Federal Sanctions. Payments provided for under this Agreement will be denied for new Members when, and for so long as, payment for those Members is denied by CMS in accordance with the requirements in 42 C.F.R. § 438.730. Agreement Term This Agreement, including any amendments and any changes made by notice to adjust the Capitation Rates, shall be effective upon signature of all parties and will terminate on December 31, 2026. Thereafter, HCA reserves the right to renew this Agreement for an additional one (1)-year period(s), not to exceed eight (8) years for the total term of the Agreement. HCA reserves the right to extend this Agreement for an additional period or periods of time consistent with extensions of the 1115(a) Waiver provided that HCA notifies the CONTRACTOR in writing of its intention to do so at least six (6) months prior to the Agreement expiration date. An extension of the term of this Agreement will be made effective through an amendment to the Agreement.
Federal Sanctions. (1) Section 1903 (m)(5)(A) and (B) of the Social Security Act vests the Secretary of HHS with the authority to deny Medicaid payments to a health plan for members who enroll after the date on which the health plan has been found to have committed one of the violations set forth in the Agreement. State payments for the CONTRACTOR’S members are automatically denied whenever, and for so long as, Federal payment for such members has been denied as a result of the commission of such violations. The following violations can trigger denial of payment pursuant to section 1903(m)(5) of the Social Security Act:
A. substantial failure to provide required medically necessary items or services when the failure has adversely affected or has substantial likelihood of adversely affecting a member;
B. imposition of premiums on Medicaid members in excess of permitted premiums;
C. discrimination among Medicaid beneficiaries with respect to enrollment, re-enrollment, or disenrollment on the basis of Medicaid beneficiaries’ health status or requirements for health care services;
D. misrepresentation or falsification of certain information; or
E. failure to cover emergency services under Section 1932(b)(2) of the Social Security Act when the failure affects or has a substantial likelihood of adversely affecting a member.
(2) HSD/MAD may also deny payment if HSD/MAD learns that a CONTRACTOR subcontracts with an individual provider, an entity, or an entity with an individual who is an officer, director, agent or manager or person with more than five percent (5%) of beneficial ownership of an entity’s equity, that has been convicted of crimes specified in the Section 1128 of the Social Security Act, or who has a contractual relationship with an entity convicted of a crime specified in Section 1128.
(3) HSD/MAD shall notify the Secretary of Health and Human Services of noncompliance with subparagraph A. above. HSD/MAD may allow continuance of the Agreement unless the Secretary directs otherwise but may not renew or otherwise extend the duration of the existing Agreement with the CONTRACTOR unless the Secretary provides to HSD/MAD and Congress a written statement describing the compelling reasons that exist for renewing and extending the Agreement.
(4) This section is subject to the “Non-exclusivity of Remedy” language below.
Federal Sanctions. (A) Section 1903 (m)(5)(A) and (B) of the Social Security Act vests the Secretary of Health and Human Services with the authority to deny Medicaid payments to a health plan for Members who enroll after the date on which the health plan has been found to have committed one of the violations set forth in the Agreement. State payments for the CONTRACTOR’s Members are automatically denied whenever, and for so long as, Federal payment for such Members has been denied as a result of the commission of such violations and in accordance with the requirements of 42 C.F.R. §438.730. The following violations can trigger denial of payment pursuant to §1903(m)(5) of the Social Security Act:
(1) substantial failure to provide required Medically Necessary items or necessary social services when the failure has adversely affected or has substantial likelihood of adversely affecting a Member;
(2) imposition of premiums on CONTRACTOR’s Members in excess of any permitted premium;
(3) discrimination among Members with respect to enrollment, re-enrollment, or disenrollment on the basis of Member’s health status or requirements for health care services;
(4) misrepresentation or falsification of certain information; or
(5) failure to cover emergency services under §1932(b)(2) of the Social Security Act when the failure affects or has a substantial likelihood of adversely affecting a Member.
(B) The State may also deny payment if the State learns that a CONTRACTOR subcontracts with an individual provider, an entity, or an entity with an individual who is an officer, director, agent or manager or person with more than five percent (5%) of beneficial ownership of an entity’s equity, that has been convicted of crimes specified in the §1128 of the Social Security Act, or who has a contractual relationship to provide services hereunder with an entity convicted of a crime specified in §1128.
(C) The State shall notify the Secretary of Health and Human Services of noncompliance with the provisions of this Section. The State may allow continuance of the Agreement unless the Secretary directs otherwise but may not renew or otherwise extend the duration of the existing Agreement with the CONTRACTOR unless the Secretary provides to the State and Congress a written statement describing the compelling reasons that exist for renewing and extending the Agreement.
(D) This Section is subject to the “Non-exclusivity of Remedy” language below.
Federal Sanctions. A Practitioner or HDO may reapply once the sanction is lifted.
Federal Sanctions. Payments provided for under this Contract will be denied for new Enrollees when, and for so long as, payment for those Enrollees is denied by CMS in accordance with the requirements in 42 C.F.R. 438.730.
