E SCOPE OF WORK. This Scope of Work is part of a Contract to provide risk-based managed care services to Medicaid beneficiaries enrolled in the State of Indiana’s Hoosier Care Connect program. The State shall contract on a statewide basis with managed care entities (MCEs) with a demonstrated capacity to actively manage and coordinate care for low income disabled populations. This includes specific experience and demonstrated success in operating care coordination programs for low income individuals with significant health needs. MCEs must meet all applicable requirements of Medicaid managed care organizations under Sections 1903(m) and 1932 of the Social Security Act, as well as the implementing regulations set forth in 42 CFR 438, and IC 12 - 15 as may be amended.
E SCOPE OF WORK. The Contractor shall inform members that information is available upon request in alternative formats and how to obtain them. OMPP defines alternative formats as braille, large font letters, audio recordings, languages other than English and verbal explanation of written materials. When a member has requested materials in preferred alternative format, this shall be documented in the member’s record. The Contractor shall supply future materials in the requested and preferred format to the member. The Contractor may review with the member and document the specific type the member wishes to receive in a specific format versus other formats. For example, a member may wish to receive certain materials in braille and other materials in audio recordings. Unless a member specifically states their alternative format request is a one-time request, the Contractor shall consider the request an ongoing request and supply all future materials in the preferred format to the member. For first-time or one-time requests from a member, the Contractor shall mail the alternative version of the document in no more than seven (7) business days from the date of the request. If, for example, the member received a wellness visit reminder flyer and called the Contractor to ask for the flyer to be sent in braille, the Contractor shall take no more than seven (7) business days to mail the braille version from the date of the member request call. For first-time or one-time requests from a member, when the mailing is governed by NCQA or statutory requirements, the Contract shall have two (2) additional days from the NCQA or statutory timeframe to mail the document if no mailing has yet been sent to the member. For first-time or one-time requests from a member, when the mailing is governed by NCQA or statutory requirements and the statutory notice has already been fulfilled with a regular printed letter, the Contractor shall mail the alternate version of the document in no more than seven (7) business days from the date of the request. For existing on-going alternate format requests, the Contractor shall have two (2) additional business days from when the document would normally be required to be mailed, to mail the document in the alternate format. If, for example, a member had previously requested materials in braille, and an ID card would be sent to the member in five (5) business days, the timeline would be seven (7) business days for the braille version. The additional two (2) days ...
E SCOPE OF WORK subcontract. In addition, all subcontractors shall fulfill the requirements of the Contract (and any relevant amendments) that are appropriate to any service or activity delegated under the subcontract. ▪ The Contractor shall submit a plan to the State on how the subcontractor will be monitored for debarred employees. ▪ For the purposes of an audit, evaluation, or inspection by the State, CMS, the DHHS Inspector General, the Comptroller General or their designees, the subcontractor shall make available for ten (10) years from the final date of the contract period or from the date of completion of any audit, whichever is later, its premises, physical facilities, equipment, books, records contracts, computer, or other electronic systems relating to its Medicaid enrollees per 42 CFR 438.230(c)(3)(iii) and 42 CFR 438.3(k). This contract term shall specify that if the state, CMS, or the DHHS Inspector General determine that there is a reasonable possibility of fraud or similar risk, the above State and Federal agencies may inspect, evaluate, and audit the subcontractor at any time. ▪ The Contractor shall comply with all subcontract requirements specified in 42 CFR 438.230, which contains federal subcontracting requirements. All subcontracts, provider contracts, agreements or other arrangements by which the Contractor intends to deliver services required under the Contract, whether or not characterized as a subcontract under the Contract, are subject to review and approval by FSSA and must be sufficient to assure the fulfillment of the requirements of 42 CFR 434.6, which addresses general requirements for all Medicaid contracts and subcontracts. FSSA may waive its right to review subcontracts, provider contracts, agreements or other arrangements. Such waiver shall not constitute a waiver of any subcontract requirement. ▪ The subcontract shall specify the activities and obligations, and related reporting responsibilities per 42 CFR 438.230(c)(1)(i)-(ii) and 42 CFR 438.3(k). OMPP reserves the right to audit the Contractor’s subcontractors’ self-reported data and change reporting requirements at any time with reasonable notice. OMPP may require corrective actions and will assess liquidated damages, as specified in Contract Exhibit
E SCOPE OF WORK. An individual or entity who is (or is affiliated with a person/entity that is) debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non- procurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order No. 12549, which relates to debarment and suspension; • An individual or entity who is an affiliate, as defined in the Federal Acquisition Regulation, of a person described above; or • An individual or entity that is excluded from participation in any Federal health care program under section 1128 or 1128A of the Act. The relationships include directors, officers or partners of the Contractor, persons with beneficial ownership of five percent (5%) or more of the Contractor’s equity, network providers, subcontractors, or persons with an employment, consulting or other arrangement with the Contractor for the provision of items and services that are significant and material to the Contractor's obligations under the Contract. In accordance with Section 1932(d)(1) of the Social Security Act, 42 CFR 438.608(C)(1), 42 CFR 438.610(a), 42 CFR 438.610(b), 42 CFR 438.610(c), SMDL 6/12/08, SMDL 1/16/09, and Exec. Order No. 2549, the Contractor shall provide written disclosure of any of the prohibited relationships described above. If FSSA finds that the Contractor is in violation of this regulation, FSSA will notify the Secretary of noncompliance and determine if the Contract will be continued or terminated in accordance with 42 CFR 438.610(d).
E SCOPE OF WORK. As maximization of drug rebates is heavily dependent on cooperation by the Contractor with the State or the State’s designated rebate vendor, the Contractor must respond to all inquiries from the State or the vendor pertaining to all drug rebate matters in a timely fashion. The Contractor must acknowledge receipt of such inquiries in writing (e.g., by e-mail) within two (2) business days of receipt, and in that acknowledgement provide a best estimate of when a final response will be provided.
E SCOPE OF WORK. Failure to provide services in a timely manner, as defined by the State; • Failure of a Contractor to act within the required timeframes; • For a resident of a rural area with only one Contractor, the denial of a member’s request to exercise his or her right, under 42 CFR 438.52(b)(2)(ii), to obtain services outside the network (if applicable); or • Denial of a member’s request to dispute a financial liability including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities. In accordance with 42 CFR 438.10(c), the Contractor must notify the requesting provider, and give the member written notice, of any decision considered an “adverse benefit determination” taken by the Contractor, including any decision by the Contractor to deny a service authorization request (a request for the provision of a service by or on behalf of a member), or to authorize a service in an amount, duration or scope that is less than requested. The notice must meet the requirements of 42 CFR 438.404(b) and CFR 438.402(b)-(c), and must include: • The adverse benefit determination the Contractor has taken or intends to take; • The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge reasonable access to and copies of all documents, records, and other information relevant to the enrollee’s adverse benefit determination; • The member’s or the provider’s right to request an appeal and the procedure for requesting such an appeal, including information on exhausting the Contractor’s one level of appeal; • The procedure to request an external grievance procedure (External Review by Independent Review Organization) following exhaustion of the Contractor appeals process; • The procedure to request a State fair hearing following exhaustion of the Contractor appeals process; • The circumstances under which expedited resolution is available and how to request it; and • The member’s right to have benefits continue pending resolution of the appeal, how to request continued benefits and the circumstances under which the member may be required to pay the costs of these services.
E SCOPE OF WORK. For further information on Hospice services consult all applicable reference materials including, Indiana Medicaid Medical Policy Manual, the Hospice Module and the Prior Authorization Module, Managed Care Programs Policies and Procedures Manual.
E SCOPE OF WORK. In performing MTM functions, the Contractor must demonstrate a thorough understanding of the federal regulations and guidelines which direct the monitoring, oversight, intervention and reporting of psychotropic drug utilization in children and adolescents. Further, in performing MTM functions the Contractor must collaborate and cooperate with the prescriber interventions made as a result of the Indiana Psychotropic Medication Initiative.
3.6.2.1 Comprehensive Medication Review (CMR) The Contractor must offer a minimum level of MTM services to each member enrolled in the program that includes interventions with members and prescribers. CMR must include: • Medication action plan; • Personal medication list; • Summary of recommendations; and • Medication refill reminders.
E SCOPE OF WORK. OTC Drug Formulary and Contraception Formularies and the Pharmacy Supplements Formulary and as updated by the DUR Board. Any additions to the Contractor OTC Drug Formulary are required to only be from participating rebating labelers. The formulary (i.e., SUPDL) and non-formulary (i.e., non-SUPDL) covered drug lists shall be made readily available to providers in the Contractor’s network and to members by linking to the Pharmacy Services page on xxxxx://xxx.xx.xxx/medicaid/. The formulary and non-formulary covered drug lists shall be updated and posted on or before the intended implementation date to reflect all changes in the status of a drug or addition of new drugs. The Contractor shall also support e-Prescribing technologies to communicate the formulary SUPDL and non-formulary drug lists and covered drugs to prescribers through electronic medical records (EMRs) and e-Prescribing applications. Refer to Section 3.8.5 for additional requirements on e-Prescribing. Consistent with the requirements of Section 6.8, the Contractor shall develop provider education and outreach aimed at educating providers about the Hoosier Care Connect formulary as well as the utilization of e-Prescribing technologies to ensure appropriate prescribing for members based on the member’s benefit plan. The Contractor shall assure that non-drug products approved for use in compounding are not subject to rebating manufacturer requirements.
E SCOPE OF WORK. Preventive care and wellness information; • Member handbook information as outlined in Section 4.4.2; • Information on behavioral health covered services and resources; • A secure portal through which members may complete the health screening described in Section 5.1.1; and • Formulary drug lists in a machine-readable file and format as specified by the Secretary per 42 CFR 438.10(i)(3) and 42 CFR 457.1207.
