HOOSIER HEALTHWISE 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 Healthwise program. The State is looking to contract on a statewide basis with managed care entities (MCEs) with a demonstrated capacity to actively manage care for this low income population. Because Hoosier Healthwise is financed in part by federal Medicaid funds, Contractors shall meet all applicable requirements of Medicaid managed care organizations under Section 1903(m) and 1932 of the Social Security Act, as well as the implementing regulations set forth in 00 XXX 000, which defines requirements for Medicaid managed care programs. Contractors shall also ensure that its network providers, including out-of-state providers, enroll in the Indiana Health Coverage Programs (IHCP) before they begin providing health care services to members. Further information about IHCP provider enrollment is located at: Unless otherwise indicated, the requirements set forth in this Scope of Work apply to the Contractor’s responsibilities under the Hoosier Healthwise program.
HOOSIER HEALTHWISE SCOPE OF WORK. Prior to the Contract effective date, FSSA will provide a series of orientation sessions to assist the Contractor in developing its internal operations to support the requirements of the Contract (i.e., data submission, data transmissions, reporting formats, etc.). The Contractor shall have in place sufficient administrative and clinical staff and organizational components to comply with all Hoosier Healthwise program requirements and standards. The Contractor shall manage the functional linkage of the following major operational areas: Administrative and fiscal management Member services Provider services Marketing Provider enrollment Network development and management Quality management and improvement Utilization and care management Special investigations and waste, fraud and abuse detection Behavioral and physical health Information systems Performance data reporting and encounter claims submission Claims payments Grievances and appeals
HOOSIER HEALTHWISE SCOPE OF WORK. Key Staff The Contractor shall employ the key staff members listed below. The State requires the Contractor to have key staff members dedicated full-time to the Contractor’s Indiana Medicaid product lines. In some instances key staff must be dedicated to Hoosier Healthwise. Contractor must employ sufficient staff to achieve compliance with contractual requirements and performance metrics. The Contractor shall have an office in the State of Indiana from which, at a minimum, key staff members physically perform the majority of their daily duties and responsibilities, and a major portion of the Contractor’s operations take place. The Contractor shall be responsible for all costs related to securing and maintaining the facility for interim start-up support and the subsequent operational facility. Upon award of the Contract, the Contractor shall deliver the final staffing plan within thirty (30) calendar days after notice of award; such plan will include a resume for each proposed key staff person outlined below for acceptance by FSSA. FSSA reserves the right to approve or disapprove all initial and replacement key staff prior to their assignment to Hoosier Healthwise FSSA shall have the right to require that the Contractor remove any individual (whether or not key staff) from assignment to the program. The Contractor shall ensure the location of any staff or operational functions outside of the State of Indiana does not compromise the delivery of integrated services and the seamless experience for members and providers. The Contractor shall be responsible for ensuring all staff functions conducted outside of the State of Indiana are readily reportable to OMPP at all times to ensure such locations does not hinder the State’s ability to monitor the Contractor’s performance and compliance with Contract requirements. Indiana-based staff shall maintain a full understanding of the operations conducted outside of the State of Indiana, and must be prepared to discuss these operations with OMPP upon request, including during unannounced OMPP site visits. Except in the circumstance of the unforeseeable loss of a key staff member’s services, the Contractor shall provide written notification to OMPP of anticipated vacancies of key staff within five (5) business days of receiving the key staff person’s notice to terminate employment or five (5) business days before the vacancy occurs, whichever occurs first. At that time, the Contractor shall present OMPP with an interim p...
HOOSIER HEALTHWISE SCOPE OF WORK. Requirements for Reinsurance Companies The Contractor shall submit documentation that the reinsurer follows the National Association of Insurance Commissioners' (NAIC) Reinsurance Accounting Standards. The Contractor shall be required to obtain reinsurance from insurance organizations that have Standard and Poor's claims- paying ability ratings of "AA" or higher and a Xxxxx’x bond rating of “A1” or higher, unless otherwise approved by OMPP. Subcontractors Subcontractors’ reinsurance coverage requirements must be clearly defined in the reinsurance agreement. Subcontractors should be encouraged to obtain their own stop-loss coverage with the above-mentioned terms. If subcontractors do not obtain reinsurance on their own, the Contractor is required to forward appropriate recoveries from stop- loss coverage to applicable subcontractors.
HOOSIER HEALTHWISE SCOPE OF WORK. The MLR calculation shall be performed separately for each program. The MLR for the Hoosier Healthwise program shall be calculated separately from other managed care programs. For each MLR reporting year, a preliminary calculation will be performed with six months of incurred claims run-out, and a final calculation will be performed with 18 months of incurred claims run-out. Incurred claims reported in the MLR should relate only to members who were enrolled with the MCE on the date 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 MCE 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 MCE should ensure all subcontracts provide for sufficient transparency to allow for this required reporting. The Contractor shall maintain, at minimum, a MLR of eighty-five percent (85%) for its Hoosier Healthwise line of business. The Contractor is required to submit MLR reporting as described in the MCE Reporting Manual for Hoosier Healthwise. FSSA shall recoup excess capitation paid to the Contractor in the event that the Contractor’s MLR is less than eighty-five percent (85%) for the Hoosier Healthwise line of business.
HOOSIER HEALTHWISE SCOPE OF WORK. To claim reimbursement for the Contractor’s Adjusted Fee the Contractor shall submit a certified copy of its full Annual Fee assessment within sixty (60) days of receipt, together with the allocation of the Annual Fee attributable specifically to its premiums under this Contract. The Contractor shall also submit the calculated adjustment for the impact of non-deductibility of the Annual Fee attributable specifically to its premiums under this Contract, and any other data deemed necessary by the State to validate the reimbursement amount. These materials shall be submitted under the signatures of either its Financial Officer or Executive leadership (e.g., President, Chief Executive Office, Executive Director), certifying the accuracy, truthfulness and completeness of the data provided.
HOOSIER HEALTHWISE SCOPE OF WORK provide shall monitor the financial stability of subcontractor(s) whose payments are equal to or greater than five percent (5%) of premium/revenue. The Contractor shall obtain the following information from the subcontractor at least quarterly and use it to monitor the subcontractor’s performance: A statement of revenues and expenses A balance sheet Cash flows and changes in equity/fund balance IBNR estimates At least annually, the Contractor must obtain the following additional information from the subcontractor and use this information to monitor the subcontractor’s performance: audited financial statements including statement of revenues and expenses, balance sheet, cash flows and changes in equity/fund balance and an actuarial opinion of the IBNR estimates. The Contractor shall make these documents available to OMPP upon request and OMPP reserves the right to review these documents during Contractor site visits. The Contractor shall comply with 42 CFR 438.230 and the following subcontracting requirements: The Contractor shall obtain the approval of FSSA before subcontracting any portion of the project’s requirements. Subcontractors may include, but are not limited to a transportation broker, behavioral health organizations (BHOs) and Physician Hospital Organizations (PHOs). The Contractor shall give FSSA a written request and submit a draft contract or model provider agreement at least sixty (60) calendar days prior to the use of a subcontractor. If the Contractor makes subsequent changes to the duties included in the subcontractor contract, it shall notify FSSA sixty (60) calendar days prior to the revised contract effective date and submit the amendment for review and approval. FSSA must approve changes in vendors for any previously approved subcontracts. The Contractor shall evaluate prospective subcontractors’ abilities to perform delegated activities prior to contracting with the subcontractor to perform services associated with the Hoosier Healthwise program. The Contractor shall have a written agreement in place that specifies the subcontractor’s responsibilities and provides an option for revoking delegation or imposing other sanctions if performance is inadequate. The written agreement shall be in compliance with all the State of Indiana statutes, and will be subject to the provisions thereof. The subcontract cannot extend beyond the term of the State’s Contract with the Contractor. The Contractor shall collect performance and ...
HOOSIER HEALTHWISE SCOPE OF WORK. The Contractor shall utilize a Pharmacy and Therapeutics Committee which shall meet regularly to make recommendations for changes to the PDL and/or formulary. In accordance with IC 00-00-00-00, prior to removing one (1) or more drugs from the PDL and/or formulary or otherwise placing new PA criteria on one
(1) or more drugs, the Contractor shall submit the proposed change to the OMPP which shall forward the proposal to the DUR Board. Such changes shall be submitted at least thirty-five (35) calendar days in advance of the proposed change. The Contractor shall also meet with OMPP staff, as directed by OMPP, to answer questions about the clinical rationale for the proposed change. The DUR Board will provide a recommendation regarding approval of the proposed change to the PDL and/or formulary in accordance with the terms of IC 12-15-35-
HOOSIER HEALTHWISE SCOPE OF WORK. The Contractor shall provide OMPP with the information necessary for the DUR Board to conduct this review in the timeframe and format specified by OMPP. In addition to the DUR Board approval, the Contractor shall also seek the advice of the Mental Health Medicaid Quality Advisory Committee, as required in IC 12-15- 35.5, prior to implementing a restriction on a mental health drug described in IC 12-15-35.5-3(b). The Contractor shall supply, on a quarterly basis, a report to the Office and the DUR Board of the number of member days of missed therapy due to prior authorization. The format of this report will be agreed upon by the Contractor, the Office and the DUR Board. In addition, the Contractor shall comply with any additional reporting requests required for submission to the DUR Board. Please refer to the Hoosier Healthwise MCE Reporting Manual for more information on pharmacy reporting requirements. The Contractor shall provide the DUR Board statistics at the DUR Board’s monthly meetings. These statistics may include information on drug utilization or prior authorization reports as requested by the State.
HOOSIER HEALTHWISE SCOPE OF WORK. Independently developed and implemented PA criteria will be displayed, in a common format, alongside fee for service and other Contractor criteria. Additionally, the Contractor shall implement retrospective drug use review to identify patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, among physicians, pharmacists and individuals receiving benefits, or associated with specific drugs or groups of drugs.
