| I. |
THE
VENDOR HEREBY AGREES:
|
|
1.
|
To
provide services according to the terms and conditions set forth
in this
Contract, Attachment
I,
Scope of Services, and all other attachments named herein which are
attached hereto and incorporated by
reference.
|
| 2. |
To
perform as an independent vendor and not as an agent, representative,
or
employee of the Agency.
|
| 3. |
To
recognize that the State of Florida, by virtue of its sovereignty,
is not
required to pay any taxes on the services or goods purchased under
the
terms of this Contract.
|
| B. |
Federal
Laws and Regulations
|
| 1. |
The
Vendor shall comply with the provisions of 45 CFR, Part 74, and/or
45 CFR,
Part 92, and other applicable regulations as specified in Attachments
I and II.
|
| 2. |
This
Contract contains federal funding in excess of $25,000. Pursuant
to 45
CFR, Part 76, if this Contract contains federal funding in excess
of
$25,000, the Vendor must, upon Contract execution, complete the
Certification Regarding Debarment, Suspension, Ineligibility, and
Voluntary Exclusion Contracts/Subcontracts, Attachment
IV.
|
| 3. |
This
Contract contains federal funding in excess of $100,000. The Vendor
must,
upon Contract execution, complete the Certification Regarding Lobbying
form, Attachment
V.
If a Disclosure of Lobbying Activities form, Standard Form LLL, is
required, it may be obtained from the Agency’s Contract Manager. All
disclosure forms as required by the Certification Regarding Lobbying
form
must be completed and returned to the Agency’s Contract
Manager.
|
| C. |
Audits
and Records
|
|
1.
|
To
maintain books, records, and documents (including electronic storage
media) pertinent to performance under this Contract in accordance
with
generally accepted accounting procedures and practices which sufficiently
and properly reflect all revenues and expenditures of funds provided
by
the Agency under this Contract.
|
|
2.
|
To
assure that these records shall be subject at all reasonable times
to
inspection, review, or audit by state personnel and other personnel
duly
authorized by the Agency, as well as by federal
personnel.
|
|
3.
|
To
maintain and file with the Agency such progress, fiscal and inventory
reports as specified in Attachment
II,
and other reports as the Agency may require within the period of
this
Contract. In addition, access to relevant computer data and applications
which generated such reports should be made available upon
request.
|
|
4.
|
To
ensure that all related party transactions are disclosed to the Agency
Contract Manager.
|
|
5.
|
To
include these aforementioned audit and record keeping requirements
in all
approved subcontracts and
assignments.
|
| D. |
Retention
of Records
|
|
1.
|
To
retain all financial records, supporting documents, statistical records,
and any other documents (including electronic storage media) pertinent
to
performance under this Contract for a period of five (5) years after
termination of this Contract, or if an audit has been initiated and
audit
findings have not been resolved at the end of five (5) years, the
records
shall be retained until resolution of the audit
findings.
|
| E. |
Monitoring
|
|
1.
|
To
provide reports as specified in Attachment
II.
These reports will be used for monitoring progress or performance
of the
contractual services as specified in Attachment
II.
|
|
2.
|
To
permit persons duly authorized by the Agency to inspect any records,
papers, documents, facilities, goods and services of the Vendor which
are
relevant to this Contract.
|
| F. |
Indemnification
|
|
1.
|
To
the extent required by law, the Vendor will be self-insured against,
or
will secure and maintain during the life of the Contract, Worker’s
Compensation Insurance for all his employees connected with the work
of
this project and, in case any work is subcontracted, the Vendor shall
require the subcontractor similarly to provide Worker’s Compensation
Insurance for all of the latter’s employees unless such employees engaged
in work under this Contract are covered by the Vendor’s self insurance
program. Such self insurance or insurance coverage shall comply with
the
Florida Worker’s Compensation law. In the event hazardous work is being
performed by the Vendor under this Contract and any class of employees
performing the hazardous work is not protected under Worker’s Compensation
statutes, the Vendor shall provide, and cause each subcontractor
to
provide, adequate insurance satisfactory to the Agency, for the protection
of his employees not otherwise
protected.
|
|
2.
|
The
Vendor shall secure and maintain Commercial General Liability insurance
including bodily injury, property damage, personal & advertising
injury and products and completed operations. This insurance will
provide
coverage for all claims that may arise from the services and/or operations
completed under this Contract, whether such services and/or operations
are
by the Vendor or anyone directly, or indirectly employed by him.
Such
insurance shall include a Hold Harmless Agreement in favor of the
State of
Florida and also include the State of Florida as an Additional Named
Insured for the entire length of the Contract. The Vendor is responsible
for determining the minimum limits of liability necessary to provide
reasonable financial protections to the Vendor and the State of Florida
under this Contract.
|
|
3.
|
All
insurance policies shall be with insurers licensed or eligible to
transact
business in the State of Florida. The Vendor’s current certificate of
insurance shall contain a provision that the insurance will not be
canceled for any reason except after thirty (30) days written notice
to
the Agency’s Contract Manager.
|
|
Toneither
assign the responsibility of this Contract to another party nor
subcontract for any of the work contemplated under this Contract
without
prior written approval of the Agency.
No such approval by the Agency of any assignment or subcontract shall
be
deemed in any event or in any manner to provide for the incurrence
of any
obligation of the Agency in addition to the total dollar amount agreed
upon in this Contract. All such assignments or subcontracts shall
be
subject to the conditions of this Contract and to any conditions
of
approval that the Agency shall deem
necessary.
|
|
To provide financial reports to the Agency as specified in Attachment
II.
|
|
To
return to the Agency any overpayments due to unearned funds or funds
disallowed pursuant to the terms of this Contract that were disbursed
to
the Vendor by the Agency. The Vendor shall return any overpayment
to the
Agency within forty (40) calendar days after either discovery by
the
Vendor, its independent auditor, or notification by the Agency, of
the
overpayment.
|
|
2.
|
RESPECT
of Florida
|
|
It
is expressly understood and agreed that any articles that are the
subject
of, or required to carry out, this Contract shall be purchased from
a
nonprofit agency for the blind or for the severely handicapped that
is
qualified pursuant to Chapter 413, Florida Statutes, in the same
manner
and under the same procedures set forth in Section 413.036(1) and
(2),
Florida Statutes; and for purposes of this Contract the person, firm,
or
other business entity carrying out the provisions of this Contract
shall
be deemed to be substituted for the state agency insofar as dealings
with
such qualified nonprofit agency are
concerned.
|
|
RESPECT
of Florida.
2475
Apalachee Parkway, Suite 205
Tallahassee,
Florida 32301-4946
(850)
487-1471
Website:
www.respectofflorida.org
|
|
3.
|
Procurement
of Products or Materials with Recycled
Content
|
|
1.
|
Title
VI of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000d et
seq., which prohibits discrimination on the basis of race, color,
or
national origin.
|
|
2.
|
Section
504 of the Rehabilitation Act of 1973, as amended,
29 U.S.C. 794, which prohibits discrimination on the basis of
handicap.
|
|
3.
|
Title
IX of the Education Amendments of 1972, as amended,
20 U.S.C. 1681 et seq., which prohibits discrimination on the
basis of sex.
|
|
4.
|
The
Age Discrimination Act of 1975, as amended, 42 U.S.C. 6101 et seq.,
which
prohibits discrimination on the basis of
age.
|
|
5.
|
Section
654 of the Omnibus Budget Reconciliation Act of 1981, as amended,
42 U.S.C. 9849, which prohibits discrimination on the basis of
race, creed, color, national origin, sex, handicap, political affiliation
or beliefs.
|
|
6.
|
The
Americans with Disabilities Act of 1990, P.L. 101-336, which prohibits
discrimination on the basis of disability and requires reasonable
accommodation for persons with
disabilities.
|
|
7.
|
All
regulations, guidelines, and standards as are now or may be lawfully
adopted under the above statutes.
|
|
Anentity
or affiliate who has been placed on the discriminatory vendor list
may not
submit a bid, proposal, or reply on a contract to provide any goods
or
services to a public entity; may not submit a bid, proposal, or reply
on a
contract with a public entity for the construction or repair of a
public
building or public work; may not submit bids, proposals, or replies
on
leases of real property to a public entity; may not be awarded or
perform
work as a contractor, supplier, subcontractor, or consultant under
a
contract with any public entity; and may not transact business with
any
public entity. The Florida Department of Management Services is
responsible for maintaining the discriminatory vendor list and intends
to
post the list on its website. Questions regarding the discriminatory
vendor list may be directed to the Florida Department of Management
Services, Office of Supplier Diversity at (850)
487-0915.
|
|
1.
|
To
submit bills for fees or other compensation for services or expenses
in
sufficient detail for a proper pre-audit and post-audit
thereof.
|
|
2.
|
Where
applicable, to submit bills for any travel expenses in accordance
with
Section 112.061, Florida Statutes.
|
|
3.
|
To
provide units of deliverables, including reports, findings, and drafts,
in
writing and/or in an electronic format agreeable to both parties,
as
specified in Attachment
II, to
be received and accepted by the Contract Manager prior to
payment.
|
|
4.
|
To
comply with the criteria and final date by which such criteria must
be met
for completion of this Contract as specified in Section III, Paragraph
A.
of this Contract.
|
|
5.
|
To
allow public access to all documents, papers, letters, or other material
made or received by the Vendor in conjunction with this Contract,
unless
the records are exempt from Section 24(a) of Article I of the State
Constitution and Section 119.07(1), Florida Statutes. It is expressly
understood that substantial evidence of the Vendor's refusal to comply
with this provision shall constitute a breach of
Contract.
|
|
Q.
|
Use
Of Funds For Lobbying
Prohibited
|
|
A
person or affiliate who has been placed on the convicted vendor list
following a conviction for a public entity crime may not be awarded
or
perform work as a contractor, supplier, subcontractor, or consultant
under
a contract with any public entity, and may not transact business
with any
public entity in excess of the threshold amount provided in Section
287.017, Florida Statutes, for category two, for a period of 36 months
from the date of being placed on the convicted vendor
list.
|
|
To
comply with the Department of Health and Human Services Privacy
Regulations in the Code of Federal Regulations, Title 45, Sections
160 and
164, regarding disclosure of protected health information as specified
in
Attachment
III.
|
|
Not to
use or disclose any confidential information, including social security
numbers that may be supplied under this Contract pursuant to law,
and also
including the identity or identifying information concerning a Medicaid
recipient or services under this Contract for any purpose not in
conformity with state and federal laws, except upon written consent
of the
recipient, or his/her guardian.
|
|
To
comply with Section 274A (e) of the Immigration and Nationality Act.
The
Agency shall consider the employment by any contractor of unauthorized
aliens a violation of this Act. If the Vendor knowingly employs
unauthorized aliens, such violation shall be cause for unilateral
cancellation of this Contract. The Vendor shall be responsible for
including this provision in all subcontracts with private organizations
issued as a result of this
Contract.
|
|
To
pay for contracted services according to the conditions of Attachment
I
in
an amount not to exceed $380,666,421.00
subject to the availability of funds. The State of Florida's performance
and obligation to pay under this Contract is contingent upon an annual
appropriation by the Legislature.
|
|
Section
215.422, Florida Statutes, provides that agencies have 5 working
days to
inspect and approve goods and services, unless bid specifications,
Contract or purchase order specifies otherwise. With the exception
of
payments to health care providers for hospital, medical, or other
health
care services, if payment is not available within forty (40) days,
measured from the latter of the date the invoice is received or the
goods
or services are received, inspected and approved, a separate interest
penalty set by the Comptroller pursuant to Section 55.03, F. S.,
will be
due and payable in addition to the invoice amount. To obtain the
applicable interest rate, please contact the Agency’s Fiscal Section at
(850) 488-5869, or utilize the Department of Financial Services website
at
www.dfs.state.fl.us/interest.html.
Payments to health care providers for hospitals, medical or other
health
care services, shall be made not more than 35 days from the date
of
eligibility for payment is determined, and the daily interest rate
is
.0003333%. Invoices returned to a vendor due to preparation errors
will
result in a payment delay. Invoice payment requirements do not start
until
a properly completed invoice is provided to the Agency. A Vendor
Ombudsman, whose duties include acting as an advocate for vendors
who may
be experiencing problems in obtaining timely payment(s) from a State
agency, may be contacted at (850) 410-9724 or by calling the State
Comptroller’s Hotline,
1-800-848-3792.
|
|
1.
|
The
Agency’s Contract Manager’s name, address and telephone number for this
Contract is as follows:
|
| 2. |
The
Vendor’s Contract Manager’s name, address and telephone number for this
Contract is as follows:
|
|
3.
|
All
matters shall be directed to the Contract Managers for appropriate
action
or disposition. A change in Contract Manager by either party shall
be
reduced to writing through an amendment to this Contract by the
Agency.
|
|
1.
|
Modifications
of provisions of this Contract shall only be valid when they have
been
reduced to writing and duly signed during the term of the Contract.
The
parties agree to renegotiate this Contract if federal and/or state
revisions of any applicable laws, or regulations make changes in
this
Contract necessary.
|
|
2.
|
The
rate of payment and the total dollar amount may be adjusted retroactively
to reflect price level increases and changes in the rate of payment
when
these have been established through the appropriations process and
subsequently identified in the Agency's operating
budget.
|
|
1.
|
The
name (Vendor name as shown on Page 1 of this Contract) and mailing
address
of the official payee to whom the payment shall be
made:
|
|
2.
|
The
name of the contact person and street address where financial and
administrative records are
maintained:
|
|
This
Contract and its attachments as referenced herein contain all the
terms
and conditions agreed upon by the
parties.
|
|
STATE
OF FLORIDA, AGENCY FOR
HEALTH
CARE ADMINISTRATION
|
||||
|
SIGNED
BY:
|
/s/ Todd S. Farha |
SIGNED
BY:
|
/s/ Thomas Arnold | |
|
NAME:
|
Todd
S. Farha
|
NAME:
|
Thomas W. Arnold
|
|
|
TITLE:
|
President and CEO
|
TITLE:
|
Deputy Secretary, Medicaid
|
|
|
DATE:
|
6/26/06 |
DATE:
|
6/26/06 | |
| 1. |
Policies
and Procedures
|
| 2. |
Benefit
Grid/Customized Benefit Package
|
|
a.
|
The
Health Plan shall be paid capitation payments for each Agency Service
Area, based upon Exhibits 3 through 7, Tables 2 through 6, attached
hereto, depending on whether the Health Plan contracts for both the
Comprehensive Component and the Catastrophic Component, or Comprehensive
Component only, and whether the Health Plan is a Specialty Plan.
Kick
Payments shall be paid based upon the amounts specified in Exhibit
8,
Table 7, attached hereto, for covered transplant services and Exhibit
9,
Table 8, attached hereto, for covered obstetrical delivery
services.
|
|
b.
|
The
Health Plans overall payment will be dependent upon the actual Plan
Factor
and the percentage adjustment deducted for the Enhanced Benefits
Accounts.
Each month the Agency will provide, in writing, the Health Plan with
its
Plan Factor.
|
|
c.
|
All
payments made to the Health Plan shall be in accordance with this
section
(Section C, Method of Payment) and Attachment II, Section XIII, Payment
Methodology.
|
| a. |
The
Agency must approve, in writing, any increase in the Health Plan’s maximum
Enrollment level for each operational county and subpopulation to
be
served, as applicable. Such approval shall not be unreasonably withheld,
and shall be based upon the Health Plan’s satisfactory performance of
terms of the Contract and upon the Agency’s approval of the Health Plan’s
administrative and service resources, as specified in this Contract,
in
support of each Enrollment level.
|
| b. |
Exhibit
2, Table 1, attached hereto, indicates the Health Plan’s maximum
authorized Enrollment levels for each Medicaid Reform county and
each
applicable authorized eligibility category.
|
| a. |
Table
2 - Capitation Rates for Comprehensive Component and Catastrophic
Component Health Plans for each Medicaid Reform county for Children
and
Families and the Aged and Disabled without Medicare eligibility
categories. .
|
| b. |
Table
3 - Capitation Rates for Comprehensive Component Only Health Plans
for
each Medicaid Reform county for Children and Families and the Aged
and
Disabled without Medicare eligibility categories.
|
| c. |
Table
4 - Capitation Rate Table for SSI Medicare Part B Only and SSI Medicare.
Parts A and B Enrollees for all Medicaid Reform Counties.
|
| d. |
Table
5 - Capitation Rates for HIV/AIDS Populations for each Medicaid Reform
county.
|
| e. |
Table
6 - Capitation Rates for Medicaid Reform counties for All Medicaid
Reform
counties.
|
| a. |
Table
7 - Covered Transplant Services.
|
| b. |
Table
8 - Obstetrical Delivery Services, regardless of whether or not the
Health
Plan is at risk for the Comprehensive Component only, or is at risk
for
both the Comprehensive Component and the Catastrophic Component.
|
| (i) |
Broward
- Children and Families
|
|
Covered
Service Category
|
|
Visit/Script
Limit
|
Limit
Period
|
Dollar
Limit
|
Limit
Period (Annual)
|
Copay
Amount
|
Copay
Application
|
||
|
(Annual/
Monthly)
|
|||||||||
|
Hospital
Inpatient
|
|||||||||
|
Behavioral
Health
|
|
|
|
|
|
0
|
admit
|
||
|
Physical
Health
|
|
|
|
|
|
0
|
admit
|
||
|
|
|||||||||
|
Transplant
Services
|
|||||||||
|
Transplant
Services
|
|
|
|
|
|
|
|
||
|
|
|||||||||
|
Outpatient-services
|
|||||||||
|
Emergency
Room
|
|
|
|
|
|
|
|
||
|
Medical/Drug
Therapies (Chemo, Dialysis)
|
|
|
|
|
|
|
|
||
|
Ambulatory
Surgery - ASC
|
|
|
|
|
|
|
|
||
|
Hospital
Outpatient Surgery
|
|
|
|
|
|
0
|
visit
|
||
|
Lab/X-ray
|
|
|
|
|
|
0
|
day
|
||
|
Hospital
Outpatient Services NOS
|
|
|
|
|
Annual
|
0
|
visit
|
||
|
Outpatient
Therapy (PT/RT)
|
|
|
|
|
Annual
|
|
|
||
|
Outpatient
Therapy (OT/ST)
|
|
|
|
|
|
|
|
||
|
|
|||||||||
|
Maternity
and Family Planning Services
|
|||||||||
|
Inpatient
Hospital
|
|
|
|
|
|
|
|
||
|
Birthing
Centers
|
|
|
|
|
|
|
|
||
|
Physician
Care
|
|
|
|
|
|
|
|
||
|
Family
Planning
|
|
|
|
|
|
|
|
||
|
Pharmacy
|
|
|
|
|
|
|
|
||
|
|
|||||||||
|
Physician
and Phys Extender Services (non maternity)
|
|||||||||
|
EPSDT
|
|
|
|
|
|
|
|
||
|
Primary
Care Physician
|
|
|
|
|
|
0
|
visit
|
||
|
Specialty
Physician
|
|
|
|
|
|
0
|
visit
|
||
|
ARNP/Physician
Assistant
|
|
|
|
|
|
0
|
visit
|
||
|
Clinic
(FQHC, RHC)
|
|
|
|
|
|
0
|
visit
|
||
|
Clinic
(CHD)
|
|
|
|
|
|
|
|
||
|
Other
|
|
|
|
|
|
|
|
||
|
|
|||||||||
|
Other
Outpatient Professional Services
|
|||||||||
|
Home
Health Services
|
|
24
|
Annual
|
|
Annual
|
0
|
visit
|
||
|
Chiropractor
|
|
24
|
Annual
|
|
Annual
|
0
|
visit
|
||
|
Podiatrist
|
|
24
|
Annual
|
|
Annual
|
0
|
visit
|
||
|
Dental
Services
|
|
|
|
|
Annual
|
0
|
coinsurance
|
||
|
Vision
Services
|
|
|
|
|
Annual
|
0
|
visit
|
||
|
Hearing
Services
|
|
|
|
|
Annual
|
|
|
||
|
|
|||||||||
|
Outpatient
Mental Health
|
|||||||||
|
Outpatient
Mental Health
|
|
|
|
|
|
0
|
visit
|
||
|
|
|||||||||
|
Outpatient
Pharmacy
|
|||||||||
|
Outpatient
Pharmacy
|
|
|
Annual
|
|
Annual
|
|
|
||
|
|
|||||||||
|
Other
Services
|
|||||||||
|
Ambulance
|
|
|
|
|
|
|
|
||
|
Non-emergent
Transporation
|
|
|
|
|
|
0
|
trip
|
||
|
Durable
Medical Equipment
|
|
|
|
|
Annual
|
|
|
||
|
Expanded
Benefit
|
|||||||||
|
Adult
Dental
|
Adult
dental expanded to include unlimited fillings, periodontic deep
cleanings,
annual exam, two cleanings per year, and x-rays.
|
||||||||
|
Circumcision
|
Routine
newborn circumcision up to one year of age.
|
||||||||
|
Over
the Counter Benefit
|
Agency
approved over-the-counter drug benefit, not to exceed $25 per
household,
per month. Limited to non-prescription drugs containing a National
Drug
Code number, first aid and birth control supplies. Benefit must
be offered
through a plan’s pharmacy or plan’s
subcontractor.
|
||||||||
| (ii) |
Broward
- Elderly and Disabled
|
|
Covered
Service Category
|
|
Visit/Script
Limit
|
Limit
Period
|
Dollar
Limit
|
Limit
Period (Annual)
|
Copay
Amount
|
Copay
Application
|
|
(Annual/
Monthly)
|
|||||||
|
Hospital
Inpatient
|
|||||||
|
Behavioral
Health
|
|
|
|
|
|
0
|
admit
|
|
Physical
Health
|
|
|
|
|
|
0
|
admit
|
|
|
|||||||
|
Transplant
Services
|
|||||||
|
Transplant
Services
|
|
|
|
|
|
|
|
|
|
|||||||
|
Outpatient-services
|
|||||||
|
Emergency
Room
|
|
|
|
|
|
|
|
|
Medical/Drug
Therapies (Chemo, Dialysis)
|
|
|
|
|
|
|
|
|
Ambulatory
Surgery - ASC
|
|
|
|
|
|
|
|
|
Hospital
Outpatient Surgery
|
|
|
|
|
|
0
|
visit
|
|
Lab/X-ray
|
|
|
|
|
|
0
|
day
|
|
Hospital
Outpatient Services NOS
|
|
|
|
|
Annual
|
0
|
visit
|
|
Outpatient
Therapy (PT/RT)
|
|
|
|
|
Annual
|
|
|
|
Outpatient
Therapy (OT/ST)
|
|
|
|
|
|
|
|
|
|
|||||||
|
Maternity
and Family Planning Services
|
|||||||
|
Inpatient
Hospital
|
|
|
|
|
|
|
|
|
Birthing
Centers
|
|
|
|
|
|
|
|
|
Physician
Care
|
|
|
|
|
|
|
|
|
Family
Planning
|
|
|
|
|
|
|
|
|
Pharmacy
|
|
|
|
|
|
|
|
|
|
|||||||
|
Physician
and Phys Extender Services (non maternity)
|
|||||||
|
EPSDT
|
|
|
|
|
|
|
|
|
Primary
Care Physician
|
|
|
|
|
|
0
|
visit
|
|
Specialty
Physician
|
|
|
|
|
|
0
|
visit
|
|
ARNP/Physician
Assistant
|
|
|
|
|
|
0
|
visit
|
|
Clinic
(FQHC, RHC)
|
|
|
|
|
|
0
|
visit
|
|
Clinic
(CHD)
|
|
|
|
|
|
|
|
|
Other
|
|
|
|
|
|
|
|
|
|
|||||||
|
Other
Outpatient Professional Services
|
|||||||
|
Home
Health Services
|
|
120
|
Annual
|
|
Annual
|
0
|
visit
|
|
Chiropractor
|
|
24
|
Annual
|
|
Annual
|
0
|
visit
|
|
Podiatrist
|
|
24
|
Annual
|
|
Annual
|
0
|
visit
|
|
Dental
Services
|
|
|
|
|
Annual
|
0
|
coinsurance
|
|
Vision
Services
|
|
|
|
|
Annual
|
0
|
visit
|
|
Hearing
Services
|
|
|
|
|
Annual
|
|
|
|
|
|||||||
|
Outpatient
Mental Health
|
|||||||
|
Outpatient
Mental Health
|
|
|
|
|
|
0
|
visit
|
|
|
|||||||
|
Outpatient
Pharmacy
|
|||||||
|
Outpatient
Pharmacy
|
|
16
|
Monthly
|
|
Annual
|
|
|
|
|
|||||||
|
Other
Services
|
|||||||
|
Ambulance
|
|
|
|
|
|
|
|
|
Non-emergent
Transporation
|
|
|
|
|
|
0
|
trip
|
|
Durable
Medical Equipment
|
|
|
|
|
Annual
|
|
|
|
Adult
Dental
|
Adult
dental expanded to include unlimited fillings, periodontic deep
cleanings,
crowns, clear fillings, restorations, annual exam, two cleanings
per year,
and x-rays.
|
|
Circumcision
|
Routine
newborn circumcision up to one year of age.
|
|
Over
the Counter Benefit
|
Agency
approved over-the-counter drug benefit, not to exceed $25 per
household,
per month. Limited to non-prescription drugs containing a National
Drug
Code number, first aid and birth control supplies. Benefit must
be offered
through a plan’s pharmacy or plan’s subcontractor.
|
|
Meals
on Wheels
|
10
meals within 15 days of post discharge (medically
necessary)
|
| (iii) |
Duval
- Children and Families
|
|
Covered
Service Category
|
|
Visit/Script
Limit
|
Limit
Period
|
Dollar
Limit
|
Limit
Period (Annual)
|
Copay
Amount
|
Copay
Application
|
|
(Annual/
Monthly)
|
|||||||
|
Hospital
Inpatient
|
|||||||
|
Behavioral
Health
|
|
|
|
|
|
0
|
admit
|
|
Physical
Health
|
|
|
|
|
|
0
|
admit
|
|
|
|||||||
|
Transplant
Services
|
|||||||
|
Transplant
Services
|
|
|
|
|
|
|
|
|
|
|||||||
|
Outpatient-services
|
|||||||
|
Emergency
Room
|
|
|
|
|
|
|
|
|
Medical/Drug
Therapies (Chemo, Dialysis)
|
|
|
|
|
|
|
|
|
Ambulatory
Surgery - ASC
|
|
|
|
|
|
|
|
|
Hospital
Outpatient Surgery
|
|
|
|
|
|
0
|
visit
|
|
Lab/X-ray
|
|
|
|
|
|
0
|
day
|
|
Hospital
Outpatient Services NOS
|
|
|
|
|
Annual
|
0
|
visit
|
|
Outpatient
Therapy (PT/RT)
|
|
|
|
|
Annual
|
|
|
|
Outpatient
Therapy (OT/ST)
|
|
|
|
|
|
|
|
|
|
|||||||
|
Maternity
and Family Planning Services
|
|||||||
|
Inpatient
Hospital
|
|
|
|
|
|
|
|
|
Birthing
Centers
|
|
|
|
|
|
|
|
|
Physician
Care
|
|
|
|
|
|
|
|
|
Family
Planning
|
|
|
|
|
|
|
|
|
Pharmacy
|
|
|
|
|
|
|
|
|
|
|||||||
|
Physician
and Phys Extender Services (non maternity)
|
|||||||
|
EPSDT
|
|
|
|
|
|
|
|
|
Primary
Care Physician
|
|
|
|
|
|
0
|
visit
|
|
Specialty
Physician
|
|
|
|
|
|
0
|
visit
|
|
ARNP/Physician
Assistant
|
|
|
|
|
|
0
|
visit
|
|
Clinic
(FQHC, RHC)
|
|
|
|
|
|
0
|
visit
|
|
Clinic
(CHD)
|
|
|
|
|
|
|
|
|
Other
|
|
|
|
|
|
|
|
|
|
|||||||
|
Other
Outpatient Professional Services
|
|||||||
|
Home
Health Services
|
|
24
|
Annual
|
|
Annual
|
0
|
visit
|
|
Chiropractor
|
|
24
|
Annual
|
|
Annual
|
0
|
visit
|
|
Podiatrist
|
|
24
|
Annual
|
|
Annual
|
0
|
visit
|
|
Dental
Services
|
|
|
|
|
Annual
|
0
|
coinsurance
|
|
Vision
Services
|
|
|
|
|
Annual
|
0
|
visit
|
|
Hearing
Services
|
|
|
|
|
Annual
|
|
|
|
|
|||||||
|
Outpatient
Mental Health
|
|||||||
|
Outpatient
Mental Health
|
|
|
|
|
|
0
|
visit
|
|
|
|||||||
|
Outpatient
Pharmacy
|
|||||||
|
Outpatient
Pharmacy
|
|
|
Annual
|
|
Annual
|
|
|
|
|
|||||||
|
Other
Services
|
|||||||
|
Ambulance
|
|
|
|
|
|
|
|
|
Non-emergent
Transporation
|
|
|
|
|
|
0
|
trip
|
|
Durable
Medical Equipment
|
|
|
|
|
Annual
|
|
|
|
Adult
Dental
|
Adult
dental expanded to include unlimited fillings, periodontic deep
cleanings,
annual exam, two cleanings per year and x-rays.
|
|
Circumcision
|
Routine
newborn circumcision up to one year of age.
|
|
Over
the Counter Benefit
|
Agency
approved over-the -counter drug benefit, not to exceed $25 per
household,
per month. Limited to non-prescription drugs containing a National
Drug
Code number, first aid and birth control supplies. Benefit must
be offered
through a plan’s pharmacy or plan’s
subcontractor.
|
| (iv) |
Duval
- Elderly and Disabled
|
|
Covered
Service Category
|
|
Visit/Script
Limit
|
Limit
Period
|
Dollar
Limit
|
Limit
Period (Annual)
|
Copay
Amount
|
Copay
Application
|
|
(Annual/
Monthly)
|
|||||||
|
Hospital
Inpatient
|
|||||||
|
Behavioral
Health
|
|
|
|
|
|
0
|
admit
|
|
Physical
Health
|
|
|
|
|
|
0
|
admit
|
|
|
|||||||
|
Transplant
Services
|
|||||||
|
Transplant
Services
|
|
|
|
|
|
|
|
|
|
|||||||
|
Outpatient-services
|
|||||||
|
Emergency
Room
|
|
|
|
|
|
|
|
|
Medical/Drug
Therapies (Chemo, Dialysis)
|
|
|
|
|
|
|
|
|
Ambulatory
Surgery - ASC
|
|
|
|
|
|
|
|
|
Hospital
Outpatient Surgery
|
|
|
|
|
|
0
|
visit
|
|
Lab/X-ray
|
|
|
|
|
|
0
|
day
|
|
Hospital
Outpatient Services NOS
|
|
|
|
|
Annual
|
0
|
visit
|
|
Outpatient
Therapy (PT/RT)
|
|
|
|
|
Annual
|
|
|
|
Outpatient
Therapy (OT/ST)
|
|
|
|
|
|
|
|
|
|
|||||||
|
Maternity
and Family Planning Services
|
|||||||
|
Inpatient
Hospital
|
|
|
|
|
|
|
|
|
Birthing
Centers
|
|
|
|
|
|
|
|
|
Physician
Care
|
|
|
|
|
|
|
|
|
Family
Planning
|
|
|
|
|
|
|
|
|
Pharmacy
|
|
|
|
|
|
|
|
|
|
|||||||
|
Physician
and Phys Extender Services (non maternity)
|
|||||||
|
EPSDT
|
|
|
|
|
|
|
|
|
Primary
Care Physician
|
|
|
|
|
|
0
|
visit
|
|
Specialty
Physician
|
|
|
|
|
|
0
|
visit
|
|
ARNP/Physician
Assistant
|
|
|
|
|
|
0
|
visit
|
|
Clinic
(FQHC, RHC)
|
|
|
|
|
|
0
|
visit
|
|
Clinic
(CHD)
|
|
|
|
|
|
|
|
|
Other
|
|
|
|
|
|
|
|
|
|
|||||||
|
Other
Outpatient Professional Services
|
|||||||
|
Home
Health Services
|
|
120
|
Annual
|
|
Annual
|
0
|
visit
|
|
Chiropractor
|
|
24
|
Annual
|
|
Annual
|
0
|
visit
|
|
Podiatrist
|
|
24
|
Annual
|
|
Annual
|
0
|
visit
|
|
Dental
Services
|
|
|
|
|
Annual
|
0
|
coinsurance
|
|
Vision
Services
|
|
|
|
|
Annual
|
0
|
visit
|
|
Hearing
Services
|
|
|
|
|
Annual
|
|
|
|
|
|||||||
|
Outpatient
Mental Health
|
|||||||
|
Outpatient
Mental Health
|
|
|
|
|
|
0
|
visit
|
|
|
|||||||
|
Outpatient
Pharmacy
|
|||||||
|
Outpatient
Pharmacy
|
|
16
|
Monthly
|
|
Annual
|
|
|
|
|
|||||||
|
Other
Services
|
|||||||
|
Ambulance
|
|
|
|
|
|
|
|
|
Non-emergent
Transporation
|
|
|
|
|
|
0
|
trip
|
|
Durable
Medical Equipment
|
|
|
|
|
Annual
|
|
|
|
Adult
Dental
|
Adult
dental expanded to include unlimited fillings, periodontic deep
cleanings,
crowns, clear fillings, restorations, annual exam, two cleanings
per year
and x-rays.
|
|
Circumcision
|
Routine
newborn circumcision up to one year of age..
|
|
Over
the Counter Benefit
|
Agency
approved over-the -counter drug benefit, not to exceed $25 per
household,
per month. Limited to non-prescription drugs containing a National
Drug
Code number, first aid and birth control supplies. Benefit must
be offered
through a plan’s pharmacy or plan’s subcontractor.
|
|
Meals
on Wheels
|
10
meals within 15 days of post discharge (medically
necessary)
|
|
Eligibility
Category/ Population
|
County
|
Health
Plan Provider Number
|
Plan
Type
(Comp
or Comp & Catastrophic)
|
Maximum
Enrollment Level
|
|
TANF
|
Duval
|
Comprehensive
& Catastrophic
|
55,000
|
|
|
SSI
|
Duval
|
Comprehensive
& Catastrophic
|
||
|
HIV/AIDS
|
||||
|
Children
with Chronic Conditions
|
|
Eligibility
Category/ Population
|
County
|
Health
Plan Provider Number
|
Plan
Type
(Comp
or Comp & Catastrophic)
|
Maximum
Enrollment Level
|
|
TANF
|
Broward
|
Comprehensive
& Catastrophic
|
13,500
|
|
|
SSI
|
Broward
|
Comprehensive
& Catastrophic
|
||
|
HIV/AIDS
|
||||
|
Children
with Chronic Conditions
|
|
Age
Range
|
FY0607
Discounted Reform rates Under Current Methodology
|
Percentage
of Current Methodology
|
75%
of Current Methodology
|
Preliminary
FY0607 Base rates for Risk Adjusted Methodology
|
Budget
Neutrality Factor
|
FY0607
Base rates for Risk Adjusted Methodology after Budget
Neutrality
|
Percentage
of Risk Adjusted Methodology
|
25%
of Risk Adjusted Methodology
|
Final
Rate (with Enhanced Benefit Adjustment)
|
|
a
|
b
|
c
|
d
|
e
|
f
|
g
|
h
|
i
|
j
|
|
Eligibility
Category:
|
Children
and Family
|
||||||||
|
Month
0-2 All
|
$688.92
|
75%
|
$516.69
|
$117.60
|
1.18930
|
$139.86
|
25%
|
$34.97
|
$551.66
|
|
Month
3-11 All
|
$180.09
|
75%
|
$135.07
|
$117.60
|
1.18930
|
$139.86
|
25%
|
$34.97
|
$170.04
|
|
1-5
All
|
$94.03
|
75%
|
$70.52
|
$117.60
|
1.18930
|
$139.86
|
25%
|
$34.97
|
$105.49
|
|
6-13
All
|
$77.55
|
75%
|
$58.16
|
$117.60
|
1.18930
|
$139.86
|
25%
|
$34.97
|
$93.13
|
|
14-20
Female
|
$107.54
|
75%
|
$80.65
|
$117.60
|
1.18930
|
$139.86
|
25%
|
$34.97
|
$115.62
|
|
14-20
Male
|
$74.59
|
75%
|
$55.94
|
$117.60
|
1.18930
|
$139.86
|
25%
|
$34.97
|
$90.91
|
|
21-54
Female
|
$181.88
|
75%
|
$136.41
|
$117.60
|
1.18930
|
$139.86
|
25%
|
$34.97
|
$171.37
|
|
21-54
Male
|
$131.39
|
75%
|
$98.54
|
$117.60
|
1.18930
|
$139.86
|
25%
|
$34.97
|
$133.51
|
|
55+
All
|
$288.52
|
75%
|
$216.39
|
$117.60
|
1.18930
|
$139.86
|
25%
|
$34.97
|
$251.36
|
|
Composite
Based on Total Casemonths
|
$110.18
|
$139.86
|
$117.60
|
||||||
|
Eligibility
Category:
|
Aged
and Disabled
|
||||||||
|
Month
0-2 All
|
$15,308.07
|
75%
|
$11,481.05
|
$777.12
|
1.20785
|
$938.64
|
25%
|
$234.66
|
$11,715.71
|
|
Month
3-11 All
|
$3,277.86
|
75%
|
$2,458.40
|
$777.12
|
1.20785
|
$938.64
|
25%
|
$234.66
|
$2,693.06
|
|
1-5
All
|
$550.34
|
75%
|
$412.75
|
$777.12
|
1.20785
|
$938.64
|
25%
|
$234.66
|
$647.42
|
|
6-13
All
|
$317.37
|
75%
|
$238.03
|
$777.12
|
1.20785
|
$938.64
|
25%
|
$234.66
|
$472.69
|
|
14-20
All
|
$319.91
|
75%
|
$239.93
|
$777.12
|
1.20785
|
$938.64
|
25%
|
$234.66
|
$474.59
|
|
21-54
All
|
$825.64
|
75%
|
$619.23
|
$777.12
|
1.20785
|
$938.64
|
25%
|
$234.66
|
$853.89
|
|
55+
All
|
$833.65
|
75%
|
$625.24
|
$777.12
|
1.20785
|
$938.64
|
25%
|
$234.66
|
$859.90
|
|
Composite
Based on Total Casemonths
|
$723.28
|
$938.64
|
$777.12
|
|
Age
Range
|
FY0607
Discounted Reform rates Under Current Methodology
|
Percentage
of Current Methodology
|
75%
of Current Methodology
|
Preliminary
FY0607 Base rates for Risk Adjusted Methodology
|
Budget
Neutrality Factor
|
FY0607
Base rates for Risk Adjusted Methodology after Budget
Neutrality
|
Percentage
of Risk Adjusted Methodology
|
25%
of Risk Adjusted Methodology
|
Final
Rate (with Enhanced Benefit Adjustment)
|
|
a
|
b
|
c
|
d
|
e
|
f
|
g
|
h
|
i
|
j
|
|
Eligibility
Category:
Children and Family
|
|||||||||
|
Month
0-2 All
|
$738.35
|
75%
|
$553.76
|
$125.17
|
1.13200
|
$141.69
|
25%
|
$35.42
|
$589.19
|
|
Month
3-11 All
|
$192.52
|
75%
|
$144.39
|
$125.17
|
1.13200
|
$141.69
|
25%
|
$35.42
|
$179.81
|
|
1-5
All
|
$98.55
|
75%
|
$73.91
|
$125.17
|
1.13200
|
$141.69
|
25%
|
$35.42
|
$109.33
|
|
6-13
All
|
$74.83
|
75%
|
$56.12
|
$125.17
|
1.13200
|
$141.69
|
25%
|
$35.42
|
$91.55
|
|
14-20
Female
|
$109.44
|
75%
|
$82.08
|
$125.17
|
1.13200
|
$141.69
|
25%
|
$35.42
|
$117.50
|
|
14-20
Male
|
$73.83
|
75%
|
$55.37
|
$125.17
|
1.13200
|
$141.69
|
25%
|
$35.42
|
$90.80
|
|
21-54
Female
|
$192.76
|
75%
|
$144.57
|
$125.17
|
1.13200
|
$141.69
|
25%
|
$35.42
|
$179.99
|
|
21-54
Male
|
$139.38
|
75%
|
$104.53
|
$125.17
|
1.13200
|
$141.69
|
25%
|
$35.42
|
$139.95
|
|
55+
All
|
$305.74
|
75%
|
$229.31
|
$125.17
|
1.13200
|
$141.69
|
25%
|
$35.42
|
$264.73
|
|
Composite
Based on Total Casemonths
|
$119.67
|
$141.69
|
$125.17
|
||||||
|
Eligibility
Category:
Aged and Disabled
|
|||||||||
|
Month
0-2 All
|
$13,652.29
|
75%
|
$10,239.22
|
$635.88
|
1.14045
|
$725.19
|
25%
|
$181.30
|
$10,420.52
|
|
Month
3-11 All
|
$2,911.78
|
75%
|
$2,183.83
|
$635.88
|
1.14045
|
$725.19
|
25%
|
$181.30
|
$2,365.13
|
|
1-5
All
|
$493.16
|
75%
|
$369.87
|
$635.88
|
1.14045
|
$725.19
|
25%
|
$181.30
|
$551.16
|
|
6-13
All
|
$300.32
|
75%
|
$225.24
|
$635.88
|
1.14045
|
$725.19
|
25%
|
$181.30
|
$406.54
|
|
14-20
All
|
$294.02
|
75%
|
$220.51
|
$635.88
|
1.14045
|
$725.19
|
25%
|
$181.30
|
$401.81
|
|
21-54
All
|
$741.27
|
75%
|
$555.95
|
$635.88
|
1.14045
|
$725.19
|
25%
|
$181.30
|
$737.25
|
|
55+
All
|
$736.02
|
75%
|
$552.01
|
$635.88
|
1.14045
|
$725.19
|
25%
|
$181.30
|
$733.31
|
|
Composite
Based on Total Casemonths
|
$606.11
|
$725.19
|
$635.88
|
||||||
|
Area
________
|
|||||||||||
|
Age
Range
|
|
FY0607
Discounted Reform rates Under Current Methodology
|
Percentage
of Current Methodology
|
75%
of Current Methodology
|
FY0607
Base Rates for Risk-Adjusted Methodology
|
Percentage
of Risk-Adjusted Methodology
|
25%
of Risk-Adjusted Methodology
|
Budget
Neutrality Factor
|
Budget
Adjusted of 25% of Risk Adjusted Method-ology
|
Blended
Rate (Risk = 1.00)
|
Final
Rate (with Enhanced Benefit Adjustment)
|
|
(a)
|
|
(b)
|
(c)
|
(d)
|
(e)
|
(f)
|
(g)
|
(h)
|
(i)
|
(j)
|
(k)
|
|
Eligibility
Category:
|
Children
and Family
|
||||||||||
|
Month
0-2 All
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
Month
3-11 All
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
1-5
All
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
6-13
All
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
14-20
Female
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
14-20
Male
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
21-54
Female
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
21-54
Male
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
55+
All
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
Composite
|
|
$
|
$
|
||||||||
|
Eligibility
Category:
|
Aged
and Disabled
|
||||||||||
|
Month
0-2 All
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
Month
3-11 All
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
1-5
All
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
6-13
All
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
14-20
All
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
21-54
All
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
55+
All
|
$
|
75%
|
$
|
$
|
25%
|
$
|
$
|
$
|
|||
|
Composite
|
$
|
$
|
|||||||||
|
Under
Age 65
|
Age
65 & Over
|
|
|
SSI/Parts
A & B
|
$146.72
|
$98.34
|
|
SSI/Part
B Only
|
$300.24
|
$300.24
|
|
Under
Age 65
|
Age
65 & Over
|
|
|
SSI/Parts
A & B
|
$136.17
|
$91.25
|
|
SSI/Part
B Only
|
$210.84
|
$210.84
|
|
Capitation
Rate
|
|
|
HIV
(No Medicare)
|
$950.48
|
|
AIDS
(No Medicare)
|
$2133.29
|
|
HIV-SSI/Parts
A & B, SSI Part B Only
|
$177.88
|
|
AIDS-SSI/Parts
A & B, SSI Part B Only
|
$249.55
|
|
Capitation
Rate
|
|
|
HIV
(No Medicare)
|
$1484.87
|
|
AIDS
(No Medicare)
|
$3155.16
|
|
HIV-SSI/Parts
A & B, SSI Part B Only
|
$213.18
|
|
AIDS-SSI/Parts
A & B, SSI Part B Only
|
$299.07
|
|
Age
<
1 Yr
|
Age
1 Yr
|
Age
2 - 20 Yrs
|
|
|
Children
with Chronic Conditions
|
$
|
$
|
$
|
|
CPT
Code
|
Transplant
CPT Code Description
|
Children/Adolescents
or Adult
|
Payment
Amount
|
|
32851
|
lung
single, without bypass
|
Children/Adolescents
|
$320,800.00
|
|
32851
|
lung
single, without bypass
|
Adult
|
$238,000.00
|
|
32852
|
lung
single, with bypass
|
Children/Adolescents
|
$320,800.00
|
|
32852
|
lung
single, with bypass
|
Adult
|
$238,000.00
|
|
32853
|
lung
double, without bypass
|
Children/Adolescents
|
$320,800.00
|
|
32853
|
lung
double, without bypass
|
Adult
|
$238,000.00
|
|
32854
|
lung
double, with bypass
|
Children/Adolescents
|
$320,800.00
|
|
32854
|
lung
double, with bypass
|
Adult
|
$238,000.00
|
|
33945
|
heart
transplant with or without recipient cardiectomy
|
Children/Adolescents
|
$162,000.00
|
|
33945
|
heart
transplant with or without recipient cardiectomy
|
Adult
|
$162,000.00
|
|
47135
|
liver,
allotransplation, orthotopic, partial or whole from cadaver
or living
donor
|
Children/Adolescents
|
$122,600.00
|
|
47135
|
liver,
allotransplation, orthotopic, partial or whole from cadaver
or living
donor
|
Adult
|
$122,600.00
|
|
47136
|
liver,
heterotopic, partial or whole from cadaver or living
donor any
age
|
Children/Adolescents
|
$122,600.00
|
|
47136
|
liver,
heterotopic, partial or whole from cadaver or living
donor any
age
|
Adult
|
$122,600.00
|
|
CPT
Code
|
Obstetrical
Delivery CPT Code Description
|
Payment
Amount
|
|
59409
|
Vaginal
delivery only
|
$4,143.00
|
|
59410
|
Vaginal
delivery including postpartum care
|
|
|
59515
|
Cesarean
delivery including postpartum care
|
|
|
59612
|
Vaginal
delivery only, after previous cesarean delivery
|
|
|
59614
|
Vaginal
delivery only, after previous cesarean delivery including postpartum
care
|
|
|
59622
|
Cesarean
delivery only, following attempted vaginal delivery after previous
cesarean delivery including postpartum
care
|
|
CPT
Code
|
Obstetrical
Delivery CPT Code Description
|
Payment
Amount
|
|
59409
|
Vaginal
delivery only
|
$4,097.62
|
|
59410
|
Vaginal
delivery including postpartum care
|
|
|
59515
|
Cesarean
delivery including postpartum care
|
|
|
59612
|
Vaginal
delivery only, after previous cesarean delivery
|
|
|
59614
|
Vaginal
delivery only, after previous cesarean delivery including postpartum
care
|
|
|
59622
|
Cesarean
delivery only, following attempted vaginal delivery after previous
cesarean delivery including postpartum
care
|
| A. |
Definitions
|
|
2.
|
Medically
Necessary or Medical Necessity for those services furnished in a
Hospital
on an inpatient basis cannot, consistent with the provisions of
appropriate medical care, be effectively furnished more economically
on an
outpatient basis or in an inpatient facility of a different
type.
|
|
3.
|
The
fact that a provider has prescribed, recommended or approved medical
or
allied goods or services does not, in itself, make such care, goods
or
services Medically Necessary, a Medical Necessity or a Covered
Service/Benefit.
|
|
B.
|
Acronyms
|
| A. |
Background
|
|
1.
|
Effective
July 1, 2006, the Agency for Health Care Administration will begin
implementing Medicaid Reform in the counties of Broward and Duval.
At the
end of the first year of implementation, Medicaid Reform will be
extended
to Nassau, Clay and Baker counties. Medicaid Reform will transform
the
Medicaid program by empowering Medicaid Recipients to take control
of
their health care, providing more choices for Recipients, and enhancing
their health status through increased health literacy and incentives
to
engage in healthy behaviors.
|
|
2.
|
The
principles governing Medicaid Reform
are:
|
| a. |
Patient
Responsibility and Empowerment;
|
| b. |
Marketplace
Decisions;
|
| c. |
Bridging
Public and Private Coverage; and
|
| d. |
Sustainable
Growth Rate.
|
|
3.
|
These
principles will empower Medicaid Recipients, provide flexibility
to
Providers, and facilitate program management for government.
|
| B. |
Purpose
|
| C. |
Responsibilities
of the State of Florida (the State) and the Agency for Health Care
Administration (the Agency)
|
| 1. |
The
Agency will be responsible for administering the Medicaid program,
including all aspects of Medicaid Reform. The Agency will administer
contracts, monitor Health Plan performance, and provide oversight
in all
aspects of the Health Plan’s
operations.
|
| 2. |
The
State of Florida has sole authority for determining eligibility for
Medicaid and whether Medicaid Recipients are mandated to enroll in,
may
enroll in, or may not enroll in Medicaid
Reform.
|
| 3. |
The
Agency or its Agent will review the Florida Medicaid Management
Information System (FMMIS) file daily and will send written notification
and information to all Potential Enrollees. A Potential Enrollee
will have
thirty (30) Calendar Days to select a Health Plan.
|
| 4. |
The
Agency or its Agent will Auto-Assign Mandatory Potential Enrollees
who do
not select a Health Plan during their choice period to a Health Plan
using
a pre-established algorithm.
|
| 5. |
Enrollment
in a Health Plan, whether chosen or Auto-Assigned, will be effective
at
12:01 a.m. on the first (1st) Calendar Day of the month following
Potential Enrollee selection or Auto-Assignment, for those Potential
Enrollees who choose or are Auto- Assigned to a Health Plan on or
between
the first (1st) Calendar Day of the month and the Penultimate Saturday
of
the month. For those Enrollees who choose or are Auto-Assigned a
Health
Plan between the Sunday after the Penultimate Saturday and before
the last
Calendar Day of the month, Enrollment in a Health Plan will be effective
on the first (1st) Calendar Day of the second (2nd) month after choice
or
Auto-assignment.
|
| 6. |
The
Agency or its Agent will notify the Health Plan of an Enrollee’s selection
or assignment to a Health Plan.
|
| 7. |
The
Agency or it Agent will send a written confirmation notice to Enrollees
identifying the chosen or Auto-Assigned Health Plan. If the Enrollee
has
not chosen a PCP, the confirmation notice will advise the Enrollee
that a
PCP will be chosen for him/her. Notice to the Enrollee will be made
in
writing and sent via Surface Mail. Notice to the Health Plan will
be made
via file transfer.
|
| 8. |
Conditioned
on continued eligibility, Mandatory Enrollees will have a Lock-In
period
of twelve (12) consecutive months. After an initial ninety (90) day
change
period, Mandatory Enrollees will only be able to disenroll from their
Health Plan for Cause. The Agency or its Agent will notify Enrollees
at
least once every twelve (12) months, and at least sixty (60) Calendar
Days
prior to the date the Lock-In period ends (the Open Enrollment period),
that they have the opportunity to change Health Plans. Enrollees
who do
not make a choice will be deemed to have chosen to remain with their
current Health Plan, unless the current Health Plan no longer participates
in Medicaid Reform. In this case, the Enrollee will be Auto-Assigned
to a
new Health Plan.
|
| 9. |
The
Agency or its Agent will automatically re-enroll an Enrollee into
the
Health Plan in which he or she was most recently enrolled if the
Enrollee
has a temporary loss of eligibility, defined for purposes of this
Contract
as less than 180 Calendar Days. In this instance, for Mandatory Potential
Enrollee, the Lock-In period will continue as though there had been
no
break in eligibility, keeping the original twelve (12) month period.
|
| 10. |
If
a temporary loss of eligibility has caused the Enrollee to miss the
Open
Enrollment period, the Agency or its Agent will enroll the Enrollee
in the
Health Plan in which he or she was enrolled prior to the loss of
eligibility. The Enrollee will have ninety (90) Calendar Days to
disenroll
without Cause.
|
| 11. |
The
State will issue a Medicaid identification (ID) number to a newborn
upon
notification from the Health Plan, the hospital, or other authorized
Medicaid provider, consistent with the unborn activation process.
|
| 12. |
The
Agency or its Agent will notify Enrollees of their right to request
Disenrollment as follows:
|
|
(1)
|
During
the ninety (90) days following the Enrollee's initial Enrollment,
or the
date the Agency or its Agent sends the Enrollee notice of the enrollment,
whichever is later;
|
|
(2)
|
At
least every twelve (12) months;
|
|
(3)
|
If
the temporary loss of Medicaid eligibility has caused the Enrollee
to miss
the Open Enrollment period; or
|
| (4) |
When
the Agency or its Agent grants the Enrollee the right to terminate
Enrollment without Cause. The Agency or its Agent determines the
Enrollee's right to terminate Enrollment on a case-by-case basis.
|
| (5) |
If
the individual chooses to opt out and enroll in their employer-sponsored
health insurance plan.
|
| 13. |
The
Agency or its Agent will process all Disenrollments from the Health
Plan.
The Agency or its Agent will make final determinations about granting
Disenrollment requests and will notify the Health Plan via file transfer
and the Enrollee via Surface Mail of any Disenrollment decision.
Enrollees
dissatisfied with an Agency determination may have access to the
Medicaid
Fair Hearing process.
|
| 14. |
When
Disenrollment is necessary because an Enrollee loses Medicaid eligibility,
Disenrollment shall be immediate.
|
| 15. |
The
Agency and/or its Agent shall determine the activities and behaviors
that
qualify for contributions to the individual’s Enhanced Benefit Account.
|
| 16. |
The
Agency will conduct periodic monitoring of the Health Plan’s operations
for compliance with the provisions of the Contract and applicable
federal
and State laws and regulations.
|
| D. |
General
Responsibilities of the Health Plan
|
| 1. |
The
Health Plan shall comply with all provisions of this Contract and
its
amendments, if any, and shall act in good faith in the performance
of the
Contract's provisions. The Health Plan shall develop and maintain
written
policies and procedures to implement all provisions of this Contract.
The
Health Plan agrees that failure to comply with all provisions of
this
Contract shall result in the assessment of penalties and/or termination
of
the Contract, in whole or in part, as set forth in this
Contract.
|
| 2. |
The
Health Plan shall comply with all pertinent Agency rules in effect
throughout the duration of the
Contract.
|
| 3. |
The
Health Plan shall comply with all current Florida Medicaid Handbooks
("Handbooks") as noticed in the Florida Administrative Weekly ("FAW"),
or
incorporated by reference in rules relating to the provision of services
set forth in Section V Covered Services, and Section VI, Behavioral
Health
Care, except where the provisions of the Contract alter the requirements
set forth in the Handbooks promulgated in the Florida Administrative
Code
(FAC) unless a customized benefit package has been certified by the
Agency. In addition, the Health Plan shall comply with the limitations
and
exclusions in the Handbooks, unless otherwise specified by this Contract.
In no instance may the limitations or exclusions imposed by the Health
Plan be more stringent than those specified in the Handbooks, unless
authorized in the Customized Benefit Package by the Agency. The Health
Plan may not arbitrarily deny or reduce the amount, duration or scope
of a
required service solely because of the diagnosis, type of illness,
or
condition. The Health Plan may exceed Handbook limits by offering
Expanded
Services, as described in Section V, Covered Services or through
its
approved Customized Benefit package.
|
| 4. |
The
Capitated PSN may only choose to offer a Specialty Plan for Medicaid
Recipients in:
|
|
a.
|
Temporary
Assistance to Needy Families (TANF) eligibility
category;
|
|
b.
|
Supplemental
Security Income (SSI) eligibility category;
or
|
|
c.
|
Children
with Chronic Conditions.
|
| 5. |
The
Health Plan may offer Expanded Services, as described in Section
V,
Covered Services to Enrollees, in addition to the required services
and
Quality Enhancements. The Health Plan shall define with specificity
its
Expanded Services in regards to amount, duration and scope, and obtain
approval, in writing, by the Agency prior to
implementation.
|
| 6. |
This
Contract including all attachments and exhibits, represents the entire
agreement between the Health Plan and the Agency and supersedes all
other
contracts between the parties when it is executed by duly authorized
signatures of the Health Plan and the Agency. Correspondence and
memoranda
of understanding do not constitute part of this Contract. In the
event of
a conflict of language between the Contract and the attachments,
the
provisions of the Contract shall govern. The Agency reserves the
right to
clarify any contractual relationship in writing and such clarification
shall govern. Pending final determination of any dispute over any
Agency
decision, the Health Plan shall proceed diligently with the performance
of
its duties as specified under the Contract and in accordance with
the
direction of the Agency's Division of
Medicaid.
|
| 7. |
The
Health Plan shall have a Quality Improvement program that ensures
enhancement of quality of care and emphasizes improving the quality
of
patient outcomes. The Agency may restrict the Health Plan’s Enrollment
activities if the Health Plan does not meet acceptable Quality Improvement
and performance indicators, based on HEDIS reports and other outcome
measures to be determined by the Agency. Such restrictions may include,
but shall not be limited to, the termination of mandatory
assignments.
|
| 8. |
The
Health Plan must demonstrate that it has adequate knowledge of Medicaid
programs, provision of health care services, disease management
initiatives, medical claims data, and the capability to design and
implement cost savings methodologies. The Health Plan must demonstrate
the
capacity for financial analyses, as necessary to fulfill the requirements
of this Contract. Additionally, the Health Plan must meet all requirements
for doing business in the State of Florida.
|
| 9. |
The
Health Plan may be required to provide to the Agency or its Agent
information or data that is not specified under this Contract. In
such
instances, and at the direction of the Agency, the Health Plan shall
fully
cooperate with such requests and furnish all information in a timely
manner, in the format in which it is requested. The Health Plan shall
have
at least thirty (30) Calendar Days to fulfill such ad hoc
requests.
|
| 10. |
The
Health Plan shall fully cooperate with, and provide necessary data
to, the
Agency and its Agent for the design, management, operations and monitoring
of the Enhanced Benefits Program.
|
| 11. |
A
Health Plan, who accepts the Comprehensive Component of the Capitation
Rate only, shall continue to provide all Covered Services to each
Enrollee, who reaches the Catastrophic Component Threshold. The Health
Plan shall continue to apply its QM and UM program components, as
well as
other administrative policies and protocols to the delivery of care
and
services to the Enrollees who meet the threshold. The Health Plan
may
submit documentation for reimbursement for Covered Services costs as
outlined in Section XIII., Method of Payment, subsection D. Claims
Payment
for Health Plans Providing the Comprehensive Component Only.
|
| 12. |
When
the cost of an Enrollee’s Covered Services reaches the Benefit Maximum of
$550,000 in a Contract Year, the Health Plan shall assist the Enrollee
in
obtaining necessary health care services in the community. The Health
Plan
shall continue to coordinate the care received by the Enrollee in
the
community. The Health Plan shall resume all responsibilities for
the
provision of Covered Services at the beginning of the Contract Year
(September 1) following the year in which the Maximum Benefit was
reached
by the Enrollee.
|
| 13. |
Health
Maintenance Organizations and other licensed managed care organizations
shall enroll all network providers with the Agency’s Fiscal Agent, no
later than November 30, 2006, using the Agency’s streamlined Provider
Enrollment process. All Capitated PSNs shall use the streamlined
Provider
Enrollment process to enroll network providers prior to contract
execution.
|
| 14. |
The
Health Plans shall collect and submit Encounter Data for each Contract
Year in the format required by the Agency and within the time frames
specified by the Agency. An encounter guide along with technical
assistance will be forthcoming. At a minimum the Health Plans shall
be
responsible for the following:
|
| a. |
Health
Plans shall collect and submit to the Agency or its designee, enrollee
service level encounter data for all covered
services.
|
| b. |
Encounter
data shall be submitted following HIPAA standards, namely the ANSI
X12N
837 Transaction formats (P - Professional, I - Institutional, and
D -
Dental), and the National Council for Prescription Drug Programs
NCPDP
format (for Pharmacy services).
|
| c. |
All
covered services rendered to health plan enrollees shall result in
the
creation of an encounter record.
|
| A. |
Eligibility
|
| 1. |
Mandatory
Populations
|
| 2. |
Voluntary
Populations
|
| 3. |
Excluded
Populations
|
| B. |
Enrollment
|
| 1. |
General
Provisions
|
| 2. |
Enrollment
in a Specialty Plan
|
| 3. |
Enrollment
with a Primary Care Provider
(PCP)
|
| 4. |
Newborn
Enrollment
|
| 5. |
Enrollment
Cessation
|
| 6. |
Enrollment
Notice
|
| C. |
Disenrollment
|
| 1. |
General
Provisions
|
| 2. |
Cause
for Disenrollment
|
|
(1)
|
The
Enrollee moves out of the Service Area or his/her address is
incorrect.
|
|
(2)
|
The
Provider is no longer with the Health
Plan.
|
|
(3)
|
The
Enrollee is excluded from
enrollment.
|
|
(4)
|
A
substantiated marketing violation
occurred.
|
|
(5)
|
The
Enrollee is prevented from participating in the development of his/her
treatment plan.
|
|
(6)
|
The
Enrollee has an active relationship with a provider who is not on
the
Health Plan's panel, but is on the panel of another Health
Plan.
|
|
(7)
|
The
Enrollee is in the wrong Health Plan due to an
error.
|
|
(8)
|
The
Health Plan no longer participates in the
county.
|
|
(9)
|
The
State has imposed intermediate sanctions upon the Health Plan, as
specified in 42 CFR 438.702(a)(3).
|
|
(10)
|
The
Enrollee needs related services to be performed concurrently, but
not all
related services are available within the Health Plan network; or,
the
Enrollee's PCP has determined that receiving the services separately
would
subject the Enrollee to unnecessary
risk.
|
|
(11)
|
The
Health Plan does not, because of moral or religious objections, cover
the
service the Enrollee seeks.
|
|
(12)
|
The
Enrollee missed his/her Open Enrollment due to a temporary loss of
eligibility, defined as 180 days or
less.
|
|
(13)
|
Other
reasons per 42 CFR 438.56(d)(2), including, but not limited to, poor
quality of care; lack of access to services covered under the Contract;
inordinate or inappropriate changes of PCPs; service access impairments
due to significant changes in the geographic location of services;
lack of
access to Providers experienced in dealing with the Enrollee’s health care
needs; or fraudulent Enrollment.
|
| 3. |
Involuntary
Disenrollment
|
|
(1)
|
For
an Enrollee who continues not to comply with a recommended plan of
health
care or misses three (3) consecutive appointments within a continuous
six
(6) month period. Such requests must be submitted at least sixty
(60)
Calendar Days prior to the requested effective
date.
|
|
(2)
|
For
an Enrollee whose behavior is disruptive, unruly, abusive or uncooperative
to the extent that his or her Enrollment in the Health Plan seriously
impairs the organization's ability to furnish services to either
the
Enrollee or other Enrollees. This Section does not apply to Enrollees
with
mental health diagnoses if the Enrollee’s behavior is attributable to the
mental illness.
|
| (1) |
Health
diagnosis;
|
| (2) |
Adverse
changes in an Enrollee’s health
status;
|
| (3) |
Utilization
of medical services;
|
| (4) |
Diminished
mental capacity;
|
| (5) |
Pre-existing
medical condition;
|
| (6) |
Uncooperative
or disruptive behavior resulting from the Enrollee’s special needs (with
the exception of C.3.g.2 above);
|
| (7) |
Attempt
to exercise rights under the Health Plan's Grievance System;
or
|
| (8) |
Request
of one (1) PCP to have an Enrollee assigned to a different Provider
out of
the Health Plan.
|
| A. |
Enrollee
Services
|
| 1. |
General
Provisions
|
|
(1)
|
Telephone
contact at the telephone number obtained from the local telephone
directory, directory assistance, city directory, or other
directory.
|
|
(2)
|
Telephone
contact with DCF and Families Economic Self-Sufficiency Services
Office
staff to determine if they have updated address information and telephone
number.
|
|
(3)
|
Routine
checks (at least once a month for the first three (3) months of
Enrollment) on services or claims authorized or denied by the Health
Plan
to determine if the Enrollee has received services, and to locate
updated
address and telephone number
information.
|
| 2. |
Requirements
for Written Materials
|
|
(1)
|
Fry
Readability Index;
|
|
(2)
|
PROSE
The Readability Analyst (software developed by Education Activities,
Inc.);
|
|
(3)
|
Gunning
FOG Index;
|
|
(4)
|
McLaughlin
SMOG Index;
|
|
(5)
|
The
Flesch-Kincaid Index; or
|
|
(6)
|
Other
software approved by the Agency.
|
| 3. |
New
Enrollee Materials
|
| 4. |
Enrollee
Handbook Requirements
|
|
(1)
|
Table
of Contents;
|
|
(2)
|
Terms
and conditions of Enrollment including the reinstatement process;
|
|
(3)
|
Description
of the Open Enrollment process;
|
|
(4)
|
Description
of services provided, including limitations and general restrictions
on
Provider access, exclusions and out-of-network use;
|
|
(5)
|
Procedures
for obtaining required services, including second opinions, and
authorization requirements, including those services available without
Prior Authorization;
|
|
(6)
|
Toll-free
telephone number of the appropriate Area Medicaid Office;
|
|
(7)
|
Emergency
Services and procedures for obtaining services both in and out of
the
Health Plan’s Service Area, including explanation that Prior Authorization
is not required for Emergency Services, the locations of any emergency
settings and other locations at which Providers and Hospitals furnish
Emergency Services and Post-Stabilization Care Services, and use
of the
911-telephone system or its
equivalent;
|
|
(8)
|
The
extent to which, and how, after-hours and emergency coverage is provided,
and that the Enrollee has a right to use any Hospital or other setting
for
Emergency Care;
|
|
(9)
|
Procedures
for Enrollment, including Enrollee rights and protections;
|
| 5. |
Provider
Directory
|
| 6. |
Enrollee
ID Card
|
|
(1)
|
The
Enrollee's name and Medicaid ID
number;
|
|
(3)
|
A
telephone number that a non-contracted provider may call for billing
information.
|
| 7. |
Toll-free
Help Line
|
|
(1)
|
One
hundred percent (100%) of all calls are answered within four (4)
rings
(these calls may be placed in a
queue);
|
|
(2)
|
The
wait time in the queue shall not exceed three (3)
minutes;
|
|
(3)
|
The
Blocked Call rate does not exceed one percent (1%); and
|
|
(4)
|
The
rate of Abandoned Calls does not exceed five percent (5%).
|
| 8. |
Cultural
Competency
|
| 9. |
Translation
Services
|
| B. |
Marketing
|
| 1. |
General
Provisions
|
| 2. |
Prohibited
Activities
|
|
(1)
|
The
Medicaid Recipient must enroll in the Health Plan in order to obtain
Medicaid, or in order to avoid losing Medicaid benefits;
|
|
(2)
|
The
Health Plan is endorsed by any federal, State or county government,
the
Agency, or CMS, or any other organization which has not certified
its
endorsement in writing to the Health
Plan;
|
|
(3)
|
Marketing
Representatives are employees or representatives of the federal,
State or
county government, or of anyone other than the Health Plan or the
organization by whom they are
reimbursed;
|
|
(4)
|
The
State or county recommends that a Medicaid Recipient enroll with
the
Health Plan; and/or
|
|
(5)
|
A
Medicaid Recipient will lose benefits under the Medicaid program
or any
other health or welfare benefits to which the Recipient is legally
entitled, if the Recipient does not enroll with the Health
Plan.
|
| 3. |
Permitted
Activities
|
| 4. |
Approval
Process
|
|
(1)
|
A
Health Plan shall submit its bi-monthly Marketing schedule to the
Agency,
two (2) weeks in advance of each month. The Marketing Schedule may
be
revised if a Health Plan provides notice to the Agency one (1) week
prior
to the Public Event or the Health Fair. The Agency may expedite this
process as needed.
|
|
(2)
|
The
Agency will approve or deny the Health Plan's bi-monthly Marketing
schedule and revision request no later than five (5) Business Days
from
receipt of the schedule and/or revision request.
|
|
(3)
|
The
Health Plan shall use the standard Agency format. Such format will
include
minimum requirements for necessary information. The Agency will explain
in
writing what is sufficient information for each
requirement.
|
|
(4)
|
The
Agency will establish a statewide log to track the approval and
disapproval of Health Fairs and Public
Events.
|
|
(5)
|
The
Agency may provide verbal approvals or disapprovals to meet the five
(5)
Business Day requirement, but the Agency will follow up in writing
with
specific reasons for disapprovals within five (5) Business Days of
verbal
disapprovals.
|
| 5. |
Provider
Compliance
|
| 6. |
Marketing
Representatives
|
| 7. |
Request
for Benefit Information (RBI)
Activities
|
|
(1)
|
Name;
|
|
(2)
|
Address
(home and mailing);
|
|
(3)
|
County
of residence;
|
|
(4)
|
Telephone
number;
|
|
(5)
|
Date
of Application;
|
|
(6)
|
Applicant’s
signature or signature of parent or guardian;
and,
|
|
(7)
|
Marketing
Representative’s signature and DFS license
number.
|
| A. |
Covered
Services
|
|
a.
|
Amount,
duration and scope may vary for durable medical supplies (DME) with
the
exception of any prosthetic/orthotic supply priced over $3,000 on
the
Medicaid fee schedule and except for motorized wheelchairs, which
must be
covered up to the State Plan limit.
|
|
b.
|
Dialysis
services, contraceptives, and chemotherapy-related medical and
pharmaceutical services must be covered up to the State Plan limit.
|
|
c.
|
Hearing
services for non-pregnant adults may vary amount, duration and scope
except for hearing aid services, which must be covered up to the
State
Plan limit.
|
|
d.
|
The
CBP must meet the Agency’s actuarial equivalency and sufficiency standards
for the population or populations which will be covered by the CBP.
|
|
e.
|
The
Health Plan shall submit its CBP to the Agency for recertification
of
actuarial equivalency and sufficiency standards on an annual basis.
|
|
Health
Plan Covered Service Chart
|
|
Advanced
Registered Nurse Practitioner Services
|
|
Ambulatory
Surgical Centers
|
|
Birth
Center Services
|
|
Child
Health Check-Up Services
|
|
Chiropractic
Services
|
|
Community
Mental Health Services
|
|
County
Health Department Services
|
|
Dental
Services
|
|
Durable
Medical Equipment and Medical Supplies
|
|
Dialysis
Services
|
|
Emergency
Room Services
|
|
Family
Planning Services
|
|
Federally
Qualified Health Center Services
|
|
Freestanding
Dialysis Centers
|
|
Hearing
Services
|
|
Home
Health Care Services
|
|
Hospital
Services - Inpatient
|
|
Hospital
Services - Outpatient
|
|
Immunizations
|
|
Independent
Laboratory Services
|
|
Licensed
Midwife Services
|
|
Optometric
Services
|
|
Physician
Services
|
|
Physician
Assistant Services
|
|
Podiatry
Services
|
|
Portable
X-ray Services
|
|
Prescribed
Drugs
|
|
Primary
Care Case Management Services
|
|
Rural
Health Clinic Services
|
|
Targeted
Case Management
|
|
Therapy
Services: Occupational
|
|
Therapy
Services: Physical
|
|
Therapy
Services: Respiratory
|
|
Therapy
Services: Speech
|
|
Transplant
Services
|
|
Transportation
Services
|
|
Vision
Services
|
| B. |
Expanded
Services
|
|
1.
|
Expanded
Behavioral Health Services - respite care services, prevention services
in
the community, parental education programs, community-based therapeutic
services for adults, and any other new and innovative interventions
or
services designed to improve the mental well-being of
Enrollees.
|
|
2.
|
The
Health Plan may offer an Agency-approved over-the-counter expanded
drug
benefit, not to exceed twenty-five dollars ($25.00) per household,
per
month. Such benefits shall be limited to nonprescription drugs containing
a National Drug Code ("NDC") number, first aid supplies and birth
control
supplies. Such benefits must be offered through the Health Plan's
pharmacy
or the Health Plan's agreement with a pharmacy. The Health Plan shall
make
payments for the over-the-counter drug benefit directly to the
pharmacy.
|
|
3.
|
Adult
Dental Services - routine preventive services, diagnostic and restorative
services, radiology services and discounts on dental
services.
|
|
4.
|
Adult
Vision Services - eye exams, eye glasses and contact
lens.
|
|
5.
|
Adult
Hearing Services - hearing evaluations, hearing aid devices and hearing
aid repairs.
|
| C. |
Excluded
Services
|
|
1.
|
The
Health Plan is not obligated to provide for any services not specified
in
this Contract. Enrollees who require services available through Medicaid
but not specified by this Contract shall receive the services through
the
Medicaid Fee-for-Service reimbursement system unless those services
have
been limited by the Health Plan’s Agency-approved CBP. In such cases, the
Health Plan's responsibility is limited to case management and referral.
Therefore, the Health Plan shall determine the need for the services
and
refer the Enrollee to the appropriate service provider. The Health
Plan
may request assistance from the local Medicaid Field Office for referral
to the appropriate service setting.
|
|
2.
|
The
Health Plan shall consult the DCF office to identify appropriate
methods
of assessment and referral for those Enrollees requiring long-term
care
institutional services, institutional services for persons with
developmental disabilities or state hospital services. The Health
Plan is
responsible for transition and referral of these Enrollees to appropriate
service providers, including helping the Enrollees to obtain an attending
physician. The Plan shall disenroll all Enrollees requiring these
services
in accordance with Section III.C.3.a.(3) of this
Contract.
|
| D. |
Moral
or Religious Objections
|
|
1.
|
The
Agency within one hundred and twenty (120) Calendar Days prior to
adopting
the policy with respect to any
service.
|
|
2.
|
Enrollees
thirty (30) Calendar Days prior to adopting the policy with respect
to any
service.
|
| E. |
Customized
Benefit Package
|
|
1.
|
The
Health Plans may choose to have a benefit package for non-pregnant
adults,
which includes all of the Covered Services described above in this
section
and those in Section VI, Behavioral Health Care, or may choose to
offer a
Customized Benefit Package (CBP).
|
|
2.
|
Should
a Health Plan choose to offer a CBP, the Health Plan shall provide
all of
the Covered Services described above in this section and those in
Section
VI, Behavioral Health Care, to pregnant women, Children/Adolescents,
and
Enrollees with a HIV/AIDS diagnoses as identified by the
Agency.
|
|
3.
|
Approved
CBPs must comport with the Benefit Grid and the attached instructions
found in Attachment I that have been tested for actuarial equivalency
and
sufficiency of benefits, before being approved by the
Agency.
|
|
a.
|
Actuarial
equivalency is tested by using a Benefit Plan Evaluation Model
that:
|
|
(1)
|
Compares
the value of the level of benefits in the proposed package to the
value of
the current Medicaid State Plan package for the average member of
the
covered population; and
|
|
(2)
|
Ensures
that the overall level of benefits is
appropriate.
|
|
b.
|
Sufficiency
is tested by comparing the proposed CBP to State established standards.
The standards are based on the covered population’s historical use of
Medicaid State Plan services. These standards are used to ensure
that the
proposed CBP is adequate to cover the needs of the vast majority
of the
Enrollees.
|
|
c.
|
If,
in its CBP, the Health Plan limits a service to a maximum annual
dollar
value, the Health Plan must calculate the dollar value of the service
using the Medicaid fee schedule. If the Health Plan limits pharmacy
services to a maximum annual dollar value, pharmacy dollar values
are
evaluated at a pre-rebate level.
|
| F. |
Coverage
Provisions
|
|
1.
|
Advance
Directives
|
|
(1)
|
Their
rights under the law of the State of Florida, including the right
to
accept or refuse medical, surgical, or behavioral health treatment
and the
right to formulate Advance Directives;
and
|
|
(2)
|
The
Health Plan's written policies respecting the implementation of those
rights, including a statement of any limitation regarding the
implementation of Advance Directives as a matter of
conscience.
|
|
2.
|
Child
Health Check-Up Program (CHCUP)
|
|
3.
|
Cost
Sharing
|
|
4.
|
Dental
|
|
5.
|
Emergency
Services
|
|
(1)
|
Require
Prior Authorization for an Enrollee to receive pre-Hospital transport
or
treatment or for Emergency Services and
Care;
|
|
(2)
|
Specify
or imply that Emergency Services and Care are covered by the Health
Plan
only if secured within a certain period of
time;
|
|
(3)
|
Use
terms such as "life threatening" or "bona fide" to qualify the kind
of
emergency that is covered; or
|
|
(4)
|
Deny
payment based on a failure by the Enrollee or the Hospital to notify
the
Health Plan before, or within a certain period of time after, Emergency
Services and Care were given.
|
|
(1)
|
The
physician, or the appropriate personnel, shall indicate on
the Enrollee's chart the results of all screenings, examinations
and
evaluations.
|
|
(2)
|
The
Health Plan shall compensate the provider for all screenings, evaluations
and examinations that are reasonably calculated to assist the provider
in
arriving at the determination as to whether the Enrollee's condition
is an
Emergency Medical Condition.
|
|
(3)
|
The
Health Plan shall for all Emergency Services and
Care.
|
|
(4)
|
If
the provider determines that an Emergency Medical Condition does
not
exist, the Health Plan is not required to pay for services rendered
subsequent to the provider's
determination.
|
|
(1)
|
Notify
the Health Plan as soon as possible before discharging the Enrollee
from
the emergency care area; or
|
|
(2)
|
Notify
the Health Plan within twenty-four (24) hours or on the next Business
Day
after admission of the Enrollee as an inpatient to the
Hospital.
|
|
(1)
|
Post-Stabilization
Care Services that were pre-approved by the Health
Plan;
|
|
(2)
|
Post-Stabilization
Care Services that were not pre-approved by the Health Plan because
the
Health Plan did not respond to the treating provider's request for
pre-approval within one (1) hour after the treating provider sent
the
request;
|
|
(3)
|
The
treating Provider could not contact the Health Plan for pre-approval;
and
|
|
(4)
|
Those
Post-Stabilization Care Services that a treating physician viewed
as
Medically Necessary after stabilizing an Emergency Medical Condition.
These are non-emergency services; the Health Plan can choose not
to cover
if provided by a nonparticipating provider, except in those circumstances
detailed in k. (1), (2), and (3) above.
|
|
(1)
|
The
nonparticipating provider's
charges;
|
|
(2)
|
The
usual and customary provider charges for similar services in the
community
where the services were provided;
|
|
(3)
|
The
amount mutually agreed to by the Health Plan and the nonparticipating
provider within sixty (60) Calendar Days after the nonparticipating
provider submits a claim; or
|
|
(4)
|
The
Medicaid rate.
|
|
6.
|
Emergency
Services - Behavioral Health
Services
|
|
7.
|
Family
Planning Services
|
|
8.
|
Hospital
Services — Inpatient
|
|
(1)
|
Denying
the mother or newborn child eligibility, or continued eligibility,
to
enroll or renew coverage under the terms of the Health Plan, solely
for
the purpose of avoiding the NMHPA
requirements;
|
|
(2)
|
Providing
monetary payments or rebates to mothers to encourage them to accept
less
than the minimum protections available under
NMHPA;
|
|
(3)
|
Penalizing
or otherwise reducing or limiting the reimbursement of an attending
physician because the physician provided care in a manner consistent
with
NMHPA;
|
|
(4)
|
Providing
incentives (monetary or otherwise) to an attending physician to induce
the
physician to provide care in a manner inconsistent with NMHPA;
and
|
|
(5)
|
Restricting
for any portion of the forty-eight (48) hour, or ninety-six (96)
hour,
period prescribed by NMHPA in a manner that is less favorable than
the
Benefits provided for any preceding portion of the Hospital
stay.
|
|
(6)
|
The
Health Plan shall pay for any Medically Necessary duration of stay
in a
noncontracted facility which results from a medical emergency until
such
time as the Plan can safely transport the Enrollee to a Plan participating
facility.
|
|
9.
|
Hospital
Services — Outpatient
|
|
(1)
|
Is
provided under the direction of a dentist at a licensed Hospital;
and
|
|
(2)
|
Is
Medically Necessary; or
|
|
(3)
|
The
Health Plan shall pay for any Medically Necessary duration of stay
in a
noncontracted facility which results from a medical emergency until
such
time as the Plan can safely transport the Enrollee to a Plan participating
facility.
|
|
10.
|
Hospital
Services — Ancillary
Services
|
|
11.
|
Hysterectomies,
Sterilizations and Abortions
|
|
12.
|
Immunizations
|
|
(1)
|
In
making a medical judgment in accordance with accepted medical practices,
such compliance is deemed medically inappropriate;
or
|
|
(2)
|
The
particular requirement is not in compliance with Florida law, including
Florida law relating to religious or other
exemptions.
|
|
13.
|
Pregnancy
Related Requirements
|
|
(1)
|
The
Health Plan shall ensure that the Provider uses the DOH prenatal
risk form
(DH Form 3134), which can be obtained from the local CHD.
|
|
(2)
|
The
Health Plan shall ensure that the Provider retains a copy of the
completed
screening instrument in the Enrollee's Medical Record and provides
a copy
to the Enrollee.
|
|
(3)
|
The
Health Plan shall ensure that the Provider submits the completed
DH Form
3134 to the CHD in the county in which the prenatal screen was completed
within ten (10) Business Days of
completion.
|
|
(4)
|
The
Health Plan shall collaborate with the Healthy Start care coordinator
within the Enrollee's county of residence to assure risk appropriate
care
is delivered.
|
|
(1)
|
If
the referral is to be made at the same time the Healthy Start risk
screen
is administered, the Provider may indicate on the risk screening
form that
the Enrollee or infant is invited to participate based on factors
other
than score; or
|
|
(2)
|
If
the determination is made subsequent to risk screening, the Participating
Provider may refer the Enrollee or infant directly to the Healthy
Start
care coordinator based on assessment of actual or potential factors
associated with high risk, such as HIV, hepatitis B, substance abuse
or
domestic violence.
|
|
(1)
|
The
Health Plan shall provide:
|
|
(2)
|
For
subsequent WIC certifications, the Health Plan shall ensure that
Providers
coordinate with the local WIC office to provide the above referral
data
from the most recent CHCUP.
|
|
(3)
|
Each
time the Health Plan completes a WIC Referral Form, the Health Plan
shall
ensure that the Provider gives a copy of the WIC Referral Form to
the
Enrollee and retains a copy in the Enrollee's Medical
Record.
|
|
(1)
|
The
Health Plan shall ensure that its Providers, in accordance with Florida
law, offer all pregnant women counseling an HIV testing at the initial
prenatal care visit and again at twenty-eight (28) to thirty-two
(32)
weeks.
|
|
(2)
|
The
Health Plan shall ensure that its Providers attempt to obtain a signed
objection if a pregnant woman declines an HIV test. See Section 384.31,
F.S., 2004 and 64D-3.019, F.A.C.
|
|
(3)
|
The
Health Plan shall ensure that all pregnant women who are infected
with HIV
are counseled about and offered the latest antiretroviral regimen
recommended by the U.S. Department of Health & Human Services. (U.S.
Department of Health & Human Services, Public Health Service Task
Force Report entitled Recommendations for the Use of Antiretroviral
Drugs
in Pregnant HIV-1 Infected Women for Maternal Health and Interventions
to
Reduce Perinatal HIV-1 Transmission in the United States. To receive
a
copy of the guidelines, contact the DOH, Bureau of HIV/AIDS at (850)
245-4334, or go to http://aidsinfo.nih.gov/guidelines/.)
|
|
(1)
|
The
Health Plan shall ensure that the Providers perform a second HBsAg
test
between twenty-eight (28) and thirty-two (32) weeks of pregnancy
for all
pregnant Enrollees who tested negative at the first (1st) prenatal
visit
and are considered high-risk for Hepatitis B infection. This test
shall be
performed at the same time that other routine prenatal screening
is
ordered.
|
|
(2)
|
All
HBsAg-positive women shall be reported to the local CHD and to Healthy
Start, regardless of their Healthy Start screening
score.
|
|
(1)
|
The
Health Plan shall ensure that its Providers test infants born to
HBsAg-positive Enrollees for HBsAg and Hepatitis B surface antibodies
(anti-HBs) six (6) months after the completion of the vaccine series
to
monitor the success or failure of the
therapy.
|
|
(2)
|
The
Health Plan shall ensure that Providers report to the local CHD a
positive
HBsAg result in any child aged twenty-four (24) months or less within
twenty-four (24) hours of receipt of the positive test
results.
|
|
(3)
|
The
Health Plan shall ensure that infants born to Enrollees who are
HBsAg-positive are referred to Healthy Start regardless of their
Healthy
Start screening score.
|
|
(1)
|
The
Health Plan shall report the following information - name, date of
birth,
race, ethnicity, address, infants, contacts, laboratory test performed,
date the sample was collected, the due date or EDC, whether or not
the
Enrollee received prenatal care, and immunization dates for infants
and
contacts.
|
|
(2)
|
The
Health Plan shall use the Perinatal Hepatitis B Case and Contact
Report (DH Form 1876) for reporting purposes.
|
|
(1)
|
Prenatal
Care - The Health Plan shall:
|
|
(2)
|
Nutritional
Assessment/Counseling - The Health Plan shall ensure that its Providers
supply nutritional assessment and counseling to all pregnant Enrollees.
The Health Plan shall:
|
|
(3)
|
Obstetrical
Delivery - The Health Plan shall develop and use generally accepted
and
approved protocols for both low risk and high risk deliveries which
reflect the highest standards of the medical profession, including
Healthy
Start and prenatal screening, and ensure that all Providers use these
protocols.
|
|
(4)
|
Newborn
Care - The Health Plan shall make certain that its Providers supply
the
highest level of care for the Newborn beginning immediately after
birth.
Such level of care shall include, but not be limited to, the
following:
|
|
(5)
|
Postpartum
Care - The Health Plan shall:
|
|
14.
|
Prescribed
Drug Services
|
|
(1)
|
The
Health Plan shall make available those drugs and dosage forms listed
in
the PDL.
|
|
(2)
|
The
Health Plan shall not arbitrarily deny or reduce the amount, duration
or
scope of prescriptions solely based on the Enrollee’s diagnosis, type of
illness or condition. The Health Plan may place appropriate limits
on
prescriptions based on criteria such as Medical Necessity, or for
the
purpose of utilization control, provided the Health Plan reasonably
expects said limits to achieve the purpose of the Prescribed Drug
Services
set forth in the Medicaid State Plan.
|
|
(3)
|
The
Health Plan shall make available those drugs not on the PDL, when
requested and approve, if the drugs on the PDL have been used in
a step
therapy sequence or when other documentation is provided.
|
|
(1)
|
An
unreasonable delay in filling the
prescription;
|
|
(2)
|
A
denial of the prescription;
|
|
(3)
|
The
reduction of a prescribed good or service;
and/or
|
|
(4)
|
The
termination of a prescription.
|
|
(1)
|
The
Health Plan shall maintain a log of all correspondences and communications
from Enrollees relating to the HSA Ombudsman process. The “Ombudsman Log”
shall contain, at a minimum, the Enrollee’s name, address and telephone
number and any other contact information, the reason for the participating
pharmacy location’s denial (and unreasonable delay in filling a
prescription, a denial of a prescription and/or the termination of
a
prescription), the pharmacy’s name (and store number, if applicable), the
date of the call, a detailed explanation of the final resolution,
and the
name of prescribed good or service.
|
|
(2)
|
The
Health Plan’s Enrollees are third party beneficiaries for this Section of
the Contract.
|
|
(3)
|
The
Health Plan shall conduct HSA surveys on an annual basis, of no less
than
five percent (5%) of all participating pharmacy locations to ensure
compliance with the HSA.
|
| (a) |
The
Health Plan may survey less than five percent (5%), with written
approval
from the Agency, if the Health Plan can show that the number of
participating pharmacies it surveys is a statistically significant
sample
that adequately represents the pharmacies that have contracted with
the
Health Plan to provide pharmacy
services.
|
| (b) |
The
Health Plan shall not include in the HSA Survey any participating
pharmacy
location that the Health Plan found to be in complete compliance
with the
HSA requirements within the last twelve
months.
|
| (c) |
The
Health Plan shall require all participating pharmacy locations that
fail
any aspect of the HSA survey to undergo mandatory training within
six (6)
months and then be re-evaluated within one (1) month of the Health
Plan’s
HSA training to ensure that the participating pharmacy location is
in
compliance with the HSA.
|
|
(4)
|
The
Health Plan shall offer to train all new and existing participating
pharmacy locations regarding the HSA
requirements.
|
|
(5)
|
The
Health Plan may delegate any or all functions to one (1) or more
Pharmacy
Benefits Administrators (PBA), so long as none of the PBAs are owned,
operated, related to, or subsidiaries of, any pharmacy. Before entering
into a Subcontract, the Health Plan
shall:
|
| (a) |
Provide
a copy of the model Subcontract between the Health Plan and the PBA
to the
Bureau of Managed Health Care;
|
| (b) |
Receive
written approval from the Bureau of Managed Health Care for the use
of
said model Subcontract; and
|
| (c) |
Work
with the Fiscal Agent to integrate the
systems.
|
|
(1)
|
Writes
in his or her own handwriting on the valid prescription that the
drug is
Medically Necessary; as determined by
section 465.025, F.S
and
|
|
(2)
|
The
prescriber submits the functionally equivalent of the FDA MedWatch
form to
the Health Plan, in his or her own handwriting, that an Enrollee
has had
an adverse reaction to a generic drug or has had, in his or her medical
opinion, better results when taking the brand-name
drug.
|
|
15.
|
Quality
Enhancements
|
|
(1)
|
Children's
Programs - The Health Plan shall provide regular general wellness
programs
targeted specifically toward Enrollees from birth to the age of five
(5),
or the Health Plan shall make a good faith effort to involve Enrollees
in
existing community Children's
Programs.
|
|
(2)
|
Domestic
Violence - The Health Plan shall ensure that PCPs screen Enrollees
for
signs of domestic violence and shall offer referral services to applicable
domestic violence prevention community agencies.
|
|
(3)
|
Pregnancy
Prevention - The Health Plan shall conduct regularly scheduled Pregnancy
Prevention programs, or shall make a good faith effort to involve
Enrollees in existing community Pregnancy Prevention programs, such
a the
Abstinence Education Program. The programs shall be targeted towards
teen
Enrollees, but shall be open to all Enrollees, regardless of age,
gender,
pregnancy status or parental consent.
|
|
(4)
|
Prenatal/Postpartum
Pregnancy Programs - The Health Plan shall provide regular home visits,
conducted by a home health nurse or aide, and counseling and educational
materials to pregnant and postpartum Enrollees who are not in compliance
with the Health Plan's prenatal and postpartum programs. The Health
Plan
shall coordinate its efforts with the local Healthy Start Care Coordinator
to prevent duplication of services.
|
|
(5)
|
Smoking
Cessation - The Health Plan shall conduct regularly scheduled Smoking
Cessation programs as an option for all Enrollees, or the Health
Plan
shall make a good faith effort to involve Enrollees in existing community
or Smoking Cessation programs. The Health Plan shall provide Smoking
Cessation counseling to Enrollees. The Health Plan shall provide
Participating PCPs with the Quick Reference Guide to assist in identifying
tobacco users and supporting and delivering effective Smoking Cessation
interventions. (The Quick Reference Guide is a distilled version
of the
Public Health Service sponsored Clinical Practice Guideline, Treating
Tobacco Use & Dependence. The Plan can obtain copies of the Quick
Reference guide by contacting the DHHS, Agency for Health Care Research
& Quality (AHR) Publications Clearinghouse at (800) 358-9295 or P.O.
Box 8547, Silver Spring, MD 20907.)
|
|
(6)
|
Substance
Abuse - The Health Plan shall offer Substance Abuse screening training
to
its Providers on an annual basis.
|
|
(a)
|
Initial
contact with a new Enrollee;
|
|
(b)
|
Routine
physical examinations;
|
|
(c)
|
Initial
prenatal contact;
|
|
(d)
|
When
the Enrollee evidences serious over-utilization of medical, surgical,
trauma or emergency services; and
|
|
(e)
|
When
documentation of emergency room visits suggests the
need.
|
|
16.
|
Protective
Custody
|
|
17.
|
Therapy
Services
|
|
a.
|
Refer
Enrollees to appropriate Participating Providers for further assessment
and treatment of conditions;
|
|
b.
|
Offer
Enrollees scheduling assistance in making treatment appointments
and
obtaining transportation; and
|
|
c.
|
Provide
for care management in order to follow the Enrollee’s progress from
screening through his/her course of
treatment.
|
|
18.
|
Transportation
|
|
(1)
|
Shall
assure that Transportation providers are appropriately licensed and
insured in accordance with the provisions of the Transportation
Handbook;
|
|
(2)
|
Must
provide Transportation Services for all Enrollees seeking necessary
Medicaid services;
|
|
(3)
|
Is
not obligated to follow the requirements of the Commission for the
Transportation Disadvantaged or the Transportation Coordinating Boards
as
set forth in Chapter 427, F.S., 2004; unless the Health Plan has
chosen to
coordinate services with the CTD;
|
|
(4)
|
Shall
be responsible for the cost of transporting an Enrollee from a
nonparticipating facility or Hospital to a participating facility
or
Hospital if the reason for transport is solely for the Health Plan's
convenience; and
|
|
(5)
|
Shall
approve claims for Transportation Services providers in accordance
with
the requirements set forth in this
Contract.
|
|
(1)
|
The
Health Plan shall provide a copy of the model Participating Transportation
Subcontract to the Bureau of Managed Health
Care.
|
|
(2)
|
The
Health Plan may subcontract with more than one Transportation services
Provider.
|
|
(3)
|
The
Health Plan shall maintain oversight of any third party providing
services
on the Health Plan's behalf.
|
|
(1)
|
How
the Health Plan will determine eligibility for each
Enrollee;
|
|
(2)
|
The
Health Plan's course of action as to how it will determine what type
of
Transportation to provide to a particular
Enrollee;
|
|
(3)
|
The
Health Plan's procedure for providing Prior Authorization to Enrollees
requesting Transportation Services;
|
|
(4)
|
The
Health Plan's comprehensive employee training program to investigate
potential fraud;
|
|
(5)
|
How
the Health Plan will review Transportation Providers who demonstrate
a
pattern or practice of:
|
|
(6)
|
How
the Health Plan will review Transportation Providers
that:
|
|
(7)
|
How
the Health Plan will provide Transportation Services outside of the
Health
Plan's service area. The Health Plan shall state clearly the guidelines
it
will use in order to control costs when providing Transportation
Services
outside of the Health Plan's service
area.
|
|
(1)
|
The
Health Plan shall ensure compliance with the minimum liability insurance
requirement of $100,000 per person and $200,000 per incident for
all
Transportation services purchased or provided for the Transportation
disadvantaged through the Health Plan. See
section 768.28(5), F.S.
The Health Plan shall indemnify and hold harmless the local, State,
and
federal governments and their entities and the Agency from any liabilities
arising out of or due to an accident or negligence on the part of
the
Health Plan and/or all Transportation Providers under contract to
the
Health Plan. The Health Plan may act as a Transportation Provider,
in
which case it must follow all requirements set forth below for
Transportation Providers.
|
|
(2)
|
The
Health Plan, and all Transportation Providers, shall ensure that
all
operations and services are in compliance with all federal and State
safety requirements, including, but not limited to, section 341.061(2)(a),
Florida Statutes, and Chapter 14-90,
F.A.C.
|
|
(3)
|
The
Health Plan, and all Transportation Providers, shall ensure continuing
compliance with all applicable State or federal laws relating to
drug
testing, including, but not limited to, to section 112.0455, Florida
Statutes, 2004, Rule 14-17.012, Chapters 59A-24 and 60L-19, F.A.C.,
41
U.S.C. 701, 49 C.F.R., Parts 29 and 382, and 46 C.F.R., Parts 4,
5, 14,
and 16.
|
|
(4)
|
The
Health Plan and all Transportation Providers shall adhere to the
following
standards, including, but not limited to, the
following:
|
|
i.
|
Wheelchairs;
|
|
ii.
|
Child
seats;
|
|
iii.
|
Stretchers;
|
|
iv.
|
Secured
oxygen;
|
|
v.
|
Personal
assistive devices; and/or
|
|
vi.
|
Intravenous
devices.
|
|
(1)
|
Address
the following safety elements and
requirements:
|
|
(2)
|
Shall
submit an annual safety certification to the Agency verifying the
following:
|
|
(3)
|
The
Health Plan shall suspend immediately a Transportation Provider if,
in the
sole discretion of the Health Plan, and at any time, continued use
of that
Transportation Provider, is unsafe for passenger service or poses
a
potential danger to public safety.
|
|
(4)
|
Address
the following security
requirements:
|
|
(5)
|
Shall
establish criteria and procedures for selection, qualification, and
training of all drivers. The criteria shall include, at a minimum,
the
following:
|
|
i.
|
The
Health Plan’s/Transportation Provider’s safety and operational policies
and procedures;
|
|
ii.
|
Operational
vehicle and equipment inspections;
|
|
iii.
|
Vehicle
equipment familiarization;
|
|
iv.
|
Basic
operations and maneuvering;
|
|
v.
|
Boarding
and alighting passengers;
|
|
vi.
|
Operation
of wheelchair lift and other special equipment and driving
conditions;
|
|
vii.
|
Defensive
driving;
|
|
viii.
|
Passenger
assistance and securement;
|
|
ix.
|
Handling
of emergencies and security threats;
and
|
|
x.
|
Security
and threat awareness.
|
|
i.
|
Communication
and handling of unsafe conditions, security threats, and
emergencies;
|
|
ii.
|
Familiarization
and operation of safety and emergency equipment, wheelchair lift
equipment, and restraining devices;
and
|
|
iii.
|
Application
and compliance with applicable federal and State rules and regulations.
The provisions in Sections 10.8.14.h.5(e) and (f), above, shall not
apply
to personnel licensed and authorized by the Plan/Transportation Provider
to drive, move, or road test a vehicle in order to perform repairs
or
maintenance services where it has been determined that such temporary
operation does not create an unsafe operating condition or create
a hazard
to public safety.
|
|
i.
|
Records
of vehicle driver background checks and
qualifications;
|
|
ii.
|
Detailed
descriptions of training administered and completed by each vehicle
driver;
|
|
iii.
|
A
record of each vehicle driver’s duty status, which shall include total
days worked, on-duty hours, driving hours and time of reporting on-
and
off-duty each day; and
|
|
iv.
|
Any
documents required to be prepared by this
Contract.
|
|
(6)
|
Shall
establish a maintenance policy and procedures for preventative and
routine
maintenance for all vehicles. The maintenance policy and procedures
shall
ensure, at a minimum, that:
|
|
i.
|
Identification
of the vehicle, including make, model, and license number or other
means
of positive identification and
ownership;
|
|
ii.
|
Date,
mileage, and type of inspection, maintenance, lubrication, or repair
performed;
|
|
iii.
|
Date,
mileage, and description of each inspection, maintenance, and lubrication
intervals performed;
|
|
iv.
|
If
not owned by the Health Plan/Transportation Provider, the name of
any
person or lessor furnishing any vehicle;
and
|
|
v.
|
The
name and address of any entity or contractor performing an inspection,
maintenance, lubrication, or
repair.
|
|
(7)
|
The
Health Plan/Transportation Provider shall investigate, or cause to
be
investigated, any event involving a vehicle or taking place on Health
Plan/Transportation Provider controlled property resulting in a fatality,
injury, or property damage as
follows:
|
|
i.
|
Each
corrective action plan shall identify the action to be taken by the
Health
Plan/Transportation Provider and the schedule for its implementation;
and
|
|
ii.
|
The
Health Plan/Transportation Provider must monitor and track the
implementation of each corrective action
plan.
|
|
(1)
|
Medical
examinations may be performed and recorded according to qualification
standards adopted by the Health Plan/Transportation Provider, provided
the
medical examination qualification standards adopted by the Health
Plan/Transportation Provider meet or exceed those provided in Department
Form Number 725-030-11, Medical Examination Report for Bus Transit
System
Driver, Rev. 07/05, hereby incorporated by reference. Copies of Form
Number 725-030-11 are available from the Florida Department of
Transportation, Public Transit Office, 605 Suwannee Street, Mail
Station
26, Tallahassee, Florida 32399-0450 or on-line at
www.dot.state.fl.us/transit.
|
|
(2)
|
Medical
examinations shall be performed by a Doctor of Medicine or Osteopathy,
a
Physician Assistant (PA) or ARNP licensed or certified by the State
of
Florida. The examination shall be conducted in person, and not via
the
Internet. If medical examinations are performed by a PA or ARNP,
they must
be performed under the supervision or review of a Doctor of Medicine
or
Osteopathy.
|
|
(3)
|
The
Health Plan/Transportation Provider shall have on file proof of medical
examination, i.e., a completed and signed medical examination report
for
each driver, dated within the past 24 months. Medical examination
reports
of employee drivers shall be maintained by the Health Plan/Transportation
Provider for a minimum of five (5) years from the date of the
examination.
|
|
(1)
|
The
Health Plan/Transportation Provider shall not permit a driver to
drive a
vehicle when such driver’s license has been suspended, canceled or
revoked. The Health Plan/Transportation Provider shall require a
driver
who receives a notice that his or her license to operate a motor
vehicle
has been suspended, canceled, or revoked notify his or her employer
of the
contents of the notice immediately, and no later than the end of
the
business day following the day he or she received the
notice.
|
|
(2)
|
At
all times, the Health Plan/Transportation Provider shall operate
vehicles
in compliance with applicable traffic regulations, ordinances and
laws of
the jurisdiction in which they are being
operated.
|
|
(3)
|
The
Health Plan/Transportation Provider shall not permit or require a
driver
to drive more than twelve (12) hours in any one 24-hour period, or
drive
after having been on duty for sixteen (16) hours in any one twenty-four
(24) hour period. The Health Plan/Transportation Provider shall not
permit
a driver to drive until the driver fulfills the requirement of a
minimum
eight (8) consecutive hours off-duty. A driver’s work period shall begin
from the time he or she first reports for duty to his or her employer.
A
driver is permitted to exceed his or her regulated hours in order
to reach
a regularly established relief or dispatch point, provided the additional
driving time does not exceed one (1)
hour.
|
|
(4)
|
The
Health Plan/Transportation Provider shall not permit or require a
driver
to be on duty more than seventy-two (72) hours in any period of seven
(7)
consecutive days; however, twenty-four (24) consecutive hours off-duty
shall constitute the end of any such period of seven (7) consecutive
days.
The Health Plan/Transportation Provider shall ensure that a driver
who has
reached the maximum 72 hours of on-duty time during the seven (7)
consecutive days has a minimum of twenty-four (24) consecutive hours
off-duty before returning to on-duty
status.
|
|
(5)
|
A
driver is permitted to drive for more than the regulated hours for
safety
and protection of the public due to conditions such as adverse weather,
disaster, security threat, a road or traffic condition, medical emergency
or an accident.
|
|
(6)
|
The
Health Plan/Transportation Provider shall not permit or require any
driver
to drive when his or her ability is impaired, or likely to be impaired,
by
fatigue, illness, or other causes, as to make it unsafe for the driver
to
begin or continue driving.
|
|
(7)
|
The
Health Plan/Transportation Provider shall require pre-operational
or daily
inspection of all vehicles and reporting of all defects and deficiencies
likely to affect safe operation or cause mechanical
malfunctions.
|
|
i.
|
Service
brakes;
|
|
ii.
|
Parking
brakes;
|
|
iii.
|
Tires
and wheels;
|
|
iv.
|
Steering;
|
|
v.
|
Horn;
|
|
vi.
|
Lighting
devices;
|
|
vii.
|
Windshield
wipers;
|
|
viii.
|
Rear
vision mirrors;
|
|
ix.
|
Passenger
doors and seats;
|
|
x.
|
Exhaust
system;
|
|
xi.
|
Equipment
for transporting wheelchairs; and
|
|
xii.
|
Safety,
security, and emergency equipment.
|
|
(1)
|
The
Health Plan/Transportation Provider shall ensure that vehicles procured
and operated meet the following requirements, at a
minimum:
|
|
(2)
|
Proof
of strength and structural integrity tests on new vehicles procured
shall
be submitted by manufacturers or the Health Plan/Transportation Providers
to the Department of Transportation. (See 14-90,
F.A.C.)
|
|
(3)
|
The
Health Plan/Transportation Provider shall ensure that every vehicle
operated in the State in connection with this Contract shall be equipped
as follows:
|
|
i.
|
Each
exterior rear vision mirror, on Type I buses shall have a minimum
reflective surface of fifty (50) square inches and the right (curbside)
mirror shall be located on the bus so that the lowest part of the
mirror
and its mounting is a minimum eighty (80) inches above the ground.
All
Type I buses shall be equipped with an inside rear vision mirror
capable
of giving the driver a clear view of seated or standing passengers.
Buses
having a passenger exit door that is located inconveniently for the
driver’s visual control shall be equipped with additional interior
mirror(s), enabling the driver to view the passenger exit door. The
exterior right (curbside) rear vision mirror and its mounting on
Type I
buses may be located lower than 80 inches from the ground, provided
such
buses are used exclusively for paratransit services. See
section 341.031, F.S.
|
|
ii.
|
In
lieu of interior mirrors, trailer buses and articulated buses may
be
equipped with closed circuit video systems or adult monitors in voice
control with the driver.
|
|
i.
|
Every
Type I bus manufactured on or after February 7, 1988, shall be equipped
with a storage battery(ies) electrical power main disconnect switch.
The
disconnect switch shall be practicably located in an accessible location
adjacent to or near to the battery(ies) and be legibly and permanently
marked for identification.
|
|
ii.
|
Every
storage battery on each public-sector bus shall be mounted with proper
retainment devices in a compartment which provides adequate ventilation
and drainage.
|
|
(4)
|
Standee
Line and Warning - Every vehicle designed and constructed to allow
standees shall be plainly marked with a line of contrasting color
at least
two (2) inches wide or be equipped with some other means to indicate
that
any passenger is prohibited from occupying a space forward of a
perpendicular plane drawn through the rear of the driver’s seat and
perpendicular to the longitudinal axis of the vehicle. A sign shall
be
posted at or near the front of the vehicle stating that it is a violation
for a vehicle to be operated with passengers occupying an area forward
of
the line.
|
|
(5)
|
Handrails
and Stanchions - Every vehicle designed and constructed to allow
standees
shall be equipped with overhead grab rails for standee passengers.
Overhead grab rails shall be continuous, except for a gap at the
rear exit
door, and terminate into vertical stanchions or turn up into a ceiling
fastener.
|
|
(6)
|
Flooring,
Steps, and Thresholds - Flooring, steps, and thresholds on all vehicles
shall have slip resistant surfaces without protruding or sharp edges,
lips, or overhangs, to prevent tripping hazards. All step edges and
thresholds shall have a band of color(s) running the full width of
the
step or edge which contrasts with the step tread and riser, either
light-on-dark or dark-on-light.
|
|
(7)
|
Doors
- Power activated doors on all vehicles shall be equipped with a
manual
device designed to release door closing
pressure.
|
|
(8)
|
Emergency
Exits - All vehicles shall have an emergency exit door, or in lieu
thereof, shall be provided with emergency escape push-out windows.
Each
emergency escape window shall be in a form of a parallelogram with
dimensions of not less than 18" by 24", and each shall contain an
area of
not less than 432 square inches. There shall be a sufficient number
of
such push-out or kick-out windows in each vehicle to provide a total
escape area equivalent to 67 square inches per seat, including the
driver’s seat.
|
|
(9)
|
Tires
and Wheels - Tires shall be properly inflated in accordance with
manufacturer’s recommendations.
|
|
i.
|
Less
than 4/32 (1/8) of an inch, measured at any point on a major tread
groove
for tires on the steering axle of all vehicles. The measurements
shall not
be made where tie bars, humps, or fillets are
located.
|
|
ii.
|
Less
than 2/32 (1/16) of an inch, measured at any point on a major tread
groove
for all other tires of all vehicles. The measurements shall not be
made
where tie bars, humps, or fillets are
located.
|
|
(1)
|
The
Health Plan/Transportation Provider shall require that all vehicles
be
inspected in accordance with the vehicle inspection procedures set
forth
above.
|
|
(2)
|
It
is the Health Plan’s/Transportation Provider’s responsibility to ensure
that each individual performing a vehicle safety inspection is qualified
as follows:
|
|
(3)
|
The
Health Plan/Transportation Provider shall ensure that each vehicle
receiving a safety inspection is checked for compliance with the
safety
devices and equipment requirements as referenced or specified above.
Specific operable equipment and devices include the
following:
|
|
(4)
|
A
safety inspection report shall be prepared by the individual(s) performing
the inspection and shall include the
following:
|
|
(5)
|
Records
of annual safety inspections and documentation of any required corrective
actions shall be retained, for compliance review, a minimum of five
(5)
years by the Health Plan/Transportation
Provider.
|
|
(1)
|
The
estimated number of one-way passenger trips to be provided in the
following categories, as defined in the Transportation
Handbook:
|
|
(2)
|
The
actual amount of funds expended and the total number of trips provided
during the previous fiscal year;
and
|
|
(3)
|
The
operating financial statistics for the previous fiscal
year.
|
| A. |
General
Provisions
|
|
1.
|
The
Health Plan shall provide Medically Necessary Behavioral Health Services
for all Enrollees pursuant to this Contract. The Health Plan shall
provide
a full range of Behavioral Health Services authorized under the State
Plan
and specified by this Contract.
|
|
2.
|
The
Health Plan shall provide the following services as described in
the
Hospital Inpatient Handbook, Mental Health Targeted Case Management
Coverage & Limitations Handbook, and the Community Behavioral Health
Services Coverage & Limitations Handbook (the Handbooks). The Health
Plan shall not alter the amount, duration and scope of such services
from
that specified in the Handbooks. The Health Plan shall not establish
service limitations that are lower than, or inconsistent with the
Handbooks.
|
|
a.
|
Inpatient
hospital care for psychiatric conditions (ICD-9-CM codes 290 through
290.43, 293.0 through 298.9, 300 through 301.9, 302.7, 306.51 through
312.4 and 312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and
315.9);
|
|
b.
|
Outpatient
hospital care for psychiatric conditions (ICD-9-CM codes 290 through
290.43, 293 through 298.9, 300 through 301.9, 302.7, 306.51 through
312.4
and 312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and
315.9);
|
|
c.
|
Psychiatric
physician services (for psychiatric specialty codes 42, 43, 44 and
ICD-9-CM codes 290 through 290.43, 293.0 through 298.9, 300 through
301.9,
302.7, 306.51 through 312.4 and 312.81 through 314.9, 315.3, 315.31,
315.5, 315.8, and 315.9);
|
|
d.
|
Community
mental health services (ICD-9-CM codes 290 through 290.43, 293.0
through
298.9, 300 through 301.9, 302.7, 306.51 through 312.4 and 312.81
through
314.9, 315.3, 315.31, 315.5, 315.8, and 315.9); and for these procedure
codes H0001, H0001HN; H0001H0, H0001TS; H0031; H0031 HO; H0031HN;
H0031TS;
H0032; H0032TS; H0046; H0047; H2000; H2000HO; H2000HP; H2010HO; H2010HE;
H2010HF; H2010HQ; H2012; H2012HF; H2017; H2019; H2019HM; M2019HN;
H2019HO;
H2019HQ; H2019HR; H2030; T1007; T1007TS; T1015; T1015HE; T1015HF;
T1023HE;
or T1023HF.
|
|
e.
|
Mental
Health Targeted Case Management (Children: T1017HA; Adults: T1017);
and
|
|
f.
|
Mental
Health Intensive Targeted Case Management (Adults:
T1017HK).
|
|
a.
|
Specialized
Therapeutic Foster Care;
|
|
b.
|
Therapeutic
Group Care Services;
|
|
c.
|
Behavioral
Health Overlay Services;
|
|
d.
|
Community
Substance Abuse Services, except as required by this Contract;
|
|
e.
|
Residential
Care;
|
|
f.
|
Sub-acute
Inpatient Psychiatric Program (SIPP) Services;
|
|
g.
|
Clubhouse
Services.
|
|
h.
|
Comprehensive
Behavioral Assessment, and
|
|
i.
|
Florida
Assertive Community Treatment Services (FACT)
|
|
The
PSN shall NOT be responsible for the provision of mental health services
to enrollees assigned to a FACT team by the DCF Substance Abuse and
Mental
Health Program (SAMH) Office. These individuals will be disenrolled
from
the plan and receive all mental health services through the funding
mechanism developed by DCF/SAMH and AHCA and re-enrolled in the plan
upon
discharge from the FACT Team Services. The FACT Team providers are
responsible for notifying Medicaid of admissions and
discharges
|
| B. | Expanded Services |
|
1.
|
Inpatient
Hospital Services
|
|
2.
|
Outpatient
Hospital Services
|
|
3.
|
Physician
Services
|
|
4.
|
Community
Mental Health Services - Covered
Services
|
|
(1)
|
These
services include psychological testing (standardized tests) and
evaluations that assess the enrollee’s functioning in all areas. All
evaluations must be appropriate to the age, developmental level and
functioning of the enrollee. All evaluations must include a clinical
summary that integrates all the information gathered and identifies
enrollee’s needs. The evaluation should prioritize the clinical needs,
evaluate the effectiveness of any prior treatment, and include
recommendations for interventions and services to be
provided.
|
|
d.
|
Medical
and Psychiatric Services
|
|
e.
|
Behavioral
Health Therapy Services:
|
|
f.
|
Community
Support and Rehabilitative
Services
|
|
g.
|
Therapeutic
Behavioral On-Site Services for Children and Adolescents
(TBOS):
|
|
Therapeutic
Behavioral On-Site Services are community services and natural supports
for children with serious emotional disturbances. Clinical services
include the provision of a professional level therapeutic service
that may
include the teaching of problem solving skills, behavioral strategies,
normalization activities and other treatment modalities that are
determined to be medically necessary. These services should be designed
to
maximize strengths and reduce behavior problems or functional deficits
stemming from the existence of a mental health disorder. Social services
include interventions designed for the restoration, modification,
and
maintenance of social, personal adjustment and basic living
skills.
|
|
|
These
services are intended to maintain the child in the home and to prevent
reliance upon a more intensive, restrictive, and costly mental health
placement. They are also focused on helping the child possess the
physical, emotional, and intellectual skills to live, learn and work
in
their own communities. Coverage must include the provision of these
services outside of the traditional office setting. The services
must be
provided where they are needed, in the home, school, childcare centers
or
other community sites.
|
|
5.
|
Mental
Health Targeted Case
Management
|
|
(1)
|
The
Health Plan shall have Case Management services available to
Children/Adolescents who have a serious emotional disturbance as
defined
as: a Child/Adolescent with a defined mental disorder; a level of
functioning which requires two or more coordinated mental health
services
to be able to live in the community; and be at imminent risk of out
of
home mental health treatment
placement.
|
|
(2)
|
The
health plan must have case management services available for adults
who:
|
|
(3)
|
Mental
health targeted Case Management services shall be available to all
Enrollees within the principles and guidelines described as
follows:
|
|
(4)
|
The
Health Plan will not be required to seek approval from the DCF, District
Substance Abuse and Mental Health Program Office for client eligibility
or
mental health targeted Case Management agency or individual provider
certification. The staffing requirements for Case Management services
are
found in Section VII.E..7, Provider Network, Behavioral Health Services,
in this Contract.
|
|
(1)
|
Mental
Health Targeted Case Management services include working with the
Enrollee
and the Enrollee’s natural support system to develop and promote a needs
assessment-based service plan. The service plan reflects the services
or
supports needed to meet the needs identified in an individualized
assessment of the following areas: education or employment, physical
health, mental health, substance abuse, social skills, independent
living
skills, and support system status. The approach used should identify
and
utilize the strengths, abilities, cultural characteristics, and informal
supports of the enrollee, family, and other natural support systems.
Targeted case managers focus on overcoming barriers by collaborating
and
coordinating with Providers and the Enrollee to assist in the attainment
of service plan goals. The targeted case manager takes the lead in
both
coordinating services/treatment and assessing the effectiveness of
the
services provided. A strengths-based approach to providing services
is
consistent with the values of individuality and uniqueness and promotes
participant self-direction and choice. The planning process is vital
to
achieving desired outcomes for the individual. The person must have
a
sense of ownership about his/her goals, and the goals must have true
meaning and vitality for him/her.
|
|
(2)
|
When
targeted case management recipients enrolled in the health plan are
hospitalized in an acute care setting or held in a county jail or
juvenile
detention facility, the health plan shall maintain contact with the
individual and shall participate actively in the discharge planning
processes.
|
|
(3)
|
Case
managers are also responsible for coordination and collaboration
with the
parents or guardians of Children/Adolescents who receive mental health
targeted Case Management services. The Health Plan shall make reasonable
efforts to assure that case managers include the parents or guardians
of
Enrollees in the process of providing targeted Case Management services.
Integration of the parent’s input and involvement with the case manager
and other Providers shall be reflected in Medical Record documentation
and
monitored through the Health Plan’s quality of care monitoring activities.
Involvement with the child’s school and/or childcare center must also be a
component of case management with
children
|
|
(1)
|
The
Health Plan shall have a Case Management program, including clinical
guidelines and protocol that addresses the issues
below:
|
|
(2)
|
The
Case Management program shall have services available based on the
individual needs of the Enrollees receiving the service. The service
should reflect a flexible system that allows movement within a continuum
of care that addresses the changing needs and abilities of
Enrollees.
|
|
6.
|
Intensive
Case Management
|
| · |
Has
resided in a state mental health treatment facility for at least
6 months
in the past 36 months;
|
| · |
Resides
in the community and has had two or more admissions to a state mental
health treatment facility in the past 36
months;
|
| · |
Resides
in the community and has had three or more admissions to a crisis
stabilization unit, short-term residential facility, inpatient psychiatric
unit, or any combination of these facilities within the past 12 months;
or
|
| · |
Resides
in the community and, due to a mental illness, exhibits behavior
or
symptoms that could result in long-term hospitalization if frequent
interventions for an extended period of time were not
provided.
|
|
8.
|
Community
Services for Enrollees Involved with the Criminal Justice
System
|
|
9.
|
Treatment
and Coordination of Care for Enrollees with Medically Complex
Conditions
|
| (1) |
Mental
health disorders due to or involving a general medical condition,
specifically -9-CM Diagnoses 293.0 through 294.1, 294.9, 307.89,
and
310.1; and
|
| (2) |
Eating
disorders - ICD-9-CM Diagnoses 307.1, 307.50, 307.51, and
307.52
|
|
10.
|
Monitoring
of Enrollees Admitted to Children’s Residential Treatment (Levels I - IV)
Programs
|
|
11.
|
Coordination
of Children’s Services
|
|
C.
|
Psychiatric
Evaluations for Enrollees Applying for Nursing Home
Admission
|
|
D.
|
Assessment
and Treatment of Mental Health Residents Who Reside in Assisted Living
Facilities (ALF) that hold a Limited Mental Health
License
|
|
The
Health Plan must develop and implement a plan to ensure compliance
with
Section 394.4574, F.S., related to services provided to residents
of
licensed assisted living facilities that hold a limited mental health
license. A cooperative agreement, as defined in 400.402, F.S., must
be
developed with the ALF if an enrollee is a resident of the ALF. The
Health
Plan must ensure that appropriate assessment services are provided
to plan
enrollees and that medically necessary mental health care services
are
available to all enrollees who reside in this type of
setting.
|
|
A
community living support plan, as defined in Section I, Definitions
and
Acronyms, must be developed for each enrollee who is a resident of
an ALF,
and it must be updated annually. The Health Plan case manager is
responsible for ensuring that the community living support plan is
implemented as written.
|
|
E.
|
Individuals
with Special Health Care Needs:
|
| · |
Developed
by the enrollee's direct service mental health care professional
with
enrollee participation and in consultation with any specialists caring
for
the enrollee;
|
| · |
Approved
by the plan in a timely manner if this approval is required;
and
|
| · |
Developed
in accordance with any applicable Agency quality assurance and utilization
review standards.
|
|
G.
|
Provision
of Behavioral Health Services When Not Covered by the Health
Plan
|
|
H.
|
Behavioral
Health Services Care Coordination and Management
|
|
a.
|
Reviewed
the Enrollee's treatment plan;
|
|
b.
|
Developed
an appropriate written transition plan;
and
|
|
.a
|
Up
to four (4) sessions of individual or group
therapy;
|
|
.b
|
One
(1) psychiatric medical session;
|
|
.c
|
Two
(2) one-hour intensive therapeutic on-site;
or
|
|
.d
|
Six
(6) days of day treatment services.
|
|
a.
|
Enrollees
admitted to an acute care facility (inpatient Hospital or crisis
stabilization unit) shall receive appropriate services upon discharge
from
the acute care facility.
|
|
b.
|
The
Health Plan shall have follow-up services available to Enrollees
within
twenty-four (24) hours of discharge from an acute care facility,
provided
the acute care facility notified the Health Plan that it had provided
services to the Enrollee.
|
|
c
|
The
Health Plan shall continue the medication prescribed by a State mental
health facility to the Enrollee for at least ninety (90) days after
the
State mental health facility discharges the Enrollee, unless the
Health
Plan's prescribing psychiatrist, in consultation and agreement with
the
State mental health facility's prescribing physician, determines
that the
medications:
|
|
I.
|
Discharge
Planning
|
|
(a)
|
Assign
a case manager to oversee the care given to the
Enrollee;
|
|
(b)
|
Develop
an individualized discharge plan, in collaboration with the Enrollee
where
appropriate, for the next service or program or the Enrollee's discharge,
anticipating the Enrollee's movement along a continuum of services;
and
|
|
(c)
|
Make
best efforts to ensure a smooth transition to the next service or
community;
|
|
(d)
|
Document
all significant efforts related to these activities, including the
Enrollee's active participation in discharge
planning.
|
|
J.
|
Transition
Plan
|
|
(1)
|
The
Enrollee is a patient at a community behavioral health center and
the
center has discussed the Enrollee's care with the Health
Plan.
|
|
(2)
|
If,
following contact with the Health Plan, there is no Behavioral Health
Care
Provider readily available and the Enrollee's condition would not
permit a
delay in treatment.
|
|
(a)
|
Four
(4) sessions of outpatient behavioral health counseling or
therapy;
|
|
(b)
|
One
(1) outpatient psychiatric physician session;
|
|
(c)
|
Two
(2) one-hour intensive therapeutic on-site sessions;
or
|
|
(d)
|
Six
(6) days of day treatment services.
|
|
K.
|
Functional
Assessments
|
|
L.
|
Outreach
Program
|
|
(a)
|
Enrollees
with severe and persistent mental illness;
|
|
(b)
|
Children/Adolescents
with severe emotional disturbances;
and
|
|
(c)
|
Enrollees
with clinical depression.
|
|
M.
|
Behavioral
Health Subcontracts
|
|
N.
|
Optional
Services
|
|
O.
|
Community
Coordination and
Collaboration
|
|
P.
|
Behavioral
Health Managed Care Local Advisory
Group
|
| · |
Assure
representation at all scheduled
meetings;
|
| · |
Provide
information requested by advisory group
members;
|
| · |
Follow
up on identified issues of concern related to the provision of services
or
administration of the Health Plan;
and
|
| · |
Share
pertinent information about Quality improvement findings and outreach
activities with the group.
|
| A. |
General
Provisions
|
|
1.
|
The
Health Plan shall have sufficient facilities, service locations,
service
sites and personnel to provide the Covered Services described in
Section V
and Behavioral Health Care described in Section VI.
|
|
2.
|
The
Health Plan shall provide the Agency with adequate assurances that
the
Health Plan has the capacity to provide Covered Services to all Enrollees
up to the maximum enrollment level in each county, including assurances
that the Health Plan:
|
|
3.
|
When
designing the Provider network, the Health Plan shall take the following
into consideration as required by 42 CFR
438.206:
|
|
4.
|
Health
Maintenance Organizations and other licensed managed care organizations
shall enroll all network providers with the Agency’s Fiscal Agent, no
later than November 30, 2006, using the Agency’s streamlined Provider
Enrollment process. All Capitated PSNs shall use the streamlined
Provider
Enrollment process to enroll network providers prior to contract
execution.
|
|
5.
|
Each
Provider shall maintain Hospital privileges if Hospital privileges
are
required for the delivery of Covered Services. The Health Plan may
use
admitting panels to comply with this
requirement.
|
|
6.
|
If
the Health Plan is unable to provide Medically Necessary services
to an
Enrollee, the Health Plan must cover these services by using providers
and
services that are not providers in the Health Plan's network, in
an
adequate and timely manner, for as long as the Health Plan is unable
to
provide the Medically Necessary services within the Health Plan's
network.
|
|
7.
|
The
Health Plan shall allow each Enrollee to choose his or her Providers
to
the extent possible and
appropriate.
|
|
8.
|
The
Health Plan shall require each Provider to have a unique Florida
Medicaid
Provider number, in accordance with the requirement of Section X,
C. jj.,
of this Contract. By May 2007, the Health Plan shall require each
Provider
to have a National Provider Identifier (NPI) in accordance with section
1173(b) of the Social Security Act, as enacted by section
4707(a) of the Balanced Budget Act of
1997.
|
|
9.
|
The
Health Plan shall provide the Agency with documentation of compliance
with
access requirements:
|
|
(1)
|
Changes
in Health Plan services or Service Area;
and
|
|
(2)
|
Enrollment
of a new population in the Health
Plan.
|
|
10.
|
The
Health Plan shall have procedures to inform Potential Enrollees and
Enrollees of any changes to service delivery and/or the Provider
network
including the following:
|
|
11.
|
The
Health Plan shall have procedures to document when a decision is
made to
not include individual or groups of providers in its network and
must give
the affected providers written notice of the reason for its decision.
|
| B. |
Primary
Care Providers
|
|
1.
|
The
Health Plan shall enter into agreements with a sufficient number
of PCPs
to ensure adequate accessibility for Enrollees of all ages. The Health
Plan shall select and approve its PCPs. The Health Plan shall ensure
its
approved PCPs agree to the following:
|
|
2.
|
The
Health Plan shall provide the
following:
|
|
(1)
|
Family
Practice;
|
|
(2)
|
General
Practice;
|
|
(3)
|
Obstetrics
or Gynecology;
|
|
(4)
|
Pediatrics;
and
|
|
(5)
|
Internal
Medicine.
|
|
3.
|
At
least annually, the Health Plan shall review each PCPs average wait
times
to ensure services are in compliance with Section VII, D. Appointment
Waiting Times and Geographic Access
Standards.
|
|
4.
|
The
Health Plan shall assign a pediatrician or other appropriate primary
care
physician to all pregnant Enrollees for the care of their newborn
babies
no later than the beginning of the last trimester of gestation. If
the
Health Plan was not aware that the Enrollee was pregnant until she
presented for delivery, the Health Plan shall assign a pediatrician
or a
primary care physician to the newborn baby within one (1) Business
Day
after birth. The Health Plan shall advise all Enrollees of the Enrollees’
responsibility to notify their Health Plan and their DCF public assistance
specialists (case workers) of their pregnancies and the births of
their
babies.
|
| C. |
Minimum
Standards
|
|
1.
|
Emergency
Services and Emergency Services Facilities
|
|
2.
|
General
Acute Care Hospital
|
|
3.
|
Birth
Delivery Facility
|
|
4.
|
Birthing
Center
|
|
5.
|
Regional
Perinatal Intensive Care Centers (RPICC)
|
|
6.
|
Neonatal
Intensive Care Unit (NICU)
|
|
7.
|
Certified
Nurse Midwife Services
|
|
8.
|
Pharmacy
|
|
9.
|
Access
for Persons with Disabilities
|
|
10.
|
Health,
Cleanliness and Safety
|
| D. |
Appointment
Waiting Times and Geographic Access
Standards
|
|
1.
|
The
Health Plans must assure that PCP services and referrals to Participating
Specialists are available on a timely basis, as
follows:
|
|
2.
|
All
PCP's and Hospital services must be available within an average of
thirty
(30) minutes travel time from an Enrollee's residence. All Participating
Specialists and ancillary services must be within an average of sixty
(60)
minutes travel time from an Enrollee's residence. The Agency may
waive
this requirement, in writing, for Rural areas and where there are
no PCPs
or Hospitals within the thirty (30) minute average travel
time.
|
|
3.
|
The
Health Plan shall provide a designated emergency services facility
within
an average of thirty (30) minutes travel time from an Enrollee's
residence, that provides care on a twenty-four (24) hours a day,
seven (7)
days a week basis. Each designated emergency service facility shall
have
one (1) or more physicians and one (1) or more nurses on duty in
the
facility at all times. The Agency may waive the travel time requirement,
in writing, in Rural areas.
|
|
4.
|
For
Rural areas, if the Health Plan is unable to enter into an agreement
with
specialty or ancillary service providers within the required sixty
(60)
minute average travel time, the Agency may waive, in writing, the
requirement.
|
|
5.
|
At
least one (1) pediatrician or one (1) CHD, FQHC or RHC within an
average
of thirty (30) minutes travel time from an Enrollee's residence,
provided
that this requirement remains consistent with the other minimum time
requirements of this Contract. In order to meet this requirement,
the
pediatrician(s), CHD, FQHC, and/or RHC must provide access to care
on a
twenty-four (24) hours a day, seven days a week basis. The Agency
may
waive this requirement, in writing, for Rural areas and where there
are no
pediatricians, CHDs, FQHCs or RHCs within the thirty (30) minute
average
travel time.
|
| E. |
Behavioral
Health Services
|
|
1.
|
The
Health Plan shall have at least one (1) certified adult psychiatrist
and
at least one (1) board certified child psychiatrist (or one (1) child
psychiatrist who meets all education and training criteria for Board
Certification) that are available within thirty (30) minutes average
travel time for Urban areas and sixty (60) minutes average travel
time for
Rural areas of all Enrollees.
|
|
2.
|
For
Rural areas, if the Health Plan does not have a Provider with the
necessary experience, the Agency may waive, in writing, the requirements
in E.1 above.
|
|
3.
|
The
Health Plan shall ensure that outpatient staff includes at least
one (1)
FTE Direct Service Behavioral Health Provider per 1,500 Enrollees.
The
Agency expects the Health Plan’s staffing pattern for direct service
Providers to reflect the ethnic and racial composition of the
community.
|
|
4.
|
The
Health Plan’s array of Direct Service Behavioral Health Providers for
adults and Children/Adolescents shall include Providers that are
licensed
or eligible for licensure, and demonstrate two (2) years of clinical
experience in the following specialty areas or with the following
populations:
|
|
5.
|
All
Direct Service Behavioral Health Providers and mental health targeted
case
managers serving the Children/Adolescent population shall be certified
by
DCF to administer CFARS (or other rating scale required by DCF or
the
Agency).
|
|
6.
|
Mental
health targeted case managers shall not be counted as Direct Service
Behavioral Health Providers.
|
|
7.
|
For
Case Management services, the Health Plan shall provide staff that
meets
the following minimum requirements:
|
|
8.
|
Case
Management supervision must be provided by a person who has a master’s
degree in a human services field and three (3) years of professional
full
time experience serving this target population or a person with a
bachelor’s degree and five (5) years of full time or equivalent Case
Management experience. For supervising case managers who work only
with
adults, two (2) years of full time experience is required. The supervisors
must have had the approved Health Plan training in Case Management
or have
documentation that they have prior equivalent
training.
|
|
9.
|
The
Health Plan shall have access to no less than one (1) fully accredited
psychiatric community Hospital bed per 2,000 Enrollees, as appropriate
for
both Children/Adolescents and adults. Specialty psychiatric Hospital
beds
may be used to count toward this requirement when psychiatric community
Hospital beds are not available within a particular community.
Additionally, the Health Plan shall have access to sufficient numbers
of
accredited Hospital beds on a medical/surgical unit to meet the need
for
medical detoxification treatment.
|
|
10.
|
The
Health Plan’s facilities must be licensed, as required by law and rule,
accessible to the handicapped, in compliance with federal Americans
with
Disabilities Act guidelines, and have adequate space, supplies, good
sanitation, and fire, safety, and disaster preparedness and recovery
procedures in operation.
|
|
11.
|
The
Health Plan shall ensure that it has Providers that are qualified
to serve
Enrollees and experienced in serving severely emotionally disturbed
Children/Adolescents and severely and persistent mentally ill adults.
The
Health Plan shall maintain documentation of its Providers’ experience in
the Providers' credentialing file.
|
|
12.
|
The
Health Plan shall adhere to the staffing ratio of at least one (1)
FTE
Behavioral Health Care Case Manager for twenty (20) Children/Adolescents
and at least one (1) FTE Behavioral Health Care Case Manager per
forty
(40) adults. Direct Service Behavioral Health Care Providers shall
not
count as Behavioral Health Care Case
Managers.
|
|
13.
|
Prior
to commencement of Behavioral Health Services, the Health Plan shall
enter
into agreements for coordination of care and treatment of Enrollees,
jointly or sequentially served, with county community mental health
care
center(s) that are not a part of the Health Plan's Participating Provider
network. The Health Plan shall enter into similar agreements with
agencies
funded pursuant to Chapter 394, F.S., 2004. The Agency shall approve
all
model agreements between the Health Plan and county community mental
health center(s)/agencies before the Health Plan enters into the
agreement. This requirement shall not apply if the Health Plan provides
the Agency with documentation that shows the Health Plan has made
a good
faith effort to contract with county community mental health
center(s)/agencies, but could not reach an
agreement.
|
|
14.
|
The
Health Plan shall request current behavioral health care provider
information from all new Enrollees upon enrollment. The Health Plan
shall
solicit these behavioral health services providers to participate
in the
Health Plan's network. The Health Plan may request in writing that
the
Agency grant exemption to a Health Plan from soliciting a specific
behavioral health services provider on a case-by-case
basis.
|
|
15.
|
To
the maximum extent possible, the Health Plan shall contract for the
provision of Behavioral Health Services with the State's community
mental
health centers designated by the Agency and
DCF.
|
| F. |
Specialists
and Other Providers
|
|
1.
|
In
addition to the above requirements, the Health Plan shall assure
the
availability of the following specialists, as appropriate for both
adults
and pediatric members, on at least a referral basis. The Health Plan
shall
use Participating Specialists with pediatric expertise for
Children/Adolescents when the need for pediatric specialty care is
significantly different from the need for adult specialty care (for
example a pediatric cardiologist for Children/Adolescents with congenital
heart defects).
|
|
2.
|
If
the infectious disease specialist does not have expertise in HIV
and its
treatment and care, then the Health Plan must have another Provider
with
such expertise.
|
|
3.
|
The
Health Plan shall make a good faith effort to execute memoranda of
agreement with the local CHDs to provide services which may include,
but
are not limited to, family planning services, services for the treatment
of sexually transmitted diseases, other public health related diseases,
tuberculosis, immunizations, foster care emergency shelter medical
screenings, and services related to Healthy Start prenatal and post
natal
screenings. The Health Plan shall provide documentation of its good
faith
effort upon the Agency’s request.
|
|
4.
|
Notwithstanding
Section VIII.B.2, Certain Public Providers, of this Contract, the
Health
Plan shall pay, without prior authorization, at the contracted rate
or the
Medicaid Fee-for-Service rate, all valid claims initiated by any
CHD for
office visits, prescribed drugs, laboratory services directly related
to
DCF emergency shelter medical screening, and tuberculosis. The Health
Plan
need not reimburse the CHD until the CHD notifies the Plan and provides
the Plan with copies of the appropriate medical records and provides
the
Enrollee's PCP with the results of any tests and associated office
visits.
|
|
5.
|
The
Health Plan shall make a good faith effort to execute a contract
with a
Federally Qualified Health Center (FQHC), and if applicable, a Rural
Health Clinic (RHC). The Health Plan shall reimburse FQHCs and RHCs
at
rates comparable to those rates paid for similar services in the
FQHC's or
RHC's community. The Health Plan shall report to the Agency, on a
quarterly basis, the payment rates and the payment amounts made to
FQHCs
and RHCs for contractual services provided by these
entities.
|
|
6.
|
The
Health Plan shall permit female Enrollees to have direct access to
a
women's health specialist within the network for Covered Services
necessary to provide women's routine and preventive health care services.
This is in addition to an Enrollee's designated PCP, if that Provider
is
not a women's health specialist.
|
|
1.
|
The
Provider network will be integrated and consist of PCPs and specialists
who are trained to provide services for a particular condition or
population;
|
|
2.
|
If
the Specialty Plan has been developed for individuals with a particular
disease state, the network will contain a sufficient number of board
certified specialists in the care and management of the disease.
Because
individuals have multiple diagnoses, there should be a sufficient
number
of specialists to manage different diagnoses as
well;
|
|
3.
|
A
defined network of facilities used for inpatient care shall be included
with accredited tertiary hospitals and hospitals that have been designated
for specific conditions, appropriate for the Specialty Plan population
(e.g., end stage renal disease centers, comprehensive hemophilia
centers;
|
|
4.
|
Specialty
pharmacies when appropriate; and
|
|
5.
|
A
range of community based care options as alternatives to hospitalization
and institutionalization.
|
| H. |
Continuity
of Care
|
|
1.
|
The
Health Plan shall allow Enrollees in active treatment to continue
care
with a terminated treating provider when such care is Medically Necessary,
through completion of treatment of a condition for which the Enrollee
was
receiving care at the time of the termination, until the Enrollee
selects
another treating Provider, or during the next Open Enrollment period.
None
of the above may exceed six (6) months after the termination of the
Provider's contract.
|
|
2.
|
The
Health Plan shall allow pregnant Enrollees who have initiated a course
of
prenatal care, regardless of the trimester in which care was initiated,
to
continue care with a terminated treating provider until completion
of
postpartum care.
|
|
3.
|
Notwithstanding
the provisions in this subsection, a terminated provider may refuse
to
continue to provide care to an Enrollee who is abusive or
noncompliant.
|
|
4.
|
For
continued care under this subsection, the Health Plan and the terminated
provider shall continue to abide by the same terms and conditions
as
existed in the terminated contract.
|
|
5.
|
The
requirements set forth in this subsection shall not apply to providers
who
have been terminated from the Health Plan for
Cause.
|
|
6.
|
The
Health Plan shall develop and maintain policies and procedures for
the
above requirements.
|
| I. |
Network
Changes
|
|
1.
|
The
Health Plan shall notify the Agency within seven (7) Business Days
of any
significant changes to the Health Plan network. A significant change
is
defined as:
|
|
2.
|
The
Health Plan shall have procedures to address changes in the Health
Plan
network that negatively affect the ability of Enrollees to access
services, including access to a culturally diverse Provider network.
Significant changes in network composition that negatively impact
Enrollee
access to services may be grounds for Contract termination or Agency
determined sanctions.
|
|
3.
|
If
a PCP ceases participation in the Health Plan network, the Health
Plan
shall send written notice to the Enrollees who have chosen the Provider
as
their PCP. This notice shall be issued no less than ninety (90) Calendar
Days prior to the effective date of the termination and no more than
ten
(10) Calendar Days after receipt or issuance of the termination notice.
|
| A. |
Quality
Improvement
|
| 1. |
General
Requirements
|
|
2.
|
Specific
Required Components of the
QIP
|
|
3.
|
Health
Plan QI Activities
|
| i. |
An
overview explaining how and why the project was selected, as well
as its
relevance to the Health Plan Enrollees and
Providers;
|
| ii. |
The
study question;
|
| iii. |
The
study population;
|
| iv. |
The
quantifiable measures to be used, including a goal or
benchmark;
|
| v. |
Baseline
methodology;
|
| vi. |
Data
sources;
|
| vii. |
Data
collection methodology;
|
| viii. |
Data
collection cycle;
|
| ix. |
Data
analysis cycle;
|
| x. |
Results
with quantifiable measures;
|
| xi. |
Analysis
with time period and the measures
covered;
|
| xii. |
Analysis
and identification of opportunities for improvement;
and
|
| xiii. |
An
explanation of all interventions to be
taken.
|
| i. |
Identify
reasonable and appropriate
objectives;
|
| ii. |
Provide
necessary services to meet the identified objectives;
and
|
| iii. |
Include
retrospective reviews that confirm that the care provided, and its
outcomes, were consistent with the approved treatment plans and
appropriate for the Enrollees'
needs.
|
| i. |
Perform
a quarterly review of a random selection of ten percent (10%) or
fifty
(50) medical records, whichever is more, of Enrollees who received
Behavioral Health Services during the previous quarter;
and
|
| ii. |
Elements
of these reviews shall include, but not be limited to:
|
|
(a)
|
Management
of specific diagnoses;
|
|
(b)
|
Appropriateness
and timeliness of care;
|
|
(c)
|
Comprehensiveness
of and compliance with the plan of
care;
|
|
(d)
|
Evidence
of special screening for high risk Enrollees and/or conditions;
and
|
|
(e)
|
Evidence
of appropriate coordination of
care.
|
|
(6)
|
The
Health Plan must review a reasonable number of records at each site
to
determine compliance. Five (5) to ten (10) records per site is a
generally-accepted target, though additional reviews must be completed
for
large group practices or when additional data is necessary in specific
instances.
|
|
(7)
|
The
Health Plan shall report the results of all Medical Record reviews
to the
Agency within thirty (30) Calendar Days of the
review.
|
|
(8)
|
The
Health Plan must submit to the Agency for written approval and maintain
a
written strategy for conducting Medical Record reviews. The strategy
must
include, at a minimum, the following:
|
|
(1)
|
The
Health Plan shall have a Peer Review process which:
|
|
(1)
|
The
Health Plan shall be responsible the credentialing and recredentialing
of
its Provider network. Hospital ancillary Providers are not required
to be
independently credentialed if those Providers only provide services
to the
Health Plan Enrollees through the
Hospital.
|
|
(2)
|
The
Health Plan shall establish and verify credentialing and recredentialing
criteria for all professional Providers that, at a minimum, meet
the
Agency's Medicaid participation standards. The Agency’s criterion
includes:
|
|
(3)
|
The
Health Plan's credentialing files must document the education, experience,
prior training and ongoing service training for each staff member
or
Provider rendering Behavioral Health
Services.
|
|
(4)
|
The
following additional requirements apply to physicians and must ensure
compliance with 42 CFR 438.214:
|
|
4.
|
Agency
Oversight
|
|
(1)
|
The
Health Plan shall furnish specific data requested by the Agency in
order
to conduct the Medical Record
audit.
|
|
(2)
|
If
the Medical Record audit indicates that Quality of care is not acceptable,
pursuant to contractual requirements, the Agency shall sanction the
Health
Plan, in accordance with the provisions of Section XIV, Sanctions,
and may
immediately terminate all Enrollment activities and Mandatory Assignments,
until the Health Plan attains an acceptable level of Quality of care
as
determined by the Agency.
|
|
(1)
|
The
Health Plan shall provide all information requested by the EQRO and/or
the
Agency, including, but not limited to quality outcomes concerning
timeliness of, and Enrollee access to, Covered
Services.
|
|
(2)
|
The
Health Plan shall cooperate with the EQRO during the Medical Record
review, which will be done at least one (1) time per year.
|
|
(3)
|
If
the EQRO indicates that the Quality of care is not within acceptable
limits set forth in this Contract, the Agency shall sanction the
Health
Plan, in accordance with the provisions of Section XIV, Sanctions
and may
immediately terminate all Enrollment activities and Mandatory Assignments
until the Health Plan attains a satisfactory level of Quality of
care as
determined by the EQRO.
|
| B. |
Utilization
Management (UM)
|
|
1.
|
General
Requirements
|
|
(1)
|
The
Health Plan must have written approval from the Agency for its Service
Authorization protocols and for any changes to the original protocols.
|
|
(2)
|
The
Health Plan's Service Authorization systems shall provide the
authorization number and effective dates for authorization to
Participating Providers and non-participating
Providers.
|
|
(3)
|
The
Health Plan's Service Authorization systems shall provide written
confirmation of all denials of authorization to providers. (See 42
C.F.R.
438.210(c)).
|
|
(a)
|
Inpatient
emergency admissions (within ten (10)
days);
|
|
(b)
|
Obstetrical
care (at first visit);
|
|
(c)
|
Obstetrical
admissions exceeding forty-eight (48) hours for vaginal delivery
and
ninety-six (96) hours for caesarean section;
and
|
|
(d)
|
Transplants.
|
|
(4)
|
Only
a licensed psychiatrist may authorize a denial for an initial or
concurrent authorization of any request for Behavioral Health Services.
The psychiatrist's review shall be part of the UM process and not
part of
the clinical review, which may be requested by a Provider or the
Enrollee,
after the issuance of a denial.
|
|
(5)
|
The
Health Plan shall provide post authorization to County Health Departments
(CHD) for the provision of emergency shelter medical screenings provided
for clients of DCF.
|
|
(6)
|
Health
Plans with automated authorization systems may not require paper
authorization as a condition of receiving
treatment.
|
|
2.
|
Certain
Public Providers
|
|
(1)
|
The
diagnosis and treatment of sexually transmitted diseases and other
communicable diseases, such as tuberculosis and human immunodeficiency
syndrome;
|
|
(2)
|
The
provision of immunizations;
|
|
(3)
|
Family
planning services and related
pharmaceuticals;
|
|
(4)
|
School
health services listed in (1), (2) and (3) above, and for services
rendered on an urgent basis by such Providers;
and,
|
|
(5)
|
In
the event that a vaccine-preventable disease emergency is declared,
the
Health Plan shall authorize claims from the County Health Department
for
the cost of the administration of
vaccines.
|
|
3.
|
Notice
of Action
|
|
(1)
|
The
Action the Health Plan has taken or intends to
take.
|
|
(2)
|
The
reasons for the Action, customized for the circumstances of the
Enrollee.
|
|
(3)
|
The
Enrollee’s or the Provider's (with written permission of the Enrollee)
right to file an Appeal.
|
|
(4)
|
The
procedures for filing an Appeal.
|
|
(5)
|
The
circumstances under which expedited resolution is available and how
to
request it.
|
|
(6)
|
Enrollee
rights to request that Benefits continue pending the resolution of
the
Appeal, how to request that Benefits be continued, and the circumstances
under which the Enrollee may be required to pay the costs of these
services.
|
|
(1)
|
At
least ten (10) Calendar Days before the date of the Action or fifteen
(15)
Calendar Days if the notice is sent by Surface Mail (five [5] Calendar
Days if the Health Plan suspects Fraud on the part of the Enrollee.
(See
42 C.F.R. 431.211, 42 C.F.R. 431.213 and 42 C.F.R. 431.214)
|
|
(2)
|
For
denial of the claim, at the time of any Action affecting the
claim.
|
|
(3)
|
For
standard Service Authorization decisions that deny or limit services,
as
quickly as the Enrollee’s health condition requires, but no later than
fourteen (14) Calendar Days following receipt of the request for
service.
(See 42 C.F.R. 438.201(d)(1))
|
|
(4)
|
If
the Health Plan extends the time frame for notification, it
must:
|
|
(5)
|
If
the Health Plan fails to reach a decision within the time frames
described
above, the failure on the part of the Health Plan shall be considered
a
denial and is an Action adverse to the Enrollee. (See 42 C.F.R.
438.210(d))
|
|
(6)
|
For
expedited Service Authorization decisions, within the three (3) Business
Days (with the possibility of a fourteen (14) Calendar Day extension)
(See
42 C.F.R. 438.210(d)(2))
|
|
(7)
|
The
Health Plan shall provide timely approval or denial of authorization
of
out-of-network use through the assignment of a Prior Authorization
number,
which refers to and documents the approval. The Health Plan shall
provide
written follow-up documentation of the approval or the denial to
the
out-of-network provider within five (5) Business Days from the request
for
approval.
|
|
(8)
|
The
Health Plan shall determine when exceptional referrals to out-of-network
specially qualified providers are needed to address the unique medical
needs of an Enrollee (e.g., when an Enrollee’s medical condition requires
testing by a geneticist). The Health Plan shall develop and maintain
policies and procedures for such
referrals.
|
|
4.
|
Care
Management
|
|
5.
|
New
Enrollee Procedures
|
|
(1)
|
Enrollees
who voluntarily enrolled; and
|
|
(2)
|
Those
Enrollees who were automatically reenrolled after regaining Medicaid
eligibility.
|
|
(1)
|
Prior
existing orders;
|
|
(2)
|
Provider
appointments, e.g. dental appointments, surgeries, etc.;
and
|
|
(3)
|
Prescriptions
(including prescriptions at non-participating
pharmacies).
|
|
(1)
|
Was
adjudicated incompetent in accordance with the law;
|
|
(2)
|
Is
found by his or her Provider to be medically incapable of understanding
his or her rights; or
|
|
(3)
|
Exhibits
a significant communication
barrier.
|
|
6.
|
Disease
Management
|
|
(1)
|
Provider
and Enrollee profiling;
|
|
(2)
|
Specialized
disease-specific physician care;
|
|
(3)
|
Intensive
care management;
|
|
(4)
|
Provider
education;
|
|
(5)
|
Enrollee
education;
|
|
(6)
|
Clinical
practice guidelines;
|
|
(7)
|
Severity
and risk assessments of the Enrollee
population;
|
|
(8)
|
Screening
to verify the Enrollee’s initial diagnosis, any complications and the
severity of the Enrollee’s illness;
and
|
|
(9)
|
Interventions
designed to improve compliance and prevent acute events, which may
include:
|
|
7.
|
Incentive
Programs
|
|
8.
|
Practice
Guidelines
|
|
(1)
|
Are
based on valid and reliable clinical evidence or a consensus of Health
Care Professionals in a particular
field;
|
|
(2)
|
Consider
the needs of the Enrollees;
|
|
(3)
|
Are
adopted in consultation with Providers;
and
|
|
(4)
|
Are
reviewed and updated periodically, as appropriate. ( See 42 CFR
438.236(b))
|
|
10.
|
Out-of-Plan
Use of Non-Emergency
Services
|
| A. |
General
Requirements
|
| 1. |
The
Health Plan must develop, implement, and maintain a Grievance System
that
complies with federal laws and regulations, including 42 CFR 431.200
and
438, Subpart F, “Grievance System.”
|
| 2. |
The
Grievance System must include an external grievance resolution process
modeled after the subscriber assistance program panel, as created
in
section 408.7056, F.S., and referred to in this contract as the
Beneficiary Assistance Program.
|
| 3. |
The
Grievance System must include written policies and procedures that
are
approved in writing, by the Agency.
|
| 4. |
The
Health Plan must give Enrollees reasonable assistance in completing
forms
and other procedural steps, including, but not limited to, providing
interpreter services and toll-free numbers with TTY/TDD and interpreter
capability.
|
| 5. |
The
Health Plan must acknowledge receipt of each Grievance and
Appeal.
|
| 6. |
The
Health Plan must ensure that decision makers about Grievances and
Appeals
were not involved in previous levels of review or decision making
and are
Health Care Professionals with appropriate clinical expertise in
treating
the Enrollee’s condition or disease when deciding any of the
following:
|
| 7. |
The
Health Plan shall provide information regarding the Grievance System
to
Enrollees as described in Section IV., A., 2. and 3. The information
shall
include, but not be limited to:
|
| a. |
Enrollee
rights to file Grievances and Appeals and requirements and time frames
for
filing.
|
| b. |
The
availability of assistance in the filing
process.
|
| c. |
The
address, toll-free telephone number, and the office hours of the
Grievance
coordinator.
|
| d. |
The
method for obtaining a Medicaid fair hearing, the rules that govern
representation at the hearing, and the DCF address for pursuing a
fair
hearing, which is:
|
| e. |
A
description of the Beneficiary Assistance Program, the types of Grievances
and Appeals that can be forwarded to the Beneficiary Assistance Program
and directions for doing so.
|
| f. |
A
statement assuring Enrollees that the Health Plan, its Providers
or the
Agency will not retaliate against an Enrollee for submitting a Grievance,
an Appeal or a request for a Medicaid fair hearing.
|
| g. |
Enrollee
rights to request continuation of Benefits during an Appeal or Medicaid
fair hearing process and, if the Health Plan’s Action is upheld in a
hearing, the fact that the Enrollee may be liable for the cost of
said
Benefits.
|
| h. |
Notice
that the Health Plan must continue Enrollee Benefits
if:
|
|
(1)
|
The
Appeal is filed timely, meaning on or before the later of the
following:
|
| i. |
Within
ten (10) Calendar Days of the date on the notice of Action (Fifteen
(15)
Calendar Days if the notice is sent via Surface Mail),
and
|
| ii. |
The
intended effective date of the Health Plan’s proposed Action.
|
|
(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
authorization period has not
expired.
|
|
(5)
|
The
Enrollee requests extension of
Benefits.
|
| i. |
The
Health Plan must provide information about the Grievance System and
its
respective policies, procedures, and timeframes, to all Providers
and
subcontractors at the time they enter into a subcontract/Provider
contract. The Health Plan must clearly specify all procedural steps
in the
Provider manual, including the address, telephone number, and office
hours
of the Grievance coordinator.
|
| 8. |
The
Health Plan must maintain records of Grievances and Appeals for tracking
and trending for QI and to fulfill reporting requirements as described
in
Section XII., Reporting
Requirements.
|
| B. |
Grievance
Process
|
| 1. |
Filing
a Grievance
|
| a. |
A
Grievance is any expression of dissatisfaction by an Enrollee, about
any
matter other than an Action. A Provider, acting on behalf of the
Enrollee
and with the Enrollee’s written consent, may also file a
Grievance.
|
| b. |
A
Grievance may be filed orally.
|
| 2. |
Grievance
Resolution
|
| a. |
The
Health Plan must resolve each Grievance and provide the Enrollee
with a
notice of the Grievance disposition within ninety (90) days of its
receipt.
|
| b. |
The
Grievance must be resolved more expeditiously, within twenty four
(24)
hours, if the Enrollee’s health condition requires, as found in
s409.91211(3)(q), F.S.
|
| c. |
The
notice of disposition must be in writing and include the results
and the
date of Grievance resolution.
|
| d. |
The
Health Plan must provide the Agency with a copy of the notice of
disposition upon request.
|
| e. |
The
Health Plan must ensure that punitive action is not taken against
a
Provider who files a Grievance on an Enrollee’s behalf or supports an
Enrollee’s Grievance as required in s. 409.9122(12),
F.S.
|
| 3. |
Submission
to the Beneficiary Assistance
Program
|
|
(1)
|
The
quality of health care services; or
|
|
(2)
|
Matters
pertaining to the contractual relationship between an Enrollee and
the
Health Plan.
|
| C. |
Appeal Process
|
| 1. |
Filing
an Appeal
|
| 2. |
Resolution
of Appeals
|
|
(1)
|
The
Appeal is filed timely, meaning on or before the later of the
following:
|
|
(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
Authorization period has not
expired.
|
|
(5)
|
The
Enrollee requests extension of
Benefits.
|
|
(1)
|
The
Enrollee withdraws the Appeal.
|
|
(2)
|
Ten
(10) Calendar Days (Fifteen (15) Calendar Days if the notice is sent
via
Surface Mail) pass from the date of the Health Plan’s adverse decision,
and the Enrollee has not requested a Medicaid fair hearing with
continuation of Benefits.
|
|
(3)
|
A
Medicaid fair hearing decision adverse to the Enrollee is made.
|
|
(4)
|
The
authorization expires or authorized service limits are
met.
|
|
(1)
|
Notice
of the Enrollee’s right to request a Medicaid fair
hearing.
|
|
(2)
|
Information
about how to request a Medicaid fair hearing, including the DCF address
for pursuing a Medicaid fair hearing, which
is:
|
|
(3)
|
Notice
of the right to continue to receive Benefits pending a Medicaid fair
hearing.
|
|
(4)
|
Information
about how to request the continuation of
Benefits.
|
|
(5)
|
Notice
that if the Health Plan’s action is upheld in a Medicaid fair hearing, the
Enrollee may be liable for the cost of any continued
Benefits.
|
| 3. |
Post
Appeal Resolution
|
| 4. |
Expedited
Process
|
|
(1)
|
Inform
the Enrollee of the limited time available for the Enrollee to present
evidence and allegations of fact or law, in person and/or in
writing.
|
|
(2)
|
Resolve
each expedited Appeal and provide notice, as expeditiously as the
Enrollee’s health condition requires, not to exceed seventy-two (72) hours
after the Health Plan receives the Appeal.
|
|
(3)
|
Provide
written notice of disposition that includes the results and date
of
expedited Appeal resolution, and for decisions not wholly in the
Enrollee’s favor, that includes:
|
|
(1)
|
Transfer
the Appeal to the standard time frame of no longer than forty-five
(45)
days from the day the Health Plan receives the Appeal with a possible
fourteen (14) day extension.
|
|
(2)
|
Make
reasonable efforts to provide prompt oral notice of the
denial.
|
|
(3)
|
Provide
written notice of the denial within two (2) Calendar
Days.
|
|
(4)
|
Fulfill
all general Health Plan duties listed
above.
|
| 5. |
Submission
to the Beneficiary Assistance
Program
|
|
(1)
|
The
availability of health care services or the coverage of Benefits,
or an
adverse determination about Benefits made pursuant to UM;
or
|
|
(2)
|
Claims
payment, handling, or reimbursement for
Benefits.
|
| D. |
Medicaid
Fair Hearing System
|
| 1. |
Request
for a Medicaid Fair
Hearing
|
| 2. |
Health
Plan Responsibilities
|
|
(1)
|
The
Medicaid fair hearing is filed timely, meaning on or before the later
of
the following:
|
|
(2)
|
The
Medicaid fair hearing involves the termination, suspension, or reduction
of a previously authorized course of
treatment.
|
|
(3)
|
The
services were ordered by an authorized
provider.
|
|
(4)
|
The
authorization period has not
expired.
|
|
(5)
|
The
Enrollee requests extension of
Benefits.
|
|
(1)
|
The
Enrollee withdraws the request for a Medicaid fair
hearing.
|
|
(2)
|
Ten
(10) Calendar Days pass from the date of the Health Plan’s adverse
decision and the Enrollee has not requested a Medicaid fair hearing
with
continuation of Benefits until a Medicaid fair hearing decision is
reached. (Fifteen (15) Calendar Days if the notice is sent via Surface
Mail)
|
|
(3)
|
A
Medicaid fair hearing decision adverse to the Enrollee is
made.
|
|
(4)
|
The
authorization expires or authorized service limits are
met.
|
| 3. |
Post
Medicaid Fair Hearing
Decision
|
| A. |
General
Provisions
|
|
3.
|
The
Health Plan must provide that compensation to individuals or entities
that
conduct utilization management activities is not structured so as
to
provide incentives for the individual or entity to deny, limit, or
discontinue medically necessary services to any
Enrollee.
|
| B. |
Staffing
|
| C. |
Provider
Contracts Requirements
|
|
i.
|
This
clause must survive the termination of the Provider Contract, including
breach due to Insolvency, and
|
|
ii.
|
The
Agency may waive this requirement for itself, but not Health Plan
Enrollees, for damages in excess of the statutory cap on damages
for
public entities if the Provider is a public health entity with statutory
immunity (all such waivers must be approved in writing by the
Agency);
|
| ee. |
Require
that the Provider secure and maintain during the life of the Provider
Contract worker's compensation insurance (complying with the Florida's
Worker's Compensation Law) for all of its employees connected with
the
work under this Contract unless such employees are covered by the
protection afforded by the Health
Plan;
|
| ff. |
Make
provisions for a waiver of those terms of the Provider Contract,
which, as
they pertain to Medicaid Recipients, are in conflict with the
specifications of this Contract;
|
| gg. |
Contain
no provision that in any way prohibits or restricts the Provider
from
entering into a commercial contract with any other plan (pursuant
to s.
641.315, F.S.);
|
| hh. |
Contain
no provision requiring the Provider to contract for more than one
Health
Plan product or otherwise be excluded (pursuant to s. 641.315, F.S.);
|
| ii. |
Contain
no provision that prohibits the Provider from providing inpatient
services
in a contracted hospital to an Enrollee if such services are determined
to
be medically necessary and covered services under this
Contract;.
|
| jj. |
Require
all Providers to apply for a National Provider Identification number
(NPI)
within ninety (90) days of final execution of this Contract or within
ninety (90) days of final execution of the Provider contract, whichever
is
later. Providers can obtain their NPIs through the National Plan
and
Provider Enumerator System located at: .
Additionally, the Provider contract shall require the Provider to
submit
all NPIs for its physicians and other health care providers to the
Health
Plan within fifteen (15) Business Days of receipt. The Health Plan
shall
report the Providers’ NPIs as part of its Provider Network Report, in a
manner to be determined by the Agency, and in its Provider Directory,
to
the Agency or its Choice Counselor/Enrollment Broker, as set forth
in
Section XII, Reporting
Requirements.
|
| kk. |
Require
Providers to cooperate fully in any investigation by the Agency,
Medicaid
Program Integrity (MPI), or Medicaid Fraud Control Unit (MFCU), or
any
subsequent legal action that may result from such an
investigation.
|
| D. |
Provider
Termination
|
| E. |
Provider
Services
|
|
1.
|
General
Provisions
|
|
2.
|
Provider
Handbooks
|
|
3.
|
Education
and Training
|
|
4.
|
Provider
Relations
|
|
5.
|
Toll-free
Provider Telephone Help
Line
|
|
6.
|
Provider
Complaint System
|
|
(1)
|
Allow
providers forty-five (45) Calendar Days to file a written
complaint;
|
|
(2)
|
Have
dedicated staff for providers to contact via telephone, electronic
mail,
or in person, to ask questions, file a Provider complaint and resolve
problems;
|
|
(3)
|
Identify
a staff person specifically designated to receive and process provider
complaints;
|
|
(4)
|
Thoroughly
investigate each provider complaint using applicable statutory,
regulatory, Contractual and Provider contract provisions, collecting
all
pertinent facts from all parties and applying the Health Plan’s written
policies and procedures; and
|
|
(5)
|
Ensure
that Health Plan executives with the authority to require corrective
action are involved in the provider complaint
process.
|
| F. |
Medical
Records Requirements
|
|
1.
|
The
Health Plan shall maintain Medical Records for each Enrollee in accordance
with this section. Medical Records shall include the Quality, quantity,
appropriateness, and timeliness of services performed under this
Contract.
|
|
2.
|
The
Health Plan shall maintain a behavioral health Medical Record for
each
Enrollee. Each Enrollee's behavioral health Medical Record shall
include:
|
|
(1)
|
The
physician or other service provider;
|
|
(2)
|
Date
of service;
|
|
(3)
|
The
units of service provided; and
|
|
(4)
|
The
type of service provided.
|
| G. |
Claims
Payment
|
|
1.
|
The
Health Plan shall reimburse providers for the delivery of authorized
services pursuant to section 641.3155 F.S. including, but not limited
to:
|
|
(1)
|
The
date of service or discharge from an inpatient setting;
or
|
|
(2)
|
The
provider has been furnished with the correct name and address of
the
Enrollee’s Health Plan.
|
|
2.
|
The
Health Plan shall reimburse providers for Medicare deductibles and
co-insurance payments for Medicare dually eligible members according
to
the lesser of the following:
|
|
3.
|
In
accordance with section 409.912 F.S., the Health Plan shall reimburse
any
Hospital or physician that is outside the Health Plan’s authorized
geographic service area for Health Plan authorized services provided
by
the Hospital or physician to
Enrollees:
|
|
(1)
|
The
usual and customary charge made to the general public by the Hospital
or
physician; or
|
|
(2)
|
The
Florida Medicaid reimbursement rate established for the Hospital
or
physician.
|
|
4.
|
The
Health Plan shall have a process for handling and addressing the
resolution of provider complaints concerning claims issues. The process
shall be in compliance with 641 .3155
F.S.
|
|
5.
|
The
Health Plan shall have claims processing and payment performance
metrics
including those for quality, accuracy and timeliness and include
a process
for measurement and monitoring, and for the development and implementation
of interventions for improvement. These metrics must be approved
in
writing by the Agency.
|
|
6.
|
Pursuant
to 42CFR447.45, the Health Plan shall have a claims processing and
payment
system, such that:
|
| H. |
Encounter
Data
|
| 1. |
All
encounters shall be submitted in the standard HIPAA transaction formats,
namely the ANSI X12N 837 Transaction formats (P - Professional, I
-
Institutional, and D - Dental), and the National Council for Prescription
Drug Programs NCPDP format (for Pharmacy
services).
|
| 2. |
Health
Plans shall collect and submit to the Agency or its designee, enrollee
service level encounter data for all covered services. Health Plans
will
be held responsible for errors or noncompliance resulting from their
own
actions or the actions of an agent authorized to act on their
behalf.
|
| 3. |
Health
Plans shall have the capability to convert all information that enters
their claims systems via hard copy paper claims to encounter data
to be
submitted in the appropriate HIPAA compliant
formats.
|
| 4. |
Complete
and accurate encounters shall be provided to the Agency. Health Plans
will
implement review procedures to validate encounter data submitted
by
providers. The historical encounter data submission shall be retained
for
a period not less than five years following generally accepted retention
guidelines.
|
| 5. |
Health
Plans shall require each Provider to have a unique Florida Medicaid
Provider number, in accordance with the requirement of Section X,
C. jj.
of this Contract.
|
| 6. |
Health
Plans will designate sufficient IT and staffing resources to perform
these
encounter functions as determined by generally accepted best industry
practices.
|
| I. |
Fraud
Prevention
|
|
1.
|
The
Health Plan shall establish functions and activities governing program
integrity in order to reduce the incidence of Fraud and Abuse and
shall
comply with all State and federal program integrity requirements,
including the applicable provisions of chapters 358, 414, 641 and
932 in
Florida law and s. 409.912 (21) and (22). (See 42 CFR
438.608)
|
|
2.
|
The
Health Plan shall designate a compliance officer with sufficient
experience in health care, who shall have the responsibility and
authority
for carrying out the provisions of the Fraud and Abuse policies and
procedures. The Health Plan shall have adequate staffing and resources
to
investigate unusual incidents and develop and implement corrective
action
plans to assist the Health Plan in preventing and detecting potential
Fraud and Abuse activities.
|
|
3.
|
The
Health Plan shall have internal controls and policies and procedures
in
place that are designed to prevent, detect and report known or suspected
Fraud and Abuse activities.
|
|
4.
|
The
Health Plan shall submit its Fraud and Abuse policies and procedures
to
the Bureau of Managed Health Care for written approval before
implementation. At a minimum, the policies and procedures
shall:
|
|
(1)
|
Claims
edits;
|
|
(2)
|
Post-processing
review of claims;
|
|
(3)
|
Provider
profiling and credentialing, including a review process for claims
that
shall include Providers and nonparticipating
providers:
|
|
(4)
|
Prior
Authorization;
|
|
(5)
|
Utilization
Management;
|
|
(6)
|
Relevant
Subcontract and Provider contract provisions;
and
|
|
(7)
|
Pertinent
provisions from the Provider handbook and the Enrollee
handbook.
|
|
(1)
|
Make
available to the Agency, MPI and/or MFCU any and all administrative,
contractual, financial and Medical Records relating to the delivery
of
items or services for which Medicaid monies are expended;
and
|
|
(2)
|
Allow
access to the Agency, MPI and/or MFCU to any place of business and
all
Medical Records, as required by State and/or federal law. The Agency,
MPI
and MFCU shall have access during normal business hours, except under
special circumstances when the Agency, MPI and MFCU shall have after
hour
admission. The Agency, MPI and/or MFCU shall determine the need for
special circumstances.
|
|
5.
|
The
Health Plan shall comply with all reporting requirements set forth
in
Section XII., Reporting
Requirements.
|
|
6.
|
The
Health Plan shall meet with the Agency periodically, at the Agency’s
request, to discuss fraud, abuse, neglect and overpayment issues.
For
purpose of this section, the Health Plan Compliance Officer shall
be the
point of contact for the Health Plan and the Agency’s Medicaid Fraud and
Abuse Liaison shall be the point of contact for the
Agency.
|
| A. |
General
Provisions
|
| 1. |
Systems
Functions.
The Health Plan shall have Information management processes and
Information Systems (hereafter referred to as Systems) that enable
it to
meet Agency and federal reporting requirements and other Contract
requirements and that are in compliance with this Contract and all
applicable State and federal laws, rules and regulations including
HIPAA.
|
| 2. |
Systems
Capacity.
The Health Plan’s Systems shall possess capacity sufficient to handle the
workload projected for the begin date of operations and will be scaleable
and flexible so they can be adapted as needed, within negotiated
timeframes, in response to changes in Contract requirements, increases
in
enrollment estimates, etc.
|
| 3. |
E-Mail
System.
The Health Plan shall provide a continuously available electronic
mail
communication link (E-mail system) with the Agency. This system shall
be:
available from the workstations of the designated Health Plan contacts;
and capable of attaching and sending documents created using software
products other than Health Plan’s systems, including the Agency’s
currently installed version of Microsoft Office and any subsequent
upgrades as adopted.
|
| 4. |
Participation
in Information Systems Work Groups/Committees.
The Health Plan shall meet as requested by the Agency to coordinate
activities and develop cohesive systems strategies across vendors
and
agencies that actively participate in the reform initiative.
|
| 5. |
Connectivity
to the Agency/State Network and Systems.
The Health Plan shall be responsible for establishing connectivity
to the
Agency’s/the State’s wide area data communications network, and the
relevant information systems attached to this network, in accordance
to
all applicable Agency and/or State policies, standards and guidelines.
|
| B. |
Data
and Document Management
Requirements
|
| a. |
Health
Plan Systems shall conform to the standard transaction code sets
specified
in Section XI.I.
|
| b. |
The
Health Plan’s Systems shall conform to HIPAA standards for data and
document management that are currently under development within one
hundred twenty (120) Calendar Days of the standard’s effective date or, if
earlier, the date stipulated by CMS or the
Agency.
|
| c. |
The
Health Plan shall partner with the Agency in the management of standard
transaction code sets specific to the Agency. Furthermore, the Health
Plan
shall partner with the Agency in the development and implementation
planning of future standard code sets not specific to HIPAA or other
federal efforts and shall conform to these standards as stipulated
in the
plan to implement the standards.
|
| 2. |
Data
Model and Accessibility.
Health Plan Systems shall be Structured Query Language (SQL) and/or
Open
Database Connectivity (ODBC) compliant; alternatively, Health Plan
Systems
shall employ a relational data model in the architecture of its databases
in addition to a relational database management system (RDBMS) to
operate
and maintain them.
|
| 3. |
Data
and Document Relationships.
The Health Plan shall house indexed images of documents used by Enrollees
and providers to transact with the Health Plan in the appropriate
database(s) and document management systems so as to maintain the
logical
relationships between certain documents and certain data.
|
| 4. |
Information
Retention.
Information in Health Plan systems shall be maintained in electronic
form
for three years in live Systems and, for audit and reporting purposes,
for
seven years in live and/or archival
Systems.
|
| 5. |
Information
Ownership.
All Information, whether data or documents, and reports that contain
or
make references to said Information, involving or arising out of
this
Contract is owned by the Agency. The Health Plan is expressly prohibited
from sharing or publishing the Agency information and reports without
the
prior written consent of the Agency. In the event of a dispute regarding
the sharing or publishing of information and reports, the Agency’s
decision on this matter shall be final and not subject to change.
|
| C. |
System
and Data Integration
Requirements
|
| a. |
Health
Plan Systems shall be able to transmit, receive and process data
in
HIPAA-compliant formats that are in use as of the Contract Execution
Date;
these formats are detailed in Section
XI.J.
|
| b. |
Health
Plan Systems shall be able to transmit, receive and process data
in the
Agency-specific formats and/or methods that are in use on the Contract
Execution Date, as specified in Section
XI.J.
|
| c. |
Health
Plan Systems shall conform to future federal and/or Agency specific
standards for data exchange within one hundred twenty (120) Calendar
Days
of the standard’s effective date or, if earlier, the date stipulated by
CMS or the Agency. The Health Plan shall partner with the Agency
in the
management of current and future data exchange formats and methods
and in
the development and implementation planning of future data exchange
methods not specific to HIPAA or other Federal effort. Furthermore,
the
Health Plan shall conform to these standards as stipulated in the
plan to
implement such standards.
|
| a. |
The
Health Plan shall receive, process and update enrollment files sent
daily
by the Agency or its Agent.
|
| b. |
The
Health Plan shall update its eligibility/Enrollment databases within
twenty-four (24) hours of receipt of said files.
|
| c. |
The
Health Plan shall transmit to the Agency or its Agent, in a periodicity
schedule, format and data exchange method to be determined by the
Agency,
specific data it may garner from an Enrollee including third party
liability data.
|
| d. |
The
Health Plan shall be capable of uniquely identifying a distinct Medicaid
Recipient across multiple Systems within its Span of
Control.
|
| D. |
Systems Availability, Performance and Problem Management
Requirements
|
| 1. |
Availability
of Critical Systems Functions.
|
| 2. |
Availability
of Data Exchange Functions.
|
| 3. |
Availability
of Other Systems Functions.
|
| 4. |
Problem
Notification.
|
| a. |
Upon
discovery of any problem within its Span of Control that may jeopardize
or
is jeopardizing the availability and performance of all Systems functions
and the availability of information in said Systems, including any
problems impacting scheduled exchanges of data between the Health
Plan and
the Agency and/or its Agent(s), the Health Plan shall notify the
applicable Agency staff via phone, fax and/or electronic mail within
fifteen (15) minutes of such discovery. In its notification the Health
Plan shall explain in detail the impact to critical path processes
such as
enrollment management and claims submission
processes.
|
| b. |
The
Health Plan shall provide to appropriate Agency staff information
on
System Unavailability events, as well as status updates on problem
resolution. At a minimum these up-dates shall be provided on an hourly
basis and made available via electronic mail and/or telephone.
|
| 5. |
Recovery
from Unscheduled System Unavailability.
|
| 6. |
Exceptions
to System Availability Requirement.
|
| 7. |
Corrective
Action Plan.
|
| 8. |
Business
Continuity-Disaster Recovery (BC-DR) Plan
|
| a. |
Regardless
of the architecture of its Systems, the Health Plan shall develop
and be
continually ready to invoke a business continuity and disaster recovery
(BC-DR) plan that is reviewed and prior-approved by the Agency.
|
| b. |
At
a minimum the Health Plan’s BC-DR plan shall address the following
scenarios: (1) the central computer installation and resident software
are
destroyed or damaged, (2) System interruption or failure resulting
from
network, operating hardware, software, or operational errors that
compromises the integrity of transactions that are active in a live
system
at the time of the outage, (3) System interruption or failure resulting
from network, operating hardware, software or operational errors
that
compromises the integrity of data maintained in a live or archival
system,
(4) System interruption or failure resulting from network, operating
hardware, software or operational errors that does not compromise
the
integrity of transactions or data maintained in a live or archival
system
but does prevent access to the System, i.e. causes unscheduled System
Unavailability.
|
| c. |
The
Health Plan shall periodically, but no less than annually, perform
comprehensive tests of its BC-DR plan through simulated disasters
and
lower level failures in order to demonstrate to the Agency that it
can
restore System functions per the standards outlined elsewhere in
this
Section of the Contract.
|
| d. |
In
the event that the Health Plan fails to demonstrate in the tests
of its
BC-DR plan that it can restore system functions per the standards
outlined
in this Contract, the Health Plan shall be required to submit to
the
Agency a corrective action plan in accordance with Section XIV (Sanctions)
of this Contract that describes how the failure will be resolved.
The
corrective action plan shall be delivered within ten (10) Business
Days of
the conclusion of the test.
|
| E. |
System Testing and Change Management Requirements
|
| 1. |
Notification
and Discussion of Potential System Changes.
|
| 2. |
Response
to Agency Reports of Systems Problems not Resulting in System
Unavailability.
|
| a. |
Within
seven (7) Calendar Days of receipt the Health Plan shall respond
in
writing to notices of system problems.
|
| b. |
Within
twenty (20) Calendar Days, the correction will be made or a Requirements
Analysis and Specifications document will be due.
|
| c. |
The
Health Plan will correct the deficiency by an effective date to be
determined by the Agency.
|
| 3. |
Valid
Window for Certain System Changes.
|
| 4. |
Testing
|
| a. |
The
Health Plan shall work with the Agency pertaining to any testing
initiative as required by the Agency.
|
| b. |
The
Health Plan shall provide sufficient system access to allow the Agency
and/or independent testing of the Health Plan’s systems during and
subsequent to readiness review.
|
| F. |
Information
Systems Documentation Requirements
|
| 1. |
Types
of Documentation.
|
| 2. |
Content
of System Process and Procedure Manuals.
|
| 3. |
Content
of System User Manuals.
|
| 4. |
Changes
to Manuals.
|
| a. |
When
a System change is subject to Agency sign off, the Health Plan shall
draft
revisions to the appropriate manuals prior to Agency sign off of
the
change.
|
| b. |
Updates
to the electronic version of these manuals shall occur in real time;
updates to the printed version of these manuals shall occur within
ten
(10) Business Days of the update taking
effect.
|
| 5. |
Availability
of/Access to Documentation.
|
| G. |
Reporting Requirements - Specific to Information Management and Systems
Functions and Capabilities - and Technological Capabilities
|
| 1. |
Reporting
Requirements.
|
| 2. |
Reporting
Capabilities.
|
| H. |
Other
Requirements
|
| a. |
At
such time that the Agency requires, the Health Plan shall participate
and
cooperate with the Agency to implement, within a reasonable timeframe,
a
secure, Web-accessible Community Health Records for
Enrollees.
|
| b. |
The
design of the vehicle(s) for accessing the Community Health Record,
the
health record format and design shall comply with all HIPAA and related
regulations.
|
| c. |
The
Health Plan shall also cooperate with the Agency in the continuing
development of the state’s health care data site (FloridaHealthStat).
|
| I. |
Compliance
with Standard Coding
Schemes
|
| 1. |
Compliance
with HIPAA-Based Code Sets.
|
| a. |
Logical
Observation Identifier Names and Codes
(LOINC)
|
| b. |
Health
Care Financing Administration Common Procedural Coding System
(HCPCS)
|
| c. |
Home
Infusion EDI Coalition (HEIC) Product Codes
|
| d. |
National
Drug Code (NDC)
|
| e. |
National
Council for Prescription Drug Programs
(NCPDP)
|
| f. |
International
Classification of Diseases (ICD-9)
|
| g. |
Diagnosis
Related Group (DRG)
|
| h. |
Claim
Adjustment Reason Codes
|
| i. |
Remittance
Remarks Codes
|
| 2. |
Compliance
with Other Code Sets.
|
|
a.
|
As
described in all AHCA Medicaid Reimbursement Handbooks, for all "Covered
Entities", as defined under the HIPAA, and which submit transactions
in
paper format (non-electronic
format).
|
|
b.
|
As
described in all AHCA Medicaid Reimbursement Handbooks for all
"Non-covered Entities", as defined under the
HIPAA.
|
| J. |
Data
Exchange and Formats and Methods Applicable to Health
Plans
|
| 1. |
HIPAA-Based
Formatting Standards.
|
| 2. |
Methods
for Data Exchange.
|
| 3. |
Agency-Based
Formatting Standards and Methods.
|
| a. |
Provider
network data
|
| b. |
Case
management fees
|
| c. |
Administrative
payments
|
| A. |
Health
Plan Reporting
Requirements
|
|
1.
|
The
Health Plan shall comply with all Reporting Requirements set forth
by the
Agency in this Contract.
|
|
a.
|
The
Health Plan is responsible for assuring the accuracy, completeness,
and
timely submission of each report.
|
|
b.
|
The
Health Plan’s chief executive officer (CEO), chief financial officer
(CFO), or an individual who reports to the CEO or CFO and who has
delegated authority to certify the Health Plan’s reports, must attest,
based on his/her best knowledge, information, and belief, that all
data
submitted in conjunction with the reports and all documents requested
by
the Agency are accurate, truthful, and complete. (42 C.F.R. 438.606(a)
and
(b))
|
|
c.
|
The
Health Plan must submit its certification at the same time it submits
the
certified data reports. (42 C.F.R.
438.606(c))
|
|
d.
|
Before
October 1 of each year, the Health Plan shall deliver to the Agency
a
certification by an Agency-approved independent auditor that the
Performance Measure data reported for the previous calendar year
have been
fairly and accurately presented.
|
|
e.
|
Deadlines
for report submission referred to in this Contract specify the actual
time
of receipt at the Agency, not the date the file was postmarked or
transmitted.
|
|
f.
|
If
a reporting due date falls on a weekend, the report shall be due
to the
Agency on the following Monday.
|
|
g.
|
All
reports to be filed on a quarterly basis shall be filed on a calendar
year
quarter.
|
|
2.
|
The
Agency shall furnish the Health Plan with the appropriate reporting
formats, instructions, submission timetables, and technical assistance,
as
required.
|
|
3.
|
The
Agency reserves the right to modify the Reporting Requirements, with
a
ninety (90) Calendar Day notice to allow the Health Plan to complete
implementation, unless otherwise required by law.
|
|
4.
|
The
Agency shall provide the Health Plan with written notification of
any
modifications to the Reporting Requirements.
|
|
6.
|
If
the Health Plan fails to submit the required reports accurately and
within
the timeframes specified below, the Agency shall fine or otherwise
sanction the Health Plan in accordance with Section XIV,
Sanctions.
|
| 7. |
The
Health Plan must use the following naming convention for all submitted
reports. Unless otherwise noted, each report will have an 8-digit
file
name, constructed as follows:
|
|
Digit
1
|
Report
Identifier
|
Indicates
the report type. Use G for grievance report;
|
|
Digits
2, 3, and 4
|
Plan
Identifier
|
Indicates
the specific Health Plan submitting the data by the use of three
(3)
unique alpha digits. Comports to the Health Plan identifier used
in
exchanging data with the enrollment broker.
|
|
Digits
5 and 6
|
Year
|
Indicates
the year. For example, reports submitted in 2006 should indicate
06.
|
|
Digits
7 and 8
|
Time
Period
|
For
reports submitted on a quarterly basis, use Q1, Q2, Q3 or Q4. For
reports
submitted monthly, use the appropriate month, such as 01, 02, 03,
etc.
|
|
9.
|
For
financial reporting, the Health Plan shall complete the spreadsheets
and
mail the diskette or compact disk to the address indicated above
or
transmit it electronically to the Agency at the email address noted
above.
Additionally, the Health Plan must also send financial reports to
the
following e-mail address:
|
|
Health
Plan Reports Required by AHCA
|
|||
|
Report
Name
|
Level
of Analysis
|
Frequency
|
Submission
Media
|
|
834
Transaction
Enrollment/Disenrollment
|
Location
Level
|
Monthly
|
File
Transfer Protocol (FTP) to the Agency or its Agent via a secure Internet
site
|
|
Grievance
System Reporting
Table
2
|
Individual
Level
|
Quarterly,
within 45 Calendar Days of end of reporting quarter
|
Electronic
mail or diskette
|
|
Provider
Network Report
Table
3
|
Location
Level
|
At
least monthly
|
FTP
to Choice Counselor vendor
|
|
Marketing
Representative Report
Table
4
|
Health
Plan Level
|
Monthly
|
Electronic
mail
|
|
Enhanced
Benefit Report
Table
5
|
Enrollee
Level
|
Monthly
|
Electronic
Mail
|
|
Catastrophic
Costs Report
Table
6
|
Enrollee
Level
|
Monthly,
as needed
|
Electronic
Mail
|
|
Critical
Incidents
|
Enrollee
Level
|
Daily
, as needed
|
Electronic
Mail
|
|
Results
of the HSA Survey
|
Health
Plan Level
|
Biannually,
on February 1 and August 1
|
Electronic
mail or diskette
|
|
Performance
Measures
|
Health
Plan Level
|
Annually,
for previous calendar year, due October 1
|
Electronic
mail, CD ROM or diskette submission
|
|
Financial
Reporting
|
Health
Plan Level
|
Quarterly,
within 45 Calendar Days of end of reporting quarter
|
Diskette
|
|
Audited
Financial Report
|
Health
Plan Level
|
Annually,
within 90 Calendar Days of end of Health Plan Fiscal Year
|
Electronic
mail or diskette
|
|
Suspected
Fraud Reporting
|
Individual
Level
|
As
described in
Section
X, H.
|
Electronic
Mail
|
|
Denials
of Authorization
Tables
7 and 7A
|
Enrollee
Level
|
Monthly
within 14 Calendar Days of the end of the month being
reported
|
Electronic
mail or diskette
|
|
Systems
Availability and Performance Report
Table
8
|
Health
Plan Level
|
Monthly,
within fifteen (15) Calendar Days of the end of the reporting
month
|
Electronic
Mail
|
|
Claims
Inventory Summary Reports
Tables
9, 9a, 9b and 9c
|
Health
Plan Level
|
Quarterly,
within forty five (45) Calendar Days of the end of the reporting
quarter
|
Electronic
Mail
|
|
Child
Health Check Up Reports
Tables
10 and 10a
|
Health
Plan Level
|
Annually
for previous federal fiscal year (Oct.-Sept.) due by January 15.
Audited
report due by Oct. 1
|
Electronic
Mail
|
|
Pharmacy
Encounter Data
|
Health
Plan Level
|
Quarterly,
within 30 days of the end of the quarter
|
Electronic
Mail
|
|
Health
Plan Benefit Package
Table
11
|
Health
Plan Level
|
Annual
re-certification by
June
30
|
Electronic
Mail
|
|
Transportation
Services
|
Health
Plan Level
|
||
|
Behavioral
Health Specific Reporting
|
|||
|
Enrollee
Satisfaction Survey Summary
Table
12
|
Health
Plan Level
|
Semi-annually,
due sixty (60) days after the end of the six months being reported.
|
Hard
Copy
|
|
Stakeholders
Satisfaction Survey Summary
Table
13
|
Health
Plan Level
|
Semi-annually,
due sixty (60) days after the end of the six months being reported.
|
Hard
Copy
|
|
Grievance
System Report
Table
2
|
Individual
Level
|
Quarterly,
within 45 days of end of reporting quarter
|
Via
AHCA secure RTP site
|
|
Critical
Incident
Summary
Table
14
|
Health
Plan Level
|
Monthly
— Due on the 15th of the month- Contains previous calendar month’s
data
|
Via
AHCA secure FTP site
|
|
Critical
Incidents
Table
14a
|
Individual
|
Immediately
upon occurrence
|
Via
AHCA secure FTP site
|
|
Required
Staff/Providers
Table
15
|
Health
Plan Level
|
Quarterly
— Due forty-five (45) after the end of the quarter being reported -
Contains data for the entire quarter
|
Via
AHCA secure FTP site.
|
|
FARS/CFARS
Table
16
|
Biannually,
due no later than forty-five (45) days after the reporting
period.
|
Via
AHCA secure FTP site
|
|
|
Encounter
Data
Table
17
|
Individual
Level
|
Quarterly
- Due forty five (45) days after the end of the quarter being
reported.
|
Via
AHCA secure FTP site
|
|
Minority
Reporting
|
Health
Plan Level
|
Monthly
- Due 15 days after the end of the month being reported
|
Electronic
Mail
|
| B. |
Enrollment/Disenrollment
Reports:
|
|
1.
|
The
Agency or its Agent will report Enrollment/Disenrollment information
to
the PSN.
|
|
2.
|
The
Health Plan shall review the Enrollment/Disenrollment reports for
accuracy
and will notify the Agency within three (3) Business Days of any
discrepancies. Failure to notify the Agency of any discrepancies
within
three (3) Business Days shall lead
to fines and other sanctions as detailed in Section XIV,
Sanctions.
|
|
3.
|
The
Enrollment/Disenrollment Reports will use HIPAA-compliant standard
transactions. The Agency or its Agent will use the X12N 834 transaction
for all Enrollee maintenance and reporting. The PSN must be capable
of
receiving and processing X12N 834 transactions.
|
| C. |
Grievance
System
|
|
1.
|
The
Health Plan shall submit the Grievance System report to the Agency
for
Health Care Administration via the Agency’s secure FTP server or
on a diskette or CD.
|
|
2.
|
The
report is due forty-five (45) Calendar Days following the end of
the
reported quarter.
|
| 3. |
The
Health
Plan must
submit the Grievance System report each quarter. If no new Grievances
or
Appeals have been filed with the Health
Plan,
or if the status of an unresolved Appeal has not changed to 'Resolved,'
please submit one (1) record only. This record must contain the PLAN_ID
field only, with the first 7-digits of the 9-digit Medicaid provider
number.
|
|
4.
|
The
report shall contain information about Grievances and Appeals concerning
both medical and behavioral health
issues.
|
|
Field
Name
|
Length
|
Start
Column
|
End
Column
|
Description
|
|
|
PLAN_ID
|
9
|
1
|
9
|
The
nine digit Medicaid provider number.
|
|
|
RECIP_ID
|
9
|
10
|
18
|
The
recipient’s 9 digit Medicaid ID number
|
|
|
LAST_NAME
|
20
|
19
|
38
|
The
recipient’s last name
|
|
|
FIRST_NAME
|
10
|
39
|
48
|
The
recipient’s first name
|
|
|
MID_INIT
|
1
|
49
|
49
|
The
recipient’s middle initial
|
|
|
GRV_DATE
|
10
|
50
|
59
|
The
date of the grievance (MM/DD/CCYY)
|
|
|
GRV_TYPE
|
2
|
60
|
61
|
1. Quality
of Care
2. Access
to Care
3. Emergency
Services
4. Not
Medically Necessary
5. Pre-Existing
Condition
6. Excluded
Benefit
7. Billing
Dispute
8. Contract
Interpretation
|
1.
Enrollment/Disenrollment
2.
Termination of Contract
3.
Services after termination
4.
Unauthorized out of plan svcs
5.
Unauthorized in-plan svcs
6.
Benefits available in plan
7.
Experimental/ Investigational
8.
Other
|
|
APP_DATE
|
10
|
62
|
71
|
The
date of the appeal (MM/DD/CCYY)
|
|
|
APP_ACTION
|
1
|
72
|
72
|
The
type of action (42 CFR 438.400):
|
|
|
1. The
denial or limited authorization of a requested service, including
the type
or level of service.
2. The
reduction, suspension, or termination of a previously authorized
service.
3. The
denial, in whole or in part, of payment for a service.
4. The
failure to provide services in a timely manner, as defined by the
state.
5. The
failure of the plan to act within the time frames provided in Sec.
438.408(b).
6. For
a resident of a rural area with only one managed care entity, the
denial
of a Medicaid enrollee’s request to exercise his or her right, under Sec.
438.52(b)(2)(ii), to obtain services outside the network.
|
|||||
|
DISP_DATE
|
10
|
73
|
82
|
The
date of the Disposition (MM/DD/CCYY)
|
|
|
DISP_TYPE
|
2
|
83
|
84
|
The
Disposition of the Appeal / Grievance:
|
|
|
1. Referral
made to specialist
2. PCP
Appointment made
3. Bill
Paid
4. Procedure
scheduled
5. Reassigned
PCP
6. Reassigned
Center
7. Disenrolled
Self
8. Disenrolled
by plan
|
1. In
HMO QA Review
2. In
HMO Grievance System
3. Referred
to Area Office
4. Member
sent OLC form
5. Lost
contact with member
6. Hospitalized
/ Institutionalized
7. Confirmed
original decision
8. Reinstated
in HMO
9. Other
|
||||
|
DISP_STAT
|
1
|
85
|
85
|
R
=
Resolved
|
U
=
Unresolved
|
|
Note:
Any grievance or appeal first reported as unresolved must be reported
again when resolved. Grievances and appeals that are resolved in
the
quarter prior to reporting should be reported for the first time
as
resolved.
|
|||||
|
EXPED_REQ
|
1
|
86
|
86
|
Indicate
whether the appeal was an expedited request
Y
=Yes N = No Note: This field is required for all reported
appeals.
|
|
|
FILE_TYPE
|
2
|
87
|
88
|
Indicate
whether the report is related to Grievance or Appeal and a behavioral
health service respectively
G
=
Grievance Report GB = Grievance Behavioral Report
A
=
Appeal Report AB = Appeal Behavioral Report
|
|
|
ORIGINATOR
|
1
|
89
|
89
|
1
=
An enrollee
2
=
A provider, acting on behalf of the enrollee and with the enrollee’s
written consent
|
|
| D. |
Provider
Reporting
|
|
1.
|
The
Health
Plan shall
submit its provider directory as described in Section IV, A.5, Provider
Directory, of this Contract, to the Agency or its Choice
Counselor/Enrollment Broker at least on a monthly basis via FTP.
|
|
2.
|
The
Health Plan shall ensure that the Provider Network Report as described
in
Table 3 of this Section is an electronic representation of the Health
Plan’s complete network of Providers, not a listing of entities for whom
the Health Plan has paid claims.
|
|
3.
|
The
Provider Network Report shall be in an ASCII flat file and must be
a
complete refresh of the Health Plan’s Provider information. Plans will
receive final instructions regarding file naming, Plan Code (see
layout
below), file transfers, file submission frequency and schedule and
other
issues prior to implementation.
|
|
4.
|
The
Health Plan shall submit the Provider Network Report on the Monday
preceding the second to the last Saturday of each month. If the Monday
deadline falls on a holiday, the PSN shall submit the file on the
Friday
before the holiday. The Health Plan may choose to submit the Provider
Network Report a second time each month, on the third Business Day
before
the end of the month. This reporting schedule is subject to change
upon
notice from the Agency.
|
|
Field
Name
|
Field
Length
|
Required
Field
|
Field
Format
|
Justification
|
Comments
|
|
Plan
Code
|
9
|
X
|
alpha
|
Left
with leading zeros
|
This
is the 9 digit Medicaid Provider ID number specific to the county
of HMO/
operation.
|
|
Provider
Type
|
1
|
X
|
alpha
|
Left
|
Identifies
the provider’s general area of service with an alpha character, as
follows:
P
=
Primary Care Provider (PCP)
I
=
Individual Practitioner other than a PCP
B
=
Birthing Center
T
=
Therapy
G
=
Group Practice (includes FQHCs and RHCs)
H
=
Hospital
C
=
Crisis Stabilization Unit
D
=
Dentist
R
=
Pharmacy
A
=
Ancillary Provider (DME providers, Home Health Care
Agencies,
etc.)
|
|
Plan
Provider Number
|
15
|
X
|
alpha
|
Left
with leading zeros
|
Unique
number assigned to the provider by the plan.
|
|
Group
Affiliation
|
15
|
Required
for all groups and providers who are members of a group
|
alpha
|
Left
with leading zeros
|
The
unique provider number assigned by the HMO/ to the group practice.
This
field is required for all providers who are members of a group,
such as
PCPs and specialists. The group affiliation number must be the
same for
all providers who are members of that group. A record is also
required for
each group practice being reported. For groups, this identification
number
must be the same as the plan provider number.
|
|
SSN
or FEIN
|
9
|
X
|
alpha
|
Left
with leading zeros
|
Social
Security Number of Federal Identification Number for the individual
provider or the group practice.
|
|
Provider
last name
|
30
|
X
|
alpha
|
Left
|
The
last name of the provider, or the first 30 characters of the
name of the
group. (Please do not include courtesy titles such as Dr., Mr.,
Ms., since
this titles can interfere with electronic searches of the data.)
This
field should also be used to note hospital name. UPPER CASE ONLY
PLEASE.
|
|
Provider
first name
|
30
|
X
|
alpha
|
Left
|
The
first name of the provider, or the continuation of the name of
the group.
Please do not include provider middle name in this field. Middle
name
field has been added at the end of the file for this purpose.
UPPER CASE
ONLY PLEASE.
|
|
Address
line 1
|
30
|
X
|
alpha
|
Left
|
Physical
location of the provider or practice. Do not use P.O. Box or
mailing
address is different from practice location. UPPER CASE ONLY
PLEASE.
|
|
Address
line 2
|
30
|
alpha
|
Left
|
||
|
City
|
30
|
X
|
alpha
|
Left
Left
|
Physical
city location of the provider or practice. UPPER CASE ONLY
PLEASE
|
|
Zip
Code
|
9
|
X
|
numeric
|
Left
with trailing zeros
|
Physical
zip code location of the provider or practice. Accuracy is important,
since address information is one of the standard items used to
search for
providers that are located in close proximity to the member.
|
|
Phone
area code
|
3
|
numeric
|
Left
|
||
|
Phone
number
|
7
|
numeric
|
Left
|
Please
note that the format does not allow for use of a
hyphen.
|
|
|
Phone
extension
|
4
|
numeric
|
Left
|
||
|
Sex
|
1
|
alpha
|
Left
|
The
gender of the provider. Valid values: M = male; F = Female; U
=
Unknown
|
|
|
PCP
Indicator
|
1
|
X
|
alpha
|
Left
|
Used
to indicate if an individual provider is a primary care physician,
or for
the , a medical home. Valid values: P = Yes, the provider is
a PCP/medical
home; N = No, the provider is not a PCP/medical home. This field
should
not be used to note group providers as PCPs, since members must
be
assigned to specific providers, not group practices.
|
|
Provider
Limitation
|
1
|
Required
if PCP Indicator = P
|
alpha
|
Left
|
X
=
Accepting new patients
N
=
Not accepting new patients but remaining a contracted network
provider
L
=
Not accepting new patients; leaving the network (Please note
the “L”
designation at the earliest opportunity)
P
=
Only accepting current patients
C
=
Accepting children only
A
=
Accepting adults only
R
=
Refer member to HMO/ member services
F
=
Only accepting female patients
S
=
Only serving children through CMS (MediPass/PSN only)
|
|
HMO//MediPass
Indicator
|
1
|
X
|
alpha
|
Left
|
H
=
HMO/
This
field must be completed with this designation for each record
submitted by
the HMO/.
|
|
Evening
hours
|
1
|
alpha
|
Left
|
Y
=
Yes; N = No
|
|
|
Saturday
hours
|
1
|
alpha
|
Left
|
Y
=
Yes; N = No
|
|
|
Age
restrictions
|
20
|
alpha
|
Left
|
Populate
this field with free-form text, to identify any age restriction
the
provider may have on their practice.
|
|
|
Primary
Specialty
|
3
|
Required
if Provider Type = P or I
|
numeric
|
Left
with leading zeros
|
Insert
the 3 digit code that most closely describes
001
Adolescent Medicine
002
Allergy
003
Anesthesiology
004
Cardiovascular Medicine
005
Dermatology
006
Diabetes
007
Emergency Medicine
008
Endocrinology
009
Family Practice
010
Gastroenterology
011
General Practice
012
Preventative Medicine
013
Geriatrics
014
Gynecology
015
Hematology
016
Immunology
017
Infectious Diseases
018
Internal Medicine
019
Neonatal/Perinatal
020
Neoplastic Diseases
021
Nephrology
022
Neurology
023
Neurology/Children
024
Neuropathology
025
Nutrition
026
Obstetrics
027
OB-GYN
028
Occupational Medicine
029
Oncology
030
Ophthalmology
031
Otolaryngology
032
Pathology
033
Pathology, Clinical
034
Pathology, Forensic
035
Pediatrics
036
Pediatric Allergy
037
Pediatric Cardiology
038
Pediatric Oncology &Hematology
039
Pediatric Nephrology
040
Pharmacology
041
Physical Medicine and Rehab
042
Psychiatry
043
Psychiatry, Child
044
Psychoanalysis
045
Public Health
046
Pulmonary Diseases
047
Radiology
048
Radiology, Diagnostic
049
Radiology, Pediatric
050
Radiology, Therapeutic
051
Rheumatology
052
Surgery, Abdominal
053
Surgery, Cardiovascular
054
Surgery, Colon / Rectal
055
Surgery, General
056
Surgery, Hand
057
Surgery, Neurological
058
Surgery, Orthopedic
059
Surgery, Pediatric
060
Surgery, Plastic
061
Surgery, Thoracic
062
Surgery, Traumatic
063
Surgery, Urological
064
Other Physician Specialty
065
Maternal/Fetal
066
Assessment Practitioner
067
Therapeutic Practitioner
068
Consumer Directed Care
069
Medical
Oxygen Retailer
070
Adult Dentures Only
071
General Dentistry
072
Oral Surgeon (Dentist)
073
Pedodontist
074
Other Dentist
075
Adult Primary Care Nurse Practitioner
076
Clinical Nurse Spec
077
College Health Nurse Practitioner
078
Diabetic Nurse Practitioner
079
Brain
& Spinal Injury Medicine
080
Family/Emergency Nurse Practitioner
081
Family Planning Nurse Practitioner
082
Geriatric Nurse Practitioner
083
Maternal/Child Family Planning Nurse Practitioner
084
Reg. Nurse Anesthetist
085
Certified Registered Nurse Midwife
086
OB/GYN Nurse Practitioner
087
Pediatric Neonatal
088
Orthodontist
089
Assisted Living for the Elderly
090
Occupational Therapist
091
Physical Therapist
092
Speech Therapist
093
Respiratory Therapist
100
Chiropractor
101
Optometrist
102
Podiatrist
103
Urologist
104
Hospitalist
BH1
Psychology, Adult
BH2
Psychology, Child
BH3
Mental Health Counselor
BH4
Community Mental Health Center
BH5
Clubhouse (TBD)
|
|
Specialty
2
|
3
|
numeric
|
Left
with leading
|
Use
codes listed above.
|
|
|
Specialty
3
|
3
|
numeric
|
Left
with leading
|
Use
codes listed above.
|
|
|
Language
1
|
2
|
numeric
|
Left
with leading
|
01
= English
02
= Spanish
03
= Haitian Creole
04
= Vietnamese
05
= Cambodian
06
= Russian
07
= Laotian
08
= Polish
09
= French
10
= Other
|
|
|
Language
2
|
2
|
numeric
|
Use
codes listed above.
|
||
|
Language
3
|
2
|
numeric
|
Use
codes listed above.
|
||
|
Hospital
Affiliation 1
|
9
|
numeric
|
Left
with leading zeros
|
Hospital
with which the provider is affiliated. Use the AHCA ID for accurate
identification,
|
|
|
Hospital
Affiliation 2
|
9
|
numeric
|
Left
with leading zeros
|
as
above
|
|
|
Hospital
Affiliation 3
|
9
|
numeric
|
Left
with leading zeros
|
as
above
|
|
|
Hospital
Affiliation 4
|
9
|
numeric
|
Left
with leading zeros
|
as
above
|
|
|
Hospital
Affiliation 5
|
9
|
numeric
|
Left
with leading zeros
|
as
above
|
|
|
Wheel
Chair Access
|
1
|
alpha
|
Indicates
if the provider’s office is wheelchair accessible. Use Y = Yes or N =
No.
|
||
|
#
of HMO/ Members
|
4
|
X
|
numeric
|
Left
with leading zeros
|
Information
must be provided for PCPs only. Indicates the total number of
patients who
are enrolled in submitting plan. For providers who practice at
multiple
locations, the number of HMO/ members specific to each physical
location
must be specified.
|
|
Active
Patient Load
|
4
|
X
|
numeric
|
Left
with leading zeros
|
Total
Active Patient Load, as defined in contract
|
|
Professional
License Number
|
10
|
X
|
alpha/
numeric
|
Must
be included for all health care professionals. License number
is formatted
with up to 3 alpha characters followed by up to 7 numeric digits.
|
|
|
AHCA
Hospital ID1
AHCA provided the list of AHCA IDs for hospitals to plans on
8-26-05.
|
8
|
Required
if Provider Type = “H”
|
numeric
|
Left
with leading zeros
|
The
number assigned by the Agency to uniquely identify each specific
hospital
by physical location. Any out of state hospital for which an
AHCA ID is
not included should be designated with the pseudo-number
99999999.
|
|
County
Health Department (CHD) Indicator
|
1
|
X
|
alpha
|
Used
to designate whether the individual or group provider is associated
only
with a county health department. Y = Yes; N = No. This field
must be
completed for all PCP and specialty providers.
|
|
|
Filler
|
47
|
X
|
| E. |
Marketing
Representative Report
|
|
Plan
Information
|
Marketing
Representative Information
|
|
Plan
Name
|
Last
Name
|
|
Address
|
First
Name
|
|
Contact
Person
|
DOI
License Number
|
|
Phone
|
Address
|
|
Fax
|
City
|
| F. |
Enhanced Benefits Report
|
| G. |
Catastrophic Component Threshold and Benefit Maximum
Report
|
|
$25,000
or $450,000 Thresholds Reached/Report to AHCA
|
|||||||||||||||||||
|
RECIP
|
DOS
|
DOP
|
UNIT/DAY
|
AMOUNT
|
APPCD
|
TRPROV
|
TRTYPE
|
DIAG1
|
DIAG2
|
DIAG3
|
DIAG4
|
DIAG5
|
PROCD
|
MOD1
|
MOD
2
|
NDC
|
DRUGQTY
|
P2PROV
|
P2TYPE
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| H. |
Critical Incidents
|
| I. |
Hernandez
Settlement Agreement (HAS)
Report
|
|
(c)
|
Those
HSA areas in which the pharmacy locations were delinquent;
and
|
|
(d)
|
The
process by which the Health Plan selected the pharmacy
locations.
|
| J. |
Performance Measure Report
|
|
1.
|
The
Health Plan shall report the performance measures described in Section
VIII, A.3.c.
|
|
2.
|
The
Health Plan shall calculate the performance measures based on the
calendar
year (January 1 through December 31), unless otherwise
specified.
|
|
3.
|
The
performance measure report is due by October 1 after the measurement
year.
|
| K. |
Financial
Reporting
|
|
1.
|
The
Health Plan shall complete the spreadsheet supplied by the
Agency.
|
|
2.
|
Audited
financial reports — The Health Plan shall submit to the Agency annual
audited financial statements and four (4) quarterly unaudited financial
statements.
|
|
a.
|
The
audited financial statements are due no later than three (3) calendar
months after the end of the Health Plan’s fiscal
year.
|
|
b.
|
The
Health Plan shall submit the quarterly unaudited financial statements
no
later than forty-five (45) days after each calendar quarter and shall
use
generally accepted accounting principles in preparing the unaudited
quarterly financial statements, which shall include, but not be limited
to, the following:
|
| (2) |
A
Statement of Cash Flows; and
|
|
c.
|
The
Health Plan shall submit the annual and quarterly financial statements
using, an Agency-supplied template, by electronic transmission to
the
following e-mail address:
|
|
d.
|
The
Health Plan shall submit annual and quarterly financial statements
that
are specific to the operations of the Health Plan rather than to
a parent
or umbrella organization.
|
| L. |
Suspected
Fraud Reporting
|
|
1.
|
Provider
Fraud and Abuse
|
|
a.
|
The
name of the provider;
|
|
b.
|
The
assigned Medicaid provider number and the tax identification
number;
|
|
c
|
A
description of the suspected fraudulent act;
and
|
|
d.
|
The
narrative report must be sent to the Health Plan’s analyst at the Bureau
of Managed Health Care, MPI and
MFCU.
|
|
a.
|
Upon
detection of all instances of fraudulent claims or acts by an Enrollee,
the Health Plan shall file a report with the Agency and MPI.
|
|
b.
|
The
report shall contain, at a minimum:
|
|
(5)
|
The
narrative report must be sent to the Health Plan’s analyst at the Bureau
of Managed Health Care and MPI.
|
|
3.
|
Failure
to report instances of suspected Fraud and Abuse is a violation of
law and
subject to the penalties provided by
law.
|
| M. |
Denials of Authorization Reporting Requirements
|
|
1.
|
The
Health Plan shall report, on a monthly basis, denials of authorization
for
services in the following
categories:
|
| 3. |
The
Health Plan shall report all Denials of Authorization in accordance
with
the format set forth in Table 7 and 7-A,
below.
|
|
Inpatient
Pre-Certification
|
Inpatient
Concurrent
|
Specialty
Care
|
Ancillary
Services
|
|
|
Enrollee
ID #
|
||||
|
Service
Requested
|
||||
|
Date
of Request
|
||||
|
Date
of Denial
|
||||
|
Denial
Reason
|
||||
|
Denial
Appealed Yes/No
|
|
Inpatient
Pre-Certification
|
Inpatient
Con-Current
|
Specialty
Care
|
Ancillary
Services
|
|
|
Total
Authorizations Requested
|
||||
|
Total
Authorizations Denied
|
||||
|
Average
Number of Calendar Days Between Request and Denial
|
||||
|
Longest
Number of Calendar Days Between Request and Denial
|
||||
|
Total
Number of Denials Appealed
|
| N. |
Systems Availability and Performance
Report
|
|
System
Availability and Performance Report
|
||||||
|
System
|
|
Total
Up Time
|
Total
Down Time
|
Total
UNSCHEDULED Down Time ("Outage Time")
|
|
|
|
Measurement
Period
|
Up
Time During Period
|
Up
Time During Period
|
During
Period
|
Notes/Comments
|
||
|
system
1
|
||||||
|
system2
|
|
|
||||
|
system3
|
|
|
||||
|
system4
|
|
|
||||
|
system5
|
||||||
|
system6
|
|
|
||||
|
system7
|
|
|
||||
|
system8
|
|
|
||||
|
system9
|
|
|
||||
|
system10
|
|
|
||||
| O. |
Claims Inventory Summary
Report
|
|
00/00/00
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
days
|
|
days
|
|
days
|
|
days
|
|
days
|
|
TOTAL
|
|
PROVIDER
|
1-30
|
%
|
31-60
|
%
|
61-90
|
%
|
91-120
|
%
|
120+
|
%
|
CLAIMS
|
|
PRIMARY
CARE
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
SPECIALTY
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
OTHER
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
HOSPITALS:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
00/00/00
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
days
|
|
days
|
|
days
|
|
days
|
|
days
|
|
TOTAL
|
|
PROVIDER
|
1-30
|
%
|
31-60
|
%
|
61-90
|
%
|
91-120
|
%
|
120+
|
%
|
CLAIMS
|
|
PRIMARY
CARE
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
SPECIALTY
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
OTHER
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
HOSPITALS:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
00/00/00
|
|
|
|
|
|
|
|
|
|||
|
|
days
|
|
days
|
|
days
|
|
days
|
|
days
|
|
TOTAL
|
|
PROVIDER
|
1-30
|
%
|
31-60
|
%
|
61-90
|
%
|
91-120
|
%
|
120+
|
%
|
CLAIMS
|
|
PRIMARY
CARE
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
SPECIALTY
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
OTHER
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
HOSPITALS:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
|
0%
|
0
|
|
|
00/00/00
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
days
|
|
days
|
|
days
|
|
days
|
|
days
|
|
TOTAL
|
|
PROVIDER
|
1-30
|
%
|
31-60
|
%
|
61-90
|
%
|
91-120
|
%
|
120+
|
%
|
CLAIMS
|
|
PRIMARY
CARE
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
|
SPECIALTY
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
|
OTHER
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
HOSPITALS:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
|
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
|
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
0%
|
0
|
|
00/00/00
|
Inventory
|
|
|
|
|
|
|
(Ending
Inventory from Previous quarter)
|
|
|
|
|
|
|
Beginning
|
Claims
|
|
|
Ending
|
|
PROVIDER
|
Inventory
|
Received
|
Claims
Paid
|
Claims
Denied
|
Inventory
|
|
PRIMARY
CARE
|
|
0
|
0
|
0
|
0
|
|
SPECIALTY
|
|
0
|
0
|
0
|
0
|
|
OTHER
|
|
0
|
0
|
0
|
0
|
|
|
|
|
|
|
|
|
HOSPITALS:
|
|
|
|
|
|
|
|
|
0
|
0
|
0
|
0
|
|
|
|
0
|
0
|
0
|
0
|
|
|
|
0
|
0
|
0
|
0
|
| P. |
Child Health Check-Up
Reports
|
|
1.
|
The
Child Health Check Up, CMS 416 Report shall be submitted annually
and in
the formats as presented in Tables 10. The reporting period is the
federal
fiscal year. The report is due on January 1, following the reporting
period. Before October 1 following each reporting period, the Health
Plan
shall deliver to the Agency a certification by an Agency approved
independent auditor that the Child Health Check-Up data has been
fairly
and accurately presented. This filing requires a copy of the audited
reports and a copy of the auditors' letter of
opinion.
|
|
2.
|
For
each of the following line items, report total counts by the age
groups
indicated. In cases where calculations are necessary, perform separate
calculations for the total column and each age group. Report age
based
upon the child's age as of September 30 of the federal fiscal
year.
|
|
3.
|
Health
Plans must continue to ensure that all five age-appropriate elements
of an
CHCUP screen, as defined by law, are provided to CHCUP eligible
Enrollees
|
|
4.
|
This
number should not
reflect sick visits or episodic visits provided to children unless
an
initial or periodic screen was also performed during the visit. However,
it may reflect a screen outside of the normal state periodicity schedule
that is used as a "catch-up" CHCUP screening. (A catch-up CHCUP screening
is defined as a complete
screening that is provided to bring a child up-to-date with the State's
screening periodicity schedule.) Use data reflecting date
of service
within the fiscal year for such screening services or other documentation
of such services. Do
not count MediKids Enrollees, who have had a
check-up.
The
CPT-4 codes to be used to document the receipt of an initial or periodic
screen are as follows:
|
|
a.
|
If
the number entered in Line 4 is greater than 1, the number 1 is used.
If
the number in Line 4 is less than or equal to 1, the number in Line
4 is
used. This eliminates situations where more than one visit is expected
in
any age group in a year.
|
|
b.
|
The
number from calculation 1 is multiplied by the number in Line 1 and
entered on Line 8.
|
|
For
reporting on the CMS-416 only count the referral codes "T" and
"V".
|
||
|
U
|
Complete
Normal
|
|
|
Indicator
is used when there are no referrals made.
|
||
|
2
|
Abnormal,
Treatment Initiated
|
|
|
Indicator
is used when a child is currently under treatment for referred diagnostic
or corrective health problem.
|
||
|
T
|
Abnormal,
Recipient Referred
|
|
|
Indicator
is used for referrals to another provider for diagnostic or corrective
treatments or scheduled for another appointment with check-up provider
for
diagnostic or corrective treatment for at least one health problem
identified during an initial or
|
||
|
V
|
Patient
Refused Referral
|
|
|
Indicator
is used when the patient refused a referral.
|
||
|
5.
|
For
purposes of reporting information on dental services, unduplicated
means that each child is counted once for each
line of data
requested. Example: a child would be counted once on Line 12a for
receiving any dental service and would be counted again for Line
12b
and/or 12c if the child received a preventive and/or treatment dental
service. These numbers should reflect services received in managed
care.
Lines 12b and 12c do not
equal total services reflected on Line
12a.
|
|
6.
|
To
report the number of screening blood lead tests do the following:
Count
the number of times CPT code 83655 ("lead") or any State-specific
(local)
codes used for a blood lead test reported with any ICD-9-CM except
with
diagnosis codes 984 (.0 - .9) ("Toxic Effects of Lead and Its Compounds"),
E861.5 ("Accidental Poisoning by Petroleum Products, Other Solvents
and
Their Vapors NEC: Lead Paints"), and E866.0 (Accidental Poisoning
by Other
Unspecified Solid and Liquid Substances: Lead and Its Compounds and
Fumes"). These specific ICD-9-CM diagnosis codes are used to identify
people who are lead poisoned. Blood lead tests done in these individuals
should not be counted as a screening blood lead test. This
is a federally mandated test for ages 12 months, 24 months and between
the
ages of 36 - 72 months
who have not been previously screened for lead
poisoning.
|
|
|
Enter
Data in Blue Colored Out-Lined Cells Only
|
CHILD
HEALTH CHECK-UP REPORT (CHCUP) [CMS-416]
|
|||||||
|
Seven
Digit Medicaid Provider Number :
|
|
This
report is due to the Agency no later than January
15.
|
|||||||
|
Plan
Name :
|
|
|
|
||||||
|
|
Federal
Fiscal Year :
|
October
1, 2004 - September 30, 2005
|
|
|
The
Audited Report is due October 1.
|
||||
|
|
Age
Groups
|
|
|
|
|
|
|||
|
|
|
Less
than 1 Year
|
1-2
Years *
|
3-5
Years
|
6-9
Years
|
10-14
Years
|
15-18
Years
|
19-20
Years
|
Total
All Years
|
|
1.
|
Total
Individuals Eligible for CHCUP (Unduplicated)
|
|
|
|
|
|
|
|
|
|
2a.
|
State
Periodicity Schedule
|
6
|
4
|
3
|
2
|
5
|
4
|
2
|
26
|
|
2b.
|
Number
of Years in Age Group
|
1
|
2
|
3
|
4
|
5
|
4
|
2
|
21
|
|
2c.
|
Annualized
State Periodicity Schedule
|
6.00
|
2.00
|
1.00
|
0.50
|
1.00
|
1.00
|
1.00
|
1.24
|
|
3a.
|
Total
Months of Eligibility
|
|
|
|
|
|
|
|
|
|
3b.
|
Average
Period of Eligibility
|
|
|
|
|
|
|
|
|
|
4.
|
Expected
Number of screenings per Eligible
|
|
|
|
|
|
|
|
|
|
5.
|
Expected
Number of screenings
|
|
|
|
|
|
|
|
|
|
6.
|
Total
Screens Received
|
|
|
|
|
|
|
|
|
|
7.
|
Screening
Ratio
|
|
|
|
|
|
|
|
|
|
|
8.
|
Total
Eligible who should receive at least one Initial or periodic
screening
|
|
|
|
|
|
|
|
#VALUE!
|
|
|
9.
|
Total
Eligibles receiving at least one Initial or periodic screen
(Unduplicated)
|
|
|
|
|
|
|
|
|
|
|
10.
|
Participation
Ratio
|
|
|
|
|
|
|
|
|
|
|
11.
|
Total
eligibles referred for corrective treatment (Unduplicated)
|
|
|
|
|
|
|
|
|
|
|
12a.
|
Total
Eligibles receiving any dental services (Unduplicated)
|
|
|
|
|
|
|
|
0
|
|
|
12b.
|
Total
Eligibles receiving preventative dental services (Unduplicated)
|
|
|
|
|
|
|
|
0
|
|
|
12c.
|
Total
Eligibles receiving dental treatment services (Unduplicated)
|
|
|
|
|
|
|
|
0
|
|
|
13.
|
Total
Eligibles Enrolled in Plan
|
|
|
|
|
|
|
|
|
|
|
14.
|
Total
number of Screening Blood Lead Tests
|
|
|
|
|
|
|
|
|
|
|
*
Includes 12-month visit
|
||||||||||
|
1.
|
The
Child Health Check Up, CMS 416 Report shall be submitted annually
and in
the formats as presented in Tables 10 and 10a. The reporting period
is the
federal fiscal year. The report is due on January 1, following the
reporting period. Before October 1 following each reporting period,
the
Health Plan shall deliver to the Agency a certification by an Agency
approved independent auditor that the Child Health Check-Up data
has been
fairly and accurately presented. This filing requires a copy of the
audited reports and a copy of the auditors' letter of
opinion.
|
|
2.
|
For
each of the following line items, report total counts by the age
groups
indicated. In cases where calculations are necessary, formulas have
been
inserted to pre-calculate the field. Report age based
upon the child's age as of September 30 of the Federal fiscal
year.
|
|
3.
|
Health
Plans must continue to ensure that all five age-appropriate elements
of an
CHCUP screen, as defined by law, are provided to CHCUP eligible
Enrollees.
|
|
4.
|
This
number should not
reflect sick visits or episodic visits provided to Children/Adolescents
unless an initial or periodic screen was also performed during the
visit.
However, it may reflect a screen outside of the normal State periodicity
schedule that is used as a "catch-up" CHCUP screening. (A catch-up
CHCUP
screening is defined as a complete
screening that is provided to bring a Child/Adolescent up-to-date
with the
State's screening periodicity schedule.) Use data reflecting date
of service
within the fiscal year for such screening services or other documentation
of such services. Do
not
count MediKids Enrollees, who have had a check-up. The
CPT-4 codes to be used to document the receipt of an initial or periodic
screen are as follows:
|
| Enter Data in Blue Colored Out-Lined Cells ONLY - This report reflects only those eligibles that have at least 8 months of continuous enrollment - State Required | FL 60% SCREENING RATIO - CHILD HEALTH CHECK-UP REPORT (CHCUP) - 8 MONTHS CONTINUOUS ENROLLMENT |
|
|
|||||||||||||||||||
|
|
|
||||||||||||||||||
|
Seven
Digit Medicaid Provider ID Number :
|
|
The
unaudited report is due to the Agency no later than January
15.
The audited report is due October 1.
|
|||||||||||||||||
|
Plan
Name :
|
|
F.S.
409.912 & Section 10.8.1, Medicaid HMO Contract
|
|||||||||||||||||
|
|
Federal
Fiscal Year :
|
October
1, 2004 - September 30, 2005
|
REQUIRED
FILING
|
||||||||||||||||
|
|
Age
Groups
|
|
|
|
|
|
|
|
|||||||||||
|
|
|
Less
than 1 Year
|
1-2
Years *
|
3-5
Years
|
6-9
Years
|
10-14
Years
|
15-18
Years
|
19-20
Years
|
Total
All Years
|
||||||||||
|
1.
|
Total
Individuals Eligible for CHCUP with 8 months continuous enrollment
(Unduplicated)
|
|
|
|
|
|
|
|
|
||||||||||
|
2a.
|
State
Periodicity Schedule
|
6
|
4
|
3
|
2
|
5
|
4
|
2
|
26
|
||||||||||
|
2b.
|
Number
of Years in Age Group
|
1
|
2
|
3
|
4
|
5
|
4
|
2
|
21
|
||||||||||
|
2c.
|
Annualized
State Periodicity Schedule
|
6.00
|
2.00
|
1.00
|
0.50
|
1.00
|
1.00
|
1.00
|
1.24
|
||||||||||
|
3a.
|
Total
Months of Eligibility
|
|
|
|
|
|
|
|
|
||||||||||
|
3b.
|
Average
Period of Eligibility
|
|
|
|
|
|
|
|
|
||||||||||
|
4.
|
Expected
Number of screenings per Eligible
|
|
|
|
|
|
|
|
|
||||||||||
|
5.
|
Expected
Number of screenings
|
||||||||||||||||||
|
6.
|
Total
Screens Received
|
||||||||||||||||||
|
7.
|
Screening
Ratio - F.S. 409.912 & Section 10.8.1, Medicaid HMO
Contract
|
||||||||||||||||||
| 1. |
Any
claims paid during the payment period should be submitted within
30 days
after the end of the quarter.
|
| 2. |
Only
the final adjudication of claims should be
submitted.
|
| 3. |
The
File Naming Convention is: [health plan abbreviation]_[current date]_[file
type]_[Production]_[file#]_[total # of files].format. For example:
ABC_07312006_Rx_Production_1_7.txt
|
| 4. |
The
files must be accompanied by a field layout and the records must
have
carriage-returns and line-feeds for record/file
separation.
|
| 5. |
All
Medicaid pharmacy data should be submitted via CD to Bureau of Health
Systems Development and shall be timely, accurate, complete, and
certified. Each submission requires a concurrent certification
letter.
|
| 6. |
The
minimal data requirements include the Plan ID, Transaction Reference
number (claim identifier), NDC code, Date of Service (CCYYMMDD),
Medicaid
ID as assigned by the state, and Process/payment date
(CCYYMMDD).
|
| 7. |
The
format is expected to change to NCPDP as the Agency is developing
the
companion guide and the Plans shall conform to this change upon
notification.
|
|
Covered
Service Category
|
AHCA
Standard for Adult Coverage
|
Day/Visit
Limit
|
Limit
Period
(Annual/Monthly)
|
Dollar
Limit
|
Limit
Period
(Annual/Monthly)
|
Copay
Amount
|
Copay
Application
|
||
|
1
|
Hospital
Inpatient
|
45
days
|
|||||||
|
Behavioral
Health
|
day
or admit
|
||||||||
|
Physical
Health
|
day
or admit
|
||||||||
|
|
|||||||||
|
2
|
Transplant
Services
|
all
medically nec
|
|||||||
|
|
|||||||||
|
3
|
Outpatient
|
||||||||
|
Emergency
Room
|
all
medically nec
|
||||||||
|
Medical/Drug
Therapies (Chemo, Dialysis)
|
all
medically nec
|
||||||||
|
Ambulatory
Surgery - ASC
|
all
mecially nec.
|
||||||||
|
Hospital
Outpatient Surgery
|
all
medically nec
|
visit
|
|||||||
|
Independent
Lab / Portable X-ray
|
all
medically nec
|
day
|
|||||||
|
Hospital
Outpatient Services NOS
|
sufficiency
tested
|
visit
|
|||||||
|
Outpatient
Therapy (PT/RT)
|
coverage
|
visit
|
|||||||
|
Outpatient
Therapy (OT/ST)
|
not
applicable
|
||||||||
|
|
|||||||||
|
4
|
Maternity
and Family Planning Services
|
all
medically nec
|
|||||||
|
Inpatient
Hospital
|
all
medically nec
|
||||||||
|
Birthing
Centers
|
all
medically nec
|
||||||||
|
Physician
Care
|
all
medically nec
|
||||||||
|
Family
Planning
|
all
medically nec
|
||||||||
|
Pharmacy
|
all
medically nec
|
||||||||
|
5
|
Physician
and Phys Extender Services (non maternity)
|
||||||||
|
EPSDT
|
not
applicable
|
||||||||
|
Primary
Care Physician
|
all
medically nec
|
visit
|
|||||||
|
Specialty
Physician
|
all
medically nec
|
visit
|
|||||||
|
ARNP
/ Physician Assistant
|
all
medically nec
|
visit
|
|||||||
|
Clinic
(FQHC, RHC)
|
all
medically nec
|
visit
|
|||||||
|
Clinic
(CHD)
|
all
medically nec
|
||||||||
|
Other
|
all
medically nec
|
visit
|
|||||||
|
6
|
Other
Outpatient Professional Services
|
||||||||
|
Home
Health Services
|
sufficiency
tested
|
visit
|
|||||||
|
Chiropractor
|
coverage
|
visit
|
|||||||
|
Podiatrist
|
coverage
|
visit
|
|||||||
|
Dental
Services
|
coverage
|
visit
|
|||||||
|
Vision
Services
|
coverage
|
visit
|
|||||||
|
Hearing
Services
|
coverage
|
visit
|
|||||||
|
|
|||||||||
|
7
|
Outpatient
Mental Health
|
all
medically nec
|
visit
|
||||||
|
8
|
Outpatient
Pharmacy
|
sufficiency
tested
|
|||||||
|
Generic
Pharmacy
|
|||||||||
|
Brand
Pharmacy
|
|||||||||
|
|
|||||||||
|
9
|
Other
Services
|
||||||||
|
Ambulance
|
all
medically nec
|
||||||||
|
Non-emergent
Transportation
|
all
medically nec
|
trip
|
|||||||
|
Durable
Medical Equipment
|
sufficiency
tested
|
||||||||
|
Additional
Services (if applicable)*
|
Projected
PMPM
|
||||||||
|
10
|
|||||||||
|
11
|
|||||||||
|
12
|
|||||||||
|
13
|
|||||||||
|
14
|
|||||||||
|
*
Attach benefit description and supporting documentation.
|
|||||||||
| a. |
A
call log broken down by month that includes the following
information:
|
| i. |
Number
of calls received;
|
| ii. |
Average
time required to answer a call;
|
| iii. |
Number
of abandoned calls;
|
| iv. |
Percentage
of calls that are abandoned;
|
| v. |
Average
abandonment time; and
|
| vi. |
Average
call time.
|
| b. |
A
listing of the total number of reservations of Transportation Services
by
month, level of service and percentage of level of service utilized,
to
include, but not be limited to, the
following:
|
| i. |
Ambulatory
transportation;
|
| ii. |
Long
haul ambulatory transportation;
|
| iii. |
Wheelchair
transportation;
|
| iv. |
Stretcher
transportation;
|
| v. |
Ambulatory
multiload transportation;
|
| vi. |
Wheelchair
multiload transportation;
|
| vii. |
Mass
transit pending transportation;
|
| viii. |
Mass
transit transportation;
|
| ix. |
Mass
transit transportation (Enrollee has pass);
and
|
| x. |
Mass
transit transportation (sent pass to
Enrollee).
|
| c. |
A
listing of the total number of authorized uses of Transportation
Services,
by month, level of service and percentage of level of service utilized,
to
include, but not be limited to, the
following:
|
| i. |
Ambulatory
transportation;
|
| ii. |
Long
haul ambulatory transportation;
|
| iii. |
Wheelchair
transportation;
|
| iv. |
Stretcher
transportation;
|
| v. |
Ambulatory
multiload transportation;
|
| vi. |
Wheelchair
multiload transportation;
|
| vii. |
Mass
transit pending transportation;
|
| viii. |
Mass
transit transportation;
|
| ix. |
Mass
transit transportation (Enrollee has pass);
and
|
| x. |
Mass
transit transportation (sent pass to
Enrollee).
|
| d. |
A
listing of the total number of canceled trips, by month, level of
service
and percentage of level of service utilized, to include, but not
be
limited to, the following:
|
| i. |
Ambulatory
transportation;
|
| ii. |
Long
haul ambulatory transportation;
|
| iii. |
Wheelchair
transportation;
|
| iv. |
Stretcher
transportation;
|
| v. |
Ambulatory
multiload transportation;
|
| vi. |
Wheelchair
multiload transportation;
|
| vii. |
Mass
transit pending transportation;
|
| viii. |
Mass
transit transportation;
|
| ix. |
Mass
transit transportation (Enrollee has pass);
and
|
| x. |
Mass
transit transportation (sent pass to
Enrollee).
|
| e. |
A
listing of the total number of denied Transportation Services, by
month,
and a detailed description of why the Plan denied the Transportation
Service request.
|
| f. |
A
listing of the total number of authorized trips, by facility type,
for
each month and level of service.
|
| g. |
A
listing of the total number of Transportation Service claims and
payments,
by facility type, for each month and level of
service.
|
| 2. |
Establish
a performance measure to evaluate the safety of the Transportation
Services provided by Participating Transportation Providers. The
Plan
shall report the results of the evaluation to the Agency on August
15th of
each year;
|
| 3. |
Establish
a performance measure to evaluate the reliability of the vehicles
utilized
by Participating Transportation Providers. The Plan shall report
the
results of the evaluation to the Agency on August 15th of each year;
and
|
| 4. |
Establish
a performance measure to evaluate the quality of service provided
by a
Participating Transportation Provider. The Plan shall report the
results
of the evaluation to the Agency on August 15th of each
year.
|
| 5. |
Certification
- Each Health Plan/Participating Transportation Provider shall submit
an
annual safety and security certification in accordance with 14-90.10,
F.A.C., 2004 and shall submit to any and all Safety and Security
Inspections and Reviews in accordance with 14-90.12, F.A.C.,
2004.
|
| 6. |
The
Plan shall report the following by August 15th
of
each year:
|
| a. |
The
estimated number of one-way passenger trips to be provided in the
following categories:
|
| i. |
Ambulatory
transportation;
|
| ii. |
Long
haul ambulatory transportation;
|
| iii. |
Wheelchair
transportation;
|
| iv. |
Stretcher
transportation;
|
| v. |
Ambulatory
multiload transportation;
|
| vi. |
Wheelchair
multiload transportation;
|
| vii. |
Mass
transit pending transportation;
|
| viii. |
Mass
transit transportation;
|
| ix. |
Mass
transit transportation (Enrollee has pass);
and
|
| x. |
Mass
transit transportation (sent pass to
Enrollee).
|
| b. |
The
actual amount of funds expended and the total number of trips provided
during the previous fiscal year;
and
|
| c. |
The
operating financial statistics for the previous fiscal
year.
|
|
a.
|
In
all
areas in which the Health Plan provides Behavioral Health
Services,
the Health Plan shall conduct a Behavioral Health Services Enrollee
Satisfaction Survey in both English and
Spanish.
|
|
b.
|
The
Health Plan shall report the Enrollee Satisfaction Survey Summary
to the
Agency in accordance with the requirements set forth in Table 9,
Enrollee
Satisfaction Survey Summary, below.
|
|
Number
of surveys distributed
|
|
|
Number
of surveys completed
|
|
|
Method
used
|
|
|
Number
of Responses for each item on the survey
|
|
|
Item
Numbers
|
Agree
|
Disagree
|
No
Response
|
|
1
|
|||
|
2
|
|||
|
3
|
|||
|
4
|
|||
|
5
|
|||
|
6
|
|||
|
7
|
|||
|
8
|
|||
|
9
|
|||
|
10
|
|||
|
Significant
findings or results that will be addressed:
|
|||
|
a.
|
The
Health Plan shall submit to the Agency the results of a Stakeholders’
Satisfaction Survey Summary.
|
|
b.
|
The
Health Plan shall report the results from the survey in accordance
with
Table 10, Stakeholders’ Satisfaction Survey Summary,
below.
|
|
Types
of Stakeholders Surveyed
|
DCF
Counselors
|
Community
Based Care Providers
|
Foster
Parents
|
Consumer
Advocacy Groups
|
Parents
of SED Children
|
Out-of-Plan
Providers (specify)
|
Others
|
|
Number
of Surveys Distributed
|
|||||||
|
Number
of surveys completed in each type
|
|||||||
|
Method
used for distribution
|
|
Summary
of Responses:
|
|
Significant
findings or results that will be addressed:
|
|
a.
|
For
Providers and providers under contract with DCF, the State’s operating
procedures for incident reporting and client risk protection establishes
departmental procedures and guidelines for reporting information
related
to the incidents specified in this Section. See CF Operating Procedure
No.
215-6, November 1, 1998.
|
|
b.
|
The
critical incident reporting requirements set forth in this section
do not
replace the abuse, neglect and exploitation reporting system established
by the State. Additionally, the Health Plan must report to the Agency
in
accordance with the format in Table 14, Critical Incidents Summary,
and
Table 14-A, Critical Incident Individual,
below.
|
|
c.
|
The
definitions of reportable critical incidents apply to the Health
Plan,
Providers (participating and non-participating) and any
subcontractees/delgatees providing services to
Enrollees.
|
|
d.
|
The
Health Plan shall report the following events immediately to the
Agency,
in accordance with the format set forth in Table 10-A, Critical Incident
Individual, below:
|
|
(e)
|
An
accident or other incident that occurs while the Enrollee is in a
facility
operated or contracted by the Health Plan or in an acute care
facility.
|
|
(2)
|
Enrollee
Injury or Illness - A medical condition that requires medical treatment
by
a licensed health care professional and which is sustained, or allegedly
is sustained, due to an accident, act of abuse, neglect or other
incident
occurring while an Enrollee is in a Facility operated or contracted
by the
Health Plan or while the Enrollee is in an acute care
facility.
|
|
(3)
|
Sexual
Battery - An allegation of sexual battery, as determined by medical
evidence or law enforcement involvement, by:
|
|
(b)
|
An
employee of the Health Plan, a provider or a subcontractee, an Enrollee;
and/or
|
|
(c)
|
An
Enrollee on an employee of the Health Plan, a provider or a
subcontractee.
|
|
e.
|
The
Health Plan shall immediately report to the Agency, in accordance
with the
format in Table 14-A, Critical Incident Individual, below, if one
(1) or
more of the following events occur:
|
|
(2)
|
Medication
errors involving Children/Adolescents in the care or custody of DCF.
|
|
f.
|
The
Health Plan shall report monthly to the Agency, in accordance with
the
format in Table 14 Critical Incidents Summary, below, a summary of
all
critical incidents.
|
|
g.
|
In
addition to supplying a quarterly Critical Incidents Summary, the
Health
Plan shall also report Critical Incidents in the manner prescribed
by the
appropriate district’s DCF Alcohol, Drug Abuse Mental Health office, using
the appropriate DCF reporting forms and
procedures.
|
|
Incident
Type
|
# of
Events
|
|
Enrollee
Death - Suicide
|
|
|
Enrollee
Death - Homicide
|
|
|
Enrollee
Death - Abuse/Neglect
|
|
|
Enrollee
Death - other
|
|
|
Enrollee
Injury or Illness
|
|
|
Sexual
Battery
|
|
|
Medication
Errors - acute care
|
|
|
Medication
Errors - children
|
|
|
Enrollee
Suicide Attempt
|
|
|
Altercations
requiring Medical Interventions
|
|
|
Enrollee
Escape
|
|
|
Enrollee
Elopement
|
|
|
Other
reportable incidents
|
|
|
Total
|
|
Enrollee
Medicaid ID#:
|
|
|
Date
of Incident:
|
|
|
Location
of Incident:
|
|
|
Critical
Incident Type:
|
|
|
Details
of Incident: (Include
enrollee’s age, gender, diagnosis, current medication, source of
information, all reported details about the event, action taken by
Health
Plan or provider, and any other pertinent information)
|
|
|
Follow
up planned or required: (Include
information related to any Health Plan or provider protocol that
applies
to event.)
|
|
|
Assigned
provider:
|
|
|
Report
submitted by:
|
|
|
Date
of submission:
|
|
Non-Clinical
Specialties
|
Therapeutic
Specialty Areas With 2 Years Clinical
Experience
|
|||||||||||||||
|
Positions
|
Total
|
Bi-Lingual
|
Expert
Witness
|
Court
Ordered Evals
|
Adoption/
Attachment
Issues
|
Post
Traumatic Stress Syndrome
|
Dual
Diagnosis (Mental Disorder/ Substance Abuse)
|
Gender/
Sexual Issues
|
Geriatrics/
Aging Issues
|
Separation,
Grief & Loss
|
Easting
Disorders
|
Adolescent/
Children’s Issues
|
Sexual
/ Physical Abuse
—Child
|
Sexual
Physical Abuse
—
Adult
|
Domestic
Violence
—
Child
|
Domestic
Violence
—
Adult
|
|
Adult
Psychiatrists
|
||||||||||||||||
|
Child
Psychiatrists
|
||||||||||||||||
|
Other
Physicians
|
||||||||||||||||
|
Psychiatric
ARNPs
|
||||||||||||||||
|
Psychologists
|
||||||||||||||||
|
Master
Level Clinicians (LCSW, LMFT, LMHC, MFCC)_
|
||||||||||||||||
|
Bachelor
Level
|
||||||||||||||||
|
RN
|
||||||||||||||||
|
Unduplicated
Totals
|
||||||||||||||||
|
Table
16
FARS/CFARS
Reporting
|
||||
|
O***YY06.txt
(January through June, due August 15) OR
|
||||
|
O***YY12.txt
(July through December, due February 15)
|
||||
|
Data
Element Name
|
Length
|
Start
Column
|
End
Column
|
Description
|
|
Recipient
ID
|
9
|
1
|
9
|
9-Digit
Medicaid ID Number of plan member
|
|
Recipient
DOB
|
10
|
10
|
19
|
Plan
member’s date of birth (MM/DD/CCYY)
|
|
Provider
ID
|
9
|
20
|
28
|
9-Digit
Medicaid HMO ID Number
|
|
Assessment
Type
|
1
|
29
|
29
|
Designate
the type of functional assessment that was done using “F: for FARS or “C”
for CFARS
|
|
Initial
Date
|
10
|
30
|
39
|
Date
of initial assessment (MM/DD/CCYY)
|
|
Initial
Score
|
2
|
40
|
41
|
Initial
overall assessment score
|
|
6
Month Date
|
10
|
42
|
51
|
Date
of 6 month assessment, if applicable** (MM/DD/CCYY)
|
|
6
Month Score
|
2
|
52
|
53
|
6
month overall assessment score, if applicable**
|
|
Discharge
Date
|
10
|
54
|
63
|
Date
of Discharge (MM/DD/CCYY)
|
|
Discharge
Score
|
2
|
64
|
65
|
Overall
assessment score at discharge
|
|
**
Note: Discharge date may occur prior to the 6 month
assessment.
|
||||
|
b.
|
Hospital
Outpatient Services - Provider Type 01, Claim Input Indicator
“O”
|
|
4.
|
Physician
Services - Provider Type 25 (MD) or 26 (DO) with a specialty code
of
"42"Psychiatrist, "43”Child Psychiatrist, or "44"
Psychoanalysis
|
|
5.
|
Advanced
Nurse Practitioner Provider Type 30 (ARNP) with a specialty Code
of “76” -
Clinical Nurse Specialist.
|
|
Field
Name
|
Field
Length
|
Comments
|
|
Medicaid
ID
|
9
|
First
9 digits of the Enrollee ID number
|
|
Plan
ID
|
9
|
9
digit Medicaid ID of the Health Plan in which Enrollee was Enrolled
on the
first date of service
|
|
Service
Type
|
1
|
I Hospital
Inpatient
C CSU
O Hospital
Outpatient
P Physician
(MD or DO)
A Advanced
Nurse Practitioner, ARNP
H Comm.
Mental Health, Mental Health Practitioner
T Targeted
Case Management
L Locally
Defined or Optional Service
|
|
First
Date of Service
|
8
|
For
Inpatient and CSU encounters, this equals the admit date. Use YYYYMMDD
format.
|
|
Revenue
Code
|
4
|
Use
only for Hospital Inpatient and Hospital Outpatient
Encounters
|
|
Procedure
Code
|
5
|
5
digit CPT or HCPCS Procedure Code (For Inpatient Claims only, use
the
ICD9-CM Procedure Code.)
|
|
Procedure
Modifier 1
|
2
|
|
|
Procedure
Modifier 2
|
2
|
|
|
Units
of Service
|
3
|
For
Inpatient and CSU encounters, report the number of covered days.
For all
other encounters, use the units of service referenced in the appropriate
Medicaid Coverage and Limitations Handbook.
|
|
Diagnosis
|
6
|
Primary
Diagnosis Code
|
|
Provider
Type
|
1
|
1 M.D.
2 D.O.
3 A.R.N.P.
4 P.A.
5 Community
Mental Health Center
6 Licensed
Psychologist, LCSW, LMFT, LMHC
7 Other
|
|
Provider
ID Type
|
1
|
Type
of unique identifier for the direct service provider:
A
=
AHCA ID
M
=
Medicaid Provider ID
L
=
Professional License Number
|
|
Provider
ID
|
9
|
Unique
identifier for the direct service provider
|
|
Amount
Paid
|
10
|
Costs
associated with the claim. Format with an explicit decimal point
and 2
decimal places but no explicit commas. Optional.
|
|
Run
Date
|
8
|
The
date the file was prepared. Use YYYYMMDD format
|
|
Claim
Reference Number
|
25
|
The
Health Plan’s internal unique claim record
identifier
|
|
2)
|
Services
subcontracted related to this
Contract;
|
|
3)
|
Dates
of services (beginning and ending);
|
|
4)
|
Total
dollar amount paid to subvendor for services related to this Contract;
or
|
|
5)
|
A
statement that no minority subvendors were used during this
period.
|
|
A.
|
Payment
Overview. This
is a fixed price (unit cost) Contract. The Agency will manage this
fixed
price Contract for the delivery of Covered Services to Enrollees.
The
Agency or its Fiscal Agent shall make payment to the Health Plan
on a
monthly basis for the Health Plan’s satisfactory performance of its duties
and responsibilities as set forth in this Contract. To accommodate
payments, the Health Plan is enrolled as a Medicaid provider with
the
Fiscal Agent. Payments
made to the Health Plan resulting from this Contract include monthly
Capitation Rate payments for either a Comprehensive Component or
a
Comprehensive Component and Catastrophic Component, both of which
contain
risk adjustments, and were developed for particular Medicaid populations,
and may contain an adjustment to collect amounts for the Enhanced
Benefit
Accounts fund. The Agency may also pay Health Plans for obstetrical
delivery and transplant services through Kick Payments; for Covered
Services that are over the Catastrophic Component Threshold, if the
Health
Plan has contracted for the Comprehensive Component only; and for Child
Health Check-Up (CHCUP) incentive payments, if any, as specified
below.
|
| 1. |
The
Agency’s Capitation Rate payments shall meet the following
requirements:
|
| a. |
Medicaid
Reform Capitation Rates will begin with the September 1, 2006 Capitation
Rate payments.
|
|
(a)
|
The
Agency will pay the Health Plan the HIV/AIDS Capitation Rate only
for
those Enrollees who have been identified and verified as having an
HIV/AIDS diagnosis. The HIV/AIDS Capitation Rate is provided in the
Capitation Rate Table 5 in Attachment I.
|
|
(b)
|
The
Agency will pay the Health Plan the Capitation Rate for Children
with
Chronic Conditions only if the Enrollee meets the requirements for
the
Children with Chronic Conditions and is enrolled in a Specialty Plan
for
for Children with Chronic Conditions based on the rates specified
in Table
6.
|
| b. |
For
each eligibility category indicated, and for each age group indicated,
the
Agency will make a capitation payment for Enrollees as provided for
in the
Capitation Rate tables in Attachment I and as described below.
|
|
(a)
|
Age
ranges for the eligibility categories for which the Capitation Rates
are
calculated.
|
|
(b)
|
Contract
Year 2006-2007 Medicaid Reform rates under current Capitation Rate
methodology.
|
|
(c)
|
Percentage
of current methodology used for determining
rates.
|
|
(d)
|
Current
methodology capitation amount (component) based on the percentage
of
current methodology Capitation Rates
used.
|
|
(e)
|
Preliminary
base rate for Contract Year Risk-Adjusted methodology with Enhanced
Benefit adjustment. The Enhanced Benefit adjustment is a per Health
Plan
percentage amount that is deposited into the Enhanced Benefit Accounts
fund (see also subsection F.2. of this Attachment).
|
|
(f)
|
Budget
neutrality factor: an actuarially-derived factor to ensure that aggregate
costs do not increase or decrease.
|
|
(g)
|
Base
rates for Risk-Adjusted Methodology after Budget Neutrality: Capitation
amount based on the percentage of Risk-Adjusted methodology Capitation
Rates used multiplied by the budget neutrality factor
(f).
|
|
(h)
|
Percentage
of Risk-Adjusted methodology used for determining rates (the Agency’s
Risk-Adjusted Capitation Rate methodology is based on eligibility,
claims
and encounter data).
|
|
(i)
|
25%
of Risk Adjusted Methodology: The capitation amount based on the
percentage of Risk-Adjusted methodology (h) multiplied by the Base
Rates
column for Risk-Adjusted methodology after budget neutrality factor
(g).
|
| i. |
The
Agency assigns the Health Plan a Risk-Adjusted Plan Factor which
designates the aggregated risk of the Health Plan’s enrolled population.
|
| ii. |
During
the first (1st)
two (2) Contract years, the Health Plan’s Risk-Adjusted Plan Factor will
not vary more than ten percent (10%) from the aggregate weighted
mean of
all Medicaid Reform Health Plans within the same Service Area for
the
respective eligibility categories.
|
|
(j)
|
Final
Rate (with Enhanced Benefit Adjustment): The current methodology
capitation amount (d) added to the 25% of Risk-Adjusted methodology
amount
(i). The final rate provided in Attachment I is an estimate based
on a
Plan Factor of 1.0. Note: The actual final monthly Capitation Rate(s)
paid
to the Health Plan will be based on the Health Plan’s actual Plan Factor
and reduced by the actual percentage deducted to fund the Enhanced
Benefit
Accounts.
|
|
(i)
|
HIV/AIDS
Specialty Plan Enrollees who are family members of Enrollees identified
as
diagnosed with HIV/AIDS, and who are not identified as diagnosed
with
HIV/AIDS, will receive a Capitation Rate based on their respective
eligibility categories in Capitation Rate Tables 2 or 3 in Attachment
I.
In developing the capitation rates for these family members, a Plan
Factor
of 1.0 will be assigned until the Agency determines that the Health
Plan
has enough of population of such Enrollees as to warrant its own
Plan
Factor.
|
|
c.
|
The
Risk-Adjusted Capitation Rates paid by the Agency are either for
the
Comprehensive Component or Comprehensive Component and Catastrophic
Component as specified below.
|
| (1) |
Health
Plans are required to provide the Comprehensive Component and the
Catastrophic Component to Enrollees in the following
manner:
|
|
(a)
|
For
Contracts serving Broward County and/or Duval County, Health Plans
that
are not Capitated PSNs are required to provide both the Comprehensive
Component and Catastrophic Components. This means that the Health
Plan is
responsible for the cost of providing Covered Services up to the
Benefit
Maximum determined by the Agency for the Contract Year.
|
|
(b)
|
For
Contracts serving Broward County and/or Duval County, Health Plans
that
are Capitated PSNs must provide the Comprehensive Component and may
choose
to provide the Catastrophic Component. The Capitated PSN’s choice will be
documented in Attachment I.
|
|
(c)
|
For
Contracts serving Baker County, Clay County and/or Nassau County,
the
Health Plan is required to provide the Comprehensive Component and
may
choose to provide the Catastrophic Component to its Enrollees in
those
counties.
|
|
a.
|
By
signature on this Contract, the parties explicitly agree that this
Section
shall not independently convey any inherent rights, responsibilities
or
obligations of either party, relative to these rates, and shall not
itself
be the basis for any cause of administrative, legal or equitable
action
brought by either party. In the event that the rates certified by
the
actuary and approved by CMS are different from the rates included
in this
Contract, the Health Plan agrees to accept a reconciliation performed
by
the Agency to bring payments to the Health Plan in line with the
approved
rates. The Agency may amend and use the CMS-approved rates by notice
in a
Contract amendment to the Health Plan.
|
|
b.
|
Upon
receipt of CMS approval of the September 1, 2006 - August 31, 2007
Capitation Rates (remainder of the 2006-2007 Contract year), the
Agency
shall amend this Contract to reflect CMS-approved and actuarially
certified Capitation Rates effective September 1, 2006. The Health
Plan’s
Capitation Rates for this Contract period (September 1, 2006 - August
31,
2007) will be weighted so that seventy-five percent (75%) is based
on
current Capitation Rate methodology and twenty-five percent (25%)
is based
on the Risk-Adjusted Capitation Rate
methodology.
|
|
c.
|
Upon
CMS approval of the September 1, 2007 - August 31, 2008 Capitation
Rates,
the Agency shall amend this Contract to reflect CMS-approved and
actuarially certified Capitation Rates effective September 1, 2007.
The
Health Plan’s Capitation Rates for the September 1, 2007 - August 31, 2008
Contract Year will be weighted so that fifty percent (50%) is based
on
current Capitation Rate methodology and fifty percent (50%) is based
on
the Risk-Adjusted Capitation Rate
methodology.
|
|
d.
|
Upon
CMS approval of the September 1, 2008 - August 31, 2009 Capitation
Rates,
the Agency shall amend this Contract to reflect CMS-approved and
actuarially certified Capitation Rates effective September 1, 2008.
The
Health Plan’s Capitation Rates shall be fully Risk-Adjusted for the
September 1, 2008 - August 31, 2009 Contract
Year.
|
|
a.
|
The
Health Plan is obligated to provide services pursuant to the terms
of this
Contract for all Enrollees for whom the Health Plan has received
capitation payment or for whom the Agency has assured the Health
Plan that
the capitation payment is
forthcoming.
|
|
b.
|
To
ensure a seamless health care delivery system for the Enrollee, if
the
Health Plan contracts for the Comprehensive Component only, the Health
Plan continues to be responsible for coordinating, managing, and
delivering all Enrollee care up to the Benefit Maximum regardless
of
whether the cost of the Enrollee’s Covered Services is above and beyond
the Catastrophic Component
Threshold.
|
|
c.
|
Regardless
of whether the Health Plan is at risk for the Comprehensive Component
only
or for both the Comprehensive Component and the Catastrophic Component,
the Health Plan continues to be responsible for the coordinating
and
managing all Enrollee care even if the cost of the Enrollee’s Covered
Services is above and beyond the Benefit Maximum.
|
|
a.
|
The
Health Plan shall use the Unborn Activation Process to enroll all
babies
born to pregnant Enrollees as specified in Section III, Eligibility
and
Enrollment, B.3.
|
|
b.
|
The
Health Plan is responsible for payment of all Covered Services provided
to
Newborns enrolled through the Unborn Activation
Process.
|
|
a.
|
For
Health Plans under Contract to provide the Comprehensive Component
only,
Agency reimbursements to the Health Plan for Kick Payment services
will be
counted toward the Health Plan’s Catastrophic Component Threshold. Once
the Catastrophic Component Threshold has been met, the Agency will
continue to reimburse the Health Plan any Kick Payment services delivered
by the Health Plan at the Kick Payment
amounts.
|
|
b.
|
For
purposes of Kick Payments, an obstetrical delivery includes all births
resulting from the delivery; therefore, if an obstetrical delivery
results
in multiple births, the Agency will reimburse the Health Plan through
one
Kick Payment only. Obstetrical deliveries also include still births
as
specified in the Medicaid Physicians Services
Handbook.
|
|
c.
|
For
Health Plans under Contract as a Specialty Plan, Agency reimbursements
to
the Health Plans for Kick Payment services will be counted toward
the
Enrollee’s Benefit Maximum.
|
|
a.
|
The
Health Plan must have provided the covered Kick Payment service to
the
recipient while he or she was enrolled in the Health Plan;
and
|
|
b.
|
The
Health Plan must submit any required documentation to the Agency
upon its
request in order to receive the Kick Payment applicable to the Covered
Service provided.
|
|
a.
|
For
each transplant provided, the Health Plan must submit an accurate
and
complete CMS-1500 Claim Form and (“CMS-1500”) Operative Report to the
Fiscal Agent within the required Medicaid Fee-for-Service claims
submittal
timeframes
|
|
b.
|
The
Health Plan must list itself as both the Pay-to and the Treating
Provider
on the CMS-1500 Claim Form; and
|
|
c.
|
The
Health Plan must use the following list of transplant procedure codes
relative to the type of transplant performed when completing Field
24 D on
the CMS-1500:
|
|
CPT
Code
|
Transplant
CPT Code Description
|
|
32851
|
lung
single, without bypass
|
|
32852
|
lung
single, with bypass
|
|
32853
|
lung
double, without bypass
|
|
32854
|
lung
double, with bypass
|
|
33945
|
heart
transplant with or without recipient cardiectomy
|
|
47135
|
liver,
allotransplation, orthotopic, partial or whole from cadaver or living
donor
|
|
47136
|
liver,
heterotopic, partial or whole from cadaver or living donor any
age
|
|
a.
|
The
Health Plan must submit an accurate and complete CMS-1500 Claim Form
in
sufficient time to be received by the Fiscal Agent within six (6)
months
following the date of service
(delivery);
|
|
b.
|
The
Health Plan must list itself as both the Pay-to and the Treating
Provider
on the CMS-1500 Claim Form; and
|
|
c.
|
The
Health Plan must use the following list of delivery procedure codes
relative to the type of delivery performed when completing Field
24 D on
the CMS-1500:
|
|
CPT
Code
|
Obstetrical
Delivery CPT Code Description
|
|
59409
|
Vaginal
delivery only
|
|
59410
|
Vaginal
delivery including postpartum care
|
|
59515
|
Cesarean
delivery including postpartum care
|
|
59612
|
Vaginal
delivery only, after previous cesarean delivery
|
|
59614
|
Vaginal
delivery only, after previous cesarean delivery including postpartum
care
|
|
59622
|
Cesarean
delivery only, following attempted vaginal delivery after previous
cesarean delivery including postpartum
care
|
|
D.
|
Claims
Payment for Health Plans Accepting Financial Risk for the Comprehensive
Component Only
|
| 1. |
The
amount of the incentive payment shall be calculated as follows: the
ratio
of a qualified Health Plan’s screenings to the total of all Health Plans’
screenings will be multiplied by the total amount in the fund for
the
incentive payment. The ratios will be based on the Health Plans’ audited
CHCUP reports. The total amount in the fund will be determined at
the
discretion of the Agency. In no event shall the total monies allotted
to
the incentive program be in excess of the incentive payment fund.
|
|
a.
|
July
1, for costs estimated for the Enrollment and Disenrollment services
rendered by the Choice Counselor/Enrollment Broker for July and the
following two (2) months;
|
|
b.
|
October
1, for costs related to the Enrollment and Disenrollment services
rendered
by the Choice Counselor/Enrollment Broker for October and the
following two (2) months;
|
|
c.
|
January
1, for costs related to the Enrollment and Disenrollment services
rendered
by the Choice Counselor/Enrollment Broker for January and the
following two (2) months; and
|
|
d.
|
April
1, for costs related to maintaining the third party Enrollment and
Disenrollment services contract for April and the following two (2)
months.
|
|
a.
|
Adjustments
to funds previously paid and to be paid may be required. Funds previously
paid shall be adjusted when Capitation Rate calculations are determined
to
have been in error, or when capitation payments have been made for
Medicaid Recipients who are determined to be ineligible for Health
Plan
Enrollment during the period for which the capitation payments were
made.
In such events, the Health Plan agrees to refund any overpayment
and the
Agency agrees to pay any
underpayment.
|
|
b.
|
If
the Agency receives legislative direction as specified in Section
XIII,
subsection F.1., Payment Assessments, Choice Counseling, respectively,
the
Agency shall annually, or more frequently, determine the actual
expenditures for Enrollment and Disenrollment services rendered by
the
Choice Counselor/Enrollment Broker. The Agency will compare Capitation
Rate assessments to the actual expenditures for such Enrollment and
Disenrollment services. The following factors will enter into the
cost
settlement process:
|
|
(1)
|
If
the amount of Capitation Rate assessments are less than the actual
cost of
providing Enrollment and Disenrollment services rendered by the Choice
Counselor/Enrollment Broker, the Health Plan shall pay the difference
to
the Agency within thirty (30) Calendar Days of
settlement.
|
|
(2)
|
If
the amount of capitation assessments exceeds the actual cost of providing
Enrollment, and Disenrollment services, the Agency will pay the difference
to the Health Plan within thirty (30) Calendar Days of the
settlement.
|
|
c.
|
As
the Agency adjusts the Plan Factor based on updated historical data,
the
Health Plan’s Capitation Rates will be adjusted according to the
methodology indicated in the Capitation Rate
tables.
|
|
d.
|
The
Agency may adjust the Health Plan’s Capitation Rates if the percentage
deducted for the Enhanced Benefit Accounts fund is modified due to
program
needs.
|
|
A.
|
General
Provisions
|
|
1.
|
The
Health Plan shall comply with all requirements and performance standards
set forth in this Contract. In the event the Agency identifies a
violation
of this Contract, or other non-compliance with this Contract, the
Health
Plan shall submit a corrective action plan (CAP) within three (3)
Calendar
Days of the date of receiving notification of the violation or
non-compliance from the Agency.
|
|
2.
|
Within
five (5) Business Days of receiving the CAP the Agency will either
approve
or disapprove the CAP. If disapproved, the Health Plan shall resubmit,
within ten (10) Business Days, a new CAP that addresses the concerns
identified by the Agency.
|
|
3.
|
Upon
approval of the CAP, whether the initial CAP or the revised CAP,
the
Health Plan shall implement the CAP within the time frames specified
by
the Agency.
|
|
4.
|
Except
where specified below, the Agency shall impose a monetary sanction
of $100
per day on the Health Plan for each Calendar Day that the approved
CAP is
not implemented to the satisfaction of the
Agency
|
|
B.
|
Specific
Sanctions
|
|
As
described in 42 CFR 438.700, the Agency may impose any of the following
sanctions against a Health Plan if it determines that a Health Plan
has
violated any provision of this Contract, or any applicable
statutes.
|
|
1.
|
Suspension
of the Health Plan’s Voluntary Enrollments and participation in the
Mandatory Assignment process for
Enrollment.
|
|
2.
|
Suspension
or revocation of payments to the Health Plan for Enrollees during
the
sanction period.
|
|
3.
|
For
any nonwillful violation of the Contract, the Agency shall impose
a fine,
not to exceed $2,500 per Violation. In no event shall such fine exceed
an
aggregate amount of $10,000 for all nonwillful Violations arising
out of
the same action.
|
|
4.
|
With
respect to any knowing and willful violation of the Contract the
Agency
shall impose a fine upon the Health Plan in an amount not to exceed
$20,000 for each such violation. In no event shall such fine exceed
an
aggregate amount of $100,000 for all knowing and willful violations
arising out of the same action.
|
|
5.
|
If
the Health Plan fails to carry out substantive terms of the Contract
or
fails to meet applicable requirements in 42 CFR 438.700, the Agency
shall
terminate the Contract. After the Agency notifies the Health Plan
that it
intends to terminate the Contract, the Agency shall give the Health
Plan's
Enrollees written notice of the State's intent to terminate the Contract
and allow the Enrollees to disenroll immediately without
Cause.
|
|
6.
|
The
Agency may impose intermediate sanctions in accordance with 42 CFR
438.702, including, but not limited
to:
|
|
a.
|
Civil
monetary penalties in the amounts specified in this
contract.
|
|
b.
|
Appointment
of temporary management for the Health Plan. Rules for temporary
management pursuant to 42 CFR 438.706 are as
follows:
|
|
(1)
|
The
State may impose temporary management only if it finds (through on-site
survey, Enrollee Grievances, financial audits, or any other means)
that:
|
|
i.
|
There
is continued egregious behavior by the Health Plan, including but
not
limited to behavior that is described in 42 CFR
438.700;
|
|
ii.
|
There
is substantial risk to Enrollees'
health;
|
|
iii.
|
The
sanction is necessary to ensure the health of the Health Plan’s
Enrollees;
|
|
iv.
|
While
improvements are made to remedy the Health Plan’s violation(s) under 42
CFR 438.700; or
|
|
v.
|
Until
there is an orderly termination or reorganization of the Health
Plan.
|
|
(2)
|
The
State must impose temporary management (regardless of any other sanction
that may be imposed) if it finds that the Health Plan has repeatedly
failed to meet substantive requirements in 42 CFR 438.706. The State
must
also grant Enrollees the right to terminate Enrollment without Cause,
as
described in 42 CFR 438.702(a)(3), and must notify the affected Enrollees
of their right to terminate
Enrollment.
|
|
(3)
|
The
State shall not delay imposition of temporary management to provide
a
hearing before imposing this
sanction.
|
|
(4)
|
The
State shall not terminate temporary management until it determines
that
the Health Plan can ensure that the sanctioned behavior will not
recur.
|
|
c.
|
Granting
Enrollees the right to terminate Enrollment without Cause and notifying
affected Enrollees of their right to
disenroll.
|
|
d.
|
Suspension
or limitation of all new Enrollment, including Mandatory Enrollment,
after
the effective date of the sanction.
|
|
e.
|
Suspension
of payment for Enrollees after the effective date of the sanction
and
until CMS or the Agency is satisfied that the reason for imposition
of the
sanction no longer exists and is not likely to
recur.
|
|
f.
|
Before
imposing any intermediate sanctions, the State must give the Health
Plan
timely notice according to 42 CFR
438.710.
|
|
7.
|
If
the Health Plan’s CHCUP Screening compliance rate is below sixty percent
(60%), it must submit to the Agency, and implement, an Agency accepted
CAP. If the Health Plan does not meet the standard established in
the CAP
during the time period indicated in the plan, the Agency has the
authority
to impose sanctions in accordance with this
section.
|
|
8.
|
Unless
the duration of a sanction is specified, a sanction shall remain
in effect
until the Agency is satisfied that the basis for imposing the sanction
has
been corrected and is not likely to
recur.
|
|
9.
|
The
Agency reserves the right to withhold all or a portion of the Health
Plans
monthly administrative allocation for any amount owed pursuant to
this
section.
|
| A. |
Insolvency
Protection
|
| B. |
Insolvency
Protection for a Capitated Provider Service Network
(PSN)
|
| a. |
The
capitated PSN shall maintain a minimum surplus in an amount that
is the
greater of $1 million or 1.5 percent of projected annual
premiums.
|
| b. |
In
lieu of the requirements above, the Agency consider the following:
|
| i. |
If
the organization is a public entity, the Agency may take under advisement
a statement from the public entity that a county supports the managed
care
plan with the county’s full faith and credit. In order to qualify for the
Agency’s consideration, the county must own, operate, manage, administer,
or oversee the managed care plan, either partly or wholly, through
a
county department or agency;
|
| ii. |
The
state guarantees the solvency of the
organization;
|
| iii. |
The
organization is a federally qualified health center or is controlled
by
one or more federally qualified health centers and meets the solvency
standards established by the state for such organization pursuant
to s.
409.912(4)(c), Florida Statutes; or
|
| iv. |
The
entity meets the financial standards for federally approved
provider-sponsored organizations as defined in 42CFR ss. 422.380
-
422.390.
|
| C. |
Surplus
Start Up Account
|
| D. |
Surplus
Requirement
|
| E. |
Interest
|
| F. |
Inspection
and Audit of Financial
Records
|
| G. |
Physician
Incentive Plans
|
|
1.
|
Physician
incentive plans shall comply with 42 CFR 417.479, 42 CFR 438.6(h),
42 CFR
422.208 and 42 CFR 422.210. Health Plans shall make no specific payment
directly or indirectly under a physician incentive plan to a physician
or
physician group as an inducement to reduce or limit medically necessary
services furnished to an individual Enrollee. Incentive plans must
not
contain provisions which provide incentives, monetary or otherwise,
for
the withholding of medically necessary
care.
|
|
2.
|
The
Health Plan shall disclose information on physician incentive plans
listed
in 42 CFR 417.479(h)(1) and 417.479(i) at the times indicated in
42 CFR
417.479(d)-(g). All such arrangements must be submitted to the Agency
for
approval, in writing, prior to use. If any other type of withhold
arrangement currently exists, it must be omitted from all
subcontracts.
|
|
H.
|
Third
Party Resources
|
|
a.
|
If
the Health Plan has determined that third party liability exists
for part
or all of the services provided directly by the Health Plan to an
Enrollee, the Health Plan shall make reasonable efforts to recover
from
third party liable sources the value of services
rendered.
|
|
b.
|
If
the Health Plan has determined that third party liability exists
for part
or all of the services provided to an Enrollee by a Subcontractor
or
referral Provider, and the third party is reasonably expected to
make
payment within 120 Calendar Days, the Health Plan may pay the
Subcontractor or referral Provider only the amount, if any, by which
the
Subcontractor's allowable claim exceeds the amount of the anticipated
third party payment; or, the Health Plan may assume full responsibility
for third party collections for service provided through the Subcontractor
or referral Provider.
|
|
c.
|
The
Health Plan may not withhold payment for services provided to an
Enrollee
if third party liability or the amount of liability cannot be determined,
or if payment shall not be available within a reasonable time, beyond
120
calendar days from the date of
receipt.
|
|
d.
|
When
both the Agency and the Health Plan have liens against the proceeds
of a
third party resource, the Agency shall prorate the amount due to
Medicaid
to satisfy such liens under section 409.910, F.S., between the Agency
and
the Health Plan. This prorated amount shall satisfy both liens in
full.
|
|
e.
|
The
Agency may, at its sole discretion, offer to provide third party
recovery
services to the Health Plan. If the Health Plan elects to authorize
the
Agency to recover on its behalf, the Health Plan shall be required
to
provide the necessary data for recovery in the format prescribed
by the
Agency. All recoveries, less the Agency’s cost to recover shall be income
to the plan. The cost to recover shall be expressed as a percentage
of
recoveries and shall be fixed at the time the plan elects to authorize
the
Agency to recover on its behalf.
|
|
f.
|
All
funds recovered from third parties shall be treated as income for
the
Health Plan.
|
| I. |
Fidelity
Bonds
|
| A. |
Agency
Contract Management
|
|
1.
|
The
Division of Medicaid within the Agency shall be responsible for management
of the Contract. The Division of Medicaid shall make all statewide
policy
decision-making or contract interpretation. In addition, the Division
of
Medicaid shall be responsible for the interpretation of all federal
and
State laws, rules and regulations governing or in any way affecting
this
Contract. Management shall be conducted in good faith with the best
interest of the State and the Medicaid Recipients it serves being
the
prime consideration. The Agency shall provide final interpretation
of
general Medicaid policy. When interpretations are required, the Health
Plan shall submit written requests to the Agency’s contract
manager.
|
|
2.
|
The
terms of this Contract do not limit or waive the ability, authority
or
obligation of the Office of Inspector General, Bureau of Medicaid
Program
Integrity, its contractors, or other duly constituted government
units
(State or federal) to audit or investigate matters related to, or
arising
out of this Contract.
|
|
3.
|
The
Contract shall only be amended as
follows:
|
| B. |
Applicable
Laws and Regulations
|
| C. |
Assignment
|
|
1.
|
Except
as provided below or with the prior written approval of the Agency,
which
approval shall not be unreasonably withheld, this Contract and the
monies
which may become due are not to be assigned, transferred, pledged
or
hypothecated in any way by the Health Plan, including by way of an
asset
or stock purchase of the Health Plan and shall not be subject to
execution, attachment or similar process by the Health
Plan.
|
| D. |
Attorney's
Fees
|
| E. |
Conflict
of Interest
|
| F. |
Contract
Variation
|
| G. |
Court
of Jurisdiction or Venue
|
| H. |
Damages
for Failure to Meet Contract
Requirements
|
| I. |
Disputes
|
| J. |
Force
Majeure
|
| K. |
Legal
Action Notification
|
| L. |
Licensing
|
| M. |
Misuse
of Symbols, Emblems, or Names in Reference to
Medicaid
|
| N. |
Offer
of Gratuities
|
| O. |
Subcontracts
|
|
1.
|
The
Health Plan is responsible for all work performed under this Contract,
but
may, with the written prior approval of the Agency, enter into
Subcontracts for the performance of work required under this Contract.
All
Subcontracts must comply with 42 CFR 438.230. All Subcontracts and
amendments executed by the Health Plan shall meet the following
requirements. All Subcontractors must be eligible for participation
in the
Medicaid program; however, the Subcontractor is not required to
participate in the Medicaid program as a provider. The Agency encourages
use of minority business enterprise Subcontractors. See Section X.C.,
Administration and Management, Provider Contracts, of this Contract,
for
provisions and requirements specific to Provider
contracts.
|
|
2.
|
No
Subcontract which the Health Plan enters into with respect to performance
under the Contract shall in any way relieve the Health Plan of any
responsibility for the performance of duties under this Contract.
The
Health Plan shall assure that all tasks related to the Subcontract
are
performed in accordance with the terms of this Contract. The Health
Plan
shall identify in its Subcontracts any aspect of service that may
be
further subcontracted by the
Subcontractor.
|
|
3.
|
All
model and executed Subcontracts and amendments used by the Health
Plan
under this Contract must be in writing, signed, and dated by the
Health
Plan and the Subcontractor and meet the following
requirements:
|
|
i.
|
The
Health Plan agrees to make payment to all subcontractors in a timely
fashion.
|
|
ii.
|
Provide
for prompt submission of information needed to make
payment.
|
|
iii.
|
Make
full disclosure of the method and amount of compensation or other
consideration to be received from the Health Plan.
|
|
iv.
|
Require
an adequate record system be maintained for recording services, charges,
dates and all other commonly accepted information elements for services
rendered to the Health Plan.
|
|
v.
|
Specify
that the Health Plan shall assume responsibility for cost avoidance
measures for third party collections in accordance with Section XV.
F.,
Financial Requirements, Third Party Liability.
|
|
i.
|
Provide
that the Agency and DHHS may evaluate through inspection or other
means
the quality, appropriateness and timeliness of services
performed.
|
|
ii.
|
Provide
for inspections of any records pertinent to the contract by the Agency
and
DHHS.
|
|
iii.
|
Require
that records be maintained for a period not less than five (5) years
from
the close of the Contract and retained further if the records are
under
review or audit until the review or audit is complete. (Prior approval
for
the disposition of records must be requested and approved by the
Health
Plan if the Subcontract is
continuous.)
|
|
iv.
|
Provide
for monitoring and oversight by the Health Plan and the Subcontractor
to
provide assurance that all licensed medical professionals are Credentialed
in accordance with the Health Plan’s and the Agency’s Credentialing
requirements as found in Section VIII.A.3.h Credentialing and
Recredentialing, of this Contract, if the Health Plan has delegated
the
Credentialing to a Subcontractor.
|
|
v.
|
Provide
for monitoring of services rendered to Enrollees sponsored by the
Provider.
|
|
i.
|
Identify
the population covered by the
Subcontract.
|
|
ii.
|
Provide
for submission of all reports and clinical information required by
the
Health Plan, including Child Health Check-Up reporting (if
applicable).
|
|
iii.
|
Provide
for the participation in any internal and external quality improvement,
utilization review, peer review, and grievance procedures established
by
the Health Plan.
|
|
i.
|
Require
safeguarding of information about Enrollees according to 42 CFR,
Part
438.224.
|
|
ii.
|
Require
compliance with HIPAA privacy and security
provisions.
|
|
iii.
|
Require
an exculpatory clause, which survives Subcontract termination including
breach of Subcontract due to insolvency, that assures that Medicaid
Recipients or the Agency may not be held liable for any debts of
the
Subcontractor.
|
|
iv.
|
If
there is a Health Plan physician incentive plan, include a statement
that
the Health Plan shall make no specific payment directly or indirectly
under a physician incentive plan to a Subcontractor as an inducement
to
reduce or limit Medically Necessary services to an Enrollee, and
that all
incentive plans shall not contain provisions which provide incentives,
monetary or otherwise, for the withholding of Medically Necessary
care;
|
|
4.
|
Contain
a clause indemnifying, defending and holding the Agency and the Health
Plan Enrollees harmless from and against all claims, damages, causes
of
action, costs or expense, including court costs and reasonable attorney
fees to the extent proximately caused by any negligent act or other
wrongful conduct arising from the Subcontract agreement. This clause
must
survive the termination of the Subcontract, including breach due
to
Insolvency. The Agency may waive this requirement for itself, but
not
Health Plan Enrollees, for damages in excess of the statutory cap
on
damages for public entities if the Subcontractor is a public health
entity
with statutory immunity. All such waivers must be approved in writing
by
the Agency.
|
|
5.
|
Require
that the Subcontractor secure and maintain during the life of the
Subcontract worker's compensation insurance for all of its employees
connected with the work under this Contract unless such employees
are
covered by the protection afforded by the Health Plan. Such insurance
shall comply with the Florida's Worker's Compensation
Law.
|
|
6.
|
Specify
that if the Subcontractor delegates or Subcontracts any functions
of the
Health Plan, that the Subcontract or delegation includes all the
requirements of this Contract.
|
|
7.
|
Make
provisions for a waiver of those terms of the Subcontract, which,
as they
pertain to Medicaid Recipients, are in conflict with the specifications
of
this Contract.
|
|
8.
|
Provide
for revoking delegation or imposing other sanctions if the Subcontractor's
performance is inadequate.
|
|
9.
|
The
Health Plan must provide that compensation to individuals or entities
that
conduct utilization management activities is not structured so as
to
provide incentives for the individual or entity to deny, limit, or
discontinue medically necessary services to any
Enrollee.
|
| P. |
Hospital
Subcontracts
|
| Q. |
Termination
Procedures
|
|
1.
|
In
conjunction with section III.B., Termination, on page eight (8) of
the
Agency's Standard Contract, termination procedures are required.
The
Health Plan agrees to extend the thirty (30) Calendar Days notice
found in
section III.B.1., Termination at Will, on page eight (8) of the Agency's
Standard Contract to ninety (90) Calendar Days notice. The party
initiating the termination shall render written notice of termination
to
the other party by certified mail, return receipt requested, or in
person
with proof of delivery, or by facsimile letter followed by certified
mail,
return receipt requested. The notice of termination shall specify
the
nature of termination, the extent to which performance of work under
the
Contract is terminated, and the date on which such termination shall
become effective. In accordance with 1932(e)(4), Social Security
Act, the
Agency shall provide the plan with an opportunity for a hearing prior
to
termination for cause. This does not preclude the Agency from terminating
without cause.
|
|
2.
|
Upon
receipt of final notice of termination, on the date and to the extent
specified in the notice of termination, the Health Plan
shall:
|
| R. |
Waiver
|
| S. |
Withdrawing
Services from a County
|
| T. |
MyFloridaMarketPlace
Vendor Registration
|
| U. |
MyFloridaMarketplace
Vendor Registration and Transaction Fee Exemption
|
| V. |
Ownership
and Management Disclosure
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1.
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Federal
and State laws require full disclosure of ownership, management and
control of Disclosing Entities.
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(1)
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A
person with an ownership interest or control interest means a person
or
corporation that:
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(2)
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The
percentage of direct ownership or control is calculated by multiplying
the
percent of interest which a person owns, by the percent of the Health
Plan's assets used to secure the obligation. Thus, if a person owns
ten
percent (10%) of a note secured by sixty percent (60%) of the Health
Plan's assets, the person owns six percent (6%) of the Health
Plan.
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(3)
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The
percent of indirect ownership or control is calculated by multiplying
the
percentage of ownership in each organization. Thus, if a person owns
ten
percent (10%) of the stock in a corporation, which owns eighty percent
(80%) of the Health Plan stock, the person owns 8 percent (8%) of
the
Health Plan.
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(1)
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Changes
in management are defined as any change in the management control
of the
Health Plan. Examples of such changes are those listed below or equivalent
positions by another title.
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(1)
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In
accordance with section 409.907, F.S., Health Plans with an initial
contract beginning on or after July 1, 1997, shall submit, prior
to
execution of a contract, complete sets of fingerprints of principals
of
the plan to the Agency for the purpose of conducting a criminal history
record check.
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(2)
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Principals
of the Health Plan shall be as defined in section 409.907,
F.S.
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| W. |
Minority
Recruitment and Retention
Plan
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| X. |
Independent
Provider
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| Y. |
General
Insurance Requirements
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| Z. |
Worker's
Compensation Insurance
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| AA. |
State
Ownership
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| BB. |
Disaster
Plan
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| 1. |
Definitions.
Unless specifically stated in this Attachment, the definition of
the terms
contained herein shall have the same meaning and effect as defined
in 45
C.F.R. 160 and 164.
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| 2. |
Use
and Disclosure of Protected Health Information.
The Vendor shall not use or disclose protected health information
other
than as permitted by this Contract or by federal and state law.
The Vendor
will use appropriate safeguards to prevent the use or disclosure
of
protected health information for any purpose not in conformity
with this
Contract and federal and state law. The Vendor will implement
administrative, physical, and technical safeguards that reasonably
and
appropriately protect the confidentiality, integrity, and availability
of
electronic protected health information the Vendor creates, receives,
maintains, or transmits on behalf of the Agency.
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3.
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Use
and Disclosure of Information for Management, Administration, and
Legal
Responsibilities.
The Vendor is permitted to use and disclose protected health information
received from the Agency for the proper management and administration
of
the Vendor or to carry out the legal responsibilities of the Vendor,
in
accordance with 45 C.F.R. 164.504(e)(4). Such disclosure is only
permissible where required by law, or where the
Vendor obtains reasonable assurances from the person to whom the
protected
health information is disclosed that: (1) the protected health
information
will be held confidentially, (2) the protected health information
will be
used or further disclosed only as required by law or for the purposes
for
which it was disclosed to the person, and (3) the person notifies
the
Vendor of any instance of which it is aware in which the confidentiality
of the protected health information has been
breached.
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4.
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Disclosure
to Third Parties.
The Vendor will not divulge, disclose, or communicate protected
health
information to any third party for any purpose not in conformity
with this
Contract without prior written approval from the Agency. The Vendor
shall
ensure that any agent, including a subcontractor, to whom it provides
protected health information received from, or created or received
by the
Vendor on behalf of, the Agency agrees to the same terms, conditions,
and
restrictions that apply to the Vendor with respect to protected
health
information.
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1.
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Each
Vendor whose contract/subcontract equals or exceeds $25,000 in
federal
monies must sign this certification prior to execution of each
contract/subcontract. Additionally, Vendors who audit federal programs
must also sign, regardless of the contract amount. The
Agency for Health Care Administration cannot contract with these
types of
Vendors if they are debarred or suspended by the federal
government.
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2.
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This
certification is a material representation of fact upon which reliance
is
placed when this contract/subcontract is entered into. If it is
later
determined that the signer knowingly rendered an erroneous certification,
the Federal Government may pursue available remedies, including
suspension
and/or debarment.
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3.
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The
Vendor shall provide immediate written notice to the contract manager
at
any time the Vendor learns that its certification was erroneous
when
submitted or has become erroneous by reason of changed
circumstances.
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4.
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The
terms "debarred," "suspended," "ineligible," "person," "principal,"
and
"voluntarily excluded," as used in this certification, have the
meanings
set out in the Definitions and Coverage sections of rules implementing
Executive Order 12549. You may contact the contract manager for
assistance
in obtaining a copy of those
regulations.
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5.
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The
Vendor agrees by submitting this certification that, it shall not
knowingly enter into any subcontract with a person who is debarred,
suspended, declared ineligible, or voluntarily excluded from participation
in this contract/subcontract unless authorized by the Federal
Government.
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6.
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The
Vendor further agrees by submitting this certification that it
will
require each subcontractor of this contract/subcontract, whose
payment
will equal or exceed $25,000 in federal monies, to submit a signed
copy of
this certification.
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7.
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The
Agency for Health Care Administration may rely upon a certification
of a
Vendor that it is not debarred, suspended, ineligible, or voluntarily
excluded from contracting/subcontracting unless it knows that the
certification is erroneous.
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8.
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This
signed certification must be kept in the contract manager's contract
file.
Subcontractor's certifications must be kept at the contractor's
business
location.
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| (1) |
The
prospective Vendor certifies, by signing this certification, that
neither
he nor his principals is presently debarred, suspended, proposed
for
debarment, declared ineligible, or voluntarily excluded from participation
in this contract/subcontract by any federal department or
agency.
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(2)
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Where
the prospective Vendor is unable to certify to any of the statements
in
this certification, such prospective Vendor shall attach an explanation
to
this certification.
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| (1) |
No
federal appropriated funds have been paid or will be paid, by or
on behalf
of the undersigned, to any person for influencing or attempting to
influence an officer or employee of any agency, a member of congress,
an
officer or employee of congress, or an employee of a member of congress
in
connection with the awarding of any federal contract, the making
of any
federal grant, the making of any federal loan, the entering into
of any
cooperative agreement, and the extension, continuation, renewal,
amendment, or modification of any federal contract, grant, loan,
or
cooperative agreement.
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| (2) |
If
any funds other than federal appropriated funds have been paid or
will be
paid to any person for influencing or attempting to influence an
officer
or employee of any agency, a member of congress, an officer or employee
of
congress, or an employee of a member of congress in connection with
this
federal contract, grant, loan, or cooperative agreement, the undersigned
shall complete and submit Standard Form-LLL, “Disclosure Form to Report
Lobbying,” in accordance with its
instructions.
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| (3) |
The
undersigned shall require that the language of this certification
be
included in the award documents for all sub-awards at all tiers (including
subcontracts, sub-grants, and contracts under grants, loans, and
cooperative agreements) and that all sub-recipients shall certify
and
disclose accordingly.
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/s/
Todd
S.
Farha
Signature
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6/26/06
Date
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Todd
S.
Farha
Name
of Authorized Individual
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FAR 001
Application or Contract Number
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HealthEase Health Plan of Florida, Inc. P.O. Box
26011, Tampa, FL 33623
Name and Address of Organziation
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