separate reports. If enhanced access is not possible (i.e., no Providers available for contracting or available Providers only practice part-time) the Contractor must describe the limitations. The Contractor may indicate whether a Provider’s office is a primary, secondary, tertiary, etc. location.
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|
4.8.13.4
|
The Contractor shall be required to utilize the most recent GeoAccess program versions available and update periodically as appropriate. GeoCoder software is required to be used along with the GeoAccess application package.
|
|
4.8.13.5
|
The Contractor shall be required to report monthly the total number of provider applications received, the total number of applications pending a determination, and the total of each of the approved and denied applications.
|
|
4.8.13.6
|
The Contractor shall be required to ensure that all complete provider applications are processed and loaded within 30 days of receipt by the Contractor or its designated subcontracted vendor.
|
4.8.14
|
Waiting Maximums and Appointment Requirements
|
|
4.8.14.1
|
The Contractor shall require that all network Providers offer hours of operation that are no less than the hours of operation offered to commercial and Fee-for-Service patients. The Contractor shall encourage its PCPs to offer After-Hours office care in the evenings and on weekends.
|
|
4.8.14.2
|
The Contractor shall have in its network the capacity to ensure that waiting times for appointments do not exceed the following:
|
PCPs (routine visits)
|
Not to exceed 14 calendar days
|
PCP (adult sick visit)
|
Not to exceed 24 hours
|
PCP (pediatric sick visit)
|
Not to exceed 24 hours
|
Specialists
|
Not to exceed 30 Calendar Days
|
Dental Providers (routine visits)
|
Not to exceed 21 Calendar Days
|
Dental Providers (urgent care)
|
Not to exceed 48 hours
|
Elective Hospitalizations
|
30 Calendar Days
|
Mental health Providers
|
14 Calendar Days
|
Urgent Care Providers
|
Not to exceed 24 hours
|
Emergency Providers
|
Immediately (24 hours a day, 7 days a week) and without prior authorization
|
|
4.8.14.3
|
The Contractor shall have in its network the capacity to ensure that waiting times in the provider office does not exceed the following for pediatrics and adults:
|
Scheduled Appointments
|
Waiting times shall not exceed 60 minutes. After 30 minutes, patient must be given an update on waiting time with an option of waiting or rescheduling appointment.
|
Work-in or Walk-In Appointments
|
Waiting times shall not exceed 90 minutes. After 45 minutes, patient must be given an update on waiting time with an option of waiting or rescheduling appointment
|
|
4.8.14.4
|
The Contractor shall ensure that provider response times for returning calls after-hours are as follows:
|
Urgent Calls
|
Shall not exceed 20 minutes
|
Other Calls
|
Shall not exceed one hour
|
|
4.8.14.5
|
The Contractor shall provide adequate capacity for initial visits for pregnant women within fourteen (14) Calendar Days and visits for Health Check eligible children within ninety (90) Calendar Days of Enrollment into the CMO plan.
|
|
4.8.14.6
|
The Contractor shall take corrective action if there is a failure to comply with these waiting times.
|
4.8.15
|
Credentialing
|
|
4.8.15.1
|
The Contractor shall maintain written policies and procedures for the Credentialing and Re-Credentialing of network Providers, using standards established by National Committee Quality Assurance (NCQA), Joint Commission on Accreditation Healthcare Organization (JCAHO), or American Accreditation Healthcare Commission/URAC. At a minimum, the Contractor shall require that each Provider be credentialed in accordance with State law and Federal regulations. The Contractor may impose more stringent Credentialing criteria than the State requires. The Contractor shall Credential all completed applications packets within 120 calendar days of receipt.
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|
4.8.15.2
|
Credentialing policies and procedures shall include: the verification of the existence and maintenance of credentials, licenses, certificates, and insurance coverage of each Provider from a primary source; a methodology and process for Re-Credentialing Providers; a description of the initial quality assessment of private practitioner offices and other patient care settings; and procedures for disciplinary action, such as reducing, suspending, or terminating Provider privileges.
|
|
4.8.15.3
|
Upon the request of DCH, the Contractor shall make available all licenses, insurance certificates, and other documents of network Providers. The Contractor shall also make available to DCH each quarter the total number of provider applications by date that have been received, the number of applications pending a determination, credentialed, and approved and denied. These reports should be catalogued date in such a way to allow age tracking of each provider application submitted and the specific reason that credentialing for any of the applications was delayed beyond 120 days.
|
|
4.8.15.4
|
Contractors shall submit its Provider Credentialing and re-Credentialing Policies and Procedures to DCH as updated.
|
|
4.8.15.5
|
The Contractor’s application review decision must include specific documentation to support the decision to accept or decline a provider. The Contractor must include instructions regarding how a provider can appeal a decision to deny the provider’s application.
|
|
4.8.15.6
|
The Contractor shall notify DCH within ten (10) days of the Contractor’s denial of a provider credentialing application either for program integrity-related reasons or due to limitations placed on the provider’s ability to participate for program integrity-related reasons.
|
4.8.16
|
Mainstreaming
|
|
4.8.16.1
|
The Contractor shall encourage that all In-Network Providers accept Members and P4HB Participants for treatment, unless they have a full panel (2500 members and P4HB Participants) and are accepting no new GF or commercial patients. The Contractor shall ensure that In-Network Providers do not intentionally segregate Members and P4HB Participants in any way from other persons receiving services.
|
|
4.8.16.2
|
The Contractor shall ensure that Members and P4HB Participants are provided services without regard to race, color, creed, sex, religion, age, national origin, ancestry, marital status, sexual preference, health status, income status, or physical or mental disability.
|
4.8.17
|
Coordination Requirements
|
|
4.8.17.1
|
The Contractor shall coordinate and work collaboratively with all divisions within DCH, as well as with other State agencies, and with other CMO plans operating within the same Service Region for administration of the Georgia Families program.
|
|
4.8.17.2
|
The Contractor shall also coordinate with local education agencies in the Referral and provision of children’s intervention services provided through the school to ensure Medical Necessity and prevent duplication of services.
|
|
4.8.17.3
|
The Contractor shall coordinate the services furnished to its Members and P4HB Participants with the service the Member and P4HB Participant receives outside the CMO plan, including services received through any other managed care entity.
|
|
4.8.17.4
|
The Contractor shall coordinate with all NET vendors.
|
|
4.8.17.5
|
DCH strongly encourages the Contractor to Contract with Providers of essential community services who would normally Contract with the State as well as other public agencies and with non-profit organizations that have maintained a historical base in the community.
|
|
4.8.17.6
|
The Contractor shall implement procedures to ensure that in the process of coordinating care each Member’s or P4HB Participants privacy is protected consistent with the confidentiality requirements in 45 CFR 160 and 45 CFR 164.
|
4.8.18
|
Network Changes
|
|
4.8.18.1
|
The Contractor shall notify DCH within seven (7) Business Days of any significant changes to the Provider network or, if applicable, to any Subcontractors’ Provider network. A significant change is defined as:
|
·
|
A decrease in the total number of PCPs by more than five percent (5%);
|
·
|
A loss of all Providers in a specific specialty where another Provider in that specialty is not available within sixty (60) miles;
|
·
|
A loss of a hospital in an area where another contracted hospital of equal service ability is not available within thirty (30) miles; or
|
·
|
Other adverse changes to the composition of the network, which impair or deny the Members’ or P4HB Participants adequate access to In-Network Providers.
|
|
4.8.18.2
|
The Contractor shall have procedures to address changes in the health plan Provider network that negatively affect the ability of Members or P4HB Participants to access services, including access to a culturally diverse Provider network. Significant changes in network composition that negatively impact Member or P4HB Participant access to services may be grounds for Contract termination or State determined remedies.
|
|
4.8.18.3
|
If a PCP ceases participation in the Contractor’s Provider network the Contractor shall send written notice to the Members and P4HB Participants who have chosen the Provider as their PCP. This notice shall be issued no less than thirty (30) Calendar Days prior to the effective date of the termination and no more than ten (10) Calendar Days after receipt or issuance of the termination notice.
|
|
4.8.18.4
|
If a Member or P4HB Participant is in a prior authorized ongoing course of treatment with any other participating Provider who becomes unavailable to continue to provide services, the Contractor shall notify the Member or P4HB Participant in writing within ten (10) Calendar Days from the date the Contractor becomes aware of such unavailability.
|
4.8.18.5
|
These requirements to provide notice prior to the effective dates of termination shall be waived in instances where a Provider becomes physically unable to care for Members due to illness, a Provider dies, the Provider moves from the Service Region and fails to notify the Contractor, or when a Provider fails Credentialing. Under these circumstances, notice shall be issued immediately upon the Contractor becoming aware of the circumstances.
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4.8.18.6
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Continuity of Care Plan is required to be submitted to DCH 60 days prior to anticipated mass Network changes (as defined in 4.8.18.1) that will impact membership.
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4.8.19
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Out-of-Network Providers
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4.8.19.1
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If the Contractor’s network is unable to provide Medically Necessary Covered Services to a particular Member, the Contractor shall adequately and timely cover these services Out-of-Network for the Member. The Contractor must inform the Out-of Network Provider that the member cannot be balance billed.
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4.8.19.2
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The Contractor shall coordinate with Out-of-Network Providers regarding payment. For payment to Out-of-Network, or non-participating Providers, the following guidelines apply:
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·
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If the Contractor offers the service through an In-Network Provider(s), and the Member chooses to access the service (i.e., it is not an emergency) from an Out-of-Network Provider, the Contractor is not responsible for payment.
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·
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If the service is not available from an In-Network Provider, but the Contractor has three (3) Documented Attempts to contract with the Provider, the Contractor is not required to pay more than Medicaid FFS rates for the applicable service, less ten percent (10%).
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·
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If the service is available from an In-Network Provider, but the service meets the Emergency Medical Condition standard, and the Contractor has three (3) Documented Attempts to contract with the Provider, the Contractor is not required to pay more than Medicaid FFS rates for the applicable service, less ten percent (10%).
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·
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When paying out of state providers in an emergency situation: Be advised that the CMOs shall not allow a member to be held accountable for payment under these circumstances.
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·
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If the service is not available from an In-Network Provider and the Member requires the service and is referred for treatment to an Out-of-Network Provider, the payment amount is a matter between the CMO and the Out-of-Network Provider.
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4.8.19.3
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In the event that needed services are not available from an In-Network Provider and the Member must receive services from an Out-of-Network Provider, the Contractor must ensure that the Member is not charged more than it would have if the services were furnished within the network.
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4.8.20.1
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The Contractor shall comply with the responsibilities outlined in the “Memorandum of Understanding for the PeachCare Partnership Program” executed on February 18, 2008.
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4.8.20.2
|
The Contractor shall cooperate with DCH in making any updates or revisions to the Memorandum, as necessary.
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4.8.21
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Reporting Requirements
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4.8.21.1
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The Contractor shall submit to DCH quarterly Provider Network Adequacy and Capacity Reports (included Policies and Procedures) as described in Section 4.18.4.10.
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4.8.21.2
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The Contractor shall submit to DCH quarterly Timely Access Reports as described in Section 4.18.4.1.
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4.9.1
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General Provisions
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4.9.1.1
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The Contractor shall provide information to all Providers about GF in order to operate in full compliance with the GF Contract and all applicable federal and State regulations.
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4.9.1.2
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The Contractor shall monitor Provider knowledge and understanding of Provider requirements, and take corrective actions to ensure compliance with such requirements.
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4.9.1.3
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The Contractor shall submit to DCH for review and prior approval all materials and information to be distributed and/or made available.
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4.9.1.4
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All Provider Handbooks and bulletins must be in compliance with State and federal laws.
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4.9.1.5
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Contractor must proactively seek DCH’s written approval of the Contractor’s interpretation of policies in the Georgia Medicaid Policy Manual when such policies are referenced in Provider contracts or communications. DCH’s review and response will be completed within sixty (60) calendar days of the Contractor’s written request for approval of its policy interpretation. DCH’s written response shall be final regarding any dispute of the meaning of that policy language. In the event the Contractor misinterprets a Medicaid policy which is communicated to Providers, the Contractor must submit a written corrective action plan to DCH within three (3) business days of notice from DCH. Contractor will be required to retroactively correct and adjust any previously adjudicated claims or correct any other actions resulting from the misinterpreted policy language within thirty (30) calendar days of approval of the corrective action plan.
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4.9.2
|
Provider Handbooks
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4.9.2.1
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The Contractor shall issue a Provider Handbook to all network Providers at the time the Provider Contract is signed. The Contractor may choose not to distribute the Provider Handbook via mail, provided it submits a written notification to all Providers that explains how to obtain the Provider Handbook from the CMO’s Web site. This notification shall also detail how the Provider can request a hard copy from the CMO at no charge to the Provider. All Provider Handbooks and bulletins shall be in compliance with State and federal laws. The Provider Handbook shall serve as a source of information regarding GF Covered Services, policies and procedures, statutes, regulations, telephone access and special requirements to ensure all Contract requirements are being met. At a minimum, the Provider Handbook shall include the following information:
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·
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Description of the GF;
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·
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Covered Services;
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·
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Emergency Service responsibilities;
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·
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Health Check/EPSDT program services and standards;
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·
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Policies and procedures of the Provider complaint system;
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·
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Information on the Member Grievance System, including the Member’s right to a State Administrative Law Hearing, the timeframes and requirements, the availability of assistance in filing, the toll-free numbers and the Member’s right to request continuation of Benefits while utilizing the Grievance System;
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·
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Medical Necessity standards and practice guidelines;
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·
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Practice protocols, including guidelines pertaining to the treatment of chronic and complex Conditions;
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·
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PCP responsibilities;
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·
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Other Provider or Subcontractor responsibilities;
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·
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Prior Authorization, Pre-Certification, and Referral procedures;
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·
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Protocol for Encounter Data element reporting/records;
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·
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Medical Records standard;
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·
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Claims submission protocols and standards, including instructions and all information necessary for a clean or complete Claim;
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·
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Payment policies;
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·
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The Contractor’s Cultural Competency Plan; and
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·
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Member rights and responsibilities.
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·
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Description of the Demonstration;
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·
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Practice protocols for the Demonstration;
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·
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Other Provider responsibilities pertaining to the Demonstration;
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·
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Coding requirements pertaining to the Demonstration;
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·
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Prior Authorization, Pre-Certification, and Referral procedures pertaining to the Demonstration;
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·
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P4HB Participants rights and responsibilities
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4.9.2.2
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The Contractor shall disseminate bulletins as needed to incorporate any needed changes to the Provider Handbook.
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4.9.2.3
|
The Contractor shall submit the Provider Handbook to DCH for review and approval and as updated. Any updates or revisions shall be submitted to DCH for review and approval at least 30 days prior to distribution.
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4.9.3
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Education and Training
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4.9.3.1
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The Contractor shall provide training to all Providers and their staff regarding the requirements of the Contract and special needs of Members. The Contractor shall conduct initial training within thirty (30) Calendar Days of placing a newly Contracted Provider on active status. The Contractor shall also conduct ongoing training as deemed necessary by the Contractor or DCH in order to ensure compliance with program standards and the GF Contract.
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4.9.3.1.1
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The Contractor shall provide training to all Demonstration Family Planning and IPC service Providers and their staffs regarding the requirements of the Demonstration and the Contract provisions related to the Demonstration and special needs of the P4HB Participants. The Contractor shall conduct initial training within thirty (30) Calendar Days of placing a newly contracted Provider on active status. The Contractor shall also conduct ongoing training as deemed necessary by the Contractor or DCH in order to ensure compliance with the Demonstration’s standards and the Contract.
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4.9.3.1.2
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The Contractor’s Demonstration Provider network will utilize the Preconception Care Toolkit for Georgia for preconception health education and counseling.
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4.9.3.2
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The Contractor shall submit the Provider Training Manual and Training Schedule to DCH for review and approval as updated.
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4.9.3.3
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The Contractor shall submit the Provider Rep Field Visit Report Ad-Hoc as described in Section 4.18.6.3.
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4.9.4
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Provider Relations
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4.9.4.1
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The Contractor shall establish and maintain a formal Provider relations function to timely and adequately respond to inquiries, questions and concerns from network Providers. The Contractor shall implement policies addressing the compliance of Providers with the requirements of GF, institute a mechanism for Provider dispute resolution and execute a formal system of terminating Providers from the network.
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4.9.4.2
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The Contractor shall provide for a Provider Relations Liaison to carry out the Provider Relations functions. There shall be at least one (1) Provider Relations Liaison in each Service Region.
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4.9.5
|
Toll-free Provider Services Telephone Line
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4.9.5.1
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The Contractor shall operate a toll-free telephone line to respond to Provider questions, comments and inquiries.
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4.9.5.2
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The Contractor shall develop Telephone line Policies and Procedures that address staffing, personnel, hours of operation, access and response standards, monitoring of calls via recording or other means, and compliance with standards.
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4.9.5.3
|
The Contractor shall submit these Telephone line Policies and Procedures, including performance standards, to DCH for review and approval as updated.
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4.9.5.4
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The Contractor’s call center systems shall have the capability to track call management metrics identified in Attachment L.
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4.9.5.5
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Pursuant to OCGA 30-20A-7.1, the telephone line shall be staffed twenty-four (24) hours a day, seven (7) days a week to respond to Prior Authorization and Pre-certification requests. This telephone line shall have staff to respond to Provider questions in all other areas, including the Provider complaint system, Provider responsibilities, etc. between the hours of 7:00am and 7:00pm EST Monday through Friday, excluding State holidays.
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4.9.5.6
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The Contractor shall develop performance standards and monitor Telephone Line performance by recording calls and employing other monitoring activities. At a minimum, the standards shall require that, on a monthly basis, eighty percent (80%) of calls are answered by a person within thirty (30) seconds, the Blocked Call rate does not exceed one percent (1%), and the rate of Abandoned Calls does not exceed five percent (5%).
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4.9.5.7
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The Contractor shall insure that after regular business hours the non-Prior Authorization/Pre-certification line is answered by an automated system with the capability to provide callers with operating hour’s information and instructions on how to verify Enrollment for a Member with an Emergency or Urgent Medical Condition. The requirement that the Contractor shall provide information to Providers on how to verify Enrollment for a Member with an Emergency or Urgent Medical Condition shall not be construed to mean that the Provider must obtain verification before providing Emergency Services.
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4.9.5.8
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The Contractor shall develop Call Center Quality Criteria and Protocols to measure and monitor the accuracy of responses and phone etiquette as it relates to the Toll-free Telephone Line. The Contractor shall submit the Call Center Quality Criteria and Protocols to DCH for review and approval as updated.
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4.9.6
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Internet Presence/Web Site
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4.9.6.1
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The Contractor shall dedicate a section of its Web Site to Provider services and provide at a minimum, the capability for Providers to make inquiries and receive responses through the Medicaid fiscal agent Web Site, (www.ghp.georgia.gov).
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4.9.6.2
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In addition to the specific requirements outlined above, the Contractor’s Web Site shall be functionally equivalent, with respect to functions described in this Contract, to the Web Site maintained by the State’s Medicaid fiscal agent (www.ghp.georgia.gov).
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4.9.6.3
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The Contractor shall submit Web site screenshots to DCH for review and approval as updated.
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4.9.6.4
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The Contractor shall maintain a website that allows Providers to submit, process, edit (only if original submission is in an electronic format), rebill, and adjudicate claims electronically. To the extent a Provider has the capability; each care management organization shall submit payments to Providers electronically and submit remittance advices to Providers electronically within one business day of when payment is made. To the extent that any of these functions involve covered transactions under 45 C.F.R. Section 162.900, et seq., then those transactions also shall be conducted in accordance with applicable federal requirements.
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4.9.6.5
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The Contractor shall post on its website a searchable list of all providers with which the care management organization has contracted. At a minimum, this list shall be searchable by provider name, specialty, and location. At a minimum, the list shall be updated once each month.
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4.9.7
|
Provider Complaint System
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4.9.7.1
|
The Contractor shall establish a Provider Complaint system that permits a Provider to dispute the Contractor’s policies, procedures, or any aspect of a Contractor’s administrative functions.
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4.9.7.2
|
The Contractor shall submit its Provider Complaint System Policies and Procedures to DCH for review and approval quarterly and annually and as updated thereafter.
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4.9.7.3
|
The Contractor shall include its Provider Complaint System Policies and Procedures in its Provider Handbook that is distributed to all network Providers. This information shall include, but not be limited to, specific instructions regarding how to contact the Contractor’s Provider services to file a Provider complaint and which individual(s) have the authority to review a Provider complaint.
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4.9.7.4
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The Contractor shall distribute the Provider Complaint System Policies and Procedures to Out-of-Network Providers with the remittance advice of the processed Claim. The Contractor may distribute a summary of these Policies and Procedures if the summary includes information on how the Provider may access the full Policies and Procedures on the Web site. This summary shall also detail how the Provider can request a hard copy from the CMO at no charge to the Provider.
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4.9.7.5
|
As a part of the Provider Complaint System, the Contractor shall:
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·
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Allow Providers thirty (30) Calendar Days to file a written complaint;
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·
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Allow Providers to consolidate complaints or appeals of multiple claims that involve the same or similar payment or coverage issues, regardless of the number of individual patients or payment claims included in the bundled complaint or appeal.
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·
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Allow a Provider that has exhausted the care management organization’s internal appeals process related to a denied or underpaid claim or group of claims bundled for appeal the option either to pursue the administrative review process described in O.C.G.A. § 49-4-153(e) or to select binding arbitration by a private arbitrator who is certified by a nationally recognized association that provides training and certification in alternative dispute resolution. If the care management organization and the Provider are unable to agree on an association, the rules of the American Arbitration Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be selected according to the rules of his or her certifying association. Arbitration conducted pursuant to this Code section shall be binding on the parties. The arbitrator shall conduct a hearing and issue a final ruling within 90 days of being selected, unless the care management organization and the Provider mutually agree to extend this deadline. All costs of arbitration, not including attorney’s fees, shall be shared equally by the parties.
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·
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For all claims that are initially denied or underpaid by the Contractor but eventually determined or agreed to have been owed by the Contractor to a provider of health care services, the Contractor shall pay, in addition to the amount determined to be owed, interest of twenty percent (20%) per annum (based on simple interest calculations), calculated from fifteen (15) business days after the date the claim was submitted. A care management organization shall pay all interest required to be paid under this provision or Code Section 33-24-59.5 automatically and simultaneously whenever payment is made for the claim giving rise to the interest payment.
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·
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All interest payments shall be accurately identified on the associated remittance advice submitted by the care management organization to the Provider.
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·
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Require that the reason for the complaint is clearly documented;
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·
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Require that Providers exhaust the Contractor’s internal Provider Complaint process prior to requesting an Administrative Law Hearing (State Fair Hearing);
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·
|
Have dedicated staff for Providers to contact via telephone, electronic mail, or in person, to ask questions, file a Provider Complaint and resolve problems;
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·
|
Identify a staff person specifically designated to receive and process Provider Complaints;
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·
|
Thoroughly investigate each GF Provider Complaint using applicable statutory, regulatory, and Contractual provisions, collecting all pertinent facts from all parties and applying the Contractor’s written policies and procedures; and
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·
|
Ensure that CMO plan executives with the authority to require corrective action are involved in the Provider Complaint process.
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|
4.9.7.6
|
In the event the outcome of the review of the Provider Complaint is adverse to the Provider, the Contractor shall provide a written Notice of Adverse Action to the Provider. The Notice of Adverse Action shall state that Providers may request an Administrative Law Hearing in accordance with O.C.G.A. § 49-4-153, O.C.G.A. § 50-13-13 and O.C.G.A. § 50-13-15.
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4.9.7.7
|
The Contractor shall notify the Providers that a request for an Administrative Law Hearing must include the following information:
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·
|
A clear expression by the Provider that he/she wishes to present his/her case to an Administrative Law Judge;
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·
|
Identification of the Action being appealed and the issues that will be addressed at the hearing;
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·
|
A specific statement of why the Provider believes the Contractor’s Action is wrong; and
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·
|
A statement of the relief sought.
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4.9.7.8
|
DCH has delegated its statutory authority to receive hearing requests to the Contractor. The Contractor shall include with the Notice of Adverse Action the Contractor’s address where a Provider’s request for an Administrative Law Hearing should be sent in accordance with O.C.G.A. § 49-4-153(e).
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4.9.7.9
|
Claims Adjustment Requests
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·
|
Positive Adjustments: When a Provider can substantiate that additional reimbursement is appropriate, the Provider may adjust and resubmit a claim. Provider shall be given the option to submit the written request, Explanation of Payment and all claims related documentation either electronically or by U.S. mail. All documentation must be received within three (3) months from the end of the month of payment. The adjustment request must include sufficient documentation to identify each claim identified in the request. The Contractor may return incomplete requests without further action provided it notifies the Provider of the basis for the incomplete status and allows the Provider ten (10) calendar days to resubmit the adjustment request. The Provider shall be required to submit documentation that supports the requested claims adjustment. If a positive adjustment is warranted, the Contractor shall make additional reimbursement upon processing of the request. If an adjustment is not warranted, the Provider will be notified via written correspondence from the Contractor.
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·
|
Negative Adjustments: When a Provider believes a negative adjustment is appropriate, the Provider may adjust and resubmit a claim. Provider shall be given the option to submit the written request, Explanation of Payment and all claims related documentation either electronically or by U.S. mail. If a negative adjustment is warranted, Contractor may either deduct the payment from future reimbursement or request from the Provider and required by the Provider’s contract with the Contractor.
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·
|
The Contractor shall respond to all adjustment requests within 30 days of receipt.
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4.9.8
|
Reporting Requirements
|
4.9.8.1
|
The Contractor shall submit to DCH monthly Telephone and Internet Activity Reports as described in Section 4.18.3.1.
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4.9.8.2
|
The Contractor shall submit to DCH monthly Provider Complaints Reports as described in Section 4.18.3.10.
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4.10
|
PROVIDER CONTRACTS AND PAYMENTS
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4.10.1
|
Provider Contracts
|
4.10.1.1
|
The Contractor shall comply with all DCH procedures for contract review and approval submission. Memoranda of Agreement (MOA) shall not be permitted. Letters of Intent shall only be permitted in accordance with Section 4.8.1.10.
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4.10.1.2
|
The Contractor shall submit to DCH for review and approval a model for each type of Provider Contract as updated.
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4.10.1.3
|
Any significant changes to the model Provider Contract shall be submitted to DCH for review and approval no later than thirty (30) Calendar Days prior to the Enrollment of Members and P4HB Participants into the CMO plan.
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4.10.1.4
|
Upon request, the Contractor shall provide DCH with free copies of all executed Provider Contracts.
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4.10.1.5
|
The Contractor shall not require Providers to participate or accept other plans or products offered by the care management organization unrelated to providing care to members and P4HB Participants, nor reduce the funding available for members and P4HB Participants as a result of payment of such penalties.. Any care management organization which violates this prohibition shall be subject to a penalty of $1,000.00 per violation.
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4.10.1.6
|
The Contractor shall not enter into any exclusive contract agreements with providers that exclude other health care providers from contract agreements for network participation.
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4.10.1.7
|
Health care providers may not, as a condition of contracting with a CMO, require the CMO to contract with or not contract with another health care provider. A provider who violates this probation will be subject to a $1,000 per violation penalty.
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4.10.1.8
|
If a Provider has complied with all of DCH’s published procedures for verifying a patient’s eligibility for Medicaid benefits through the established common verification process, DCH must reimburse the Provider for all covered services provided to the patient within the 72 hours following the verification, if such services are denied by a CMO or DCH because the patient is not enrolled as shown in the verification process. DCH would be able to pursue a case of action against a person who had contributed to the incorrect verification.
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4.10.1.9
|
In addition to addressing the CMO plan licensure requirements, the Contractor’s Provider Contracts shall:
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·
|
Prohibit the Provider from seeking payment from the Member for any Covered Services provided to the Member and P4HB Participant within the terms of the Contract and require the Provider to look solely to the Contractor for compensation for services rendered, with the exception of nominal cost sharing pursuant to the Georgia State Medicaid Plan, the Georgia State Medicaid Policies and Procedures Manuals, and the GF Contract;
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·
|
Require the Provider to cooperate with the Contractor’s quality improvement and Utilization Review and management activities;
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·
|
Include provisions for the immediate transfer to another PCP or Contractor if the Member’s and P4HB Participants health or safety is in jeopardy;
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·
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Not prohibit a Provider from discussing treatment or non-treatment options with Members and P4HB Participants that may not reflect the Contractor’s position or may not be covered by the Contractor;
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·
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Not prohibit a Provider from acting within the lawful scope of practice, from advising or advocating on behalf of a Member for the Member’s and P4HB Participants health status, medical care, or treatment or non-treatment options, including any alternative treatments that might be self-administered;
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·
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Not prohibit a Provider from advocating on behalf of the Member and P4HB Participant in any Grievance System or Utilization Review process, or individual authorization process to obtain necessary Health Care services;
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·
|
Require Providers to meet appointment waiting time standards pursuant to Section 4.8.14.2 of this Contract;
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·
|
Provide for continuity of treatment in the event a Provider’s participation terminates during the course of a Member’s or P4HB Participants treatment by that Provider;
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·
|
Prohibit discrimination with respect to participation, reimbursement, or indemnification of any Provider who is acting within the scope of his or her license or certification under applicable State law, solely based on such license or certification. This provision should not be construed as any willing provider law, as it does not prohibit Contractors from limiting Provider participation to the extent necessary to meet the needs of the Members. Additionally, this provision shall not preclude the Contractor from using different reimbursement amounts for different specialties or for different practitioners in the same specialty. This provision also does not interfere with measures established by the Contractor that are designed to maintain Quality and control costs;
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·
|
Prohibit discrimination against Providers serving high-risk populations or those that specialize in Conditions requiring costly treatments;
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·
|
Specify that CMS and DCH will have the right to inspect, evaluate, and audit any pertinent books, financial records, documents, papers, and records of any Provider involving financial transactions related to the GF Contract;
|
·
|
Specify Covered Services and populations;
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·
|
Require Provider submission of complete and timely Encounter Data, pursuant to Section 4.17.4.2 of the GF Contract;
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·
|
Include the definition and standards for Medical Necessity, pursuant to the definition in Section 4.5.4 of this Contract;
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·
|
Specify rates of payment. The Contractor ensures that Providers will accept such payment as payment in full for Covered Services provided to Members and P4HB Participants, as deemed Medically Necessary and appropriate under the Contractor’s Quality Improvement and Utilization Management program, less any applicable Member and P4HB Participants cost sharing pursuant to the GF Contract;
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·
|
Provide for timely payment to all Providers for Covered Services to Members and P4HB Participants. Pursuant to O.C.G.A. 33-24-59.5(b) (1) once a clean claim has been received, the CMO(s) will have 15 Business Days within which to process and either transmit funds for payment electronically for the claim or mail a letter or notice denying it, in whole or in part giving the reasons for such denial.
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·
|
Specify acceptable billing and coding requirements;
|
·
|
Require that Providers comply with the Contractor’s Cultural Competency plan;
|
·
|
Require that any marketing materials developed and distributed by Providers be submitted to the Contractor to submit to DCH for approval;
|
·
|
Specify that in the case of newborns the Contractor shall be responsible for any payment owed to Providers for services rendered prior to the newborn’s Enrollment with the Contractor;
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·
|
Specify that the Contractor shall not be responsible for any payments owed to Providers for services rendered prior to a Member’s or P4HB Participants Enrollment with the Contractor, even if the services fell within the established period of retroactive eligibility;
|
·
|
Comply with 42 CFR 434 and 42 CFR 438.6;
|
·
|
Require Providers to collect Member and P4HB Participant co-payments as specified in Attachment K;
|
·
|
Not employ or subcontract with individuals on the State or Federal Exclusions list;
|
·
|
Prohibit Providers from making Referrals for designated health services to Health Care entities with which the Provider or a Member or P4HB Participant of the Provider’s family has a Financial Relationship.
|
·
|
Require Providers of transitioning Members and P4HB Participants to cooperate in all respects with Providers of other CMO plans to assure maximum health outcomes for Members and P4HB Participants;
|
·
|
Not require that Providers sign exclusive Provider Contracts with the Contractor if the Provider is a CAH, FQHC, or RHC;
|
·
|
Contain a provision stating that in the event DCH is due funds from a Provider; who has exhausted or waived the administrative review process, if applicable, the Contractor shall reduce payment by one hundred percent (100%) to that Provider until such time as the amount owed to DCH is recovered;
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·
|
Contain a provision giving notice that the Contractor’s negotiated rates with Providers shall be adjusted in the event the Commissioner of DCH directs the Contractor to make such adjustments in order to reflect budgetary changes to the Medical Assistance program; and
|
·
|
Require the Contractor to notify the Provider in writing no less than thirty (30) calendar days prior to any adjustments to the Provider's contracted reimbursement rates.
|
|
4.10.2
|
Provider Termination
|
4.10.2.1
|
The Contractor shall comply with all State and federal laws regarding Provider termination. In its Provider Contracts the Contractor shall:
|
·
|
Specify that in addition to any other right to terminate the Provider Contract, and notwithstanding any other provision of this Contract, DCH may request Provider termination immediately, or the Contractor may immediately terminate on its own, a Provider’s participation under the Provider Contract if a Provider fails to abide by the terms and conditions of the Provider Contract, as determined by DCH, or, in the sole discretion of DCH, fails to come into compliance within fifteen (15) Calendar Days after a receipt of notice from the Contractor specifying such failure and requesting such Provider to abide by the terms and conditions hereof;
|
·
|
Specify that any Provider whose participation is terminated under the Provider Contract for any reason shall utilize the applicable appeals procedures outlined in the Provider Contract. No additional or separate right of appeal to DCH or the Contractor is created as a result of the Contractor’s act of terminating, or decision to terminate any Provider under this Contract. Notwithstanding the termination of the Provider Contract with respect to any particular Provider, this Contract shall remain in full force and effect with respect to all other Providers;
|
|
4.10.2.2
|
The Contractor shall notify DCH at least forty-five (45) Calendar Days prior to the effective date of the suspension, termination, or withdrawal of a Provider from participation in the Contractor’s network. If the termination was “for cause”, the Contractor may terminate, suspend, or withdraw the Provider immediately and shall notify DCH in writing within one business day of the termination with the reasons for termination.
|
|
4.10.2.3
|
The Contractor shall notify the Members pursuant to Section 4.10.2 of this Contract.
|
4.10.3
|
Provider Insurance
|
|
4.10.3.1
|
The Contractor shall require each Provider (with the exception of Section 4.10.3.2 below, and FQHCs that are section 330 grantees) to maintain, throughout the terms of the Contract, at its own expense, professional and comprehensive general liability, and medical malpractice, insurance. Such comprehensive general liability policy of insurance shall provide coverage in an amount established by the Contractor pursuant to its written Contract with the Provider. Such professional liability policy of insurance shall provide a minimum coverage in the amount of one million dollars ($1,000,000) per occurrence, and three million dollars ($3,000,000) annual aggregate. Providers may be allowed to self-insure if the Provider establishes an appropriate actuarially determined reserve. DCH reserves the right to waive this requirement if necessary for business need.
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4.10.3.2
|
The Contractor shall require allied mental health professionals to maintain, throughout the terms of the Contract, professional and comprehensive general liability, and medical malpractice, insurance. Such comprehensive general liability policy of insurance shall provide coverage in an amount established by the Contractor pursuant to its written Contract with Provider. Such professional liability policy of insurance shall provide a minimum coverage in the amount of one million dollars ($1,000,000) per occurrence, and one million dollars ($1,000,000) annual aggregate. These Providers may also be allowed to self insure if the Provider establishes an appropriate actuarially determined reserve.
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4.10.3.3
|
In the event any such insurance is proposed to be reduced, terminated or canceled for any reason, the Contractor shall provide to DCH and Department of Insurance (DOI) at least thirty (30) Calendar Days prior written notice of such reduction, termination or cancellation. Prior to the reduction, expiration and/or cancellation of any insurance policy required hereunder, the Contractor shall require the Provider to secure replacement coverage upon the same terms and provisions so as to ensure no lapse in coverage, and shall furnish DCH and DOI with a Certificate of Insurance indicating the receipt of the required coverage at the request of DCH or DOI.
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4.10.3.4
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The Contractor shall require Providers to maintain insurance coverage (including, if necessary, extended coverage or tail insurance) sufficient to insure against claims arising at any time during the term of the GF Contract, even though asserted after the termination of the GF Contract. DCH or DOI, at its discretion, may request that the Contractor immediately terminate the Provider from participation in the program upon the Provider’s failure to abide by these provisions. The provisions of this Section shall survive the expiration or termination of the GF Contract for any reason.
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4.10.4
|
Provider Payment
|
|
4.10.4.1
|
With the exceptions noted below, the Contractor shall negotiate rates with Providers and such rates shall be specified in the Provider Contract. DCH prefers that Contractors pay Providers on a Fee for Service basis, however if the Contractor does enter into a capitated arrangement with Providers, the Contractor shall continue to require all Providers to submit detailed Encounter Data, including those Providers that may be paid a Capitation Payment.
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4.10.4.2
|
The Contractor shall be responsible for issuing an IRS Form (1099) in accordance with all federal laws, regulations and guidelines.
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4.10.4.3
|
When the Contractor negotiates a contract with a Critical Access Hospital (CAH), pursuant to Section 4.8.5.2 of the GF Contract, the Contractor shall pay the CAH a payment rate based on 101% allowable costs incurred by the CAH. DCH may require the Contractor to adjust the rate paid to CAHs if so directed by the State of Georgia’s Appropriations Act.
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·
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A critical access hospital must provide notice to a care management organization and DCH of any alleged breaches in its contract by such care management organization.
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·
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If a critical access hospital satisfies the requirement of Title 33 of the Official Code of Georgia Annotated (Medicaid Care Management Organizations Act), and if DCH concludes, after notice and hearing, that a care management organization has substantively and repeatedly breached a term of its contract with a critical access hospital, the department is authorized to require the care management organization to pay damages to the critical access hospital in an amount not to exceed three times the amount owed. Notwithstanding the foregoing, nothing in Title 33 of the Official Code of Georgia Annotated (Medicaid Care Management Organizations Act) shall be interpreted to limit the authority of DCH to establish additional penalties or fines against a care management organization for failure to comply with the contract between a care management organization and DCH.
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4.10.4.4
|
When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor shall pay the PPS rates for Core Services and other ambulatory services per encounter. The rates are established as described in §1001.1 of the Manual. At Contractor’s discretion, it may pay more than the PPS rates for these services.
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4.10.4.4.1
|
Payment Reports must consist of all covered service claim types each month, inclusive of all of the below claims data:
|
·
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Early and Periodic Screening, Diagnosis and Treatment
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|
4.10.4.5
|
Upon receipt of notice from DCH that it is due funds from a Provider, who has exhausted or waived the administrative review process, if applicable, the Contractor shall reduce payment to the Provider for all claims submitted by that Provider by one hundred percent (100%), or such other amount as DCH may elect, until such time as the amount owed to DCH is recovered. The Contractor shall promptly remit any such funds recovered to DCH in the manner specified by DCH. To that end, the Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH.
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4.10.4.6
|
The Contractor shall adjust its negotiated rates with Providers to reflect budgetary changes to the Medical Assistance program, as directed by the Commissioner of DCH; to the extent, such adjustments can be made within funds appropriated to DCH and available for payment to the Contractor. The Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH.
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4.10.5
|
Reporting Requirements
|
|
The Contractor shall submit to DCH monthly FQHC and RHC Reports as described in Section 4.18.3.9.
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4.10.6
|
Provider Payment Agreement
|
|
4.10.6.1
|
The Contractor shall increase benefit payments to Providers in an amount consistent with the provider rate increases included in the State of Georgia’s fiscal year 2011 budget. This enhanced rate shall be effective for dates of service beginning July 1, 2010 until repealed or modified by legislative action or DCH policy changes.
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4.10.6.2
|
The Contractor will provide reports as requested by DCH to enable DCH to determine the amount of the increase in benefit payments to Providers as referenced in Section 4.10.6.1. The report will include, but not be limited to monthly reports, by hospital, that provide the following data for each claim paid:
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·
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Claim Number
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·
|
Date of Service
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Date of Payment
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Base Paid amount
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·
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Add-on Paid amount
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·
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Interest Paid Amount
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Total Paid amount
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4.11
|
UTILIZATION MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES
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4.11.1
|
Utilization Management
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4.11.1.1
|
The Contractor shall provide assistance to Members and Providers to ensure the appropriate Utilization of resources, using the following program components: Prior Authorization and Pre-Certification, prospective review, concurrent review, retrospective review, ambulatory review, second opinion, discharge planning and case management. Specifically, the Contractor shall have written Utilization Management Policies and Procedures that:
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·
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Include protocols and criteria for evaluating Medical Necessity, authorizing services, and detecting and addressing over-Utilization and under-Utilization. Such protocols and criteria shall comply with federal and State laws and regulations.
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·
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Address which services require PCP Referral; which services require Prior-Authorization and how requests for initial and continuing services are processed, and which services will be subject to concurrent, retrospective or prospective review.
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·
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Describe mechanisms in place that ensure consistent application of review criteria for authorization decisions.
|
·
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Require that all Medical Necessity determinations be made in accordance with DCH’s Medical Necessity definition as stated in Section 4.5.4.
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4.11.1.1
|
The Contractor shall submit the Utilization Management Policies and Procedures to DCH for review and prior approval within quarterly and as changed.
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4.11.1.2
|
Network Providers may participate in Utilization Review activities in their own Service Region to the extent that there is not a conflict of interest. The Utilization Management Policies and Procedures shall define when such a conflict may exist and shall describe the remedy.
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4.11.1.3
|
The Contractor shall have a Utilization Management Committee comprised of network Providers within each Service Region. The Contractor may have one (1) independent Utilization Management Committee for all of the Service Regions in which it is operating, if there is representation from each Service Region on the Committee. The Utilization Management committee is accountable to the Medical Director and governing body of the Contractor. The Utilization Management Committee shall meet on a regular basis and maintain records of activities, findings, recommendations, and actions. Reports of these activities shall be made available to DCH upon request.
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4.11.1.4
|
The Contractor, and any delegated Utilization Review agent, shall not permit or provide compensation or anything of value to its employees, agents, or contractors based on:
|
·
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Either a percentage of the amount by which a Claim is reduced for payment or the number of Claims or the cost of services for which the person has denied authorization or payment; or
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·
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Any other method that encourages the rendering of a Proposed Action.
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4.11.2
|
Prior Authorization and Pre-Certification
|
4.11.2.1
|
The Contractor shall not require Prior Authorization or Pre-Certification for Emergency Services, Post-Stabilization Services, or Urgent Care services, as described in Section 4.6.1, 4.6.2, and 4.6.3.
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4.11.2.2
|
The Contractor shall require Prior Authorization and/or Pre-Certification for all non-emergent and non-urgent inpatient admissions except for normal newborn deliveries.
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4.11.2.3
|
The Contractor may require Prior Authorization and/or Pre-Certification for all non-emergent, Out-of-Network services.
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4.11.2.4
|
Prior Authorization and Pre-Certification shall be conducted by a currently licensed, registered or certified Health Care Professional who is appropriately trained in the principles, procedures and standards of Utilization Review.
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4.11.2.5
|
The Contractor shall notify the Provider of Prior Authorization determinations in accordance with the following timeframes:
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4.11.2.5.1
|
Standard Service Authorizations. Prior Authorization decisions for non-urgent services shall be made within fourteen (14) Calendar Days of receipt of the request for services. An extension may be granted for an additional fourteen (14) Calendar Days if the Member, P4HB Participant or the Provider requests an extension, or if the Contractor justifies to DCH a need for additional information and the extension is in the Member’s or P4HB Participant’s interest.
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4.11.2.5.2
|
Expedited Service Authorizations. In the event a Provider indicates, or the Contractor determines, that following the standard timeframe could seriously jeopardize the Member’s or P4HB Participant’s life or health the Contractor shall make an expedited authorization determination and provide notice within twenty-four (24) hours. The Contractor may extend the twenty-four (24) hour period for up to five (5) Business Days if the Member, P4HB Participant or the Provider requests an extension, or if the Contractor justifies to DCH a need for additional information and the extension is in the Member’s or P4HB Participant’s interest.
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4.11.2.5.3
|
Authorization for services that have been delivered. Determinations for authorization involving health care services that have been delivered shall be made within thirty (30) Calendar Days of receipt of the necessary information.
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4.11.2.6
|
The Contractor’s policies and procedures for authorization shall include consulting with the requesting Provider when appropriate.
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4.11.3
|
Referral Requirements and P4HB Participants
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4.11.3.1
|
The Contractor may require that Members obtain a Referral from their PCP prior to accessing non-emergency specialized services.
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4.11.3.2
|
In the Utilization Management Policies and Procedures discussed in Section 4.11.1.1, the Contractor shall address:
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·
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When a Referral from the Member’s PCP is required;
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·
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How a Member obtains a Referral to an In-Network Provider or an Out-of-Network Provider when there is no Provider within the Contractor’s network that has the appropriate training or expertise to meet the particular health needs of the Member;
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·
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How a Member with a Condition which requires on-going care from a specialist may request a standing Referral; and
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·
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How a Member with a life-threatening Condition or disease, which requires specialized medical care over a prolonged period of time, may request and obtain access to a specialty care center.
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4.11.3.3
|
The Contractor shall prohibit Providers from making Referrals for designated health services to Health Care entities with which the Provider or a Member of the Provider’s family has a Financial Relationship.
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4.11.3.4
|
DCH strongly encourages the Contractor to develop electronic, web-based Referral processes and systems. In the event a Referral is made via the telephone, the Contractor shall ensure that the Contractor, the Provider and DCH maintain Referral data, including the final decision, in a data file that can be accessed electronically.
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4.11.3.5
|
In conjunction with the other Utilization Management policies, the Contractor shall submit the Referral processes to DCH for review and approval.
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4.11.4.1
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Contractors shall identify and facilitate transitions for Members that are moving from one CMO to another or from a CMO to a fee-for service provider and require additional or distinctive assistance during a period of transition. When relinquishing Members, the Contractor shall cooperate with the receiving CMO plan or FFS Medicaid regarding the course of on-going care with a specialist or other Provider. Priority will be given to members who have medical conditions or circumstances such as:
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·
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Members who are currently hospitalized.
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·
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Pregnancy; women who are high risk and in third trimester, or are within 30 days of their anticipated delivery date
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Major organ or tissue transplantation services which are in process, or have been authorized
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·
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Chronic illness, which has placed the member in a high-risk category and/or resulted in hospitalization or placement in nursing, or other, facilities, and/or
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·
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Members who are in treatment such as Chemotherapy, radiation therapy, or Dialysis.
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·
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Members with ongoing needs such as Specialized Durable medical equipment including ventilators and other respiratory assistance equipment
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·
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Current Home health services
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·
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Medically necessary transportation on a scheduled basis and
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·
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Prescription medications requiring prior authorizations
|
·
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The Contractor will monitor Providers to ensure transition of care from one entity to another to include discharge planning as appropriate. Procedures that are scheduled to occur after their new CMO effective date, but that have been authorized by either DCH or the patients original CMO prior to their new CMO effective date will be covered by the patients new CMO for 30 days.
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·
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Members that are in ongoing outpatient treatment or that are receiving medication that has been covered by DCH or another CMO prior to their new CMO effective date will be covered by the new CMO for at least 30 days to allow time for clinical review, and if necessary transition of care. The CMO will not be obligated to cover services beyond 30 days, even if the DCH authorization was for a period greater than 30 days.
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4.11.4.1.1
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The Contractor shall identify and facilitate transitions for P4HB Participants that are moving from one CMO to another and require additional or distinctive assistance during the period of transition. When relinquishing P4HB Participants, the Contractor shall cooperate with the receiving CMO plan regarding the course of ongoing care.
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4.11.4.1.2
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The Contractor will monitor Providers to ensure transition of care from one entity to another. Demonstration related procedures that are scheduled to occur after a P4HB Participant’s new CMO effective date, but that were authorized by the P4HB Participant’s original CMO prior to her new CMO effective date will be covered by the P4HB Participant’s new CMO for thirty (30) days.
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4.11.4.1.3
|
P4HB Participants that are in ongoing Demonstration related outpatient treatment or that are receiving Demonstration related medication that has been covered by another CMO prior to their new CMO effective date will be covered by the new CMO for at least thirty (30) days to allow time for clinical review, and if necessary, transition of care. If it is determined the P4HB Participant is still in need of those treatments and/or medications, the CMO will be obligated to cover those Demonstration related Services beyond thirty (30) days.
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4.11.4.2
|
Inpatient Acute Coverage Responsibility
|
|
4.11.4.2.1
|
Members enrolled in a CMO that are hospitalized in an acute inpatient hospital facility will remain the responsibility of that CMO until they are discharged from the facility, even if they change to a different CMO, or they become eligible for coverage under FFS Medicaid during their inpatient stay. The CMO is not required to cover services for a member that has no Medicaid benefits, if the member remains an acute inpatient and loses Medicaid eligibility during the stay; the CMO is only responsible for payment until the last day of Medicaid eligibility.
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4.11.4.2.1.1
|
Inpatient care for newborns born on or after their mother’s effective date will be the responsibility of the mother’s assigned CMO.
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4.11.4.2.1.2
|
Members that become eligible and enrolled in any retro-active program (such as SSI) after the date of an inpatient hospitalization shall remain the responsibility of the CMO until they are discharged from inpatient acute hospital care. These members will remain the responsibility of the CMO for all covered services, even if the start date for SSI eligibility is made retroactive to a date prior to the inpatient acute hospitalization.
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4.11.4.2.1.3
|
The admitting CMO will continue to receive capitation payment for every month that the member continues to be hospitalized and enrolled in a CMO and will be responsible for all medical claims during the period that they are receiving capitation. At discharge, and upon notice of such discharge, DCH will reassign the member to FFS or the new CMO following the normal monthly process.
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4.11.4.2.1.4
|
Upon notification that a hospitalized member will be transitioning to a new CMO, or to FFS Medicaid, the current CMO will work with the new CMO or FFS Medicaid to ensure that coordination of care and appropriate discharge planning occurs.
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4.11.4.2.1.5
|
When relinquishing Members, the Contractor shall cooperate with the receiving CMO plan regarding the course of on-going care with a specialist or other Provider.
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4.11.4.2.1.6
|
Contractors must identify and facilitate coordination of care for all Georgia Families members during changes or transitions between Contractors, as well as transitions to FFS Medicaid. Members with special circumstances (such as those listed below) may require additional or distinctive assistance during a period of transition. Policies or protocols must be developed to address these situations. Special circumstances include members designated as having “special health care needs”, as well as members who have medical conditions or circumstances such as:
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·
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Pregnancy (especially women who are high risk and in third trimester, or are within 30 days of their anticipated delivery date)
|
·
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Major organ or tissue transplantation services which are in process, or have been authorized
|
·
|
Chronic illness, which has placed the member in a high-risk category and/or resulted in hospitalization or placement in nursing, or other, facilities, and/or
|
·
|
Significant medical conditions, (e.g., diabetes, hypertension, pain control or orthopedics) that require ongoing care of specialist appointments.
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·
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Members who are in treatment such as:
|
o
|
Chemotherapy and/or radiation therapy, or
|
o
|
Dialysis.
|
·
|
Members with ongoing needs such as:
|
o
|
Durable medical equipment including ventilators and other respiratory assistance equipment
|
o
|
Home health services
|
o
|
Medically necessary transportation on a scheduled basis
|
o
|
Prescription medications, and/or
|
·
|
Other services not indicated in the State Plan, but covered by Title XIX for Early and Periodic Screening, Diagnosis and Treatment eligible members.
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·
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Members who are currently hospitalized.
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4.11.4.2.1.7
|
A P4HB Participant that is hospitalized in an acute inpatient hospital facility will remain the responsibility of that P4HB Participant’s original CMO until she is discharged from the facility, even if she changes to a different CMO or becomes eligible for other coverage during her inpatient stay. The CMO is not required to cover Demonstration related Services for a P4HB Participant that has no Demonstration benefits. If the P4HB Participant remains an acute inpatient and loses Demonstration eligibility during the stay, the CMO is only responsible for payment until the last day of Demonstration eligibility.
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4.11.4.3.1
|
Members enrolled in a CMO that are receiving services in a long-term care facility will remain the responsibility of the admitting CMO until disenrolled from the CMO by DCH.
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4.11.4.3.2
|
For the purposes of this requirement, long-term care facilities include Nursing Homes, Skilled Nursing Facilities, Psychiatric Residential Treatment Facilities and other facilities that provide long-term non-acute care.
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4.11.4.3.3
|
Upon disenrollment from the CMO, the financial responsibility for services provided to the member transitions to the member’s new CMO or FFS.
|
4.11.4.3.4
|
Members that are in ongoing non acute treatment in an inpatient facility that has been covered by DCH or another CMO prior to their new CMO effective date will be covered by the new CMO for at least 30 days to allow time for clinical review, and if necessary transition of care. The CMO will not be obligated to cover services beyond 30 days, even if the DCH authorization was for a period greater than 30 days.
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4.11.4.4.1
|
The Contractor shall maintain and operate a formalized discharge-planning program that includes a comprehensive evaluation of the Member’s health needs and identification of the services and supplies required to facilitate appropriate care following discharge from an institutional clinical setting.
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4.11.5.1
|
Effective January 01, 2009, DCH will permit transfers from a higher level of care, back to a lower level (referred to as a back transfer). The transfer is subject to medical necessity review and the payment policies outlined in the contract with the payer.
|
|
4.11.5.2
|
Each request will be reviewed on an individual basis to determine if the transfer is appropriate. The length of stay for the transferring hospital and for the return to the originating hospital will also be evaluated to determine if the transfer is appropriate.
|
|
4.11.5.3
|
If a transfer back to a hospital provides a lower level of care does occur, the facility receiving the back-transfer will be eligible for reimbursement if prior authorization is obtained from the applicable payer and according to the payment agreement of that payer.
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4.11.5.4
|
That hospital Providers fully understand this policy; each CMO will document provider education bulletins that will outline their CMO “back transfer” pre certification requirements along with the billing procedures.
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4.11.5.5
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It is the responsibility of the Contractor to review policy updates that are made periodically made to the Georgia Medicaid Manuals.
|
|
4.11.6
|
Court-Ordered Evaluations and Services
|
|
In the event a Member requires Medicaid-covered services ordered by a State or federal court, the Contractor shall fully comply with all court orders while maintaining appropriate Utilization Management practices.
|
|
4.11.7
|
Second Opinions
|
|
4.11.7.1
|
The Contractor shall provide for a second opinion in any situation when there is a question concerning a diagnosis or the options for surgery or other treatment of a health Condition when requested by any Member of the Health Care team, a Member, parent(s) and/or guardian (s), or a social worker exercising a custodial responsibility.
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|
4.11.7.2
|
The second opinion must be provided by a qualified Health Care Professional within the network, or the Contractor shall arrange for the Member to obtain one outside the Provider network.
|
|
4.11.7.3
|
The second opinion shall be provided at no cost to the Member.
|
|
4.11.8.1
|
The Contractor is responsible for care coordination – a set of member-centered, goal-oriented, culturally relevant and logical steps to assure that a member receives needed services in a supportive, effective, efficient, timely and cost-effective manner. Care Coordination includes Case Management, Disease Management, Transition of Care and Discharge Planning.
|
4.11.8.2
|
The Contractor shall develop and implement a Care Coordination system to ensure and promote:
|
·
|
Timely access and delivery of Health Care and services required by Members;
|
·
|
Continuity of Members’ care; and
|
·
|
Coordination and integration of Members’ care.
|
|
4.11.8.3
|
Policies and procedures are designed to accommodate the specific cultural and linguistic needs of the Contractor’s Members and include, at a minimum, the following elements:
|
·
|
The provision of an individual needs assessment and diagnostic assessment; the development of an individual treatment plan, as necessary, based on the needs assessment; the establishment of treatment objectives; the monitoring of outcomes; and a process to ensure that treatment plans are revised as necessary.
|
·
|
A strategy to ensure that all Members and/or authorized family members or guardians are involved in treatment planning
|
·
|
Procedures and criteria for making Referrals to specialists and sub-specialists;
|
·
|
Procedures and criteria for maintaining care plans and Referral Services when the Member changes PCPs; and
|
·
|
Capacity to implement, when indicated, case management functions such as individual needs assessment, including establishing treatment objectives, treatment follow-up, monitoring of outcomes, or revision of treatment plan.
|
|
4.11.8.4
|
The Contractor shall submit the Care Coordination Policies and Procedures to DCH for review and approval within ninety (90) Calendar Days of Contract Award and as updated thereafter.
|
|
4.11.9.1
|
The Contractor’s Case Management system shall emphasize prevention, continuity of care, and coordination of care. The system will advocate for, and link Members to, services.
|
|
4.11.9.1.1
|
The Contractor’s Case Management system shall emphasize prevention, continuity of care, and coordination of care for P4HB Participants in the IPC component of the
|
Demonstration.
|
·
|
Early identification of Members who have or may have special needs;
|
·
|
Assessment of a Member’s risk factors;
|
·
|
Development of a plan of care;
|
·
|
Referrals and assistance to ensure timely access to Providers;
|
·
|
Coordination of care actively linking the Member to Providers, medical services, residential, social and other support services where needed;
|
·
|
Monitoring;
|
·
|
Continuity of care;
|
·
|
Follow up and;
|
·
|
Documentation
|
|
4.11.9.2.1
|
Case Management functions for the IPC component of the Demonstration include:
|
·
|
Early identification of P4HB IPC Participants who have or may have special needs;
|
·
|
Assessment of a P4HB IPC Participant’s risk factors;
|
·
|
Development of a plan of care;
|
·
|
Referrals and assistance to ensure timely access to Providers included and external to the Contractor’s network;
|
·
|
Coordination of care actively linking the P4HB IPC Participant to In-Network and out of network Providers, medical services, residential, social and other support services where needed;
|
·
|
Resource Mothers Outreach
|
·
|
Monitoring;
|
·
|
Continuity of care;
|
·
|
Follow up; and
|
·
|
Documentation
|
|
4.11.9.2.2
|
Details pertaining to Resource Mothers Outreach are incorporated n Attachment P to this Contract. The Contractor must utilize the Resource Mothers Training Manual specified by DCH as the training manual for the Resource Mothers Outreach.
|
|
4.11.9.2.3
|
The Contractor must monitor the effectiveness of the Resource Mothers Outreach and ensure such Outreach activities comply with the Resource Mothers Training Manual.
|
|
4.11.9.3
|
The Contractor shall be responsible for the Case Management of their Members and shall make special effort to identify Members who have the greatest need for Case Management, including those who have catastrophic or other high-cost or high-risk Conditions including pregnant women under 21, high risk pregnancies and infants and toddlers with established risk for developmental delays.
|
|
4.11.9.4
|
The Contractor will submit quarterly reports to DCH which include specified Case Management Program data as described in Section 4.18.4.12.
|
4.11.10
|
Disease Management
|
|
4.11.10.1
|
The Contractor shall develop disease management programs for individuals with Chronic Conditions. These programs must target the prevalent chronic diseases within the Contractor’s population.
|
4.11.10.2
|
The Contractor must notify DCH of the disease management programs it initiates and terminates and provide evidence, on an annual basis of the effectiveness of such programs for its enrolled members.
|
|
4.11.10.3
|
The Contractor must submit Quarterly status reports to DCH which include specified Disease Management Program data as described in Section 4.18.4.13 in addition to the annual report.
|
|
4.11.10.4
|
The Contractor will submit Quarterly reports to DCH which include specified Disease Management Program data as described in Section 4.18.4.13.
|
4.11.11
|
Discharge Planning
|
|
4.11.11.1
|
The Contractor shall maintain and operate a formalized discharge-planning program that includes a comprehensive evaluation of the Member’s health needs and identification of the services and supplies required to facilitate appropriate care following discharge from an institutional clinical setting.
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|
4.11.12
|
Reporting Requirements
|
|
4.11.12.1
|
The Contractor shall submit to DCH quarterly Case Management and Disease Management Reports as described in 4.18.4.12 and 4.18.4.13.
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4.11.12.2
|
The Contractor shall submit to DCH quarterly Prior Authorization and Pre-Certification Reports as described in Section 4.18.4.9.
|
|
4.11.12.3
|
The Contractor shall submit to DCH all reports as outlined in the Demonstration Quality Strategy identified in Attachment O of this Contract.
|
4.12
|
QUALITY IMPROVEMENT
|
4.12.1
|
General Provisions
|
4.12.1.1
|
The Contractor shall provide for the delivery of Quality care with the primary goal of improving the health status of Members and, where the Member’s Condition is not amenable to improvement, maintain the Member’s current health status by implementing measures to prevent any further decline in Condition or deterioration of health status. This shall include the identification of Members at risk of developing Conditions, the implementation of appropriate interventions and designation of adequate resources to support the intervention(s).
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4.12.1.2
|
The Contractor shall seek input from, and work with, Members, Providers and community resources and agencies to actively improve the Quality of care provided to Members.
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4.12.1.3
|
The Contractor shall establish a multi-disciplinary Quality Oversight Committee to oversee all Quality functions and activities. This committee shall meet at least quarterly, but more often if warranted.
|
|
4.12.2.1
|
The Contractor shall support and comply with Georgia Families Quality Strategic Plan. The Quality Strategic Plan is designed to improve the Quality of Care and Service rendered to GF members (as defined in Title 42 of the Code of Federal Regulations (42 CFR) 431.300 et seq. (Safeguarding Information on Applicants and Recipients); 42 CFR 438.200 et seq. (Quality Assessment and Performance Improvement Including Health Information Systems), and 45 CFR Part 164 (HIPAA Privacy Requirements).
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4.12.2.2
|
The GF Quality Strategic Plan promotes improvement in the quality of care provided to enrolled members through established processes. DCH Managed Care & Quality staff’ oversight of the Contractor includes:
|
·
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Monitoring and evaluating the Contractor’s service delivery system and provider network, as well as its own processes for quality management and performance improvement;
|
·
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Implementing action plans and activities to correct deficiencies and/or increase the quality of care provided to enrolled members,
|
·
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Initiating performance improvement projects to address trends identified through monitoring activities, reviews of complaints and allegations of abuse, provider credentialing and profiling, utilization management reviews, etc.;
|
·
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Monitoring compliance with Federal, State and Georgia Families requirements;
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·
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Ensuring the Contractor’s coordination with State registries;
|
·
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Ensuring Contractor executive and management staff participation in the quality management and performance improvement processes;
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·
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Ensure that the development and implementation of quality management and performance improvement activities include contracted provider participation and information provided by members, their families and guardians, and
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·
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Identifying the Contractor’s best practices for performance and quality improvement.
|
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4.12.3.1
|
The Contractor shall comply with the Georgia Families Quality Management requirements to improve the health outcomes for all Georgia Families members. Improved health outcomes will be documented using established performance measures. Georgia Families uses the Healthcare Effectiveness Data and Information Set (HEDIS) and the Agency for Healthcare Research and Quality (AHRQ) technical specifications for some of the quality and health improvement performance measures.
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|
4.12.3.2
|
Several of the HEDIS measures utilize hybrid methodology, that is, they require a medical record review in addition to the administrative data requirement for measurement reporting. The number of required record reviews is determined by the specifications for each HEDIS measure.
|
|
4.12.3.3
|
While the Contractor must meet the Georgia Families Performance Measure Targets for each measure, it is equally important that the Contractor continually improve health outcomes from year to year. The Contractor shall strive to meet the performance measure targets established by Georgia Families. The performance measure targets for each performance measure are defined in Attachment M. Performance targets for the HEDIS measures are based on national Medicaid Managed Care HEDIS audit means and percentiles as reported by NCQA.
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|
4.12.3.4
|
Georgia Families may also require a CAPA/PC form that addresses the lack of performance measure target achievements and identifies steps that will lead toward improvements. This evidence-based CAPA/PC form must be received by Georgia Families within 30 days of receipt of notification of lack of achievement of performance targets from Georgia Families. The CAPA/PC form must be approved by Georgia Families prior to implementation. Georgia Families may conduct follow up on-site reviews to verify compliance with a CAPA/PC form. Georgia Families may impose Category 3 Liquidated Damages on Contractors who do not meet the performance measure targets for any one performance measure.
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|
4.12.3.5
|
The performance measures apply to the member populations as specified by the measures’ technical specifications. Contractor performance is evaluated annually on the reported rate for each measure. Performance Measures, benchmarks, and/or specifications may change annually to comply with industry standards and updates.
|
|
4.12.3.6
|
Each contractor must validate each performance measure and submit to DCH no later than June 30 of each year.
|
REPORT
|
DUE DATE
|
REPORTS DIRECTED TO:
|
Performance Improvement Project Proposal(s)
|
Annually June 30
|
Georgia Families/ Quality Management Unit
|
Quality Assurance Performance Improvement Plan
|
Annually June 30
|
Georgia Families/ Quality Management Unit
|
Quality Assessment Performance Improvement Program Evaluation
|
Annually June 30
|
Georgia Families/ Quality Management Unit
|
Performance Improvement Project Baseline Report
|
Annually June 30
|
Georgia Families/ Quality Management Unit
|
Performance Improvement Project Final Evaluation Report (including any new QM/PI activities implemented as a result of the project)
|
Annually June 30
|
Georgia Families/ Quality Management Unit
|
Corrective Action Preventive Action Plan/Performance Concerns for deficiencies noted in:
1. An Operations Field Review
2. A Focused Review
3. QM/PI Plan
4. Performance related to Quality Measures
|
30 days after receipt of notice to submit a Corrective Action Preventive Action Plan (CAPA) unless otherwise stated.
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Georgia Families/ Quality Management Unit
|
Performance Measures Report
|
Annually June 30
|
Georgia Families/ Quality Management Unit
|
4.12.5
|
Quality Assessment Performance Improvement (QAPI) Program
|
|
4.12.5.1
|
The Contractor shall have in place an ongoing QAPI program consistent with 42 CFR 438.240.
|
4.12.5.2
|
The Contractor’s QAPI program shall be based on the latest available research in the area of Quality assurance and at a minimum must include:
|
·
|
A method of monitoring, analysis, evaluation and improvement of the delivery, Quality and appropriateness of Health Care furnished to all Members (including under and over Utilization of services), including those with special Health Care needs;
|
·
|
Written policies and procedures for Quality assessment, Utilization Management and continuous Quality improvement that are periodically assessed for efficacy;
|
·
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A health information system sufficient to support the collection, integration, tracking, analysis and reporting of data;
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·
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Designated staff with expertise in Quality assessment, Utilization Management and continuous Quality improvement;
|
·
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Reports that are evaluated, indicated recommendations that are implemented, and feedback provided to Providers and Members;
|
·
|
A methodology and process for conducting and maintaining Provider profiling;
|
·
|
Ad-Hoc Reports to the Contractor’s multi-disciplinary Quality oversight committee and DCH on results, conclusions, recommendations and implemented system changes;
|
·
|
Annual performance improvement projects (PIPs) that focus on clinical and non-clinical areas; and
|
·
|
Annual Reports on performance improvement projects and a process for evaluation of the impact and assessment of the Contractor’s QAPI program.
|
|
4.12.5.3
|
The Contractor’s QAPI Program Plan must be submitted to DCH for review and approval as updated.
|
|
4.12.5.4
|
The Contractor shall submit any changes to its QAPI Program Plan to DCH for review and prior approval sixty (60) Calendar Days prior to implementation of the change.
|
|
4.12.5.5
|
Upon the request of DCH, the Contractor shall provide any information and documents related to the implementation of the QAPI program.
|
4.12.6
|
Performance Improvement Projects
|
|
4.12.6.1
|
As part of its QAPI program, the Contractor shall conduct clinical and non-clinical performance improvement projects in accordance with DCH and federal protocols. In designing its performance improvement projects, the Contractor shall:
|
·
|
Show that the selected area of study is based on a demonstration of need and is expected to achieve measurable benefit to the Member (rationale);
|
·
|
Establish clear, defined and measurable goals and objectives that the Contractor shall achieve in each year of the project;
|
·
|
Measure performance using Quality indicators that are objective, measurable, clearly defined and that allow tracking of performance and improvement over time;
|
·
|
Implement interventions designed to achieve Quality improvements;
|
·
|
Evaluate the effectiveness of the interventions;
|
·
|
Establish standardized performance measures (such as HEDIS or another similarly standardized product);
|
·
|
Plan and initiate activities for increasing or sustaining improvement; and
|
·
|
Document the data collection methodology used (including sources) and steps taken to assure data is valid and reliable.
|
|
4.12.6.2
|
Each performance improvement project must be completed in a period determined by DCH, to allow information on the success of the project in the aggregate to produce new information on Quality of care each year.
|
|
4.12.6.3 The Contractor shall perform the following required performance improvement projects, as agreed upon by the Parties (see Section 4.12.6.5), beginning January 1, 2012, ongoing for the duration of the GF Contract period:
|
·
|
Well-child visits;
|
·
|
ADHD Medication follow up;
|
·
|
Immunization rates;
|
·
|
Dental-children
|
·
|
Obesity-children
|
·
|
Comprehensive Diabetes Care;
|
·
|
Avoidable Emergency room utilization;
|
·
|
Member satisfaction, and
|
·
|
Provider satisfaction
|
|
4.12.6.5
|
Each PIP will use the study question and study indicators agreed upon by DCH and the CMOs.
|
|
4.12.6.6
|
Each CMO will submit the designated PIPs to DCH and/or the EQRO using the DCH specified template and format by June 30 of each contract year with the exception of the member satisfaction PIP which is due by August 1.
|
|
4.12.6.7
|
The EQRO will evaluate the CMOs’ PIP performance on an annual basis. DCH reserves the right to request modification of the PIPs based on this evaluation. Modifications will be discussed with each CMO prior to implementation.
|
4.12.7
|
Practice Guidelines
|
|
4.12.7.1
|
The Contractor shall adopt a minimum of three (3) evidence-based clinical practice guidelines. Such guidelines shall:
|
·
|
Be based on the health needs and opportunities for improvement identified as part of the QAPI program;
|
·
|
Be based on valid and reliable clinical evidence or a consensus of Health Care Professionals in the particular field;
|
·
|
Consider the needs of the Members;
|
·
|
Be adopted in consultation with network Providers; and
|
·
|
Be reviewed and updated periodically as appropriate.
|
|
4.12.7.2
|
The Contractor shall submit all Practice Guidelines in use, which shall include a methodology for measuring and assessing compliance, to DCH for review and prior approval as part of the QAPI program plan as updated.
|
|
4.12.7.3
|
The Contractor shall disseminate the guidelines to all affected Providers and, upon request, to Members.
|
|
4.12.7.4
|
The Contractor shall ensure that decisions for Utilization Management, Member education, coverage of services, and other areas to which the guidelines apply are consistent with the guidelines.
|
|
4.12.7.5
|
In order to ensure consistent application of the guidelines the Contractor shall encourage Providers to utilize the guidelines, and shall measure compliance with the guidelines, until ninety percent (90%) or more of the Providers are consistently in compliance. The Contractor may use Provider incentive strategies to improve Provider compliance with guidelines.
|
|
4.12.8.1
|
Focus Studies examine a specific aspect of health care (such as prenatal care) for a defined point in time. These studies are usually based on information extracted from medical records or Contractor administrative data such as enrollment files and encounter/claims data. Steps that may be taken by the Contractor when conducting focus studies are:
|
·
|
Selecting the Study Topic(s)
|
·
|
Defining the Study Question(s)
|
·
|
Selecting the Study Indicator(s)
|
·
|
Identifying a representative and generalizable study population
|
·
|
Documenting sound sampling techniques utilized (if applicable)
|
·
|
Collecting reliable data
|
·
|
Analyzing data and interpreting study results
|
|
4.12.8.2
|
The Contractor may perform, at DCH discretion, a Focused Study to examine a specific aspect of health care (such as prenatal care) for a defined point in time. The Focused Study will have a calendar year study period and the results will be reported to DCH by June 30th following the year of the study.
|
4.12.9
|
Patient Safety Plan
|
|
4.12.9.1
|
The Contractor shall have a structured Patient Safety Plan to address concerns or complaints regarding clinical care. This plan must include written policies and procedures for processing of Member complaints regarding the care they received. Such policies and procedures shall include:
|
·
|
A system of classifying complaints according to severity;
|
·
|
A review by the Medical Director and a mechanism for determining which incidents will be forwarded to Peer Review and Credentials Committees; and
|
·
|
A summary of incident(s), including the final disposition, included in the Provider profile.
|
|
4.12.9.2
|
The Contractor shall submit the Patient Safety Plan to DCH for review and approval as updated.
|
|
4.12.11
|
External Quality Review
|
|
DCH will contract with an External Quality Review Organization (EQRO) to conduct annual, external, independent reviews of the Quality outcomes, timeliness of, and access to, the services covered in this Contract. The Contractor shall collaborate with DCH’s EQRO to develop studies, surveys and other analytic activities to assess the Quality of care and services provided to Members and to identify opportunities for CMO plan improvement. To facilitate this process the Contractor shall supply data, including but not limited to Claims data and Medical Records, to the EQRO.
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4.12.12
|
Reporting Requirements
|
|
4.12.12.1
|
The Contractor’s Quality Oversight Committee shall submit to DCH Quality Oversight Committee Reports - Ad Hoc as described in Section 4.12.5.2
|
|
4.12.12.2
|
The Contractor shall submit to DCH Performance Improvement Project Reports no later than June 30 of the contract year as described in Section 4.12.6.
|
|
4.12.12.3
|
The Contractor shall submit to DCH annual Focused Studies Reports no later than June 30 of the contract year as described in Section 4.12.8.
|
|
4.12.12.4
|
The Contractor shall submit to DCH annual Patient Safety Plan Reports no later than June 30 of the contract year as described in Section 4.12.9.
|
4.13
|
FRAUD AND ABUSE
|
4.13.1
|
Program Integrity
|
|
4.13.1.1
|
The Contractor shall have a Program Integrity Program, including a mandatory compliance plan, designed to guard against Fraud and Abuse. This Program Integrity Program shall include policies, procedures, and standards of conduct for the prevention, detection, reporting, and corrective action for suspected cases of Fraud and Abuse in the administration and delivery of services under this Contract.
|
|
4.13.1.2
|
The Contractor shall submit its Program Integrity Policies and Procedures, which include the compliance plan and pharmacy lock-in program described below, to DCH for approval as updated.
|
4.13.2
|
Compliance Plan
|
|
4.13.2.1
|
The Contractor’s compliance plan shall include, at a minimum, the following:
|
·
|
The designation of a Compliance Officer who is accountable to the Contractor’s senior management and is responsible for ensuring that policies to establish effective lines of communication between the Compliance Officer and the Contractor’s staff, and between the Compliance Officer and DCH staff, are followed;
|
·
|
Provision for internal monitoring and auditing of reported Fraud and Abuse violations, including specific methodologies for such monitoring and auditing;
|
·
|
Policies to ensure that all officers, directors, managers and employees know and understand the provisions of the Contractor’s Fraud and Abuse compliance plan;
|
·
|
Policies to establish a compliance committee that periodically meets and reviews Fraud and Abuse compliance issues;
|
·
|
Policies to ensure that any individual who reports CMO plan violations or suspected Fraud and Abuse will not be retaliated against;
|
·
|
Policies of enforcement of standards through well-publicized disciplinary standards;
|
·
|
Provision of a data system, resources and staff to perform the Fraud and Abuse and other compliance responsibilities;
|
·
|
Procedures for the detection of Fraud and Abuse that includes, at a minimum, the following:
|
o
|
Claims edits
|
o
|
Post-processing review of Claims;
|
o
|
Provider profiling and Credentialing;
|
o
|
Quality Control; and
|
o
|
Utilization Management.
|
·
|
Written standards for organizational conduct;
|
·
|
Effective training and education for the Compliance Officer and the organization’s employees, management, board Members, and Subcontractors;
|
·
|
Inclusion of information about Fraud and Abuse identification and reporting in Provider and Member materials;
|
·
|
Provisions for the investigation, corrective action and follow-up of any suspected Fraud and Abuse reports; and
|
·
|
Procedures for reporting suspected Fraud and Abuse cases to the State Program Integrity Unit, including timelines and use of State approved forms.
|
|
4.13.2.2
|
As part of the Program Integrity Program, the Contractor shall implement a pharmacy lock-in program. The policies, procedures and criteria for establishing a lock-in program shall be submitted to DCH for review and approval as part of the Program Integrity Policies and Procedures discussed in Section 4.13.1. The pharmacy lock-in program shall:
|
·
|
Allow Members to change pharmacies for good cause, as determined by the Contractor after discussion with the Provider(s) and the pharmacist. Valid reasons for change should include recipient relocation or the pharmacy does not provide the prescribed drug;
|
·
|
Provide Case management and education reinforcement of appropriate medication use;
|
·
|
Annually assess the need for lock-in for each Member; and
|
·
|
Require that the Contractor’s Compliance Officer report on the program on a monthly basis to DCH.
|
·
|
A member will not be allowed to transfer to another pharmacy, PCP, or CMO while enrolled in their existing CMO’s pharmacy lock-in program.
|
4.13.3
|
Coordination with DCH and Other Agencies
|
|
4.13.3.1
|
The Contractor shall cooperate and assist any State or federal agency charged with the duty of identifying, investigating, or prosecuting suspected Fraud and Abuse cases, including permitting access to the Contractor’s place of business during normal business hours, providing requested information, permitting access to personnel, financial and Medical Records, and providing internal reports of investigative, corrective and legal actions taken relative to the suspected case of Fraud and Abuse.
|
4.13.3.2
|
The Contractor’s Compliance Officer shall work closely, including attending quarterly meetings, with DCH’s program integrity staff to ensure that the activities of one entity do not interfere with an ongoing investigation being conducted by the other entity.
|
|
4.13.3.3
|
The Contractor shall inform DCH immediately about known or suspected cases and it shall not investigate or resolve the suspicion without making DCH aware of, and if appropriate involved in, the investigation, as determined by DCH.
|
4.13.4
|
Reporting Requirements
|
|
4.13.4.1 The Contractor shall submit to DCH a monthly Fraud and Abuse Report, as described in Section 4.18.3.5. This Report shall include information on the pharmacy lock-in program described in Section 4.13.2.2. This report shall also include information on the prohibition of affiliations with individuals debarred and suspended described in Section 31.19.
|
4.14
|
INTERNAL GRIEVANCE/APPEALS SYSTEM
|
4.14.1
|
General Requirements
|
|
4.14.1.1
|
The Contractor’s Grievance System shall include a process to address Grievances. The Contractor’s Appeals Process shall include an Administrative Review process and access to the State’s Administrative Law Hearing (State Fair Hearing) system. The Contractor’s Appeals Process shall include an internal process that must be exhausted by the Member or P4HB Participant prior to accessing an Administrative Law Hearing.
|
|
4.14.1.2
|
The Contractor shall develop written Grievance System and Appeals Process Policies and Procedures that detail the operation of the Grievance System and the Appeals Process. The Contractor’s policies and procedures shall be available in the Member’s and P4HB Participants primary language. The Grievance System and Appeals Process Policies and Procedures shall be submitted to DCH for review and approval as updated.
|
|
4.14.1.3
|
The Contractor shall process each Grievance and Administrative Review using applicable State and federal statutory, regulatory, and GF Contractual provisions, and the Contractor’s written policies and procedures. Pertinent facts from all parties must be collected during the investigation.
|
4.14.1.4
|
The Contractor shall give Members and P4HB Participants any reasonable assistance in completing forms and taking other procedural steps for both Grievances and Administrative Reviews. This includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTD and interpreter capability.
|
4.14.1.5
|
The Contractor shall acknowledge receipt of each filed Grievance and Administrative Review in writing within ten (10) Business Days of receipt. The Contractor shall have procedures in place to notify all Members and P4HB Participant in their primary language of Grievance and Appeal resolutions.
|
|
4.14.1.6
|
The Contractor shall ensure that the individuals who make decisions on Grievances and Administrative Reviews were not involved in any previous level of review or decision-making; and are Health Care Professionals who have the appropriate clinical expertise, as determined by DCH, in treating the Member’s and P4HB Participants Condition or disease if deciding any of the following:
|
·
|
An Appeal of a denial that is based on lack of Medical Necessity;
|
·
|
A Grievance regarding denial of expedited resolutions of an Administrative Review; and
|
·
|
Any Grievance or Administrative Review that involves clinical issues.
|
|
4.14.1.7.1
|
If the decision of the CMO review maintains the denial of service, a letter will be sent to the parent detailing the reason for denial. If the parent elects to dispute the decision, the parent will have the option of having the decision reviewed by the Formal Appeals Committee. The request should be sent to:
|
|
4.14.1.7.2
|
The decision of the Formal Grievance Committee will be the final recourse available to the member. In reference to the Formal Grievance level, the State assures:
|
·
|
Enrollees receive timely written notice of any documentation that includes the reasons for the determination, an explanation of applicable rights to review, 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.
|
·
|
Enrollees have the opportunity for an independent, external review of a delay, denial, reduction, suspension, termination of health services, failure to approve, or provide payment for health services in a timely manner. The independent review is available at the Formal Grievance level.
|
·
|
Decisions are written when reviewed by DCH and the Formal Grievance Committee.
|
·
|
Enrollees have the opportunity to represent themselves or have representatives in the process at the Formal Grievance level.
|
·
|
Enrollees have the opportunity to timely review their files and other applicable information relevant to the review of the decision. While this is assured at each level of review, members will be notified of the timeframes for the appeals process once an appeal is file with the Formal Grievance Committee.
|
·
|
Enrollees have the opportunity to fully participate in the review process, whether the review is conducted in person or in writing.
|
·
|
Reviews that are not expedited due to an enrollee’s medical condition will be completed within 90 calendar days of the date of a request is made.
|
·
|
Reviews that are expedited due to an enrollee’s medical condition shall be completed within 72 hours of the receipt of the request.
|
4.14.2
|
Grievance Process
|
4.14.2.1
|
A Member, Member’s Authorized Representative, or P4HB Member may file a Grievance to the Contractor either orally or in writing. A Grievance may be filed about any matter other than a Proposed Action. A Provider cannot file a Grievance on behalf of a Member or P4HB Member.
|
4.14.2.2
|
The Contractor shall ensure that the individuals who make decisions on Grievances that involve clinical issues are Health Care Professionals who have the appropriate clinical expertise, as determined by DCH, in treating the Member or P4HB Member’s Condition or disease and who were not involved in any previous level of review or decision-making.
|
4.14.2.3
|
The Contractor shall provide written notice of the disposition of the Grievance as expeditiously as the Member or P4HB Member’s health Condition requires but must be completed within ninety (90) days but shall not exceed ninety (90) Calendar Days of the filing date.
|
4.14.3
|
Proposed Action
|
|
4.14.3.1
|
All Proposed Actions shall be made by a physician, or other peer review consultant, who has appropriate clinical expertise in treating the Member or P4HB Member’s Condition or disease.
|
4.14.3.2
|
In the event of a Proposed Action, the Contractor shall notify the Member or P4HB Member in writing. The Contractor shall also provide written notice of a Proposed Action to the Provider. This notice must meet the language and format requirements in accordance with Section 4.3.2 of this Contract and be sent in accordance with the timeframes described in Section 4.14.3.4.
|
4.14.3.3
|
The notice of Proposed Action must contain the following:
|
·
|
The Action the Contractor has taken or intends to take, including the service or procedure that is subject to the Action.
|
·
|
Additional information, if any, that could alter the decision.
|
·
|
The specific reason used as the basis of the action.
|
·
|
The reasons for the Action must have a factual basis and legal/policy basis.
|
·
|
The Member or P4HB Member’s right to file an Administrative Review through the Contractor’s internal Grievance System as described in Section 4.14.
|
·
|
The Provider’s right to file a Provider Complaint as described in Section 4.9.7;
|
·
|
The requirement that a Member or P4HB Member exhaust the contractor’s internal Administrative Review Process;
|
·
|
The circumstances under which expedited review is available and how to request it; and
|
·
|
The Member or P4HB Member’s right to have Benefits continue pending resolution of the Administrative Review with the Contractor, Member or P4HB Member instructions on how to request that Benefits be continued, and the circumstances under which the Member or P4HB Member may be required to pay the costs of these services.
|
|
4.14.3.4
|
The Contractor shall mail the Notice of Proposed Action within the following timeframes:
|
4.14.3.4.1
|
For termination, suspension, or reduction of previously authorized Covered Services at least ten (10) Calendar Days before the date of Proposed Action or not later than the date of Proposed Action in the event of one of the following exceptions:
|
·
|
The Contractor has factual information confirming the death of a Member or P4HB Member.
|
·
|
The Contractor receives a clear written statement signed by the Member or P4HB Member that he or she no longer wishes services or gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information.
|
·
|
The post office returns Contractor mail directed to the Member or P4HB Member indicating no forwarding address and the Member’s whereabouts are unknown and (refer to 42 CFR 431.231(d) for procedures if the Member or P4HB Member’s whereabouts become known).
|
·
|
The Member or P4HB Member’s Provider prescribes an immediate change in the level of medical care.
|
4.14.3.4.2
|
The date of action will occur in less than ten (days), in accordance with 42 C.F.R. §483.12(a) (5) (ii), which provides exceptions to the 30 days’ notice requirements of 42 C.F.R. § 483.12(a) (5) (i).
|
4.14.3.4.3
|
The Contractor may shorten the period of advance notice to five (5) Calendar Days before date of action if the Contractor has facts indicating that action should be taken because of probable Member or P4HB Member Fraud and the facts have been verified, if possible, through secondary sources.
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4.14.3.4.5
|
For denial of payment, at the time of any Proposed Action affecting the Claim.
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4.14.3.4.6
|
For standard Service Authorization decisions that deny or limit services, within the timeframes required in Section 4.11.2.5.1.
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4.14.3.4.7
|
If the Contractor extends the timeframe for the decision and issuance of notice of Proposed Action according to Section 4.11.2.5, the Contractor shall give the Member or P4HB Member written notice of the reasons for the decision to extend the timeframe and inform the enrollee of the right to file a Grievance if he or she disagrees with that decision. The Contractor shall issue and carry out its determination as expeditiously as the Member or P4HB Member’s health requires and no later than the date the extension expires.
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4.14.3.4.8
|
For authorization decisions not reached within the timeframes required in Section 4.11.2.5 for either standard or expedited Service Authorizations, Notice of Proposed Action shall be mailed on the date the timeframe expires, as this constitutes a denial and is thus a Proposed Action.
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4.14.4
|
Administrative Review Process
|
4.14.4.1
|
An Administrative Review is the request for review of a “Proposed Action”. The Member, the Member’s Authorized Representative, P4HB Member or the Provider acting on behalf of the Member with the Member’s written consent, may file an Administrative Review either orally or in writing. Unless the Member or Provider requests expedited review, the Member, the Member’s Authorized Representative, or the Provider acting on behalf of the Member with the Member’s written consent, must follow an oral filing with a written, signed, request for Administrative Review.
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4.14.4.2
|
The Member, the Member’s Authorized Representative, P4HB Member or the Provider acting on behalf of the Member with the Member’s written consent, may file an Administrative Review with the Contractor within thirty (30) Calendar Days from the date of the notice of Proposed Action.
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4.14.4.3
|
Administrative Reviews shall be filed directly with the Contractor, or its delegated representatives. The Contractor may delegate this authority to an Administrative Review committee, but the delegation must be in writing.
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4.14.4.4
|
The Contractor shall ensure that the individuals who make decisions on Administrative Reviews are individuals who were not involved in any previous level of review or decision-making; and who are Health Care Professionals who have the appropriate clinical expertise in treating the Member’s Condition or disease if deciding any of the following:
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·
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An Administrative Review of a denial that is based on lack of Medical Necessity.
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·
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An Administrative Review that involves clinical issues.
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4.14.4.5
|
The Administrative Review process shall provide the Member, the Member’s Authorized Representative, P4HB Member or the Provider acting on behalf of the Member with the Member’s written consent, a reasonable opportunity to present evidence and allegations of fact or law, in person, as well as in writing. The Contractor shall inform the Member or P4HB Member of the limited time available to provide this in case of expedited review.
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4.14.4.6
|
The Administrative Review process must provide the Member, the Member’s Authorized Representative, P4HB Member or the Provider acting on behalf of the Member with the Member’s written consent, opportunity, before and during the Administrative Review process, to examine the Member or P4HB Member’s case file, including Medical Records, and any other documents and records considered during the Administrative Review process.
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4.14.4.7
|
The Administrative Review process must include as parties to the Administrative Review the Member, the Member’s Authorized Representative, the Provider acting on behalf of the Member with the Member’s written consent, P4HB Member or the legal representative of a deceased Member’s estate.
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4.14.4.8
|
The Contractor shall resolve each Administrative Review and provide written notice of the resolution, as expeditiously as the Member or P4HB Member’s health Condition requires but shall not exceed forty-five (45) Calendar Days from the date the Contractor receives the Administrative Review. For expedited reviews and notice to affected parties, the Contractor has no longer than three (3) working days or as expeditiously as the Member or P4HB Member’s physical or mental health condition requires, whichever is sooner. If the Contractor denies a Member or P4HB Member’s request for expedited review, it must transfer the Administrative Review to the timeframe for standard resolution specified herein and must make reasonable efforts to give the Member or P4HB Member prompt oral notice of the denial, and follow up within two (2) Calendar Days with a written notice. The Contractor shall also make reasonable efforts to provide oral notice for resolution of an expedited review of an Administrative Review.
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4.14.4.9
|
The Contractor may extend the timeframe for standard or expedited resolution of the Administrative Review by up to fourteen (14) Calendar Days if the Member, Member’s Authorized Representative, P4HB Member or the Provider acting on behalf of the Member with the Member’s written consent, requests the extension or the Contractor demonstrates (to the satisfaction of DCH, upon its request) that there is need for additional information and how the delay is in the Member or P4HB Member’s interest. If the Contractor extends the timeframe, it must, for any extension not requested by the Member or P4HB Member, give the Member or P4HB Member written notice of the reason for the delay.
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4.14.5
|
Notice of Adverse Action
|
|
4.14.5.1
|
If the Contractor upholds the Proposed Action in response to an Administrative Review filed by the Member or P4HB Member, the Contractor shall issue a Notice of Adverse Action within the timeframes described in Section 4.14.4.8 and 4.14.4.9.
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4.14.5.2
|
The Notice of Adverse Action shall meet the language and format requirements as specified in 4.3 and include the following:
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·
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The results and date of the Adverse Action including the service or procedure that is subject to the Action.
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·
|
Additional information, if any, that could alter the decision.
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·
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The specific reason used as the basis of the action.
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·
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The right to request a State Administrative Law Hearing within thirty (30) Calendar Days. The time for filing will begin when the filing is date stamped;
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·
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The right to continue to receive Benefits pending a State Administrative Law Hearing;
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·
|
How to request the continuation of Benefits;
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·
|
Information explaining that the Member or P4HB Member may be liable for the cost of any continued Benefits if the Contractor’s action is upheld in a State Administrative Law Hearing.
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·
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Circumstances under which expedited resolution is available and how to request it.
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4.14.6
|
Administrative Law Hearing
|
4.14.6.1
|
The State will maintain an independent Administrative Law Hearing process as defined in O.C.G.A. §49-4-153 and as required by federal law, 42 CFR 431.200. The Administrative Law Hearing process shall provide Members or P4HB Members an opportunity for a hearing before an impartial Administrative Law Judge. The Contractor shall comply with decisions reached as a result of the Administrative Law Hearing process.
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4.14.6.2
|
The Contractor is responsible for providing counsel to represent its interests. DCH is not a party to case and will only provide counsel to represent its own interests.
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4.14.6.3
|
A Member, Member’s Authorized Representative, or P4HB Member may request in writing an Administrative Law Hearing within thirty (30) Calendar Days of the date the Notice of Adverse Action is mailed by the Contractor. The parties to the Administrative Law Hearing shall include the Contractor as well as the Member, Member’s Authorized Representative, P4HB Member or representative of a deceased Member’s estate. A Provider cannot request an Administrative Law Hearing on behalf of a Member or P4HB Member. DCH reserves the right to intervene on behalf of the interest of either party.
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4.14.6.4
|
The hearing request and a copy of the adverse action letter must be received by the Contractor within 30 days or less from the date that the notice of action was mailed.
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4.14.6.5
|
A Member may request a Continuation of Benefits as described in Section 4.14.7 while an Administrative Law Hearing is pending.
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4.14.6.6
|
The Contractor shall make available any records and any witnesses at its own expense in conjunction with a request pursuant to an Administrative Law Hearing.
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4.14.7
|
Continuation of Benefits while the Contractor Appeal and Administrative Law Hearing are Pending
|
|
4.14.7.1
|
As used in this Section, “timely” filing means filing on or before the later of the following:
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·
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Within ten (10) Calendar Days of the Contractor mailing the Notice of Adverse Action.
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·
|
The intended effective date of the Contractor’s Proposed Action.
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|
4.14.7.2
|
The Contractor shall continue the Member or P4HB Member’s Benefits if the Member, P4HB Member or the Member’s Authorized Representative files the Appeal timely; the Appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; the services were ordered by an authorized Provider; the original period covered by the original authorization has not expired; and the Member or P4HB Member requests extension of the Benefits.
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4.14.7.3
|
If, at the Member or P4HB Member’s request, the Contractor continues or reinstates the Member or P4HB Member’s benefit while the Appeal or Administrative Law Hearing is pending, the Benefits must be continued until one of the following occurs:
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·
|
The Member or P4HB Member withdraws the Appeal or request for the Administrative Law Hearing.
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·
|
Ten (10) Calendar Day pass after the Contractor mails the Notice of Adverse Action, unless the Member or P4HB Member, within the ten (10) Calendar Day timeframe, has requested an Administrative Law Hearing with continuation of Benefits until an Administrative Law Hearing decision is reached.
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·
|
An Administrative Law Judge issues a hearing decision adverse to the Member or P4HB Member.
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·
|
The time period or service limits of a previously authorized service has been met.
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4.14.7.4
|
If the final resolution of Appeal is adverse to the Member or P4HB Member, that is, upholds the Contractor action, the Contractor may recover from the Member the cost of the services furnished to the Member or P4HB Member while the Appeal is pending, to the extent that they were furnished solely because of the requirements of this Section.
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|
4.14.7.5
|
If the Contractor or the Administrative Law Judge reverses a decision to deny, limit, or delay services that were not furnished while the Appeal was pending, the Contractor shall authorize or provide these disputed services promptly, and as expeditiously as the Member or P4HB Member’s health condition requires.
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4.14.7.6
|
If the Contractor or the Administrative Law Judge reverses a decision to deny authorization of services, and the Member or P4HB Member received the disputed services while the Appeal was pending, the Contractor shall pay for those services.
|
4.14.8
|
Reporting Requirements
|
4.14.8.1
|
The Contractor shall log and track all Grievances, Proposed Actions, Appeals and Administrative Law Hearing requests, as described in Section 4.18.4.5.
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4.14.8.2
|
The Contractor shall maintain records of Grievances, whether received verbally or in writing, that include a short, dated summary of the problems, name of the grievant, date of the Grievance, date of the decision, and the disposition.
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4.14.8.3
|
The Contractor shall maintain records of Appeals, whether received verbally or in writing, that include a short, date summary of the issues, name of the appellant, date of Appeal, date of decision, and the resolution.
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4.14.8.4
|
DCH may publicly disclose summary information regarding the nature of Grievances and Appeals and related dispositions or resolutions in consumer information materials.
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4.14.8.5
|
The Contractor shall submit quarterly Grievance System Reports to DCH as described in Section 4.18.4.5.
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4.15
|
ADMINISTRATION AND MANAGEMENT
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4.15.1
|
General Provisions
|
4.15.1.1
|
The Contractor shall be responsible for the administration and management of all requirements of this Contract. All costs related to the administration and management of this Contract shall be the responsibility of the Contractor.
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|
4.15.2
|
Place of Business and Hours of Operation
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4.15.2.1
|
The Contractor shall maintain a central business office within the Service Region in which it is operating. If the Contractor is operating in more than one (1) Service Region, there must be one (1) central business office and an additional office in each Service Region. If a Contractor is operating in two (2) or more contiguous Service Regions, the Contractor may establish one (1) central business office for all Service Regions. This business office must be centrally located within the contiguous Service Regions and in a location accessible for foot and vehicle traffic. The Contractor may establish more than one (1) business office within a Service Region, but must designate one (1) of the offices as the central business office.
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4.15.2.2
|
All documentation must reflect the address of the location identified as the legal, duly licensed, central business office. This business office must be open at least between the hours of 8:30 a.m. and 5:30 p.m. EST, Monday through Friday. The Contractor shall ensure that the office(s) are adequately staffed to ensure that Members and Providers receive prompt and accurate responses to inquiries.
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4.15.2.3
|
The Contractor shall ensure that all business offices and all staff that perform functions and duties, related to this Contract are located within the United States.
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4.15.2.4
|
The Contractor shall provide live access, through its telephone hot line as described in Section 4.3.7 and Section 4.9.5. The Contractor shall provide access twenty-four (24) hours a day, seven (7) days per week to its Web site.
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4.15.3
|
Training
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|
4.15.3.1
|
The Contractor shall conduct on-going training for its entire staff, in all departments, to ensure appropriate functioning in all areas and to ensure that staff is aware of all programmatic changes.
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4.15.3.2
|
The Contractor shall submit a staff-training plan to DCH for review and approval as updated.
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4.15.3.3
|
The Contractor designated staff are required to attend DCH in-service training on an Ad-Hoc basis. DCH will determine the type and scope of the training.
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4.15.4
|
Data and Report Certification
|
4.15.4.1
|
The Contractor shall certify all data pursuant to 42 CFR 438.606. The data that must be certified include, but are not limited to, Enrollment information, Encounter Data, Contractual Reports and other information required by the State and contained in Contracts, proposals and related documents. The data must be certified by one of the following: the Contractor’s Chief Executive Officer, the Contractor’s Chief Financial Officer, or an individual who has delegated authority to sign for, and who Reports directly to the Contractor’s Chief Executive Officer or Chief Financial Officer. The certification must attest, based on best knowledge, information, and belief, as follows:
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·
|
By virtue of submission, the Contractor attests to the accuracy, completeness, and truthfulness of the data, reports, and other documents provided to the State.
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·
|
Inaccurate data, reports, and other documents provided to the State by the Contractor are subject to applicable Liquidated Damages.
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4.15.4.2
|
The Contractor shall submit the certification concurrently with the certified data.
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4.16
|
CLAIMS MANAGEMENT
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4.16.1
|
General Provisions
|
4.16.1.1
|
The Contractor shall utilize the same time frames and deadlines for submission, processing, payment, denial, adjudication, and appeal of Medicaid and Demonstration claims. Demonstration claims will be processed as all other Medicaid claims are processed using the time frames and deadlines that DCH uses on claims its pays directly. The Contractor shall administer an effective, accurate and efficient claims processing function that adjudicates and settles Provider Claims for Covered Services that are filed within the time frames specified by DCH (see Part I. Policy and Procedures for Medicaid/PeachCare for Kids® Manual) and in compliance with all applicable State and federal laws, rules and regulations.
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4.16.1.2
|
The Contractor shall maintain a Claims management system that can identify date of receipt (the date the Contractor receives the Claim as indicated by the date-stamp), real-time-accurate history of actions taken on each Provider Claim (i.e. paid, denied, suspended, Appealed, etc.), and date of payment (the date of the check or other form of payment).
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4.16.1.3
|
At a minimum, the Contractor shall run one (1) Provider payment cycle per week, on the same day each week, as determined by DCH.
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4.16.1.4
|
The Contractor shall support an Automated Clearinghouse (ACH) mechanism that allows Providers to request and receive electronic funds transfer (EFT) of Claims payments.
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4.16.1.5
|
The Contractor shall encourage that its Providers, as an alternative to the filing of paper-based Claims, submit and receive Claims information through electronic data interchange (EDI), i.e. electronic Claims. Electronic Claims must be processed in adherence to information exchange and data management requirements specified in Section 4.17. As part of this Electronic Claims Management (ECM) function, the Contractor shall also provide on-line and phone-based capabilities to obtain Claims processing status information.
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4.16.1.6
|
The Contractor shall generate Explanation of Benefits and Remittance Advices in accordance with State standards for formatting, content and timeliness and will verify that recipients have received the services indicated on the Explanation of Benefits received and the Remittance Advices.
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4.16.1.7
|
The Contractor shall not pay any Claim submitted by a Provider who is excluded or suspended from the Medicare, Medicaid or SCHIP programs for Fraud, abuse or waste or otherwise included on the Department of Health and Human Services Office of Inspector General exclusions list, or employs someone on this list. The Contractor shall not pay any Claim submitted by a Provider that is on payment hold under the authority of DCH or its Agent(s).
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4.16.1.8
|
Not later than the fifteenth (15) business day after the receipt of a Provider Claim that does not meet Clean Claim requirements, the Contractor shall suspend the Claim and request in writing (notification via e-mail, the CMO plan Web Site/Provider Portal or an interim Explanation of Benefits satisfies this requirement) all outstanding information such that the Claim can be deemed clean. Upon receipt of all the requested information from the Provider, the CMO plan shall complete processing of the Claim within fifteen (15) Business Days.
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4.16.1.9
|
If a Provider submits a claim to a responsible health organization for services rendered within 72 hours after the Provider verifies the eligibility of the patient with that responsible health organization, the responsible health organization shall reimburse the Provider in an amount equal to the amount to which the Provider would have been entitled if the patient had been enrolled as shown in the eligibility verification process. After resolving the Provider’s claim, if the responsible health organization made payment for a patient for whom it was not responsible, then the responsible health organization may pursue a cause of action against any person who was responsible for payment of the services at the time they were provided but may not recover any payment made to the Provider.
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4.16.1.10
|
The Contractor shall not apply any penalty for failure to file claims in a timely manner, for failure to obtain prior authorization, or for the provider not being a participating provider in the person’s network, and the amount of reimbursement shall be that person’s applicable rate for the service if the provider is under contract with that person or the rate paid by DCH for the same type of claim that it pays directly if the provider is not under contract with that person.
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4.16.1.11
|
The Contractor shall inform all network Providers about the information required to submit a Clean Claim as a provision within the Contractor/Provider Contract. The Contractor shall make available to network Providers Claims coding and processing guidelines for the applicable Provider type. The Contractor shall notify Providers ninety (90) Calendar Days before implementing changes to Claims coding and processing guidelines.
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4.16.1.12
|
The Contractor shall perform Quarterly scheduled Global Claims Analyses to ensure an effective, accurate, and efficient claims processing function that adjudicates and settles provider claims. In addition, the contractor shall assume all costs associated with Claim processing, including the cost of reprocessing/resubmission, due to processing errors caused by the Contractor or to the design of systems within the Contractor’s span of control.
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4.16.1.13
|
In addition to the specific Web site requirements outlined above, the Contractor’s Web site shall be functionally equivalent to the Web site maintained by the State’s Medicaid fiscal agent.
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4.16.2
|
Other Considerations
|
|
4.16.2.1
|
An adjustment to a paid Claim shall not be counted as a Claim for the purposes of reporting.
|
|
4.16.2.2
|
Electronic Claims shall be treated as identical to paper-based Claims for the purposes of reporting.
|
4.16.3.1
|
The Georgia Families program utilizes encounter data to determine the adequacy of medical services and to evaluate the quality of care rendered to members. DCH will use the following requirements to establish the standards for the submission of data and to measure the compliance of the Contractor to provide timely and accurate information. Encounter data from the Contractor also allows DCH to budget available resources, set contractor capitation rates, monitor utilization, follow public health trends and detect potential fraud. Most importantly, it allows the Division of Managed Care and Quality to make recommendations that can lead to the improvement of healthcare outcomes.
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4.16.3.2
|
The Contractor shall work with all contracted Providers to implement standardized billing requirements to enhance the quality and accuracy of the billing data submitted to the health plan.
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4.16.3.3
|
The Contractor shall instruct contracted Providers that the Georgia State Medicaid ID number is mandatory, and must be documented in record. The Contractor will emphasize to Providers the need for a unique GA Medicaid number for each practice location.
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4.16.3.4
|
The Contractor shall submit to Fiscal Agent weekly cycles of data files. All identified errors shall be submitted to the Contractor from the Fiscal Agent each week. The Contractor shall clean up and resubmit the corrected file to the Fiscal Agent within seven (7) Business Days of receipt.
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4.16.3.5
|
The Contractor is required to submit 100% of Critical Data Elements such as state Medicaid ID numbers, NPI numbers, SSN numbers, Member Name, and DOB. These items must match the states eligibility and provider file.
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4.16.3.6
|
The Contractor submitted claims must consistently include:
|
·
|
Patient name
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·
|
Date of birth
|
·
|
Place of service
|
·
|
Date of service
|
·
|
Type of service
|
·
|
Units of service
|
·
|
Diagnosis-primary & secondary
|
·
|
Treating provider
|
·
|
NPI number
|
·
|
Tax Identification Number
|
·
|
Facility code
|
·
|
A unique TCN
|
·
|
All additionally required CMS 1500 or UB 04 codes
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·
|
CMO Paid Amount
|
|
4.16.3.7 For each submission of claims per 4.16.3.5 and 4.16.3.6, Contractor must provide the following Cash Disbursements data elements:
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·
|
Provider/Payee Number
|
·
|
Name
|
·
|
Address
|
·
|
City
|
·
|
State
|
·
|
Zip
|
·
|
Check date
|
·
|
Check number
|
·
|
Check amount
|
·
|
Check code ( i.e. EFT, paper check, etc)
|
|
4.16.3.8
|
The Contractor shall maintain an Encounter Error Rate of <5% weekly as monitored by the Fiscal Agent and DCH. The Encounter Error Rate is the occurrence of a single error in any Transaction Control Number (TCN) or encounter claim counts as an error for that encounter (this is regardless of how many other errors are detected in the TCN.)
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|
4.16.3.9
|
The Contractors failure to comply with defined standard(s) will be subject to a CAPA/PC and may be liable for liquidated damages (LD’s).
|
4.16.4
|
Reporting Requirements
|
|
The Contractor shall submit to DCH monthly Claims Processing Reports as described in section 4.18.3.4.
|
4.16.5
|
Emergency Health Care Services
|
4.16.5.1
|
The Contractor shall not deny or inappropriately reduce payment to a provider of emergency health care services for any evaluation, diagnostic testing, or treatment provided to a recipient of medical assistance for an emergency condition; or
|
4.16.5.2
|
Make payment for emergency health care services contingent on the recipient or provider of emergency health care services providing any notification, either before or after receiving emergency health care services.
|
4.16.5.3
|
In processing claims for emergency health care services, a care management organization shall consider, at the time that a claim is submitted, at least the following criteria:
|
·
|
The age of the patient;
|
·
|
The time and day of the week the patient presented for services;
|
·
|
The severity and nature of the presenting symptoms;
|
·
|
The patient’s initial and final diagnosis; and
|
·
|
Any other criteria prescribed by DCH, including criteria specific to patients less than 18 years of age.
|
4.16.5.4
|
The Contractor shall configure or program its automated claims processing system to consider at least the conditions and criteria described in this subsection for claims presented for emergency health care services.
|
4.16.5.5
|
If a provider that has not entered into a contract with a care management organization provides emergency health care services or post-stabilization services to that care management organization’s member, the care management organization shall reimburse the non contracted provider for such emergency health care services and post-stabilization services at a rate equal to the rate paid by DCH for Medicaid claims that it reimburses directly.
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4.17
|
INFORMATION MANAGEMENT AND SYSTEMS
|
4.17.1
|
General Provisions
|
|
4.17.1.1
|
The Contractor shall have Information management processes and Information Systems (hereafter referred to as Systems) that enable it to meet GF requirements, State and federal reporting requirements, all other Contract requirements and any other applicable State and federal laws, rules and regulations including HIPAA.
|
4.17.1.2
|
The Contractor is responsible for maintaining a system that shall possess capacity sufficient to handle the workload projected for the start of the program and will be scalable and flexible enough to adapt as needed, within negotiated timeframes, in response to program or Enrollment changes.
|
|
4.17.1.3
|
The Contractor shall provide a Web-accessible system hereafter referred to as the DCH Portal that designated DCH and other state agency resources can use to access Quality and performance management information as well as other system functions and information as described throughout this Contract. Access to the DCH Portal shall be managed as described in section 4.17.5.
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|
4.17.1.4
|
The Contractor shall attend DCH’s Systems Work Group meetings as scheduled by DCH. The Systems Work Group will meet on a designated schedule as agreed to by DCH, its agents and every Contractor.
|
|
4.17.1.5
|
The Contractor shall provide a continuously available electronic mail communication link (E-mail system) with the State. This system shall be:
|
·
|
Available from the workstations of the designated Contractor contacts; and
|
·
|
Capable of attaching and sending documents created using software products other than Contractor systems, including the State’s currently installed version of Microsoft Office and any subsequent upgrades as adopted.
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4.17.1.6
|
By no later than the 30th of April of each year, the Contractor will provide DCH with an annual progress/status report of the Contractor’s system refresh plan for the upcoming State fiscal year. The plan will outline how Systems within the Contractor’s Span of Control will be systematically assessed to determine the need to modify, upgrade and/or replace application software, operating hardware and software, telecommunications capabilities, information management policies and procedures, and/or systems management policies and procedures in response to changes in business requirements, technology obsolescence, staff turnover and other relevant factors. The systems refresh plan will also indicate how the Contractor will insure that the version and/or release level of all of its System components (application software, operating hardware, operating software) are always formally supported by the original equipment manufacturer (OEM), software development firm (SDF) or a third party authorized by the OEM and/or SDF to support the System component.
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|
4.17.1.7
|
The Contractor is responsible for all costs associated with the Contractors system refresh plan.
|
|
4.17.2.1
|
The Contractor shall have in place or develop initiatives towards electronic health information exchange and health care transparency that would encourage the use of qualified electronic health records, personal health records (PHRs), and make available to Providers and members increased information on cost and quality of care through health information technology.
|
4.17.2.2
|
The Contractor shall develop an incentive program for the adoption and utilization of electronic health records that result in improvements in the quality and cost of health care services.
|
|
4.17.2.3
|
The Contractor will work with DCH on the HITECH Act provisions as mandated by CMS.
|
4.17.3
|
Global System Architecture and Design Requirements
|
|
4.17.3.1
|
The Contractor shall comply with federal and State policies, standards and regulations in the design, development and/or modification of the Systems it will employ to meet the aforementioned requirements and in the management of Information contained in those Systems. Additionally, the Contractor shall adhere to DCH and State-specific system and data architecture preferences as indicated in this Contract.
|
·
|
Employ a relational data model in the architecture of its databases and relational database management system (RDBMS) to operate and maintain them;
|
·
|
Be SQL and ODBC compliant;
|
·
|
Adhere to Internet Engineering Task Force/Internet Engineering Standards Group standards for data communications, including TCP and IP for data transport;
|
·
|
Conform to standard code sets detailed in Attachment L;
|
·
|
Contain industry standard controls to maintain information integrity applicable to privacy and security, especially PHI. These controls shall be in place at all appropriate points of processing. The controls shall be tested in periodic and spot audits following a methodology to be developed jointly and mutually agreed upon by the Contractor and DCH; and
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·
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Partner with the State in the development of future standard code sets, not specific to HIPAA or other federal effort and will conform to such standards as stipulated by DCH.
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4.17.3.3
|
Where Web services are used in the engineering of applications, the Contractor’s Systems shall conform to World Wide Web Consortium (W3C) standards such as XML, UDDI, WSDL and SOAP so as to facilitate integration of these Systems with DCH and other State systems that adhere to a service-oriented architecture.
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4.17.3.4
|
Audit trails shall be incorporated into all Systems to allow information on source data files and documents to be traced through the processing stages to the point where the Information is finally recorded. The audit trails shall:
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·
|
Contain a unique log-on or terminal ID, the date, and time of any create/modify/delete action and, if applicable, the ID of the system job that effected the action;
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·
|
Have the date and identification “stamp” displayed on any on-line inquiry;
|
·
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Have the ability to trace data from the final place of recording back to its source data file and/or document shall also exist;
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·
|
Be supported by listings, transaction Reports, update Reports, transaction logs, or error logs;
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·
|
Facilitate auditing of individual Claim records as well as batch audits; and
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·
|
Be maintained for seven (7) years in either live and/or archival systems. The duration of the retention period may be extended at the discretion of and as indicated to the Contractor by the State as needed for ongoing audits or other purposes.
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4.17.3.5
|
The Contractor shall house indexed images of documents used by Members and Providers to transact with the Contractor in the appropriate database(s) and document management systems to maintain the logical relationships between certain documents and certain data.
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4.17.3.6
|
The Contractor shall institute processes to insure the validity and completeness of the data it submits to DCH. At its discretion, DCH will conduct general data validity and completeness audits using industry-accepted statistical sampling methods. Data elements that will be audited include but are not limited to: Member ID, date of service, Provider ID, category and sub category (if applicable) of service, diagnosis codes, procedure codes, revenue codes, date of Claim processing, and date of Claim payment.
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4.17.3.7
|
Where a System is herein required to, or otherwise supports, the applicable batch or on-line transaction type, the system shall comply with HIPAA-standard transaction code sets as specified in Attachment L.
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4.17.3.8
|
The Contractor System(s) shall conform to HIPAA standards for information exchange.
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4.17.3.9
|
The layout and other applicable characteristics of the pages of Contractor Web sites shall be compliant with Federal “section 508 standards” and Web Content Accessibility Guidelines developed and published by the Web Accessibility Initiative.
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4.17.3.10
|
Contractor Systems shall conform to any applicable Application, Information and Data, Middleware and Integration, Computing Environment and Platform, Network and Transport, and Security and Privacy policy and standard issued by GTA as stipulated in the appropriate policy/standard. These policies and standards can be accessed at: http://gta.georgia.gov/00/channel_modifieddate/0,2096,1070969_6947051,00.html
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4.17.4
|
Data and Document Management Requirements
|
|
In order to meet programmatic, reporting and management requirements, the Contractor’s systems shall serve as either the Authoritative Host of key data and documents or the host of valid, replicated data and documents from other systems. Attachment L lays out the requirements for managing (capturing, storing and maintaining) data and documents for the major information types and subtypes associated with the aforementioned programmatic, reporting and management requirements.
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4.17.5
|
System and Data Integration Requirements
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4.17.5.1
|
All of the Contractor’s applications, operating software, middleware, and networking hardware and software shall be able to interface with the State’s systems and will conform to standards and specifications set by the Georgia Technology Authority and the agency that owns the system. These standards and specifications are detailed in Attachment L.
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4.17.5.2
|
The Contractor’s System(s) shall be able to transmit and receive transaction data to and from the MMIS as required for the appropriate processing of Claims and any other transaction that may be performed by either System.
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4.17.5.2.1
|
The Contractor shall generate encounter data files no less than weekly (or at a frequency defined by DCH) from its claims management system(s) and/or other sources. The files will contain settled Claims and Claim adjustments and encounters from Providers with whom the Contractor has a capitation arrangement for the most recent month for which all such transactions were completed. The Contractor will provide these files electronically to DCH and/or its designated agent in adherence to the procedure and format indicated in Attachment L.
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4.17.5.2.2
|
The Contractor’s System(s) shall be capable of generating all required files in the prescribed formats (as referenced in Attachment L) for upload into state Systems used specifically for program integrity and compliance purposes.
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4.17.5.3
|
The Contractor’s System(s) shall possess mailing address standardization functionality in accordance with US Postal Service conventions.
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4.17.6
|
System Access Management and Information Accessibility Requirements
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4.17.6.1
|
The Contractor’s System shall employ an access management function that restricts access to varying hierarchical levels of system functionality and Information. The access management function shall:
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·
|
Restrict access to Information on a "need to know" basis, e.g. users permitted inquiry privileges only will not be permitted to modify information;
|
·
|
Restrict access to specific system functions and information based on an individual user profile, including inquiry only capabilities; global access to all functions will be restricted to specified staff jointly agreed to by DCH and the Contractor; and
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·
|
Restrict attempts to access system functions (both internal and external) to three (3), with a system function that automatically prevents further access attempts and records these occurrences.
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·
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At a minimum, follow the GTA Security Standard and Access Management protocols.
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4.17.6.2
|
The Contractor shall make System Information available to duly Authorized Representatives of DCH and other State and federal agencies to evaluate, through inspections or other means, the quality, appropriateness and timeliness of services performed.
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4.17.6.3
|
The Contractor shall have procedures to provide for prompt electronic transfer of System Information upon request to In-Network or Out-of-Network Providers for the medical management of the Member in adherence to HIPAA and other applicable requirements.
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|
4.17.6.4
|
All Information, whether data or documents, and reports that contain or make references to said Information, involving or arising out of this Contract is owned by DCH. The Contractor is expressly prohibited from sharing or publishing DCH information and reports without the prior written consent of DCH. In the event of a dispute regarding the sharing or publishing of information and reports, DCH’s decision on this matter shall be final and not subject to change.
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4.17.7
|
Systems Availability and Performance Requirements
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|
4.17.7.1
|
The Contractor will ensure that Member and Provider portal and/or phone-based functions and information, such as confirmation of CMO Enrollment (CCE) and electronic claims management (ECM), Member services and Provider services, are available to the applicable System users twenty-four (24) hours a day, seven (7) Days a week, except during periods of scheduled System Unavailability agreed upon by DCH and the Contractor. Unavailability caused by events outside of a Contractor’s span of control is outside of the scope of this requirement.
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4.17.7.2
|
The Contractor shall ensure that at a minimum, all other System functions and Information are available to the applicable system users between the hours of 7:00 a.m. and 7:00 p.m. Monday through Friday.
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4.17.7.3
|
The Contractor shall ensure that the average response time that is controllable by the Contractor is no greater than the requirements set forth below, between 7:00 am and 7:00 pm, Monday through Friday for all applicable system functions except a) during periods of scheduled downtime, b) during periods of unscheduled unavailability caused by systems and telecommunications technology outside of the Contractor’s span of control or c) for Member and Provider portal and phone-based functions such as CCE and ECM that are expected to be available twenty-four (24) hours a day, seven (7) days a week:
|
·
|
Record Search Time – The response time shall be within three (3) seconds for ninety-eight percent (98%) of the record searches as measured from a representative sample of DCH System Access Devices, as monitored by the Contractor;
|
·
|
Record Retrieval Time – The response time will be within three (3) seconds for ninety-eight percent (98%) of the records retrieved as measured from a representative sample of DCH System Access Devices;
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·
|
On-line Adjudication Response Time – The response time will be within five (5) seconds ninety-nine percent (99%) of the time as measured from a representative sample of user System Access Devices.
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4.17.7.4
|
The Contractor shall develop an automated method of monitoring the CCE and ECM functions on at least a thirty (30) minute basis twenty-four (24) hours a day, seven (7) Days per week. The monitoring method shall separately monitor for availability and performance/response time each component of the CCE and ECM systems, such as the voice response system, the PC software response, direct line use, the swipe box method and ECM on-line pharmacy system.
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4.17.7.5
|
Upon discovery of any problem within its Span of Control that may jeopardize System availability and performance as defined in this Section of the Contract, the Contractor shall notify the DCH Director, Contract Compliance and Resolution, in person, via phone, electronic mail and/or surface mail.
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4.17.7.6
|
The Contractor shall deliver notification as soon as possible but no later than 7:00 pm if the problem occurs during the business day and no later than 9:00 am the following business day if the problem occurs after 7:00 pm.
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4.17.7.7
|
Where the operational problem results in delays in report distribution or problems in on-line access during the business day, the Contractor shall notify the DCH Director, Contract Compliance and Resolution, within fifteen (15) minutes of discovery of the problem, in order for the applicable work activities to be rescheduled or be handled based on System Unavailability protocols.
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4.17.7.8
|
The Contractor shall provide to the DCH Director, Contract Compliance and Resolution, information on System Unavailability events, as well as status updates on problem resolution. These up-dates shall be provided on an hourly basis and made available via electronic mail, telephone and the Contractor’s Web Site/DCH Portal.
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4.17.7.9
|
Unscheduled System Unavailability of CCE and ECM functions, caused by the failure of systems and telecommunications technologies within the Contractor’s Span of Control will be resolved, and the restoration of services implemented, within thirty (30) minutes of the official declaration of System Unavailability. Unscheduled System Unavailability to all other Contractor System functions caused by systems and telecommunications technologies within the Contractor’s Span of Control shall be resolved, and the restoration of services implemented, within four (4) hours of the official declaration of System Unavailability.
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4.17.7.10
|
Cumulative System Unavailability caused by systems and telecommunications technologies within the Contractor’s span of control shall not exceed one (1) hour during any continuous five (5) Day period.
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|
4.17.7.11
|
The Contractor shall not be responsible for the availability and performance of systems and telecommunications technologies outside of the Contractor’s Span of Control. Contractor is obligated to work with identified vendors to resolve and report system availability and performance issues. Reference Section 23.5.1.5 – (Liquidated Damages)
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4.17.7.12
|
Full written documentation that includes a CAPA/PC that describes what caused the problem, how the problem will be prevented from occurring again, and within a set time frame for resolution must be submitted to DCH within five (5) Business Days of the problem’s occurrence.
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4.17.7.13
|
Regardless of the architecture of its Systems, the Contractor shall develop and be continually ready to invoke a business continuity and disaster recovery (BC-DR) plan that at a minimum addresses the following scenarios: (a) the central computer installation and resident software are destroyed or damaged, (b) System interruption or failure resulting from network, operating hardware, software, or operational errors that compromises the integrity of transactions that are active in a live system at the time of the outage, (c) System interruption or failure resulting from network, operating hardware, software or operational errors that compromises the integrity of data maintained in a live or archival system, (d) System interruption or failure resulting from network, operating hardware, software or operational errors that does not compromise the integrity of transactions or data maintained in a live or archival system but does prevent access to the System, i.e. causes unscheduled System Unavailability.
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4.17.7.14
|
The Contractor shall periodically, but no less than annually, test its BC-DR plan through simulated disasters and lower level failures in order to demonstrate to the State that it can restore System functions per the standards outlined elsewhere in this Contract. The Contractor will prepare a report of the results of these tests and present to DCH staff within five (5) business days of test completion.
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4.17.7.15
|
In the event that the Contractor fails to demonstrate in the tests of its BC-DR plan that it can restore system functions per the standards outlined in this Contract, the Contractor shall be required to submit to the State a CAPA/PC that describes how the failure will be resolved. The CAPA/PC will be delivered within five (5) Business Days of the conclusion of the test.
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4.17.7.16
|
The Contractor shall submit monthly System Availability and Performance Report to DCH as described in section 4.18.3.3
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4.17.8
|
System User and Technical Support Requirements
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4.17.8.1
|
The Contractor shall provide Systems Help Desk (SHD) services to all DCH staff and the other agencies that may have direct access to Contractor systems.
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4.17.8.2
|
The SHD shall be available via local and toll free telephone service and via e-mail from 7 a.m. to 7 p.m. EST Monday through Friday, with the exception of State holidays. Upon State request, the Contractor shall staff the SHD on a State holiday, Saturday, or Sunday at the Contractor’s expense.
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4.17.8.3
|
SHD staff shall answer user questions regarding Contractor System functions and capabilities; report recurring programmatic and operational problems to appropriate Contractor or DCH staff for follow-up; redirect problems or queries that are not supported by the SHD, as appropriate, via a telephone transfer or other agreed upon methodology; and redirect problems or queries specific to data access authorization to the appropriate State login account administrator.
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4.17.8.4
|
The Contractor shall submit to DCH for review and approval its SHD Standards. At a minimum, these standards shall require that between the hours of 7 a.m. and 7 p.m. EST ninety percent (90%) of calls are answered by the fourth (4th) ring, the call abandonment rate is five percent (5%) or less, the average hold time is two (2) minutes or less, and the blocked call rate does not exceed one percent (1%).
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4.17.8.5
|
Individuals who place calls to the SHD between the hours of 7 p.m. and 7 a.m. EST shall be able to leave a message. The Contractor’s SHD shall respond to messages by noon the following Business Day.
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4.17.8.6
|
Recurring problems not specific to System Unavailability identified by the SHD shall be documented and reported to Contractor management within one (1) Business Day of recognition so that deficiencies are promptly corrected.
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4.17.8.7
|
Additionally, the Contractor shall have an IT service management system that provides an automated method to record, track, and report on all questions and/or problems reported to the SHD. The service management system shall:
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·
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Assign a unique number to each recorded incident;
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·
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Create State defined extract files that contain summary information on all problems/issues received during a specified time frame;
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·
|
Escalate problems based on their priority and the length of time they have been outstanding;
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·
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Perform key word searches that are not limited to certain fields and allow for searches on all fields in the database;
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·
|
Notify support personnel when a problem is assigned to them and re-notify support personnel when an assigned problem has escalated to a higher priority;
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·
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List all problems assigned to a support person or group;
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·
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Perform searches for duplicate problems when a new problem is entered;
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·
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Allow for entry of at least five hundred (500) characters of free form text to describe problems and resolutions; and
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·
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Generate Reports that identify categories of problems encountered, length of time for resolution, and any other State-defined criteria.
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4.17.8.8
|
The Contractor’s call center systems shall have the capability to track call management metrics identified in Attachment L.
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4.17.9.1
|
The Contractor shall absorb the cost of routine maintenance, inclusive of defect correction, System changes required to effect changes in State and federal statute and regulations, and production control activities, of all Systems within its Span of control.
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4.17.9.2
|
The Contractor shall provide DCH, prior written notice of non-routine System changes excluding changes prompted by events described in Section 4.17.6 and including proposed corrections to known system defects, within ten (10) Calendar Days of the projected date of the change. As directed by the state, the Contractor shall discuss the proposed change in the Systems Work Group.
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4.17.9.3
|
The Contractor shall respond to State reports of System problems not resulting in System Unavailability and shall perform the needed changes according to the following timeframes:
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·
|
Within five (5) Calendar Days of receipt, the Contractor shall respond in writing to notices of system problems.
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·
|
Within fifteen (15) Calendar Days, the correction will be made or a Requirements Analysis and Specifications document will be due.
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·
|
The Contractor will correct the deficiency by an effective date to be determined by DCH.
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·
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Contractor systems will have a system-inherent mechanism for recording any change to a software module or subsystem.
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4.17.9.4
|
The Contractor shall put in place procedures and measures for safeguarding the State from unauthorized modifications to Contractor Systems.
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4.17.9.5
|
Unless otherwise agreed to in advance by DCH as part of the activities described in Section 4.17.8.3, scheduled System Unavailability to perform System maintenance, repair and/or upgrade activities shall take place between 11 p.m. on a Saturday and 6 a.m. on the following Sunday.
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4.17.10.1
|
The Contractor shall provide for the physical safeguarding of its data processing facilities and the systems and information housed therein. The Contractor shall provide DCH with access to data facilities upon DCH request. The physical security provisions shall be in effect for the life of this Contract.
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4.17.10.2
|
The Contractor shall restrict perimeter access to equipment sites, processing areas, and storage areas through a card key or other comparable system, as well as provide accountability control to record access attempts, including attempts of unauthorized access.
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4.17.10.3
|
The Contractor shall include physical security features designed to safeguard processor site(s) through required provision of fire retardant capabilities, as well as smoke and electrical alarms, monitored by security personnel.
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4.17.10.4
|
The Contractor shall ensure that the operation of all of its systems is performed in accordance with State and federal regulations and guidelines related to security and confidentiality and meet all privacy and security requirements of HIPAA regulations. Relevant publications are included in Attachment L.
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4.17.10.5
|
The Contractor will put in place procedures, measures and technical security to prohibit unauthorized access to the regions of the data communications network inside of a Contractor’s Span of Control.
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·
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42 CFR Part 431 Subpart F (confidentiality of information concerning applicants and Members of public medical assistance programs);
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·
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42 CFR Part 2 (confidentiality of alcohol and drug abuse records); and
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·
|
Special confidentiality provisions related to people with HIV/AIDS and mental illness.
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4.17.10.7
|
The Contractor shall provide its Members with a privacy notice as required by HIPAA. The Contractor shall provide the State with a copy of its Privacy Notice for its filing.
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4.17.11
|
Information Management Process and Information Systems Documentation Requirements
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|
4.17.11.1
|
The Contractor shall ensure that written System Process and Procedure Manuals document and describe all manual and automated system procedures for its information management processes and information systems.
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4.17.11.2
|
The Contractor shall develop, prepare, print, maintain, produce, and distribute distinct System Design and Management Manuals, User Manuals and Quick/Reference Guides, and any updates thereafter, for DCH and other agency staff that use the DCH Portal.
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|
4.17.11.3
|
The System User Manuals shall contain information about, and instructions for, using applicable System functions and accessing applicable system data.
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4.17.11.4
|
When a System change is subject to State sign off, the Contractor shall draft revisions to all appropriate manuals impacted by the system change i.e. user manuals, technical specifications etc. prior to State sign off the change.
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|
4.17.11.5
|
All of the aforementioned manuals and reference guides shall be available in printed form and on-line via the DCH Portal. The manuals will be published in accordance to the applicable DCH and/or Georgia Technology Authority (GTA) standard.
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|
4.17.11.6
|
Updates to the electronic version of these manuals shall occur in real time; updates to the printed version of these manuals shall occur within ten (10) Business Days of the update taking effect.
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4.17.12
|
Reporting Requirements
|
4.18
|
REPORTING REQUIREMENTS
|
4.18.1
|
General Procedures
|
|
4.18.1.1
|
The Contractor shall comply with all the reporting requirements established by this Contract. The Contractor shall create Reports using the formats, including electronic formats, instructions, and timetables as specified by DCH, at no cost to DCH. DCH may modify reports, specifications, templates, or timetables as necessary during the contract year. Contractor changes to the format must be approved by DCH prior to implementation. The Contractor shall transmit and receive all transactions and code sets required by the HIPAA regulations in accordance with Section 21.2. The Contractor’s failure to submit the Reports as specified may result in the assessment of liquidated damages as described in Section 23.0.
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4.18.1.1.1
|
The Contractor shall submit the Deliverables and Reports for DCH review and approval according to the following timelines, unless otherwise indicated:
|
·
|
Annual Reports shall be submitted within thirty (30) Calendar Days following the twelfth (12th) month of the contract year ending June 30th.
|
·
|
Quarterly Reports shall be submitted by April 30, July 30, October 30, and January 30, for the quarter immediately preceding the due date;
|
·
|
Monthly Reports shall be submitted within fifteen (15) Calendar Days of the end of each month; and
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·
|
Weekly Reports shall be submitted on the same day of each week, as determined by DCH.
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4.18.1.2
|
For reports required by DOI and DCH, the Contractor shall submit such reports according to the DOI schedule of due dates, unless otherwise indicated. While such schedule may be duplicated in this Contract, should the DOI schedule of due dates be amended at a future date, the due dates in this Contract shall automatically change to the new DOI due dates.
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4.18.1.3
|
The Contractor shall, upon request of DCH, generate any additional data or reports at no additional cost to DCH within a time period prescribed by DCH. The Contractor’s responsibility shall be limited to data in its possession.
|
4.18.2
|
Weekly Reporting
|
|
At this time, no weekly reports are due.
|
4.18.3
|
Monthly Reporting
|
4.18.3.1
|
Telephone and Internet Activity Report
|
|
4.18.3.1.1
|
This information may be submitted as a summary report, in a format to be determined by DCH. The Contractor shall maintain, and make available at the request of DCH, any and all supporting documentation. Each Telephone and Internet Activity Report shall include the following information:
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·
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Call volume;
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·
|
E-mail volume;
|
·
|
Average call length;
|
·
|
Average hold time;
|
·
|
Abandoned Call rate;
|
·
|
Accuracy rate based on CMO’s Call Center Quality Criteria and Protocols;
|
·
|
Content of call or email and resolution; and
|
·
|
Blocked Call rate.
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|
4.18.3.2
|
Eligibility and Enrollment Reconciliation Report
|
|
4.18.3.2.1
|
Pursuant to Section 4.1.4.2, the Contractor shall submit an Eligibility and Enrollment Reconciliation Report that reconciles eligibility data to the Contractor’s Enrollment records. The written report shall verify that the Contractor has an Enrollment record for all Members that are eligible for Enrollment in the CMO plan.
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4.18.3.3
|
System Availability and Performance Report
|
|
4.18.3.3.1
|
Pursuant to Section 4.17.6, the Contractor shall submit a System Availability and Performance Report that shall report the following information:
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·
|
Record Search Time
|
·
|
Record Retrieval Time
|
·
|
Screen Edit Time
|
·
|
New Screen/Page Time
|
·
|
Print Initiation Time
|
·
|
Confirmation of CMO Enrollment Response Time
|
·
|
Online Claims Adjudication Response Time
|
|
4.18.3.4
|
Claims Processing Report
|
|
4.18.3.4.1
|
Pursuant to Section 4.16.4, the Contractor shall submit a Claims Processing Report that documents the claims processing activities for the following claim types:
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·
|
Physicians
|
·
|
Institutional
|
·
|
Professional
|
·
|
Pharmacy
|
·
|
Dental
|
·
|
Vision
|
·
|
Behavioral
|
|
4.18.3.4.2
|
Number and dollar value of Claims processed by Provider type and processing status (adjudicated and paid, adjudicated and not paid, suspended, appealed, denied);
|
·
|
Aging of Claims: number, dollar value and status of Claims filed in most recent and prior months (defined as six (6) months previous) by Provider type and processing status; and
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·
|
Cumulative percentage for the current fiscal year of Clean Claims processed and paid within thirty (30) calendar and ninety (90) Calendar Days of receipt.
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|
4.18.3.5
|
Fraud and Abuse Report
|
|
4.18.3.5.1
|
Pursuant to Section 4.13, the Contractor shall submit a Fraud and Abuse Report which shall include, at a minimum, the following:
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·
|
Source of complaint;
|
·
|
Alleged persons or entities involved;
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·
|
Nature of complaint;
|
·
|
Approximate dollars involved;
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·
|
Date of the complaint;
|
·
|
Disciplinary action imposed;
|
·
|
Administrative disposition of the case;
|
·
|
Investigative activities, corrective actions, prevention efforts, and results; and
|
·
|
Trending and analysis as it applies to: Utilization Management; Claims management; post-processing review of Claims; and Provider profiling.
|
|
4.18.3.5.2
|
Pursuant to Section 31.19, the Contractor shall submit, attached to the Fraud and Abuse Report, all disclosures required under Section 31.19.
|
|
4.18.3.6
|
Medical Loss Ratio Report
|
|
4.18.3.6.1
|
Pursuant to Section 8.6.2, the Contractor shall submit monthly, a Medical Loss Ratio report that captures medical expenses relative to capitation payments received on a cumulative year to date basis. The Medical Loss Ratio report shall include:
|
·
|
Capitation payments received;
|
·
|
Medical expenses by provider grouping including, but not limited to:
|
o
|
Direct payments to Providers for covered medical services;
|
o
|
Capitated payments to Providers; and
|
o
|
Payments to subcontractors for covered benefits and services.
|
|
4.18.3.6.3
|
Actuarial certification that the report, including the estimate of IBNR, has been reviewed for accuracy; and
|
|
Pursuant to Section 4.1.4.1, the Contractor shall submit a Member Data Conflict Report. The report shall include data conflicts that may affect the Member’s eligibility for Georgia Families including, but not limited to, name changes, date of birth, duplicate records, social security number or gender.
|
|
Pursuant to Section 4.8.12.1, the Contractor shall submit a Dental Utilization Participation Report that maintains an appropriate number of Dental providers (both general and specialty) in network for the service area based on claims data which shall include, at a minimum, the following:
|
·
|
Total number or unique enrolled providers
|
·
|
Total number of unique participating providers
|
·
|
Unique participating providers by county
|
·
|
Provider listing of unique participating provider with claims paid/denied data included.
|
|
Pursuant to 4.10.5, the Contractor shall submit monthly FQHC and RHC Payment Reports that identify Contractor payments made to each FQHC and RHC for each Covered Service provided to Members.
|
|
4.18.3.10
|
Provider Complaints Report
|
|
Pursuant to Section 4.9.8.2 the Contractor shall submit a Provider Complaints Report that includes, at a minimum, the following:
|
·
|
Number of complaints by type;
|
·
|
Type of assistance provided; and
|
·
|
Administrative disposition of the case.
|
4.18.4
|
Quarterly Reporting
|
|
4.18.4.1
|
Timely Access Report
|
|
Pursuant to Section 4.8.14, the Contractor shall submit Timely Access Reports that monitor the time lapsed between a Member’s initial request for an office appointment and the date of the appointment. These data for the Timely Access Reports may be collected using statistical sampling methods (including periodic Member and/or Provider surveys). The report shall include:
|
·
|
Total number of appointment requests;
|
·
|
Total number of requests that meet the waiting time standards;
|
·
|
Total number of requests that exceed the waiting time standards; and
|
·
|
Average waiting time for those requests that exceed the waiting time standards. Information for items iii and iv shall be provided for each provider type/class.
|
|
Pursuant to Section 5.8, the Contractor shall submit a Contractor Notifications Report that includes all DCH requested updated information within 10 days of verification; subsequently a quarterly summary must be provided that includes but is not limited to:
|
·
|
Relationship of Parties
|
·
|
Criminal Background
|
·
|
Confidentiality Requirements
|
·
|
Insurance Coverage
|
·
|
Payment Bond & Letter of Credit
|
·
|
Compliance with Federal Laws
|
·
|
Conflict of Interest and Contractor Independence
|
·
|
Drug Free Workplace
|
·
|
Business Associate Agreement
|
·
|
System Status
|
·
|
Key staff or Senior Level Management
|
·
|
Current Corporate and Local Organization Chart
|
·
|
Unclaimed Payments from the Prior Year
|
|
4.18.4.4
|
Utilization Management Report
|
|
4.18.4.4.1
|
Utilization Management Reports must include an analysis of data and identification of opportunities for improvement and follow up of the effectiveness of the intervention. Utilization data is to be reported based on claim data. The reports shall include specific data elements that are defined by DCH such that all CMOs are reporting a common data set.
|
|
4.18.4.4.2
|
The Contractor shall submit a Utilization Management Report on Utilization patterns and aggregate trend analysis. The Contractor shall also submit individual physician profiles to DCH, as requested. These Reports should provide to DCH analysis and interpretation of Utilization patterns, including but not limited to, high volume services, high risk services, services driving cost increases, including prescription drug utilization; Fraud and Abuse trends; and Quality and disease management. The Contractor shall provide ad hoc reports pursuant to the requests of DCH. The Contractor shall submit its proposed reporting mechanism, including but not limited to focus of study, data sources to DCH for approval.
|
|
4.18.4.4.3
|
The Contractor shall select three (3) of the following elements to monitor in its physician profiles. Each element should be measured against an established threshold.
|
·
|
Member access (encounters per member per year, new patient visit within 6 months, ER use per member per year, etc.)
|
·
|
Preventive care (EPSDT rates, breast cancer screening rates, immunizations, etc.)
|
·
|
Disease management (asthma ER/IP encounters, HBA1C rates, etc.)
|
·
|
Pharmacy utilization (generics, asthma medications, etc.)
|
|
4.18.4.5
|
Grievance System Report
|
|
Pursuant to Section 4.14.8.1 the Contractor shall submit a summary of Grievance, Appeals and Administrative Law Hearing requests. The report shall, at a minimum, include the following:
|
·
|
Number of complaints by type;
|
·
|
Type of assistance provided; and
|
·
|
Administrative disposition of the case.
|
|
4.18.4.6
|
Reserved.
|
·
|
A quarterly report on the form prescribed by the National Association of Insurance Commissioners (NAIC) for Health Maintenance Organizations (HMOs) pursuant to Section 8.6.6; and
|
·
|
A quarterly income statement on the form prescribed by the NAIC for HMOs pursuant to Section 8.6.6.
|
|
Pursuant to Section 16.0, the Contractor shall submit a Subcontractor Agreement Report. The Subcontractor Agreement Report shall include:
|
|
i.
|
All signed agreements for services provided (direct or indirect) to or on behalf of the Contractor’s assigned membership or contracted Providers that includes:
|
·
|
Name of Subcontractor
|
·
|
Services provided by Subcontractor
|
·
|
Terms of the subcontracted agreement
|
·
|
Subcontractor contact information
|
ii.
|
Monitoring schedule (at least twice per year)
|
|
4.18.4.9
|
Prior Authorization and Pre-Certification Report
|
|
4.18.4.9.1
|
Pursuant to Section 4.11.1, the Contractor shall submit Prior Authorization and Pre-Certification Reports that summarize all requests in the preceding quarter for Prior Authorization and Pre-Certification. The Report shall include, at a minimum, the following information:
|
·
|
Total number of completed requests for Standard Service Authorizations;
|
·
|
Total number of completed requests for Expedited Service Authorizations;
|
·
|
Percent of completed requests within timeliness standards by type of service;
|
·
|
Total number of completed requests authorized by type of service;
|
·
|
Total number or completed requests denied by type of service; and
|
·
|
Percent of completed requests denied by type of service;
|
·
|
Patterns and aggregate trend analysis
|
|
4.18.4.9.2
|
The Contractor must submit the Quality Management Report Analysis form to DCH with each submission of the quarterly Prior Authorization and Pre-Certification Report. In addition to providing an overall analysis of the data being submitted, the Contractor must also include the following:
|
·
|
An explanation if less than 80% of the Standard Service Authorizations are approved within the contractual timeliness standards for each of the following services - Medical Inpatient, Medical Outpatient, Therapy, Behavioral Health including inpatient AND outpatient services, Vision, and Dental ;
|
·
|
An explanation if less than 80% of the Expedited Service Authorizations are approved within the contractual timeliness standards for each of the following services – Pharmacy, Medical Inpatient, Medical Outpatient, Therapy, Behavioral Health including inpatient AND outpatient services, Vision, and Dental ;
|
·
|
Reasons for denials (e.g., lack of medical necessity, required additional information, does not meet criteria, non-covered service, member not eligible, member exceeds age limit, etc.);
|
·
|
An explanation if greater than or equal to 20% of the Standard Service Authorizations are denied for each of the following services - Medical Inpatient, Medical Outpatient, Therapy, Behavioral Health including inpatient AND outpatient services, Vision, and Dental; and
|
·
|
An explanation if greater than or equal to 20% of the Expedited Service Authorizations are denied for each of the following services – Pharmacy, Medical Inpatient, Medical Outpatient, Therapy, Behavioral Health including inpatient AND outpatient services, Vision, and Dental.
|
|
4.18.4.10
|
Provider Network Adequacy and Capacity Report
|
|
4.18.4.10.1
|
Pursuant to Section 4.8.1, the Contractor shall submit a Provider Network Adequacy and Capacity Report quarterly that demonstrates that the Contractor offers an appropriate range of preventive, Primary Care and specialty services that is adequate for the anticipated number of Members for the service area and that its network of Providers is sufficient in number, mix and geographic distribution to meet the needs of the anticipated number of Members in the service area.
|
|
4.18.4.10.2
|
This Provider Network Adequacy and Capacity Report shall list all Providers enrolled in the Contractor’s Provider network, including but not limited to, physicians, hospitals, FQHC/RHCs, home health agencies, pharmacies, Durable Medical Equipment vendors, behavioral health specialists, ambulance vendors, and dentists. Each Provider shall be identified by a unique identifying Provider number as specified in Section 4.8.1.5. This unique identifier shall appear on all Encounter Data transmittals. In addition to the listing, the Provider Network Adequacy and Capacity Report shall identify:
|
·
|
Provider additions and deletions from the preceding month;
|
·
|
All OB/GYN Providers participating in the Contractor’s network, and those with open panels; and
|
·
|
List of Primary Care Providers with open panels.
|
|
4.18.4.10.3
|
The Reports shall be submitted to DCH at the following times:
|
·
|
Upon DCH request;
|
·
|
Upon Enrollment of a new population in the Contractor's plan; and
|
·
|
Any time there has been a significant change in the Contractor’s operations that would affect adequate capacity and services. A significant change is defined as any of the following:
|
o
|
A decrease in the total number of PCPs by more than five percent (5%);
|
o
|
A loss of Providers in a specific specialty where another Provider in that specialty is not available within sixty (60) miles; or
|
o
|
A loss of a hospital in an area where another CMO plan hospital of equal service ability is not available within thirty (30) miles; or
|
o
|
Other adverse changes to the composition of the network, which impair or deny the Members’ adequate access to CMO plan Providers.
|
|
4.18.4.11.1
|
The Contractor shall provide a Hospital Statistical and Reimbursement Report (HS&R) to a hospital provider upon request by the hospital or DCH using the same format that is used by DCH in completing HS&R reports within 30 days or receipt of such request.
|
|
4.18.4.11.2
|
Contractor will provide DCH with a quarterly report due thirty (30) days after the end of the quarter, indicating all HS&R reports requested, the requesting hospital, date requested by hospital and date provided to hospital.
|
|
4.18.4.11.3
|
Contractor must provide the HS&R report to the requesting hospital within thirty (30) days of request. If delinquent in providing the HS&R Report, Contractor is subject to an assessment of liquidated damages in the amount of $1,000 per day penalty starting on the thirty-first day after the request and continuing until the report is provided. Payment of the penalty will be to DCH to be deposited in the Indigent Care Trust Fund. Contractor shall not reduce the funding available for health care services for Members as a result of payment of such penalties.
|
|
4.18.4.11.4
|
It is the Contractor’s responsibility to provide an HS&R Report that is accurate and includes the same data elements provided in the HS&R reports produced by DCH. DCH may, at its discretion, audit HS&R reports provided to hospitals. If these reports contain inaccuracies that would negatively impact a hospital’s ability to produce accurate Medicare reports or if the Contractor is unable to provide cash records of payments to the requesting hospital that reconcile with payment amounts on the HS&R report, Contractor will be subject to a $1,000 penalty for each HS&R report containing inaccurate information. Payment of the penalty will be to DCH to be deposited in the Indigent Care Trust Fund. The Contractor will then have thirty (30) days to provide a corrected report to DCH and the requesting hospital. Contractor is subject to a $1,000 per day penalty starting on the thirty-first day after the request and continuing until the report is provided. Payment of the penalty will be to DCH to be deposited in the Indigent Care Trust Fund.
|
|
4.18.4.17
|
EPSDT Report
|
|
4.18.4.17.1
|
Pursuant to Section 4.7.6.1 the Contractor shall submit an EPSDT Report for Medicaid Members and PeachCare for Kids® members that identifies at a minimum the following:
|
·
|
Number of live births;
|
·
|
Number of initial newborn visits within twenty-four (24) hours of birth;
|
·
|
Number of Members that received an initial health visit and screening within ninety (90) Calendar Days of Enrollment;
|
|
4.18.4.17.2
|
Reports shall capture Medicaid Members and PeachCare for Kids® Members.
|
|
4.18.4.17.3
|
DCH, at its sole discretion, may add additional data to the EPSDT Report if DCH determines that it is necessary for monitoring purposes.
|
|
Pursuant to Section 4.13, the Contractor shall submit the following Pharmacy Audit Reports:
|
·
|
Top 10 Pharmacies by Recovery
|
·
|
Top 25 Drugs by Total Claims
|
·
|
Top 25 Drugs by Recovery
|
·
|
Top 10 Discrepancies by Recoupment
|
·
|
Paid cost per Member per month
|
·
|
Average ingredient cost per prescription
|
·
|
Number of scripts per Member per year
|
·
|
Average cost of a brand prescription
|
·
|
Average cost of a generic prescription
|
4.18.5
|
Annual Reports
|
|
4.18.5.1
|
Performance Improvement Projects Reports
|
|
Pursuant to Section 4.12.6, the Contractor shall submit a Performance Improvement Projects Report no later than June 30 of each contract year that includes the study design, analysis, status and results on performance improvement projects. Status Reports on Performance Improvement Projects may be requested more frequently by DCH.
|
|
4.18.5.2
|
Focused Studies Report
|
|
Pursuant to Section 4.12.8.1, the Contractor shall, by July 1, submit the Focus Studies proposal that includes study topics, study questions, study indicators, and the study population for each of the two required focused studies to DCH for approval. The Contractor shall submit annual Reports on the focused studies, which includes analysis and results, no later than the June 30 of each contract year.
|
|
4.18.5.3
|
Patient Safety Reports
|
|
Pursuant to Section 4.12.9, the Contractor shall submit a Patient Safety Report no later than June 30 of each contract year that includes, at a minimum, the following:
|
·
|
A system of classifying complaints according to severity;
|
·
|
Review by Medical Director and mechanism for determining which incidents will be forwarded to Peer Review and Credentials Committees; and
|
·
|
Summary of incident(s) included in Provider Profile.
|
|
Pursuant to Section 4.17.1.6, the Contractor shall submit to DCH a Systems Refresh Plan no later than April 30 of each contract year.
|
|
4.18.5.5
|
Independent Audit and Income Statement
|
·
|
An annual report on the form prescribed by the National Association of Insurance Commissioners (NAIC) for Health Maintenance Organizations (HMO) pursuant to Section 8.6.6;
|
·
|
An annual income statement pursuant to Section 8.6.6; and
|
·
|
An annual audit of its business transactions pursuant to Section 8.6.6.
|
4.18.5.6
|
“SAS 70” and “SSAE 16” Reports
|
4.18.5.6.1
|
Pursuant to Section 8.6.4.1, the Contractor shall submit to DCH an annual SAS 70 Report conducted by an independent auditing firm.
|
4.18.5.6.2
|
Pursuant to Section 8.6.4.1, each Contractor’s Material Subcontractor shall submit to DCH an annual SAS 70 Report conducted by an independent auditing firm. For reporting periods ending on or after June 15, 2011, the Material Subcontractor shall submit to DCH an annual SSAE 16 Report in lieu of the SAS 70 Report.
|
4.18.5.6.3
|
SAS 70 or SSAE 16 Reports shall be due May 15 of each year and apply to the preceding twelve (12) month period April through March. The Contractor and its Material Subcontractors shall submit the first SSAE 16 Report (in lieu of the SAS 70 Report) to DCH on May 15, 2012 for the period April 2011 through March 2012.
|
|
4.18.5.7
|
Disclosure of Information on Annual Business Transactions
|
|
Pursuant to Section 8.6.5 and Section 31.20, the Contractor shall submit to DCH, in a format specified by DCH, an annual Disclosure of Information on Annual Business Transactions.
|
4.18.5.8
|
Unclaimed Property Report
|
|
Pursuant to Section 8.6.7, the Contractor shall submit an annual report on the form prescribed by the Section 8.6.7 to DCH and the Georgia Department of Revenue.
|
|
4.18.5.9 Unclaimed Payments Report
|
|
Under Georgia Code Title 44, Chapter 12, Article 5, all insurance companies must report annually on unclaimed payments from the prior year.
|
|
4.18.5.10
|
Performance Measures
|
|
The performance measures apply to the member populations as specified by the measures’ technical specifications. Contractor performance is evaluated annually on the reported rate for each measure as referenced in Section 4.12.3.
|
4.18.6
|
Ad Hoc Reports
|
|
4.18.6.1
|
State Quality Monitoring Reports
|
·
|
The availability of services;
|
·
|
The adequacy of the Contractor’s capacity and services;
|
·
|
The Contractor’s coordination and continuity of care for Members;
|
·
|
The coverage and authorization of services;
|
·
|
The Contractor’s policies and procedures for selection and retention of Providers;
|
·
|
The Contractor’s compliance with Member information requirements in accordance with 42CFR 438.10;
|
·
|
The Contractor’s compliance with Title 45 of the Code of Federal Regulations relative to Member’s confidentiality;
|
·
|
The Contractor’s compliance with Member Enrollment and Disenrollment requirements and limitations;
|
·
|
The Contractor’s Grievance System;
|
·
|
The Contractor’s oversight of all sub contractual relationships and delegations therein;
|
·
|
The Contractor’s adoption of practice guidelines, including the dissemination of the guidelines to Providers and Provider’s application of them;
|
·
|
The Contractor’s quality assessment and performance improvement program; and
|
·
|
The Contractor’s health information systems.
|
|
4.18.6.2
|
Third Party Liability and Coordination of Benefits Report
|
|
4.18.6.3
|
Provider Rep Field Visit Report
|
|
The Contractor shall submit the Provider Rep Field Visit Report on an as-needed-basis, according to the guidelines outlined under Section 4.9.3. The purpose of this report is to show that the CMOs conduct training within thirty (30) Calendar Days of placing a newly Contracted Provider on active status. The Contractor shall also conduct ongoing training as deemed necessary by the Contractor or DCH in order to ensure compliance with program standard and the GHF Contract.
|
|
4.18.6.4
|
Quality Oversight Committee Report
|
|
Pursuant to Section 4.12.12.1, the Contractor shall submit a Quality Oversight Committee Report that shall include a summary of results, conclusions, recommendations and implemented system changes for the QAPI program.
|
|
4.18.6.5
|
72 Hour Eligibility Rule Report
|
|
Pursuant to Section 4.16.1.9, the Contractor shall submit on an as needed basis, a 72 Hour Eligibility Rule Report demonstrating that the contracted Provider verified member eligibility within 72 hours of the service being rendered.
|
|
5.2.1
|
DCH will provide written notice of disapproval of a Deliverable to the Contractor within fourteen (14) Calendar Days of submission if it is disapproved. DCH may, at its sole discretion, elect to review a deliverable longer than fourteen (14) calendar days.
|
|
5.2.2
|
The notice of disapproval shall state the reasons for disapproval as specifically as is reasonably necessary and the nature and extent of the corrections required for meeting the Contract requirements.
|
|
Within fourteen (14) Calendar Days of receipt of a notice of disapproval, the Contractor shall make the corrections and resubmit the Deliverable.
|
|
Within thirty (30) Calendar Days following resubmission of any disapproved Deliverable, DCH will give written notice to the Contractor of approval, Conditional approval or disapproval.
|
|
|
In the event that DCH fails to respond to a Contractor’s submission or resubmission within the applicable time period, the Contractor should notify DCH of the outstanding request:
|
|
5.6.1
|
By submitting a Deliverable or report, the Contractor represents that to the best of its knowledge, it has performed the associated tasks in a manner that will, in concert with other tasks, meet the objectives stated or referred to in the Contract.
|
|
5.6.2
|
By approving a Deliverable or report, DCH represents only that it has reviewed the Deliverable or report and detected no errors or omissions of sufficient gravity to defeat or substantially threaten the attainment of those objectives and to warrant the Withholding or denial of payment for the work completed. DCH’S acceptance of a Deliverable or report does not discharge any of the Contractor’s Contractual obligations with respect to that Deliverable or report.
|
5.7
|
CONTRACT DELIVERABLES
|
Deliverable
|
Contract
Section
|
Due Date
|
PCP Auto-assignment Policies
|
2.3.3
|
As updated
|
Member Handbook
|
4.3.3
|
As updated
|
Provider Directory
|
4.3.5
|
As updated
|
Sample Member ID card
|
4.3.6
|
As updated
|
Telephone Hotline Policies and Procedures (Member and Provider)
|
4.3.7
4.9.5
|
As updated
|
Call Center Quality Criteria and Protocols
|
4.3.7.9
4.9.5.8
|
As updated
|
Web site Screenshots
|
4.3.8
4.9.6
|
As updated
|
Cultural Competency Plan
|
4.3.9.3
|
As updated
|
Marketing Plan and Materials
|
4.4
|
As updated
|
Provider Marketing Materials
|
4.4.4
|
As updated
|
MH/SA Policies and Procedures
|
4.6.11
|
As updated
|
EPSDT policies and procedures
|
4.7
|
As updated
|
Provider Selection and Retention Policies and Procedures
|
4.8.1.6
|
As updated
|
Provider Network Listing spreadsheet for all requested Provider types and Provider Letters of Intent or executed Signature Pages of Provider Contracts not previously submitted as part of the RFP response
|
4.8
|
As updated
|
Final Provider Network Listing spreadsheet for all requested Provider types, Signature Pages for all Providers, and written acknowledgements from all Providers part of a PPO, IPO, or other network stating they know they are in the Contractor’s network, know they are accepting Medicaid patients, and are accepting the terms and conditions of the Provider Contract.
|
4.8.1.8
|
As updated
|
Network Adequacy Policies and Procedures
|
4.18.4.10
|
As updated.
|
PCP Selection Policies and Procedures
|
4.8.2.2
|
As updated
|
Credentialing and Re-Credentialing Policies and Procedures
|
4.8.15
|
As updated
|
Provider Handbook
|
4.9.2
|
As updated
|
Provider Training Manuals
|
4.9.3.2
|
As updated
|
Provider Complaint System Policies and Procedures
|
4.9.7
|
As updated
|
Utilization Management Policies and Procedures
|
4.11
|
As updated
|
Care Coordination and Case Management Policies and Procedures
|
4.11
|
As updated
|
Quality Assessment and Performance Improvement Program Plan
|
4.12.5
|
As updated
|
Focused Studies
|
4.12.8.1
|
1st day of the 4th Quarter of the 1st year
|
Patient Safety Plan
|
4.12.9
|
As updated
|
Program Integrity Policies and Procedures
|
4.13
|
As updated
|
Grievance System Policies and Procedures
|
4.14
|
As updated
|
Staff Training Plan
|
4.15.3
|
As updated
|
Claims Management
|
4.16
|
As updated
|
Business Continuity Plan
|
4.17.7.13
|
As updated
|
System Users Manuals and Guides
|
4.17.7
|
As updated
|
Information Management Policies and Procedures
|
4.17
|
As updated
|
Subcontractor Agreements
|
16.0
|
As updated
|
5.8
|
CONTRACT REPORTS
|
Report
|
Contract Section
|
Due Date
|
Member Data Conflict Report
|
4.18.3.7
|
Monthly
|
Telephone and Internet Activity Report
|
4.18.3.1
|
Monthly
|
Eligibility and Enrollment Reconciliation Report
|
4.18.3.2
|
Monthly
|
Prior Authorization and Pre-Certification Report
|
4.18.4.9
|
Quarterly
|
Claims Processing Report
|
4.18.4
|
Monthly
|
System Availability and Performance Report
|
4.18.3.3
|
Monthly
|
Medical Loss Ratio Report
|
4.18.3.6
|
Monthly
|
EPSDT Report
|
4.18.4.17
|
Quarterly
|
Timely Access Report
|
4.18.4.1
|
Quarterly
|
Provider Complaints Report
|
4.18.3.10
|
Monthly
|
FQHC & RHC Report
|
4.18.3.9
|
Monthly
|
Quality Oversight Committee Report
|
4.12.5.2
|
Ad-Hoc
|
Contractor Information Report
|
14.1.3
|
Quarterly
|
Subcontractor Information Report
|
16.0
|
Quarterly
|
Fraud and Abuse Report
|
4.18.3.5
|
Monthly
|
Grievance System Report
|
4.18.4.5
|
Quarterly
|
Cost Avoidance and Post Payment Recovery Report
|
4.18.6.6
|
Ad Hoc
|
Independent Audit and Income Statement
|
4.18.5.5
|
Quarterly
|
Hospital Statistical and Reimbursement Report
|
4.18.4.11
|
Quarterly
|
Subcontractor Agreement Report
|
4.18.4.8
|
Quarterly
|
Performance Improvement Projects Report
|
4.18.5.1
|
Annually
|
Focused Studies Report
|
4.18.5.2
|
Annually
|
Patient Safety Report
|
4.18.5.3
|
Annually
|
System Refresh Plan
|
4.18.5.4
|
Annually
|
Independent Audit and Income Statement
|
4.18.5.5
|
Annually
|
“SAS 70” Report & “SSAE 16” Report
|
4.18.5.6
|
Annually
|
Disclosure of Information on Annual Business Transactions
|
4.18.5.7
|
Annually and any time there is a change.
|
State Quality Monitoring Report
|
4.18.6.1
|
Upon request by DCH
|
Provider Network Adequacy and Capacity Report
|
4.18.4.10
|
Quarterly; and
Any time there is a significant change.
|
Third Party Liability and Coordination of Benefits Report
|
4.18.6.1.2
|
Ad-Hoc
|
Contractor Notifications
|
4.18.4.34
|
Within 10 Days of verifications, also a
Quarterly summary report
|
Dental Utilization Report
|
4.18.3.8
|
Monthly
|
Case Management Report
|
4.18.4.12
|
Quarterly
|
Disease Management
|
4.18.4.13
|
Quarterly
|
Unclaimed Property Report
|
4.18.5.8
|
Annually
|
Unclaimed Payment Report
|
4.18.5.9
|
Annually
|
Health Check Record Review
|
4.18.4.20
|
Quarterly
|
Informing Activity
|
4.18.4.14
|
Quarterly
|
CMS 416
|
4.18.4.15
|
Quarterly
|
Initial Screen Report
|
4.18.4.16
|
Quarterly
|
Demonstration Reports
|
See Attachments O and Q
|
See Attachments O and Q
|
Disclosure of Ownership and Control Interest Statement
|
8.6.5 and 31.20
|
Annually and within 35 days of any change in ownership of the Contractor
|
Performance Measures
|
4.18.5.10
|
Annually
|
Utilization Management
|
4.18.4.4
|
Quarterly
|
Prior Authorization/Pre-Certification
|
4.18.4.9
|
Quarterly
|
Pharmacy Audit Report
|
4.18.4.18
|
Quarterly
|
Pharmacy Cost Report
|
4.18.4.19
|
Quarterly
|
7.1.1
|
DCH will compensate the Contractor a prepaid, per member per month capitation rate for each GF Member enrolled in the Contractor’s plan (See Attachment H). The number of enrolled Members in each rate cell category will be determined by the records maintained in the Medicaid Member Information System (MMIS) maintained by DCH’s fiscal agent. The monthly compensation will be the final negotiated rate for each rate cell multiplied by the number of enrolled Members in each rate cell category. The Contractor must provide to DCH, and keep current, its tax identification number, billing address, and other contact information. Pursuant to the terms of this Contract, should DCH assess liquidated damages or other remedies or actions for noncompliance or deficiency with the terms of this Contract, such amount shall be withheld from the prepaid, monthly compensation for the following month, and for continuous consecutive months thereafter until such noncompliance or deficiency is corrected.
|
7.1.1.1
|
DCH will compensate the Contractor on a per member per month basis for each P4HB Participant enrolled in the Contractor’s plan (See Attachment R). The number of enrolled P4HB Participants in each rate cell category will be determined by the records maintained in the Medicaid Member Information System (MMIS) maintained by DCH’s fiscal agent. The monthly compensation will be the final negotiated rate for each rate cell multiplied by the number of enrolled P4HB Participants in each rate cell category. The Contractor must provide to DCH, and keep current, its tax identification number, billing address, and other contact information. Pursuant to the terms of this Contract, should DCH assess liquidated damages or other remedies or actions for noncompliance or deficiency with the terms of this Contract, such amount shall be withheld from the monthly compensation for the following month, and for continuous consecutive months thereafter until such noncompliance or deficiency is corrected.
|
7.1.2
|
The relevant Deliverables shall be mailed to the Project Leader named in the Notice provision of this Contract.
|
7.1.3
|
The total of all payments made by DCH to Contractor under this Contract shall not exceed the per Member per month Capitation payments agreed to under Attachment H, which has been provided for through the use of State or federal grants or other funds. With the exception of payments provided to the Contractor in accordance with Section 7.2 on Performance Incentives, DCH will have no responsibility for payment beyond that amount. Also as specified in Section 7.2.1.1, the total of all payments to the Contract will not exceed one hundred and five percent (105%) of the Capitation payment pursuant to 42 CFR 438.6 (hereinafter the “maximum funds”). It is expressly understood that the total amount of payment to the Contractor will not exceed the maximum funds provided above, unless Contractor has obtained prior written approval, in the form of a Contract amendment, authorizing an increase in the total payment. Additionally, the Contractor agrees that DCH will not pay or otherwise compensate the Contractor for any work that it performs in excess of the Maximum Funds.
|
7.2
|
Performance Incentives
|
7.2.1
|
The Contractor may be eligible for financial performance incentives subject to availability of funding. In order to be eligible for the financial performance incentives described below the Contractor must be fully compliant in all areas of the Contract. All incentives must comply with the federal managed care Incentive Arrangement requirements pursuant to 42 CFR 438.6 and the State Medicaid Manual 2089.3.
|
|
7.2.1.1
|
The total of all payments paid to the Contractor under this Contract shall not exceed one hundred and five percent (105%) of the Capitation payment pursuant to 42 CFR 438.6.
|
|
7.2.1.2
|
The amount of financial performance incentive and allocation methodology is developed solely by DCH.
|
7.2.2
|
Health Check Screening Initiative
|
·
|
The Contractor could become eligible for a performance incentive payment if the Contractor’s performance exceeds the minimum compliance standard for Health Check visits.
|
·
|
The payment to the Contractor, if any, shall depend upon the percentage of Health Check well-child visits and screens achieved by the Contractor in excess of the minimum required compliance standard of eighty percent (80%). Payment shall be based on information obtained from Encounter Data.
|
8.1.1
|
The Contractor shall be responsible for the sound financial management of the CMO plan.
|
8.2.1
|
The Contractor shall establish and maintain such net worth, working capital and financial reserves as required pursuant to O.C.G.A. § 33-21.
|
8.2.2
|
The Contractor shall provide assurances to the State that its provision against the risk of insolvency is adequate such that its Members shall not be liable for its debts in the event of insolvency.
|
8.2.3
|
As part of its accounting and budgeting function, the Contractor shall establish an actuarially sound process for estimating and tracking incurred but not reported costs. As part of its reserving process, the Contractor shall conduct annual reviews to assess its reserving methodology and make adjustments as necessary.
|
8.3.1
|
DCH will not administer a Reinsurance program funded from capitation payment Withholding.
|
8.3.2
|
In addition to basic financial measures required by State law and discussed in section 8.2.1 and section 26, the Contractor shall meet financial viability standards. The Contractor shall maintain net equity (assets minus liability) equal to at least one (1) month’s capitation payments under this Contract. In addition, the Contractor shall maintain a current ratio (current assets/current liabilities) of greater than or equal to 1.0.
|
8.3.3
|
In the event the Contractor does not meet the minimum financial viability standards outlined in 8.3.2, the Contractor shall obtain Reinsurance that meets all DOI requirements. While commercial Reinsurance is not required, DCH recommends that Contractors obtain commercial Reinsurance rather than self-insuring. The Contractor may not obtain a reinsurance policy from an offshore company; the insurance carrier, the insurance carrier’s agents and the insurance carrier’s subsidiaries must be domestic.
|
8.4
|
THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS
|
8.4.1
|
Third party liability refers to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured or self-funded, or commercial carrier, automobile insurance and worker’s compensation) or program, that is, or may be, liable to pay all or part of the Health Care expenses of the Member.
|
|
8.4.1.1
|
Pursuant to Section 1902(a)(25) of the Social Security Act and 42 CFR 433 Subpart D, DCH hereby authorizes the Contractor as its agent to identify and cost avoid Claims for all CMO plan Members, including PeachCare for Kids® Members.
|
|
8.4.1.2
|
The Contractor shall make reasonable efforts to determine the legal liability of third parties to pay for services furnished to CMO plan Members. To the extent permitted by State and federal law, the Contractor shall use Cost Avoidance processes to ensure that primary payments from the liable third party are identified, as specified below.
|
|
8.4.1.3
|
If the Contractor is unsuccessful in obtaining necessary cooperation from a Member to identify potential Third Party Resources after sixty (60) Calendar Days of such efforts, the Contractor may inform DCH, in a format to be determined by DCH, that efforts have been unsuccessful.
|
8.4.2.1
|
The Contractor shall cost avoid all Claims or services that are subject to payment from a third party health insurance carrier, and may deny a service to a Member if the Contractor is assured that the third party health insurance carrier will provide the service, with the exception of those situations described below in Section 8.4.2.2. However, if a third party health insurance carrier requires the Member to pay any cost-sharing amounts (e.g., co-payment, coinsurance, deductible), the Contractor shall pay the cost sharing amounts. The Contractor’s liability for such cost sharing amounts shall not exceed the amount the Contractor would have paid under the Contractor’s payment schedule for the service.
|
8.4.2.2
|
Further, the Contractor shall not withhold payment for services provided to a Member if third party liability, or the amount of third party liability, cannot be determined, or if payment will not be available within sixty (60) Calendar Days.
|
8.4.2.3
|
The requirement of Cost Avoidance applies to all Covered Services except Claims for labor and delivery, including inpatient hospital care and postpartum care, prenatal services, preventive pediatric services, and services provided to a dependent covered by health insurance pursuant to a court order. For these services, the Contractor shall ensure that services are provided without regard to insurance payment issues and must provide the service first. The Contractor shall then coordinate with DCH or it agent to enable DCH to recover payment from the potentially liable third party.
|
8.4.2.4
|
If the Contractor determines that third party liability exists for part or all of the services rendered, the Contractor shall:
|
·
|
Notify Providers and supply third party liability data to a Provider whose Claim is denied for payment due to third party liability; and
|
·
|
Pay the Provider only the amount, if any, by which the Provider’s allowable Claim exceeds the amount of third party liability.
|
|
8.4.3.1
|
DCH may determine whether the Contractor complies with this Section by inspecting source documents for timeliness of billing and accounting for third party payments.
|
8.5.1
|
The Contractor may establish physician incentive plans pursuant to federal and State regulations, including 42 CFR 422.208 and 422.210, and 42 CFR 438.6.
|
8.5.2
|
The Contractor shall disclose any and all such arrangements to DCH, and upon request, to Members. Such disclosure shall include:
|
·
|
Whether services not furnished by the physician or group are covered by the incentive plan;
|
·
|
The type of Incentive Arrangement;
|
·
|
The percent of Withhold or bonus; and,
|
·
|
The panel size and if patients are pooled, the method used.
|
8.5.3
|
Upon request, the Contractor shall report adequate information specified by the regulations to DCH in order that DCH will adequately monitor the CMO plan.
|
8.5.4
|
If the Contractor’s physician incentive plan includes services not furnished by the physician/group, the Contractor shall: (1) ensure adequate stop loss protection to individual physicians, and must provide to DCH proof of such stop loss coverage, including the amount and type of stop loss; and (2) conduct annual Member surveys, with results disclosed to DCH, and to Members, upon request.
|
8.5.5
|
Such physician incentive plans may not provide for payment, directly or indirectly, to either a physician or physician group as an inducement to reduce or limit medically necessary services furnished to an individual.
|
8.6
|
REPORTING REQUIREMENTS
|
8.6.1
|
The Contractor shall submit to DCH the quarterly Cost Avoidance Reports as described in Section 4.18.6.6.
|
8.6.2
|
The Contractor shall submit to DCH monthly Medical Loss Ratio Reports that detail direct medical expenditures for Members and premiums paid by the Contractor, as described in Section 4.18.3.6.
|
8.6.3
|
The Contractor shall submit to DCH Third Party Liability and Coordination of Benefits Reports within ten (10) Business Days of verification of available Third Party Resources to a Member, as described in Section 4.18.6.2. The Contractor shall report any known changes to such resources in the same manner.
|
8.6.4
|
Effective for reporting periods ending on or after June 15, 2011, the Contractor, at its sole expense, shall submit by May 15 (or a later date if approved by DCH) of each year a “Reporting on Controls at a Service Organization”, meeting all standards and requirements of the AICPA’s SSAE 16 “type 2” report, for the Contractor’s operations performed for DCH under this Contract. Such report shall cover a period of no less than nine (9) months, ending March 31 of that year (2012). Subsequent reports shall cover 12 months ending on March 31 of that year.
|
8.6.4.1
|
Statement on Standards for Attestation Engagements (SSAE) Number 16 (SSAE 16), Reporting on Controls at a Service Organization, is an attestation standard developed by the American Institute of Certified Public Accountants (AICPA) which shall replace the SAS 70 and is effective for such auditors’ reports for periods ending on or after June 15, 2011.
|
8.6.4.2
|
For more information on the AICPA’s “Statement on Standards for Attestation Engagements No. 16, Reporting on Controls at a Service Organization,” Contractor may refer to this AICPA website: http://www.aicpa.org/News/FeaturedNews/Pages/SASNo70Transformed%E2%80%93ChangesAheadforStandardonServiceOrganizations.aspx
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8.6.4.3
|
The audit shall be conducted by an independent auditing firm, which has SAS 70 and SSAE No. 16 audit experience. The auditor must meet all AICPA standards for independence. The selection of, and contract with the independent auditor shall be subject to the approval of DCH and the State Auditor. Since such audits are not intended to fully satisfy all auditing requirements of DCH, the State Auditor reserves the right to fully and completely audit at their discretion the Contractor’s operation, including all aspects, which will have effect upon the DCH account, either on an interim audit basis or at the end of the State’s fiscal year. DCH also reserves the right to designate other auditors or reviewers to examine the Contractor’s operations and records for monitoring and/or stewardship purposes.
|
8.6.4.4
|
The independent auditing firm shall simultaneously deliver identical reports of its findings and recommendations to the Contractor and DCH within forty-five (45) Calendar Days after the close of each review period. The audit shall be conducted and the report shall be prepared in accordance with generally accepted auditing standards for such audits as defined in the publications of the AICPA, entitled Statement on Standards for Attestation Engagements (SSAE) Number 16 (SSAE 16), Reporting on Controls at a Service Organization.
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8.6.4.5
|
The Contractor shall respond to the audit findings and recommendations within thirty (30) Calendar Days of receipt of the audit and shall submit an acceptable proposed corrective action to DCH. The Contractor shall implement the CAPA/PC within forty (40) Calendar Days of its approval by DCH. Such response shall address, at minimum, any opinion other than a clean opinion; any testing exception; and any other exception, deficiency, weakness, opportunity for improvement, or recommendation reported by the independent auditor.
|
8.6.5
|
The Contractor shall submit to DCH a “Disclosure of Ownership and Control Interest Statement.
|
8.6.5.1
|
The Contractor shall disclose to DCH full and complete information regarding ownership, financial transactions and persons convicted of criminal activity related to Medicare, Medicaid, or the federal Title XX programs in the time and manner set forth in accordance with federal and state requirements, including 42 CFR §455.104.
|
8.6.5.2
|
The Contractor and its subcontractors shall collect the disclosure of health care-related criminal conviction information as required by 42 CFR§ 455.106 and establish policies and procedures to ensure that applicable criminal convictions are reported timely to the State. The Contractor shall screen their employees and contractors initially and on an ongoing monthly basis to determine whether any of them has been excluded from participation in Medicare, Medicaid, CHIP, or any Federal health care programs (as defined in Section 1128B(f) of the Social Security Act) and not employ or contract with an individual or entity that has been excluded. The results of said screenings shall be provided to the DCH on a monthly basis. The word “contractors” in this section shall refer to all individuals listed on the disclosure form including providers and non-providers such as board members, owners, agents, managing employees, etc.
|
8.6.5.3
|
Definition of A Party in Interest – As defined in section 1318(b) of the Public Health Service Act, a party in interest is:
|
·
|
Any director, officer, partner, or employee responsible for management or administration of an HMO; any person who is directly or indirectly the beneficial owner of more than five percent (5%) of the equity of the HMO; any person who is the beneficial owner of a mortgage, deed of trust, note, or other interest secured by, and valuing more than five percent (5%) of the HMO; or, in the case of an HMO organized as a nonprofit corporation, an incorporator or Member of such corporation under applicable State corporation law;
|
·
|
Any organization in which a person as described in the above section is a director, officer or partner; has directly or indirectly a beneficial interest of more than five percent (5%) of the equity of the HMO; or has a mortgage, deed of trust, note, or other interest valuing more than five percent (5%) of the assets of the HMO;
|
·
|
Any person directly or indirectly controlling, controlled by, or under common control with a HMO; or
|
·
|
Any spouse, child, or parent of an individual as described in section 8.6.5.1.
|
8.6.5.4
|
The Contractor shall disclose the name and address of each person with an ownership or control interest in the disclosing entity or in any Provider, subcontractor or fiscal agent in which the disclosing entity has direct or indirect ownership of five percent (5%) or more and whether any of the persons named pursuant to this requirement is related to another as spouse, parent, child, or sibling. This disclosure shall include the name of any other disclosing entity in which a person with an ownership or control interest in the disclosing entity also has an ownership or control interest.
|
8.6.5.5
|
The Contractor shall disclose the identity of any Provider or subcontractor with whom the Contractor has had significant business transactions, defined as those totaling more than twenty-five thousand dollars ($25,000) during the twelve (12) month period ending on the date of the disclosure, and any significant business transactions between the Contractor, any wholly owned supplier, or between the Contractor and any Provider or subcontractor, during the five (5) year period ending on the date of the disclosure.
|
8.6.5.6
|
The Contractor shall disclose the identity of any person who has an ownership or control interest in the Contractor, or is an agent or managing employee of the Contractor and who has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, or the federal Title XX services program since the inception of those programs.
|
8.6.5.7
|
Types of Transactions Which Must Be Disclosed – Business transactions which must be disclosed include:
|
·
|
Any sale, exchange or lease of any property between the Contractor and a party in interest;
|
·
|
Any lending of money or other extension of credit between the Contractor and a party in interest; and
|
·
|
Any furnishing for consideration of goods, services (including management services) or facilities between the Contractor and the party in interest. This does not include salaries paid to employees for services provided in the normal course of their employment;
|
|
8.6.5.3
|
The information which must be disclosed in the transactions listed in Section 8.6.5.7 between the Contractor and a party of interest includes:
|
·
|
The name of the party in interest for each transaction;
|
·
|
A description of each transaction and the quantity or units involved;
|
·
|
The accrued dollar value of each transaction during the fiscal year; and
|
·
|
Justification of the reasonableness of each transaction.
|
8.6.6
|
The Contractor shall submit all necessary reports, documentation, to DOI as required by State law, which may include, but is not limited to the following:
|
·
|
Pursuant to State law and regulations, an annual report on the form prescribed by the National Association of Insurance Commissioners (NAIC) for HMOs, on or before March 1 of each calendar year.
|
·
|
An annual income statement detailing the Contractor’s fourth quarter and year to date earned revenue and incurred expenses as a result of this Contract on or before March 1 of each year. This annual income statement shall be accompanied by a Medical Loss Ratio report for the corresponding period and a reconciliation of the Medical Loss Ratio report to the annual NAIC filing on an accrual basis.
|
·
|
Pursuant to state law and regulations, a quarterly report on the form prescribed by the NAIC for HMOs filed on or before May 15 for the first quarter of the year, August 15 for the second quarter of the year, and November 15, for the third quarter of the year.
|
·
|
A quarterly income statement detailing the Contractor’s quarterly and year to date earned revenue and incurred expenses because of this contract filed on or before May 15, for the first quarter of the year, August 15, for the second quarter of the year, and November 15, for the third quarter of the year. Each quarterly income statement shall be accompanied by a Medical Loss Ratio report for the corresponding period and reconciliation of the Medical Loss Ratio report to the quarterly NAIC filing on an accrual basis.
|
·
|
An annual independent audit of its business transactions to be performed by a licensed and certified public accountant, in accordance with National Association of Insurance Commissioners Annual Statement Instructions regarding the Annual Audited Financial Report, including but not limited to the financial transactions made under this contract.
|
8.6.7
|
The Contractor shall submit all necessary reports, documentation, to the Department of Revenue as required by State law, which may include, but is not limited to the following for Unclaimed Property Reports:
|
·
|
Pursuant to State law and regulations, an annual report on the form prescribed by the Georgia Department of Revenue for Unclaimed Property Reports for all Insurance Companies are due on or before May 1 of each calendar year.
|
9.1
|
Contractor will forthwith pay all taxes lawfully imposed upon it with respect to this Contract or any product delivered in accordance herewith. DCH makes no representation whatsoever as to the liability or exemption from liability of Contractor to any tax imposed by any governmental entity.
|
9.2
|
The Contractor shall remit the Quality Assessment fee, as provided for in O.C.G.A. §31-8-170 et seq., in the manner prescribed by DCH.
|
9.3
|
Furthermore, Contractor shall be responsible for payment of all expenses related to, based on, or arising from salaries, benefits, employment taxes (whether State or Federal) and insurance (whether health, disability, personal, or retirement) for its employees, designees, or assignees.
|
|
DCH, the State Department of Audits and Accounts, the U.S. Department of Health and Human Services, the General Accounting Office, the Comptroller General of the United States, if applicable, or their Authorized Representatives, shall have the right to enter into the premises of the Contractor and/or all Subcontractors, or such other places where duties under this Contract are being performed for DCH, to inspect, monitor or otherwise evaluate the services or any work performed pursuant to this Contract. All inspections and evaluations of work being performed shall be conducted with prior notice and during normal business hours. All inspections and evaluations shall be performed in such a manner as will not unduly delay work.
|
12.1
|
The Contractor agrees that any papers, materials and other documents that are produced or that result, directly or indirectly, from or in connection with the Contractor’s provision of the services under this Contract shall be the property of DCH upon creation of such documents, for whatever use that DCH deems appropriate, and the Contractor further agrees to execute any and all documents, or to take any additional actions that may be necessary in the future to effectuate this provision fully. In particular, if the work product or services include the taking of photographs or videotapes of individuals, the Contractor shall obtain the written consent from such individuals authorizing the use by DCH of such photographs, videotapes, and names in conjunction with such use. Contractor shall also obtain necessary releases from such individuals, releasing DCH from any and all Claims or demands arising from such use.
|
12.2
|
The Contractor shall be responsible for the proper custody and care of any State-owned property furnished for the Contractor’s use in connection with the performance of this Contract. The Contractor will also reimburse DCH for its loss or damage, normal wear and tear excepted, while such property is in the Contractor’s custody or use.
|
12.3
|
The Parties agree that access to or review of documents or materials by DCH or any other agency of State Government for informational or educational purposes shall not be regarded as having been “received” by DCH or such other agency within the meaning of O.C.G.A. Section 50-18-70 (a), except insofar as (1) copies of such documents or materials are retained and maintained by a State agency for future reference or use in the performance of State functions, or (2) the creation of such documents or materials, and approval of the specific content of such documents or materials, is expressly required by this Contract or any amendment thereto. The Parties further agree that Manuals, instructions, or other documents or materials created by Contractor for the use, information, and /or direction of its own employees, and that describe Contractor’s internal procedures, policies, staffing, systems, operations, methodologies, or the like, shall not be regarded as records received or maintained by Contractor in the performance of a service or function for or on behalf of DCH, notwithstanding that such documents or materials may describe procedures, policies, systems, methodologies, operations, or the like that are applied or followed by Contractor in the course of fulfilling its obligations under this Contract.
|
|
All data created from information, documents, messages (verbal or electronic), reports, or meetings involving or arising out of this Contract is owned by DCH, hereafter referred to as DCH Data. The Contractor shall make all data available to DCH, who will also provide it to CMS upon request. The Contractor is expressly prohibited from sharing or publishing DCH Data or any information relating to Medicaid data without the prior written consent of DCH. In the event of a dispute regarding what is or is not DCH Data, DCH’s decision on this matter shall be final and not subject to Appeal.
|
§
|
Procure for the Department the right to continue using the deliverables; or,
|
§
|
Modify or replace the deliverables to comply with the specifications so that no violation of any intellectual property right occurs. If Contractor fails to comply with the terms and conditions set forth in this section, DCH shall have the option to terminate the Contract.
|
|
The Parties also understand and agree that any upgrades or enhancements to software programs, hardware, or other equipment, whether electronic or physical, shall be made at the Contractor’s expense only, unless the upgrade or enhancement is made at DCH’s request and solely for DCH’s use. Any upgrades or enhancements requested by and made for DCH’s sole use shall become DCH’s property without exception or limitation. The Contractor agrees that it will facilitate DCH’s use of such upgrade or enhancement and cooperate in the transfer of ownership, installation, and operation by DCH.
|
|
·
|
The Contractor warrants and represents that all persons, including independent Contractors and consultants assigned by it to perform this Contract, shall be employees or formal agents of the Contractor and shall have the credentials necessary (i.e., licensed, and bonded, as required) to perform the work required herein. The Contractor shall include a similar provision in any contract with any Subcontractor selected to perform work hereunder. The Contractor also agrees that DCH may approve or disapprove the Contractor’s Subcontractors or its staff assigned to this Contract prior to the proposed staff assignment. DCH’s decision on this matter shall not be subject to Appeal.
|
·
|
The Contractor shall insure that all personnel involved in activities that involve clinical or medical decision making have a valid, active, and unrestricted license to practice. On at least an annual basis, the CMO and its subcontractors will verify that staff has a current license that is in good standing and will provide a list to DCH of licensed staff and current licensure status.
|
·
|
In addition, the Contractor warrants that all persons assigned by it to perform work under this Contract shall be employees or authorized Subcontractors of the Contractor and shall be fully qualified, as required in the RFP and specified in the Contractor’s proposal and in this Contract, to perform the services required herein. Personnel commitments made in the Contractor's proposal shall not be changed unless approved by DCH in writing. Staffing will include the named individuals at the levels of effort proposed.
|
·
|
The Contractor shall provide and maintain sufficient qualified personnel and staffing to enable the Deliverables to be provided in accordance with the RFP, the Contractor's proposal and this Contract. The Contractor shall submit to DCH a detailed staffing plan, including the employees and management for all CMO functions.
|
·
|
At a minimum, the Contractor shall provide the following staff:
|
o
|
An Executive Administrator who is a full-time administrator with clear authority over the general administration and implementation of the requirements detailed in this Contract.
|
o
|
A Medical Director who is a licensed physician in the State of Georgia. The Medical Director shall be actively involved in all major clinical program components of the CMO plan, shall be responsible for the sufficiency and supervision of the Provider network, and shall ensure compliance with federal, State and local reporting laws on communicable diseases, child abuse, neglect, etc.
|
o
|
A Quality Improvement/Utilization Director.
|
o
|
A Chief Financial Officer who oversees all budget and accounting systems.
|
o
|
An Information Management and Systems Director and a complement of technical analysts and business analysts as needed to maintain the operations of Contractor Systems and to address System issues in accordance with the terms of this contract.
|
o
|
A Pharmacist who is licensed in the State of Georgia;
|
o
|
A Dental Consultant who is a licensed dentist in the State of Georgia.
|
o
|
A Mental Health Coordinator who is a licensed mental health professional in the State of Georgia.
|
o
|
A Member Services Director.
|
o
|
A Provider Services Director.
|
o
|
A Provider Relations Liaison.
|
o
|
A Grievance/Complaint Coordinator.
|
o
|
Compliance Officer.
|
o
|
A Prior Authorization/Pre-Certification Coordinator who is a physician, registered nurse, or physician’s assistant licensed in the State of Georgia.
|
o
|
Sufficient staff in all departments, including but not limited to, Member services, Provider services, and prior authorization and concurrent review services to ensure appropriate functioning in all areas.
|
·
|
The Contractor shall conduct on-going training of staff in all departments to ensure appropriate functioning in all areas.
|
·
|
The Contractor shall comply with all staffing/personnel obligations set out in the RFP and this Contract, including but not limited to those pertaining to security, health, and safety issues.
|
14.1.1
|
The Contractor shall notify DCH in the event of any changes to key staff, including the Executive Administrator, Medical Director, Quality Improvement/Utilization Director, Management Information Systems Director, and Chief Financial Officer. The Contractor shall replace any of the key staff with a person of equivalent experience, knowledge and talent. This notification shall take place within five (5) business days of the resignation/termination.
|
14.1.2
|
DCH also may require the removal or reassignment of any Contractor employee or Subcontractor employee that DCH deems to be unacceptable. DCH’s decision on this matter shall not be subject to Appeal. Notwithstanding the above provisions, the Parties acknowledge and agree that the Contractor may terminate any of its employees designated to perform work or services under this Contract, as permitted by applicable law. In the event of Contractor termination of any key staff identified in Section 14.0.4, the Contractor shall provide DCH with immediate notice of the termination, the reason(s) for the termination, and an action plan for replacing the discharged employee.
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14.1.3
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The Contractor must submit to DCH quarterly the Contractor Information Report that includes but is not limited to the changes to Contractor’s local staff information as well as local and corporate organizational charts.
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Should the Contractor at any time: 1) refuse or neglect to supply adequate and competent supervision; 2) refuse or fail to provide sufficient and properly skilled personnel, equipment, or materials of the proper quality or quantity; 3) fail to provide the services in accordance with the timeframes, schedule or dates set forth in this Contract; or 4) fail in the performance of any term or condition contained in this Contract, DCH may (in addition to any other contractual, legal or equitable remedies) proceed to take any one or more of the following actions after five (5) Calendar Days written notice to the Contractor:
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Withhold any monies then or next due to the Contractor;
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Obtain the services or their equivalent from a third party, pay the third party for same, and Withhold the amount so paid to third party from any money then or thereafter due to the Contractor; or
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Withhold monies in the amount of any damage caused by any deficiency or delay in the services.
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15.1
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The Contractor shall, upon request, provide DCH with a resume and satisfactory criminal background check or an attestation that a satisfactory criminal background check has been completed of any of its staff or Subcontractor’s staff assigned to or proposed to be assigned to any aspect of the performance of this Contract.
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16.0
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SUBCONTRACTS
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16.1.1
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The Contractor will not subcontract or permit anyone other than Contractor personnel to perform any of the work, services, or other performances required of the Contractor under this Contract, or assign any of its rights or obligations hereunder, without the prior written consent of DCH. Prior to hiring or entering into an agreement with any Subcontractor, any and all Subcontractors shall be approved by DCH. DCH reserves the right to inspect all subcontract agreements at any time during the Contract period. Upon request from DCH, the Contractor shall provide in writing the names of all proposed or actual Subcontractors. The Contractor is solely accountable for all functions and responsibilities contemplated and required by this Contract, whether the Contractor performs the work directly or through a Subcontractor.
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16.1.2
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All contracts between the Contractor and Subcontractors must be in writing and must specify the activities and responsibilities delegated to the Subcontractor. The contracts must also include provisions for revoking delegation or imposing other sanctions if the Subcontractor’s performance is inadequate.
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16.1.3
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All contracts must ensure that the Contractor evaluates the prospective Subcontractor’s ability to perform the activities to be delegated; monitors the Subcontractor’s performance on an ongoing basis and subjects it to formal review according to a periodic schedule established by DCH and consistent with industry standards or State laws and regulations; and identifies deficiencies or areas for improvement and that corrective action is taken.
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16.1.4
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The Contractor shall give DCH immediate notice in writing by registered mail or certified mail of any action or suit filed by any Subcontractor and prompt notice of any Claim made against the Contractor by any Subcontractor or vendor that, in the opinion of Contractor, may result in litigation related in any way to this Contract.
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16.1.5
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All Subcontractors must fulfill the requirements of 42 CFR 438.6 as appropriate.
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16.1.6
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All Provider contracts shall comply with the requirements and provisions as set forth in Section 4.10 of this Contract.
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16.1.7
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The Contractor shall submit a Subcontractor Information Report to include, but is not limited to: Subcontractor name, services provided, effective date of the subcontracted agreement.
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16.1.8
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The Contractor shall submit to DCH a written notification of any subcontractor terminations at least ninety (90) days prior to the effective date of the termination.
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16.2
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COST OR PRICING BY SUBCONTRACTORS
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16.2.1
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The Contractor shall submit, or shall require any Subcontractors hereunder to submit, cost or pricing data for any subcontract to this Contract prior to award. The Contractor shall also certify that the information submitted by the Subcontractor is, to the best of their knowledge and belief, accurate, complete and current as of the date of agreement, or the date of the negotiated price of the subcontract to the Contract or amendment to the Contract. The Contractor shall insert the substance of this Section in each subcontract hereunder.
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16.2.2
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If DCH determines that any price, including profit or fee negotiated in connection with this Contract, or any cost reimbursable under this Contract was increased by any significant sum because of the inaccurate cost or pricing data, then such price and cost shall be reduced accordingly and this Contract and the subcontract shall be modified in writing to reflect such reduction.
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17.1
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Contractor shall have, obtain, and maintain in good standing any licenses, certificates and permits, whether State or federal, that are required prior to and during the performance of work under this Contract. Contractor agrees to provide DCH with certified copies of all licenses, certificates and permits that may be necessary, upon DCH’s request.
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17.2
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The Contractor warrants that it is qualified to do business in the State and is not prohibited by its articles of incorporation, bylaws or any law of the State under which it is incorporated from performing the services under this Contract. The Contractor shall have and maintain a Certificate of Authority pursuant to O.C.G.A. §33-21, and shall obtain and maintain in good standing any Georgia-licenses, certificates and permits, whether State or federal, that are required prior to and during the performance of work under this Contract. Loss of the licenses, certificates, permits, or Certificate of Authority for health maintenance organizations shall be cause for termination of the Contract pursuant to Section 22 of this Contract. In the event the Certificate of Authority, or any other license or permit is canceled, revoked, suspended or expires during the term of this Contract, the Contractor shall inform the State immediately and cease all activities under this Contract, until further instruction from DCH. The Contractor agrees to provide DCH with certified copies of all licenses, certificates and permits necessary upon request.
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17.2
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The Contractor shall be accredited by the National Committee for Quality Assurance (NCQA) for MCO, URAC (Health Plan accreditation), Accreditation Association for Ambulatory Health Care (AAAHC) for MCO, or Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for MCO, or shall be actively seeking and working towards such accreditation. The Contractor shall provide to DCH upon request any and all documents related to achieving such accreditation and DCH shall monitor the Contractor’s progress towards accreditation. DCH may require that the Contractor achieve such accreditation by year three of this Contract.
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17.3
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The Contractor shall notify DCH within fifteen calendar days of any accrediting organization noted deficiencies as well as any accreditations that have been rescinded by a recognized accrediting organization.
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17.4
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The Contractor warrants that there is no claim, legal action, counterclaim, suit, arbitration, governmental investigation or other legal, administrative, or tax proceeding, or any order, decree or judgment of any court, governmental agency, or arbitration tribunal that is in progress, pending, or threatened against or relating to Contractor or the assets of Contractor that would individually or in the aggregate have a material adverse effect on Contractor’s ability to perform the obligations contemplated by this Agreement. Without limiting the generality of the representation of the immediately preceding sentence, Contractor is not currently the subject of a voluntary or involuntary petition in bankruptcy, does not presently contemplate filing any such voluntary petition, and is not aware of any intention on the part of any other person, or entity, to file such an involuntary petition against it.
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18.1
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DCH takes no title to any of the Contractor’s goods used in providing the services and/or Deliverables hereunder and the Contractor shall bear all risk of loss for any goods used in performing work pursuant to this Contract.
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18.2
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The Parties agree that DCH may reasonably rely upon the representations and certifications made by the Contractor, including those made by the Contractor in the Contractor’s response to the RFP and this Contract, without first making an independent investigation or verification.
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18.3
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The Parties also agree that DCH may reasonably rely upon any audit report, summary, analysis, certification, review, or work product that the Contractor produces in accordance with its duties under this Contract, without first making an independent investigation or verification.
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19.0
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PROHIBITION OF GRATUITIES AND LOBBYIST DISCLOSURES
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19.1
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The Contractor, in the performance of this Contract, shall not offer or give, directly or indirectly, to any employee or agent of the State, any gift, money or anything of value, or any promise, obligation, or contract for future reward or compensation at any time during the term of this Contract, and shall comply with the disclosure requirements set forth in O.C.G.A. § 45-1-6.
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19.2
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The Contractor also states and warrants that it has complied with all disclosure and registration requirements for vendor lobbyists as set forth in O.C.G.A. § 21-5-1, et seq. and all other applicable law, including but not limited to registering with the State Ethics Commission. In addition, the Contractor states and warrants that no federal money has been used for any lobbying of State officials, as required under applicable federal law. For the purposes of this Contract, vendor lobbyists are those who lobby State officials on behalf of businesses that seek a contract to sell goods or services to the State or oppose such contract.
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The Contractor agrees to maintain books, records, documents, and other evidence pertaining to the costs and expenses of this Contract to the extent and in such detail as will properly reflect all costs for which payment is made under the provisions of this Contract and/or any document that is a part of this Contract by reference or inclusion. The Contractor’s accounting procedures and practices shall conform to generally accepted accounting principles, and the costs properly applicable to the Contract shall be readily ascertainable.
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20.1
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RECORDS RETENTION REQUIREMENTS
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The Contractor shall preserve and make available all of its records pertaining to the performance under this Contract for a period of seven (7) years from the date of final payment under this Contract, and for such period, if any, as is required by applicable statute or by any other section of this Contract. If the Contract is completely or partially terminated, the records relating to the work terminated shall be preserved and made available for period of seven (7) years from the date of termination or of any resulting final settlement. Records that relate to Appeals, litigation, or the settlements of Claims arising out of the performance of this Contract, or costs and expenses of any such agreements as to which exception has been taken by the State Contractor or any of his duly Authorized Representatives, shall be retained by Contractor until such Appeals, litigation, Claims or exceptions have been disposed of.
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20.2
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ACCESS TO RECORDS
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The State and federal standards for audits of DCH agents, contractors, and programs are applicable to this section and are incorporated by reference into this Contract as though fully set out herein.
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Pursuant to the requirements of 42 CFR 434.6(a) (5) and 42 CFR 434.38, the Contractor shall make all of its books, documents, papers, Provider records, Medical Records, financial records, data, surveys and computer databases available for examination and audit by DCH, the State Attorney General, the State Health Care Fraud Control Unit, the State Department of Audits, and/or authorized State or federal personnel. Any records requested hereunder shall be produced immediately for review at DCH or sent to the requesting authority by mail within fourteen (14) Calendar Days following a request. All records shall be provided at the sole cost and expense of the Contractor. DCH shall have unlimited rights to access, use, disclose, and duplicate all information and data in any way relating to this Contract in accordance with applicable State and federal laws and regulations. DCH shall not be restricted in the number of times it may audit, visit, inspect, review or otherwise monitor Contractor and any subcontractors during the term of this Contract. DCH will only conduct audits as determined reasonably necessary by the Department.
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The Department may issue subpoenas to Contractor, which require the Contractor or its agents (e.g. employees, subcontractors) to: produce and permit inspection and copying of designated books, papers, documents, or other tangible items; and/or attend and give testimony at a deposition or hearing. The Contractor agrees to comply with all subpoenas issued by the Department or parties acting on behalf of the Department. The Contractor understands that it is ultimately responsible for its agents’ compliance with the subpoenas described herein.
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During the entire life of the Contract, the Contractor and all subcontractors shall provide DCH with copies of its annual report and all disclosure or reporting statements or forms filed with the State of Georgia and/or the Securities and Exchange Commission (SEC) as soon as they are prepared in final form and are otherwise available for distribution or filing. In the event that the Contractor is not required to or does not prepare either an annual report or SEC disclosure or reporting statements or forms by virtue of being a subsidiary of another corporation, it shall fulfill the requirements of this section, with respect to all such documents for any parent corporation, which reflect, report or include any of its operations on any basis. In addition, upon the written request of the Program Manager, the Contractor and all subcontractors shall furnish DCH with the most recent un-audited and audited copies of its current balance sheet within fourteen (14) calendar days of its receipt of such request.
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20.3
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MEDICAL RECORD REQUESTS
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The Contractor shall ensure a copy of the Member’s Medical Record is made available, without charge, upon the written request of the Member or Authorized Representative within fourteen (14) Calendar Days of the receipt of the written request.
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The Contractor shall ensure that Medical Records are furnished at no cost to a new PCP, Out-of-Network Provider or other specialist, upon Member’s request, no later than fourteen (14) Calendar Days following the written request.
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21.1
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GENERAL CONFIDENTIALITY REQUIREMENTS
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The Contractor shall treat all information, including Medical Records and any other health and Enrollment information that identifies a particular Member or that is obtained or viewed by it or through its staff and Subcontractors performance under this Contract as confidential information, consistent with the confidentiality requirements of 45 CFR parts 160 and 164. The Contractor shall not use any information so obtained in any manner, except as may be necessary for the proper discharge of its obligations. Employees or authorized Subcontractors of the Contractor who have a reasonable need to know such information for purposes of performing their duties under this Contract shall use personal or patient information, provided such employees and/or Subcontractors have first signed an appropriate non-disclosure agreement that has been approved and maintained by DCH. The Contractor shall remove any person from performance of services hereunder upon notice that DCH reasonably believes that such person has failed to comply with the confidentiality obligations of this Contract. The Contractor shall replace such removed personnel in accordance with the staffing requirements of this Contract. DCH, the Georgia Attorney General, federal officials as authorized by federal law or regulations, or the Authorized Representatives of these parties shall have access to all confidential information in accordance with the requirements of State and federal laws and regulations.
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21.2
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HIPAA COMPLIANCE
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The Contractor shall assist DCH in its efforts to comply with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and its amendments, rules, procedures, and regulations. To that end, the Contractor shall cooperate and abide by any requirements mandated by HIPAA or any other applicable laws. Contractor warrants that it will cooperate with DCH, including cooperation with DCH privacy officials and other compliance officers required by HIPAA and its regulations, in the course of performance of this Contract so that both parties will be in compliance with HIPAA. The Contractor acknowledges that HIPAA may require the Contractor and DCH to sign documents for compliance purposes, including but not limited to a Business Associate Agreement. The Contractor shall cooperate with DCH on these matters, sign whatever documents may be required for HIPAA compliance, and abide by their terms and conditions. Contractor also agrees to abide by the terms and conditions of DCH policies and procedures regarding privacy and security.
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22.1
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GENERAL PROCEDURES
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This Contract may terminate, or may be terminated, by DCH for any or all of the following reasons:
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Default by the Contractor, upon thirty (30) Calendar Days’ notice;
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Convenience of DCH, upon thirty (30) Calendar Days’ notice;
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Immediately, in the event of insolvency, Contract breach, or declaration of bankruptcy by the Contractor; or
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Immediately, when sufficient appropriated funds no longer exist for the payment of DCH's obligation under this Contract.
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22.2
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TERMINATION BY DEFAULT
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22.2.1
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In the event DCH determines that the Contractor has defaulted by failing to carry out the substantive terms of this Contract or failing to meet the applicable requirements in 1932 and 1903(m) of the Social Security Act, DCH may terminate the Contract in addition to or in lieu of any other remedies set out in this Contract or available by law.
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22.2.2
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Prior to the termination of this Contract, DCH will:
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Provide written notice of the intent to terminate at least thirty (30) Calendar Days prior to the termination date, the reason for the termination, and the time and place of a hearing to give the Contractor an opportunity to Appeal the determination and/or cure the default;
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Provide written notice of the decision affirming or reversing the proposed termination of the Contract, and for an affirming decision, the effective date of the termination; and
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For an affirming decision, give Members or the Contractor notice of the termination and information consistent with 42 CFR 438.10 on their options for receiving Medicaid services following the effective date of termination.
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22.3
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TERMINATION FOR CONVENIENCE
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DCH may terminate this Contract for convenience and without cause upon thirty (30) Calendar Days’ written notice. Termination for convenience shall not be a breach of the Contract by DCH. The Contractor shall be entitled to receive, and shall be limited to, just and equitable compensation for any satisfactory authorized work performed as of the termination date Availability of funds shall be determined solely by DCH.
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22.4
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TERMINATION FOR INSOLVENCY OR BANKRUPTCY
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The Contractor’s insolvency, or the Contractor’s filing of a petition in bankruptcy, shall constitute grounds for termination for cause. In the event of the filing of a petition in bankruptcy, the Contractor shall immediately advise DCH. If DCH reasonably determines that the Contractor's financial condition is not sufficient to allow the Contractor to provide the services as described herein in the manner required by DCH, DCH may terminate this Contract in whole or in part, immediately or in stages. The Contractor's financial condition shall be presumed not sufficient to allow the Contractor to provide the services described herein, in the manner required by DCH if the Contractor cannot demonstrate to DCH's satisfaction that the Contractor has risk reserves and a minimum net worth sufficient to meet the statutory standards for licensed health care plans. The Contractor shall cover continuation of services to Members for the duration of period for which payment has been made, as well as for inpatient admissions up to discharge.
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22.5
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TERMINATION FOR INSUFFICIENT FUNDING
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In the event that federal and/or State funds to finance this Contract become unavailable, DCH may terminate the Contract in writing with thirty (30) Calendar Days’ notice to the Contractor. The Contractor shall be entitled to receive, and shall be limited to, just and equitable compensation for any satisfactory authorized work performed as of the termination date. Availability of funds shall be determined solely by DCH.
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22.6
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TERMINATION PROCEDURES
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22.6.1
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DCH will issue a written notice of termination to the Contractor by certified mail, return receipt requested, or in person with proof of delivery. The notice of termination shall cite the provision of this Contract giving the right to terminate, the circumstances giving rise to termination, and the date on which such termination shall become effective. Termination shall be effective at 11:59 p.m. EST on the termination date.
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22.6.2
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Upon receipt of notice of termination or on the date specified in the notice of termination and as directed by DCH, the Contractor shall:
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Stop work under the Contract on the date and to the extent specified in the notice of termination;
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Place no further orders or Subcontract for materials, services, or facilities, except as may be necessary for completion of such portion of the work under the Contract as is not terminated
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Terminate all orders and Subcontracts to the extent that they relate to the performance of work terminated by the notice of termination;
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Assign to DCH, in the manner and to the extent directed by the Contract Administrator, all of the right, title, and interest of Contractor under the orders or subcontracts so terminated, in which case DCH will have the right, at its discretion, to settle or pay any or all Claims arising out of the termination of such orders and Subcontracts;
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With the approval of the Contract Administrator, settle all outstanding liabilities and all Claims arising out of such termination or orders and subcontracts, the cost of which would be reimbursable in whole or in part, in accordance with the provisions of the Contract;
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Complete the performance of such part of the work as shall not have been terminated by the notice of termination;
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Take such action as may be necessary, or as the Contract Administrator may direct, for the protection and preservation of any and all property or information related to the Contract that is in the possession of Contractor and in which DCH has or may acquire an interest;
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Promptly make available to DCH, or another CMO plan acting on behalf of DCH, any and all records, whether medical or financial, related to the Contractor's activities undertaken pursuant to this Contract. Such records shall be provided at no expense to DCH;
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Promptly supply all information necessary to DCH, or another CMO plan acting on behalf of DCH, for reimbursement of any outstanding Claims at the time of termination; and
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Submit a termination plan to DCH for review and approval that includes the following terms:
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o
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Maintain Claims processing functions as necessary for ten (10) consecutive months in order to complete adjudication of all Claims;
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Comply with all duties and/or obligations incurred prior to the actual termination date of the Contract, including but not limited to, the Appeal process as described in Section 4.14;
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o
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File all Reports concerning the Contractor’s operations during the term of the Contract in the manner described in this Contract;
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Ensure the efficient and orderly transition of Members from coverage under this Contract to coverage under any new arrangement developed by DCH in accordance with procedures set forth in Section 4.11.4;
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o
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Maintain the financial requirements, and insurance set forth in this Contract until DCH provides the Contractor written notice that all continuing obligations of this Contract have been fulfilled; and
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Submit Reports to DCH every thirty (30) Calendar Days detailing the Contractor’s progress in completing its continuing obligations under this Contract until completion.
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22.6.3
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Upon completion of these continuing obligations, the Contractor shall submit a final report to DCH describing how the Contractor has completed its continuing obligations. DCH will advise, within twenty (20) Calendar Days of receipt of this report, if all of the Contractor’s obligations are discharged. If DCH finds that the final report does not evidence that the Contractor has fulfilled its continuing obligations, then DCH will require the Contractor to submit a revised final report to DCH for approval.
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22.7
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TERMINATION CLAIMS
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22.7.1
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After receipt of a notice of termination, the Contractor shall submit to the Contract Administrator any termination claim in the form, and with the certification prescribed by, the Contract Administrator. Such claim shall be submitted promptly but in no event later than ten (10) months from the effective date of termination. Upon failure of the Contractor to submit its termination claim within the time allowed, the Contract Administrator may, subject to any review required by the State procedures in effect as of the date of execution of the Contract, determine, on the basis of information available, the amount, if any, due to the Contractor by reason of the termination and shall thereupon cause to be paid to the Contractor the amount so determined.
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22.7.2
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Upon receipt of notice of termination, the Contractor shall have no entitlement to receive any amount for lost revenues or anticipated profits or for expenditures associated with this Contract or any other contract. Upon termination, the Contractor shall be paid in accordance with the following:
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At the Contract price(s) for completed Deliverables and/or services delivered to and accepted by DCH; and/or
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At a price mutually agreed upon by the Contractor and DCH for partially completed Deliverables and/or services.
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22.7.3
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In the event the Contractor and DCH fail to agree in whole or in part as to the amounts with respect to costs to be paid to the Contractor in connection with the total or partial termination of work pursuant to this article, DCH will determine, on the basis of information available, the amount, if any, due to the Contractor by reason of termination and shall pay to the Contractor the amount so determined.
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23.1.1
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In the event the Contractor fails to meet the terms, conditions, or requirements of this Contract and financial damages are difficult or impossible to ascertain exactly, the Contractor agrees that DCH may assess liquidated damages, not penalties, against the Contractor for the deficiencies. The Parties further acknowledge and agree that the specified liquidated damages are reasonable and the result of a good faith effort by the Parties to estimate the actual harm caused by the Contractor’s breach. The Contractor’s failure to meet the requirements in this Contract will be divided into four (4) categories of events.
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23.1.2
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Notwithstanding any sanction or liquidated damages imposed upon the Contractor other than Contract termination, the Contractor shall continue to provide all Covered Services and care management.
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23.2.1
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Liquidated damages up to $100,000 per violation may be imposed for Category 1 events. For Category 1 events, the Contractor shall submit a written CAPA/PC to DCH for review and approval prior to implementing the corrective action. Category 1 events are monitored by DCH to determine compliance and shall include and constitute the following:
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Acts that discriminate among Members on the basis of their health status or need for health care services; and
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Misrepresentation of actions or falsification of information furnished to CMS or the State.
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Failure to implement requirements stated in the Contractor’s proposal, the RFP, this Contract, or other material failures in the Contractor’s duties.
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Failure to participate in a readiness and/or annual review.
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Failure to provide an adequate provider network of physicians, pharmacies, hospitals, and other specified health care Providers in order to assure member access to all Covered Services.
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23.3.1
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Liquidated damages up to $25,000 per violation may be imposed for the Category 2 events. For Category 2 events, the Contractor shall submit a written CAPA/PC to DCH for review and approval prior to implementing the corrective action. Category 2 events are monitored by DCH to determine compliance and include the following:
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Substantial failure to provide medically necessary services that the Contractor is required to provide under law, or under this Contract, to a Member covered under this Contract;
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Misrepresentation or falsification of information furnished to a Member, Potential Member, or health care Provider;
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Failure to comply with the requirements for physician incentive plans, as set forth in 42 CFR 422.208 and 422.210;
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Distribution directly, or indirectly, through any Agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information;
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Violation of any other applicable requirements of section 1903(m) or 1932 of the Social Security Act and any implementing regulations;
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Failure of the Contractor to assume full operation of its duties under this Contract in accordance with the transition timeframes specified herein;
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Imposition of premiums or charges on Members that are in excess of the premiums or charges permitted under the Medicaid program (the State will deduct the amount of the overcharge and return it to the affected Member).
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Failure to resolve Member Appeals and Grievances within the timeframes specified in this Contract;
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Failure to ensure client confidentiality in accordance with 45 CFR 160 and 45 CFR 164; and an incident of noncompliance will be assessed as per member and/or per HIPAA regulatory violation.
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Violation of a subcontracting requirement in the Contract.
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23.4.1
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Liquidated damages up to $5,000.00 per day may be imposed for Category 3 events. For Category 3 events, a written CAPA/PC may be required and corrective action must be taken. In the case of Category 3 events, if corrective action is taken within four (4) Business Days, then liquidated damages may be waived at the discretion of DCH. Category 3 events are monitored by DCH to determine compliance and shall include the following:
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Failure to submit required Reports and Deliverables in the timeframes prescribed in Section 4.18 and Section 5.7;
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Submission of incorrect or deficient Deliverables or Reports as determined by DCH;
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Failure to comply with the Claims processing standards as follows:
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o
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Failure to process and finalize to a paid or denied status ninety-seven percent (97%) of all Clean Claims within fifteen (15) Business Days during a fiscal year;
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o
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Failure to pay Providers interest at an eighteen percent (18%) annual rate, calculated daily for the full period during which a clean, unduplicated Claim is not adjudicated within the claims processing deadlines. For all claims that are initially denied or underpaid by the Contractor but eventually determined or agreed to have been owed by the Contractor to a provider of health care services, the Contractor shall pay, in addition to the amount determined to be owed, interest of twenty percent (20%) per annum (based on simple interest calculations), calculated from 15 calendar days after the date the claim was submitted. A Contractor shall pay all interest required to be paid under this provision or Code Section 33-24-59.5 automatically and simultaneously whenever payment is made for the claim giving rise to the interest payment. All interest payments shall be accurately identified on the associated remittance advice submitted by the Contractor to the Provider. A Contractor shall not be responsible for the penalty described in this subsection if the health care provider submits a claim containing a material omission or inaccuracy in any of the data elements required for a complete standard health care claim form as prescribed under 45 C.F.R. Part 162 for electronic claims, a CMS Form 1500 for non-electronic claims, or any claim prescribed by DCH.
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Failure to comply with the eighty percent (80%) of screening ratio on the Contractor’s CMS-416 Health Check as described Section 4.7.3.8.
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Failure to achieve the Performance Target for any one Quality Performance Measure.
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Failure to provide an initial visit within fourteen (14) Calendar Days for all newly enrolled women who are pregnant in accordance with Sections 4.6.9.1.
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Failure to comply with the Notice of Proposed Action and Notice of Adverse Action requirements as described in Sections 4.14.3 and 4.14.5.
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Failure to comply with any CAPA/PC as required by DCH.
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Failure to seek, collect and/or report third party information as described in Section 8.4.
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Failure to comply with the Contractor staffing requirements as described in Section 14.2.
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Failure of Contractor to issue written notice to Members upon Provider’s notice of termination in the Contractor’s plan as described in Section 4.10.2.3.
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·
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Failure to comply with federal law regarding sterilizations, hysterectomies, and abortions and as described in Section 4.6.5.
|
·
|
Failure to submit acceptable member and provider directed materials or documents in a timely manner, i.e., member and provider directories, handbooks, policies and procedures.
|
·
|
Failure to comply with the required Demonstration Reports and Deliverables as prescribed in Attachments O and Q.
|
·
|
Failure to achieve annual targeted reductions in the Pregnancy Rate as identified in Attachment O.
|
·
|
Failure to deliver effective Demonstration services as evidenced by lack of achievement of annual targeted LBW and VLBW reduction targets as identified in Attachment O.
|
23.5.1
|
Liquidated damages as specified below may be imposed for Category 4 events. Imposition of liquidated damages will not relieve the Contractor from submitting and implementing CAPA/PC or corrective action as determined by DCH. Category 4 events are monitored by DCH to determine compliance and include the following:
|
23.5.1.1
|
Failure to implement the business continuity-disaster recovery (BC-DR) plan as follows:
|
·
|
Implementation of the (BC-DR) plan exceeds the proposed time by two (2) or less Calendar Days: five thousand dollars ($5,000) per day up to day 2;
|
·
|
Implementation of the (BC-DR) plan exceeds the proposed time by more than (2) and up to five (5) Calendar Days: ten thousand dollars ($10,000) per each day beginning with Day 3 and up to Day 5;
|
·
|
Implementation of the (BC-DR) plan exceeds the proposed time by more than five (5) and up to ten (10) Calendar Days, twenty-five thousand dollars ($25,000) per day beginning with Day 6 and up to Day 10; and
|
·
|
Implementation of the (BC-DR) plan exceeds the proposed time by more than ten (10) Calendar Days: fifty thousand dollars ($50,000) per each day beginning with Day 11.
|
23.5.1.2
|
Unscheduled System Unavailability (other than CCE and ECM functions described below) occurring during a continuous five (5) Business Day period, may be assessed as follows:
|
·
|
Greater than or equal to two (2) and less than twelve (12) hours cumulative: up to one hundred twenty-five dollars ($125) for each thirty (30) minutes or portions thereof;
|
·
|
Greater than or equal to twelve (12) and less than twenty-four (24) hours cumulative: up to two hundred fifty dollars ($250) for each thirty (30) minutes or portions thereof; and
|
·
|
Greater than or equal to twenty-four (24) hours cumulative: up to five hundred dollars ($500) for each thirty (30) minutes or portions thereof up to a maximum of twenty-five thousand dollars ($25,000) per occurrence.
|
23.5.1.3
|
Confirmation of CMO Enrollment (CCE) or Electronic Claims Management (ECM) system downtime. In any calendar week, penalties may be assessed as follows for downtime outside the State’s control of any component of the CCE and ECM systems, such as the voice response system and PC software response system:
|
·
|
Less than twelve (12) hours cumulative: up to two hundred fifty dollars ($250) for each thirty (30) minutes or portions thereof;
|
·
|
Greater than or equal to twelve (12) and less than twenty-four (24) hours cumulative: up to five hundred ($500) for each thirty (30) minutes or portions thereof; and
|
·
|
Greater than or equal to twenty-four (24) hours cumulative: up to one thousand dollars ($1,000) for each thirty (30) minutes or portions thereof up to a maximum of fifty thousand dollars ($50,000) per occurrence.
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23.5.1.4
|
Failure to make available to the state and/or its agent readable, valid extracts of Encounter Information for a specific month within fifteen (15) Calendar Days of the close of the month: five hundred dollars ($500) per day. After fifteen (15) Calendar Days of the close of the month: two thousand dollars ($2000) per day.
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23.5.1.5
|
Failure to correct a system problem not resulting in System Unavailability within the allowed timeframe, where failure to complete was not due to the action or inaction on the part of DCH as documented in writing by the Contractor:
|
·
|
One (1) to fifteen (15) Calendar Days late: two hundred and fifty dollars ($250) per Calendar Day for Days 1 through 15;
|
·
|
Sixteen (16) to thirty (30) Calendar Days late: five hundred dollars ($500) per Calendar Day for Days 16 through 30; and
|
·
|
More than thirty (30) Calendar Days late: one thousand dollars ($1,000) per Calendar Day for Days 31 and beyond.
|
23.5.1.6
|
Failure to meet the Telephone Hotline performance standards:
|
·
|
$1,000.00 for each percentage point that is below the target answer rate of eighty percent (80%) in thirty (30) seconds;
|
·
|
$1,000.00 for each percentage point that is above the target of a one percent (1%) Blocked Call rate; and
|
·
|
$1,000.00 for each percentage point that is above the target of a five percent (5%) Abandoned Call rate.
|
|
23.6
|
OTHER REMEDIES
|
|
In addition other liquidated damages described above for Category 1-4 events, DCH may impose the following other remedies:
|
·
|
Appointment of temporary management of the Contractor as provided in 42 CFR 438.706, if DCH finds that the Contractor has repeatedly failed to meet substantive requirements in section 1903 (m) or section 1932 of the Social Security Act;
|
·
|
Granting Members the right to terminate Enrollment without cause and notifying the affected Members of their right to disenroll;
|
·
|
Suspension of all new Enrollment, including default Enrollment, after the effective date of remedies;
|
·
|
Suspension of payment to the Contractor for Members enrolled after the effective date of the remedies and until CMS or DCH is satisfied that the reason for imposition of the remedies no longer exists and is not likely to occur;
|
·
|
Termination of the Contract if the Contractor fails to carry out the substantive terms of the Contract or fails to meet the applicable requirements in 1932 and 1903(m) of the Social Security Act;
|
·
|
Civil Monetary Fines in accordance with 42 CFR 438.704; and
|
·
|
Additional remedies allowed under State statute or State regulation that address areas of non-compliance specified in 42 CFR 438.700.
|
|
|
23.7
|
NOTICE OF REMEDIES
|
|
Prior to the imposition of either liquidated damages or other remedies, DCH will issue a written notice of remedies that will include the following:
|
·
|
A citation to the law, regulation or Contract provision that has been violated;
|
·
|
The remedies to be applied and the date the remedies will be imposed;
|
·
|
The basis for DCH’s determination that the remedies should be imposed;
|
·
|
Request for a CAPA/PC, if applicable; and
|
·
|
The time frame and procedure for the Contractor to dispute DCH’s determination. A Contractor’s dispute of a liquidated damage or remedies shall not stay the effective date of the proposed liquidated damage or remedies.
|
|
The Contractor hereby releases and agrees to indemnify and hold harmless DCH, the State of Georgia and its departments, agencies and instrumentalities (including the State Tort Claims Trust Fund, the State Authority Liability Trust Fund, The State Employee Broad Form Liability Funds, the State Insurance and Hazard Reserve Fund, and other self-insured funds, all such funds hereinafter collectively referred to as the "Funds") from and against any and all claims, demands, liabilities, losses, costs or expenses, and attorneys' fees, caused by, growing out of, or arising from this Contract, due to any act or omission on the part of the Contractor, its agents, employees, customers, invitees, licensees or others working at the direction of the Contractor or on its behalf, or due to any breach of this Contract by the Contractor, or due to the application or violation of any pertinent federal, State or local law, rule or regulation. This indemnification extends to the successors and assigns of the Contractor, and this indemnification survives the termination of the Contract and the dissolution or, to the extent allowed by the law, the bankruptcy of the Contractor.
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25.1
|
The Contractor shall, at a minimum, prior to the commencement of work, procure the insurance policies identified below at the Contractor’s own cost and expense and shall furnish DCH with proof of coverage at least in the amounts indicated. It shall be the responsibility of the Contractor to require any Subcontractor to secure the same insurance coverage as prescribed herein for the Contractor, and to obtain a certificate evidencing that such insurance is in effect. In the event that any such insurance is proposed to be reduced, terminated or cancelled for any reason, the Contractor shall provide to DCH at least thirty (30) Calendar Days written notice. Prior to the reduction, expiration and/or cancellation of any insurance policy required hereunder, the Contractor shall secure replacement coverage upon the same terms and provisions to ensure no lapse in coverage, and shall furnish, at the request of DCH, a certificate of insurance indicating the required coverage’s. The Contractor shall maintain insurance coverage sufficient to insure against claims arising at any time during the term of the Contract. The provisions of this Section shall survive the expiration or termination of this Contract for any reason. In addition, the Contractor shall indemnify and hold harmless DCH and the State from any liability arising out of the Contractor’s or its Subcontractor’s untimely failure in securing adequate insurance coverage as prescribed herein:
|
25.1.1
|
Workers’ Compensation Insurance, the policy(ies) to insure the statutory limits established by the General Assembly of the State of Georgia. The Workers’ Compensation Policy must include Coverage B – Employer’s Liability Limits of:
|
·
|
Bodily injury by accident: five hundred thousand dollars ($500,000) each accident;
|
·
|
Bodily Injury by Disease: five hundred thousand dollars ($500,000) each employee; and
|
·
|
One million dollars ($1,000,000) policy limits.
|
25.1.2
|
The Contractor shall require all Subcontractors performing work under this Contract to obtain an insurance certificate showing proof of Worker’s Compensation Coverage.
|
25.1.3
|
The Contractor shall have commercial general liability policy(ies) as follows:
|
·
|
Combined single limits of one million dollars ($1,000,000) per person and three million dollars ($3,000,000) per occurrence;
|
·
|
On an “occurrence” basis; and
|
·
|
Liability for property damage in the amount of three million dollars ($3,000,000) including contents coverage for all records maintained pursuant to this Contract.
|
26.1
|
Within five (5) Business Days of Contract Execution, Contractor shall obtain and maintain in force and effect an irrevocable letter of credit in the amount representing one half of one month’s Net Capitation Payment associated with the actual GF lives in the Atlanta and Central Service Regions enrolled in Contractor’s plan. On or before July 2 each following year, Contractor shall modify the amount of the irrevocable letter of credit currently in force and effect to equal one-half of the average of the Net Capitation Payments paid to the Contractor for the months of January, February and March. If at any time during the year, the actual GF lives enrolled in Contractor’s plan increases or decreases by more than twenty-five percent, DCH, at its sole discretion, may increase or decrease the amount required for the irrevocable letter of credit.
|
26.2
|
DCH may also, at its discretion, redeem Contractor’s irrevocable letter of credit in the amount(s) of actual damages suffered by DCH if DCH determines that the Contractor is (1) unable to perform any of the terms and conditions of the Contract or if (2) the Contractor is terminated by default or bankruptcy or material breach that is not cured within the time specified by DCH, or under both conditions described at one (1) and two (2).
|
26.3
|
During the Contract period, Contractor shall obtain and maintain a payment bond from an entity licensed to do business in the State of Georgia and acceptable to DCH with sufficient financial strength and creditworthiness to assume the payment obligations of Contractor in the event of a default in payment arising from bankruptcy, insolvency, or other cause. Said bond shall be delivered to DCH within five (5) Business Days of Contract Execution and shall be in the amount of Five Million Dollars ($5,000,000.00). On or before July 2, of each following year, Contractor shall modify the amount of the bond to equal the average of the Net Capitation Payments paid to the Contractor for the months of January, February and March.
|
26.4
|
If at any time during the year, the actual GF lives enrolled in Contractor’s plan increases or decreases by more than twenty-five percent, DCH, at its sole discretion, may increase or decrease the amount required for the bond.
|
27.0
|
COMPLIANCE WITH ALL LAWS
|
27.1
|
NON-DISCRIMINATION
|
|
The Contractor agrees to comply with applicable federal and State laws, rules and regulations, and the State’s policy relative to nondiscrimination in employment practices because of political affiliation, religion, race, color, sex, physical handicap, age, or national origin including, but not limited to, Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Education Amendments of 1972 as amended; the Age Discrimination Act of 1975, as amended; Equal Employment Opportunity (45 CFR 74 Appendix A (1), Executive Order 11246 and 11375) and the Americans with Disability Act of 1993 (including but not limited to 28 C.F.R. § 35.100 et seq.). Nondiscrimination in employment practices is applicable to employees for employment, promotions, dismissal and other elements affecting employment.
|
27.2
|
DELIVERY OF SERVICE AND OTHER FEDERAL LAWS
|
27.2.1
|
The Contractor agrees that all work done as part of this Contract is subject to CMS approval and will comply fully with applicable administrative and other requirements established by applicable federal and State laws and regulations and guidelines, including but not limited to section 1902(a)(7) of the Social Security Act and DCH Medicaid and PeachCare for Kids® Policies and Procedures manuals, and assumes responsibility for full compliance with all such applicable laws, regulations, and guidelines, and agrees to fully reimburse DCH for any loss of funds or resources or overpayment resulting from non-compliance by Contractor, its staff, agents or Subcontractors, as revealed in subsequent audits. The provisions of the Fair Labor Standards Act of 1938 (29 U.S.C. § 201 et seq.) and the rules and regulations as promulgated by the United States Department of Labor in Title XXIX of the Code of Federal Regulations are applicable to this Contract. Contractor shall agree to conform with such federal laws as affect the delivery of services under this Contract including but not limited to the Titles VI, VII, XIX, XXI of the Social Security Act, the Federal Rehabilitation Act of 1973, the Davis Bacon Act (40 U.S.C. § 276a et seq.), the Copeland Anti-Kickback Act (40 U.S.C. § 276c), the Clean Air Act (42 U.S.C. 7401 et seq.) and the Federal Water Pollution Control Act as Amended (33 U.S.C. 1251 et seq.); the Byrd Anti-Lobbying Amendment (31 U.S.C. 1352); and Debarment and Suspension (45 CFR 74 Appendix A (8) and Executive Order 12549 and 12689); the Contractor shall agree to conform to such requirements or regulations as the United States Department of Health and Human Services may issue from time to time. Authority to implement federal requirements or regulations will be given to the Contractor by DCH in the form of a Contract amendment.
|
27.2.2
|
The Contractor shall include notice of grantor agency requirements and regulations pertaining to reporting and patient rights under any contracts involving research, developmental, experimental or demonstration work with respect to any discovery or invention which arises or is developed in the course of or under such contract, and of grantor agency requirements and regulations pertaining to copyrights and rights in data.
|
27.2.3
|
The Contractor shall recognize mandatory standards and policies relating to energy efficiency, which are contained in the State energy conservation plan issues in compliance with the Energy Policy and Conservation Act (Pub. L. 94-165).
|
27.3
|
COST OF COMPLIANCE WITH APPLICABLE LAWS
|
|
The Contractor agrees that it will bear any and all costs (including but not limited to attorneys’ fees, accounting fees, research costs, or consultant costs) related to, arising from, or caused by compliance with any and all laws, such as but not limited to federal and State statutes, case law, precedent, regulations, policies, and procedures which exist at the time of the execution of this Contract. The Contractor further agrees that it will bear any and all costs (including but not limited to attorneys’ fees, accounting fees, research costs, or consultant costs) related to, arising from, or caused by compliance with any and all laws, such as but not limited to federal and state statutes, case law, precedent, regulations, policies, and procedures which become effective or are amended throughout the life of the Contract. In the event of a disagreement on this matter, DCH’s determination on this matter shall be conclusive and not subject to Appeal.
|
27.4
|
GENERAL COMPLIANCE
|
|
Additionally, the Contractor agrees to comply and abide by all laws, rules, regulations, statutes, policies, or procedures that may govern the Contract, the deliverables in the Contract, or either Party’s responsibilities. To the extent that applicable laws, rules, regulations, statutes, policies, or procedures – either those in effect at the time of the execution of this Contract, or those which become effective or are amended during the life of the Contract – require the Contractor to take action or inaction, any costs, expenses, or fees associated with that action or inaction shall be borne and paid by the Contractor solely.
|
|
Any dispute concerning a question of fact or obligation related to or arising from this Contract that is not disposed of by mutual agreement shall be decided by the Contract Administrator who shall reduce his or her decision to writing and mail or otherwise furnish a copy to the Contractor. The written decision of the Contract Administrator shall be final and conclusive, unless the Contractor mails or otherwise furnishes a written Appeal to the Commissioner of DCH within ten (10) Calendar Days from the date of receipt of such decision. The decision of the Commissioner or a duly Authorized Representative for the determination of such Appeal shall be final and conclusive. In connection with any Appeal proceeding under this provision, the Contractor shall be afforded an opportunity to be heard and to offer evidence in support of its Appeal. Pending a final decision of a dispute hereunder, the Contractor shall proceed diligently with the performance of the Contract.
|
29.0
|
CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE
|
29.1
|
No official or employee of the State of Georgia or the federal government who exercises any functions or responsibilities in the review or approval of the undertaking or carrying out of the GF program shall, prior to the completion of the project, voluntarily acquire any personal interest, direct or indirect, in this Contract or the proposed Contract.
|
29.2
|
The Contractor covenants that it presently has no interest and shall not acquire any interest, direct or indirect, that would conflict in any material manner or degree with, or have a material adverse effect on the performance of its services hereunder. The Contractor further covenants that in the performance of the Contract no person having any such interest shall be employed.
|
29.3
|
All of the parties hereby certify that the provisions of O.C.G.A. §45-10-20 through §45-10-28, which prohibit and regulate certain transactions between State officials and employees and the State of Georgia, have not been violated and will not be violated in any respect throughout the term.
|
29.4
|
In addition, it shall be the responsibility of the Contractor to maintain independence and to establish necessary policies and procedures to assist the Contractor in determining if the actual Contractors performing work under this Contract have any impairment to their independence. To that end, the Contractor shall submit a written plan to DCH within five (5) Business Days of Contract Award in which it outlines its Impartiality and Independence Policies and Procedures relating to how it monitors and enforces Contractor and Subcontractor impartiality and independence. The Contractor further agrees to take all necessary actions to eliminate threats to impartiality and independence, including but not limited to reassigning, removing, or terminating Contractors or Subcontractors.
|
30.1
|
All notices under this Contract shall be deemed duly given upon delivery, if delivered by hand, or three (3) Calendar Days after posting, if sent by registered or certified mail, return receipt requested, to a party hereto at the addresses set forth below or to such other address as a party may designate by notice pursuant hereto.
|
30.2
|
It shall be the responsibility of the Contractor to inform the Contract Administrator of any change in address in writing no later than five (5) Business Days after the change.
|
31.1
|
CHOICE OF LAW OR VENUE
|
|
This Contract shall be governed in all respects by the laws of the State of Georgia. Any lawsuit or other action brought against DCH, the State based upon, or arising from this Contract shall be brought in a court or other forum of competent jurisdiction in Fulton County in the State of Georgia.
|
31.2
|
ATTORNEY’S FEES
|
|
In the event that either party deems it necessary to take legal action to enforce any provision of this Contract, and in the event DCH prevails, the Contractor agrees to pay all expenses of such action including reasonable attorney’s fees and costs at all stages of litigation as awarded by the court, a lawful tribunal, hearing officer or administrative law judge. If the Contractor prevails in any such action, the court or hearing officer, at its discretion, may award costs and reasonable attorney’s fees to the Contractor. The term legal action shall be deemed to include administrative proceedings of all kinds, as well as all actions at law or equity.
|
|
The terms, provisions, representations and warranties contained in this Contract shall survive the delivery or provision of all services or Deliverables hereunder.
|
31.4
|
DRUG-FREE WORKPLACE
|
|
The Contractor shall certify to DCH that a drug-free workplace shall be provided for the Contractor’s employees during the performance of this Contract as required by the “Drug-Free Workplace Act”, O.C.G.A. § 50-24-1, et seq. and applicable federal law. The Contractor will secure from any Subcontractor hired to work in a drug-free workplace such similar certification. Any false certification by the Contractor or violation of such certification, or failure to carry out the requirements set forth in the code, may result in the Contractor being suspended, terminated or debarred from the performance of this Contract.
|
31.5
|
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER MATTERS
|
|
The Contractor certifies that it is not presently debarred, suspended, proposed for debarment or declared ineligible for award of contracts by any federal or State agency.
|
31.6
|
WAIVER
|
|
The waiver by DCH of any breach of any provision contained in this Contract shall not be deemed to be a waiver of such provision on any subsequent breach of the same or any other provision contained in this Contract and shall not establish a course of performance between the parties contradictory to the terms hereof.
|
31.7
|
FORCE MAJEURE
|
|
Neither party to this Contract shall be responsible for delays or failures in performance resulting from acts beyond the control of such party. Such acts shall include, but not be limited to, acts of God, strikes, riots, lockouts, and acts of war, epidemics, fire, earthquakes, or other disasters.
|
|
This Contract and all of its terms, conditions, requirements, and amendments shall be binding on DCH, the Contractor, and their respective successors and permitted assigns.
|
|
31.9
|
TIME IS OF THE ESSENCE
|
|
Time is of the essence in this Contract. Any reference to “Days” shall be deemed Calendar Days unless otherwise specifically stated.
|
31.10
|
AUTHORITY
|
|
DCH has full power and authority to enter into this Contract, and the person acting on behalf of and signing for the Contractor has full authority to enter into this Contract, and the person signing on behalf of the Contractor has been properly authorized and empowered to enter into this Contract on behalf of the Contractor and to bind the Contractor to the terms of this Contract. Each party further acknowledges that it has had the opportunity to consult with and/or retain legal counsel of its choice, read this Contract, understands this Contract, and agrees to be bound by it.
|
31.11
|
ETHICS IN PUBLIC CONTRACTING
|
|
The Contractor understands, states, and certifies that it made its proposal to the RFP without collusion or fraud and that it did not offer or receive any kickbacks or other inducements from any other Contractor, supplier, manufacturer, or Subcontractor in connection with its proposal to the RFP.
|
31.12
|
CONTRACT LANGUAGE INTERPRETATION
|
|
The Contractor and DCH agree that in the event of a disagreement regarding, arising out of, or related to, Contract language interpretation, DCH’s interpretation of the Contract language in dispute shall control and govern. DCH’s interpretation of the Contract language in dispute shall not be subject to Appeal under any circumstance.
|
31.13
|
ASSESSMENT OF FEES
|
|
The Contractor and DCH agree that DCH may elect to deduct any assessed fees from payments due or owing to the Contractor or direct the Contractor to make payment directly to DCH for any and all assessed fees. The choice is solely and strictly DCH’s choice.
|
31.14
|
COOPERATION WITH OTHER CONTRACTORS
|
31.14.1
|
In the event that DCH has entered into, or enters into, agreements with other contractors for additional work related to the services rendered hereunder, the Contractor agrees to cooperate fully with such other contractors. The Contractor shall not commit any act that will interfere with the performance of work by any other contractor.
|
31.14.2
|
Additionally, if DCH eventually awards this Contract to another contractor, the Contractor agrees that it will not engage in any behavior or inaction that prevents or hinders the work related to the services contracted for in this Contract. In fact, the Contractor agrees to submit a written turnover plan and/or transition plan to DCH within thirty (30) Days of receiving the Department’s intent to terminate letter. The Parties agree that the Contractor has not successfully met this obligation until the Department accepts its turnover plan and/or transition plan.
|
31.14.3
|
The Contractor’s failure to cooperate and comply with this provision, shall be sufficient grounds for DCH to halt all payments due or owing to the Contractor until it becomes compliant with this or any other contract provision. DCH’s determination on the matter shall be conclusive and not subject to Appeal.
|
31.15
|
SECTION TITLES NOT CONTROLLING
|
|
The Section titles used in this Contract are for reference purposes only and shall not be deemed a part of this Contract.
|
|
31.16
|
LIMITATION OF LIABILITY/EXCEPTIONS
|
|
Nothing in this Contract shall limit the Contractor’s indemnification liability or civil liability arising from, based on, or related to claims brought by DCH or any third party or any claims brought against DCH or the State by a third party or the Contractor.
|
31.17
|
COOPERATION WITH AUDITS
|
31.17.1
|
The Contractor agrees to assist and cooperate with the Department in any and all matters and activities related to or arising out of any audit or review, whether federal, private, or internal in nature, at no cost to the Department.
|
31.17.2
|
The parties also agree that the Contractor shall be solely responsible for any costs it incurs for any audit related inquiries or matters. Moreover, the Contractor may not charge or collect any fees or compensation from DCH for any matter, activity, or inquiry related to, arising out of, or based on an audit or review.
|
31.18
|
HOMELAND SECURITY CONSIDERATIONS
|
31.18.1
|
The Contractor shall perform the services to be provided under this Contract entirely within the boundaries of the United States. In addition, the Contractor will not hire any individual to perform any services under this Contract if that individual is required to have a work visa approved by the U.S. Department of Homeland Security and such individual has not met this requirement.
|
31.18.2
|
If the Contractor performs services, or uses services, in violation of the foregoing paragraph, the Contractor shall be in material breach of this Contract and shall be liable to the Department for any costs, fees, damages, claims, or expenses it may incur. Additionally, the Contractor shall be required to hold harmless and indemnify DCH pursuant to the indemnification provisions of this Contract.
|
31.18.3
|
The prohibitions in this Section shall also apply to any and all agents and Subcontractors used by the Contractor to perform any services under this Contract.
|
31.19
|
PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED
|
31.19.1
|
The Contractor shall not knowingly have a relationship with an individual, or an affiliate of an individual, who is debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order No. 12549. For the purposes of this Section, a “relationship” is described as follows:
|
·
|
A director, officer or partner of the Contractor;
|
·
|
A person with beneficial ownership of five percent (5%) or more of the Contractor entity; and
|
·
|
A person with an employment, consulting or other arrangement with the Contractor’s obligations under its Contract with the State.
|
31.19.2
|
The Contractor shall submit a monthly Program Integrity Exception List report that identifies Providers, owners, agents, employees, subcontractors and contractors (as defined in Section 8.6.5.2) that have been reported on the HHS-OIG LEIE (List of Excluded Individuals/Entities) (http://oig.hhs.gov/fraud/exclusions/exclusions_list.asp) and/or the CMS MED (Medicare Exclusion Database).
|
31.19.3
|
All disclosures required under this Section shall be included in the Contractor’s monthly Fraud and Abuse Report (See Sections 4.13.4 and 4.18.3.5.2).
|
31.20
|
OWNERSHIP AND FINANCIAL DISCLOSURE
|
31.20.1
|
The Contractor shall disclose each person or corporation with an ownership or control interest of five percent (5%) or more in the Contractor’s entity for the prior twelve (12) month period as required in Section 8.6.5 of this Contract. For the purposes of this Section, a person or corporation with an ownership or control interest shall mean a person or corporation:
|
·
|
That owns directly or indirectly five percent (5%) or more of the Contractor’s capital or stock or received five percent (5%) or more of its profits;
|
·
|
That has an interest in any mortgage, deed of trust, note, or other obligation secured in whole or in part by the Contractor or by its property or assets, and that interest is equal to or exceeds five percent (5%) of the total property and assets of the Contractor; and
|
·
|
That is an officer or director of the Contractor (if it is organized as a corporation) or is a partner in the Contractor’s organization (if it is organized as a partnership).
|
|
No amendment, waiver, termination or discharge of this Contract, or any of the terms or provisions hereof, shall be binding upon either party unless confirmed in writing. None of the Solicitation Documents may be modified or amended, except by writing executed by both parties. Additionally, CMS approval may be required before any such amendment is effective. DCH will determine, in its sole discretion, when such CMS approval is required. Any agreement of the parties to amend, modify, eliminate or otherwise change any part of this Contract shall not affect any other part of this Contract, and the remainder of this Contract shall continue to be of full force and effect as set out herein.
|
|
Contractor shall not assign this Contract, in whole or in part, without the prior written consent of DCH, and any attempted assignment not in accordance herewith shall be null and void and of no force or effect.
|
|
Any section, subsection, paragraph, term, condition, provision, or other part of this Contract that is judged, held, found or declared to be voidable, void, invalid, illegal or otherwise not fully enforceable shall not affect any other part of this Contract, and the remainder of this Contract shall continue to be of full force and effect as set out herein.
|
35.0
|
COMPLIANCE WITH AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT ORGANIZATIONS (O.C.G.A. § 50-20-1 ET SEQ.)
|
|
The Contractor agrees to comply at all times with the provisions of the Federal Single Audit Act (hereinafter called the Act) as amended from time to time, all applicable implementing regulations, including but not limited to any disclosure requirements imposed upon non-profit organizations by the Georgia Department of Audits as a result of the Act, and to make complete restitution to DCH of any payments found to be improper under the provisions of the Act by the Georgia Department of Audits, the Georgia Attorney General’s Office or any of their respective employees, agents, or assigns.
|
|
This Contract constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, representations or contracts. No written or oral agreements, representatives, statements, negotiations, understandings, or discussions that are not set out, referenced, or specifically incorporated in this Contract shall in any way be binding or of effect between the parties.
|
1.
|
Publishing a statement notifying employees that the unlawful manufacture, sale, distribution, dispensation, possession or use of a controlled substance or marijuana is prohibited in Contractor’s workplace and specifying the actions that will be taken against employees for violations of such policy;
|
2.
|
Establishing a drug-free awareness program to inform employees about:
|
a.
|
The dangers of drug abuse in the workplace;
|
b.
|
Contractor’s policy of maintaining a drug-free workplace;
|
c.
|
Any available drug counseling, rehabilitation, and employee assistance programs; and
|
d.
|
The penalties that may be imposed upon employees for drug abuse violations;
|
3.
|
Providing each employee with a copy of the statement provided for in paragraph (1) of this certification;
|
4.
|
Notifying each employee in the statement provided for in paragraph (1) that, as a condition of employment, the employee shall:
|
a.
|
Abide by the terms of the statement; and
|
b.
|
Notify Contractor of any criminal drug statute conviction for a violation occurring in the workplace no later than five calendar days after such conviction;
|
5.
|
Notifying DCH within ten calendar days after receiving notice under subparagraph 4(b) from an employee or otherwise receiving actual notice of such conviction;
|
6.
|
Taking one of the following actions, within 30 days of receiving notice under subparagraph 4(b), with respect to any employee who is so convicted;
|
a.
|
Taking appropriate personnel action against such an employee, up to and including termination; or
|
b.
|
Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a federal, state, or local health, law enforcement, or other appropriate agency;
|
7.
|
Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs 1, 2, 3, 4, 5, and 6.
|
A.
|
CERTIFICATION
|
(1)
|
The Contractor certifies, to the best of its knowledge and belief, that—
|
(i)
|
The Contractor and/or any of its Principals—
|
(a)
|
(c)
|
(ii)
|
(2)
|
“Principals,” for purposes of this certification, means officers, directors, owners, partners, and, persons having primary management or supervisory responsibilities within a business entity (e.g., general manager, plant manager, head of a subsidiary, division, or business segment; and similar positions).
|
B.
|
The Contractor shall provide immediate written notice to the Contracting Officer if, at any time prior to Contract Award, the Contractor learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
|
C.
|
A certification that if any of the items in paragraph (a) of this provision exist will not necessarily result in Withholding of an award under this solicitation. However, the certification will be considered in connection with a determination of the Contractor’s responsibility. Failure of the Contractor to furnish a certification or provide such additional information as requested by the Contracting Officer may render the Contractor non-responsible.
|
D.
|
Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render, in good faith, the certification required by paragraph (a) of this provision. The knowledge and information of a Contractor is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.
|
E.
|
The certification in paragraph (a) of this provision is a material representation of fact upon which reliance was placed when making award. If it is later determined that the Contractor knowingly rendered an erroneous certification, in addition to other remedies available to the Government, the Contracting Officer may terminate the Contract resulting from this solicitation for default.
|
·
|
Financial statements for the previous year;
|
·
|
Employee list;
|
·
|
Employee salaries;
|
·
|
Employees’ reimbursable expenses; and
|
·
|
CAPA/PC
|
1.
|
Terms used but not otherwise defined in this Agreement shall have the same meaning as those terms in the Privacy Rule and the Security Rule, published as the Standards for Privacy and Security of Individually Identifiable Health Information in 45 C.F.R. Parts 160 and 164 (“Privacy Rule” and “Security Rule”).
|
2.
|
Except as limited in this Agreement, Contractor may use or disclose PHI only to extent necessary to meet its responsibilities as set forth in the Contract provided that such use or disclosure would not violate the Privacy Rule or the Security Rule, if done by DCH.
|
3.
|
Unless otherwise Provided by Law, Contractor agrees that it will:
|
A.
|
Not request, create, receive, use or disclose PHI other than as permitted or required by this Agreement, the Contract, or as required by law.
|
B.
|
Establish, maintain and use appropriate safeguards to prevent use or disclosure of the PHI other than as provided for by this Agreement or the Contract.
|
C.
|
Implement and use administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the electronic protected health information that it creates, receives, maintains, or transmits on behalf of DCH.
|
D.
|
Mitigate, to the extent practicable, any harmful effect that may be known to Contractor from a use or disclosure of PHI by Contractor in violation of the requirements of this Agreement, the Contract or applicable regulations.
|
E.
|
Ensure that its agents or subcontractors are subject to at least the same obligations that apply to Contractor under this Agreement and ensure that its agents or subcontractors comply with the conditions, restrictions, prohibitions and other limitations regarding the request for, creation, receipt, use or disclosure of PHI, that are applicable to Contractor under this Agreement and the Contract.
|
F.
|
Ensure that its agents and subcontractors, to whom it provides protected health information, agree to implement reasonable and appropriate safeguards to protect the information.
|
G.
|
Report to DCH any use or disclosure of PHI that is not provided for by this Agreement or the Contract and to report to DCH any security incident of which it becomes aware. Contractor agrees to make such report to DCH in writing in such form as DCH may require within three (3) business days after Contractor becomes aware of the unauthorized use or disclosure or of the security incident.
|
H.
|
Make any amendment(s) to PHI in a Designated Record Set that DCH directs or agrees to pursuant to 45 CFR 164.526 at the request of DCH or an Individual, within five (5) business days after request of DCH or of the Individual. Contractor also agrees to provide DCH with written confirmation of the amendment in such format and within such time as DCH may require.
|
I.
|
Provide access to PHI in a Designated Record Set, to DCH upon request, within five (5) business days after such request, or, as directed by DCH, to an Individual. Contractor also agrees to provide DCH with written confirmation that access has been granted in such format and within such time as DCH may require.
|
J.
|
Give the Secretary of the U.S. Department of Health and Human Services (the “Secretary”) or the Secretary’s designees access to Contractor’s books and records and policies, practices or procedures relating to the use and disclosure of PHI for or on behalf of DCH within five (5) business days after the Secretary or the Secretary’s designees request such access or otherwise as the Secretary or the Secretary’s designees may require. Contractor also agrees to make such information available for review, inspection and copying by the Secretary or the Secretary’s designees during normal business hours at the location or locations where such information is maintained or to otherwise provide such information to the Secretary or the Secretary’s designees in such form, format or manner as the Secretary or the Secretary’s designees may require.
|
K.
|
Document all disclosures of PHI and information related to such disclosures as would be required for DCH to respond to a request by an Individual or by the Secretary for an accounting of disclosures of PHI in accordance with 45 C.F.R. § 164.528.
|
L.
|
Provide to DCH or to an Individual, information collected in accordance with Section 3. I. of this Agreement, above, to permit DCH to respond to a request by an Individual for an accounting of disclosures of PHI as provided in the Privacy Rule.
|
4.
|
Unless otherwise Provided by Law, DCH agrees that it will:
|
A.
|
Notify Contractor of any new limitation in DCH’s Notice of Privacy Practices in accordance with the provisions of the Privacy Rule if, and to the extent that, DCH determines in the exercise of its sole discretion that such limitation will affect Contractor’s use or disclosure of PHI.
|
B.
|
Notify Contractor of any change in, or revocation of, permission by an Individual for DCH to use or disclose PHI to the extent that DCH determines in the exercise of its sole discretion that such change or revocation will affect Contractor’s use or disclosure of PHI.
|
C.
|
Notify Contractor of any restriction regarding its use or disclosure of PHI that DCH has agreed to in accordance with the Privacy Rule if, and to the extent that, DCH determines in the exercise of its sole discretion that such restriction will affect Contractor’s use or disclosure of PHI.
|
D.
|
Prior to agreeing to any changes in or revocation of permission by an Individual, or any restriction, to use or disclose PHI as referenced in subsections b. and c. above, DCH agrees to contact Contractor to determine feasibility of compliance. DCH agrees to assume all costs incurred by Contractor in compliance with such special requests.
|
|
|
|
5. The Term of this Agreement shall be effective as of October 18, 2011, and shall terminate when all of the PHI provided by DCH to Contractor, or created or received by Contractor on behalf of DCH, is destroyed or returned to DCH, or, if it is infeasible to return or destroy PHI, protections are extended to such information, in accordance with the termination provisions in this Section.
|
|
A. Termination for Cause. Upon DCH’s knowledge of a material breach by Contractor, DCH shall either:
|
1)
|
Provide an opportunity for Contractor to cure the breach within a reasonable period of time, which shall be within 30 days after receiving written notification of the breach by DCH;
|
2)
|
If Contractor fails to cure the breach, terminate the contract upon 30 days’ notice; or
|
3)
|
If neither termination nor cure is feasible, DCH shall report the violation to the Secretary of the Department of Health and Human Services.
|
1)
|
Upon termination of this Agreement, for any reason, DCH and Contractor shall determine whether return of PHI is feasible. If return of the PHI is not feasible, Contractor agrees to continue to extend the protections of Sections 3 (A) through (J) of this Agreement and applicable law to such PHI and limit further use of such PHI, except as otherwise permitted or required by this Agreement, for as long as Contractor maintains such PHI. If Contractor elects to destroy the PHI, Contractor shall notify DCH in writing that such PHI has been destroyed and provide proof, if any exists, of said destruction. This provision shall apply also to PHI that is in the possession of subcontractors or agents of Contractor. Neither Contractor nor its agents nor subcontractors shall retain copies of the PHI.
|
2)
|
Contractor agrees that it will limit its further use or disclosure of PHI only to those purposes DCH may, in the exercise of its sole discretion, deem to be in the public interest or necessary for the protection of such PHI, and will take such additional actions as DCH may require for the protection of patient privacy and the safeguarding, security and protection of such PHI.
|
3)
|
If neither termination nor cure is feasible, DCH shall report the violation to the Secretary. Particularly in the event of a pattern of activity or practice of Contractor that constitutes a material breach of Contractor’s obligations under the Contract and this agreement; DCH shall invoke termination procedures or report to the Secretary.
|
4)
|
Section 5. B. of this Agreement, regarding the effect of termination or expiration, shall survive the termination of this Agreement.
|
|
7. All other terms and conditions contained in the Contract and any amendment thereto, not amended by this Agreement, shall remain in full force and effect.
|
Attachment H
|
|||
Peach State Health Plan
|
|||
FY11
|
|||
FY 11
|
|||
Region
|
Aid Category
|
Age/Gender Group
|
Peach State Health Plan
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
0 - 2 Months, Male and Female
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
3 - 11 Months, Male and Female
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
1 - 5 Years, Male and Female
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
6 - 13 Years, Male and Female
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
14 - 20 Years, Female
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
14 - 20 Years, Male
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
21 - 44 Years, Female
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
21 - 44 Years, Male
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
45+ Years, Female
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
45+ Years, Male
|
$ ***
|
Atlanta
|
PeachCare
|
0 - 2 Months, Male and Female
|
$ ***
|
Atlanta
|
PeachCare
|
3 - 11 Months, Male and Female
|
$ ***
|
Atlanta
|
PeachCare
|
1 - 5 Years, Male and Female
|
$ ***
|
Atlanta
|
PeachCare
|
6 - 13 Years, Male and Female
|
$ ***
|
Atlanta
|
PeachCare
|
14 - 20 Years, Female
|
$ ***
|
Atlanta
|
PeachCare
|
14 - 20 Years, Male
|
$ ***
|
Atlanta
|
Breast and Cervical Cancer
|
Breast and Cervical Cancer
|
$ ***
|
Atlanta
|
Maternity Delivery/Kick Payment
|
Maternity Delivery/Kick Payment
|
$ ***
|
Atlanta
|
NICU Kick
|
NICU Kick
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
0 - 2 Months, Male and Female
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
3 - 11 Months, Male and Female
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
1 - 5 Years, Male and Female
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
6 - 13 Years, Male and Female
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
14 - 20 Years, Female
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
14 - 20 Years, Male
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
21 - 44 Years, Female
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
21 - 44 Years, Male
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
45+ Years, Female
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
45+ Years, Male
|
$ ***
|
Central
|
PeachCare
|
0 - 2 Months, Male and Female
|
$ ***
|
Central
|
PeachCare
|
3 - 11 Months, Male and Female
|
$ ***
|
Central
|
PeachCare
|
1 - 5 Years, Male and Female
|
$ ***
|
Central
|
PeachCare
|
6 - 13 Years, Male and Female
|
$ ***
|
Central
|
PeachCare
|
14 - 20 Years, Female
|
$ ***
|
Central
|
PeachCare
|
14 - 20 Years, Male
|
$ ***
|
Central
|
Breast and Cervical Cancer
|
Breast and Cervical Cancer
|
$ ***
|
Central
|
Maternity Delivery/Kick Payment
|
Maternity Delivery/Kick Payment
|
$ ***
|
Central
|
NICU Kick
|
NICU Kick
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
0 - 2 Months, Male and Female
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
3 - 11 Months, Male and Female
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
1 - 5 Years, Male and Female
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
6 - 13 Years, Male and Female
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
14 - 20 Years, Female
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
14 - 20 Years, Male
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
21 - 44 Years, Female
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
21 - 44 Years, Male
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
45+ Years, Female
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
45+ Years, Male
|
$ ***
|
Southwest
|
PeachCare
|
0 - 2 Months, Male and Female
|
$ ***
|
Southwest
|
PeachCare
|
3 - 11 Months, Male and Female
|
$ ***
|
Southwest
|
PeachCare
|
1 - 5 Years, Male and Female
|
$ ***
|
Southwest
|
PeachCare
|
6 - 13 Years, Male and Female
|
$ ***
|
Southwest
|
PeachCare
|
14 - 20 Years, Female
|
$ ***
|
Southwest
|
PeachCare
|
14 - 20 Years, Male
|
$ ***
|
Southwest
|
Breast and Cervical Cancer
|
Breast and Cervical Cancer
|
$ ***
|
Southwest
|
Maternity Delivery/Kick Payment
|
Maternity Delivery/Kick Payment
|
$ ***
|
Southwest
|
NICU Kick
|
NICU Kick
|
$ ***
|
Georgia Legal Services Program
1-800-498-9469
(Statewide legal services, EXCEPT For the counties served by Atlanta)
|
Georgia Advocacy Office
1-800-537-2329
(Statewide advocacy for persons with disabilities or mental illness)
|
Atlanta Legal Aid
404-377-0701 - (DeKalb & Gwinnett Counties)
770-528-2565 - (Cobb County)
404-524-5811 - (Fulton County)
404-669-0233 - (South Fulton & Clayton County)
678-376-4545 - (Gwinnett County)
|
Atlanta
|
Central
|
East
|
North
|
SE
|
SW
|
Barrow
|
Baldwin
|
Burke
|
Banks
|
Appling
|
Atkinson
|
Bartow
|
Bibb
|
Columbia
|
Catoosa
|
Bacon
|
Baker
|
Butts
|
Bleckley
|
Emanuel
|
Chattooga
|
Brantley
|
Ben Hill
|
Carroll
|
Chattahoochee
|
Glascock
|
Clarke
|
Bryan
|
Berrien
|
Cherokee
|
Crawford
|
Greene
|
Dade
|
Bulloch
|
Brooks
|
Clayton
|
Crisp
|
Hancock
|
Dawson
|
Camden
|
Calhoun
|
Cobb
|
Dodge
|
Jefferson
|
Elbert
|
Candler
|
Clay
|
Coweta
|
Dooly
|
Jenkins
|
Fannin
|
Charlton
|
Clinch
|
DeKalb
|
Harris
|
Lincoln
|
Floyd
|
Chatham
|
Coffee
|
Douglas
|
Heard
|
McDuffie
|
Franklin
|
Effingham
|
Colquitt
|
Fayette
|
Houston
|
Putnam
|
Gilmer
|
Evans
|
Cook
|
Forsyth
|
Jones
|
Richmond
|
Gordon
|
Glynn
|
Decatur
|
Fulton
|
Lamar
|
Screven
|
Habersham
|
Jeff Davis
|
Dougherty
|
Gwinnett
|
Laurens
|
Taliaferro
|
Hall
|
Liberty
|
Early
|
Haralson
|
Macon
|
Warren
|
Hart
|
Long
|
Echols
|
Henry
|
Marion
|
Washington
|
Jackson
|
McIntosh
|
Grady
|
Jasper
|
Meriwether
|
Wilkes
|
Lumpkin
|
Montgomery
|
Irwin
|
Newton
|
Monroe
|
Madison
|
Pierce
|
Lanier
|
|
Paulding
|
Muscogee
|
Morgan
|
Tattnall
|
Lee
|
|
Pickens
|
Peach
|
Murray
|
Toombs
|
Lowndes
|
|
Rockdale
|
Pike
|
Oconee
|
Ware
|
Miller
|
|
Spalding
|
Pulaski
|
Oglethorpe
|
Wayne
|
Mitchell
|
|
Walton
|
Talbot
|
Polk
|
Quitman
|
||
Taylor
|
Rabun
|
Randolph
|
|||
Telfair
|
Stephens
|
Seminole
|
|||
Treutlen
|
Towns
|
Schley
|
|||
Troup
|
Union
|
Stewart
|
|||
Twiggs
|
Walker
|
Sumter
|
|||
Upson
|
White
|
Terrell
|
|||
Wheeler
|
Whitfield
|
Thomas
|
|||
Wilcox
|
Tift
|
||||
Wilkinson
|
Turner
|
||||
Johnson
|
Webster
|
||||
Worth
|
|||||
Service
|
Additional Exceptions
|
Co-Pay Amount
|
|||
Ambulatory Surgical Centers
|
A $3 co-payment to be deducted from the surgical procedure code billed. In the case of multiple surgical procedures, only one $3 amount will be deducted per date of service.
|
||||
FQHC/RHCs
|
A $2 co-payment on all FQHC and RHC.
|
||||
Outpatient
|
A $3 member co-payment is required on all non-emergency outpatient hospital visits
|
||||
Inpatient
|
Members who are admitted from an emergency department or following the receipt of urgent care or are transferred from a different hospital, from a skilled nursing facility, or from another health facility are exempted from the inpatient co-payment.
|
A co-payment of $12.50 will be imposed on hospital inpatient services
|
|||
Emergency Department
|
A $3 co-payment will be imposed if the Condition is not an Emergency Medical Condition
|
||||
Oral Maxiofacial Surgery
|
Effective with dates of service July 1, 2005, the Division is implementing a tiered member co-payment scale as described in 42CFR447.54 on all evaluation and management procedure codes (99201 - 99499) including the ophthalmologic services procedure codes (92002 - 92014) used by physicians or physicians’ assistants.
The tiered co-payment amounts are as follows:
State’s payment for the service Maximum co-payment chargeable to recipient
$10.00 or less - $0.50
$10.01 to $25.00 - $1.00
$25.01 to $50.00 - $2.00
$50.01 or more - $3.00
|
||||
Prescription Drugs
|
Drug Cost:
<$10.01
$10.01 - $25.00
$25.01 - $50.00
>$50.01
|
Co-pay Amount
$.50
$1.00
$2.00
$3.00
|
L.1.1 Member Data and Related Documents
|
|||
Subtype
ID
|
Subtype Name / Description
|
Role of CMO
System
|
Data Management Requirements
|
1.1
|
Unique member identifier
(UMI)
|
Authoritative host;
retain relationship
to Fiscal Agent-
assigned member
identifier
|
The UMI should span member's
lifetime and should serve as an index
to obtain member-specific
information across multiple sub
systems/databases of a single CMO
|
1.2
|
Fiscal Agent-assigned member
identifier
|
Receive original
record and updates
from Fiscal Agent
|
Retain relationship to UMI
|
1.3
|
Member enrollment and
enrollment status changes in
Contractor's CMO
|
Receive original
record and updates
from DCH and/or
its agent
|
The CMO shall retain in its "live"
systems the most recent 7-year history
(or less if member dies within 7-year
period) of enrollment status changes,
including multiple re-enrollments and
disenrollments of the same member,
indexed by and linked to the
member's UMI and Fiscal Agent-
assigned member identifier.
|
1.4
|
Member demographic profile
|
Reconcile as
needed to data
kept by DCH
and/or its agent
|
Includes family relationships, age,
sex, pregnancy and incarceration
flags, standardized address linked to
GCS service region and standard
location codes (zip code,
municipality, county, etc.)
|
1.5
|
Member financial, insurance
and employment profile
|
TPL: exchange
data with DCH
and/or its agent.
Other: reconcile
as needed to data
kept by DCH
and/or its agent
|
Includes TPL data that my need to
be provided to multiple CMO's and
may include capitation rate cell to
which the Member is associated.
|
1.6
|
Member assignments to PCP
and, if applicable, to CMO sub
programs/"plan options"
|
Authoritative host
|
L.1.2 Provider Data and Related Documents
|
|||
Subtype
ID
|
Subtype Name / Description
|
Role of CMO
System
|
Data Management Requirements
|
2.1
|
Unique provider identifier
(UPI)
|
Authoritative host; retain
relationship to Fiscal Agent-
assigned Provider ID
|
The UPI wil meet the requirements
of the National Provider
ID (NPI) standards of HIPAA and
will retain relationships to existing
GA IDs. NPI requirements include
indentifying providers using the NPI
and/or utlizing standards consistent
with NPI and HIPAA requirements
that identify a unique number for a
provider. Also, maintaining an on-line
cross-reference of all old provider #'s
to new provider #'s and historical
information linked to the NPI.
|
2.2
|
Provider CMO affiliation
|
Authoritative host
|
The CMO will retain a 7-year history
(or less if member dies within the 7 year
period) of enrollment status changes,
including multiple re-enrollments and
disenrollments of the same provider;
indexed by and linked to the
provider's UPI.
|
2.3
|
Contractor-Provider
agreement document
|
Authoritative host
|
Signed; indexed by and linked to the provider's UPI.
|
2.4
|
Provider location(s)
|
Reconcile as needed to data
kept by DCH and/or its
agent
|
Includes location codes that enable
map and GIS based rederings of
network coverage and capacity by
provider type and geographic area.
Include standardized office/practice
address (es).
|
2.5
|
Provider credentializing Information
|
Authoritative host for non-
mandated Providers (year 1)
- receive original record and
updates from Fiscal Agent;
Authoritative host for all
Providers thereafter
|
At a minimum: licensure status, board
eligibility/certification. Includes
indexed images of applicable
documents.
|
2.6
|
Provider specialties,
affiliation and relation to
other provider Information
|
Authoritative host; reconcile
as needed to data kept by
DCH and/or its agent
|
Specialties for which s/he is certified,
professional affiliations,
group/practice associations, hospital
admitting privileges. Includes
indexed images of applicable
documents.
|
2.7
|
Provider descriptive
|
Authoritative host for non-
mandated Providers (year 1)
- receive original record and
updates from Fiscal Agent;
Authoritative host for all
Providers thereafter
|
Race, sex, languages spoken by
him/her and staff, education and
training
|
Subtype ID
|
Subtype Name/Description
|
Role of CMO System
|
Data Management Requirements
|
2.8
|
Provider medical and service profile
|
Authoritative host; reconcile as needed to data kept by DCH and/or its agent
|
Member assessments, reported incidents, malpractice cases, etc. Includes indexed images of applicable documents.
|
2.9
|
Provider financial
|
Authoritative host; reconcile as needed to data kept by DCH and/or its agent
|
At a minimum: FEINs/tax IDs, 1099s. Includes indexed images of applicable documents.
|
Subtype ID
|
Subtype Name/Description
|
Role of CMO System
|
Data Management Requirements
|
3.1
|
Claim data including subsequent claim adjustment
|
Authoritative host; provide to State and/or its agent following format and procedure in Attachment L5.
|
Capture data elements per applicable standard format/layout to be adopted by all CMOs (UB-92, CMS-1500, ADA, NCPDP). Capture EPSDT flags where applicable; all claim adjustments shall be logically linked to the original claim (parent/child data relationship). Contractor shall retain up to seven (7) years of Claims history per Member (less if Member dies within 7-year period).
|
3.2
|
Encounter data from sub-captitated provider
|
Authoritative host; provide to State and/or its agent following format and procedure in Attachment L5.
|
Encounter data from sub-capitated provider shall be equivalent (in terms of fields captured per record) to data obatained from claim submissions (ref. 3.1). Contractor shall retain up to seven (7) years of history of this type of Encounter data per Member (less if Member dies within 7-year period).
|
3.1 CMO systems will flag all services related to Federal EPSDT requirements, including diagnostic and treatment services resulting from an EPSDT requirements, including diagnostic and treatment services resulting from an EPSDT screening service, for the purposes of consolidated EPSDT activity reporting (e.g. CMS form 416) and other managment applications.
|
Subtype ID
|
Subtype Name/Description
|
Role of CMO System
|
Data Management Requirements
|
4.1
|
In-network specialist referrals
|
Authoritative host
|
7-year history (or less if member dies within 7-year period) of all medical management transactions by member. Capture and retain link/logical relationship to subsequent claim(s).
|
4.2
|
In-network authorizations
|
Authoritative host
|
7-year history (or less if member dies within 7-year period) of all medical management transactions by member. Capture and retain link/logical relationship to subsequent claim(s).
|
4.3
|
Out-of-network service referrals and authorizations
|
Authoritative host
|
7-year history (or less if member dies within 7-year period) of all medical management transactions by member. Capture and retain link/logical relationship to subsequent claim(s).
|
4.4
|
"Transition" service authorizations
|
Receive original record DCH and/or its agent
|
Service authorizations issued by DCH and/or its agent during period prior to enrollment in CMO. Retain history of all of these authorizations. Capture and retain link/logical relationship to subsequent claim(s).
|
Subtype ID
|
Subtype Name/Description
|
Role of CMO System
|
Data Management Requirements
|
5.1
|
Focused studies
|
Authoritative host
|
Unique ID per study; codify results for summarization and analysis based on scheme TBD.
|
5.2
|
Member (clinical) safety - reported incidents/occurrences
|
Authoritative host
|
Unique ID per reported incident/occurrence; codify for summarization and analysis based on scheme TBD.
|
I.
|
Upon DCH’s receipt of written notice from CMS indicating that agency’s approval of the revised capitation rates, to be effective for SFY 2012 (July 1, 2011 to June 30, 2012), the parties shall delete the current Attachment H, Capitation Payment, in its entirety and replace it with the new Attachment H, Capitation Payment, contained at Exhibit 1 to this Amendment. In the event CMS disapproves revision of the capitation rates as described herein, this amendment shall have no effect. DCH shall notify Contractor in writing upon receipt of the CMS decision regarding the revision of the capitation rates.
|
II.
|
DCH and Contractor agree that they have assumed an obligation to perform the covenants, agreements, duties and obligations of the Contract, as modified and amended herein, and agree to abide by all the provisions, terms and conditions contained in the Contract as modified and amended.
|
III.
|
This Amendment shall be binding and inure to the benefit of the parties hereto, their heirs, representatives, successors and assigns. Whenever the provisions of this Amendment and the Contract are in conflict, the provisions of this Amendment shall take precedence and control.
|
VI.
|
It is understood by the Parties hereto that, if any part, term, or provision of this Amendment or this entire Amendment is held to be illegal or in conflict with any law of this State, then DCH, at its sole option, may enforce the remaining unaffected portions or provisions of this Amendment or of the Contract and the rights and obligations of the parties shall be construed and enforced as if the Contract or Amendment did not contain the particular part, term or provision held to be invalid.
|
VII.
|
This Amendment shall become effective as stated herein and shall remain effective for so long as the Contract is in effect.
|
VIII.
|
This Amendment shall be construed in accordance with the laws of the State of Georgia.
|
IX.
|
All other terms and conditions contained in the Contract and any amendment thereto, not amended by this Amendment, shall remain in full force and effect.
|
Attachment H
|
|||
Peach State Health Plan
|
|||
FY12
|
|||
FY 12
|
|||
Region
|
Aid Category
|
Age/Gender Group
|
Peach State Health Plan
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
0 - 2 Months, Male and Female
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
3 - 11 Months, Male and Female
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
1 - 5 Years, Male and Female
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
6 - 13 Years, Male and Female
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
14 - 20 Years, Female
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
14 - 20 Years, Male
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
21 - 44 Years, Female
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
21 - 44 Years, Male
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
45+ Years, Female
|
$ ***
|
Atlanta
|
Medicaid (LIM/Refugee/RSM)
|
45+ Years, Male
|
$ ***
|
Atlanta
|
PeachCare
|
0 - 2 Months, Male and Female
|
$ ***
|
Atlanta
|
PeachCare
|
3 - 11 Months, Male and Female
|
$ ***
|
Atlanta
|
PeachCare
|
1 - 5 Years, Male and Female
|
$ ***
|
Atlanta
|
PeachCare
|
6 - 13 Years, Male and Female
|
$ ***
|
Atlanta
|
PeachCare
|
14 - 20 Years, Female
|
$ ***
|
Atlanta
|
PeachCare
|
14 - 20 Years, Male
|
$ ***
|
Atlanta
|
Breast and Cervical Cancer
|
Breast and Cervical Cancer
|
$ ***
|
Atlanta
|
Maternity Delivery/Kick Payment
|
Maternity Delivery/Kick Payment
|
$ ***
|
Atlanta
|
NICU Kick
|
NICU Kick
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
0 - 2 Months, Male and Female
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
3 - 11 Months, Male and Female
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
1 - 5 Years, Male and Female
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
6 - 13 Years, Male and Female
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
14 - 20 Years, Female
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
14 - 20 Years, Male
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
21 - 44 Years, Female
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
21 - 44 Years, Male
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
45+ Years, Female
|
$ ***
|
Central
|
Medicaid (LIM/Refugee/RSM)
|
45+ Years, Male
|
$ ***
|
Central
|
PeachCare
|
0 - 2 Months, Male and Female
|
$ ***
|
Central
|
PeachCare
|
3 - 11 Months, Male and Female
|
$ ***
|
Central
|
PeachCare
|
1 - 5 Years, Male and Female
|
$ ***
|
Central
|
PeachCare
|
6 - 13 Years, Male and Female
|
$ ***
|
Central
|
PeachCare
|
14 - 20 Years, Female
|
$ ***
|
Central
|
PeachCare
|
14 - 20 Years, Male
|
$ ***
|
Central
|
Breast and Cervical Cancer
|
Breast and Cervical Cancer
|
$ ***
|
Central
|
Maternity Delivery/Kick Payment
|
Maternity Delivery/Kick Payment
|
$ ***
|
Central
|
NICU Kick
|
NICU Kick
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
0 - 2 Months, Male and Female
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
3 - 11 Months, Male and Female
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
1 - 5 Years, Male and Female
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
6 - 13 Years, Male and Female
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
14 - 20 Years, Female
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
14 - 20 Years, Male
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
21 - 44 Years, Female
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
21 - 44 Years, Male
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
45+ Years, Female
|
$ ***
|
Southwest
|
Medicaid (LIM/Refugee/RSM)
|
45+ Years, Male
|
$ ***
|
Southwest
|
PeachCare
|
0 - 2 Months, Male and Female
|
$ ***
|
Southwest
|
PeachCare
|
3 - 11 Months, Male and Female
|
$ ***
|
Southwest
|
PeachCare
|
1 - 5 Years, Male and Female
|
$ ***
|
Southwest
|
PeachCare
|
6 - 13 Years, Male and Female
|
$ ***
|
Southwest
|
PeachCare
|
14 - 20 Years, Female
|
$ ***
|
Southwest
|
PeachCare
|
14 - 20 Years, Male
|
$ ***
|
Southwest
|
Breast and Cervical Cancer
|
Breast and Cervical Cancer
|
$ ***
|
Southwest
|
Maternity Delivery/Kick Payment
|
Maternity Delivery/Kick Payment
|
$ ***
|
Southwest
|
NICU Kick
|
NICU Kick
|
$ ***
|
Part 1: Parties to the Contract:
|
This Contract Amendment (the “Amendment”) is between the Texas Health and Human Services Commission (HHSC), an administrative agency within the executive department of the State of Texas, having its principal office at 4900 North Lamar Boulevard, Austin, Texas 78751, and Superior HealthPlan, Inc. (HMO) a corporation organized under the laws of the State of Texas, having its principal place of business at: 2100 South IH-35, Suite 202, Austin, Texas 78704. HHSC and HMO may be referred to in this Amendment individually as a “Party” and collectively as the “Parties.”
The Parties hereby agree to amend their original contract, HHSC contract number 529-06-0280-00014 (the “Contract”) as set forth herein. The Parties agree that the terms of the Contract will remain in effect and continue to govern except to the extent modified in this Amendment.
This Amendment is executed by the Parties in accordance with the authority granted in Attachment A to the HHSC Managed Care Contract document, “HHSC Uniform Managed Care Contract Terms & Conditions,” Article 8, “Amendments and Modifications.”
|
||
Part 2: Effective Date of Amendment:
|
Part 3: Contract Expiration Date
|
Part 4: Operational Start Date:
|
January 1, 2012
|
August 31, 2013
|
STAR and CHIP HMOs: September 1, 2006
STAR+PLUS HMOs: February 1, 2007
CHIP Perinatal HMOs: January 1, 2007
|
Part 5: Project Managers:
|
||
HHSC:
Scott Schalchlin
Director, Health Plan Operations
11209 Metric Boulevard, Building H
Austin, Texas 78758
Phone: 512-491-1866
Fax: 512-491-1969
HMO:
Susan Erickson
Director of Contract Management
2100 South IH-35, Suite 202
Austin, Texas 78704
Phone: 512-692-1465
Fax: 512-692-1474
E-mail: serickson@centene.com
|
||
Part 6: Deliver Legal Notices to:
|
||
HHSC:
General Counsel
4900 North Lamar Boulevard, 4th Floor
Austin, Texas 78751
Fax: 512-424-6586
HMO:
Superior HealthPlan
2100 South IH-35, Suite 202
Austin, Texas 78704
Fax: 512-692-1435
|
|
||
Part 7: HMO Programs and Service Areas:
|
||
This Contract applies to the following HHSC HMO Programs and Service Areas (check all that apply). All references in the Contract Attachments to HMO Programs or Service Areas that are not checked are superfluous and do not apply to the HMO.
|
Service Areas:
|
þ Bexar
|
þ Lubbock
|
||
o Dallas
|
þ Nueces
|
|||
þ El Paso
|
o Tarrant
|
|||
o Harris
|
þ Travis
|
|||
o Jefferson |
Service Areas:
|
þ Bexar
|
þ Nueces
|
||
o Harris
|
o Travis
|
|||
o Jefferson |
Core Service Areas:
|
þ Bexar
|
þ Lubbock
|
||
o Dallas
|
þ Nueces
|
|||
þ El Paso
|
o Tarrant
|
|||
o Harris
|
þ Travis
|
Optional Service Areas:
|
þ Bexar
|
þ Lubbock
|
||
þ El Paso
|
þ Nueces
|
|||
o Harris
|
þ Travis
|
Core Service Areas:
|
þ Bexar
|
þ Lubbock
|
||
o Dallas
|
þ Nueces
|
|||
þ El Paso
|
o Tarrant
|
|||
o Harris
|
þ Travis
|
Optional Service Areas:
|
þ Bexar
|
þ Lubbock
|
||
þ El Paso
|
þ Nueces
|
|||
o Harris
|
þ Travis
|
Part 8: Payment
|
Part 8 of the HHSC Managed Care Contract document, “Payment,” is modified to add the capitation rates for Rate Period 6.
|
Service Area: BEXAR
|
Rate Period 6 Capitation Rates
|
Rate Period 6 Capitation Rates | ||||||||
Rate Cell
|
(9/1/11 - 12/31/11) | (1/1/12 - 2/29/11) | ||||||||
1 |
TANF Child > 12 months
|
$
|
***
|
$ | *** | |||||
2 |
TANF child ≤ 12 months
|
$
|
***
|
$ | *** | |||||
3 |
TANF Adult
|
$
|
***
|
$ | *** | |||||
4 |
Pregnant Woman
|
$
|
***
|
$ | *** | |||||
5 |
Newborn ≤ 12 months
|
$
|
***
|
$ | *** | |||||
6 |
Expansion Child > 12 months
|
$
|
***
|
$ | *** | |||||
7 |
Expansion child ≤ 12 months
|
$
|
***
|
$ | *** | |||||
8 |
Federal Mandate child
|
$
|
***
|
$ | *** | |||||
9 |
Delivery Supplemental Payment
|
$
|
***
|
$ | *** |
Service Area: EL PASO
|
Rate Period 6 Capitation Rates
|
Rate Period 6 Capitation Rates
|
||||||||
Rate Cell
|
(9/1/11 - 12/31/11)
|
(1/1/12 - 2/29/11) | ||||||||
1 |
TANF Child > 12 months
|
$
|
***
|
$ | *** | |||||
2 |
TANF child ≤ 12 months
|
$
|
***
|
$ | *** | |||||
3 |
TANF Adult
|
$
|
***
|
$ | *** | |||||
4 |
Pregnant Woman
|
$
|
***
|
$ | *** | |||||
5 |
Newborn ≤ 12 months
|
$
|
***
|
$ | *** | |||||
6 |
Expansion Child > 12 months
|
$
|
***
|
$ | *** | |||||
7 |
Expansion child ≤ 12 months
|
$
|
***
|
$ | *** | |||||
8 |
Federal Mandate child
|
$
|
***
|
$ | *** | |||||
9 |
Delivery Supplemental Payment
|
$
|
***
|
$ | *** |
Service Area: LUBBOCK
|
Rate Period 6 Capitation Rates
|
Rate Period 6 Capitation Rates
|
||||||||
Rate Cell
|
(9/1/11 - 12/31/11)
|
(1/1/12 - 2/29/11) | ||||||||
1 |
TANF Child > 12 months
|
$
|
***
|
$ | *** | |||||
2 |
TANF child ≤ 12 months
|
$
|
***
|
$ | *** | |||||
3 |
TANF Adult
|
$
|
***
|
$ | *** | |||||
4 |
Pregnant Woman
|
$
|
***
|
$ | *** | |||||
5 |
Newborn ≤ 12 months
|
$
|
***
|
$ | *** | |||||
6 |
Expansion Child > 12 months
|
$
|
***
|
$ | *** | |||||
7 |
Expansion child ≤ 12 months
|
$
|
***
|
$ | *** | |||||
8 |
Federal Mandate child
|
$
|
***
|
$ | *** | |||||
9 |
Delivery Supplemental Payment
|
$
|
***
|
$ | *** |
Service Area: NUECES
|
Rate Period 6 Capitation Rates
|
Rate Period 6 Capitation Rates
|
||||||||
Rate Cell
|
(9/1/11 - 12/31/11)
|
(1/1/12 - 2/29/11) | ||||||||
1 |
TANF Child > 12 months
|
$
|
***
|
$ | *** | |||||
2 |
TANF child ≤ 12 months
|
$
|
***
|
$ | *** | |||||
3 |
TANF Adult
|
$
|
***
|
$ | *** | |||||
4 |
Pregnant Woman
|
$
|
***
|
$ | *** | |||||
5 |
Newborn ≤ 12 months
|
$
|
***
|
$ | *** | |||||
6 |
Expansion Child > 12 months
|
$
|
***
|
$ | *** | |||||
7 |
Expansion child ≤ 12 months
|
$
|
***
|
$ | *** | |||||
8 |
Federal Mandate child
|
$
|
***
|
$ | *** | |||||
9 |
Delivery Supplemental Payment
|
$
|
***
|
$ | *** |
Service Area: TRAVIS
|
Rate Period 6 Capitation Rates |
Rate Period 6 Capitation Rates
|
||||||||
Rate Cell
|
(9/1/11 - 12/31/11)
|
(1/1/12 - 2/29/11) | ||||||||
1 |
TANF Child > 12 months
|
$
|
***
|
$ | *** | |||||
2 |
TANF child ≤ 12 months
|
$
|
***
|
$ | *** | |||||
3 |
TANF Adult
|
$
|
***
|
$ | *** | |||||
4 |
Pregnant Woman
|
$
|
***
|
$ | *** | |||||
5 |
Newborn ≤ 12 months
|
$
|
***
|
$ | *** | |||||
6 |
Expansion Child > 12 months
|
$
|
***
|
$ | *** | |||||
7 |
Expansion child ≤ 12 months
|
$
|
***
|
$ | *** | |||||
8 |
Federal Mandate child
|
$
|
***
|
$ | *** | |||||
9 |
Delivery Supplemental Payment
|
$
|
***
|
$ | *** |
STAR+PLUS Service Area: BEXAR
|
Rate Period 6 Capitation Rates
|
Rate Period 6 Capitation Rates
|
||||||||
Rate Cell
|
(9/1/11 - 12/31/11)
|
(1/1/12 - 2/29/11) | ||||||||
1. |
Medicaid Only Standard Rate
|
$
|
***
|
$
|
*** | |||||
2. |
Medicaid Only 1915(C) Nursing Facility Waiver Rate
|
$
|
***
|
$ | *** | |||||
3. |
Dual Eligible Standard Rate
|
$
|
***
|
$ | *** | |||||
4. |
Dual Eligible 1915(C) Nursing Facility Waiver Rate
|
$
|
***
|
$ | *** | |||||
5. |
Nursing Facility – Medicaid Only
|
$
|
***
|
$ | *** | |||||
6. |
Nursing Facility – Dual Eligible
|
$
|
***
|
$ | *** |
STAR+PLUS Service Area: NUECES
|
Rate Period 6 Capitation Rates
|
Rate Period 6 Capitation Rates
|
||||||||
Rate Cell
|
(9/1/11 - 12/31/11)
|
(1/1/12 - 2/29/11) | ||||||||
1. |
Medicaid Only Standard Rate
|
$
|
***
|
$ | *** | |||||
2. |
Medicaid Only 1915(C) Nursing Facility Waiver Rate
|
$
|
***
|
$ | *** | |||||
3. |
Dual Eligible Standard Rate
|
$
|
***
|
$ | *** | |||||
4. |
Dual Eligible 1915(C) Nursing Facility Waiver Rate
|
$
|
***
|
$ | *** | |||||
5. |
Nursing Facility – Medicaid Only
|
$
|
***
|
$ | *** | |||||
6. |
Nursing Facility – Dual Eligible
|
$
|
***
|
$ | *** |
Service Area: BEXAR
|
||||||||
Rate Cell
|
Rate Period 6 Capitation Rates
|
|||||||
1. |
< Age 1
|
$
|
***
|
|||||
2. |
Ages 1 through 5
|
$
|
***
|
|||||
3. |
Ages 6 through 14
|
$
|
***
|
|||||
4. |
Ages 15 through 18
|
$
|
***
|
Service Area: EL PASO
|
||||||||
Rate Cell
|
Rate Period 6 Capitation Rates
|
|||||||
1. |
< Age 1
|
$
|
***
|
|||||
2. |
Ages 1 through 5
|
$
|
***
|
|||||
3. |
Ages 6 through 14
|
$
|
***
|
|||||
4. |
Ages 15 through 18
|
$
|
***
|
Service Area: LUBBOCK
|
||||||||
Rate Cell
|
Rate Period 6 Capitation Rates
|
|||||||
1. |
< Age 1
|
$
|
***
|
|||||
2. |
Ages 1 through 5
|
$
|
***
|
|||||
3. |
Ages 6 through 14
|
$
|
***
|
|||||
4. |
Ages 15 through 18
|
$
|
***
|
Service Area: NUECES
|
||||||||
Rate Cell
|
Rate Period 6 Capitation Rates
|
|||||||
1. |
< Age 1
|
$
|
***
|
|||||
2. |
Ages 1 through 5
|
$
|
***
|
|||||
3. |
Ages 6 through 14
|
$
|
***
|
|||||
4. |
Ages 15 through 18
|
$
|
***
|
Service Area: TRAVIS
|
||||||||
Rate Cell
|
Rate Period 6 Capitation Rates
|
|||||||
1. |
< Age 1
|
$
|
***
|
|||||
2. |
Ages 1 through 5
|
$
|
***
|
|||||
3. |
Ages 6 through 14
|
$
|
***
|
|||||
4. |
Ages 15 through 18
|
$
|
***
|
Service Area: BEXAR
|
||||||||
Rate Cell
|
Rate Period 6 Capitation Rates
|
|||||||
1. |
Perinate Newborn 0% to 185%
|
$
|
***
|
|||||
2. |
Perinate Newborn Above 185% to 200%
|
$
|
***
|
|||||
3. |
Perinate 0% to 185%
|
$
|
***
|
|||||
4. |
Perinate Above 185% to 200%
|
$
|
***
|
Service Area: EL PASO
|
||||||||
Rate Cell
|
Rate Period 6 Capitation Rates
|
|||||||
1. |
Perinate Newborn 0% to 185%
|
$
|
***
|
|||||
2. |
Perinate Newborn Above 185% to 200%
|
$
|
***
|
|||||
3. |
Perinate 0% to 185%
|
$
|
***
|
|||||
4. |
Perinate Above 185% to 200%
|
$
|
***
|
Service Area: LUBBOCK
|
||||||||
Rate Cell
|
Rate Period 6 Capitation Rates
|
|||||||
1. |
Perinate Newborn 0% to 185%
|
$
|
***
|
|||||
2. |
Perinate Newborn Above 185% to 200%
|
$
|
***
|
|||||
3. |
Perinate 0% to 185%
|
$
|
***
|
|||||
4. |
Perinate Above 185% to 200%
|
$
|
***
|
Service Area: NUECES
|
||||||||
Rate Cell
|
Rate Period 6 Capitation Rates
|
|||||||
1. |
Perinate Newborn 0% to 185%
|
$
|
***
|
|||||
2. |
Perinate Newborn Above 185% to 200%
|
$
|
***
|
|||||
3. |
Perinate 0% to 185%
|
$
|
***
|
|||||
4. |
Perinate Above 185% to 200%
|
$
|
***
|
Service Area: TRAVIS
|
||||||||
Rate Cell
|
Rate Period 6 Capitation Rates
|
|||||||
1. |
Perinate Newborn 0% to 185%
|
$
|
***
|
|||||
2. |
Perinate Newborn Above 185% to 200%
|
$
|
***
|
|||||
3. |
Perinate 0% to 185%
|
$
|
***
|
|||||
4. |
Perinate Above 185% to 200%
|
$
|
***
|
Part 9: Contract Attachments:
|
Part 10: Special Provision for Nueces Service Area
|
Part 11: Signatures:
|
The Parties have executed this Contract Amendment in their capacities as stated below with authority to bind their organizations on the dates set forth by their signatures. By signing this Amendment, the Parties expressly understand and agree that this Amendment is hereby made part of the Contract as though it were set out word for word in the Contract.
Texas Health and Human Services Commission
/s/ Billy Millwee
Billy Milwee, Deputy Executive Commissioner for Health Services
Date: 12/9/11
Superior HealthPlan, Inc.
/s/ Thomas Wise
By: Thomas Wise
Title: President and CEO
Date: 11/28/11
|
STATUS1
|
DOCUMENT REVISION2
|
EFFECTIVE DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial version of the Uniform Managed Care Contract Terms & Conditions
|
|
Revision
|
1.1
|
June 30, 2006
|
Revised version of the Uniform Managed Care Contract Terms & Conditions that includes provisions applicable to MCOs participating in the STAR+PLUS Program.
Article 2, “Definitions,” is amended to add or modify the following definitions: 1915(c) Nursing Facility Waiver; Community-based Long Term Care Services; Court-ordered Commitment; Default Enrollment; Dual Eligibles; Eligibles; Functionally Necessary Covered Services; HHSC Administrative Services Contractor; HHSC HMO Programs or HMO Programs; Medicaid HMOs; Medical Assistance Only; Member; Minimum Data Set For Home Care (MSD-HC); Nursing Facility Cost Ceiling; Nursing Facility Level of Care; Outpatient Hospital Service; Qualified and Disabled Working Individual (QDWI); Qualified Medicare Beneficiary; Service Coordination; Service Coordinator; Specified Low-income Medicare Beneficiary (SMBL); STAR+PLUS or STAR+PLUS Program; STAR+PLUS HMO; Supplemental Security Income (SSI).
Article 4, “Contract Administration and Management,” is amended to add Sections 4.02(a)(12) and 4.04.1, relating to the STAR+PLUS Service Coordinator.
Article 8, “Amendments and Modifications,” Section 8.06 is amended to clarify that CMS must approve all amendments to STAR and STAR+PLUS HMO contracts.
Article 10, “Terms and Conditions of Payment,” Section 10.05.1 is added to include the Capitation Rate structure provisions relating to STAR+PLUS. Section 10.11 is modified to apply only to STAR and CHIP. Section 10.11.1 is added to include the Experience Rebate provisions relating to STAR+PLUS.
|
Revision
|
1.2
|
September 1, 2006
|
Revised version of the Uniform Managed Care Contract Terms & Conditions that includes provisions applicable to MCOs participating in the STAR and CHIP Programs.
Section 4.04(a) is amended to change the reference from “Texas Board of Medical Examiners” to “Texas Medical Board”.
Article 5 is amended to clarify the following sections: 5.02(e)(5), regarding disenrollment of Members; 5.02(i), regarding disenrollment of foster care children; and 5.04(b), regarding CHIP eligibility and enrollment for babies of CHIP Members
|
STATUS1
|
DOCUMENT REVISION2
|
EFFECTIVE DATE
|
DESCRIPTION3
|
Article 10 is amended to clarify the following sections: 10.01(d), regarding the fixed monthly Capitation Rate components; 10.10(c), regarding updating the state system for Members who become eligible for SSI. Section 10.17 is added regarding recoupment for federal disallowance.
Article 17 is amended to clarify the following section: 17.01, naming HHSC as an additional insured.
|
|||
Revision
|
1.3
|
September 1, 2006
|
Article 2 is amended to modify and add the following definitions to include the CHIP Perinatal Program- Appeal, CHIP Perinatal Program, CHIP Perinatal HMO, CHIP Perinate, CHIP Perinate Newborn, Covered Services, Complaint, Delivery Supplemental Payment, Eligibles, Experience Rebate, HHSC Administrative Services Contractor, Major Population Group, Member, Optional Service Area, and Service Management.
Article 5 is amended to add the following sections: 5.04.1 CHIP Perinatal eligibility and enrollment; 5.05(c) CHIP Perinatal HMOs.
Article 10 is amended to apply to the CHIP Perinatal Program. Section 10.06(a) is amended to add the Capitation Rates Structure for CHIP Perinates and CHIP Perinate Newborns. Section 10.06(e) is added to include a description of the rate-setting methodology for the CHIP Perinatal Program. 10.09(b) is modified to include CHIP Perinatal Program; Section 10.11 is amended to add the CHIP Perinatal Program to the STAR and CHIP Experience Rebate. Section 10.12(c) amended to clarify cost sharing for the CHIP Perinatal Program.
|
Revision
|
1.4
|
September, 1 2006
|
Contract amendment did not revise Attachment A HHSC Uniform Managed Care Terms and Conditions
|
Revision
|
1.5
|
January 1, 2007
|
Revised version of the Uniform Managed Care Contract Terms & Conditions that includes provisions applicable to MCOs participating in the STAR, STAR+PLUS, CHIP, and CHIP Perinatal Programs.
Section 5.04(a) is amended to clarify the period of CHIP continuous coverage.
Section 5.04.1 is amended to clarify the process for a CHIP Perinatal Newborn to move into CHIP at the end of the 12month CHIP Perinatal Program eligibility.
Section 5.08 is added to include STAR+PLUS special default language.
Section 10.06.1 is amended to correct the FPL percentages for CHIP Perinates and CHIP Perinate Newborns.
Section 17.01 is amended to clarify the insurance requirements for the HMOs and Network Providers and to remove the insurance requirements for Subcontractors.
|
STATUS1
|
DOCUMENT REVISION2
|
EFFECTIVE DATE
|
DESCRIPTION3
|
Section 17.02(b) is added to clarify that a separate Performance Bond is not needed for the CHIP Perinatal Program.
|
|||
Revision
|
1.6
|
February 1, 2007
|
Contract amendment did not revise Attachment A HHSC Uniform Managed Care Terms and Conditions
|
Revision
|
1.7
|
July 1, 2007
|
Article 2 is modified to correct and align definition for “Clean Claim” with the UMCM.
Section 4.08(c) is modified to add a cross-reference to new Attachment B-1, Section 8.1.1.2.
Section 5.05(a), Medicaid HMOs, is amended to clarify provisions regarding enrollment into Medicaid Managed Care from Medicaid Fee-for-Service while in the hospital, changing HMOs while in the hospital, and addressing which HMO is responsible for professional and hospital charges during the hospital stay.
New Section 10.05.1 (c) is added to clarify capitation payments (delays in payment and levels of capitation) for Members certified to receive STAR+PLUS Waiver Services.
Section 10.06.1 is modified to include the CHIP Perinatal pass through for delivery physician services for women under 185% FPL.
Section 10.11 is modified to include treatment of the new Incentives and Disincentives (within the Experience Rebate determination); additionally, several clarifications are added with respect to the continuing accrual of any unpaid interest, etc.
Section 10.11.1 is modified to include treatment of the new Incentives and Disincentives (within the Experience Rebate determination); additionally, several clarifications are added with respect to the continuing accrual of any unpaid interest, etc.
|
Revision
|
1.8
|
September 1, 2007
|
Article 2 is modified to add definitions for Migrant Farmworker and FWC as a result of the Frew litigation corrective action plans.
Article 2 is modified to reflect legislative changes required by SB 10 to the definition for Value-added Services.
New Section 5.03.1 is added to clarify the enrollment process for infants born to pregnant women in STAR+PLUS.
Section 5.04 is modified to reflect legislative changes required by HB 109.
Section 10.18 is added to clarify the required pass through of physician rate increases for all programs to comply with HHSC directives.
|
STATUS1
|
DOCUMENT REVISION2
|
EFFECTIVE DATE
|
DESCRIPTION3
|
Revision
|
1.9
|
December 1, 2007
|
Section 10.11(d) is modified to increase the Experience rebate loss carry forward from 1 year to 2 years.
Section 10.11(e) is modified to eliminate the plan's responsibility to submit the actuarial certification on the 90 day FSR.
Section 10.11.1 (d) is modified to increase the Experience rebate loss carry forward from 1 year to 2 years.
Section 10.11.1 (e) is modified to eliminate the plan's responsibility to submit the actuarial certification on the 90 day FSR.
|
Revision | 1.10 | March 1, 2008 |
Article 2 is modified to remove the word “administrative” from the definition for Allowable Expenses”.
Article 2 is modified to update the definition for Affiliate.
Section 4.08 is modified to provide consistency of language in sections 4.08(b)(3), and to obligate the HMOs to provide HHSC with copies of amended Subcontracts.
Section 7.05 is modified to update the requirements regarding with state and federal anti-discrimination laws.
Section 10.06.1 is modified to clarify the CHIP Perinatal pass through for delivery physician services for women under 185% FPL.
Section 10.11 (b) is modified to change the heading in the table from Experience Rebate as a % of Revenues to Pre-tax Income as a % of Revenues
Section 10.11 (c) (1) is modified to remove the word “administrative” from the title of UMCM chapter reference.
Section 10.11 (e) (4) is modified to remove the word “administrative” from the title of UMCM chapter reference.
Section 10.11.1 (b) is modified to establish new STAR+PLUS rebate brackets for Rate Period 2 and after.
Section 10.11.1 (c) (1) is modified to remove the word “administrative” from the title of UMCM chapter reference.
|
Revision | 1.11 | September 1, 2008 |
Article 2 is modified to add definitions for Discharge and Transfer.
Article 2 is modified to remove the “Pediatric and Family” qualifier from Advanced Practice Nurses in the definition for PCP.
Section 5.02 is modified to clarify that only Medicaid HMOs have a limited right to request that a Member be disenrolled.
Section 5.03 is modified to clarify that newborns must remain in their mother’s Medicaid HMO for at least 90 days following the date of birth, unless the mother request s a plan change.
Section 5.05(a), is modified to clarify provisions regarding enrollment into Medicaid Managed Care from Medicaid Fee-for-Service while in the hospital and changing HMOs while in the hospital.
Section 5.05(c) is modified to clarify the span of coverage for CHIP Perinate Newborns who are in the hospital on the effective date of disenrollment.
Section 05.07.1 is added to establish a special temporary STAR default process for service areas with HMOs that did not contract with HHSC prior to September 1, 2006.
Section 05.08.1 is added to establish a special temporary STAR+PLUS default process for service areas with HMOs that did not contract with HHSC prior to September 1, 2006.
Section 09.06 is added to require the HMOs to notify HHSC of legal and other proceedings, and related events.
Section 10.11 (e) is modified to clarify the settlement process.
Section 10.11 (f) is modified to require the payment of interest on any Experience Rebate unpaid 35 days after the due date for the 90-day FSR Report.
Section 10.11.1 (e) is modified to reference the process defined in Sections 10.11 (e) and (f).
Section 10.11.1 (f) is deleted as part of the Section 10.11.1 (e) alignment with the process defined in Sections 10.11 (e) and (f).
Section 10.11.2 is added to institute the STAR, CHIP, CHIP Perinatal, and STAR+PLUS Administrative Expense Cap.
Section 10.12 (b) is modified to address federal CHIP regulations.
Section 11.07 is modified to remove extraneous word.
|
Revision | 1.12 | March 1, 2009 |
Article 2 is modified to add the definitions for Bariatric Supplemental Payment and TP 13; and to clarify the definitions for Migrant Farmworker, TP 40, and TP 45.
Section 5.05 is modified to add item (a)(6) to clarify movement from STAR+PLUS to STAR Health; add item (a)(7) regarding movement from STAR, STAR+PLUS, or FFS due to SSI status; clarify item (c); and add item (d) regarding effective date of SSI status. These ratifications of existing policies and processes are effective 9/1/08. Any future change to such policies or processes will require adjustments to the capitation payments.
Section 5.07.1 is modified to include the Harris Expansion Service Area.
Section 10.06.1(a) is modified to accurately reflect the percentage breakdown.
Section 10.09(b) is modified to accurately reflect the percentage breakdown.
Section 10.10(c) is modified to conform to clarifications in Section 5.05(d).
Section 10.11.2 is modified to add Bariatric Supplemental Payments.
Section 10.11.2(d) is modified to correct a contract reference.
Section 10.19, Bariatric Supplemental Payment for STAR and STAR+PLUS HMOs is added.
|
Revision | 1.13 | September 1, 2009 |
All references to “THSteps” are changed to “Texas Health Steps”
Article 2 is amended to add the definitions for Rate Period 3, and Rate Period 4.
Section 5.05 is amended to clarify that Hospital facility charges for inpatient mental health Covered Services will be paid by the STAR+PLUS HMO.
Section 5.09 Default Methodology for Frew Incentives and Disincentives is added.
Section 7.02 is modified to add references to 1 T.A.C. Part 15, Chapter 371 and the Frew Consent Decree and Alberto N. Partial Settlement Agreements
Section 10.11(a) is amended to change “Rate Year” to “Rate Period”
Section 10.11(b) is amended to reflect the change in the SFY 2010 sharing tier structure for the Experience Rebate.
Section 10.11(d) is amended to clarify the two year loss carry forward.
Section 10.11(e) is amended to clarify the required documentation for non-scheduled payments.
Section 10.11.1(a) is amended to change “Rate Year” to “Rate Period” and to clarify when the HMO must pay an Experience Rebate.
Section 10.11.1(b) is amended to reflect the change in the SFY 2010 sharing tier structure for the Experience Rebate.
Section 10.11.1(d) is amended to clarify the two year loss carry forward.
Section 10.12 is modified to include CHIP enrollees in prohibition against liability for payment (Balance Billing).
Section 12.15 is added to establish a pre-termination process.
Section 17.01(a) is modified to provide clarification of required insurance coverage, including deletion of Standard Worker’s
Section 17.01(b) is modified to correctly identify the type of professional liability coverage required.
Section 17.01(c)(4) is modified to require that HHSC is named as loss payee of insurance coverage.
Section 17.01(c)(5) is modified to require continuous coverage during Term of Contract.
Section 17.01(c)(6) is modified to require notification prior to reduction in coverage and to add provision to insurance policy
requiring 30-day notice prior to reduction in, cancellation, or non-renewal of, the policy.
Section 17.02(a) is modified to align the performance bond requirements with insurance practices by requiring one bond per MCO with a defined term and amount and to require annual renewal of the bond.
Section 17.02(c) is added to establish a process for release of previous performance bonds received by HHSC.
|
Revision | 1.14 | December 1, 2009 | Section 17.02 (a) is modified to require the single bond per MCO with a defined term and amount beginning in SFY2010. |
Revision | 1.15 | March 1, 2010 | Article 2 is amended to revise the definition for "Material Subcontractor or Major Subcontractor" |
Revision | 1.16 | September 1, 2010 |
All references to “Frew vs. Hawkins” are changed to “Frew vs. Suehs”.
Definition of CHIP Perinate Newborn is modified.
Definition for Medicaid HMOs is modified to include the STAR Health Program.
Definition for Primary care Physician or Primary Care Provider (PCP) is modified to clarify that APNs and PAs must practice under the supervision of a PCP.
Definitions for Rate Periods 5 and 6 are added.
Section 4.02 is amended to clarify that STAR+PLUS HMOs must notify HHSC when the management/leadership for the STAR+PLUS Service Coordinators changes.
Section 4.08(b)(3) and (4) are modified to clarify the timeframes for notification.
Section 5.04.1 is modified to reflect changes to CHIP Perinatal Program eligibility, effective 9/1/10. The section is also modified to clarify that CHIP Perinatal members have 90 days to select an HMO if defaulted upon enrollment.
Section 5.05 is modified to reflect changes to CHIP Perinatal Program eligibility, effective 9/1/10, and to remove (d)(4) reference to ICM Program.
Section 7.07 is amended to add subsection (b).
Section 9.02(c) is modified to add “the Medicaid Fraud Control Unit of the Texas Attorney General's Office or its designee”.
Section 10.06.1 has been modified to clarify the CHIP Perinate Newborn 0% to 185% rate cell
|
Revision | 1.17 | December 1, 2010 | Contract amendment did not revise Attachment A HHSC Uniform Managed Care Terms and Conditions |
Revision | 1.18 | March 1, 2011 |
Definition of "Major Population Group" is modified
The definition of "Medically Necessary" is revised to address the review criteria applicable to children in Medicaid, consistent with 42 USC § 1396(r)(5) and Alberto N requirements. The HMOs are already contractually obligated to comply with these requirments, so the change is for clarification only.
Definition of "Outpatient Hospital Services" is modifed to remove language that is included in UMCM.
Definition of "Post-stabilization Care Services" is modified.
Definition of "Texas Health Network" is deleted.
Definition of "Uniform Managed Care Manual" is modified.
Section 4.08 is modified to prohibit Medicaid payments to entities located outside the U.S. in conformance with the Affordable Care Act.
Section 4.10 is modifed to prohibit medicaid payments to entities located outside the U.S. in conformance with the Affordable Care Act.
Section 5.04 is modified to clarify that infants born to CHIP members are not automatically enrolled in CHIP.
Section 5.05(a)(3) is modified to correct contract cross-reference.
Section 7.02(a) is modified to remove case identification information from the Frew and Alberto N items.
Section 8.06 is revised to apply generally to all HMO contracts.
Section 9.01 is revised to clarify the requirments for record retention in accordance with Federal requirments.
Section 10.11.1 is modified to let the HMOs consoldiate their DFW STAR+PLUS experience with their other STAR+PLUS products.
|
Revision | 1.19 | September 1, 2011 |
Definition for Expansion Counties is added.
Definition for Fair Hearing is modified.
Definition for PPACA is added.
Definition for Transition Phase is modified.
Section 4.08 is modified to add language for the ACA requirement regarding Healthcare Acquired Conditions (HAC).
Section 4.10 is modified to add language for the ACA requirement regarding Healthcare Acquired Conditions (HAC).
Section 7.08, “Historically Underutilized Business Participation Requirements” is added.
Section 9.01 is modified to clarify compliance with 45 CFR 74.53.
Section 10.01(d) is modified to remove pass through funds for high volume providers from the list of Capitation Rate components.
Section 10.08(a) is modified to include a new item addressing the State’s right to recoup if the CMS has imposed a payment denial as a sanction (42 CFR §438.726(b)), and to modify (a)(1-2).
Section 10.19 is modified to remove the Bariatric Supplemental Payment for dates of service on or after September 1, 2011, when all funding will be included in the capitation rates.
Section 11.08, “Information Security” is added.
Section 12.02(d) is modified to refer to the circumstances prompting temporary management in 42 C.F.R. §438.706.
|
Revision | 1.20 | January 1, 2012 | Contract amendment did not revise Attachment A HHSC Uniform Managed Care Terms and Conditions |
1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
|
Responsibility for Inpatient Stay Services
|
||
Exception
|
Hospital Facility Charges
|
Professional Services Charges
|
Member Retroactively Enrolled in STAR per Section 5.03
|
STAR HMO
|
STAR HMO
|
Member ≤ 12 Months of Age Who Is Prospectively Enrolled in STAR
|
Medicaid FFS*
|
STAR HMO
|
Member ≤ 12 Months of Age Who Is Prospectively Enrolled in STAR+PLUS
|
STAR+PLUS HMO for Inpatient Mental Health Covered Services
Medicaid FFS for all Other Inpatient Facility Services*
|
STAR+PLUS HMO
|
Pre-Tax Income as a % of Revenues
|
HMO Share
|
HHSC Share
|
< 3%
|
100%
|
0%
|
> 3% and < 7%
|
75%
|
25%
|
> 7% and < 10%
|
50%
|
50%
|
> 10% and < 15%
|
25%
|
75%
|
> 15%
|
0%
|
100%
|
Pre-tax Income as a % of Revenues
|
HMO Share
|
HHSC Share
|
≤ 3%
|
100%
|
0%
|
> 3% and ≤ 5%
|
80%
|
20%
|
> 5% and ≤ 7%
|
60%
|
40%
|
> 7% and ≤ 9%
|
40%
|
60%
|
> 9% and ≤ 12%
|
20%
|
80%
|
> 12%
|
0%
|
100%
|
Pre-tax Income as a % of Revenues
|
HMO Share
|
HHSC Share
|
< 3%
|
50%
|
50%
|
> 3%
|
75%
|
25%
|
Pre-tax Income as a % of Revenues
|
HMO Share
|
HHSC Share
|
≤ 2%
|
100%
|
0%
|
> 2% and ≤ 6%
|
75%
|
25%
|
> 6% and ≤ 10%
|
50%
|
50%
|
> 10% and ≤ 15%
|
25%
|
75%
|
> 15%
|
0%
|
100%
|
Pre-tax Income as a % of Revenues
|
HMO Share
|
HHSC Share
|
≤ 3%
|
100%
|
0%
|
> 3% and ≤ 5%
|
80%
|
20%
|
> 5% and ≤ 7%
|
60%
|
40%
|
> 7% and ≤ 9%
|
40%
|
60%
|
> 9% and ≤ 12%
|
20%
|
80%
|
> 12%
|
0%
|
100%
|
|
(1) The total premiums paid by HHSC (earned by the HMO), and corresponding Member Months, will be taken from the relevant FSR (or audit report) for the Rate Period.
|
|
(2) There are two components of the administrative expense portion of the Capitation Rate structure: the percentage rate to apply against the total premiums paid (the “percentage of premium” within the administrative expenses), and, the dollar rate per Member Month (the “fixed amount” within the administrative expenses). These will be taken from the supporting details associated with the official notification of final Capitation Rates, as supplied by HHSC. This notification is sent to the HMOs during the annual rate setting process via email, labeled as “the final rate exhibits for your health plan.” The email has one or more spreadsheet files attached, which are particular to the given HMO. The spreadsheet(s) show the fixed amount and percentage of premium components for the administrative component of the Capitation Rate.
|
1. Multiply the predetermined administrative expense rate structure “fixed amount,” or dollar rate per Member Month (for example, $11.00), by the actual number of Member Months for the Program and Service Area during the Rate Period (for example, 70,000):
|
|
• $11.00 x 70,000 = $770,000.
|
2. Multiply the predetermined percent of premiums in the administrative expense rate structure (for example, 5.75%), by the actual aggregate premiums earned for the Program and Service Area during the Rate Period (for example, $6,000,000).
|
|
• 5.75% x $6,000,000 = $345,000.
|
3. For SFY 2009, add the totals of items 1-2 and multiply the sum by the adjustment factor of 1.05. To this product, add applicable premium taxes and maintenance taxes (for example, $112,000), to determine the Admin Cap for the Program and Service Area:
|
|
• 1.05($770,000 + $345,000) + $112,000 = $1,282,750.
|
In this example, $1,282,750 would be the Admin Cap for a single Program in a given Service Area for an HMO in a particular Rate Period.
|
|
• $770,000 + $345,000 + $112,000 = $1,227,000.
|
|
In this example, $1,227,000 would be the Admin Cap for a single Program in a given Service Area for an HMO in a particular Rate Period.
|
DOCUMENT HISTORY LOG
|
|||
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial version Attachment B-1, Section 6
|
|
Revision
|
1.1
|
June 30, 2006
|
Revised version of the Attachment B-1, Section 6, that includes provisions applicable to MCOs participating in the STAR+PLUS Program.
Section 6.3.2.1, Experience Rebate Reward, is modified to delete references to the selected performance indicators and the Quality Challenge Pool.
Section 6.3.2.2, Performance-Based Capitation Rate, is modified to include STAR+PLUS and to add Additional STAR+PLUS Performance Indicators. Section 6.3.2.3, Quality Challenge Award, is modified to include STAR+PLUS. Section 6.3.2.5, STAR+PLUS Hospital Inpatient Performance Based Capitation Rate: Hospital Inpatient Stay Cost Incentives and Disincentives, is added.
Section 6.3.2.5.1, STAR+PLUS Hospital Inpatient Disincentive – Administrative Fee at Risk, is added.
Section 6.3.2.5.2, STAR+PLUS Hospital Inpatient Incentive – Shared Savings Award, is added.
|
Revision
|
1.2
|
September 1, 2006
|
Revised version of the Attachment B-1, Section 6, that includes provisions applicable to MCOs participating in the STAR and CHIP Programs.
Section 6.3.2.2, Performance-Based Capitation Rate, modifies the standard performance indicator for the Behavioral Health Hotline to change the maximum abandonment rate from 5% to 7% (except in the Dallas Core Service Area).
Section 6.3.2.3, Quality Challenge Award, is modified to reflect the new start date for the Quality Challenge Award, which will not be implemented until State Fiscal Year 2008.
|
Revision
|
1.3
|
September 1, 2006
|
Revised version of the Attachment B-1, Section 6, that includes provisions applicable to MCOs participating in the CHIP Perinatal Program.
Section 6.3.2.1 modified to clarify that the Experience Rebate Reward incentive may apply to the CHIP Perinatal Program at a later date.
Section 6.3.2.2 modified to clarify that the Performance-based Capitation Rate will not apply for the CHIP Perinatal Program in SFY 2007.
|
Revision
|
1.4
|
September 1, 2006
|
Contract amendment did not revise Attachment B-1 Section 6 – Premium Payment, Incentives, and Disincentives
|
Revision
|
1.5
|
January 1, 2007
|
Contract amendment did not revise Attachment B-1 Section 6 – Premium Payment, Incentives, and Disincentives
|
Revision
|
1.6
|
February 1, 2007
|
Revised version of the Attachment B-1, Section 6, that includes provisions applicable to MCOs participating in the STAR+PLUS Program.
Section 6.3.2.5 is modified to clarify the months included in Rate Period 1.
|
Revision
|
1.7
|
July 1, 2007
|
Contract amendment did not revise Attachment B-1 Section 6 – Premium Payment, Incentives, and Disincentives
|
Revision
|
1.8
|
September 1, 2007
|
Section 6.3 is modified as a result of SB 10 legislation and the Frew litigation to prohibit HMOs from passing down financial disincentives or sanctions to providers.
Section 6.3.1.1 is modified as a result of the Frew litigation to allow HHSC to post information regarding poor HMO performance on the HHSC website.
Section 6.3.2.2 is modified to clarify language regarding the Performance Indicator Dashboard and the reapportionment of points for the 1% at-risk premium.
Section 6.3.2.3 is modified as a result of the Frew litigation to clarify language.
New Section 6.3.2.6 is added as a result of the Frew litigation to clarify requirements for additional incentives and disincentives.
|
Revision
|
1.9
|
December 1, 2007
|
Section 6.3.2.3 is modified to outline the calculation methodology for STAR, STAR+PLUS, and CHIP.
|
Revision | 1.10 | March 1, 2008 | Contract amendment did not revise Attachment B-1 Section 6 - Premium Payment, Incentives, and Disincentives. |
Revision | 1.11 | September 1, 2008 | Contract amendment did not revise Attachment B-1 Section 6 - Premium Payment, Incentives, and Disincentives. |
Revision | 1.12 | March 1, 2009 | Section 6.2.1 is modified to add Bariatric Supplemental Payments. |
Revision | 1.13 | September 1, 2009 |
Section 6.3.2.2 is modified to remove the list of performance indicators.
Section 6.3.2.5.1 is amended to clarify the 22% reduction.
Section 6.3.2.7 Frew Incentives and Disincentives is added.
Section 6.3.2.8 Nursing Facility Utilization Disincentive – 1% At-Risk Performance Indicator is added
|
Revision | 1.14 | December 1, 2009 | Contract amendment did not revise Attachment B-1 Section 6 - Premium Payment, Incentives, and Disincentives |
Revision | 1.15 | March 1, 2010 | Contract amendment did not revise Attachment B-1 Section 6 - Premium Payment, Incentives, and Disincentives |
Revision | 1.16 | September 1, 2010 | Section 6.3.2.7 reference to "Frew v. Hawkins" changed to "Frew v. Suehs". |
Revision | 1.17 | December 1, 2010 | Contract amendment did not revise Attachment B-1 Section 6 - Premium Payment, Incentives, and Disincentives |
Revision | 1.18 | March 1, 2011 | Section 6.3.2.8 is modified to remove "1% At-Risk Performance Indicator" from the section name, and to clarify that nursing facility utilization will be measured in the Performance Based Capitation Rate and the Quality Challenge Award. |
Revision | 1.19 | September 1, 2011 |
Section 6.3.2.2 is revised to exempt the Contiguous Expansion counties for the 2011 calendar year.
Section 6.3.2.3 is revised to exempt the Contiguous Expansion counties for the 2011 calendar year.
|
Revision | 1.20 | January 1, 2012 | Contract amendment did not revise Attachment B-1 Section 6 - Premium Payment, Incentives, and Disincentives |
1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
|
6. Premium Payment, Incentives, and Disincentives
|
6.1 Capitation Rate Development
|
6.2 Financial Payment Structure and Provisions
|
6.2.1 Capitation Payments
|
6.3 Performance Incentives and Disincentives
|
6.3.1 Non-financial Incentives
|
6.3.1.1 Performance Profiling
|
6.3.1.2 Auto-assignment Methodology for Medicaid HMOs
|
6.3.2 Financial Incentives and Disincentives
|
6.3.2.1 Experience Rebate Reward
|
6.3.2.3 Quality Challenge Award
|
6.3.2.5 STAR+PLUS Hospital Inpatient Performance-Based Capitation Rate: Hospital Inpatient Stay Cost Incentives & Disincentives
|
6.3.2.5.2 STAR+PLUS Hospital Inpatient Incentive – Shared Savings Award
|
6.3.2.6 Additional Incentives and Disincentives
|
DOCUMENT HISTORY LOG
|
||||
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
|
Baseline
|
n/a
|
Initial version Attachment B-1, Section 7
|
||
Revision
|
1.1
|
June 30, 2006
|
Revised version of the Attachment B-1, Section 7, that includes provisions applicable to MCOs participating in the STAR+PLUS Program.
Sections 7.1 to 7.3 modified to include STAR+PLUS.
|
|
Revision
|
1.2
|
September 1, 2006
|
Revised version of the Attachment B-1, Section 7, that includes provisions applicable to MCOs participating in the STAR and CHIP Programs.
Section 7.3.1.7, Operations Readiness, changes reference from “Operational Date” to “Effective Date.”
|
|
Revision
|
1.3
|
September 1, 2006
|
Revised version of the Attachment B-1, Section 7, that includes provisions applicable to MCOs participating in the CHIP Perinatal Program.
Sections 7.2, 7.3, and 7.3.1.2 through 7.3.1.7 modified to include the CHIP Perinatal Program.
|
|
Revision
|
1.4
|
September 1, 2006
|
Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements
|
|
Revision
|
1.5
|
January 1, 2007
|
Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements
|
|
Revision
|
1.6
|
February 1, 2007
|
Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements
|
|
Revision
|
1.7
|
July 1, 2007
|
Section 7.3.1.9 is modified to add a cross-reference to Attachment B-1, Sections 8.1.1.2 and 8.1.18.
|
|
Revision
|
1.8
|
September 1, 2007
|
Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements
|
|
Revision
|
1.9
|
December 1, 2007
|
Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements
|
|
Revision | 1.10 | March 1, 2008 | Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements | |
Revision | 1.11 | September 1, 2008 | Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements | |
Revision | 1.12 | March 1, 2009 | Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements | |
Revision | 1.13 | September 1, 2009 | Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements | |
Revision | 1.14 | December 1, 2009 | Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements | |
Revision | 1.15 | March 1, 2010 | Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements | |
Revision | 1.16 | September 1, 2010 | Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements | |
Revision | 1.17 | December 1, 2010 | Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements | |
Revision | 1.18 | March 1, 2011 | Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements | |
Revision | 1.19 | September 1, 2011 |
Contract amendment did not revise Attachment B-1 Section 7 – Transition Phase Requirements
|
|
Revision | 1.20 | January 1, 2012 |
|
|
1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
|
|
7. Transition Phase Requirements
|
|
7.1 Introduction
|
|
7.2 Transition Phase Scope for HMOs
|
|
7.3 Transition Phase Schedule and Tasks
|
|
7.3.1 Transition Phase Tasks
|
|
7.3.1.1 Contract Start-Up and Planning
|
|
• define project management and reporting standards;
|
|
• establish communication protocols between HHSC and the HMO;
|
|
• establish contacts with other HHSC contractors;
|
|
• establish a schedule for key activities and milestones; and
|
|
• clarify expectations for the content and format of Contract Deliverables.
|
|
7.3.1.2 Administration and Key HMO Personnel
|
|
7.3.1.3 Financial Readiness Review
|
|
1. The Contractor’s legal name, trade name, or any other name under which the Contractor does business, if any.
|
|
2. The address and telephone number of the Contractor’s headquarters office.
|
|
3. A copy of its current Texas Department of Insurance Certificate of Authority to provide HMO or ANHC services in the applicable Service Area(s). The Certificate of Authority must include all counties in the Service Area(s) for which the Contractor is proposing to serve HMO Members.
|
|
4. Indicate with a “Yes-HMO”, “Yes-ANHC” or “No” in the applicable cell(s) of the Column B of the following chart whether the Contractor is currently certified by TDI as an HMO or ANHC in all counties in each of the CSAs in which the Contractor proposes to participate in one or more of the HHSC HMO Programs. If the Contractor is not proposing to serve a CSA for a particular HMO Program, the Contractor should leave the applicable cells in the table empty.
|
Column A
|
Column B
|
Column C
|
Core Service Area (CSA)
|
TDI Certificate of Authority
|
Counties/Partial Counties without a TDI Certificate of Authority
|
Bexar
|
||
Dallas
|
||
El Paso
|
||
Harris
|
||
Lubbock
|
||
Nueces
|
||
Tarrant
|
||
Travis
|
||
Webb
|
|
5. For Contractors serving any CHIP and CHIP Perinatal OSAs, indicate with a “Yes-HMO”, “Yes-ANHC” or “No” in the applicable cell(s) of the Column C of the following chart whether the Contractor is currently certified by TDI as an HMO or ANHC in the entire county in the OSA. If the Contractor is not proposing to serve an OSA, the Contractor should leave the applicable cells in the table empty.
|
CHIP Program
|
|||
Column A
|
Column B
|
Column C
|
|
Core Service Area (CSA)
|
Affiliated CHIP OSA
|
TDI Certificate of Authority
|
|
Bexar
|
|||
El Paso
|
|||
Harris
|
|||
Lubbock
|
|||
Nueces
|
|||
Travis
|
CHIP Perinatal Program
|
||
Column A
|
Column B
|
Column C
|
Core Service Area (CSA)
|
Affiliated CHIP OSA
|
TDI Certificate of Authority
|
Bexar
|
||
El Paso
|
||
Harris
|
||
Lubbock
|
||
Nueces
|
||
Travis
|
|
6. If the Contractor proposes to participate in STAR or STAR+PLUS and seeks to be considered as an organization meeting the requirements of Section §533.004(a) or (e) of the Texas Government Code, describe how the Contractor meets the requirements of §§533.004(a)(1), (a)(2), (a)(3), or (e) for each proposed Service Areas.
|
|
7. The type of ownership (proprietary, partnership, corporation).
|
|
8. The type of incorporation (for profit, not-for-profit, or non-profit) and whether the Contractor is publicly or privately owned.
|
|
9. If the Contractor is an Affiliate or Subsidiary, identify the parent organization.
|
|
10. If any change of ownership of the Contractor’s company is anticipated during the 12 months following the Proposal due date, the Contractor must describe the circumstances of such change and indicate when the change is likely to occur.
|
|
11. The name and address of any sponsoring corporation or others who provide financial support to the Contractor and type of support, e.g., guarantees, letters of credit, etc. Indicate if there are maximum limits of the additional financial support.
|
|
12. The name and address of any health professional that has at least a five percent financial interest in the Contractor and the type of financial interest.
|
|
13. The names of officers and directors.
|
|
14. The state in which the Contractor is incorporated and the state(s) in which the Contractor is licensed to do business as an HMO. The Contractor must also indicate the state where it is commercially domiciled, if applicable.
|
|
15. The Contractor’s federal taxpayer identification number.
|
|
16. The Contractor’s Texas Provider Identifier (TPI) number if the Contractor is Medicaid-enrolled in Texas.
|
|
17. Whether the Contractor had a contract terminated or not renewed for non-performance or poor performance within the past five years. In such instance, the Contractor must describe the issues and the parties involved, and provide the address and telephone number of the principal terminating party. The Contractor must also describe any corrective action taken to prevent any future occurrence of the problem leading to the termination.
|
|
18. A current Certificate of Good Standing issued by the Texas Comptroller of Public Accounts, or an explanation for why this form is not applicable to the Contractor.
|
|
19. Whether the Contractor has ever sought, or is currently seeking, National Committee for Quality Assurance (NCQA) or American Accreditation HealthCare Commission (URAC) accreditation status, and if it has or is, indicate:
|
|
• its current NCQA or URAC accreditation status;
|
|
• if NCQA or URAC accredited, its accreditation term effective dates; and
|
|
• if not accredited, a statement describing whether and when NCQA or URAC accreditation status was ever denied the Contractor.
|
|
1. A signed letter of commitment from each Material Subcontractor that states the Material Subcontractor’s willingness to enter into a Subcontractor agreement with the Contractor and a statement of work for activities to be subcontracted. Letters of Commitment must be provided on the Material Subcontractor’s official company letterhead and signed by an official with the authority to bind the company for the subcontracted work. The Letter of Commitment must state, if applicable, the company’s certified HUB status.
|
|
2. The Material Subcontractor’s legal name, trade name, or any other name under which the Material Subcontractor does business, if any.
|
|
3. The address and telephone number of the Material Subcontractor’s headquarters office.
|
|
4. The type of ownership (e.g., proprietary, partnership, corporation).
|
|
5. The type of incorporation (i.e., for profit, not-for-profit, or non-profit) and whether the Material Subcontractor is publicly or privately owned.
|
|
6. If a Subsidiary or Affiliate, the identification of the parent organization.
|
|
7. The name and address of any sponsoring corporation or others who provide financial support to the Material Subcontractor and type of support, e.g., guarantees, letters of credit, etc. Indicate if there are maximum limits of the additional financial support.
|
|
8. The name and address of any health professional that has at least a five percent (5%) financial interest in the Material Subcontractor and the type of financial interest.
|
|
9. The state in which the Material Subcontractor is incorporated, commercially domiciled, and the state(s) in which the organization is licensed to do business.
|
|
10. The Material Subcontractor’s Texas Provider Identifier if Medicaid-enrolled in Texas.
|
|
11. The Material Subcontractor’s federal taxpayer identification number.
|
|
12. Whether the Material Subcontractor had a contract terminated or not renewed for non-performance or poor performance within the past five years. In such instance, the Contractor must describe the issues and the parties involved, and provide the address and telephone number of the principal terminating party. The Contractor must also describe any corrective action taken to prevent any future occurrence of the problem leading to the termination.
|
|
13. Whether the Material Subcontractor has ever sought, or is currently seeking, National Committee for Quality Assurance (NCQA) or American Accreditation HealthCare Commission (URAC) accreditation or certification status, and if it has or is, indicate:
|
|
• its current NCQA or URAC accreditation or certification status;
|
|
• if NCQA or URAC accredited or certified, its accreditation or certification term effective dates; and
|
|
• if not accredited, a statement describing whether and when NCQA or URAC accreditation status was ever denied the Material Subcontractor.
|
|
1. Submit an organizational chart (labeled Chart A), showing the corporate structure and lines of responsibility and authority in the administration of the Bidder’s business as a health plan.
|
|
2. Submit an organizational chart (labeled Chart B) showing the Texas organizational structure and how it relates to the proposed Service Area(s), including staffing and functions performed at the local level. If Chart A represents the entire organizational structure, label the submission as Charts A and B.
|
|
3. Submit an organizational chart (labeled Chart C) showing the Management Information System (MIS) staff organizational structure and how it relates to the proposed Service Area(s) including staffing and functions performed at the local level.
|
|
4. If the Bidder is proposing to use a Material Subcontractor(s), the Bidder shall include an organizational chart demonstrating how the Material Subcontractor(s) will be managed within the Bidder’s Texas organizational structure, including the primary individuals at the Bidder’s organization and at each Material Subcontractor organization responsible for overseeing such Material Subcontract. This information may be included in Chart B, or in a separate organizational chart(s).
|
|
5. Submit a brief narrative explaining the organizational charts submitted, and highlighting the key functional responsibilities and reporting requirements of each organizational unit relating to the Bidder’s proposed management of the HMO Program(s), including its management of any proposed Material Subcontractors.
|
|
1. Briefly describe any regulatory action, sanctions, and/or fines imposed by any federal or Texas regulatory entity or a regulatory entity in another state within the last 3 years, including a description of any letters of deficiencies, corrective actions, findings of non-compliance, and/or sanctions. Please indicate which of these actions or fines, if any, were related to Medicaid or CHIP programs. HHSC may, at its option, contact these clients or regulatory agencies and any other individual or organization whether or not identified by the Contractor.
|
|
2. No later than ten (10) days after the Contract Effective Date, submit documentation that demonstrates that the HMO has secured the required insurance and bonds in accordance with TDI requirements and Attachment B-1, Section 8.
|
|
3. Submit annual audited financial statement for fiscal years 2004 and 2005 (2005 to be submitted no later than six months after the close of the fiscal year).
|
|
4. Submit an Affiliate Report containing a list of all Affiliates and for HHSC’s prior review and approval, a schedule of all transactions with Affiliates that, under the provisions of the Contract, will be allowable as expenses in the FSR Report for services provided to the HMO by the Affiliate. Those should include financial terms, a detailed description of the services to be provided, and an estimated amount that will be incurred by the HMO for such services during the Contract Period.
|
|
7.3.1.4 System Testing and Transfer of Data
|
|
7.3.1.5 System Readiness Review
|
|
1. Joint Interface Plan.
|
|
2. Disaster Recovery Plan
|
|
3. Business Continuity Plan
|
|
4. Risk Management Plan, and
|
|
5. Systems Quality Assurance Plan.
|
|
7.3.1.6 Demonstration and Assessment of System Readiness
|
|
7.3.1.7 Operations Readiness
|
|
1. Develop new, or revise existing, operations procedures and associated documentation to support the HMO’s proposed approach to conducting operations activities in compliance with the contracted scope of work.
|
|
2. Submit to HHSC, a listing of all contracted and credentialed Providers, in a HHSC approved format including a description of additional contracting and credentialing activities scheduled to be completed before the Operational Start Date.
|
|
3. Prepare and implement a Member Services staff training curriculum and a Provider training curriculum.
|
|
4. Prepare a Coordination Plan documenting how the HMO will coordinate its business activities with those activities performed by HHSC contractors and the HMO’s Material Subcontractors, if any. The Coordination Plan will include identification of coordinated activities and protocols for the Transition Phase.
|
|
5. Develop and submit to HHSC the draft Member Handbook, draft Provider Manual, draft Provider Directory, and draft Member Identification Card for HHSC’s review and approval. The materials must at a minimum meet the requirements specified in Section 8.1.5 and include the Critical Elements to be defined in the HHSC Uniform Managed Care Manual.
|
|
6. Develop and submit to HHSC the HMO’s proposed Member complaint and appeals processes for Medicaid, CHIP, and CHIP Perinatal as applicable to the HMO’s Program participation.
|
|
7. Provide sufficient copies of the final Provider Directory to the HHSC Administrative Services Contractor in sufficient time to meet the enrollment schedule.
|
|
8. Demonstrate toll-free telephone systems and reporting capabilities for the Member Services Hotline, the Behavioral Health Hotline, and the Provider Services Hotline.
|
|
9. Submit a written Fraud and Abuse Compliance Plan to HHSC for approval no later than 30 days after the Contract Effective Date. See Section 8.1.19, Fraud and Abuse, for the requirements of the plan, including new requirements for special investigation units. As part of the Fraud and Abuse Compliance Plan, the HMO shall:
|
|
• designate executive and essential personnel to attend mandatory training in fraud and abuse detection, prevention and reporting. Executive and essential fraud and abuse personnel means HMO staff persons who supervise staff in the following areas: data collection, provider enrollment or disenrollment, encounter data, claims processing, utilization review, appeals or grievances, quality assurance and marketing, and who are directly involved in the decision-making and administration of the fraud and abuse detection program within the HMO. The training will be conducted by the Office of Inspector General, Health and Human Services Commission, and will be provided free of charge. The HMO must schedule and complete training no later than 90 days after the Effective Date.
|
|
• designate an officer or director within the organization responsible for carrying out the provisions of the Fraud and Abuse Compliance Plan.
|
|
• The HMO is held to the same requirements and must ensure that, if this function is subcontracted to another entity, the subcontractor also meets all the requirements in this section and the Fraud and Abuse section as stated in Attachment B-1, Section 8.
|
|
• Note: STAR+PLUS HMOs who have already submitted and received HHSC’s approval for their Fraud and Abuse Compliance Plans must submit acknowledgement that the HMO’s approved Fraud and Abuse Compliance Plan also applies to the STAR+PLUS program, or submit a revised Fraud and Abuse Compliance Plan for HHSC’s approval, with an explanation of changes to be made to incorporate the STAR+PLUS program into the plan, by July 10, 2006.
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• CHIP Perinatal HMOs who have already submitted and received HHSC’s approval for their Fraud and Abuse Compliance Plans must submit acknowledgement that the HMO’s approved Fraud and Abuse Compliance Plan also applies to the CHIP Perinatal Program, or submit a revised Fraud and Abuse Compliance Plan for HHSC’s approval, with an explanation of changes to be made to incorporate the CHIP Perinatal program into the plan, by September 15, 2006.
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• Complete hiring and training of STAR+PLUS Service Coordination staff, no later than 45 days prior to the STAR+PLUS Operational Start Date.
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7.3.1.8 Assurance of System and Operational Readiness
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7.3.1.9 Post-Transition
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1. freeze enrollment into the HMO’s plan for the affected HMO Program(s) and Service Area(s);
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2. freeze enrollment into the HMO’s plan for all HMO Programs or for all Service Areas of an affected HMO Program;
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3. impose contractual remedies, including liquidated damages; or
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4. pursue other equitable, injunctive, or regulatory relief.
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DOCUMENT HISTORY LOG
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STATUS1
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DOCUMENT
REVISION2
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EFFECTIVE
DATE
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DESCRIPTION3
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Baseline
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n/a
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Initial version Attachment B-1, Section 8
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Revision
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1.1
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June 30, 2006
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Revised version of the Attachment B-1, Section 8, that includes provisions applicable to MCOs participating in the STAR+PLUS Program.
Section 8.1.1.1, Performance Evaluation, is modified to include STAR+PLUS Performance Improvement Goals.
Section 8.1.2, Covered Services, is modified to include Functionally Necessary Community Long-term Care Services for STAR+PLUS.
Section 8.1.2.1 Value-Added Services, is modified to add language allowing for the HMO to distinguish between the Dual Eligible and non-Dual Eligible populations.
Section 8.1.2.2 Case-by-Case Added Services, is modified to clarify for STAR+Plus members it is based on functionality.
Section 8.1.3, Access to Care, is modified to include STAR+PLUS Functional Necessity and 1915(c) Nursing Facility Waiver clarifications.
Section 8.1.4, Provider Network, is modified to include STAR+PLUS.
Section 8.1.4.2, Primary Care Providers, is modified to include STAR+PLUS
Section 8.1.4.8, Provider Reimbursement, is modified to include Functionally Necessary Long-term care services for STAR+PLUS.
Section 8.1.7.7, Provider Profiling, is modified to include STAR+PLUS.
Sections 8.1.12 and 8.1.12.2, Services for People with Special Health Care Needs, are modified to include STAR+PLUS.
Section 8.1.13, Service Management for Certain Populations, is modified to include STAR+PLUS.
Section 8.1.14, Disease Management, is modified to include STAR+PLUS.
Section 8.2, Additional Medicaid HMO Scope of Work, is modified to include STAR+PLUS.
Section 8.3, Additional STAR+PLUS Scope of Work, is added.
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Revision
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1.2
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September 1, 2006
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Revised version of Attachment B-1, Section 8, that includes provisions applicable to MCOs participating in the STAR and CHIP Programs.
Section 8.1.1.1, Performance Evaluation, is modified to clarify that the HMOs goals are Service Area and Program specific; when the percentages for Goals 1 and 2 are to be negotiated; and when Goal 3 is to be negotiated.
Section 8.1.2.1, Value-Added Services, is modified to add language allowing for the addition of two Value-added Services during the Transition Phase of the Contract and to clarify the effective dates for Value Added Services for the Transition Phase and the Operation Phase of the Contract.
Section 8.1.3.2, Access to Network Providers, is modified to delete references to Open Panels.
Section 8.1.4, Provider Network, is modified to clarify that “Out-of-Network reimbursement arrangements” with certain providers must be in writing.
Section 8.1.5.1, Member Materials, is modified to clarify the date that the member ID card and the member handbook are to be sent to members.
Section 8.1.5.6, Member Hotline, is modified to clarify the hotline performance requirements.
Section 8.1.17.2, Financial Reporting Requirements, is modified to clarify that the Bonus Incentive Plan refers to the Employee Bonus Incentive Plan. It has also been modified to clarify the reports and deliverable due dates and to change the name of the Claims Summary Lag Report and clarify that the report format has been moved to the Uniform Managed Care Manual.
Section 8.1.18.5, Claims Processing Requirements, is modified to revise the claims processing requirements and move many of the specifics to the Uniform Managed Care Manual.
Section 8.1.20, Reporting Requirements, is modified to clarify the reports and deliverable due dates.
Section 8.1.20.2, Reports, is modified to delete the Claims Data Specifications Report, amend the All Claims Summary Report, and add two new provider-related reports to the contract.
Section 8.2.2.10, Cooperation with Immunization Registry, is added to comply with legislation, SB 1188 sec. 6(e)(1), 79th Legislature, Regular Session, 2005.
Section 8.2.2.11, Case Management for Children and Pregnant Women, is added.
Section 8.2.5.1, Provider Complaints, is modified to include the 30-day resolution requirement.
Section 8.2.10.2, Non-Reimbursed Arrangements with Local Public Health Entities, is modified to update the requirements and delete the requirement for an MOU.
Section 8.2.11, Coordination with Other State Health and Human Services (HHS) Programs, is modified to update the requirements and delete the requirement for an MOU.
Section 8.4.2, CHIP Provider Complaint and Appeals, is modified to include the 30-day resolution requirement.
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Revision
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1.3
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September 1, 2006
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Revised version of Attachment B-1, Section 8, that includes provisions applicable to MCOs participating in the CHIP Perinatal Program.
Section 8.1.1.1, Performance Evaluation, is modified to clarify that HHSC will negotiate and implement Performance Improvement Goals for the first full State Fiscal Year following the CHIP Perinatal Operational Start Date
Section 8.1.2, Covered Services is amended to: (a) clarify that Fee For Service will pay the Hospital costs for CHIP Perinate Newborns; (b) add a reference to new Attachment B-2.2 concerning covered services; (c) add CHIP Perinate references where appropriate.
Section 8.1.2.2 Case-by-Case Added Services, is modified to clarify that this does not apply to the CHIP Perinatal Program.
Section 8.1.3, Access to Care, is amended to include emergency services limitations.
Section 8.1.3.2, Access to Network Providers, is amended to include the Provider access standards for the CHIP Perinatal Program.
Section 8.1.4.2 Primary Care Providers, is modified to clarify the development of the PCP networks between the CHIP Perinates and the CHIP Perinate Newborns.
Section 8.1.4.6 Provider Manual, Materials and Training, modified to include the CHIP Perinatal Program
Section 8.1.4.9 Termination of Provider Contracts modified to include the CHIP Perinatal Program.
Section 8.1.5.2 Member Identification (ID) Card, modified to include the CHIP Perinatal Program.
Section 8.1.5.3 Member Handbook, modified to include the CHIP Perinatal Program.
Section 8.1.5.4 Provider Directory, modified to include the CHIP Perinatal Program.
Section 8.1.5.6 Member Hotline, modified to include the CHIP Perinatal Program.
Section 8.1.5.7 Member Education, modified to include the CHIP Perinatal Program.
Section 8.1.5.9 Member Complaint and Appeal Process, modified to include the CHIP Perinatal Program.
Section 8.1.7.7, Provider Profiling, is modified to include the CHIP Perinatal Program.
Section 8.1.12, Services for People with Special Health Care Needs, modified to clarify between CHIP Perinatal Program and CHIP Perinatal Newborn.
Section 8.1.13, Service Management for Certain Populations, modified to clarify the CHIP Perinatal Program.
Section 8.1.15, Behavioral Health (BH) Network and Services, modified to clarify between CHIP Perinatal and Perinate members.
Section 8.1.17.2, Financial Reporting Requirements, modified to include the CHIP Perinatal Program.
Section 8.1.18.3, System-wide Functions, modified to include the CHIP Perinatal Program.
Section 8.1.18.5, Claims Processing Requirements, modified to include the CHIP Perinatal Program.
Section 8.1.19, Fraud and Abuse, modified to include the CHIP Perinatal Program
Section 8.1.20.2, Provider Termination Report and Provider Network Capacity Report, is modified to include the CHIP Perinatal Program.
Section 8.5, Additional Scope of Work for CHIP Perinatal Program HMOs, is added to Attachment B-1.
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Revision
|
1.4
|
September 1, 2006
|
Contract amendment did not revise Attachment B-1, Section 8-Operations Phase Requirements.
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|
Revision
|
1.5
|
January 1, 2007
|
Revised version of the Attachment B-1, Section 8, that includes provisions applicable to MCOs participating in the STAR and STAR+PLUS Program.
Section 8.1.2 is modified to include a reference to STAR and STAR+PLUS covered services.
Section 8.1.20.2 is modified to update the references to the Uniform Managed Care Manual for the “Summary Report of Member Complaints and Appeals” and the “Summary Report of Provider Complaints.”
Section 8.2.2.5 is modified to require the Provider to coordinate with the Regional Health Authority.
Section 8.2.4 is amended to clarify cost settlements and encounter rates for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) for STAR and STAR+PLUS service areas.
Section 8.3.2.4 is amended to clarify the timeframe for initial STAR+PLUS assessments. Section 8.3.3 is amended to: (1) clarify the use of the DHS Form
2060; (2) require the HMO to complete the Individual Service Plan (ISP), Form 3671 for each Member receiving 1915(c) Nursing Facility Waiver Services; (3) require HMOs to complete Form 3652 and Form 3671annually at reassessment; (4) allow the HMOs to administer the Minimum Data Set for Home Care (MDS-HC) instrument for non-waiver STAR+PLUS Members over the course of the first year of operation; (5) allow HMOs to submit other supplemental assessment instruments.
Section 8.3.4 is modified to include the criteria for participation in 1915(c) nursing facility waiver services.
Section 8.3.4.3 is amended to remove the six-month timeframe for Nursing Facility Cost Ceiling. Deletes provision stating DADS Commissioner may grant exceptions in individual cases.
Section 8.3.5 is amended to delete the requirement that HMOs use the Consumer Directed Services option for the delivery of Personal Attendant Services. The new language provides HMOs with three options for delivering these services. The options are described in the following new subsections: 8.3.5.1, Personal Attendant Services Delivery Option – Self-Directed Model; 8.3.5.2, Personal Attendant Services Delivery Option – Agency Model, Self-Directed; and 8.3.5.3, Personal Attendant Services Delivery Option – Agency Model.
Section 8.3.7.3 is modified to reflect the changes made by the HMO workgroup regarding enhanced payments for attendant care. The section also includes a reference to new Attachment B-7, which contains the HMO’s methodology for implementing and paying the enhanced payments.
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Revision
|
1.6
|
February 1, 2007
|
Revised version of the Attachment B-1, Section 8, that includes provisions applicable to MCOs participating in the STAR+PLUS and CHIP Perinatal Programs.
Section 8.1 is modified to clarify the Operational Start Date of the STAR+PLUS Program.
Section 8.1.3.2 is modified to allow exceptions to hospital access standards on a case-by-case basis only for HMOs participating in the CHIP Perinatal Program.
Section 8.3.3 is modified to clarify when the 12-month period begins for the STAR+PLUS HMOs to complete the MDS-HC instruments for non-1915(c) Nursing Facility Waiver Members who are receiving Community-based Long-term Care Services.
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|
Revision
|
1.7
|
July 1, 2007
|
New Section 8.1.1.2 is added to require the HMOs to pay for any additional readiness reviews beyond the original ones conducted before the Operational Start Date.
Section 8.1.5.5 is modified to add a requirement that all HMOs must list Home Health Ancillary providers on their websites, with an indicator for Pediatric services.
Section 8.1.17.2 is modified to remove the requirement that the Claims Lag Report separate claims by service categories.
Section 8.1.18 is modified to update the cross-references to sections of the contract addressing remedies and damages and to add cross-references to sections of the contract addressing Readiness Reviews.
Section 8.1.18.5 is modified to require the HMO to make an electronic funds transfer payment process available when processing claims for Medically Necessary covered STAR+PLUS services.
Section 8.1.19 is modified to comply with a new federal law that requires entities that receive or make Medicaid payments of at least $5 million annually to educate employees, contractors and agents and to implement policies and procedures for detecting and preventing fraud, waste and abuse.
Section 8.1.20.2 is modified to require Provider Termination Reports for STAR+PLUS as required by the Dashboard. The amendment also requires Claims Summary Reports be submitted by claim type.
Section 8.2.7.5 is modified to comply with the settlement agreement in the Alberto N. litigation.
Section 8.3.4.3 is modified to remove references to the cost cap for 1915(c) Nursing Facility Waiver services.
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|
Revision
|
1.8
|
September 1, 2007
|
Section 8.1.2.1 is modified to reflect legislative changes required by SB 10.
Section 8.1.3.2 is modified to reflect legislative changes required by SB 10.
Section 8.1.5.6 is modified to comply with the Frew litigation corrective action plans.
New Section 8.1.5.6.1 is added to comply with the Frew litigation corrective action plans.
Section 8.1.5.7 is modified to comply with the Frew litigation corrective action plans.
Section 8.1.11 is modified to delete language included in error and to clarify the coverage for children in foster care.
Section 8.1.13 is added to comply with the Frew litigation corrective action plans.
Section 8.1.17.2 is modified to reflect legislative changes required by SB 10.
Section 8.1.20.2 is modified to comply with the Frew litigation corrective action plans by adding two new reports: Medicaid Medical Check-ups Report and Medicaid FWC Report.
Section 8.2.2.3 is modified to comply with Frew litigation correction action plans.
New Section 8.2.2.12 is added to comply with the Frew litigation correction action plans to enhance care for children of Migrant Farmworkers. Section 8.2.4 is modified to clarify cost settlement requirements and
encounter and payment reporting requirements for the Nueces Service Area and the STAR+PLUS Service Areas.
Section 8.2.7.4 is amended to reflect the new fair hearings process for Medicaid Members that will be effective 9/1/07.
Section 8.2.11 is modified to comply with the Frew litigation corrective action plans.
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|
Revision
|
1.9
|
December 1, 2007
|
Section 8.1.17.1 is modified to include provider contracts in the documentation HMOs must provide upon request and the timeframes in which documents must be provided.
Section 8.1.17.2 is modified to eliminate the plan's responsibility to submit the actuarial certification on the 90 day FSR.
Section 8.1.20.2 is modified to change the name of the Medicaid Medical Check-ups Report to the Medicaid Managed Care Texas Health Steps Medical Checkups Annual Report (90-Day FREW Report) and to clarify the term “not previously enrolled”.
Section 8.2.2.8 is modified to reflect changes as a result of the Alberto N litigation Second Partial Settlement Agreement. Services for person under age 21 are being carved out of the STAR Program and provided through the Personal Care Services (PCS) benefit in traditional Medicaid Fee-for-Service.
Section 8.2.7.4 is modified to clarify the HMO’s role in filling out the request for Fair Hearing and to conform to Fair Hearings time requirements.
Section 8.2.12 is modified to remove the outdated reference to 42 C.F.R. 434.28.
Section 8.3.4 is modified to specify that plan of care at initial determination must be 200% or less of nursing facility cost.
Section 8.3.5 is modified to clarify when the HMO must provide PAS information to Members receiving PAS services.
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Revision | 1.10 | March 31, 2008 |
Section 8.1.4.4 is modified to add language regarding expedited credentialing as required by HB 1594.
Section 8.1.12.2 is modified to transfer the Medical Transportation Program back to HHSC.
Section 8.1.17 is modified to add a reference to Federal Acquisition Regulations (“FAR”).
Section 8.1.20.2 is modified to change the name of the Medicaid FWC Report to the Children of Migrant Farm Workers Annual Report (FWC Annual Report) Section 8.2.4 is modified to include Municipal Health Department’s Public Clinics.
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Revision | 1.11 | September 1, 2008 |
Section 8.1.4 is modified to reflect waiver requirements.
Section 8.1.4.2 is modified to remove the “Pediatric and Family” qualifier from Advanced Practice Nurses.
Section 8.1.4.7 is modified to require the HMOs to pay all reasonable costs for HHSC to conduct onsite monitoring of the HMO’s Provider Hotline functions.
Section 8.1.5.6 is modified to require the HMOs to pay all reasonable costs for HHSC to conduct onsite monitoring of the HMO’s Member Hotline functions.
Section 8.1.14 is modified to require the HMO to coordinate continuity of care for Members in Disease Management who change plans.
Section 8.1.15.3 is modified to clarify the first sentence.
Section 8.1.18.1 is modified to clarify encounter data submission requirements.
Section 8.1.18.2 is modified to require HMOs to follow applicable JIPs and required field submissions. This requirement has been moved from Attachment B-1, Section 8.1.20.2.
Section 8.1.20.2 is modified to require the HMOs to submit copies of all internal and external audit reports. The requirement to follow applicable JIPs and required field submissions has been moved to Attachment B-1, Section 8.1.18.2.
Section 8.2.1 is modified to add a cross reference to Section 8.1.14 for specific requirements for Members transferring to and from the HMO’s DM Program.
Section 8.2.2.3.1 is added to require the HMO to educate Texas Health Steps providers on the availability of the Oral Evaluation and Fluoride Varnish (OEVS) Medicaid benefit.
Section 8.2.4 is modified to require the HMOs to pay full encounter rates to RHCs on or after September 1, 2008.
Section 8.2.7.2 is modified to align contract references to TDI’s recodification.
Section 8.3.3 is modified to reflect current Waiver requirements and the conversion from the TILE to the RUG assessment instrument.
Section 8.3.4.1 is modified to reflect the conversion from the TILE to the RUG assessment instrument.
Section 8.3.4.2 is modified to reflect the conversion from the TILE to the RUG assessment instrument.
Section 8.3.4.3 is modified to reflect current Waiver requirements and the conversion from the TILE to the RUG assessment instrument.
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Revision | 1.12 | March 1, 2009 |
Section 8.1.2.1 is modified to conform to timeframes for the Health Plan Comparison Chart process.
Section 8.1.4 is modified to include performance standards for out of network utilization.
Section 8.1.5.5 is modified to require the HMOs to update their online provider directory at least twice a month.
Section 8.1.5.6 is modified to clarify the maximum acceptable hold time.
Section 8.1.15.3 is modified to clarify the maximum acceptable hold time and to require the HMOs to pay all reasonable costs for HHSC to conduct onsite monitoring of the HMO’s Behavioral Health Hotline functions.
Section 8.1.17.2 is modified to add Bariatric Supplemental Payment Reports and to clarify DSH report language.
Section 8.1.19 is modified to clarify that a written Fraud and Abuse compliance plan must be submitted annually and to list the legal citations.
Section 8.1.20.2 (h) Hotline Reports is modified to correct a contract reference.
Section 8.2.2.8 is modified to reflect that Nursing facilities services will be carved out of the capitation payment to the HMOs.
Section 8.3.2.7 is modified to reflect a corrective action plan required by CMS to address the funding methodology used by HHSC to pay for nursing facility services used by STAR+PLUS members. Nursing facilities services will be carved out of the capitation payment to the HMOs.
Section 8.3.3 is modified to change the name from “Children’s Comprehensive Assessment Form (CCAF Form)” to “Personal Care Assessment Form (PCAF Form)”, to require PCAF reassessments every 12 months, and to allow HMOs until the end of the ISP period to submit the reassessment paperwork.
Section 8.3.4.4 is modified to allow the use of General Revenue to cover costs above the 200% limit.
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Revision | 1.13 | September 1, 2009 |
All references to “check-ups” are changed to “checkups”
All references to “Medicaid Provider Procedures Manual” are changed to “Texas Medicaid Provider Procedures Manual”
All references to “THSteps” are changed to “Texas Health Steps”
Section 8.1.1.1 is modified to update Goal 3, change SFY2007 to SFY2010, and clarify the applicability of Goals 1 and 2.
Section 8.1.2 is modified to delete the reference to the Texas Health Steps Manual.
Section 8.1.3.1 is amended to change from checkup requirement from “60” days to “90” days and to replace the reference to the AAP periodicity schedule with the Texas Health Steps periodicity schedule.
Section 8.1.3.2 is revised to provide additional clarity as it relates to Qualified Mental Health Providers – Community Services (QMHP-CS).
Section 8.1.4.2 is amended to change the reference from the “THSteps Manual” to the “Texas Medicaid Provider Procedures Manual” and to clarify requirements for CHIP and Medicaid.
Section 8.1.17.2 is modified to require CHIP and CHIP Perinatal HMOs to submit TPR reports.
Section 8.1.18.1 is modified in compliance with HB 1218 to require HMOs to submit encounter data not later than the 30th day after the last day of the month in which the claim was adjudicated.
Section 8.1.20.2 (j) is modified to remove the references to “annual”, change “check-ups” to checkups”, and change “90-Day FREW Report” to “Frew 90-Day Reports”.
Section 8.1.20.2 (l) Frew Quarterly Monitoring Report is added.
Section 8.1.20.2 (m) Frew Health Care Provider Training Report is added.
Section 8.2.2.2 is amended to prohibit HMO from requiring pre-authorization for family planning services.
Section 8.2.2.3 is amended to change from checkup requirement from “60” days to “90” days; change the periodicity schedule from “AAP” to “Texas Health Steps”; remove the reference to the Texas Department of Transportation; add “Corrective Action Orders” to the training requirements; change “DSHS THSteps outreach staff” to “the Texas Health Steps outreach unit”; change “again within two weeks from the time of birth” to “in accordance with the Texas Health Steps periodicity schedule”; change “two-week follow-up” to “newborn follow ups”; to spell out the acronym for ACIP; and change “HCFA 1500” to “CMS 1500”.
Section 8.3.2.8 is added to require all STAR+PLUS plans to provide or have applied to provide MA/SNP services in all counties in which they offer STAR+PLUS services.
Section 8.3.5 is amended to change the name from “Personal Attendant Services” to “Consumer Directed Services Options” and “In-Home or Out-of-Home Respite” is added as an option.
Section 8.3.5.1 is amended to delete “Personal Attendant Services Delivery Option” from the name of the section and “In-Home or Out-of-Home Respite” is added as an option.
Section 8.3.5.2 is amended to delete “Personal Attendant Services Delivery Option” from the name of the section and “In-Home or Out-of-Home Respite” is added as an option.
Section 8.3.5.3 is amended to delete “Personal Attendant Services Delivery Option” from the name of the section and “In-Home or Out-of-Home Respite” is added as an option.
Section 8.3.6.3 is modified to remove references to the DADS enhancement program.
Section 8.4.5 Third Party Liability and Recovery is added to clarify the third party recovery requirements for CHIP HMOs.
Section 8.4.6 is added to require CHIP HMOs to pay full encounter rates.
Section 8.5.4 Dental Coverage for CHIP Perinate Newborn Members is added to clarify that the dental coverage requirements applicable to CHIP Members also apply to CHIP Perinate Newborns.
Section 8.5.5 Third Party Liability and Recovery is added to clarify the third party recovery requirements for CHIP Perinatal HMOs.
Section 8.5.6 is added to require CHIP Perinatal HMOs to pay full encounter rates.
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Revision | 1.14 | December 1, 2009 |
Section 17.02(a) is modified to require the single bond per MCO with a defined term and amount beginning in SFY2010.
Section 8.1.3.2 is revised to update the TAC citation.
Section 8.1.4.4 is amended to add references to 42 C.F.R. §438.12 and 28 T.A.C. §11.1402.
Section 8.1.12.2 is modified to remove references to PACT.
Section 8.1.17.2 DSH Reports is modified to change the report due dates.
Section 8.1.18 is modified to change the notification period from “generally 90 days” to “no later than 180 days prior to the planned change or implementation”.
Section 8.1.18.2 is modified to require HMOs to submit their Disaster Recovery Plan, Business Continuity Plan, and Security Plan annually and to require HMOs to include checklists when submitting modified JIPs, Risk Management Plans and Systems Quality Assurance Plans.
Section 8.2.2.8 is modified to remove references to PACT and to clarify that for STAR+PLUS, while inpatient stays are non-capitated, mental health inpatient stays are capitated.
Section 8.4.6 is modified to omit the CHIP reporting requirement for FQHC and RHC payments.
Section 8.5.6 is modified to omit the CHIP Perinatal Program reporting requirement for FQHC and RHC payments.
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Revision | 1.15 | March 1, 2010 |
Section 8.1.3.1 is revised to conform to THSteps policy regarding timeliness of medical checkups for existing members ages 36 months and older which will be effective 9/1/10.
Section 8.1.17.2 Financial Disclosure Report is revised to conform to federal requirements.
Section 8.2.2.3 is revised to conform to THSteps policy regarding timeliness of medical checkups for existing members ages 36 months and older which will be effective 9/1/10.
Section 8.2.8.2 “Substance Abuse Benefit” is added. This amendment will be effective the later of: September 1, 2010 or upon final approval of the Medicaid State Plan, 1915(b) STAR+PLUS waiver and/or the 1915(b) STAR waiver, as applicable to the HMO Program.
Section 8.3.6.5 “STAR+PLUS Handbook” is added.
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Revision | 1.16 | September 1, 2010 |
All references to “Frew vs. Hawkins” are changed to “Frew vs. Suehs”.
Section 8.1.1.1 is modified to establish new Overarching Goals for FY2011 and to remove Service Areas as a category for sub-goals.
Section 8.1.1.2 is modified to change the title to “Additional Readiness Reviews and Monitoring Efforts”, to clarify that HHSC may conduct desk and/or onsite reviews as part of its normal Contract monitoring activities, and to require the HMOs to pay all reasonable costs for HHSC to conduct those onsite reviews.
Section 8.1.2.1 is modified to conform to timeframes for the Health Plan Comparison Chart process.
Section 8.1.4.2 is modified to remove Certified Nurse Midwives and add Advanced Practice Nurses to the list of Providers eligible to be PCPs.
Section 8.1.5.5 is modified to require identification of providers that provide long-term services and supports.
Section 8.1.17.2 Financial Disclosure Report is revised to clarify federal requirements.
Section 8.1.18 is modified to require the HMOs to pay all reasonable costs for HHSC to conduct onsite reviews.
Section 8.1.18.5 is modified to conform to the timeframes for notification in Attachment A, Section 4.08(b)(3).
New Section 8.1.18.6 is added, as required by Section 6507 of the Patient Protection and Affordable Care Act of 2010 (PPACA).
Section 8.1.20.2 (j) is modified to remove “Frew 90-Day Reports” from the name of the report; to clarify what constitutes an Existing Member; and to remove the definition of “New Members”.
Section 8.1.20.2 (n) Frew Provider Recognition Report is added.
Section 8.2.2.8 is amended to clarify disenrollment for utilizing DADS hospice services and to add Span of Coverage exceptions for STAR and STAR+PLUS members described in Attachment A, Section 5.05(a)(2).
Section 8.2.5.1 is modified to add liquidated damages.
Section 8.5.2 is modified to clarify that the HMO not the Provider must respond to Providers’ appeals.
Section 8.2.7.1 is modified to add liquidated damages.
Section 8.2.8.2 “Substance Abuse Benefit” is modified to clarify that this section does not apply to the Dallas Service Area and that HMOs must contract with all qualified interested STPs. This amendment will be effective the later of: September 1, 2010 or upon final approval of the Medicaid State Plan, 1915(b) STAR+PLUS waiver and/or the 1915(b) STAR waiver, as applicable to the HMO Program.
Section 8.2.9 is modified to change “date of service” to “date of adjudication”.
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Revision | 1.17 | December 1, 2010 | Contract amendment did not revise Attachment B-1, Section 8-Operations Phase Requirements. | |
Revision | 1.18 | March 1, 2010 |
Section 8.1.1.1 is modified to change all "Performance Improvement Projects" and to establish new Overarching Goals for FY2011.
Section 8.1.3.2 is revised to be consistent with the TDI requirement to allow pregnant Members past the 24th week of pregnancy to remain under the coare of their current OB/GYN, even if provider is Out-of-Network.
Section 8.1.4.8 is modified to prohibit Medicaid payments to entities located outside the U.S. in conformance with the Affordable Care Act.
Section 8.1.19 is modified to require HMOs to designate a primary and secondary contact for all OIG requests and to outline the process and timeframes for responding to the OIG.
Immunization requirements from Section 8.2.2.3 "Texas Health Steps (EPSDT)" are moved to new Section 8.1.21 "Immunizations" as the requirements apply to both Medicaid and CHIP.
Section 8.2.1 is revised to conform to the TDI requirement to allow pregnant Members past the 24th week of pregnancy to remain under the care of their current OB/GYN, even if provider is Out-of-Network.
Section 8.2.2.3 is modified to reorder requirements and add subsection headings. Additional training requirements are added to the new Section 8.1.21 "Immunizations" as the requirements apply to both Medicaid and CHIP.
Section 8.2.2.4 is amended to clarify that the 45 hour and 96 hour limits do not apply to neonatal care.
Section 8.2.2.8 is amended to add "Texas Health Steps environmental lead investigation (ELI)". Remainder of list is renumbered. In addition, the section is amended to clarify disenrollment for utilizing DADS hospice services to add Span of Coverage exceptions for STAR and STAR+PLUS members described in Attachment A, Section 5.05(a)(2).
Section 8.2.5.1 is revised to add the 98% standard for complaint resolution and to remove the 30 day request for extension requirementfor complaints received directly by the HMO.
Section 8.3.1.1 is modified to change the name from 'Community-based Long-Term Care Services Available to all All Members' to "Community-based Long-Term Services and Supports Available to All Members" and to clarify that "Personal Assistance Services" is also called "Primary Home Care" for (b) Waiver Members.
Section 8.3.1.2 is revised to change the name from "1915(c) Nursing Facility Waiver Services Available to Members Who Qualify for 1915(c) Nursing Facility Waiver Services" to "1915(c) STAR+PLUS Waiver Services Available to Members Who Qualify for 1915(c) STAR+PLUS Waiver Services" and to update the licensure and certification requirements.
Section 8.3.6.6 is added to require STAR+PLUS HMOs to contact Members at least twice a year and to document that contact.
Section 8.4.2 is revised to add the 98% standard for complaint resolution.
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Revision | 1.19 | September 1, 2011 |
Section 8.1.1.1 is modified to remove redundant language.
Section 8.1.4 is modified to require HMOs to contract with any willing ambulance provider that meets the HMO’s credentialing requirements and agrees to the HMO’s contract terms and rates.
Section 8.1.4.8 is modified to add language for the ACA requirement regarding Healthcare Acquired Conditions (HAC) pursuant to the Patient Protection and Affordable Care Act of 2010 (Pubic Law 111–148) as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), together known as the Affordable Care Act (ACA). Section 2702 of ACA prohibits federal payments to States for any amount expended under Medicaid for health care-acquired conditions.
Section 8.1.4.8.1 is added pursuant to the Patient Protection and Affordable Care Act of 2010 (Pubic Law 111–148) as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), together known as the
Affordable Care Act (ACA). Section 2702 of ACA prohibits federal payments to States for any amount expended under Medicaid for health care-acquired conditions.
Section 8.1.4.9 is modified to clarify compliance with 42 CFR 438.10(f)(5).
Section 8.1.5.6 is modified to add clarification that the HMOs provide oral interpretive services free of charge, as required by 42 CFR 438.10(c)(4).
Section 8.1.7.8 is modified to clarify current federal physician incentive plan requirements for Medicaid, and to add these requirements for CHIP.
Section 8.1.8, Second Paragraph, is amended to refer to federal regulations regarding medical record content.
Section 8.1.9 is modified to clarify the age requirements.
Section 8.1.12.1 is modified to clarify that appropriate health care professionals must perform assessments, as required by 42 CFR 438.208(c)(2).
Section 8.1.17.2 is modified to add the dates of service for which Bariatric Supplemental Reports are required.
Section 8.1.18.5 is modified pursuant to the Patient Protection and Affordable Care Act of 2010 (Pubic Law 111–148) as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), together known as the Affordable Care Act (ACA). Section 6401(b)(7) of the ACA requires the State to require all ordering or referring providers or other professionals to be enrolled in the program and that the national provider identifier (NPI) of any ordering or referring physician or other professional to be specified on the claims for payments for Medicaid and CHIP.
Section 8.1.19 is modified to correct references to the Texas Government Code.
Section 8.2.1 is modified to require the HMOs to honor prior authorizations for acute care services and continue Community-based Long Term Care Services for Members in the Expansion Counties.
Section 8.2.4 is modified to require the HMOs to pay FQHCs at the full encounter rate effective 9/1/11.
Section 8.2.7.1 is modified to remove the requirement to maintain a local telephone number for Member Complaints and to clarify that the HMO provide oral interpretive services free of charge, as required by 42 CFR 438.10(c)(4) . The section is also modified to clarify that the HMO must provide written notice of complaints resolutions that cannot be resolved orally, in accordance with 42 CFR 438.408(d)(1).
Section 8.2.7.2 is modified to remove the requirement to maintain a local telephone number for Member Appeals and to clarify that the HMO provide oral interpretive services free of charge, as required by 42 CFR 438.10(c)(4).
Section 8.3.2.4 is modified to require the HMOs to honor prior authorizations for Members in the Expansion Counties.
Section 8.3.2.8 Prioritization Plan is added.
Section 8.3.4.1 is modified to clarify the SPW eligibility process.
Section 8.3.4.2 is modified to clarify the MAO eligibility process.
Section 8.3.5 is modified to add the new CDS benefits.
Section 8.3.5.1 is modified to add the new CDS benefits and the section name is changed from “Self-Directed Model” to “Consumer Directed Option Model”.
Section 8.3.5.2 is modified to add the new CDS benefits and the section name is changed from “Agency Model, Self-Directed” to “Service Related Option Model”.
Section 8.3.5.3 is modified to add the new CDS benefits.
Section 8.3.6.1 is modified to add training requirements for LTSS Providers in the Expansion Counties.
Section 8.3.6.4 is deleted in its entirety.
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Revision | 1.30 | Contract amendment did not revise Attachment B-1, Section 8-Operations Phase Requirements. | ||
1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
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8. OPERATIONS PHASE REQUIREMENTS
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8.1 General Scope of Work
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1. select the study topic(s);
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2. define the study question(s);
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3. select the study indicator(s);
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4. use a representative and generalizable study population;
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5. use sound sampling techniques (if sampling is used);
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6. collect reliable data;
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7. implement intervention and improvement strategies;
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8. analyze data and interpret study results;
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9. plan for real improvement; and
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10. achieve sustained improvement.
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1. previous coverage, if any, or the reason for termination of such coverage;
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2. health status;
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3. confinement in a health care facility; or
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4. for any other reason.
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a. Define and describe the proposed Value-added Service;
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b. Specify the Service Areas and HMO Programs for the proposed Value-added Service;
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c. Identify the category or group of mandatory Members eligible to receive the Value-added Service if it is a type of service that is not appropriate for all mandatory Members;
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d. Note any limits or restrictions that apply to the Value-added Service;
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e. Identify the Providers responsible for providing the Value-added Service;
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f. Describe how the HMO will identify the Value-added Service in administrative (Encounter) data;
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g. Propose how and when the HMO will notify Providers and mandatory Members about the availability of such Value-added Service;
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h. Describe how a Member may obtain or access the Value-added Service; and
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i. Include a statement that the HMO will provide such Value-added Service for at least 12 months from the September 1 effective date.
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(1) HHSC-specified co-payments for CHIP Members, where applicable; and
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(2) STAR+PLUS Members who qualify for 1915(c) Nursing Facility Waiver services and enter a 24-hour setting will be required to pay the provider of care room and board costs and any income in excess of the personal needs allowance, as established by HHSC. If the HMO provides Members who do not qualify for the 1915(c) Nursing Facility Waiver services in a 24-hour setting as an alternative to nursing facility or hospitalization, the Member will be required to pay the provider of care room and board costs and any income in excess of the personal needs allowance, as established by HHSC.
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1. Emergency Services must be provided upon Member presentation at the service delivery site, including at non-network and out-of-area facilities;
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2. Urgent care, including urgent specialty care, must be provided within 24 hours of request.
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3. Routine primary care must be provided within 14 days of request;
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4. Initial outpatient behavioral health visits must be provided within 14 days of request;
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5. Routine specialty care referrals must be provided within 30 days of request;
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6. Pre-natal care must be provided within 14 days of request, except for high-risk pregnancies or new Members in the third trimester, for whom an appointment must be offered within five days, or immediately, if an emergency exists;
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7. Preventive health services for adults must be offered to a Member within 90 days of request; and
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8. Preventive health services for children, including well-child checkups should be offered to CHIP Members in accordance with the American Academy of Pediatrics (AAP) periodicity schedule. Medicaid HMOs should utilize the Texas Health Steps periodicity schedule. For a New Members under age 21, overdue or upcoming well-child checkups, including Texas Health Steps medical checkups, should be offered as soon as practicable, but in no case later than 14 days of enrollment for newborns, and no later than 90 days of enrollment for all other eligible child Members. Effective September 1, 2010, the Texas Health Steps annual medical checkup for an Existing Member age 36 months and older is due on the child’s birthday. The annual medical checkup is considered timely if it occurs no later than 364 calendar days after the child’s birthday. For purposes of this requirement, the terms “New Member” and “Existing Member” are defined in Chapter 12.4 of the Uniform Managed Care Manual.
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1. the Provider assumes all HMO PCP responsibilities for such Members in a specific age group under age 21,
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2. the Provider has a history of practicing as a PCP for the specified age group as evidenced by the Provider’s primary care practice including an established patient population under age 20 and within the specified age range, and
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3. the Provider has admitting privileges to a local hospital that includes admissions to pediatric units.
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1. The office telephone is answered after-hours by an answering service, which meets language requirements of the Major Population Groups and which can contact the PCP or another designated medical practitioner. All calls answered by an answering service must be returned within 30 minutes;
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2. The office telephone is answered after normal business hours by a recording in the language of each of the Major Population Groups served, directing the patient to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider’s telephone. Another recording is not acceptable; and
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3. The office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP or another designated medical practitioner, who can return the call within 30 minutes.
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1. The office telephone is only answered during office hours;
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2. The office telephone is answered after-hours by a recording that tells patients to leave a message;
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3. The office telephone is answered after-hours by a recording that directs patients to go to an Emergency Room for any services needed; and
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4. Returning after-hours calls outside of 30 minutes.
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1. Covered Services and the Provider’s responsibilities for providing and/or coordinating such services. Special emphasis must be placed on areas that vary from commercial coverage rules (e.g., Early Intervention services, therapies and DME/Medical Supplies); and for Medicaid, making referrals and coordination with Non-capitated Services;
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2. Relevant requirements of the Contract;
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3. The HMO’s quality assurance and performance improvement program and the Provider’s role in such a program; and
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4. The HMO’s policies and procedures, especially regarding in-network and Out-of-Network referrals.
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1. 99% of calls are answered by the fourth ring or an automated call pick-up system is used;
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2. no more than one percent of incoming calls receive a busy signal;
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3. the average hold time is 2 minutes or less; and
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4. the call abandonment rate is 7% or less.
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1. the Member’s name;
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3. the effective date of the PCP assignment (excluding CHIP Perinates);
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4. the PCP’s name, address (optional for all products), and telephone number (excluding CHIP Perinates);
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5. the name of the HMO;
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6. the 24-hour, seven (7) day a week toll-free Member services telephone number and BH Hotline number operated by the HMO; and
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7. any other critical elements identified in the Uniform Managed Care Manual.
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1. Written in Major Population Group languages (which under this contract include only English and Spanish);
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2. Culturally appropriate;
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3. Written for understanding at the 6th grade reading level; and
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4. Be geared to the health needs of the enrolled HMO Program population.
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1. Knowledgeable about Covered Services;
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2. Able to answer non-technical questions pertaining to the role of the PCP, as applicable;
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3. Able to answer non-clinical questions pertaining to referrals or the process for receiving authorization for procedures or services;
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4. Able to give information about Providers in a particular area;
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5. Knowledgeable about Fraud, Abuse, and Waste and the requirements to report any conduct that, if substantiated, may constitute Fraud, Abuse, or Waste in the HMO Program;
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6. Trained regarding Cultural Competency;
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7. Trained regarding the process used to confirm the status of persons with Special Health Care Needs;
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8. For Medicaid members, able to answer non-clinical questions pertaining to accessing Non-capitated Services.
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9. For Medicaid Members, trained regarding: a) the emergency prescription process and what steps to take to immediately address problems when pharmacies do not provide a 72-hour supply of emergency medicines; and b) DME processes for obtaining services and how to address common problems.
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10. For CHIP Members, able to give correct cost-sharing information relating to premiums, co-pays or deductibles, as applicable. (Cost-sharing does not apply to CHIP Perinates or CHIP Perinate Newborns.)
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1. 99% of calls are answered by the fourth ring or an automated call pick-up system;
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2. no more than one percent (1%) of incoming calls receive a busy signal;
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3. at least 80% of calls must be answered by toll-free line staff within 30 seconds measured from the time the call is placed in queue after selecting an option;
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4. the call abandonment rate is 7% or less; and
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5. the average hold time is 2 minutes or less.
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8.1.5.6.1 Nurseline
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1. How the HMO system operates, including the role of the PCP;
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2. Covered Services, limitations and any Value-added Services offered by the HMO;
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3. The value of screening and preventive care, and
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4. How to obtain Covered Services, including:
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a. Emergency Services;
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b. Accessing OB/GYN and specialty care;
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c. Behavioral Health Services;
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d. Disease Management programs;
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e. Service Coordination, treatment for pregnant women, Members with Special Health Care Needs, including Children with Special Health Care Needs; and other special populations;
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f. Early Childhood Intervention (ECI) Services;
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g. Screening and preventive services, including well-child care (Texas Health Steps medical checkups for Medicaid Members);
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h. For CHIP Members, Member co-payments
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i. Suicide prevention;
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j. Identification and health education related to Obesity; and
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k. Obtaining 72 hour supplies of emergency prescriptions from pharmacies enrolled with HHSC as Medicaid providers.
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1. Evaluate performance using objective quality indicators;
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2. Foster data-driven decision-making;
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3. Recognize that opportunities for improvement are unlimited;
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4. Solicit Member and Provider input on performance and QAPI activities;
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5. Support continuous ongoing measurement of clinical and non-clinical effectiveness and Member satisfaction;
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6. Support programmatic improvements of clinical and non-clinical processes based on findings from on-going measurements; and
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7. Support re-measurement of effectiveness and Member satisfaction, and continued development and implementation of improvement interventions as appropriate.
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1. Is organization-wide, with clear lines of accountability within the organization;
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2. Includes a set of functions, roles, and responsibilities for the oversight of QAPI activities that are clearly defined and assigned to appropriate individuals, including physicians, other clinicians, and non-clinicians;
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3. Includes annual objectives and/or goals for planned projects or activities including clinical and non-clinical programs or initiatives and measurement activities; and
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4. Evaluates the effectiveness of clinical and non-clinical initiatives.
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2. Establishing PCP, Provider, group, Service Area or regional Benchmarks for areas profiled, where applicable, including STAR, STAR+PLUS, CHIP and CHIP Perinatal Program-specific Benchmarks, where appropriate; and
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3. Providing feedback to individual PCPs and Providers regarding the results of their performance and the overall performance of the Provider Network.
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1. Use the results of its Provider profiling activities to identify areas of improvement for individual PCPs and Providers, and/or groups of Providers;
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2. Establish Provider-specific quality improvement goals for priority areas in which a Provider or Providers do not meet established HMO standards or improvement goals;
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3. Develop and implement incentives, which may include financial and non-financial incentives, to motivate Providers to improve performance on profiled measures; and
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4. At least annually, measure and report to HHSC on the Provider Network and individual Providers’ progress, or lack of progress, towards such improvement goals.
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1. whether the Member’s PCP or other Providers are participating in the HMO’s physician incentive plan;
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2. whether the HMO uses a physician incentive plan that affects the use of referral services;
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3. the type of incentive arrangement; and
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4. whether stop-loss protection is provided.
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1. Whether the physician incentive plan covers services that are not furnished by a physician or physician group. The HMO is only required to report on items 2-4 below if the physician incentive plan covers services that are not furnished by a physician or physician group.
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2. The type of incentive arrangement (e.g., withhold, bonus, capitation);
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3. The percent of withhold or bonus (if applicable);
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4. The panel size, and if patients are pooled, the method used (HHSC approval is required for the method used); and
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1. Procedures to evaluate the need for Medically Necessary Covered Services;
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2. The clinical review criteria used, the information sources, the process used to review and approve the provision of Covered Services;
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3. The method for periodically reviewing and amending the UM clinical review criteria; and
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4. The staff position functionally responsible for the day-to-day management of the UM function.
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• Within three (3) business days after receipt of the request for authorization of services;
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• Within one (1) business day for concurrent hospitalization decisions; and
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• Within one (1) hour for post-stabilization or life-threatening conditions, except that for Emergency Medical Conditions and Emergency Behavioral Health Conditions, the HMO must not require prior authorization.
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1. Consistent application of review criteria that are compatible with Members’ needs and situations;
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2. Determinations to deny or limit services are made by physicians under the direction of the Medical Director;
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3. Appropriate personnel are available to respond to utilization review inquiries 8:00 a.m. to 5:00 p.m., Monday through Friday, with a telephone system capable of accepting utilization review inquiries after normal business hours. The HMO must respond to calls within one business day;
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4. Confidentiality of clinical information; and
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5. Quality is not adversely impacted by financial and reimbursement-related processes and decisions.
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1. Routinely assess the effectiveness and the efficiency of the UM Program;
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2. Evaluate the appropriate use of medical technologies, including medical procedures, drugs and devices;
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3. target areas of suspected inappropriate service utilization;
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4. Detect over- and under-utilization;
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5. Routinely generate Provider profiles regarding utilization patterns and compliance with utilization review criteria and policies;
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6. Compare Member and Provider utilization with norms for comparable individuals;
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7. Routinely monitor inpatient admissions, emergency room use, ancillary, and out-of-area services;
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• A court order (Order) entered by a Court of Continuing Jurisdiction placing a child under the protective custody of TDFPS.
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• A TDFPS Service Plan entered by a Court of Continuing Jurisdiction placing a child under the protective custody of TDFPS.
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• A TDFPS Service Plan voluntarily entered into by the parents or person having legal custody of a Member and TDFPS.
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1. Providing medical records to TDFPS;
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2. Scheduling medical and Behavioral Health Services appointments within 14 days unless requested earlier by TDFPS; and
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3. Recognition of abuse and neglect, and appropriate referral to TDFPS.
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1. Participate in hospital discharge planning;
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2. Participate in pre-admission hospital planning for non-emergency hospitalizations;
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3. Develop specialty care and support service recommendations to be incorporated into the Service Plan; and
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4. Provide information to the Member, or when applicable, the Member’s legal guardian concerning the specialty care recommendations.
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• Community Resource Coordination Groups (CRCGs);
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• Early Childhood Intervention (ECI) Program;
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• Local school districts (Special Education);
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• Health and Human Services Commission’s Medical Transportation Program (MTP);
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• Texas Department of Assistive and Rehabilitative Services (DARS) Blind Children’s Vocational Discovery and Development Program;
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• Texas Department of State Health (DSHS) services, including community mental health programs, and Title V Maternal and Child Health and Children with Special Health Care Needs (CSHCN) Programs;
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• Other state and local agencies and programs such as food stamps, and the Women, Infants, and Children’s (WIC) Program;
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• Civic and religious organizations and consumer and advocacy groups, such as United Cerebral Palsy, which also work on behalf of the MSHCN population.
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1. High-cost catastrophic cases;
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2. Women with high-risk pregnancies (STAR and STAR+PLUS Programs only);
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3. Individuals with mental illness and co-occurring substance abuse; and
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4. FWC (STAR and STAR+PLUS Programs only).
|
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1. Patient self-management education;
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2. Provider education;
|
|
3. Evidence-based models and minimum standards of care;
|
|
4. Standardized protocols and participation criteria;
|
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5. Physician-directed or physician-supervised care;
|
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6. Implementation of interventions that address the continuum of care;
|
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7. Mechanisms to modify or change interventions that are not proven effective; and
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8. Mechanisms to monitor the impact of the DM Program over time, including both the clinical and the financial impact.
|
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1. Implement a system for Providers to request specific DM interventions;
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2. Give Providers information, including differences between recommended prevention and treatment and actual care received by Members enrolled in a DM Program, and information concerning such Members’ adherence to a service plan; and
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3. For Members enrolled in a DM Program, provide reports on changes in a Member’s health status to their PCP.
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1. 99% of calls are answered by the fourth ring or an automated call pick-up system;
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2. no incoming calls receive a busy signal;
|
|
3. at least 80% of calls must be answered by toll-free line staff within 30 seconds measured from the time the call is placed in queue after selecting an option;
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4. the call abandonment rate is 7% or less; and
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5. the average hold time is 2 minutes or less.
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1. Maintain accounting records for each applicable HMO Program separate and apart from other corporate accounting records;
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2. Maintain records for all claims payments, refunds and adjustment payments to providers, capitation payments, interest income and payments for administrative services or functions and must maintain separate records for medical and administrative fees, charges, and payments;
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3. Maintain an accounting system that provides an audit trail containing sufficient financial documentation to allow for the reconciliation of billings, reports, and financial statements with all general ledger accounts; and
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4. Within 60 days after Contract execution, submit an accounting policy manual that includes all proposed policies and procedures the HMO will follow during the duration of the Contract. Substantive modifications to the accounting policy manual must be approved by HHSC.
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1. Cooperate with the State and federal governments in their evaluation, inspection, audit, and/or review of accounting records and any necessary supporting information;
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2. Permit authorized representatives of the State and federal governments full access, during normal business hours, to the accounting records that the State and the Federal government determine are relevant to the Contract. Such access is guaranteed at all times during the performance and retention period of the Contract, and will include both announced and unannounced inspections, on-site audits, and the review, analysis, and reproduction of reports produced by the HMO;
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3. Make copies of any accounting records or supporting documentation relevant to the Contract, including Network Provider agreements, available to HHSC or its agents within seven (7) Business Days, or as otherwise specified by HHSC, of receiving a written request from HHSC for specified records or information. If such documentation is not made available as requested, the HMO agrees to reimburse HHSC for all costs, including, but not limited to, transportation, lodging, and subsistence for all State and federal representatives, or their agents, to carry out their inspection, audit, review, analysis, and reproduction functions at the location(s) of such accounting records; and
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4. Pay any and all additional costs incurred by the State and federal government that are the result of the HMO’s failure to provide the requested accounting records or financial
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information within ten (10) business days of receiving a written request from the State or federal government.
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1. A list of all Affiliates, and
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2. For HHSC’s prior review and approval, a schedule of all transactions with Affiliates that, under the provisions of the Contract, will be allowable as expenses in the FSR Report for services provided to the HMO by the Affiliate. Those should include financial terms, a detailed description of the services to be provided, and an estimated amount that will be incurred by the HMO for such services during the Contract Period.
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• unduplicated reports of bariatric surgeries;
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• bariatric surgeries that the HMO has paid under the group of procedure codes defined as allowable for bariatric reimbursement, as designated in the “Texas Medicaid Providers Procedures Manual”, including the Texas Medicaid Bulletins; and
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• bariatric surgeries that were performed no earlier than 210 days prior to the date HHSC receives the Report, or that were included in the Report within thirty days from the date of discharge from the hospital for the stay related to the bariatric surgery, whichever is later. If a medical service provider does not submit a claim to the HMO by the deadline described herein, the HMO may request and exception to include the claim in the BSP report. HHSC may, at its sole discretion, grant or deny the request.
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1. a Financial Disclosure Report prior to the start of Operations;
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2. an updated Financial Disclosure Report no later than 30 days after the end of each Contract Year; and
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3. a “change notification” abbreviated version of the report, no later than 30 days after any of the following events:
|
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a. entering into, renewing, modifying, or terminating a relationship with an affiliated party;
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b. after any change in control, ownership, or affiliations; or,
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c. after any material change in, or need for addition to, the information previously disclosed.
|
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1. Enrollment/Eligibility Subsystem;
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2. Provider Subsystem;
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3. Encounter/Claims Processing Subsystem;
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4. Financial Subsystem;
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5. Utilization/Quality Improvement Subsystem;
|
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6. Reporting Subsystem;
|
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7. Interface Subsystem; and
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8. TPR Subsystem, as applicable to each HMO Program.
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1. A new plan is brought into the HMO Program;
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2. An existing plan begins business in a new Service Area;
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3. An existing plan changes location;
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4. An existing plan changes its processing system, including changes in Material Subcontractors performing MIS or claims processing functions; and
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5. An existing plan in one or two HHSC HMO Programs is initiating a Contract to participate in any additional HMO Programs.
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1. Joint Interface Plan;
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2. Risk Management Plan; and
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3. Systems Quality Assurance Plan.
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1. Process electronic data transmission or media to add, delete or modify membership records with accurate begin and end dates;
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2. Track Covered Services received by Members through the system, and accurately and fully maintain those Covered Services as HIPAA-compliant Encounter transactions;
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3. Transmit or transfer Encounter Data transactions on electronic media in the HIPAA format to the contractor designated by HHSC to receive the Encounter Data;
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4. Maintain a history of changes and adjustments and audit trails for current and retroactive data;
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5. Maintain procedures and processes for accumulating, archiving, and restoring data in the event of a system or subsystem failure;
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6. Employ industry standard medical billing taxonomies (procedure codes, diagnosis codes) to describe services delivered and Encounter transactions produced;
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7. Accommodate the coordination of benefits;
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8. Produce standard Explanation of Benefits (EOBs);
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9. Pay financial transactions to Providers in compliance with federal and state laws, rules and regulations;
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10. Ensure that all financial transactions are auditable according to GAAP guidelines.
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11. Relate and extract data elements to produce report formats (provided within the Uniform Managed Care Manual) or otherwise required by HHSC;
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12. Ensure that written process and procedures manuals document and describe all manual and automated system procedures and processes for the MIS;
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13. Maintain and cross-reference all Member-related information with the most current Medicaid, CHIP or CHIP Perinatal Program Provider number; and
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14. Ensure that the MIS is able to integrate pharmacy data from HHSC’s Drug Vendor file (available through the Virtual Private Network (VPN)) into the HMO’s Member data.
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1. Establish written policies for all employees, managers, officers, contractors, subcontractors, and agents of the HMO, which provide detailed information about the False Claims Act, administrative remedies for false claims and statements, any state laws pertaining to civil or criminal penalties for false claims, and whistleblower protections under such laws, as described in Section 1902(a)(68)(A).
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2. Include as part of such written policies, detailed provisions regarding the HMO’s policies and procedures for detecting and preventing fraud, waste, and abuse.
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3. Include in any employee handbook a specific discussion of the laws described in Section 1902(a)(68)(A), the rights of employees to be protected as whistleblowers, and the HMO’s policies and procedures for detecting and preventing fraud, waste, and abuse.
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1. All information required under the Contract, including but not limited to, the reporting requirements or other information related to the performance of its responsibilities hereunder as reasonably requested by the HHSC; and
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2. Any information in its possession sufficient to permit HHSC to comply with the Federal Balanced Budget Act of 1997 or other Federal or state laws, rules, and regulations. All information must be provided in accordance with the timelines, definitions, formats and instructions as specified by HHSC. Where practicable, HHSC may consult with HMOs to establish time frames and formats reasonably acceptable to both parties.
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(a) Claims Summary Report - The HMO must submit quarterly Claims Summary Reports to HHSC by HMO Program, Service Area and claim type by the 30th day following the end of the reporting period unless otherwise specified. Claim Types include facility and/or professional services for Acute Care, Behavioral Health, Vision, and Long Term Services and Supports. Within each claim type, claims data must be reported separately on the UB and CMS 1500 claim forms. The format for the Claims Summary Report is contained in Chapter 5, Section 5.6.1 of the Uniform Managed Care Manual.
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(b) QAPI Program Annual Summary Report - The HMO must submit a QAPI Program Annual Summary in a format and timeframe as specified in the Uniform Managed Care Manual.
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(c) Fraudulent Practices Report - Utilizing the HHSC-Office of Inspector General (OIG) fraud referral form, the HMO’s assigned officer or director must report and refer all possible acts of waste, abuse or fraud to the HHSC-OIG within 30 working days of receiving the reports of possible acts of waste, abuse or fraud from the HMO’s Special Investigative Unit (SIU). The report and referral must include: an investigative report identifying the allegation, statutes/regulations violated or considered, and the results of the investigation; copies of program rules and regulations violated for the time period in question; the estimated overpayment identified; a summary of the interviews conducted; the encounter data submitted by the provider for the time period in question; and all supporting documentation obtained as
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the result of the investigation. This requirement applies to all reports of possible acts of waste, abuse and fraud.
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(d) Provider Termination Report: (CHIP (including integrated CHIP Perinatal Program data), STAR, and STAR+PLUS) - MCO must submit a quarterly report that identifies any providers who cease to participate in MCO's provider network, either voluntarily or involuntarily. The report must be submitted to HHSC in the format specified by HHSC, no later than 30 days after the end of the reporting period.
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(e) PCP Network & Capacity Report: (CHIP only (including integrated CHIP Perinatal Program data)) - For the CHIP Program, MCO must submit a quarterly report listing all unduplicated PCPs in the MCO's Provider Network. For the CHIP Perinatal Program, the Perinatal Newborns are assigned PCPs that are part of the CHIP PCP Network. The report must be submitted to HHSC in the format specified by HHSC, no later than 30 days after the end of the reporting quarter.
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(f) Summary Report of Member Complaints and Appeals - The HMO must submit quarterly Member Complaints and Appeals reports. The HMO must include in its reports Complaints and Appeals submitted to its subcontracted risk groups (e.g., IPAs) and any other subcontractor that provides Member services. The HMO must submit the Complaint and Appeals reports electronically on or before 45 days following the end of the state fiscal quarter, using the format specified by HHSC in the HHSC Uniform Managed Care Manual, Chapter 5.4.2.
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(g) Summary Report of Provider Complaints - The HMO must submit Provider complaints reports on a quarterly basis. The HMO must include in its reports complaints submitted by providers to its subcontracted risk groups (e.g., IPAs) and any other subcontractor that provides Provider services. The complaint reports must be submitted electronically on or before 45 days following the end of the state fiscal quarter, using the format specified by HHSC in the HHSC Uniform Managed Care Manual, Chapter 5.4.2.
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(h) Hotline Reports - The HMO must submit, on a quarterly basis, a status report for the Member Hotline, the Behavioral Health Services Hotline, and the Provider Hotline in comparison with the performance standards set out in Sections 8.1.5.6, 8.1.15.3, and 8.1.4.7. The HMO shall submit such reports using a format to be prescribed by HHSC in consultation with the HMOs.
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(i) Audit Reports – The HMO must comply with the Uniform Managed Care Manual’s requirements regarding notification and/or submission of audit reports.
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(j) Medicaid Managed Care Texas Health Steps Medical Checkups Reports – Medicaid HMOs must submit reports identifying the number of New Members and Existing Members receiving Texas Health Steps medical checkups.
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(k) Children of Migrant Farm Workers Annual Report (FWC Annual Report) Beginning in SFY 2008, Medicaid HMOs must submit an annual report, in the timeframe and format described in the Uniform Managed Care Manual, about the identification of and delivery of services to children of migrant farm workers (FWC). The report will include a description and results of the each of the following:
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(1) the HMO’s efforts to identify as many community and statewide groups that work with FWC as possible within each of its Service Areas;
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(2) the HMO’s efforts to coordinate and cooperate with as many of such groups as possible; and
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(3) the HMO’s efforts to encourage the community groups to assist in the identification of FWC.
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(l) Frew Quarterly Monitoring Report
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(m) Frew Health Care Provider Training Report
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(n) Frew Provider Recognition Report
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1. More than 90 days after a Member enrolls in the HMO’s Program, or
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2. For more than nine (9) months in the case of a Member who, at the time of enrollment in the HMO, has been diagnosed with and receiving treatment for a terminal illness and remains enrolled in the HMO.
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1. The HMO does not respond to a request for pre-approval within 1 hour;
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2. The HMO cannot be contacted; or
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3. The HMO representative and the treating physician cannot reach an agreement concerning the Member’s care and a Network physician is not available for consultation. In this situation, the HMO must give the treating physician the opportunity to consult with a Network physician and the treating physician may continue with care of the patient until an HMO physician is reached. The HMO’s financial responsibility ends as follows: the HMO physician with privileges at the treating hospital assumes responsibility for the Member’s care; the HMO physician assumes responsibility for the Member’s care through transfer; the HMO representative and the treating physician reach an agreement concerning the Member’s care; or the Member is discharged.
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1. Texas Health Steps benefits;
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2. the periodicity schedule for Texas Health Steps medical checkups and immunizations;
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3. the required elements of Texas Health Steps medical checkups;
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4. providing or arranging for all required lab screening tests (including lead screening), and Comprehensive Care Program (CCP) services available under the Texas Health Steps program to Members birth through age 20;
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5. Medical Transportation services avilable to Members such as rides to healthcare service by bus, taxi, van, airfare, etc., gas money, mileage reimbursement, meals and lodging when away from home;
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6. importance of updating contact information to ensure accurate provider directories and the Medicaid Online Povider Lookup;
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7. information about HMO's process for acceleration of THSteps services for Children of Migrant Farm Workers;
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8. missed appointment referrals and assistance provided by the THSteps Outreach and Informing Unit; and
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9. administrative issues such as claims filing and services available to Members.
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1. Pregnancy planning and perinatal health promotion and education for reproductive- age women;
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2. Perinatal risk assessment of non-pregnant women, pregnant and postpartum women, and infants up to one year of age;
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3. Access to appropriate levels of care based on risk assessment, including emergency care;
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4. Transfer and care of pregnant women, newborns, and infants to tertiary care facilities when necessary;
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5. Availability and accessibility of OB/GYNs, anesthesiologists, and neonatologists capable of dealing with complicated perinatal problems; and
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6. Availability and accessibility of appropriate outpatient and inpatient facilities capable of dealing with complicated perinatal problems.
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1. Texas Health Steps dental (including orthodontia);
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2. Texas Health Steps environmental lead investigation (ELI)
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3. Early Childhood Intervention (ECI) case management/service coordination;
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4. DSHS targeted case management;
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5. DSHS mental health rehabilitation;
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6. DSHS case management for Children and Pregnant Women;
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7. Texas School Health and Related Services (SHARS);
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8. Department of Assistive and Rehabilitative Services Blind Children’s Vocational Discovery and Development Program;
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9. Tuberculosis services provided by DSHS-approved providers (directly observed therapy and contact investigation);
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10. Vendor Drug Program (out-of-office drugs);
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11. Health and Human Services Commission’s Medical Transportation;
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12. DADS hospice services (all Members are disenrolled from their health plan upon enrollment into hospice except STAR+PLUS members);
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13. Audiology services and hearing aids for children (birth through age 20) (hearing screening services are provided through the Texas Health Steps Program and are capitated).
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14. For STAR+PLUS, Inpatient Stays are Non-capitated (with the exception of inpatient mental health services, which are capitated).
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15. For STAR, Personal Care Services for persons under age 21 are Non-capitated Services.
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16. For STAR+PLUS, nursing facility services are Non-capitated Services; and
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17. For Members who are enrolled in STAR or STAR+PLUS during and Inpatient Stay under one of the exceptions identified in Attachment A, Section 5.05(a)(2), Hospital facility charges associated with the Inpatient Stay are Non-Capitated Services under the circumstances described in Attachment A, Section 5.05(a)(2)..
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• Identification of community and statewide groups that work with FWC Members within the HMO’s Service Areas;
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• Participation of the community groups in assisting with the identification of FWC Members;
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• Appropriate aggressive efforts to reach each identified FWC to provide timely medical checkups and follow up care if needed;
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• Methods to maintain accurate, current lists of all identified FWC Members;
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• Methods that the HMO and its Subcontractors will implement to maintain the confidentiality of information about the identity of FWC; and
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• Methods to provide accelerated services to FWC.
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1. Agree to accept the HMO’s Provider reimbursement rate for the provider type; and
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2. Meet the standard credentialing requirements of the HMO, provided that lack of board certification or accreditation by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) is not the sole grounds for exclusion from the Provider Network.
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1. Prior to September 1, 2007: For claims accruing prior to September 1, 2007, cost settlements apply to all Service Areas except the Nueces Service Area and the STAR+PLUS Service Areas. The HMOs serving the Nueces Service Area and the STAR+PLUS Service Areas must pay the full encounter rates to the FQHCs and RHCs for claims accruing before September 1, 2007.
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2. September 1, 2007 to September 1, 2008: For claims accruing on or after September 1, 2007 but prior to September 1, 2008, HMOs are not required to pay full encounter rates to the FQHCs and RHCs. Therefore, HHSC cost settlements for FQHC’s will continue to apply to all STAR and STAR+PLUS Service Areas for this period of time.
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3. On or after September 1, 2008: HMOs are required to pay the full encounter rates to RHCs for claims accruing on or after September 1, 2008; therefore, HHSC cost settlements will not apply to RHCs for this period of time. However, HMOs are not required to pay the full encounter rates to FQHCs for claims accruing on or after September 1, 2008; therefore, HHSC cost settlements will apply to FQHCs for this period of time.
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3. On or after September 1, 2011: HMOs are required to pay the full encounter rates to FQHCs for claims accruing on or after September 1, 2011. HHSC cost settlements will not apply to FQHCs after that date.
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1. the Nueces Service Area and the STAR+PLUS Service Areas for claims accruing before September 1, 2007, since the HMOs in those Areas will pay the full encounter rates to the FQHCs and RHCs for this period of time; and
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2. for claims paid to RHCs on or after September 1, 2008, because the HMOs will pay full encounter rates to RHCs for this period of time.
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3. for claims paid to FQHCs on or after September 1, 2011, because the HMOs will pay full encounter rates to FQHCs for this period of time.
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1. Date;
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2. Identification of the individual filing the Complaint;
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3. Identification of the individual recording the Complaint;
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4. Nature of the Complaint;
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5. Disposition of the Complaint (i.e., how the HMO resolved the Complaint);
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6. Corrective action required; and
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7. Date resolved.
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The HMO must provide designated Member Advocates to assist Members in understanding and using the HMO’s Complaint system as described in Section 8.2.7.9. The HMO’s Member Advocates must assist Members in writing or filing a Complaint and monitoring the Complaint through the HMO’s Complaint process until the issue is resolved.
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1) Date notice is sent;
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2) Effective date of the Action;
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3) Date the Member or his or her representative requested the Appeal;
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4) Date the Appeal was followed up in writing;
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5) Identification of the individual filing;
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6) Nature of the Appeal; and
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7) Disposition of the Appeal, and notice of disposition to Member.
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1. The Member or his or her representative files the Appeal timely as defined in this Contract:
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2. The Appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;
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3. The services were ordered by an authorized provider;
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4. The original period covered by the original authorization has not expired; and
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5. The Member requests an extension of the benefits.
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1. The Member withdraws the Appeal;
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2. Ten (10) days pass after the HMO mails the notice resolving the Appeal against the Member, unless the Member, within the 10-day timeframe, has requested a Fair Hearing with continuation of benefits until a Fair Hearing decision can be reached; or
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3. A state Fair Hearing officer issues a hearing decision adverse to the Member or the time period or service limits of a previously authorized service has been met.
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(1) Transfer the Appeal to the timeframe for standard resolution, and
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(2) Make a reasonable effort to give the Member prompt oral notice of the denial, and follow up within two (2) calendar days with a written notice.
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2. The Action the HMO has taken or intends to take;
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3. The reasons for the Action (If the Action taken is based upon a determination that the requested service is not medically necessary, the HMO must provide an explanation of the medical basis for the decision, application of policy or accepted standards of medical practice to the individuals medical circumstances, in it’s notice to the member.);
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4. The Member’s right to access the HMO’s Appeal process.
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5. The procedures by which the Member may Appeal the HMO’s Action;
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6. The circumstances under which expedited resolution is available and how to request it;
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7. The circumstances under which a Member may continue to receive benefits pending resolution of the Appeal, how to request that benefits be continued, and the circumstances under which the Member may be required to pay the costs of these services;
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8. The date the Action will be taken;
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9. A reference to the HMO policies and procedures supporting the HMO’s Action;
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10. An address where written requests may be sent and a toll-free number that the Member can call to request the assistance of a Member representative, file an Appeal, or request a Fair Hearing;
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11. An explanation that Members may represent themselves, or be represented by a provider, a friend, a relative, legal counsel or another spokesperson;
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12. A statement that if the Member wants a Fair Hearing on the Action, the Member must make the request for a Fair Hearing within 90 days of the date on the notice or the right to request a hearing is waived;
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13. A statement explaining that the HMO must make its decision within 30 days from the date the Appeal is received by the HMO, or 3 business days in the case of an Expedited Appeal; and
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14. A statement explaining that the hearing officer must make a final decision within 90 days from the date a Fair Hearing is requested.
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1. For termination, suspension, or reduction of previously authorized Medicaid-covered services, within the timeframes specified in 42 C.F.R.§§ 431.211, 431.213, and 431.214;
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2. For denial of payment, at the time of any Action affecting the claim;
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3. For standard service authorization decisions that deny or limit services, within the timeframe specified in 42 C.F.R.§ 438.210(d)(1);
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4. If the HMO extends the timeframe in accordance with 42 C.F.R. §438.210(d)(1), it must:
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5. give the Member written notice of the reason for the decision to extend the timeframe and inform the Member of the right to file an Appeal if he or she disagrees with that decision; and
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6. issue and carry out its determination as expeditiously as the Member’s health condition requires and no later than the date the extension expires;
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7. For service authorization decisions not reached within the timeframes specified in 42 C.F.R.§ 438.210(d) (which constitutes a denial and is thus an adverse Action), on the date that the timeframes expire; and
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8. For expedited service authorization decisions, within the timeframes specified in 42 C.F.R. 438.210(d).
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1. The right to request a Fair Hearing;
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|
2. How to request a Fair Hearing;
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3. The circumstances under which the Member may continue to receive benefits pending a Fair Hearing;
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4. How to request the continuation of benefits;
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5. If the HMO’s Action is upheld in a Fair Hearing, the Member may be liable for the cost of any services furnished to the Member while the Appeal is pending; and
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6. Any other information required by 1 T.A.C. Chapter 357 that relates to a managed care organization’s notice of disposition of an Appeal.
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1. Their rights and responsibilities,
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2. The Complaint process,
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3. The Appeal process,
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4. Covered Services available to them, including preventive services, and
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5. Non-capitated Services available to them.
|
1. Describe the Behavioral Health Services indicated in detail in the Provider Procedures Manual and in the Texas Medicaid Bulletin, include the amount, duration, and scope of basic and Value-added Services, and the HMO’s responsibility to provide these services;
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2. Describe criteria, protocols, procedures and instrumentation for referral of Medicaid Members from and to the HMO and the LMHA;
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3. Describe processes and procedures for referring Members with SPMI or SED to the LMHA for assessment and determination of eligibility for rehabilitation or targeted case management services;
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4. Describe how the LMHA and the HMO will coordinate providing Behavioral Health Services to Members with SPMI or SED;
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5. Establish clinical consultation procedures between the HMO and LMHA including consultation to effect referrals and on-going consultation regarding the Member’s progress;
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6. Establish procedures to authorize release and exchange of clinical treatment records;
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7. Establish procedures for coordination of assessment, intake/triage, utilization review/utilization management and care for persons with SPMI or SED;
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8. Establish procedures for coordination of inpatient psychiatric services (including Court- ordered Commitment of Members under 21) in state psychiatric facilities within the LMHA’s catchment area;
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9. Establish procedures for coordination of emergency and urgent services to Members;
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10. Establish procedures for coordination of care and transition of care for new Members who are receiving treatment through the LMHA; and
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1. Sexually Transmitted Diseases (STDs) services;
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|
2. Confidential HIV testing;
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|
3. Immunizations;
|
|
4. Tuberculosis (TB) care;
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|
5. Family Planning services;
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|
6. Texas Health Steps medical checkups, and
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7. Prenatal services.
|
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1. Identify care managers who will be available to assist public health providers and PCPs in efficiently referring Members to the public health providers, specialists, and health-related service providers either within or outside the HMO’s Network; and
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2. Inform Members that confidential healthcare information will be provided to the PCP, and educate Members on how to better utilize their PCPs, public health providers, emergency departments, specialists, and health-related service providers.
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1. Report to public health entities regarding communicable diseases and/or diseases that are preventable by immunization as defined by state law;
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|
2. Notify the local Public Health Entity, as defined by state law, of communicable disease outbreaks involving Members;
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|
3. Educate Members and Providers regarding WIC services available to Members; and
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4. Coordinate with local public health entities that have a child lead program, or with DSHS regional staff when the local public health entity does not have a child lead program, for follow-up of suspected or confirmed cases of childhood lead exposure.
|
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1. Require Providers to use the DSHS Bureau of Laboratories for specimens obtained as part of a Texas Health Steps medical checkup, including Texas Health Steps newborn screens, lead testing, and hemoglobin/hematocrit tests;
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|
2. Notify Providers of the availability of vaccines through the Texas Vaccines for Children Program;
|
|
3. Work with HHSC and Providers to improve the reporting of immunizations to the statewide ImmTrac Registry;
|
|
4. Educate Providers and Members about the Department of State Health Services (DSHS) Case Management for Children and Pregnant Women (CPW) services available;
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|
5. Coordinate services with CPW specifically in regard to an HMO Member’s health care needs that are identified by CPW and referred to the HMO;
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|
6. Participate, to the extent practicable, in the community-based coalitions with the Medicaid-funded case management programs in the Department of Assistive and Rehabilitative Services (DARS), the Department of Aging and Disability Services (DADS), and DSHS;
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7. Cooperate with activities required of state and local public health authorities necessary to conduct the annual population and community based needs assessment;
|
|
8. Report all blood lead results, coordinate and follow-up of suspected or confirmed cases of childhood lead exposure with the Childhood Lead Poisoning Prevention Program in DSHS; and
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|
9. Coordinate with Texas Health Steps.
|
|
1. A Member’s right to self-determination in making health care decisions;
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|
2. The Advance Directives Act, Chapter 166, Texas Health and Safety Code, which includes:
|
|
a. A Member’s right to execute an advance written directive to physicians and family or surrogates, or to make a non-written directive to administer, withhold or withdraw life-sustaining treatment in the event of a terminal or irreversible condition;
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|
b. A Member’s right to make written and non-written out-of-hospital do-not-resuscitate (DNR) orders;
|
|
c. A Member’s right to execute a Medical Power of Attorney to appoint an agent to make health care decisions on the Member’s behalf if the Member becomes incompetent; and
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|
3. The Declaration for Mental Health Treatment, Chapter 137, Texas Civil Practice and Remedies Code, which includes: a Member’s right to execute a Declaration for Mental Health Treatment in a document making a declaration of preferences or instructions regarding mental health treatment.
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Community Long-Term Care Services Available to All Members
|
|
Service
|
Licensure and Certification Requirements
|
Personal Attendant Services/Primary Home Care
|
The Provider must be licensed by DADS as a Home and Community Support Services Agency (HCSSA). The level of licensure required depends on the type of service delivered. NOTE: For primary home care and client managed attendant care, the agency may have only the Personal Assistance Services level of licensure.
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Day Activity and Health Services (DAHS)
|
The Provider must be licensed by DADS Regulatory Division, as an adult day care provider. To provide DAHS, the Provider must provide the range of services required for DAHS.
|
Community Long-Term Care Services Under the 1915(c) STAR+PLUS Waiver
|
|
Service
|
Licensure and Certification Requirements
|
Personal Attendant Services
|
The Provider must be licensed by DADs as a Home and Community Support Services Agency (HCSSA). The level of licensure required depends on the type of service delivered. For Primary Home Care and Client Managed Attendant Care, the agency may have only the Personal Assistance Services level of licensure.
|
Assisted Living
|
The Provider must be licensed by the Texas Department of Aging and Disability Services, Long Term Care Regulatory Division in accordance with 40 T.A.C, Part 1, Chapter 92. The type of licensure determines what services may be provided.
|
Emergency Response Service Provider
|
Licensed by the Texas Deparement of State Health Services as a Personal Emergency Response Services Agency under T.A.C, Title 25, Part 1, Chapter 140, Subchapter B.
|
Nursing Services | Licensed Registered Nurse by the Texas Board of Nursing under 22 T.A.C, Part 11, Chapter 217. |
Adult Foster Home
|
Adult foster care homes serving three (3) or fewer participants must comply with requirements outlined in 40 TAC, Part 1, Chapter 48, Subchapter K. Adult foster care homes serving four (4) participants must be licensed by DADS as an assisted living facility under 40 TAC Part 1, Chapter 92.
|
Respite Care | Licensed by DADS as a Home and Community Support Services Agency (HCSSA) under T.A.C., Title 40, Part 1, Chapter 97. |
Home Delivered
Meals
|
Providers must comply with requirments for providing home delivered meal services, which include requirements such as dietary requirements, food temperature, delivery times, and training of volunteers and others who deliver meals. In accordance with T.A.C., Title 40, Part 1, Chapter 55.
|
Physical
Therapy (PT) Services
|
Licensed Physical Therapist through the Texas Board of Physical Therapy Examiners, Chapter 453.
|
Occupational
Therapy (OT) Services
|
Licensed Occupational Therapist through the Texas Board of Occupational Therapy Examiners, Chapter 454.
|
Speech, Hearing, and Language Therapy Services
|
Licensed Speech Therapist Through the Department of State Health Services under TAC, Part 32, Chapter 741.
|
Consumer Directed Services (CDS)
|
No licensure or certification requirements. Must have completed required training by DADS. CDSAs contracted by DADS are assumed to have completed the training.
|
Transition Assistance Services
|
The Provider must comply with the requirements for delivery of TAS, which includes requirements such as allowable purchases, cost limits, and time frames for delivery. TAS providers must demonstrate knowledge of, and experience in, successfully serving individuals who require home and community-based services.
|
Minor Home Modification
|
No licensure or certification requirements.
|
Adaptive Aids and Medicaid Equipment
|
No licensure or certification requirements.
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Medical supplies
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No licensure or certification requirements.
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1. State/federal agencies (e.g., those agencies with jurisdiction over aging, public health, substance abuse, mental health/retardation, rehabilitation, developmental disabilities, income support, nutritional assistance, family support agencies, etc.);
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2. social service agencies (e.g., Area Agencies on Aging, residential support agencies, independent living centers, supported employment agencies, etc.);
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3. city and county agencies (e.g., welfare departments, housing programs, etc.);
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4. civic and religious organizations; and
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5. consumer groups, advocates, and councils (e.g., legal aid offices, consumer/family support groups, permanency planning, etc.).
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1. review of existing DADS long-term care services plans;
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2. preparation of a transition plan that ensures continuous care under the Member’s existing Care Plan during the transfer into the HMO’s Network while the HMO conducts an appropriate assessment and development of a new plan, if needed;
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3. if durable medical equipment or supplies had been ordered prior to enrollment but have not been received by the time of enrollment, coordination and follow-through to ensure that the Member receives the necessary supportive equipment and supplies without undue delay; and
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4. payment to the existing provider of service under the existing authorization until the HMO has completed the assessment and service plans and issued new authorizations.
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• the state's treatment professionals determine that such placement is appropriate;
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• the affected persons do not oppose such treatment; and
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• the placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others who are receiving state supported disability services.
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• at initial assessment;
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• at annual reassessment or annual contact with the STAR+PLUS Member;
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• at any time when a STAR+PLUS Member receiving PHC/PAS/Respite/Nursing/PT/OT/SLT requests the information; and
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• in the Member Handbook.
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1. Covered Services and the Provider’s responsibilities for providing such services to STAR+PLUS Members and billing the HMO for such services. The HMO must place special emphasis on Community Long-term Care Services and STAR+PLUS requirements, policies, and procedures that vary from Medicaid Fee-for-Service and commercial coverage rules, including payment policies and procedures.
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2. Inpatient Stay hospital services and the authorization and billing of such services for STAR+PLUS Members.
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3. Relevant requirements of the STAR+PLUS Contract, including the role of the Service Coordinator;
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4. Processes for making referrals and coordinating Non-capitated Services;
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5. The HMO’s quality assurance and performance improvement program and the Provider’s role in such programs; and
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6. The HMO’s STAR+PLUS policies and procedures, including those relating to Network and Out-of-Network referrals.
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7. For Expansion Counties with an Operational Start Date of 9/1/2011, the process for continuing up to six (6) months of Community-based Long Term Care Services for Members receiving those services as of the Operational Start Date, including provider billing practices for these services and whom to contact at the HMO for assistance with this process.
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8.4 Additional CHIP Scope of Work
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1. Agree to accept the HMO’s Provider reimbursement rate for the provider type; and
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2. Meet the standard credentialing requirements of the HMO, provided that lack of board certification or accreditation by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) is not the sole grounds for exclusion from the Provider Network.
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DOCUMENT HISTORY LOG
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||||
STATUS1
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DOCUMENT
REVISION2
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EFFECTIVE
DATE
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DESCRIPTION3
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Baseline
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n/a
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Initial version Attachment B-1, Section 7
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||
Revision
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1.1
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June 30, 2006
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Contract amendment to include STAR+PLUS program. No change to this Section.
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Revision
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1.2
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September 1, 2006
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Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements
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Revision
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1.3
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September 1, 2006
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Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements
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Revision
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1.4
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September 1, 2006
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Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements
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Revision
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1.5
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January 1, 2007
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Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements
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Revision
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1.6
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February 1, 2007
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Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements
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Revision
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1.7
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July 1, 2007
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Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements
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Revision
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1.8
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September 1, 2007
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Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements
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Revision
|
1.9
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December 1, 2007
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Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements
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Revision | 1.10 | March 1, 2008 |
Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements
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Revision | 1.11 | September 1, 2008 |
Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements
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Revision | 1.12 | March 1, 2009 | Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements | |
Revision | 1.13 | September 1, 2009 | Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements | |
Revision | 1.14 | December 1, 2009 | Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements | |
Revision | 1.15 | March 1, 2010 | Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements | |
Revision | 1.16 | September 1, 2010 | Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements | |
Revision | 1.17 | December 1, 2010 | Contract amendment did not revise Attachment B-1 Section 9 – Turnover Requirements | |
Revision | 1.18 | March 1, 2011 | Contract amendment did not revise Attachment B-1 Section 9 - Turnover Requirements. | |
Revision | 1.19 | September 1, 2011 | Contract amendment did not revise Attachment B-1 Section 9 - Turnover Requirements. | |
Revision | 1.20 | January 1, 2012 | Contract amendment did not revise Attachment B-1 Section 9 - Turnover Requirements. | |
1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
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DOCUMENT HISTORY LOG
|
|||
STATUS1
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DOCUMENT
REVISION2
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EFFECTIVE
DATE
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DESCRIPTION3
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Baseline
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n/a
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Initial version Attachment B-2, Covered Services
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Revision
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1.1
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June 30, 2006
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Revised Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS Covered Services.
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Revision
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1.2
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September 1. 2006
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Revised Attachment B-2 to include provisions applicable to MCOs participating in the STAR and CHIP Programs.
STAR Covered Services, Services Included under the HMO Capitation Payment, is modified to clarify the STAR covered services related to “optometry” and “vision.”
CHIP Covered Services is modified to correct services related to artificial aids including surgical implants.
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Revision
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1.3
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September 1, 2006
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Contract amendment did not revise Attachment B-2, Covered Services.
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Revision
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1.4
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September 1, 2006
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Contract amendment did not revise Attachment B-2, Covered Services.
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Revision
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1.5
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January 1, 2007
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Contract amendment did not revise Attachment B-2, Covered Services.
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Revision
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1.6
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February 1, 2007
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Contract amendment did not revise Attachment B-2, Covered Services.
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Revision
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1.7
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July 1, 2007
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Contract amendment did not revise Attachment B-2, Covered Services.
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Revision
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1.8
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September 1, 2007
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CHIP Covered Services are modified to comply with legislative changes required by HB 109 to eliminate the 6 month enrollment period effective 9/1/07.
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Revision
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1.9
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December 1, 2007
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Contract amendment did not revise Attachment B-2, Covered Services.
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Revision | 1.10 | March 1, 2008 |
Contract amendment did not revise Attachment B-2, Covered Services.
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Revision | 1.11 | September 1, 2008 | Attachment B-2, Covered Services is modified to include additional covered services resulting from the Frew Settlement. |
Revision | 1.12 | March 1, 2009 |
Contract amendment did not revise Attachment B-2, Covered Services.
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Revision | 1.13 | September 1, 2009 |
All references to “check-ups” are changed to “checkups”
Annual adult well check is removed from the list of enhanced benefits and added to “Services included under the HMO capitation payment”.
STAR Covered Services “Services included under the HMO capitation payment” is modified to remove “birthing center services” and add “Birthing services provided by a certified nurse midwife in a birthing center”.
CHIP Covered Services “Inpatient General Acute and Inpatient Rehabilitation Hospital Services” is modified clarify the requirements regarding miscarriage and non-viable pregnancy, as well as orthodontic services for treatment of craniofacial anomalies.
CHIP Covered Services “Outpatient Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center” is modified to clarify the requirements regarding miscarriage and non-viable pregnancy, as well as orthodontic services for treatment of craniofacial anomalies.
CHIP Covered Services “Physician/Physician Extender Professional Services” is modified to clarify the requirements regarding miscarriage and non-viable pregnancy.
CHIP Covered Services “Durable Medical Equipment (DME), Prosthetic Devices and Disposable Medical Supplies” is modified to clarify the requirements regarding dental devices.
CHIP Covered Services “Outpatient Mental Health Services” is revised to provide additional clarity as it relates to Qualified Mental Health Providers – Community Services (QMHP-CS).
CHIP Exclusions From Covered Services is modified to clarify requirements regarding dental devices.
CHIP DME/Supplies is modified to clarify the requirements regarding dental devices.
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Revision | 1.14 | December 1, 2009 |
“Services included under the HMO capitation payment” is modified to remove references to PACT.
CHIP Covered Services “Inpatient General Acute and Inpatient Rehabilitation Hospital Services” is modified to clarify the requirements regarding orthodontic services for treatment of craniofacial anomalies. It is also modified to clarify the requirements of Section 2103(f)(2) of the Social Security Act, as amended by CHIPRA. This provision requires CHIP health plans to comply with the Title 42 U.S.C., Chapter 6A, Subchapter XXV, Part A, Subpart 2, 300gg-6.
CHIP Covered Services “Outpatient Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center” is modified to clarify the requirements regarding orthodontic services for treatment of craniofacial anomalies. It is also modified to clarify the requirements of Section 2103(f)(2) of the Social Security Act, as amended by CHIPRA. This provision requires CHIP health plans to comply with Title 42 U.S.C., Chapter 6A, Subchapter XXV, Part A, Subpart 2, 300gg-6.
CHIP Covered Services “Physician/Provider Extender Professional Services” is modified to clarify the requirements regarding orthodontic services for treatment of craniofacial anomalies. It is also modified to clarify the requirements of 2103(f)(2) of the Social Security Act, as amended by CHIPRA. This provision requires CHIP health plans to comply with Title 42 U.S.C., Chapter 6A, Subchapter XXV, Part A, Subpart 2, 300gg-6.
CHIP Covered Services “Durable Medical Equipment (DME), Prosthetic Devices and Disposable Medical supplies” is modified to ad external breast prostheses.
CHIP Covered Services “Outpatient Mental Health Services” is revised to update the TAC citation.
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Revision | 1.15 | March 1, 2010 |
“Services included under the HMO capitation payment” is modified to add substance abuse services. This amendment will be effective the later of: September 1, 2010 or upon final approval of the Medicaid State Plan, 1915(b) STAR+PLUS waiver and/or the 1915(b) STAR waiver, as applicable to the HMO Program
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Revision | 1.16 | September 1, 2010 |
STAR Covered Services is modified to waive the 30 visit limit for outpatient mental health services (as required by Mental Health Parity requirements).
“Services included under the HMO capitation payment” is modified to clarify the substance abuse services; correct the error of adding the general category of “inpatient mental health services for Adults”; and to replace “certified nurse midwife” with “physician or Advanced Practice Nurse” and add the word “licensed” to Birthing Services. In addition, “mastectomy, breast reconstruction, and related follow-up procedures” and “Birthing services provided by a licensed birthing center” are added.
CHIP Covered Services “Inpatient General Acute and Inpatient Rehabilitation Hospital Services” is modified to add “external breast prostheses”.
CHIP Covered Services “Outpatient Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center” is modified to add “external breast prostheses”.
CHIP Covered Services “Physician/Physician Extender Professional Services” is modified to add “external breast prostheses”.
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Revision | 1.17 | December 1, 2010 | CHIP Hospice Care Services modified to require concurrent CHIP and hospice care services to comply with the federal requirements from Section 2302 of the Patient Protection and Affordable Care Acts of 2010 (P.L. 111-148). By law, CHIP health plans were required to provide concurrent hospice care services effective August 1, 2010. |
Revision | 1.18 | March 1, 2011 |
Services included under the HMO capitation payment is modified to remove the services effective prior to the effective dates of the State Plan and 1915(b) STAR Waiver.
Services included under the HMO capitation payment is modified to add a reference to "Cancer screening, diagnostic, and treatment services". These services are already 1905(a) covered services, therefore adding this reference does not impact the HMOs' rates.
CHIP Inpatient Mental Health Services is modified to comply with the federal requirements of the Mental Health Parity and Addiction Equity Act of Children's Health Insurance Program Reauthorization Act of 2009 (P.L. 111-3). Also modified to clarify the court-ordered service requirement.
CHIP Inpatient Substance Abuse Treatment Services is modified to comply with the federal requirements of the Mental Health Parity and Additction Equity Act of 2008 (MHPAEA), as applied to CHIP by the Children's Health Insurance Program Reauthorization Act of 2009 (P.L. 111-3).
CHIP Outpatient Substance Abuse Treatment Services is modified to comply with the federal requirements of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) as applied to CHIP by the Children's Health Insurance Program Reauthorization Act of 2009 (P.L. 111-3).
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Revision | 1.19 | September 1, 2011 | Attachment B-2 is modified effective September 1, 2011 and subject to CMS approval, to remove the waiverof the three prescription limit for adults. |
Revision | 1.20 | January 1, 2012 |
Contract amendment did not revise Attachment B-2, Covered Services.
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1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
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1) waiver of the three-prescription per month limit;
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2) waiver of the 30-day spell-of-illness limitation under fee-for-services; and
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Subject to CMS approval, the waiver of the three-prescription per month limit will no longer be an enhanced benefit for adult STAR members. HHSC will provide Medicaid HMOs with advance written notice of the effective date of this change, which it anticipates will be on or after September 1, 2011. Members enrolled in a 1915(c) waiver program will still have access to unlimited prescriptions as a benefit of that program.
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·
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Ambulance services
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·
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Audiology services, including hearing aids, for adults (audiology services and hearing aids for children are a non-capitated service)
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·
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(These services are not subject to the quantitative treatment limitations that apply under traditional, fee-for-service Medicaid coverage. The services may be subject to the HMO's non-quantitative treatmetn limiations, provided such limitations comply with the requirements of the Mental Health Parity and Addiction Equity Act of 2008.) Behavioral Health Services, including:
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·
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Inpatient mental health services for Children (under age 21)
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·
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Outpatient mental health services
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·
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Psychiatry services
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·
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Counseling services for adults (21 years of age and over)
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·
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Outpatient substance use disorder treatment services including:
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o Assessment
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o Detoxification services
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o Counseling treatment
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o Medication assisted therapy
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·
|
Residential substance use disorder treatment services including:
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o Detoxification services
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·
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Substance use disorder treatment (including room and board)
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·
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Birthing services provided by a physician or Advanced Practice Nurse in a licensed birthing center
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·
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Birthing services provided by a licensed birthing center
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·
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Cancer screening, diagnostic, and treatment services
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·
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Chiropractic services
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·
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Dialysis
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·
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Durable medical equipment and supplies
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·
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Emergency Services
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·
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Family planning services
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·
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Home health care services
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·
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Hospital services, including inpatient and outpatient
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·
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Laboratory
|
·
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Mastectomy, breast reconstruction, and related follow-up procedures, including:
|
·
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inpatient services; outpatient services provided at an outpatient hospital and ambulatory health care center as clinically appropriate; and physician and professional services provided in an office, inpatient, or outpatient setting for:
|
·
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all stages of reconstruction on the breast(s) on which medically necessary mastectomy procedure(s) have been performed;
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·
|
surgery and reconstruction on the other breast to produce symmetrical appearance;
|
·
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treatment of physical complications from the mastectomy and treatment of lymphedemas; and
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·
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prophylactic mastectomy to prevent the development of breast cancer.
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·
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external breast prosthesis for the breast(s) on which medically necessary mastectomy procedure(s) have been performed.
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·
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Medical checkups and Comprehensive Care Program (CCP) Services for children (under age 21) through the Texas Health Steps Program
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·
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Oral evaluation and fluoride varnish in the Medical Home in conjunction with Texas Health Steps medical checkup for children 6 months through 35 months of age.
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·
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Podiatry
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·
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Prenatal care
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·
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Primary care services
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·
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Preventive services including an annual adult well check for patients 21 years of age and over
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·
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Radiology, imaging, and X-rays
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·
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Specialty physician services
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·
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Therapies – physical, occupational and speech
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·
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Transplantation of organs and tissues
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·
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Vision (Includes optometry and glasses. Contact lenses are only covered if they are medically necessary for vision correction, which can not be accomplished by glasses.)
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Covered Benefit
|
Description
|
Inpatient General Acute and Inpatient Rehabilitation Hospital Services
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Services include, but are not limited to, the following:
Hospital-provided Physician or Provider services
Semi-private room and board (or private if medically necessary as certified by attending)
General nursing care
Special duty nursing when medically necessary
ICU and services
Patient meals and special diets
Operating, recovery and other treatment rooms
Anesthesia and administration (facility technical component)
Surgical dressings, trays, casts, splints
Drugs, medications and biologicals
Blood or blood products that are not provided free-of-charge to the patient and their administration
X-rays, imaging and other radiological tests (facility technical component)
Laboratory and pathology services (facility technical component)
Machine diagnostic tests (EEGs, EKGs, etc.)
Oxygen services and inhalation therapy
Radiation and chemotherapy
Access to DSHS-designated Level III perinatal centers or Hospitals meeting equivalent levels of care
In-network or out-of-network facility and Physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section.
Hospital, physician and related medical services, such as anesthesia, associated with dental care
Inpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero). Inpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to:
- dilation and curettage (D&C) procedures;
- appropriate provider-administered medications;
- ultrasounds, and
- histological examination of tissue samples.
Surgical implants
Other artificial aids including surgical implants
Inpatient services for a mastectomy and breast reconstruction include:
- all stages of reconstruction on the affected breast;
- external breast prosthesis for the breast(s) on which medically necessary mastectomy procedure(s) have been performed
- surgery and reconstruction on the other breast to produce symmetrical appearance; and
- treatment of physical complications from the mastectomy and treatment of lymphedemas.
Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12-month period limit
Pre-surgical or post-surgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined plan to treat:
- cleft lip or palate;
- severe skeletal and/or congenital craniofacial deviations; or
- severe facial asymmetry secondary skeletal defects, congenital syndromal conditions and/or tumor growth or its treatment.
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Skilled Nursing
Facilities
(Includes Rehabilitation
Hospitals)
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Services include, but are not limited to, the following:
Semi-private room and board
Regular nursing services
Rehabilitation services
Medical supplies and use of appliances and equipment furnished by the facility
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Outpatient Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center
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Services include, but are not limited to, the following services provided in a hospital clinic or emergency room, a clinic or health center, hospital-based emergency department or an ambulatory health care setting:
X-ray, imaging, and radiological tests (technical component)
Laboratory and pathology services (technical component)
Machine diagnostic tests
Ambulatory surgical facility services
Drugs, medications and biologicals
Casts, splints, dressings
Preventive health services
Physical, occupational and speech therapy
Renal dialysis
Respiratory services
Radiation and chemotherapy
Blood or blood products that are not provided free-of-charge to the patient and the administration of these products
Outpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero). Inpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to:
- dilation and curettage (D&C) procedures;
- appropriate provider-administered medications;
- ultrasounds, and
- histological examination of tissue samples.
Facility and related medical services, such as anesthesia, associated with dental care, when provided in a licensed ambulatory surgical facility.
Surgical implants
Other artificial aids including surgical implants
Outpatient services provided at an oupatient hospital and ambultory health care center for a mastectomy and breast reconstruction as clinically appropriate, include:
- all stages of reconstruction on the affected breast;
- external breast prosthesis for the breast(s) on which medically necessary mastectomy procedure(s) have been performed
- surgery and reconstruction on the other breast to produce symmetrical appearance; and
- treatment of physical complications from mastectomy and treatment of lymphedemas.
Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12-month period limit
Pre-surgical or post-surgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined plan to treat:
- cleft lip or palate;
- severe skeletal and/or congenital craniofacial deviations; or
- severe facial asymmetry secondary skeletal defects, congenital syndromal conditions and/or tumor growth or its treatment.
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Physician/Physician
Extender Professional Services
|
Services include, but are not limited to, the following:
American Academy of Pediatrics recommended well-child exams and preventive health services (including, but not limited to, vision and hearing screening and immunizations)
Physician office visits, in-patient and out-patient services
Laboratory, x-rays, imaging and pathology services, including technical component and/or professional interpretation
Medications, biologicals and materials administered in Physician’s office
Allergy testing, serum and injections
Professional component (in/outpatient) of surgical services, including:
- Surgeons and assistant surgeons for surgical procedures including appropriate follow-up care
- Administration of anesthesia by Physician (other than surgeon) or CRNA
- Second surgical opinions
- Same-day surgery performed in a Hospital without an over-night stay
- Invasive diagnostic procedures such as endoscopic examinations
Hospital-based Physician services (including Physician-performed technical and interpretive components)
Physician and professional services for a mastectomy and breast reconstruction include:
- all stages of reconstruction on the affected breast;
- external breast prosthesis for the breast(s) on which medically necessary mastectomy procedure(s) have been performed
- surgery and reconstruction on the other breast to produce symmetrical appearance; and
- treatment of physical complications from the mastectomy and treatment of lymphedemas.
In-network and out-of-network Physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section.
Physician services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero). Inpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to:
- dilation and curettage (D&C) procedures;
- appropriate provider-administered medications;
- ultrasounds, and
- histological examination of tissue samples.
Physician services medically necessary to support a dentist providing dental services to a CHIP member such as general anesthesia or intravenous (IV) sedation.
Pre-surgical or post-surgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined plan to treat:
- cleft lip or palate;
- severe skeletal and/or congenital craniofacial deviations; or
- severe facial asymmetry secondary skeletal defects, congenital syndromal conditions and/or tumor growth or its treatment.
|
Durable Medical Equipment (DME), Prosthetic Devices and
Disposable Medical Supplies
|
$20,000 12-month period limit for DME, prosthetics, devices and disposable medical supplies (diabetic supplies and equipment are not counted against this ccap). Services include DME (equipment which can withstand repeated use and is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of Illness, Injury, or Disability, and is appropriate for use in the home), including devices and supplies that are medically necessary and necessary for one or more activities of daily living and appropriate to assist in the treatment of a medical condition, including:
Orthotic braces and orthotics
Dental devices
Prosthetic devices such as artificial eyes, limbs, braces, and external breast prostheses
Prosthetic eyeglasses and contact lenses for the management of severe ophthalmologic disease
Hearing aids
Diagnosis-specific disposable medical supplies, including diagnosis-specific prescribed specialty formula and dietary supplements. (See Attachment A)
|
Home and Community Health Services
|
Services that are provided in the home and community, including, but not limited to:
Home infusion
Respiratory therapy
Visits for private duty nursing (R.N., L.V.N.)
Skilled nursing visits as defined for home health purposes (may include R.N. or L.V.N.).
Home health aide when included as part of a plan of care during a period that skilled visits have been approved.
Speech, physical and occupational therapies.
Services are not intended to replace the CHILD'S caretaker or to provide relief for the caretaker
Skilled nursing visits are provided on intermittent level and not intended to provide 24-hour skilled nursing services
Services are not intended to replace 24-hour inpatient or skilled nursing facility services
|
Inpatient Mental Health Services |
Mental health services, including for serious mental illness, furnished in a free-standing psychiatric hospital, psychiatric units of general acute care hospitals and state-operated facilities, including, but not limited to:
Neuropsychological and psychological testing.
When inpatient psychiatric services are ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities, the court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with juridiction over the matter for determination.
Does not require PCP referral
|
Outpatient Mental Health Services |
Mental health services, including for serious mental illness, provided on an outpatient basis, including, but not limited to:
The visits can be furnished in a variety of community-based settings (including school and home-based) or in a state-operated facility
Neuropsychological and psychological testing
Medication management
Rehabilitative day treatments
Residential treatment services
Sub-acute outpatient services (partial hospitalization or rehabilitative day treatment)
Skills training (psycho-educational skill development)
When outpatient psychiatric services are ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities, the court order serves as binding detemination of medical necessity. Any modification or termination of services must be presented to the court with jursidiction over the matter for determination
A Qualified Mental Health Provider – Community Services (QMHP-CS), is defined by the Texas Department of State Health Services (DSHS) in Title 25 T.A.C., Part I, Chapter 412, Subchapter G, Division 1, §412.303(48). QMHP-CSs shall be providers working through a DSHS-contracted Local Mental Health Authority or a separate DSHS-contracted entity. QMHP-CSs shall be supervised by a licensed mental health professional or physician and provide services in accordance with DSHS standards. Those services include individual and group skills training (which can be components of interventions such as day treatment and in-home services), patient and family education, and crisis services
Does not require PCP referral
|
Inpatient Substance Abuse Treatment Services |
Services include, but are not limited to:
Inpatient and residential substance abuse treatment services including detoxification and crisis stabilization, and 24-hour residential rehabilitation programs
Does not require PCP referral
|
Outpatient Substance Abuse Treatment Services |
Outpatient substance abuse treatment services include, but are not limited to, the following:
Prevention and intervention services that are provided by physician and non-physician providers, such as screening, assessment and referral for chemical dependency disorders.
Intensive outpatient services
Partial hospitalization
Intensive outpatient services is defined as an organized non-residential service providing structured group and individual therapy, education services, and life skills training which consists of at least 10 hours per week for four to 12 weeks, but less than 24 hours per day
Outpatient treatement service is defined as consisting of at least one or two hours per week providing structured group and individual therapy, educational services, and life skills training
Does not require PCP referral
|
Rehabilitation Services |
Services include, but are not limited to, the following:
Habilitation (the process of supplying a child with the means to reach age-appropriate developmental milestones through therapy or treatment) and rehabilitation services include, but are not limited to the following:
Physical, occupational and speech therapy
Developmental assessment
|
Hospice Care Services |
Services include, but are not limited to, the following:
Palliative care, including medical and support services, for those children who have six months or less to live, to keep patients comfortable during the last weeks and months before death
Treatment services , including treatment related to the terminal illness
Up to a maximum of 120 days with a 6 month life expectancy
Patients electing hospice services may cancel this election at anytime
Services apply to the hospice diagnosis
|
Emergency Services, including Emergency Hospitals, Physicians, and Ambulance Services |
HMO cannot require authorization as a condition for payment for emergency conditions or labor and delivery.
Covered services include, but are not limited to, the following:
Emergency services based on prudent lay person definition of emergency health condition
Hospital emergency department room and ancillary services and physician services 24 hours a day, 7 days a week, both by in-network and out-of-network providers
Medical screening examination
Stabilization services
Access to DSHS designated Level 1 and Level II trauma centers or hospitals meeting equivalent levels of care for emergency services
Emergency ground, air and water transportation
Emergency dental services, limited to fractured or dislocated jaw, traumatic damage to teeth, and removal of cysts.
|
Transplants |
Services include, but are not limited to, the following:
Using up-to-date FDA guidelines, all non-experimental human organ and tissue transplants and all forms of non-experimental corneal, bone marrow and peripheral stem cell transplants, including donor medical expenses.
|
Vision Benefit |
The health plan may reasonably limit the cost of the frames/lenses.
Services include:
One examination of the eyes to determine the need for and prescription for corrective lenses per 12-month period, without authorization
One pair of non-prosthetic eyewear per 12-month period
|
Chiropractic Services |
Services do not require physician prescription and are limited to spinal subluxation
|
Tobacco Cessation
Program
|
Covered up to $100 for a 12- month period limit for a plan- approved program
Health Plan defines plan-approved program.
May be subject to formulary requirements.
|
[Value-added services]
|
See Attachment B-3
|
|
Inpatient and outpatient infertility treatments or reproductive services other than prenatal care, labor and delivery, and care related to disease, illnesses, or abnormalities related to the reproductive system
|
|
Personal comfort items including but not limited to personal care kits provided on inpatient admission, telephone, television, newborn infant photographs, meals for guests of patient, and other articles which are not required for the specific treatment of sickness or injury
|
|
Experimental and/or investigational medical, surgical or other health care procedures or services which are not generally employed or recognized within the medical community
|
|
Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court
|
|
Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility.
|
|
Mechanical organ replacement devices including, but not limited to artificial heart
|
|
Hospital services and supplies when confinement is solely for diagnostic testing purposes, unless otherwise pre-authorized by Health Plan
|
|
Prostate and mammography screening
|
|
Elective surgery to correct vision
|
|
Gastric procedures for weight loss
|
|
Cosmetic surgery/services solely for cosmetic purposes
Dental devices soley for cosmetic purposes
|
|
Out-of-network services not authorized by the Health Plan except for emergency care and physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section
|
|
Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity, except for the services associated with the treatment for morbid obesity as part of a treatment plan approved by the Health Plan
|
|
Acupuncture services, naturopathy and hypnotherapy
|
|
Immunizations solely for foreign travel
|
|
Routine foot care such as hygienic care
|
|
Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails)
|
|
Replacement or repair of prosthetic devices and durable medical equipment due to misuse, abuse or loss when confirmed by the Member or the vendor
|
|
Corrective orthopedic shoes
|
|
Convenience items
|
|
Orthotics primarily used for athletic or recreational purposes
|
|
Custodial care (care that assists a child with the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a parent. This care does not require the continuing attention of trained medical or paramedical personnel.) This exclusion does not apply to hospice services.
|
|
Housekeeping
|
|
Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities
|
|
Services or supplies received from a nurse, which do not require the skill and training of a nurse
|
|
Vision training and vision therapy
|
|
Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered except when ordered by a Physician/PCP
|
|
Donor non-medical expenses
|
|
Charges incurred as a donor of an organ when the recipient is not covered under this health plan
|
SUPPLIES
|
COVERED
|
EXCLUDED
|
COMMENTS/MEMBER
CONTRACT PROVISIONS
|
Ace Bandages
|
X
|
Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply.
|
|
Alcohol, rubbing
|
X
|
Over-the-counter supply.
|
|
Alcohol, swabs (diabetic)
|
X
|
Over-the-counter supply not covered, unless RX provided at time of dispensing.
|
|
Alcohol, swabs
|
X
|
Covered only when received with IV therapy or central line kits/supplies.
|
|
Ana Kit Epinephrine
|
X
|
A self-injection kit used by patients highly allergic to bee stings.
|
|
Arm Sling
|
X
|
Dispensed as part of office visit.
|
|
Attends (Diapers)
|
X
|
Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan
|
|
Bandages
|
X
|
||
Basal Thermometer
|
X
|
Over-the-counter supply.
|
|
Batteries – initial
|
X
|
.
|
For covered DME items
|
Batteries – replacement
|
X
|
For covered DME when replacement is necessary due to normal use.
|
|
Betadine
|
X
|
See IV therapy supplies.
|
|
Books
|
X
|
||
Clinitest
|
X
|
For monitoring of diabetes.
|
|
Colostomy Bags
|
See Ostomy Supplies.
|
||
Communication Devices
|
X
|
||
Contraceptive Jelly
|
X
|
Over-the-counter supply. Contraceptives are not covered under the plan.
|
|
Cranial Head Mold
|
X
|
||
Diabetic Supplies
|
X
|
Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips.
|
|
Dental Devices | X | Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention. | |
Diapers/Incontinent Briefs/Chux
|
X
|
Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan
|
|
Diaphragm
|
X
|
Contraceptives are not covered under the plan.
|
|
Diastix
|
X
|
For monitoring diabetes.
|
|
Diet, Special
|
X
|
||
Distilled Water
|
X
|
||
Dressing Supplies/Central Line
|
X
|
Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change.
|
|
Dressing Supplies/Decubitus
|
X
|
Eligible for coverage only if receiving covered home care for wound care.
|
|
Dressing Supplies/Peripheral IV Therapy
|
X
|
Eligible for coverage only if receiving home IV therapy.
|
|
Dressing Supplies/Other
|
X
|
||
Dust Mask
|
X
|
||
Ear Molds
|
X
|
Custom made, post inner or middle ear surgery
|
|
Electrodes
|
X
|
Eligible for coverage when used with a covered DME.
|
|
Enema Supplies
|
X
|
Over-the-counter supply.
|
|
Enteral Nutrition
Supplies
|
X
|
Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are
eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease
|
|
Eye Patches
|
X
|
Covered for patients with amblyopia.
|
|
Formula
|
X
|
Exception: Eligible for coverage only for chronic hereditary metabolic disorders a non-function or disease of the structures that normally permit food to reach the small bowel; or malabsorption due to disease (expected to last longer than 60 days when prescribed by the physician and authorized by plan.) Physician documentation to justify prescription of formula must include:
• Identification of a metabolic disorder, dysphagia that results in a medical need for a liquid diet, presence of a gastrostomy, or disease resulting in malabsorption that requires a medically necessary nutritional product
Does not include formula:
• For members who could be sustained on an age-appropriate diet.
• Traditionally used for infant feeding
• In pudding form (except for clients with documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product)
• For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met.
Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally.
|
|
Gloves
|
X
|
Exception: Central line dressings or wound care provided by home care agency.
|
|
Hydrogen Peroxide
|
X
|
Over-the-counter supply.
|
|
Hygiene Items
|
X
|
||
Incontinent Pads
|
X
|
Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan
|
|
Insulin Pump (External) Supplies
|
X
|
Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item.
|
|
Irrigation Sets, Wound Care
|
X
|
Eligible for coverage when used during covered home care for wound care.
|
|
Irrigation Sets, Urinary
|
X
|
Eligible for coverage for individual with an indwelling urinary catheter.
|
|
IV Therapy Supplies
|
X
|
Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy.
|
|
K-Y Jelly
|
X
|
Over-the-counter supply.
|
|
Lancet Device
|
X
|
Limited to one device only.
|
|
Lancets
|
X
|
Eligible for individuals with diabetes.
|
|
Med Ejector
|
X
|
||
Needles and
Syringes/Diabetic
|
See Diabetic Supplies
|
||
Needles and Syringes/IV and Central Line
|
See IV Therapy and Dressing Supplies/Central Line.
|
||
Needles and Syringes/Other
|
X
|
Eligible for coverage if a covered IM or SubQ medication is being administered at home.
|
|
Normal Saline
|
See Saline, Normal
|
||
Novopen
|
X
|
||
Ostomy Supplies
|
X
|
Items eligible for coverage include: belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, and pouch deodorant.
Items not eligible for coverage include: scissors, room deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and lotions.
|
|
Parenteral Nutrition/Supplies
|
X
|
Necessary supplies (e.g., tubing, filters, connectors, etc.) are eligible for coverage when the Health Plan has authorized the parenteral nutrition.
|
|
Saline, Normal
|
X
|
Eligible for coverage:
a) when used to dilute medications for nebulizer treatments;
b) as part of covered home care for wound care;
c) for indwelling urinary catheter irrigation.
|
|
Stump Sleeve
|
X
|
||
Stump Socks
|
X
|
||
Suction Catheters
|
X
|
||
Syringes
|
See Needles/Syringes.
|
||
Tape
|
See Dressing Supplies, Ostomy Supplies, IV Therapy Supplies.
|
||
Tracheostomy Supplies
|
X
|
Cannulas, Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for coverage.
|
|
Under Pads
|
See Diapers/Incontinent Briefs/Chux.
|
||
Unna Boot
|
X
|
Eligible for coverage when part of wound care in the home setting. Incidental charge when applied during office visit.
|
|
Urinary, External Catheter & Supplies
|
X
|
Exception: Covered when used by incontinent male where injury to the urethra prohibits use of an indwelling catheter ordered by the PCP and approved by the plan
|
|
Urinary, Indwelling Catheter & Supplies
|
X
|
Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal saline if needed.
|
|
Urinary, Intermittent
|
X
|
Cover supplies needed for intermittent or straight catherization.
|
|
Urine Test Kit
|
X
|
When determined to be medically necessary.
|
|
Urostomy supplies
|
See Ostomy Supplies.
|
DOCUMENT HISTORY LOG
|
||||
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
|
Baseline
|
n/a
|
Initial version of Attachment B-2, Covered Services.
|
||
Revision
|
1.1
|
June 30, 2006
|
Revised Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS Covered Services. This is the initial version of Attachment B-2.1, STAR+PLUS Covered Services, which lists the Acute Care Services and the Community Based Long Term Care Services.
|
|
Revision
|
1.2
|
September 1, 2006
|
Contract Amendment did not revise Attachment B-2.1- STAR+PLUS Covered Services.
|
|
Revision
|
1.3
|
September 1, 2006
|
Contract Amendment did not revise Attachment B-2.1- STAR+PLUS Covered Services.
|
|
Revision
|
1.4
|
September 1, 2006
|
Contract Amendment did not revise Attachment B-2.1- STAR+PLUS Covered Services.
|
|
Revision
|
1.5
|
January 1, 2007
|
Revised Attachment B-2.1, STAR+PLUS Covered Services, to include inpatient and outpatient mental health services for adults.
|
|
Revision
|
1.6
|
February 1, 2007
|
Revised Attachment B-2.1, STAR+PLUS Covered Services, to exclude inpatient mental health services for adults and children, and to establish monetary limits on Transition Assistance Services.
Personal Attendant Services is clarified to include the three service delivery options described in Attachment B-1, Section 8.3.5. Consumer Directed Personal Attendant Services is deleted from the list since it is one of the three service delivery options under Personal Attendant Services.
|
|
Revision
|
1.7
|
June 1, 2007
|
Revised Attachment B-2.1, STAR+PLUS Covered Services, to include inpatient mental health services for adults and children and to include effective dates by service area.
|
|
Revision
|
1.8
|
September 1, 2007
|
Contract Amendment did not revise Attachment B-2.1- STAR+PLUS Covered Services.
|
|
Revision
|
1.9
|
December 1, 2007
|
Contract Amendment did not revise Attachment B-2.1- STAR+PLUS Covered Services.
|
|
Revision | 1.10 | March 1, 2008 |
Contract Amendment did not revise Attachment B-2.1- STAR+PLUS Covered Services.
|
|
Revision | 1.11 | September 1, 2008 | Attachment B-2.1 - STAR+PLUS Covered Services is modified to include additional covered services resulting from the Frew Settlement. | |
Revision | 1.12 | March 1, 2009 | Attachment B-2.1- STAR+PLUS Covered Services is modified to exclude nursing home services. | |
Revision | 1.13 | September 1, 2009 |
All references to “check-ups” are changed to “checkups”
Annual adult well check is removed from the list of enhanced benefits and added to “Services included under the HMO capitation payment”.
“Services included under the HMO capitation payment” is modified to remove “birthing center services” and add “Birthing services provided by a certified nurse midwife in a birthing center”.
“1915(c) NF Waiver Services” is modified to add “In-Home or Out-of-Home Respite Services”, to clarify that all covered services are medically necessary, and to clarify that that Medical Supplies not available under the Medicaid State Plan are covered.
|
|
Revision | 1.14 | December 1, 2009 |
"Acute Care Services" is modified to clarify that the 30-day spell-of-illness limit is waived for inpatient behavioral health services.
Services included under the HMO capitation payment" is modified to remove references to PACT.
|
|
Revision | 1.15 | March 1, 2010 |
“Services included under the HMO capitation payment” is modified to add substance abuse services. This amendment will be effective the later of: September 1, 2010 or upon final approval of the Medicaid State Plan, 1915(b) STAR+PLUS waiver and/or the 1915(b) STAR waiver, as applicable to the HMO Program.
|
|
Revision | 1.16 | September 1, 2010 |
“Acute Care Services” is modified to add an enhanced benefit (waiver of 30 visit limit for outpatient mental health services).
“Services included under the HMO capitation payment” is modified to clarify the substance abuse services added by the last amendment; and to replace “certified nurse midwife” with “physician or Advanced Practice Nurse” and add the word “licensed” to Birthing Services. In addition, “mastectomy, breast reconstruction, and related follow-up procedures” and “Birthing services provided by a licensed birthing center” are added.
|
|
Revision | 1.17 | December 1, 2010 |
Contract Amendment did not revise Attachment B-2.1- STAR+PLUS Covered Services.
|
|
Revision | 1.18 | March 1, 2011 |
Services included under the HMO capitation payment is modified to remove the services effective prior to the effective dates of the State Plan and 1915(b) STAR Waiver.
Services included under the HMO capitation payment is modified to add "Cancer screening, diagnostic, and treatment services". These services are already 1905(a) covered services, therefore adding this reference does not impact the HMOs' rates.
|
|
Revision | 1.19 | September 1, 2011 | Attachment B-2.1 is modified to remove the waiver of the 30-day spell of illness for physical health in conformance with the 1915(b) waiver. In addition, effective September 1, 2011 and subject to CMS approval, the waiver of the three prescription limit for adults is removed. | |
Revision | 1.20 | January 1, 2012 |
|
|
1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
|
|
1. waiver of the three-prescription per month limit, for members not covered by Medicare; and
|
|
2. waiver of the 30-day spell-of-illness limit for inpatient behavioral health services.
|
|
• Ambulance services
|
|
• (These services are not subject to the quantitative treatment limitations that apply under traditional, fee-for-service Medicaid coverage. The services may be subject to the HMO's non-quantitative treatment limiations, provided such limitations comply with the requirments of the Mental Health Parity and Addiction Equity Act of 2008.) Behavioral Health Services, including:
|
|
o Inpatient mental health services for Adults and Children (Effective 6/01/07 in the Harris Service Area; and effective 9/01/07 in the Bexar, Nueces and Travis Service Areas.)
|
|
o Outpatient mental health services for Adults and Children
|
|
o Psychiatry services
|
|
o Counseling services for adults (21 years of age and over)
|
|
o Substance use disorder treatment services, including
|
|
o Outpatient services, including:
|
|
o Assessment
|
|
o Detoxification services
|
|
o Counseling treatment
|
|
o Medication assisted therapy
|
|
o Residential services, including
|
|
o Detoxification services
|
|
o Substance use disorder treatment (including room and board)
|
|
o Medication assisted therapy
|
|
• Birthing services provided by a physician or Advanced Practice Nurse in a licensed birthing center
|
|
• Birthing services provided by a licensed birthing center
|
|
• Cancer screening, diagnostic, and treatment services
|
|
• Chiropractic services
|
|
• Dialysis
|
|
• Durable medical equipment and supplies
|
|
• Emergency Services
|
|
• Family planning services
|
|
• Home health care services
|
|
• Hospital services, outpatient
|
|
• Laboratory
|
|
• Mastectomy, breast reconstruction, and related follow-up procedures, including:
|
|
o outpatient services provided at an outpatient hospital and ambulatory health care center as clinically appropriate; and physician and professional services provided in an office, inpatient, or outpatient setting for:
|
|
o all stages of reconstruction on the breast(s) on which medically necessary mastectomy procedure(s) have been performed;
|
|
o surgery and reconstruction on the other breast to produce symmetrical appearance;
|
|
o treatment of physical complications from the mastectomy and treatment of lymphedemas; and
|
|
o prophylactic mastectomy to prevent the development of breast cancer.
|
|
o external breast prosthesis for the breast(s) on which medically necessary mastectomy procedure(s) have been performed.
|
|
• Medical checkups and Comprehensive Care Program (CCP) Services for children (under age 21) through the Texas Health Steps Program
|
|
• Oral evaluation and fluoride varnish in the Medical Home in conjunction with Texas Health Steps medical checkup for children 6 months through 35 months of age.
|
|
• Optometry, glasses, and contact lenses, if medically necessary
|
|
• Podiatry
|
|
• Prenatal care
|
|
• Primary care services
|
|
• Preventive services including an annual adult well check for patients 21 years of age and over
|
|
• Radiology, imaging, and X-rays
|
|
• Specialty physician services
|
|
• Therapies – physical, occupational and speech
|
|
• Transplantation of organs and tissues
|
|
• Vision
|
|
o Personal Attendant Services – All Members of a STAR+PLUS HMO may receive medically and functionally necessary Personal Attendant Services (PAS).
|
|
o Day Activity and Health Services – All Members of a STAR+PLUS HMO may receive medically and functionally necessary Day Activity and Health Care Services (DAHS).
|
• 1915 (c) Nursing Facility Waiver Services for those Members who qualify for such services
|
|
o Personal Attendant Services (including the three service delivery options: Self-Directed; Agency Model, Self-Directed; and Agency Model)
o In-Home or Out-of-Home Respite Services
|
|
o Nursing Services (in home)
|
|
o Emergency Response Services (Emergency call button)
|
|
o Home Delivered Meals
|
|
o Minor Home Modifications
|
|
o Adaptive Aids and Medical Equipment
|
|
o Medical Supplies
|
|
o Physical Therapy, Occupational Therapy, Speech Therapy
|
|
o Adult Foster Care
|
|
o Assisted Living
|
o Transition Assistance Services (These services are limited to a maximum of $2,500.00. If the HMO determines that no other resources are available to pay for the basic services/items needed to assist a Member, who is leaving a nursing facility, with setting up a household, the HMO may authorize up to $2,500.00 for Transition Assistance Services (TAS). The $2,500.00 TAS benefit is part of the expense ceiling when determining the Total Annual Individual Service Plan (ISP) Cost.) |
DOCUMENT HISTORY LOG
|
|||
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial version of Attachment B-2, Covered Services
|
|
Revision
|
1.1
|
June 30, 2006
|
Revised Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS Covered Services.
|
Revision
|
1.2
|
September 1, 2006
|
Revised Attachment B-2, Covered Services, by updating provisions applicable to MCOs participating in the STAR and CHIP Programs.
|
Revision
|
1.3
|
September 1, 2006
|
Revised Attachment B-2, Covered Services, by adding Attachment B-2.2, CHIP Perinatal Covered Services. This is the initial version of Attachment B-2.2, which lists the CHIP Perinatal Covered Services, exclusions and DME/Supplies.
|
Revision
|
1.4
|
September 1, 2006
|
Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services.
|
Revision
|
1.5
|
January 1, 2007
|
Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services.
|
Revision
|
1.6
|
February 1, 2007
|
Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services.
|
Revision
|
1.7
|
July 1, 2007
|
Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services.
|
Revision
|
1.8
|
September 1, 2007
|
Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services.
|
Revision
|
1.9
|
December 1, 2007
|
Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services.
|
Revision | 1.10 | March 1, 2008 |
Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services.
|
Revision | 1.11 | September 1, 2008 |
Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services.
|
Revision | 1.12 | March 1, 2009 | Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. |
Revision | 1.13 | September 1, 2009 |
CHIP Perinatal Covered Services “Inpatient General Acute and Inpatient Rehabilitation Hospital Services” is modified to clarify the requirements regarding miscarriage and non-viable pregnancy.
CHIP Perinatal Covered Services “Outpatient Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center” is modified to clarify the requirements regarding miscarriage and non-viable pregnancy.
CHIP Perinatal Covered Services “Physician/Physician
Extender Professional Services” is modified to clarify the requirements regarding miscarriage and non-viable pregnancy.
CHIP Perinatal Covered Services “Emergency Services, including Emergency Hospitals, Physicians, and Ambulance Services” is modified to clarify the requirements regarding miscarriage and non-viable pregnancy.
“Outpatient Mental Health Services” is revised to provide additional clarity as it relates to Qualified Mental Health Providers – Community Services (QMHP-CS).
CHIP Perinatal Program Exclusions From Covered Services For CHIP Perinates is modified to clarify the requirements regarding miscarriage and non-viable pregnancy.
|
Revision | 1.14 | December 1, 2009 | Outpatient Mental Health Services is revised to update the TAC citation. |
Revision | 1.15 | March 1, 2010 | Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. |
Revision | 1.16 | September 1, 2010 |
Attachment B-2.2 is modified to clarify the 12-month enrollment period is for the CHIP Perinate Newborn beginning with the month of enrollment as a CHIP Perinate.
CHIP Perinatal Covered Services “Inpatient General Acute and Inpatient Rehabilitation Hospital Services” for Perinate Newborns is modified to remove the CHIP Perinate Newborn 0% to 185% category and to add outpatient services and orthodontic services to conform to CHIP Covered Services in Attachment B-2.
CHIP Perinatal Covered Services “Inpatient General Acute and Inpatient Rehabilitation Hospital Services” for Perinates is modified to remove the CHIP Perinate Newborn 0% to 185% category.
CHIP Perinatal Covered Services “Outpatient Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center” for Perinate Newborns is modified to add outpatient services and orthodontic services to conform to CHIP Covered Services in Attachment B-2.
CHIP Perinatal Covered Services “Physician/Physician Extender Professional Services” for Perinate Newborns is modified to add outpatient services and orthodontic services to conform to CHIP Covered Services in Attachment B-2.
CHIP Perinatal Covered Services “Durable Medical Equipment (DME), Prosthetic Devices and Disposable Medical Supplies” for Perinate Newborns is modified to add dental devices and external breast prostheses to conform to CHIP Covered Services in Attachment B-2.
The first bullet under “Exclusions from Covered Services for CHIP Perinates” is clarified.
The first bullet under “Exclusions from Covered Services for CHIP Perinate Newborns” is removed. “Dental Devices solely for cosmetic purposes” is added to conform to CHIP Covered Services in Attachment B-2.
“CHIP & CHIP Perinatal Program DME/Supplies” is modified to add “Dental Devices” to conform to CHIP Covered Services in Attachment B-2.
|
Revision | 1.17 | December 1, 2010 | CHIP Hospice Care Services is modified to require concurrent CHIP and hospice care services to comply with the federal requirements from Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148). By law, CHIP health plans were required to provide concurrent hospice care services effective August 1, 2010. |
Revision | 1.18 | March 1, 2010 |
Inpatient Mental Health Services for CHIP Perinate Newborns is modified to comply with the federal requirements of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), as applied to CHIP by the Children’s Health Insurance Program Reauthorization Act of 2009 (P.L. 111-3). Also modified to clarify the court-ordered service requirement.
Outpatient Mental Health Services for CHIP Perinate Newborns is modified to comply with the federal requirements of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) as applied to CHIP by the Children’s Health Insurance Program Reauthorization Act of 2009 (P.L. 111-3). Also modified to clarify the court-ordered service requirement.
Inpatient Substance Abuse Treatment Services for CHIP Perinate Newborns is modified to comply with the federal requirements of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) as applied to CHIP by the CHIP Reauthorization Act of 2009 (P.L. 111-3).
Outpatient Substance Abuse Treatment Services for CHIP Perinate Newborns is modified to comply with the federal requirements of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) as applied to CHIP by the CHIP Reauthorization Act of 2009 (P.L. 111-3).
CHIP Perinatal Program Exclusions from Covered Services for CHIP Perinates is modified to clarify that CHIP does not provide coverage for members traveling outside of the U.S. CHIP Perinatal Program Exclusions from Covered Services for CHIP Perinate Newborns is modified to clarify that CHIP does not provide coverage for members traveling outside of the U.S.
|
Revision | 1.19 | September 1, 2011 | Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. |
Revision | 1.20 | January 1, 2012 | Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. |
1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
|
Covered
Benefit
|
CHIP Perinate Newborn
|
CHIP Perinate
|
Inpatient General Acute and Inpatient Rehabilitation Hospital Services
|
Services include, but are not limited to, the following:
Hospital-provided Physician or Provider services
Semi-private room and board (or private if medically necessary as certified by attending)
General nursing care
Special duty nursing when medically necessary
ICU and services
Patient meals and special diets
Operating, recovery and other treatment rooms
Anesthesia and administration (facility technical component)
Surgical dressings, trays, casts, splints
Drugs, medications and biologicals
Blood or blood products that are not provided free-of-charge to the patient and their administration
X-rays, imaging and other radiological tests (facility technical component)
Laboratory and pathology services (facility technical component)
Machine diagnostic tests (EEGs, EKGs, etc.)
Oxygen services and inhalation therapy
Radiation and chemotherapy
Access to DSHS-designated Level III perinatal centers or Hospitals meeting equivalentlevels of care
In-network or out-of-network facility and Physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section.
Hospital, physician and related medical services, such as anesthesia, associated with dental care
Surgical implants
Other artificial aids including surgical implants
Inpatient services for a mastectomy and breast reconstruction include:
all stages of reconstruction on the affected breast;
surgery and reconstruction on the other breast to produce symmetrical appearance; and
treatment of physical complications from the mastectomy and treatment of lymphedemas.
Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12-month period limit.
Pre-surgical or post-surgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment plan to treat:
cleft lip and/or palate; or
severe traumatic skeletal and/or congenital craniofacial deviations; or
severe facial asymmetry secondary to skeletal defects, congenital syndromal conditions and/or tumor growth or its treatment.
|
For CHIP Perinates in families with incomes at or below 185% of the Federal Poverty Level, the facility charges are not a covered benefit; however, professional services charges associated with labor with delivery are a covered benefit.
For CHIP Perinates in families with incomes between 185% and 200% of the Federal Poverty Level, benefits are limited to professional service charges and facility charges associated with labor with delivery until birth, and services related tomiscarriage or a non-viable pregnancy.
Services include:
Operating, recovery and other treatment rooms
Anesthesia and administration (facility technical component
Medically necessary surgical services are limited to services that directly relate to the delivery of the unborn child, and services related to miscarriage or non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero).
Inpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero) are a covered benefit. Inpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to:
dilation and curettage (D&C) procedures;
appropriate provider-administered medications;
ultrasounds, and
histological examination of tissue samples
|
Skilled Nursing
Facilities
(Includes Rehabilitation
Hospitals)
|
Services include, but are not limited to, the following:
Semi-private room and board
Regular nursing services
Rehabilitation services
Medical supplies and use of appliances and equipment furnished by the facility
|
Not a covered benefit.
|
Outpatient Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center
|
Services include, but are not limited to, the following services provided in a hospital clinic or emergency room, a clinic or health center, hospital-based emergency department or an ambulatory health care setting:
X-ray, imaging, and radiological tests (technical component)
Laboratory and pathology services (technical component)
Machine diagnostic tests
Ambulatory surgical facility services
Drugs, medications and biologicals
Casts, splints, dressings
Preventive health services
Physical, occupational and speech therapy
Renal dialysis
Respiratory services
Radiation and chemotherapy
Blood or blood products that are not provided free-of-charge to the patient and the administration of these products
Facility and related medical services, such as anesthesia, associated with dental care, when provided in a licensed ambulatory surgical facility.
Surgical implants
Other artificial aids including surgical implants
Outpatient services provided at an outpatient hosptial or ambulatory health care center for a mastectomy and breast reconstruction as clinically appropriate, include:
- all stages of reconstruction on the affected breast;
- surgery and reconstruction on the other breast to produces symmetrical appearance; and
- treatment of physical complications from the mastectomy and treatment of lymphedemas.
Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12-month period limit.
Pre-surgical or post-surgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment plan to treat:
cleft lip and/or palate; or
severe traumatic skeletal and/or congenital craniofacial deviations; or
severe facial asymmetry secondary to skeletal defects, congenital syndromal conditions and/or tumor growth or its treatment.
|
Services include, the following services provided in a hospital clinic or emergency room, a clinic or health center, hospital-based emergency department or an ambulatory health care setting:
X-ray, imaging, and radiological tests (technical component)
Laboratory and pathology services (technical component)
Machine diagnostic tests
Drugs, medications and biologicals that are medically necessary prescription and injection drugs.
Outpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero) are a covered benefit. Inpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to:
dilation and curettage (D&C) procedures;
appropriate provider-administered medications;
ultrasounds, and
histological examination of tissue samples
(1) Laboratory and radiological services are limited to services that directly relate to ante partum care and/or the delivery of the covered CHIP Perinate until birth.
(2) Ultrasound of the pregnant uterus is a covered benefit when medically indicated. Ultrasound may be indicated for suspected genetic defects, high-risk pregnancy, fetal growth retardation, or gestational age confirmation or miscarriage or non-viable pregnancy.
(3) Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion (FIUT) and Ultrasonic Guidance for Cordocentesis, FIUT are covered benefits with an appropriate diagnosis.
(4) Laboratory tests are limited to: nonstress testing, contraction, stress testing, hemoglobin or hematocrit repeated once a trimester and at 32-36 weeks of pregnancy; or complete blood count (CBC), urinanalysis for protein and glucose every visit, blood type and RH antibody screen; repeat antibody screen for Rh negative women at 28 weeks followed by RHO immune globulin
administration if indicated; rubella antibody titer, serology for syphilis, hepatitis B surface antigen, cervical cytology, pregnancy test, gonorrhea test, urine culture, sickle cell test, tuberculosis (TB) test, human immunodeficiency virus (HIV) antibody screen, Chlamydia test, other laboratory tests not specified but deemed medically necessary, and multiple marker screens for neural tube defects (if the client initiates care between 16 and 20 weeks); screen for gestational diabetes at 24-28 weeks of pregnancy; other lab tests as indicated by medical condition of client.
|
Physician/
Physician
Extender Professional Services
|
Services include, but are not limited to, the following:
American Academy of Pediatrics recommended well-child exams and preventive health services (including, but not limited to, vision and hearing screening and immunizations)
Physician office visits, in-patient and out-patient services
Laboratory, x-rays, imaging and pathology services, including technical component and/or professional interpretation
Medications, biologicals and materials administered in Physician’s office
Allergy testing, serum and injections
Professional component (in/outpatient) of surgical services, including:
- Surgeons and assistant surgeons for surgical procedures including appropriate follow-up care
- Administration of anesthesia by Physician (other than surgeon) or CRNA
- Second surgical opinions
- Same-day surgery performed in a Hospital without an over-night stay
- Invasive diagnostic procedures such as endoscopic examinations
Hospital-based Physician services (including Physician-performed technical and interpretive components)
Physician and professional services for mastectomy and breast reconstruction include:
- all stages of reconstruction on the affected breast;
- surgery and reconstruction on the other breast to produces symmetrical appearance; and
- treatment of physical complications from the mastectomy and treatment of lymphedemas.
In-network and out-of-network Physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section.
Physician services medically necessary to support a dentist providing dental services to a CHIP member such as general anesthesia or intravenous (IV) sedation.
Pre-surgical or post-surgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment plan to treat:
cleft lip and/or palate; or
severe traumatic skeletal and/or congenital craniofacial deviations; or
severe facial asymmetry secondary to skeletal defects, congenital syndromal conditions and/or tumor growth or its treatment.
|
Services include, but are not limited to the following:
Medically necessary physician services are limited to prenatal and postpartum care and/or the delivery of the covered unborn child until birth
Physician office visits, in-patient and out-patient services
Laboratory, x-rays, imaging and pathology services including technical component and /or professional interpretation
Medically necessary medications, biologicals and materials administered in Physician’s office
Professional component (in/outpatient) of surgical services, including:
o Surgeons and assistant surgeons for surgical procedures directly related to the labor with delivery of the covered unborn child until birth.
o Administration of anesthesia by Physician (other than surgeon) or CRNA
o Invasive diagnostic procedures directly related to the labor with delivery of the unborn child.
Hospital-based Physician services (including Physician performed technical and interpretive components)
Professional component of the ultrasound of the pregnant uterus when medically indicated for suspected genetic defects, high-risk pregnancy, fetal growth retardation, or gestational age confirmation.
Professional component of Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion (FIUT) and Ultrasonic Guidance for Amniocentesis, Cordocentrsis, and FIUT.
Professional component associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero) are a covered benefit. Inpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to:
dilation and curettage (D&C) procedures;
appropriate provider-administered medications;
ultrasounds, and
histological examination of tissue samples
|
Prenatal Care and Pre-Pregnancy Family Services and Supplies
|
Not a covered benefit.
|
Services are limited to an initial visit and subsequent prenatal (ante partum) care visits that include:
(1) One visit every four weeks for the first 28 weeks or pregnancy;
(2) one visit every two to three weeks from 28 to 36 weeks of pregnancy; and
(3) one visit per week from 36 weeks to delivery.
More frequent visits are allowed as Medically Necessary. Benefits are limited to:
Limit of 20 prenatal visits and 2 postpartum visits (maximum within 60 days) without documentation of a complication of pregnancy. More frequent visits may be necessary for high-risk pregnancies. High-risk prenatal visits are not limited to 20 visits per pregnancy. Documentation supporting medical necessity must be maintained in the physician’s files and is subject to retrospective review.
Visits after the initial visit must include:
interim history (problems, marital status, fetal status);
physical examination (weight, blood pressure, fundalheight, fetal position and size, fetal heart rate, extremities) and
laboratory tests (urinanalysis for protein and glucose every visit; hematocrit or hemoglobin repeated once a trimester and at 32-36 weeks of pregnancy; multiple marker screen for fetal abnormalities offered at 16-20 weeks of pregnancy; repeat antibody screen for Rh negative women at 28 weeks followed by Rho immune globulin administration if indicated; screen for gestational diabetes at 24-28 weeks of pregnancy; and other lab tests as indicated by medical condition of client).
|
Durable Medical Equipment (DME), Prosthetic Devices and
Disposable Medical Supplies
|
$20,000 12-month period limit for DME, prosthetics, devices and disposable medical supplies (diabetic supplies and equipment are not counted against this cap). Services include DME (equipment which can withstand repeated use and is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of Illness, Injury, or Disability, and is appropriate for use in the home), including devices and supplies that are medically necessary and necessary for one or more activities of daily living and appropriate to assist in the treatment of a medical condition, including:
Orthotic braces and orthotics
Dental devices
Prosthetic devices such as artificial eyes, limbs, braces and external breast prostheses
Prosthetic eyeglasses and contact lenses for the management of severe ophthalmologic disease
Hearing aids
Diagnosis-specific disposable medical supplies, including diagnosis-specific prescribed specialty formula and dietary supplements. (See Attachment A)
|
Not a covered benefit.
|
Home and Community Health Services
|
Services that are provided in the home and community, including, but not limited to:
Home infusion
Respiratory therapy
Visits for private duty nursing (R.N., L.V.N.)
Skilled nursing visits as defined for home health purposes (may include R.N. or L.V.N.).
Home health aide when included as part of a plan of care during a period that skilled visits have been approved.
Speech, physical and occupational therapies.
Services are not intended to replace the CHILD'S caretaker or to provide relief for the caretaker
Skilled nursing visits are provided on intermittent level and not intended to provide 24-hour skilled nursing services
Services are not intended to replace 24-hour inpatient or skilled nursing facility services
|
Not a covered benefit.
|
Inpatient Mental Health Services
|
Mental health services, including for serious mental illness, furnished in a free-standing psychiatric hospital, psychiatric units of general acute care hospitals and state-operated facilities, including, but not limited to:
Neuropsychological and psychological testing.
When inpatient psychiatric services are ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities, the court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination
Does not require PCP referral |
Not a covered benefit.
|
Outpatient Mental Health Services
|
Mental health services, including for serious mental illness, provided on an outpatient basis, including, but not limited to:
Medication management visits do not count against the outpatient visit limit.
The visits can be furnished in a variety of community-based settings (including school and home-based) or in a state-operated facility
Neuropsychological and psychological testing
Medication management
Rehabilitative day treatments
Residential treatment services
Sub-acute outpatient services (partial hospitalization or rehabilitative day treatment)
Skills training (psycho-educational skill development)
When outpatient psychiatric services are ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities, the court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination
A Qualified Mental Health Provider – Community Services (QMHP-CS), is defined by the Texas Department of State Health Services (DSHS) in Title 25 T.A.C., Part I, Chapter 412, Subchapter G, Division 1, §412.303(48). QMHP-CSs shall be providers working through a DSHS-contracted Local Mental Health Authority or a separate DSHS-contracted entity. QMHP-CSs shall be supervised by a licensed mental health professional or physician and provide services in accordance with DSHS standards. Those services include individual and group skills training (which can be components of interventions such as day treatment and in-home services), patient and does not require PCP referral |
Not a covered benefit.
|
||
Inpatient Substance Abuse Treatment Services
|
Services include, but are not limited to:
Inpatient and residential substance abuse treatment services including detoxification and crisis stabilization, and 24-hour residential rehabilitation programs
Does not require PCP referral
|
Not a covered benefit.
|
Outpatient Substance Abuse Treatment Services
|
Services include, but are not limited to, the following:
Prevention and intervention services that are provided by physician and non-physician providers, such as screening, assessment and referral for chemical dependency disorders.
Intensive outpatient services
Partial hospitalization
Intensive outpatient services is defined as an organized non-residential service providing structured group and individual therapy, educational services, and life skills training which consists of at least 10 hours per week for four to 12 weeks, but less than 24 hours per day
Outpatient treatment service is defined as consisting of at least one to two hours per week providing structured group and individual therapy, educational services, and life skills training
Does not require PCP referral
|
Not a covered benefit.
|
Rehabilitation Services
|
Services include, but are not limited to, the following:
Habilitation (the process of supplying a child with the means to reach age-appropriate developmental milestones through therapy or treatment) and rehabilitation services include, but are not limited to the following:
Physical, occupational and speech therapy
Developmental assessment
|
Not a covered benefit.
|
Hospice Care Services
|
Services include, but are not limited to:
Palliative care, including medical and support services, for those children who have six months or less to live, to keep patients comfortable during the last weeks and months before death
Treatment services, including treatment related to the terminal illness
Up to a maximum of 120 days with a 6 month life expectancy
Patients electing hospice services may cancel this election at anytime
Services apply to the hospice diagnosis
|
Not a covered benefit.
|
Emergency Services, including Emergency Hospitals, Physicians, and Ambulance Services
|
HMO cannot require authorization as a condition for payment for emergency conditions labor and
delivery.
Covered services include, but are not limited to, the following:
Emergency services based on prudent lay person definition of emergency health condition
Hospital emergency department room and ancillary services and physician services 24 hours a day, 7 days a week, both by in-network and out-of-network providers
Medical screening examination
Stabilization services
Access to DSHS designated Level 1 and Level II trauma centers or hospitals meeting equivalent levels of care for emergency services
Emergency ground, air and water transportation
Emergency dental services, limited to fractured or dislocated jaw, traumatic damage to teeth, and removal of cysts.
|
HMO cannot require authorization as a condition for payment for emergency conditions related to labor with delivery.
Covered services are limited to those emergency services that are directly related to the delivery of the unborn child until birth.
Emergency services based on prudent lay person definition of emergency health condition
Medical screening examination to determine emergency when directly related to the delivery of the covered unborn child.
Stabilization services related to the labor with delivery of the covered unborn child.
Emergency ground, air and water transportation for labor and threatened labor is a covered benefit
Benefit limits: Post-delivery services or complications resulting in the need for emergency services for the mother of the CHIP Perinate are not a covered benefit.
|
Transplants
|
Services include, but are not limited to, the following:
Using up-to-date FDA guidelines, all non-experimental human organ and tissue transplants and all forms of non-experimental corneal, bone marrow and peripheral stem cell transplants, including donor medical expenses.
|
Not a covered benefit.
|
Vision Benefit
|
The health plan may reasonably limit the cost of the frames/lenses.
Services include:
One examination of the eyes to determine the need for and prescription for corrective lenses per 12-month period, without authorization
One pair of non-prosthetic eyewear per 12-month period
|
Not a covered benefit.
|
Chiropractic Services
|
Services do not require physician prescription and are limited to spinal subluxation.
|
Not a covered benefit.
|
Tobacco Cessation
Program
|
Covered up to $100 for a 12- month period limit for a plan- approved program
Health Plan defines plan-approved program.
May be subject to formulary requirements.
|
Not a covered benefit.
|
Case Management and Care Coordination Services
|
These services include outreach informing, case management, care coordination and community referral.
|
Covered benefit.
|
Value-added services
|
See Attachment B-3.2
|
|
For CHIP Perinates in families with incomes at or below 185% of the Federal Poverty Level, inpatient facility charges are not a covered benefit if associated with the initial Perinatal Newborn admission. "Initial Perinatal Newborn admission" means the hospitalization associated with the birth.
|
|
Inpatient and outpatient treatments other than prenatal care, labor with delivery, and postpartum care related to (a) miscarriage and (b) a non-viable pregnancy, and postpartum care related to the covered unborn child until birth.
|
|
Inpatient mental health services.
|
|
Outpatient mental health services.
|
|
Durable medical equipment or other medically related remedial devices.
|
|
Disposable medical supplies.
|
|
Home and community-based health care services.
|
|
Nursing care services.
|
|
Dental services.
|
|
Inpatient substance abuse treatment services and residential substance abuse treatment services.
|
|
Outpatient substance abuse treatment services.
|
|
Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders.
|
|
Hospice care.
|
|
Skilled nursing facility and rehabilitation hospital services.
|
|
Emergency services other than those directly related to the labor with delivery of the covered unborn child.
|
|
Transplant services.
|
|
Tobacco Cessation Programs.
|
|
Chiropractic Services.
|
|
Medical transportation not directly related to the labor or threatened labor and/or delivery of the covered unborn child.
|
|
Personal comfort items including but not limited to personal care kits provided on inpatient admission, telephone, television, newborn infant photographs, meals for guests of patient, and other articles which are not required for the specific treatment related to labor with delivery or post partum care.
|
|
Experimental and/or investigational medical, surgical or other health care procedures or services which are not generally employed or recognized within the medical community
|
|
Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court
|
|
Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility.
|
|
Coverage while traveling outside of the United States and U.S. Terriotries (including Puerto Rico, U.S. Virgin Islands, Commonwealth of Northern Mariana Islands, Guam, and American Samoa).
|
|
Mechanical organ replacement devices including, but not limited to artificial heart
|
|
Hospital services and supplies when confinement is solely for diagnostic testing purposes and not a part of labor with delivery
|
|
Prostate and mammography screening
|
|
Elective surgery to correct vision
|
|
Gastric procedures for weight loss
|
|
Cosmetic surgery/services solely for cosmetic purposes
|
|
Out-of-network services not authorized by the Health Plan except for emergency care related to the labor with delivery of the covered unborn child.
|
|
Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity
|
|
Acupuncture services, naturopathy and hypnotherapy
|
|
Immunizations solely for foreign travel
|
|
Routine foot care such as hygienic care
|
|
Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails)
|
|
Corrective orthopedic shoes
|
|
Convenience items
|
|
Orthotics primarily used for athletic or recreational purposes
|
|
Custodial care (care that assists with the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a caregiver. This care does not require the continuing attention of trained medical or paramedical personnel.)
|
|
Housekeeping
|
|
Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities
|
|
Services or supplies received from a nurse, which do not require the skill and training of a nurse
|
|
Vision training, vision therapy, or vision services
|
|
Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered
|
|
Donor non-medical expenses
|
|
Charges incurred as a donor of an organ
|
|
Inpatient and outpatient infertility treatments or reproductive services other than prenatal care, labor and delivery, and care related to disease, illnesses, or abnormalities related to the reproductive system
|
|
Personal comfort items including but not limited to personal care kits provided on inpatient admission, telephone, television, newborn infant photographs, meals for guests of patient, and other articles which are not required for the specific treatment of sickness or injury
|
|
Experimental and/or investigational medical, surgical or other health care procedures or services which are not generally employed or recognized within the medical community
|
|
Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court
|
|
Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility.
|
|
Coverage while traveling outside of the United States and U.S. Terriotries (including Puerto Rico, U.S. Virgin Islands, Commonwealth of Northern Mariana Islands, Guam, and American Samoa).
|
|
Mechanical organ replacement devices including, but not limited to artificial heart
|
|
Hospital services and supplies when confinement is solely for diagnostic testing purposes, unless otherwise pre-authorized by Health Plan
|
|
Prostate and mammography screening
|
|
Elective surgery to correct vision
|
|
Gastric procedures for weight loss
|
|
Cosmetic surgery/services solely for cosmetic purposes
|
|
Dental Devices solely for cosmetic purposes
Out-of-network services not authorized by the Health Plan except for emergency care and physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section
|
|
Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity, except for the services associated with the treatment for morbid obesity as part of a treatment plan approved by the Health Plan
|
|
Acupuncture services, naturopathy and hypnotherapy
|
|
Immunizations solely for foreign travel
|
|
Routine foot care such as hygienic care
|
|
Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails)
|
|
Replacement or repair of prosthetic devices and durable medical equipment due to misuse, abuse or loss when confirmed by the Member or the vendor
|
|
Corrective orthopedic shoes
|
|
Convenience items
|
|
Orthotics primarily used for athletic or recreational purposes
|
|
Custodial care (care that assists a child with the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a parent. This care does not require the continuing attention of trained medical or paramedical personnel.) This exclusion does not apply to hospice services.
|
|
Housekeeping
|
|
Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities
|
|
Services or supplies received from a nurse, which do not require the skill and training of a nurse
|
|
Vision training and vision therapy
|
|
Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered except when ordered by a Physician/PCP
|
|
Donor non-medical expenses
|
|
Charges incurred as a donor of an organ when the recipient is not covered under this health plan
|
SUPPLIES
|
COVERED
|
EXCLUDED
|
COMMENTS/MEMBER
CONTRACT PROVISIONS
|
Ace Bandages
|
X
|
Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply.
|
|
Alcohol, rubbing
|
X
|
Over-the-counter supply.
|
|
Alcohol, swabs (diabetic)
|
X
|
Over-the-counter supply not covered, unless RX provided at time of dispensing.
|
|
Alcohol, swabs
|
X
|
Covered only when received with IV therapy or central line kits/supplies.
|
|
Ana Kit Epinephrine
|
X
|
A self-injection kit used by patients highly allergic to bee stings.
|
|
Arm Sling
|
X
|
Dispensed as part of office visit.
|
|
Attends (Diapers)
|
X
|
Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan.
|
|
Bandages
|
X
|
||
Basal Thermometer
|
X
|
Over-the-counter supply.
|
|
Batteries – initial
|
X
|
.
|
For covered DME items
|
Batteries – replacement
|
X
|
For covered DME when replacement is necessary due to normal use.
|
|
Betadine
|
X
|
See IV therapy supplies.
|
|
Books
|
X
|
||
Clinitest
|
X
|
For monitoring of diabetes.
|
|
Colostomy Bags
|
See Ostomy Supplies.
|
||
Communication Devices
|
X
|
||
Contraceptive Jelly
|
X
|
Over-the-counter supply. Contraceptives are not covered under the plan.
|
|
Cranial Head Mold
|
X
|
||
Dental Devices | X | Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention. | |
Diabetic Supplies
|
X
|
Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips.
|
|
Diapers/Incontinent Briefs/Chux
|
X
|
Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan
|
|
Diaphragm
|
X
|
Contraceptives are not covered under the plan.
|
|
Diastix
|
X
|
For monitoring diabetes.
|
|
Diet, Special
|
X
|
||
Distilled Water
|
X
|
||
Dressing Supplies/Central Line
|
X
|
Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change.
|
|
Dressing Supplies/Decubitus
|
X
|
Eligible for coverage only if receiving covered home care for wound care.
|
|
Dressing Supplies/Peripheral IV Therapy
|
X
|
Eligible for coverage only if receiving home IV therapy.
|
|
Dressing Supplies/Other
|
X
|
||
Dust Mask
|
X
|
||
Ear Molds
|
X
|
Custom made, post inner or middle ear surgery
|
|
Electrodes
|
X
|
Eligible for coverage when used with a covered DME.
|
|
Enema Supplies
|
X
|
Over-the-counter supply.
|
|
Enteral Nutrition Supplies
|
X
|
Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease
|
|
Eye Patches
|
X
|
Covered for patients with amblyopia.
|
|
Formula
|
X
|
Exception: Eligible for coverage only for chronic hereditary metabolic disorders a non-function or disease of the structures that normally permit food to reach the small bowel; or malabsorption due to disease (expected to last longer than 60 days when prescribed by the physician and authorized by plan.) Physician documentation to justify prescription of formula must include:
• Identification of a metabolic disorder, dysphagia that results in a medical need for a liquid diet, presence of a gastrostomy, or disease resulting in malabsorption that requires a medically necessary nutritional product
Does not include formula:
• For members who could be sustained on an age-appropriate diet.
• Traditionally used for infant feeding
• In pudding form (except for clients with documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product)
• For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met.
Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally.
|
|
Gloves
|
X
|
Exception: Central line dressings or wound care provided by home care agency.
|
|
Hydrogen Peroxide
|
X
|
Over-the-counter supply.
|
|
Hygiene Items
|
X
|
||
Incontinent Pads
|
X
|
Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan
|
|
Insulin Pump (External) Supplies
|
X
|
Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item.
|
|
Irrigation Sets, Wound Care
|
X
|
Eligible for coverage when used during covered home care for wound care.
|
|
Irrigation Sets, Urinary
|
X
|
Eligible for coverage for individual with an indwelling urinary catheter.
|
|
IV Therapy Supplies
|
X
|
Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy.
|
|
K-Y Jelly
|
X
|
Over-the-counter supply.
|
|
Lancet Device
|
X
|
Limited to one device only.
|
|
Lancets
|
X
|
Eligible for individuals with diabetes.
|
|
Med Ejector
|
X
|
||
Needles and Syringes/Diabetic
|
See Diabetic Supplies
|
||
Needles and Syringes/IV and Central Line
|
See IV Therapy and Dressing Supplies/Central Line.
|
||
Needles and Syringes/Other
|
X
|
Eligible for coverage if a covered IM or SubQ medication is being administered at home.
|
|
Normal Saline
|
See Saline, Normal
|
||
Novopen
|
X
|
||
Ostomy Supplies
|
X
|
Items eligible for coverage include: belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, and pouch deodorant.
Items not eligible for coverage include: scissors, room deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and lotions.
|
|
Parenteral Nutrition/Supplies
|
X
|
Necessary supplies (e.g., tubing, filters, connectors, etc.) are eligible for coverage when the Health Plan has authorized the parenteral nutrition.
|
|
Saline, Normal
|
X
|
Eligible for coverage:
a) when used to dilute medications for nebulizer treatments;
b) as part of covered home care for wound care;
c) for indwelling urinary catheter irrigation.
|
|
Stump Sleeve
|
X
|
||
Stump Socks
|
X
|
||
Suction Catheters
|
X
|
||
Syringes
|
See Needles/Syringes.
|
||
Tape
|
See Dressing Supplies, Ostomy Supplies, IV Therapy Supplies.
|
||
Tracheostomy Supplies
|
X
|
Cannulas, Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for coverage.
|
|
Under Pads
|
See Diapers/Incontinent Briefs/Chux.
|
||
Unna Boot
|
X
|
Eligible for coverage when part of wound care in the home setting. Incidental charge when applied during office visit.
|
|
Urinary, External Catheter & Supplies
|
X
|
Exception: Covered when used by incontinent male where injury to the urethra prohibits use of an indwelling catheter ordered by the PCP and approved by the plan
|
|
Urinary, Indwelling Catheter & Supplies
|
X
|
Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal saline if needed.
|
|
Urinary, Intermittent
|
X
|
Cover supplies needed for intermittent or straight catherization.
|
|
Urine Test Kit
|
X
|
When determined to be medically necessary.
|
|
Urostomy supplies
|
See Ostomy Supplies.
|
DOCUMENT HISTORY LOG
|
|||
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial version of Attachment B-3, Value-added Services.
|
|
Revision
|
1.1
|
June 30, 2006
|
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision
|
1.2
|
September 1, 2006
|
Revised the Physical Health Value-added Services to include Home Visits to New Mothers. Revised the certification provision by changing the start date for the 12-month provision of services.
|
Revision
|
1.3
|
September 1, 2006
|
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision
|
1.4
|
September 1, 2006
|
Contract amendment removed the separate signature requirement for Attachment B-3, Value-added Services. By signing the Contract and/or Contract Amendment, the HMO certifies that it will provide the Value-added Services from September 1, 2006 through August 31, 2007.
|
Revision
|
1.5
|
January 1, 2007
|
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision
|
1.6
|
February 1, 2007
|
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision
|
1.7
|
July 1, 2007
|
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision
|
1.8
|
September 1, 2007
|
Revised Attachment B-3, Value-added Services, to reflect newly negotiated Value-added Services for FY 2008.
|
Revision
|
1.9
|
December 1, 2007
|
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision | 1.10 | March 1, 2008 |
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision | 1.11 | September 1, 2008 | Revised Attachment B-3, Value-added Services, to reflect newly negotiated Value-added Services for FY 2009. |
Revision | 1.12 | March 1, 2009 |
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision | 1.13 | September 1, 2009 | Revised Attachment B-3, Value-added Services, to reflect newly negotiated Value-added Services for FY 2010. |
Revision | 1.14 | December 1, 2009 |
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision | 1.15 | March 1, 2010 |
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision | 1.16 | September 1, 2010 | Revised Attachement B-3, Value-added Services, to reflect newly negotiated Value-added Services for FY 2011. |
Revision | 1.17 | December 1, 2010 |
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision | 1.18 | March 1, 2011 | Revised Attachement B-3, Value-added Services, to reflect mid-year negotiated Value-added Services for FY 2011. |
Revision | 1.19 | September 1, 2011 | Revised Attachment B-3, Value-added Services, to add the Bexar, El Paso, Lubbock, Nueces, and Travis contiguous counties as a result of the Contiguous Counties Expansion and to reflect negotiated Value-added Services for FY 2012. |
Revision | 1.20 | January 1, 2012 |
|
1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
|
Physical Health Value-added Services
|
||||||||
Value-added Service
|
Description of Value-added Services and Members Eligible to Receive the Services
|
Limitations or Restrictions
|
Provider(s) responsible for providing this service
|
|||||
NurseWise | Twenty-four hour nurse advice line | Available to all members by calling the Member Services toll-free number | NurseWIse, an affiliate of Centene Corporation | |||||
Transportation |
HMO will offer alternative transportation to HMO members that have trouble accessing the State's Medical Transportation Program in a timely manner to ensure access to their provider appointments. In addition, HMO will provide transportation to non-medical services such as health education programs, nutrition classes, and birth preparation classes. HMO's member service staff will approve and coordinate the transportation service and the type of transportation provided.
|
Members in the Nueces Service Area. The Transportation Authority in this area will not agree to allow the plan to purchase bus vouchers or tokens.
The bus tokens or other alternative transportation must be requested in advance of a provider visit and authorized by Superior’s Member Services Department.
|
Transit Authorities in applicable Service Area. | |||||
Dental Benefit |
Basic dental benefits for pregnant Members age 21 and over. The following services, categorized by procedural code, are covered:
Preventive
D0120 Periodic oral evaluation
D0140 Limited oral evaluation
D0150 Comprehensive oral evaluation (initial)
D0170 Re-evaluation limited, problem focused
Radiographs
D0220 Intraoral periapical first film
D0230 Intraoral periapical each add'l film
D0270 Bitewing single film
D0272 Bitewings two film
D0274 Bitewings four film
D0330 Panoramic
Cleanings
D1110 Prophy-adult
D1204 Topical application of fluoride (prophy not included) adult
D1206 Fluoride varnish
|
Each Member is eligible to receive $250 in dental services per benefit year, from dentists who are contracted with Delta Dental Insurance Company. The Member must be pregnant at the time of receiving any dental service to be covered under this benefit.
|
Licensed dentists under contract with Delta Dental Insurance Company
|
|||||
Vision
|
Members can choose between an enhanced selection of prescription eyeglasses OR $100 towards the cost of any features or frames not covered under Medicaid. Members will be offered a selection of 50 standard-size frames at no cost to Member. Member will be able to choose from three frame styles, each in a choice of three colors.
|
If Member opts for the $100 allowance, Members are responsible for any charges that exceed the $100 allowance. Disposable contact lenses are excluded from this $100 allowance. This Value-Added benefit is only allowed one time per benefit period (i.e. 24-months).
OR
The enhanced choice of new prescription eyeglasses is available once per 24-month period. Coverage is for new frames and lenses and does not cover additional features such as tints and coating.
Providers must prescribe new glasses in compliance with the following specifications:
Frames
• American-made, unless foreign-made frames are comparable in quality and are less expensive
• Serviceable and able to meet statutory quality standards
• Composed of new materials
Lenses
• Plastic or clear glass (if applicable)
• Heat or chemically treated dress eyewear able to meet standards of the American Standard Prescription Requirements for first-quality glass lenses
• Composed of new materials
• A minimum kryptoc of 22 mm flat top lens or equivalent if bifocal
• A minimum flat top 7/25 lens or equivalent if trifocal
|
Total Vision Health Plan’s provider network which includes Optometrists and Opticians
|
|||||
Sports Physicals | One annual physical exam that is required for participation in sporting events for enrolled Members. Member must be currently enrolled and attending school, and the exam must be provided by a Superior contracted provider. | One exam in each 12 month enrollment period | Superior contracted providers | |||||
Pre-programmed Cell Phones for High-Risk Pregnant Women
|
Superior will provide pre-programmed cell phones to pregnant women who have been identified as high-risk through its OB case management program. The cell phones may be used to contact the Member’s OB, Superior, NurseWise and any other key representative of Member’s choice at any time the Member has a concern she wishes to discuss over the telephone, including the appropriateness of seeking medical care in person.
|
Only one cell phone will be provided per high-risk pregnant Member (although lost phones will be replaced). The phone must be returned to Superior within 4 weeks of the Member’s delivery of the baby.
|
Superior HealthPlan Case Management staff
|
|||||
Prenatal health and birthing classes
|
Classes will be provided by SHP staff or facilitated by SHP and offered in SHP offices and other locations convenient to Members throughout the Service Areas. The classes are led by a registered nurse with the assistance of a CONNECTIONS/Promotoras representative. They cover the basics of prenatal care, including nutrition; the risk of smoking and benefits of smoking cessation; the progress of a fetus through the pregnancy; the importance of regular follow-up with medical providers; common health issues that occur during pregnancy; and, a review of SHP StartSmart and CONNECTIONS programs (e.g., availability of pre-programmed cell phones for high-risk pregnant women without good telecommunication support).
|
None
|
Superior’s CONNECTIONS staff
|
|||||
Home visits to New Mothers
|
Superior Social Work and/or CONNECTIONS staff will make home visits to any Member with a new baby. This visit provides for resource and education coordination as identified in the visit, and ensures Members and the new babies are keeping all post natal and newborn doctor visits. This benefit is available to all Superior Members who have delivered a baby.
|
Only that a member consent to the home visit.
|
Superior’s CONNECTIONS and Social Work staff provide this service.
|
|||||
Gift Program for Pregnant Women | Infant Car Safety seat for members who attend at least one baby shower. Baby Showers will be held no less than monthly, in each of the El Paso and Nueces SDAs. Members will be allowed one care seat per pregnancy and must show their Superior ID card at the shower to qualify. Member must be pregnant and currently enrolled with Superior to be eligible for the infant car seat. | STAR Pregnant women in Nueces and El Paso SDA ONLY | MCA |
Behavioral Health Value-added Services for Members Under 21
|
|||||||
Value-added Service
|
Description of Value-added Services and Members Eligible to Receive the Services
|
Limitations or Restrictions
|
Provider(s) responsible for providing this service
|
||||
Behavioral Health
|
Diversionary Services: These are services
intended to provide support to Members at high risk for hospitalization or acute care readmissision by helping them remain in the community setting, where they will be eligible to receive wraparound care, acute residential treatment, crisis stabilization services or other services that would help avoid unnecessary hospitalization.
|
These services must be authorized by Superior’s Behavioral Health Subcontractor on a case-by-case basis.
|
It is anticipated that these services will be rendered by providers under contract with Superior’s Behavioral Health Subcontractor.
|
||||
Behavioral Health
|
Superior’s Behavioral Health Subcontractor will authorize Behavioral Health practitioners in medical settings to provide health psychology interventions focused on the effective management of chronic medical conditions. These might include psycho-educational groups for chronic conditions, individual coaching for patients with chronic disease states, or skills training activities.
|
These services must be authorized by Superior’s Behavioral Health Subcontractor. The authorization will be tied to medical necessity.
|
It is anticipated that these services will be rendered by Superior’s behavioral health practitioners located in Superior’s contracted Federally Qualified Health Centers.
|
||||
Behavioral Health
|
Intensive Outpatient Treatment/Day Treatment (IOP)- Used as an alternative to or step down from more restrictive levels of care. | These services must be authorized by Superior’s Behavioral Health Material Subcontractor. In addition, the service will be authorized for greater than one and one half hours, but less than five hours per day. Amount, duration, and scope are based on medical necessity. |
It is anticipated that Superior’s contracted Behavioral Health Providers in each Service Area will render this service.
|
||||
Behavioral Health
|
Partial Hospitalization/Extended Day Treatment- An alternative to, or a step down from, inpatient care.
|
These services must be authorized by Superior’s Behavioral Health Subcontractor. Services are authorized for a minimum of five hours, but for less than 24-hours per day. The amount, duration, and scope will be based on medical necessity.
|
It is anticipated that Superior’s contracted Behavioral Health Providers in each Service Area will render this service.
|
||||
Behavioral Health | Rehabilitation/skills training. These are services provided to pregnant and parenting substance abusers at MHMR centers or in other treatment settings, focusing both on substance abuse and parenting issues. An augmentation of standard substance abuse treatment to focus on the special needs of this population. This benefit is available to all Members. It is geared to pregnant women and parenting Members. | These services must be authorized by Superior’s Behavioral Health Subcontractor. In addition, the service will be authorized for15-minute increments. The amount, duration, and scope are based on medical necessity. |
It is anticipated that Superior’s contracted MHMR providers specializing in Rehabilitation/Skills training in each Service Area will render this service.
|
Behavioral Health Value-added Services for Members 21 and Over
|
||||||||
Value-added Service
|
Description of Value-added Services and Members Eligible to Receive the Services
|
Limitations or Restrictions
|
Provider(s) responsible for providing this service
|
|||||
Behavioral Health
|
Diversionary Services: These are services
intended to provide support to Members at high risk for hospitalization or acute care readmissision by helping them remain in the community setting, where they will be eligible to receive wraparound care, acute residential treatment, crisis stabilization services or other services that would help avoid unnecessary hospitalization.
|
These services must be authorized by Superior’s Behavioral Health Subcontractor on a case-by-case basis.
|
It is anticipated that these services will be rendered by providers under contract with Superior’s Behavioral Health Subcontractor.
|
|||||
Behavioral Health
|
Superior’s Behavioral Health Subcontractor, will authorize Behavioral Health practitioners in medical settings to provide health psychology interventions focused on the effective management of chronic medical conditions. These might include psycho-educational groups for chronic conditions, individual coaching for patients with chronic disease states, or skills training activities.
|
These services must be authorized by Superior’s Behavioral Health Subcontractor. The authorization will be tied to medical necessity.
|
It is anticipated that these services will be rendered by Superior’s behavioral health practitioners located in Superior’s contracted Federally Qualified Health Centers.
|
|||||
Behavioral Health
|
Intensive Outpatient Treatment/Day Treatment (IOP)- Used as an alternative to or step down from more restrictive levels of care.
|
These services must be authorized by Superior’s Behavioral Health Subcontractor. In addition, the service will be authorized for greater than one and one half hours, but less than five hours per day. Amount, duration, and scope are based on medical necessity.
|
It is anticipated that Superior’s contracted Behavioral Health Providers in each Service Area will render this service.
|
|||||
Behavioral Health
|
Partial Hospitalization/Extended Day Treatment- An alternative to, or a step down from, inpatient care.
|
These services must be authorized by Superior’s Behavioral Health Subcontractor. Services are authorized for a minimum of five hours, but for less than 24-hours per day. The amount, duration, and scope will be based on medical necessity.
|
It is anticipated that Superior’s contracted Behavioral Health Providers in each Service Area will render this service.
|
|||||
Behavioral Health | Rehabilitation/skills training. These are services provided to pregnant and parenting substance abusers at MHMR centers or in other treatment settings, focusing both on substance abuse and parenting issues. An augmentation of standard substance abuse treatment to focus on the special needs of this population. This benefit is available to all Members. It is geared to pregnant women and parenting Members. | These services must be authorized by Superior’s Behavioral Health Subcontractor. In addition, the service will be authorized for15-minute increments. The amount, duration, and scope are based on medical necessity. | It is anticipated that Superior’s contracted MHMR providers specializing in Rehabilitation/Skills training in each Service Area will render this service. |
1. Explain how and when Providers and Members will be notified about the availability of the value-added services to be provided.
|
Value Added Services information will be included in the Superior Provider Manual and also during training sessions. Members will receive this information via the Plan Comparison Chart, in the Member Handbook, with New Member Packets, Connections/Promotoras and during orientations. Periodically, Superior will also highlight Value Added Services in the Provider and Member Newsletters.
Members in the Nueces and El Paso SDAs will be made aware of this benefit, in addition to the mediums listed above, also through Member Advisory Committees, OB Case Management Program materials and staff, Plan-sponsored baby showers, OB START SMART Pregnancy Program and Materials, Plan-sponsored health events, or other HHSC-approved/sponsored events in which Superior participates. In addition, Providers will be informed about this VAS through email communications, and face to face orientations and visits with providers.
|
2. Describe how a Member may obtain or access the value-added services to be provided.
|
See explanations provided above for accessing services.
A Member may access the Home Visits to New Mothers service by accepting a home visit appointment from a Superior Social Work or CONNECTIONS staff member.
With respect to the Transportation Value-added Service, “alternative transportation” refers to taxi cab services, which will be pre-authorized on a case-by-case basis for Members with respect to whom bus service is not accessible or convenient or where the particular health condition of the Member makes taxi cab services a medically preferable alternative to waiting for and riding a bus to a medical appointment.
The Member can visit any Superior network provider to receive the sports physical. The Member must be enrolled with Superior at the time of the exam, and the provider must bill the appropriate code for reimbursement.
With respect to the Car Safety seat, the Member will be able to receive the seat immediately following attendance at one of Superior's Start Smart baby shower education classes. Member must show ID and Superior membership card to receive this benefit.
|
Superior will track the value added services through our claims system for those value-adds for which HIPAA-compliant procedural codes are available (vision, dental, behavioral health). Superior will create a specific benefit category to track and report the value added services 'separately' from our 'capitated' service data. In addition, Superior will have the ability to pass this information to the State utilizing the encounter submission process, as long as the State is able to segregate the value adds data from the capitated services data.
For transportation services, Superior will maintain an electronic file of transportation services provided for Superior’s membership.
Sports physicals will be included with encounter data and identified with the applicable procedural code.
Home visits to new mothers are tracked through Superior’s case management system. Each staff member logs each member visit and the outcome/findings of the visit in Superior’s computer system. Superior will work with HHSC to establish the most efficient transmission of the data.
Distribution of pre-programmed cell phones will be tracked via the OB Case Management Team
Attendance at prenatal classes will be tracked via Connections/Promotoras staff.
The Diversionary Behavioral Health Services will be identified by Rev 900, CPT 90899, and HCPC code H2021/H2022.
|
DOCUMENT HISTORY LOG
|
|||
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial version of Attachment B-3, Value-added Services.
|
|
Revision
|
1.1
|
June 30, 2006
|
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision
|
1.2
|
September 1. 2006
|
Revised Physical Health Value-added Services to include Home Visits to New Mothers. Revised the certification provision by changing the start date for the 12-month provision of services.
|
Revision
|
1.3
|
September 1, 2006
|
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision
|
1.4
|
September 1, 2006
|
Contract amendment removed the separate signature requirement for Attachment B-3, Value-added Services. By signing the Contract and/or Contract Amendment, the HMO certifies that it will provide the Value-added Services from September 1, 2006 through August 31, 2007.
|
Revision
|
1.5
|
January 1, 2007
|
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision
|
1.6
|
February 1, 2007
|
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision
|
1.7
|
July 1, 2007
|
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision
|
1.8
|
September 1, 2007
|
Revised Attachment B-3, Value-added Services, to reflect newly negotiated Value-added Services for FY 2008.
|
Revision
|
1.9
|
December 1, 2007
|
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision | 1.10 | March 1, 2008 |
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision | 1.11 | September 1, 2008 |
Revised Attachment B-3, Value-added Services, to reflect newly negotiated Value-added Services for FY 2009.
|
Revision | 1.12 | March 1, 2009 |
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision | 1.13 | September 1, 2009 |
Revised Attachment B-3, Value-added Services, to reflect newly negotiated Value-added Services for FY 2010.
|
Revision | 1.14 | December 1, 2009 |
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision | 1.15 | March 1, 2010 |
Contract amendment did not revise Attachment B-3, Value-added Services.
|
Revision | 1.16 | September 1, 2010 |
Revised Attachment B-3, Value-added Services, to reflect newly negotiated Value-added Services for FY 2011.
|
Revision | 1.17 | December 1, 2010 | Contract amendment did not revise Attachment B-3, Value-added Services. |
Revision | 1.18 | March 1, 2011 | Contract amendment did not revise Attachment B-3, Value-added Services. |
Revision | 1.19 | September 1, 2011 |
Revised Attachment B-3, Value-added Services, to reflect newly negotiated Value-added Services for FY 2011.
|
Revision | 1.20 | January 1, 2012 | Contract amendment did not revise Attachment B-3, Value-added Services. |
1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
|
Physical Health Value-added Services
|
|||
Value-added Service
|
Description of Value-added Services and Members Eligible to Receive the Services
|
Limitations or Restrictions
|
Provider(s) responsible for providing this service
|
NurseWise
|
Twenty-four hour nurse advice line
|
Available to all members by calling the Member Services toll-free number
|
NurseWise, an affiliate of Centene Corporation
|
Transportation
|
For Members in need of transportation that cannot access transportation in a timely manner, Superior will provide alternative transportation to ensure that Members have a means of accessing their provider appointment.
|
Members in the Nueces Service Area. The Transportation Authority in this area will not agree to allow the plan to purchase bus vouchers or tokens.
The bus tokens or other alternative transportation must be requested in advance of a provider visit and authorized by Superior’s Member Services
Department. |
Transit Authorities in applicable Service Area.
|
Vision
|
20% discount off of Upgraded Hardware- The Member will receive a 20% discount on upgraded hardware.
|
There is no limitation on the number of times the discount can be utilized.
|
TVHP contracted providers.
|
Sports Physicals | One annual physical exam that is required for participation in sporting events for enrolled Members. Member must be currently enrolled and attending school, and the exam must be provided by a Superior contracted provider. | One exam in each 12 month CHIP enrollment period | Superior contracted providers |
Pre-programmed Cell Phones for High-Risk Pregnant Women |
Superior will provide pre-programmed cell phones to pregnant women who have been identified as high-risk through its OB case management program. The cell phones may be used to contact the Member’s OB, Superior, NurseWise and any other key representative of Member’s choice at any time the Member has a concern she wishes to discuss over the telephone, including the appropriateness of seeking medical care in person.
|
Only one cell phone will be provided per high-risk pregnant Member (although lost phones will be replaced). The phone must be returned to Superior within 4 weeks of the Member’s delivery of the baby.
|
Superior HealthPlan Case Management staff. |
Prenatal health and birthing classes |
Classes will be provided by SHP staff or facilitated by SHP and offered in SHP offices and other locations convenient to Members throughout the Service Areas. The classes are led by a registered nurse with the assistance of a CONNECTIONS/Promotoras representative. They cover the basics of prenatal care, including nutrition; the risk of smoking and benefits of smoking cessation; the progress of a fetus through the pregnancy; the importance of regular follow-up with medical providers; common health issues that occur during pregnancy; and, a review of SHP StartSmart and CONNECTIONS programs (e.g., availability of pre-programmed cell phones for high-risk pregnant women without good telecommunication support).
|
None | Superior's CONNECTIONS staff |
Home visits to New Mothers |
Superior Social Work and/or CONNECTIONS staff will make home visits to any Member with a new baby. This visit provides for resource and education coordination as identified in the visit, and ensures Members and the new babies are keeping all post natal and newborn doctor visits. This benefit is available to all Superior Members who have delivered a baby.
|
Only that a Member consent to the home visit. | Superior's CONNECTIONS and Social Work staff |
Gift Program for Pregnant Women |
Infant Car Safety seat for members who attend at least one baby shower. Baby Showers will be held no less than monthly, in each of the El Paso and Nueces SDAs. Members will be allowed one car seat per pregnancy and must show their Superior ID card at the shower to qualify. Member must be pregnant and currently enrolled with Superior to be eligible for the infant car seat.
|
CHIP Pregnant women in Nueces, Bexar and El Paso SDA ONLY | MCA |
Behavioral Health Value-added Services for Members Birth Through Age 20
|
|||
Value-added Service
|
Description of Value-added Services and Members Eligible to Receive the Services
|
Limitations or Restrictions
|
Provider(s) responsible for providing this service
|
Behavioral Health Value-added Services for Members 21 and Over
|
|||
Value-added Service
|
Description of Value-added Services and Members Eligible to Receive the Services
|
Limitations or Restrictions
|
Provider(s) responsible for providing this service
|
1. Explain how and when Providers and Members will be notified about the availability of the value-added services to be provided.
|
Value Added Services information will be included in the Superior Provider Manual and also during training sessions. Members will receive this information via the Plan Comparison Chart, in the Member Handbook, with New Member Packets and during orientations. Periodically, Superior will also highlight Value Added Services in the Provider and Member Newsletters.
|
2. Describe how a Member may obtain or access the value-added services to be provided.
|
See explanations provided above for accessing services.
With respect to the Transportation Value-added Service, “alternative transportation” refers to taxi cab services, which will be pre-authorized on a case-by-case basis for members with respect to whom bus service is not accessible or convenient or where the particular health condition of the member makes taxi cab services a medically preferable alternative to waiting for and riding a bus to a medical appointment.
The Member can visit any Superior network provider to receive the sports physical. The Member must be enrolled with Superior at the time of the exam, and the provider must bill the appropriate code for reimbursement.
|
Superior will track the value added services through our claims system for those value-adds for which HIPAA-compliant procedural codes are available (such as vision). Superior will create a specific benefit category to track and report the value added services 'separately' from our 'capitated' service data. In addition, Superior will have the ability to pass this information to the State utilizing the encounter submission process, as long as the State is able to segregate the value adds data from the capitated services data.
Sports physicals will be included with encouter data and identified with the applicable procedural code.
For transportation services, Superior will maintain an electronic file of transportation services provided for Superior’s membership.
|
DOCUMENT HISTORY LOG
|
|||
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
1.0
|
Initial version of Attachment B-3, Value-added Services
|
|
Revision
|
1.1
|
June 30, 2006
|
Revised Attachment B-3, Value Added Services, by adding Attachment B-3.1, STAR+PLUS Value Added Services. This is the initial version of Attachment B-3.1, STAR+PLUS VAS.
|
Revision
|
1.2
|
September 1, 2006
|
Contract amendment did not revise Attachment B-3.1, STAR+PLUS Value Added Services
|
Revision
|
1.3
|
September 1, 2006
|
Contract amendment did not revise Attachment B-3.1, STAR+PLUS Value Added Services
|
Revision
|
1.4
|
September 1, 2006
|
Contract amendment removed the separate signature requirement for Attachment B-3.1, STAR+PLUS Value-added Services. By signing the Contract and/or Contract Amendment, the HMO certifies that it will provide the Value-added Services from January 1, 2007 through August 31, 2007.
|
Revision
|
1.5
|
January 1, 2007
|
Revised Attachment B-3.1, STAR+PLUS Value Added Services to state that only non-dual members are eligible for dental benefits and to clarify description of Out-of-Home Respite.
|
Revision
|
1.6
|
February 1, 2007
|
Revised Attachment B-3.1, STAR+PLUS Value Added Services, to clarify the coverage period for the VAS.
|
Revision
|
1.7
|
July 1, 2007
|
Revised Attachment B-3.1, STAR+PLUS Value Added Services, to clarify the coverage period for the VAS.
|
Revision
|
1.8
|
September 1, 2007
|
Revised Attachment B-3-1, STAR+PLUS Value-added Services, to reflect newly negotiated Value-added Services for FY 2008.
|
Revision
|
1.9
|
December 1, 2007
|
Contract amendment did not revise Attachment B-3.1, STAR+PLUS Value Added Services
|
Revision | 1.10 | March 1, 2008 | Revised Attachment B-3-1, STAR+PLUS Value-added Services, to reflect mid year negotiated Value-added Services for FY 2008. |
Revision | 1.11 | September 1, 2008 |
Revised Attachment B-3-1, STAR+PLUS Value-added Services, to reflect newly negotiated Value-added Services for FY 2009.
|
Revision | 1.12 | March 1, 2009 |
Contract amendment did not revise Attachment B-3.1, STAR+PLUS Value Added Services
|
Revision | 1.13 | September 1, 2009 |
Revised Attachment B-3-1, STAR+PLUS Value-added Services, to reflect newly negotiated Value-added Services for FY 2010.
|
Revision | 1.14 | December 1, 2009 |
Contract amendment did not revise Attachment B-3.1, STAR+PLUS Value Added Services
|
Revision | 1.15 | March 1, 2010 |
Contract amendment did not revise Attachment B-3.1, STAR+PLUS Value Added Services
|
Revision | 1.16 | September 1, 2010 |
Revised Attachment B-3-1, STAR+PLUS Value-added Services, to reflect newly negotiated Value-added Services for FY 2011.
|
Revision | 1.17 | December 1, 2010 |
Contract amendment did not revise Attachment B-3.1, STAR+PLUS Value Added Services
|
Revision | 1.18 | March 1, 2011 | Contract amendment did not revise Attachment B-3.1, STAR+PLUS Value Added Services |
Revisions | 1.19 | September 1, 2011 |
Revised Attachment B-3-1, STAR+PLUS Value-added Services, to add the Bexar and Nueces contiguous counties as a result of the Contiguous Counties Expansion and to reflect negotiated Value-added Services for FY 2012.
|
Revisions | 1.20 | January 1, 2012 | Contract amendment did not revise Attachment B-3.1, STAR+PLUS Value Added Services |
1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
|
Physical Health Value-added Services
|
|||
Value-added Service
|
Description of Value-added Services and Members Eligible to Receive the Services
|
Limitations or Restrictions
|
Provider(s) responsible for providing this service
|
NurseWise
|
Twenty-four hour nurse advice line
|
Available to all members by calling the Member Services toll-free number
|
NurseWise, an affiliate of Centene Corporation
|
Dental
|
Basic dental coverage. The following services, categorized by CPT code, are covered:
Preventive
D0120 Periodic oral evaluation
D0140 Limited oral evaluation
D0150 Comprehensive oral evaluation (initial)
D0170 Re-evaluation limited, problem focused
Radiographs
D0220 Intraoral periapical first film
D0230 Intraoral periapical each add'l film
D0270 Bitewing single film
D0272 Bitewings two film
D0274 Bitewings four film
D0330 Panoramic
Cleanings
D1110 Prophy-adult
D1204 Topical application of fluoride (prophy not included) adult
D1206 Fluoride varnish
|
Only non-dual Members aged 21 years and over are eligible for dental benefits.
Each non-dual Member is eligible to receive $250 in dental services per benefit year, from dentists who are contracted with Delta Dental Insurance Company.
|
Licensed dentists under contract with Delta Dental Insurance Company
|
Vision |
Members will be provided an enhanced choice of prescription eyeglasses. Members will be offered a selection of 50 standard-size frames at no cost to Member. The Member will be able to choose from three frame styles, each in a choice of three colors. The provider must include an all-metal frame in lieu of a colored frame.
|
Only non-dual Members aged 21 years and over are eligible for vision benefits.
The enhanced choice of new prescription eyeglasses is available once per 24-month period. Coverage is for new frames and lenses and does not cover additional features such as tints and coating.
Providers must prescribe new glasses in compliance with the following specifications:
Frames
• American-made, unless foreign-made frames are comparable in quality and are less expensive
• Serviceable and able to meet statutory quality standards
• Composed of new materials
Lenses
• Plastic or clear glass (if applicable)
• Heat or chemically treated dress eyewear able to meet standards of the American Standard Prescription Requirements for first-quality glass
lenses
• Composed of new materials
• A minimum kryptoc of 22 mm flat top lens or equivalent if bifocal
• A minimum flat top 7/25 lens or equivalent if trifocal
|
Total Vision Health Plan’s provider network which includes Optometrists and Opticians
|
Pre-programmed Cell Phones for High-Risk Pregnant Women
|
Superior will provide pre-programmed cell phones to pregnant women who have been identified as high-risk through its OB case management program. The cell phones may be used to contact the Member’s OB, Superior, NurseWise and any other key representative of Member’s choice at any time the Member has a concern she wishes to discuss over the telephone, including the appropriateness of seeking medical care in person
|
Only non-dual Members are eligible for the cell phone
Only one cell phone will be provided per high-risk pregnant Member (although lost phones will be replaced). The phone must be returned to Superior within 4 weeks of the Member’s delivery of the baby.
|
Superior HealthPlan Case Management staff
|
Prenatal health and birthing classes
|
Classes will be provided by SHP staff or facilitated by SHP and offered in SHP offices and other locations convenient to Members throughout the Service Areas. The classes are led by a registered nurse with the assistance of a CONNECTIONS/Promotoras representative. They cover the basics of prenatal care, including nutrition; the risk of smoking and benefits of smoking cessation; the progress of a fetus through the pregnancy; the importance of regular follow-up with medical providers; common health issues that occur during pregnancy; and, a review of SHP StartSmart and CONNECTIONS programs (e.g., availability of pre-programmed cell phones for high-risk pregnant women without good telecommunication support). |
None.
|
Superior’s CONNECTIONS staff
|
Nutritional Dietary Support | Members will have access to ten (10) home delivered prepared meals at the time of discharge planning resulting from an acute inpatient hospital stay or discharge from a Nursing facility back into the community setting. | Members must contact Service Coordination for authorization. Available only to non-STAR+PLUS Waiver (SPW) members only. Limited to 10 meals Per year. | Superior contracted Home Delivered Meals providers |
Gift Program for Pregnant Members
|
Infant Car Safety seat for members who attend at least one baby shower. Baby Showers will be held no less than monthly, in Nueces SDA. Members will be allowed one car seat per pregnancy and must show their Superior ID card at the shower to qualify. Member must be pregnant and currently enrolled with Superior to be eligible for the infant car seat. |
STAR+PLUS Pregnant women in Nueces SDA ONLY
|
MCA
|
Transportation
|
HMO will offer tokens or vouchers for alternative transportation to HMO members that have trouble accessing the State's Medical Transportation Program in a timely manner to ensure access to their provider appointments. HMO's Member Services staff will approve and coordinate the transportation service and the type of transportation provided.
|
Bus tokens or other alternative transportation must be requested in advance of a provider visit and authorized by Superior’s Member Services Department.
|
Transit Authorities in applicable Service Area
|
Behavioral Health Value-added Services for Members 21 and Over
|
||||
Value-added Service
|
Description of Value-added Services and Members Eligible to Receive the Services
|
Limitations or Restrictions
|
Provider(s) responsible for providing this service
|
|
Behavioral Health
|
Health Psychology Interventions provided by a behavioral health practitioner in a medical setting that focuses on the effective management of chronic medical conditions. This might include psycho-educational groups for chronic conditions, individual coaching for patients with chronic disease states, or skills training activities.
|
Limited to non-dual Members only. Services must be authorized and is based on medical necessity.
|
Network Federally Qualified Health Centers (FQHCs)
|
|
Behavioral Health
|
Intensive Outpatient Treatment/Day Treatment (IOP)- Used as an alternative to step down from more restrictive levels of care.
|
Limited to non-dual Members only. Services must be authorized and is based on medical necessity. Services will be authorized for greater than one and one half hours, but less than five hours per day.
|
It is anticipated that behavioral health providers within the Service Area will render this service.
|
|
Behavioral Health
|
Partial Hospitalization/Extended Day Treatment- An alternative to, or a step down from, inpatient care.
|
Limited to non-dual Members only. Services must be authorized and is based on medical necessity. Services will be authorized for a minimum of five hours, but for less than 24-hours per day.
|
It is anticipated that behavioral health providers within the Service Area will render this service.
|
|
Behavioral Health
|
Diversionary Services: These are services
intended to provide support to Members at high risk for hospitalization or acute care readmissision by helping them remain in the community setting, where they will be eligible to receive wraparound care, acute residential treatment, crisis stabilization services or other services that would help avoid unnecessary hospitalization.
|
These services must be authorized by Superior's Behavioral Health Subcontractor on a case-by-case basis.
|
It is anticipated that behavioral health providers within the Service Area will render this service.
|
1. Explain how and when Providers and Members will be notified about the availability of the value-added services to be provided.
|
|
Value added services information will be included in the Superior Provider Manual and also during training sessions. Members will receive this information via the Plan Comparison Chart, in the Member Handbook, with New Member Packets, through Service Coordination and Member Services, and during orientations. Periodically, Superior will also highlight Value Added Services in the Provider and member Newsletters.
|
2. Describe how a Member may obtain or access the value-added services to be provided.
|
See explanations provided above for accessing services.
|
3. Describe how the HMO will identify the Value-added Service in administrative (encounter) data.
|
Superior will track value added services through our claims system for those value-adds for which HIPAA-compliant procedural codes are available (podiatry, etc.). Superior will create specific benefit categories to track and report the value added services “separately” from our “capitated” service data. In addition, Superior will have the ability to pass this information to the State utilizing the encounter submission process, as long as the State is able to segregate the value adds data from the capitated services data.
For dental and vision services, Superior will receive a data file from the dental and vision vendors to capture all utilization of dental value added benefits.
Distribution of pre-programmed cell phones will be tracked via the Superior OB Case Management Team
Attendance at prenatal classes will be tracked via Superior’s Connections/Promotoras staff.
For transportation services, Superior will maintain an electronic file of transportation services provided for Superior’s membership.
The Diversionary Behavioral Health Services will be identified by Rev 900, CPT 90899, and HCPC code H2021/H2022.
|
DOCUMENT HISTORY LOG
|
|||
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
1.0
|
Initial version of Attachment B-3, Value-added Services
|
|
Revision
|
1.1
|
June 30, 2006
|
Revised Attachment B-3, Value Added Services, by adding Attachment B-3.1, STAR+PLUS Value Added Services.
|
Revision
|
1.2
|
September 1, 2006
|
Contract amendment did not revise Attachment B-3, Value Added Services
|
Revision
|
1.3
|
September 1, 2006
|
Revised Attachment B-3, Value Added Services, by adding Attachment B-3.2, CHIP Perinatal Program Value Added Services. This is the initial version of Attachment B-3.2, CHIP Perinatal Program Value Added Services.
|
Revision
|
1.4
|
September 1, 2006
|
Contract amendment removed the separate signature requirement for Attachment B-3.2, CHIP Perinatal Program Value-added Services. By signing the Contract and/or Contract Amendment, the HMO certifies that it will provide the Value-added Services from January 1, 2007 through August 31, 2007.
|
Revision
|
1.5
|
January 1, 2007
|
Contract amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value Added Services.
|
Revision
|
1.6
|
February 1, 2007
|
Contract amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value Added Services.
|
Revision
|
1.7
|
July 1, 2007
|
Contract amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value Added Services.
|
Revision
|
1.8
|
September 1, 2007
|
Revised Attachment B-3.2, CHIP Perinatal Program Value-added Services, to reflect newly negotiated Value-added Services for FY 2008.
|
Revision
|
1.9
|
December 1, 2007
|
Contract amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value Added Services.
|
Revision | 1.10 | March 1, 2008 | Contract amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value Added Services |
Revision | 1.11 | September 1, 2008 |
Revised Attachment B-3.2, CHIP Perinatal Program Value-added Services, to reflect newly negotiated Value-added Services for FY 2009.
|
Revision | 1.12 | March 1, 2009 |
Contract amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value Added Services.
|
Revision | 1.13 | September 1, 2009 | Revised Attachment B-3.2, CHIP Perinatal Program Value-added Services, to reflect newly negotiated Value-added Services for FY 2010. |
Revision | 1.14 | December 1, 2009 |
Contract amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value Added Services.
|
Revision | 1.15 | March 1, 2010 |
Contract amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value Added Services.
|
Revision | 1.16 | September 1, 2010 | Revised Attachment B-3.2, CHIP Perinatal Program Value-added Services, to reflect newly negotiated Value-added Services for FY 2011. |
Revision | 1.17 | December 1, 2010 |
Contract amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value Added Services.
|
Revision | 1.18 | March 1, 2011 | Contract amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value Added Services. |
Revision | 1.19 | September 1, 2011 | Revised Attachment B-3.2, CHIP Perinatal Program Value-added Services, to reflect newly negotiated Value-added Services for FY 2012. |
Revision | 1.20 | January 1, 2012 | Contract amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value Added Services. |
1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
|
Physical Health Value-added Services
|
|||
Value-added Service
|
Description of Value-added Services and Members Eligible to Receive the Services
|
Limitations or Restrictions
|
Provider(s) responsible for providing this service
|
Behavioral Health Value-added Services for Members Under 21
|
|||
Value-added Service
|
Description of Value-added Services and Members Eligible to Receive the Services
|
Limitations or Restrictions
|
Provider(s) responsible for providing this service
|
Behavioral Health Value-added Services for Members 21 and Over
|
|||
Value-added Service
|
Description of Value-added Services and Members Eligible to Receive the Services
|
Limitations or Restrictions
|
Provider(s) responsible for providing this service
|
1. Explain how and when Providers and Members will be notified about the availability of the value-added services to be provided.
|
2. Describe how a Member may obtain or access the value-added services to be provided.
|
3. Describe how the HMO will identify the Value-added Service in administrative (encounter) data.
|
DOCUMENT HISTORY LOG
|
||||
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
|
Baseline
|
n/a
|
Initial version Attachment B-4, Performance Improvement Goals.
|
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Revision
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1.1
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June 30, 2006
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Contract amendment to include STAR+PLUS Program. Revised Attachment B-4, Performance Improvement Goals Template, by adding Attachment B-4.1, FY2008 Performance Improvement Goals Template. No change to this Section.
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Revision
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1.2
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September 1, 2006
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Revised version of Attachment B-4 that includes provisions applicable to MCOs participating in the STAR and CHIP Programs.
Updates the attachment to reflect the changes made in Attachment B-1, Section 8.1.1.1.
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Revision
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1.3
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September 1, 2006
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Contract amendment did not revise Attachment B-4, Performance Improvement Goals.
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Revision
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1.4
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September 1, 2006
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Contract amended to include Attachment B-4 Performance Improvement Goals for SFY2007 and format change
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Revision
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1.5
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January 1, 2007
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Contract amendment did not revise Attachment B-4, Performance Improvement Goals.
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Revision
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1.6
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February 1, 2007
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Contract amendment did not revise Attachment B-4, Performance Improvement Goals.
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Revision
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1.7
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July 1, 2007
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Contract amendment did not revise Attachment B-4, Performance Improvement Goals.
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Revision
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1.8
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September 1, 2007
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Revised Attachment B-4, to replace FY2007 Performance Improvement Goals with newly negotiated FY2008 Performance Improvement Goals by Program and by Service Area. Attachment B-4.1, FY2008 Performance Improvement Goals Template, is deleted as duplicative.
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Revision
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1.9
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December 1, 2007
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Contract amendment did not revise Attachment B-4, Performance Improvement Goals.
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Revision | 1.10 | March 1, 2008 |
Contract amendment did not revise Attachment B-4, Performance Improvement Goals.
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Revision | 1.11 | September 1, 2008 | Revised Attachment B-4, to replace FY2008 Performance Improvement Goals with newly negotiated FY2009 Performance Improvement Goals by Program and by Service Area. | |
Revision | 1.12 | March 1, 2009 | Contract amendment did not revise Attachment B-4, Performance Improvement Goals | |
Revision | 1.13 | September 1, 2009 |
Revised Attachment B-4, to replace FY2009 Performance Improvement Goals with newly negotiated FY2010 Performance Improvement Goals by Program and by Service Area.
Attachment B-4 is modified to clarify the aplicability of Goals 1 and 2, updated Goal 3 for STAR, CHIP, and CHIP Perinatal, and add a Goal 3 for STAR+PLUS.
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Revision | 1.14 | December 1, 2009 | Contract amendment did not revise Attachment B-4, Performance Improvement Goals | |
Revision | 1.15 | March 1, 2010 | Contract amendment did not revise Attachment B-4, Performance Improvement Goals | |
Revision | 1.16 | September 1, 2010 |
Revised Attachment B-4, to replace FY2010 Performance Improvement Goals with newly negotiated FY2011 Performance Improvement Goals by Program.
Attachment B-4 is modified to remove Service Areas as a category for sub-goals; update Goal 1 for STAR, STAR+PLUS, CHIP, and CHIP Perinatal; update Goal 2 for STAR, STAR+PLUS, and CHIP; and remove Goal 3 for all programs.
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Revision | 1.17 | December 1, 2010 | Contract amendment did not revise Attachment B-4, Performance Improvement Goals | |
Revision | 1.18 | March 1, 2011 | Attachment B-4 is revised to change the name from "Performance Improvement Goals" to "Performance Improvement Projects" and to reflect negotiated Performance Improvement Projects for FY 2011. | |
Revision | 1.19 | September 1, 2011 | Attachment B-4 is modified to reflect HHSC's two Overarching Goals for each Program and the negotiated third Overarching Goal for FY2012. The remainder of the template is deleted and the identification of the Performance Improvement Projects is moved to UMCM. | |
Revision | 1.20 | January 1, 2012 | Contract amendment did not revise Attachment B-4, Performance Improvement Projects | |
1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
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A. Health Plan Information
Plan Name: Superior HealthPlan
HMO Program: CHIP
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B. Overarching Goal
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Goal 1:
Reduce emergency department utilization due to Ambulatory Care Sensitive Condition (ACSC) through improved treatment. (CHIP)
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Goal 2:
Increase access or utilization of preventative care. (CHIP)
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Goal 3:
Increase utilization of Disease Management programs.
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A. Health Plan Information
Plan Name: Superior HealthPlan
HMO Program: STAR
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B. Overarching Goal
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Goal 1:
Reduce emergency department utilization due to Ambulatory Care Sensitive Condition (ACSC) through improved treatment. (STAR)
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Goal 2:
Improve access to specialty care. (STAR)
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Goal 3:
Reduce NICU utilization through increased peripartum management.
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A. Health Plan Information
Plan Name: Superior HealthPlan
HMO Program: STAR+PLUS
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B. Overarching Goal
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Goal 1:
Improve member understanding and utilization of service coordination. (STAR+PLUS)
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Goal 2:
Reduce Nursing Facility admission rates. (STAR+PLUS)
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Goal 3:
Increase utilization of Disease Management programs.
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DOCUMENT HISTORY LOG
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STATUS1
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DOCUMENT
REVISION2
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EFFECTIVE
DATE
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DESCRIPTION3
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Baseline
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n/a
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Initial version of Attachment B-5, Deliverables/Liquidated Damage Matrix.
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Revision
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1.1
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June 30, 2006
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Contract amendment did not revise Attachment B-5, Deliverables/Liquidated Damage Matrix.
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Revision
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1.2
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September 1, 2006
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Amended Attachment B-5, Deliverables/Liquidated Damages Matrix, to add a footnote clarifying the deliverable due dates. Also amended the provisions regarding Claims Processing Requirements and the Reporting Requirements for the Claims Summary Report.
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Revision
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1.3
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September 1, 2006
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Amended Attachment B-5, Deliverables/Liquidated Damages Matrix, performance standard for Provider Directories for the CHIP Perinatal Program.
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Revision
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1.4
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September 1, 2006
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Contract amendment did not revise Attachment B-5, Deliverables/Liquidated Damage Matrix.
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Revision
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1.5
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January 1, 2007
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Contract amendment did not revise Attachment B-5, Deliverables/Liquidated Damage Matrix.
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Revision
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1.6
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February 1, 2007
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Contract amendment did not revise Attachment B-5, Deliverables/Liquidated Damage Matrix.
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Revision
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1.7
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July 1, 2007
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Amended Attachment B-5, Deliverables/Liquidated Damages Matrix, to add clarifications to the provisions addressing Claims Processing Requirements and the Reporting Requirements for the Claims Summary Report.
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Revision
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1.8
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September 1, 2007
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Contract amendment did not revise Attachment B-5, Deliverables/Liquidated Damage Matrix.
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Revision
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1.9
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December 1, 2007
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Contract amendment did not revise Attachment B-5, Deliverables/Liquidated Damage Matrix.
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Revision | 1.10 | March 1, 2008 |
Amended Attachment B-5 to add or revise performance standards and liquidated damages regarding: Failure to Perform an Administrative Service; Failure to Provide a Covered Service; Behavioral Health Services Hotline; Member Services Hotline; and Provider Hotline.
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Revision | 1.11 | September 1, 2008 |
Amended Attachment B-5 to revise performance standards regarding: Line 1 – Failure to Perform an Administrative Service and Line 2 – Failure to Provide a Covered Service; and to replace the MDS-HC instrument with the Community Medical Necessity and Level of Care Assessment Instrument in the Performance Standard for Line 21 – Contract Amendment B-1 RFP §8.3.3 – STAR+PLUS Assessment Instruments
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Revision | 1.12 | March 1, 2009 |
Lines 8, 9, and 13 are modified to add a performance standard, measurement assessment, and damages for each 30 second time increment, or portion thereof, by which the average hold time exceeds the maximum acceptable hold time.
Line 15 is modified to clarify reporting timeframes and requirements.
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Revision | 1.13 | September 1, 2009 |
Line 16.5 Contract Attachment B-1 RFP §8.1.18.1 Encounter Data is added.
Line 21 Performance Standard is amended to clarify type of wiaver services.
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Revision | 1.14 | December 1, 2009 | Line 21 Service/Component is amended to clarify contract references and Performance Standard is modified to require that assessment instructions must be submitted within 45 days | |
Revision | 1.15 | March 1, 2010 | Line 3 modified to conform to language in Attachment A, Sections 4.08(b)(3) and (4). | |
Revision | 1.16 | September 1, 2010 |
Item 3 is modified to conform to language in Attachment A, Sections 4.08(b)(3) and (4).
Item 8 is added to add liquidated damages for Out-of-Network Utilization.
Item 22 is added to add liquidated damages for timely HMO response to complaints.
All subsequent items are renumbered.
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Revision | 1.17 | December 1, 2010 |
Contract amendment did not revise Attachment B-5, Deliverables/Liquidated Damage Matrix.
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Revision | 1.18 | March 1, 2011 |
Item 11 modified to add liquidated damages for failing to submit timely HMO response to Provider complaints.
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Revision | 1.19 | September 1, 2011 |
Item 11 modified to clarify liquidated damages for failing to submit timely HMO response to Provider complaints.
Item 22 is modified to clarify liquidated damages for timely HMO response to complaints.
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Revision | 1.20 | January 1, 2012 |
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1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
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Service/
Component1
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Performance Standard2
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Measurement Period3
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Measurement Assessment4
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Liquidated Damages
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1. |
General Requirement:
Failure to Perform an Administrative Service
Contract Attachment A HHSC Uniform Managed Care Contract Terms and Conditions,
Contract Attachment B-1 RFP §§ 6, 7, 8 and 9
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The HMO fails to timely perform an HMO Administrative Service that is not otherwise associated with a performance standard in this matrix and, in the determination of HHSC, such failure either: (1) results in actual harm to a Member or places a Member at risk of imminent harm, or (2) materially affects HHSC’s ability to administer the Program(s).
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Ongoing
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Each incident of non-compliance per HMO Program and SA.
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HHSC may assess up to $5,000 per calendar day for each incident of non-compliance per HMO Program and SA.
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2. |
General Requirement:
Failure to Profide a Covered Service
Contract Attachment A HHSC Uniform Managed Care Contract Terms and Conditions,
Contract Attachment B-1 RFP §§ 6, 7, 8 and 9
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The HMO fails to timely provide a HMO Covered Service that is not otherwise associated with a performance standard in this matrix and, in the determination of HHSC, such failure results in actual harm to a Member or places a Member at risk of imminent harm.
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Ongoing | Each calendar day of non-compliance. |
HHSC may assess up to $7,500.00 per day for each incident of non-compliance.
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3. | Contract Attachment A HHSC Uniform Managed Care Contract Terms and Conditions, Section 4.08 Subcontractors |
(i) three (3) Business Days after receiving notice from a Material Subcontractor of its intent to terminate a Subcontract;
(ii) 180 calendar days prior to the termination date of a Material Subcontract for MIS systems operation or reporting;
(iii) 90 calendar days prior to the termination date of a Material Subcontract for non-MIS HMO Administrative Services; and
(iv) 30 calendar days prior to the termination date of any other Material Subcontract.
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Transition, Measured Quarterly during the Operations Period | Each calendar day of non-compliance, per HMO Program, per SA.. | HHSC may assess up to $5,000 per calendar day of non-compliance |
4. |
Contract Attachment B-1 RFP §§ 6, 7, 8 and 9
Uniform Managed Care Manual
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All reports and deliverables as specified in Sections 6, 7, 8 and 9 of Attachment B-1 must be submitted according to the timeframes and requirements stated in the Contract (including all attachments) and HHSC’s Uniform Managed Care Manual. (Specific Reports or deliverables listed separately in this matrix are subject to the specified liquidated damages.) |
Transition Period, Quarterly during Operations Period
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Each calendar day of non-compliance, per HMO Program, per SA.
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HHSC may assess up to $250 per calendar day if the report/deliverable is late, inaccurate, or incomplete.
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5. |
Contract Attachment B-1, RFP §7.3 --Transition Phase Schedule
Contract Attachment B-1, RFP §7.3.1 -- Transition Phase Tasks
Contract Attachment B-1, RFP §8.1 -- General Scope
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The HMO must be operational no later than the agreed upon Operations Start Date. HHSC, or its agent, will determine when the HMO is considered to be operational based on the requirements in Section 7 and 8 of Attachment B-1. | Operations Start Date | Each calendar da of non-compliance, per HMO Program, per Service Area (SA). | HHSC may asses up to $10,000 per calendar day for each day beyond the Operations Start date that the HMO is not operational until the day that the HMO is operational, including all systems. |
6. |
Contract Attachment B-1 RFP §7.3.1.5 -- Systems Readiness Review
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The HMO must submit to HHSC or to the designated Readiness Review Contractor the following plans for review, by December 14, 2005 for STAR and CHIP, and by July 31, 2006 for STAR+PLUS:
• Joint Interface Plan;
• Disaster Recovery Plan;
• Business Continuity Plan;
• Risk Management Plan; and
- Systems Quality Assurance Plan.
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Transition Period
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Each calendar day of non-compliance, per report, per HMO Program, and per SA.
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HHSC may asses up to $1,000 per calendar day for each day a deliverable is late, inaccurate or incomplete.
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7. |
Contract Attachment B-1 RFP 7.3.1.7 - Operations Readiness
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Final versions of the Provider Directory must be submitted to the Administrative Services Contractor no later than 95 days prior to the Operational Start Date for the CHIP, STAR, and STAR+PLUS HMOs, and no later than 30 days prior to the Operational Start Date for the CHIP Perinatal HMOs.
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Transition Peroid |
Each calendar day of non-compliance, per directory, per HMO Program and per SA.
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HHSC may assess up to $1,000 per calendar day for each day the directory is late, inaccurate or incomplete.
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8. | Contract Attachment B-1 RFP §8.1.4 Provider Network
UMCM Chapter 5.38 Out of Network Utilization Report
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(1) No more than 15 percent of an MCO's total hospital admissions, by service delivery area, may occur in out-of-network facilities.
(2) No more than 20 percent of an MCO's total emergency room visits, by service delivery area, may occur in out-of-network facilities
(3) No more than 20 percent of total dollars billed to an MCO for "other outpatient services" may be billed by out-of-network providers.
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Measured Quarterly beginning March 1, 2010.
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Per incident of non-compliance, per Medicaid HMO, per Service Area. | HHSC may assess up to $25,000 per quarter, per standard, per Medicaid HMO, per Service Area. |
9. |
Contract Attachment B-1 RFP §8.1.4.7 -- Provider Hotline
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A. The HMO must operate a toll-free Provider telephone hotline that Provider inquiries from 8 AM - 5 PM, local time for the Service Area, Monday through Friday, excluding State-approved holidays.
B. Performance Standards.
1. Call pickup rate - At least 99% of calls are answered on or before the fourth ring or an automated call pick up system is used.
2. Call hold rate - The average hold time is two minutes or less.
3. Call abandonment rate - Call abandonment rate is 7% or less.
C. Average hold time is 2 minutes or less.
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Operations and Turnover |
A. Each incident of non-compliance per. HMO Program and SA.
B. Each percentage point below the standard for 1 and 2 and each percentage point above the standard for 3 per HMO Program and SA.
C Per month, for each 30 second time increment, or portion thereof, by which the average hold time exceeds the maximum acceptable hold time.
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HHSC may assess:
A. Per HMO Program and SA, up to $100.00 for each hour or portion thereof that appropriately staffed toll-free lines are not operational. If the MCO's failure to meet the performance standard is caused by a Force Majeure Event, HHSC will not assess liquidated damages unless the MCO fails to implement its Disaster Recovery Plan.
B.Up to $100.00 per HMO Program and SA for each percentage point for each standard that the HMO fails to meet the requirements for a monthly reporting period for any HMO operated toll-free lines.
C. Up to $100.00 may be assessed fore each 30 second time increment, or portion thereof, by which the MCO's average hold time exceeds the maximum acceptable hold time.
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10. | Contract Attachment B-1 RFP §8.1.5.6 -- Member Services Hotline | A. The HMO must operate a toll-free hotline that Members can call 24 hours a day, seven (7) days a week.
B. Performance Standards.
1. Call pickup rate - At least 99% of calls are answered on or before the fourth ring or an automated call pick up system is used.
2. Call hold rate - At least 80% of calls must be answered by toll-free line staff within 30 seconds.
3. Call abandonment rate - Call abandonment rate is 7% or less.
C. Averag hold time is 2 minutes or less.
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Ongoing during Operations Turnover |
A. Each incident of non-compliance per. HMO Program and SA.
B. Each percentage point below the standard for 1 and 2 and each percentage point above the standard for 3 per HMO Program and SA.
C. Per month, for each 30 second time increment, or portion threof, by which the average hold time exceeds the maximum acceptable hold time.
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HHSC may assess:
A. Per HMO Program and SA, up to $100.00 for each hour or portion thereof that toll-free lines are not operational. If the MCO's failure to meet the performance standard is caused by a Force Majeure Event, HHSC will not assess liquidated damages unless the MCO fails to implement its Disaster Recovery Plan.
B. Per HMO Program and SA, up to $100.00 for each percentage point for each standard that the HMO fails to meet the requirements for a monthly reporting period for any HMO operated toll-free lines.
C. Up to $100.00 may be assessed fore each 30 second time increment, or portion thereof, by which the MCO's average hold time exceeds the maximum acceptable hold time.
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11. |
Contract Attachment B-1 RFP §8.1.5.9 -- Member Complaint and Appeal Process
Contract Attachment B-1 RFP §8.2.5.1 -- Provider Complaints
Contract Attachment B-1 RFP §8.2.7.1 -- Member Complaint Process
Contract Attachment B-1 RFP §8.4.3 – CHIP Member Complaint and Appeal Process
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The HMO must resolve at least 98% of Member and Provider Complaints within 30 calendar days from the date the Complaint is received by the HMO.
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Measured Quarterly during the Operations Period | Per reporting period, per HMO Program, per SA. | HHSC may assess up to $250 per reporting period if the HMO fails to meet the performance standard. |
12. |
Contract Attachment B-1 RFP §8.1.5.9 -- Member Complaint and Appeal Process
Contract Attachment B-1 RFP §8.2.7.2 -- Mediciad Standard Member Appeal Process
Contract Attachment B-1 RFP §8.4.3 – CHIP Member Complaint and Appeal Process
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The HMO must resolve at least 98% of Member Appeals within 30 calendar days from the date the Appeal is filed with the HMO. | Measured Quarterly during the Operations Period | Per reporting peorid, per HMO Program, per SA. | HHSC may assess up to $500 per reporting period if the HMO fails to meet the performance standard. |
13. |
Contract Attachment B-1 RFP §8.1.6 -- Marketing & Prohibited Practices
Uniform Managed Care Manual
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The HMO may not engage in prohobited marketing practices. |
Transition, Measured Quarterly during the Operations Period
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Per incident of non-compliance.
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HHSC may assess up to $1,000 per incident of non-compliance.
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14. | Contract Attachment B-1 RFP §8.1.15.3 -- Behavioral Health services Hotline |
A. The HMO must have an emergency and crisis Behavioral Health services Hotline available 24 hours a day, seven (7) days a week, toll-free throught the Service Area(s).
B. Crisis hotline staff must include
or have access to qualified Behavioral Health Service professionals to assess behavioral health emergencies.
C. The HMO must ensure that the toll-free Behavioral Health Services Hotline meets the following minimum requiremetns for the HMO Program:
1. Call pickup rate - At least 99% of calls are answered on or before the fourth ring or an automated call pick up system.
2. Call hold rate - At least 80% of calls must be answered by toll-free line staff within 30 seconds.
3. Call abandonment rate - Call abandonment rate is 7% or less.
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Operations and Turnover |
A. Each incident of non-compliance per HMO Program and SA.
B. Each incident of non-compliance per HMO Program and SA.
C. Per HMO Program and SA, per month, each percentage point below the standard for 1 and 2 and each percentage point above the standard for 3.
D. Per month, for each 30 second time increment, or portion threof, by which the average hold time exceeds the maximum acceptable hold time.
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HHSC may assess:
A. Up to $100.00 for each hour or portion thereof that appropriately staffed toll-free lines are not operational. If the MCO's failure to meet the performance standard is caused by a Force Majeure Event, HHSC will not assess liquidated damages unless the MCO fails to implement its Disaster Recovery Plan.
B. Up to $100.00 per incident for each occurence that HHSC identifies through its recurring monitoring process that toll-free line staff were not qualified or did not have access to qualified professionals to assess behavioral health emergencies.
C.Up to $100.00 for each percentage point for each standard that the HMO fails to meet the requirements for a monthly reporting period for any HMO operated toll-free lines.
D. Up to $100.00 may be assessed fore each 30 second time increment, or portion thereof, by which the MCO's average hold time exceeds the maximum acceptable hold time.
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15. |
Contract Attachment B-1 RFP §8.1.17.2 --Financial Reporting Requirements
Uniform Managed Care Manual - Chapter 5
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Financial Statistical Reports (FSR):
For each HMO Program and SA, the HMO must file quarterly and annual FSRs. Quarterly reports are due no later than 30 days after the conclusion of each State Fiscal Quarter (SFQ). The first annual report is due no later than 120 days after the end of each Contract Year and the second annual report is due no later than 365 days after the end of each Contract Year.
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Quarterly during the Operations Period
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Per calendar day of non-compliance, per HMO Program, per SA.
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HHSC may assess up to $1,000 per calendar day, a quarterly or annual report is late, inaccurate or incomplete.
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16. |
Contract Attachment B-1 RFP §8.1.17.2 -- Financial Reporting Requirements:
Uniform Managed Care Manual - Chapter 5
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Medicaid Disproportionate Share Hospital (DSH) Reports: The Medicaid HMO must submit, on an annual basis, preliminary and final DSH Reports. The Preliminary report is due no later than June 1st after each reporting year, and the final report is due no later than July 1st after each reporting year.
This standard does not apply to CHIP HMOs.
Any claims added after July 1st shall include supporting claim documentation for HHSC validation.
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Measured during 4th Quarter of the Operations Period (6/1 - 8/31)
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Per calendar day of non-compliance per HMO Program, per SA.
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HHSC may assess up to $1,000 per calendar day, per program, per service area, for each day the report is late, incorrect, inaccurate or incomplete
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17. |
Contract Attachment B-1 RFP §8.1.18 – Management Information System (MIS) Requirements
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The HMO’s MIS must be able to resume operations within 72 hours of employing its Disaster Recovery Plan. |
Measured Quarterly during the Operations Period
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Per calendar day of non-compliance per HMO Program, per SA.
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HHSC may assess up to $5,000 per calendar day of non-compliance
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18. | Contract Attachment B-1 RFP §8.1.18.n Encounter Data |
The HMO must submit Encounter Data transmissions and include all Encounter Data and Encounter Data adjustments processed by the HMO on a monthly basis, not later than the 30th calendar day after the last day of the month in which the claim(s) are adjudicated. Additionally, the HMO will be subject to liquidated damages if the Quarterly Encounter Reconciliation Report (which reconciles the year-to-date paid claims reported in the Financial Statistical Report (FSR) to the appropriate paid dollars reported in the Texas Encounter Data (TED) Warehouse) includes more than a 2% variance (i.e., less than a 98% match).
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Measured Quarterly during Operations Period
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Per incident of non-compliance, per HMO Program, per Service Area (SA)
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HHSC may assess up to $2,500 per Quarter, per Program, per SA if the HMO fails to submit monthly encounter data. HHSC may assess up to $5,000 per quarter, per Program, per SA for each additional quarter that the HMO fails to submit monthly Encounter Data.
SA if the MCO falls below the 98% match standard. HHSC may assess up to $5,000 per Quarter, per Program, per SA for each additional Quarter that the MCO falls below the 98% match standard.
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19. |
Contract Attachment B-1 RFP §8.1.18.3 – Management Information System (MIS) Requirements: System-Wide Functions
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The HMO’s MIS system must meet all requirements in Section 8.1.18.3 of Attachment B-1.
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Measured Quarterly during the Operations Period |
Per calendar day of non-compliance per HMO Program, per SA.
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HHSC may assess up to $5,000 per calendar day of non-compliance.
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20. |
Contract Attachment B-1 RFP §8.1.18.5 -- Claims Processing Requirements
Unifrom Managed Care Manual Chapter 2
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The HMO must adjudicate all provider Clean Claims within 30 days of receipt by the HMO. The HMO must pay providers interest at an 18% per annum, calculated daily for the full period in which the Clean
Claim remains unadjudicated beyond the 30-day claims processing deadline. Interest owed the provider must be paid on the same date that the claim is adjudicated.
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Measured Quarterly during the Operations Period |
Per incident of non-compliance.
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HHSC may assess up to $1,000 per claim if the HMO fails to timely pay interest.
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21. |
Contract Attachment B-1 RFP §8.1.18.5 -- Claims Processing Requirements
Unifrom Managed Care Manual - Chapter 2
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The HMO must comply with the claims processing requirements and standards as described in Section 8.1.18.5 of Attachment B-1 and in Chapter 2 of the Uniform Managed Care Manual.
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Measured Quarterly during the Operations Period |
Per quarterly reporting period, per HMO Program, per Service Area, per claim type.
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HHSC may assess liquidated damages of up to $5,000 for the first quarter that an HMO’s Claims Performance percentages by claim type, by Program, and by service area, fall below the performance standards. HHSC may assess up to $25,000 per quarter for each additional quarter that the Claims Performance percentages by claim type, by Program, and by service area, fall below the performance standards.
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22. | Attachment B-1 RFP §8.1.20 Reporting Requirements
Attachment B-1 RFP §8.2.5.1 Provider Complaints
Attachment B-1 RFP §8.2.7.1 Member Complaint Process
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The HMO fails to submit a timely response to an HHSC Member or Provider Complaint received by HHSC and referred to the HMO by the specified due date. The HMO response must be submitted according to the timeframes and requirements stated within the HMO Notification Correspondence (letter, email, etc). | Measured on a Quarterly Basis | Each incident of non-compliance per HMO Program and SA | HHSC may assess up to $250 per calendar day for each day beyond the due date specified within the HMO Notification Correspondence. |
23. |
Contract Attachment B-1 RFP §8.1.20.2-- Reporting Requirements
Uniform Managed Care Manual Chapters 2 and 5
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Claims Summary Report:
The HMO must submit quarterly, Claims Summary Reports to HHSC by HMO Program, by Service Area, and by claim type, by the 30th day following the reporting period unless otherwise specified.
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Measured Quarterly during the Operations Period | Per calendar day of non-compliance, per HMO Program, Service Area, per claim type. |
HHSC may assess up to $1,000 per calendar day the report is late, inaccurate, or incomplete.
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24. |
Contract Attachment B-1 RFP §8.3.3 – STAR+PLUS Assessment Instruments
Attachment B-1 RFP §8.3.4.1 - For Members
Attachment B-1 RFP §8.3.4.2 - For Medical Assistance Only (MAO) Non-Member Applicants
|
The Community Medical Necessity and Level of Care (MN LOC) Assessment Instrument must be completed and electronically submitted via the TMHP portal in the specified format within 45 days: 1) from the date of referral for 1915(c) Waiver services for MAO applicants; 2) from the date of the Member's request for 1915(c) Waiver services for current Members requesting an upgrade; or 3) prior to the annual ISP expiration date for all Members receiving 1915(c) Waiver services as specified in Section 8.3.3.
|
Operations, Turnover | Per calendar day of non-compliance, per Service Area. |
HHSC may assess up to $500 per calendar day per Service Area, for each day a report is late, inaccurate or incomplete.
|
25. | Contract Attachment B-1 RFP §9.2 -- Transfer of Data | The HMO must transfer all data regarding the provision of Covered Services to Members to HHSC or a new HMO, at the sole discrection of HHSC and as directed by HHSC. All transferred data must comply with the Contract requirements, including HIPAA. | Measured at Time of Transfer of Data and ongoing after the Transfer of Data until satisfactorily completed | Per incident of non-compliance (failure to provide data and/or failure to provide data in required format), per HMO Program, per SA. | HHSC may assess up to $10,000 per calendar day the data is late, inaccurate or incomplete. |
26. | Contract Attachment B-1 RFP §9.3 -- Turnover Services | Six months prior to the end of the contract period or any extension thereof, the HMO must propose a Turnover Plan covering the possible turnover of the records and information maintained to either the State (HHSC) or a successor HMO. | Measured at Six Months prior to the end of the contract period or any extension thereof and ongoing until satisfactorily completed | Each calendar day of non-compliance per HMO Program, per SA. |
HHSC may assess up to $1,000 per calendar day the Plan is late, inaccurate, or incomplete.
|
27. |
Contract Attachment B-1 RFP §9.4-- Post-Turnover Services
|
The HMO must provide the State (HHSC) with a Turnover Results report documenting the completion and results of each step of the Turnover Plan 30 days after the Turnover of Operations. | Measured 30 days after the Turnover of Operations | Each calendar day of non-compliance per HMO Program, per SA. | HHSC may assess up to $250 per calendar day the report is late, inaccurate or incomplete. |
DOCUMENT HISTORY LOG
|
|||
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
January 1, 2007
|
Initial version of Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments Methodology, was incorporated into Version 1.5 of the Contract.
|
Revision
|
1.6
|
February 1, 2007
|
Contract amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments Methodology.
|
Revision
|
1.7
|
July 1, 2007
|
Contract amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments Methodology.
|
Revision
|
1.8
|
September 1, 2007
|
Contract amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments Methodology.
|
Revision
|
1.9
|
December 1, 2007
|
Contract amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments Methodology.
|
Revision | 1.10 | March 1, 2008 |
Contract amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments Methodology.
|
Revision | 1.11 | September 1, 2008 |
Contract amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments Methodology.
|
Revision | 1.12 | March 1, 2009 |
Contract amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments Methodology.
|
Revision | 1.13 | September 1, 2009 | Attachment B-7 is modified to remove references to the DADS enhancement program. |
Revision | 1.14 | December 1, 2009 |
Contract amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments Methodology.
|
Revision | 1.15 | March 1, 2010 |
Contract amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments Methodology.
|
Revision | 1.16 | September 1, 2010 |
Contract amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments Methodology.
|
Revision | 1.17 | December 1, 2010 | Contract amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments Methodology. |
Revision | 1.18 | March 1, 2011 | Contract amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced Paymetns Methodology. |
Revision | 1.19 | September 1, 2011 | Contract amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced Paymetns Methodology. |
Revision | 1.20 | January 1, 2012 | Contract amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced Paymetns Methodology. |
1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions
2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
|
I. Provider Contracting
|
(a) Description of criteria the HMO will use to allow participation in the STAR+PLUS Attendant Care Enhanced Payments.
(b) Description of any limitations or restrictions.
|
||
Superior HealthPlan will only allow those providers that are currently participating in the DADS Attendant Compensation Rate Enhancements to participate in the STAR+PLUS Attendant Care Enhanced Payments. SHP will have an enrollment period corresponding to the DADS enrollment period to allow new providers to participate in the SHP Attendant Care Enhanced Payments.
|
|||
II. Payment for STAR+PLUS Attendant Care Enhanced Payments
|
Description of methodology the HMO will use to pay for the Attendant Care Enhanced Payments. Provide sufficient detail to fully explain the planned methodology.
|
||
Superior will not use the DADS rates. SHP will establish an additional amount to be added on to the unit rate by type of service.
|
|||
III. Timing of the Attendant Care Enhanced Payments
|
Description of when the payments will be made to the Providers and the frequency of payments. Also include timeframes for Providers complaints and appeals regarding enhanced payments.
|
||
The enhanced rate payment amount will be paid at the time of claims payment so the frequency will depend on the frequency with which providers file their claims. Provider complaints and appeals will be handled through the normal complaint and appeal process and finalized within 30 days from receipt.
|
|||
IV. Assurances from Participating Providers
|
Description of how the HMO will ensure that the participating Providers are using the enhancement funds to compensate direct care workers as intended by the 2000-01 General Appropriations Act (Rider 27, House Bill 1, 76th Legislature, Regular Session, 1999) and by T.A.C. Title 1, Part 15, Chapter 355.
|
||
Participating Providers will be required by contract to complete and submit an affidavit annually stating they applied the enhancement funds to the compensation for direct care staff. Compensation may include increased hourly rates, bonuses, paid holidays or additional benefits such as employer paid insurance.
|
|||
V. Monitoring of Attendant Care Enhanced Payments
|
Explanation of the Monitoring Process that the HMO will use to monitor whether the Attendant Care Enhanced Payments are used for the purposes intended by the Texas Legislature.
|
||
Each Provider’s compliance with the attendant compensation spending requirement for the reporting period will be monitored on an annual basis via the submission of the affidavit stating they applied the enhancement funds to the compensation for direct care staff. Compensation may include increased hourly rates, bonuses, paid holidays or additional benefits such as employer paid insurance. In addition, providers may be audited on as as-needed basis to ensure financial records support the pass through of the enhanced funds. Enhanced payments could potentially be recouped for those Providers who fail to pass the funds to their direct care staff.
|
Centene Corporation
|
||||||||||||||||
Computation of ratio of earnings to fixed charges
|
||||||||||||||||
($ in thousands)
|
||||||||||||||||
Year Ended December 31,
|
||||||||||||||||
2011
|
2010
|
2009
|
2008
|
2007
|
||||||||||||
Earnings:
|
||||||||||||||||
Pre-tax earnings from continuing operations
|
$ | 174,885 | $ | 154,282 | $ | 137,508 | $ | 136,616 | $ | 64,071 | ||||||
Addback:
|
||||||||||||||||
Fixed charges
|
27,822 | 26,141 | 23,104 | 23,128 | 20,612 | |||||||||||
Subtract:
|
||||||||||||||||
Non-controlling interest
|
2,855 | (3,435 | ) | (2,574 | ) | - | - | |||||||||
Interest capitalized
|
- | (1,089 | ) | (116 | ) | - | - | |||||||||
Total earnings
|
$ | 205,562 | $ | 175,899 | $ | 157,922 | $ | 159,744 | $ | 84,683 | ||||||
Fixed Charges:
|
||||||||||||||||
Interest expensed and capitalized
|
$ | 20,320 | $ | 19,081 | $ | 16,434 | $ | 16,673 | $ | 15,626 | ||||||
Interest component of rental payments (1)
|
7,502 | 7,060 | 6,670 | 6,455 | 4,986 | |||||||||||
Total fixed charges
|
$ | 27,822 | $ | 26,141 | $ | 23,104 | $ | 23,128 | $ | 20,612 | ||||||
Ratio of earnings to fixed charges
|
7.39 | 6.73 | 6.84 | 6.91 | 4.11 | |||||||||||
(1) Estimated at 33% of rental expense as a reasonable approximation of the interest factor.
|
Absolute Total Care, Inc. a South Carolina corporation
|
Access Health Solutions, LLC, a Florida LLC
|
AECC Total Vision Health Plan of Texas, Inc., a Texas corporation
|
Bankers Reserve Life Insurance Company of Wisconsin, a Wisconsin corporation
|
Bridgeway Health Solutions of Arizona LLC, an Arizona LLC
|
Bridgeway Health Solutions, LLC, a Delaware LLC
|
Buckeye Community Health Plan, Inc., an Ohio corporation
|
Casenet, LLC, a Delaware LLC
|
CBHSP Arizona, Inc., an Arizona corporation
|
CCTX Holdings, LLC, a Delaware LLC
|
Celtic Group, Inc., a Delaware corporation
|
Celtic Insurance Company, an Illinois corporation
|
CeltiCare Health Plan Holdings LLC, a Delaware LLC
|
CeltiCare Health Plan of Massachusetts, Inc., a Massachusetts corporation
|
CenCorp Health Solutions, Inc., a Delaware corporation
|
Cenpatico Behavioral Health of Arizona, LLC, an Arizona LLC
|
Cenpatico Behavioral Health of Maricopa LLC, an Arizona LLC
|
Cenpatico Behavioral Health of Texas, Inc., a Texas corporation
|
Cenpatico Behavioral Health of Wisconsin, LLC, a Wisconsin LLC
|
Cenpatico Behavioral Health, LLC, a California LLC
|
Cenpatico CeltiCare Integrated Services, Inc., a Massachusetts corporation |
Cenpatico of Florida, Inc., a Florida corporation |
Cenpatico of Louisiana, Inc., a Louisiana corporation |
Cenphiny Management, LLC, a Delaware LLC
|
Centene Center LLC, a Delaware LLC
|
Centene Company of Texas, LP, a Texas limited partnership
|
Centene Corporation, a Delaware corporation
|
Centene Holdings, LLC, a Delaware LLC
|
Centene Management Company, LLC, a Wisconsin LLC
|
CMC Real Estate Company, LLC, a Delaware LLC
|
Coordinated Care Corporation, Inc., d/b/a Managed Health Services, an Indiana corporation
|
Family Care & Workforce Diversity Consultants LLC, d/b/a Worklife Innovations, a Connecticut LLC
|
Hallmark Life Insurance Company, an Arizona corporation
|
Healthy Louisiana Holdings LLC, a Delaware LLC |
IlliniCare Health Plan, Inc., an Illinois corporation
|
Integrated Mental Health Management, LLC, a Texas LLC
|
Integrated Mental Health Services, a Texas corporation
|
Kentucky Spirit Health Plan, Inc, a Kentucky corporation |
LBB Industries, Inc., a Texas corporation
|
Louisiana Health Care Connections, Inc., a Louisiana corporation |
Magnolia Health Plan Inc., a Mississippi corporation
|
Managed Health Services Illinois, Inc., an Illinois corporation |
Managed Health Services Insurance Corporation, a Wisconsin corporation
|
Novasys Health , Inc., a Delaware corporation
|
Nurse Response, Inc., a Delaware corporation
|
NurseWise Holdings, LLC, a Delaware LLC
|
NurseWise, LP, a Delaware limited partnership
|
Nurtur Health, Inc., a Delaware corporation
|
Ocucare Systems, Inc., a Florida corporation
|
OptiCare IPA of New York, Inc., a New York corporation
|
OptiCare Managed Vision, Inc., a Delaware corporation
|
OptiCare Vision Company, Inc., a Delaware corporation
|
OptiCare Vision Insurance Company, Inc., a South Carolina corporation
|
Peach State Health Plan, Inc., a Georgia corporation
|
Physicians Choice LLC, d/b/a Palmetto Administrative Services, a South Carolina LLC
|
Phytrust of South Carolina LLC, a Florida LLC
|
RX Direct, Inc., a Texas corporation
|
Sunshine Consulting Services, Inc., a Delaware corporation
|
Sunshine Health Holding Company, a Florida corporation
|
Sunshine State Health Plan, Inc., a Florida corporation
|
Superior HealthPlan, Inc., a Texas corporation
|
Total Vision, Inc., a Delaware corporation
|
U.S. Script, Inc., a Delaware corporation
|
University Health Plans, Inc., a New Jersey corporation
|
Wellness By Choice, LLC, a New York limited liability company
|
1.
|
I have reviewed this Annual Report on Form 10-K of Centene Corporation;
|
2.
|
Based on my knowledge, this report does not contain any untrue statement of a material fact or omit to state a material fact necessary to make the statements made, in light of the circumstances under which such statements were made, not misleading with respect to the period covered by this report;
|
3.
|
Based on my knowledge, the financial statements, and other financial information included in this report, fairly present in all material respects the financial condition, results of operations and cash flows of the registrant as of, and for, the periods presented in this report;
|
4.
|
The registrant’s other certifying officer and I are responsible for establishing and maintaining disclosure controls and procedures (as defined in Exchange Act Rules13a-15(e) and 15d-15(e)) and internal control over financial reporting (as defined in Exchange Act Rules 13a-15(f) and 15d-15(f)) for the registrant and have:
|
|
a.
|
Designed such disclosure controls and procedures, or caused such disclosure controls and procedures to be designed under our supervision, to ensure that material information relating to the registrant, including its consolidated subsidiaries, is made known to us by others within those entities, particularly during the period in which this report is being prepared;
|
|
b.
|
Designed such internal control over financial reporting, or caused such internal control over financial reporting to be designed under our supervision, to provide reasonable assurance regarding the reliability of financial reporting and the preparation of financial statements for external purposes in accordance with generally accepted accounting principles;
|
|
c.
|
Evaluated the effectiveness of the registrant’s disclosure controls and procedures and presented in this report our conclusions about the effectiveness of the disclosure controls and procedures, as of the end of the period covered by this report based on such evaluation; and
|
|
d.
|
Disclosed in this report any change in the registrant’s internal control over financial reporting that occurred during the registrant’s fourth fiscal quarter that has materially affected, or is reasonably likely to materially affect, the registrant’s internal control over financial reporting; and
|
5.
|
The registrant’s other certifying officer and I have disclosed, based on our most recent evaluation of internal control over financial reporting, to the registrant’s auditors and the audit committee of the registrant’s board of directors (or persons performing the equivalent functions):
|
|
a.
|
All significant deficiencies and material weaknesses in the design or operation of internal control over financial reporting which are reasonably likely to adversely affect the registrant’s ability to record, process, summarize and report financial information; and
|
|
b.
|
Any fraud, whether or not material, that involves management or other employees who have a significant role in the registrant’s internal control over financial reporting.
|
/s/ MICHAEL F. NEIDORFF
|
Michael F. Neidorff
|
Chairman and Chief Executive Officer
(principal executive officer)
|
1.
|
I have reviewed this Annual Report on Form 10-K of Centene Corporation;
|
2.
|
Based on my knowledge, this report does not contain any untrue statement of a material fact or omit to state a material fact necessary to make the statements made, in light of the circumstances under which such statements were made, not misleading with respect to the period covered by this report;
|
3.
|
Based on my knowledge, the financial statements, and other financial information included in this report, fairly present in all material respects the financial condition, results of operations and cash flows of the registrant as of, and for, the periods presented in this report;
|
4.
|
The registrant’s other certifying officer and I are responsible for establishing and maintaining disclosure controls and procedures (as defined in Exchange Act Rules13a-15(e) and 15d-15(e)) and internal control over financial reporting (as defined in Exchange Act Rules 13a-15(f) and 15d-15(f)) for the registrant and have:
|
|
a.
|
Designed such disclosure controls and procedures, or caused such disclosure controls and procedures to be designed under our supervision, to ensure that material information relating to the registrant, including its consolidated subsidiaries, is made known to us by others within those entities, particularly during the period in which this report is being prepared;
|
|
b.
|
Designed such internal control over financial reporting, or caused such internal control over financial reporting to be designed under our supervision, to provide reasonable assurance regarding the reliability of financial reporting and the preparation of financial statements for external purposes in accordance with generally accepted accounting principles;
|
|
c.
|
Evaluated the effectiveness of the registrant’s disclosure controls and procedures and presented in this report our conclusions about the effectiveness of the disclosure controls and procedures, as of the end of the period covered by this report based on such evaluation; and
|
|
d.
|
Disclosed in this report any change in the registrant’s internal control over financial reporting that occurred during the registrant’s fourth fiscal quarter that has materially affected, or is reasonably likely to materially affect, the registrant’s internal control over financial reporting; and
|
5.
|
The registrant’s other certifying officer and I have disclosed, based on our most recent evaluation of internal control over financial reporting, to the registrant’s auditors and the audit committee of the registrant’s board of directors (or persons performing the equivalent functions):
|
|
a.
|
All significant deficiencies and material weaknesses in the design or operation of internal control over financial reporting which are reasonably likely to adversely affect the registrant’s ability to record, process, summarize and report financial information; and
|
|
b.
|
Any fraud, whether or not material, that involves management or other employees who have a significant role in the registrant’s internal control over financial reporting.
|
/s/ WILLIAM N. SCHEFFEL
|
William N. Scheffel
|
Executive Vice President and Chief Financial Officer (principal financial officer)
|
(1)
|
the Report fully complies with the requirements of Section 13(a) or 15(d) of the Securities Exchange Act of 1934; and
|
(2)
|
the information contained in the Report fairly presents, in all material respects, the financial condition and results of operations of the Company.
|
/s/ MICHAEL F. NEIDORFF
|
Michael F. Neidorff
|
Chairman and Chief Executive Officer
(principal executive officer)
|
(1)
|
the Report fully complies with the requirements of Section 13(a) or 15(d) of the Securities Exchange Act of 1934; and
|
(2)
|
the information contained in the Report fairly presents, in all material respects, the financial condition and results of operations of the Company.
|
/s/ WILLIAM N. SCHEFFEL
|
William N. Scheffel
|
Executive Vice President and Chief Financial Officer (principal financial officer)
|
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