Common use of MCO Performance Clause in Contracts

MCO Performance. The MCO is expected to meet or exceed all the Department’s objectives and standards, as set forth in the Contract. All areas of responsibility and all Contract requirements will be subject to performance evaluation by the Department. A designated representative of the MCO and a designated representative of the Department may meet as requested by either party, to review the performance of the MCO under this Contract. Written minutes of such meetings will be kept. In the event of any disagreement regarding the performance of services by the MCO under this Contract, the designated representatives must discuss the performance problem and negotiate in good faith in an effort to resolve the disagreement. For purposes of this Contract, an item of non-compliance/non-performance means a specific action of the MCO or its Subcontractor, agent and/or consultant that: • Violates a provision of this Contract including Appendices; • Fails to meet an agreed measure of performance and/or standard; or • Represents a failure of the MCO to be reasonably responsive to a reasonable request of the Department for information, assistance, or support within the timeframe specified by the Department. Non-performance of this Contract includes, but is not limited to: • Failing substantially to provide Medically Necessary covered services that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; • Failing substantially to provide covered SNS that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; • Imposing premiums, copays, or charges that are in excess of the premiums, copays, or charges permitted under the Medicaid program; • Acting to discriminate among enrollees on the basis of their health status or need for health care services, including terminating of enrollment or refusal to reenroll an individual, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by individuals whose medical condition or history indicates probable need for substantial future medical services; • Misrepresenting or falsifying information that the MCO furnishes to CMS, ACF, or to the State; • Misrepresenting or falsifying of information that the MCO furnishes to an enrollee, potential enrollee, health care provider or SNS provider; • Distributing directly, or indirectly through any agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; • Failing to maintain an adequate network of properly credentialed providers; • Failing to comply with the provider reimbursement requirements of this Contract; • Failing to comply with the reporting requirements of this Contract; • A pattern of inappropriately denying payments for emergency-related services; or • Violating the requirements of sections 1903(m) or 1932 of the Social Security Act, and any implementing regulations.

MCO Performance. The MCO is expected to meet or exceed all the Department’s BMS’ objectives and standards, as set forth in the Contract. All areas of responsibility and all Contract requirements will be subject to performance evaluation by the DepartmentBMS. A designated representative of the MCO and a designated representative of the Department BMS may meet as requested by either party, to review the performance of the MCO under this Contract. Written minutes of such meetings will be kept. In the event of any disagreement regarding the performance of services by the MCO under this Contract, the designated representatives must discuss the performance problem and negotiate in good faith in an effort to resolve the disagreement. For purposes of this Contract, an item of non-compliance/non-performance means a specific action of the MCO or its Subcontractor, agent and/or consultant that: • Violates a provision of this Contract including Appendices; • Fails to meet an agreed measure of performance and/or standard; or • Represents a failure of the MCO to be reasonably responsive to a reasonable request of the Department BMS for information, assistance, or support within the timeframe specified by the DepartmentBMS. Non-performance of this Contract includes, but is not limited to: • Failing substantially to provide Medically Necessary covered services that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; • Failing substantially to provide covered SNS that the MCO is required to provide, under law or under its Contract with the DepartmentBMS, to an enrollee covered under the Contract; • Imposing premiums, copays, or charges that are in excess of the premiums, copays, or charges permitted under the Medicaid program; • Acting to discriminate among enrollees on the basis of their health status or need for health care services, including terminating of enrollment or refusal to reenroll an individualenrollee, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by individuals enrollees whose medical condition or history indicates probable need for substantial future medical services; • Misrepresenting or falsifying information that the MCO furnishes to CMS, ACF, CMS or to the State; • Misrepresenting or falsifying of information that the MCO furnishes to an enrollee, potential enrollee, or health care provider or SNS provider; • Distributing directly, or indirectly through any agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; • Failing to maintain an adequate network of properly credentialed providers; • Failing to comply with the provider reimbursement requirements of this Contract; • Failing to comply with the reporting requirements of this Contract; • A pattern of inappropriately denying payments for emergency-related services; or • Violating the requirements of sections 1903(m) or 1932 of the Social Security Act, and any implementing regulations.

MCO Performance. The MCO is expected to meet or exceed all the Department’s objectives and standards, as set forth in the Contract. All areas of responsibility and all Contract requirements will be subject to performance evaluation by the Department. A designated representative of the MCO and a designated representative of the Department may meet as requested by either party, to review the performance of the MCO under this Contract. Written minutes of such meetings will be kept. In the event of any disagreement regarding the performance of services by the MCO under this Contract, the designated representatives must discuss the performance problem and negotiate in good faith in an effort to resolve the disagreement. For purposes of this Contract, an item of non-compliance/non-performance means a specific action of the MCO or its Subcontractor, agent and/or consultant that: • Violates a provision of this Contract including Appendices; • Fails to meet an agreed measure of performance and/or standard; or • Represents a failure of the MCO to be reasonably responsive to a reasonable request of the Department for information, assistance, or support within the timeframe specified by the Department. NonThe Department will consider the following items as Contract non-performance of this Contract includesperformance, including but is not limited to: • Failing substantially to provide Medically Necessary covered services that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; • Failing substantially to provide covered SNS that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; • Imposing premiums, copays, or charges that are in excess of the premiums, copays, or charges permitted under the Medicaid program; • Acting to discriminate among enrollees on the basis of their health status or need for health care services, including terminating of enrollment or refusal to reenroll an individuala recipient, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by individuals recipients whose medical condition or history indicates probable need for substantial future medical services; • Misrepresenting or falsifying information that the MCO furnishes to CMS, ACF, CMS or to the State; • Misrepresenting or falsifying of information that the MCO furnishes to an enrollee, potential enrollee, or health care provider or SNS provider; • Distributing directly, or indirectly through any agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; • Failing to maintain an adequate network of properly credentialed providers; • Failing to comply with the provider reimbursement requirements of this Contract; • Failing to comply with the reporting requirements of this Contract; • A pattern of inappropriately denying payments for emergency-related services; or • Violating the requirements of sections 1903(m) or 1932 of the Social Security Act, and any implementing regulations.

MCO Performance. The MCO is expected to meet or exceed all the Department’s BMS’ objectives and standards, as set forth in the Contract. All areas of responsibility and all Contract requirements will be subject to performance evaluation by the DepartmentBMS. A designated representative of the MCO and a designated representative of the Department BMS may meet as requested by either party, to review the performance of the MCO under this Contract. Written minutes of such meetings will be kept. In the event of any disagreement regarding the performance of services by the MCO under this Contract, the designated representatives must discuss the performance problem and negotiate in good faith in an effort to resolve the disagreement. For purposes of this Contract, an item of non-compliance/non-performance means a specific action of the MCO or its Subcontractor, agent and/or consultant that: •  Violates a provision of this Contract including Appendices; •  Fails to meet an agreed measure of performance and/or standard; or •  Represents a failure of the MCO to be reasonably responsive to a reasonable request of the Department BMS for information, assistance, or support within the timeframe specified by the DepartmentBMS. Non-performance of this Contract includes, but is not limited to: •  Failing substantially to provide Medically Necessary covered services that the MCO is required to provide, under law or under its Contract with the DepartmentBMS, to an enrollee covered under the Contract; • Failing substantially to provide covered SNS that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; •  Imposing premiums, copays, or charges to enrollees that are in excess of the premiums, copays, or charges permitted under the Medicaid program; •  Acting to discriminate among enrollees on the basis of their health status or need for health care services, including terminating of enrollment or refusal to reenroll an individualenrollee, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by individuals enrollees whose medical condition or history indicates probable need for substantial future medical services; •  Misrepresenting or falsifying information that the MCO furnishes to CMS, ACF, CMS or to the State; •  Misrepresenting or falsifying of information that the MCO furnishes to an enrollee, potential enrollee, or health care provider or SNS provider; •  Distributing directly, or indirectly through any agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; •  Failing to maintain an adequate network of properly credentialed providers; •  Failing to comply with the provider reimbursement requirements of this Contract; •  Failing to comply with the reporting requirements of this Contract; •  A pattern of inappropriately denying payments for emergency-related services; or •  Violating the requirements of sections 1903(m) or 1932 of the Social Security Act, and any implementing regulations.

MCO Performance. The MCO is expected to meet or exceed all the Department’s objectives and standards, as set forth in the Contract. All areas of responsibility and all Contract requirements will be subject to performance evaluation by the Department. A designated representative of the MCO and a designated representative of the Department may meet as requested by either party, to review the performance of the MCO under this Contract. Written minutes of such meetings will be kept. In the event of any disagreement regarding the performance of services by the MCO under this Contract, the designated representatives must discuss the performance problem and negotiate in good faith in an effort to resolve the disagreement. For purposes of this Contract, an item of non-compliance/non-performance means a specific action of the MCO or its Subcontractor, agent and/or consultant that: •  Violates a provision of this Contract including Appendices; •  Fails to meet an agreed measure of performance and/or standard; or •  Represents a failure of the MCO to be reasonably responsive to a reasonable request of the Department for information, assistance, or support within the timeframe specified by the Department. Non-performance of this Contract includes, but is not limited to: •  Failing substantially to provide Medically Necessary covered services that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; •  Failing substantially to provide covered SNS that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; •  Imposing premiums, copays, or charges that are in excess of the premiums, copays, or charges permitted under the Medicaid program; •  Acting to discriminate among enrollees on the basis of their health status or need for health care services, including terminating of enrollment or refusal to reenroll an individual, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by individuals whose medical condition or history indicates probable need for substantial future medical services; •  Misrepresenting or falsifying information that the MCO furnishes to CMS, ACF, or to the State; •  Misrepresenting or falsifying of information that the MCO furnishes to an enrollee, potential enrollee, health care provider or SNS provider; •  Distributing directly, or indirectly through any agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; •  Failing to maintain an adequate network of properly credentialed providers; •  Failing to comply with the provider reimbursement requirements of this Contract; •  Failing to comply with the reporting requirements of this Contract; •  A pattern of inappropriately denying payments for emergency-related services; or •  Violating the requirements of sections 1903(m) or 1932 of the Social Security Act, and any implementing regulations.

MCO Performance. The MCO is expected to meet or exceed all the Department’s BMS’ objectives and standards, as set forth in the Contract. All areas of responsibility and all Contract requirements will be subject to performance evaluation by the DepartmentBMS. A designated representative of the MCO and a designated representative of the Department BMS may meet as requested by either party, to review the performance of the MCO under this Contract. Written minutes of such meetings will be kept. In the event of any disagreement regarding the performance of services by the MCO under this Contract, the designated representatives must discuss the performance problem and negotiate in good faith in an effort to resolve the disagreement. For purposes of this Contract, an item of non-compliance/non-performance means a specific action of the MCO or its Subcontractor, agent and/or consultant that: • Violates a provision of this Contract including Appendices; • Fails to meet an agreed measure of performance and/or standard; or • Represents a failure of the MCO to be reasonably responsive to a reasonable request of the Department BMS for information, assistance, or support within the timeframe specified by the DepartmentBMS. Non-performance of this Contract includes, but is not limited to: • Failing substantially to provide Medically Necessary covered services that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; • Failing substantially to provide covered SNS that the MCO is required to provide, under law or under its Contract with the DepartmentBMS, to an enrollee covered under the Contract; • Imposing premiums, copays, or charges to enrollees that are in excess of the premiums, copays, or charges permitted under the Medicaid or WVCHIP program; • Acting to discriminate among enrollees on the basis of their health status or need for health care services, including terminating of enrollment or refusal to reenroll an individualenrollee, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by individuals enrollees whose medical condition or history indicates probable need for substantial future medical services; • Misrepresenting or falsifying information that the MCO furnishes to CMS, ACF, CMS or to the State; • Misrepresenting or falsifying of information that the MCO furnishes to an enrollee, potential enrollee, or health care provider or SNS provider; • Distributing directly, or indirectly through any agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; • Failing to maintain an adequate network of properly credentialed providers; • Failing to comply with the provider reimbursement requirements of this Contract; • Failing to comply with the reporting requirements of this Contract; • A pattern of inappropriately denying payments for emergency-related services; or • Violating the requirements of sections 1903(m) or 1932 of the Social Security Act, and any implementing regulations.

MCO Performance. The MCO is expected to meet or exceed all the Department’s objectives and standards, as set forth in the Contractcontract. All areas of responsibility and all Contract contract requirements will be subject to performance evaluation by the Department. A designated representative of the MCO and a designated representative of the Department may meet as requested by either party, to review the performance of the MCO under this Contractcontract. Written minutes of such meetings will be kept. In the event of any disagreement regarding the performance of services by the MCO under this Contractcontract, the designated representatives must discuss the performance problem and negotiate in good faith in an effort to resolve the disagreement. For purposes of this Contractcontract, an item of non-compliance/non-performance means a specific action of the MCO or its Subcontractorsubcontractor, agent and/or consultant that: •  Violates a provision of this Contract contract including AppendicesExhibits; •  Fails to meet an agreed measure of performance and/or standard; or •  Represents a failure of the MCO to be reasonably responsive to a reasonable request of the Department for information, assistance, or support within the timeframe specified by the Department. NonThe Department will consider the following items as contract non-performance of this Contract includesperformance, including but is not limited to: •  Failing substantially to provide Medically Necessary covered medically necessary services that the MCO is required to provide, under law or under its Contract contract with the Department, to an enrollee covered under the Contractcontract; • Failing substantially to provide covered SNS that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; •  Imposing premiums, copays, or charges that are in excess of the premiums, copays, or charges permitted under the Medicaid program; •  Acting to discriminate among enrollees on the basis of their health status or need for health care services, including terminating of enrollment or refusal to reenroll an individuala recipient, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by individuals recipients whose medical condition or history indicates probable need for substantial future medical services; •  Misrepresenting or falsifying information that the MCO furnishes to CMS, ACF, CMS or to the State; •  Misrepresenting or falsifying of information that the MCO furnishes to an enrollee, potential enrollee, or health care provider or SNS provider; •  Distributing directly, or indirectly through any agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; •  Failing to maintain an adequate network of properly credentialed providers; •  Failing to comply with the provider reimbursement requirements of this Contractcontract; •  Failing to comply with the reporting requirements of this Contractcontract; •  A pattern of inappropriately denying payments for emergency-related services; or •  Violating the requirements of sections 1903(m) or 1932 of the Social Security Act, and any implementing regulations.

MCO Performance. The MCO is expected to meet or exceed all the Department’s objectives and standards, as set forth in the Contract. All areas of responsibility and all Contract requirements will be subject to performance evaluation by the Department. A designated representative of the MCO and a designated representative of the Department may meet as requested by either party, to review the performance of the MCO under this Contract. Written minutes of such meetings will be kept. In the event of any disagreement regarding the performance of services by the MCO under this Contract, the designated representatives must discuss the performance problem and negotiate in good faith in an effort to resolve the disagreement. For purposes of this Contract, an item of non-compliance/non-performance means a specific action of the MCO or its Subcontractor, agent and/or consultant that: •  Violates a provision of this Contract including Appendices; •  Fails to meet an agreed measure of performance and/or standard; or •  Represents a failure of the MCO to be reasonably responsive to a reasonable request of the Department for information, assistance, or support within the timeframe specified by the Department. Non The Department will consider the following items as Contract non-performance of this Contract includesperformance, including but is not limited to: •  Failing substantially to provide Medically Necessary covered services that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; • Failing substantially to provide covered SNS that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; •  Imposing premiums, copays, or charges that are in excess of the premiums, copays, or charges permitted under the Medicaid program; •  Acting to discriminate among enrollees on the basis of their health status or need for health care services, including terminating of enrollment or refusal to reenroll an individuala recipient, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by individuals recipients whose medical condition or history indicates probable need for substantial future medical services; •  Misrepresenting or falsifying information that the MCO furnishes to CMS, ACF, CMS or to the State; •  Misrepresenting or falsifying of information that the MCO furnishes to an enrollee, potential enrollee, or health care provider or SNS provider; •  Distributing directly, or indirectly through any agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; •  Failing to maintain an adequate network of properly credentialed providers; •  Failing to comply with the provider reimbursement requirements of this Contract; •  Failing to comply with the reporting requirements of this Contract; •  A pattern of inappropriately denying payments for emergency-related services; or •  Violating the requirements of sections 1903(m) or 1932 of the Social Security Act, and any implementing regulations.

MCO Performance. The MCO is expected to meet or exceed all the Department’s BMS’ objectives and standards, as set forth in the Contract. All areas of responsibility and all Contract requirements will be subject to performance evaluation by the DepartmentBMS. A designated representative of the MCO and a designated representative of the Department BMS may meet as requested by either party, to review the performance of the MCO under this Contract. Written minutes of such meetings will be kept. In the event of any disagreement regarding the performance of services by the MCO under this Contract, the designated representatives must discuss the performance problem and negotiate in good faith in an effort to resolve the disagreement. For purposes of this Contract, an item of non-compliance/non-performance means a specific action of the MCO or its Subcontractor, agent and/or consultant that: •  Violates a provision of this Contract including Appendices; •  Fails to meet an agreed measure of performance and/or standard; or •  Represents a failure of the MCO to be reasonably responsive to a reasonable request of the Department BMS for information, assistance, or support within the timeframe specified by the DepartmentBMS. Non-performance of this Contract includes, but is not limited to: •  Failing substantially to provide Medically Necessary covered services that the MCO is required to provide, under law or under its Contract with the DepartmentBMS, to an enrollee covered under the Contract; • Failing substantially to provide covered SNS that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; •  Imposing premiums, copays, or charges to enrollees that are in excess of the premiums, copays, or charges permitted under the Medicaid or WVCHIP program; •  Acting to discriminate among enrollees on the basis of their health status or need for health care services, including terminating of enrollment or refusal to reenroll an individualenrollee, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by individuals enrollees whose medical condition or history indicates probable need for substantial future medical services; •  Misrepresenting or falsifying information that the MCO furnishes to CMS, ACF, CMS or to the State; •  Misrepresenting or falsifying of information that the MCO furnishes to an enrollee, potential enrollee, or health care provider or SNS provider; •  Distributing directly, or indirectly through any agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; •  Failing to maintain an adequate network of properly credentialed providers; •  Failing to comply with the provider reimbursement requirements of this Contract; •  Failing to comply with the reporting requirements of this Contract; •  A pattern of inappropriately denying payments for emergency-related services; or •  Violating the requirements of sections 1903(m) or 1932 of the Social Security Act, and any implementing regulations.

MCO Performance. The MCO is expected to meet or exceed all the Department’s objectives and standards, as set forth in the Contract. All areas of responsibility and all Contract contract requirements will be subject to performance evaluation by the Department. A designated representative of the MCO and a designated representative of the Department may meet as requested by either party, to review the performance of the MCO under this Contract. Written minutes of such meetings will be kept. In the event of any disagreement regarding the performance of services by the MCO under this Contract, the designated representatives must discuss the performance problem and negotiate in good faith in an effort to resolve the disagreement. For purposes of this Contract, an item of non-compliance/non-performance means a specific action of the MCO or its Subcontractor, agent and/or consultant that: • Violates a provision of this Contract contract including Appendices; • Fails to meet an agreed measure of performance and/or standard; or • Represents a failure of the MCO to be reasonably responsive to a reasonable request of the Department for information, assistance, or support within the timeframe specified by the Department. NonThe Department will consider the following items as contract non-performance of this Contract includesperformance, including but is not limited to: • Failing substantially to provide Medically Necessary covered services that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; • Failing substantially to provide covered SNS that the MCO is required to provide, under law or under its Contract contract with the Department, to an enrollee covered under the Contract; • Imposing premiums, copays, or charges that are in excess of the premiums, copays, or charges permitted under the Medicaid program; • Acting to discriminate among enrollees on the basis of their health status or need for health care services, including terminating of enrollment or refusal to reenroll an individuala recipient, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by individuals recipients whose medical condition or history indicates probable need for substantial future medical services; • Misrepresenting or falsifying information that the MCO furnishes to CMS, ACF, CMS or to the State; • Misrepresenting or falsifying of information that the MCO furnishes to an enrollee, potential enrollee, or health care provider or SNS provider; • Distributing directly, or indirectly through any agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; • Failing to maintain an adequate network of properly credentialed providers; • Failing to comply with the provider reimbursement requirements of this Contract; • Failing to comply with the reporting requirements of this Contract; • A pattern of inappropriately denying payments for emergency-related services; or • Violating the requirements of sections 1903(m) or 1932 of the Social Security Act, and any implementing regulations.

MCO Performance. The MCO is expected to meet or exceed all the Department’s objectives and standards, as set forth in the Contractcontract. All areas of responsibility and all Contract contract requirements will be subject to performance evaluation by the Department. A designated representative of the MCO and a designated representative of the Department may meet as requested by either party, to review the performance of the MCO under this Contractcontract. Written minutes of such meetings will be kept. In the event of any disagreement regarding the performance of services by the MCO under this Contractcontract, the designated representatives must discuss the performance problem and negotiate in good faith in an effort to resolve the disagreement. For purposes of this Contractcontract, an item of non-compliance/non-performance means a specific action of the MCO or its Subcontractorsubcontractor, agent and/or consultant that: •  Violates a provision of this Contract contract including AppendicesExhibits; •  Fails to meet an agreed measure of performance and/or standard; or •  Represents a failure of the MCO to be reasonably responsive to a reasonable request of the Department for information, assistance, or support within the timeframe specified by the Department. NonThe Department will consider the following items as contract non-performance of this Contract includesperformance, including but is not limited to: •  Failing substantially to provide Medically Necessary covered medically necessary services that the MCO is required to provide, under law or under its Contract contract with the Department, to an enrollee covered under the Contractcontract; • Failing substantially to provide covered SNS that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; •  Imposing premiums, copays, or charges that are in excess of the premiums, copays, or charges permitted under the Medicaid program; •  Acting to discriminate among enrollees on the basis of their health status or need for health care services, including terminating of enrollment or refusal to reenroll an individuala recipient, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by individuals recipients whose medical condition or history indicates probable need for substantial future medical services; •  Misrepresenting or falsifying information that the MCO furnishes to CMS, ACF, CMS or to the State; •  Misrepresenting or falsifying of information that the MCO furnishes to an enrollee, potential enrollee, or health care provider or SNS provider; •  Distributing directly, or indirectly through any agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; •  Failing to maintain an adequate network of properly credentialed providers; •  Failing to comply with the provider reimbursement requirements of this Contractcontract; •  Failing to comply with the reporting requirements of this Contractcontract; •  A pattern of inappropriately denying payments for emergency-related services; or •  Violating of the requirements of sections 1903(m) or 1932 of the Social Security Act, and any implementing regulations.

MCO Performance. The MCO is expected to meet or exceed all the Department’s objectives and standards, as set forth in the Contract. All areas of responsibility and all Contract requirements will be subject to performance evaluation by the Department. A designated representative of the MCO and a designated representative of the Department may meet as requested by either party, to review the performance of the MCO under this Contract. Written minutes of such meetings will be kept. In the event of any disagreement regarding the performance of services by the MCO under this Contract, the designated representatives must discuss the performance problem and negotiate in good faith in an effort to resolve the disagreement. For purposes of this Contract, an item of non-compliance/non-performance means a specific action of the MCO or its Subcontractor, agent and/or consultant that: • Violates a provision of this Contract including Appendices; • Fails to meet an agreed measure of performance and/or standard; or • Represents a failure of the MCO to be reasonably responsive to a reasonable request of the Department for information, assistance, or support within the timeframe specified by the Department. Non• The Department will consider the following items as Contract non-performance of this Contract includesperformance, including but is not limited to: • Failing substantially to provide Medically Necessary covered services that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; • Failing substantially to provide covered SNS that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; • Imposing premiums, copays, or charges that are in excess of the premiums, copays, or charges permitted under the Medicaid program; • Acting to discriminate among enrollees on the basis of their health status or need for health care services, including terminating of enrollment or refusal to reenroll an individuala recipient, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by individuals recipients whose medical condition or history indicates probable need for substantial future medical services; • Misrepresenting or falsifying information that the MCO furnishes to CMS, ACF, CMS or to the State; • Misrepresenting or falsifying of information that the MCO furnishes to an enrollee, potential enrollee, or health care provider or SNS provider; • Distributing directly, or indirectly through any agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; • Failing to maintain an adequate network of properly credentialed providers; • Failing to comply with the provider reimbursement requirements of this Contract; • Failing to comply with the reporting requirements of this Contract; • A pattern of inappropriately denying payments for emergency-related services; or • Violating the requirements of sections 1903(m) or 1932 of the Social Security Act, and any implementing regulations.

MCO Performance. The MCO is expected to meet or exceed all the Department’s objectives and standards, as set forth in the Contract. All areas of responsibility and all Contract requirements will be subject to performance evaluation by the Department. A designated representative of the MCO and a designated representative of the Department may meet as requested by either party, to review the performance of the MCO under this Contract. Written minutes of such meetings will be kept. In the event of any disagreement regarding the performance of services by the MCO under this Contract, the designated representatives must discuss the performance problem and negotiate in good faith in an effort to resolve the disagreement. For purposes of this Contract, an item of non-compliance/non-performance means a specific action of the MCO or its Subcontractor, agent and/or consultant that: •  Violates a provision of this Contract including Appendices; •  Fails to meet an agreed measure of performance and/or standard; or •  Represents a failure of the MCO to be reasonably responsive to a reasonable request of the Department for information, assistance, or support within the timeframe specified by the Department. NonThe Department will consider the following items as Contract non-performance of this Contract includesperformance, including but is not limited to: •  Failing substantially to provide Medically Necessary covered services that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; • Failing substantially to provide covered SNS that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; •  Imposing premiums, copays, or charges that are in excess of the premiums, copays, or charges permitted under the Medicaid program; •  Acting to discriminate among enrollees on the basis of their health status or need for health care services, including terminating of enrollment or refusal to reenroll an individuala recipient, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by individuals recipients whose medical condition or history indicates probable need for substantial future medical services; •  Misrepresenting or falsifying information that the MCO furnishes to CMS, ACF, CMS or to the State; •  Misrepresenting or falsifying of information that the MCO furnishes to an enrollee, potential enrollee, or health care provider or SNS provider; •  Distributing directly, or indirectly through any agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; •  Failing to maintain an adequate network of properly credentialed providers; •  Failing to comply with the provider reimbursement requirements of this Contract; •  Failing to comply with the reporting requirements of this Contract; •  A pattern of inappropriately denying payments for emergency-related services; or •  Violating the requirements of sections 1903(m) or 1932 of the Social Security Act, and any implementing regulations.