At enrollment. At the time a participant's needs necessitate the disclosure and delivery of such information in order to allow the participant to make an informed choice. Be encouraged to involve caregivers or family members in treatment discussions and decisions. Have advance directives explained and to establish them, if the participant so desires, in accordance with 42 C.F.R. §§ 489.100 and 489.102. Receive reasonable advance notice, in writing, of any transfer to another treatment setting and the justification for the transfer. Be afforded the opportunity to file an Appeal if services are denied that he or she thinks are medically indicated, and to be able to ultimately take that Appeal to an independent external system of review. The right to receive medical and non-medical care from a team that meets the beneficiary's needs, in a manner that is sensitive to the beneficiary's language and culture, and in an appropriate care setting, including the home and community. The right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. The right to freely exercise his or her rights, and to be assured that exercising those rights will not adversely affect the way the Contractor and its providers or the State Agency treat the Enrollee. The right to receive the information required pursuant to the Contract; The right to receive timely information about plan changes. This includes the right to request and obtain the information listed in the Orientation materials at least once per year, and the right to receive notice of any significant change in the information provided in the Orientation materials at least 30 days prior to the intended effective date of the change. See 42 C.F.R. § 438.10(g). The right to be protected from liability for payment of any fees that are the obligation of the Contractor. The right not to be charged any cost sharing for Medicare Parts A and B services. APPENDIX D – RELATIONSHIP WITH FIRST TIER, DOWNSTREAM, AND RELATED ENTITIES Contractor shall ensure that any contracts or agreements with First Tier, Downstream and Related Entities performing functions on Contractor’s behalf related to the operation of the plan offered by the Contractor are in compliance with 42 C.F.R. §§ 422.504, 423.505, and 438.6(l). Contractor shall specifically ensure: Prior to contracting with any First Tier, Downstream and Related Entities, the Contractor has evaluated their ability to perform the activities to be subcontracted; That it monitors the First Tier, Downstream or Related Entities performance on an ongoing basis and performs an annual review per EOHHS requirements. If any deficiencies or areas for improvement are identified, the Contractor shall require the First Tier, Downstream or Related Entity to take corrective action. Upon request, the Contractor shall provide EOHHS with a copy of the annual review and any corrective action plans developed as a result; HHS, the Comptroller General, or their designees have the right to audit, evaluate, and inspect and books, contracts, computer or other electronic systems, including medical records and documentation of the First Tier, Downstream and Related Entities; and HHS’s, the Comptroller General’s, or their designees right to inspect, evaluate, and audit any pertinent information for any particular contract period for ten years from the final date of the contract period or from the date of completion of any audit, whichever is later. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities contain the following: Enrollee protections that include prohibiting providers from holding an Enrollee liable for payment of any fees that are the obligation of the Contractor; Language that any services or other activity performed by a First Tier, Downstream and Related Entities is in accordance with the Contractor’s contractual obligations to CMS and EOHHS; Language that specifies the delegated activities and reporting requirements; Language that provides for revocation of the delegation activities and reporting requirements or specifies other remedies in instances where CMS, EOHHS, or the Contractor determine that such parties have not performed satisfactorily; Language that specifies the performance of the parties is monitored by the Contractor on an ongoing basis; Language that specifies the First Tier, Downstream and Related Entities agree to safeguard Enrollee Privacy and confidentiality of Enrollee health records; Language that specifies the First Tier, Downstream and Related Entities must comply with all Federal and State laws, regulations and CMS instructions, including the confidentiality and disclosure of medical records, or other health and enrollment information for providers; and Language that specifies First Tier, Downstream and Related Entities shall maintain liability protection sufficient to protect itself against any losses arising from any claims against itself or any provider, including, at a minimum, workers’ compensation insurance, comprehensive liability insurance, and property damage insurance. In contracts or arrangements with First Tier, Downstream and Related Entities, the Contractor also shall include stipulations that Massachusetts general law or Massachusetts regulation will prevail if there is a conflict between the state law or state regulation where the First Tier, Downstream or Related Entities is based. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities that are for credentialing of medical providers contains the following language: The credentials of medical professionals affiliated with the party or parties will be either reviewed by the Contractor; or The credentialing process will be reviewed and approved by the Contractor and the Contractor must audit the credentialing process on an ongoing basis. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities that delegate the selection of medical or pharmacy providers must include language that the Contractor retains the right to approve, suspend, or terminate any such arrangement. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities shall state that neither the Contractor nor the provider has the right to terminate the contract without cause and shall require the provider to assist with transitioning Enrollees to new medical providers, including sharing the Enrollee’s medical record and other relevant Enrollee information as directed by the Contractor or Enrollee. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities shall state that the Contractor shall provide a written statement to a provider of the reason or reasons for termination with cause. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities for medical providers include additional provisions. Such contracts or arrangements must contain the following: Language that the Contractor is obligated to make timely payments to contracted medical providers under the terms of the contract between the Contractor and the medical provider. The contract must contain a prompt payment provision, the terms of which are developed and agreed to by both the Contractor and the relevant medical provider; Language that services are provided in a culturally competent manner to all Enrollees, including those with limited English proficiency or reading skills, and diverse culturally and ethnic backgrounds; Language that medical providers ensure that medical information is released in accordance with applicable Federal or State law, or pursuant to court orders or subpoenas; Language that medical providers maintain Enrollee records and information in an accurate and timely manner; Language that medical providers ensure timely access by Enrollees to the records and information that pertain to them; Language that Enrollees will not be held liable for Medicare Part A and B cost sharing. Specifically, Medicare Parts A and B services must be provided at zero cost-sharing to Enrollees; Language that states that medical providers shall not xxxx patients for charges for Covered Services other than pharmacy co-payments, if applicable; Language that clearly state the medical providers EMTALA obligations and must not create any conflicts with hospital actions required to comply with EMTALA; Language that states medical providers are prohibited from closing or otherwise limiting their acceptance of Enrollees as patients unless the same limitations apply to all commercially insured enrollees; Language that states the Contractor is prohibited from refusing to pay an otherwise eligible health care provider for the provision of Covered Services solely because such provider has in good faith:
Appears in 3 contracts
Samples: Three Way Contract for Capitated Model, Three Way Contract for Capitated Model, Three Way Contract for Capitated Model
At enrollment. At the time a participant's needs necessitate the disclosure and delivery of such information in order to allow the participant to make an informed choice. Be encouraged to involve caregivers or family members in treatment discussions and decisions. Have advance directives Advance Directives explained and to establish them, if the participant so desires, in accordance with 42 C.F.R. §§ 489.100 and 489.102. Receive reasonable advance notice, in writing, of any transfer to another treatment setting and the justification for the transfer. Be afforded the opportunity to file an Appeal if services are denied that he or she thinks are medically indicated, and to be able to ultimately take that Appeal to an independent external system of review. The right to receive medical and non-medical non‑medical care from a team that meets the beneficiary's needs, in a manner that is sensitive to the beneficiary's language and culture, and in an appropriate care setting, including the home and community. The right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. The right to freely exercise his or her rights, and to be assured that exercising those rights will not adversely affect the way the Contractor and its providers or the State Agency treat the Enrollee. The right to receive the information required pursuant to the Contract; The right to receive timely information about plan changes. This includes the right to request and obtain the information listed in the Orientation materials at least once per year, and the right to receive notice of any significant change in the information provided in the Orientation materials at least 30 days prior to the intended effective date of the change. See 42 C.F.R. § 438.10(g). The right to be protected from liability for payment of any fees that are the obligation of the Contractor. The right not to be charged any cost sharing for Medicare Parts A and B services. APPENDIX Appendix D – RELATIONSHIP WITH FIRST TIERRelationship with First Tier, DOWNSTREAMDownstream, AND RELATED ENTITIES and Related Entities Contractor shall ensure that any contracts or agreements with First Tier, Downstream Downstream, and Related Entities performing functions on Contractor’s behalf related to the operation of the plan offered by the Contractor are in compliance with 42 C.F.R. §§ 422.504, 423.505, 438.6(l), 438.208, and 438.6(l438.230(b). Contractor shall specifically ensure: Prior to contracting with any First Tier, Downstream Downstream, and Related Entities, the Contractor has evaluated their ability to perform the activities to be subcontracted; That it monitors the First Tier, Downstream Downstream, or Related Entities performance on an ongoing basis and performs an annual review per EOHHS requirements. If any deficiencies or areas for improvement are identified, the Contractor shall require the First Tier, Downstream Downstream, or Related Entity to take corrective action. Upon request, the Contractor shall provide EOHHS with a copy of the annual review and any corrective action plans developed as a result; HHS, the Comptroller General, or their designees have the right to audit, evaluate, and inspect and books, contracts, computer or other electronic systems, including medical records and documentation of the First Tier, Downstream Downstream, and Related Entities; and HHS’s, the Comptroller General’s, or their designees right to inspect, evaluate, and audit any pertinent information for any particular contract period for ten years from the final date of the contract period or from the date of completion of any audit, whichever is later. The First Tier, Downstream, and Related Entities make their premises, facilities, equipment, records and systems available for the purpose of any audit, evaluation or inspection described above. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities contain the following: Enrollee protections that include prohibiting providers from holding an Enrollee liable for payment of any fees that are the obligation of the Contractor; Language that any services or other activity performed by a First Tier, Downstream Downstream, and Related Entities is in accordance with the Contractor’s contractual obligations to CMS and EOHHS; Language that specifies the delegated activities and reporting requirements; Language that provides for revocation of the delegation activities and reporting requirements or specifies other remedies in instances where CMS, EOHHS, or the Contractor determine that such parties have not performed satisfactorily; Language that specifies the performance of the parties is monitored by the Contractor on an ongoing basis; Language that specifies the First Tier, Downstream Downstream, and Related Entities agree to safeguard Enrollee Privacy and confidentiality of Enrollee health records; Language that specifies the First Tier, Downstream Downstream, and Related Entities must comply with all Federal and State laws, regulations and CMS instructions, including the confidentiality and disclosure of medical records, or other health and enrollment information for providers; and Language that specifies First Tier, Downstream Downstream, and Related Entities shall maintain liability protection sufficient to protect itself against any losses arising from any claims against itself or any provider, including, at a minimum, workers’ compensation insurance, comprehensive liability insurance, and property damage insurance. In contracts or arrangements with First Tier, Downstream Downstream, and Related Entities, the Contractor also shall include stipulations that Massachusetts general law or Massachusetts regulation will prevail if there is a conflict between the state State law or state State regulation where the First Tier, Downstream Downstream, or Related Entities is based. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities that are for credentialing of medical providers contains the following language: The credentials of medical professionals affiliated with the party or parties will be either reviewed by the Contractor; or The credentialing process will be reviewed and approved by the Contractor and the Contractor must audit the credentialing process on an ongoing basis. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities that delegate the selection of medical or pharmacy providers must include language that the Contractor retains the right to approve, suspend, or terminate any such arrangement. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities shall state that neither the Contractor nor the provider has the right to terminate the contract without cause and shall require the provider to assist with transitioning Enrollees to new medical providers, including sharing the Enrollee’s medical record and other relevant Enrollee information as directed by the Contractor or Enrollee. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities shall state that the Contractor shall provide a written statement to a provider of the reason or reasons for termination with cause. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities for medical providers include additional provisions. Such contracts or arrangements must contain the following: Language that the Contractor is obligated to make timely payments to contracted medical providers under the terms of the contract between the Contractor and the medical provider. The contract must contain a prompt payment provision, the terms of which are developed and agreed to by both the Contractor and the relevant medical provider; Language that services are provided in a culturally competent manner to all Enrollees, including those with limited English proficiency or reading skills, and diverse culturally and ethnic backgrounds; Language that medical providers ensure that medical information is released in accordance with applicable Federal or State law, or pursuant to court orders or subpoenas; Language that medical providers maintain Enrollee records and information in an accurate and timely manner; Language that medical providers ensure timely access by Enrollees to the records and information that pertain to them; Language that Enrollees will not be held liable for Medicare Part A and B cost sharing. Specifically, Medicare Parts A and B services must be provided at zero cost-sharing cost‑sharing to Enrollees; Language that states that medical providers shall not xxxx bill patients for charges for Covered Services other than pharmacy co-paymentsco‑payments, if applicable; Language that clearly state the medical providers EMTALA obligations and must not create any conflicts with hospital actions required to comply with EMTALA; Language that states medical providers are prohibited from closing or otherwise limiting their acceptance of Enrollees as patients unless the same limitations apply to all commercially insured enrolleesEnrollees; Language that states the Contractor is prohibited from refusing to pay an otherwise eligible health care provider for the provision of Covered Services solely because such provider has in good faith:
Appears in 3 contracts
Samples: Three Way Contract for Capitated Model, Three Way Contract for Capitated Model, Three Way Contract for Capitated Model
At enrollment. At the time a participant's needs necessitate the disclosure and delivery of such information in order to allow the participant to make an informed choice. Be encouraged to involve caregivers or family members in treatment discussions and decisions. Have advance directives Advance Directives explained and to establish them, if the participant so desires, in accordance with 42 C.F.R. §§ 489.100 and 489.102. Receive reasonable advance notice, in writing, of any transfer to another treatment setting and the justification for the transfer. Be afforded the opportunity to file an Appeal if services are denied that he or she thinks are medically indicated, and to be able to ultimately take that Appeal to an independent external system of review. The right to receive medical and non-medical non‑medical care from a team that meets the beneficiary's needs, in a manner that is sensitive to the beneficiary's language and culture, and in an appropriate care setting, including the home and community. The right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. The right to freely exercise his or her rights, and to be assured that exercising those rights will not adversely affect the way the Contractor and its providers or the State Agency treat the Enrollee. The right to receive the information required pursuant to the Contract; The right to receive timely information about plan changes. This includes the right to request and obtain the information listed in the Orientation materials at least once per year, and the right to receive notice of any significant change in the information provided in the Orientation materials at least 30 days prior to the intended effective date of the change. See 42 C.F.R. § 438.10(g). The right to be protected from liability for payment of any fees that are the obligation of the Contractor. The right not to be charged any cost sharing for Medicare Parts A and B services. APPENDIX Appendix D – RELATIONSHIP WITH FIRST TIERRelationship with First Tier, DOWNSTREAMDownstream, AND RELATED ENTITIES and Related Entities Contractor shall ensure that any contracts or agreements with First Tier, Downstream Downstream, and Related Entities performing functions on Contractor’s behalf related to the operation of the plan offered by the Contractor are in compliance with 42 C.F.R. §§ 422.504, 423.505, 438.6(l), 438.208, and 438.6(l438.230(b). Contractor shall specifically ensure: Prior to contracting with any First Tier, Downstream Downstream, and Related Entities, the Contractor has evaluated their ability to perform the activities to be subcontracted; That it monitors the First Tier, Downstream Downstream, or Related Entities performance on an ongoing basis and performs an annual review per EOHHS requirements. If any deficiencies or areas for improvement are identified, the Contractor shall require the First Tier, Downstream Downstream, or Related Entity to take corrective action. Upon request, the Contractor shall provide EOHHS with a copy of the annual review and any corrective action plans developed as a result; HHS, the Comptroller General, or their designees have the right to audit, evaluate, and inspect and books, contracts, computer or other electronic systems, including medical records and documentation of the First Tier, Downstream Downstream, and Related Entities; and HHS’s, the Comptroller General’s, or their designees right to inspect, evaluate, and audit any pertinent information for any particular contract period for ten years from the final date of the contract period or from the date of completion of any audit, whichever is later. The First Tier, Downstream, and Related Entities make their premises, facilities, equipment, records and systems available for the purpose of any audit, evaluation or inspection described above. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities contain the following: Enrollee protections that include prohibiting providers from holding an Enrollee liable for payment of any fees that are the obligation of the Contractor; Language that any services or other activity performed by a First Tier, Downstream Downstream, and Related Entities is in accordance with the Contractor’s contractual obligations to CMS and EOHHS; Language that specifies the delegated activities and reporting requirements; Language that provides for revocation of the delegation activities and reporting requirements or specifies other remedies in instances where CMS, EOHHS, or the Contractor determine that such parties have not performed satisfactorily; Language that specifies the performance of the parties is monitored by the Contractor on an ongoing basis; Language that specifies the First Tier, Downstream Downstream, and Related Entities agree to safeguard Enrollee Privacy and confidentiality of Enrollee health records; Language that specifies the First Tier, Downstream Downstream, and Related Entities must comply with all Federal and State laws, regulations and CMS instructions, including the confidentiality and disclosure of medical records, or other health and enrollment information for providers; and Language that specifies First Tier, Downstream Downstream, and Related Entities shall maintain liability protection sufficient to protect itself against any losses arising from any claims against itself or any provider, including, at a minimum, workers’ compensation insurance, comprehensive liability insurance, and property damage insurance. In contracts or arrangements with First Tier, Downstream Downstream, and Related Entities, the Contractor also shall include stipulations that Massachusetts general law or Massachusetts regulation will prevail if there is a conflict between the state State law or state State regulation where the First Tier, Downstream Downstream, or Related Entities is based. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities that are for credentialing of medical providers contains the following language: The credentials of medical professionals affiliated with the party or parties will be either reviewed by the Contractor; or The credentialing process will be reviewed and approved by the Contractor and the Contractor must audit the credentialing process on an ongoing basis. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities that delegate the selection of medical or pharmacy providers must include language that the Contractor retains the right to approve, suspend, or terminate any such arrangement. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities shall state that neither the Contractor nor the provider has the right to terminate the contract without cause and shall require the provider to assist with transitioning Enrollees to new medical providers, including sharing the Enrollee’s medical record and other relevant Enrollee information as directed by the Contractor or Enrollee. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities shall state that the Contractor shall provide a written statement to a provider of the reason or reasons for termination with cause. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities for medical providers include additional provisions. Such contracts or arrangements must contain the following: Language that the Contractor is obligated to make timely payments to contracted medical providers under the terms of the contract between the Contractor and the medical provider. The contract must contain a prompt payment provision, the terms of which are developed and agreed to by both the Contractor and the relevant medical provider; Language that services are provided in a culturally competent manner to all Enrollees, including those with limited English proficiency or reading skills, and diverse culturally and ethnic backgrounds; Language that medical providers ensure that medical information is released in accordance with applicable Federal or State law, or pursuant to court orders or subpoenas; Language that medical providers maintain Enrollee records and information in an accurate and timely manner; Language that medical providers ensure timely access by Enrollees to the records and information that pertain to them; Language that Enrollees will not be held liable for Medicare Part A and B cost sharing. Specifically, Medicare Parts A and B services must be provided at zero cost-sharing cost‑sharing to Enrollees; Language that states that medical providers shall not xxxx patients for charges for Covered Services other than pharmacy co-paymentsco‑payments, if applicable; Language that clearly state the medical providers EMTALA obligations and must not create any conflicts with hospital actions required to comply with EMTALA; Language that states medical providers are prohibited from closing or otherwise limiting their acceptance of Enrollees as patients unless the same limitations apply to all commercially insured enrolleesEnrollees; Language that states the Contractor is prohibited from refusing to pay an otherwise eligible health care provider for the provision of Covered Services solely because such provider has in good faith:
Appears in 1 contract
At enrollment. At the time a participant's needs necessitate the disclosure and delivery of such information in order to allow the participant to make an informed choice. Be encouraged to involve caregivers or family members in treatment discussions and decisions. Have advance directives explained and to establish them, if the participant so desires, in accordance with 42 C.F.R. §§ 489.100 and 489.102. Receive reasonable advance notice, in writing, of any transfer to another treatment setting and the justification for the transfer. Be afforded the opportunity to file an Appeal if services are denied that he or she thinks are medically indicated, and to be able to ultimately take that Appeal to an independent external system of review. The right to receive medical and non-medical care from a team that meets the beneficiary's needs, in a manner that is sensitive to the beneficiary's language and culture, and in an appropriate care setting, including the home and community. The right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. The right to freely exercise his or her rights, and to be assured that exercising those rights will not adversely affect the way the Contractor and its providers or the State Agency treat the Enrollee. The right to receive the information required pursuant to the Contract; The right to receive timely information about plan changes. This includes the right to request and obtain the information listed in the Orientation materials at least once per year, and the right to receive notice of any significant change in the information provided in the Orientation materials at least 30 days prior to the intended effective date of the change. See 42 C.F.R. § 438.10(g). The right to be protected from liability for payment of any fees that are the obligation of the Contractor. The right not to be charged any cost sharing for Medicare Parts A and B services. APPENDIX D – RELATIONSHIP WITH FIRST TIER, DOWNSTREAM, AND RELATED ENTITIES Contractor shall ensure that any contracts or agreements with First Tier, Downstream and Related Entities performing functions on Contractor’s behalf related to the operation of the plan offered by the Contractor are in compliance with 42 C.F.R. §§ 422.504, 423.505, and 438.6(l). Contractor shall specifically ensure: Prior to contracting with any First Tier, Downstream and Related Entities, the Contractor has evaluated their ability to perform the activities to be subcontracted; That it monitors the First Tier, Downstream or Related Entities performance on an ongoing basis and performs an annual review per EOHHS requirements. If any deficiencies or areas for improvement are identified, the Contractor shall require the First Tier, Downstream or Related Entity to take corrective action. Upon request, the Contractor shall provide EOHHS with a copy of the annual review and any corrective action plans developed as a result; HHS, the Comptroller General, or their designees have the right to audit, evaluate, and inspect and books, contracts, computer or other electronic systems, including medical records and documentation of the First Tier, Downstream and Related Entities; and HHS’s, the Comptroller General’s, or their designees right to inspect, evaluate, and audit any pertinent information for any particular contract period for ten years from the final date of the contract period or from the date of completion of any audit, whichever is later. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities contain the following: Enrollee protections that include prohibiting providers from holding an Enrollee liable for payment of any fees that are the obligation of the Contractor; Language that any services or other activity performed by a First Tier, Downstream and Related Entities is in accordance with the Contractor’s contractual obligations to CMS and EOHHS; Language that specifies the delegated activities and reporting requirements; Language that provides for revocation of the delegation activities and reporting requirements or specifies other remedies in instances where CMS, EOHHS, or the Contractor determine that such parties have not performed satisfactorily; Language that specifies the performance of the parties is monitored by the Contractor on an ongoing basis; Language that specifies the First Tier, Downstream and Related Entities agree to safeguard Enrollee Privacy and confidentiality of Enrollee health records; Language that specifies the First Tier, Downstream and Related Entities must comply with all Federal and State laws, regulations and CMS instructions, including the confidentiality and disclosure of medical records, or other health and enrollment information for providers; and Language that specifies First Tier, Downstream and Related Entities shall maintain liability protection sufficient to protect itself against any losses arising from any claims against itself or any provider, including, at a minimum, workers’ compensation insurance, comprehensive liability insurance, and property damage insurance. In contracts or arrangements with First Tier, Downstream and Related Entities, the Contractor also shall include stipulations that Massachusetts general law or Massachusetts regulation will prevail if there is a conflict between the state law or state regulation where the First Tier, Downstream or Related Entities is based. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities that are for credentialing of medical providers contains the following language: The credentials of medical professionals affiliated with the party or parties will be either reviewed by the Contractor; or The credentialing process will be reviewed and approved by the Contractor and the Contractor must audit the credentialing process on an ongoing basis. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities that delegate the selection of medical or pharmacy providers must include language that the Contractor retains the right to approve, suspend, or terminate any such arrangement. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities shall state that neither the Contractor nor the provider has the right to terminate the contract without cause and shall require the provider to assist with transitioning Enrollees to new medical providers, including sharing the Enrollee’s medical record and other relevant Enrollee information as directed by the Contractor or Enrollee. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities shall state that the Contractor shall provide a written statement to a provider of the reason or reasons for termination with cause. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities for medical providers include additional provisions. Such contracts or arrangements must contain the following: Language that the Contractor is obligated to make timely payments to contracted medical providers under the terms of the contract between the Contractor and the medical provider. The contract must contain a prompt payment provision, the terms of which are developed and agreed to by both the Contractor and the relevant medical provider; Language that services are provided in a culturally competent manner to all Enrollees, including those with limited English proficiency or reading skills, and diverse culturally and ethnic backgrounds; Language that medical providers ensure that medical information is released in accordance with applicable Federal or State law, or pursuant to court orders or subpoenas; Language that medical providers maintain Enrollee records and information in an accurate and timely manner; Language that medical providers ensure timely access by Enrollees to the records and information that pertain to them; Language that Enrollees will not be held liable for Medicare Part A and B cost sharing. Specifically, Medicare Parts A and B services must be provided at zero cost-sharing to Enrollees; Language that states that medical providers shall not xxxx bill patients for charges for Covered Services other than pharmacy co-payments, if applicable; Language that clearly state the medical providers EMTALA obligations and must not create any conflicts with hospital actions required to comply with EMTALA; Language that states medical providers are prohibited from closing or otherwise limiting their acceptance of Enrollees as patients unless the same limitations apply to all commercially insured enrollees; Language that states the Contractor is prohibited from refusing to pay an otherwise eligible health care provider for the provision of Covered Services solely because such provider has in good faith:
Appears in 1 contract
At enrollment. At the time a participant's needs necessitate the disclosure and delivery of such information in order to allow the participant to make an informed choice. Be encouraged to involve caregivers or family members in treatment discussions and decisions. Have advance directives Advance Directives explained and to establish them, if the participant so desires, in accordance with 42 C.F.R. §§ §489.100 and 489.102. Receive reasonable advance noticeAdvance Notice, in writing, of any transfer to another treatment setting and the justification for the transfer. Be afforded the opportunity to file an Appeal if services are denied that he or she thinks are medically indicated, and to be able to ultimately take that Appeal to an independent external system of review. The right to receive medical and non-medical care from a team that meets the beneficiaryEnrollee's needs, in a manner that is sensitive to the beneficiaryEnrollee's language and culture, and in an appropriate care setting, including the home and community. The right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, a perceived safety measure, or retaliation. The right Each Enrollee is free to freely exercise his or her rights, their rights and to be assured that exercising the exercise of those rights will does not adversely affect the way the Contractor CICO and its providers Providers or the State Agency treat the Enrollee. The right to receive the information required pursuant to the Contract; The right to receive timely information about plan changes. This includes the right to request and obtain the information listed in the Orientation materials at least once per year, and and, the right to receive notice of any significant change in the information provided in the Orientation materials at least 30 thirty (30) calendar days prior to the intended effective date of the change. See 42 C.F.R. § 438.10(g). 438.10 for G and H. The right to be protected from liability for payment of any fees that are the obligation of the Contractor. CICO. The right not to be charged any cost sharing Cost Sharing for Medicare Parts A and B services. APPENDIX D – RELATIONSHIP WITH FIRST TIERRelationship With First Tier, DOWNSTREAMDownstream, AND RELATED ENTITIES Contractor And Related Entities CICO shall ensure that any contracts or agreements with First Tier, Downstream Downstream, and Related Entities performing functions on ContractorCICO’s behalf related to the operation of the plan offered by the Contractor Medicare-Medicaid Plan are in compliance with 42 C.F.R. §§ §422.504, 423.505, 438.3(k), and 438.6(l438.230(b)(1). Contractor CICO shall specifically ensure: Prior to contracting with any First Tier, Downstream and Related Entities, the Contractor has evaluated their ability to perform the activities to be subcontracted; That it monitors the First Tier, Downstream or Related Entities performance on an ongoing basis and performs an annual review per EOHHS requirements. If any deficiencies or areas for improvement are identified, the Contractor shall require the First Tier, Downstream or Related Entity to take corrective action. Upon request, the Contractor shall provide EOHHS with a copy of the annual review and any corrective action plans developed as a result; HHS, the Comptroller General, or their designees have the right to audit, evaluate, and inspect and books, contracts, computer or other electronic systems, including medical records and documentation of the First Tier, Downstream Downstream, and Related Entities; and HHS’s, the Comptroller General’s, or their designees right to inspect, evaluate, and audit any pertinent information for any particular contract period for ten (10) years from the final date of the contract period or from the date of completion of any audit, whichever is later. Contractor CICO shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities contain the following: Enrollee Enrollee protections that include prohibiting providers Providers from holding an Enrollee Enrollee liable for payment of any fees that are the obligation of the ContractorCICO; Language that any services or other activity performed by a First Tier, Downstream Downstream, and Related Entities is in accordance with the ContractorCICO’s contractual obligations to CMS and EOHHSSCDHHS; Language that specifies the delegated activities and reporting requirements; Language that provides for revocation of the delegation activities and reporting requirements or specifies other remedies in instances where CMS, EOHHS, SCDHHS or the Contractor CICO determine that such parties have not performed satisfactorily; Language that specifies the performance of the parties is monitored by the Contractor CICO on an ongoing basis, and the CICO may impose Corrective Action as necessary; Language that specifies the First Tier, Downstream Downstream, and Related Entities agree to safeguard Enrollee Enrollee Privacy and confidentiality of Enrollee Enrollee health records; and Language that specifies the First Tier, Downstream Downstream, and Related Entities must comply with all Federal and State laws, regulations regulations, and CMS instructions, including the confidentiality and disclosure of medical records, or other health and enrollment information for providers; and Language that specifies First Tier, Downstream and Related Entities shall maintain liability protection sufficient to protect itself against any losses arising from any claims against itself or any provider, including, at a minimum, workers’ compensation insurance, comprehensive liability insurance, and property damage insurance. In contracts or arrangements with First Tier, Downstream and Related Entities, the Contractor also shall include stipulations that Massachusetts general law or Massachusetts regulation will prevail if there is a conflict between the state law or state regulation where the First Tier, Downstream or Related Entities is based. Contractor CICO shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities that are for credentialing of medical providers Providers contains the following language: The credentials of medical professionals affiliated with the party or parties will be either reviewed by the ContractorCICO; or The credentialing process will be reviewed and approved by the Contractor CICO and the Contractor CICO must audit the credentialing process on an ongoing basis. Contractor CICO shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities that delegate the selection of medical or pharmacy providers Providers must include language that the Contractor CICO retains the right to approve, suspend, or terminate any such arrangement. Contractor CICO shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities shall state that neither the Contractor nor the provider has the right to terminate the contract without cause and shall require the provider Provider to provide at least sixty (60) calendar days’ notice to the CICO and assist with transitioning Enrollees Enrollees to new medical providersProviders, including sharing the Enrollee’s medical record and other relevant Enrollee Enrollee information as directed by the Contractor CICO or Enrollee. Contractor CICO shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities shall state that the Contractor CICO shall provide a written statement to a provider Provider of the reason or reasons for termination with cause. Contractor CICO shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities for medical providers Providers include additional provisions. Such contracts or arrangements must contain the following: Language that the Contractor CICO is obligated to make timely payments to pay contracted medical providers Providers under the terms of the contract between the Contractor CICO and the medical providerProvider. The contract must contain a prompt payment provision, the terms of which are developed and agreed to by both the Contractor CICO and the relevant medical providerProvider; Language that services are provided in a culturally competent manner to all EnrolleesEnrollees, including those with limited English proficiency or reading skills, and diverse culturally and ethnic backgrounds; Language that medical providers Providers abide by all Federal and State laws and regulations regarding confidentiality and disclosure of medical records, or other health and enrollment information; Language that medical Providers ensure that medical information is released in accordance with applicable Federal or State law, or pursuant to court orders or subpoenas; Language that medical providers Providers maintain Enrollee records Enrollee Medical Records and information in an accurate and timely manner; Language that medical providers Providers ensure timely access by Enrollees Enrollees to the records and information that pertain to them; and Language that Enrollees Enrollees will not be held liable for Medicare Part A and B cost sharingCost Sharing. Specifically, Medicare Parts A and B services must be provided at zero cost-sharing to Enrollees; Language Enrollees, and that states that medical providers Providers shall not xxxx bill patients for charges for Covered Services other than pharmacy co-payments, if applicable; . Language that clearly state the medical providers Providers EMTALA obligations and must not create any conflicts with hospital actions required to comply with EMTALA; . Language that states medical providers are prohibited prohibiting Providers, including, but not limited to, PCPs, from closing or otherwise limiting their acceptance of Enrollees Enrollees as patients unless the same limitations apply to all commercially insured enrollees; Enrollees. Language that states prohibits the Contractor is prohibited CICO from refusing to contract or pay an otherwise eligible health care provider Provider for the provision of Covered Services solely because such provider Provider has in good faith:: Communicated with or advocated on behalf of one or more of their prospective, current or former patients regarding the provisions, terms, or requirements of the CICO’s health benefit plans as they relate to the needs of such Provider’s patients; or Communicated with one or more of their prospective, current or former patients with respect to the method by which such Provider is compensated by the CICO for services provided to the patient. Language that states the Provider is not required to indemnify the CICO for any expenses and liabilities, including, without limitation, judgments, settlements, attorneys’ fees, court costs and any associated charges, incurred in connection with any claim or action brought against the CICO based on the CICO’s management decisions, utilization review provisions or other policies, guidelines or actions. Language that states the CICO shall require Providers to comply with the CICO’s requirements for utilization review, quality management and improvement, credentialing and the delivery of preventive health services. Language that states the CICO shall notify Providers in writing of modifications in payments, modifications in Covered Services or modifications in the CICO’s procedures, documents or requirements, including those associated with utilization review, quality management and improvement, credentialing and preventive health services, that have a substantial impact on the rights or responsibilities of the Providers, and the effective date of the modifications. The notice shall be provided thirty (30) calendar days before the effective date of such modification unless such other date for notice is mutually agreed upon between the CICO and the Provider or unless such change is mandated by CMS or SCDHHS without thirty (30) calendar days prior notice. Language that states that no payment shall be made by the CICO to a Provider for a Provider Preventable Condition; and CICO shall ensure that contracts or arrangements with First Tier, Downstream, and Related Entities for medical Providers do not include incentive plans that include a specific payment to a Provider as an inducement to deny, reduce, delay, or limit specific, Medical Necessary Services and; The Provider shall not profit from provision of Covered Services that are not Medically Necessary or medically appropriate. The CICO shall not profit from denial or withholding of Covered Services that are Medically Necessary or medically appropriate. Nothing in this section shall be construed to prohibit contracts that contain incentive plans that involve general payments such as capitation payments or shared risk agreements that are made with respect to physicians or physician groups or which are made with respect to groups of Enrollees if such agreements, which impose risk on such physicians or physician groups for the costs of medical care, services and equipment provided or authorized by another physician or health care Provider, comply with paragraph E.10, below. The CICO shall ensure that contracts or arrangements with First Tier, Downstream. and Related Entities for medical Providers includes language that prohibits the CICO from imposing a financial risk on medical Providers for the costs of medical care, services or equipment provided or authorized by another Physician or health care Provider unless such contract includes specific provisions with respect to the following: Stop-loss protection; Minimum patient population size for the Physician or Physician group; and Identification of the health care services for which the Physician or Physician group is at risk. The CICO shall ensure that all contracts or arrangements with First Tier, Downstream, and Related Entities for laboratory testing sites providing services include an additional provision that such laboratory testing sites must have either a Clinical Laboratory Improvement Amendment (CLIA) certificate or waiver of a certificate of registration along with a CLIA identification number. Nothing in this section shall be construed to restrict or limit the rights of the CICO to include as Providers religious non-medical Providers or to utilize medically based eligibility standards or criteria in deciding Provider status for religious non-medical Providers. Part D Addendum ADDENDUM TO CAPITATED FINANCIAL ALIGNMENT CONTRACT PURSUANT TO SECTIONS 1860D-1 THROUGH 1860D-43 OF THE SOCIAL SECURITY ACT FOR THE OPERATION OF A VOLUNTARY MEDICARE PRESCRIPTION DRUG PLAN The Centers for Medicare & Medicaid Services (hereinafter referred to as “CMS”), South Carolina, acting by and through the Department of Health and Human Services (SCDHHS), and [name of CICO], a Medicare-Medicaid managed care organization (hereinafter referred to as the CICO) agree to amend the contract [HXXXX] governing the CICO’s operation of a Medicare-Medicaid Plan described in § 1851(a)(2)(A) of the Social Security Act (hereinafter referred to as “the Act”) to include this addendum under which the CICO shall operate a Voluntary Medicare Prescription Drug Plan pursuant to §§1860D-1 through 1860D-43 (with the exception of §§1860D-22(a) and 1860D-31) of the Act.
Appears in 1 contract
Samples: Contract
At enrollment. At the time a participant's needs necessitate the disclosure and delivery of such information in order to allow the participant to make an informed choice. Be encouraged to involve caregivers or family members in treatment discussions and decisions. Have advance directives Advance Directives explained and to establish them, if the participant so desires, in accordance with 42 C.F.R. §§ 489.100 and 489.102. Receive reasonable advance notice, in writing, of any transfer to another treatment setting and the justification for the transfer. Be afforded the opportunity to file an Appeal if services are denied that he or she thinks are medically indicated, and to be able to ultimately take that Appeal to an independent external system of review. The right to receive medical and non-medical care from a team that meets the beneficiary's needs, in a manner that is sensitive to the beneficiary's language and culture, and in an appropriate care setting, including the home and community. The right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. The right to freely exercise his or her rights, and to be assured that exercising those rights will not adversely affect the way the Contractor and its providers or the State Agency treat the Enrollee. The right to receive the information required pursuant to the Contract; The right to receive timely information about plan changes. This includes the right to request and obtain the information listed in the Orientation materials at least once per year, and the right to receive notice of any significant change in the information provided in the Orientation materials at least 30 days prior to the intended effective date of the change. See 42 C.F.R. § 438.10(g). The right to be protected from liability for payment of any fees that are the obligation of the Contractor. The right not to be charged any cost sharing for Medicare Parts A and B services. APPENDIX D – RELATIONSHIP WITH FIRST TIER, DOWNSTREAM, AND RELATED ENTITIES Contractor shall ensure that any contracts or agreements with First Tier, Downstream Downstream, and Related Entities performing functions on Contractor’s behalf related to the operation of the plan offered by the Contractor are in compliance with 42 C.F.R. §§ 422.504, 423.505, 438.6(l), 438.208, and 438.6(l438.230(b). Contractor shall specifically ensure: Prior to contracting with any First Tier, Downstream Downstream, and Related Entities, the Contractor has evaluated their ability to perform the activities to be subcontracted; That it monitors the First Tier, Downstream Downstream, or Related Entities performance on an ongoing basis and performs an annual review per EOHHS requirements. If any deficiencies or areas for improvement are identified, the Contractor shall require the First Tier, Downstream Downstream, or Related Entity to take corrective action. Upon request, the Contractor shall provide EOHHS with a copy of the annual review and any corrective action plans developed as a result; HHS, the Comptroller General, or their designees have the right to audit, evaluate, and inspect and books, contracts, computer or other electronic systems, including medical records and documentation of the First Tier, Downstream Downstream, and Related Entities; and HHS’s, the Comptroller General’s, or their designees right to inspect, evaluate, and audit any pertinent information for any particular contract period for ten years from the final date of the contract period or from the date of completion of any audit, whichever is later. The First Tier, Downstream, and Related Entities make their premises, facilities, equipment, records and systems available for the purpose of any audit, evaluation or inspection described above. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities contain the following: Enrollee protections that include prohibiting providers from holding an Enrollee liable for payment of any fees that are the obligation of the Contractor; Language that any services or other activity performed by a First Tier, Downstream Downstream, and Related Entities is in accordance with the Contractor’s contractual obligations to CMS and EOHHS; Language that specifies the delegated activities and reporting requirements; Language that provides for revocation of the delegation activities and reporting requirements or specifies other remedies in instances where CMS, EOHHS, or the Contractor determine that such parties have not performed satisfactorily; Language that specifies the performance of the parties is monitored by the Contractor on an ongoing basis; Language that specifies the First Tier, Downstream Downstream, and Related Entities agree to safeguard Enrollee Privacy and confidentiality of Enrollee health records; Language that specifies the First Tier, Downstream Downstream, and Related Entities must comply with all Federal and State laws, regulations and CMS instructions, including the confidentiality and disclosure of medical records, or other health and enrollment information for providers; and Language that specifies First Tier, Downstream Downstream, and Related Entities shall maintain liability protection sufficient to protect itself against any losses arising from any claims against itself or any provider, including, at a minimum, workers’ compensation insurance, comprehensive liability insurance, and property damage insurance. In contracts or arrangements with First Tier, Downstream Downstream, and Related Entities, the Contractor also shall include stipulations that Massachusetts general law or Massachusetts regulation will prevail if there is a conflict between the state State law or state State regulation where the First Tier, Downstream Downstream, or Related Entities is based. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream and Related Entities that are for credentialing of medical providers contains the following language: The credentials of medical professionals affiliated with the party or parties will be either reviewed by the Contractor; or The credentialing process will be reviewed and approved by the Contractor and the Contractor must audit the credentialing process on an ongoing basis. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities that delegate the selection of medical or pharmacy providers must include language that the Contractor retains the right to approve, suspend, or terminate any such arrangement. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities shall state that neither the Contractor nor the provider has the right to terminate the contract without cause and shall require the provider to assist with transitioning Enrollees to new medical providers, including sharing the Enrollee’s medical record and other relevant Enrollee information as directed by the Contractor or Enrollee. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities shall state that the Contractor shall provide a written statement to a provider of the reason or reasons for termination with cause. Contractor shall ensure that all contracts or arrangements with First Tier, Downstream Downstream, and Related Entities for medical providers include additional provisions. Such contracts or arrangements must contain the following: Language that the Contractor is obligated to make timely payments to contracted medical providers under the terms of the contract between the Contractor and the medical provider. The contract must contain a prompt payment provision, the terms of which are developed and agreed to by both the Contractor and the relevant medical provider; Language that services are provided in a culturally competent manner to all Enrollees, including those with limited English proficiency or reading skills, and diverse culturally and ethnic backgrounds; Language that medical providers ensure that medical information is released in accordance with applicable Federal or State law, or pursuant to court orders or subpoenas; Language that medical providers maintain Enrollee records and information in an accurate and timely manner; Language that medical providers ensure timely access by Enrollees to the records and information that pertain to them; Language that Enrollees will not be held liable for Medicare Part A and B cost sharing. Specifically, Medicare Parts A and B services must be provided at zero cost-sharing to Enrollees; Language that states that medical providers shall not xxxx patients for charges for Covered Services other than pharmacy co-payments, if applicable; Language that clearly state the medical providers EMTALA obligations and must not create any conflicts with hospital actions required to comply with EMTALA; Language that states medical providers are prohibited from closing or otherwise limiting their acceptance of Enrollees as patients unless the same limitations apply to all commercially insured enrolleesEnrollees; Language that states the Contractor is prohibited from refusing to pay an otherwise eligible health care provider for the provision of Covered Services solely because such provider has in good faith:
Appears in 1 contract
