x | ANNUAL REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934 |
For the transition period from to |
Delaware | 42-1406317 | |
(State or other jurisdiction of incorporation or organization) | (I.R.S. Employer Identification Number) | |
7700 Forsyth Boulevard | ||
St. Louis, Missouri | 63105 | |
(Address of principal executive offices) | (Zip Code) |
Common Stock, $0.001 Par Value | New York Stock Exchange | |
Title of Each Class | Name of Each Exchange on Which Registered |
PAGE | |||
Part I | |||
Item 1. | Business | ||
Item 1A. | Risk Factors | ||
Item 1B. | Unresolved Staff Comments | ||
Item 2. | Properties | ||
Item 3. | Legal Proceedings | ||
Item 4. | Mine Safety Disclosures | ||
Part II | |||
Item 5. | Market for Registrant's Common Equity, Related Stockholder Matters and Issuer Purchases of Equity Securities | ||
Item 6. | Selected Financial Data | ||
Item 7. | Management's Discussion and Analysis of Financial Condition and Results of Operations | ||
Item 7A. | Quantitative and Qualitative Disclosures About Market Risk | ||
Item 8. | Financial Statements and Supplementary Data | ||
Item 9. | Changes in and Disagreements with Accountants on Accounting and Financial Disclosure | ||
Item 9A. | Controls and Procedures | ||
Item 9B. | Other Information | ||
Part III | |||
Item 10. | Directors, Executive Officers and Corporate Governance | ||
Item 11. | Executive Compensation | ||
Item 12. | Security Ownership of Certain Beneficial Owners and Management and Related Stockholder Matters | ||
Item 13. | Certain Relationships and Related Transactions, and Director Independence | ||
Item 14. | Principal Accountant Fees and Services | ||
Part IV | |||
Item 15. | Exhibits and Financial Statement Schedules | ||
Signatures |
• | our ability to accurately predict and effectively manage health benefits and other operating expenses; |
• | competition; |
• | membership and revenue projections; |
• | timing of regulatory contract approval; |
• | changes in healthcare practices; |
• | 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; |
• | changes in expected contract start dates; |
• | changes in expected closing dates and accretion for acquisitions; |
• | inflation; |
• | provider and state contract changes; |
• | new technologies; |
• | advances in medicine; |
• | reduction in provider payments by governmental payors; |
• | major epidemics; |
• | disasters and numerous other factors affecting the delivery and cost of healthcare; |
• | the expiration, cancellation or suspension of our Medicare or Medicaid managed care contracts by federal or state governments; |
• | the outcome of pending legal proceedings; |
• | availability of debt and equity financing, on terms that are favorable to us; and |
• | general economic and market conditions. |
• | 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 serve 20 states with at-risk membership totaling 2.7 million in 2013. For the year ended December 31, 2013, we had premium and service revenues from continuing operations of $10.5 billion, representing a five year Compound Annual Growth Rate, of 26.3% and generated total cash flow from operations of $382.5 million. |
• | 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 our 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. |
• | 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 in order to maximize the effectiveness of their programs. Our approach is to accomplish this while maintaining adequate levels of provider compensation and protecting our profitability. |
• | Diversified Business Lines. We continue to broaden our service offerings to address areas that we believe have been traditionally under-served 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, correctional services managed care, Health Insurance Marketplaces, in-home health services, individual health insurance, life and health management, managed vision, telehealth services, pharmacy benefits management and specialty pharmacy. 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. |
• | 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. |
• | 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 2013, we expanded our health plan in Florida with an expanded Medicaid managed care LTC contract. |
• | 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 2013, we began operating through a joint venture subsidiary, Centurion, to provide managed care in correctional facilities and also acquired AcariaHealth, an independent, comprehensive specialty pharmacy company. In 2014, we acquired U.S. Medical Management, a management services organization and provider of in-home health services for high acuity populations. 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. |
• | 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, provider compensation and minimizing fraud and abuse. 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. |
• | 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 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 2013, we began managing care for Medicaid members in California, Kansas and New Hampshire. |
• | 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. |
• | 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. For example, as a result of lower than anticipated financial performance, in July 2013, we terminated our Kentucky Medicaid managed care contract with the Commonwealth of Kentucky. |
State | Local Plan Name | First Year of Operations Under the Company | Counties Served at December 31, 2013 | Market Share (1) | At-risk Managed Care Membership at December 31, 2013 | ||||||
Arizona | Bridgeway Health Solutions | 2006 | 6 | 11.2% | 7,100 | ||||||
Arizona | Cenpatico Behavioral Health of Arizona | 2005 | 8 | 13.3% | (2) | ||||||
Arkansas | Arkansas Health and Wellness Solutions | 2014 | — | —% | — | ||||||
California | California Health and Wellness | 2013 | 19 | 56.2% | 97,200 | ||||||
Florida | Sunshine Health | 2009 | 53 | 13.3%(3) | 222,000 | ||||||
Georgia | Peach State Health Plan | 2006 | 159 | 27.6% | 318,700 | ||||||
Illinois | IlliniCare Health Plan | 2011 | 12 | 51.3% | 22,300 | ||||||
Indiana | Managed Health Services | 1995 | 92 | 27.3% | 195,500 | ||||||
Kansas | Sunflower State Health Plan | 2013 | 105 | 36.3% | 139,900 | ||||||
Louisiana | Louisiana Healthcare Connections | 2012 | 64 | 17.0% | 152,300 | ||||||
Massachusetts | CeltiCare Health Plan | 2009 | 14 | 5.2% | 12,000 | ||||||
Massachusetts | Massachusetts Partnership for Correctional Healthcare | 2013 | N/A | N/A | 10,600 | ||||||
Minnesota | Centurion of Minnesota | 2014 | — | —% | — | ||||||
Mississippi | Magnolia Health Plan | 2011 | 82 | 54.7% | 78,300 | ||||||
Missouri | Home State Health Plan | 2012 | 54 | 14.6% | 59,200 | ||||||
New Hampshire | New Hampshire Healthy Families | 2013 | 10 | 33.5% | 33,600 | ||||||
Ohio | Buckeye Community Health Plan | 2004 | 88 | 10.0% | 173,200 | ||||||
South Carolina | Absolute Total Care | 2007 | 39 | 14.0% | 91,900 | ||||||
Tennessee | Centurion of Tennessee | 2013 | N/A | N/A | 20,700 | ||||||
Texas | Superior HealthPlan | 1999 | 254 | 26.0% | 935,100 | ||||||
Washington | Coordinated Care | 2012 | 39 | 10.2% | 82,100 | ||||||
Wisconsin | Managed Health Services | 1984 | 46 | 10.2% | 71,500 | ||||||
2,723,200 |
(1) | Market share represents our % of the total at-risk members that are included in managed care programs in which we participate. |
(2) | Cenpatico Behavioral Health of Arizona provided behavioral health services for 156,600 members at December 31, 2013. |
(3) | Reflects Medicaid, ABD and CHIP programs. The Sunshine Health LTC program has a market share of 28.9%. |
• | 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 generally receive a contracted premium on a per member basis and are responsible for the medical costs and as a result, provide budget predictability. |
• | 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 to provide a seamless flow of data across our organization, enabling providers and case managers to access information, apply analytical insight and make informed decisions. |
• | 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. |
• | 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. |
• | Improved quality and medical outcomes. We have implemented programs developed to improve the quality of healthcare delivered to our members including Smart Start for your Baby, Living Well With Sickle Cell and The CentAccount Program. |
• | 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. |
• | 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. |
• | 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. |
• | 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. |
• | 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 review software. We collaborate with state and federal agencies and assist with investigation requests. We use nationally recognized standards to benchmark our processes. |
• | primary and specialty physician care |
• | inpatient and outpatient hospital care |
• | emergency and urgent care |
• | prenatal care |
• | laboratory and x-ray services |
• | home health and durable medical equipment |
• | behavioral health and substance abuse services |
• | 24-hour nurse advice line |
• | transportation assistance |
• | vision care |
• | dental care |
• | immunizations |
• | prescriptions and limited over-the-counter drugs |
• | therapies |
• | social work services |
• | care coordination |
• | Start Smart For Your Baby, or Smart Start, 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. |
• | Connections Plus is a cell phone program developed for high-risk members who have limited or no access to a safe, reliable telephone. 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. |
• | 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. |
• | Health Initiatives for Children is aimed at educating child members on a variety of health topics. In order to empower and educate children, we have partnered with a nationally recognized children's author to develop our own children's book series on topics such as obesity prevention and healthy eating, asthma, diabetes, foster care, the ills of smoking, anti-bullying and heart healthy. |
• | Health Initiatives for Teens is aimed at empowering, educating and reinforcing life skills with our teenage members. We have developed an educational series that addresses health issues, dealing with chronic diseases including diabetes and asthma, as well as teen pregnancy. |
• | Living Well with Sickle Cell is our innovative program that assists with coordination of care for our sickle cell members. Our program ensures that sickle cell members have established a medical home and work on strategies to reduce unnecessary emergency department (ED) visits through proper treatment to control symptoms and chronic complications, as well as promote self-management. |
• | My Route for Health is our adult educational series used with our case management and disease management programs. The topics of this series include how to manage asthma, COPD, diabetes, heart disease and HIV. |
• | Nurtur Diabetes Program is an innovative program that is a collaboration with our life and health management subsidiary, Nurtur Health, Inc., and our health plans that targets diabetic patients and educates them on their disease state. |
• | Community Health Record, our patient-centric electronic database, 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 database. All information is accessible |
• | The CentAccount Program offers members financial incentives for performing certain healthy behaviors. The incentives are delivered through a restricted-use prepaid debit card 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. |
• | The Asthma Management Program integrates a hands-on approach with a flexible outreach methodology that can be customized to suit different age groups and populations affected by asthma. Working through Nurtur, 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. |
• | 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. |
• | Preventive Care Programs are 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. |
• | Life and Health Management Programs are designed to help members understand their disease and treatment plans 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. |
• | 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. |
• | 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. |
• | 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 measures. |
• | 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. |
• | 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. |
• | Web-based Claims and Eligibility Resources have been implemented to provide physicians with on-line access to perform claims and eligibility inquiries. |
• | 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 members with the coordination of healthcare services in order to meet a member's specific healthcare needs |
• | incorporation of disease management, which is a comprehensive, multidisciplinary, collaborative approach to chronic illnesses such as asthma and diabetes |
• | Start Smart For Your Baby, a prenatal case management program aimed at helping women with high-risk pregnancies deliver full-term, healthy infants |
• | 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. |
• | Correctional Services. Centurion, our joint venture subsidiary with MHM Services Inc., provides comprehensive healthcare services to individuals incarcerated in Massachusetts and Tennessee state correctional facilities. Beginning in January 2014, Centurion also began operating under a new contract with the Minnesota Department of Corrections. |
• | In-Home Health Services. U.S. Medical Management, our majority owned subsidiary acquired in January 2014, provides in-home health services for high acuity populations. |
• | Individual Insurance. 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. |
• | Life and Health Management. 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 lower overall healthcare cost. |
• | Managed Vision. OptiCare Managed Vision, Inc., or 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. |
• | Telehealth Services. NurseWise LP provides 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. |
• | Pharmacy Benefits Management & Specialty Pharmacy. US Script, Inc., or 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. |
• | Care Management Software. Casenet, LLC, or Casenet, is a software provider of innovative care management solutions that automate the clinical, administrative and technical components of care management programs. During 2012, we acquired the remaining minority interest in Casenet and implemented this new software platform, which is available for sale to third parties and used by our health plans. |
• | 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 not-for-profits and 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 payment laws |
• | disclosure requirements regarding provider fee schedules and coding procedures |
• | programs to monitor and supervise the activities and financial solvency of provider groups |
• | eligibility, enrollment and dis-enrollment processes |
• | covered services |
• | eligible providers |
• | subcontractors |
• | record-keeping and record retention |
• | periodic financial and informational reporting |
• | quality assurance |
• | accreditation |
• | health education and wellness and prevention programs |
• | timeliness of claims payment |
• | financial standards |
• | safeguarding of member information |
• | fraud and abuse detection and reporting |
• | grievance procedures |
• | organization and administrative systems |
Contract | Expiration Date | Renewal or Extension | ||
Arizona - Behavioral Health | June 30, 2014 | Renewable for one additional one-year term. | ||
Arizona - LTC | September 30, 2014 | May be extended for up to two additional one-year terms. | ||
Arizona - Special Needs Plan (Medicare) | December 31, 2014 | Renewable annually for successive 12-month periods. | ||
California - Medicaid, ABD & CHIP | October 31, 2018 | Renewable up to three additional one-year terms. | ||
Florida - CHIP | September 30, 2014 | May be extended for up to two additional one-year terms. | ||
Florida - Foster Care | (1) | (1) | ||
Florida - LTC | August 31, 2018 | Renewable through the state's recertification process. | ||
Florida - Medicaid & ABD (2) | August 31, 2015 | Renewable through the state's recertification process. | ||
Florida - Special Needs Plan (Medicare) | December 31, 2014 | Renewable annually for successive 12-month periods. | ||
Georgia - Medicaid & CHIP | June 30, 2014 | Renewable for two additional one-year terms. | ||
Georgia - Special Needs Plan (Medicare) | December 31, 2014 | Renewable annually for successive 12-month periods. | ||
Illinois - ABD & LTC | April 30, 2016 | May be extended for up to five additional years. | ||
Illinois - Duals | December 31, 2015 | Renewable for two additional one-year terms. | ||
Indiana - Medicaid, CHIP & Hybrid (Healthy Indiana Plan) | December 31, 2014 | Renewable for two additional one-year terms. | ||
Kansas - Medicaid, ABD, CHIP, LTC & Foster Care | December 31, 2015 | Renewable for two additional one-year terms. | ||
Louisiana - Medicaid, CHIP, ABD & Foster Care | January 31, 2015 | Renewable for an additional two-year period through the state's recertification process. | ||
Massachusetts - Correctional Services | June 30, 2018 | Renewable for two additional one-year terms. | ||
Massachusetts - Medicaid | September 30, 2015 | May be extended for five additional one-year terms. | ||
Massachusetts - Hybrid (Commonwealth Care) | March 31, 2014 | Program ending March 31, 2014. | ||
Minnesota - Correctional Services | June 30, 2016 | May be extended for up to two and a half additional years. | ||
Mississippi - Medicaid, ABD & Foster Care | June 30, 2014 | Renewable through the state's reprocurement process. (3) |
Missouri - Medicaid, CHIP & Foster Care | June 30, 2014 | Renewable for one additional one-year term. | ||
New Hampshire - Medicaid, CHIP, Foster Care & ABD | June 30, 2015 | Renewable for one additional two-year term. | ||
Ohio - Duals | (1) | (1) | ||
Ohio - Medicaid, CHIP & ABD | June 30, 2014 | Renewable annually for successive 12-month periods. | ||
Ohio - Special Needs Plan (Medicare) | December 31, 2014 | Renewable annually for successive 12-month periods. | ||
South Carolina - Medicaid, CHIP & ABD | June 30, 2014 | Renewable through the state's recertification process. | ||
South Carolina - Duals | (1) | (1) | ||
Tennessee - Correctional Services | August 31, 2016 | Renewable through the state's reprocurement process. | ||
Texas - ABD Dallas Expansion | August 31, 2015 | May be extended for up to three additional years. | ||
Texas - ABD MRSA | August 31, 2017 | May be extended for up to five additional years. | ||
Texas - CHIP Rural Service Area | August 31, 2015 | May be extended for up to three additional years. | ||
Texas - Foster Care | February 22, 2015 | Renewable through the state's reprocurement process. | ||
Texas - Hybrid (Healthy Texas) | August 31, 2015 | (4) | ||
Texas - Medicaid, CHIP &ABD | August 31, 2015 | May be extended for up to four and a half additional years. | ||
Texas - Special Needs Plan (Medicare) | December 31, 2014 | Renewable annually for successive 12-month periods. | ||
Washington - Medicaid, CHIP, Foster Care & ABD | December 31, 2014 | Renewable through the state's recertification process. | ||
Wisconsin - Medicaid, CHIP & ABD | December 31, 2015 | Renewable through the state's recertification process every two years. | ||
Wisconsin - Network Health Plan Subcontract | December 31, 2015 | (5) | ||
Wisconsin - Special Needs Plan (Medicare) | December 31, 2014 | Renewable annually for successive 12-month periods. |
(1) | The Company has received notice of intent to award a contract, however a final contract has not yet been executed. |
(2) | The current contract expires in August 2015. In September 2013, the Florida Agency for Health Care Administration provided notice of intent to award a contract to our Florida subsidiary, Sunshine Health, in 9 of 11 regions of the Managed Medical Assistance (MMA) program. The MMA program includes TANF recipients as well as ABD and dual-eligible members. The award is subject to challenge and contract readiness periods, with enrollment expected to begin in the second quarter of 2014 and continue through October 2014. |
(3) | The current contract expires June 30, 2014. In February 2014, the State of Mississippi Department of Medicaid provided notice of intent to award a contract to our Mississippi subsidiary, Magnolia Health, to continue serving Medicaid, ABD and Foster Care members effective July 1, 2014 for a three-year period, renewable for up to two additional years. |
(4) | The Texas Health and Human Services Commission (HHSC) has communicated that the Healthy Texas program is expected to end in December 2014. |
(5) | The Company and NHP are currently in negotiation regarding any future extensions. |
Name | Age | Position | |||
Michael F. Neidorff | 71 | Chairman, President and Chief Executive Officer | |||
K. Rone Baldwin | 55 | Executive Vice President, Insurance Group Business Unit | |||
Carol E. Goldman | 56 | Executive Vice President and Chief Administrative Officer | |||
Jason M. Harrold | 44 | Executive Vice President, Specialty Company Business Unit | |||
Robert T. Hitchcock | 47 | Executive Vice President, Health Plan Business Unit | |||
Jesse N. Hunter | 38 | Executive Vice President, Chief Business Development Officer | |||
Donald G. Imholz | 61 | Executive Vice President, Operations and Chief Information Officer | |||
Edmund E. Kroll | 54 | Senior Vice President, Finance and Investor Relations | |||
C. David Minifie | 43 | Executive Vice President, Business Integration & Chief Marketing Officer | |||
William N. Scheffel | 60 | Executive Vice President, Chief Financial Officer and Treasurer | |||
Jeffrey A. Schwaneke | 38 | Senior Vice President, Corporate Controller and Chief Accounting Officer | |||
Keith H. Williamson | 61 | Executive Vice President, General Counsel and Secretary |
2014 Stock Price (through February 12, 2014) | 2013 Stock Price | 2012 Stock Price | |||||||||||||||||||||
High | Low | High | Low | High | Low | ||||||||||||||||||
First Quarter | $ | 63.09 | $ | 56.88 | $ | 48.55 | $ | 40.57 | $ | 50.36 | $ | 38.97 | |||||||||||
Second Quarter | 52.74 | 42.14 | 50.98 | 24.26 | |||||||||||||||||||
Third Quarter | 65.04 | 52.82 | 42.46 | 28.86 | |||||||||||||||||||
Fourth Quarter | 67.84 | 54.12 | 46.44 | 34.73 |
Issuer Purchases of Equity Securities Fourth Quarter 2013 | |||||||||||
Period | Total Number of Shares Purchased1 | Average Price Paid 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 Programs2 | |||||||
October 1 – October 31, 2013 | 9,311 | $ | 62.37 | — | 1,667,724 | ||||||
November 1 – November 30, 2013 | 5,363 | 57.82 | — | 1,667,724 | |||||||
December 1 – December 31, 2013 | 234,055 | 56.44 | — | 1,667,724 | |||||||
Total | 248,729 | $ | 56.69 | — | 1,667,724 | ||||||
(1) Shares acquired represent shares relinquished to the Company by certain employees for payment of taxes or option cost upon vesting of restricted stock units or option exercise. (2) Our Board of Directors adopted a stock repurchase program which allows for repurchases of up to a remaining amount of 1,667,724 shares. No duration has been placed on the repurchase program. |
December 31, | |||||||||||||||||||||||
2008 | 2009 | 2010 | 2011 | 2012 | 2013 | ||||||||||||||||||
Centene Corporation | $ | 100.00 | $ | 107.41 | $ | 128.56 | $ | 200.86 | $ | 208.02 | $ | 299.09 | |||||||||||
New York Stock Exchange Composite Index | 100.00 | 124.80 | 138.34 | 129.88 | 146.66 | 180.65 | |||||||||||||||||
S&P Supercomposite Managed Healthcare Index | 100.00 | 128.05 | 140.22 | 187.84 | 196.95 | 285.81 | |||||||||||||||||
Centene Corporation closing stock price | $ | 19.71 | $ | 21.17 | $ | 25.34 | $ | 39.59 | $ | 41.00 | $ | 58.95 | |||||||||||
Centene Corporation annual shareholder return | 7.4 | % | 19.7 | % | 56.2 | % | 3.6 | % | 43.8 | % |
Year Ended December 31, | |||||||||||||||||||
2013 | 2012 | 2011 | 2010 | 2009 | |||||||||||||||
(In thousands, except share data) | |||||||||||||||||||
Revenues: | |||||||||||||||||||
Premium | $ | 10,153,460 | $ | 7,568,889 | $ | 4,948,137 | $ | 4,192,172 | $ | 3,786,525 | |||||||||
Service | 372,580 | 112,742 | 103,765 | 91,661 | 91,758 | ||||||||||||||
Premium and service revenues | 10,526,040 | 7,681,631 | 5,051,902 | 4,283,833 | 3,878,283 | ||||||||||||||
Premium tax | 337,289 | 428,665 | 159,575 | 164,490 | 224,581 | ||||||||||||||
Total revenues | 10,863,329 | 8,110,296 | 5,211,477 | 4,448,323 | 4,102,864 | ||||||||||||||
Expenses: | |||||||||||||||||||
Medical costs | 8,994,641 | 6,781,081 | 4,191,268 | 3,584,452 | 3,230,131 | ||||||||||||||
Cost of services | 326,924 | 87,705 | 78,114 | 63,919 | 60,789 | ||||||||||||||
General and administrative expenses | 931,137 | 677,157 | 577,898 | 477,765 | 447,921 | ||||||||||||||
Premium tax expense | 333,210 | 428,354 | 160,394 | 165,118 | 225,888 | ||||||||||||||
Impairment loss | — | 28,033 | — | — | — | ||||||||||||||
Total operating expenses | 10,585,912 | 8,002,330 | 5,007,674 | 4,291,254 | 3,964,729 | ||||||||||||||
Earnings from operations | 277,417 | 107,966 | 203,803 | 157,069 | 138,135 | ||||||||||||||
Other income (expense): | |||||||||||||||||||
Investment and other income | 18,457 | 35,285 | 13,355 | 15,205 | 15,691 | ||||||||||||||
Debt extinguishment costs | — | — | (8,488 | ) | — | — | |||||||||||||
Interest expense | (26,957 | ) | (20,460 | ) | (20,320 | ) | (17,992 | ) | (16,318 | ) | |||||||||
Earnings from continuing operations, before income tax expense | 268,917 | 122,791 | 188,350 | 154,282 | 137,508 | ||||||||||||||
Income tax expense | 107,080 | 47,412 | 70,687 | 59,900 | 48,841 | ||||||||||||||
Earnings from continuing operations, net of income tax expense | 161,837 | 75,379 | 117,663 | 94,382 | 88,667 | ||||||||||||||
Discontinued operations, net of income tax expense (benefit) of $2,284, $(47,741), $(4,165), $4,388, and $(1,204), respectively | 3,881 | (86,674 | ) | (9,300 | ) | 3,889 | (2,422 | ) | |||||||||||
Net earnings (loss) | 165,718 | (11,295 | ) | 108,363 | 98,271 | 86,245 | |||||||||||||
Noncontrolling interest | 619 | (13,154 | ) | (2,855 | ) | 3,435 | 2,574 | ||||||||||||
Net earnings attributable to Centene Corporation | $ | 165,099 | $ | 1,859 | $ | 111,218 | $ | 94,836 | $ | 83,671 | |||||||||
Amounts attributable to Centene Corporation common shareholders: | |||||||||||||||||||
Earnings from continuing operations, net of income tax expense | $ | 161,218 | $ | 88,533 | $ | 120,518 | $ | 90,947 | $ | 86,093 | |||||||||
Discontinued operations, net of income tax expense (benefit) | 3,881 | (86,674 | ) | (9,300 | ) | 3,889 | (2,422 | ) | |||||||||||
Net earnings | $ | 165,099 | $ | 1,859 | $ | 111,218 | $ | 94,836 | $ | 83,671 | |||||||||
Net earnings (loss) per common share attributable to Centene Corporation: | |||||||||||||||||||
Basic: | |||||||||||||||||||
Continuing operations | $ | 2.98 | $ | 1.72 | $ | 2.40 | $ | 1.87 | $ | 2.00 | |||||||||
Discontinued operations | 0.07 | (1.68 | ) | (0.18 | ) | 0.08 | (0.06 | ) | |||||||||||
Basic earnings per common share | $ | 3.05 | $ | 0.04 | $ | 2.22 | $ | 1.95 | $ | 1.94 | |||||||||
Diluted: | |||||||||||||||||||
Continuing operations | $ | 2.87 | $ | 1.65 | $ | 2.30 | $ | 1.80 | $ | 1.94 | |||||||||
Discontinued operations | 0.07 | (1.62 | ) | (0.18 | ) | 0.08 | (0.05 | ) | |||||||||||
Diluted earnings per common share | $ | 2.94 | $ | 0.03 | $ | 2.12 | $ | 1.88 | $ | 1.89 | |||||||||
Weighted average number of common shares outstanding: | |||||||||||||||||||
Basic | 54,126,545 | 51,509,366 | 50,198,954 | 48,754,947 | 43,034,791 | ||||||||||||||
Diluted | 56,247,173 | 53,714,375 | 52,474,238 | 50,447,888 | 44,316,467 |
December 31, | ||||||||||||||||||||
2013 | 2012 | 2011 | 2010 | 2009 | ||||||||||||||||
(In thousands) | ||||||||||||||||||||
Consolidated Balance Sheet Data From Continuing Operations: | ||||||||||||||||||||
Cash and cash equivalents | $ | 974,304 | $ | 745,933 | $ | 493,532 | $ | 433,914 | $ | 400,951 | ||||||||||
Investments and restricted deposits | 940,972 | 727,157 | 652,992 | 639,983 | 585,183 | |||||||||||||||
Total assets | 3,413,483 | 2,534,612 | 2,092,530 | 1,937,852 | 1,668,772 | |||||||||||||||
Medical claims liability | 1,111,709 | 815,161 | 518,840 | 456,765 | 470,932 | |||||||||||||||
Long term debt | 665,697 | 535,481 | 348,344 | 327,824 | 307,085 | |||||||||||||||
Total stockholders' equity | 1,243,439 | 953,767 | 936,419 | 797,055 | 619,427 |
• | Year-end at-risk managed care membership of 2,723,200, an increase of 298,700 members, or 12.3% over 2012. |
• | Premium and service revenues of $10.5 billion, representing 37.0% growth year over year. |
• | Health Benefits Ratio of 88.6%, compared to 89.6% in 2012. |
• | General and Administrative expense ratio of 8.8%, compared to 8.8% in 2012. |
• | Total operating cash flows of $382.5 million, or 2.3 times net earnings. |
• | Diluted net earnings per share of $2.87, compared to $1.65 in 2012. |
• | AcariaHealth. In April 2013, we completed the acquisition of AcariaHealth, a specialty pharmacy company, for $142.5 million. The transaction consideration was financed through a combination of Centene common stock and cash on hand. |
• | California. In November 2013, our California subsidiary, California Health and Wellness Plan (CHWP), began operating under a new contract with the California Department of Health Care Services to serve Medicaid beneficiaries in 18 rural counties under the state's Medi-Cal Managed Care Rural Expansion program. Also in November 2013, CHWP began operating under a new contract to serve Medi-Cal beneficiaries in Imperial County. |
• | Florida. In August 2013, our Florida subsidiary, Sunshine Health, began operating under a contract with the Florida Agency for Health Care Administration to serve members of the Medicaid managed care LTC program. Enrollment began in August 2013 and will be implemented by region and continue through March 2014. |
• | Kansas. In January 2013, our subsidiary, Sunflower State Health Plan, began operating under a statewide contract to serve members in the state's KanCare program, which includes TANF, ABD (dual and non-dual), foster care, LTC and CHIP beneficiaries. |
• | Louisiana. In February 2012, Louisiana Healthcare Connections (LHC), began operating through a joint venture under a new contract in Louisiana to provide healthcare services to Medicaid enrollees participating in the Bayou Health program. LHC completed its three-phase membership roll-out for the three geographical service areas during the second quarter of 2012. In November 2012, the covered services provided by LHC expanded to include pharmacy benefits. During the fourth quarter of 2012, we acquired the ownership interest of our joint venture partner, bringing our ownership to 100%. |
• | Massachusetts. In July 2013, our joint venture subsidiary, Centurion, began operating under a new contract with the Department of Corrections in Massachusetts to provide comprehensive healthcare services to individuals incarcerated in Massachusetts state correctional facilities. Centurion is a joint venture between Centene and MHM Services Inc. |
• | Mississippi. In December 2012, our subsidiary, Magnolia Health Plan, began operating under an expanded contract to provide managed care services statewide to Medicaid members as well as providing behavioral health services. |
• | Missouri. In July 2012, our majority owned subsidiary, Home State Health Plan, began operating under a new contract with the Office of Administration for Missouri to serve Medicaid beneficiaries in the Eastern, Central, and Western Managed Care Regions of the state. |
• | New Hampshire. In December 2013, our subsidiary, New Hampshire Healthy Families, began operating under a new contract with the Department of Health and Human Services to serve Medicaid beneficiaries. |
• | Ohio. In July 2013, our Ohio subsidiary, Buckeye Community Health Plan (Buckeye), began operating under a new and expanded contract with Ohio Department of Job and Family Services (ODJFS) to serve Medicaid members statewide through Ohio's three newly aligned regions (West, Central/Southeast, and Northeast). Buckeye also began serving members under the ABD Children program in July 2013. |
• | Tennessee. In September 2013, our joint venture subsidiary, Centurion, began operating under a new contract to provide comprehensive healthcare services to individuals incarcerated in Tennessee state correctional facilities. |
• | Texas. In March 2012, we began operating under contracts in Texas that expanded its operations through new service areas including the 10 county Hidalgo Service Area and the Medicaid Rural Service Areas of West Texas, Central Texas and North-East Texas, as well as the addition of STAR+PLUS in the Lubbock Service Area. The expansion also added the management of outpatient pharmacy benefits in all service areas and products, as well as inpatient facility services for the STAR+PLUS program. |
• | Washington. In July 2012, we began operating under a new contract with the Washington Health Care Authority to serve Medicaid beneficiaries in the state, operating as Coordinated Care. |
• | We expect to realize the full year benefit in 2014 of business commenced during 2013 in California, Florida, Massachusetts, New Hampshire, Ohio, and Tennessee as discussed above. |
• | In February 2014, our Mississippi subsidiary, Magnolia Health Plan, was awarded a statewide managed care contract to continue serving members enrolled in the Mississippi Coordinated Access Network (MississippiCAN) program, as one of two contractors. Under the new contract, Magnolia will continue providing outpatient, behavioral health, pharmacy, vision and dental services, and will also begin providing non-emergency transportation as of July 1, 2014. |
• | In January 2014, we acquired a majority interest in U.S. Medical Management, LLC, a management services organization and provider of in-home health services for high acuity populations, for approximately $200.0 million. The transaction consideration was financed through a combination of cash on hand and 2,243,217 shares of Centene common stock |
• | In January 2014, we began serving members enrolled in Health Insurance Marketplaces in certain regions of 9 states: Arkansas, Florida, Georgia, Indiana, Massachusetts, Mississippi, Ohio, Texas and Washington. |
• | In January 2014, our CeltiCare subsidiary began operating under a new contract with the Massachusetts Executive Office of Health and Human Services to participate in the MassHealth CarePlus program in all five regions. |
• | In January 2014, Centurion began operating under a new agreement with the Minnesota Department of Corrections to provide managed healthcare services to offenders in the state's correctional facilities. |
• | In December 2013, we signed a definitive agreement to purchase a majority stake in Fidelis SecureCare of Michigan, Inc. (Fidelis), a subsidiary of Fidelis SeniorCare, Inc. The transaction is expected to close in the fourth quarter of 2014, subject to certain closing conditions including regulatory approvals, and will involve cash purchase price payments contingent on the performance of the plan over the course of 2015. Fidelis was recently selected by the Michigan Department of Community Health to provide integrated healthcare services to members who are dually eligible for Medicare and Medicaid in Macomb and Wayne counties. Enrollment is expected to commence in the fourth quarter of 2014. |
• | In November 2013, our South Carolina subsidiary, Absolute Total Care, was selected by the South Carolina Department of Health and Human Services to serve dual-eligible members as part of the state's pilot program to provide integrated and coordinated care for individuals who are eligible for both Medicare and Medicaid. Operations are expected to commence in the second half of 2014. |
• | In September 2013, the Florida Agency for Health Care Administration provided notice of intent to award a contract to our subsidiary, Sunshine Health, in 9 of 11 regions of the Managed Medical Assistance (MMA) program. The MMA program includes TANF recipients as well as ABD and dual-eligible members. The award is subject to challenge and contract readiness periods, with enrollment expected to begin in the second quarter of 2014 and continue through October 2014. In addition, we were recommended as the sole provider under a contract award for the Child Welfare Specialty Plan (Foster Care), which is expected to commence in the second quarter of 2014. |
• | In September 2013, we were awarded a contract in Texas from the Texas Health and Human Services Commission to expand our operations and serve STAR+PLUS members in two Medicaid Rural Service Areas. Enrollment is expected to begin in the second half of 2014. |
• | In November 2012, our Illinois subsidiary, IlliniCare Health Plan, was selected, contingent upon successful completion of contract negotiations, to serve dual-eligible members in Cook, DuPage, Lake, Kane, Kankakee and Will counties (Greater Chicago region) as part of the Illinois Medicare-Medicaid Alignment Initiative. Upon execution of a contract and regulatory approval, enrollment is expected to begin in 2014. |
• | In August 2012, we were notified by the ODJFS that Buckeye, our Ohio subsidiary, was selected to serve Medicaid members in a dual-eligible demonstration program in three of Ohio's pre-determined seven regions: Northeast (Cleveland), Northwest (Toledo) and West Central (Dayton). This three-year program, which is part of the state of Ohio's Integrated Care Delivery System (ICDS) expansion, will serve those who have both Medicare and Medicaid eligibility. Enrollment is expected to begin in 2014. |
December 31, | ||||||||
2013 | 2012 | 2011 | ||||||
Arizona | 7,100 | 23,500 | 23,700 | |||||
California | 97,200 | — | — | |||||
Florida | 222,000 | 214,000 | 198,300 | |||||
Georgia | 318,700 | 313,700 | 298,200 | |||||
Illinois | 22,300 | 18,000 | 16,300 | |||||
Indiana | 195,500 | 204,000 | 206,900 | |||||
Kansas | 139,900 | — | — | |||||
Louisiana | 152,300 | 165,600 | — | |||||
Massachusetts | 22,600 | 21,500 | 35,700 | |||||
Mississippi | 78,300 | 77,200 | 31,600 | |||||
Missouri | 59,200 | 59,600 | — | |||||
New Hampshire | 33,600 | — | — | |||||
Ohio | 173,200 | 157,800 | 159,900 | |||||
South Carolina | 91,900 | 90,100 | 82,900 | |||||
Tennessee | 20,700 | — | — | |||||
Texas | 935,100 | 949,900 | 503,800 | |||||
Washington | 82,100 | 57,200 | — | |||||
Wisconsin | 71,500 | 72,400 | 78,000 | |||||
Total | 2,723,200 | 2,424,500 | 1,635,300 |
December 31, | ||||||||
2013 | 2012 | 2011 | ||||||
Medicaid | 2,054,700 | 1,877,100 | 1,202,300 | |||||
CHIP & Foster Care | 275,100 | 235,200 | 210,600 | |||||
ABD & Medicare | 305,300 | 274,600 | 175,100 | |||||
Hybrid Programs | 19,000 | 29,100 | 40,500 | |||||
LTC | 37,800 | 8,500 | 6,800 | |||||
Correctional Services | 31,300 | — | — | |||||
Total | 2,723,200 | 2,424,500 | 1,635,300 |
December 31, | ||||||
2013 | 2012 | 2011 | ||||
ABD | 71,700 | 62,600 | 34,400 | |||
LTC | 28,800 | 7,700 | 6,200 | |||
Medicare | 6,500 | 5,100 | 3,200 | |||
Total | 107,000 | 75,400 | 43,800 |
2013 | 2012 | 2011 | % Change 2012-2013 | % Change 2011-2012 | |||||||||||||
Premium | $ | 10,153.4 | $ | 7,568.9 | $ | 4,948.1 | 34.1 | % | 53.0 | % | |||||||
Service | 372.6 | 112.7 | 103.8 | 230.5 | % | 8.7 | % | ||||||||||
Premium and service revenues | 10,526.0 | 7,681.6 | 5,051.9 | 37.0 | % | 52.1 | % | ||||||||||
Premium tax | 337.3 | 428.7 | 159.6 | (21.3 | )% | 168.6 | % | ||||||||||
Total revenues | 10,863.3 | 8,110.3 | 5,211.5 | 33.9 | % | 55.6 | % | ||||||||||
Medical costs | 8,994.7 | 6,781.1 | 4,191.3 | 32.6 | % | 61.8 | % | ||||||||||
Cost of services | 326.9 | 87.7 | 78.1 | 272.8 | % | 12.3 | % | ||||||||||
General and administrative expenses | 931.1 | 677.2 | 577.9 | 37.5 | % | 17.2 | % | ||||||||||
Premium tax expense | 333.2 | 428.4 | 160.4 | (22.2 | )% | 167.1 | % | ||||||||||
Impairment loss | — | 28.0 | — | (100.0 | )% | n.m. | |||||||||||
Earnings from operations | 277.4 | 107.9 | 203.8 | 156.9 | % | (47.0 | )% | ||||||||||
Investment and other income, net | (8.5 | ) | 14.8 | (15.5 | ) | (157.3 | )% | 195.9 | % | ||||||||
Earnings from continuing operations, before income tax expense | 268.9 | 122.7 | 188.3 | 119.0 | % | (34.8 | )% | ||||||||||
Income tax expense | 107.1 | 47.4 | 70.7 | 125.8 | % | (32.9 | )% | ||||||||||
Earnings from continuing operations, net of income tax | 161.8 | 75.3 | 117.6 | 114.7 | % | (35.9 | )% | ||||||||||
Discontinued operations, net of income tax expense (benefit) of $2.3, $(47.7), and $(4.2) respectively | 3.9 | (86.7 | ) | (9.3 | ) | 104.5 | % | n.m. | |||||||||
Net earnings (loss) | 165.7 | (11.4 | ) | 108.3 | n.m. | (110.4 | )% | ||||||||||
Noncontrolling interest | 0.6 | (13.2 | ) | (2.9 | ) | 104.7 | % | (360.7 | )% | ||||||||
Net earnings attributable to Centene Corporation | $ | 165.1 | $ | 1.8 | $ | 111.2 | n.m. | (98.3 | )% | ||||||||
Amounts attributable to Centene Corporation common shareholders: | |||||||||||||||||
Earnings from continuing operations, net of income tax expense | $ | 161.2 | $ | 88.5 | $ | 120.5 | 82.1 | % | (26.5 | )% | |||||||
Discontinued operations, net of income tax expense | 3.9 | (86.7 | ) | (9.3 | ) | 104.5 | % | n.m. | |||||||||
Net earnings | $ | 165.1 | $ | 1.8 | $ | 111.2 | n.m. | (98.3 | )% | ||||||||
Diluted earnings (loss) per common share attributable to Centene Corporation: | |||||||||||||||||
Continuing operations | $ | 2.87 | $ | 1.65 | $ | 2.30 | 73.9 | % | (28.3 | )% | |||||||
Discontinued operations | 0.07 | (1.62 | ) | (0.18 | ) | 104.3 | % | n.m. | |||||||||
Total diluted earnings per common share | $ | 2.94 | $ | 0.03 | $ | 2.12 | n.m. | (98.6 | )% |
2013 | 2012 | ||||
Medicaid and CHIP | 87.5 | % | 88.8 | % | |
ABD and Medicare | 90.4 | 90.7 | |||
Specialty Services | 85.4 | 92.0 | |||
Total | 88.6 | 89.6 |
2013 | 2012 | ||||||
Investment income | $ | 18.5 | $ | 15.9 | |||
Gain on sale of investments | — | 1.5 | |||||
Gain on sale of investment in convertible note | — | 17.9 | |||||
Interest expense | (27.0 | ) | (20.5 | ) | |||
Other income (expense), net | $ | (8.5 | ) | $ | 14.8 |
2013 | 2012 | % Change 2012-2013 | ||||||||
Premium and Service Revenues | ||||||||||
Managed Care | $ | 9,781.8 | $ | 7,212.0 | 35.6 | % | ||||
Specialty Services | 2,932.5 | 2,107.0 | 39.2 | % | ||||||
Eliminations | (2,188.3 | ) | (1,637.4 | ) | (33.6 | )% | ||||
Consolidated Total | $ | 10,526.0 | $ | 7,681.6 | 37.0 | % | ||||
Earnings from Operations | ||||||||||
Managed Care | $ | 197.8 | $ | 62.9 | 214.7 | % | ||||
Specialty Services | 79.6 | 45.1 | 76.4 | % | ||||||
Consolidated Total | $ | 277.4 | $ | 108.0 | 156.9 | % |
2012 | 2011 | ||||
Medicaid and CHIP | 88.8 | % | 82.0 | % | |
ABD and Medicare | 90.7 | 90.1 | |||
Specialty Services | 92.0 | 86.2 | |||
Total | 89.6 | 84.7 |
2012 | 2011 | ||||||
Investment income | $ | 15.9 | $ | 13.0 | |||
Gain on sale of investments | 1.5 | 0.3 | |||||
Gain on sale of investment in convertible note | 17.9 | — | |||||
Debt extinguishment costs | — | (8.5 | ) | ||||
Interest expense | (20.5 | ) | (20.3 | ) | |||
Other income (expense), net | $ | 14.8 | $ | (15.5 | ) |
2012 | 2011 | % Change 2011-2012 | ||||||||
Premium and Service Revenues | ||||||||||
Managed Care | $ | 7,212.0 | $ | 4,636.2 | 55.6 | % | ||||
Specialty Services | 2,107.0 | 1,190.5 | 77.0 | % | ||||||
Eliminations | (1,637.4 | ) | (774.8 | ) | (111.3 | )% | ||||
Consolidated Total | $ | 7,681.6 | $ | 5,051.9 | 52.1 | % | ||||
Earnings from Operations | ||||||||||
Managed Care | $ | 62.9 | $ | 161.9 | (61.2 | )% | ||||
Specialty Services | 45.1 | 41.9 | 7.6 | % | ||||||
Consolidated Total | $ | 108.0 | $ | 203.8 | (47.0 | )% |
Year Ended December 31, | |||||||||||
2013 | 2012 | 2011 | |||||||||
Net cash provided by operating activities | $ | 382.5 | $ | 278.7 | $ | 261.7 | |||||
Net cash used in investing activities | (342.1 | ) | (187.9 | ) | (129.1 | ) | |||||
Net cash provided by financing activities | 153.7 | 179.5 | 6.9 | ||||||||
Net increase in cash and cash equivalents | $ | 194.1 | $ | 270.3 | $ | 139.5 |
Year Ended December 31, | |||||||||||
2013 | 2012 | 2011 | |||||||||
Premium and related receivables | $ | (143.0 | ) | $ | (116.6 | ) | $ | (11.3 | ) | ||
Unearned revenue | 2.7 | 24.7 | (109.1 | ) | |||||||
Net decrease in operating cash flow | $ | (140.3 | ) | $ | (91.9 | ) | $ | (120.4 | ) |
Payments Due by Period | |||||||||||||||||||
Total | Less Than 1 Year | 1-3 Years | 3-5 Years | More Than 5 Years | |||||||||||||||
Medical claims liability | $ | 1,111,709 | $ | 1,111,709 | $ | — | $ | — | $ | — | |||||||||
Debt and interest | 775,385 | 31,180 | 62,331 | 600,725 | 81,149 | ||||||||||||||
Operating lease obligations | 126,186 | 25,350 | 50,073 | 31,963 | 18,800 | ||||||||||||||
Purchase obligations | 51,549 | 28,404 | 19,424 | 2,732 | 989 | ||||||||||||||
Other long term liabilities 1 | — | — | — | — | — | ||||||||||||||
Total | $ | 2,064,829 | $ | 1,196,643 | $ | 131,828 | $ | 635,420 | $ | 100,938 |
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 | )% | $ | 137,100 | (2.0 | )% | $ | (36,800 | ) | ||||
(1.5 | ) | 102,300 | (1.5 | ) | (27,700 | ) | ||||||
(1.0 | ) | 67,800 | (1.0 | ) | (18,500 | ) | ||||||
(0.5 | ) | 33,800 | (0.5 | ) | (9,200 | ) | ||||||
0.5 | (33,500 | ) | 0.5 | 9,200 | ||||||||
1.0 | (66,500 | ) | 1.0 | 18,700 | ||||||||
1.5 | (99,100 | ) | 1.5 | 28,000 | ||||||||
2.0 | (131,600 | ) | 2.0 | 37,300 |
(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, | |||||||||||
2013 | 2012 | 2011 | |||||||||
Balance, January 1, | $ | 815,161 | $ | 518,840 | $ | 456,765 | |||||
Incurred related to: | |||||||||||
Current year | 9,072,867 | 6,836,177 | 4,256,645 | ||||||||
Prior years | (78,226 | ) | (55,096 | ) | (65,377 | ) | |||||
Total incurred | 8,994,641 | 6,781,081 | 4,191,268 | ||||||||
Paid related to: | |||||||||||
Current year | 7,975,367 | 6,024,720 | 3,744,475 | ||||||||
Prior years | 722,726 | 460,040 | 384,718 | ||||||||
Total paid | 8,698,093 | 6,484,760 | 4,129,193 | ||||||||
Balance, December 31, | $ | 1,111,709 | $ | 815,161 | $ | 518,840 | |||||
Claims inventory, December 31 | 622,200 | 619,200 | 432,200 | ||||||||
Days in claims payable 1 | 42.4 | 38.5 | 43.4 |
1 | Days in claims payable is a calculation of medical claims liability at the end of the period divided by average expense per calendar day for the fourth quarter of each year. |
• | Appropriate leveling of care for neonatal intensive care unit hospital admissions, other inpatient hospital admissions, and observation admissions, in accordance with Interqual or other 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. |
• | Prenatal and infant health programs utilized in our Start Smart For Your Baby outreach service. |
Intangible Asset | Amortization Period | |
Purchased contract rights | 5 - 15 years | |
Provider contracts | 4 - 15 years | |
Customer relationships | 5 - 15 years | |
Trade names | 7 - 20 years |
December 31, 2013 | December 31, 2012 | ||||||
ASSETS | |||||||
Current assets: | |||||||
Cash and cash equivalents of continuing operations | $ | 974,304 | $ | 745,933 | |||
Cash and cash equivalents of discontinued operations | 63,769 | 98,019 | |||||
Total cash and cash equivalents | 1,038,073 | 843,952 | |||||
Premium and related receivables | 428,570 | 251,473 | |||||
Short term investments | 102,126 | 138,101 | |||||
Other current assets | 217,661 | 93,322 | |||||
Other current assets of discontinued operations | 13,743 | 78,977 | |||||
Total current assets | 1,800,173 | 1,405,825 | |||||
Long term investments | 791,900 | 554,770 | |||||
Restricted deposits | 46,946 | 34,286 | |||||
Property, software and equipment, net | 395,407 | 375,893 | |||||
Goodwill | 348,432 | 256,288 | |||||
Intangible assets, net | 48,780 | 20,268 | |||||
Other long term assets | 59,357 | 64,278 | |||||
Long term assets of discontinued operations | 38,305 | 62,297 | |||||
Total assets | $ | 3,529,300 | $ | 2,773,905 | |||
LIABILITIES AND STOCKHOLDERS’ EQUITY | |||||||
Current liabilities: | |||||||
Medical claims liability | $ | 1,111,709 | $ | 815,161 | |||
Accounts payable and accrued expenses | 375,862 | 219,066 | |||||
Unearned revenue | 38,191 | 34,597 | |||||
Current portion of long term debt | 3,065 | 3,373 | |||||
Current liabilities of discontinued operations | 30,294 | 157,116 | |||||
Total current liabilities | 1,559,121 | 1,229,313 | |||||
Long term debt | 665,697 | 535,481 | |||||
Other long term liabilities | 60,015 | 54,987 | |||||
Long term liabilities of discontinued operations | 1,028 | 357 | |||||
Total liabilities | 2,285,861 | 1,820,138 | |||||
Commitments and contingencies | |||||||
Stockholders’ equity: | |||||||
Common stock, $.001 par value; authorized 100,000,000 shares; 58,673,215 issued and 55,319,239 outstanding at December 31, 2013, and 55,339,160 issued and 52,329,248 outstanding at December 31, 2012 | 59 | 55 | |||||
Additional paid-in capital | 594,326 | 450,856 | |||||
Accumulated other comprehensive income: | |||||||
Unrealized (loss) gain on investments, net of tax | (2,620 | ) | 5,189 | ||||
Retained earnings | 731,919 | 566,820 | |||||
Treasury stock, at cost (3,353,976 and 3,009,912 shares, respectively) | (89,643 | ) | (69,864 | ) | |||
Total Centene stockholders’ equity | 1,234,041 | 953,056 | |||||
Noncontrolling interest | 9,398 | 711 | |||||
Total stockholders’ equity | 1,243,439 | 953,767 | |||||
Total liabilities and stockholders’ equity | $ | 3,529,300 | $ | 2,773,905 |
Year Ended December 31, | |||||||||||
2013 | 2012 | 2011 | |||||||||
Revenues: | |||||||||||
Premium | $ | 10,153,460 | $ | 7,568,889 | $ | 4,948,137 | |||||
Service | 372,580 | 112,742 | 103,765 | ||||||||
Premium and service revenues | 10,526,040 | 7,681,631 | 5,051,902 | ||||||||
Premium tax | 337,289 | 428,665 | 159,575 | ||||||||
Total revenues | 10,863,329 | 8,110,296 | 5,211,477 | ||||||||
Expenses: | |||||||||||
Medical costs | 8,994,641 | 6,781,081 | 4,191,268 | ||||||||
Cost of services | 326,924 | 87,705 | 78,114 | ||||||||
General and administrative expenses | 931,137 | 677,157 | 577,898 | ||||||||
Premium tax expense | 333,210 | 428,354 | 160,394 | ||||||||
Impairment loss | — | 28,033 | — | ||||||||
Total operating expenses | 10,585,912 | 8,002,330 | 5,007,674 | ||||||||
Earnings from operations | 277,417 | 107,966 | 203,803 | ||||||||
Other income (expense): | |||||||||||
Investment and other income | 18,457 | 35,285 | 13,355 | ||||||||
Debt extinguishment costs | — | — | (8,488 | ) | |||||||
Interest expense | (26,957 | ) | (20,460 | ) | (20,320 | ) | |||||
Earnings from continuing operations, before income tax expense | 268,917 | 122,791 | 188,350 | ||||||||
Income tax expense | 107,080 | 47,412 | 70,687 | ||||||||
Earnings from continuing operations, net of income tax expense | 161,837 | 75,379 | 117,663 | ||||||||
Discontinued operations, net of income tax expense (benefit) of $2,284, $(47,741), and $(4,165), respectively | 3,881 | (86,674 | ) | (9,300 | ) | ||||||
Net earnings (loss) | 165,718 | (11,295 | ) | 108,363 | |||||||
Noncontrolling interest | 619 | (13,154 | ) | (2,855 | ) | ||||||
Net earnings attributable to Centene Corporation | $ | 165,099 | $ | 1,859 | $ | 111,218 | |||||
Amounts attributable to Centene Corporation common shareholders: | |||||||||||
Earnings from continuing operations, net of income tax expense | $ | 161,218 | $ | 88,533 | $ | 120,518 | |||||
Discontinued operations, net of income tax expense (benefit) | 3,881 | (86,674 | ) | (9,300 | ) | ||||||
Net earnings | $ | 165,099 | $ | 1,859 | $ | 111,218 | |||||
Net earnings (loss) per common share attributable to Centene Corporation: | |||||||||||
Basic: | |||||||||||
Continuing operations | $ | 2.98 | $ | 1.72 | $ | 2.40 | |||||
Discontinued operations | 0.07 | (1.68 | ) | (0.18 | ) | ||||||
Basic earnings per common share | $ | 3.05 | $ | 0.04 | $ | 2.22 | |||||
Diluted: | |||||||||||
Continuing operations | $ | 2.87 | $ | 1.65 | $ | 2.30 | |||||
Discontinued operations | 0.07 | (1.62 | ) | (0.18 | ) | ||||||
Diluted earnings per common share | $ | 2.94 | $ | 0.03 | $ | 2.12 | |||||
Weighted average number of common shares outstanding: | |||||||||||
Basic | 54,126,545 | 51,509,366 | 50,198,954 | ||||||||
Diluted | 56,247,173 | 53,714,375 | 52,474,238 |
Year Ended December 31, | |||||||||||
2013 | 2012 | 2011 | |||||||||
Net earnings (loss) | $ | 165,718 | $ | (11,295 | ) | $ | 108,363 | ||||
Reclassification adjustment, net of tax | (875 | ) | (1,789 | ) | (549 | ) | |||||
Change in unrealized (loss) gain on investments, net of tax | (6,934 | ) | 1,217 | (114 | ) | ||||||
Other comprehensive earnings (loss) | (7,809 | ) | (572 | ) | (663 | ) | |||||
Comprehensive earnings (loss) | 157,909 | (11,867 | ) | 107,700 | |||||||
Comprehensive earnings (loss) attributable to the noncontrolling interest | 619 | (13,154 | ) | (2,855 | ) | ||||||
Comprehensive earnings attributable to Centene Corporation | $ | 157,290 | $ | 1,287 | $ | 110,555 |
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, 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 | ||||||||||||||||||||||||
Contributions 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 | ||||||||||||||||
Comprehensive Earnings: | |||||||||||||||||||||||||||||||||
Net earnings (loss) | — | — | — | — | 1,859 | — | — | (13,154 | ) | (11,295 | ) | ||||||||||||||||||||||
Change in unrealized investment gain, net of $(296) tax | — | — | — | (572 | ) | — | — | — | — | (572 | ) | ||||||||||||||||||||||
Total comprehensive earnings (loss) | (11,867 | ) | |||||||||||||||||||||||||||||||
Common stock issued for employee benefit plans | 1,752,434 | 1 | 16,725 | — | — | — | — | — | 16,726 | ||||||||||||||||||||||||
Common stock repurchases | — | — | — | — | — | 287,804 | (12,741 | ) | — | (12,741 | ) | ||||||||||||||||||||||
Stock compensation expense | — | — | 25,332 | — | — | — | — | — | 25,332 | ||||||||||||||||||||||||
Excess tax benefits from stock compensation | — | — | 10,999 | — | — | — | — | — | 10,999 | ||||||||||||||||||||||||
Purchase of noncontrolling interest | — | — | (24,181 | ) | — | — | — | — | 11,988 | (12,193 | ) | ||||||||||||||||||||||
Contribution from noncontrolling interest | — | — | — | — | — | — | — | 1,092 | 1,092 | ||||||||||||||||||||||||
Balance, December 31, 2012 | 55,339,160 | $ | 55 | $ | 450,856 | $ | 5,189 | $ | 566,820 | 3,009,912 | $ | (69,864 | ) | $ | 711 | $ | 953,767 | ||||||||||||||||
Comprehensive Earnings: | |||||||||||||||||||||||||||||||||
Net earnings (loss) | — | — | — | — | 165,099 | — | — | 619 | 165,718 | ||||||||||||||||||||||||
Change in unrealized investment loss, net of $(4,438) tax | — | — | — | (7,809 | ) | — | — | — | — | (7,809 | ) | ||||||||||||||||||||||
Total comprehensive earnings | 157,909 | ||||||||||||||||||||||||||||||||
Common stock issued for acquisition | 1,716,690 | 2 | 75,405 | — | — | — | — | — | 75,407 | ||||||||||||||||||||||||
Common stock issued for stock offering | 342,640 | — | 15,225 | — | — | — | — | — | 15,225 | ||||||||||||||||||||||||
Common stock issued for employee benefit plans | 1,274,725 | 2 | 9,796 | — | — | — | — | — | 9,798 | ||||||||||||||||||||||||
Common stock repurchases | — | — | — | — | — | 344,064 | (19,779 | ) | — | (19,779 | ) | ||||||||||||||||||||||
Stock compensation expense | — | — | 36,656 | — | — | — | — | — | 36,656 | ||||||||||||||||||||||||
Excess tax benefits from stock compensation | — | — | 6,388 | — | — | — | — | — | 6,388 | ||||||||||||||||||||||||
Contribution from noncontrolling interest | — | — | — | — | — | — | — | 8,068 | 8,068 | ||||||||||||||||||||||||
Balance, December 31, 2013 | 58,673,215 | $ | 59 | $ | 594,326 | $ | (2,620 | ) | $ | 731,919 | 3,353,976 | $ | (89,643 | ) | $ | 9,398 | $ | 1,243,439 |
Year Ended December 31, | |||||||||||
2013 | 2012 | 2011 | |||||||||
Cash flows from operating activities: | |||||||||||
Net earnings (loss) | $ | 165,718 | $ | (11,295 | ) | $ | 108,363 | ||||
Adjustments to reconcile net earnings to net cash provided by operating activities | |||||||||||
Depreciation and amortization | 67,420 | 65,866 | 58,327 | ||||||||
Stock compensation expense | 36,656 | 25,332 | 18,171 | ||||||||
Impairment loss | — | 28,033 | |||||||||
Gain on sale of investment in convertible note | — | (17,880 | ) | — | |||||||
Debt extinguishment costs | — | — | 8,488 | ||||||||
Deferred income taxes | (2,293 | ) | (14,438 | ) | 2,031 | ||||||
Changes in assets and liabilities | |||||||||||
Premium and related receivables | (142,977 | ) | (116,558 | ) | (11,306 | ) | |||||
Other current assets | (79,588 | ) | (36,818 | ) | (11,812 | ) | |||||
Other assets | (736 | ) | 2,825 | (2 | ) | ||||||
Medical claims liabilities | 171,569 | 359,792 | 149,756 | ||||||||
Unearned revenue | 2,724 | 24,707 | (109,082 | ) | |||||||
Accounts payable and accrued expenses | 151,712 | (21,474 | ) | 38,889 | |||||||
Other operating activities | 12,321 | (9,401 | ) | 9,873 | |||||||
Net cash provided by operating activities | 382,526 | 278,691 | 261,696 | ||||||||
Cash flows from investing activities: | |||||||||||
Capital expenditures | (67,835 | ) | (82,144 | ) | (73,708 | ) | |||||
Purchases of investments | (790,653 | ) | (695,687 | ) | (318,397 | ) | |||||
Sales and maturities of investments | 579,161 | 589,921 | 267,404 | ||||||||
Investments in acquisitions, net of cash acquired | (62,773 | ) | — | (4,375 | ) | ||||||
Net cash used in investing activities | (342,100 | ) | (187,910 | ) | (129,076 | ) | |||||
Cash flows from financing activities: | |||||||||||
Proceeds from exercise of stock options | 8,983 | 15,912 | 15,815 | ||||||||
Proceeds from borrowings | 180,000 | 400,500 | 419,183 | ||||||||
Proceeds from stock offering | 15,225 | — | — | ||||||||
Payment of long term debt | (41,593 | ) | (218,234 | ) | (416,283 | ) | |||||
Excess tax benefits from stock compensation | 6,380 | 10,996 | 4,435 | ||||||||
Common stock repurchases | (19,779 | ) | (12,741 | ) | (7,809 | ) | |||||
Contribution from noncontrolling interest | 8,068 | 1,092 | 813 | ||||||||
Purchase of noncontrolling interest | — | (14,429 | ) | — | |||||||
Debt issue costs | (3,589 | ) | (3,623 | ) | (9,242 | ) | |||||
Net cash provided by financing activities | 153,695 | 179,473 | 6,912 | ||||||||
Net increase in cash and cash equivalents | 194,121 | 270,254 | 139,532 | ||||||||
Cash and cash equivalents, beginning of period | 843,952 | 573,698 | 434,166 | ||||||||
Cash and cash equivalents, end of period | $ | 1,038,073 | $ | 843,952 | $ | 573,698 | |||||
Supplemental disclosures of cash flow information: | |||||||||||
Interest paid | $ | 30,009 | $ | 21,605 | $ | 27,383 | |||||
Income taxes paid | $ | 84,681 | $ | 42,877 | $ | 50,444 | |||||
Equity issued in connection with acquisition | $ | 75,425 | $ | — | $ | — |
• | 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 | 2 - 7 years | |
Furniture and equipment | 3 - 10 years | |
Leasehold improvements | 1 - 20 years |
Intangible Asset | Amortization Period | |
Purchased contract rights | 5 - 15 years | |
Provider contracts | 4 - 15 years | |
Customer relationships | 5 - 15 years | |
Trade names | 7 - 20 years |
2013 | 2012 | 2011 | ||||||
Allowances, beginning of year | 781 | 639 | 17 | |||||
Amounts charged to expense | 3,138 | 1,350 | 865 | |||||
Write-offs of uncollectible receivables | (2,801 | ) | (1,208 | ) | (243 | ) | ||
Allowances, end of year | 1,118 | 781 | 639 |
2013 | 2012 | 2011 | |||||
Texas | 37% | Texas | 40% | Georgia | 15% | ||
Ohio | 12% | ||||||
Texas | 21% |
2013 | 2012 | 2011 | |||||||
Casenet | 100 | % | 100 | % | 81 | % | |||
Centurion | 51 | % | 51 | % | 51 | % | |||
Louisiana Healthcare Connections | 100 | % | 100 | % | 51 | % | |||
Home State Health Plan | 95 | % | 95 | % | — | % |
Year Ended December 31, | |||||||||||
2013 | 2012 | 2011 | |||||||||
Net earnings attributable to Centene Corporation | $ | 161,218 | $ | 88,533 | $ | 120,518 | |||||
Transfers from (to) the noncontrolling interest: | |||||||||||
Decrease in equity for purchase of, distribution to and redemption of noncontrolling interest | — | (12,193 | ) | (289 | ) | ||||||
Increase in equity for distributions from and consolidation of noncontrolling interest | 8,068 | 1,092 | 813 | ||||||||
Net transfers from (to) noncontrolling interest | 8,068 | (11,101 | ) | 524 | |||||||
Changes from net earnings attributable to Centene Corporation and net transfers from (to) the noncontrolling interest | $ | 169,286 | $ | 77,432 | $ | 121,042 |
Employee Benefits | Lease Termination | Total | ||||||||||
Balance, December 31, 2011 | $ | — | $ | — | $ | — | ||||||
Incurred | 2,939 | — | 2,939 | |||||||||
Balance, December 31, 2012 | 2,939 | — | 2,939 | |||||||||
Incurred | 434 | 735 | 1,169 | |||||||||
Paid | (2,837 | ) | — | (2,837 | ) | |||||||
Balance, December 31, 2013 | $ | 536 | $ | 735 | $ | 1,271 |
Year Ended December 31, | ||||||||||||
2013 | 2012 | 2011 | ||||||||||
Revenues | $ | 248,327 | $ | 557,316 | $ | 129,105 | ||||||
Earnings (loss) before income taxes | $ | 6,165 | $ | (134,415 | ) | $ | (13,465 | ) | ||||
Net earnings (loss) | $ | 3,881 | $ | (86,674 | ) | $ | (9,300 | ) |
December 31, 2013 | December 31, 2012 | ||||||||
Current assets | $ | 77,512 | $ | 176,996 | |||||
Long term investments and restricted deposits | 38,305 | 60,461 | |||||||
Other assets | — | 1,836 | |||||||
Assets of discontinued operations | $ | 115,817 | $ | 239,293 | |||||
Medical claims liability | $ | 27,637 | $ | 111,141 | |||||
Accounts payable and accrued expenses | 2,657 | 45,975 | |||||||
Other liabilities | 1,028 | 357 | |||||||
Liabilities of discontinued operations | $ | 31,322 | $ | 157,473 |
December 31, 2013 | December 31, 2012 | ||||||||||||||||||||||||||||||
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 | $ | 246,085 | $ | 245 | $ | (7,494 | ) | $ | 238,836 | $ | 110,941 | $ | 581 | $ | (221 | ) | $ | 111,301 | |||||||||||||
Corporate securities | 293,912 | 2,782 | (608 | ) | 296,086 | 290,691 | 4,615 | (195 | ) | 295,111 | |||||||||||||||||||||
Restricted certificates of deposit | 5,891 | — | — | 5,891 | 5,890 | — | — | 5,890 | |||||||||||||||||||||||
Restricted cash equivalents | 26,642 | — | — | 26,642 | 14,455 | — | — | 14,455 | |||||||||||||||||||||||
Municipal securities: | |||||||||||||||||||||||||||||||
General obligation | 54,003 | 555 | (136 | ) | 54,422 | 85,440 | 1,157 | (26 | ) | 86,571 | |||||||||||||||||||||
Pre-refunded | 10,835 | 82 | — | 10,917 | 5,337 | 85 | — | 5,422 | |||||||||||||||||||||||
Revenue | 68,801 | 545 | (292 | ) | 69,054 | 82,781 | 1,313 | (30 | ) | 84,064 | |||||||||||||||||||||
Variable rate demand notes | 28,575 | — | — | 28,575 | 23,385 | — | — | 23,385 | |||||||||||||||||||||||
Asset backed securities | 138,803 | 579 | (332 | ) | 139,050 | 73,570 | 1,082 | (15 | ) | 74,637 | |||||||||||||||||||||
Mortgage backed securities | 33,974 | — | (83 | ) | 33,891 | — | — | — | — | ||||||||||||||||||||||
Cost and equity method investments | 22,239 | — | — | 22,239 | 11,298 | — | — | 11,298 | |||||||||||||||||||||||
Life insurance contracts | 15,369 | — | — | 15,369 | 15,023 | — | — | 15,023 | |||||||||||||||||||||||
Total | $ | 945,129 | $ | 4,788 | $ | (8,945 | ) | $ | 940,972 | $ | 718,811 | $ | 8,833 | $ | (487 | ) | $ | 727,157 |
December 31, 2013 | December 31, 2012 | ||||||||||||||||||||||||||||||
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 | $ | (6,188 | ) | $ | 172,365 | $ | (1,307 | ) | $ | 26,454 | $ | (219 | ) | $ | 56,033 | $ | (2 | ) | $ | 201 | |||||||||||
Corporate securities | (400 | ) | 52,725 | (207 | ) | 5,020 | (195 | ) | 44,208 | — | — | ||||||||||||||||||||
Municipal securities: | |||||||||||||||||||||||||||||||
General obligation | (72 | ) | 3,480 | (63 | ) | 2,426 | (26 | ) | 7,930 | — | — | ||||||||||||||||||||
Revenue | (292 | ) | 27,789 | — | — | (30 | ) | 3,090 | — | — | |||||||||||||||||||||
Asset backed securities | (333 | ) | 37,689 | — | — | (15 | ) | 8,192 | — | — | |||||||||||||||||||||
Mortgage backed securities | (83 | ) | 33,891 | — | — | — | — | — | — | ||||||||||||||||||||||
Total | $ | (7,368 | ) | $ | 327,939 | $ | (1,577 | ) | $ | 33,900 | $ | (485 | ) | $ | 119,453 | $ | (2 | ) | $ | 201 |
December 31, 2013 | December 31, 2012 | ||||||||||||||||||||||||||||||
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 | $ | 101,537 | $ | 102,126 | $ | 40,633 | $ | 40,637 | $ | 136,997 | $ | 138,101 | $ | 33,897 | $ | 33,928 | |||||||||||||||
One year through five years | 609,755 | 610,589 | 6,301 | 6,309 | 429,053 | 435,728 | 358 | 358 | |||||||||||||||||||||||
Five years through ten years | 157,003 | 151,221 | — | — | 93,907 | 93,778 | — | — | |||||||||||||||||||||||
Greater than ten years | 29,900 | 30,090 | — | — | 24,599 | 25,264 | — | — | |||||||||||||||||||||||
Total | $ | 898,195 | $ | 894,026 | $ | 46,934 | $ | 46,946 | $ | 684,556 | $ | 692,871 | $ | 34,255 | $ | 34,286 |
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 | $ | 974,304 | $ | — | $ | — | $ | 974,304 | |||||||
Investments available for sale: | |||||||||||||||
U.S. Treasury securities and obligations of U.S. government corporations and agencies | $ | 212,185 | $ | 12,238 | $ | — | $ | 224,423 | |||||||
Corporate securities | — | 296,086 | — | 296,086 | |||||||||||
Municipal securities: | |||||||||||||||
General obligation | — | 54,422 | — | 54,422 | |||||||||||
Pre-refunded | — | 10,917 | — | 10,917 | |||||||||||
Revenue | — | 69,054 | — | 69,054 | |||||||||||
Variable rate demand notes | — | 28,575 | — | 28,575 | |||||||||||
Asset backed securities | — | 139,050 | — | 139,050 | |||||||||||
Mortgage backed securities | $ | — | $ | 33,891 | $ | — | $ | 33,891 | |||||||
Total investments | $ | 212,185 | $ | 644,233 | $ | — | $ | 856,418 | |||||||
Restricted deposits available for sale: | |||||||||||||||
Cash and cash equivalents | $ | 26,642 | $ | — | $ | — | $ | 26,642 | |||||||
Certificates of deposit | 5,891 | — | — | 5,891 | |||||||||||
U.S. Treasury securities and obligations of U.S. government corporations and agencies | 14,413 | — | — | 14,413 | |||||||||||
Total restricted deposits | $ | 46,946 | $ | — | $ | — | $ | 46,946 | |||||||
Other long term assets: | |||||||||||||||
Interest rate swap contract | $ | — | $ | 9,576 | $ | — | $ | 9,576 | |||||||
Total assets at fair value | $ | 1,233,435 | $ | 653,809 | $ | — | $ | 1,887,244 |
Level I | Level II | Level III | Total | ||||||||||||
Assets | |||||||||||||||
Cash and cash equivalents | $ | 745,933 | $ | — | $ | — | $ | 745,933 | |||||||
Investments available for sale: | |||||||||||||||
U.S. Treasury securities and obligations of U.S. government corporations and agencies | $ | 57,114 | $ | 40,246 | $ | — | $ | 97,360 | |||||||
Corporate securities | — | 295,111 | — | 295,111 | |||||||||||
Municipal securities: | |||||||||||||||
General obligation | — | 86,571 | — | 86,571 | |||||||||||
Pre-refunded | — | 5,422 | — | 5,422 | |||||||||||
Revenue | — | 84,064 | — | 84,064 | |||||||||||
Variable rate demand notes | — | 23,385 | — | 23,385 | |||||||||||
Asset backed securities | — | 74,637 | — | 74,637 | |||||||||||
Mortgage backed securities | — | — | — | — | |||||||||||
Total investments | $ | 57,114 | $ | 609,436 | $ | — | $ | 666,550 | |||||||
Restricted deposits available for sale: | |||||||||||||||
Cash and cash equivalents | $ | 14,455 | $ | — | $ | — | $ | 14,455 | |||||||
Certificates of deposit | 5,890 | — | — | 5,890 | |||||||||||
U.S. Treasury securities and obligations of U.S. government corporations and agencies | 13,941 | — | — | 13,941 | |||||||||||
Total restricted deposits | $ | 34,286 | $ | — | $ | — | $ | 34,286 | |||||||
Other long term assets: | |||||||||||||||
Interest rate swap contract | $ | — | $ | 16,304 | $ | — | $ | 16,304 | |||||||
Total assets at fair value | $ | 837,333 | $ | 625,740 | $ | — | $ | 1,463,073 |
2013 | 2012 | ||||||
Computer software | $ | 184,983 | $ | 164,755 | |||
Building | 206,058 | 193,186 | |||||
Land | 69,705 | 70,276 | |||||
Computer hardware | 69,087 | 57,389 | |||||
Furniture and office equipment | 53,180 | 43,136 | |||||
Leasehold improvements | 56,816 | 49,808 | |||||
639,829 | 578,550 | ||||||
Less accumulated depreciation | (244,422 | ) | (202,657 | ) | |||
Property, software and equipment, net | $ | 395,407 | $ | 375,893 |
Managed Care | Specialty Services | Total | |||||||||
Balance as of December 31, 2011 | $ | 151,402 | $ | 130,579 | $ | 281,981 | |||||
Impairment | — | (25,693 | ) | (25,693 | ) | ||||||
Balance as of December 31, 2012 | 151,402 | 104,886 | 256,288 | ||||||||
Acquisition | — | 92,144 | 92,144 | ||||||||
Balance as of December 31, 2013 | $ | 151,402 | $ | 197,030 | $ | 348,432 |
Weighted Average Life in Years | |||||||||||
2013 | 2012 | 2013 | 2012 | ||||||||
Purchased contract rights | $ | 21,988 | $ | 21,988 | 7.5 | 7.5 | |||||
Provider contracts | 35,537 | 2,737 | 13.2 | 9.8 | |||||||
Customer relationships | 13,396 | 13,396 | 8.0 | 8.0 | |||||||
Trade names | 8,695 | 6,495 | 18.9 | 16.3 | |||||||
Intangible assets | 79,616 | 44,616 | 11.1 | 9.1 | |||||||
Less accumulated amortization: | |||||||||||
Purchased contract rights | (13,459 | ) | (11,010 | ) | |||||||
Provider contracts | (3,767 | ) | (1,241 | ) | |||||||
Customer relationships | (11,425 | ) | (10,214 | ) | |||||||
Trade names | (2,185 | ) | (1,883 | ) | |||||||
Total accumulated amortization | (30,836 | ) | (24,348 | ) | |||||||
Intangible assets, net | $ | 48,780 | $ | 20,268 |
Year | Expense | |||
2014 | $ | 6,800 | ||
2015 | 5,900 | |||
2016 | 5,900 | |||
2017 | 4,400 | |||
2018 | 2,600 |
Year Ended December 31, | |||||||||||
2013 | 2012 | 2011 | |||||||||
Balance, January 1, | $ | 815,161 | $ | 518,840 | $ | 456,765 | |||||
Incurred related to: | |||||||||||
Current year | 9,072,867 | 6,836,177 | 4,256,645 | ||||||||
Prior years | (78,226 | ) | (55,096 | ) | (65,377 | ) | |||||
Total incurred | 8,994,641 | 6,781,081 | 4,191,268 | ||||||||
Paid related to: | |||||||||||
Current year | 7,975,367 | 6,024,720 | 3,744,475 | ||||||||
Prior years | 722,726 | 460,040 | 384,718 | ||||||||
Total paid | 8,698,093 | 6,484,760 | 4,129,193 | ||||||||
Balance, December 31, | $ | 1,111,709 | $ | 815,161 | $ | 518,840 |
December 31, 2013 | December 31, 2012 | ||||||
Senior notes, at par | $ | 425,000 | $ | 425,000 | |||
Unamortized premium on senior notes | 6,052 | 7,823 | |||||
Interest rate swap fair value | 9,576 | 16,304 | |||||
Senior notes | 440,628 | 449,127 | |||||
Revolving credit agreement | 150,000 | — | |||||
Mortgage notes payable | 72,785 | 84,081 | |||||
Capital leases and other | 5,349 | 5,646 | |||||
Total debt | 668,762 | 538,854 | |||||
Less current portion | (3,065 | ) | (3,373 | ) | |||
Long term debt | $ | 665,697 | $ | 535,481 |
2014 | $ | 3,065 | ||
2015 | 3,188 | |||
2016 | 3,353 | |||
2017 | 428,525 | |||
2018 | 153,702 | |||
Thereafter | 61,301 | |||
Total | $ | 653,134 |
2013 | 2012 | 2011 | |||||||||
Current provision: | |||||||||||
Federal | $ | 120,858 | $ | 47,528 | $ | 63,388 | |||||
State and local | 5,857 | (4,368 | ) | 5,157 | |||||||
Total current provision | 126,715 | 43,160 | 68,545 | ||||||||
Deferred provision | (19,635 | ) | 4,252 | 2,142 | |||||||
Total provision for income taxes | $ | 107,080 | $ | 47,412 | $ | 70,687 |
2013 | 2012 | 2011 | |||||||||
Earnings from continuing operations, before income tax expense | $ | 268,917 | $ | 122,791 | $ | 188,350 | |||||
Less flow through noncontrolling interest | 960 | (2,539 | ) | (2,855 | ) | ||||||
Earnings from continuing operations, less noncontrolling interest, before income tax expense | 267,957 | 125,330 | 191,205 | ||||||||
Tax provision at the U.S. federal statutory rate | 93,785 | 43,866 | 66,922 | ||||||||
State income taxes, net of federal income tax benefit | 2,871 | (2,288 | ) | 3,381 | |||||||
Nondeductible goodwill impairment | — | 8,487 | — | ||||||||
Nondeductible compensation | 12,519 | 1,108 | 2,705 | ||||||||
Other, net | (2,095 | ) | (3,761 | ) | (2,321 | ) | |||||
Income tax expense | $ | 107,080 | $ | 47,412 | $ | 70,687 |
2013 | 2012 | ||||||
Deferred tax assets: | |||||||
Medical claims liability and other accruals | $ | 53,943 | $ | 37,413 | |||
State net operating loss carry forward | 9,530 | 9,055 | |||||
Stock compensation | 14,223 | 12,615 | |||||
Other | 30,199 | 20,573 | |||||
Deferred tax assets | 107,895 | 79,656 | |||||
Valuation allowance | (8,119 | ) | (8,180 | ) | |||
Net deferred tax assets | $ | 99,776 | $ | 71,476 | |||
Deferred tax liabilities: | |||||||
Intangible assets | $ | 18,278 | $ | 12,441 | |||
Prepaid assets | 5,621 | 4,767 | |||||
Depreciation and amortization | 30,411 | 31,741 | |||||
Other | 1,615 | 5,624 | |||||
Deferred tax liabilities | $ | 55,925 | $ | 54,573 | |||
Net deferred tax assets | $ | 43,851 | $ | 16,903 |
2013 | 2012 | ||||||
Gross unrecognized tax benefits, beginning of period | $ | 7,870 | $ | 13,552 | |||
Gross increases: | |||||||
Current year tax positions | 338 | 4,107 | |||||
Prior year tax positions | 164 | 451 | |||||
Gross decreases: | |||||||
Prior year tax positions | — | (9,925 | ) | ||||
Settlements | (4,390 | ) | (53 | ) | |||
Statute of limitation lapses | (708 | ) | (262 | ) | |||
Gross unrecognized tax benefits, end of period | $ | 3,274 | $ | 7,870 |
Shares | Weighted Average Exercise Price | Aggregate Intrinsic Value | Weighted Average Remaining Contractual Term | |||||||||
Outstanding as of December 31, 2012 | 1,299,396 | $ | 22.39 | |||||||||
Granted | 10,000 | 44.58 | ||||||||||
Exercised | (361,538 | ) | 20.32 | |||||||||
Forfeited | (663 | ) | 17.86 | |||||||||
Outstanding as of December 31, 2013 | 947,195 | $ | 23.41 | $ | 33,659 | 2.8 | ||||||
Exercisable as of December 31, 2013 | 921,462 | $ | 23.21 | $ | 32,937 | 2.7 |
Year Ended December 31, | |||||
2013 | 2012 (1) | 2011 | |||
Expected life (in years) | 5.1 | — | 5.2 | ||
Risk-free interest rate | 0.8% | — | 0.9% | ||
Expected volatility | 48.1% | — | 49.9% | ||
Expected dividend yield | — | — | — | ||
(1) No options were awarded in the year ended December 31, 2012. |
Year Ended December 31, | |||||||||||
2013 | 2012 (1) | 2011 | |||||||||
Weighted-average fair value of options granted | $ | 19.04 | $ | — | $ | 13.94 | |||||
Total intrinsic value of stock options exercised | $ | 12,845 | $ | 24,120 | $ | 11,744 | |||||
(1) No options were awarded in the year ended December 31, 2012. |
Shares | Weighted Average Grant Date Fair Value | |||||
Non-vested balance as of December 31, 2012 | 2,058,908 | $ | 37.25 | |||
Granted | 1,037,542 | 55.36 | ||||
Vested | (961,741 | ) | 33.57 | |||
Forfeited | (45,116 | ) | 38.91 | |||
Non-vested balance as of December 31, 2013 | 2,089,593 | $ | 47.90 |
2014 | $ | 25,350 | |
2015 | 25,871 | ||
2016 | 24,202 | ||
2017 | 19,336 | ||
2018 | 12,628 | ||
Thereafter | 18,800 | ||
$ | 126,187 |
2013 | 2012 | 2011 | |||||||||
Earnings attributable to Centene Corporation: | |||||||||||
Earnings from continuing operations, net of tax | $ | 161,218 | $ | 88,533 | $ | 120,518 | |||||
Discontinued operations, net of tax | 3,881 | (86,674 | ) | (9,300 | ) | ||||||
Net earnings | $ | 165,099 | $ | 1,859 | $ | 111,218 | |||||
Shares used in computing per share amounts: | |||||||||||
Weighted average number of common shares outstanding | 54,126,545 | 51,509,366 | 50,198,954 | ||||||||
Common stock equivalents (as determined by applying the treasury stock method) | 2,120,628 | 2,205,009 | 2,275,284 | ||||||||
Weighted average number of common shares and potential dilutive common shares outstanding | 56,247,173 | 53,714,375 | 52,474,238 | ||||||||
Net earnings per common share attributable to Centene Corporation: | |||||||||||
Basic: | |||||||||||
Continuing operations | $ | 2.98 | $ | 1.72 | $ | 2.40 | |||||
Discontinued operations | 0.07 | (1.68 | ) | (0.18 | ) | ||||||
Basic earnings per common share | $ | 3.05 | $ | 0.04 | $ | 2.22 | |||||
Diluted: | |||||||||||
Continuing operations | $ | 2.87 | $ | 1.65 | $ | 2.30 | |||||
Discontinued operations | 0.07 | (1.62 | ) | (0.18 | ) | ||||||
Diluted earnings per common share | $ | 2.94 | $ | 0.03 | $ | 2.12 |
Managed Care | Specialty Services | Eliminations | Consolidated Total | ||||||||||||
Premium and service revenues from external customers | $ | 9,740,720 | $ | 785,320 | $ | — | $ | 10,526,040 | |||||||
Premium and service revenues from internal customers | 41,094 | 2,147,200 | (2,188,294 | ) | — | ||||||||||
Total premium and service revenues | 9,781,814 | 2,932,520 | (2,188,294 | ) | 10,526,040 | ||||||||||
Earnings from operations | 197,844 | 79,573 | — | 277,417 | |||||||||||
Total assets | 2,817,519 | 595,964 | — | 3,413,483 |
Managed Care | Specialty Services | Eliminations | Consolidated Total | ||||||||||||
Premium and service revenues from external customers | $ | 7,124,720 | $ | 556,911 | $ | — | $ | 7,681,631 | |||||||
Premium and service revenues from internal customers | 87,319 | 1,550,096 | (1,637,415 | ) | — | ||||||||||
Total premium and service revenues | 7,212,039 | 2,107,007 | (1,637,415 | ) | 7,681,631 | ||||||||||
Earnings from operations | 62,867 | 45,099 | — | 107,966 | |||||||||||
Total assets | 2,163,347 | 371,265 | — | 2,534,612 |
Managed Care | Specialty Services | Eliminations | Consolidated Total | ||||||||||||
Premium and service revenues from external customers | $ | 4,571,430 | $ | 480,472 | $ | — | $ | 5,051,902 | |||||||
Premium and service revenues from internal customers | 64,809 | 710,002 | (774,811 | ) | — | ||||||||||
Total premium and service revenues | 4,636,239 | 1,190,474 | (774,811 | ) | 5,051,902 | ||||||||||
Earnings from operations | 161,890 | 41,913 | — | 203,803 | |||||||||||
Total assets | 1,709,271 | 383,259 | — | 2,092,530 |
For the Quarter Ended | |||||||||||||||
March 31, 2013 | June 30, 2013 | September 30, 2013 | December 31, 2013 | ||||||||||||
Total revenues | $ | 2,525,482 | $ | 2,610,538 | $ | 2,795,569 | $ | 2,931,740 | |||||||
Amounts attributable to Centene Corporation common shareholders: | |||||||||||||||
Earnings from continuing operations, net of income tax expense | $ | 22,639 | $ | 40,289 | $ | 50,325 | $ | 47,965 | |||||||
Discontinued operations, net of income tax expense (benefit) | 363 | (805 | ) | (952 | ) | 5,275 | |||||||||
Net earnings | $ | 23,002 | $ | 39,484 | $ | 49,373 | $ | 53,240 | |||||||
Net earnings (loss) per common share attributable to Centene Corporation: | |||||||||||||||
Basic: | |||||||||||||||
Continuing operations | $ | 0.43 | $ | 0.74 | $ | 0.92 | $ | 0.87 | |||||||
Discontinued operations | 0.01 | (0.02 | ) | (0.02 | ) | 0.10 | |||||||||
Basic earnings per common share | $ | 0.44 | $ | 0.72 | $ | 0.90 | $ | 0.97 | |||||||
Diluted: | |||||||||||||||
Continuing operations | $ | 0.41 | $ | 0.71 | $ | 0.88 | $ | 0.84 | |||||||
Discontinued operations | 0.01 | 0.01 | (0.01 | ) | 0.09 | ||||||||||
Diluted earnings per common share | $ | 0.42 | $ | 0.72 | $ | 0.87 | $ | 0.93 | |||||||
Health Benefits Ratio | 90.2 | % | 88.4 | % | 87.8 | % | 88.1 | % | |||||||
General & Administrative Expense Ratio | 8.4 | % | 8.9 | % | 9.1 | % | 8.9 | % | |||||||
Period end at-risk membership | 2,553,400 | 2,563,400 | 2,612,500 | 2,723,200 |
For the Quarter Ended | |||||||||||||||
March 31, 2012 | June 30, 2012 | September 30, 2012 | December 31, 2012 | ||||||||||||
Total revenues | $ | 1,562,809 | $ | 1,967,362 | $ | 2,308,075 | $ | 2,272,050 | |||||||
Amounts attributable to Centene Corporation common shareholders: | |||||||||||||||
Earnings (loss) from continuing operations, net of income tax expense (benefit) | $ | 27,072 | $ | (16,656 | ) | $ | 59,438 | $ | 18,679 | ||||||
Discontinued operations, net of income tax benefit | (3,094 | ) | (18,343 | ) | (55,619 | ) | (9,618 | ) | |||||||
Net earnings (loss) | $ | 23,978 | $ | (34,999 | ) | $ | 3,819 | $ | 9,061 | ||||||
Net earnings (loss) per common share attributable to Centene Corporation: | |||||||||||||||
Basic: | |||||||||||||||
Continuing operations | $ | 0.53 | $ | (0.32 | ) | $ | 1.15 | $ | 0.36 | ||||||
Discontinued operations | (0.06 | ) | (0.36 | ) | (1.08 | ) | (0.19 | ) | |||||||
Basic earnings per common share | $ | 0.47 | $ | (0.68 | ) | $ | 0.07 | $ | 0.17 | ||||||
Diluted: | |||||||||||||||
Continuing operations | $ | 0.51 | $ | (0.32 | ) | $ | 1.10 | $ | 0.35 | ||||||
Discontinued operations | (0.06 | ) | (0.36 | ) | (1.03 | ) | (0.18 | ) | |||||||
Diluted earnings per common share | $ | 0.45 | $ | (0.68 | ) | $ | 0.07 | $ | 0.17 | ||||||
Health Benefits Ratio | 87.1 | % | 91.2 | % | 88.7 | % | 90.7 | % | |||||||
General & Administrative Expense Ratio | 10.4 | % | 8.5 | % | 8.4 | % | 8.4 | % | |||||||
Period end at-risk membership | 2,003,800 | 2,254,000 | 2,357,600 | 2,424,500 |
December 31, | |||||||
2013 | 2012 | ||||||
ASSETS | |||||||
Current assets: | |||||||
Cash and cash equivalents | $ | 2,740 | $ | 22,279 | |||
Short term investments, at fair value (amortized cost $6,000 and $6,500, respectively) | 6,000 | 6,500 | |||||
Other current assets | 124,903 | 42,230 | |||||
Total current assets | 133,643 | 71,009 | |||||
Long term investments, at fair value (amortized cost $8,070 and $1,356, respectively) | 8,070 | 1,356 | |||||
Investment in subsidiaries | 1,667,258 | 1,298,648 | |||||
Other long term assets | 31,876 | 42,523 | |||||
Total assets | $ | 1,840,847 | $ | 1,413,536 | |||
LIABILITIES AND STOCKHOLDERS' EQUITY | |||||||
Current liabilities | $ | 4,460 | $ | 4,333 | |||
Long term debt | 590,628 | 449,127 | |||||
Other long term liabilities | 2,320 | 6,309 | |||||
Total liabilities | 597,408 | 459,769 | |||||
Stockholders' equity: | |||||||
Common stock, $.001 par value; authorized 100,000,000 shares; 58,673,215 issued and 55,319,239 outstanding at December 31, 2013, and 55,339,160 issued and 52,329,248 outstanding at December 31, 2012 | 59 | 55 | |||||
Additional paid-in capital | 594,326 | 450,856 | |||||
Accumulated other comprehensive income: | |||||||
Unrealized gain (loss) on investments, net of tax | (2,620 | ) | 5,189 | ||||
Retained earnings | 731,919 | 566,820 | |||||
Treasury stock, at cost (3,353,976 and 3,009,912 shares, respectively) | (89,643 | ) | (69,864 | ) | |||
Total Centene stockholders' equity | 1,234,041 | 953,056 | |||||
Noncontrolling interest | 9,398 | 711 | |||||
Total stockholders' equity | 1,243,439 | 953,767 | |||||
Total liabilities and stockholders' equity | $ | 1,840,847 | $ | 1,413,536 |
Year Ended December 31, | |||||||||||
2013 | 2012 | 2011 | |||||||||
Expenses: | |||||||||||
General and administrative expenses | $ | 4,196 | $ | 4,090 | $ | 4,488 | |||||
Other income (expense): | |||||||||||
Investment and other income | 983 | 19,921 | (8,790 | ) | |||||||
Interest expense | (22,623 | ) | (15,757 | ) | (15,494 | ) | |||||
Earnings (loss) before income taxes | (25,836 | ) | 74 | (28,772 | ) | ||||||
Income tax benefit | (15,191 | ) | (9,668 | ) | (12,825 | ) | |||||
Net earnings (loss) before equity in subsidiaries | (10,645 | ) | 9,742 | (15,947 | ) | ||||||
Equity in earnings from subsidiaries | 171,863 | 78,791 | 136,465 | ||||||||
Net earnings from continuing operations | $ | 161,218 | $ | 88,533 | $ | 120,518 | |||||
Net earnings per share from continuing operations: | |||||||||||
Basic earnings per common share | $ | 2.98 | $ | 1.72 | $ | 2.40 | |||||
Diluted earnings per common share | $ | 2.87 | $ | 1.65 | $ | 2.30 | |||||
Weighted average number of shares outstanding: | |||||||||||
Basic | 54,126,545 | 51,509,366 | 50,198,954 | ||||||||
Diluted | 56,247,173 | 53,714,375 | 52,474,238 |
Year Ended December 31, | |||||||||||
2013 | 2012 | 2011 | |||||||||
Cash flows from operating activities: | |||||||||||
Cash provided by operating activities | $ | 302,242 | $ | 327,940 | $ | 72,754 | |||||
Cash flows from investing activities: | |||||||||||
Net dividends from and capital contributions to subsidiaries | (417,734 | ) | (539,575 | ) | (50,581 | ) | |||||
Purchase of investments | (12,518 | ) | (7,320 | ) | (21,915 | ) | |||||
Sales and maturities of investments | 10,252 | 30,000 | 11,111 | ||||||||
Acquisitions | (67,070 | ) | — | (1,773 | ) | ||||||
Net cash used in investing activities | (487,070 | ) | (516,895 | ) | (63,158 | ) | |||||
Cash flows from financing activities: | |||||||||||
Proceeds from borrowings | 180,000 | 400,500 | 419,183 | ||||||||
Payment of long term debt | (30,000 | ) | (215,000 | ) | (413,644 | ) | |||||
Proceeds from exercise of stock options | 8,983 | 15,912 | 15,815 | ||||||||
Proceeds from stock offering | 15,225 | — | — | ||||||||
Common stock repurchases | (19,779 | ) | (12,741 | ) | (7,809 | ) | |||||
Debt issue costs | (3,589 | ) | (3,623 | ) | (9,242 | ) | |||||
Contributions from noncontrolling interest | 8,069 | 1,092 | 813 | ||||||||
Purchase of noncontrolling interest | — | (14,429 | ) | — | |||||||
Excess tax benefits from stock compensation | 6,380 | 10,996 | 4,435 | ||||||||
Net cash provided by financing activities | 165,289 | 182,707 | 9,551 | ||||||||
Net increase (decrease) in cash and cash equivalents | (19,539 | ) | (6,248 | ) | 19,147 | ||||||
Cash and cash equivalents, beginning of period | 22,279 | 28,527 | 9,380 | ||||||||
Cash and cash equivalents, end of period | $ | 2,740 | $ | 22,279 | $ | 28,527 |
(a) | Financial Statements and Schedules |
1. | Financial Statements: |
2. | Financial Statement Schedules: |
3. | The exhibits listed in the accompanying Exhibit Index are filed or incorporated by reference as part of this filing. |
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 | 3.2a | |||||||
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 | 3.1b | |||||||
3.2 | By-laws of Centene Corporation, as amended effective as of February 3, 2014 | 8-K | February 6, 2014 | 3.1 | |||||||
4.1 | 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 | * | 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 | ||||||
10.2 | * | 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 | ||||||
10.3 | * | 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 | ||||||
10.4 | * | 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 | ||||||
10.5 | * | 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 | ||||||
10.5a | * | First Amendment to the 2002 Employee Stock Purchase Plan | 10-K | February 24, 2005 | 10.9a | ||||||
10.5b | * | Second Amendment to the 2002 Employee Stock Purchase Plan | 10-K | February 24, 2006 | 10.10b | ||||||
10.6 | * | 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 | ||||||
10.7 | * | 2012 Stock Plan of Centene Corporation, shares which are registered on Form S-8 - File Number 333-180976 | DEF 14A | March 9, 2012 | 4 | ||||||
10.8 | * | Centene Corporation Non-Employee Directors Deferred Stock Compensation Plan | 10-Q | October 25, 2004 | 10.1 | ||||||
10.8a | * | First Amendment to the Non-Employee Directors Deferred Stock Compensation Plan | 10-K | February 24, 2006 | 10.12a | ||||||
10.9 | * | Centene Corporation Employee Deferred Compensation Plan | 10-K | February 22, 2010 | 10.10 | ||||||
10.10 | * | Centene Corporation 2007 Long Term Incentive Plan | 8-K | April 26, 2007 | 10.2 | ||||||
10.11 | * | Centene Corporation Short Term Executive Compensation Plan | 10-K | February 22, 2011 | 10.12 | ||||||
10.12 | * | Executive Employment Agreement between Centene Corporation and Michael F. Neidorff, dated November 8, 2004 | 8-K | November 9, 2004 | 10.1 | ||||||
10.12a | * | Amendment No. 1 to Executive Employment Agreement between Centene Corporation and Michael F. Neidorff | 10-Q | October 28, 2008 | 10.2 | ||||||
10.12b | * | Amendment No. 2 to Executive Employment Agreement between Centene Corporation and Michael F. Neidorff | 10-Q | April 28, 2009 | 10.2 | ||||||
10.12c | * | Amendment No. 3 to Executive Employment Agreement between Centene Corporation and Michael F. Neidorff | 10-Q | October 23, 2012 | 10.2 | ||||||
10.12d | * | Amendment No. 4 to Executive Employment Agreement between Centene Corporation and Michael F. Neidorff | 8-K | May 16, 2013 | 10.1 | ||||||
10.13 | * | Form of Executive Severance and Change in Control Agreement | 10-Q | October 28, 2008 | 10.3 | ||||||
10.13a | * | Amendment No. 1 to Form of Executive Severance and Change in Control Agreement | 10-Q | October 23, 2012 | 10.3 | ||||||
10.14 | * | Form of Restricted Stock Unit Agreement | 10-Q | October 28, 2008 | 10.4 | ||||||
10.15 | * | Form of Non-statutory Stock Option Agreement (Non-Employees) | 8-K | July 28, 2005 | 10.3 | ||||||
10.16 | * | Form of Non-statutory Stock Option Agreement (Employees) | 10-Q | October 28, 2008 | 10.5 | ||||||
10.17 | * | Form of Non-statutory Stock Option Agreement (Directors) | 10-K | February 23, 2009 | 10.18 | ||||||
10.18 | * | Form of Incentive Stock Option Agreement | 10-Q | October 28, 2008 | 10.6 | ||||||
10.19 | * | Form of Stock Appreciation Right Agreement | 8-K | July 28, 2005 | 10.6 | ||||||
10.20 | * | Form of Restricted Stock Agreement | 10-Q | October 25, 2005 | 10.8 | ||||||
10.21 | * | Form of Performance Based Restricted Stock Unit Agreement #1 | 10-Q | October 28, 2008 | 10.7 | ||||||
10.22 | * | Form of Performance Based Restricted Stock Unit Agreement #2 | 10-K | February 23, 2009 | 10.23 | ||||||
10.23 | * | Form of Long Term Incentive Plan Agreement | 8-K | February 7, 2008 | 10.1 | ||||||
10.24 | Credit Agreement dated as of May 21, 2013 among Centene Corporation, the various financial institutions party hereto and Barclays Bank PLC | 8-K | May 22, 2013 | 10.1 | |||||||
10.25 | ** | Contract between the Texas Health and Human Services Commission and Superior HealthPlan, Inc. | 10-Q | October 25, 2011 | 10.2 | ||||||
10.25a | ** | Amendment A (Version 2.1) to Contract between the Texas Health and Human Services Commission and Superior HealthPlan, Inc. | 10-Q | April 24, 2012 | 10.1 | ||||||
10.25b | ** | Amendment B (Version 2.2) to Contract between the Texas Health and Human Services Commission and Superior HealthPlan, Inc. | 10-Q | July 24, 2012 | 10.1 | ||||||
10.25c | ** | Amendment C (Version 2.3) to Contract between the Texas Health and Human Services Commission and Superior HealthPlan, Inc. | 10-Q | October 23, 2012 | 10.1 | ||||||
10.25d | ** | Amendment D (Version 2.4) to Contract between the Texas Health and Human Services Commission and Bankers Life Insurance Company of Wisconsin, Inc. d.b.a Superior HealthPlan Network | 10-Q | April 23, 2013 | 10.1 | ||||||
10.25e | ** | Amendment E (Version 2.5) to Contract between the Texas Health and Human Services Commission and Bankers Life Insurance Company of Wisconsin, Inc. d.b.a Superior HealthPlan Network | 10-Q | July 23, 2013 | 10.1 | ||||||
10.25f | ** | Amendment F (Version 2.6) to Contract between the Texas Health and Human Services Commission and Bankers Life Insurance Company of Wisconsin, Inc. d.b.a Superior HealthPlan Network | 10-Q | October 22, 2013 | 10.1 | ||||||
10.25g | ** | Amendment G (Version 2.7) to Contract between the Texas Health and Human Services Commission and Bankers Life Insurance Company of Wisconsin, Inc. d.b.a Superior HealthPlan Network | 10-Q | October 22, 2013 | 10.2 | ||||||
10.25h | ** | Amendment H (Version 2.8) to Contract between the Texas Health and Human Services Commission and Bankers Life Insurance Company of Wisconsin, Inc. d.b.a Superior HealthPlan Network | X | ||||||||
10.25i | ** | Amendment I (Version 2.9) to Contract between the Texas Health and Human Services Commission and Bankers Life Insurance Company of Wisconsin, Inc. d.b.a Superior HealthPlan Network | X | ||||||||
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 333‑174164, 333-187652, 333-187741, and 333-193205) and on Form S-8 (File Numbers 333‑108467, 333‑90976, 333‑83190, and 333‑180976) | 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 | |||||||||
101.1 | XBRL Taxonomy Instance Document. | X | |||||||||
101.2 | XBRL Taxonomy Extension Schema Document. | X | |||||||||
101.3 | XBRL Taxonomy Extension Calculation Linkbase Document. | X | |||||||||
101.4 | XBRL Taxonomy Extension Definition Linkbase Document. | X | |||||||||
101.5 | XBRL Taxonomy Extension Label Linkbase Document. | X | |||||||||
101.6 | 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). * 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 |
Signature | Title | |
/s/ Michael F. Neidorff | Chairman and Chief Executive Officer (principal executive officer) | |
Michael F. Neidorff | ||
/s/ William N. Scheffel | Executive Vice President and Chief Financial Officer (principal financial officer) | |
William N. Scheffel | ||
/s/ Jeffrey A. Schwaneke | Senior Vice President, Corporate Controller and Chief Accounting Officer (principal accounting officer) | |
Jeffrey A. Schwaneke | ||
/s/ Orlando Ayala | Director | |
Orlando Ayala | ||
/s/ Robert K. Ditmore | Director | |
Robert K. Ditmore | ||
/s/ Fred H. Eppinger | Director | |
Fred H. Eppinger | ||
/s/ Richard A. Gephardt | Director | |
Richard A. Gephardt | ||
/s/ Pamela A. Joseph | Director | |
Pamela A. Joseph | ||
/s/ John R. Roberts | Director | |
John R. Roberts | ||
/s/ David L. Steward | Director | |
David L. Steward | ||
/s/ Tommy G. Thompson | Director | |
Tommy G. Thompson |
Parties to the Contract: |
This 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 Bankers Reserve Life Insurance Company of Wisconsin d.b.a. Superior HealthPlan Network (MCO) an entity organized under the laws of the State of Wisconsin, having its principal place of business at 2100 South IH-35, Suite 202, Austin, Texas 78704. HHSC and MCO may be referred to in this Amendment individually as a “Party” and collectively as the “Parties.” | ||
Amendment Effective Date | Contract Expiration Date | Operational Start Date |
January 1, 2014 | August 31, 2015 | March 1, 2012 |
MCO Brand Names | ||
The MCO will use following brand name(s). The MCO acknowledges that if it requests a change to the brand name(s), it will be responsible for all costs associated with the change(s), including HHSC's costs for modifying its business rules, system identifiers, communications materials, web page, etc. STAR: Superior Health Plan STAR+PLUS: Superior Health Plan CHIP: _________________ MRSA: Superior Health Plan | ||
Project Managers | ||
HHSC: Emily Zalkovsky Director, Program Management 11209 Metric Boulevard, Building H Austin, Texas 78758 Phone: 512-491-2078 Fax: 512-491-1972 MCO: Susan Erickson Vice President 2100 South IH-35, Suite 202 Austin, Texas 78704 Phone: 512-692-1465 Ext 22032 Fax: 866-702-4830 E-mail: serickson@centene.com | ||
Legal Notice Delivery Addresses | ||
HHSC: General Counsel 4900 North Lamar Boulevard, 4th Floor Austin, Texas 78751 Fax: 512-424-6586 MCO: Superior HealthPlan 2100 South IH-35, Suite 202 Austin, Texas 78704 Fax: 866-702-4830 |
MCO Programs and Service Areas |
This Amendment applies to the following checked HHSC MCO Programs and Service Areas . All references in the Amendment or the Contract to MCO Programs or Service Areas that are not checked do not apply to the MCO. þ Medicaid STAR MCO Program þ Medicaid STAR + PLUS MCO Program o CHIP MCO Program |
Service Areas: | o Bexar | þ Medicaid RSA - Central | ||
o Dallas | þ Medicaid RSA - Northeast | |||
o El Paso | þ Medicaid RSA - West | |||
o Harris | o Nueces | |||
þ Hidalgo | o Tarrant | |||
o Jefferson | o Travis | |||
o Lubbock |
Service Areas: | o Bexar | o Jefferson | ||
o El Paso | o Lubbock | |||
o Harris | o Nueces | |||
þ Hidalgo | o Travis |
Payment |
Rate Period 2 Capitation Rates | |||||
Service Area | Hidalgo | Medicaid Rural Service Area- Central Texas | Medicaid Rural Service Area- Northeast Texas | Medicaid Rural Service Area- West Texas | |
Rate Cell | |||||
1 | Under Age 1 Child | *** | *** | *** | *** |
2 | Age 1-5 Child | *** | *** | *** | *** |
3 | Age 6-14 Child | *** | *** | *** | *** |
4 | Age 15-18 Child | *** | *** | *** | *** |
5 | Age 19-20 Child | *** | *** | *** | *** |
6 | TANF Adult | *** | *** | *** | *** |
7 | Pregnant Woman | *** | *** | *** | *** |
8 | SSI- Aged, Blind & Disabled | *** | *** | *** |
Service Area | Delivery Supplemental Payment |
Hidalgo | *** |
Medicaid Rural Service Area - Central Texas | *** |
Medicaid Rural Service Area - Northeast Texas | *** |
Medicaid Rural Service Area - West Texas | *** |
Rate Period 2 Capitation Rates | ||
STAR + PLUS Service Area: | Hidalgo | |
Rate Cell | ||
1 | Medicaid Only Standard Rate | *** |
2 | Medicaid Only HCBS STAR+PLUS Waiver Rate - Above Floor | *** |
3 | Medicaid Only HCBS STAR+PLUS Waiver Rate - Below Floor | *** |
4 | Dual Eligible Standard Rate | *** |
5 | Dual Eligible HCBS STAR+PLUS Waiver Rate- Above Floor | *** |
6 | Dual Eligible HCBS STAR+PLUS Waiver Rate- Below Floor | *** |
7 | Nursing Facility- Medicaid Only | *** |
8 | Nursing Facility- Dual Eligible | *** |
Terms and Attachments: |
Signatures |
The Parties execute this Amendment in their stated capacities with authority to bind their organizations on the dates in this section. Texas Health and Human Services Commission /s/ Chris Traylor Chris Traylor Chief Deputy Commissioner Office of the Chief Deputy Commissioner Date: 11/13/2013 Bankers Reserve Life Insurance Company of Wisconsin d.b.a. Superior HealthPlan Network /s/ Holly Munin By: Holly Munin Title: CEO Date: 10/18/2013 |
DOCUMENT HISTORY LOG | |||||||
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 | ||||
Baseline | n/a | September 1, 2011 | Initial version of the Attachment A, “Medicaid and CHIP Uniform Managed Care Contract Terms & Conditions.” | ||||
Revision | 2.1 | March 1, 2012 | Definition “1915(c) Nursing Facility Waiver” is modified to correct a cross-reference. Definition for Medically Necessary is modified for clarification. The State has determined that all acute care behavioral health and non-behavioral health services for Medicaid children fall within the scope of Texas Health Steps. Note that for LTSS, such as PCS (PAS) services for children in STAR+PLUS, the functional necessity standard for LTSS also applies (see Attachment B-1, Section 8.3.3). Definition for Rate Period 1 is modified. Section 4.04 is modified to clarify the requirements for Medical Director designees, and to clarify that the provision does not apply to prior authorization determinations made by Texas licensed pharmacists. New Section 4.11 “Prohibition Against Performance Outside of the United States” added. Section 5.02(b) is modified to clarify that MCOs may not sell or transfer their Member base. Section 5.06(a)(2) is modified to clarify the exceptions to enrollment in an MCO during an Inpatient Stay. Section 5.06(a)(3) and (4) are modified to clarify that Members cannot move from FFS to an MCO or from one MCO to another during residential treatment or residential detoxification. References to the PCCM program are removed. In addition, Section 5.06(a)(8) is modified to clarify movement requirements for SSI Members in the MRSA. Section 10.06(b) is modified to remove the Perinate Newborn 0% - 185% rate cell. Section 10.10 is modified to consolidate STAR+PLUS with STAR and CHIP for the Experience Rebate calculation. Section 10.10.1 is deleted in its entirety. Section 10.10.2 is modified to consolidate STAR+PLUS into STAR and CHIP for the Experience Rebate calculation. |
Revision | 2.2 | June 1, 2012 | Definition for Consolidated FSR Report or Consolidated Basis is added. Definition for Financial Statistical Report is added. Definitions for FSR Reporting Period, FSR Reporting Period 12/13, and FSR Reporting Period 14 are added. Definition for Material Subcontract is modified. Definition for Net Income Before Taxes is modified. Definition for Pre-tax Income is modified. Definition for Program is added. Definition for Rate Period 1 and Rate Period 2 are modified. Section 10.10 is modified to consolidate the Experience Rebate across all contracts and all programs. Section 10.10.2 is modified to consolidate the Administrative Expense Cap across all contracts and all programs. | ||||
Revision | 2.3 | September 1, 2012 | Definition for Case Management for Children and Pregnant Women is modified to remove the acronym “CPW”. Definition for Community-based Long Term Services and Supports is modified to replace references to “1915(c) Nursing Facility Waiver” with “HCBS STAR+PLUS Waiver”. Definition for “1915(c) Nursing Facility Waiver” is modified to change the name to “HCBS STAR+PLUS. Waiver” and to update references to “Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver” and “HCBS STAR+PLUS Waiver”. Definition for “HHSC MCO Programs or MCO Programs” is modified. Definition for “Medically Necessary” is modified. Definition for “Provider Materials” is added. Section 5.06(a)(4) is modified to clarify responsibility for payment. Section 5.11 is deleted in its entirety. Section 7.02 is modified to clarify that only applicable provisions of the listed laws apply to the contract. Section 10.05 is modified to replace references to “1915(c) Nursing Facility Waiver” with “HCBS STAR+PLUS Waiver”. | ||||
Revision | 2.4 | March 1, 2013 | All references to the previous Executive Commissioner Suehs are changed to his successor, Executive Commissioner Janek. Definition for “Electronic Visit Verification” is added. Section 5.02(e), Subsections (4) and (5) are modified. Section 10.16 is added to address supplemental payments to MCOs for wrap-around services for outpatient drugs and biological products for STAR-PLUS Members. |
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment A, Uniform Managed Care Contract Terms and Conditions. | ||||
Revision | 2.6 | September 1, 2013 | Definition for CAHPS is modified to correct the name to which the acronym refers. Definition for “Community Health Worker” is added. Definition for “Court-Ordered Commitment” is modified. Definition for Default Enrollment is modified to add T.A.C. reference. Definition for “DSM” is modified. Definition for “ECI” is modified. Definition for HEDIS is modified to correct the name to which the acronym refers. Definition for Primary Care Physician is modified to remove the list of provider types as being redundant. Definition for Rate Period is modified to include a third sub-period. Section 5.02(e) is modified to remove the language regarding disenrollment for ESRD and ventilator dependency. Section 5.08 is renamed “Modified Default Enrollment Process” and revised to include a process for all Programs. Section 5.09 is deleted and replaced with Section 5.08. Section 5.10 is deleted and replaced with Section 5.08. Section 7.04 is deleted in its entirety and updated within Section 7.02 Section 9.02 is modified for clarification that records must be provided “at no cost.” Section 9.04 is modified for clarification that records must be provided “at no cost.” Section 10.05(a) is modified to comply with the new STAR Risk Groups. Section 10.10.3 is modified to clarify that the Reinsurance Cap impacts only the Experience Rebate calculation. Section 11.01(c) is modified to add the missing word “may.” Section 13.01 is modified to clarify the required certifications. Section 14.08 is modified to delete outdated language | ||||
Revision | 2.7 | September 1, 2013 | Section 10.17 “Pass-through Payments for Provider Rate Increases” is added. |
Revision | 2.8 | January 1, 2014 | Definition for Expansion Children is removed. Definition for Federal Poverty Level is updated. Definition for Former Foster Care Child (FFCC) Member is added. Section 5.02 is modified to add requirement for default assignment methodologies. Section 5.04 is modified to clarify that HHSC or the ASC will enroll or disenroll Members. Section 5.05 is modified to clarify that HHSC or the ASC will transmit new Member information, to remove the FPL limits, to remove the default assignment language, and to clarify the enrollment process when CHIP Perinate coverage expires. Section 5.06 is modified to add requirements regarding movement from a STAR Health MCO to a STAR MCO. Section 10.06(b) is modified to clarify the eligibility thresholds. Section 10.09 is modified to clarify the eligibility thresholds. Section 11.01(a) is modified to correct an administrative error. Section 12.03 is modified to delete subsection (b)(8) Termination for Insolvency and all following subsections are renumbered. | ||||
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. |
• | the other entity is an Affiliate of the MCO; |
• | the Subcontract is considered by HHSC to be for a key type of service or function, including |
◦ | Administrative Services (including but not limited to third party administrator, Network administration, and claims processing); |
◦ | delegated Networks (including but not limited to behavioral health, dental, pharmacy, and vision); |
◦ | management services (including management agreements with parent) |
◦ | reinsurance; |
◦ | Disease Management; |
◦ | pharmacy benefit management (PBM) or pharmacy administrative services; or |
◦ | call lines (including nurse and medical consultation); or |
• | any other Subcontract that exceeds, or is reasonably expected to exceed, the lesser of: a) $500,000 per year, or b) 1% of the MCO’s annual Revenues under this Contract. Any Subcontracts between the MCO and a single entity that are split into separate agreements by time period, Program, or SDA, etc., will be consolidated for the purpose of this definition. |
Responsibility for Inpatient Stay Services | ||
Exception | Hospital Facility Charges | Professional Services Charges |
Member Retroactively Enrolled in STAR per §5.03 or in STAR+PLUS per §5.03.1 | MCO | MCO |
Member ≤ 12 Months of Age Who Is Prospectively Enrolled in STAR or STAR+PLUS | Medicaid FFS | MCO |
Pre-tax Income as a % of Revenues | MCO Share | HHSC Share |
≤ 3% | 100% | —% |
> 3% and ≤ 5% | 80% | 20% |
> 5% and ≤ 7% | 60% | 40% |
> 7% and ≤ 9% | 40% | 60% |
> 9% and ≤ 12% | 20% | 80% |
> 12% | —% | 100% |
DOCUMENT HISTORY LOG | |||
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 |
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-1, RFP Sections 1 – 5, “Introduction; Procurement Strategy; General Instructions & Requirements; Submission Requirements; and Evaluation Process & Criteria.” |
Revision | 2.1 | March 1, 2012 | Section 1.3 is modified to clarify that Medicaid Wrap Services will become covered services at a future date to be determined by HHSC. Section 1.8.1 is modified to clarify that Medicaid Wrap Services will become covered services at a future date to be determined by HHSC. |
Revision | 2.2 | June 1, 2012 | Contract amendment did not revise Attachment B-1, Sections 1-5, "Introduction; Procurement Strategy; General Instructions & Requirements; Submission Requirements; and Evaluation Process & Criteria." |
Revision | 2.3 | September 1, 2012 | Section 1.6.1 is modified to replace reference to the 1915(b) waiver with the Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver. Section 1.6.2 is modified to replace references to the 1915(b) and 1915(c) waivers with the Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver. Section 1.8 is modified to reference the Texas Healthcare Transformation and Quality Improvement Program (THTQIP) 1115 Waiver and HHSC”s administrative rules for identification of eligible populations. Section 1.8.1 STAR Program Eligibility is deleted in its entirety. Section 1.8.2 STAR+PLUS Eligibility is deleted in its entirety. Section 1.8.3 CHIP Program Eligibility is deleted in its entirety. |
Revision | 2.4 | March 1, 2013 | Contract amendment did not revise Attachment B-1, Sections 1-5, “Introduction; Procurement Strategy; General Instructions & Requirements; Submission Requirements; and Evaluation Process & Criteria.” |
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-1, Sections 1-5, Introduction; Procurement Strategy; General Instructions & Requirements; Submission Requirements; and Evaluation Process & Criteria. |
Revision | 2.6 | September 1, 2013 | Section 2.1 is modified to clarify that HHSC uses two dashboards. Section 4.3.7.2 is modified to correct the name to which the acronym HEDIS refers. |
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-1, Sections 1-5, "Introduction; Procurement Strategy; General Instructions & Requirements; Submission Requirements; and Evaluation Process & Criteria." |
Revision | 2.8 | January 1, 2014 | Section 1.6.3 is modified to clarify the eligibility thresholds. |
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. |
1.1 Point-of-Contact |
1.2 Procurement Schedule |
Procurement Schedule | |
Draft RFP Release Date | November 5, 2010 |
Draft RFP Respondent Comments Due | December 6, 2010 |
RFP Release Date | April 8, 2011 |
Vendor Conference | April 18, 2011 1:00pm CDT |
Respondent Questions Due | April 19, 2011 |
Letters Claiming Mandatory Contract Status Due | April 28, 2011 |
HHSC Posts Responses to Respondent Questions | April 29, 2011 |
Proposals Due | May 23, 2011 |
Deadline for Proposal Withdrawal | May 23, 2011 |
Respondent Demonstrations/Oral Presentations (HHSC option) | HHSC will not be holding presentations |
Tentative Award Announcement | August 1, 2011 |
Anticipated Contract Start Date | September 1, 2011 |
Operational Start Date | March 1, 2012 |
Medicaid State of Texas Access Reform Program (STAR); |
Medicaid STAR+PLUS Program; |
Children’s Health Insurance Program (CHIP), including the CHIP Perinatal subprogram. |
Expansion of STAR into two (2) new regions, the Hidalgo Service Area and Medicaid Rural Service Area (MRSA). |
Expansion of STAR+PLUS into the El Paso and Lubbock Service Areas, as well as the new Hidalgo Service Area. |
Adjustments to the Service Area boundaries for STAR, STAR+PLUS and CHIP Service Areas, so that the Service Areas are consistent for all Programs. |
The addition of prescription drug benefits to the managed care structure. The prescription drug benefit will no longer be carved-out of managed care and paid through HHSC’s Vendor Drug Program. Medicaid and CHIP MCOs will be responsible for recruiting and maintaining pharmacy providers and paying for pharmacy benefits. |
The addition of inpatient facility services to the managed care structure for STAR+PLUS. |
For Dual Eligible Members in the STAR+PLUS Program, the addition of Medicaid Wrap Services to the scope of Covered Services at a date determined by HHSC. |
1.4 Mission Statement |
1.5 Mission Objectives |
1. Network adequacy and access to care |
2. Quality |
3. Timeliness of claim payment |
4. Timeliness with which prenatal care is initiated |
5. Behavioral health services |
6. Delivery of health care to diverse populations |
7. Disease management requirements |
8. Service Coordination |
9. Continuity Of Care |
1.6 Overview of the HHSC MCO Programs |
1.6.1 STAR |
1.6.2 STAR+PLUS |
1.6.3 CHIP |
1.7 Other HHSC Managed Care Programs |
1.8 Eligible Populations for HHSC MCO Programs |
1.9 Authorization |
1.10 Eligible Respondents |
1.11 Term of Contract |
1.12 Development of Contracts |
1.13 Medicaid and CHIP Service Areas |
Service Areas | STAR | STAR+PLUS | CHIP MCO |
Bexar | √ | √ | √ |
Dallas | √ | √ | |
El Paso | √ | √ | √ |
Harris | √ | √ | √ |
Hidalgo | √ | √ | |
Jefferson | √ | √ | √ |
Lubbock | √ | √ | √ |
Medicaid RSA (Entire Service Area) | √ | ||
West Texas | √ | ||
Central Texas | √ | ||
Northeast Texas | √ | ||
Nueces | √ | √ | √ |
Tarrant | √ | √ | |
Travis | √ | √ | √ |
2. Procurement Strategy and Approach |
• the number of managed care Eligibles in the Service Area compared to the combined capacity of qualified MCO Respondents, and |
• statutory requirements, such as HHSC’s consideration of Proposals from an MCO owned or operated by a hospital district. |
2.1 HHSC Model Management Strategy |
2.2 Performance Measures and Associated Remedies |
3. General Instructions and Requirements |
3.1 Strategic Elements |
3.1.1 Contract Elements |
3.1.2 HHSC’s Basic Philosophy: Contracting for Results |
3.2 External Factors |
3.3 Legal and Regulatory Constraints |
3.3.1 Delegation of Authority |
3.3.2 Conflicts of Interest |
• make it difficult or impossible to fulfill its contractual obligations to HHSC in a manner that is consistent with the best interests of the State of Texas; |
• impair, diminish, or interfere with that party’s ability to render impartial or objective assistance or advice to HHSC; and/or |
• provide the party with an unfair competitive advantage in future HHSC procurements. |
3.3.3 Former Employees of a State Agency |
3.4 HHSC Amendments and Announcements Regarding this RFP |
3.5 RFP Cancellation/Partial Award/Non-Award |
3.6 Right to Reject Proposals or Portions of Proposals |
3.7 Costs Incurred |
3.8 Protest Procedures |
3.9 Vendor Conference |
3.10 Questions and Comments |
3.11 Modification or Withdrawal of Proposal |
3.12 News Releases |
3.13 Incomplete Proposals |
3.14 State Use of Proposal Information |
3.15 Property of HHSC |
3.16 Copyright Restriction |
3.17 Additional Information |
3.18 Multiple Responses |
3.19 No Joint Proposals |
3.20 Use of Subcontractors |
3.21 Texas Public Information Act |
3.22 Inducements |
3.23 Definition of Terms |
4. Submission Requirements |
4.1 General Instructions |
1. Business Specifications; and |
2. General Programmatic Proposal. |
4.1.1 Economy of Presentation |
4.1.2 Number of Copies and Packaging |
4.1.3 Due Date, Time, and Location |
4.2 Part 1 – Business Proposal |
4.2.1 Section 1 – Executive Summary |
Service Area | Proposal for STAR | Proposal for STAR+PLUS | Proposal for CHIP |
Bexar | |||
Dallas | |||
El Paso | |||
Harris | |||
Hidalgo | |||
Jefferson | |||
Lubbock | |||
Medicaid RSA (Entire Service Area) | |||
West Texas | |||
Central Texas | |||
Northeast Texas | |||
Nueces | |||
Tarrant | |||
Travis |
4.2.2 Section 2 – Respondent Identification and Information |
1. Respondent identification and basic information. |
a. The Respondent’s legal name, trade name, dba, acronym, and any other name under which the Respondent does business. |
b. The physical address, mailing address, and telephone number of the Respondent’s headquarters office. |
2. TDI Authority. A copy of the MCO’s licensure, certification, or approval to operate as an HMO, ANHC, or EPBP. If the Respondent has not received TDI approval, then submit a copy of the application filed with TDI. In accordance with RFP Section 7.2.9, the Respondent must receive TDI approval no later than 60 days after HHSC executes the Contract. |
3. Authorized Counties. Indicate whether the Respondent is currently authorized by TDI to operate as an MCO in each county in the Service Area with a “Yes-MCO,” “No MCO,” or “Partial MCO.” If the Respondent is not authorized to conduct business as an MCO in all or part of a county, it should list those areas in Column C. |
For each county listed in Column C, the Respondent must document that it applied to TDI for such approval prior to the submission of a Proposal for this RFP. The Respondent must indicate the date that it applied for such approval and the status of its application to get TDI approval in the relevant counties in this section of its submission to HHSC. |
Column A | Column B | Column C |
Service Area | TDI Authority/Status of Approval | Counties/Partial Counties without TDI Authority |
Bexar | ||
Dallas | ||
El Paso | ||
Harris | ||
Hidalgo | ||
Jefferson | ||
Lubbock | ||
Medicaid RSA (Entire Service Area) | ||
West Texas | ||
Central Texas | ||
Northeast Texas | ||
Nueces | ||
Tarrant | ||
Travis |
4. Texas Comptroller Certificate. 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 Respondent. |
5. Respondent Legal Status and Ownership. |
a. The type of ownership of the Respondent by its ultimate parent: |
• wholly-owned subsidiary of a publicly-traded corporation; |
• wholly-owned subsidiary of a private (closely-held) stock corporation; |
• subsidiary or component of a non-profit foundation; |
• subsidiary or component of a governmental entity such as a County Hospital District; |
• independently-owned member of an alliance or cooperative network; |
• joint venture (describe ultimate owners) |
• stand-alone privately-owned corporation (no parents or subsidiaries); or |
• other (describe). |
b. The legal status of the Respondent and its parent (any/all that may apply): |
(i.) Respondent is a corporation, partnership, sole proprietor, or other (describe); |
• Respondent is for-profit, or non-profit; |
• the Respondent’s ultimate parent is for-profit, or non-profit; |
• the Respondent’s ultimate parent is privately-owned, listed on a stock exchange, a component of government, or other (describe). |
c. The legal name of the Respondent’s ultimate parent (e.g., the name of a publicly-traded corporation, or a County Hospital District, etc.). |
d. The name and address of any other sponsoring corporation, or others (excluding the Respondent’s parent) who provide financial support to the Respondent, and the type of support, e.g., guarantees, letters of credit, etc. Indicate if there are maximum limits of the additional financial support. |
6. Hospital District/Non-Profit Corporation. Section 5 of the RFP requires Respondents who believe they qualify for mandatory STAR or STAR+PLUS contracts under Texas Government Code §533.004 to submit notice to HHSC no later than April 28, 2011, explaining the basis for this belief for each proposed Service Area. Please indicate whether the Respondent provided such notice to HHSC. |
7. The name and address of any health professional that has at least a five percent (5%) financial interest in the Respondent, and the type of financial interest. |
8. The full names and titles of the Respondent’s officers and directors. |
9. The state in which the Respondent is incorporated, and the state(s) in which the Respondent is licensed to do business as an MCO. The Respondent must also indicate the state where it is commercially domiciled, if outside Texas. |
10. The Respondent’s federal taxpayer identification number. |
11. If any change of ownership of the Respondent’s company or its parent is anticipated during the 12 months following the Proposal Due Date, the Respondent must describe the circumstances of such change and indicate when the change is likely to occur. |
12. Whether the Respondent or its parent (including other managed care subsidiaries of the parent) had a managed care contract terminated or not renewed for any reason within the past five (5) years. In such instance, the Respondent must describe the issues and the parties involved, and provide the address and telephone number of the principal terminating party. The Respondent must also describe any corrective action taken to prevent any future occurrence of the problem(s) that may have led to the termination or non-renewal. |
13. Whether the Respondent 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. |
14. The website address (URL) for the homepage(s) of any website(s) operated, owned, or controlled by the Respondent, including any that the Respondent may have contracted to be run by another entity. If the Respondent has a parent, then also provide the same for the parent, and any parent(s) of the parent. If none exist, provide a clear and definitive statement to that effect. |
4.2.3 Section 3 – Corporate Background and Experience |
a. client name and address; |
b. name, telephone, and e-mail address of the person HHSC could contact as a reference that can speak to the Respondent’s performance; |
c. contract size: average monthly covered lives and annual revenues; |
d. whether payments under the contract were capitated or non-capitated; |
e. contract start date and duration; |
f. whether work was performed as a prime contractor or subcontractor; and |
g. a general and brief description of the scope of services provided by the Respondent; including the covered population and services (e.g., Medicaid, CHIP, state-funded program). |
4.2.3.1 Organizational Chart |
1. an organizational chart (Chart A), showing the corporate structure and lines of responsibility and authority in the administration of the Respondent’s business as a health plan; |
2. an organizational chart (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. an organizational chart (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 Respondent is proposing to use one or more Material Subcontractors, the Respondent must include an organizational chart demonstrating how the Material Subcontractor(s) will be managed within the Respondent’s Texas organizational structure, including the primary individuals at the Respondent’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); and |
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 Respondent’s proposed management of the MCO Program(s), including its management of any proposed Material Subcontractors. |
4.2.3.2 Résumés |
1. a job description and qualifications; and |
2. the anticipated maximum caseload for each Service Coordinator (number of Members per Service Coordinator) and the assumptions the Respondent used in developing the maximum caseload estimate. |
4.2.3.3 Financial Capacity |
1. Audited Financial Statements covering the two (2) most recent years of the Respondent’s financial results. These statements must include the independent auditor’s report (audit opinion letter to the Board or shareholders), the notes to the financial statements, any written description(s) of legal issues or contingencies, and any management discussion or analysis. |
Make sure that the name and address of the firm that audits the Respondent is shown. State the date of the most-recent audit, and whether the Respondent is audited annually or otherwise. State definitively if there has, or has not, been any of the following: |
• a “going concern” statement was issued by any auditor in the last three (3) years; |
• a qualified opinion was issued by any auditor in the last three (3) years; |
• a change of audit firms in the last three (3) years; and |
• any significant delay (two (2) months or more) in completing the current audit. |
2. The most recent quarterly and annual financial statements filed with the TDI, and if the Respondent is domiciled in another state, the financial statements filed with the state insurance department in its state of domicile. The annual financial statement must include all schedules, attachments, supplements, management discussion, analysis and actuarial opinions. |
3. The most recent financial examination report issued by TDI, and also by any state insurance department in states where the Respondent operates a Medicaid, CHIP, or comparable managed care product. If any submitted financial examination report is two (2) or more years old, or if Respondent has never had a financial examination report issued, submit the anticipated approximate date of the next issuance of a TDI or state department of insurance financial examination report. |
4. The most recent Form B Registration Statement disclosure filed by Respondent with TDI, and any similar form filed with any state insurance department in other states where the Respondent operates a Medicaid, CHIP, or comparable managed care product. If Respondent is exempt from the TDI Form B filing requirement, demonstrate this and explain the nature of the exemption. |
a. SEC Form 10-K and 10-Q. If Respondent is a publicly-traded (stock-exchange-listed) corporation, then submit the most recent United States Securities and Exchange Commission (SEC) Form 10K Annual Report, and the most-recent 10-Q Quarterly report. |
b. IRS Form 990. If the Respondent is a non-profit entity, then submit the most recent annual Internal Revenue Service (IRS) Form 990 filing, complete with any and all attachments or schedules. If Respondent is a non-profit entity that is exempt from the IRS 990 filing requirement, demonstrate this and explain the nature of the exemption. |
d. Bond or debt rating analysis. If Respondent has been, in the last three (3) years, the subject of any bond rating analysis, ratings affirmation, write-up, or related report, such as by AM Best, Fitch Ratings, Moody’s, Standard & Poor, etc., submit the most-recent detailed report from each rating entity that has produced such a report. |
e. Annual Report. If Respondent produces any written “annual report” or similar item that is in addition to the above-referenced documents, submit the most recent version. This might be a yearly report or letter to shareholders, the community, regulators, lenders, customers, employees, the Respondent’s owner, or other constituents. |
f. If the Respondent has issued any press releases in the 12 months prior to the submission due date, wherein the press release mentions or discusses financial results, acquisitions, divestitures, new facilities, closures, layoffs, significant contract awards or losses, penalties/fines/sanctions, expansion, new or departing officers or directors, litigation, change of ownership, or other very similar issues, provide a copy of each such press release. HHSC does not wish to receive other types of press releases that are primarily promotional in nature. |
1. balance sheet; |
2. statement of income and expense; |
3. statement of cash flows; |
4. statement of changes in financial position (capitol & surplus; equity); |
5. independent auditor’s letter of opinion; |
6. description of organization and operation, including ownership, markets served, type of entity, number of locations and employees, and, dollar amount and type of any Respondent business outside of that with HHSC; and |
7. disclosure of any material contingencies, and any current, recent past, or known potential material litigation, regulatory proceedings, legal matters, or similar issues. |
4.2.3.4 Financial Report of Parent Organization and Corporate Guarantee |
4.2.3.5 Bonding |
4.2.4 Section 4 – Material Subcontractor Information |
1. The Material Subcontractor’s legal name, trade name, acronym, d.b.a., and any other name under which the Material Subcontractor does business. |
2. The Respondent’s estimated annual payments to the Material Subcontractor, by MCO Program. |
3. The physical address, mailing address, and telephone number of the Material Subcontractor’s headquarters office, and the name of its Chief Executive Officer. |
4. Whether the Material Subcontractor is an Affiliate of the Respondent or an unrelated third party (see the “Uniform Managed Care Contract Terms and Conditions” for the definition of “Affiliate.”) |
5. If the Material Subcontractor is an Affiliate, then provide: |
a. the name of the Material Subcontractor’s parent organization, and the Material Subcontractor’s relationship to the Respondent; |
b. the proportion, if any, of the Material Subcontractor’s total revenues that are received from non-Affiliates. If the Material Subcontractor has significant revenues from non-Affiliates, then also indicate the portion, if any, of those external (non-Affiliate) revenues that are for services similar to those that the Respondent would procure under the proposed Subcontract; |
c. a description of the proposed method of pricing under the Subcontract; |
d. indicate if the Respondent presently procures, or has ever procured, similar services from a non-Affiliate; |
e. the number of employees (staff and management) who are dedicated full-time to the Affiliate’s business; |
f. whether the Affiliate’s office facilities are completely separate from the Respondent and the Respondent’s parent. If not, identify the approximate number of square feet of office space that are dedicated solely to the Affiliate’s business; |
g. attach an organization chart for the Affiliate, showing head count, Key Personnel names, titles, and locations; and |
h. indicate if the staff and management of the Affiliate are directly employed by the Affiliate itself, or are they actually, from a technical legal perspective, employed by a different legal entity (such as a parent corporation). What corporation’s name shows up on the employee’s W2 form? |
6. A description of each Material Subcontractor’s corporate background and experience, including its estimated annual revenues from unaffiliated parties, number of employees, location(s), and identification of three (3) major clients. |
7. A signed letter of commitment from each Material Subcontractor that states the Material Subcontractor’s willingness to enter into a Subcontractor agreement with the Respondent, and a statement of work for activities to be subcontracted. Letters of Commitment must be provided on the Material Subcontractor’s official company letterhead, 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. |
8. The type of ownership [e.g., wholly-owned subsidiary of a publicly-traded corporation; wholly-owned subsidiary of a private (closely-held) stock corporation; subsidiary or component of a non-profit foundation; subsidiary or component of a governmental entity such as a County Hospital District; independently-owned member of an alliance or cooperative network; joint venture (describe owners); etc.] Indicate the name of the ultimate owner (e.g., the name of a publicly-traded corporation or a County Hospital District). |
9. Indicate status (any/all that may apply): sole proprietor, partnership, corporation, for-profit, non-profit, privately owned, and/or listed on a stock exchange. If a Subsidiary or Affiliate, name of the direct and ultimate parent organization. |
10. The name and address of any sponsoring corporation or others who provide financial support to the Material Subcontractor and the type of support, e.g., guarantees, letters of credit, etc. Indicate if there are maximum limits of the additional financial support. |
11. 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. |
12. The state in which the Material Subcontractor is incorporated, commercially domiciled, and the state(s) in which the organization is licensed to do business. |
13. The Material Subcontractor’s federal taxpayer identification number. |
14. Whether the Material Subcontractor had a managed care contract terminated or not renewed for any reason within the past five (5) years. In such instance, the Respondent must describe the issues, the parties involved, and provide the address and telephone number of the principal terminating party. The Respondent must also describe any corrective action taken to prevent any future occurrence of the problem that may have lead to the termination. |
15. 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. |
16. The website address (URL) for the homepage(s) of any website(s) operated, owned, or controlled by the Material Subcontractor, including any websites run by another entity on the Material Subcontractor’s behalf. If the Material Subcontractor has a parent, then also provide the same for the parent organization, and any parent(s) of the parent organization. If none exist, provide a clear and definitive statement to this effect. |
4.2.5 Section 5 – Historically Underutilized Business (HUB) Participation |
4.2.5.1 Introduction |
4.2.5.2 HHSC’s Administrative Rules |
4.2.5.3 HUB Participation Goal |
4.2.5.4 Required HUB Subcontracting Plan |
4.2.5.5 CPA Centralized Master Bidders List |
• 948-07: Administration Services, Health |
• 958-56: Health Care Management Services (Including Managed Care Services) |
• 915-49: High Volume, Telephone Call Answering Services (See 915-05 for Low Volume Services) |
4.2.5.6 HUB Subcontracting Procedures – If a Respondent Intends to Subcontract |
1. a description of the scope of work to be subcontracted; |
2. information regarding the location to review project plans or specifications; |
3. information about bonding and insurance requirements; |
4. required qualifications and other contract requirements; and |
5. a description of how the subcontractor can contact the Respondent. |
4.2.5.7 Alternatives to Good Faith Effort Requirements (Applies Only to Mentor Protégé and Professional Services Contracts) |
1. include a fully executed copy of the Mentor Protégé Agreement, which must be registered with the CPA prior to submission to HHSC; and |
2. identify areas of the HSP that will be performed by the protégé. |
4.2.5.8 HUB Subcontracting Procedures – If a Respondent Does Not Intend to Subcontract |
1. evidence of sufficient Respondent staffing to meet the RFP requirements; |
2. monthly payroll records showing the Respondent staff fully dedicated to the contract; and |
3. documentation proving employment of qualified personnel holding the necessary licenses and certificates required to perform the Scope of Work. |
4.2.5.9 Post-award HSP Requirements |
4.2.6 Section 6 – Certifications and Other Required Forms |
1. Child Support Certification; |
2. Debarment, Suspension, Ineligibility, and Voluntary Exclusion of Covered Contracts; |
3. Federal Lobbying Certification; |
4. Nondisclosure Statement; |
5. Required Certifications; and |
6. Respondent Information and Disclosures. |
4.3 Part 2 – Programmatic Proposal |
1. Section 1 – Proposed Programs, Service Area, and Capacity |
2. Section 2 – Experience Providing Covered Services |
3. Section 3 – Value-added Services |
4. Section 4 – Access to Care |
5. Section 5 – Provider Network Provisions |
6. Section 6 – Member Services |
7. Section 7 – Quality Assessment and Performance Improvement |
8. Section 8 – Utilization Management |
9. Section 9 – Early Childhood Intervention (ECI) |
10. Section 10 – Services for People with Special Health Care Needs |
11. Section 11 – Care Management/Service Coordination |
12. Section 12 – Disease Management (DM)/Health Home Services |
13. Section 13 – Behavioral Health Services and Network |
14. Section 14 – Management Information Systems Requirements |
15. Section 15 – Fraud and Abuse |
16. Section 16 – Pharmacy Services |
17. Section 17 – Transition Plan |
18. Section 18 – Additional Requirements Regarding Dual Eligibles |
4.3.1 Section 1 – Proposed Programs, Service Area, and Capacity |
1. complete the MCO Program Proposed Service Area and Capacity table found in the Procurement Library, which must include for each proposed Service Area indicated in Table 1 of the Respondent’s Executive Summary, an estimate of the number of HHSC MCO Members the Bidder has the capacity to serve in each MCO Program bid on the Operational Start Date; |
2. describe the calculations and assumptions used to arrive at these Service Area capacity projections. In developing these projections, the Respondent should consider the capacity of its Network, including its PCP Network, its Behavioral Health Services Network, its specialty care Network, its Pharmacy Network, and for STAR+PLUS, its home and community-based services Network. Respondents should specify: |
• the anticipated STAR, STAR+PLUS, or CHIP Program enrollment, as applicable; |
• the expected utilization of services, taking into consideration the characteristics and health care needs of specific populations represented in the particular HHSC MCO Program; |
• the numbers and types (in terms of training, experience, and specialization) of providers required to furnish the Covered Services; |
• the numbers of Network Providers and providers with signed contracts, LOAs, or LOIs who are not accepting new patients, by MCO Program; |
• the geographic location of providers and HHSC MCO members, considering travel time, the means of transportation ordinarily used by HHSC MCO members, and whether the location provides physical access for members with disabilities; and |
• generally describe anticipated Service Area capacity changes, if any, for each of the proposed Service Areas over the Initial Contract Period; and |
3. generally describe methods that the MCO will use to ensure access to all Covered Services upon potential population growth due to changes in law, including growth resulting from the Patient Protection and Affordable Care Act and Health Care and Education Reconciliation Act of 2010. |
4.3.2 Section 2 – Experience Providing Covered Services |
1. briefly describe the Respondent’s experience providing, on a capitated basis, Acute Care services, including Behavioral Health Services, equivalent or comparable to Covered Services included in the MCO Programs bid (STAR Covered Services are described in Attachment B-1, CHIP Covered Services are described in Attachment B-1.1, and STAR+PLUS Covered Services are described in Attachment B-1.2). The description should indicate: |
a. the extent to which the Respondent has experience providing such Acute Care services for a managed care population(s) comparable to the population in the MCO Programs bid; and |
b. the Respondent’s experience providing such Acute Care services in Texas, and in the Respondent’s proposed Service Areas, if applicable; |
2. indicate which STAR or CHIP Covered Service(s) (in whole or in part) the Respondent does not have experience providing on a capitated basis or does not have experience providing to a comparable Medicaid or CHIP population; |
3. for STAR+PLUS Respondents, briefly describe the Respondent’s experience providing managed Community-based Long-Term Services and Supports and Acute Care services equivalent or comparable to STAR+PLUS Covered Services described in Attachment B-1.2. The description should indicate: |
a. the extent to which the Respondent has experience providing Community-based Long-Term Services and Supports and Acute Care services for a managed care population(s) comparable to the population in STAR+PLUS; and |
b. the Respondent’s experience providing such Community-based Long-Term Services and Supports in Texas, and in the Respondent’s proposed Service Areas, if applicable; |
4. indicate which STAR+PLUS Covered Service(s) (in whole or in part) the Respondent does not have experience providing on a capitated basis or does not have experience providing to a comparable Medicaid population; |
5. briefly describe the Respondent’s proposal for providing Covered Services, including any plans for expansions of its Provider Network in any of the proposed Service Areas prior to a Readiness Review. If the Respondent proposes to use a Material Subcontractor to provide or manage Behavioral Health Services, Pharmacy Services, or any other Covered Service, the Respondent must describe its relationship with the Material Subcontractor, as required by Section 4.3; |
6. for STAR Respondents for the Medicaid Rural Service Area, describe the Respondent’s experience in providing Medicaid wrap-around services for Dual Eligibles entitled to these benefits. If the Respondent does not have experience in providing these services, indicate how the Respondent intends to meet this requirement; and |
7. for STAR+PLUS Respondents, describe the Respondent’s experience in providing Service Coordination for Dual Eligibles. Respondent should specifically describe the processes and procedures used to coordinate Medicare services with Medicaid Community-based Long-Term Services and Supports and related services. If the Respondent does not have experience coordinating these services, indicate how the Respondent intends to meet this requirement. |
4.3.3 Section 3 – Value-added Services |
1. define and describe the Value-added Service; |
2. specify the applicable Service Areas for the proposed Value-added Services; |
3. identify the category or group of Members eligible to receive the proposed Value-added Services if it is a type of service that is not appropriate for all Members; |
4. note any limitations or restrictions that apply to the Value-added Services; |
5. for each Service Area, identify the types of Providers responsible for providing the Value-added Service, including any limitations on Provider capacity if applicable. |
6. propose how and when Providers and Members will be notified about the availability of such Value-added Service; |
7. describe how a Member may obtain or access the Value-added Service; |
8. include a statement that the Respondent will provide any Value-added Service(s) that are approved by HHSC for at least 12 months after the Operational Start Date of the Contract; and |
9. describe if, and how, the Respondent will identify the Value-added Service in administrative data (Encounter Data). |
4.3.4 Section 4 – Access to Care |
4.3.4.1 Travel Distances |
1. adults with access to PCPs (STAR and STAR+PLUS only): |
a. Percentage and number of adult Members with access to one (1) Open-Panel, age-appropriate Network PCP within 30 miles, and the average number of miles within which adults have such access; |
b. Percentage and number of adult Members with access to two (2) Open-Panel, age-appropriate Network PCPs within 30 miles, and the average number of miles within which adults have such access; |
2. children with access to PCPs: |
a. Percentage and number of child Members with access to one (1) Open-Panel, age-appropriate Network PCP within 30 miles, and the average number of miles within which children have such access; |
b. Percentage and number of child Members with access to two (2) Open-Panel, age-appropriate Network PCPs within 30 miles, and the average number of miles within which children have such access; |
3. access to cardiologists (STAR and STAR+PLUS only): |
a. Percentage and number of adult Members with access to one (1) Network cardiologist within 75 miles, and the average number of miles within which adults have such access; |
b. Percentage and number of adult Members with access to two (2) Network cardiologists within 75 miles, and the average number of miles within which adults have such access; |
4. access to Acute Care Hospitals: |
a. Percentage and number of Members with access to a Network Acute Care Hospital within 30 miles; |
5. access to outpatient Behavioral Health Services Providers (does not apply to the STAR Dallas Service Area, where Behavioral Health services are provided through NorthSTAR): |
a. Percentage and number of Members with access to one (1) Network outpatient Behavioral Health Service Provider within 75 miles, and the average number of miles within which Members have such access; |
b. Percentage and number of Members with access to two (2) Network outpatient Behavioral Health Providers within 75 miles, and the average number of miles within which Members have such access; |
6. access to OB/GYNs (does not apply to CHIP Members or CHIP Perinatal Newborn Members – but does apply to CHIP Perinate Members (unborn children)): |
a. Percentage and number of female Members over age 19 with access to one (1) Network OB/GYN within 75 miles, and the average number of miles within which such female Members have such access (applies to Medicaid Members and CHIP Perinate Members in both urban and rural areas); |
b. Percentage and number of female Members over age 19 with access to two (2) Network OB/GYNs within 75 miles, and the average number of miles within which such female Members have such access(applies to Medicaid Members and CHIP Perinate Members in both urban and rural areas); |
c. Percentage and number of CHIP Perinate Members in rural areas with access to one (1) Network OB/GYN within 125 miles, and the average number of miles within which such Members have such access; |
d. Percentage and number of CHIP Perinate Members in rural areas with access to one (1) Network OB/GYN within 125 miles, and the average number of miles within which such Members have such access; |
7. access to otolaryngologists (STAR and CHIP only): |
a. Percentage and number of child Members with access to one (1) Network otolaryngologist (ENT) within 75 miles, and the average number of miles within which children have such access; and |
b. Percentage and number of child Members with access to two (2) Network otolaryngologists (ENTs) within 75 miles, and the average number of miles within which children have such access; and |
8. access to Pharmacies: |
a. Percentage and number Members with access to one (1) Network pharmacy within 15 miles, and the average number of miles within which Members have such access; |
b. Percentage and number Members with access to two (2) Network pharmacies within 15 miles, and the average number of miles within which Members have such access; |
c. Percentage and number Members with access to one (1) 24 hour Network pharmacy within 75 miles, and the average number of miles within which Members have such access; and |
d. Percentage and number Members with access to two (2) 24 hour Network pharmacies within 75 miles, and the average number of miles within which Members have such access. |
4.3.4.2 Assessing Access to Care |
1. Identify the process(es) by which the Respondent must measure and regularly verify: |
a. Network compliance, including pharmacy, regarding travel distance access in Section 8.1.3.2; |
b. Provider compliance regarding appointment access standards in Section 8.1.3.1, and |
c. PCP compliance with after-hours coverage standards in Section 8.1.4.2. |
2. Describe the steps the Respondent has taken in the past when it identified: |
a. a deficiency in its compliance with plan or state travel distance access standards; |
b. a Provider that was not meeting plan or state appointment access standards, and |
c. a PCP that was not in compliance with the plan or state after-hours coverage requirements. |
If the Respondent has not taken such steps listed in 2a, b, or c above with regularity, describe how it proposes to take such steps in the future. |
3. Describe the processes the Respondent implement to accommodate additional Members and to ensure the access standards are met if actual enrollment exceeds projected enrollment. |
4.3.5 Section 5 – Provider Network Provisions |
4.3.5.1 Provider Network |
1. For each Service Area in which the Respondent proposes to participate in the STAR, STAR+PLUS, and/or CHIP Program, the Respondent must submit a complete listing of proposed Network Providers for each of the following Acute Care provider types. Such listing must indicate for each provider type: the name, address, and NPI and/or TPI, if applicable, of the Providers with signed contracts, LOIs or LOAs. If the Respondent’s Provider Network is identical across more than one MCO Program within a Service Area, the Respondent may submit one Excel file worksheet for the Service Area that specifies the applicable MCO Programs. The Respondent must include in an Excel file at least the two (2) nearest Providers meeting each of the following provider type descriptions. The Respondent must also include in the Excel file all Providers in the designated provider type within the Service Area. The listing must include separate lists of each provider type in the order listed below and a separate worksheet for each proposed Service Area: |
a. Acute Care Hospitals, inpatient and outpatient services; |
b. Hospitals providing Level 1 trauma care; |
c. Hospitals providing Level 2 trauma care; |
d. Hospitals designated as transplant centers; |
e. Hospitals designated as Children’s Hospitals by the CMS; |
f. other Hospitals with specialized pediatric services; |
g. Psychiatric Hospitals providing mental health services, inpatient and outpatient; |
h. Other facilities or clinics that provide outpatient mental health services; |
i. Hospitals providing substance abuse services, inpatient and outpatient; and |
j. other facilities or clinics providing outpatient substance abuse services. |
2. For STAR+PLUS only, identify a list of Community-based Long-Term Services and Supports Providers with whom the Respondent has a signed contract, LOI or LOA. These Providers should be listed by type, name, and address. Respondent should also list the array of Community-based Long-Term Services and Supports each of these entities provides. |
a. Personal Assistance Services (PAS); |
b. Day Activity and Health Services (DAHS); |
c. adaptive aids and medical supplies; |
d. adult foster care; |
e. assisted living and residential care services; |
f. emergency response services; |
g. home delivered meals; |
h. in-home skilled nursing care; |
i. dental services; |
j. minor home modifications; |
k. respite care; |
l. therapy – occupational; |
m. therapy – physical; |
n. therapy – speech, hearing, and/or language pathology services; |
o. consumer directed services; and |
p. transition assistance services. |
3. Identify the types of Providers the Respondent allows to be PCPs for adults, PCPs for children, OB/GYNs, and outpatient Behavioral Health Service Providers. The Respondent should identify its contract requirements for these provider types and any exceptions. For example, Respondent should note under what circumstances, if any, an internist is allowed to be a PCP for children, or a family practitioner is allowed to be an OB/GYN. |
4.3.5.2 Significant Traditional Providers |
4.3.5.3 Provider Network Capacity |
1. indicate which, if any, Covered Services are not available from a qualified Provider in the Respondent’s proposed Network in the Service Area and how the Respondent proposes to provide such Covered Services to Members in the Service Area; and |
2. briefly describe how deficiencies will be addressed when the Provider Network is unable to provide a Member with appropriate access to Covered Services due to lack of a qualified Network Provider within the travel distance of the Member’s residence specified in Section 8.1.3.2. The description should include, but not be limited to, how the Respondent will address deficiencies in the Network related to: |
a. the lack of an age-appropriate Network PCP with an Open-Panel within the required travel distance of the Member’s residence; |
b. for female Members, the lack of an Network OB/GYN with an open practice within the travel distance of the Member’s residence; |
c. the lack of a Network cardiologist within the travel distance of the Member’s residence (STAR and STAR+PLUS only); and |
d. the lack of a Network pharmacy within the travel distance of the Member’s residence. |
4.3.5.4 Credentialing and Re-credentialing |
1. Describe the Respondent’s minimum credentialing and/or licensure requirements and procedures for Acute Care Providers by type of Provider, and demonstrate how the Respondent ensures, or proposes to ensure, that the minimum credentialing requirements are met. Such description must demonstrate compliance with Section 8.1.4.4. |
2. Describe the re-credentialing process or process between re-credentialing cycles for Acute Care Providers and how the Respondent will capture and assess the following information: |
a. Member Complaints and Appeals; |
b. results from quality reviews and Provider quality profiling; |
c. utilization management information; and |
d. information from licensing and accreditation agencies. |
3. For STAR+PLUS only, describe the Respondent’s minimum credentialing and/or licensure requirements and procedures for Providers of Community-based Long-Term Services and Supports by type of Provider, and how Respondent will ensure that the minimum credentialing and licensing requirements are met by any Provider rendering Covered Services. |
4. For STAR+PLUS only, describe the re-credentialing process for Providers of Community-based Long-Term Services and Supports. The description of the re-credentialing process should include how the Respondent will capture and assesses the following information: |
a. Member Complaints and Appeals; |
b. results from quality reviews and quality Provider profiling; |
c. utilization management information; and |
d. information from licensing and accreditation agencies. |
5. A Respondent currently operating in Texas must separately report the following information for its Texas Network. A Respondent not currently operating in Texas must separately report the same information for a managed care program it operates in another state that is similar to the MCO Program bid: |
a. the percentage of providers in its Network re-credentialed in the past three (3) years, for the following provider types: primary care physician, specialty care provider, and masters-level outpatient Behavioral Health Service providers; and |
b. the number and percentage of providers in its Network who were subjected to the regularly scheduled re-credentialing process over the past 24 months that were denied continued Network status. |
4.3.5.5 Provider Hotline |
1. normal hours of operation of the hotline; |
2. staffing for the hotline; |
3. training for the hotline staff on Covered Services and HHSC MCO Program requirements; |
4. the routing of calls among hotline staff to ensure timely and appropriate response to provider inquiries; |
5. responsibilities of hotline staff, if any, in addition to responding to HHSC Provider Hotline calls (e.g., responding to non-Network provider calls and/or HHSC Member Hotline calls); |
6. after-hours procedures and available services; |
7. provider hotline telephone reports for the most recent four (4) quarters with data that show the monthly call volume, the monthly trends for average speed of answer (where answer is defined by reaching a live voice, not an automated call system) and the monthly trends for the abandonment rate; and |
8. Whether the Provider Hotline has the capability to administer automated surveys to callers at the end of calls. |
4.3.5.6 Provider Training |
1. Provide a brief description of the proposed Provider training programs for each MCO Program bid. For STAR+PLUS only, distinguish between training programs for Acute Care Providers and Community-based Long-Term Services and Supports Providers. The description should include: |
a. the types of programs to be offered, including the modality of training; |
b. what topics will be covered; |
c. which Providers will be invited to attend; |
d. how the Respondent proposes to maximize Provider participation; |
e. how Provider training programs will be evaluated; |
f. the frequency of Provider training; and |
g. for STAR+PLUS Long Term Services and Supports providers in El Paso, Lubbock, and Hidalgo, who have never submitted traditional claim forms, a brief summary of additional methods to assist these providers. |
2. Briefly describe two (2) examples of recent Provider training programs relevant to each of the MCO Programs bid. These examples must include: |
a. a description of the training program; |
b. a summary of distributed materials (the actual materials are not to be submitted); |
c. number and type of attendees; and |
d. results of any evaluations from the training. |
4.3.6 Section 6 – Member Services |
4.3.6.1 Member Services Staffing |
1. Provide an organizational chart of the Member Services Department, showing the placement of Member Services within the Respondent’s organization and showing the key staff within the Member Services Department. |
2. Explain the functions of the Member Services staff, including brief job descriptions and qualifications. |
3. Describe the curriculum for training to be provided to Member Services representatives, including when the training is conducted and how the training addresses: |
a. Covered Services, including Behavioral Health Services and Community-based Long Term Services and Supports; |
b. MCO Program requirements; |
c. Cultural Competency; and |
d. providing assistance to Members with limited English proficiency. |
4. Identify the turnover rate for Member Services staff in the past two (2) years. A Respondent operating any HHSC MCO Program must provide the staff turnover rate for each of its MCO Programs. A Respondent not currently operating an HHSC MCO rogram must provide its Member Services staff turnover rate for a comparable managed care program and identify the managed care program. |
5. For STAR+PLUS only, identify the number and professional background of Member Services staff that the Respondent intends to dedicate to the Service Coordination function. |
6. Identify the percentage of Member Services staff who will be physically located in the Service Area. |
4.3.6.2 Member Hotline |
1. normal hours of operation; |
2. number of Member Hotline staff, expressed in the number of full time employees (FTEs) per 1000 Members who are available 8:00 a.m. to 5:00 p.m., local time in the Service Area, Monday through Friday, excluding state-approved holidays; |
3. routing of calls among Member Hotline staff to ensure timely and accurate response to Member inquiries; |
4. responsibilities of Member Hotline staff, if any, in addition to responding to HHSC Member Hotline calls, (e.g., responding to non-HHSC Member calls and/or HHSC Provider Hotline or Behavioral Health Hotline calls); |
5. after-hours procedures and available services, including those provided to non-English speaking Members in Major Population Groups; |
6. the number and percentage of FTE Member Hotline staff who are bilingual in English and Spanish; |
7. the number and percentage of FTE Member Hotline staff who are multi-lingual for any additional language, by language spoken; |
8. for STAR+PLUS only, the number and percentage of FTE Member Hotline staff dedicated to the Service Coordination function; |
9. Member Hotline telephone reports for the most recent four (4) quarters with data that show the monthly trends for call volume, monthly trends for average speed of answer (where answer is defined by reaching a live voice, not an automated call system) and monthly trends for the abandonment rate; and |
10. Whether the Member Hotline has the capability to administer automated surveys to callers at the end of calls. |
4.3.6.3 Member Service Scenarios |
1. a Member has received a bill for payment of Covered Services from a Network Provider or Out-of-Network Provider; |
2. a Member is unable to reach her PCP after normal business hours; |
3. a Member is having difficulty scheduling an appointment for preventive care with her PCP, |
4. for STAR+PLUS only, a Member is having difficulty scheduling an appointment for preventive care with her Medicare PCP; |
5. for STAR+PLUS only, a Member is in urgent need of meals, adaptive aids, or other Community-Based Long- Term Services and Supports and is unable to reach their Service Coordinator or provider, |
6. a Member becomes ill while traveling outside of the Service Area, and |
7. a Member has a request for a specific medication that the pharmacy is unable to provide. |
4.3.6.4 Cultural Competency |
1. Describe how the Respondent will ensure culturally competent services to people of all cultures, races, ethnic backgrounds, and religions as well as those with disabilities in a manner that recognizes values, affirms, and respects the worth of the individuals and protects and preserves the dignity of each. |
2. Describe how the Respondent will develop intervention strategies and work with Network Providers to avoid disparities in the delivery of medical services to diverse populations. |
4.3.6.5 Member Complaint and Appeal Processes |
1. describe the process the Respondent will put in place for the review of Member Complaints and Appeals, including which staff will be involved; |
2. provide a flowchart that depicts the process the Respondent will employ, from the receipt of a request through each phase of the review to notification of disposition, including providing notice of access to HHSC Fair Hearings; |
3. document the MCO’s average time for resolution over the past 12 months for Member Complaints and Appeals (excluding Expedited Appeals), from date of receipt to date of notification of disposition; and |
4. for STAR and STAR+PLUS only, describe the number and job descriptions of Member Advocates, how Members are informed of the availability of Member Advocates, and how Members access Advocates. |
4.3.6.6 Marketing Activities and Prohibited Practices |
1. describe the basis for each sanction or corrective action, and |
2. explain how the Respondent would ensure that it would not commit any practices prohibited by the CMS or HHSC in its Marketing activities. |
4.3.6.7 Continuity of Care (for STAR and STAR+PLUS only) |
4.3.6.8 Objection to Providing Certain Services |
4.3.6.9 Coordination of Services for Dual Eligibles |
4.3.7 Section 7 – Quality Assessment and Performance Improvement |
4.3.7.1 Clinical Initiatives |
1. For each MCO Program bid, describe data-driven clinical initiatives that the Respondent initiated within the past 24 months that have yielded improvement in clinical care for a managed care population comparable to the population bid and document two (2) statistically significant improvements generated by the Respondent’s clinical initiatives. |
2. For STAR+PLUS only, propose two (2) clinical initiatives focused on Community-based Long-Term Services and Supports for STAR+PLUS Members, including how Members will be involved in such initiatives and the Respondent’s experience implementing similar clinical initiatives. |
3. For each MCO Program bid, describe two (2) new or ongoing Acute Care clinical initiatives that the Respondent proposes to pursue in the first year of the Contract. Document why each topic warrants quality improvement investment, and describe the Respondent’s measurable goals for the initiative. |
4. For STAR+PLUS only, describe the planned approach the Respondent will take towards quality assessment and ongoing review of providers with whom it intends to contract, using the following provider types as an example: |
5. For Respondents that already participate in an HHSC MCO Program, provide a copy of the most recent QAPI Plan. For Respondents that do not participate in an HHSC MCO Program, provide a copy of a 2009 quality assurance plan for a comparable managed care population. |
6. Many Texas Medicaid and CHIP children reportedly receive their immunizations through Local Health Departments. Discuss the impact this has on creating a Medical Home for child Members, and what steps, if any, the Respondent proposes to take to improve child preventive services delivery. |
4.3.7.2 Healthcare Effectiveness Data and Information Set (HEDIS) and Other Quality Data |
4.3.7.3 Clinical Practice Guidelines |
1. For each MCO Program bid, describe two (2) clinical guidelines that are relevant to the enrolled populations and that the Respondent believes are currently not being adhered to at a satisfactory level. |
2. Describe what steps the Respondent will take to increase compliance with the clinical guidelines noted in its response to question number 1 above. |
3. Provide a general description of the Respondent’s process for developing and updating clinical guidelines, and for disseminating them to participating Providers. |
4.3.7.4 Provider Profiling |
1. Describe the Respondent’s practice of profiling the quality of care delivered by Network PCPs, and any other Acute Care Providers (e.g., high volume specialists, Hospitals), including the methodology for determining which and how many Providers will be profiled. |
2. For STAR+PLUS, describe the Respondent’s method to ensure the quality of care delivered by Long-Term Services and Supports Providers. |
3. Submit sample quality profile reports used by the Respondent, or proposed for future use (identify which). |
4. Describe the rationale for selecting the performance measures presented in the sample profile reports. |
5. Describe the proposed frequency with which the Respondent will distribute such reports to Network Providers, and identify which Providers will receive such profile reports. |
4.3.7.5 Network Management |
1. the steps the Respondent will take with each profiled Provider following the production of each profile report, including a description of how the Respondent will motivate and facilitate improvement in the performance of each profiled Provider; |
2. the process and timeline the Respondent proposes for periodically assessing Provider progress on its implementation of strategies to attain improvement goals; |
3. how the Respondent will reward Providers who demonstrate continued excellence and/or significant performance improvement over time, through non-financial or financial means, including pay-for-performance; |
4. how the Respondent will share “best practice” methods or programs with Providers of similar programs in its Network; |
5. how the Respondent will take action with Providers who demonstrate continued unacceptable performance and performance that does not improve over time; |
6. the steps the Respondent will take with a Provider that specifically is not meeting HHSC contractual access standards; and |
7. the extent to which the Respondent currently operates a Network management program consistent with HHSC requirements in Section 8.1.7.8, and measurable results it has achieved from such Network management efforts. |
4.3.8 Section 8 – Utilization Management |
4.3.9 Section 9 – Early Childhood Intervention (ECI) |
1. Describe the Respondent’s experience with, and general approach to, providing ECI services, including how the Respondent will identify such individuals. |
2. Describe procedures and protocols for using the IFSP information to develop a Member Care Plan and authorize services. |
3. Describe procedures and protocols for developing and including the interdisciplinary team in the assessment and care planning process. |
4. Describe the process by which the Respondent will provide the IFSP and other necessary information to the PCP. |
4.3.10 Section 10 – Services for People with Special Health Care Needs |
1. Describe the Respondent’s experience with, and general approach to, providing services for adults with Special Health Care Needs (STAR and STAR+PLUS only), including how the Respondent will identify such individuals and the criteria it will use in assessing whether an adult is a Member with Special Health Care Needs (MSHCN). |
2. Describe the Respondent’s experience with, and general approach to, providing services for Children with Special Health Care Needs (CSHCN), including how the Respondent will identify such individuals and the criteria it will use in assessing whether a Member is a CSHCN. |
3. Describe the process for initially and periodically assessing Members’ needs for services, and identify the staff performing the assessments and their credentials. |
4. Describe procedures and protocols for using the assessment information to develop a Member Care Plan and authorize services. |
5. Describe procedures and protocols for including the Member and/or Member’s Representative in the assessment and care planning process. |
6. Describe the process by which the Respondent will allow MSHCN to have: |
a. direct access to a specialist as appropriate for the Member’s condition and identified needs, such as a standing referral to a specialty physician; and |
b. access to non-primary care physician specialists as PCPs, as required by 28 T.A.C. § 11.900 and Section 8.1.3. |
4.3.11 Section 11 – Care Management and/or Service Coordination |
1. Describe the Respondent’s experience providing Care Management and/or Service Coordination to members with high-cost catastrophic situations (e.g., recent spinal cord injury) and the Respondent’s proposal for implementing high-cost catastrophic Care Management and/or Service Coordination, including how the Respondent will identify Members for high cost catastrophic Care Management and/or Service Coordination, and the criteria used to identify such Members. |
2. Describe the Respondent’s experience providing Care Management and/or Service Coordination services to Members with the following serious health care conditions, as applicable to the MCO Programs bid, and the Respondent’s proposal for offering Care Management and/or Service Coordination services to these Members. Include how Members will be identified for Care Management and/or Service Coordination, and the criteria used to identify such Members: |
a. women with high-risk pregnancies (STAR only); and |
b. individuals with mental illness and co-occurring substance abuse. |
3. Identify any measurable results in terms of clinical outcomes and program savings that have resulted from the Respondent’s Care Management and/or Service Coordination initiatives. |
4. For STAR+PLUS only, describe the duties and responsibilities of the Service Coordinator to authorize Community-based Long-Term Services and Supports. The Respondent must describe in detail how the Service Coordinator will function in relation to the Member’s PCP for: |
a. Dual Eligible STAR+PLUS Members receiving both Medicaid and Medicare services from the MCO, and |
b. Dual Eligible STAR+PLUS Members receiving Medicare services through either fee-for-service Medicare or another Medicare MCO. |
5. For STAR+PLUS only, submit detailed information, including protocols and procedures, for identifying Members requiring Service Coordination, and for providing the Service Coordination function to them. The information should include how the protocols and procedures vary for: |
a. Dual Eligible STAR+PLUS Members receiving both Medicaid and Medicare services from the MCO, and for |
b. Dual Eligible STAR+PLUS Members receiving Medicare services through either fee-for-service Medicare or another Medicare MCO. |
6. For STAR+PLUS only, describe the circumstances or conditions when the Member would require a licensed nurse or other allied health care provider as a Service Coordinator. |
7. For STAR+PLUS only, submit criteria for identifying and training certain Members and their Member Representative(s) to coordinate and direct the Member’s own care, to the extent the Member is capable of doing so. Criteria should include those used to enable the Member and family to select, train, and supervise providers of Community-based Long-Term Services and Supports. |
8. For STAR+PLUS only, describe the criteria and processes for advising Members of, and assisting them to access, the most appropriate, least restrictive home and community-based services as alternatives to institutional care. Additionally, describe how the Respondent will ensure that the Member is given the opportunity to make an informed choice among the options for care settings. |
9. For STAR+PLUS only, submit a list of the relevant community organizations in each proposed STAR+PLUS Service Area with which the Respondent will coordinate services for Members and to which it will refer Members for services. |
10. For STAR+PLUS only, describe the process for initially and periodically assessing Members’ needs for services. |
11. For STAR+PLUS only, describe how the Respondent will identify Members who are at risk of nursing facility placement. |
12. For STAR+PLUS only, submit all functional assessment instruments proposed for use and describe how the assessment instrument(s) will be employed to identify the Member’s need for Community-based Long-Term Services and Supports. (Note: If the MCO is allowed to modify a functional assessment instrument required by the State, HHSC must approve the proposed instrument prior to implementation. See Section 8.3.3 for more information.) |
13. For STAR+PLUS only, identify who will perform each assessment and specify their credentials. |
14. Describe procedures and protocols for using the assessment information to develop a Member Service/Care Plan and authorize services. |
15. Describe procedures and protocols for including the Member and/or Member’s Representative in the assessment and care planning process. |
16. For STAR+PLUS only, provide a description of the appropriate staffing ratio of Service Coordinators to Members, and the Respondent’s target ratio of Service Coordinators to Members. |
4.3.12 Section 12 – Disease Management (DM)/Health Home Services |
1. Describe the Respondent’s experience in implementing Disease Management/Health Home Services programs for populations comparable to the proposed HHSC MCO Program. |
2. Identify any measurable results in terms of clinical outcomes and program savings that have resulted from the Respondent’s Disease Management/Health Home Services initiatives, and briefly describe the analyses used to identify such outcomes and savings. |
3. Identify the process by which the Respondent proposes to provide Members with Disease Management/Health Home Services. Describe how the Respondent will identify Members in need of such Disease Management/Health Home Services program, the proposed outreach approach, and the Disease Management/Health Home Services program components for Members of different risk levels. |
4. Describe the process by which the Respondent will ensure continuity of care with the Member’s previous Disease Management/Health Home Services program(s), if any. |
4.3.13 Section 13 – Behavioral Health Services and Network |
4.3.13.1 Behavioral Health Services Hotline |
1. verification that it is, or will be, staffed 24 hours per day, 365 days per year; |
2. staffing of Behavioral Health Services Hotline staff, including clinical credentials; |
3. routing of calls among Behavioral Health Services Hotline staff to ensure timely and accurate response to Member inquiries; |
4. the curriculum for training to be provided to Behavioral Health Services Hotline representatives, including when the training will be conducted and how the training will address a) Covered Services; b) HHSC MCO Program requirements; c) Cultural Competency; and d) providing assistance to Members with limited English proficiency. |
5. responsibilities of Behavioral Health Services Hotline staff, if any, in addition to responding to HHSC Member Hotline calls, (e.g., responding to non-HHSC member calls and/or HHSC Provider Hotline or Member Hotline calls ); |
6. the number and percentage of FTE Behavioral Health Services Hotline staff who are bilingual in English and Spanish; |
7. the number and percentage of FTE Behavioral Health Services Hotline staff who are multi-lingual for any additional language, by language spoken; |
8. Behavioral Health Services telephone reports for the most recent four (4) quarters with data that show the monthly trends for call volume, monthly trends for average speed of answer (where answer is defined by reaching a live voice, not an automated call system), and monthly trends for the abandonment rate; and |
9. whether the Behavioral Health Services Hotline has the capability to administer automated surveys to callers at the end of calls. |
4.3.13.2 Behavioral Health Provider Network Expertise |
1. For each proposed Service Area, identify Behavioral Health Service Providers with expertise in providing services to each of the following populations, as applicable to the Respondent’s Proposal. |
a. substance abusers; |
b. children and adolescents; |
c. persons with a dual diagnosis of mental health and substance abuse; and |
d. services for linguistic and cultural minorities. |
2. Indicate the criteria the Respondent will use to determine that such Behavioral Health Providers have the requisite expertise. |
4.3.13.3 Coordination of Behavioral Health Care |
1. Describe the Respondent’s approach to coordinating Behavioral Health Service delivery with primary care services delivered by a Member’s PCP, and vice versa. |
2. Describe or propose innovative programs and identify Network Providers contracted to serve special populations through integrated medical/Behavioral Health Service delivery models. Describe the program model services, treatment approach, special considerations, and expected outcomes for the special populations. |
3. Describe the process by which the Respondent will ensure the delivery of outpatient Behavioral Health Services within seven (7) days of inpatient discharge for Behavioral Health Services. |
4.3.13.4 Behavioral Health Quality Management |
1. Identify the areas Respondent believes to be the greatest opportunities for clinical quality improvement in behavioral health in each MCO Program bid and provide supporting information. |
2. Discuss the approaches the Respondent will pursue to realize one such opportunity for each MCO Program bid. |
3. Describe how the Respondent proposes to integrate behavioral health into its quality assurance program, as described in Section 8.1.7.5. |
4.3.13.5 Behavioral Health Emergency Services |
4.3.14 Section 14 – Management Information System (MIS) Requirements |
1. describe the Management Information System (MIS) the Respondent will implement, including how the MIS will comply with Health Insurance Portability and Accountability Act of 1996 (HIPAA). The response must address the requirements of Section 8.1.18. At a minimum, the description should address: |
a. hardware and system architecture specifications; |
b. data and process flows for all key business processes in Section 8.1.18.3; and |
c. attest to the availability of the data elements required to produce required management reports; |
2. if claims processing and payment functions are outsourced, provide the above information for the Material Subcontractor; |
3. describe how the Respondent would ensure accuracy, timeliness, and completeness of Encounter Data submissions for each of the MCO Programs bid; |
4. describe the Respondent’s ability and experience in performing coordination of benefits and Third Party Liability/Third Party Recovery (TPL/TPR); |
5. describe the Respondent’s ability and experience in allowing providers to submit claims electronically and its ability and experience in processing electronic claims payments to providers: |
a. if currently processing claims electronically, generally describe the type and volume of provider claims received electronically in the previous year versus paper claims for each claim type; |
b. if currently making claims payments to providers electronically, generally describe the type and volume of provider claims payment processed electronically; |
c. does the MCO provide a no-cost alternative for providers to allow billing without the use of a clearinghouse? If so please describe; and |
d. does the MCO include attendant care payments as part of the regular claims payment process (for STAR+PLUS only)? If so please describe; |
6. describe the Respondent’s experience and capability to comply with the Internet website requirements of Section 8.1.5.5, and briefly describe any additional website capabilities that the Respondent proposes to offer to Members or Providers; |
7. provide acknowledgment and verification that the Respondent’s proposed systems are 5010 compliant by submitting a copy of the 5010 compliancy plan, and proposed timeline for meeting the deadlines for being 5010 compliant; and |
8. describe the Respondent’s capability to pay providers via direct deposit and its experience in doing so, including the percentage, number, and types of providers paid via direct deposit in the most recent 12 month period for which the Respondent has such statistics. If the Respondent operates in Texas, the Respondent must provide this information related to its experience in Texas. If the Respondent does not currently operate in Texas, the Respondent must provide this information for a state in which the Respondent currently operates a managed care program similar to the MCO Programs bid. |
4.3.15 Section 15 – Fraud and Abuse |
4.3.16 Section 16 – Pharmacy Services |
1. The Respondent must describe the processes it will use to manage the pharmacy benefit under both of the following scenarios: |
a. HHSC requires the MCO to implement the Medicaid and CHIP formularies and preferred drug lists (PDLs); and |
b. the MCO is allowed to establish its own formularies and PDLs. |
2. The Respondent must describe the policies and procedures for how mail-order pharmacies will be available to Members. |
3. The Respondent must identify the rationale for requiring prior authorizations, identify the types of drugs that normally require prior authorization, and describe the policies and procedures for the prior authorization process. |
4. The Respondent must describe how rebates will be negotiated (if HHSC determines that the MCO will perform this service), identified, and reported. |
5. The Respondent must describe the policies and procedures for drug utilization reviews, including ensuring prospective reviews take place at the dispensing pharmacy’s point of sale (POS). |
6. The Respondent must describe its policies and procedures for targeted interventions for Network Providers over-utilizing certain drugs. |
4.3.17 Section 17 – Transition Plan |
1. Briefly describe the Respondent’s experience establishing and maintaining electronic interfaces with other contractors responsible for portions of Medicaid and CHIP operations. A Respondent with experience participating in one or more MCO Programs must clearly note its experience in establishing and maintaining such interfaces in Texas. A Respondent without experience establishing and maintaining electronic interfaces with other contractors responsible for Medicaid or CHIP operations must note its experience in establishing and maintaining similar electronic interfaces with similar contractors. |
2. A Respondent that is proposing to participate in an HHSC MCO Program in a Service Area for the first time must, for each MCO Program bid, briefly describe its Transition Plan for all proposed Service Areas, including major activities related to the System Readiness Review and the Operational Readiness Review, including Network development, internal system testing, and proposed schedule to comply with the anticipated Operational Start Date and other requirements described in Section 7. The Respondent must clearly indicate in which Service Area(s) it currently does not operate as an MCO and any differences in its transition approach by Service Area. |
3. A Respondent that is currently a contractor for an HHSC MCO Program must, for each such MCO Program, briefly describe its Transition Plan, including major activities related to the System Readiness Review and the Operational Readiness Review, such as Network Development, internal system testing, and schedule to comply with the anticipated Operational Start Date and other requirements described in Section 7. The Respondent must clearly indicate in which Service Area(s) it currently does not operate as an MCO, and any differences in its transition approach by Service Area. |
4.3.18 Section 18 – Additional Requirements Regarding Dual Eligibles (for STAR+PLUS only) |
1. Submit evidence of Respondent’s MA Dual SNP contract with CMS if any, including the contract number and counties/zip codes served, or submit documentation showing that an application for such a contract has or will be submitted to CMS. For Respondents that do not already have an MA Dual SNP contract and who intend to obtain one, describe the plans for submitting an application and obtaining such a contract. The description should include the timeline for submitting the application and the proposed counties/zip codes for coverage. |
2. Describe the Respondent’s experience in providing Medicare encounter data in HIPAA-compliant formats to federal or state authorities. |
3. Describe how the Respondent intends to coordinate care for Dual Eligible Members, including: |
a. How the Respondent will identify Long-Term Services and Supports providers in the relevant Service Areas. |
b. The processes and procedures Respondent will use to coordinate the delivery of Community-based Long-Term Services and Supports with Medicare benefits for Dual Eligible Members. |
c. The training Respondent will provide to staff and providers regarding Community-based Long-Term Services and Supports and the coordination of those services with Medicare benefits. |
4. Describe how the Respondent will work with the State to share information regarding Medicare and Medicaid participating providers, Member complaints, and HEDIS data. |
5. Evaluation Process and Criteria |
5.1 Overview of Evaluation Process |
5.2 Evaluation Criteria |
• The extent to which the Respondent’s proposal demonstrates an ability to accomplish the missions and objectives for this procurement, including: |
• the extent to which the proposal meets HHSC’s needs, and the MCO Program clients’ needs for high quality and accessible medical care; |
• The degree to which the proposal demonstrates program innovation, adaptability, and exceptional customer service; and |
• the extent to which the Respondent accepts without reservation or exception the RFP’s terms and conditions, including Attachment A, “Uniform Managed Care Contract Terms and Conditions.” |
• Indicators of probable performance under the Contract, including past performance in Texas or comparable experience; financial resources and solvency, including the impact on the Respondent’s and its Subcontractors’ ability to perform, and relevant organizational experience. |
• Effect of the acquisition on agency productivity; including the level of effort and resources required to monitor the Respondent’s performance and maintain a good working relationship with the Respondent. |
1. proposals from Texas institutions providing graduate medical education; |
2. proposals that include substantial participation by Network providers who are Significant Traditional Providers (STP). HHSC defines “substantial participation” as proposals that include at least 50 percent of the STPs in a Service Area. The Respondent must either have a Network Provider agreement in place with the STP, or a Letter of Intent/Letter of Agreement to participate in the Network. A listing of STPs for the new Service Areas can be found in the Procurement Library; and |
3. proposals that ensure continuity of coverage for Medicaid Members for at least three (3) months beyond the period of Medicaid eligibility. For purposes of this provision, HHSC defines “continuity of coverage” as providing the full set of Covered Services. |
5.3 Initial Compliance Screening |
5.4 Competitive Field Determinations |
5.5 Oral Presentations and Site Visits |
5.6 Best and Final Offer |
5.7 Discussions with Respondents |
• obtaining clarification of proposal ambiguities; |
• requesting modifications to a proposal; and/or |
• obtaining a best and final offer of services. |
5.8 Contract Awards |
DOCUMENT HISTORY LOG | ||||||
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 | |||
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-1, RFP Section 6, “Incentives & Disincentives.” | |||
Revision | 2.1 | March 1, 2012 | Contract amendment did not revise Attachment B-1, RFP Section 6, "Incentives & Disincentives." | |||
Revision | 2.2 | June 1, 2012 | Section 6.3.2.1 is modified to change "Rate Period 1" to "FSR Reporting Period 12/13." Section 6.3.2.2 is modified to change "Rate Period" to "FSR Reporting Period." | |||
Revision | 2.3 | September 1, 2012 | Section 6.3.2.5 is modified to remove auto-assignment default methodology. | |||
Revision | 2.4 | March 1, 2013 | All references to the previous Executive Commissioner Suehs are changed to his successor, Executive Commissioner Janek. | |||
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-1, RFP Section 6, "Incentives & Disincentives." | |||
Revision | 2.6 | September 1, 2013 | Section 6.2.1 is modified to remove the reference to Bariatric Supplemental Payments. Section 6.3.1.2 is modified to provide HHSC more flexibility to implement reward-based assignment methodologies. Section 6.3.2.2 is modified to add the word “Program” to the section title. Section 6.3.2.3 is renamed “Performance-Incentive Program”. Subsection 6.3.2.3.1 “Quality Challenge Award” is renamed “Quality Challenge Award Program” and to add clarifying language. Subsection 6.3.2.3.2 State-MCO Shared Savings Program is added. | |||
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-1, RFP Section 6, "Incentives & Disincentives." | |||
Revision | 2.8 | January 1, 2014 | Contract amendment did not revise Attachment B-1, RFP Section 6, "Incentives & 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 MCOs |
6.3.2 Financial Incentives and Disincentives |
6.3.2.4 Remedies and Liquidated Damages |
6.3.2.5 Frew Incentives and Disincentives |
6.3.2.6 Nursing Facility Utilization Disincentive |
6.3.2.7 Additional Incentives and Disincentives |
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 | |||
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-1, RFP Section 7, “Transition Phase Requirements.” | |||
Revision | 2.1 | March 1, 2012 | Section 7.1 is modified to add termination of the contract to the list of remedies for failure to timely satisfy Readiness Review requirements. | |||
Revision | 2.2 | June 1, 2012 | Contract amendment did not revise Attachment B-1, Section 7, "Transition Phase Requirements." | |||
Revision | 2.3 | September 1, 2012 | Contract amendment did not revise Attachment B-1, Section 7, "Transition Phase Requirements." | |||
Revision | 2.4 | March 1, 2013 | Contract amendment did not revise Attachment B-1, Section 7, “Transition Phase Requirements.” | |||
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-1, Section 7, “Transition Phase Requirements.” | |||
Revision | 2.6 | September 1, 2013 | Section 7.2.8.1 is modified for clarification and to comply with requirements of SB 7, 83R. | |||
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-1, Section 7, “Transition Phase Requirements.” | |||
Revision | 2.8 | January 1, 2014 | Contract amendment did not revise Attachment B-1, Section 7, “Transition 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. |
7. Transition Phase Requirements |
7.1 Introduction |
7.2 Transition Phase Schedule and Tasks |
7.2.1 Contract Start-Up and Planning |
• define project management and reporting standards; |
• establish communication protocols between HHSC and the MCO; |
• 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. |
7.2.2 Administration and Key MCO Personnel |
7.2.3 Organizational Readiness Review |
7.2.4 Financial Readiness Review |
7.2.4.1 Employee Bonus and/or Incentive Payment Plan |
7.2.5 System Testing and Transfer of Data |
7.2.6 System Readiness Review |
1. Disaster Recovery Plan;* |
2. Business Continuity Plan*; |
3. Security Plan; |
4. Joint Interface Plan; |
5. Risk Management Plan; and |
6. Systems Quality Assurance Plan. |
7.2.7 Demonstration and Assessment of System Readiness |
7.2.8 Operations Readiness |
• | routinely updating formulary data following receipt of HHSC's daily files (no less frequently than weekly, and off-cycle upon HHSC's request); |
• | prior authorization of drugs, including how HHSC's preferred drug lists (PDLs) will be incorporated into prior authorization systems and processes. The MCO must adopt HHSC's prior authorization policies unless HHSC grants a written exception, and HHSC's approval is required for all Clinical Edit policies; |
• | implementing drug utilization review; |
• | overriding standard drug utilization review criteria and clinical edits when Medically Necessary based on the individual Member's circumstances (e.g, overriding quantity limitations, drug-drug interactions, refill too soon, etc.); |
• | call center operations, including how the MCO will ensure that staff for all appropriate hotlines are trained to respond to prior authorization inquiries and other inquiries regarding pharmacy services, and |
• | monitoring the PBM Subcontractor. |
• | 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 MCO staff persons who: (1) are directly involved in the decision-making and administration of the fraud and abuse detection program within the MCO, and (2) 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. The training will be conducted by the Office of Inspector General, Health and Human Services Commission, and will be provided free of charge. The MCO must schedule and complete training no later than 90 days after the Contract's Effective Date. |
• | Designate an officer or director within the organization responsible for carrying out the provisions of the Fraud and Abuse Compliance Plan. |
• | For STAR+PLUS MCOs, complete hiring and training of Service Coordination staff no later than 45 days prior to the Operational Start Date. |
7.2.8.2 Value-Added Services |
7.2.9 Assurance of System and Operational Readiness |
7.2.10 TDI and Centers for Medicare and Medicaid Services (CMS) Licensure, Certification or Approval |
7.2.11 Post-Transition |
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 |
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-1, RFP Section 8, “Operations Phase Requirements.” |
Revision | 2.1 | March 1, 2012 | Section 8.1.1.1 is modified to change the timeframes for PIPs from SFY to calendar year and to revise the due dates. Section 8.1.3 is modified to clarify PCP requirement’s application (does not apply to CHIP Perinates (unborn children) and add a requirement regarding timely access to Network Providers, as required by 42 CFR §438.206(c)(1)(ii). Section 8.1.3.2 is modified to add pharmacy access requirements effective 9/1/12. These standards are derived from Medicare Part D access standards, and the standards currently being met in the fee-for-service program. Section 8.1.4 is modified to require MCOs to enter into network provider agreements with any willing State Hospital and to clarify requirements for contracting with specialty pharmacies. Section 8.1.5.5 is modified to require the MCOs to include a link to financial literacy information on the OCCC web page as required by HB 2615. Section 8.1.8 is modified to add prior authorizations by pharmacists. Section 8.1.17 is modified to remove the requirement to submit an accounting policy manual. Section 8.1.17.1 “Financial Disclosure Report” is renamed “MCO Disclosure Statement” and the submission date is updated. Section 8.1.18.1 is modified to require MCOs to submit pharmacy encounter data no later than 25 calendar days after the date of adjudication. Section 8.1.18.4 is modified to clarify claims transaction formats for pharmacy claims. Section 8.1.18.5 is modified to require MCOs to maintain a mechanism to receive claims in addition to the HHSC claims portal. Section 8.1.19 is modified to require MCOs to designate a primary and secondary contact for all OIG requests and to outline the process and timeframes for responding to the OIG, to change the 60 day timeline for submitting the annual plan to 90 days, and to require MCOs to ensure their subcontractors receiving or making annual Medicaid payments of at least $5 million comply with 1902(a)(68)(A) of the Social Security Act. Section 8.1.20.2 is modified to add DUR reporting requirements. Section 8.1.21 is revised to delete MCO developed PDLs and to clarify the reimbursement process. Section 8.1.21.1 is revised to clarify legal references and Clinical Edit requirements, and to add requirements regarding 340B drugs. Section 8.1.21.4 is modified to add requirements for the rebate dispute resolution process. Section 8.1.21.5 is modified to clarify that HHSC will provide up to 1 year of medication history to the MCOs for new Members with previous Medicaid eligibility. Section 8.1.21.9 is modified to clarify requirements for contracting with specialty pharmacies. |
Section 8.1.21.10 is deleted in its entirety. Section 8.1.23.1 is modified that copayment amounts are capped at the MCO’s cost and that CHIP copayments do not apply to preventive services or pregnancy-related services. Section 8.1.24 is modified to clarify that MCOs must notify Medicaid and CHIP Providers of availability of vaccines through Texas Vaccines for Children Program and work with HHSC and Providers to improve the reporting of immunizations to the statewide ImmTrac Registry. Section 8.2.2.3.4 is modified to require MCOs to use standard Texas Health Steps language in their Member Materials as provided in the UMCM. Section 8.2.2.8 is amended to clarify the requirements regarding non-capitated dental services and to add “Texas Health Steps environmental lead investigation (ELI)”. Remainder of list is renumbered. Section 8.2.4.2 is modified to add a reference to Gov’t Code §533.005(a)(19). Section 8.2.8 is modified to add the phrase “unless an exception applies under federal law” to the first sentence. Section 8.2.13 is modified to specify that MCOs may be required to provide other wrap-around services at a date to be determined by HHSC. Section 8.3.2 is modified to require the MCO to consider the availability of the PACE program when considering whether to refer a member to a nursing facility or other long-term care facility. Section 8.3.7.1 is modified to clarify the MA Dual SNP requirements. Section 8.4.3 is modified to correct a cross-reference. | |||
Revision | 2.2 | June 1, 2012 | Section 8.1.21 is modified to add pharmaceutical delivery requirements. |
Revision | 2.3 | September 1, 2012 | Section 8.1.1.1 is modified to conform to the timelines in the UMCM. Section 8.1.3 is modified to replace references to “1915(c) STAR+PLUS Waiver” with “HCBS STAR+PLUS Waiver”. Section 8.1.3.2 is modified to clarify language regarding additional benchmark performance standards. Section 8.1.4 is modified to correct reference to TMPPM. Section 8.1.4.6 is modified to require HHSC review of all provider materials relating to Medicaid managed care or CHIP. Section 8.1.4.8 is modified to clarify the applicable federal regulations. Section 8.1.5.1 is modified to prohibit the MCOs from including any language in their member materials which limits the members' ability to contest or appeal denial of a benefit. Section 8.1.5.2 is modified to clarify that PCP name is not required for Dual Eligible STAR+PLUS Members or CHIP Perinates. Section 8.1.5.7 is modified to remove the acronym “CPW”. Section 8.1.9 is modified to clarify the requirements regarding IFSPs. Section 8.1.12.2 is modified to remove the acronym “CPW”. Section 8.1.14 is renamed and modified to remove all references to Health Home Services. Section 8.1.14.1 is renamed and modified to remove all references to Health Home Services. Section 8.1.14.2 is renamed and modified to remove all references to Health Home Services. Section 8.1.19 is modified to update the time frames for responding to the OIG and to add language regarding Credible Allegation of Fraud notices. Section 8.1.20.2 items (j) and (l) are modified to correct UMCM references. Items (n) and (o) are modified to include pharmacy providers. Item (s) “Medicaid Managed Care Texas Health Steps Medical Checkups Quarterly Utilization Reports” is added. Section 8.1.20.2 is modified to add STAR+PLUS LTSS Utilization reporting requirements. Section 8.1.24 is modified to change the Texas Health Steps Periodicity Schedule to ACIP Immunization Schedule. Section 8.1.25 is modified to replace references to “1915(c) STAR+PLUS Waiver” with “HCBS STAR+PLUS Waiver”. Section 8.1.26 Health Home Services is added. Section 8.1.26.1 Health Home Services and Participating Providers is added. Section 8.1.26.2 MCO Health Home Services Evaluation is added Section 8.2.2.3.2 is modified to correct the acronym for Oral Evaluation and Fluoride Varnish. |
Section 8.2.2.3.3 is modified to clarify statutory authority. Section 8.2.2.3.5 is modified to add training requirements for pharmacy and DME. Section 8.2.2.8 is modified to remove the acronym “CPW”. Section 8.2.2.11 is modified to replace the acronym CPW with “Case Management for Children and Pregnant Women” and the acronym THSteps with “Texas Health Steps”. Section 8.2.7.1 is modified to correct URL for UM guidelines. Section 8.2.8 is modified to clarify the pay and chase requirements for prenatal and preventative care, and recoveries in the context of state child support enforcement actions (SSA §1902(a)(25)(E) and (F); and to correct contract cross reference. Section 8.2.10 is modified to remove the acronym “CPW” and to replace it with Case Management for Children and Pregnant Women. Section 8.3.1.1 is modified to clarify eligibility for DAHS. Section 8.3.1.2 is modified to replace references to “1915(c) STAR+PLUS Waiver” with “HCBS STAR+PLUS Waiver” and to add DAHS to the list of Community Based LTSS under the HCBS STAR+PLUS Waiver. Section 8.3.2.6 is modified to replace references to “1915(c) Nursing Facility Waiver” with “HCBS STAR+PLUS Waiver”. Section 8.3.2.8 is modified to update the MAO reference. Section 8.3.3 is modified to replace references to “1915(c) Nursing Facility Waiver” with “HCBS STAR+PLUS Waiver”. Section 8.3.4 is modified to replace references to “1915(c) Nursing Facility Waiver” with “HCBS STAR+PLUS Waiver” and to increase the cost of care threshold from 200% to 202%. Section 8.3.4.1 is modified to replace references to “1915(c) STAR+PLUS Waiver” and “SPW” with “HCBS STAR+PLUS Waiver”. In addition, risk criteria language is removed. Section 8.3.4.2 is modified to change the section name from “For Medical Assistance Only (MAO) Non-Member Applicants” to “For 217-Like Group Applicants' and to replace references to “1915(c) STAR+PLUS Waiver” and “SPW” with “HCBS STAR+PLUS Waiver”. In addition, risk criteria language is removed. Section 8.3.4.3 is modified to replace references to “1915(c) Nursing Facility Waiver” with “HCBS STAR+PLUS Waiver”. Section 8.3.5 is modified to replace references to “1915(c) STAR+PLUS Waiver” with “HCBS STAR+PLUS Waiver”. Section 8.3.6.4 is modified to replace references to the 1915(b) and 1915(c) waivers with the Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver. Section 8.4.3 is modified for consistency with the Medicaid pay and chase requirements. |
Revision | 2.4 | March 1, 2013 | All references to the previous Executive Commissioner Suehs are changed to his successor, Executive Commissioner Janek. Section 8.1.2.1 is modified to add language regarding reducing or deleting Value-added Services. Section 8.1.3.2 is modified to clarify network provider access and compliance rating. Section 8.1.4.11 Provider Advisory Groups is added. Section 8.1.5.10 Member Advisory Groups is added. Section 8.1.18.5 is modified to add new language modeled off of insurance code requirements. Section 8.2.3 is modified to add new language regarding terminating Significant Traditional Providers. Section 8.2.13 is modified to address supplemental payments to MCOs for wrap-around services for outpatient drugs and biological products for STAR+PLUS Members. Section 8.2.13.1 Medicaid Wrap-Around Services for Outpatient Drugs and Biological Products is added. Section 8.3.1.1 is modified to delete Personal Attendant Services and delete language after (DAHS) is the service column. Section 8.3.1.2 is modified to delete DAHS service description and Licensure and Certification Requirements and modify Personal Assistance Services. 8.3.6.6 Electronic Visit Verification is added. |
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-1, |
Revision | 2.6 | September 1, 2013 | Section 8.1.1.1 is modified to remove references to overarching goals and to clarify that HHSC will provide the PIP topics. Section 8.1.2.1 is modified to clarify that MCOs may not charge copayments for Value-added Services, but may offer discounts for non-covered services as Value-added Services as required by SB 632. Section 8.1.3.1 is modified to clarify timeframes for PCP referrals. Section 8.1.3.2 is modified to add a requirement for 2 PCPs within 30 miles for Medicaid child Members to comply with the Frew Corrective Action order. Section 8.1.4 is modified to add new pharmacy requirements as required by SB 1106 and HB 1358. Section 8.1.4.2 is modified for clarification and to comply with requirements of SB 406, 83R. Section 8.1.4.4 is modified to add timeframes for completing the credentialing process and to comply with requirements of SB 365, 83R. |
Section 8.1.4.8 is modified to clarify the MCO's obligations for payment and Network Provider agreements and to comply with requirements of SB 7, 83R. Section 8.1.4.8.1 is modified to correct “Provider Preventable Conditions” to “Potentially Preventable Complications”. Section 8.1.4.8.2 is modified to clarify provider incentives. Section 8.1.4.10 is modified for clarification and to comply with requirements of SB 1401, 83R. Section 8.1.4.12 Provider Protection Plan is added as required by SB 1150, 83R. Section 8.1.5.5 is modified to allow MCOs to offer provider search functionality on their websites instead of PDF versions of the Provider Directory. In addition, duplicative language is removed. Section 8.1.5.6 is modified to require the MCO's Member Services representatives to be trained regarding the override process for Members in the HHSC-OIG Lock-in Program. Section 8.1.5.6.1 is modified to require the MCO's nurseline staff to be trained regarding the override process for Members in the HHSC-OIG Lock-in Program. Section 8.1.5.7 is modified to allow MCOs to use certified community health workers/promotoras to conduct outreach and member education activities. Section 8.1.5.9 is modified to correct cross references. Section 8.1.8 is modified to update the URL for UM guidelines. Section 8.1.8.1 “Compliance with State and Federal Prior Authorization Requirements” is added as required by SB8, SB 644, and SB1216, 83R. Section 8.1.9 is modified to update the T.A.C. references and to align the age reference with the definition. Section 8.1.14 is modified to add a new Subsection 8.1.14.1 Special Populations. Subsequent subsections are renumbered. Section 8.1.14.3 is modified to add requirements for special populations. Section 8.1.15 is modified to clarify which DSM edition is referenced. Section 8.1.15.7 is modified to delete the duplicative definition. The term “Court-Ordered Commitment” is defined in Attachment A. Section 8.1.18.1 is modified to require MCO Provider Agreements to comply with Texas Gov't. Code regarding reimbursement of claims based on orders or referrals by supervising providers. Section 8.1.18.5 is modified for clarification, for consistency with Section 1213.005 of the Insurance Code, and to comply with requirements of House Bill 15, 83R |
Section 8.1.19 is modified to include the HHSC-OIG Lock-in Program. Section 8.1.20 is modified for clarification that records must be provided “at no cost.” Section 8.1.20.1 is modified to correct the name to which the acronym HEDIS refers. Section 8.1.20.2 is modified to add Service Coordination reporting requirements. Section 8.1.21 Pharmacy Services is modified to reorganize the section and to add requirements as required by SB 644, HB 1358, 83R. Section 8.1.21.1 Formulary and Preferred Drug List (PDL) is added. Section 8.1.21.2 Prior Authorization for Prescription Drugs is modified to add “and 72-hour Emergency Supplies” to the title and to add requirements as required by SB 644, HB 1358, 83R Section 8.1.21.3 Coverage Exclusions is modified for clarity. Section 8.1.21.5 Pharmacy Rebate Program is modified to require MCOs to include NDCs on all encounters. Section 8.1.21.6 Drug Utilization Review (DUR) Program is modified to add requirements as required by SB 644, HB 1358, 83R Section 8.1.21.7 Pharmacy Benefit manager (PBM) is modified to add requirements as required by SB 644, HB 1358, 83R Section 8.1.21.8 Financial Disclosures for Pharmacy Services is modified for clarity. Section 8.1.21.9 Limitations Regarding Registered Sex Offenders is modified for clarity Section 8.1.21.10 Specialty Drugs is modified to add requirements as required by SB 644, HB 1358, 83R Section 8.1.21.11 Maximum Allowable Cost (MAC) Requirements is added. Section 8.1.21.12 Mail-order and Delivery is added. Section 8.1.21.13 Health Resources and Services Administration 340B Discount Drug Program is added. Section 8.1.21.14 Pharmacy Claims and File Processing is added. Section 8.1.21.15 Pharmacy Audits is added. Section 8.1.21.16 E-prescribing is added. Section 8.1.22 is modified to add more detail regarding FQHC/RHC payments. Section 8.1.27 Cancellation of Product Orders is added. Section 8.2.2.4 is modified to include education and care coordination for Members who are at high risk for pre-term labor. |
Section 8.2.2.8 is modified to add ECI Specialized Skills Training, to clarify the requirements for DADS hospice services, and to add court-ordered commitments to inpatient mental health facilities as a condition of probation. Section 8.2.4.2 is modified for clarification and to comply with requirements of SB 7, 83R. Section 8.2.13 is modified to clarify the language. Section 8.2.13.1 is modified to clarify the language. Section 8.3.2 is modified to add new subsections 8.3.2.1 “Service Coordination Plan Requirements,” and 8.3.2.2 “Service Coordination Structure.” Subsequent subsections are renumbered. Section 8.3.2.3 is modified to include minimum requirements for Service Coordinators. Section 8.3.4.3 is modified to require the MCO to inform the Member about CDS during the annual reassessment. Section 8.3.4.4 STAR+PLUS Utilization Reviews is added as required by SB 348, 83R. Section 8.3.7.2 is modified to remove the reference to Attachment B-6. Section 8.3.8 Minimum Wage Requirements for STAR+PLUS Attendants in Community Settings Reviews is added as required by Article II, Rider 61 of the General Appropriations Act (83R). | |||
Revision | 2.7 | September 1, 2013 | Section 8.2.16 “Supplemental Payments for Qualified Providers” is added. Additional detail regarding the process, including payment and reporting requirements will be added to the UMCM. |
Revision | 2.8 | January 1, 2014 | Section 8.1.4.4 is modified to clarify the timeframes for completing the credentialing process. Section 8.1.12.2 is modified to add Former Foster Care Child (FFCC) Members. Section 8.1.13 is modified to add Former Foster Care Child (FFCC) Members. Section 8.1.21.6 is modified to add requirements for assessing prescribing patterns for psychotropic medications. Section 8.1.21.14 is modified to clarify timeframes. Section 8.3.6.6 Cost Reporting for LTSS Providers is added. |
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. |
8. OPERATIONS PHASE REQUIREMENTS |
8.1 General Scope of Work |
8.1.1 Administration and Contract Management |
8.1.1.1 Performance Evaluation |
8.1.2 Covered Services |
1. previous coverage, if any, or the reason for termination of such coverage; |
2. health status; |
3. confinement in a health care facility; or |
4. for any other reason. |
8.1.3 Access to Care |
• | In urban counties, at least 75 percent of Members must have access to a Network Pharmacy within 2 miles of the Member's residence; |
• | In suburban counties, at least 55 percent of Members must have access to a Network Pharmacy within 5 miles of the Member's residence; |
• | In rural counties, at least 90 percent of Members must have access to a Network Pharmacy within 15 miles of the Member's residence; and |
• | In urban, suburban, and rural counties, at least 90 percent of Members must have access to a 24-hour pharmacy within 75 miles of the Member's residence. |
• | In urban counties, at least 80 percent of Members must have access to a Network Pharmacy within 2 miles of the Member's residence; |
• | In suburban counties, at least 75 percent of Members must have access to a Network Pharmacy within 5 miles of the Member's residence; |
• | In rural counties, at least 90 percent of Members must have access to a Network Pharmacy within 15 miles of the Member's residence; and |
• | In urban, suburban, and rural counties, at least 90 percent of Members must have access to a 24-hour pharmacy within 75 miles of the Member's residence. |
8.1.4 Provider Network |
1. 99% of calls are answered by the fourth ring or an automated call pick-up system is used; |
2. no more than one percent (1%) of incoming calls receive a busy signal; |
3. the average hold time is two (2) minutes or less; and |
4. the call abandonment rate is seven percent (7%) or less. |
• | Section 2702 of PPACA, entitled "Payment Adjustment for Health Care-Acquired Conditions;" |
• | Section 6505 of PPACA, entitled "Prohibition on Payments to Institutions or Entities Located Outside of the United States;" and |
• | Section 1202 of the Health Care and Education Reconciliation Act as amended by PPACA, entitled "Payments to Primary Care Physicians." |
8.1.4.10 Out-of-State Providers |
• | Provide for timely and accurate claims adjudication and proper claims payment in accordance with UMCM Chapters 2.0 through 2.2. |
• | Include Network Provider training and education on the requirements for claims submission and appeals, including the MCO's policies and procedures (see also Section 8.1.4.6, "Provider Relations Including Manual, Materials and Training.") |
• | Ensure Member access to care, in accordance with Section 8.1.3, "Access to Care," and the UMCM's Geo-Mapping requirements (see UMCM Chapters 5.14.1 through 5.14.4.) |
• | Ensure prompt credentialing, as required by Section 8.1.4.4, "Provider Credentialing and Re-credentialing." |
• | Ensure compliance with state and federal standards regarding prior authorizations, as described in Sections 8.1.8, "Utilization Management," and 8.1.21.2, "Prior Authorization for Prescription Drugs and 72-Hour Emergency Supplies." |
• | Include other measures developed by HHSC or a provider protection plan workgroup, or measures developed by the MCO and approved by HHSC. |
8.1.5 Member Services |
8.1.5.6.1 Nurseline |
8.1.6 Marketing and Prohibited Practices |
8.1.7 Quality Assessment and Performance Improvement |
1. evaluate performance using objective quality indicators; |
2. foster data-driven decision-making; |
3. recognize that opportunities for improvement are unlimited; |
4. solicit Member and Provider input on performance and QAPI activities; |
5. support continuous ongoing measurement of clinical and non-clinical effectiveness and Member satisfaction; |
6. support programmatic improvements of clinical and non-clinical processes based on findings from ongoing measurements; and |
7. support re-measurement of effectiveness and Member satisfaction, and continued development and implementation of improvement interventions as appropriate. |
1. is organization-wide, with clear lines of accountability within the organization; |
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; |
3. includes annual objectives and/or goals for planned projects or activities including clinical and non-clinical programs or initiatives and measurement activities; and |
4. evaluates the effectiveness of clinical and non-clinical initiatives. |
1. developing PCP and Provider-specific reports that include a multi-dimensional assessment of a PCP or Provider’s performance using clinical, administrative, and Member satisfaction indicators of care that are accurate, measurable, and relevant to the enrolled population; |
2. establishing PCP, Provider, group, Service Area or regional Benchmarks for areas profiled, where applicable, including STAR, STAR+PLUS, and CHIP Program-specific Benchmarks, where appropriate; and |
3. providing feedback to individual PCPs and Providers regarding the results of their performance and the overall performance of the Provider Network. |
1. use the results of its Provider profiling activities to identify areas of improvement for individual PCPs and Providers, and/or groups of Providers; |
2. establish Provider-specific quality improvement goals for priority areas in which a Provider or Providers do not meet established MCO standards or improvement goals; |
3. develop and implement incentives, which may include financial and non-financial incentives, to motivate Providers to improve performance on profiled measures; and |
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. |
1. whether the Member’s PCP or other Providers are participating in the MCO’s physician incentive plan; |
2. whether the MCO uses a physician incentive plan that affects the use of referral services; |
3. the type of incentive arrangement; and |
4. whether stop-loss protection is provided. |
1. Whether the physician incentive plan covers services that are not furnished by a physician or physician group. The MCO 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. |
2. The type of incentive arrangement (e.g., withhold, bonus, capitation); |
3. The percent of withhold or bonus (if applicable); |
4. The panel size, and if patients are pooled, the method used (HHSC approval is required for the method used); and |
8.1.8 Utilization Management |
8.1.9 Early Childhood Intervention (ECI) |
8.1.10 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) - Specific Requirements |
8.1.11 Coordination with Texas Department of Family and Protective Services |
1. a court order (Order) entered by a Court of Continuing Jurisdiction placing a child under the protective custody of TDFPS; |
2. a TDFPS Service Plan entered by a Court of Continuing Jurisdiction placing a child under the protective custody of TDFPS; and |
3. a TDFPS Service Plan voluntarily entered into by the parents or person having legal custody of a Member and TDFPS. |
1. providing medical records to TDFPS; |
2. scheduling medical and Behavioral Health Services appointments within 14 days unless requested earlier by TDFPS; and |
3. recognition of abuse and neglect, and appropriate referral to TDFPS. |
8.1.12 Services for People with Special Health Care Needs |
8.1.13 Service Management for Certain Populations |
8.1.14 Disease Management (DM) |
8.1.15 Behavioral Health (BH) Network and Services |
1. 99% of calls are answered by the fourth ring or an automated call pick-up system; |
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; |
4. the call abandonment rate is seven percent (7%) or less; and |
5. the average hold time is two (2) minutes or less. |
8.1.16 Financial Requirements for Covered Services |
8.1.17 Accounting and Financial Reporting Requirements |
1. maintain accounting records for each applicable MCO Program separate and apart from other corporate accounting records; |
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; |
3. ensure and provide access to HHSC and/or its auditors or agents to the detailed records and supporting documentation for all costs incurred by the MCO. The MCO must ensure such access to its Subcontractors, including Affiliates, for any costs billed to or passed to the MCO with respect to an MCO Program; |
4. 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 |
1. the “Health Annual Statement” and the “Annual Audited Financial Report” including all schedules, attachments, exhibits, supplements, management discussion, supplemental filings, etc., and any other annual financial filings (including any filings that may take the place of the above-named annual financial filings, and any financial filings that occur less frequently than on a quarterly basis); |
2. the annual figures for controlled risk-based capital; and |
3. the quarterly financial statements. |
1. the complete registration restatement that was due to TDI by approximately May 2010; |
2. each annual registration amendment form (which is due to TDI within 120 days of the end of the MCO’s parent’s fiscal year), commencing with the most recent one that the MCO has filed after May 2010; |
3. future complete five-year registration re-statements (the first of which will be due to TDI by approximately May 2015); and |
4. any other registration statement amendments or re-statements that may be submitted to TDI, per TDI regulations. |
1. SEC Form 10-K. For publicly-traded (stock-exchange-listed) for-profit corporations, submit the most-recent annual SEC Form 10K filing. |
2. IRS Form 990. For nonprofit entities, submit the most recent annual IRS Form 990 filing, complete with any and all attachments or schedules. If a nonprofit entity is exempt from the IRS 990 filing requirement, demonstrate this and explain the nature of the exemption. |
3. If the MCO is a nonprofit entity that is a component or subsidiary of a County Hospital District, or otherwise an entity of a government, then submit the annual financial statements as prepared under the relevant rules or statutes governing annual financial reporting and disclosure for the MCO and/or its parent, including all attachments, schedules, and supplements. |
4. Annual Report. The MCO must submit this report if it is different than or supplementary to the audited financial statements or Form 10-K required herein, and if it is distributed to either shareholders, customers, employees, owner(s), parent, bank or creditor(s), donors, the community, or to any regulatory body or constituents, or is otherwise externally distributed or posted. |
5. Bond or debt rating analysis. If the MCO or its ultimate parent has been the subject of any bond rating analysis, ratings affirmation, write-up, or related report, such as by AM Best, Fitch Ratings, Moody’s, Standard & Poor, etc., submit the most recent complete detailed report from each rating entity that has produced such a report. |
8.1.18 Management Information System Requirements |
1. Enrollment/Eligibility Subsystem; |
2. Provider Subsystem; |
3. Encounter/Claims Processing Subsystem; |
4. Financial Subsystem; |
5. Utilization/Quality Improvement Subsystem; |
6. Reporting Subsystem; |
7. Interface Subsystem; and |
8. TPL/TPR Subsystem, as applicable to each MCO Program. |
1. a new plan is brought into the MCO Program; |
2. an existing plan begins business in a new Service Area or a Service Area expansion; |
3. an existing plan changes location; |
4. an existing plan changes its processing system, including changes in Material Subcontractors performing MIS or claims processing functions; and |
5. an existing plan in one (1) or two (2) HHSC MCO Programs is initiating a Contract to participate in any additional MCO Programs. |
8.1.18.2 MCO Deliverables related to MIS Requirements |
1. Joint Interface Plan; |
2. Risk Management Plan; and |
3. Systems Quality Assurance Plan. |
1. process electronic data transmission or media to add, delete or modify membership records with accurate begin and end dates; |
2. track Covered Services received by Members through the system, and accurately and fully maintain those Covered Services as HIPAA-compliant Encounter transactions; |
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; |
4. maintain a history of changes and adjustments and audit trails for current and retroactive data; |
5. maintain procedures and processes for accumulating, archiving, and restoring data in the event of a system or subsystem failure; |
6. employ industry standard medical billing taxonomies (procedure codes, diagnosis codes, NDC codes) to describe services delivered and Encounter transactions produced; |
7. accommodate the coordination of benefits; |
8. produce standard Explanation of Benefits (EOBs) for providers; |
9. Pay financial transactions to Network Providers and Out-of-Network providers in compliance with federal and state laws, rules and regulations; |
10. ensure that all financial transactions are auditable according to GAAP guidelines; |
11. ensure that Financial Statistical Reports (FSRs) comply with Uniform Managed Care Manual Chapter 6.1, “Cost Principles for Expenses,” with respect to segregating costs that are allowable for inclusion in HHSC-designed financial reports; |
12. relate and extract data elements to produce report formats (provided within the Uniform Managed Care Manual) or otherwise required by HHSC; |
13. ensure that written process and procedures manuals document and describe all manual and automated system procedures and processes for the MIS; and |
14. maintain and cross-reference all Member-related information with the most current Medicaid, or CHIP Program Provider number. |
8.1.18.6 National Correct Coding Initiative |
8.1.19 Fraud and Abuse |
8.1.20 General Reporting Requirements |
8.1.21.9 Limitations Regarding Registered Sex Offenders |
• | the drug is listed as "A" or "B" rated in the most recent version of the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book, has an "NR" or "NA" rating or similar rating by a nationally recognized reference; and |
• | the drug is generally available for purchase by pharmacies in Texas from national or regional wholesalers and is not obsolete. |
8.1.22 Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) |
8.1.23 Payment by Members. |
1. inform Members of costs for non-covered services prior to rendering such services; and |
2. obtain a signed private pay form from such Members. |
8.1.23.1 Cost Sharing |
8.1.24 Immunizations |
8.1.25 Dental Coverage |
8.1.26 Health Home Services |
8.2 Additional Medicaid MCO Scope of Work |
8.2.1 Continuity of Care and Out-of-Network Providers |
1. more than 90 days after a Member enrolls in the MCO’s Program, or |
2. for more than nine (9) months in the case of a Member who, at the time of enrollment in the MCO, has been diagnosed with and receiving treatment for a terminal illness and remains enrolled in the MCO. |
8.2.2 Provisions Related to Covered Services for Medicaid Members |
1. the MCO does not respond to a request for pre-approval within one (1) hour; |
2. the MCO cannot be contacted; or |
3. the MCO 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 MCO 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 Network physician is reached. The MCO’s financial responsibility ends as follows: the Network physician with privileges at the treating Hospital assumes responsibility for the Member’s care; the Network physician assumes responsibility for the Member’s care through transfer; the MCO representative and the treating physician reach an agreement concerning the Member’s care; or the Member is discharged. |
8.2.3 Medicaid Significant Traditional Providers |
8.2.4 Provider Complaints and Appeals |
8.2.5 Member Rights and Responsibilities |
8.2.6 Medicaid Member Complaint and Appeal System |
1. date; |
2. identification of the individual filing the Complaint; |
3. identification of the individual recording the Complaint; |
4. nature of the Complaint; |
5. disposition of the Complaint (i.e., how the MCO resolved the Complaint); |
6. corrective action required; and |
7. date resolved. |
1. date notice is sent; |
2. effective date of the Action; |
3. date the Member or his or her representative requested the Appeal; |
4. date the Appeal was followed up in writing; |
5. identification of the individual filing; |
6. nature of the Appeal; and |
7. disposition of the Appeal, including a copy of the notice of disposition and the date it was sent to Member. |
1. the Member or his or her representative files the Appeal timely as defined in this Contract: |
2. the Appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; |
3. the services were ordered by an authorized provider; |
4. the original period covered by the original authorization has not expired; and |
5. the Member requests an extension of the benefits. |
1. transfer the Appeal to the timeframe for standard resolution, and |
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. |
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; |
2. for denial of payment, at the time of any Action affecting the claim; |
3. for standard service authorization decisions that deny or limit services, within the timeframe specified in 42 C.F.R.§ 438.210(d)(1); |
4. if the MCO extends the timeframe in accordance with 42 C.F.R. §438.210(d)(1), it must: |
a. 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 |
b. issue and carry out its determination as expeditiously as the Member’s health condition requires and no later than the date the extension expires; |
5. 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 |
6. for expedited service authorization decisions, within the timeframes specified in 42 C.F.R. 438.210(d). |
1. the right to request a Fair Hearing; |
2. how to request a Fair Hearing; |
3. The circumstances under which the Member may continue to receive benefits pending a Fair Hearing; |
4. how to request the continuation of benefits; |
5. if the MCO’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 |
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. |
1. their rights and responsibilities, |
2. the Complaint process, |
3. the Appeal process, |
4. Covered Services available to them, including preventive services, and |
5. Non-capitated Services available to them. |
8.2.7 Additional Medicaid Behavioral Health Provisions |
8.2.8 Third Party Liability and Recovery and Coordination of Benefits |
8.2.9 Coordination with Public Health Entities |
1. Sexually Transmitted Diseases (STDs) services; |
2. confidential HIV testing; |
3. immunizations; |
4. tuberculosis (TB) care; |
5. Family Planning services; |
6. Texas Health Steps medical checkups, and |
7. prenatal services. |
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 MCO’s Network; and |
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. |
1. report to Public Health Entities regarding communicable diseases and/or diseases that are preventable by immunization as defined by state law; |
2. notify the local Public Health Entity of communicable disease outbreaks involving Members; and |
3. educate Members and Providers regarding WIC services available to Members. |
8.2.10 Coordination with Other State Health and Human Services (HHS) Programs |
8.2.11 Advance Directives |
1. a Member’s right to self-determination in making health care decisions; |
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; |
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 |
3. 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. |
8.2.12 SSI Members |
8.2.13 Medicaid Wrap-Around Services |
8.2.14 Medical Transportation |
8.3 Additional STAR+PLUS Scope of Work |
8.3.1 Covered Community-Based Long-Term Services and Supports |
Community-based Long-Term Services and Supports Available to All Members | |
Service | Licensure and Certification Requirements |
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. |
Day Activity and Health Services (DAHS) | The Provider must be licensed by the DADS Regulatory Division as an adult day care provider. To provide DAHS, the Provider must provide the range of services required for DAHS. |
Community-based Long-Term Services and Supports under the HCBS STAR+PLUS Waiver | |
Service | Licensure and Certification Requirements |
Personal Assistance 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 Services | 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 Department of State Health Services as a Personal Emergency Response Services Agency under 25 T.A.C., 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. The registered nurse must comply with the requirements for delivery of nursing services, which include requirements such as compliance with the Texas Nurse Practice Act and delegation of nursing tasks. The licensed vocational nurse must practice under the supervision of a registered nurse, licensed to practice in the State. |
Adult Foster Care | Adult foster care homes serving three (3) or fewer participants must comply with requirements outlined in 40 T.A.C., 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 T.A.C., Part 1, Chapter 92. |
Dental | Licensed by the Texas State Board of Dental Examiners as a Dentist under 22 T.A.C., Part 5, Chapter 101. |
Respite Care | Licensed by DADS as a Home and Community Support Services Agency (HCSSA) under 40 T.A.C., Part 1, Chapter 97. |
Home Delivered Meals | Providers must comply with requirement of 40 T.A.C., Part 1, Chapter 55 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. |
Physical Therapy (PT) Services | Licensed Physical Therapist through the Texas Board of Physical Therapy Examiners, Chapter 453 of the Texas Occupations Code. |
Occupational Therapy (OT) Services | Licensed Occupational Therapist through the Texas Board of Occupational Therapy Examiners, Chapter 454 of the Texas Occupations Code. |
Speech, Hearing, and Language Therapy Services | Licensed Speech Therapist through the Department of State Health Services. |
Consumer Directed Services (CDS) | No licensure or certification requirements. The Providers must complete DADS’ required training. Current CDSAs contracted by DADS are assumed to have completed the training. |
Transition Assistance Services (TAS) | The Provider must comply with the requirements for delivery of TAS, which include requirements such as allowable purchases, cost limits, and timeframes 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 Medical Equipment | No licensure or certification requirements. |
Medical Supplies | No licensure or certification requirements. |
8.3.2 Service Coordination |
• | how outreach to Members will be conducted; |
• | how Members are assessed and their service plans developed (the initial identification of Members' needed services and supports); |
• | how Members will be identified as needing an assessment when changes in their health or life circumstances occur; |
• | the Member's needs and preferences; |
• | the minimum number of service coordination contacts a Member will receive per year; |
• | how service coordination will be provided (face-to-face, telephone contact, etc.); and |
• | how these service coordination services will be tracked by the MCO. |
• | Level 1 Members: Highest level of utilization |
• | Includes HCBS SPW recipients and Members with complex medical needs. |
• | MCOs must provide Level 1 Members with a single identified person as their assigned Service Coordinator. |
• | All Level 1 Members must receive a minimum of two face-to-face service coordination contacts annually. |
• | Level 2 Members: Lower risk/utilization |
• | MCOs must provide Level 2 Members with a single identified person as their assigned Service Coordinator. Members and required assessments are as follows. |
• | Members receiving LTSS for Personal Assistance Services or Day Activity and Health Services (PAS and DAHS) must receive a minimum of one face-to-face and one telephonic service coordination contact annually. |
• | Members with a history of behavioral health issues (multiple outpatient visits, hospitalization, or institutionalization within the past year) must receive a minimum of one face-to-face and one telephonic service coordination contact annually. |
• | Members with a history of substance abuse (multiple outpatient visits, hospitalization, or institutionalization within the past year) must receive a minimum of one face-to-face and one telephonic service coordination contact annually. |
• | Dual Eligibles who do not meet Level 1 requirements must receive a minimum of two telephonic service coordination contacts annually. |
• | Level 3 Members: Members who do not qualify as Level 1 or Level 2 |
• | MCO must make at least two telephonic service coordination outreach contacts yearly. |
• | Level 3 Members are not required to have a named Service Coordinator, unless they request service coordination services. |
• | A description of service coordination; and |
• | The MCO's Service Coordination phone number. |
• | The name of their Service Coordinator; |
• | The phone number of their Service Coordinator; |
• | The minimum number of contacts they will receive every year; and |
• | The types of contacts they will receive. |
• | Behavioral health |
• | Substance abuse |
• | Local resources (e.g., basic needs like housing, food, utility assistance) |
• | Pediatrics |
• | LTSS |
• | End of life/advanced illness |
• | Acute care |
• | Preventive care |
• | Cultural competency |
• | Pharmacology |
• | Nutrition |
• | Texas Promoting Independence strategies |
• | Consumer Directed Services options |
• | Person-directed planning |
• | A Service Coordinator for a Level 1 Member must be a registered nurse (RN) or nurse practitioner (NP). Licensed vocational nurses (LVNs) employed as Service Coordinators before March 1, 2013 will be allowed to continue in that role. |
• | A Service Coordinator for a Level 2 or 3 Member must have an undergraduate or graduate degree in social work or a related field or be an LVN, RN, NP, or physician's assistant (PA); or have a minimum of a high school diploma or GED and direct experience with the ABD/SSI population in three of the last five years. |
• | Service Coordinators for Level 3 Members must have experience in meeting the needs of the member population served (for example, people with disabilities). |
• | Service Coordinators must possess knowledge of the principles of most integrated settings, including federal and state requirements. |
• | Service Coordinators must complete 16 hours of service coordination training every two years. MCOs must administer the training, which must include: |
1. review of existing Long-Term Services and Supports plans prepared by DADS or another STAR+PLUS MCO; |
2. preparation of a transition plan that ensures continuous care under the Member’s existing Care Plan during the transfer into the MCO’s Network while the MCO conducts an appropriate assessment and development of a new plan, if needed; |
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 |
4. payment to the existing provider of service under the existing authorization for up to six (6) months, until the MCO has completed the assessment and Service Plans and issued new authorizations. |
1. the Member’s history; |
2. summary of current medical and social needs and concerns; |
3. short and long term needs and goals; |
4. a list of services required, their frequency, and |
5. a description of who will provide such services. |
8.3.3 STAR+PLUS Assessment Instruments |
8.3.4 HCBS STAR+PLUS Waiver Service Eligibility |
8.3.5 Consumer Directed Services Options |
8.3.6 Community Based Long-term Services and Supports Providers |
1. Covered Services and the Provider’s responsibilities for providing such services to STAR+PLUS Members and billing the MCO. The MCO must place special emphasis on Community Long-term Services and Supports and STAR+PLUS requirements, policies, and procedures that vary from Medicaid Fee-for-Service and commercial coverage rules, including payment policies and procedures; |
2. relevant requirements of the STAR+PLUS Contract, including the role of the Service Coordinator; |
3. processes for making referrals and coordinating Non-capitated Services; |
4. the MCO’s quality assurance and performance improvement program and the Provider’s role in such programs; and |
5. the MCO’s STAR+PLUS policies and procedures, including those relating to Network and Out-of-Network referrals. |
6. For STAR+PLUS in the El Paso, Hidalgo and Lubbock Service Areas with an Operational Start Date of 3/1/2012, 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 MCO for assistance with this process. |
8.3.7 Additional Requirements Regarding Dual Eligibles |
8.3.7.1 Coordination of Services for Dual Eligibles |
8.3.7.2 MA Dual SNP Agreement |
• | Day Activity Health Care Services (DAHS); |
• | Primary Home Care (PHC); |
• | Personal Assistance Services (PAS); and |
• | Texas Health Steps Personal Care Services (PCS). |
8.4 Additional CHIP Scope of Work |
8.4.1 CHIP Provider Complaint and Appeals |
8.4.2 CHIP Member Complaint and Appeal Process |
8.4.3 Third Party Liability and Recovery, and Coordination of Benefits |
8.4.4 Perinatal Services for Traditional CHIP Members |
1. pregnancy planning and perinatal health promotion and education for reproductive-age women; |
2. perinatal risk assessment of non-pregnant women, pregnant and postpartum women, and infants up to one year of age; |
3. access to appropriate levels of care based on risk assessment, including emergency care; |
4. transfer and care of pregnant women, newborns, and infants to tertiary care facilities when necessary; |
5. availability and accessibility of OB/GYNs, anesthesiologists, and neonatologists capable of dealing with complicated perinatal problems; and |
6. availability and accessibility of appropriate outpatient and inpatient facilities capable of dealing with complicated perinatal problems. |
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 | |||
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-1, RFP Section 9, “Turnover Requirements.” | |||
Revision | 2.1 | March 1, 2012 | Contract amendment did not revise Attachment B-1, RFP Section 9, "Turnover Requirements." | |||
Revision | 2.2 | June 1, 2012 | Contract amendment did not revise Attachment B-1, Section 9, "Turnover Requirements." | |||
Revision | 2.3 | September 1, 2012 | Contract amendment did not revise Attachment B-1, Section 9, "Turnover Requirements." | |||
Revision | 2.4 | March 1, 2013 | Contract amendment did not revise Attachment B-1, Section 9, “Turnover Requirements.” | |||
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-1, Section 9, “Turnover Requirements.” | |||
Revision | 2.6 | September 1, 2013 | Contract amendment did not revise Attachment B-1, Section 9, “Turnover Requirements.” | |||
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-1, Section 9, “Turnover Requirements.” | |||
Revision | 2.8 | January 1, 2014 | 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. |
9. Turnover Requirements |
9.1 Introduction |
9.2 Turnover Plan |
1. The least disruption in the delivery of Covered Services to Members during the transition to a subsequent contractor. |
2. Cooperation with HHSC and a subsequent contractor in notifying Members of the transition, as requested and in the form required or approved by HHSC. |
3. Cooperation with HHSC and a subsequent contractor in transferring information to HHSC or a subsequent contractor, as requested and in the form required or approved by HHSC. |
1. The MCO’s approach and schedule for the transfer of data and information, as described above. |
2. The quality assurance process that the MCO will use to monitor Turnover activities. |
3. The MCO’s approach to training HHSC or a subsequent contractor’s staff in the operation of its business processes. |
9.3 Transfer of Data |
1. Data, information and services necessary and sufficient to enable HHSC to map all Texas data from the MCO's system(s) to the replacement system(s) of HHSC or a successor contractor, including a comprehensive data dictionary as defined by HHSC. |
2. All necessary data, information and services will be provided in the format defined by HHSC, and must be HIPAA compliant. |
3. All of the data, information and services mentioned in this section must be provided and performed in a manner by the MCO using its best efforts to ensure the efficient administration of the contract. The data and information must be supplied in media and format specified by HHSC and according to the schedule approved by HHSC in the Turnover Plan. The data, information and services provided pursuant to this section must be provided at no additional cost to HHSC. |
9.4 Turnover Services |
9.5 Post-Turnover Services |
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 | |||
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-2, “STAR Covered Services.” | |||
Revision | 2.1 | March 1, 2012 | Attachment B-2 is modified to reinstate the waiver of the three prescription limit for adults language and to clarify the waiver of the $200,000 individual annual limit on inpatient services. STAR Covered Services is modified to add “Cancer screening, diagnostic, and treatment services” and “Prenatal care services rendered in a birthing center” as clarification items and to clarify the requirements for services provided in free-standing psychiatric hospitals and chemical dependency treatment facilities in lieu of the acute care hospital setting. | |||
Revision | 2.2 | June 1, 2012 | Contract amendment did not revise Attachment B-2, "STAR Covered Services." | |||
Revision | 2.3 | September 1, 2012 | STAR Covered Services is modified to remove the reference to Dual Eligible STAR Members in the MRSA | |||
Revision | 2.4 | March 1, 2013 | Contract amendment did not revise Attachment B-2, “STAR Covered Services.” | |||
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-2, “STAR Covered Services.” | |||
Revision | 2.6 | September 1, 2013 | STAR Covered Services is modified to remove the reference to the Texas Medicaid Bulletin. | |||
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-2, “STAR Covered Services.” |
Revision | 2.8 | January 1, 2014 | Inpatient General Acute and Inpatient Rehabilitation Hospital Services (CHIP Perinatal Coverage) is modified to clarify the eligibility thresholds. Birthing Center Services (CHIP Perinatal Coverage) is modified to clarify the eligibility thresholds. Exclusions for CHIP Perinatal is modified to clarify the eligibility thresholds. | |||
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. |
• Ambulance services |
• Audiology services, including hearing aids, for adults and children |
• Behavioral Health Services*, including: |
o Inpatient mental health services for Children (birth through age 20) |
o Acute inpatient mental health services for Adults |
o Outpatient mental health services |
o Psychiatry services |
o Counseling services for adults (21 years of age and over) |
o Outpatient substance use disorder treatment services including: |
o Assessment |
o Detoxification services |
o Counseling treatment |
o Medication assisted therapy |
o Residential substance use disorder treatment services including: |
o Detoxification services |
o Substance use disorder treatment (including room and board) |
*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 MCO’s non-quantitative treatment limitations, provided such limitations comply with the requirements of the Mental Health Parity and Addiction Equity Act of 2008. |
• Birthing services provided by a physician and certified nurse midwife (CNM) 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 |
• Early Childhood Intervention (ECI) services |
• Emergency Services |
• Family planning services |
• Home health care services |
• Hospital services, including inpatient and outpatient |
o The MCO may provide inpatient services for acute psychiatric conditions in a free-standing psychiatric hospital in lieu of an acute care inpatient hospital setting. |
o The MCO may provide substance use disorder treatment services in a chemical dependency treatment facility in lieu of an acute care inpatient hospital setting. |
• Laboratory |
• Mastectomy, breast reconstruction, and related follow-up procedures, including: |
• 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: |
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. |
• 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 (birth through age 20) 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. |
• Outpatient drugs and biologicals; including pharmacy-dispensed and provider-administered outpatient drugs and biologicals |
• Drugs and biologicals provided in an inpatient setting |
• Podiatry |
• Prenatal care |
• Prenatal care provided by a physician, certified nurse midwife (CNM), nurse practitioner (NP), clinical nurse specialist (CNS), and physician assistant (PA) in a licensed birthing center |
• 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 (Includes optometry and glasses. Contact lenses are only covered if they are medically necessary for vision correction, which can not be accomplished by glasses.) |
DOCUMENT HISTORY LOG | |||
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 |
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-2.1, “CHIP Covered Services.” |
Revision | 2.1 | March 1, 2012 | “Birthing Center Services” is added as a clarification item. “Services Rendered by a Certified Nurse Midwife or physician in a licensed birthing center” is added as a clarification item. Attachment B-2.1 is modified to clarify Drug Benefits for CHIP Perinate Members. CHIP Exclusions from Covered Services is modified to clarify that over the counter drugs, contraceptives, and medications prescribed for weight loss or gain are not a covered benefit. CHIP Exclusions from Covered Services for CHIP Perinates is modified to clarify that over the counter drugs contraceptives, and medications prescribed for weight loss or gain are not a covered benefit. |
Revision | 2.2 | June 1, 2012 | Contract amendment did not revise Attachment B-2.1, "CHIP Covered Services." |
Revision | 2.3 | September 1, 2012 | Contract amendment did not revise Attachment B-2.1, “CHIP Covered Services.” |
Revision | 2.4 | March 1, 2013 | CHIP Exclusions from Covered Services is modified to add Coverage while traveling outside of the United States and U.S. Territories. |
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-2.1, “CHIP Covered Services.” |
Revision | 2.6 | September 1, 2013 | Contract amendment did not revise Attachment B-2.1, “CHIP Covered Services.” |
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-2.1, “CHIP Covered Services.” |
Revision | 2.8 | January 1, 2014 | Inpatient General Acute and Inpatient Rehabilitation Hospital Services (CHIP Perinatal Coverage) is modified to clarify the eligibility thresholds. is modified to clarify the eligibility thresholds. Birthing Center Services (CHIP Perinatal Coverage) is modified to clarify the eligibility thresholds. Exclusions for CHIP Perinatal is modified to clarify the eligibility thresholds |
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 Members and CHIP Perinate Newborn Members | CHIP Perinate Members (Unborn Child) |
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 | For CHIP Perinates in families with income at or below the Medicaid eligibility threshold (Perinates who qualify for Medicaid once born), 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 income above the Medicaid eligibility threshold (Perinates who do not qualify for Medicaid once born), benefits are limited to professional service charges and facility charges associated with labor with delivery until birth, and services related to miscarriage or a non-viable pregnancy. Services include: ¤ Operating, recovery and other treatment rooms ¤ Anesthesia and administration (facility technical component |
¤ 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: | 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. |
¤ 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 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. | ||
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 ¤ Outpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero). Outpatient 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 outpatient hospital and ambulatory 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 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). Outpatient 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, 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. (5) Surgical 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. |
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, inpatient and outpatient 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 | 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, inpatient and outpatient 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: ¤ Surgeons and assistant surgeons for surgical procedures directly related to the labor with delivery of the covered unborn child until birth. ¤ Administration of anesthesia by Physician (other than surgeon) or CRNA ¤ Invasive diagnostic procedures directly related to the labor with delivery of the unborn child. ¤ Surgical services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero.) ¤ Hospital-based Physician services (including Physician performed technical and interpretive components) |
¤ 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). Physician 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 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. | ¤ 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). Professional 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 | Covered, unlimited prenatal care and medically necessary care related to diseases, illness, or abnormalities related to the reproductive system, and limitations and exclusions to these services are described under inpatient, outpatient and physician services. Primary and preventive health benefits do not include pre-pregnancy family reproductive services and supplies, or prescription medications prescribed only for the purpose of primary and preventive reproductive health care. | Services are limited to an initial visit and subsequent prenatal (ante partum) care visits that include: (1) One (1) visit every four (4) weeks for the first 28 weeks or pregnancy; (2) one (1) visit every two (2) to three (3) weeks from 28 to 36 weeks of pregnancy; and (3) one (1) 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 two (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). |
Birthing Center Services | Covers birthing services provided by a licensed birthing center. Limited to facility services (e.g., labor and delivery) Limitation: Applies only to CHIP members. | Covers birthing services provided by a licensed birthing center. Limited to facility services related to labor with delivery. Applies only to CHIP Perinate Members (unborn child) with income above the Medicaid eligibility threshold (who will not qualify for Medicaid once born). |
Services Rendered by a Certified Nurse Midwife or physician in a licensed birthing center | CHIP Members: Covers prenatal services and birthing services rendered in a licensed birthing center. CHIP Perinate Newborn Members: Covers services rendered to a newborn immediately following delivery. | Covers prenatal services and birthing services rendered in a licensed birthing center. Prenatal services subject to the following limitations: Services are limited to an initial visit and subsequent prenatal (ante partum) care visits that include: (1) one (1) visit every four (4) weeks for the first 28 weeks or pregnancy; (2) one (1) visit every two (2) to three (3) weeks from 28 to 36 weeks of pregnancy; and (3) one (1) 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 two (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 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: ¤ 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 family education, and crisis services 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 (6) 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 | MCO 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 layperson definition of emergency health condition ¤ Hospital emergency department room and ancillary services and physician services 24 hours a day, seven (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, removal of cysts, and treatment relating to oral abscess of tooth or gum origin. | MCO 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 ¤ Emergency ground, air and water transportation for an emergency associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero) 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 (1) examination of the eyes to determine the need for and prescription for corrective lenses per 12-month period, without authorization ¤ One (1) 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. |
Drug Benefits | Services include, but are not limited to, the following: ¤ • Outpatient drugs and biologicals; including pharmacy-dispensed and provider-administered outpatient drugs and biologicals; and ¤ • Drugs and biologicals provided in an inpatient setting. | Not a covered benefit unless identified elsewhere in this table. |
[Value-added services] | See RFP Attachment B-2.1 |
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 |
Contraceptive medications prescribed only for the purpose of primary and preventive reproductive health care (i.e., cannot be prescribed for family planning) |
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 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 |
Medications prescribed for weight loss or gain |
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 |
Over-the-counter medications |
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 |
Coverage while traveling outside of the United States and U.S. Territories (including Puerto Rico, U.S. Virgin Islands, Commonwealth of Northern Mariana Islands, Guam, and American Samoa) |
For CHIP Perinates in families with income at or below the Medicaid eligibility threshold (Perinates who qualify for Medicaid once born), 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. |
Contraceptive medications prescribed only for the purpose of primary and preventive reproductive health care (i.e. cannot be prescribed for family planning) |
Inpatient and outpatient treatments other than prenatal care, labor with delivery, services 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 labor or threatened labor, miscarriage or non-viable pregnancy, 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. Territories (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 |
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. |
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 |
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-2.2, “STAR+PLUS Covered Services.” |
Revision | 2.1 | March 1, 2012 | Attachment B-2.2 is modified to reinstate the waiver of the three prescription limit for adults language and to add the waiver of the $200,000 individual annual limit on inpatient services. STAR+PLUS Covered Services is modified to clarify the requirements regarding services provided in free-standing psychiatric hospitals and chemical dependency treatment facilities in lieu of the acute care hospital setting. Services included under the HMO capitation payment is modified to clarify the requirements for "Prenatal care services rendered in a birthing center." |
Revision | 2.2 | June 1, 2012 | Contract amendment did not revise Attachment B-2.2, "STAR+PLUS Covered Services." |
Revision | 2.3 | September 1, 2012 | Community Based Long Term Care Services is modified to replace references to “1915(c) STAR+PLUS Waiver” and “1915(c) Nursing Facility Waiver” with “HCBS STAR+PLUS Waiver”. |
Revision | 2.4 | March 1, 2013 | Contract amendment did not revise Attachment B-2.2, “STAR+PLUS Covered Services.” |
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-2.2, “STAR+PLUS Covered Services.” |
Revision | 2.6 | September 1, 2013 | Acute Care Services is modified to remove the waiver of the 30-day spell of illness as required by Article II, Rider 51 of the General Appropriations Act (83R), and to remove the reference to the Texas Medicaid Bulletin. |
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-2.2, “STAR+PLUS Covered Services.” |
Revision | 2.8 | January 1, 2014 | Contract amendment did not revise Attachment B-2.2, “STAR+PLUS 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. |
• Ambulance services |
• Audiology services, including hearing aids, for adults and children |
• Behavioral Health Services*, including: |
o Inpatient mental health services for Adults and Children |
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: |
Assessment |
Detoxification services |
Counseling treatment |
Medication assisted therapy |
o Residential services, including |
Detoxification services |
Substance use disorder treatment (including room and board) |
*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 MCO’s non-quantitative treatment limitations, provided such limitations comply with the requirements of the Mental Health Parity and Addiction Equity Act of 2008. |
• 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 |
• Early Childhood Intervention (ECI) services |
• Emergency Services |
• Family planning services |
• Home health care services |
• Hospital services, inpatient and 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 (birth through age 20) 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 six (6) months through 35 months of age. |
• Optometry, glasses, and contact lenses, if medically necessary |
• Outpatient drugs and biologicals; including pharmacy-dispensed and provider-administered outpatient drugs and biologicals |
• Drugs and biologicals provided in an inpatient setting |
• 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 |
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 |
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-3, "Deliverables/Liquidated Damages Matrix." |
Revision | 2.1 | March 1, 2012 | Contract amendment did not revise Attachment B-3, "Deliverables/Liquidated Damages Matrix." |
Revision | 2.2 | June 1, 2012 | Contract amendment did not revise Attachment B-3, "Deliverables/Liquidated Damages Matrix." |
Revision | 2.3 | September 1, 2012 | Item 27 is modified to remove the quarterly reports for item (a), add pharmacy to items (d) and (e), and to add item (f) Medicaid Managed Care Texas Health Steps Medical Checkups Quarterly Utilization Reports. Item 28 is modified to replace references to “1915 (c) Waiver” with “HCBS STAR +PLUS Waiver”. |
Revision | 2.4 | March 1, 2013 | Item 19 is modified to clarify liquidated damage assessment and variance. |
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-3, "Deliverables/Liquidated Damages Matrix." |
Revision | 2.6 | September 1, 2013 | Items 4, 6, 7, 16, 23, 24, 26, 27, 28, 29, 30, and 31 are modified to add “not submitted” to the LD. Items 10 and 21 are modified and items 28-31 are added to include pharmacy requirements. All subsequent items are renumbered. Items 21 and 22 are modified to include pharmacy claims. Item 24 is modified to change the name of the report. Item 27 is modified to remove quarterly from the measurement period. |
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-3, "Deliverables/Liquidated Damages Matrix." |
Revision | 2.8 | January 1, 2014 | Contract amendment did not revise Attachment B-3, "Deliverables/Liquidated Damages Matrix." |
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. |
# | Service/ Component1 | Performance Standard2 | Measurement Period3 | Measurement Assessment4 | Liquidated Damages |
1. | General Requirement: Failure to Perform an Administrative Service Contract Attachment A, "Uniform Managed Care Contract Terms and Conditions", Contract Attachment B-1, RFP §§ 6, 7, 8 and 9 | The MCO fails to timely perform an MCO 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). | Ongoing | Each incident of non-compliance per MCO Program and SA. | HHSC may assess up to $5,000.00 per calendar day for each incident of non-compliance per MCO Program and SA. |
2. | General Requirement: Failure to Provide a Covered Service Contract Attachment A, "Uniform Managed Care Contract Terms and Conditions", Contract Attachment B-1, RFP §§ 6, 7, 8 and 9 | The MCO fails to timely provide a MCO 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. | Ongoing | Each calendar day of non-compliance | HHSC may assess up to $ 7,500.00 per day for each incident of non-compliance. |
3. | Contract Attachment A, "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 MCO Administrative Services; and (iv) 30 calendar days prior to the termination date of any other Material Subcontract. | Transition, Measured Quarterly during the Operations Period | Each calendar day of non-compliance, per MCO 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 | 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 the 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 | Each calendar day of non-compliance, per MCO Program, per SA. | HHSC may assess up to $250 per calendar day if the report/deliverable is not submitted, late, inaccurate, or incomplete. |
5. | Contract Attachment B-1, RFP §7.2 Transition Phase Schedule Contract Attachment B-1, RFP §7.2.1 Contract Start-Up and Planning Contract Attachment B-1, RFP §8.1 General Scope | The MCO must be operational no later than the agreed upon Operations Start Date. HHSC, or its agent, will determine when the MCO is considered to be operational based on the requirements in Section 7 and 8 of Attachment B-1. | Operations Start Date | Each calendar day of non-compliance, per MCO Program, per Service Area (SA). | HHSC may assess up to $10,000 per calendar day for each day beyond the Operations Start date that the MCO is not operational until the day that the MCO is operational, including all systems. |
6. | Contract Attachment B-1, RFP §7.2.5 System Readiness Review | The MCO must submit to HHSC or to the designated Readiness Review Contractor the following plans for review, no later than 120 days prior to Operational Start Date: • Joint Interface Plan; • Disaster Recovery Plan; • Business Continuity Plan; • Risk Management Plan; and • Systems Quality Assurance Plan. | Transition Period | Each calendar day of non-compliance, per report, per MCO Program, and per SA. | HHSC may assess up to $1,000 per calendar day for each day a deliverable is not submitted, late, inaccurate or incomplete. |
7. | Contract Attachment B-1, RFP §7.2.7 Operations Readiness | 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. | Transition Period | Each calendar day of non-compliance, per directory, per MCO Program and per SA. | HHSC may assess up to $1,000 per calendar day for each day the directory is not submitted, late, inaccurate or incomplete. |
8. | Attachment B-1, RFP Sections 7.2.8.1 and 8.1.19 | The MCO must submit or comply with the requirements of the HHSC-approved Fraud and Abuse Compliance Plan. | Transition, Operations, and Turnover | Each incident of noncompliance, per MCO Program | HHSC may assess up to $250 per calendar day for each incident of noncompliance, per MCO Program. |
9. | Contract Attachment B-1, RFP §8.1.4 Provider Network UMCM Chapter 5.38 Out of Network Utilization Report | (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. | Measured Quarterly beginning March 1, 2010. | Per incident of non-compliance, per Medicaid MCO, per Service Area. | HHSC may assess up to $25,000 per quarter, per standard, per Medicaid MCO, per Service Area. |
10. | Contract Attachment B-1, RFP §8.1.4.7 Provider Hotline; §8.1.21.1 Prior Authorization for Prescription Drugs and 72-Hour Emergency Supplies | A. The MCO must operate a toll-free Provider telephone hotline for 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 abandonment rate— Call abandonment rate is seven percent (7%) or less. C. Average hold time is two (2) minutes or less. | Operations and Turnover | A. Each incident of non-compliance per MCO Program and SA. B. Each percentage point below the standard for 1 and each percentage point above the standard for 2 per MCO 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. | HHSC may assess: A. Per MCO 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 MCO Program and SA for each percentage point for each standard that the MCO fails to meet the requirements for a monthly reporting period for any MCO operated toll-free lines. C. Up to $100.00 may be assessed for each 30 second time increment, or portion thereof, by which the MCO’s average hold time exceeds the maximum acceptable hold time. |
11. | Contract Attachment B-1, RFP §8.1.5.6 Member Services Hotline | A. The MCO 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 forth 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 seven percent (7%) or less. C. Average hold time is two (2) minutes or less. | Ongoing during Operations and Turnover | A. Each incident of non-compliance per. MCO Program and SA. B. Each percentage point below the standard for 1 and 2 and each percentage point above the standard for 3 per MCO 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. | HHSC may assess: A. Per MCO 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 MCO Program and SA, up to $100.00 for each percentage point for each standard that the MCO fails to meet the requirements for a monthly reporting period for any MCO operated toll-free lines. C. Up to $100.00 may be assessed for each 30 second time increment, or portion thereof, by which the MCO’s average hold time exceeds the maximum acceptable hold time. |
12. | Contract Attachment B-1, RFP §8.1.5.9 Member Complaint and Appeal Process 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 Contract Attachment B-1, RFP §8.2.4.1 Provider Complaints | The MCO must resolve at least 98% of Member and Provider Complaints within 30 calendar days from the date the Complaint is received by the MCO. | Measured Quarterly during the Operations Period | Per reporting period, per MCO Program, per SA. | HHSC may assess up to $250 per reporting period if the MCO fails to meet the performance standard. |
13. | Contract Attachment B-1, RFP §8.1.5.9 Member Complaint and Appeal Process Contract Attachment B-1, RFP §8.2.7.2 Medicaid Standard Member Appeal Process Contract Attachment B-1, RFP § 8.4.3 CHIP Member Complaint and Appeal Process | The MCO must resolve at least 98% of Member Appeals within 30 calendar days from the date the Appeal is filed with the MCO. | Measured Quarterly during the Operations Period | Per reporting period, per MCO Program, per SA. | HHSC may assess up to $500 per reporting period if the MCO fails to meet the performance standard. |
14. | Contract Attachment B-1, RFP §8.1.6 Marketing & Prohibited Practices Uniform Managed Care Manual Chapter 4.3 | The MCO may not engage in prohibited marketing practices. | Transition, Measured Quarterly during the Operations Period | Per incident of non-compliance. | HHSC may assess up to $1,000 per incident of non-compliance. |
15. | Contract Attachment B-1, RFP §8.1.15.3 Behavioral Health Services Hotline | A. The MCO must have an emergency and crisis Behavioral Health services Hotline available 24 hours a day, seven (7) days a week, toll-free throughout the Service Area(s). B. Crisis hotline staff must include or have access to qualified Behavioral Health Services professionals to assess behavioral health emergencies. C. The MCO must ensure that the toll-free Behavioral Health Services Hotline meets the following minimum performance requirements for the MCO Program: 1. Call pickup rate: 99% of calls are answered by 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: The call abandonment rate is seven percent (7%) or less. D. Average hold time is two (2) minutes or less. | Operations and Turnover | A. Each incident of non-compliance per MCO Program and SA. B. Each incident of non-compliance per MCO Program and SA. C. Per MCO 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 thereof, by which the average hold time exceeds the maximum acceptable hold time. | 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 occurrence that HHSC identifies through its recurring monitoring processes 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 MCO fails to meet the requirements for a monthly reporting period for any MCO operated toll-free lines. D. Up to $100.00 may be assessed for each 30 second time increment, or portion thereof, by which the MCO’s average hold time exceeds the maximum acceptable hold time. |
16. | Contract Attachment B-1, RFP §8.1.17.1 Financial Reporting Requirements Uniform Managed Care Manual Chapter 5.0 | Financial Statistical Reports (FSR): For each MCO Program and SA, the MCO 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. | Quarterly during the Operations Period | Per calendar day of non-compliance, per MCO Program, per SA. | HHSC may assess up to $1,000 per calendar day a quarterly or annual report is not submitted, late, inaccurate or incomplete. |
17. | Contract Attachment B-1, RFP §8.1.17.1 Financial Reporting Requirements: Uniform Managed Care Manual Chapter 5.0 | Medicaid Disproportionate Share Hospital (DSH) Reports: The Medicaid MCO 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 or CHIP Perinatal Programs. Any claims added after July 1st shall include supporting claim documentation for HHSC validation. | Measured during 4th Quarter of the Operations Period (6/1–8/31) | Per calendar day of non-compliance, per MCO Program, per SA. | 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. |
18. | Contract Attachment B-1, RFP §8.1.18 Management Information System (MIS) Requirements | The MCO’s MIS must be able to resume operations within 72 hours of employing its Disaster Recovery Plan. | Measured Quarterly during the Operations Period | Per calendar day of non-compliance, per MCO Program, per SA. | HHSC may assess up to $5,000 per calendar day of non-compliance |
19. | Contract Attachment B-1, RFP §8.1.18.1 Encounter Data | The MCO must submit Encounter Data transmissions and include all Encounter Data and Encounter Data adjustments processed by the MCO 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. Pharmacy Encounter Data must be submitted no later than 25 calendar days after the date of adjudication and include all Encounter Data and Encounter Data adjustments. Additionally, the MCO will be subject to liquidated damages if the Quarterly Encounter Reconciliation Report (which reconciles the yearto- 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. | Measured Quarterly during Operations Period | Per incident of non-compliance, per MCO Program, per Service Area (SA) | Liquidated Damages: a) Failure to submit Encounter Data: 1. HHSC may assess up to $2,500 per Financial Arrangement Code, per month (or every 25 days for Pharmacy Encounter Data), per Program, per SA if the MCO fails to submit encounter data in a quarter. 2. HHSC may assess up to $5,000 per Financial Arrangement Code, per month (or every 25 days for Pharmacy Encounter Data), per Program, per SA for each month in any subsequent quarter that the MCO fails to submit Encounter Data. b) Encounter Data Reconciliation: Additionally, HHSC may assess up to $2,500 per Quarter, per Program, per SA if the MCO is not within the 2% variance. HHSC may assess up to $5,000 per Quarter, per Program, per SA for each additional Quarter that the MCO is not within the 2% variance. |
20. | Contract Attachment B-1, RFP §8.1.18.3 System-Wide Functions | The MCO’s MIS system must meet all requirements in Section 8.1.18.3 of Attachment B-1. | Measured Quarterly during the Operations Period | Per calendar day of non-compliance, per MCO Program, per SA. | HHSC may assess up to $5,000 per calendar day of non-compliance. |
21. | Contract Attachment B-1, RFP §8.1.18.5 Claims Processing Requirements and §8.1.21.14 Pharmacy Claims and File Processing Uniform Managed Care Manual Chapter 2.0 and 2.2 | The MCO must adjudicate all provider Clean Claims within 30 days of receipt by the MCO. The MCO must pay providers interest at 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 to the provider must be paid on the same date as the claim. The MCO must adjudicate all Clean Claims for outpatient pharmacy benefits within (1) 18 days after receipt by the MCO if submitted electronically, or (2) 21 days after receipt by the MCO if submitted non-electronically. The MCO must pay providers interest at 18% per annum, calculated daily for the full period in which the Clean Claim remains unadjudicated beyond the 18-day or 21-day claims-processing deadline. Interest owed to the provider must be paid on the same date as the claim. | Measured Quarterly during the Operations Period | Per incident of non-compliance. | HHSC may assess up to $1,000 per claim if the MCO fails to pay interest timely. |
22. | Contract Attachment B-1, RFP §8.1.18.5 Claims Processing Requirements Uniform Managed Care Manual Chapters 2.0 and 2.2 | The MCO must comply with the claims processing requirements and standards as described in Section 8.1.18.5 of Attachment B-1 and in Chapters 2.0 and 2.2 of the Uniform Managed Care Manual. | Measured Quarterly during the Operations Period | Per quarterly reporting period, per MCO Program, per Service Area, per claim type. | HHSC may assess liquidated damages of up to $5,000 for the first quarter that an MCO’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. |
23. | Attachment B-1, RFP Section 8.1.19 | The MCO must respond to Office of Inspector General request for information in the manner and format requested. | Transition, Operations, and Turnover | Each calendar day of noncompliance, per MCO Program. | HHSC may assess up to $250 per calendar day, per MCO Program, that the report is not submitted, late, inaccurate, or incomplete. |
24. | Attachment B-1, RFP Section 8.1.20.2, UMCM Chapter 5.5 | The MCO must submit a Fraudulent Practices Report to the HHSC-OIG within 30 Business Days of receiving a report of possible Waste, Abuse, or Fraud from the MCO’s Special Investigative Unit (SIU). The MCO must submit quarterly MCO Open Case List Reports. | Transition, Operations, and Turnover | Each calendar day of noncompliance, per MCO Program. | HHSC may assess up to $250 per calendar day, per MCO Program, that the report is not submitted, late, inaccurate, or incomplete. |
25. | Attachment B-1, RFP §8.1.20.2 Reports Attachment B-1, RFP §8.2.5.1 Provider Complaints Attachment B-1, RFP §8.2.7.1 Member Complaint Process | The MCO fails to submit a timely response to an HHSC Member or Provider Complaint received by HHSC and referred to the MCO by the specified due date. The MCO response must be submitted according to the timeframes and requirements stated within the MCO Notification Correspondence (letter, email, etc). | Measured on a Quarterly Basis | Each incident of non-compliance per MCO Program and SA | HHSC may assess up to $250 per calendar day for each day beyond the due date specified within the MCO Notification Correspondence. |
26. | Contract Attachment B-1, RFP §8.1.20.2 Reports Uniform Managed Care Manual Chapters 2.0 and 5.0 | Claims Summary Report: The MCO must submit quarterly, Claims Summary Reports to HHSC by MCO Program, by Service Area, and by claim type, by the 30th day following the reporting period unless otherwise specified. | Measured Quarterly during the Operations Period | Per calendar day of non-compliance, per MCO Program, per Service Area, per claim type. | HHSC may assess up to $1,000 per calendar day the report is not submitted, late, inaccurate, or incomplete. |
27. | Contract Attachment B-1, RFP §8.1.20.2 Reports; Uniform Managed Care Manual Chapter 12 Frew | (a) Medicaid Managed Care Texas Health Steps Medical Checkups Reports - The MCO must submit an annual report of the number of New Members and Existing Members that receive timely Texas Health Steps (THSteps) medical checkups or refuse to obtain medical checkups. (b) Children of Migrant Farm Workers Annual Plan and Children of Migrant Farm Workers Annual Report - The MCO must submit an annual plan that describes how the MCO will identify and provide accelerated services to Children of Migrant Farm Workers and an annual report that summarizes the MCO's migrant efforts as stated in its annual plan. (c) Frew Quarterly Monitoring Report - The MCO must submit each quarter responses to questions on this report's template addressing the status of Frew Consent Decree paragraphs. | (a) Annually (b) Annually (c) Quarterly (d) Annually (e) Quarterly (f) Quarterly | (a) Per calendar day of non-compliance per Program. (b) Plan: Per calendar day of non-compliance. Report: Per calendar day of non-compliance per Program and Service Area. (c) Per calendar day of non-compliance per MCO. (d) Per calendar day of non-compliance per MCO. (e) Per calendar day of non-compliance per MCO. (f) Per calendar day of non-compliance per Program. | HHSC may assess up to $1,000 per calendar day for the first measurement period the reports are not submitted, late, inaccurate, or incomplete. HHSC may assess up to $5,000 per calendar day for each consecutive measurement period that a subsequent report is not submitted, late, inaccurate, or incomplete. In addition, HHSC may assess up to $2,500 per calendar day for any report resubmissions that are not submitted, late, inaccurate, or incomplete within each measurement period. |
(d) Frew Annual Provider Training Report - The MCO must submit an annual report of health care and pharmacy provider training conducted throughout the year on Texas Health Steps, Frew, and/or pharmacy benefit education topics that includes the number of Medicaid providers that received training and feedback received on the subject matter and methodology of the training. (e) Frew Provider Recognition Report - The MCO must submit a quarterly report of Medicaid enrolled healthcare and pharmacy providers who attended the MCO's training on Frew, Texas Health Steps, and/or pharmacy benefit education topics and consented to being recognized as having attended training on the HHSC website. (f) Medicaid Managed Care Texas Health Steps Medical Checkups Quarterly Utilization Reports - Each State Fiscal Quarter, the MCO must submit a report of the number and percent of Members birth through age 20 receiving at least one Texas Health Steps medical checkup in total and broken down by various age groups. |
28 | Contract Attachment B-1, §8.1.21.1 Formulary and Preferred Drug List | The MCO fails to allow Network Providers free access to a point-of- care web-based application accessible to smart phones, tablets, or similar technology. The application must also identify preferred/non-preferred drugs; Clinical Edits, and any preferred drugs that can be substituted for non-preferred drugs. The MCO must update this information at least weekly. | Ongoing | Each calendar day of non-compliance | HHSC may assess up to $5,000 per calendar day for each incident of non-compliance per MCO Program. |
29 | Contract Attachment B-1, §8.1.21.2 Prior Authorization (PA) for Prescription Drugs and 72-Hour Emergency Supplies | The MCO fails to reimburse a pharmacy for providing a 72-hour emergency supply as outlined in this section or fails to make a prior authorization determination within 24 hours of the request. | Ongoing | Each incident of noncompliance | HHSC may assess up to $5,000 per incident of non-compliance per MCO Program. |
30 | Contract Attachment B-1, §8.1.21.5 Pharmacy Rebate Program Uniform Managed Care Manual, Chapters 2.0 and 2.2 | The MCO fails to include valid national drug codes (NDCs) on encounters for outpatient prescription drugs, including physician-administered drugs. | Ongoing | Each incident of noncompliance | HHSC may assess up to $500 for each incident of non-compliance per MCO Program. |
31 | Contract Attachment B-1, §8.1.21.16 E-Prescribing | The MCO fails to provide timely data updates to the national e-prescribing network | Ongoing | Each calendar day of Non compliance | HHSC may assess up to $5,000 per calendar day of non-compliance per MCO Program. |
32. | 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 §8.3.4.2 217-Like Group 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 HCBS STAR+PLUS Waiverservices for 217-Like Group applicants; 2) from the date of the Member's request for HCBS STAR+PLUS Waiver services for current Members requesting an upgrade; or 3) prior to the annual ISP expiration date for all Members receiving HCBS STAR+PLUS 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 not submitted, late, inaccurate or incomplete. |
33. | Contract Attachment B-1, RFP §9.3 Transfer of Data | The MCO must transfer all data regarding the provision of Covered Services to Members to HHSC or a new MCO, at the sole discretion 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 MCO Program, per SA. | HHSC may assess up to $10,000 per calendar day the data is not submitted,late, inaccurate or incomplete. |
34. | Contract Attachment B-1, RFP §9.4 Turnover Services | Six (6) months prior to the end of the contract period or any extension thereof, the MCO must propose a Turnover Plan covering the possible turnover of the records and information maintained to either the State (HHSC) or a successor MCO. | Measured at Six (6) 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 MCO Program, per SA. | HHSC may assess up to $1,000 per calendar day the Plan is not submitted, late, inaccurate, or incomplete. |
35. | Contract Attachment B-1, RFP §9.5 Post-Turnover Services | The MCO 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 MCO program, per SA. | HHSC may assess up to $250 per calendar day the report is not submitted, late, inaccurate or incomplete. |
(a) the right to require Beneficiary to proceed against Subsidiary; |
(b) all requirements of presentment, protest or default and notices of presentment, protest or default; |
(c) any right to require Beneficiary to proceed against Subsidiary or to pursue any other remedy in Beneficiary's power whatsoever; |
(d) notice of acceptance of this Guarantee; |
(e) notice of any amendments, work authorizations, extensions of time for performance, changes in the work, or other acts by Beneficiary affecting Subsidiary's rights or obligations under the Contract; |
(f) notice of any breach or claim of breach by Subsidiary, provided Beneficiary has complied with any required notice provisions to Subsidiary under the Contract; |
(g) any defense arising out of the exercise by Beneficiary of any right or remedy it may have with respect to the Contract, including the right to amend or modify the Contract and the right to waive or delay the exercise of any rights it may otherwise have against Subsidiary; |
(h) notice of the settlement or compromise of any claim of Beneficiary against Subsidiary relating to any of Subsidiary’s obligations under the Contract; and |
(i) the benefit of suretyship defenses generally. |
(a) all other provisions hereof shall remain in full force and effect in such jurisdiction and shall be liberally construed in favor of Beneficiary in order to carry out the intentions of the parties hereto as nearly as may be possible; and |
(b) such invalidity, illegality or unenforceability shall not affect the validity or enforceability of such provision in any other jurisdiction. |
Parties to the Contract: |
This 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 Bankers Reserve Life Insurance Company of Wisconsin d.b.a. Superior HealthPlan Network (MCO), an entity organized under the laws of the State of Wisconsin, having its principal place of business at 2100 South IH-35, Suite 202, Austin, Texas 78704. HHSC and MCO may be referred to in this Amendment individually as a “Party” and collectively as the “Parties.” | ||
Amendment Effective Date | Contract Expiration Date | Operational Start Date |
February 1, 2014 | August 31, 2015 | March 1, 2012 |
MCO Brand Names | ||
The MCO will use following brand name(s). The MCO acknowledges that if it requests a change to the brand name(s), it will be responsible for all costs associated with the change(s), including HHSC's costs for modifying its business rules, system identifiers, communications materials, web page, etc. STAR: Superior Health Plan STAR+PLUS: Superior Health Plan CHIP: MRSA: Superior HealthPlan | ||
Project Managers | ||
HHSC: Emily Zalkovsky Director, Program Management 11209 Metric Boulevard, Building H Austin, Texas 78758 Phone: 512-491-2078 Fax: 512-491-1972 MCO: Susan Erickson Vice President 2100 South IH-35, Suite 202 Austin, Texas 78704 Phone: 512-692-1465 Ext 22032 Fax: 866-702-4830 E-mail: serickson@centene.com | ||
Legal Notice Delivery Addresses | ||
HHSC: General Counsel 4900 North Lamar Boulevard, 4th Floor Austin, Texas 78751 Fax: 512-424-6586 MCO: Superior HealthPlan 2100 South IH-35, Suite 202 Austin, Texas 78704 Fax: 866-702-4830 |
MCO Programs and Service Areas |
This Amendment applies to the following checked HHSC MCO Programs and Service Areas . All references in the Amendment or the Contract to MCO Programs or Service Areas that are not checked do not apply to the MCO. þ Medicaid STAR MCO Program þ Medicaid STAR + PLUS MCO Program o CHIP MCO Program |
Service Areas: | o Bexar | þ Medicaid RSA - Central | ||
o Dallas | þ Medicaid RSA - Northeast | |||
o El Paso | þ Medicaid RSA - West | |||
o Harris | o Nueces | |||
þ Hidalgo | o Tarrant | |||
o Jefferson | o Travis | |||
o Lubbock |
Service Areas: | o Bexar | o Jefferson | ||
o El Paso | o Lubbock | |||
o Harris | o Nueces | |||
þ Hidalgo | o Travis |
Payment |
Rate Period 2 Capitation Rates | |||||
Service Area: | Hidalgo | Medicaid Rural Service Area - Central Texas | Medicaid Rural Service Area - Northeast Texas | Medicaid Rural Service Area - West Texas | |
Rate Cell | |||||
1 | Under Age 1 Child | *** | *** | *** | *** |
2 | Age 1-5 Child | *** | *** | *** | *** |
3 | Age 6-14 Child | *** | *** | *** | *** |
4 | Age 15-18 Child | *** | *** | *** | *** |
5 | Age 19-20 Child | *** | *** | *** | *** |
6 | TANF Adult | *** | *** | *** | *** |
7 | Pregnant Woman | *** | *** | *** | *** |
8 | SSI - Aged, Blind, & Disabled | *** | *** | *** |
Service Area | Delivery Supplemental Payment |
Hidalgo | *** |
Medicaid Rural Service Area - Central Texas | *** |
Medicaid Rural Service Area - Northeast Texas | *** |
Medicaid Rural Service Area - West Texas | *** |
Rate Period 2 Capitation Rates | ||
STAR + PLUS Service Area: | Hidalgo | |
Rate Cell | ||
1 | Medicaid Only Standard Rate | *** |
2 | Medicaid Only HCBS STAR+PLUS Waiver Rate - Above Floor | *** |
3 | Medicaid Only HCBS STAR+PLUS Waiver Rate - Below Floor | *** |
4 | Dual Eligible Standard Rate | *** |
5 | Dual Eligible HCBS STAR+PLUS Waiver Rate- Above Floor | *** |
6 | Dual Eligible HCBS STAR+PLUS Waiver Rate- Below Floor | *** |
7 | Nursing Facility - Medicaid Only | *** |
8 | Nursing Facility - Dual Eligible | *** |
Terms and Attachments: |
Signatures |
The Parties execute this Amendment in their stated capacities with authority to bind their organizations on the dates in this section. Texas Health and Human Services Commission /s/ Chris Traylor Chris Traylor Chief Deputy Commissioner Office of the Chief Deputy Commissioner Date: 12/23/2013 Bankers Reserve Life Insurance Company of Wisconsin d.b.a. Superior HealthPlan Network /s/ Holly Munin By: Holly Munin Title: CEO Date: 11/14/2013 |
DOCUMENT HISTORY LOG | |||||||
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 | ||||
Baseline | n/a | September 1, 2011 | Initial version of the Attachment A, “Medicaid and CHIP Uniform Managed Care Contract Terms & Conditions.” | ||||
Revision | 2.1 | March 1, 2012 | Definition “1915(c) Nursing Facility Waiver” is modified to correct a cross-reference. Definition for Medically Necessary is modified for clarification. The State has determined that all acute care behavioral health and non-behavioral health services for Medicaid children fall within the scope of Texas Health Steps. Note that for LTSS, such as PCS (PAS) services for children in STAR+PLUS, the functional necessity standard for LTSS also applies (see Attachment B-1, Section 8.3.3). Definition for Rate Period 1 is modified. Section 4.04 is modified to clarify the requirements for Medical Director designees, and to clarify that the provision does not apply to prior authorization determinations made by Texas licensed pharmacists. New Section 4.11 “Prohibition Against Performance Outside of the United States” added. Section 5.02(b) is modified to clarify that MCOs may not sell or transfer their Member base. Section 5.06(a)(2) is modified to clarify the exceptions to enrollment in an MCO during an Inpatient Stay. Section 5.06(a)(3) and (4) are modified to clarify that Members cannot move from FFS to an MCO or from one MCO to another during residential treatment or residential detoxification. References to the PCCM program are removed. In addition, Section 5.06(a)(8) is modified to clarify movement requirements for SSI Members in the MRSA. Section 10.06(b) is modified to remove the Perinate Newborn 0% - 185% rate cell. Section 10.10 is modified to consolidate STAR+PLUS with STAR and CHIP for the Experience Rebate calculation. Section 10.10.1 is deleted in its entirety. Section 10.10.2 is modified to consolidate STAR+PLUS into STAR and CHIP for the Experience Rebate calculation. |
Revision | 2.2 | June 1, 2012 | Definition for Consolidated FSR Report or Consolidated Basis is added. Definition for Financial Statistical Report is added. Definitions for FSR Reporting Period, FSR Reporting Period 12/13, and FSR Reporting Period 14 are added. Definition for Material Subcontract is modified. Definition for Net Income Before Taxes is modified. Definition for Pre-tax Income is modified. Definition for Program is added. Definition for Rate Period 1 and Rate Period 2 are modified. Section 10.10 is modified to consolidate the Experience Rebate across all contracts and all programs. Section 10.10.2 is modified to consolidate the Administrative Expense Cap across all contracts and all programs. | ||||
Revision | 2.3 | September 1, 2012 | Definition for Case Management for Children and Pregnant Women is modified to remove the acronym “CPW”. Definition for Community-based Long Term Services and Supports is modified to replace references to “1915(c) Nursing Facility Waiver” with “HCBS STAR+PLUS Waiver”. Definition for “1915(c) Nursing Facility Waiver” is modified to change the name to “HCBS STAR+PLUS. Waiver” and to update references to “Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver” and “HCBS STAR+PLUS Waiver”. Definition for “HHSC MCO Programs or MCO Programs” is modified. Definition for “Medically Necessary” is modified. Definition for “Provider Materials” is added. Section 5.06(a)(4) is modified to clarify responsibility for payment. Section 5.11 is deleted in its entirety. Section 7.02 is modified to clarify that only applicable provisions of the listed laws apply to the contract. Section 10.05 is modified to replace references to “1915(c) Nursing Facility Waiver” with “HCBS STAR+PLUS Waiver”. | ||||
Revision | 2.4 | March 1, 2013 | All references to the previous Executive Commissioner Suehs are changed to his successor, Executive Commissioner Janek. Definition for “Electronic Visit Verification” is added. Section 5.02(e), Subsections (4) and (5) are modified. Section 10.16 is added to address supplemental payments to MCOs for wrap-around services for outpatient drugs and biological products for STAR-PLUS Members. |
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment A, Uniform Managed Care Contract Terms and Conditions. | ||||
Revision | 2.6 | September 1, 2013 | Definition for CAHPS is modified to correct the name to which the acronym refers. Definition for “Community Health Worker” is added. Definition for “Court-Ordered Commitment” is modified. Definition for Default Enrollment is modified to add T.A.C. reference. Definition for “DSM” is modified. Definition for “ECI” is modified. Definition for HEDIS is modified to correct the name to which the acronym refers. Definition for Primary Care Physician is modified to remove the list of provider types as being redundant. Definition for Rate Period is modified to include a third sub-period. Section 5.02(e) is modified to remove the language regarding disenrollment for ESRD and ventilator dependency. Section 5.08 is renamed “Modified Default Enrollment Process” and revised to include a process for all Programs. Section 5.09 is deleted and replaced with Section 5.08. Section 5.10 is deleted and replaced with Section 5.08. Section 7.04 is deleted in its entirety and updated within Section 7.02 Section 9.02 is modified for clarification that records must be provided “at no cost.” Section 9.04 is modified for clarification that records must be provided “at no cost.” Section 10.05(a) is modified to comply with the new STAR Risk Groups. Section 10.10.3 is modified to clarify that the Reinsurance Cap impacts only the Experience Rebate calculation. Section 11.01(c) is modified to add the missing word “may.” Section 13.01 is modified to clarify the required certifications. Section 14.08 is modified to delete outdated language |
Revision | 2.7 | September 1, 2013 | Section 10.17 “Pass-through Payments for Provider Rate Increases” is added. | ||||
Revision | 2.8 | January 1, 2014 | Definition for Expansion Children is removed. Definition for Federal Poverty Level is updated. Definition for Former Foster Care Child (FFCC) Member is added. Section 5.02 is modified to add requirement for default assignment methodologies. Section 5.04 is modified to clarify that HHSC or the ASC will enroll or disenroll Members. Section 5.05 is modified to clarify that HHSC or the ASC will transmit new Member information, to remove the FPL limits, to remove the default assignment language, and to clarify the enrollment process when CHIP Perinate coverage expires. Section 5.06 is modified to add requirements regarding movement from a STAR Health MCO to a STAR MCO. Section 10.06(b) is modified to clarify the eligibility thresholds. Section 10.09 is modified to clarify the eligibility thresholds. Section 11.01(a) is modified to correct an administrative error. Section 12.03 is modified to delete subsection (b)(8) Termination for Insolvency and all following subsections are renumbered. |
Revision | 2.9 | February 1, 2014 | Definition for Capitation Payment is modified to include associated Administrative Services. Definition for Child (or Children) with Special Health Care Needs (CSHCN) is clarified. Definition for Clean Claim is clarified to include Nursing Facility Services. Definition for Cognitive Rehabilitation Therapy is added. Definition for Community Services Specialist (CSSP) is added. Definition for Electronic Visit Verification System is added. Definition for Employment Assistance is added. Definition for Family Partner is added. Definition for Fee-for-Service (FFS) is clarified that payment is made after the service is provided. Definition for ICF-IID Program is added. Definition for IDD Waiver is added. Definition for Licensed Medical Personnel is added. Definition for Licensed Practitioner of the Healing Arts is added. Definition for Local IDD Authority is added. Definition for Local Mental Health Authority is modified to reference the legal citation. Definition for Material Subcontract is modified to clarify excluded subcontractors. Definition for MCO Administrative Services is modified to include all required deliverables outside of the Covered Services. Definition for Medical Home is modified to have the meaning assigned in Gov’t Code 533.0029. Definition for Member with Special Health Care Needs (MSHCN) is modified. Definition for Mental Health Rehabilitative Services is added. Definition for Nursing Facility is added. Definition for PASRR is added. Definition for PASRR Level I Screening is added. Definition for PASRR Level II Evaluation is added. Definition for PASRR Specialized Services is added. Definition for Peer Provider is added. Definition for Population Risk Group or Risk Group is modified to add defined criteria. Definition for SED is modified to remove the reference to LMHAs. Definition for SPMI is modified to remove the reference to LMHAs. Definition for Supported Employment is added. |
Revision | 2.9 | February 1, 2014 | Definition for Targeted Case Management is added. Definition for Texas Medicaid Bulletin is removed. Definition for Texas Medicaid Provider Procedures Manual is modified to remove the reference to the Texas Medicaid Bulletin. Section 4.08 is renamed Subcontractors and Agreements with Third Parties and is modified to include language from Section 4.10 Agreements with Third Parties. Section 4.10 MCO Agreements with Third Parties is deleted in its entirety. Section 5.06 Span of Coverage is modified to update the requirements effective through August, 31, 2014 and to add requirements effective September 1, 2014. Section 10.01 is modified to clarify the calculation of the monthly Capitation Payment. Section 10.02 is modified to include Liquidated Damages due and unpaid including any associated interest. Section 10.08 is modified to clarify the requirements for adjustments. Section 10.10 is modified to include Liquidated Damages assessment. Section 10.10.2 is modified to clarify the data sources and to update the calculation example. Section 13.02 is modified to include an obligation to comply with 41 U.S.C. § 423. | ||||
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. |
• | the other entity is an Affiliate of the MCO; |
• | the Subcontract is considered by HHSC to be for a key type of service or function, including |
◦ | Administrative Services (including but not limited to third party administrator, Network administration, and claims processing); |
◦ | delegated Networks (including but not limited to behavioral health, dental, pharmacy, and vision); |
◦ | management services (including management agreements with parent) |
◦ | reinsurance; |
◦ | Disease Management; |
◦ | pharmacy benefit management (PBM) or pharmacy administrative services; or |
◦ | call lines (including nurse and medical consultation); or |
• | any other Subcontract that exceeds, or is reasonably expected to exceed, the lesser of: a) $500,000 per year, or b) 1% of the MCO’s annual Revenues under this Contract. Any Subcontracts between the MCO and a single entity that are split into separate agreements by time period, Program, or SDA, etc., will be consolidated for the purpose of this definition. |
Scenario | Hospital Facility Charge | All Other Covered Services | ||
1 | Member Retroactively Enrolled in STAR or STAR+PLUS | New MCO | New MCO | |
2 | Member Prospectively Moves from FFS to STAR or STAR+PLUS | FFS | New MCO | |
3 | Member Moves from STAR to STAR Health | Former STAR MCO | New STAR Health MCO | |
4 | Member Moves from STAR+PLUS to STAR Health | Former STAR+PLUS MCO | New STAR Health MCO | |
5 | Adult Member Moves from STAR Health to STAR | Former STAR Health MCO | New STAR MCO | |
6 | Child Member in Non-MRSA STAR Service Area Moves to STAR+PLUS (Based on Change in SSI Status) | Former STAR MCO | New STAR+PLUS MCO | |
7 | Adult Member in Non-MRSA STAR Service Area Moves to STAR+PLUS (Based on Change in SSI Status) | Former STAR MCO | New STAR+PLUS MCO |
Scenario | Hospital Facility Charge | All Other Covered Services | ||
1 | Voluntary Child Member Moves from STAR MRSA to FFS (Includes Change Based on SSI Status) | Former STAR MCO | FFS | |
2 | Voluntary Child Member Moves from STAR+PLUS to FFS (Includes Change Based on SSI Status) | Former STAR+PLUS MCO | FFS | |
3 | Member Moves from STAR to FFS (Disenrolled at MCO’s Request) | Former STAR MCO | FFS | |
4 | Member Moves from STAR+PLUS to FFS (Disenrolled at MCO’s Request) | Former STAR+PLUS MCO | FFS |
Scenario | CDTF Charge | All Other Covered Services | ||
1 | Member Retroactively Enrolled in STAR or STAR+PLUS | New MCO | New MCO | |
2 | Member Prospectively Moves from FFS to STAR or STAR+PLUS | New MCO | New MCO | |
3 | Member Moves from STAR to STAR Health | Former STAR MCO | New STAR Health MCO | |
4 | Member Moves from STAR+PLUS to STAR Health | Former STAR+PLUS MCO | New STAR Health MCO | |
5 | Adult Member Moves from STAR Health to STAR | Former STAR Health MCO | New STAR MCO | |
6 | Child Member in Non-MRSA STAR Service Area Moves to STAR+PLUS (Based on Change in SSI Status) | Former STAR MCO | New STAR+PLUS MCO | |
7 | Adult Member in Non-MRSA STAR Service Area Moves to STAR+PLUS (Based on Change in SSI Status) | Former STAR MCO | New STAR+PLUS MCO |
Scenario | CDTF Charge | All Other Covered Services | ||
1 | Voluntary Child Member Moves from STAR MRSA to FFS (Includes Change Based on SSI Status) | Former STAR MCO | FFS | |
2 | Voluntary Child Member Moves from STAR+PLUS to FFS (Includes Change Based on SSI Status) | Former STAR+PLUS MCO | FFS | |
3 | Member Moves from STAR to FFS (Disenrolled at MCO’s Request) | Former STAR MCO | FFS | |
4 | Member Moves from STAR+PLUS to FFS (Disenrolled at MCO’s Request) | Former STAR+PLUS MCO | FFS |
Scenario | Hospital Facility Charge | All Other Covered Services | ||
1 | Member Retroactively Enrolled in STAR or STAR+PLUS | New MCO | New MCO | |
2 | Member Prospectively Moves from FFS to STAR or STAR+PLUS | FFS | New MCO | |
3 | Member Moves between STAR MCOs | Former MCO | New MCO | |
4 | Member Moves between STAR+PLUS MCOs | Former STAR+PLUS MCO | New STAR+PLUS MCO | |
5 | Member Moves from STAR to STAR Health | Former STAR MCO | New STAR Health MCO | |
6 | Member Moves from STAR+PLUS to STAR Health | Former STAR+PLUS MCO | New STAR Health MCO | |
7 | Member Moves from STAR to STAR+PLUS | Former STAR MCO | New STAR+PLUS MCO | |
8 | Adult Member Moves from STAR Health to STAR | Former STAR Health MCO | New STAR MCO |
Scenario | Hospital Facility Charge | All Other Covered Services | ||
1 | Voluntary Child Member Moves from STAR+PLUS to FFS (Includes Change Based on SSI Status) | Former STAR+PLUS MCO | FFS | |
2 | Member Moves from STAR to FFS (Disenrolled at MCO’s Request) | Former STAR MCO | FFS | |
3 | Member Moves from STAR+PLUS to FFS (Disenrolled at MCO’s Request) | Former STAR+PLUS MCO | FFS |
Scenario | CDTF Charge | All Other Covered Services | ||
1 | Member Retroactively Enrolled in STAR or STAR+PLUS | New MCO | New MCO | |
2 | Member Prospectively Moves from FFS to STAR or STAR+PLUS | New MCO | New MCO | |
3 | Member Moves from STAR to STAR Health | Former STAR MCO | New STAR Health MCO | |
4 | Member Moves from STAR+PLUS to STAR Health | Former STAR+PLUS MCO | New STAR Health MCO | |
5 | Adult Member Moves from STAR Health to STAR | Former STAR Health MCO | New STAR MCO | |
6 | Child Member in Non-MRSA STAR Service Area Moves to STAR+PLUS (Based on Change in SSI Status) | Former STAR MCO | New STAR+PLUS MCO | |
7 | Adult Member in Non-MRSA STAR Service Area Moves to STAR+PLUS (Based on Change in SSI Status) | Former STAR MCO | New STAR+PLUS MCO |
Scenario | CDTF Charge | All Other Covered Services | ||
1 | Voluntary Child Member Moves from STAR+PLUS to FFS (Includes Change Based on SSI Status) | Former STAR+PLUS MCO | FFS | |
2 | Member Moves from STAR to FFS (Disenrolled at MCO’s Request) | Former STAR MCO | FFS | |
3 | Member Moves from STAR+PLUS to FFS (Disenrolled at MCO’s Request) | Former STAR+PLUS MCO | FFS |
Scenario | Nursing Facility Charge | All Other Covered Services | ||
1 | Member Moves from FFS to STAR+PLUS | New STAR+PLUS MCO | New STAR+PLUS MCO | |
2 | Member Moves between STAR+PLUS MCOs | New STAR+PLUS MCO | New STAR+PLUS MCO |
Pre-tax Income as a % of Revenues | MCO Share | HHSC Share |
≤ 3% | 100% | —% |
> 3% and ≤ 5% | 80% | 20% |
> 5% and ≤ 7% | 60% | 40% |
> 7% and ≤ 9% | 40% | 60% |
> 9% and ≤ 12% | 20% | 80% |
> 12% | —% | 100% |
DOCUMENT HISTORY LOG | |||
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 |
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-1, RFP Sections 1 – 5, “Introduction; Procurement Strategy; General Instructions & Requirements; Submission Requirements; and Evaluation Process & Criteria.” |
Revision | 2.1 | March 1, 2012 | Section 1.3 is modified to clarify that Medicaid Wrap Services will become covered services at a future date to be determined by HHSC. Section 1.8.1 is modified to clarify that Medicaid Wrap Services will become covered services at a future date to be determined by HHSC. |
Revision | 2.2 | June 1, 2012 | Contract amendment did not revise Attachment B-1, Sections 1-5, "Introduction; Procurement Strategy; General Instructions & Requirements; Submission Requirements; and Evaluation Process & Criteria." |
Revision | 2.3 | September 1, 2012 | Section 1.6.1 is modified to replace reference to the 1915(b) waiver with the Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver. Section 1.6.2 is modified to replace references to the 1915(b) and 1915(c) waivers with the Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver. Section 1.8 is modified to reference the Texas Healthcare Transformation and Quality Improvement Program (THTQIP) 1115 Waiver and HHSC”s administrative rules for identification of eligible populations. Section 1.8.1 STAR Program Eligibility is deleted in its entirety. Section 1.8.2 STAR+PLUS Eligibility is deleted in its entirety. Section 1.8.3 CHIP Program Eligibility is deleted in its entirety. |
Revision | 2.4 | March 1, 2013 | Contract amendment did not revise Attachment B-1, Sections 1-5, “Introduction; Procurement Strategy; General Instructions & Requirements; Submission Requirements; and Evaluation Process & Criteria.” |
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-1, Sections 1-5, Introduction; Procurement Strategy; General Instructions & Requirements; Submission Requirements; and Evaluation Process & Criteria. |
Revision | 2.6 | September 1, 2013 | Section 2.1 is modified to clarify that HHSC uses two dashboards. Section 4.3.7.2 is modified to correct the name to which the acronym HEDIS refers. |
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-1, Sections 1-5, "Introduction; Procurement Strategy; General Instructions & Requirements; Submission Requirements; and Evaluation Process & Criteria." |
Revision | 2.8 | January 1, 2014 | Section 1.6.3 is modified to clarify the eligibility thresholds. |
Revision | 2.9 | February 1, 2014 | Section 1.6.3 is modified to clarify that in this contract CSHCN is defined as a specific DSHS program. Section 2.1 is modified to add MCO Report Cards. Section 4.3.10 is modified to clarify that use of the term CSHCN refers to a specific DSHS program. |
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. |
1.1 Point-of-Contact |
1.2 Procurement Schedule |
Procurement Schedule | |
Draft RFP Release Date | November 5, 2010 |
Draft RFP Respondent Comments Due | December 6, 2010 |
RFP Release Date | April 8, 2011 |
Vendor Conference | April 18, 2011 1:00pm CDT |
Respondent Questions Due | April 19, 2011 |
Letters Claiming Mandatory Contract Status Due | April 28, 2011 |
HHSC Posts Responses to Respondent Questions | April 29, 2011 |
Proposals Due | May 23, 2011 |
Deadline for Proposal Withdrawal | May 23, 2011 |
Respondent Demonstrations/Oral Presentations (HHSC option) | HHSC will not be holding presentations |
Tentative Award Announcement | August 1, 2011 |
Anticipated Contract Start Date | September 1, 2011 |
Operational Start Date | March 1, 2012 |
Medicaid State of Texas Access Reform Program (STAR); |
Medicaid STAR+PLUS Program; |
Children’s Health Insurance Program (CHIP), including the CHIP Perinatal subprogram. |
Expansion of STAR into two (2) new regions, the Hidalgo Service Area and Medicaid Rural Service Area (MRSA). |
Expansion of STAR+PLUS into the El Paso and Lubbock Service Areas, as well as the new Hidalgo Service Area. |
Adjustments to the Service Area boundaries for STAR, STAR+PLUS and CHIP Service Areas, so that the Service Areas are consistent for all Programs. |
The addition of prescription drug benefits to the managed care structure. The prescription drug benefit will no longer be carved-out of managed care and paid through HHSC’s Vendor Drug Program. Medicaid and CHIP MCOs will be responsible for recruiting and maintaining pharmacy providers and paying for pharmacy benefits. |
The addition of inpatient facility services to the managed care structure for STAR+PLUS. |
For Dual Eligible Members in the STAR+PLUS Program, the addition of Medicaid Wrap Services to the scope of Covered Services at a date determined by HHSC. |
1.4 Mission Statement |
1.5 Mission Objectives |
1. Network adequacy and access to care |
2. Quality |
3. Timeliness of claim payment |
4. Timeliness with which prenatal care is initiated |
5. Behavioral health services |
6. Delivery of health care to diverse populations |
7. Disease management requirements |
8. Service Coordination |
9. Continuity Of Care |
1.6 Overview of the HHSC MCO Programs |
1.6.1 STAR |
1.6.2 STAR+PLUS |
1.6.3 CHIP |
1.7 Other HHSC Managed Care Programs |
1.8 Eligible Populations for HHSC MCO Programs |
1.9 Authorization |
1.10 Eligible Respondents |
1.11 Term of Contract |
1.12 Development of Contracts |
1.13 Medicaid and CHIP Service Areas |
Service Areas | STAR | STAR+PLUS | CHIP MCO |
Bexar | √ | √ | √ |
Dallas | √ | √ | |
El Paso | √ | √ | √ |
Harris | √ | √ | √ |
Hidalgo | √ | √ | |
Jefferson | √ | √ | √ |
Lubbock | √ | √ | √ |
Medicaid RSA (Entire Service Area) | √ | ||
West Texas | √ | ||
Central Texas | √ | ||
Northeast Texas | √ | ||
Nueces | √ | √ | √ |
Tarrant | √ | √ | |
Travis | √ | √ | √ |
2. Procurement Strategy and Approach |
• the number of managed care Eligibles in the Service Area compared to the combined capacity of qualified MCO Respondents, and |
• statutory requirements, such as HHSC’s consideration of Proposals from an MCO owned or operated by a hospital district. |
2.1 HHSC Model Management Strategy |
2.2 Performance Measures and Associated Remedies |
3. General Instructions and Requirements |
3.1 Strategic Elements |
3.1.1 Contract Elements |
3.1.2 HHSC’s Basic Philosophy: Contracting for Results |
3.2 External Factors |
3.3 Legal and Regulatory Constraints |
3.3.1 Delegation of Authority |
3.3.2 Conflicts of Interest |
• make it difficult or impossible to fulfill its contractual obligations to HHSC in a manner that is consistent with the best interests of the State of Texas; |
• impair, diminish, or interfere with that party’s ability to render impartial or objective assistance or advice to HHSC; and/or |
• provide the party with an unfair competitive advantage in future HHSC procurements. |
3.3.3 Former Employees of a State Agency |
3.4 HHSC Amendments and Announcements Regarding this RFP |
3.5 RFP Cancellation/Partial Award/Non-Award |
3.6 Right to Reject Proposals or Portions of Proposals |
3.7 Costs Incurred |
3.8 Protest Procedures |
3.9 Vendor Conference |
3.10 Questions and Comments |
3.11 Modification or Withdrawal of Proposal |
3.12 News Releases |
3.13 Incomplete Proposals |
3.14 State Use of Proposal Information |
3.15 Property of HHSC |
3.16 Copyright Restriction |
3.17 Additional Information |
3.18 Multiple Responses |
3.19 No Joint Proposals |
3.20 Use of Subcontractors |
3.21 Texas Public Information Act |
3.22 Inducements |
3.23 Definition of Terms |
4. Submission Requirements |
4.1 General Instructions |
1. Business Specifications; and |
2. General Programmatic Proposal. |
4.1.1 Economy of Presentation |
4.1.2 Number of Copies and Packaging |
4.1.3 Due Date, Time, and Location |
4.2 Part 1 – Business Proposal |
4.2.1 Section 1 – Executive Summary |
Service Area | Proposal for STAR | Proposal for STAR+PLUS | Proposal for CHIP |
Bexar | |||
Dallas | |||
El Paso | |||
Harris | |||
Hidalgo | |||
Jefferson | |||
Lubbock | |||
Medicaid RSA (Entire Service Area) | |||
West Texas | |||
Central Texas | |||
Northeast Texas | |||
Nueces | |||
Tarrant | |||
Travis |
4.2.2 Section 2 – Respondent Identification and Information |
1. Respondent identification and basic information. |
a. The Respondent’s legal name, trade name, dba, acronym, and any other name under which the Respondent does business. |
b. The physical address, mailing address, and telephone number of the Respondent’s headquarters office. |
2. TDI Authority. A copy of the MCO’s licensure, certification, or approval to operate as an HMO, ANHC, or EPBP. If the Respondent has not received TDI approval, then submit a copy of the application filed with TDI. In accordance with RFP Section 7.2.9, the Respondent must receive TDI approval no later than 60 days after HHSC executes the Contract. |
3. Authorized Counties. Indicate whether the Respondent is currently authorized by TDI to operate as an MCO in each county in the Service Area with a “Yes-MCO,” “No MCO,” or “Partial MCO.” If the Respondent is not authorized to conduct business as an MCO in all or part of a county, it should list those areas in Column C. |
For each county listed in Column C, the Respondent must document that it applied to TDI for such approval prior to the submission of a Proposal for this RFP. The Respondent must indicate the date that it applied for such approval and the status of its application to get TDI approval in the relevant counties in this section of its submission to HHSC. |
Column A | Column B | Column C |
Service Area | TDI Authority/Status of Approval | Counties/Partial Counties without TDI Authority |
Bexar | ||
Dallas | ||
El Paso | ||
Harris | ||
Hidalgo | ||
Jefferson | ||
Lubbock | ||
Medicaid RSA (Entire Service Area) | ||
West Texas | ||
Central Texas | ||
Northeast Texas | ||
Nueces | ||
Tarrant | ||
Travis |
4. Texas Comptroller Certificate. 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 Respondent. |
5. Respondent Legal Status and Ownership. |
a. The type of ownership of the Respondent by its ultimate parent: |
• wholly-owned subsidiary of a publicly-traded corporation; |
• wholly-owned subsidiary of a private (closely-held) stock corporation; |
• subsidiary or component of a non-profit foundation; |
• subsidiary or component of a governmental entity such as a County Hospital District; |
• independently-owned member of an alliance or cooperative network; |
• joint venture (describe ultimate owners) |
• stand-alone privately-owned corporation (no parents or subsidiaries); or |
• other (describe). |
b. The legal status of the Respondent and its parent (any/all that may apply): |
(i.) Respondent is a corporation, partnership, sole proprietor, or other (describe); |
• Respondent is for-profit, or non-profit; |
• the Respondent’s ultimate parent is for-profit, or non-profit; |
• the Respondent’s ultimate parent is privately-owned, listed on a stock exchange, a component of government, or other (describe). |
c. The legal name of the Respondent’s ultimate parent (e.g., the name of a publicly-traded corporation, or a County Hospital District, etc.). |
d. The name and address of any other sponsoring corporation, or others (excluding the Respondent’s parent) who provide financial support to the Respondent, and the type of support, e.g., guarantees, letters of credit, etc. Indicate if there are maximum limits of the additional financial support. |
6. Hospital District/Non-Profit Corporation. Section 5 of the RFP requires Respondents who believe they qualify for mandatory STAR or STAR+PLUS contracts under Texas Government Code §533.004 to submit notice to HHSC no later than April 28, 2011, explaining the basis for this belief for each proposed Service Area. Please indicate whether the Respondent provided such notice to HHSC. |
7. The name and address of any health professional that has at least a five percent (5%) financial interest in the Respondent, and the type of financial interest. |
8. The full names and titles of the Respondent’s officers and directors. |
9. The state in which the Respondent is incorporated, and the state(s) in which the Respondent is licensed to do business as an MCO. The Respondent must also indicate the state where it is commercially domiciled, if outside Texas. |
10. The Respondent’s federal taxpayer identification number. |
11. If any change of ownership of the Respondent’s company or its parent is anticipated during the 12 months following the Proposal Due Date, the Respondent must describe the circumstances of such change and indicate when the change is likely to occur. |
12. Whether the Respondent or its parent (including other managed care subsidiaries of the parent) had a managed care contract terminated or not renewed for any reason within the past five (5) years. In such instance, the Respondent must describe the issues and the parties involved, and provide the address and telephone number of the principal terminating party. The Respondent must also describe any corrective action taken to prevent any future occurrence of the problem(s) that may have led to the termination or non-renewal. |
13. Whether the Respondent 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. |
14. The website address (URL) for the homepage(s) of any website(s) operated, owned, or controlled by the Respondent, including any that the Respondent may have contracted to be run by another entity. If the Respondent has a parent, then also provide the same for the parent, and any parent(s) of the parent. If none exist, provide a clear and definitive statement to that effect. |
4.2.3 Section 3 – Corporate Background and Experience |
a. client name and address; |
b. name, telephone, and e-mail address of the person HHSC could contact as a reference that can speak to the Respondent’s performance; |
c. contract size: average monthly covered lives and annual revenues; |
d. whether payments under the contract were capitated or non-capitated; |
e. contract start date and duration; |
f. whether work was performed as a prime contractor or subcontractor; and |
g. a general and brief description of the scope of services provided by the Respondent; including the covered population and services (e.g., Medicaid, CHIP, state-funded program). |
4.2.3.1 Organizational Chart |
1. an organizational chart (Chart A), showing the corporate structure and lines of responsibility and authority in the administration of the Respondent’s business as a health plan; |
2. an organizational chart (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. an organizational chart (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 Respondent is proposing to use one or more Material Subcontractors, the Respondent must include an organizational chart demonstrating how the Material Subcontractor(s) will be managed within the Respondent’s Texas organizational structure, including the primary individuals at the Respondent’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); and |
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 Respondent’s proposed management of the MCO Program(s), including its management of any proposed Material Subcontractors. |
4.2.3.2 Résumés |
1. a job description and qualifications; and |
2. the anticipated maximum caseload for each Service Coordinator (number of Members per Service Coordinator) and the assumptions the Respondent used in developing the maximum caseload estimate. |
4.2.3.3 Financial Capacity |
1. Audited Financial Statements covering the two (2) most recent years of the Respondent’s financial results. These statements must include the independent auditor’s report (audit opinion letter to the Board or shareholders), the notes to the financial statements, any written description(s) of legal issues or contingencies, and any management discussion or analysis. |
Make sure that the name and address of the firm that audits the Respondent is shown. State the date of the most-recent audit, and whether the Respondent is audited annually or otherwise. State definitively if there has, or has not, been any of the following: |
• a “going concern” statement was issued by any auditor in the last three (3) years; |
• a qualified opinion was issued by any auditor in the last three (3) years; |
• a change of audit firms in the last three (3) years; and |
• any significant delay (two (2) months or more) in completing the current audit. |
2. The most recent quarterly and annual financial statements filed with the TDI, and if the Respondent is domiciled in another state, the financial statements filed with the state insurance department in its state of domicile. The annual financial statement must include all schedules, attachments, supplements, management discussion, analysis and actuarial opinions. |
3. The most recent financial examination report issued by TDI, and also by any state insurance department in states where the Respondent operates a Medicaid, CHIP, or comparable managed care product. If any submitted financial examination report is two (2) or more years old, or if Respondent has never had a financial examination report issued, submit the anticipated approximate date of the next issuance of a TDI or state department of insurance financial examination report. |
4. The most recent Form B Registration Statement disclosure filed by Respondent with TDI, and any similar form filed with any state insurance department in other states where the Respondent operates a Medicaid, CHIP, or comparable managed care product. If Respondent is exempt from the TDI Form B filing requirement, demonstrate this and explain the nature of the exemption. |
a. SEC Form 10-K and 10-Q. If Respondent is a publicly-traded (stock-exchange-listed) corporation, then submit the most recent United States Securities and Exchange Commission (SEC) Form 10K Annual Report, and the most-recent 10-Q Quarterly report. |
b. IRS Form 990. If the Respondent is a non-profit entity, then submit the most recent annual Internal Revenue Service (IRS) Form 990 filing, complete with any and all attachments or schedules. If Respondent is a non-profit entity that is exempt from the IRS 990 filing requirement, demonstrate this and explain the nature of the exemption. |
d. Bond or debt rating analysis. If Respondent has been, in the last three (3) years, the subject of any bond rating analysis, ratings affirmation, write-up, or related report, such as by AM Best, Fitch Ratings, Moody’s, Standard & Poor, etc., submit the most-recent detailed report from each rating entity that has produced such a report. |
e. Annual Report. If Respondent produces any written “annual report” or similar item that is in addition to the above-referenced documents, submit the most recent version. This might be a yearly report or letter to shareholders, the community, regulators, lenders, customers, employees, the Respondent’s owner, or other constituents. |
f. If the Respondent has issued any press releases in the 12 months prior to the submission due date, wherein the press release mentions or discusses financial results, acquisitions, divestitures, new facilities, closures, layoffs, significant contract awards or losses, penalties/fines/sanctions, expansion, new or departing officers or directors, litigation, change of ownership, or other very similar issues, provide a copy of each such press release. HHSC does not wish to receive other types of press releases that are primarily promotional in nature. |
1. balance sheet; |
2. statement of income and expense; |
3. statement of cash flows; |
4. statement of changes in financial position (capitol & surplus; equity); |
5. independent auditor’s letter of opinion; |
6. description of organization and operation, including ownership, markets served, type of entity, number of locations and employees, and, dollar amount and type of any Respondent business outside of that with HHSC; and |
7. disclosure of any material contingencies, and any current, recent past, or known potential material litigation, regulatory proceedings, legal matters, or similar issues. |
4.2.3.4 Financial Report of Parent Organization and Corporate Guarantee |
4.2.3.5 Bonding |
4.2.4 Section 4 – Material Subcontractor Information |
1. The Material Subcontractor’s legal name, trade name, acronym, d.b.a., and any other name under which the Material Subcontractor does business. |
2. The Respondent’s estimated annual payments to the Material Subcontractor, by MCO Program. |
3. The physical address, mailing address, and telephone number of the Material Subcontractor’s headquarters office, and the name of its Chief Executive Officer. |
4. Whether the Material Subcontractor is an Affiliate of the Respondent or an unrelated third party (see the “Uniform Managed Care Contract Terms and Conditions” for the definition of “Affiliate.”) |
5. If the Material Subcontractor is an Affiliate, then provide: |
a. the name of the Material Subcontractor’s parent organization, and the Material Subcontractor’s relationship to the Respondent; |
b. the proportion, if any, of the Material Subcontractor’s total revenues that are received from non-Affiliates. If the Material Subcontractor has significant revenues from non-Affiliates, then also indicate the portion, if any, of those external (non-Affiliate) revenues that are for services similar to those that the Respondent would procure under the proposed Subcontract; |
c. a description of the proposed method of pricing under the Subcontract; |
d. indicate if the Respondent presently procures, or has ever procured, similar services from a non-Affiliate; |
e. the number of employees (staff and management) who are dedicated full-time to the Affiliate’s business; |
f. whether the Affiliate’s office facilities are completely separate from the Respondent and the Respondent’s parent. If not, identify the approximate number of square feet of office space that are dedicated solely to the Affiliate’s business; |
g. attach an organization chart for the Affiliate, showing head count, Key Personnel names, titles, and locations; and |
h. indicate if the staff and management of the Affiliate are directly employed by the Affiliate itself, or are they actually, from a technical legal perspective, employed by a different legal entity (such as a parent corporation). What corporation’s name shows up on the employee’s W2 form? |
6. A description of each Material Subcontractor’s corporate background and experience, including its estimated annual revenues from unaffiliated parties, number of employees, location(s), and identification of three (3) major clients. |
7. A signed letter of commitment from each Material Subcontractor that states the Material Subcontractor’s willingness to enter into a Subcontractor agreement with the Respondent, and a statement of work for activities to be subcontracted. Letters of Commitment must be provided on the Material Subcontractor’s official company letterhead, 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. |
8. The type of ownership [e.g., wholly-owned subsidiary of a publicly-traded corporation; wholly-owned subsidiary of a private (closely-held) stock corporation; subsidiary or component of a non-profit foundation; subsidiary or component of a governmental entity such as a County Hospital District; independently-owned member of an alliance or cooperative network; joint venture (describe owners); etc.] Indicate the name of the ultimate owner (e.g., the name of a publicly-traded corporation or a County Hospital District). |
9. Indicate status (any/all that may apply): sole proprietor, partnership, corporation, for-profit, non-profit, privately owned, and/or listed on a stock exchange. If a Subsidiary or Affiliate, name of the direct and ultimate parent organization. |
10. The name and address of any sponsoring corporation or others who provide financial support to the Material Subcontractor and the type of support, e.g., guarantees, letters of credit, etc. Indicate if there are maximum limits of the additional financial support. |
11. 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. |
12. The state in which the Material Subcontractor is incorporated, commercially domiciled, and the state(s) in which the organization is licensed to do business. |
13. The Material Subcontractor’s federal taxpayer identification number. |
14. Whether the Material Subcontractor had a managed care contract terminated or not renewed for any reason within the past five (5) years. In such instance, the Respondent must describe the issues, the parties involved, and provide the address and telephone number of the principal terminating party. The Respondent must also describe any corrective action taken to prevent any future occurrence of the problem that may have lead to the termination. |
15. 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. |
16. The website address (URL) for the homepage(s) of any website(s) operated, owned, or controlled by the Material Subcontractor, including any websites run by another entity on the Material Subcontractor’s behalf. If the Material Subcontractor has a parent, then also provide the same for the parent organization, and any parent(s) of the parent organization. If none exist, provide a clear and definitive statement to this effect. |
4.2.5 Section 5 – Historically Underutilized Business (HUB) Participation |
4.2.5.1 Introduction |
4.2.5.2 HHSC’s Administrative Rules |
4.2.5.3 HUB Participation Goal |
4.2.5.4 Required HUB Subcontracting Plan |
4.2.5.5 CPA Centralized Master Bidders List |
• 948-07: Administration Services, Health |
• 958-56: Health Care Management Services (Including Managed Care Services) |
• 915-49: High Volume, Telephone Call Answering Services (See 915-05 for Low Volume Services) |
4.2.5.6 HUB Subcontracting Procedures – If a Respondent Intends to Subcontract |
1. a description of the scope of work to be subcontracted; |
2. information regarding the location to review project plans or specifications; |
3. information about bonding and insurance requirements; |
4. required qualifications and other contract requirements; and |
5. a description of how the subcontractor can contact the Respondent. |
4.2.5.7 Alternatives to Good Faith Effort Requirements (Applies Only to Mentor Protégé and Professional Services Contracts) |
1. include a fully executed copy of the Mentor Protégé Agreement, which must be registered with the CPA prior to submission to HHSC; and |
2. identify areas of the HSP that will be performed by the protégé. |
4.2.5.8 HUB Subcontracting Procedures – If a Respondent Does Not Intend to Subcontract |
1. evidence of sufficient Respondent staffing to meet the RFP requirements; |
2. monthly payroll records showing the Respondent staff fully dedicated to the contract; and |
3. documentation proving employment of qualified personnel holding the necessary licenses and certificates required to perform the Scope of Work. |
4.2.5.9 Post-award HSP Requirements |
4.2.6 Section 6 – Certifications and Other Required Forms |
1. Child Support Certification; |
2. Debarment, Suspension, Ineligibility, and Voluntary Exclusion of Covered Contracts; |
3. Federal Lobbying Certification; |
4. Nondisclosure Statement; |
5. Required Certifications; and |
6. Respondent Information and Disclosures. |
4.3 Part 2 – Programmatic Proposal |
1. Section 1 – Proposed Programs, Service Area, and Capacity |
2. Section 2 – Experience Providing Covered Services |
3. Section 3 – Value-added Services |
4. Section 4 – Access to Care |
5. Section 5 – Provider Network Provisions |
6. Section 6 – Member Services |
7. Section 7 – Quality Assessment and Performance Improvement |
8. Section 8 – Utilization Management |
9. Section 9 – Early Childhood Intervention (ECI) |
10. Section 10 – Services for People with Special Health Care Needs |
11. Section 11 – Care Management/Service Coordination |
12. Section 12 – Disease Management (DM)/Health Home Services |
13. Section 13 – Behavioral Health Services and Network |
14. Section 14 – Management Information Systems Requirements |
15. Section 15 – Fraud and Abuse |
16. Section 16 – Pharmacy Services |
17. Section 17 – Transition Plan |
18. Section 18 – Additional Requirements Regarding Dual Eligibles |
4.3.1 Section 1 – Proposed Programs, Service Area, and Capacity |
1. complete the MCO Program Proposed Service Area and Capacity table found in the Procurement Library, which must include for each proposed Service Area indicated in Table 1 of the Respondent’s Executive Summary, an estimate of the number of HHSC MCO Members the Bidder has the capacity to serve in each MCO Program bid on the Operational Start Date; |
2. describe the calculations and assumptions used to arrive at these Service Area capacity projections. In developing these projections, the Respondent should consider the capacity of its Network, including its PCP Network, its Behavioral Health Services Network, its specialty care Network, its Pharmacy Network, and for STAR+PLUS, its home and community-based services Network. Respondents should specify: |
• the anticipated STAR, STAR+PLUS, or CHIP Program enrollment, as applicable; |
• the expected utilization of services, taking into consideration the characteristics and health care needs of specific populations represented in the particular HHSC MCO Program; |
• the numbers and types (in terms of training, experience, and specialization) of providers required to furnish the Covered Services; |
• the numbers of Network Providers and providers with signed contracts, LOAs, or LOIs who are not accepting new patients, by MCO Program; |
• the geographic location of providers and HHSC MCO members, considering travel time, the means of transportation ordinarily used by HHSC MCO members, and whether the location provides physical access for members with disabilities; and |
• generally describe anticipated Service Area capacity changes, if any, for each of the proposed Service Areas over the Initial Contract Period; and |
3. generally describe methods that the MCO will use to ensure access to all Covered Services upon potential population growth due to changes in law, including growth resulting from the Patient Protection and Affordable Care Act and Health Care and Education Reconciliation Act of 2010. |
4.3.2 Section 2 – Experience Providing Covered Services |
1. briefly describe the Respondent’s experience providing, on a capitated basis, Acute Care services, including Behavioral Health Services, equivalent or comparable to Covered Services included in the MCO Programs bid (STAR Covered Services are described in Attachment B-1, CHIP Covered Services are described in Attachment B-1.1, and STAR+PLUS Covered Services are described in Attachment B-1.2). The description should indicate: |
a. the extent to which the Respondent has experience providing such Acute Care services for a managed care population(s) comparable to the population in the MCO Programs bid; and |
b. the Respondent’s experience providing such Acute Care services in Texas, and in the Respondent’s proposed Service Areas, if applicable; |
2. indicate which STAR or CHIP Covered Service(s) (in whole or in part) the Respondent does not have experience providing on a capitated basis or does not have experience providing to a comparable Medicaid or CHIP population; |
3. for STAR+PLUS Respondents, briefly describe the Respondent’s experience providing managed Community-based Long-Term Services and Supports and Acute Care services equivalent or comparable to STAR+PLUS Covered Services described in Attachment B-1.2. The description should indicate: |
a. the extent to which the Respondent has experience providing Community-based Long-Term Services and Supports and Acute Care services for a managed care population(s) comparable to the population in STAR+PLUS; and |
b. the Respondent’s experience providing such Community-based Long-Term Services and Supports in Texas, and in the Respondent’s proposed Service Areas, if applicable; |
4. indicate which STAR+PLUS Covered Service(s) (in whole or in part) the Respondent does not have experience providing on a capitated basis or does not have experience providing to a comparable Medicaid population; |
5. briefly describe the Respondent’s proposal for providing Covered Services, including any plans for expansions of its Provider Network in any of the proposed Service Areas prior to a Readiness Review. If the Respondent proposes to use a Material Subcontractor to provide or manage Behavioral Health Services, Pharmacy Services, or any other Covered Service, the Respondent must describe its relationship with the Material Subcontractor, as required by Section 4.3; |
6. for STAR Respondents for the Medicaid Rural Service Area, describe the Respondent’s experience in providing Medicaid wrap-around services for Dual Eligibles entitled to these benefits. If the Respondent does not have experience in providing these services, indicate how the Respondent intends to meet this requirement; and |
7. for STAR+PLUS Respondents, describe the Respondent’s experience in providing Service Coordination for Dual Eligibles. Respondent should specifically describe the processes and procedures used to coordinate Medicare services with Medicaid Community-based Long-Term Services and Supports and related services. If the Respondent does not have experience coordinating these services, indicate how the Respondent intends to meet this requirement. |
4.3.3 Section 3 – Value-added Services |
1. define and describe the Value-added Service; |
2. specify the applicable Service Areas for the proposed Value-added Services; |
3. identify the category or group of Members eligible to receive the proposed Value-added Services if it is a type of service that is not appropriate for all Members; |
4. note any limitations or restrictions that apply to the Value-added Services; |
5. for each Service Area, identify the types of Providers responsible for providing the Value-added Service, including any limitations on Provider capacity if applicable. |
6. propose how and when Providers and Members will be notified about the availability of such Value-added Service; |
7. describe how a Member may obtain or access the Value-added Service; |
8. include a statement that the Respondent will provide any Value-added Service(s) that are approved by HHSC for at least 12 months after the Operational Start Date of the Contract; and |
9. describe if, and how, the Respondent will identify the Value-added Service in administrative data (Encounter Data). |
4.3.4 Section 4 – Access to Care |
4.3.4.1 Travel Distances |
1. adults with access to PCPs (STAR and STAR+PLUS only): |
a. Percentage and number of adult Members with access to one (1) Open-Panel, age-appropriate Network PCP within 30 miles, and the average number of miles within which adults have such access; |
b. Percentage and number of adult Members with access to two (2) Open-Panel, age-appropriate Network PCPs within 30 miles, and the average number of miles within which adults have such access; |
2. children with access to PCPs: |
a. Percentage and number of child Members with access to one (1) Open-Panel, age-appropriate Network PCP within 30 miles, and the average number of miles within which children have such access; |
b. Percentage and number of child Members with access to two (2) Open-Panel, age-appropriate Network PCPs within 30 miles, and the average number of miles within which children have such access; |
3. access to cardiologists (STAR and STAR+PLUS only): |
a. Percentage and number of adult Members with access to one (1) Network cardiologist within 75 miles, and the average number of miles within which adults have such access; |
b. Percentage and number of adult Members with access to two (2) Network cardiologists within 75 miles, and the average number of miles within which adults have such access; |
4. access to Acute Care Hospitals: |
a. Percentage and number of Members with access to a Network Acute Care Hospital within 30 miles; |
5. access to outpatient Behavioral Health Services Providers (does not apply to the STAR Dallas Service Area, where Behavioral Health services are provided through NorthSTAR): |
a. Percentage and number of Members with access to one (1) Network outpatient Behavioral Health Service Provider within 75 miles, and the average number of miles within which Members have such access; |
b. Percentage and number of Members with access to two (2) Network outpatient Behavioral Health Providers within 75 miles, and the average number of miles within which Members have such access; |
6. access to OB/GYNs (does not apply to CHIP Members or CHIP Perinatal Newborn Members – but does apply to CHIP Perinate Members (unborn children)): |
a. Percentage and number of female Members over age 19 with access to one (1) Network OB/GYN within 75 miles, and the average number of miles within which such female Members have such access (applies to Medicaid Members and CHIP Perinate Members in both urban and rural areas); |
b. Percentage and number of female Members over age 19 with access to two (2) Network OB/GYNs within 75 miles, and the average number of miles within which such female Members have such access(applies to Medicaid Members and CHIP Perinate Members in both urban and rural areas); |
c. Percentage and number of CHIP Perinate Members in rural areas with access to one (1) Network OB/GYN within 125 miles, and the average number of miles within which such Members have such access; |
d. Percentage and number of CHIP Perinate Members in rural areas with access to one (1) Network OB/GYN within 125 miles, and the average number of miles within which such Members have such access; |
7. access to otolaryngologists (STAR and CHIP only): |
a. Percentage and number of child Members with access to one (1) Network otolaryngologist (ENT) within 75 miles, and the average number of miles within which children have such access; and |
b. Percentage and number of child Members with access to two (2) Network otolaryngologists (ENTs) within 75 miles, and the average number of miles within which children have such access; and |
8. access to Pharmacies: |
a. Percentage and number Members with access to one (1) Network pharmacy within 15 miles, and the average number of miles within which Members have such access; |
b. Percentage and number Members with access to two (2) Network pharmacies within 15 miles, and the average number of miles within which Members have such access; |
c. Percentage and number Members with access to one (1) 24 hour Network pharmacy within 75 miles, and the average number of miles within which Members have such access; and |
d. Percentage and number Members with access to two (2) 24 hour Network pharmacies within 75 miles, and the average number of miles within which Members have such access. |
4.3.4.2 Assessing Access to Care |
1. Identify the process(es) by which the Respondent must measure and regularly verify: |
a. Network compliance, including pharmacy, regarding travel distance access in Section 8.1.3.2; |
b. Provider compliance regarding appointment access standards in Section 8.1.3.1, and |
c. PCP compliance with after-hours coverage standards in Section 8.1.4.2. |
2. Describe the steps the Respondent has taken in the past when it identified: |
a. a deficiency in its compliance with plan or state travel distance access standards; |
b. a Provider that was not meeting plan or state appointment access standards, and |
c. a PCP that was not in compliance with the plan or state after-hours coverage requirements. |
If the Respondent has not taken such steps listed in 2a, b, or c above with regularity, describe how it proposes to take such steps in the future. |
3. Describe the processes the Respondent implement to accommodate additional Members and to ensure the access standards are met if actual enrollment exceeds projected enrollment. |
4.3.5 Section 5 – Provider Network Provisions |
4.3.5.1 Provider Network |
1. For each Service Area in which the Respondent proposes to participate in the STAR, STAR+PLUS, and/or CHIP Program, the Respondent must submit a complete listing of proposed Network Providers for each of the following Acute Care provider types. Such listing must indicate for each provider type: the name, address, and NPI and/or TPI, if applicable, of the Providers with signed contracts, LOIs or LOAs. If the Respondent’s Provider Network is identical across more than one MCO Program within a Service Area, the Respondent may submit one Excel file worksheet for the Service Area that specifies the applicable MCO Programs. The Respondent must include in an Excel file at least the two (2) nearest Providers meeting each of the following provider type descriptions. The Respondent must also include in the Excel file all Providers in the designated provider type within the Service Area. The listing must include separate lists of each provider type in the order listed below and a separate worksheet for each proposed Service Area: |
a. Acute Care Hospitals, inpatient and outpatient services; |
b. Hospitals providing Level 1 trauma care; |
c. Hospitals providing Level 2 trauma care; |
d. Hospitals designated as transplant centers; |
e. Hospitals designated as Children’s Hospitals by the CMS; |
f. other Hospitals with specialized pediatric services; |
g. Psychiatric Hospitals providing mental health services, inpatient and outpatient; |
h. Other facilities or clinics that provide outpatient mental health services; |
i. Hospitals providing substance abuse services, inpatient and outpatient; and |
j. other facilities or clinics providing outpatient substance abuse services. |
2. For STAR+PLUS only, identify a list of Community-based Long-Term Services and Supports Providers with whom the Respondent has a signed contract, LOI or LOA. These Providers should be listed by type, name, and address. Respondent should also list the array of Community-based Long-Term Services and Supports each of these entities provides. |
a. Personal Assistance Services (PAS); |
b. Day Activity and Health Services (DAHS); |
c. adaptive aids and medical supplies; |
d. adult foster care; |
e. assisted living and residential care services; |
f. emergency response services; |
g. home delivered meals; |
h. in-home skilled nursing care; |
i. dental services; |
j. minor home modifications; |
k. respite care; |
l. therapy – occupational; |
m. therapy – physical; |
n. therapy – speech, hearing, and/or language pathology services; |
o. consumer directed services; and |
p. transition assistance services. |
3. Identify the types of Providers the Respondent allows to be PCPs for adults, PCPs for children, OB/GYNs, and outpatient Behavioral Health Service Providers. The Respondent should identify its contract requirements for these provider types and any exceptions. For example, Respondent should note under what circumstances, if any, an internist is allowed to be a PCP for children, or a family practitioner is allowed to be an OB/GYN. |
4.3.5.2 Significant Traditional Providers |
4.3.5.3 Provider Network Capacity |
1. indicate which, if any, Covered Services are not available from a qualified Provider in the Respondent’s proposed Network in the Service Area and how the Respondent proposes to provide such Covered Services to Members in the Service Area; and |
2. briefly describe how deficiencies will be addressed when the Provider Network is unable to provide a Member with appropriate access to Covered Services due to lack of a qualified Network Provider within the travel distance of the Member’s residence specified in Section 8.1.3.2. The description should include, but not be limited to, how the Respondent will address deficiencies in the Network related to: |
a. the lack of an age-appropriate Network PCP with an Open-Panel within the required travel distance of the Member’s residence; |
b. for female Members, the lack of an Network OB/GYN with an open practice within the travel distance of the Member’s residence; |
c. the lack of a Network cardiologist within the travel distance of the Member’s residence (STAR and STAR+PLUS only); and |
d. the lack of a Network pharmacy within the travel distance of the Member’s residence. |
4.3.5.4 Credentialing and Re-credentialing |
1. Describe the Respondent’s minimum credentialing and/or licensure requirements and procedures for Acute Care Providers by type of Provider, and demonstrate how the Respondent ensures, or proposes to ensure, that the minimum credentialing requirements are met. Such description must demonstrate compliance with Section 8.1.4.4. |
2. Describe the re-credentialing process or process between re-credentialing cycles for Acute Care Providers and how the Respondent will capture and assess the following information: |
a. Member Complaints and Appeals; |
b. results from quality reviews and Provider quality profiling; |
c. utilization management information; and |
d. information from licensing and accreditation agencies. |
3. For STAR+PLUS only, describe the Respondent’s minimum credentialing and/or licensure requirements and procedures for Providers of Community-based Long-Term Services and Supports by type of Provider, and how Respondent will ensure that the minimum credentialing and licensing requirements are met by any Provider rendering Covered Services. |
4. For STAR+PLUS only, describe the re-credentialing process for Providers of Community-based Long-Term Services and Supports. The description of the re-credentialing process should include how the Respondent will capture and assesses the following information: |
a. Member Complaints and Appeals; |
b. results from quality reviews and quality Provider profiling; |
c. utilization management information; and |
d. information from licensing and accreditation agencies. |
5. A Respondent currently operating in Texas must separately report the following information for its Texas Network. A Respondent not currently operating in Texas must separately report the same information for a managed care program it operates in another state that is similar to the MCO Program bid: |
a. the percentage of providers in its Network re-credentialed in the past three (3) years, for the following provider types: primary care physician, specialty care provider, and masters-level outpatient Behavioral Health Service providers; and |
b. the number and percentage of providers in its Network who were subjected to the regularly scheduled re-credentialing process over the past 24 months that were denied continued Network status. |
4.3.5.5 Provider Hotline |
1. normal hours of operation of the hotline; |
2. staffing for the hotline; |
3. training for the hotline staff on Covered Services and HHSC MCO Program requirements; |
4. the routing of calls among hotline staff to ensure timely and appropriate response to provider inquiries; |
5. responsibilities of hotline staff, if any, in addition to responding to HHSC Provider Hotline calls (e.g., responding to non-Network provider calls and/or HHSC Member Hotline calls); |
6. after-hours procedures and available services; |
7. provider hotline telephone reports for the most recent four (4) quarters with data that show the monthly call volume, the monthly trends for average speed of answer (where answer is defined by reaching a live voice, not an automated call system) and the monthly trends for the abandonment rate; and |
8. Whether the Provider Hotline has the capability to administer automated surveys to callers at the end of calls. |
4.3.5.6 Provider Training |
1. Provide a brief description of the proposed Provider training programs for each MCO Program bid. For STAR+PLUS only, distinguish between training programs for Acute Care Providers and Community-based Long-Term Services and Supports Providers. The description should include: |
a. the types of programs to be offered, including the modality of training; |
b. what topics will be covered; |
c. which Providers will be invited to attend; |
d. how the Respondent proposes to maximize Provider participation; |
e. how Provider training programs will be evaluated; |
f. the frequency of Provider training; and |
g. for STAR+PLUS Long Term Services and Supports providers in El Paso, Lubbock, and Hidalgo, who have never submitted traditional claim forms, a brief summary of additional methods to assist these providers. |
2. Briefly describe two (2) examples of recent Provider training programs relevant to each of the MCO Programs bid. These examples must include: |
a. a description of the training program; |
b. a summary of distributed materials (the actual materials are not to be submitted); |
c. number and type of attendees; and |
d. results of any evaluations from the training. |
4.3.6 Section 6 – Member Services |
4.3.6.1 Member Services Staffing |
1. Provide an organizational chart of the Member Services Department, showing the placement of Member Services within the Respondent’s organization and showing the key staff within the Member Services Department. |
2. Explain the functions of the Member Services staff, including brief job descriptions and qualifications. |
3. Describe the curriculum for training to be provided to Member Services representatives, including when the training is conducted and how the training addresses: |
a. Covered Services, including Behavioral Health Services and Community-based Long Term Services and Supports; |
b. MCO Program requirements; |
c. Cultural Competency; and |
d. providing assistance to Members with limited English proficiency. |
4. Identify the turnover rate for Member Services staff in the past two (2) years. A Respondent operating any HHSC MCO Program must provide the staff turnover rate for each of its MCO Programs. A Respondent not currently operating an HHSC MCO rogram must provide its Member Services staff turnover rate for a comparable managed care program and identify the managed care program. |
5. For STAR+PLUS only, identify the number and professional background of Member Services staff that the Respondent intends to dedicate to the Service Coordination function. |
6. Identify the percentage of Member Services staff who will be physically located in the Service Area. |
4.3.6.2 Member Hotline |
1. normal hours of operation; |
2. number of Member Hotline staff, expressed in the number of full time employees (FTEs) per 1000 Members who are available 8:00 a.m. to 5:00 p.m., local time in the Service Area, Monday through Friday, excluding state-approved holidays; |
3. routing of calls among Member Hotline staff to ensure timely and accurate response to Member inquiries; |
4. responsibilities of Member Hotline staff, if any, in addition to responding to HHSC Member Hotline calls, (e.g., responding to non-HHSC Member calls and/or HHSC Provider Hotline or Behavioral Health Hotline calls); |
5. after-hours procedures and available services, including those provided to non-English speaking Members in Major Population Groups; |
6. the number and percentage of FTE Member Hotline staff who are bilingual in English and Spanish; |
7. the number and percentage of FTE Member Hotline staff who are multi-lingual for any additional language, by language spoken; |
8. for STAR+PLUS only, the number and percentage of FTE Member Hotline staff dedicated to the Service Coordination function; |
9. Member Hotline telephone reports for the most recent four (4) quarters with data that show the monthly trends for call volume, monthly trends for average speed of answer (where answer is defined by reaching a live voice, not an automated call system) and monthly trends for the abandonment rate; and |
10. Whether the Member Hotline has the capability to administer automated surveys to callers at the end of calls. |
4.3.6.3 Member Service Scenarios |
1. a Member has received a bill for payment of Covered Services from a Network Provider or Out-of-Network Provider; |
2. a Member is unable to reach her PCP after normal business hours; |
3. a Member is having difficulty scheduling an appointment for preventive care with her PCP, |
4. for STAR+PLUS only, a Member is having difficulty scheduling an appointment for preventive care with her Medicare PCP; |
5. for STAR+PLUS only, a Member is in urgent need of meals, adaptive aids, or other Community-Based Long- Term Services and Supports and is unable to reach their Service Coordinator or provider, |
6. a Member becomes ill while traveling outside of the Service Area, and |
7. a Member has a request for a specific medication that the pharmacy is unable to provide. |
4.3.6.4 Cultural Competency |
1. Describe how the Respondent will ensure culturally competent services to people of all cultures, races, ethnic backgrounds, and religions as well as those with disabilities in a manner that recognizes values, affirms, and respects the worth of the individuals and protects and preserves the dignity of each. |
2. Describe how the Respondent will develop intervention strategies and work with Network Providers to avoid disparities in the delivery of medical services to diverse populations. |
4.3.6.5 Member Complaint and Appeal Processes |
1. describe the process the Respondent will put in place for the review of Member Complaints and Appeals, including which staff will be involved; |
2. provide a flowchart that depicts the process the Respondent will employ, from the receipt of a request through each phase of the review to notification of disposition, including providing notice of access to HHSC Fair Hearings; |
3. document the MCO’s average time for resolution over the past 12 months for Member Complaints and Appeals (excluding Expedited Appeals), from date of receipt to date of notification of disposition; and |
4. for STAR and STAR+PLUS only, describe the number and job descriptions of Member Advocates, how Members are informed of the availability of Member Advocates, and how Members access Advocates. |
4.3.6.6 Marketing Activities and Prohibited Practices |
1. describe the basis for each sanction or corrective action, and |
2. explain how the Respondent would ensure that it would not commit any practices prohibited by the CMS or HHSC in its Marketing activities. |
4.3.6.7 Continuity of Care (for STAR and STAR+PLUS only) |
4.3.6.8 Objection to Providing Certain Services |
4.3.6.9 Coordination of Services for Dual Eligibles |
4.3.7 Section 7 – Quality Assessment and Performance Improvement |
4.3.7.1 Clinical Initiatives |
1. For each MCO Program bid, describe data-driven clinical initiatives that the Respondent initiated within the past 24 months that have yielded improvement in clinical care for a managed care population comparable to the population bid and document two (2) statistically significant improvements generated by the Respondent’s clinical initiatives. |
2. For STAR+PLUS only, propose two (2) clinical initiatives focused on Community-based Long-Term Services and Supports for STAR+PLUS Members, including how Members will be involved in such initiatives and the Respondent’s experience implementing similar clinical initiatives. |
3. For each MCO Program bid, describe two (2) new or ongoing Acute Care clinical initiatives that the Respondent proposes to pursue in the first year of the Contract. Document why each topic warrants quality improvement investment, and describe the Respondent’s measurable goals for the initiative. |
4. For STAR+PLUS only, describe the planned approach the Respondent will take towards quality assessment and ongoing review of providers with whom it intends to contract, using the following provider types as an example: |
5. For Respondents that already participate in an HHSC MCO Program, provide a copy of the most recent QAPI Plan. For Respondents that do not participate in an HHSC MCO Program, provide a copy of a 2009 quality assurance plan for a comparable managed care population. |
6. Many Texas Medicaid and CHIP children reportedly receive their immunizations through Local Health Departments. Discuss the impact this has on creating a Medical Home for child Members, and what steps, if any, the Respondent proposes to take to improve child preventive services delivery. |
4.3.7.2 Healthcare Effectiveness Data and Information Set (HEDIS) and Other Quality Data |
4.3.7.3 Clinical Practice Guidelines |
1. For each MCO Program bid, describe two (2) clinical guidelines that are relevant to the enrolled populations and that the Respondent believes are currently not being adhered to at a satisfactory level. |
2. Describe what steps the Respondent will take to increase compliance with the clinical guidelines noted in its response to question number 1 above. |
3. Provide a general description of the Respondent’s process for developing and updating clinical guidelines, and for disseminating them to participating Providers. |
4.3.7.4 Provider Profiling |
1. Describe the Respondent’s practice of profiling the quality of care delivered by Network PCPs, and any other Acute Care Providers (e.g., high volume specialists, Hospitals), including the methodology for determining which and how many Providers will be profiled. |
2. For STAR+PLUS, describe the Respondent’s method to ensure the quality of care delivered by Long-Term Services and Supports Providers. |
3. Submit sample quality profile reports used by the Respondent, or proposed for future use (identify which). |
4. Describe the rationale for selecting the performance measures presented in the sample profile reports. |
5. Describe the proposed frequency with which the Respondent will distribute such reports to Network Providers, and identify which Providers will receive such profile reports. |
4.3.7.5 Network Management |
1. the steps the Respondent will take with each profiled Provider following the production of each profile report, including a description of how the Respondent will motivate and facilitate improvement in the performance of each profiled Provider; |
2. the process and timeline the Respondent proposes for periodically assessing Provider progress on its implementation of strategies to attain improvement goals; |
3. how the Respondent will reward Providers who demonstrate continued excellence and/or significant performance improvement over time, through non-financial or financial means, including pay-for-performance; |
4. how the Respondent will share “best practice” methods or programs with Providers of similar programs in its Network; |
5. how the Respondent will take action with Providers who demonstrate continued unacceptable performance and performance that does not improve over time; |
6. the steps the Respondent will take with a Provider that specifically is not meeting HHSC contractual access standards; and |
7. the extent to which the Respondent currently operates a Network management program consistent with HHSC requirements in Section 8.1.7.8, and measurable results it has achieved from such Network management efforts. |
4.3.8 Section 8 – Utilization Management |
4.3.9 Section 9 – Early Childhood Intervention (ECI) |
1. Describe the Respondent’s experience with, and general approach to, providing ECI services, including how the Respondent will identify such individuals. |
2. Describe procedures and protocols for using the IFSP information to develop a Member Care Plan and authorize services. |
3. Describe procedures and protocols for developing and including the interdisciplinary team in the assessment and care planning process. |
4. Describe the process by which the Respondent will provide the IFSP and other necessary information to the PCP. |
4.3.10 Section 10 – Services for People with Special Health Care Needs |
1. Describe the Respondent’s experience with, and general approach to, providing services for adults with Special Health Care Needs (STAR and STAR+PLUS only), including how the Respondent will identify such individuals and the criteria it will use in assessing whether an adult is a Member with Special Health Care Needs (MSHCN). |
2. Describe the Respondent’s experience with, and general approach to, providing services for children with special health care needs, including how the Respondent will identify such individuals and the criteria it will use in assessing whether a Member has special health care needs. |
3. Describe the process for initially and periodically assessing Members’ needs for services, and identify the staff performing the assessments and their credentials. |
4. Describe procedures and protocols for using the assessment information to develop a Member Care Plan and authorize services. |
5. Describe procedures and protocols for including the Member and/or Member’s Representative in the assessment and care planning process. |
6. Describe the process by which the Respondent will allow MSHCN to have: |
a. direct access to a specialist as appropriate for the Member’s condition and identified needs, such as a standing referral to a specialty physician; and |
b. access to non-primary care physician specialists as PCPs, as required by 28 T.A.C. § 11.900 and Section 8.1.3. |
4.3.11 Section 11 – Care Management and/or Service Coordination |
1. Describe the Respondent’s experience providing Care Management and/or Service Coordination to members with high-cost catastrophic situations (e.g., recent spinal cord injury) and the Respondent’s proposal for implementing high-cost catastrophic Care Management and/or Service Coordination, including how the Respondent will identify Members for high cost catastrophic Care Management and/or Service Coordination, and the criteria used to identify such Members. |
2. Describe the Respondent’s experience providing Care Management and/or Service Coordination services to Members with the following serious health care conditions, as applicable to the MCO Programs bid, and the Respondent’s proposal for offering Care Management and/or Service Coordination services to these Members. Include how Members will be identified for Care Management and/or Service Coordination, and the criteria used to identify such Members: |
a. women with high-risk pregnancies (STAR only); and |
b. individuals with mental illness and co-occurring substance abuse. |
3. Identify any measurable results in terms of clinical outcomes and program savings that have resulted from the Respondent’s Care Management and/or Service Coordination initiatives. |
4. For STAR+PLUS only, describe the duties and responsibilities of the Service Coordinator to authorize Community-based Long-Term Services and Supports. The Respondent must describe in detail how the Service Coordinator will function in relation to the Member’s PCP for: |
a. Dual Eligible STAR+PLUS Members receiving both Medicaid and Medicare services from the MCO, and |
b. Dual Eligible STAR+PLUS Members receiving Medicare services through either fee-for-service Medicare or another Medicare MCO. |
5. For STAR+PLUS only, submit detailed information, including protocols and procedures, for identifying Members requiring Service Coordination, and for providing the Service Coordination function to them. The information should include how the protocols and procedures vary for: |
a. Dual Eligible STAR+PLUS Members receiving both Medicaid and Medicare services from the MCO, and for |
b. Dual Eligible STAR+PLUS Members receiving Medicare services through either fee-for-service Medicare or another Medicare MCO. |
6. For STAR+PLUS only, describe the circumstances or conditions when the Member would require a licensed nurse or other allied health care provider as a Service Coordinator. |
7. For STAR+PLUS only, submit criteria for identifying and training certain Members and their Member Representative(s) to coordinate and direct the Member’s own care, to the extent the Member is capable of doing so. Criteria should include those used to enable the Member and family to select, train, and supervise providers of Community-based Long-Term Services and Supports. |
8. For STAR+PLUS only, describe the criteria and processes for advising Members of, and assisting them to access, the most appropriate, least restrictive home and community-based services as alternatives to institutional care. Additionally, describe how the Respondent will ensure that the Member is given the opportunity to make an informed choice among the options for care settings. |
9. For STAR+PLUS only, submit a list of the relevant community organizations in each proposed STAR+PLUS Service Area with which the Respondent will coordinate services for Members and to which it will refer Members for services. |
10. For STAR+PLUS only, describe the process for initially and periodically assessing Members’ needs for services. |
11. For STAR+PLUS only, describe how the Respondent will identify Members who are at risk of nursing facility placement. |
12. For STAR+PLUS only, submit all functional assessment instruments proposed for use and describe how the assessment instrument(s) will be employed to identify the Member’s need for Community-based Long-Term Services and Supports. (Note: If the MCO is allowed to modify a functional assessment instrument required by the State, HHSC must approve the proposed instrument prior to implementation. See Section 8.3.3 for more information.) |
13. For STAR+PLUS only, identify who will perform each assessment and specify their credentials. |
14. Describe procedures and protocols for using the assessment information to develop a Member Service/Care Plan and authorize services. |
15. Describe procedures and protocols for including the Member and/or Member’s Representative in the assessment and care planning process. |
16. For STAR+PLUS only, provide a description of the appropriate staffing ratio of Service Coordinators to Members, and the Respondent’s target ratio of Service Coordinators to Members. |
4.3.12 Section 12 – Disease Management (DM)/Health Home Services |
1. Describe the Respondent’s experience in implementing Disease Management/Health Home Services programs for populations comparable to the proposed HHSC MCO Program. |
2. Identify any measurable results in terms of clinical outcomes and program savings that have resulted from the Respondent’s Disease Management/Health Home Services initiatives, and briefly describe the analyses used to identify such outcomes and savings. |
3. Identify the process by which the Respondent proposes to provide Members with Disease Management/Health Home Services. Describe how the Respondent will identify Members in need of such Disease Management/Health Home Services program, the proposed outreach approach, and the Disease Management/Health Home Services program components for Members of different risk levels. |
4. Describe the process by which the Respondent will ensure continuity of care with the Member’s previous Disease Management/Health Home Services program(s), if any. |
4.3.13 Section 13 – Behavioral Health Services and Network |
4.3.13.1 Behavioral Health Services Hotline |
1. verification that it is, or will be, staffed 24 hours per day, 365 days per year; |
2. staffing of Behavioral Health Services Hotline staff, including clinical credentials; |
3. routing of calls among Behavioral Health Services Hotline staff to ensure timely and accurate response to Member inquiries; |
4. the curriculum for training to be provided to Behavioral Health Services Hotline representatives, including when the training will be conducted and how the training will address a) Covered Services; b) HHSC MCO Program requirements; c) Cultural Competency; and d) providing assistance to Members with limited English proficiency. |
5. responsibilities of Behavioral Health Services Hotline staff, if any, in addition to responding to HHSC Member Hotline calls, (e.g., responding to non-HHSC member calls and/or HHSC Provider Hotline or Member Hotline calls ); |
6. the number and percentage of FTE Behavioral Health Services Hotline staff who are bilingual in English and Spanish; |
7. the number and percentage of FTE Behavioral Health Services Hotline staff who are multi-lingual for any additional language, by language spoken; |
8. Behavioral Health Services telephone reports for the most recent four (4) quarters with data that show the monthly trends for call volume, monthly trends for average speed of answer (where answer is defined by reaching a live voice, not an automated call system), and monthly trends for the abandonment rate; and |
9. whether the Behavioral Health Services Hotline has the capability to administer automated surveys to callers at the end of calls. |
4.3.13.2 Behavioral Health Provider Network Expertise |
1. For each proposed Service Area, identify Behavioral Health Service Providers with expertise in providing services to each of the following populations, as applicable to the Respondent’s Proposal. |
a. substance abusers; |
b. children and adolescents; |
c. persons with a dual diagnosis of mental health and substance abuse; and |
d. services for linguistic and cultural minorities. |
2. Indicate the criteria the Respondent will use to determine that such Behavioral Health Providers have the requisite expertise. |
4.3.13.3 Coordination of Behavioral Health Care |
1. Describe the Respondent’s approach to coordinating Behavioral Health Service delivery with primary care services delivered by a Member’s PCP, and vice versa. |
2. Describe or propose innovative programs and identify Network Providers contracted to serve special populations through integrated medical/Behavioral Health Service delivery models. Describe the program model services, treatment approach, special considerations, and expected outcomes for the special populations. |
3. Describe the process by which the Respondent will ensure the delivery of outpatient Behavioral Health Services within seven (7) days of inpatient discharge for Behavioral Health Services. |
4.3.13.4 Behavioral Health Quality Management |
1. Identify the areas Respondent believes to be the greatest opportunities for clinical quality improvement in behavioral health in each MCO Program bid and provide supporting information. |
2. Discuss the approaches the Respondent will pursue to realize one such opportunity for each MCO Program bid. |
3. Describe how the Respondent proposes to integrate behavioral health into its quality assurance program, as described in Section 8.1.7.5. |
4.3.13.5 Behavioral Health Emergency Services |
4.3.14 Section 14 – Management Information System (MIS) Requirements |
1. describe the Management Information System (MIS) the Respondent will implement, including how the MIS will comply with Health Insurance Portability and Accountability Act of 1996 (HIPAA). The response must address the requirements of Section 8.1.18. At a minimum, the description should address: |
a. hardware and system architecture specifications; |
b. data and process flows for all key business processes in Section 8.1.18.3; and |
c. attest to the availability of the data elements required to produce required management reports; |
2. if claims processing and payment functions are outsourced, provide the above information for the Material Subcontractor; |
3. describe how the Respondent would ensure accuracy, timeliness, and completeness of Encounter Data submissions for each of the MCO Programs bid; |
4. describe the Respondent’s ability and experience in performing coordination of benefits and Third Party Liability/Third Party Recovery (TPL/TPR); |
5. describe the Respondent’s ability and experience in allowing providers to submit claims electronically and its ability and experience in processing electronic claims payments to providers: |
a. if currently processing claims electronically, generally describe the type and volume of provider claims received electronically in the previous year versus paper claims for each claim type; |
b. if currently making claims payments to providers electronically, generally describe the type and volume of provider claims payment processed electronically; |
c. does the MCO provide a no-cost alternative for providers to allow billing without the use of a clearinghouse? If so please describe; and |
d. does the MCO include attendant care payments as part of the regular claims payment process (for STAR+PLUS only)? If so please describe; |
6. describe the Respondent’s experience and capability to comply with the Internet website requirements of Section 8.1.5.5, and briefly describe any additional website capabilities that the Respondent proposes to offer to Members or Providers; |
7. provide acknowledgment and verification that the Respondent’s proposed systems are 5010 compliant by submitting a copy of the 5010 compliancy plan, and proposed timeline for meeting the deadlines for being 5010 compliant; and |
8. describe the Respondent’s capability to pay providers via direct deposit and its experience in doing so, including the percentage, number, and types of providers paid via direct deposit in the most recent 12 month period for which the Respondent has such statistics. If the Respondent operates in Texas, the Respondent must provide this information related to its experience in Texas. If the Respondent does not currently operate in Texas, the Respondent must provide this information for a state in which the Respondent currently operates a managed care program similar to the MCO Programs bid. |
4.3.15 Section 15 – Fraud and Abuse |
4.3.16 Section 16 – Pharmacy Services |
1. The Respondent must describe the processes it will use to manage the pharmacy benefit under both of the following scenarios: |
a. HHSC requires the MCO to implement the Medicaid and CHIP formularies and preferred drug lists (PDLs); and |
b. the MCO is allowed to establish its own formularies and PDLs. |
2. The Respondent must describe the policies and procedures for how mail-order pharmacies will be available to Members. |
3. The Respondent must identify the rationale for requiring prior authorizations, identify the types of drugs that normally require prior authorization, and describe the policies and procedures for the prior authorization process. |
4. The Respondent must describe how rebates will be negotiated (if HHSC determines that the MCO will perform this service), identified, and reported. |
5. The Respondent must describe the policies and procedures for drug utilization reviews, including ensuring prospective reviews take place at the dispensing pharmacy’s point of sale (POS). |
6. The Respondent must describe its policies and procedures for targeted interventions for Network Providers over-utilizing certain drugs. |
4.3.17 Section 17 – Transition Plan |
1. Briefly describe the Respondent’s experience establishing and maintaining electronic interfaces with other contractors responsible for portions of Medicaid and CHIP operations. A Respondent with experience participating in one or more MCO Programs must clearly note its experience in establishing and maintaining such interfaces in Texas. A Respondent without experience establishing and maintaining electronic interfaces with other contractors responsible for Medicaid or CHIP operations must note its experience in establishing and maintaining similar electronic interfaces with similar contractors. |
2. A Respondent that is proposing to participate in an HHSC MCO Program in a Service Area for the first time must, for each MCO Program bid, briefly describe its Transition Plan for all proposed Service Areas, including major activities related to the System Readiness Review and the Operational Readiness Review, including Network development, internal system testing, and proposed schedule to comply with the anticipated Operational Start Date and other requirements described in Section 7. The Respondent must clearly indicate in which Service Area(s) it currently does not operate as an MCO and any differences in its transition approach by Service Area. |
3. A Respondent that is currently a contractor for an HHSC MCO Program must, for each such MCO Program, briefly describe its Transition Plan, including major activities related to the System Readiness Review and the Operational Readiness Review, such as Network Development, internal system testing, and schedule to comply with the anticipated Operational Start Date and other requirements described in Section 7. The Respondent must clearly indicate in which Service Area(s) it currently does not operate as an MCO, and any differences in its transition approach by Service Area. |
4.3.18 Section 18 – Additional Requirements Regarding Dual Eligibles (for STAR+PLUS only) |
1. Submit evidence of Respondent’s MA Dual SNP contract with CMS if any, including the contract number and counties/zip codes served, or submit documentation showing that an application for such a contract has or will be submitted to CMS. For Respondents that do not already have an MA Dual SNP contract and who intend to obtain one, describe the plans for submitting an application and obtaining such a contract. The description should include the timeline for submitting the application and the proposed counties/zip codes for coverage. |
2. Describe the Respondent’s experience in providing Medicare encounter data in HIPAA-compliant formats to federal or state authorities. |
3. Describe how the Respondent intends to coordinate care for Dual Eligible Members, including: |
a. How the Respondent will identify Long-Term Services and Supports providers in the relevant Service Areas. |
b. The processes and procedures Respondent will use to coordinate the delivery of Community-based Long-Term Services and Supports with Medicare benefits for Dual Eligible Members. |
c. The training Respondent will provide to staff and providers regarding Community-based Long-Term Services and Supports and the coordination of those services with Medicare benefits. |
4. Describe how the Respondent will work with the State to share information regarding Medicare and Medicaid participating providers, Member complaints, and HEDIS data. |
5. Evaluation Process and Criteria |
5.1 Overview of Evaluation Process |
5.2 Evaluation Criteria |
• The extent to which the Respondent’s proposal demonstrates an ability to accomplish the missions and objectives for this procurement, including: |
• the extent to which the proposal meets HHSC’s needs, and the MCO Program clients’ needs for high quality and accessible medical care; |
• The degree to which the proposal demonstrates program innovation, adaptability, and exceptional customer service; and |
• the extent to which the Respondent accepts without reservation or exception the RFP’s terms and conditions, including Attachment A, “Uniform Managed Care Contract Terms and Conditions.” |
• Indicators of probable performance under the Contract, including past performance in Texas or comparable experience; financial resources and solvency, including the impact on the Respondent’s and its Subcontractors’ ability to perform, and relevant organizational experience. |
• Effect of the acquisition on agency productivity; including the level of effort and resources required to monitor the Respondent’s performance and maintain a good working relationship with the Respondent. |
1. proposals from Texas institutions providing graduate medical education; |
2. proposals that include substantial participation by Network providers who are Significant Traditional Providers (STP). HHSC defines “substantial participation” as proposals that include at least 50 percent of the STPs in a Service Area. The Respondent must either have a Network Provider agreement in place with the STP, or a Letter of Intent/Letter of Agreement to participate in the Network. A listing of STPs for the new Service Areas can be found in the Procurement Library; and |
3. proposals that ensure continuity of coverage for Medicaid Members for at least three (3) months beyond the period of Medicaid eligibility. For purposes of this provision, HHSC defines “continuity of coverage” as providing the full set of Covered Services. |
5.3 Initial Compliance Screening |
5.4 Competitive Field Determinations |
5.5 Oral Presentations and Site Visits |
5.6 Best and Final Offer |
5.7 Discussions with Respondents |
• obtaining clarification of proposal ambiguities; |
• requesting modifications to a proposal; and/or |
• obtaining a best and final offer of services. |
5.8 Contract Awards |
DOCUMENT HISTORY LOG | ||||||
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 | |||
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-1, RFP Section 6, “Incentives & Disincentives.” | |||
Revision | 2.1 | March 1, 2012 | Contract amendment did not revise Attachment B-1, RFP Section 6, "Incentives & Disincentives." | |||
Revision | 2.2 | June 1, 2012 | Section 6.3.2.1 is modified to change "Rate Period 1" to "FSR Reporting Period 12/13." Section 6.3.2.2 is modified to change "Rate Period" to "FSR Reporting Period." | |||
Revision | 2.3 | September 1, 2012 | Section 6.3.2.5 is modified to remove auto-assignment default methodology. | |||
Revision | 2.4 | March 1, 2013 | All references to the previous Executive Commissioner Suehs are changed to his successor, Executive Commissioner Janek. | |||
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-1, RFP Section 6, "Incentives & Disincentives." | |||
Revision | 2.6 | September 1, 2013 | Section 6.2.1 is modified to remove the reference to Bariatric Supplemental Payments. Section 6.3.1.2 is modified to provide HHSC more flexibility to implement reward-based assignment methodologies. Section 6.3.2.2 is modified to add the word “Program” to the section title. Section 6.3.2.3 is renamed “Performance-Incentive Program”. Subsection 6.3.2.3.1 “Quality Challenge Award” is renamed “Quality Challenge Award Program” and to add clarifying language. Subsection 6.3.2.3.2 State-MCO Shared Savings Program is added. | |||
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-1, RFP Section 6, "Incentives & Disincentives." | |||
Revision | 2.8 | January 1, 2014 | Contract amendment did not revise Attachment B-1, RFP Section 6, "Incentives & Disincentives." |
Revision | 2.9 | February 1, 2014 | Section 6.3.2.3.2 is renamed Other Incentive Programs’ and updated. | |||
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 MCOs |
6.3.2 Financial Incentives and Disincentives |
6.3.2.4 Remedies and Liquidated Damages |
6.3.2.5 Frew Incentives and Disincentives |
6.3.2.6 Nursing Facility Utilization Disincentive |
6.3.2.7 Additional Incentives and Disincentives |
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 | |||
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-1, RFP Section 7, “Transition Phase Requirements.” | |||
Revision | 2.1 | March 1, 2012 | Section 7.1 is modified to add termination of the contract to the list of remedies for failure to timely satisfy Readiness Review requirements. | |||
Revision | 2.2 | June 1, 2012 | Contract amendment did not revise Attachment B-1, Section 7, "Transition Phase Requirements." | |||
Revision | 2.3 | September 1, 2012 | Contract amendment did not revise Attachment B-1, Section 7, "Transition Phase Requirements." | |||
Revision | 2.4 | March 1, 2013 | Contract amendment did not revise Attachment B-1, Section 7, “Transition Phase Requirements.” | |||
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-1, Section 7, “Transition Phase Requirements.” | |||
Revision | 2.6 | September 1, 2013 | Section 7.2.8.1 is modified for clarification and to comply with requirements of SB 7, 83R. | |||
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-1, Section 7, “Transition Phase Requirements.” | |||
Revision | 2.8 | January 1, 2014 | Contract amendment did not revise Attachment B-1, Section 7, “Transition Phase Requirements.” | |||
Revision | 2.9 | February 1, 2014 | Contract amendment did not revise Attachment B-1, Section 7, “Transition 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. |
7. Transition Phase Requirements |
7.1 Introduction |
7.2 Transition Phase Schedule and Tasks |
7.2.1 Contract Start-Up and Planning |
• define project management and reporting standards; |
• establish communication protocols between HHSC and the MCO; |
• 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. |
7.2.2 Administration and Key MCO Personnel |
7.2.3 Organizational Readiness Review |
7.2.4 Financial Readiness Review |
7.2.4.1 Employee Bonus and/or Incentive Payment Plan |
7.2.5 System Testing and Transfer of Data |
7.2.6 System Readiness Review |
1. Disaster Recovery Plan;* |
2. Business Continuity Plan*; |
3. Security Plan; |
4. Joint Interface Plan; |
5. Risk Management Plan; and |
6. Systems Quality Assurance Plan. |
7.2.7 Demonstration and Assessment of System Readiness |
7.2.8 Operations Readiness |
• | routinely updating formulary data following receipt of HHSC's daily files (no less frequently than weekly, and off-cycle upon HHSC's request); |
• | prior authorization of drugs, including how HHSC's preferred drug lists (PDLs) will be incorporated into prior authorization systems and processes. The MCO must adopt HHSC's prior authorization policies unless HHSC grants a written exception, and HHSC's approval is required for all Clinical Edit policies; |
• | implementing drug utilization review; |
• | overriding standard drug utilization review criteria and clinical edits when Medically Necessary based on the individual Member's circumstances (e.g, overriding quantity limitations, drug-drug interactions, refill too soon, etc.); |
• | call center operations, including how the MCO will ensure that staff for all appropriate hotlines are trained to respond to prior authorization inquiries and other inquiries regarding pharmacy services, and |
• | monitoring the PBM Subcontractor. |
• | 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 MCO staff persons who: (1) are directly involved in the decision-making and administration of the fraud and abuse detection program within the MCO, and (2) 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. The training will be conducted by the Office of Inspector General, Health and Human Services Commission, and will be provided free of charge. The MCO must schedule and complete training no later than 90 days after the Contract's Effective Date. |
• | Designate an officer or director within the organization responsible for carrying out the provisions of the Fraud and Abuse Compliance Plan. |
• | For STAR+PLUS MCOs, complete hiring and training of Service Coordination staff no later than 45 days prior to the Operational Start Date. |
7.2.8.2 Value-Added Services |
7.2.9 Assurance of System and Operational Readiness |
7.2.10 TDI and Centers for Medicare and Medicaid Services (CMS) Licensure, Certification or Approval |
7.2.11 Post-Transition |
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 |
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-1, RFP Section 8, “Operations Phase Requirements.” |
Revision | 2.1 | March 1, 2012 | Section 8.1.1.1 is modified to change the timeframes for PIPs from SFY to calendar year and to revise the due dates. Section 8.1.3 is modified to clarify PCP requirement’s application (does not apply to CHIP Perinates (unborn children) and add a requirement regarding timely access to Network Providers, as required by 42 CFR §438.206(c)(1)(ii). Section 8.1.3.2 is modified to add pharmacy access requirements effective 9/1/12. These standards are derived from Medicare Part D access standards, and the standards currently being met in the fee-for-service program. Section 8.1.4 is modified to require MCOs to enter into network provider agreements with any willing State Hospital and to clarify requirements for contracting with specialty pharmacies. Section 8.1.5.5 is modified to require the MCOs to include a link to financial literacy information on the OCCC web page as required by HB 2615. Section 8.1.8 is modified to add prior authorizations by pharmacists. Section 8.1.17 is modified to remove the requirement to submit an accounting policy manual. Section 8.1.17.1 “Financial Disclosure Report” is renamed “MCO Disclosure Statement” and the submission date is updated. Section 8.1.18.1 is modified to require MCOs to submit pharmacy encounter data no later than 25 calendar days after the date of adjudication. Section 8.1.18.4 is modified to clarify claims transaction formats for pharmacy claims. Section 8.1.18.5 is modified to require MCOs to maintain a mechanism to receive claims in addition to the HHSC claims portal. Section 8.1.19 is modified to require MCOs to designate a primary and secondary contact for all OIG requests and to outline the process and timeframes for responding to the OIG, to change the 60 day timeline for submitting the annual plan to 90 days, and to require MCOs to ensure their subcontractors receiving or making annual Medicaid payments of at least $5 million comply with 1902(a)(68)(A) of the Social Security Act. Section 8.1.20.2 is modified to add DUR reporting requirements. Section 8.1.21 is revised to delete MCO developed PDLs and to clarify the reimbursement process. Section 8.1.21.1 is revised to clarify legal references and Clinical Edit requirements, and to add requirements regarding 340B drugs. Section 8.1.21.4 is modified to add requirements for the rebate dispute resolution process. Section 8.1.21.5 is modified to clarify that HHSC will provide up to 1 year of medication history to the MCOs for new Members with previous Medicaid eligibility. Section 8.1.21.9 is modified to clarify requirements for contracting with specialty pharmacies. |
Section 8.1.21.10 is deleted in its entirety. Section 8.1.23.1 is modified that copayment amounts are capped at the MCO’s cost and that CHIP copayments do not apply to preventive services or pregnancy-related services. Section 8.1.24 is modified to clarify that MCOs must notify Medicaid and CHIP Providers of availability of vaccines through Texas Vaccines for Children Program and work with HHSC and Providers to improve the reporting of immunizations to the statewide ImmTrac Registry. Section 8.2.2.3.4 is modified to require MCOs to use standard Texas Health Steps language in their Member Materials as provided in the UMCM. Section 8.2.2.8 is amended to clarify the requirements regarding non-capitated dental services and to add “Texas Health Steps environmental lead investigation (ELI)”. Remainder of list is renumbered. Section 8.2.4.2 is modified to add a reference to Gov’t Code §533.005(a)(19). Section 8.2.8 is modified to add the phrase “unless an exception applies under federal law” to the first sentence. Section 8.2.13 is modified to specify that MCOs may be required to provide other wrap-around services at a date to be determined by HHSC. Section 8.3.2 is modified to require the MCO to consider the availability of the PACE program when considering whether to refer a member to a nursing facility or other long-term care facility. Section 8.3.7.1 is modified to clarify the MA Dual SNP requirements. Section 8.4.3 is modified to correct a cross-reference. | |||
Revision | 2.2 | June 1, 2012 | Section 8.1.21 is modified to add pharmaceutical delivery requirements. |
Revision | 2.3 | September 1, 2012 | Section 8.1.1.1 is modified to conform to the timelines in the UMCM. Section 8.1.3 is modified to replace references to “1915(c) STAR+PLUS Waiver” with “HCBS STAR+PLUS Waiver”. Section 8.1.3.2 is modified to clarify language regarding additional benchmark performance standards. Section 8.1.4 is modified to correct reference to TMPPM. Section 8.1.4.6 is modified to require HHSC review of all provider materials relating to Medicaid managed care or CHIP. Section 8.1.4.8 is modified to clarify the applicable federal regulations. Section 8.1.5.1 is modified to prohibit the MCOs from including any language in their member materials which limits the members' ability to contest or appeal denial of a benefit. Section 8.1.5.2 is modified to clarify that PCP name is not required for Dual Eligible STAR+PLUS Members or CHIP Perinates. Section 8.1.5.7 is modified to remove the acronym “CPW”. Section 8.1.9 is modified to clarify the requirements regarding IFSPs. Section 8.1.12.2 is modified to remove the acronym “CPW”. Section 8.1.14 is renamed and modified to remove all references to Health Home Services. Section 8.1.14.1 is renamed and modified to remove all references to Health Home Services. Section 8.1.14.2 is renamed and modified to remove all references to Health Home Services. Section 8.1.19 is modified to update the time frames for responding to the OIG and to add language regarding Credible Allegation of Fraud notices. Section 8.1.20.2 items (j) and (l) are modified to correct UMCM references. Items (n) and (o) are modified to include pharmacy providers. Item (s) “Medicaid Managed Care Texas Health Steps Medical Checkups Quarterly Utilization Reports” is added. Section 8.1.20.2 is modified to add STAR+PLUS LTSS Utilization reporting requirements. Section 8.1.24 is modified to change the Texas Health Steps Periodicity Schedule to ACIP Immunization Schedule. Section 8.1.25 is modified to replace references to “1915(c) STAR+PLUS Waiver” with “HCBS STAR+PLUS Waiver”. Section 8.1.26 Health Home Services is added. Section 8.1.26.1 Health Home Services and Participating Providers is added. Section 8.1.26.2 MCO Health Home Services Evaluation is added Section 8.2.2.3.2 is modified to correct the acronym for Oral Evaluation and Fluoride Varnish. |
Section 8.2.2.3.3 is modified to clarify statutory authority. Section 8.2.2.3.5 is modified to add training requirements for pharmacy and DME. Section 8.2.2.8 is modified to remove the acronym “CPW”. Section 8.2.2.11 is modified to replace the acronym CPW with “Case Management for Children and Pregnant Women” and the acronym THSteps with “Texas Health Steps”. Section 8.2.7.1 is modified to correct URL for UM guidelines. Section 8.2.8 is modified to clarify the pay and chase requirements for prenatal and preventative care, and recoveries in the context of state child support enforcement actions (SSA §1902(a)(25)(E) and (F); and to correct contract cross reference. Section 8.2.10 is modified to remove the acronym “CPW” and to replace it with Case Management for Children and Pregnant Women. Section 8.3.1.1 is modified to clarify eligibility for DAHS. Section 8.3.1.2 is modified to replace references to “1915(c) STAR+PLUS Waiver” with “HCBS STAR+PLUS Waiver” and to add DAHS to the list of Community Based LTSS under the HCBS STAR+PLUS Waiver. Section 8.3.2.6 is modified to replace references to “1915(c) Nursing Facility Waiver” with “HCBS STAR+PLUS Waiver”. Section 8.3.2.8 is modified to update the MAO reference. Section 8.3.3 is modified to replace references to “1915(c) Nursing Facility Waiver” with “HCBS STAR+PLUS Waiver”. Section 8.3.4 is modified to replace references to “1915(c) Nursing Facility Waiver” with “HCBS STAR+PLUS Waiver” and to increase the cost of care threshold from 200% to 202%. Section 8.3.4.1 is modified to replace references to “1915(c) STAR+PLUS Waiver” and “SPW” with “HCBS STAR+PLUS Waiver”. In addition, risk criteria language is removed. Section 8.3.4.2 is modified to change the section name from “For Medical Assistance Only (MAO) Non-Member Applicants” to “For 217-Like Group Applicants' and to replace references to “1915(c) STAR+PLUS Waiver” and “SPW” with “HCBS STAR+PLUS Waiver”. In addition, risk criteria language is removed. Section 8.3.4.3 is modified to replace references to “1915(c) Nursing Facility Waiver” with “HCBS STAR+PLUS Waiver”. Section 8.3.5 is modified to replace references to “1915(c) STAR+PLUS Waiver” with “HCBS STAR+PLUS Waiver”. Section 8.3.6.4 is modified to replace references to the 1915(b) and 1915(c) waivers with the Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver. Section 8.4.3 is modified for consistency with the Medicaid pay and chase requirements. |
Revision | 2.4 | March 1, 2013 | All references to the previous Executive Commissioner Suehs are changed to his successor, Executive Commissioner Janek. Section 8.1.2.1 is modified to add language regarding reducing or deleting Value-added Services. Section 8.1.3.2 is modified to clarify network provider access and compliance rating. Section 8.1.4.11 Provider Advisory Groups is added. Section 8.1.5.10 Member Advisory Groups is added. Section 8.1.18.5 is modified to add new language modeled off of insurance code requirements. Section 8.2.3 is modified to add new language regarding terminating Significant Traditional Providers. Section 8.2.13 is modified to address supplemental payments to MCOs for wrap-around services for outpatient drugs and biological products for STAR+PLUS Members. Section 8.2.13.1 Medicaid Wrap-Around Services for Outpatient Drugs and Biological Products is added. Section 8.3.1.1 is modified to delete Personal Attendant Services and delete language after (DAHS) is the service column. Section 8.3.1.2 is modified to delete DAHS service description and Licensure and Certification Requirements and modify Personal Assistance Services. 8.3.6.6 Electronic Visit Verification is added. |
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-1, |
Revision | 2.6 | September 1, 2013 | Section 8.1.1.1 is modified to remove references to overarching goals and to clarify that HHSC will provide the PIP topics. Section 8.1.2.1 is modified to clarify that MCOs may not charge copayments for Value-added Services, but may offer discounts for non-covered services as Value-added Services as required by SB 632. Section 8.1.3.1 is modified to clarify timeframes for PCP referrals. Section 8.1.3.2 is modified to add a requirement for 2 PCPs within 30 miles for Medicaid child Members to comply with the Frew Corrective Action order. Section 8.1.4 is modified to add new pharmacy requirements as required by SB 1106 and HB 1358. Section 8.1.4.2 is modified for clarification and to comply with requirements of SB 406, 83R. Section 8.1.4.4 is modified to add timeframes for completing the credentialing process and to comply with requirements of SB 365, 83R. |
Section 8.1.4.8 is modified to clarify the MCO's obligations for payment and Network Provider agreements and to comply with requirements of SB 7, 83R. Section 8.1.4.8.1 is modified to correct “Provider Preventable Conditions” to “Potentially Preventable Complications”. Section 8.1.4.8.2 is modified to clarify provider incentives. Section 8.1.4.10 is modified for clarification and to comply with requirements of SB 1401, 83R. Section 8.1.4.12 Provider Protection Plan is added as required by SB 1150, 83R. Section 8.1.5.5 is modified to allow MCOs to offer provider search functionality on their websites instead of PDF versions of the Provider Directory. In addition, duplicative language is removed. Section 8.1.5.6 is modified to require the MCO's Member Services representatives to be trained regarding the override process for Members in the HHSC-OIG Lock-in Program. Section 8.1.5.6.1 is modified to require the MCO's nurseline staff to be trained regarding the override process for Members in the HHSC-OIG Lock-in Program. Section 8.1.5.7 is modified to allow MCOs to use certified community health workers/promotoras to conduct outreach and member education activities. Section 8.1.5.9 is modified to correct cross references. Section 8.1.8 is modified to update the URL for UM guidelines. Section 8.1.8.1 “Compliance with State and Federal Prior Authorization Requirements” is added as required by SB8, SB 644, and SB1216, 83R. Section 8.1.9 is modified to update the T.A.C. references and to align the age reference with the definition. Section 8.1.14 is modified to add a new Subsection 8.1.14.1 Special Populations. Subsequent subsections are renumbered. Section 8.1.14.3 is modified to add requirements for special populations. Section 8.1.15 is modified to clarify which DSM edition is referenced. Section 8.1.15.7 is modified to delete the duplicative definition. The term “Court-Ordered Commitment” is defined in Attachment A. Section 8.1.18.1 is modified to require MCO Provider Agreements to comply with Texas Gov't. Code regarding reimbursement of claims based on orders or referrals by supervising providers. Section 8.1.18.5 is modified for clarification, for consistency with Section 1213.005 of the Insurance Code, and to comply with requirements of House Bill 15, 83R |
Section 8.1.19 is modified to include the HHSC-OIG Lock-in Program. Section 8.1.20 is modified for clarification that records must be provided “at no cost.” Section 8.1.20.1 is modified to correct the name to which the acronym HEDIS refers. Section 8.1.20.2 is modified to add Service Coordination reporting requirements. Section 8.1.21 Pharmacy Services is modified to reorganize the section and to add requirements as required by SB 644, HB 1358, 83R. Section 8.1.21.1 Formulary and Preferred Drug List (PDL) is added. Section 8.1.21.2 Prior Authorization for Prescription Drugs is modified to add “and 72-hour Emergency Supplies” to the title and to add requirements as required by SB 644, HB 1358, 83R Section 8.1.21.3 Coverage Exclusions is modified for clarity. Section 8.1.21.5 Pharmacy Rebate Program is modified to require MCOs to include NDCs on all encounters. Section 8.1.21.6 Drug Utilization Review (DUR) Program is modified to add requirements as required by SB 644, HB 1358, 83R Section 8.1.21.7 Pharmacy Benefit manager (PBM) is modified to add requirements as required by SB 644, HB 1358, 83R Section 8.1.21.8 Financial Disclosures for Pharmacy Services is modified for clarity. Section 8.1.21.9 Limitations Regarding Registered Sex Offenders is modified for clarity Section 8.1.21.10 Specialty Drugs is modified to add requirements as required by SB 644, HB 1358, 83R Section 8.1.21.11 Maximum Allowable Cost (MAC) Requirements is added. Section 8.1.21.12 Mail-order and Delivery is added. Section 8.1.21.13 Health Resources and Services Administration 340B Discount Drug Program is added. Section 8.1.21.14 Pharmacy Claims and File Processing is added. Section 8.1.21.15 Pharmacy Audits is added. Section 8.1.21.16 E-prescribing is added. Section 8.1.22 is modified to add more detail regarding FQHC/RHC payments. Section 8.1.27 Cancellation of Product Orders is added. Section 8.2.2.4 is modified to include education and care coordination for Members who are at high risk for pre-term labor. |
Section 8.2.2.8 is modified to add ECI Specialized Skills Training, to clarify the requirements for DADS hospice services, and to add court-ordered commitments to inpatient mental health facilities as a condition of probation. Section 8.2.4.2 is modified for clarification and to comply with requirements of SB 7, 83R. Section 8.2.13 is modified to clarify the language. Section 8.2.13.1 is modified to clarify the language. Section 8.3.2 is modified to add new subsections 8.3.2.1 “Service Coordination Plan Requirements,” and 8.3.2.2 “Service Coordination Structure.” Subsequent subsections are renumbered. Section 8.3.2.3 is modified to include minimum requirements for Service Coordinators. Section 8.3.4.3 is modified to require the MCO to inform the Member about CDS during the annual reassessment. Section 8.3.4.4 STAR+PLUS Utilization Reviews is added as required by SB 348, 83R. Section 8.3.7.2 is modified to remove the reference to Attachment B-6. Section 8.3.8 Minimum Wage Requirements for STAR+PLUS Attendants in Community Settings Reviews is added as required by Article II, Rider 61 of the General Appropriations Act (83R). | |||
Revision | 2.7 | September 1, 2013 | Section 8.2.16 “Supplemental Payments for Qualified Providers” is added. Additional detail regarding the process, including payment and reporting requirements will be added to the UMCM. |
Revision | 2.8 | January 1, 2014 | Section 8.1.4.4 is modified to clarify the timeframes for completing the credentialing process. Section 8.1.12.2 is modified to add Former Foster Care Child (FFCC) Members. Section 8.1.13 is modified to add Former Foster Care Child (FFCC) Members. Section 8.1.21.6 is modified to add requirements for assessing prescribing patterns for psychotropic medications. Section 8.1.21.14 is modified to clarify timeframes. Section 8.3.6.6 Cost Reporting for LTSS Providers is added. |
Revision | 2.9 | February 1, 2014 | Section 8.1.1.1 is modified to clarify that absent HHSC’s direction the MCO may choose to collaborate with other MCOs in the Service Area on one PIP per year. Section 8.1.1.1.1 MCO Report Cards is added. Section 8.1.2 is modified to remove the reference to Texas Medicaid Bulletins. Section 8.1.3 is modified to clarify Member payment responsibilities for services in a 24-hour setting as an alternative to Nursing Facility or hospitalization and for services in a Nursing Facility. Section 8.1.3.2 is modified to remove the definition of Qualified Mental Health Provider from Outpatient Behavioral Health Service Provider Access. In addition, Nursing Facility Access and Mental Health Rehabilitative Service Provider Access are added. |
Section 8.1.4 is modified to clarify licensure or certification requirements for all providers. In addition, Nursing Facility Services, Hospice Services, and Mental Health Rehabilitative Services are added. Section 8.1.4.2 is modified to include physicians serving Members residing in Nursing Facilities. Section 8.1.4.4 is modified to require MCOs to use state-identified credentialing criteria for Nursing Facilities. In addition, a sub-section heading is added for 8.1.4.4.1 Expedited Credentialing Process. Section 8.1.4.6 is modified to require STAR+PLUS MCOs to assign a provider relations specialist proficient in Nursing Facility billing to each Nursing Facility. In addition, the role of Service Coordinators and early notification of and participation in discharge planning are added to the required Provider training. In addition, requirements for Mental health Rehabilitative Services are added. Section 8.1.4.8 is modified to update the UMCM chapter reference. Section 8.1.4.8.1 is modified to include CHIP. Section 8.1.4.8.3 Nursing Facility Incentives is added. Section 8.1.4.10 is modified to add TAC reference for pharmacy. Section 8.1.4.12 is modified to update the UMCM chapter reference. Section 8.1.5.2 is modified to clarify that the PCP’s name and telephone number are not required for Nursing Facility residents. Section 8.1.5.7 is modified to add Service Coordination for Cognitive Rehabilitation Therapy, Nursing Facility residents; Nursing Facility Services; discharge planning, transitional care, and other education programs for Nursing Facility residents; and supported employment and employment services. Section 8.1.5.11 Member Eligibility is added. Section 8.1.8 is modified to add that compensation to individuals or entities conducting UM activities cannot be structured to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services as required by 42 C.F.R. 438.210(e). Section 8.1.12.1 is modified to delete unnecessary information and clarify use of the term CSHCN. Section 8.1.12.2 is modified to clarify use of the term CSHCN. Section 8.1.15.8 is modified to remove the requirement to comply with additional BH requirements as described in Section 8.2.8. Section 8.1.18.5 is modified to add timeframes for Nursing Facility claims and to clarify the MCO must provide a web portal at no cost to the Provider and its functionality. Section 8.1.19 is modified to require the MCOs to meet all requirements in Texas Government Code § 531.105. Section 8.1.20.2 is modified to add Nursing Facility Reports. Section 8.1.23 is modified to allow STAR+PLUS MCOs to assist with the collection of applied income from Nursing Facility Members. Section 8.1.28 Preadmission Screening and Resident Review (PASRR) Referring Entity Requirements is added. Section 8.2.1 is modified to clarify timeframes for prior authorizations for transitioning Members. Section 8.2.2.8 is modified to add PASRR Evaluations; and to clarify DSHS Targeted Case Management, Personal Care Services and Nursing Facility Services. Section 8.2.3 is modified to add Nursing Facilities as STPs for STAR+PLUS. Section 8.2.7.1 Local Mental Health Authority (LMHA) will be deleted in its entirety effective September 1, 2014. Section 8.2.7.3 Mental Health Rehabilitative Services and Targeted Case Management Services is added. Section 8.3.1 is clarified that LTSS providers must be licensed or certified. Section 8.3.1.1 is modified to clarify that MCOs must ensure access to PAS and DAHS for qualified STAR+PLUS Members. Section 8.3.1.2 is modified to add licensure, certification and other minimum qualification requirements for Employment Assistance, Supported Employment, Support Consultation, and Cognitive Rehabilitation Therapy. In addition, Consumer Directed Services (CDS) is renamed Financial Management Services and the requirements for Adult Foster Care are clarified. Section 8.3.2.1 is modified to add Level 1 requirements for Members in Nursing Facilities. Section 8.3.2.2 is modified to add Behavioral Health outpatient services and Mental Health Rehabilitative Services, and Employment Assistance/Supported Employment. Section 8.3.2.3 is modified to clarify Member needs, and to add Employment Assistance/Supported Employment and Targeted Case management for Members receiving Mental Health Rehabilitative Services. Section 8.3.2.5 is modified to require the MCO to provide discharge planning, transition care, and other education programs to Network Providers regarding all available long term care settings and options. In addition Nursing Facilities are added. Section 8.3.2.6 is modified to include Nursing Facility Services and to change Service Plan to transition plan. Section 8.3.2.8 Nursing Facilities will be deleted in its entirety effective September 1, 2014. Section 8.3.2.9 MCO Four-Month Liability for Nursing Facility Care will be deleted in its entirety effective September 1, 2014. Section 8.3.3 is modified to add assessment requirements for Members in Nursing Facilities. Section 8.3.6.3 is modified to include Nursing Facility Providers. Section 8.3.6.7 Electronic Visit Verification is added. The UMCM chapter is under development. Section 8.3.9 Nursing Facility Services Available to All Members is added. Section 8.3.9.1 Preadmission Screening and Resident Review (PASRR) is added. Section 8.3.9.2 Participation in Texas Promoting Independence Initiative’ is added. Section 8.3.9.3 Nursing Facilities Training is added. Section 8.3.9.4 Nursing Facility Claims Adjudication, Payment, and File Processing is added. Section 8.3.10 Acute Care Services for Recipients of ICF-IID Program and IDD Waiver services is added. Section 8.3.11 Cognitive Rehabilitation Therapy is added. |
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. |
8. OPERATIONS PHASE REQUIREMENTS |
8.1 General Scope of Work |
8.1.1 Administration and Contract Management |
8.1.1.1 Performance Evaluation |
8.1.2 Covered Services |
1. previous coverage, if any, or the reason for termination of such coverage; |
2. health status; |
3. confinement in a health care facility; or |
4. for any other reason. |
8.1.3 Access to Care |
• | In urban counties, at least 75 percent of Members must have access to a Network Pharmacy within 2 miles of the Member's residence; |
• | In suburban counties, at least 55 percent of Members must have access to a Network Pharmacy within 5 miles of the Member's residence; |
• | In rural counties, at least 90 percent of Members must have access to a Network Pharmacy within 15 miles of the Member's residence; and |
• | In urban, suburban, and rural counties, at least 90 percent of Members must have access to a 24-hour pharmacy within 75 miles of the Member's residence. |
• | In urban counties, at least 80 percent of Members must have access to a Network Pharmacy within 2 miles of the Member's residence; |
• | In suburban counties, at least 75 percent of Members must have access to a Network Pharmacy within 5 miles of the Member's residence; |
• | In rural counties, at least 90 percent of Members must have access to a Network Pharmacy within 15 miles of the Member's residence; and |
• | In urban, suburban, and rural counties, at least 90 percent of Members must have access to a 24-hour pharmacy within 75 miles of the Member's residence. |
8.1.4 Provider Network |
1. 99% of calls are answered by the fourth ring or an automated call pick-up system is used; |
2. no more than one percent (1%) of incoming calls receive a busy signal; |
3. the average hold time is two (2) minutes or less; and |
4. the call abandonment rate is seven percent (7%) or less. |
• | Section 2702 of PPACA, entitled "Payment Adjustment for Health Care-Acquired Conditions;" |
• | Section 6505 of PPACA, entitled "Prohibition on Payments to Institutions or Entities Located Outside of the United States;" and |
• | Section 1202 of the Health Care and Education Reconciliation Act as amended by PPACA, entitled "Payments to Primary Care Physicians." |
8.1.4.10 Out-of-State Providers |
• | Provide for timely and accurate claims adjudication and proper claims payment in accordance with UMCM Chapters 2.0 through 2.3. |
• | Include Network Provider training and education on the requirements for claims submission and appeals, including the MCO's policies and procedures (see also Section 8.1.4.6, "Provider Relations Including Manual, Materials and Training.") |
• | Ensure Member access to care, in accordance with Section 8.1.3, "Access to Care," and the UMCM's Geo-Mapping requirements (see UMCM Chapters 5.14.1 through 5.14.4.) |
• | Ensure prompt credentialing, as required by Section 8.1.4.4, "Provider Credentialing and Re-credentialing." |
• | Ensure compliance with state and federal standards regarding prior authorizations, as described in Sections 8.1.8, "Utilization Management," and 8.1.21.2, "Prior Authorization for Prescription Drugs and 72-Hour Emergency Supplies." |
• | Include other measures developed by HHSC or a provider protection plan workgroup, or measures developed by the MCO and approved by HHSC. |
8.1.5 Member Services |
8.1.5.6.1 Nurseline |
8.1.6 Marketing and Prohibited Practices |
8.1.7 Quality Assessment and Performance Improvement |
1. evaluate performance using objective quality indicators; |
2. foster data-driven decision-making; |
3. recognize that opportunities for improvement are unlimited; |
4. solicit Member and Provider input on performance and QAPI activities; |
5. support continuous ongoing measurement of clinical and non-clinical effectiveness and Member satisfaction; |
6. support programmatic improvements of clinical and non-clinical processes based on findings from ongoing measurements; and |
7. support re-measurement of effectiveness and Member satisfaction, and continued development and implementation of improvement interventions as appropriate. |
1. is organization-wide, with clear lines of accountability within the organization; |
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; |
3. includes annual objectives and/or goals for planned projects or activities including clinical and non-clinical programs or initiatives and measurement activities; and |
4. evaluates the effectiveness of clinical and non-clinical initiatives. |
1. developing PCP and Provider-specific reports that include a multi-dimensional assessment of a PCP or Provider’s performance using clinical, administrative, and Member satisfaction indicators of care that are accurate, measurable, and relevant to the enrolled population; |
2. establishing PCP, Provider, group, Service Area or regional Benchmarks for areas profiled, where applicable, including STAR, STAR+PLUS, and CHIP Program-specific Benchmarks, where appropriate; and |
3. providing feedback to individual PCPs and Providers regarding the results of their performance and the overall performance of the Provider Network. |
1. use the results of its Provider profiling activities to identify areas of improvement for individual PCPs and Providers, and/or groups of Providers; |
2. establish Provider-specific quality improvement goals for priority areas in which a Provider or Providers do not meet established MCO standards or improvement goals; |
3. develop and implement incentives, which may include financial and non-financial incentives, to motivate Providers to improve performance on profiled measures; and |
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. |
1. whether the Member’s PCP or other Providers are participating in the MCO’s physician incentive plan; |
2. whether the MCO uses a physician incentive plan that affects the use of referral services; |
3. the type of incentive arrangement; and |
4. whether stop-loss protection is provided. |
1. Whether the physician incentive plan covers services that are not furnished by a physician or physician group. The MCO 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. |
2. The type of incentive arrangement (e.g., withhold, bonus, capitation); |
3. The percent of withhold or bonus (if applicable); |
4. The panel size, and if patients are pooled, the method used (HHSC approval is required for the method used); and |
8.1.8 Utilization Management |
8.1.9 Early Childhood Intervention (ECI) |
8.1.10 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) - Specific Requirements |
8.1.11 Coordination with Texas Department of Family and Protective Services |
1. a court order (Order) entered by a Court of Continuing Jurisdiction placing a child under the protective custody of TDFPS; |
2. a TDFPS Service Plan entered by a Court of Continuing Jurisdiction placing a child under the protective custody of TDFPS; and |
3. a TDFPS Service Plan voluntarily entered into by the parents or person having legal custody of a Member and TDFPS. |
1. providing medical records to TDFPS; |
2. scheduling medical and Behavioral Health Services appointments within 14 days unless requested earlier by TDFPS; and |
3. recognition of abuse and neglect, and appropriate referral to TDFPS. |
8.1.12 Services for People with Special Health Care Needs |
8.1.13 Service Management for Certain Populations |
8.1.14 Disease Management (DM) |
8.1.15 Behavioral Health (BH) Network and Services |
1. 99% of calls are answered by the fourth ring or an automated call pick-up system; |
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; |
4. the call abandonment rate is seven percent (7%) or less; and |
5. the average hold time is two (2) minutes or less. |
8.1.16 Financial Requirements for Covered Services |
8.1.17 Accounting and Financial Reporting Requirements |
1. maintain accounting records for each applicable MCO Program separate and apart from other corporate accounting records; |
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; |
3. ensure and provide access to HHSC and/or its auditors or agents to the detailed records and supporting documentation for all costs incurred by the MCO. The MCO must ensure such access to its Subcontractors, including Affiliates, for any costs billed to or passed to the MCO with respect to an MCO Program; |
4. 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 |
1. the “Health Annual Statement” and the “Annual Audited Financial Report” including all schedules, attachments, exhibits, supplements, management discussion, supplemental filings, etc., and any other annual financial filings (including any filings that may take the place of the above-named annual financial filings, and any financial filings that occur less frequently than on a quarterly basis); |
2. the annual figures for controlled risk-based capital; and |
3. the quarterly financial statements. |
1. the complete registration restatement that was due to TDI by approximately May 2010; |
2. each annual registration amendment form (which is due to TDI within 120 days of the end of the MCO’s parent’s fiscal year), commencing with the most recent one that the MCO has filed after May 2010; |
3. future complete five-year registration re-statements (the first of which will be due to TDI by approximately May 2015); and |
4. any other registration statement amendments or re-statements that may be submitted to TDI, per TDI regulations. |
1. SEC Form 10-K. For publicly-traded (stock-exchange-listed) for-profit corporations, submit the most-recent annual SEC Form 10K filing. |
2. IRS Form 990. For nonprofit entities, submit the most recent annual IRS Form 990 filing, complete with any and all attachments or schedules. If a nonprofit entity is exempt from the IRS 990 filing requirement, demonstrate this and explain the nature of the exemption. |
3. If the MCO is a nonprofit entity that is a component or subsidiary of a County Hospital District, or otherwise an entity of a government, then submit the annual financial statements as prepared under the relevant rules or statutes governing annual financial reporting and disclosure for the MCO and/or its parent, including all attachments, schedules, and supplements. |
4. Annual Report. The MCO must submit this report if it is different than or supplementary to the audited financial statements or Form 10-K required herein, and if it is distributed to either shareholders, customers, employees, owner(s), parent, bank or creditor(s), donors, the community, or to any regulatory body or constituents, or is otherwise externally distributed or posted. |
5. Bond or debt rating analysis. If the MCO or its ultimate parent has been the subject of any bond rating analysis, ratings affirmation, write-up, or related report, such as by AM Best, Fitch Ratings, Moody’s, Standard & Poor, etc., submit the most recent complete detailed report from each rating entity that has produced such a report. |
8.1.18 Management Information System Requirements |
1. Enrollment/Eligibility Subsystem; |
2. Provider Subsystem; |
3. Encounter/Claims Processing Subsystem; |
4. Financial Subsystem; |
5. Utilization/Quality Improvement Subsystem; |
6. Reporting Subsystem; |
7. Interface Subsystem; and |
8. TPL/TPR Subsystem, as applicable to each MCO Program. |
1. a new plan is brought into the MCO Program; |
2. an existing plan begins business in a new Service Area or a Service Area expansion; |
3. an existing plan changes location; |
4. an existing plan changes its processing system, including changes in Material Subcontractors performing MIS or claims processing functions; and |
5. an existing plan in one (1) or two (2) HHSC MCO Programs is initiating a Contract to participate in any additional MCO Programs. |
8.1.18.2 MCO Deliverables related to MIS Requirements |
1. Joint Interface Plan; |
2. Risk Management Plan; and |
3. Systems Quality Assurance Plan. |
1. process electronic data transmission or media to add, delete or modify membership records with accurate begin and end dates; |
2. track Covered Services received by Members through the system, and accurately and fully maintain those Covered Services as HIPAA-compliant Encounter transactions; |
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; |
4. maintain a history of changes and adjustments and audit trails for current and retroactive data; |
5. maintain procedures and processes for accumulating, archiving, and restoring data in the event of a system or subsystem failure; |
6. employ industry standard medical billing taxonomies (procedure codes, diagnosis codes, NDC codes) to describe services delivered and Encounter transactions produced; |
7. accommodate the coordination of benefits; |
8. produce standard Explanation of Benefits (EOBs) for providers; |
9. Pay financial transactions to Network Providers and Out-of-Network providers in compliance with federal and state laws, rules and regulations; |
10. ensure that all financial transactions are auditable according to GAAP guidelines; |
11. ensure that Financial Statistical Reports (FSRs) comply with Uniform Managed Care Manual Chapter 6.1, “Cost Principles for Expenses,” with respect to segregating costs that are allowable for inclusion in HHSC-designed financial reports; |
12. relate and extract data elements to produce report formats (provided within the Uniform Managed Care Manual) or otherwise required by HHSC; |
13. ensure that written process and procedures manuals document and describe all manual and automated system procedures and processes for the MIS; and |
14. maintain and cross-reference all Member-related information with the most current Medicaid, or CHIP Program Provider number. |
• | Client eligibility verification |
• | Submission of electronic claims |
• | Prior Authorization requests |
• | Claims appeals and reconsiderations |
• | Exchange of clinical data and other documentation necessary for prior authorization and claim processing |
8.1.18.6 National Correct Coding Initiative |
8.1.19 Fraud and Abuse |
8.1.20 General Reporting Requirements |
8.1.21.9 Limitations Regarding Registered Sex Offenders |
• | the drug is listed as "A" or "B" rated in the most recent version of the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book, has an "NR" or "NA" rating or similar rating by a nationally recognized reference; and |
• | the drug is generally available for purchase by pharmacies in Texas from national or regional wholesalers and is not obsolete. |
8.1.22 Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) |
8.1.23 Payment by Members. |
8.1.23.1 Cost Sharing |
8.1.24 Immunizations |
8.1.25 Dental Coverage |
8.1.26 Health Home Services |
8.2 Additional Medicaid MCO Scope of Work |
8.2.1 Continuity of Care and Out-of-Network Providers |
1. more than 90 days after a Member enrolls in the MCO’s Program, or |
2. for more than nine (9) months in the case of a Member who, at the time of enrollment in the MCO, has been diagnosed with and receiving treatment for a terminal illness and remains enrolled in the MCO. |
8.2.2 Provisions Related to Covered Services for Medicaid Members |
1. the MCO does not respond to a request for pre-approval within one (1) hour; |
2. the MCO cannot be contacted; or |
3. the MCO 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 MCO 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 Network physician is reached. The MCO’s financial responsibility ends as follows: the Network physician with privileges at the treating Hospital assumes responsibility for the Member’s care; the Network physician assumes responsibility for the Member’s care through transfer; the MCO representative and the treating physician reach an agreement concerning the Member’s care; or the Member is discharged. |
8.2.3 Medicaid Significant Traditional Providers |
8.2.4 Provider Complaints and Appeals |
8.2.5 Member Rights and Responsibilities |
8.2.6 Medicaid Member Complaint and Appeal System |
1. date; |
2. identification of the individual filing the Complaint; |
3. identification of the individual recording the Complaint; |
4. nature of the Complaint; |
5. disposition of the Complaint (i.e., how the MCO resolved the Complaint); |
6. corrective action required; and |
7. date resolved. |
1. date notice is sent; |
2. effective date of the Action; |
3. date the Member or his or her representative requested the Appeal; |
4. date the Appeal was followed up in writing; |
5. identification of the individual filing; |
6. nature of the Appeal; and |
7. disposition of the Appeal, including a copy of the notice of disposition and the date it was sent to Member. |
1. the Member or his or her representative files the Appeal timely as defined in this Contract: |
2. the Appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; |
3. the services were ordered by an authorized provider; |
4. the original period covered by the original authorization has not expired; and |
5. the Member requests an extension of the benefits. |
1. transfer the Appeal to the timeframe for standard resolution, and |
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. |
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; |
2. for denial of payment, at the time of any Action affecting the claim; |
3. for standard service authorization decisions that deny or limit services, within the timeframe specified in 42 C.F.R.§ 438.210(d)(1); |
4. if the MCO extends the timeframe in accordance with 42 C.F.R. §438.210(d)(1), it must: |
a. 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 |
b. issue and carry out its determination as expeditiously as the Member’s health condition requires and no later than the date the extension expires; |
5. 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 |
6. for expedited service authorization decisions, within the timeframes specified in 42 C.F.R. 438.210(d). |
1. the right to request a Fair Hearing; |
2. how to request a Fair Hearing; |
3. The circumstances under which the Member may continue to receive benefits pending a Fair Hearing; |
4. how to request the continuation of benefits; |
5. if the MCO’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 |
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. |
1. their rights and responsibilities, |
2. the Complaint process, |
3. the Appeal process, |
4. Covered Services available to them, including preventive services, and |
5. Non-capitated Services available to them. |
8.2.7 Additional Medicaid Behavioral Health Provisions |
8.2.8 Third Party Liability and Recovery and Coordination of Benefits |
8.2.9 Coordination with Public Health Entities |
1. Sexually Transmitted Diseases (STDs) services; |
2. confidential HIV testing; |
3. immunizations; |
4. tuberculosis (TB) care; |
5. Family Planning services; |
6. Texas Health Steps medical checkups, and |
7. prenatal services. |
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 MCO’s Network; and |
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. |
1. report to Public Health Entities regarding communicable diseases and/or diseases that are preventable by immunization as defined by state law; |
2. notify the local Public Health Entity of communicable disease outbreaks involving Members; and |
3. educate Members and Providers regarding WIC services available to Members. |
8.2.10 Coordination with Other State Health and Human Services (HHS) Programs |
8.2.11 Advance Directives |
1. a Member’s right to self-determination in making health care decisions; |
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; |
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 |
3. 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. |
8.2.12 SSI Members |
8.2.13 Medicaid Wrap-Around Services |
8.2.14 Medical Transportation |
8.3 Additional STAR+PLUS Scope of Work |
8.3.1 Covered Community-Based Long-Term Services and Supports |
Community-based Long-Term Services and Supports Available to All Members | |
Service | Licensure and Certification Requirements |
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. |
Day Activity and Health Services (DAHS) | The Provider must be licensed by the DADS Regulatory Division as an adult day care provider. To provide DAHS, the Provider must provide the range of services required for DAHS. |
Community-based Long-Term Services and Supports under the HCBS STAR+PLUS Waiver | |
Service | Licensure and Certification Requirements |
Personal Assistance 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. |
Employment Assistance (effective September 1, 2014) | The Provider must meet all of the criteria in one of these three options. Option 1: a bachelor's degree in rehabilitation, business, marketing, or a related human services field; and one year of documented experience providing employment assistance or supported employment services to people with disabilities in a professional or personal setting. Option 2: an associate's degree in rehabilitation, business, marketing, or a related human services field; and two years of documented experience providing employment assistance or supported employment services to people with disabilities in a professional or personal setting. Option 3: a high school diploma or GED; and three years of documented experience providing employment assistance or supported employment services to people with disabilities in a professional or personal setting. |
Supported Employment (effective September 1, 2014) | The Provider must meet all of the criteria in one of these three options. Option 1: a bachelor's degree in rehabilitation, business, marketing, or a related human services field; and one year of documented experience providing employment assistance or supported employment services to people with disabilities in a professional or personal setting. Option 2: an associate's degree in rehabilitation, business, marketing, or a related human services field; and two years of documented experience providing employment assistance or supported employment services to people with disabilities in a professional or personal setting.Option 3: a high school diploma or GED; and three years of documented experience providing employment assistance or supported employment services to people with disabilities in a professional or personal setting. |
Assisted Living Services | 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 Department of State Health Services as a Personal Emergency Response Services Agency under 25 T.A.C., 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. The registered nurse must comply with the requirements for delivery of nursing services, which include requirements such as compliance with the Texas Nurse Practice Act and delegation of nursing tasks. The licensed vocational nurse must practice under the supervision of a registered nurse, licensed to practice in the State. |
Cognitive Rehabilitation Therapy (effective March 1, 2014) | Psychologist must be licensed under Texas Occupations Code Chapter 501. Speech and language pathologists must be licensed under Texas Occupations Code Chapter 401. Occupational Therapist must be licensed under Texas Occupations Code Chapter 454. |
Adult Foster Care | Adult foster care homes must meet the minimum standards described in the STAR+PLUS Handbook Section 7100 found at http://www.dads.state.tx.us/handbooks/sph/. Adult foster care homes serving four or more participants must be licensed by DADS under 40 Tex. Admin. Code Chapter 92. |
Dental | Licensed by the Texas State Board of Dental Examiners as a Dentist under 22 T.A.C., Part 5, Chapter 101. |
Respite Care | Licensed by DADS as a Home and Community Support Services Agency (HCSSA) under 40 T.A.C., Part 1, Chapter 97. |
Home Delivered Meals | Providers must comply with requirement of 40 T.A.C., Part 1, Chapter 55 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. |
Physical Therapy (PT) Services | Licensed Physical Therapist through the Texas Board of Physical Therapy Examiners, Chapter 453 of the Texas Occupations Code. |
Occupational Therapy (OT) Services | Licensed Occupational Therapist through the Texas Board of Occupational Therapy Examiners, Chapter 454 of the Texas Occupations Code. |
Speech, Hearing, and Language Therapy Services | Licensed Speech Therapist through the Department of State Health Services. |
Financial Management Services | The Providers must complete DADS’ required training. Current FMSAs contracted by DADS are assumed to have completed the training. |
Support Consultation | Providers must be certified by the Department of Aging and Disability Services. |
Transition Assistance Services (TAS) | The Provider must comply with the requirements for delivery of TAS, which include requirements such as allowable purchases, cost limits, and timeframes 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 Medical Equipment | No licensure or certification requirements. |
Medical Supplies | No licensure or certification requirements. |
8.3.2 Service Coordination |
• | how outreach to Members will be conducted; |
• | how Members are assessed and their service plans developed (the initial identification of Members' needed services and supports); |
• | how Members will be identified as needing an assessment when changes in their health or life circumstances occur; |
• | the Member's needs and preferences; |
• | the minimum number of service coordination contacts a Member will receive per year; |
• | how service coordination will be provided (face-to-face, telephone contact, etc.); and |
• | how these service coordination services will be tracked by the MCO. |
• | Level 1 Members: Highest level of utilization |
• | Includes HCBS SPW, Nursing Facility, and other Members with complex medical needs. |
• | MCOs must provide Level 1 Members with a single identified person as their assigned Service Coordinator. Beginning September 1, 2014, all Members within a Nursing Facility must have the same assigned Service Coordinator. HHSC must provide written approval for any exceptions. |
• | At a minimum, beginning September 1, 2014, all Level 1 Members in a Nursing Facility must receive quarterly face-to-face visits, including Nursing Facility care planning meetings or other interdisciplinary team meetings. |
• | All other Level 1 Members must receive a minimum of two face-to-face service coordination contacts annually. |
• | Level 2 Members: Lower risk/utilization |
• | MCOs must provide Level 2 Members with a single identified person as their assigned Service Coordinator. Members and required assessments are as follows. |
• | Members receiving LTSS for Personal Assistance Services or Day Activity and Health Services (PAS and DAHS) must receive a minimum of one face-to-face and one telephonic service coordination contact annually. |
• | Members with a history of behavioral health issues (multiple outpatient visits, hospitalization, or institutionalization within the past year) must receive a minimum of one face-to-face and one telephonic service coordination contact annually. |
• | Members with a history of substance abuse (multiple outpatient visits, hospitalization, or institutionalization within the past year) must receive a minimum of one face-to-face and one telephonic service coordination contact annually. |
• | Dual Eligibles who do not meet Level 1 requirements must receive a minimum of two telephonic service coordination contacts annually. |
• | Level 3 Members: Members who do not qualify as Level 1 or Level 2 |
• | MCO must make at least two telephonic service coordination outreach contacts yearly. |
• | Level 3 Members are not required to have a named Service Coordinator, unless they request service coordination services. |
• | A description of service coordination; and |
• | The MCO's Service Coordination phone number. |
• | The name of their Service Coordinator; |
• | The phone number of their Service Coordinator; |
• | The minimum number of contacts they will receive every year; and |
• | The types of contacts they will receive. |
• | Behavioral health, including outpatient services and Mental Health Rehabilitative Services (Mental Health Rehabilitative Services become Covered Services September 1, 2014) |
• | Substance abuse |
• | Local resources (such as basic needs like housing, food, utility assistance) |
• | Pediatrics |
• | LTSS |
• | End of life/advanced illness |
• | Acute care |
• | Preventive care |
• | Cultural competency |
• | Pharmacology |
• | Nutrition |
• | Texas Promoting Independence strategies |
• | Consumer Directed Services options |
• | Person-directed planning |
• | Employment Assistance and Supported Employment (become Covered Services September 1, 2014) |
• | PASRR requirements (effective September 1, 2014) |
• | A Service Coordinator for a Level 1 Member must be a registered nurse (RN) or nurse practitioner (NP). Licensed vocational nurses (LVNs) employed as Service Coordinators before March 1, 2013 will be allowed to continue in that role. |
• | A Service Coordinator for a Level 2 or 3 Member must have an undergraduate or graduate degree in social work or a related field or be an LVN, RN, NP, or physician's assistant (PA); or have a minimum of a high school diploma or GED and direct experience with the ABD/SSI population in three of the last five years. |
• | Service Coordinators for Level 3 Members must have experience in meeting the needs of the member population served (for example, people with disabilities). |
• | Service Coordinators must possess knowledge of the principles of most integrated settings, including federal and state requirements. |
• | Service Coordinators must complete 16 hours of service coordination training every two years. MCOs must administer the training, which must include: |
8.3.3 STAR+PLUS Assessment Instruments |
8.3.4 HCBS STAR+PLUS Waiver Service Eligibility |
8.3.5 Consumer Directed Services Options |
8.3.6 Community Based Long-term Services and Supports Providers |
1. Covered Services and the Provider’s responsibilities for providing such services to STAR+PLUS Members and billing the MCO. The MCO must place special emphasis on Community Long-term Services and Supports and STAR+PLUS requirements, policies, and procedures that vary from Medicaid Fee-for-Service and commercial coverage rules, including payment policies and procedures; |
2. relevant requirements of the STAR+PLUS Contract, including the role of the Service Coordinator; |
3. processes for making referrals and coordinating Non-capitated Services; |
4. the MCO’s quality assurance and performance improvement program and the Provider’s role in such programs; and |
5. the MCO’s STAR+PLUS policies and procedures, including those relating to Network and Out-of-Network referrals. |
6. For STAR+PLUS in the El Paso, Hidalgo and Lubbock Service Areas with an Operational Start Date of 3/1/2012, 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 MCO for assistance with this process. |
8.3.7 Additional Requirements Regarding Dual Eligibles |
8.3.7.1 Coordination of Services for Dual Eligibles |
8.3.7.2 MA Dual SNP Agreement |
• | Day Activity Health Care Services (DAHS); |
• | Primary Home Care (PHC); |
• | Personal Assistance Services (PAS); and |
• | Texas Health Steps Personal Care Services (PCS). |
Nursing Facility Services Available to All Members | |
Service | Licensure and Certification Requirements |
Nursing Facility | The MCOs must use state-identified credentialing criteria for Nursing Facilities. At a minimum, the Nursing Facility must hold a valid certification and license and must contract with DADS. Credentialing documentation of the Nursing Facilities in the STAR+PLUS MCO’s Provider Network meets all licensure requirements as established in 40 Tex. Admin. Code Chapter 19. Credentialing documentation must be submitted to HHSC upon request. |
• | Covered Services and the Provider’s responsibilities for providing services to Members and billing the MCO for the services. The MCO must place special emphasis on Nursing Facility Services and STAR+PLUS requirements, policies, and procedures that vary from Medicaid Fee-for-Service and commercial coverage rules, including payment policies and procedures. |
• | The transition process of up to six (months for the continuation of Nursing Facility for Members receiving those services at the time of program implementation, including provider billing practices for these services and who to contact at the MCO for assistance with this process. |
• | Relevant requirements of the STAR+PLUS Contract, including the role of the Service Coordinator; |
• | Processes for making referrals and coordinating Non-capitated Services; |
• | The MCO’s quality assurance and performance improvement program and the Provider’s role in these programs; and |
• | The MCO’s STAR+PLUS policies and procedures, including those relating to Network and Out-of-Network referrals. |
8.4 Additional CHIP Scope of Work |
8.4.1 CHIP Provider Complaint and Appeals |
8.4.2 CHIP Member Complaint and Appeal Process |
8.4.3 Third Party Liability and Recovery, and Coordination of Benefits |
8.4.4 Perinatal Services for Traditional CHIP Members |
1. pregnancy planning and perinatal health promotion and education for reproductive-age women; |
2. perinatal risk assessment of non-pregnant women, pregnant and postpartum women, and infants up to one year of age; |
3. access to appropriate levels of care based on risk assessment, including emergency care; |
4. transfer and care of pregnant women, newborns, and infants to tertiary care facilities when necessary; |
5. availability and accessibility of OB/GYNs, anesthesiologists, and neonatologists capable of dealing with complicated perinatal problems; and |
6. availability and accessibility of appropriate outpatient and inpatient facilities capable of dealing with complicated perinatal problems. |
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 | |||
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-1, RFP Section 9, “Turnover Requirements.” | |||
Revision | 2.1 | March 1, 2012 | Contract amendment did not revise Attachment B-1, RFP Section 9, "Turnover Requirements." | |||
Revision | 2.2 | June 1, 2012 | Contract amendment did not revise Attachment B-1, Section 9, "Turnover Requirements." | |||
Revision | 2.3 | September 1, 2012 | Contract amendment did not revise Attachment B-1, Section 9, "Turnover Requirements." | |||
Revision | 2.4 | March 1, 2013 | Contract amendment did not revise Attachment B-1, Section 9, “Turnover Requirements.” | |||
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-1, Section 9, “Turnover Requirements.” | |||
Revision | 2.6 | September 1, 2013 | Contract amendment did not revise Attachment B-1, Section 9, “Turnover Requirements.” | |||
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-1, Section 9, “Turnover Requirements.” | |||
Revision | 2.8 | January 1, 2014 | Contract amendment did not revise Attachment B-1, Section 9, “Turnover Requirements.” | |||
Revision | 2.9 | February 1, 2014 | 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. |
9. Turnover Requirements |
9.1 Introduction |
9.2 Turnover Plan |
1. The least disruption in the delivery of Covered Services to Members during the transition to a subsequent contractor. |
2. Cooperation with HHSC and a subsequent contractor in notifying Members of the transition, as requested and in the form required or approved by HHSC. |
3. Cooperation with HHSC and a subsequent contractor in transferring information to HHSC or a subsequent contractor, as requested and in the form required or approved by HHSC. |
1. The MCO’s approach and schedule for the transfer of data and information, as described above. |
2. The quality assurance process that the MCO will use to monitor Turnover activities. |
3. The MCO’s approach to training HHSC or a subsequent contractor’s staff in the operation of its business processes. |
9.3 Transfer of Data |
1. Data, information and services necessary and sufficient to enable HHSC to map all Texas data from the MCO's system(s) to the replacement system(s) of HHSC or a successor contractor, including a comprehensive data dictionary as defined by HHSC. |
2. All necessary data, information and services will be provided in the format defined by HHSC, and must be HIPAA compliant. |
3. All of the data, information and services mentioned in this section must be provided and performed in a manner by the MCO using its best efforts to ensure the efficient administration of the contract. The data and information must be supplied in media and format specified by HHSC and according to the schedule approved by HHSC in the Turnover Plan. The data, information and services provided pursuant to this section must be provided at no additional cost to HHSC. |
9.4 Turnover Services |
9.5 Post-Turnover Services |
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 | |||
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-2, “STAR Covered Services.” | |||
Revision | 2.1 | March 1, 2012 | Attachment B-2 is modified to reinstate the waiver of the three prescription limit for adults language and to clarify the waiver of the $200,000 individual annual limit on inpatient services. STAR Covered Services is modified to add “Cancer screening, diagnostic, and treatment services” and “Prenatal care services rendered in a birthing center” as clarification items and to clarify the requirements for services provided in free-standing psychiatric hospitals and chemical dependency treatment facilities in lieu of the acute care hospital setting. | |||
Revision | 2.2 | June 1, 2012 | Contract amendment did not revise Attachment B-2, "STAR Covered Services." | |||
Revision | 2.3 | September 1, 2012 | STAR Covered Services is modified to remove the reference to Dual Eligible STAR Members in the MRSA | |||
Revision | 2.4 | March 1, 2013 | Contract amendment did not revise Attachment B-2, “STAR Covered Services.” | |||
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-2, “STAR Covered Services.” | |||
Revision | 2.6 | September 1, 2013 | STAR Covered Services is modified to remove the reference to the Texas Medicaid Bulletin. | |||
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-2, “STAR Covered Services.” |
Revision | 2.8 | January 1, 2014 | Inpatient General Acute and Inpatient Rehabilitation Hospital Services (CHIP Perinatal Coverage) is modified to clarify the eligibility thresholds. Birthing Center Services (CHIP Perinatal Coverage) is modified to clarify the eligibility thresholds. Exclusions for CHIP Perinatal is modified to clarify the eligibility thresholds. | |||
Revision | 2.9 | February 1, 2014 | STAR Covered Services include Medically Necessary: is modified to add telemedicine and telemonitoring. | |||
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. |
• Ambulance services |
• Audiology services, including hearing aids, for adults and children |
• Behavioral Health Services*, including: |
o Inpatient mental health services for Children (birth through age 20) |
o Acute inpatient mental health services for Adults |
o Outpatient mental health services |
o Psychiatry services |
o Counseling services for adults (21 years of age and over) |
o Outpatient substance use disorder treatment services including: |
o Assessment |
o Detoxification services |
o Counseling treatment |
o Medication assisted therapy |
o Residential substance use disorder treatment services including: |
o Detoxification services |
o Substance use disorder treatment (including room and board) |
*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 MCO’s non-quantitative treatment limitations, provided such limitations comply with the requirements of the Mental Health Parity and Addiction Equity Act of 2008. |
• Birthing services provided by a physician and certified nurse midwife (CNM) 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 |
• Early Childhood Intervention (ECI) services |
• Emergency Services |
• Family planning services |
• Home health care services |
• Hospital services, including inpatient and outpatient |
o The MCO may provide inpatient services for acute psychiatric conditions in a free-standing psychiatric hospital in lieu of an acute care inpatient hospital setting. |
o The MCO may provide substance use disorder treatment services in a chemical dependency treatment facility in lieu of an acute care inpatient hospital setting. |
• Laboratory |
• Mastectomy, breast reconstruction, and related follow-up procedures, including: |
• 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: |
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. |
• 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 (birth through age 20) 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. |
• Outpatient drugs and biologicals; including pharmacy-dispensed and provider-administered outpatient drugs and biologicals |
• Drugs and biologicals provided in an inpatient setting |
• Podiatry |
• Prenatal care |
• Prenatal care provided by a physician, certified nurse midwife (CNM), nurse practitioner (NP), clinical nurse specialist (CNS), and physician assistant (PA) in a licensed birthing center |
• 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 (Includes optometry and glasses. Contact lenses are only covered if they are medically necessary for vision correction that can not be accomplished by glasses.) |
• Telemedicine |
• Telemonitoring (effective October 1, 2013, through August 31, 2015) |
DOCUMENT HISTORY LOG | |||
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 |
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-2.1, “CHIP Covered Services.” |
Revision | 2.1 | March 1, 2012 | “Birthing Center Services” is added as a clarification item. “Services Rendered by a Certified Nurse Midwife or physician in a licensed birthing center” is added as a clarification item. Attachment B-2.1 is modified to clarify Drug Benefits for CHIP Perinate Members. CHIP Exclusions from Covered Services is modified to clarify that over the counter drugs, contraceptives, and medications prescribed for weight loss or gain are not a covered benefit. CHIP Exclusions from Covered Services for CHIP Perinates is modified to clarify that over the counter drugs contraceptives, and medications prescribed for weight loss or gain are not a covered benefit. |
Revision | 2.2 | June 1, 2012 | Contract amendment did not revise Attachment B-2.1, "CHIP Covered Services." |
Revision | 2.3 | September 1, 2012 | Contract amendment did not revise Attachment B-2.1, “CHIP Covered Services.” |
Revision | 2.4 | March 1, 2013 | CHIP Exclusions from Covered Services is modified to add Coverage while traveling outside of the United States and U.S. Territories. |
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-2.1, “CHIP Covered Services.” |
Revision | 2.6 | September 1, 2013 | Contract amendment did not revise Attachment B-2.1, “CHIP Covered Services.” |
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-2.1, “CHIP Covered Services.” |
Revision | 2.8 | January 1, 2014 | Inpatient General Acute and Inpatient Rehabilitation Hospital Services (CHIP Perinatal Coverage) is modified to clarify the eligibility thresholds. Birthing Center Services (CHIP Perinatal Coverage) is modified to clarify the eligibility thresholds. Exclusions for CHIP Perinatal is modified to clarify the eligibility thresholds. |
Revision | 2.9 | February 1, 2014 | Contract amendment did not revise Attachment B-2.1, “CHIP 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 Members and CHIP Perinate Newborn Members | CHIP Perinate Members (Unborn Child) |
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 | For CHIP Perinates in families with income at or below the Medicaid eligibility threshold (Perinates who qualify for Medicaid once born), 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 income above the Medicaid eligibility threshold (Perinates who do not qualify for Medicaid once born), benefits are limited to professional service charges and facility charges associated with labor with delivery until birth, and services related to miscarriage or a non-viable pregnancy. Services include: ¤ Operating, recovery and other treatment rooms ¤ Anesthesia and administration (facility technical component |
¤ 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: | 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. |
¤ 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 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. | ||
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 ¤ Outpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero). Outpatient 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 outpatient hospital and ambulatory 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 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). Outpatient 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, 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. (5) Surgical 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. |
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, inpatient and outpatient 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 | 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, inpatient and outpatient 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: ¤ Surgeons and assistant surgeons for surgical procedures directly related to the labor with delivery of the covered unborn child until birth. ¤ Administration of anesthesia by Physician (other than surgeon) or CRNA ¤ Invasive diagnostic procedures directly related to the labor with delivery of the unborn child. ¤ Surgical services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero.) ¤ Hospital-based Physician services (including Physician performed technical and interpretive components) |
¤ 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). Physician 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 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. | ¤ 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). Professional 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 | Covered, unlimited prenatal care and medically necessary care related to diseases, illness, or abnormalities related to the reproductive system, and limitations and exclusions to these services are described under inpatient, outpatient and physician services. Primary and preventive health benefits do not include pre-pregnancy family reproductive services and supplies, or prescription medications prescribed only for the purpose of primary and preventive reproductive health care. | Services are limited to an initial visit and subsequent prenatal (ante partum) care visits that include: (1) One (1) visit every four (4) weeks for the first 28 weeks or pregnancy; (2) one (1) visit every two (2) to three (3) weeks from 28 to 36 weeks of pregnancy; and (3) one (1) 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 two (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). |
Birthing Center Services | Covers birthing services provided by a licensed birthing center. Limited to facility services (e.g., labor and delivery) Limitation: Applies only to CHIP members. | Covers birthing services provided by a licensed birthing center. Limited to facility services related to labor with delivery. Applies only to CHIP Perinate Members (unborn child) with income above the Medicaid eligibility threshold (who will not qualify for Medicaid once born). |
Services Rendered by a Certified Nurse Midwife or physician in a licensed birthing center | CHIP Members: Covers prenatal services and birthing services rendered in a licensed birthing center. CHIP Perinate Newborn Members: Covers services rendered to a newborn immediately following delivery. | Covers prenatal services and birthing services rendered in a licensed birthing center. Prenatal services subject to the following limitations: Services are limited to an initial visit and subsequent prenatal (ante partum) care visits that include: (1) one (1) visit every four (4) weeks for the first 28 weeks or pregnancy; (2) one (1) visit every two (2) to three (3) weeks from 28 to 36 weeks of pregnancy; and (3) one (1) 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 two (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 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: ¤ 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 family education, and crisis services 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 (6) 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 | MCO 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 layperson definition of emergency health condition ¤ Hospital emergency department room and ancillary services and physician services 24 hours a day, seven (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, removal of cysts, and treatment relating to oral abscess of tooth or gum origin. | MCO 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 ¤ Emergency ground, air and water transportation for an emergency associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero) 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 (1) examination of the eyes to determine the need for and prescription for corrective lenses per 12-month period, without authorization ¤ One (1) 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. |
Drug Benefits | Services include, but are not limited to, the following: ¤ • Outpatient drugs and biologicals; including pharmacy-dispensed and provider-administered outpatient drugs and biologicals; and ¤ • Drugs and biologicals provided in an inpatient setting. | Not a covered benefit unless identified elsewhere in this table. |
[Value-added services] | See RFP Attachment B-2.1 |
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 |
Contraceptive medications prescribed only for the purpose of primary and preventive reproductive health care (i.e., cannot be prescribed for family planning) |
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 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 |
Medications prescribed for weight loss or gain |
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 |
Over-the-counter medications |
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 |
Coverage while traveling outside of the United States and U.S. Territories (including Puerto Rico, U.S. Virgin Islands, Commonwealth of Northern Mariana Islands, Guam, and American Samoa) |
For CHIP Perinates in families with income at or below the Medicaid eligibility threshold (Perinates who qualify for Medicaid once born), 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. |
Contraceptive medications prescribed only for the purpose of primary and preventive reproductive health care (i.e. cannot be prescribed for family planning) |
Inpatient and outpatient treatments other than prenatal care, labor with delivery, services 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 labor or threatened labor, miscarriage or non-viable pregnancy, 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. Territories (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 |
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. |
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 |
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-2.2, “STAR+PLUS Covered Services.” |
Revision | 2.1 | March 1, 2012 | Attachment B-2.2 is modified to reinstate the waiver of the three prescription limit for adults language and to add the waiver of the $200,000 individual annual limit on inpatient services. STAR+PLUS Covered Services is modified to clarify the requirements regarding services provided in free-standing psychiatric hospitals and chemical dependency treatment facilities in lieu of the acute care hospital setting. Services included under the HMO capitation payment is modified to clarify the requirements for "Prenatal care services rendered in a birthing center." |
Revision | 2.2 | June 1, 2012 | Contract amendment did not revise Attachment B-2.2, "STAR+PLUS Covered Services." |
Revision | 2.3 | September 1, 2012 | Community Based Long Term Care Services is modified to replace references to “1915(c) STAR+PLUS Waiver” and “1915(c) Nursing Facility Waiver” with “HCBS STAR+PLUS Waiver”. |
Revision | 2.4 | March 1, 2013 | Contract amendment did not revise Attachment B-2.2, “STAR+PLUS Covered Services.” |
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-2.2, “STAR+PLUS Covered Services.” |
Revision | 2.6 | September 1, 2013 | Acute Care Services is modified to remove the waiver of the 30-day spell of illness as required by Article II, Rider 51 of the General Appropriations Act (83R), and to remove the reference to the Texas Medicaid Bulletin. |
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-2.2, “STAR+PLUS Covered Services.” |
Revision | 2.8 | January 1, 2014 | Contract amendment did not revise Attachment B-2.2, “STAR+PLUS Covered Services.” |
Revision | 2.9 | February 1, 2014 | Services included under the MCO capitation payment is modified for consistency with the STAR Covered Services Attachment. The vision benefits have not changed. In addition, telemedicine and telemonitoring are added. Nursing Facility Services is added. HCBS STAR+PLUS Waiver Services is modified to add Dental Services, Financial Management Services, Support Consultation, Employment Assistance, Supported Employment, and Cognitive Rehabilitation Therapy. |
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. |
• Ambulance services |
• Audiology services, including hearing aids, for adults and children |
• Behavioral Health Services*, including: |
o Inpatient mental health services for Adults and Children |
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: |
Assessment |
Detoxification services |
Counseling treatment |
Medication assisted therapy |
o Residential services, including |
Detoxification services |
Substance use disorder treatment (including room and board) |
*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 MCO’s non-quantitative treatment limitations, provided such limitations comply with the requirements of the Mental Health Parity and Addiction Equity Act of 2008. |
• 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 |
• Early Childhood Intervention (ECI) services |
• Emergency Services |
• Family planning services |
• Home health care services |
• Hospital services, inpatient and 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 (birth through age 20) 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 six (6) months through 35 months of age. |
• Outpatient drugs and biologicals; including pharmacy-dispensed and provider-administered outpatient drugs and biologicals |
• Drugs and biologicals provided in an inpatient setting |
• 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 (Includes optometry and glasses. Contact lenses are only covered if they are medically necessary for vision correction that cannot be accomplished by glasses.) |
• Telemedicine |
• Telemonitoring (effective October 1, 2013, through August 31, 2015) |
STATUS1 | DOCUMENT REVISION2 | EFFECTIVE DATE | DESCRIPTION3 |
Baseline | n/a | September 1, 2011 | Initial version of Attachment B-3, "Deliverables/Liquidated Damages Matrix." |
Revision | 2.1 | March 1, 2012 | Contract amendment did not revise Attachment B-3, "Deliverables/Liquidated Damages Matrix." |
Revision | 2.2 | June 1, 2012 | Contract amendment did not revise Attachment B-3, "Deliverables/Liquidated Damages Matrix." |
Revision | 2.3 | September 1, 2012 | Item 27 is modified to remove the quarterly reports for item (a), add pharmacy to items (d) and (e), and to add item (f) Medicaid Managed Care Texas Health Steps Medical Checkups Quarterly Utilization Reports. Item 28 is modified to replace references to “1915 (c) Waiver” with “HCBS STAR +PLUS Waiver”. |
Revision | 2.4 | March 1, 2013 | Item 19 is modified to clarify liquidated damage assessment and variance. |
Revision | 2.5 | June 1, 2013 | Contract amendment did not revise Attachment B-3, "Deliverables/Liquidated Damages Matrix." |
Revision | 2.6 | September 1, 2013 | Items 4, 6, 7, 16, 23, 24, 26, 27, 28, 29, 30, and 31 are modified to add “not submitted” to the LD. Items 10 and 21 are modified and items 28-31 are added to include pharmacy requirements. All subsequent items are renumbered. Items 21 and 22 are modified to include pharmacy claims. Item 24 is modified to change the name of the report. Item 27 is modified to remove quarterly from the measurement period. |
Revision | 2.7 | September 1, 2013 | Contract amendment did not revise Attachment B-3, "Deliverables/Liquidated Damages Matrix." |
Revision | 2.8 | January 1, 2014 | Contract amendment did not revise Attachment B-3, "Deliverables/Liquidated Damages Matrix." |
Revision | 2.9 | February 1, 2014 | Item 9 Geo-Mapping is added. All subsequent items are renumbered. |
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. |
# | Service/ Component1 | Performance Standard2 | Measurement Period3 | Measurement Assessment4 | Liquidated Damages |
1. | General Requirement: Failure to Perform an Administrative Service Contract Attachment A, "Uniform Managed Care Contract Terms and Conditions", Contract Attachment B-1, RFP §§ 6, 7, 8 and 9 | The MCO fails to timely perform an MCO 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). | Ongoing | Each incident of non-compliance per MCO Program and SA. | HHSC may assess up to $5,000.00 per calendar day for each incident of non-compliance per MCO Program and SA. |
2. | General Requirement: Failure to Provide a Covered Service Contract Attachment A, "Uniform Managed Care Contract Terms and Conditions", Contract Attachment B-1, RFP §§ 6, 7, 8 and 9 | The MCO fails to timely provide a MCO 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. | Ongoing | Each calendar day of non-compliance | HHSC may assess up to $ 7,500.00 per day for each incident of non-compliance. |
3. | Contract Attachment A, "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 MCO Administrative Services; and (iv) 30 calendar days prior to the termination date of any other Material Subcontract. | Transition, Measured Quarterly during the Operations Period | Each calendar day of non-compliance, per MCO 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 | 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 the 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 | Each calendar day of non-compliance, per MCO Program, per SA. | HHSC may assess up to $250 per calendar day if the report/deliverable is not submitted, late, inaccurate, or incomplete. |
5. | Contract Attachment B-1, RFP §7.2 Transition Phase Schedule Contract Attachment B-1, RFP §7.2.1 Contract Start-Up and Planning Contract Attachment B-1, RFP §8.1 General Scope | The MCO must be operational no later than the agreed upon Operations Start Date. HHSC, or its agent, will determine when the MCO is considered to be operational based on the requirements in Section 7 and 8 of Attachment B-1. | Operations Start Date | Each calendar day of non-compliance, per MCO Program, per Service Area (SA). | HHSC may assess up to $10,000 per calendar day for each day beyond the Operations Start date that the MCO is not operational until the day that the MCO is operational, including all systems. |
6. | Contract Attachment B-1, RFP §7.2.5 System Readiness Review | The MCO must submit to HHSC or to the designated Readiness Review Contractor the following plans for review, no later than 120 days prior to Operational Start Date: • Joint Interface Plan; • Disaster Recovery Plan; • Business Continuity Plan; • Risk Management Plan; and • Systems Quality Assurance Plan. | Transition Period | Each calendar day of non-compliance, per report, per MCO Program, and per SA. | HHSC may assess up to $1,000 per calendar day for each day a deliverable is not submitted, late, inaccurate or incomplete. |
7. | Contract Attachment B-1, RFP §7.2.7 Operations Readiness | 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. | Transition Period | Each calendar day of non-compliance, per directory, per MCO Program and per SA. | HHSC may assess up to $1,000 per calendar day for each day the directory is not submitted, late, inaccurate or incomplete. |
8. | Attachment B-1, RFP Sections 7.2.8.1 and 8.1.19 | The MCO must submit or comply with the requirements of the HHSC-approved Fraud and Abuse Compliance Plan. | Transition, Operations, and Turnover | Each incident of noncompliance, per MCO Program | HHSC may assess up to $250 per calendar day for each incident of noncompliance, per MCO Program. |
9. | Attachment B-1, Section 8.1.3 Access to Care UMCM Chapter 5.14 Geo-Mapping | The MCO must comply with the contract’s mileage standards and benchmarks for member access. | Quarterly | Per incident of noncompliance, per Program, Service Area, and Provider type | HHSC may assess up to $1,000 per quarter, per Program, per Service Area, and per Provider type. |
10. | Contract Attachment B-1, RFP §8.1.4 Provider Network UMCM Chapter 5.38 Out of Network Utilization Report | (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. | Measured Quarterly beginning March 1, 2010. | Per incident of non-compliance, per Medicaid MCO, per Service Area. | HHSC may assess up to $25,000 per quarter, per standard, per Medicaid MCO, per Service Area. |
11. | Contract Attachment B-1, RFP §8.1.4.7 Provider Hotline; §8.1.21.1 Prior Authorization for Prescription Drugs and 72-Hour Emergency Supplies | A. The MCO must operate a toll-free Provider telephone hotline for 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 abandonment rate— Call abandonment rate is seven percent (7%) or less. C. Average hold time is two (2) minutes or less. | Operations and Turnover | A. Each incident of non-compliance per MCO Program and SA. B. Each percentage point below the standard for 1 and each percentage point above the standard for 2 per MCO 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. | HHSC may assess: A. Per MCO 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 MCO Program and SA for each percentage point for each standard that the MCO fails to meet the requirements for a monthly reporting period for any MCO operated toll-free lines. C. Up to $100.00 may be assessed for each 30 second time increment, or portion thereof, by which the MCO’s average hold time exceeds the maximum acceptable hold time. |
12. | Contract Attachment B-1, RFP §8.1.5.6 Member Services Hotline | A. The MCO 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 forth 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 seven percent (7%) or less. C. Average hold time is two (2) minutes or less. | Ongoing during Operations and Turnover | A. Each incident of non-compliance per. MCO Program and SA. B. Each percentage point below the standard for 1 and 2 and each percentage point above the standard for 3 per MCO 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. | HHSC may assess: A. Per MCO 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 MCO Program and SA, up to $100.00 for each percentage point for each standard that the MCO fails to meet the requirements for a monthly reporting period for any MCO operated toll-free lines. C. Up to $100.00 may be assessed for each 30 second time increment, or portion thereof, by which the MCO’s average hold time exceeds the maximum acceptable hold time. |
13. | Contract Attachment B-1, RFP §8.1.5.9 Member Complaint and Appeal Process 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 Contract Attachment B-1, RFP §8.2.4.1 Provider Complaints | The MCO must resolve at least 98% of Member and Provider Complaints within 30 calendar days from the date the Complaint is received by the MCO. | Measured Quarterly during the Operations Period | Per reporting period, per MCO Program, per SA. | HHSC may assess up to $250 per reporting period if the MCO fails to meet the performance standard. |
14. | Contract Attachment B-1, RFP §8.1.5.9 Member Complaint and Appeal Process Contract Attachment B-1, RFP §8.2.7.2 Medicaid Standard Member Appeal Process Contract Attachment B-1, RFP § 8.4.3 CHIP Member Complaint and Appeal Process | The MCO must resolve at least 98% of Member Appeals within 30 calendar days from the date the Appeal is filed with the MCO. | Measured Quarterly during the Operations Period | Per reporting period, per MCO Program, per SA. | HHSC may assess up to $500 per reporting period if the MCO fails to meet the performance standard. |
15. | Contract Attachment B-1, RFP §8.1.6 Marketing & Prohibited Practices Uniform Managed Care Manual Chapter 4.3 | The MCO may not engage in prohibited marketing practices. | Transition, Measured Quarterly during the Operations Period | Per incident of non-compliance. | HHSC may assess up to $1,000 per incident of non-compliance. |
16. | Contract Attachment B-1, RFP §8.1.15.3 Behavioral Health Services Hotline | A. The MCO must have an emergency and crisis Behavioral Health services Hotline available 24 hours a day, seven (7) days a week, toll-free throughout the Service Area(s). B. Crisis hotline staff must include or have access to qualified Behavioral Health Services professionals to assess behavioral health emergencies. C. The MCO must ensure that the toll-free Behavioral Health Services Hotline meets the following minimum performance requirements for the MCO Program: 1. Call pickup rate: 99% of calls are answered by 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: The call abandonment rate is seven percent (7%) or less. D. Average hold time is two (2) minutes or less. | Operations and Turnover | A. Each incident of non-compliance per MCO Program and SA. B. Each incident of non-compliance per MCO Program and SA. C. Per MCO 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 thereof, by which the average hold time exceeds the maximum acceptable hold time. | 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 occurrence that HHSC identifies through its recurring monitoring processes 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 MCO fails to meet the requirements for a monthly reporting period for any MCO operated toll-free lines. D. Up to $100.00 may be assessed for each 30 second time increment, or portion thereof, by which the MCO’s average hold time exceeds the maximum acceptable hold time. |
17. | Contract Attachment B-1, RFP §8.1.17.1 Financial Reporting Requirements Uniform Managed Care Manual Chapter 5.0 | Financial Statistical Reports (FSR): For each MCO Program and SA, the MCO 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. | Quarterly during the Operations Period | Per calendar day of non-compliance, per MCO Program, per SA. | HHSC may assess up to $1,000 per calendar day a quarterly or annual report is not submitted, late, inaccurate or incomplete. |
18. | Contract Attachment B-1, RFP §8.1.17.1 Financial Reporting Requirements: Uniform Managed Care Manual Chapter 5.0 | Medicaid Disproportionate Share Hospital (DSH) Reports: The Medicaid MCO 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 or CHIP Perinatal Programs. Any claims added after July 1st shall include supporting claim documentation for HHSC validation. | Measured during 4th Quarter of the Operations Period (6/1–8/31) | Per calendar day of non-compliance, per MCO Program, per SA. | 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. |
19. | Contract Attachment B-1, RFP §8.1.18 Management Information System (MIS) Requirements | The MCO’s MIS must be able to resume operations within 72 hours of employing its Disaster Recovery Plan. | Measured Quarterly during the Operations Period | Per calendar day of non-compliance, per MCO Program, per SA. | HHSC may assess up to $5,000 per calendar day of non-compliance |
20. | Contract Attachment B-1, RFP §8.1.18.1 Encounter Data | The MCO must submit Encounter Data transmissions and include all Encounter Data and Encounter Data adjustments processed by the MCO 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. Pharmacy Encounter Data must be submitted no later than 25 calendar days after the date of adjudication and include all Encounter Data and Encounter Data adjustments. Additionally, the MCO will be subject to liquidated damages if the Quarterly Encounter Reconciliation Report (which reconciles the yearto- 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. | Measured Quarterly during Operations Period | Per incident of non-compliance, per MCO Program, per Service Area (SA) | Liquidated Damages: a) Failure to submit Encounter Data: 1. HHSC may assess up to $2,500 per Financial Arrangement Code, per month (or every 25 days for Pharmacy Encounter Data), per Program, per SA if the MCO fails to submit encounter data in a quarter. 2. HHSC may assess up to $5,000 per Financial Arrangement Code, per month (or every 25 days for Pharmacy Encounter Data), per Program, per SA for each month in any subsequent quarter that the MCO fails to submit Encounter Data. b) Encounter Data Reconciliation: Additionally, HHSC may assess up to $2,500 per Quarter, per Program, per SA if the MCO is not within the 2% variance. HHSC may assess up to $5,000 per Quarter, per Program, per SA for each additional Quarter that the MCO is not within the 2% variance. |
21. | Contract Attachment B-1, RFP §8.1.18.3 System-Wide Functions | The MCO’s MIS system must meet all requirements in Section 8.1.18.3 of Attachment B-1. | Measured Quarterly during the Operations Period | Per calendar day of non-compliance, per MCO Program, per SA. | HHSC may assess up to $5,000 per calendar day of non-compliance. |
22. | Contract Attachment B-1, RFP §8.1.18.5 Claims Processing Requirements and §8.1.21.14 Pharmacy Claims and File Processing Uniform Managed Care Manual Chapter 2.0 and 2.2 | The MCO must adjudicate all provider Clean Claims within 30 days of receipt by the MCO. The MCO must pay providers interest at 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 to the provider must be paid on the same date as the claim. The MCO must adjudicate all Clean Claims for outpatient pharmacy benefits within (1) 18 days after receipt by the MCO if submitted electronically, or (2) 21 days after receipt by the MCO if submitted non-electronically. The MCO must pay providers interest at 18% per annum, calculated daily for the full period in which the Clean Claim remains unadjudicated beyond the 18-day or 21-day claims-processing deadline. Interest owed to the provider must be paid on the same date as the claim. | Measured Quarterly during the Operations Period | Per incident of non-compliance. | HHSC may assess up to $1,000 per claim if the MCO fails to pay interest timely. |
23. | Contract Attachment B-1, RFP §8.1.18.5 Claims Processing Requirements Uniform Managed Care Manual Chapters 2.0 and 2.2 | The MCO must comply with the claims processing requirements and standards as described in Section 8.1.18.5 of Attachment B-1 and in Chapters 2.0 and 2.2 of the Uniform Managed Care Manual. | Measured Quarterly during the Operations Period | Per quarterly reporting period, per MCO Program, per Service Area, per claim type. | HHSC may assess liquidated damages of up to $5,000 for the first quarter that an MCO’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. |
24. | Attachment B-1, RFP Section 8.1.19 | The MCO must respond to Office of Inspector General request for information in the manner and format requested. | Transition, Operations, and Turnover | Each calendar day of noncompliance, per MCO Program. | HHSC may assess up to $250 per calendar day, per MCO Program, that the report is not submitted, late, inaccurate, or incomplete. |
25. | Attachment B-1, RFP Section 8.1.20.2, UMCM Chapter 5.5 | The MCO must submit a Fraudulent Practices Report to the HHSC-OIG within 30 Business Days of receiving a report of possible Waste, Abuse, or Fraud from the MCO’s Special Investigative Unit (SIU). The MCO must submit quarterly MCO Open Case List Reports. | Transition, Operations, and Turnover | Each calendar day of noncompliance, per MCO Program. | HHSC may assess up to $250 per calendar day, per MCO Program, that the report is not submitted, late, inaccurate, or incomplete. |
26. | Attachment B-1, RFP §8.1.20.2 Reports Attachment B-1, RFP §8.2.5.1 Provider Complaints Attachment B-1, RFP §8.2.7.1 Member Complaint Process | The MCO fails to submit a timely response to an HHSC Member or Provider Complaint received by HHSC and referred to the MCO by the specified due date. The MCO response must be submitted according to the timeframes and requirements stated within the MCO Notification Correspondence (letter, email, etc). | Measured on a Quarterly Basis | Each incident of non-compliance per MCO Program and SA | HHSC may assess up to $250 per calendar day for each day beyond the due date specified within the MCO Notification Correspondence. |
27. | Contract Attachment B-1, RFP §8.1.20.2 Reports Uniform Managed Care Manual Chapters 2.0 and 5.0 | Claims Summary Report: The MCO must submit quarterly, Claims Summary Reports to HHSC by MCO Program, by Service Area, and by claim type, by the 30th day following the reporting period unless otherwise specified. | Measured Quarterly during the Operations Period | Per calendar day of non-compliance, per MCO Program, per Service Area, per claim type. | HHSC may assess up to $1,000 per calendar day the report is not submitted, late, inaccurate, or incomplete. |
28. | Contract Attachment B-1, RFP §8.1.20.2 Reports; Uniform Managed Care Manual Chapter 12 Frew | (a) Medicaid Managed Care Texas Health Steps Medical Checkups Reports - The MCO must submit an annual report of the number of New Members and Existing Members that receive timely Texas Health Steps (THSteps) medical checkups or refuse to obtain medical checkups. (b) Children of Migrant Farm Workers Annual Plan and Children of Migrant Farm Workers Annual Report - The MCO must submit an annual plan that describes how the MCO will identify and provide accelerated services to Children of Migrant Farm Workers and an annual report that summarizes the MCO's migrant efforts as stated in its annual plan. (c) Frew Quarterly Monitoring Report - The MCO must submit each quarter responses to questions on this report's template addressing the status of Frew Consent Decree paragraphs. | (a) Annually (b) Annually (c) Quarterly (d) Annually (e) Quarterly (f) Quarterly | (a) Per calendar day of non-compliance per Program. (b) Plan: Per calendar day of non-compliance. Report: Per calendar day of non-compliance per Program and Service Area. (c) Per calendar day of non-compliance per MCO. (d) Per calendar day of non-compliance per MCO. (e) Per calendar day of non-compliance per MCO. (f) Per calendar day of non-compliance per Program. | HHSC may assess up to $1,000 per calendar day for the first measurement period the reports are not submitted, late, inaccurate, or incomplete. HHSC may assess up to $5,000 per calendar day for each consecutive measurement period that a subsequent report is not submitted, late, inaccurate, or incomplete. In addition, HHSC may assess up to $2,500 per calendar day for any report resubmissions that are not submitted, late, inaccurate, or incomplete within each measurement period. |
(d) Frew Annual Provider Training Report - The MCO must submit an annual report of health care and pharmacy provider training conducted throughout the year on Texas Health Steps, Frew, and/or pharmacy benefit education topics that includes the number of Medicaid providers that received training and feedback received on the subject matter and methodology of the training. (e) Frew Provider Recognition Report - The MCO must submit a quarterly report of Medicaid enrolled healthcare and pharmacy providers who attended the MCO's training on Frew, Texas Health Steps, and/or pharmacy benefit education topics and consented to being recognized as having attended training on the HHSC website. (f) Medicaid Managed Care Texas Health Steps Medical Checkups Quarterly Utilization Reports - Each State Fiscal Quarter, the MCO must submit a report of the number and percent of Members birth through age 20 receiving at least one Texas Health Steps medical checkup in total and broken down by various age groups. |
29. | Contract Attachment B-1, §8.1.21.1 Formulary and Preferred Drug List | The MCO fails to allow Network Providers free access to a point-of- care web-based application accessible to smart phones, tablets, or similar technology. The application must also identify preferred/non-preferred drugs; Clinical Edits, and any preferred drugs that can be substituted for non-preferred drugs. The MCO must update this information at least weekly. | Ongoing | Each calendar day of non-compliance | HHSC may assess up to $5,000 per calendar day for each incident of non-compliance per MCO Program. |
30. | Contract Attachment B-1, §8.1.21.2 Prior Authorization (PA) for Prescription Drugs and 72-Hour Emergency Supplies | The MCO fails to reimburse a pharmacy for providing a 72-hour emergency supply as outlined in this section or fails to make a prior authorization determination within 24 hours of the request. | Ongoing | Each incident of noncompliance | HHSC may assess up to $5,000 per incident of non-compliance per MCO Program. |
31. | Contract Attachment B-1, §8.1.21.5 Pharmacy Rebate Program Uniform Managed Care Manual, Chapters 2.0 and 2.2 | The MCO fails to include valid national drug codes (NDCs) on encounters for outpatient prescription drugs, including physician-administered drugs. | Ongoing | Each incident of noncompliance | HHSC may assess up to $500 for each incident of non-compliance per MCO Program. |
32. | Contract Attachment B-1, §8.1.21.16 E-Prescribing | The MCO fails to provide timely data updates to the national e-prescribing network | Ongoing | Each calendar day of Non compliance | HHSC may assess up to $5,000 per calendar day of non-compliance per MCO Program. |
33. | 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 §8.3.4.2 217-Like Group 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 HCBS STAR+PLUS Waiverservices for 217-Like Group applicants; 2) from the date of the Member's request for HCBS STAR+PLUS Waiver services for current Members requesting an upgrade; or 3) prior to the annual ISP expiration date for all Members receiving HCBS STAR+PLUS 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 not submitted, late, inaccurate or incomplete. |
34. | Contract Attachment B-1, RFP §9.3 Transfer of Data | The MCO must transfer all data regarding the provision of Covered Services to Members to HHSC or a new MCO, at the sole discretion 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 MCO Program, per SA. | HHSC may assess up to $10,000 per calendar day the data is not submitted,late, inaccurate or incomplete. |
35. | Contract Attachment B-1, RFP §9.4 Turnover Services | Six (6) months prior to the end of the contract period or any extension thereof, the MCO must propose a Turnover Plan covering the possible turnover of the records and information maintained to either the State (HHSC) or a successor MCO. | Measured at Six (6) 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 MCO Program, per SA. | HHSC may assess up to $1,000 per calendar day the Plan is not submitted, late, inaccurate, or incomplete. |
36. | Contract Attachment B-1, RFP §9.5 Post-Turnover Services | The MCO 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 MCO program, per SA. | HHSC may assess up to $250 per calendar day the report is not submitted, late, inaccurate or incomplete. |
(a) the right to require Beneficiary to proceed against Subsidiary; |
(b) all requirements of presentment, protest or default and notices of presentment, protest or default; |
(c) any right to require Beneficiary to proceed against Subsidiary or to pursue any other remedy in Beneficiary's power whatsoever; |
(d) notice of acceptance of this Guarantee; |
(e) notice of any amendments, work authorizations, extensions of time for performance, changes in the work, or other acts by Beneficiary affecting Subsidiary's rights or obligations under the Contract; |
(f) notice of any breach or claim of breach by Subsidiary, provided Beneficiary has complied with any required notice provisions to Subsidiary under the Contract; |
(g) any defense arising out of the exercise by Beneficiary of any right or remedy it may have with respect to the Contract, including the right to amend or modify the Contract and the right to waive or delay the exercise of any rights it may otherwise have against Subsidiary; |
(h) notice of the settlement or compromise of any claim of Beneficiary against Subsidiary relating to any of Subsidiary’s obligations under the Contract; and |
(i) the benefit of suretyship defenses generally. |
(a) all other provisions hereof shall remain in full force and effect in such jurisdiction and shall be liberally construed in favor of Beneficiary in order to carry out the intentions of the parties hereto as nearly as may be possible; and |
(b) such invalidity, illegality or unenforceability shall not affect the validity or enforceability of such provision in any other jurisdiction. |
Year Ended December 31, | |||||||||||||||||||
2013 | 2012 | 2011 | 2010 | 2009 | |||||||||||||||
Earnings: | |||||||||||||||||||
Pre-tax earnings from continuing operations | $ | 268,917 | $ | 122,792 | $ | 188,349 | $ | 154,282 | $ | 137,508 | |||||||||
Addback: | |||||||||||||||||||
Fixed charges | 37,042 | 29,556 | 27,757 | 26,141 | 23,104 | ||||||||||||||
Subtract: | |||||||||||||||||||
Non-controlling interest | (619 | ) | 13,154 | 2,855 | (3,435 | ) | (2,574 | ) | |||||||||||
Interest capitalized | — | — | — | (1,089 | ) | (116 | ) | ||||||||||||
Total earnings | $ | 305,340 | $ | 165,502 | $ | 218,961 | $ | 175,899 | $ | 157,922 | |||||||||
Fixed Charges: | |||||||||||||||||||
Interest expensed and capitalized | $ | 26,957 | $ | 20,460 | $ | 20,320 | $ | 19,081 | $ | 16,434 | |||||||||
Interest component of rental payments (1) | 10,085 | 9,096 | 7,437 | 7,060 | 6,670 | ||||||||||||||
Total fixed charges | $ | 37,042 | $ | 29,556 | $ | 27,757 | $ | 26,141 | $ | 23,104 | |||||||||
Ratio of earnings to fixed charges | 8.24 | 5.60 | 7.89 | 6.73 | 6.84 | ||||||||||||||
(1) Estimated at 33% of rental expense as a reasonable approximation of the interest factor. |
List of Subsidiaries |
Absolute Total Care, Inc., a South Carolina corporation |
AcariaHealth Pharmacy #11, Inc., a Texas corporation |
AcariaHealth Pharmacy #12, Inc., a New York corporation |
AcariaHealth Pharmacy #13, Inc., a California corporation |
AcariaHealth Pharmacy #14, Inc., a California corporation |
AcariaHealth Pharmacy, Inc., a California corporation |
AcariaHealth Solutions, Inc., a Delaware corporation |
AcariaHealth, Inc., a Delaware Corporation |
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 |
Buckeye Community Health Plan, Inc., an Ohio corporation |
California Health and Wellness Plan, a California corporation |
Casenet, LLC, a Delaware LLC |
CBHSP Arizona, Inc., an Arizona corporation |
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, LLC, a California LLC |
Cenpatico Behavioral Health of Texas Inc., a Texas corporation |
Cenpatico of Louisiana, Inc., a Louisiana corporation |
Centene Center LLC, a Delaware LLC |
Centene Company of Texas, LP, a Texas limited partnership |
Centene Corporation, a Delaware corporation |
Centene Management Company, LLC, a Wisconsin LLC |
Centurion Group, Inc., a Delaware Corporation |
Centurion LLC, a Delaware LLC |
Centurion of Minnesota, LLC, a Minnesota LLC |
Centurion of Tennessee, LLC, a Tennessee LLC |
CMC Real Estate Company, LLC, a Delaware LLC |
Coordinated Care Corporation, Inc., an Indiana corporation |
Coordinated Care of Washington, Inc., a Washington corporation |
Family Care & Workforce Diversity Consultants LLC, d/b/a Worklife Innovations, a Connecticut LLC |
Granite State Health Plan, Inc., a New Hampshire corporation |
Hallmark Life Insurance Company, an Arizona corporation |
Health Plan Real Estate Holdings LLC, a Delaware LLC |
Healthy Louisiana Holdings LLC, a Delaware LLC |
Healthy Missouri Holdings, Inc., a Missouri corporation |
Home State Health Plan, Inc., a Missouri corporation |
IlliniCare Health Plan, Inc., an Illinois corporation |
Integrated Mental Health Services, a Texas corporation |
Kentucky Spirit Health Plan, Inc., a Kentucky corporation |
LBB Industries, Inc., a Texas corporation |
LifeShare Management Group, LLC, a New Hampshire LLC |
LSM Holdco, Inc., a Delaware corporation |
Louisiana Health Care Connections, Inc., a Louisiana corporation |
Magnolia Health Plan, Inc., a Mississippi corporation |
Managed Health Services Insurance Corporation, a Wisconsin corporation |
Massachusetts Partnership of Correctional Healthcare, LLC, a Massachusetts LLC |
Novasys Health, Inc., a Delaware corporation |
Nurse Response, Inc., a Delaware corporation |
NurseWise, LP, a Delaware limited partnership |
Nurtur Health, Inc., a Delaware corporation |
Ocucare Systems, Inc., a Florida 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 |
RX Direct, Inc., a Texas corporation |
Specialty Therapeutic Care Holdings, LLC, a Delaware LLC |
Specialty Therapeutic Care, GP, LLC, a Texas LLC |
Specialty Therapeutic Care, LP, a Texas limited partnership |
Sunflower State Health Plan, Inc., a Kansas 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 |
U.S. Script IPA, LLC, a New York LLC |
Wellness By Choice, LLC, a New York LLC |
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 Rules 13a-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 most recent fiscal quarter (the registrant’s fourth fiscal quarter in the case of an annual report) 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. |
Dated: | February 21, 2014 | /s/ MICHAEL F. NEIDORFF | |
Chairman, President 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 Rules 13a-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 most recent fiscal quarter (the registrant’s fourth fiscal quarter in the case of an annual report) 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. |
Dated: | February 21, 2014 | /s/ 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. |
Dated: | February 21, 2014 | /s/ MICHAEL F. NEIDORFF | |
Chairman, President 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. |
Dated: | February 21, 2014 | /s/ WILLIAM N. SCHEFFEL | |
Executive Vice President and Chief Financial Officer (principal financial officer) |
D!
M\@'Z`@,"#`(4`AT")@(O`C@"00)+`E0"70)G`G$">@*$`HX"F`*B`JP"M@+!
M`LL"U0+@`NL"]0,``PL#%@,A`RT#.`-#`T\#6@-F`W(#?@.*`Y8#H@.N`[H#
MQP/3`^`#[`/Y!`8$$P0@!"T$.P1(!%4$8P1Q!'X$C`2:!*@$M@3$!-,$X03P
M!/X%#044%]@8&!A8&)P8W!D@&
M609J!GL&C`:=!J\&P`;1!N,&]0<'!QD'*P<]!T\'80=T!X8'F0>L![\'T@?E
M!_@("P@?"#((1@A:"&X(@@B6"*H(O@C2".<(^PD0"24).@E/"60)>0F/":0)
MN@G/">4)^PH1"B<*/0I4"FH*@0J8"JX*Q0K<"O,+"PLB"SD+40MI"X`+F`NP
M"\@+X0OY#!(,*@Q##%P,=0R.#*<,P`S9#/,-#0TF#4`-6@UT#8X-J0W##=X-
M^`X3#BX.20YD#G\.FPZV#M(.[@\)#R4/00]>#WH/E@^S#\\/[!`)$"800Q!A
M$'X0FQ"Y$-<0]1$3$3$13Q%M$8P1JA')$>@2!Q(F$D429!*$$J,2PQ+C$P,3
M(Q-#$V,3@Q.D$\43Y10&%"<4211J%(L4K13.%/`5$A4T%585>!6;%;T5X!8#
M%B86219L%H\6LA;6%OH7'1=!%V47B1>N%](7]Q@;&$`891B*&*\8U1CZ&2`9
M11EK&9$9MQG=&@0:*AI1&G<:GAK%&NP;%!L[&V,;BANR&]H<`APJ'%(<>QRC
M',P<]1T>'4<=:AZ4'KX>Z1\3'SX?:1^4'[\?ZB`5($$@
M;""8(,0@\"$<(4@A=2&A( &YXS'DJ>8EYYWI&
M>J5[!'MC>\)\(7R!?.%]07VA?@%^8G["?R-_A'_E@$>`J($*@6N!S8(P@I*"
M](-7@[J$'82`A..%1X6KA@Z& W$SE@S-%')Y)"?N]V_P#>
M1_,N]2GWE8$]F#BY245<1V5%8,6@1N`29U)&=IN9\CV.)2/R)%)XX)Z#O5;7)1-"C*05,ML58<@@W$>"#52U\*FU@,"R#
M=N@=7*<`P+"HRNX9SY7J.OM3[^Q^Q6Z)G)-Q"['&/FDND=L#G`RQP,G`[GK5
M4U%3C9_:!['34445[)F%%%%`!1110`4444`%%%%`!1110`4444`%%%%`!111
M0`4444`%%%%`!1110`4444`%%%%`!1110`4444`%%%%`!1110`4444`%%%%`
M!1110`4444`%%%%`!1110`4444`%%%%`!1110`4444`%%%%`!1110`4444`%
M%%%`!1110`4444`%%%%`!1110`4444`%%%%`!1110`4444`%%%%`!1110`44
M44`%%%%`!1110`4444`%%%%`!1110`4444`%%%%`!1110`4444`%%%%`!111
M0`4444`%%%%`!1110`4444`%%%%`!1110`4444`%%%%`!1110`4444`%%%%`
M!1110`4444`%%%%`!1110`4444`%%%%`!1110`4444`%%%%`!1110`4444`%
M%%%`!1110`4444`%%%%`!1110`4444`%%%%`!1110`4444`%%%%`!1110`44
M44`%%%%`!1110`4444`%%%%`!1110!BI_P`?DO\`UQ@_]#N*TJP[J.9[R3R7
M1?W,&[?&SY^>?&,2)C]:G^SWG_/6'_OP_P#\?KR<6E[9ZEQV-6BLK[/>?\]8
M?^_#_P#Q^C[/>?\`/6'_`+\/_P#'ZPY5W*-6BLK[/>?\]8?^_#__`!^C[/>?
M\]8?^_#_`/Q^CE7<#5HK*^SWG_/6'_OP_P#\?H^SWG_/6'_OP_\`\?HY5W`+
M?_C\E_ZXP?\`H<]:M?\]8
M?^_#_P#Q^G.*ON(U:*ROL]Y_SUA_[\/_`/'Z/L]Y_P`]8?\`OP__`,?IA)X-<+=7>K6
MBF25KM$'5G,RJ,\
QQY@FZ.G/C/XS_KH:1V
M"BHKNZ6T1I'.%0%F/7"J,GI6;#XE0R&&56B<1M,PDV8$:D#<65V7J3W_`(3G
M'&<5%L9KT5BP>+(9G,>'!^?&Y&5F\M(W8*A^
2ZG::G
1EF^8@#/S$^@H`X+Q?XODEU`:>9C;6X*B
M69/OG
!C'IG-8D6O?V+86K[0V
MZ.-3DL`H$)