E SCOPE OF WORK Sample Clauses

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. Prior to the Contract start date, the Contractor must also obtain from an insurance company duly authorized to do business in the State, professional liability (malpractice) insurance for the Contractor and its Medical Director, as defined in IC 34-18-4-1. The Contractor shall also obtain workers’ compensation insurance and comprehensive liability insurance. No less than thirty (30) calendar days before the policy renewal effective date, the Contractor must submit to FSSA its certificate of insurance for each renewal period for review and approval.

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. The Contractor shall date each web page, change the date with each revision and allow users print access to the information. The website must include the information required in the Enrollment Packet as described in Section 4.4. Such information shall include, at minimum, the following: • The Contractor’s searchable provider network identifying each provider’s specialty, service location(s), hours of operation, phone numbers, public transportation access and other demographic information as described in Section 4.4.1. The Contractor must update the on-line provider network information every two (2) weeks, at a minimum; • The Contractor’s contact information for member inquiries, member grievances and appeals; • The Contractor’s member services phone number, TDD number, hours of operation and after-hours access numbers, including the 24-hour Nurse Call Line; • A member portal with access to electronic Explanation of Benefit (EOB) statements, • Preventive care and wellness information; • Information about the cost and quality of health care services, as further described in Section 4.7.9; • A description of the Contractor’s disease management, care management and complex case management programs; • The member’s rights and responsibilities, as enumerated in 42 CFR 438.100. Please see Section 4.10 for further details regarding member rights; • The member handbook; • Contractor-distributed literature regarding all health or wellness promotion programs that are offered by the Contractor; • Contractor’s marketing brochures and posters • The Health Insurance Portability and Accountability Act (HIPAA) privacy statement; • Links to FSSA’s website for general Medicaid, Hoosier Care Connect information, and referrals • Per 42 CFR 438.10(i), information on pharmacy locations and preferred drug lists applicable to each program and benefit package; • List of all prior authorization criteria for prescription drugs, including mental health drugs; • Transportation access information; • Information about how members may access dental services and how to access the Contractor’s dental network; • A list and brief description of each of the Contractor’s member outreach and education materials; • The executive summary of Contractor’s Annual Quality Assessment and Performance Improvement Program Description Summary Report;

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. ▪ The Contractor must require any third party vendor providing claims adjudication services to provide all underlying data associated with MLR reporting to the Contractor within 180 days of the end of the MLR reporting year or within 30 days of being requested by the Contractor, whichever comes sooner. • The MLR report submitted by the Contractor for each reporting year must include the following elements, as defined in 42 CFR 438.8: ▪ Number of member months in the reporting year ▪ Premium revenue ▪ Taxes ▪ Licensing fees ▪ Regulatory fees ▪ Incurred claims ▪ Expenditures for Quality Improvement activities ▪ Expenditures for Fraud prevention activities as defined in 42 CFR 438.8(e)(4) ▪ Non-claims costs ▪ Any credibility adjustment applied ▪ Remittance owed to the State, if any ▪ A comparison of the information reported on the MLR with the audited financial report ▪ A description of the aggregation method used to calculate total incurred claims ▪ A description of the methodology used to allocate expenses ▪ An attestation as to the accuracy of the calculation, in accordance with MLR standards. • Incurred Claims: ▪ Incurred claims submitted for each reporting year should include total incurred claims for the reporting year, and should not include claims incurred in prior years, regardless of when they were paid. ▪ Incurred claims reported in the MLR should relate only to members who were enrolled with the Contractor on the dates of service, based on data and information available on the reporting date. (Claims for members who were retroactively disenrolled should be recouped from providers and excluded from MLR reporting). ▪ Under sub-capitated or sub-contracted arrangements, the Contractor may only include amounts actually paid to providers for covered services and supplies as incurred claims. The non-benefit portion of sub-capitated and sub-contracted payments should be excluded from incurred claims. The Contractor should ensure all subcontracts provide for sufficient transparency to allow for this required reporting. • Expenditures may not be duplicated across expense categories or contracts: ▪ Each expenditure must be reported under only one expense category, unless a portion of the expense fits under the definition of, or criteria for, one type of expense and the remainder fits into a different type of expense, in which case the expense must be pro-rated between types of expenses. ▪ Expenditures that benefit multiple contracts or populations must be re...

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. ▪ 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. The extent to which, and how, urgent care services are provided