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. ▪ All subcontractors shall fulfill all State and federal requirements including Medicaid laws, regulations, applicable sub-regulatory guidance and contract provisions appropriate to the services or activities delegated under the 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 Contrac t Exhibit
E SCOPE OF WORK. 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 applies for Contract requirements (such as ID cards) and additional mailings at the will of the Contractor, such as a wellness visit reminder postcard. For existing on-going alternate format requests which must comply with NCQA or State law requirement, such as utilization management letters, the Contractor shall mail the documents in the alternate format within the statutory or NCQA required timeline. The Contractor shall provide notification to FSSA, to the Enrollment Broker and to its members of any covered services that the Contractor or any of its subcontractors or networks do not cover on the basis of moral or religious grounds and guidelines for how and where to obtain those services, in accordance with 42 CFR 438.102, which relates to provider-enrollee communications. This information shall be relayed to the member before and during enrollment and within ninety (90) calendar days after adopting the policy with respect to any particular service. Refer to Sectio...
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 member’s enrollment in the Contractor. This information shall be included in the member handbook. The Contractor shall notify all members of their right to request and obtain information in accordance with 42 CFR 438.10. In addition to providing the specific information required at 42 CFR 438.10(f) upon enrollment in the Welcome Packet as described in Section 4.4 the Contractor shall notify members at least once a year of their right to request and obtain this information. Individualized notice shall be given to each member of any significant change in this information at least thirty (30) days before the intended effective date of the change. Significant change is defined as any change that may impact member accessibility to the Contractor’s services and benefits. The Contractor shall comply with the information requirements at 42 CFR 438.10. All enrollment notices, informational and instructional materials must be provided in a manner and format that is easily understood. This means, written materials shall not exceed a fifth-grade reading level and be in plain language. All written materials for members or potential members shall be in a font size no smaller than 12-point. In accordance with 42 CFR 438.10(e), the State must provide potential members with general information about the basic features of managed care and information specific to each MCE operating in the potential member’s service area. At minimum, this information will include factors such as MCE service area; benefits covered; network provider information; information about the potential enrollee's/member’s right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee/member based on their specific circumstance; which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program (for mandatory and voluntary populations, the length of the enrollment period and all disenrollment opportunities available to the member must also be specified; any cost-sharing that will be imposed by the Contractor consistent with those set forth in the State plan; and the Contractor’s responsibilities for coordination of member care. The State shall provide information on Hoosier Care Connect MCEs in a comparative chart-like format. Once available, the State also intends to include Contractor quality and ...
E SCOPE OF WORK. ▪ A mechanism and process to accept medical records for a prudent layperson review with an initial claim and after a claim has processed. The Contractor must at a minimum allow a provider to submit medical records for a prudent layperson review within 120 days of a claim’s adjudication.
E SCOPE OF WORK. The Contractor may distribute or mail an informational brochure or flyer to potential members and/or provide (at its own cost, including any costs related to mailing) such brochures or flyers to the State for distribution to individuals at the time of application. The Contractor may submit promotional poster-sized wall graphics to FSSA for approval to be considered for use in the local FSSA Division of Family Resources (DFR) offices. The local DFR offices and enrollment centers may choose to display these promotional materials at their discretion. The Contractor may display these same promotional materials at community health fairs or other outreach locations. FSSA must pre-approve all promotional and informational brochures or flyers and all graphics prior to display or distribution. Refer to Section 4.9 for a description of the required approval process.
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. The plan shall be assessed by the Contractor annually and submitted to FSSA by August 1st for calendar year 2023 and by January 31st for all remaining calendar years of the Contract period. The assessment shall provide the outcome measures used to measure progress in the prior year, and any new interventions the Contractor will incorporate in the next year. The Contractor shall follow the guidance provided by the National Committee for Quality Assurance (NCQA) regarding the stratification of HEDIS measures by race and ethnicity. The Contractor shall ensure that all subcontractor’s services and sites are physically and digitally accessible, following the Americans with Disabilities Act (ADA) and Section 508 of the Rehabilitation Act (Section 508) and that all subcontractors are culturally competent.
E SCOPE OF WORK information. The Contractor shall inform the members that, upon the member’s request, the Contractor will provide information on the structure and operation of the Contractor and, in accordance with 42 CFR 438.10(f)(3), will provide information on the Contractor’s provider incentive plans. Grievance, appeal and fair hearing procedures and timeframes shall be provided to members in accordance with 42 CFR 438.10(g)(2)(xi), which requires specific information be provided to enrollees. Please see Section 4.12 for further information about grievance, appeal and fair hearing procedures as well as the kind of information that the Contractor shall provide to members. The Contractor shall be responsible for developing and maintaining member education programs designed to provide the members with clear, concise and accurate information about the Contractor’s program and the Contractor’s network. The State encourages the Contractor to incorporate community advocates, support agencies, health departments, other governmental agencies and public health associations in its outreach and member education programs. The State encourages the Contractor to develop community partnerships with these types of organizations, in particular with, community mental health centers, county health departments and community-based organizations that serve older adults and/or persons with disabilities to promote health and wellness within its membership. As required by 42 CFR 438.10(f)(1), the Contractor is required to provide written notice of a provider’s disenrollment to any member that has received primary care services from that provider or otherwise sees the provider on a regular basis going back twelve (12) calendar months. Such notice must be provided to members at least thirty (30) calendar days prior to the effective date of the termination. However, if the practice or practitioner notifies the Contractor less than thirty (30) days prior to the effective date of the termination, the Contractor shall then notify members as soon as possible but no later than fifteen (15) calendar days after receipt of the notification from the practice or practitioner. Additionally, upon the request of a member, the Contractor shall also provide information on the structure and operation of the health plan as well as information on physician incentive plans in place per 42 CFR 438.10(f)(3) and 42 CFR 438.3(i). In the first and third quarter of every Contract year, the Contractor shall identify membe...
