Common use of State Monitoring Clause in Contracts

State Monitoring. A. DHCS Monitoring Reviews and Financial Audits of Contractor DHCS shall monitor the Contractor’s operations for compliance with the provisions of this Intergovernmental Agreement and applicable federal and state law and regulations, including 42 CFR 438.66, 42 CFR 438.200, 42 CFR 438.202, 42 CFR 438.204, and 42 CFR 438.6(g). Such monitoring activities shall include, but not be limited to, inspection and auditing of Contractor services, management systems and procedures, and books and records, as DHCS deems appropriate, at any time during the Contractor's or facility's normal business hours. When monitoring activities identify areas of non- compliance, DHCS shall issue reports to the Contractor detailing findings, recommendations, and corrective action. DHCS shall specifically monitor the following in accordance with 42 CFR 438.66: 1) Beneficiary enrollment and disenrollment 2) Processing of grievances and appeals 3) Violations subject to intermediate sanctions 4) Violations of the conditions for FFP 5) All other provisions of the Agreement, as appropriate. B. DHCS Imposition of Sanctions Upon the Contractor 1) Pursuant to 42 CFR 438.700, DHCS may impose sanctions upon the Contractor if DCHS makes any of the following determinations: a) The Contractor acted or failed to act as follows: i. Fails substantially to provide medically necessary services that the Contractor is required to provide, under law or under its Intergovernmental Agreement with DHCS, to a beneficiary covered under the Intergovernmental Agreement. ii. Imposes on beneficiaries premiums or charges that are in excess of the premiums or charges permitted under the Medicaid program. iii. Acts to discriminate among beneficiaries on the basis of their health status or need for health care services. This includes termination of enrollment or refusal to reenroll a beneficiary, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by beneficiaries whose medical condition or history indicates probable need for substantial future medical services. iv. Misrepresents or falsifies information that it furnishes to CMS or to DHCS. v. Misrepresents or falsifies information that it furnishes to a beneficiary, potential beneficiary, or health care provider. 2) DHCS may base its determinations of violations on findings from onsite surveys, enrollee or other complaints, financial status, or any other source. 3) The types of intermediate sanctions that DHCS may impose upon the Contractor the above listed violations include the following: a) Civil money penalties in the amounts specified in 42 CFR §438.704. b) Suspension of payment for beneficiaries enrolled after the effective date of the sanction and until CMS or DHCS is satisfied that the reason for imposition of the sanction no longer exists and is not likely to recur. 4) DHCS retains authority to impose additional sanctions under State statutes or State regulations that address areas of noncompliance specified in 42 CFR §438.700, as well as additional areas of noncompliance. Nothing in this subsection prevents DHCS from exercising that authority. C. Postservice Postpayment Utilization Reviews 1) After the DMC services have been rendered and paid, DHCS shall conduct Postservice Postpayment (PSPP) Utilization Reviews of the subcontracted DMC providers to determine whether the DMC services were provided in accordance with Title 22, Section 51341.1. DHCS shall issue the PSPP report to the Contractor with a copy to subcontracted DMC provider. The Contractor shall be responsible for their subcontracted providers and their Contractor-run programs to ensure any deficiencies are remediated pursuant to Sections 1 and 2 herein. The Contractor shall attest the deficiencies have been remediated and are complete, pursuant to Section 23.1 (E). 2) State shall take appropriate steps in accordance with Title 22, CCR, Section 51341.1 to recover payments made if subsequent investigation uncovers evidence that the claim(s) should not have been paid or that DMC services have been improperly utilized, and/or shall take the corrective action as appropriate. If programmatic or fiscal deficiencies are identified, the Provider shall be required to submit a Corrective Action Plan (CAP) to the Contractor for review and approval prior to submission to DHCS for final approval. a) Pursuant to CCR, Title 22, Section 51341.1(o), all deficiencies identified by the PSPP review, whether or not a recovery of funds results, must be corrected and the entity that provided the services must submit a Contractor-approved CAP to the PSPP Unit within 60 days of the date of the PSPP report. i. The plan shall: a. Address each demand for recovery of payment and/or programmatic deficiency; b. Provide a specific description of how the deficiency shall be corrected; c. Specify the date of implementation of the corrective action; and d. Identify who will be responsible for correction and who will be responsible for on-going compliance. ii. DHCS shall provide written approval of the CAP to the Contractor with a copy to the Provider. If DHCS does not approve the CAP, DHCS shall provide guidance on the deficient areas and request an updated CAP from the Contractor with a copy to the Provider. The entity that provided the services must submit an updated CAP to the DMC PSPP Unit within 30 days of notification. iii. If the entity that provided the services, does not submit a CAP, or, does not implement the approved CAP provisions within the designated timeline, then DHCS may withhold funds from the Contractor until the entity that provided the services is in compliance with Exhibit A, Attachment I, Section 23.1 (E). DHCS shall inform the Contractor when funds shall be withheld. 3) Contractor and/or subcontractor may appeal DMC dispositions concerning demands for recovery of payment and/or programmatic deficiencies of specific claims. Such appeals shall be handled pursuant to Title 22, CCR, Section 51341.1(q). This section shall not apply to those grievances or complaints arising from the financial findings of an audit or examination made by or on behalf of DHCS pursuant to Exhibit B, Part II, Section 3, of this Contract. 4) State shall monitor the subcontractor’s compliance with PSPP utilization review requirements in accordance with Title 22. Counties are also required to monitor of the subcontractor’s compliance pursuant to Section 23 (C), of this Intergovernmental Agreement. The federal government may also review the existence and effectiveness of DHCS’s utilization review system. 5) Contractor shall implement and maintain compliance with the system of review described in Title 22, Section 51341.1, for the purposes of reviewing the utilization, quality, and appropriateness of covered services and ensuring that all applicable Medi-Cal requirements are met. 6) Contractor shall assure that subcontractor sites must keep a record of the beneficiaries/patients being treated at that location. Contractor shall retain beneficiary records for a minimum of three (3) years from the date of the last face- to-face contact. When an audit by the Federal Government or DHCS has been started before the expiration of the three-year period, the beneficiary records shall be maintained until completion of the audit and the final resolution of all issues as a result of the audit.

State Monitoring. A. DHCS Monitoring Reviews and Financial Audits of Contractor DHCS shall monitor the Contractor’s operations for compliance with the provisions of this Intergovernmental Agreement and applicable federal and state law and regulations, including 42 CFR 438.66, 42 CFR 438.200, 42 CFR 438.202, 42 CFR 438.204, and 42 CFR 438.6(g). Such monitoring activities shall include, but not be limited to, inspection and auditing of Contractor services, management systems and procedures, and books and records, as DHCS deems appropriate, at any time during the Contractor's or facility's normal business hours. When monitoring activities identify areas of non- compliance, DHCS shall issue reports to the Contractor detailing findings, recommendations, and corrective action. DHCS shall specifically monitor the following in accordance with 42 CFR 438.66: 1) Beneficiary enrollment and disenrollment 2) Processing of grievances and appeals 3) Violations subject to intermediate sanctions 4) Violations of the conditions for FFP 5) All other provisions of the Agreement, as appropriate. B. DHCS Imposition of Sanctions Upon the Contractor 1) Pursuant to 42 CFR 438.700, DHCS may impose sanctions upon the Contractor if DCHS makes any of the following determinations: a) The Contractor acted or failed to act as follows: i. Fails substantially to provide medically necessary services that the Contractor is required to provide, under law or under its Intergovernmental Agreement with DHCS, to a beneficiary covered under the Intergovernmental Agreement. ii. Imposes on beneficiaries premiums or charges that are in excess of the premiums or charges permitted under the Medicaid program. iii. Acts to discriminate among beneficiaries on the basis of their health status or need for health care services. This includes termination of enrollment or refusal to reenroll a beneficiary, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by beneficiaries whose medical condition or history indicates probable need for substantial future medical services. iv. Misrepresents or falsifies information that it furnishes to CMS or to DHCS. v. Misrepresents or falsifies information that it furnishes to a beneficiary, potential beneficiary, or health care provider. 2) DHCS may base its determinations of violations on findings from onsite surveys, enrollee or other complaints, financial status, or any other source. 3) The types of intermediate sanctions that DHCS may impose upon the Contractor the above listed violations include the following: a) Civil money penalties in the amounts specified in 42 CFR §438.704. b) Suspension of payment for beneficiaries enrolled after the effective date of the sanction and until CMS or DHCS is satisfied that the reason for imposition of the sanction no longer exists and is not likely to recur. 4) DHCS retains authority to impose additional sanctions under State statutes or State regulations that address areas of noncompliance specified in 42 CFR §438.700, as well as additional areas of noncompliance. Nothing in this subsection prevents DHCS from exercising that authority. C. Postservice Postpayment Utilization Reviews 1) After the DMC services have been rendered and paid, DHCS shall conduct Postservice Postpayment (PSPP) Utilization Reviews of the subcontracted DMC providers to determine whether the DMC services were provided in accordance with Title 22, Section 51341.1. DHCS shall issue the PSPP report to the Contractor with a copy to subcontracted DMC provider. The Contractor shall be responsible for their subcontracted providers and their Contractor-run programs to ensure any deficiencies are remediated pursuant to Sections 1 and 2 herein. The Contractor shall attest the deficiencies have been remediated and are complete, pursuant to Section 23.1 (E). 2) State shall take appropriate steps in accordance with Title 22, CCR, Section 51341.1 to recover payments made if subsequent investigation uncovers evidence that the claim(s) should not have been paid or that DMC services have been improperly utilized, and/or shall take the corrective action as appropriate. If programmatic or fiscal deficiencies are identified, the Provider shall be required to submit a Corrective Action Plan (CAP) to the Contractor for review and approval prior to submission to DHCS for final approval. a) Pursuant to CCR, Title 22, Section 51341.1(o), all deficiencies identified by the PSPP review, whether or not a recovery of funds results, must be corrected and the entity that provided the services must submit a Contractor-approved CAP to the PSPP Unit within 60 days of the date of the PSPP report. i. The plan shall: a. Address each demand for recovery of payment and/or programmatic deficiency; b. Provide a specific description of how the deficiency shall be corrected; c. Specify the date of implementation of the corrective action; and d. Identify who will be responsible for correction and who will be responsible for on-going compliance. ii. DHCS shall provide written approval of the CAP to the Contractor with a copy to the Provider. If DHCS does not approve the CAP, DHCS shall provide guidance on the deficient areas and request an updated CAP from the Contractor with a copy to the Provider. The entity that provided the services must submit an updated CAP to the DMC PSPP Unit within 30 days of notification. iii. If the entity that provided the services, does not submit a CAP, or, does not implement the approved CAP provisions within the designated timeline, then DHCS may withhold funds from the Contractor until the entity that provided the services is in compliance with Exhibit A, Attachment I, Section 23.1 (E). DHCS shall inform the Contractor when funds shall be withheld. 3) Contractor and/or subcontractor may appeal DMC dispositions concerning demands for recovery of payment and/or programmatic deficiencies of specific claims. Such appeals shall be handled pursuant to Title 22, CCR, Section 51341.1(q). This section shall not apply to those grievances or complaints arising from the financial findings of an audit or examination made by or on behalf of DHCS pursuant to Exhibit B, Part II, Section 3, of this Contract. 4) State shall monitor the subcontractor’s compliance with PSPP utilization review requirements in accordance with Title 22. Counties are also required to monitor of the subcontractor’s compliance pursuant to Section 23 (C), of this Intergovernmental Agreement. The federal government may also review the existence and effectiveness of DHCS’s utilization review system. 5) Contractor shall implement and maintain compliance with the system of review described in Title 22, Section 51341.1, for the purposes of reviewing the utilization, quality, and appropriateness of covered services and ensuring that all applicable Medi-Cal requirements are met. 6) Contractor shall assure that subcontractor sites must keep a record of the beneficiaries/patients being treated at that location. Contractor shall retain beneficiary records for a minimum of three (3) years from the date of the last face- to-face contact. When an audit by the Federal Government or DHCS has been started before the expiration of the three-year period, the beneficiary records shall be maintained until completion of the audit and the final resolution of all issues as a result of the audit.

State Monitoring. A. DHCS Monitoring Reviews and Financial Audits of Contractor DHCS shall monitor the Contractor’s operations for compliance with the provisions of this Intergovernmental Agreement and applicable federal and state law and regulations, including 42 CFR 438.66, 42 CFR 438.200, 42 CFR 438.202, 42 CFR 438.204, and 42 CFR 438.6(g). Such monitoring activities shall include, but not be limited to, inspection and auditing of Contractor services, management systems and procedures, and books and records, as DHCS deems appropriate, at any time during the Contractor's or facility's normal business hours. When monitoring activities identify areas of non- compliance, DHCS shall issue reports to the Contractor detailing findings, recommendations, and corrective action. DHCS shall specifically monitor the following in accordance with 42 CFR 438.66: 1) Beneficiary enrollment and disenrollment 2) Processing of grievances and appeals 3) Violations subject to intermediate sanctions 4) Violations of the conditions for FFP 5) All other provisions of the Agreement, as appropriate. B. DHCS Imposition of Sanctions Upon the Contractor 1) Pursuant to 42 CFR 438.700, DHCS may impose sanctions upon the Contractor if DCHS makes any of the following determinations: a) The Contractor acted or failed to act as follows: i. Fails substantially to provide medically necessary services that the Contractor is required to provide, under law or under its Intergovernmental Agreement with DHCS, to a beneficiary covered under the Intergovernmental Agreement. ii. Imposes on beneficiaries premiums or charges that are in excess of the premiums or charges permitted under the Medicaid program. iii. Acts to discriminate among beneficiaries on the basis of their health status or need for health care services. This includes termination of enrollment or refusal to reenroll a beneficiary, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by beneficiaries whose medical condition or history indicates probable need for substantial future medical services. iv. Misrepresents or falsifies information that it furnishes to CMS or to DHCS. v. Misrepresents or falsifies information that it furnishes to a beneficiary, potential beneficiary, or health care provider. 2) DHCS may base its determinations of violations on findings from onsite surveys, enrollee or other complaints, financial status, or any other source. 3) The types of intermediate sanctions that DHCS may impose upon the Contractor the above listed violations include the following: a) Civil money penalties in the amounts specified in 42 CFR §438.704. b) Suspension of payment for beneficiaries enrolled after the effective date of the sanction and until CMS or DHCS is satisfied that the reason for imposition of the sanction no longer exists and is not likely to recur. 4) DHCS retains authority to impose additional sanctions under State statutes or State regulations that address areas of noncompliance specified in 42 CFR §438.700, as well as additional areas of noncompliance. Nothing in this subsection prevents DHCS from exercising that authority. C. Postservice Postpayment Utilization Reviews 1) After the DMC services have been rendered and paid, DHCS shall conduct Postservice Postpayment (PSPP) Utilization Reviews of the subcontracted DMC providers to determine whether the DMC services were provided in accordance with Title 22, Section 51341.1. DHCS shall issue the PSPP report to the Contractor with a copy to subcontracted DMC provider. The Contractor shall be responsible for their subcontracted providers and their Contractor-run programs to ensure any deficiencies are remediated pursuant to Sections 1 and 2 herein. The Contractor shall attest the deficiencies have been remediated and are complete, pursuant to Section 23.1 (E). 2) State shall take appropriate steps in accordance with Title 22, CCR, Section 51341.1 to recover payments made if subsequent investigation uncovers evidence that the claim(s) should not have been paid or that DMC services have been improperly utilized, and/or shall take the corrective action as appropriate. If programmatic or fiscal deficiencies are identified, the Provider shall be required to submit a Corrective Action Plan (CAP) to the Contractor for review and approval prior to submission to DHCS for final approval. a) Pursuant to CCR, Title 22, Section 51341.1(o), all deficiencies identified by the PSPP review, whether or not a recovery of funds results, must be corrected and the entity that provided the services must submit a Contractor-approved CAP to the PSPP Unit within 60 days of the date of the PSPP report. i. The plan shall: a. Address each demand for recovery of payment and/or programmatic deficiency; b. Provide a specific description of how the deficiency shall be corrected; c. Specify the date of implementation of the corrective action; and d. Identify who will be responsible for correction and who will be responsible for on-going compliance. ii. DHCS shall provide written approval of the CAP to the Contractor with a copy to the Provider. If DHCS does not approve the CAP, DHCS shall provide guidance on the deficient areas and request an updated CAP from the Contractor with a copy to the Provider. The entity that provided the services must submit an updated CAP to the DMC PSPP Unit within 30 days of notification. iii. If the entity that provided the services, does not submit a CAP, or, does not implement the approved CAP provisions within the designated timeline, then DHCS may withhold funds from the Contractor until the entity that provided the services is in compliance with Exhibit A, Attachment I, Section 23.1 (E). DHCS shall inform the Contractor when funds shall be withheld. 3) Contractor and/or subcontractor may appeal DMC dispositions concerning demands for recovery of payment and/or programmatic deficiencies of specific claims. Such appeals shall be handled pursuant to Title 22, CCR, Section 51341.1(q). This section shall not apply to those grievances or complaints arising from the financial findings of an audit or examination made by or on behalf of DHCS pursuant to Exhibit B, Part II, Section 3, of this Contract. 4) State shall monitor the subcontractor’s compliance with PSPP utilization review requirements in accordance with Title 22. Counties are also required to monitor of the subcontractor’s compliance pursuant to Section 23 (C), of this Intergovernmental Agreement. The federal government may also review the existence and effectiveness of DHCS’s utilization review system. 5) Contractor shall implement and maintain compliance with the system of review described in Title 22, Section 51341.1, for the purposes of reviewing the utilization, quality, and appropriateness of covered services and ensuring that all applicable Medi-Cal requirements are met. 6) Contractor shall assure that subcontractor sites must keep a record of the beneficiaries/patients being treated at that location. Contractor shall retain beneficiary records for a minimum of three (3) years from the date of the last face- to-face contact. When an audit by the Federal Government or DHCS has been started before the expiration of the three-year period, the beneficiary records shall be maintained until completion of the audit and the final resolution of all issues as a result of the audit.

State Monitoring. A. DHCS Monitoring Reviews and Financial Audits of Contractor DHCS shall monitor the Contractor’s operations for compliance with the provisions of this Intergovernmental Agreement and applicable federal and state law and regulations, including 42 CFR 438.66, 42 CFR 438.200, 42 CFR 438.202, 42 CFR 438.204, and 42 CFR 438.6(g). Such monitoring activities shall include, but not be limited to, inspection and auditing of Contractor services, management systems and procedures, and books and records, as DHCS deems appropriate, at any time during the Contractor's or facility's normal business hours. When monitoring activities identify areas of non- non­ compliance, DHCS shall issue reports to the Contractor detailing findings, recommendations, and corrective action. DHCS shall specifically monitor the following in accordance with 42 CFR 438.66: 1) Beneficiary enrollment and disenrollment 2) Processing of grievances and appeals 3) Violations subject to intermediate sanctions 4) Violations of the conditions for FFP 5) All other provisions of the Agreement, as appropriate. B. DHCS Imposition of Sanctions Upon the Contractor 1) Pursuant to 42 CFR 438.700, DHCS may impose sanctions upon the Contractor if DCHS makes any of the following determinations: a) The Contractor acted or failed to act as follows: i. Fails substantially to provide medically necessary services that the Contractor is required to provide, under law or under its Intergovernmental Agreement with DHCS, to a beneficiary covered under the Intergovernmental Agreement. ii. Imposes on beneficiaries premiums or charges that are in excess of the premiums or charges permitted under the Medicaid program. iii. Acts to discriminate among beneficiaries on the basis of their health status or need for health care services. This includes termination of enrollment or refusal to reenroll a beneficiary, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by beneficiaries whose medical condition or history indicates probable need for substantial future medical services. iv. Misrepresents or falsifies information that it furnishes to CMS or to DHCS. v. Misrepresents or falsifies information that it furnishes to a beneficiary, potential beneficiary, or health care provider. 2) DHCS may base its determinations of violations on findings from onsite surveys, enrollee or other complaints, financial status, or any other source. 3) The types of intermediate sanctions that DHCS may impose upon the Contractor the above listed violations include the following: a) Civil money penalties in the amounts specified in 42 CFR §438.704. b) Suspension of payment for beneficiaries enrolled after the effective date of the sanction and until CMS or DHCS is satisfied that the reason for imposition of the sanction no longer exists and is not likely to recur. 4) DHCS retains authority to impose additional sanctions under State statutes or State regulations that address areas of noncompliance specified in 42 CFR §438.700, as well as additional areas of noncompliance. Nothing in this subsection prevents DHCS from exercising that authority. C. Postservice Postpayment Utilization Reviews 1) After the DMC services have been rendered and paid, DHCS shall conduct Postservice Postpayment (PSPP) Utilization Reviews of the subcontracted DMC providers to determine whether the DMC services were provided in accordance with Title 22, Section 51341.1. DHCS shall issue the PSPP report to the Contractor with a copy to subcontracted DMC provider. The Contractor shall be responsible for their subcontracted providers and their Contractor-run programs to ensure any deficiencies are remediated pursuant to Sections 1 and 2 herein. The Contractor shall attest the deficiencies have been remediated and are complete, pursuant to Section 23.1 (E). 2) State shall take appropriate steps in accordance with Title 22, CCR, Section 51341.1 to recover payments made if subsequent investigation uncovers evidence that the claim(s) should not have been paid or that DMC services have been improperly utilized, and/or shall take the corrective action as appropriate. If programmatic or fiscal deficiencies are identified, the Provider shall be required to submit a Corrective Action Plan (CAP) to the Contractor for review and approval prior to submission to DHCS for final approval. a) Pursuant to CCR, Title 22, Section 51341.1(o), all deficiencies identified by the PSPP review, whether or not a recovery of funds results, must be corrected and the entity that provided the services must submit a Contractor-approved CAP to the PSPP Unit within 60 days of the date of the PSPP report. i. The plan shall: a. Address each demand for recovery of payment and/or programmatic deficiency; b. Provide a specific description of how the deficiency shall be corrected; c. Specify the date of implementation of the corrective action; and d. Identify who will be responsible for correction and who will be responsible for on-going compliance. ii. DHCS shall provide written approval of the CAP to the Contractor with a copy to the Provider. If DHCS does not approve the CAP, DHCS shall provide guidance on the deficient areas and request an updated CAP from the Contractor with a copy to the Provider. The entity that provided the services must submit an updated CAP to the DMC PSPP Unit within 30 days of notification. iii. If the entity that provided the services, does not submit a CAP, or, does not implement the approved CAP provisions within the designated timeline, then DHCS may withhold funds from the Contractor until the entity that provided the services is in compliance with Exhibit A, Attachment I, Section 23.1 (E). DHCS shall inform the Contractor when funds shall be withheld. 3) Contractor and/or subcontractor may appeal DMC dispositions concerning demands for recovery of payment and/or programmatic deficiencies of specific claims. Such appeals shall be handled pursuant to Title 22, CCR, Section 51341.1(q). This section shall not apply to those grievances or complaints arising from the financial findings of an audit or examination made by or on behalf of DHCS pursuant to Exhibit B, Part II, Section 3, of this Contract. 4) State shall monitor the subcontractor’s compliance with PSPP utilization review requirements in accordance with Title 22. Counties are also required to monitor of the subcontractor’s compliance pursuant to Section 23 (C), of this Intergovernmental Agreement. The federal government may also review the existence and effectiveness of DHCS’s utilization review system. 5) Contractor shall implement and maintain compliance with the system of review described in Title 22, Section 51341.1, for the purposes of reviewing the utilization, quality, and appropriateness of covered services and ensuring that all applicable Medi-Cal requirements are met. 6) Contractor shall assure that subcontractor sites must keep a record of the beneficiaries/patients being treated at that location. Contractor shall retain beneficiary records for a minimum of three (3) years from the date of the last face- face­ to-face contact. When an audit by the Federal Government or DHCS has been started before the expiration of the three-year period, the beneficiary records shall be maintained until completion of the audit and the final resolution of all issues as a result of the audit.