HUSKY B Final Clause Samples

HUSKY B Final b. If the MCO is licensed by the State of Connecticut, the MCO shall establish and maintain capitalization and reserves as required by the Connecticut DOI. c. If the MCO is majority-owned by federally qualified health centers (FQHCs) and not licensed by the State of Connecticut, the MCO will establish and maintain sequestere'd capital of $500,000 plus two (2) percent of ongoing annual capitation premiums. 1. These funds shall be placed in a restricted account for the duration of the FQHC plan's existence, to be accessed only in the event such funds are needed to meet unpaid claims liabilities. 2. This restricted account shall be established such that any withdrawals or transfers of funds will require signatures of authorized representatives of the FQHC plan and the DEPARTMENT. 3. The initial $500,000 must be deposited into the account by the beginning of the MCO's first enrollment period. 4. The MCO must make quarterly deposits into this account so that the account balance is equal to $500,000 plus two (2) percent of the premiums received during the preceding twelve (12) months.

HUSKY B Final b. The premium charged and collected for families within Income Band 2 shall be $30 per month for families with one child or $50 per month for families with more than one child. c. The premium charged and collected for families in Income Bands 1, 2 and 3 will be the rate negotiated with the DEPARTMENT per month, per child 1. The premium for families in Income Bands 1 and 2 will be based on Medical coverage only 2. The premium for families in Income Bands 3 will be based on both Medical and Behavioral Health coverage. d. The premium provisions and amount are subject to change. The DEPARTMENT will give the MCO sixty (60) days advance notice of any premium changes unless a statutory change precludes such advance notice.

HUSKY B Final e. The MCO shall cover emergency care services furnished to a Member by a provider whether or not the provider is a part of the Member's MCO provider network at the time of the service. f. The MCO shall cover emergency care services provided while the Member is out of the State of Connecticut, including emergency care incurred while outside the country. g. The MCO shall cover all services necessary to determine whether or not an emergency condition exists, even if it is later determined that the condition was not an emergency. h. The MCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard, turned out to be non-emergent in nature. i. The determination of whether the prudent layperson standard is met must be made on a case-by-case basis. The only exception to this general rule is that the MCO may approve coverage on the basis of an ICD-9 code. j. If the screening examination leads to a clinical determination by the examining physician that an actual emergency does not exist, then the nature and extent of payment liability will be based on whether the Member had acute symptoms under the prudent layperson standard at the time of presentation. k. Once the Member's condition is stabilized, the MCO may require authorization for a hospital admission or follow-up care. I. The MCO must cover post-stabilization services attendant to the primary presenting diagnosis that were either approved by the MCO or were delivered by the emergency service provider when the MCO failed to respond to a request for pre-approval of such services within one hour of the request to approve post-stabilization care, or could not be contacted for pre-approval.

HUSKY B Final. 4. A system by which Members may obtain a covered service or services that the MCO does not provide or for which the MCO does not arrange because it would violate a religious or moral teaching of the religious institution or organization by which the MCO is owned, controlled, sponsored or affiliated. 5. Coordination and provision of well-child care services in accordance with the schedules for immunizations and periodicity of well-child care services as established by the DEPARTMENT and recommended by the American Academy of Pediatrics. 6. Coordinating with and providing a case manager to the HUSKY Pius Physical program, as indicated in Section 3.19 of this contract. 7. If notified, PCPs shall participate in the review and authorization of Individual Education Plans for Members receiving School Based Child Health services and Individual Family Service Plans for Members receiving services from the Birth to Three program. 8. The MCO shall coordinate Members' care with the Behavioral Health Partnership, as outlined in this Contract, including but not limited to section 3.16, and Appendix N.

HUSKY B Final i. All subcontracts shall also include a provision that the MCO will withhold a portion of the final payment to the subcontractor, as a surety bond to ensure compliance under the terminated subcontract. j. The MCO shall have no right to and shall not assign, transfer or delegate this contract in its entirety, or any right or duty arising under this contract without the prior written approval of the DEPARTMENT. The DEPARTMENT in its discretion may grant such written approval of an assignment, transfer or delegation provided, however, that this paragraph shall not be construed to grant the MCO any right to such approval.

HUSKY B Final b. The notice shall contain: 1. The amount of the premium that is due; 2. The date the premium was due; 3. The effective date of disenrollment for failure to pay the premium; 4. Information concerning lock-out; 5. An instruction for the applicant to immediately contact the DEPARTMENT or its agent if the applicant cannot pay the premium by the due date because of a decrease in income or other change in family circumstances; and 6. Any additional information required to be included in the notice by the DEPARTMENT. b. The MCO shall collaborate with the DEPARTMENT and its agent to establish billing and collection procedures. The MCO shall notify the Department or its agent pursuant to the agreed upon procedures if a premium is not received by the due date. Sanction: If the MCO fails to provide prior notice, as described above, or if the MCO fails to notify the DEPARTMENT or its agent of failure to pay a premium by the due date, the DEPARTMENT may impose a strike towards a Class A sanction pursuant to Section 9.05.

HUSKY B Final. Member: National Committee on Quality Assurance (NCQA): Non-citizen: Open Enrollment Period: Out-of-network Provider: Passive Billing: Post-Stabilization Services:

HUSKY B Final. MCO may have a drug management program that includes a prescription drug formulary. If the MCO has a drug formulary, the MCO shall have a prior authorization process to permit access at a minimum to all medically necessary and appropriate drugs covered for the Medicaid fee-for-service population. The MCO drug formulary must include only Food and Drug Administration approved drug products and be sufficiently broad enough in scope to meet the needs of the MCO's Members. The MCO drug formulary shall consist of a reasonable selection of drugs which do not require prior approval for each specific therapeutic drug class. c. The MCO shall submit a copy of its formulary to the DEPARTMENT no later than thirty (30) days after the effective date of this contract. The MCO shall submit any subsequent deletions to the formulary to the DEPARTMENT thirty (30) days prior to making any change. The MCO shall also submit subsequent additions to the formulary immediately without seeking prior approval by the DEPARTMENT. The DEPARTMENT reserves the right to identify deficiencies in the content or operation of the formulary. In this instance, the MCO shall have thirty (30) days to address in writing the identified deficiencies to the DEPARTMENT'S satisfaction. The MCO may request to meet with the DEPARTMENT prior to the submission of the written response. d. The MCO shall ensure that Members using maintenance drugs (drugs usually prescribed to treat long-term or chronic conditions including, but not limited to, diabetes, arthritis and high blood pressure) are informed in advance, but no less than thirty (30) days in advance of any changes to the prescription drug formulary related to such maintenance drugs if the Member using the drug will not be able to continue using the drug without a new authorization. e. The MCO shall require that its provider network of pharmacies adheres to the provisions of Connecticut General Statutes Section 20-619 (b) and (c) related to generic substitutions.

HUSKY B Final. At the time of enrollment and at least annually thereafter, the MCO shall inform its Members of the procedural steps for filing an internal appeal and requesting an external review. k. The MCO shall monitor and track PCP transfer requests and follow up on complaints made by Members as necessary. l. The MCO will participate in two (2) Member surveys. The first such survey will be an analysis of Members with special needs as defined by the DEPARTMENT after consultation with the Children's Health Council, EQRO, and the MCO, to be conducted at the DEPARTMENT'S expense. The survey will be developed and the sample will be chosen by the Children's Health Council, with input from the MCOs and the DEPARTMENT. The other survey will be an NCQA Consumer Assessment of Health Plans Survey (CAHPS) of combined HUSKY A and B Members using an independent vendor and paid for by the MCO. The MCO's CAHPS survey shall continue to include behavioral health questions. m. The MCO may provide outreach to its current Members at the time of the Member's renewal of eligibility. The outreach may involve special mailings or phone calls as reminders that the Member must complete the HUSKY renewal forms to ensure continued coverage. n. The MCO shall make appropriate referrals of Members who express the need for or may require behavioral health services to the Partnership. If a Member is in crisis, the MCO shall stay on the line with the member while connecting the Member with the Partnership.