Common use of Post-Transition Clause in Contracts

Post-Transition. The HMO will work with HHSC, Providers, and Members to promptly identify and resolve problems identified after the Operational Start Date and to communicate to HHSC, Providers, and Members, as applicable, the steps the HMO is taking to resolve the problems. If a HMO makes assurances to HHSC of its readiness to meet Contract requirements, including MIS and operational requirements, but fails to satisfy requirements set forth in this Section, or as otherwise required pursuant to the Contract, HHSC may, at its discretion do any of the following in accordance with the severity of the non-compliance and the potential impact on Members and Providers: 1. freeze enrollment into the HMO’s plan for the affected HMO Program(s) and Service Area(s); 2. freeze enrollment into the HMO’s plan for all HMO Programs or for all Service Areas of an affected HMO Program; 3. impose contractual remedies, including liquidated damages; or 4. pursue other equitable, injunctive, or regulatory relief. Refer to Attachment B-1, Sections 8.1.1.2 and 8.1.18 for additional information regarding HMO Readiness Reviews during the Operations Phase. Subject: Attachment B-1 - HHSC Joint Mediciad/XXXX XXX RFP, Section 8 STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a Initial version Attachment B-1, Section 8 Revision 1.1 June 30, 2006 Revised version of the Attachment B-1, Section 8, that includes provisions applicable to MCOs participating in the STAR+PLUS Program. Section 8.1.1.1, Performance Evaluation, is modified to include STAR+PLUS Performance Improvement Goals. Section 8.1.2, Covered Services, is modified to include Functionally Necessary Community Long-term Care Services for STAR+PLUS. Section 8.1.2.1 Value-Added Services, is modified to add language allowing for the HMO to distinguish between the Dual Eligible and non-Dual Eligible populations. Section 8.1.2.2 Case-by-Case Added Services, is modified to clarify for STAR+Plus members it is based on functionality. Section 8.1.3, Access to Care, is modified to include STAR+PLUS Functional Necessity and 1915(c) Nursing Facility Waiver clarifications. Section 8.1.4, Provider Network, is modified to include STAR+PLUS. Section 8.1.4.2, Primary Care Providers, is modified to include STAR+PLUS Section 8.1.4.8, Provider Reimbursement, is modified to include Functionally Necessary Long-term care services for STAR+PLUS. Section 8.1.7.7, Provider Profiling, is modified to include STAR+PLUS. Sections 8.1.12 and 8.1.12.2, Services for People with Special Health Care Needs, are modified to include STAR+PLUS. Section 8.1.13, Service Management for Certain Populations, is modified to include STAR+PLUS. Section 8.1.14, Disease Management, is modified to include STAR+PLUS. Section 8.2, Additional Medicaid HMO Scope of Work, is modified to include STAR+PLUS. Section 8.3, Additional STAR+PLUS Scope of Work, is added. Revision 1.2 September 1, 2006 Revised version of Attachment B-1, Section 8, that includes provisions applicable to MCOs participating in the STAR and CHIP Programs. Section 8.1.1.1, Performance Evaluation, is modified to clarify that the HMOs goals are Service Area and Program specific; when the percentages for Goals 1 and 2 are to be negotiated; and when Goal 3 is to be negotiated. Section 8.1.2.1, Value-Added Services, is modified to add language allowing for the addition of two Value-added Services during the Transition Phase of the Contract and to clarify the effective dates for Value Added Services for the Transition Phase and the Operation Phase of the Contract. Section 8.1.3.2, Access to Network Providers, is modified to delete references to Open Panels. Section 8.1.4, Provider Network, is modified to clarify that “Out-of-Network reimbursement arrangements” with certain providers must be in writing. Section 8.1.5.1, Member Materials, is modified to clarify the date that the member ID card and the member handbook are to be sent to members. Section 8.1.5.6, Member Hotline, is modified to clarify the hotline performance requirements. Section 8.1.17.2, Financial Reporting Requirements, is modified to clarify that the Bonus Incentive Plan refers to the Employee Bonus Incentive Plan. It has also been modified to clarify the reports and deliverable due dates and to change the name of the Claims Summary Lag Report and clarify that the report format has been moved to the Uniform Managed Care Manual. Section 8.1.18.5, Claims Processing Requirements, is modified to revise the claims processing requirements and move many of the specifics to the Uniform Managed Care Manual. Section 8.1.20, Reporting Requirements, is modified to clarify the reports and deliverable due dates. Section 8.1.20.2, Reports, is modified to delete the Claims Data Specifications Report, amend the All Claims Summary Report, and add two new provider-related reports to the contract. Section 8.2.2.10, Cooperation with Immunization Registry, is added to comply with legislation, SB 1188 sec. 6(e)(1), 79th Legislature, Regular Session, 2005. Section 8.2.2.11, Case Management for Children and Pregnant Women, is added. Section 8.2.5.1, Provider Complaints, is modified to include the 30-day resolution requirement. Section 8.2.10.2, Non-Reimbursed Arrangements with Local Public Health Entities, is modified to update the requirements and delete the requirement for an MOU. Section 8.2.11, Coordination with Other State Health and Human Services (HHS) Programs, is modified to update the requirements and delete the requirement for an MOU. Section 8.4.2, CHIP Provider Complaint and Appeals, is modified to include the 30-day resolution requirement.

Post-Transition. The HMO will work with HHSC, Providers, and Members to promptly identify and resolve problems identified after the Operational Start Date and to communicate to HHSC, Providers, and Members, as applicable, the steps the HMO is taking to resolve the problems. If a HMO makes assurances to HHSC of its readiness to meet Contract requirements, including MIS and operational requirements, but fails to satisfy requirements set forth in this Section, or as otherwise required pursuant to the Contract, HHSC may, at its discretion do any of the following in accordance with the severity of the non-compliance and the potential impact on Members and Providers: 1. freeze enrollment into the HMO’s plan for the affected HMO Program(s) and Service Area(s); 2. freeze enrollment into the HMO’s plan for all HMO Programs or for all Service Areas of an affected HMO Program; 3. impose contractual remedies, including liquidated damages; or 4. pursue other equitable, injunctive, or regulatory relief. Refer to Attachment B-1, Sections 8.1.1.2 and 8.1.18 for additional information regarding HMO Readiness Reviews during the Operations Phase. SubjectContractual Document (CD) Responsible Office: Attachment B-1 - HHSC Joint Mediciad/XXXX XXX RFP, Section 8 Office of General Counsel (OGC) Version 1.6 STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a Initial version Attachment B-1, Section 8 Revision 1.1 June 30, 2006 Revised version of the Attachment B-1, Section 8, that includes provisions applicable to MCOs participating in the STAR+PLUS Program. Section 8.1.1.1, Performance Evaluation, is modified to include STAR+PLUS Performance Improvement Goals. Section 8.1.2, Covered Services, is modified to include Functionally Necessary Community Long-term Care Services for STAR+PLUS. Section 8.1.2.1 Value-Added Services, is modified to add language allowing for the HMO to distinguish between the Dual Eligible and non-Dual Eligible populations. Section 8.1.2.2 Case-by-Case Added Services, is modified to clarify for STAR+Plus members it is based on functionality. Section 8.1.3, Access to Care, is modified to include STAR+PLUS Functional Necessity and 1915(c) Nursing Facility Waiver clarifications. Section 8.1.4, Provider Network, is modified to include STAR+PLUS. Section 8.1.4.2, Primary Care Providers, is modified to include STAR+PLUS Section 8.1.4.8, Provider Reimbursement, is modified to include Functionally Necessary Long-term care services for STAR+PLUS. Section 8.1.7.7, Provider Profiling, is modified to include STAR+PLUS. Sections 8.1.12 and 8.1.12.2, Services for People with Special Health Care Needs, are modified to include STAR+PLUS. Section 8.1.13, Service Management for Certain Populations, is modified to include STAR+PLUS. Section 8.1.14, Disease Management, is modified to include STAR+PLUS. Section 8.2, Additional Medicaid HMO Scope of Work, is modified to include STAR+PLUS. Section 8.3, Additional STAR+PLUS Scope of Work, is added. Revision 1.2 September 1, 2006 Revised version of Attachment B-1, Section 8, that includes provisions applicable to MCOs participating in the STAR and CHIP Programs. Section 8.1.1.1, Performance Evaluation, is modified to clarify that the HMOs goals are Service Area and Program specific; when the percentages for Goals 1 and 2 are to be negotiated; and when Goal 3 is to be negotiated. Section 8.1.2.1, Value-Added Services, is modified to add language allowing for the addition of two Value-added Services during the Transition Phase of the Contract and to clarify the effective dates for Value Added Services for the Transition Phase and the Operation Phase of the Contract. Section 8.1.3.2, Access to Network Providers, is modified to delete references to Open Panels. Section 8.1.4, Provider Network, is modified to clarify that “Out-of-Network reimbursement arrangements” with certain providers must be in writing. Section 8.1.5.1, Member Materials, is modified to clarify the date that the member ID card and the member handbook are to be sent to members. Section 8.1.5.6, Member Hotline, is modified to clarify the hotline performance requirements. Section 8.1.17.2, Financial Reporting Requirements, is modified to clarify that the Bonus Incentive Plan refers to the Employee Bonus Incentive Plan. It has also been modified to clarify the reports and deliverable due dates and to change the name of the Claims Summary Lag Report and clarify that the report format has been moved to the Uniform Managed Care Manual. Section 8.1.18.5, Claims Processing Requirements, is modified to revise the claims processing requirements and move many of the specifics to the Uniform Managed Care Manual. Section 8.1.20, Reporting Requirements, is modified to clarify the reports and deliverable due dates. Section 8.1.20.2, Reports, is modified to delete the Claims Data Specifications Report, amend the All Claims Summary Report, and add two new provider-related reports to the contract. Section 8.2.2.10, Cooperation with Immunization Registry, is added to comply with legislation, SB 1188 sec. 6(e)(1), 79th Legislature, Regular Session, 2005. Section 8.2.2.11, Case Management for Children and Pregnant Women, is added. Section 8.2.5.1, Provider Complaints, is modified to include the 30-day resolution requirement. Section 8.2.10.2, Non-Reimbursed Arrangements with Local Public Health Entities, is modified to update the requirements and delete the requirement for an MOU. Section 8.2.11, Coordination with Other State Health and Human Services (HHS) Programs, is modified to update the requirements and delete the requirement for an MOU. Section 8.4.2, CHIP Provider Complaint and Appeals, is modified to include the 30-day resolution requirement.

Post-Transition. The HMO will work with HHSC, Providers, and Members to promptly identify and resolve problems identified after the Operational Start Date and to communicate to HHSC, Providers, and Members, as applicable, the steps the HMO is taking to resolve the problems. If a HMO makes assurances to HHSC of its readiness to meet Contract requirements, including MIS and operational requirements, but fails to satisfy requirements set forth in this Section, or as otherwise required pursuant to the Contract, HHSC may, at its discretion do any of the following in accordance with the severity of the non-compliance and the potential impact on Members and Providers: 1. freeze enrollment into the HMO’s plan for the affected HMO Program(s) and Service Area(s); 2. freeze enrollment into the HMO’s plan for all HMO Programs or for all Service Areas of an affected HMO Program; 3. impose contractual remedies, including liquidated damages; or 4. pursue other equitable, injunctive, or regulatory relief. Refer to Attachment B-1, Sections 8.1.1.2 and 8.1.18 for additional information regarding HMO Readiness Reviews during the Operations Phase. Responsible Office: HHSC Office of General Counsel (OGC) Subject: Attachment B-1 - – HHSC Joint MediciadMedicaid/XXXX XXX CHIP HMO RFP, Section 8 Version 1.7 STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a Initial version Attachment B-1, Section 8 Revision 1.1 June 30, 2006 Revised version of the Attachment B-1, Section 8, that includes provisions applicable to MCOs participating in the STAR+PLUS Program. Section 8.1.1.1, Performance Evaluation, is modified to include STAR+PLUS Performance Improvement Goals. Section 8.1.2, Covered Services, is modified to include Functionally Necessary Community Long-term Care Services for STAR+PLUS. Section 8.1.2.1 Value-Added Services, is modified to add language allowing for the HMO to distinguish between the Dual Eligible and non-Dual Eligible populations. Section 8.1.2.2 Case-by-Case Added Services, is modified to clarify for STAR+Plus members it is based on functionality. Section 8.1.3, Access to Care, is modified to include STAR+PLUS Functional Necessity and 1915(c) Nursing Facility Waiver clarifications. Section 8.1.4, Provider Network, is modified to include STAR+PLUS. Section 8.1.4.2, Primary Care Providers, is modified to include STAR+PLUS Section 8.1.4.8, Provider Reimbursement, is modified to include Functionally Necessary Long-term care services for STAR+PLUS. Section 8.1.7.7, Provider Profiling, is modified to include STAR+PLUS. Sections 8.1.12 and 8.1.12.2, Services for People with Special Health Care Needs, are modified to include STAR+PLUS. Section 8.1.13, Service Management for Certain Populations, is modified to include STAR+PLUS. Section 8.1.14, Disease Management, is modified to include STAR+PLUS. Section 8.2, Additional Medicaid HMO Scope of Work, is modified to include STAR+PLUS. Section 8.3, Additional STAR+PLUS Scope of Work, is added. Revision 1.2 September 1, 2006 Revised version of Attachment B-1, Section 8, that includes provisions applicable to MCOs participating in the STAR and CHIP Programs. Section 8.1.1.1, Performance Evaluation, is modified to clarify that the HMOs goals are Service Area and Program specific; when the percentages for Goals 1 and 2 are to be negotiated; and when Goal 3 is to be negotiated. Responsible Office: HHSC Office of General Counsel (OGC) Subject: Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8 Version 1.7 STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Section 8.1.2.1, Value-Added Services, is modified to add language allowing for the addition of two Value-added Services during the Transition Phase of the Contract and to clarify the effective dates for Value Added Services for the Transition Phase and the Operation Phase of the Contract. Section 8.1.3.2, Access to Network Providers, is modified to delete references to Open Panels. Section 8.1.4, Provider Network, is modified to clarify that “Out-of-of- Network reimbursement arrangements” with certain providers must be in writing. Section 8.1.5.1, Member Materials, is modified to clarify the date that the member ID card and the member handbook are to be sent to members. Section 8.1.5.6, Member Hotline, is modified to clarify the hotline performance requirements. Section 8.1.17.2, Financial Reporting Requirements, is modified to clarify that the Bonus Incentive Plan refers to the Employee Bonus Incentive Plan. It has also been modified to clarify the reports and deliverable due dates and to change the name of the Claims Summary Lag Report and clarify that the report format has been moved to the Uniform Managed Care Manual. Section 8.1.18.5, Claims Processing Requirements, is modified to revise the claims processing requirements and move many of the specifics to the Uniform Managed Care Manual. Section 8.1.20, Reporting Requirements, is modified to clarify the reports and deliverable due dates. Section 8.1.20.2, Reports, is modified to delete the Claims Data Specifications Report, amend the All Claims Summary Report, and add two new provider-related reports to the contract. Section 8.2.2.10, Cooperation with Immunization Registry, is added to comply with legislation, SB 1188 sec. 6(e)(1), 79th Legislature, Regular Session, 2005. Section 8.2.2.11, Case Management for Children and Pregnant Women, is added. Section 8.2.5.1, Provider Complaints, is modified to include the 30-30- day resolution requirement. Section 8.2.10.2, Non-Reimbursed Arrangements with Local Public Health Entities, is modified to update the requirements and delete the requirement for an MOU. Section 8.2.11, Coordination with Other State Health and Human Services (HHS) Programs, is modified to update the requirements and delete the requirement for an MOU. Section 8.4.2, CHIP Provider Complaint and Appeals, is modified to include the 30-day resolution requirement.. Revision 1.3 September 1, 2006 Revised version of Attachment B-1, Section 8, that includes provisions applicable to MCOs participating in the CHIP Perinatal Program. Responsible Office: HHSC Office of General Counsel (OGC) Subject: Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8 Version 1.7 STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3