Conditions Endangering Performance. At its option, BMS may provide the MCO with written notice of conditions endangering Contract performance. Conditions that endanger performance include, but are not limited to, the following: • Failing to substantially provide Medically Necessary covered items and services that are required (under law or under the MCO’s Contract with BMS) to be provided to an enrollee covered under the Contract; • Imposing premiums, copays, or charges enrollees in excess of the premiums, copays, or charges permitted under the Medicaid or WVCHIP program; • Engaging in any practice that discriminates on the basis of health status or need for health care services; • Misrepresenting or falsifying information furnished to BMS, an enrollee, a potential enrollee, or health care provider; • Failing to comply with the physician incentive requirements under section 1903(m)(2)(A)(x) of the Social Security Act; or • Distributing directly or through any agent or independent contractor marketing materials that contain false or misleading information. BMS must notify the CMS Regional Office at any time any of the above conditions are found to exist or the MCO: • Is found to have performance deficiencies in any of the above areas; • Is under a CAP; • Has been assessed liquidated damages; • Has had enrollment suspended; • Has had temporary management appointed by the State; • Has had payments suspended; • Is engaged in dispute resolution; • Is being terminated for default; or • Is otherwise non-compliant or has a performance deficit as described in Article II, Section 6 of this Contract. Unless otherwise specified in the written notice of condition(s) that endanger performance, BMS, in its sole discretion, may allow the MCO an allotted amount of business days to remedy the condition(s) contained in the notice. If after such notice of conditions that endanger performance the MCO fails to remedy the conditions contained in the notice, within ten (10) business days or the time period specified in the notice, BMS may pursue other remedies under this Contract, or any intermediate remedies outlined in 42 CFR §438.702.
Conditions Endangering Performance. At its option, the Department may provide the MCO with written notice of conditions endangering Contract performance. Conditions that endanger performance include, but are not limited to, the following: • Failing to substantially provide Medically Necessary covered items and services that are required (under law or under the MCO’s Contract with the Department) to be provided to an enrollee covered under the Contract; • Imposing premiums, copays, or charges enrollees in excess of the premiums, copays, or charges permitted under the Medicaid program; • Engaging in any practice that discriminates on the basis of health status or need for health care services; • Misrepresenting or falsifying information furnished to the Department, an enrollee, a potential enrollee, or health care provider; • Failing to comply with the physician incentive requirements under section 1903(m)(2)(A)(x) of the Social Security Act; or • Distributing directly or through any agent or independent contractor marketing materials that contain false or misleading information. At any time the MCO is found to perform any of the above activities the Department must notify the CMS Regional Office. Unless otherwise specified in the written notice of condition(s) that endanger performance, the Department may allow the MCO a minimum of ten working days to remedy the condition(s) contained in the notice. If after such notice of conditions that endanger performance the MCO fails to remedy the conditions contained in the notice, within ten working days or the time period specified in the notice, the Department may pursue other remedies under this Contract or any intermediate remedies outlined in 42 CFR 438.702.
Conditions Endangering Performance. At its option, the Department may provide the MCO with written notice of conditions endangering contract performance. Conditions that endanger performance include, but are not limited to, the following: Failing to substantially provide medically necessary items and services that are required (under law or under the MCO’s contract with the Department) to be provided to an enrollee covered under the contract; Imposing premiums, copays, or charges enrollees in excess of the premiums, copays, or charges permitted under Title XIX, or engaging in any practice that discriminates on the basis of health status or need for health care services; Misrepresenting or falsifying information furnished to the Department, an enrollee, a potential enrollee, or health care provider; Failing to comply with the physician incentive requirements under section 1903(m)(2)(A)(x) of the Social Security Act; or Distributing directly or through any agent or independent contractor marketing materials that contain false or misleading information. At any time the MCO is found to perform any of the above activities the Department must notify the CMS Regional Office. Unless otherwise specified in the written notice of condition(s) that endanger performance, the Department may allow the MCO a minimum of ten working days to remedy the condition(s) contained in the notice. If after such notice of conditions that endanger performance the MCO fails to remedy the conditions contained in the notice, within ten working days or the time period specified in the notice, the Department may pursue other remedies under this contract.
