Common use of PLAN COMPLIANCE EVALUATION PROGRAM Clause in Contracts

PLAN COMPLIANCE EVALUATION PROGRAM. 1. The ADMINISTRATION shall conduct periodical evaluations of the INSURER's compliance with all terms and conditions of this contract including, but not limited to, quality, appropriateness, timeliness and reasonableness of cost and administrative expenses, said evaluation to be defined as the Plan Compliance Evaluation Program. 2. Said program will evaluate compliance of the following aspects in each areas/regions: a) Eligibility and enrollment b) Services to beneficiaries and participating providers c) Coverage of benefits d) Reporting e) Financial requirements f) Rules and Regulations g) Plan initiatives h) Quality, appropriateness, timeliness and cost of services i) Utilization j) Fraud and abuse k) Accessibility l) Grievances and Complaint handling m) Information Systems n) Electronic standards, security and privacy compliance as provided by HIPAA to include review of timetables for compliance and implementation plans o) Such aspects which the ADMINISTRATION considers necessary in order to evaluate full compliance with this contract. 3. The evaluation process will be performed throughout the contract year using specific evaluating parameters. All parameters will be derived exclusively from the Request for Proposals, the INSURER's Proposal and this contract. Each area/region will contain several parameters with each parameter having a specific numeric value adding up a subtotal per area/region and a total for the aggregate of all area/regions of evaluation. Results will be presented in a Plan Compliance Evaluation Report. The evaluating parameters will be presented to the INSURER prior to commencement of the evaluation process. 4. The INSURER shall comply with the penalties set for each parameter within the range of values predetermined by the ADMINISTRATION.

PLAN COMPLIANCE EVALUATION PROGRAM. 1. The ADMINISTRATION shall conduct periodical evaluations of the INSURER's compliance with all terms and conditions of this contract including, but not limited to, quality, appropriateness, timeliness and reasonableness of cost and administrative expenses, said evaluation to be defined as the Plan Compliance Evaluation Program. 2. Said program will evaluate compliance of the following aspects in each areas/regions: a) Eligibility and enrollment enrollment b) Services to beneficiaries and participating providers c) c. Coverage of benefits d) Reporting e) Financial requirements f) Rules and Regulations g) Plan initiatives h) Quality, appropriateness, timeliness and cost of services i) Utilization j) Fraud and abuse k) Accessibility l) Grievances and Complaint handling m) Information Systems n) Electronic standards, security and privacy compliance as provided by HIPAA to include review of timetables for compliance and implementation plans o) Such aspects which the ADMINISTRATION considers necessary in order to evaluate full compliance with this contract. 3. The evaluation process will be performed throughout the contract year using specific evaluating parameters. All parameters will be derived exclusively from the Request for Proposals, the INSURER's Proposal and this contract. Each area/region will contain several parameters with each parameter having a specific numeric value adding up a subtotal per area/region and a total for the aggregate of all area/regions of evaluation. Results will be presented in a Plan Compliance Evaluation Report. The evaluating parameters will be presented to the INSURER prior to commencement of the evaluation process. 4. The INSURER shall comply with the penalties set for each parameter within the range of values predetermined by the ADMINISTRATION.

PLAN COMPLIANCE EVALUATION PROGRAM. 1. The ADMINISTRATION shall conduct periodical evaluations of the INSURER's compliance with all terms and conditions of this contract including, but not limited to, quality, appropriateness, timeliness and reasonableness of cost and administrative expenses, said evaluation to be defined as the Plan Compliance Evaluation Program. 2. Said program will evaluate compliance of the following aspects in each areas/regions: a) Eligibility and enrollment b) Services to beneficiaries and participating providers c) Coverage of benefits d) Reporting e) Financial requirements f) Rules and Regulations g) Plan initiatives h) Quality, appropriateness, timeliness and cost of services i) Utilization j) Fraud and abuse k) Accessibility l1) Grievances and Complaint handling m) Information Systems n) Electronic standards, security and privacy compliance as provided by HIPAA to include review of timetables for compliance and implementation plans o) Such aspects which the ADMINISTRATION considers necessary in order to evaluate full compliance with this contract. 3. The evaluation process will be performed throughout the contract year using specific evaluating parameters. All parameters will be derived exclusively from the Request for Proposals, the INSURER's Proposal and this contract. Each area/region will contain several parameters with each parameter having a specific numeric value adding up a subtotal per area/region and a total for the aggregate of all area/regions of evaluation. Results will be presented in a Plan Compliance Evaluation Report. The evaluating parameters will be presented to the INSURER prior to commencement of the evaluation process. 4. The INSURER shall comply with the penalties set for each parameter within the range of values predetermined by the ADMINISTRATION. 5. Compliance with the Plan Compliance Evaluation Program is of essence to this contract and will be a determining factor in the renewal of this contract. Failure to comply with compliance requirements or parameters may also result in the termination of the contract as provided in Article XXXIII. 6. The ADMINISTRATION agrees to furnish the INSURER with the required Plan Performance Evaluation Program prior to its implementation. 7. The INSURER, as an additional tool to assure the evaluation of the insurance contract, agrees to abide, implement and develop the Health Plan-Employer Data and Information Set (HEDIS), as revised and recommended by NCQA and in accordance with the time schedule, work plan and other requirements established in Addendum XI of the RFP referring to HEDIS DATA. 8. DEFAULT AND REMEDIES under Plan Compliance Program. REMEDIES AVAILABLE TO THE ADMINISTRATION UNDER THE PLAN COMPLIANCE PROGRAM FOR INSURER'S DEFAULTS All of the listed remedies below may be exercised by the ADMINISTRATION and are in addition to all other remedies available to the ADMINISTRATION under this contract, by law or in equity, are joint and several, and may be exercised concurrently or consecutively. Exercise of any remedy in whole or in part does not limit the ADMINISTRATION in exercising all or part of any remaining remedies. Any particular default listed under subparagraph (a) to (j) below (which is not intended to be exhaustive) may be subject, when applicable, to any one or more of the following remedies: - Terminate the contract if the applicable conditions set forth in Section 10.1 are met; - Suspend payment to INSURER; - Recommend to CMS that sanctions be taken against INSURER as set out in Section 10.7; - Remove the EPSDT's component from the capitation paid to INSURER if the benchmarks(s) missed is for EPSDT's; - Assess civil monetary penalties as set out in section 10.8; and/or - Withhold premium payment. DEFAULTS BY INSURER a. FAILURE TO PERFORM AN ADMINISTRATIVE FUNCTION Failure of INSURER to perform an administrative function is a default under this contract. Administrative functions are any requirements under this contract that are not direct delivery of health care services. Administrative functions include claims payment; encounter data submission; filing any report when due; cooperating in good faith with THE ADMINISTRATION, an entity acting on behalf of THE ADMINISTRATION, or an agency authorized by statute or law to require the cooperation of INSURER in carrying out an administrative, investigative, or prosecutorial function of the program; providing or producing records upon request; or entering into contracts or implementing procedures necessary to carry out contract obligations.

PLAN COMPLIANCE EVALUATION PROGRAM. 1. The ADMINISTRATION shall conduct periodical evaluations of the INSURER's compliance with all terms and conditions of this contract including, but not limited to, quality, appropriateness, timeliness and reasonableness of cost and administrative expenses, said evaluation to be defined as the Plan Compliance Evaluation Program. 2. Said program will evaluate compliance of the following aspects in each areas/regions: a) Eligibility and enrollment b) Services to beneficiaries and participating providers c) Coverage of benefits d) Reporting e) Financial requirements f) Rules and Regulations g) Plan initiatives h) Quality, appropriateness, timeliness and cost of services i) Utilization j) Fraud and abuse k) Accessibility l) Grievances and Complaint handling m) Information Systems n) Electronic standards, security and privacy compliance as provided by HIPAA to include review of timetables for compliance and implementation plans o) Such aspects which the ADMINISTRATION considers necessary in order to evaluate full compliance with this contract. 3. The evaluation process will be performed throughout the contract year using specific evaluating parameters. All parameters will be derived exclusively from the Request for Proposals, the INSURER's Proposal and this contract. Each area/region will contain several parameters with each parameter having a specific numeric value adding up a subtotal per area/region and a total for the aggregate of all area/regions of evaluation. Results will be presented in a Plan Compliance Evaluation Report. The evaluating parameters will be presented to the INSURER prior to commencement of the evaluation process. 4. The INSURER shall comply with the penalties set for each parameter within the range of values predetermined by the ADMINISTRATION. 5. Compliance with the Plan Compliance Evaluation Program is of essence to this contract and will be a determining factor in the renewal of this contract. Failure to comply with compliance requirements or parameters may also result in the termination of the contract as provided in Article XXXIII. 6. The ADMINISTRATION agrees to furnish the INSURER with the required Plan Performance Evaluation Program prior to its implementation. 7. The INSURER, as an additional tool to assure the evaluation of the insurance contract, agrees to abide, implement and develop the Health Plan-Employer Data and Information Set (HEDIS), as revised and recommended by NCQA and in accordance with the time schedule, work plan and other requirements established in Addendum XI of the RFP referring to HEDIS DATA. 8. DEFAULT AND REMEDIES under Plan Compliance Program. REMEDIES AVAILABLE TO THE ADMINISTRATION UNDER THE PLAN COMPLIANCE PROGRAM FOR INSURER'S DEFAULTS All of the listed remedies below may be exercised by the ADMINISTRATION and are in addition to all other remedies available to the ADMINISTRATION under this contract, by law or in equity, are joint and several, and may be exercised concurrently or consecutively. Exercise of any remedy in whole or in part does not limit the ADMINISTRATION in exercising all or part of any remaining remedies. Any particular default listed under subparagraph (a) to (j) below (which is not intended to be exhaustive) may be subject, when applicable, to any one or more of the following remedies: - Terminate the contract if the applicable conditions set forth in Section 10.1 are met; - Suspend payment to INSURER; - Recommend to CMS that sanctions be taken against INSURER as set out in Section 10.7; - Remove the EPSDT's component from the capitation paid to INSURER if the benchmarks(s) missed is for EPSDT's; - Assess civil monetary penalties as set out in section 10.8; and/or - Withhold premium payment.