EXHIBIT 10.13
CONTRACT BETWEEN
THE OFFICE OF MEDICAID POLICY AND PLANNING,
THE OFFICE OF THE CHILDREN'S HEALTH INSURANCE PROGRAM
AND
HARMONY HEALTH PLAN OF ILLINOIS, INC.
This Contract is made and entered into by and between the State of Indiana
(hereinafter "State" or "State of Indiana"), through the Office of Medicaid
Policy and Planning and the Office of Children's Health Insurance Program
(hereinafter "the Offices"), of the Indiana Family and Social Services
Administration, 000 Xxxx Xxxxxxxxxx Xxxxxx, X000, Xxxxxxxxxxxx, Xxxxxxx, and
Harmony Health Plan of Illinois, Inc., 000 Xxxxx Xxxxxx Xxxxx, Xxxxx 0000,
Xxxxxxx, Xxxxxxxx, doing business as Harmony Health Plan of Indiana,
(hereinafter "Contractor").
WHEREAS, I.C. 12-15-30-1 and I.C. 12-17.6 authorize the Offices to enter
into contracts to assist in the administration of the Indiana Medicaid and the
Indiana Children's Health Insurance Program (CHIP), respectively;
WHEREAS, the State of Indiana desires to contract for services to arrange
for and to administer a risk-based managed care program (RBMC) for certain
Hoosier Healthwise enrollees in Packages A, B and C as procured through BAA 01
-28;
WHEREAS this Contract contains the payment rates under which the
Contractor shall be paid and that these rates have been determined to be
actuarially sound and not in excess of the fee-for-service upper payment limit
(FFS-UPL) specified for risk contracts in 42 CFR 447.361;
WHEREAS, the Contractor is willing and able to perform the desired
services for Hoosier Healthwise Packages A, B and C;
THEREFORE, the parties to this Contract agree that the terms and
conditions specified below will apply to services in connection with this
contract, and such terms and conditions are as follows:
I. TERM AND RENEWAL OPTION
This Contract is effective from January 1, 2001 through December 31, 2002.
At the discretion of the Offices the term may be extended for up to two
additional years. In no event shall the term exceed December 31, 2004.
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II. DEFINITIONS
For the purposes of this contract, terms no defined herein shall be
defined as they are in the documents incorporated in and attached to this
document, subject to the order of precedence spelled out in Section V of this
document.
"Contract" means this document and all documents or standards incorporated
herein, expressly including but not limited to the following documents appended
hereto and listed in chronological order and to be given precedence as described
in Section V of this document, entitled "Order of Precedence":
Attachment 1 - BAA 01 -28,released July 31, 2000;
Attachment 2 - Contractor's response to BAA 01-28, submitted September 25,
2000, excluding the following sections:
Section 5.3.8,
Section 5.4.4, Appendices A, B, C, D, H; Exhibit 5.4.4I;
Exhibit 5.4.4M; Exhibit 5.4.4O;
and,
Any other documents, standards, laws, rules or regulations incorporated by
reference in the above materials, all of which are hereby incorporated by
reference.
"Covered Services" means all services required to be arranged, administered,
managed or provided by or on behalf of the Contractor under this contract.
"Effective Date of Enrollment" means:
- The first day of the birth month of a newborn that is determined by the
Offices to be an enrolled member;
- The fifteenth day of the current month for a member who has, between the
twenty-sixth day of the previous month and the tenth day of the current
month, been determined by the Offices to be an enrolled member; and,
- The first day of the following month for a member who has, between the
eleventh day and the twenty-fifth day of a month, been determined by the
Offices to be an enrolled member.
"Enrolled Member", or "Enrollee", means a Hoosier Healthwise-eligible member
who is listed by the Offices on the enrollment rosters to receive covered
services from the Contractor or its subcontractors, employees, agents, or
providers, as of the Effective Date of Enrollment, under this contract.
"Provider" means a physician, hospital, home health agency or any other
institution, or health or other professional person or entity, which
participates in the provision of services to an enrolled
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member under BAA 01-28, whether as an independent contractor, a subcontractor,
employee, or agent of the Contractor.
"Broad Agency Announcement", or "BAA", means BAA 01-28 for providers of managed
care services, released July 31, 2000.
III. DUTIES OF THE CONTRACTOR
A. The Contractor agrees to assume financial risk for developing and managing
a health care delivery system and for arranging or administering all
Hoosier Healthwise covered services except, as set out in section 3.4.3 of
the BAA, dental care, long-term institutional care, services provided as
part of an individualized education plan (IEP) pursuant to the Individuals
with Disabilities Education Act (IDEA) at 20 U.S.C. 1400 et seq.,
behavioral health, and hospice services, in exchange for a per-enrollee,
per-month fixed fee, to certain enrollees in Hoosier Healthwise Packages
A, B and C. Wards of the State, xxxxxx children and children receiving
adoption assistance may enroll on a voluntary basis and will not be
subject to auto-assignment into the Hoosier Healthwise program. The
Contractor must, at a minimum, furnish covered services up to the limits
specified by the Medicaid and CHIP programs. The Contractor may exceed
these limits. However, in no instance may any covered service's
limitations be more restrictive than those which exist in the Indiana
Medicaid fee-for-service program for Packages A and B, and the Children's
Health Insurance Program for Package C.
B. The Contractor agrees to perform all duties and arrange and administer the
provision of all services as set out herein and contained in the BAA as
attached and the Contractor's responses to the BAA as attached, all of
which are incorporated into this Contract by reference. In addition, the
Contractor shall comply with all policies and procedures defined in any
bulletin, manual, or handbook yet to be distributed by the State or its
agents insofar as those policies and procedures provide further
clarification and are no more restrictive than any policies and procedures
contained in the BAA and any amendments to the BAA. The Contractor agrees
to comply with all pertinent state and federal statutes and regulations in
effect throughout the duration of this Contract and as they may be amended
from time to time.
C. The Contractor agrees that it will not discriminate against individuals
eligible to be covered under this Contract on the basis of health status
or need for health services; and the Contractor may not terminate an
enrollee's enrollment, or act to encourage an enrollee to terminate
his/her enrollment, because of an adverse change in the enrollee's health.
The disenrollment function will be carried out by a State contractor who
is independent of the Contractor; therefore, any request to terminate an
enrollee's enrollment must be approved by the Offices.
D. The Contractor agrees that no services or duties owed by the Contractor
under this Contract will be performed or provided by any person or entity
other than the Contractor, except as contained in written subcontracts or
other legally binding agreements. Prior to entering into
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any such subcontract or other legally binding agreement, the Contractor
shall, in each case, submit the proposed subcontract or other legally
binding agreement to the Offices for prior review and approval. Prior
review and approval of a subcontract or legally binding agreement shall
not be unreasonably delayed by the Offices. The Offices shall, in
appropriate cases and as requested by the Contractor, expedite the review
and approval process. Under no circumstances shall the Contractor be
deemed to have breached its obligations under this Contract if such breach
was a result of the Offices' failure to review and approve timely any
proposed subcontract or other legally binding agreement. If the Offices
disapprove any proposed subcontract or other legally binding agreement,
the Offices shall state with reasonable particularity the basis for such
disapproval. No subcontract into which the Contractor enters with respect
to performance under this Contract shall in any way relieve the Contractor
of any responsibility for the performance of duties under this Contract.
All subcontracts and amendments thereto executed by the Contractor under
this Contract must meet the following requirements; any existing
subcontracts or legally binding agreements which fail to meet the
following requirements shall be revised to include the requirements within
ninety (90) days from the effective date of this Contract:
1. Be in writing and specify the functions of the subcontractor.
2. Be legally binding agreements.
3. Specify the amount, duration and scope of services to be provided by
the subcontractor.
4. Provide that the Offices may evaluate, through inspection or other
means, the quality, appropriateness, and timeliness of services
performed.
5. Provide for inspections of any records pertinent to the contract by
the Offices.
6. Require an adequate record system to be maintained for recording
services, charges, dates and all other commonly accepted information
elements for services rendered to recipients under the contract.
7. Provide for the participation of the Contractor and subcontractor in
any internal and external quality assurance, utilization review,
peer review, and grievance procedures established by the Contractor,
in conjunction with the Offices.
8. Provide that the subcontractor indemnify and hold harmless the State
of Indiana, its officers, and employees from all claims and suits,
including court costs, attorney's fees, and other expenses, brought
because of injuries or damage received or sustained by any person,
persons, or property that is caused by any act or omission of the
Contractor and/or the subcontractors. The State shall not provide
such indemnification to the subcontractor.
9. Identify and incorporate the applicable terms of this Contract and
any incorporated documents. The subcontract shall provide that the
subcontractor
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agrees to perform duties under the subcontract, as those duties
pertain to enrollees, in accordance with the applicable terms and
conditions set out in this Contract, any incorporated documents, and
all applicable state and federal laws, as amended.
E. The Contractor agrees that, during the term of this Contract, it shall
maintain, with any in- network provider rendering health care services
under the BAA, provider service agreements which meet the following
requirements; any existing provider service agreements which fail to meet
the following requirements shall be revised to include the requirements
within ninety (90) days from the effective date of this Contract. The
provider service agreements shall:
1. Identify and incorporate the applicable terms of this Contract and
any incorporated documents. Under the terms of the provider services
agreement, the provider shall agree that the applicable terms and
conditions set out in this Contract, any incorporated documents, and
all applicable state and federal laws, as amended, govern the duties
and responsibilities of the provider with regard to the provision of
services to enrollees.
2. Reference a written provider claim resolution procedure as set out
in section III.Q. below.
F. The Contractor agrees that all laboratory testing sites providing services
under this Contract must have a valid Clinical Laboratory Improvement
Amendments (CLIA) certificate and comply with the CLIA regulations at 42
C.F.R. Part 493.
G. The Contractor agrees that it shall:
1. Retain, at all times during the period of this Contract, a valid
Certificate of Authority under applicable State laws issued by the
State of Indiana Department of Insurance.
2. Ensure that, during the term of this Contract, each provider
rendering health care services under the BAA is authorized to do so
in accordance with the following:
a. The provider must maintain a current Indiana Health Coverage
Programs (IHCP) provider agreement and must be duly licensed
in accordance with the appropriate state licensing board and
shall remain in good standing with said board.
b. If a provider is not authorized to provide such services under
a current IHCP provider agreement or is no longer licensed by
said board, the Contractor is obligated to terminate its
contractual relationship authorizing or requiring such
provider to provide services under the BAA. The Contractor
must terminate its contractual relationship with the provider
as soon as the Contractor has knowledge of the termination of
the provider's license or the IHCP provider agreement.
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3. Comply with the specific requirements for Health Maintenance
Organizations (HMOs) eligible to receive Federal Financial
Participation (FFP) under Medicaid, as listed in the State
Organization and General Administration Chapter of the Health Care
Financing Administration (HCFA) Medicaid Manual. These requirements
include, but are not limited to the following:
a. The Contractor shall meet the definition of HMO as specified
in the Indiana State Medicaid Plan.
b. Throughout the duration of this Contract, the Contractor shall
satisfy the Chicago Regional Office of the Health Care
Financing Authority (hereinafter called HCFA) that the
Contractor is compliant with the Federal requirements for
protection against insolvency pursuant to 42 CFR 434.20(c)(3)
and 434.50(a), the requirement that the Contractor shall
continue to provide services to Contractor enrollees until the
end of the month in which insolvency has occurred, and the
requirement that the Contractor shall continue to provide
inpatient services until the date of discharge for an enrollee
who is institutionalized when insolvency occurs. The
Contractor shall meet this requirement by posting a
performance bond pursuant to Section VII, paragraph C, of this
Contract, and satisfying the statutory reserve requirements of
the Indiana Department of Insurance.
c. The Contractor shall comply with, and shall exclude from
participation as either a provider or subcontractor of the
Contractor, any entity or person that has been excluded under
the authority of Sections 1124A, 1128 or 1128A of the Social
Security Act or does not comply with the requirements of
Section 1128(b) of the Social Security Act.
d. In the event that the HCFA determines that the Contractor has
violated any of the provisions of 42 CFR 434.67(a), HCFA may
deny payment of FFP for new enrollees of the HMO under 42 USC
1396b(m)(5)(B)(ii). The Offices shall automatically deny State
payment for new enrollees whenever, and for so long as,
Federal payment for such enrollees has been denied.
H. The Contractor shall submit proof, satisfactory to the Offices, of
indemnification of the Contractor by the Contractor's parent corporation,
if applicable, and by all of its subcontractors.
I. The Contractor shall submit proof, satisfactory to the Offices, that all
subcontractors will hold the State harmless from liability under the
subcontract. This assurance in no way relieves the Contractor of any
responsibilities under the BAA or this Contract.
J. The Contractor agrees that, prior to initially enrolling any Hoosier
Healthwise Package A, B or C enrollees, it shall go through and
satisfactorily complete the readiness review as described in the BAA. The
required readiness review shall begin before the contract
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between the Contractor and the State is finalized and executed. Within
ninety (90) days from the effective date of this Contract, the Contractor
shall make a good faith effort to resolve, to the satisfaction of the
Offices, any outstanding issues brought to the Contractor's attention by
the Offices as a result of the readiness review.
K. The Contractor shall establish and maintain a quality improvement program
that meets the requirements of 42 CFR 434.34, as well as other specific
requirements set forth in the BAA. The Offices and the HCFA may evaluate
through inspection or other means, including but not limited to, the
review of the quality assurance reports required under this Contract, and
the quality, appropriateness, and timeliness of services performed under
this Contract. The Contractor agrees to participate and cooperate, as
directed by the Offices, in the annual external quality review of the
services furnished by the Contractor.
L. In accordance with 42 CFR 434.28, the Contractor agrees that it and any of
its subcontractors shall comply with the requirements, if applicable, of
42 CFR 489, Subpart I, relating to maintaining and distributing written
policies and procedures respecting advance directives. The Contractor
shall distribute policies and procedures to adult individuals during the
enrollee enrollment process and whenever there are revisions to these
policies and procedures. The Contractor shall make available for
inspection, upon reasonable notice and request by the Offices,
documentation concerning its written policies, procedures and distribution
of such written procedures to enrollees.
M. Pursuant to 42 C.F.R. 417.479(a), the Contractor agrees that no specific
payment can be made directly or indirectly under a physician incentive
plan to a physician or physician group as an inducement to reduce or limit
medically necessary services furnished to an individual enrollee. The
Contractor must disclose to the State the information on provider
incentive plans listed in 42 C.F.R. 417.479 (h)(l) and 417.479(i) at the
times indicated at 42 C.F.R. 434.70(a)(3), in order to determine whether
the incentive plan meets the requirements of 42 C.F.R. 417(d)-(g). The
Contractor must provide the capitation data required under paragraph
(h)(l)(vi) for the previous calendar year to the State by
application/contract renewal of each year. The Contractor will provide the
information on its physician incentive plan(s) listed in 42 C.F.R.
417.479(h)(3) to any enrollee upon request.
N. The Contractor must not prohibit or restrict a health care professional
from advising an enrollee about his/her health status, medical care, or
treatment, regardless of whether benefits for such care are provided under
his Contract, if the professional is acting within the lawful scope of
practice. However, this provision does not require the Contractor to
provide coverage of a counseling or referral service if the Contractor
objects to the service on moral or religious grounds and makes available
information on its policies to potential enrollees and enrollees within
ninety (90) days after the date the Contractor adopts a change in policy
regarding such counseling or referral service.
O. In accordance with 42 U.S.C. Section 1396u-2(b)(6), the Contractor agrees
that an enrollee may not be held liable for the following:
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1. Debts of the Contractor, or its subcontractors, in the event of any
organization's insolvency;
2. Services provided to the enrollee in the event the Contractor fails
to receive payment from the Offices for such services or in the
event a provider fails to receive payment from the Contractor or
Offices; or
3. Payments made to a provider in excess of the amount that would be
owed by the enrollee if the Contractor had directly provided the
services.
P. The Offices may from time to time request and the Contractor, and all of
its subcontractors, agree that the Contractor, or its subcontractors,
shall prepare and submit additional compilations and reports as requested
by the Offices. Such requests will be limited to situations in which the
desired data is considered essential and cannot be obtained through
existing Contractor reports. The Contractor, and all of its
subcontractors, agree that a response to the request shall be submitted
within thirty (30) days from the date of the request, or by the Offices'
requested completion date, whichever is earliest. The response shall
include the additional compilations and reports as requested, or the
status of the requested information and an expected completion date. When
such requests pertain to legislative inquiries or expedited inquiries from
the Office of the Governor, the additional compilations and reports shall
be submitted by the Offices' requested completion date. Failure by the
Contractor, or its subcontractors, to comply with response time frames
shall be considered grounds for the Offices to pursue the provisions
outlined in Section 3.16.5 of the BAA. In the event that delays in
submissions are a consequence of a delay by the Offices or the Medicaid
Fiscal Agent, the time frame for submission shall be extended by the
length of time of the delay.
Q. The Contractor shall establish a written claim resolution procedure
applicable to both in-network and out-of-network providers which shall be
distributed to all in-network providers and shall be available to out-of
network providers upon request. The Contractor shall negotiate the terms
of a written claim resolution procedure with in-network providers; but if
the Contractor and an in-network provider are unable to reach agreement on
the terms of such procedure, the out-of-network provider claims
resolution procedure approved by the Offices under this section shall
govern the resolution of such in-network provider's claims with the
Contractor. The written claim resolution procedure for out-of-network
providers (and in-network providers in the absence of an agreement) must
be submitted to the Offices for approval within thirty (30) days from the
effective date of this Contract and must include, at a minimum, the
following elements:
1. A statement noting that providers objecting to determinations
involving their claims will be provided procedural due process
through the Contractor's claim resolution procedure.
2. A description of both the informal and formal claim resolution
procedures that will be available to resolve a provider's objection
to a determination involving the provider's claim.
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3. An informal claim resolution procedure which:
a. shall be available for the resolution of claims submitted to
the Contractor by the provider within the allowable claims
submission time limits under federal and state law;
b. shall precede the formal :claim resolution procedure;
c. shall be used to resolve a provider's objection to a
determination by the Contractor involving the provider's
claim, including a provider's objection to:
(1) any determination by the Contractor regarding payment for
a claim submitted by the provider including the amount of such
payment; and
(2) the Contractor's determination that a claim submitted by
the provider lacks sufficient supporting information, records,
or other materials;
d. may, at the election of a provider, be utilized to determine
the payment due for a claim in the event the Contractor fails,
within thirty (30) days after the provider submits the claim,
to notify the provider of:
(1) its determination regarding payment for the provider's
claim; or
(2) its determination that the provider's claim lacked
sufficient supporting information, records, or other
materials;
e. shall be commenced by a provider submitting to the Contractor:
(1) within sixty (60) days after the provider's receipt of
written notification of the Contractor's determination
regarding the provider's claim, the provider's written
objection to the Contractor's determination and an explanation
of the objection; or
(2) within sixty (60) days after the Contractor fails to make
a determination as described in subparagraph (d), a written
notice of the provider's election to utilize the informal
claims resolution procedure under subparagraph (d) above;
f. shall allow providers and the Contractor to make verbal
inquiries and to otherwise informally undertake to resolve the
matter submitted for resolution by the provider pursuant to
Paragraph 3.e.
4. In the event the matter submitted for informal resolution is not
resolved to the provider's satisfaction within thirty (30) days
after the provider commenced the informal claim resolution
procedure, the provider shall have sixty (60) days from that point
to submit to the Contractor written notification of the provider's
election to submit the matter to the formal claim resolution
procedure. The
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provider's notice must specify the basis of the provider's dispute
with the Contractor. The Contractor's receipt of the provider's
written notice shall commence the formal claim resolution procedure.
5. The formal claim resolution procedure shall be conducted by a panel
of one (1) or more individuals selected by the Contractor. Each
panel must be knowledgeable about the policy, legal, and clinical
issues involved in the matter that is the subject of the formal
claim resolution procedure. An individual who has been involved in
any previous consideration of the matter by the Contractor may not
serve on the panel. The Contractor's medical director, or another
licensed physician designated by the medical director, shall serve
as a consultant to the panel in the event the matter involves a
question of medical necessity or medical appropriateness.
6. The panel shall consider all information and material submitted to
it by the provider that bears directly upon an issue involved in the
matter that is the subject of the formal claim resolution procedure.
The panel shall allow the provider an opportunity to appear in
person before the panel, or to communicate with the panel through
appropriate other means if the provider is unable to appear in
person, and question the panel in regard to issues involved in the
matter. The provider shall not be required to be represented by an
attorney for purposes of the formal claim review procedure.
7. Within forty-five (45) days after the commencement of the formal
claim resolution procedure, the panel shall deliver to the provider
the panel's written determination of the matter before it. Such
determination shall be the Contractor's final position in regard to
the matter. The written determination shall include, as applicable,
a detailed explanation of the factual, legal, policy and clinical
basis of the panel's determination.
8. In the event the panel fails to deliver to the provider the panel's
written determination within forty-five (45) days after the after
the commencement of the formal claim resolution procedure, such
failure on the part of the panel shall have the effect of a denial
by the panel of the provider's claim.
9. The panel's written determination shall include notice to the
provider of the provider's right, within sixty (60) days after the
provider's receipt of the panel's written determination, to submit
to binding arbitration the matter that was the subject of the formal
claim resolution procedure. The provider shall also have the right
to submit the matter to binding arbitration if the panel has failed
to deliver its written determination to the provider within the
required forty-five (45) day period.
10. Any procedure involving binding arbitration must be conducted in
accordance with the rules and regulations of the American Health
Lawyers Association (AHLA), pursuant to the Uniform Arbitration Act
as adopted in the State of Indiana at I.C. 34-57-2, unless the
provider and Contractor mutually agree to some other binding
resolution procedure. However, any Contractor and provider
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that are subject to statutorily imposed arbitration procedures for
the resolution of these claims shall be required to follow the
statutorily imposed arbitration procedures, but only to the extent
those procedures differ from, or are irreconcilable with, the rules
and regulations of the American Health Lawyers Association (AHLA),
pursuant to the Uniform Arbitration Act as adopted in the State of
Indiana at I.C. 34-57-2. It is the intent of the Offices that the
fees and expenses of arbitration be borne by the non-prevailing
party.
11. The provider and Contractor may agree, within the requisite sixty
(60) day time period, to include in a single arbitration proceeding
matters from multiple formal claim resolution procedures involving
the Contractor and the provider. If the provider and Contractor are
not able to agree, the arbitrator, as selected in Paragraph 10
above, shall have the discretion to include in a single arbitration
proceeding matters from multiple formal claim resolution procedures
involving the Contractor and the provider.
12. For claims disputed under Paragraph 3.c.(2) above:
a. a claim that is finally determined through the Contractor's
claim resolution procedure (including arbitration) not to lack
sufficient supporting documentation shall be processed by the
Contractor within thirty (30) days after such final
determination. The processing of the claim and the
Contractor's determination involving the claim shall be
subject to Paragraph 3. c. and Paragraph 3. d. and the
Contractor's formal claim resolution procedure and binding
arbitration.
b. a claim that is finally determined through the Contractor's
claim resolution procedure (including arbitration) to lack
sufficient supporting documentation shall be processed by the
Contractor within thirty (30) days after the provider submits
to the Contractor the requisite supporting documentation. The
provider shall have thirty (30) days after written notice of
the final determination establishing that the claim lacked
sufficient supporting documentation is received by the
provider to submit the requisite supporting documentation. The
processing of the claim and the Contractor's determination
involving the claim shall be subject to Paragraph 3. c. and
Paragraph 3. d. and the Contractor's formal claim resolution
procedure and binding arbitration.
13. A Contractor may not include in its claim resolution procedures for
out-of-network providers (and in-network providers in the absence
of an agreement) elements that restrict or diminish the claim review
procedures, time periods or subject matter provided for in
paragraphs 1 through 12 above.
14. A Contractor shall maintain a log of all informally and formally
filed provider objections to determinations involving claims. The
logged information shall include the provider's name, date of
objection, nature of the objection, and
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disposition. The Contractor shall submit quarterly reports to the
Offices regarding the number and type of provider objections.
IV. PAYMENT
A. In consideration of the services to be performed by the Contractor, the
Offices agree to pay the Contractor the following amounts per month per
enrolled member as contained in the Offices' capitation payment listing
based upon the capitation rates by category as listed below:
CAPITATION RATES
CATEGORY PACKAGES A AND B PACKAGE C
------------- ------------------ ------------------
Newborns $ 355.20 $ 127.99
Preschool $ 71.80 $ 82.30
Children $ 58.22 $ 68.88
Adolescents $ 87.58 $ 97.79
Adult Males $ 247.27
Adult Females $ 93.78
Deliveries $ 3,297.96/delivery $ 3,297.96/delivery
These capitation rates will be adjusted by the medical component of the
Consumer Price Index. The initial adjustment will occur in January 2002,
with subsequent adjustments to occur annually thereafter. In the event
that the Offices adjust the fee-for-service (FFS) rates, the Offices may,
in its sole discretion, further adjust the capitation rates in accordance
with the FFS adjustment, based on the same methodology or percentage
change used for the FFS adjustment. If the Offices make such an
adjustment, it shall apply only to the specific service component of the
capitation rate that corresponds to the FFS adjustment. Any capitation
rates adjusted due to a change in the FFS program may be further adjusted
to ensure actuarial soundness. All adjustments are subject to federal
regulations that this Contract may not exceed the FFS Upper Payment Limit
(UPL).
B. All payment obligations of the Offices are subject to the encumbrance of
monies and shall be paid to the Contractor on the first Wednesday after
the fifteenth of the month.
C. The capitation payment will be prospective, based upon the number of
enrollees assigned to the Contractor as of the first of the month. The
Offices will establish an administrative procedure to allow retroactive or
other payment adjustments as necessary to implement this contract.
D. The Contractor will be provided a capitation payment listing which
includes a detailed listing of all enrollees for which the Contractor is
receiving a capitation payment.
E. The parties agree that the Offices have the option of renegotiating
actuarially sound capitation rates annually. Rates revised under this
provision shall be implemented only
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after a contract amendment is executed and approved. Contractor may submit
information for the Offices' review and consideration.
F. It is understood and agreed upon by the parties that all obligations of
the State of Indiana are contingent upon the availability and continued
appropriation of State and Federal funds, and in no event shall the State
of Indiana be liable for any payments in excess of available appropriated
funds.
G. When the Director of the State Budget Agency makes a written determination
that funds are not appropriated or otherwise available to support
continuation of performance of this Contract, the Contract shall be
cancelled. A determination by the State Budget Director that funds are not
appropriated or otherwise available to support continuation of performance
shall be final and conclusive.
V. ORDER OF PRECEDENCE
Any inconsistency or ambiguity in this Contract shall be resolved by giving
precedence in the following order:
1) The express terms of this document;
2) Attachment 1 - BAA 01-28, released July 31, 2000;
3) Attachment 2 - the Contractor's response to the BAA;
4) Any other documents, standards, laws, rules or regulations
incorporated by reference in the above materials, all of which are
hereby incorporated by reference.
VI. NOTICE
A. Whenever notice is required to be given to the other party, it shall be
made in writing and delivered to that party. Delivery shall be deemed to
have occurred if a signed receipt is obtained when delivered by hand or
according to the date on the return receipt if sent by certified mail,
return receipt requested. Notices shall be addressed as follows:
In case of notice to the Contractor: In case of notice to the Offices:
Xxxxxxx X. Xxxxx, President/CEO Xxxxxx Xxxxxxxx, Managed Care
Harmony Health Plan of Illinois, Inc. Director Office of Medicaid Policy
000 Xxxxx Xxxxxx Xxxxx, Xxxxx 0000 and Planning Family and Social
Xxxxxxx, Xxxxxxxx 00000 Services Administration 000
X. Xxxxxxxxxx Xx., XXXX X000, MS07
Xxxxxxxxxxxx, Xxxxxxx 00000
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B. Said notices shall become effective on the date of delivery or the date
specified within the notice, whichever comes later. Either party may
change its address for notification purposes by mailing a notice stating
the change and setting forth the new address.
VII. MISCELLANEOUS PROVISIONS
A. Entire Agreement. This Contract constitutes the entire agreement between
the parties with respect to the subject matter; all prior agreements,
representations, statements, negotiations, and undertakings are superseded
hereby.
B. Changes. Any changes to this Contract shall be by formal amendment of this
Contract signed by all parties required by Indiana law.
C. Performance Bond. The Contractor agrees that a performance bond in the
amount of five hundred thousand dollars ($500,000.00) will be delivered to
the Indiana Department of Administration (IDOA) within ten (10) calendar
days of the execution of this contract. Said bond will be in the form of a
cashier's check, a certified check, or a surety bond executed by a surety
company authorized to do business in the State of Indiana as approved by
the Insurance Department of State of Indiana. No other check or surety
will be accepted. The performance bond shall be made payable to the IDOA
and shall be effective for the duration of the contract and any extensions
thereof. The State reserves the right to increase the performance bond
amount if enrollment levels indicate the need for higher liquidated
damages.
D. Access To Records. The Contractor and any subcontractor shall maintain all
books, documents, papers and records which are directly pertinent to this
Contract and shall make such materials available at all reasonable times
during the contract period and for three (3) years from the date of final
payment under the Contract or until all pending matters are closed,
whichever date is later, for inspection by the Office, or any other duly
authorized representative of the State of Indiana or the Federal
government. Copies thereof shall be furnished at no cost to the State if
requested.
E. Assignment. The Contractor shall not assign or subcontract the whole or
any part of this Contract without the State's prior written consent. Such
consent will not be unreasonably withheld. The Contractor may assign its
right to receive payments to such third parties as the Contractor may
desire without the prior written consent of the State, provided that the
Contractor gives written notice (including evidence of such assignment) to
the State thirty (30) days in advance of any payment so assigned. The
assignment shall cover all unpaid amounts under this Contract and shall
not be made to more than one party.
F. Authority to Bind Contractor. Notwithstanding anything in this Contract to
the contrary, the signatory for the Contractor represents that he/she has
been duly authorized to execute contracts on behalf of the Contractor
designed above, has filed proof of such authority with the Indiana
Department of Administration, 000 Xxxx Xxxxxxxxxx Xxxxxx, X000,
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Xxxxxxxxxxxx, Xxxxxxx 00000, and has obtained all necessary or applicable
approval from the home office of the Contractor to make this Contract
fully binding upon the Contractor when his/her signature is affixed and is
not subject to home office acceptance hereto and accepted by the State of
Indiana.
G. Compliance with Laws. The Contractor agrees to comply with all applicable
Federal, State, and local laws, rules, regulations, or ordinances, and all
provisions required thereby to be included herein are hereby incorporated
by reference. The enactment of any state or federal statute or the
promulgation of regulations thereunder after execution of this Contract
shall be reviewed by the State and the Contractor to determine whether the
provisions of this Contract require formal modification.
H. Compliance with Civil Rights Laws. The Contractor and its subcontractors
hereby assure that they will comply with all Federal and Indiana Civil
Rights Laws, including, but not limited to, I.C. 22-9-1-10 and the Civil
Rights Act of 1964, to the end that they shall not discriminate against
any employee or applicant for employment, to be employed in the
performance of this Contract, with respect to his/her hire, tenure, terms,
conditions or privileges of employment or any matter directly or
indirectly related to employment, because of his/her race, color,
religion, sex, disability, national origin, ancestry or status as a
veteran. The Contractor understands that the State of Indiana is a
recipient of federal funds. Pursuant to that understanding, the
Contractor, and its subcontractors, if any, agree that if the Contractor
employs 50 or more employees and does at least $50,000 worth of business
with the State of Indiana and is not exempt, the Contractor will comply
with the reporting requirements of 41 CFR 60-1.7, if applicable. Breach of
this covenant may be regarded as a material breach of the Contract. The
State of Indiana shall comply with Section 202 of Executive Order 11246,
as amended, and 41 CFR 60-741, as amended, which are incorporated herein
by specific reference.
I. Assurance of Compliance with Civil Rights Act of 1964, Section 504 of the
Rehabilitation Act of 1973 and the Age Discrimination Act of 1975, the
Americans with Disabilities Act of 1990 and Title IX of the Education
Amendments of 1972: The Contractor agrees that it, and all of its
subcontractors and providers, will comply with the following:
1. Title VI of the Civil Rights Act of 1964 (Pub. L. 88-352), as
amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Health and Human Services (45 C.F.R.
Part 80), to the end that, in accordance with Title VI of that Act
and the Regulation, no person in the United States shall on the
ground of race, color, or national origin, be excluded from
participation in, be denied the benefits of, or be otherwise
subjected to discrimination under any program or activity for which
the Contractor receives Federal financial assistance under this
Contract.
2. Section 504 of the Rehabilitation Act of 1973 (Pub. L. 93-112), as
amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Health and Human Services (45 C.F.R.
Part 84), to the end that, in accordance with Section 504 of that
Act and the Regulation, no otherwise qualified handicapped
individual in
MCO Contract Harmony Health Plan
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the United States shall, solely by reason of his/her handicap, be
excluded from participation in, be denied the benefits of, or be
subjected to discrimination under any program or activity for which
the Contractor receives Federal financial assistance under this
Contract.
3. The Age Discrimination Act of 1975 (Pub. L. 94-135), as amended, and
all requirements imposed by or pursuant to the Regulation of the
Department of Health and Human Services (45 C.F.R. Part 91), to the
end that, in accordance with the Act and the Regulation, no person
in the United States shall, on the basis of age, be denied the
benefits of, be excluded from participation in, or be subjected to
discrimination under any program or activity for which the
Contractor receives Federal financial assistance under this
Contract.
4. The Americans with Disabilities Act of 1990 (Pub. L. 101-336), as
amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Justice (28 C.F.R. 35.101 et seq.),
to the end that in accordance with the Act and Regulation, no person
in the United States with a disability shall, on the basis of the
disability, be excluded from participation in, be denied the
benefits of, or otherwise be subjected to discrimination under any
program or activity for which the Contractor receives Federal
financial assistance under this Contract.
5. Title IX of the Education Amendments of 1972, as amended (20 U.S.C.
Sections 1681-1683, and 1685-1686), and all requirements imposed by
or pursuant to regulation, to the end that, in accordance with the
Amendments, no person in the United States shall, on the basis of
sex, be excluded from participation in, be denied the benefits of,
or otherwise be subjected to discrimination under any program or
activity for which the Contractor receives Federal financial
assistance under this Contract.
The Contractor agrees that compliance with this assurance constitutes a
condition of continued receipt of Federal financial assistance, and that
it is binding upon the Contractor, its successors, transferees and
assignees for the period during which such assistance is provided. The
Contractor further recognizes that the United States shall have the right
to seek judicial enforcement of this assurance.
J. Conflict of Interest
1. As used in this section:
"Immediate family" means the spouse and the unemancipated children
of an individual.
"Interested party" means:
a. The individual executing this Contract;
MCO Contract Harmony Health Plan
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b. An individual who has an interest of three percent (3%) or
more of the Contractor if the Contractor is not an individual;
or
c. Any member of the immediate family of an individual specified
under subdivision a. or b.
"Department" means the Indiana Department of Administration.
"Commission" means the State Ethics Commission.
2. The Department may cancel this Contract without recourse by the
Contractor if any interested party is an employee of the State of
Indiana.
3. The Department will not exercise its right of cancellation under
section 2 above if the Contractor gives the Department an opinion by
the Commission indicating that the existence of this Contract and
the employment by the State of Indiana of the interested party does
not violate any statute or code relating to ethical conduct of state
employees. The Department may take action, including cancellation of
this Contract consistent with an opinion of the Commission obtained
under this section.
4. The Contractor has an affirmative obligation under this Contract to
disclose to the Department when an interested party is or becomes an
employee of the State of Indiana. The obligation under this section
extends only to those facts which the Contractor knows or reasonably
could know.
K. Confidentiality of Data and Property Rights. The Contractor further agrees
that all information, data, findings, recommendations, and proposals, by
whatever name described and by whatever form therein, secured developed,
written, or produced by the Contractor in furtherance of this Contract,
shall be the property of the State of Indiana and that the Contractor
shall take such action as is necessary under law to preserve such property
rights in and of the State of Indiana while such property is within the
control and/or custody of the Contractor.
By this Contract the Contractor specifically waives and/or releases to the
State of Indiana any cognizable property right in the Contractor to
copyright or patent such information, data, findings, recommendations, and
proposals, that are developed exclusively in furtherance of the Contract
and not developed by the Contractor for its other lines of business and
incidentally applied to its Hoosier Healthwise line of business.
The parties acknowledge that it is in their interests for the Contractor
to develop new techniques and advances in managed care. Therefore, the
Offices hereby grant to the Contractor, subject to the confidentiality
obligations set forth in this Contract, as well as those imposed by
federal and state laws and regulations, a perpetual license to use
materials, models, methodologies and techniques developed under this
contract.
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L. Confidentiality of State of Indiana Information. The Contractor
understands and agrees that data, materials and information disclosed to
the Contractor may contain confidential and protected data; therefore, the
Contractor promises and assures that data, material, and information
gathered, based upon or disclosed to the Contractor for the purpose of
this Contract will not be disclosed to others or discussed with other
parties without the prior written consent of the State of Indiana.
M. Conveyance of Documents And Continuation of Existing Activity: Should the
Contract for whatever reason, (i.e. completion of a contract with no
renewal, or termination of service by either party), be discontinued and
the activities as provided for in the Contract for services cease, the
Contractor and any subcontractors employed by the terminating Contractor
in the performance of the duties of the Contract shall promptly convey to
the State of Indiana, copies of all vendor working papers, data collection
forms, reports, charts, programs, cost records and all other material
related to work performed on this Contract.
The Contractor and the Office shall convene immediately upon notification
of termination or non-renewal of the Contract to determine what work shall
be suspended, what work shall be completed, and the timeframe for
completion and conveyance. The Office will then provide the Contractor
with a written schedule of the completion and conveyance activities
associated with termination. Documents/materials associated with suspended
activities shall be conveyed by the Contractor to the State of Indiana
upon five days' notice from the State of Indiana. Upon completion of those
remaining activities noted on the written schedule, the Contractor shall
also convey all documents and materials to the State of Indiana upon five
days' notice from the State of Indiana.
N. Disputes. Should any disputes arise with respect to this Contract, the
Contractor and the State of Indiana agree to act immediately to resolve
any such disputes. Time is of the essence in the resolution of disputes.
The Contractor agrees that, the existence of a dispute notwithstanding, it
will continue without delay to carry out all its responsibilities under
this Contract which are not affected by the dispute. Should the Contractor
fail to continue without delay to perform its responsibilities under this
Contract in the accomplishment of all non-disputed work, any additional
costs incurred by the Contractor or the State of Indiana as a result of
such failure to proceed shall be borne by the Contractor, and the
Contractor shall make no claim against the State of Indiana for such
costs. If the Contractor and the State of Indiana cannot resolve a dispute
within ten (10) working days following notification in writing by either
party of the existence of said dispute, then the following procedure shall
apply:
1. The parties agree to resolve such matters through submission of
their dispute to the Commissioner of the Indiana Department of
Administration who shall reduce her decision to writing and mail or
otherwise furnish a copy thereof to the Contractor and the State of
Indiana within ten (10) working days after presentation of such
dispute for her decision. Her decision shall be final and conclusive
unless the Contractor mails or otherwise furnishes to the
Commissioner of Administration, within ten (10) working days after
receipt
MCO Contract Harmony Health Plan
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of the Commissioner's decision, a written appeal. Within ten (10)
working days of receipt by the Commissioner, she may reconsider her
decision. If no reconsideration is provided within ten (10) working
days the Contractor may submit the dispute to an Indiana court of
competent jurisdiction.
2. The State of Indiana may withhold payments on disputed items pending
resolution of the dispute. The non-payment by the State of Indiana
to the Contractor of one or more invoices not in dispute shall not
constitute default, however, the Contractor may bring suit to
collect such monies without following the disputes procedure
contained herein.
O. Drug-Free Workplace
1. The Contractor hereby covenants and agrees to make a good faith
effort to provide and maintain during the term of this Contract a
drug-free workplace. Contractor will give written notice to the
Office and the Indiana Department of Administration within ten (10)
days after receiving actual notice that an employee of the
Contractor has been convicted of a criminal drug violation occurring
in the Contractor's workplace.
2. In addition to subparagraph (1), if the total amount set forth in
this Contract is in excess of twenty-five thousand dollars
($25,000.00), the Contractor hereby further agrees that this
Contract is expressly subject to the terms, conditions, and
representations contained in the Drug-Free Workplace Certification.
The Certification is hereby executed by the Contractor in
conjunction with this Contract and set forth in this Contract.
3. It is further expressly agreed that the failure of the Contractor to
in good faith comply with the terms of subparagraph (1) above, or
falsifying or otherwise violating the terms of the certification
referenced in subparagraph (2) above shall constitute a material
breach of this Contract, and shall entitle the State of Indiana to
impose sanctions against the Contractor including, but not limited
to, suspension of contract payment, termination of this Contract
and/or debarment of the Contractor from doing further business with
the State of Indiana for up to three (3) years.
P. Drug-Free Workplace Certification
This Certification is required by Executive Order No. 90-5, April 12,
1990, issued by the Governor of Indiana. Pursuant to its delegated
authority, the Indiana Department of Administration is requiring the
inclusion of this certification in all contracts with the State of Indiana
in excess of $25,000.00. No award of a contract shall be made, and no
contract, purchase order or agreement, the total amount of which exceeds
$25,000.00 shall be valid, unless and until this certification has been
fully executed by the Contractor and made a part of the Contract as part
of the Contract documents. False certification or violation of the
certification may result in sanctions including, but not limited to,
suspension of contract
MCO Contract Harmony Health Plan
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payment, termination of the contract and/or debarment of contracting
opportunities with the Contractor for up to three (3) years.
The Contractor certifies and agrees that it will provide a drug-free
workplace by:
1. Publishing and providing to all of its employees a statement
notifying them that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance is
prohibited in the Contractor's workplace and specifying the actions
that will be taken against employees for violations of such
prohibition.
2. Establishing a drug-free awareness program to inform employees of
(A) the dangers of drug abuse in the workplace; (B) the Contractor's
policy of maintaining a drug-free workplace; (C) any available drug
counseling, rehabilitation, and employee assistance programs; and
(4) the penalties that may be imposed upon an employee for drug
abuse violations occurring in the workplace.
3. Notifying all employees in the statement required by subparagraph
(1) above that as a condition of continued employment the employee
will (A) abide by the terms of the statement; and (B) notify the
Contractor of any criminal drug statute conviction for a violation
occurring in the workplace no later than five (5) days after such
conviction.
4. Notify the State in writing within ten (10) days after receiving
notice from an employee under subdivision (3)(B) above, or otherwise
receiving actual notice of such conviction.
5. Within thirty (30) days after receiving notice under subdivision
(3)(B) above of a conviction, imposing the following sanctions or
remedial measures on any employee who is convicted of drug abuse
violations occurring in the workplace: (A) take appropriate
personnel action against the employee, up to and including
termination; or (B) require such employee to satisfactorily
participate in a drug abuse assistance or rehabilitation program
approved for such purposes by a Federal, State, or local health, law
enforcement, or other appropriate agency.
6. Making a good faith effort to maintain a drug-free workplace through
the implementation of subparagraphs (1) through (5).
Q. Environmental Standards. If the contract amount set forth in this Contract
is in excess of $100,000, the Contractor shall comply with all applicable
standards, orders, or requirements issued under section 305 of the Clean
Air Act (42 USC 7606), section 508 of the Clean Air Act (33 USC 1368),
Executive Order 11738, and Environmental Protection Agency regulations (40
CFR Part 15), which prohibit the use under non-exempt Federal contracts of
facilities included on the EPA List of Violating Facilities. The
Contractor shall report any violations of this paragraph to the State of
Indiana and to the United States Environmental Protection Agency Assistant
Administrator for Enforcement.
MCO Contract Harmony Health Plan
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R. Force Majeure; Suspension and Termination. In the event either party is
unable to perform any of its obligations under this Contract or to enjoy
any of its benefits because of (or if failure to perform the service is
caused by) natural disaster, actions or decrees of governmental bodies, or
communication line failure not the fault of the affected party
(hereinafter referred to as a "Force Majeure Event"), the party who has
been so affected shall immediately give notice to the other party and
shall take reasonable measures to resume performance. Upon receipt of such
notice, all obligations under this Contract shall be immediately
suspended. If the period of non-performance exceeds thirty (30) days from
the receipt of notice of the Force Majeure Event, the party whose ability
to perform has not been so affected may, by giving written notice,
terminate this Contract.
S. Governing Laws. This Contract shall be construed in accordance with and
governed by the laws of the State of Indiana and suit, if any, must be
brought in the State of Indiana.
T. Indemnification. The Contractor agrees to indemnify, defend, and hold
harmless the State of Indiana and its agents, officers, and employees from
all claims and suits including court costs, attorney's fees, and other
expenses caused by any act or omission of the Contractor and/or its
subcontractors, if any. The State shall not provide such indemnification
to the Contractor.
U. Independent Contractor. The Office and the Contractor acknowledge and
agree that in the performance of this contract, the Contractor is an
independent contractor and both parties will be acting in an individual
capacity and not an as agents, employees, partners, joint venturers,
officers, or associates of one another. The employees or agents of one
party shall not be deemed or construed to be the employees or agents of
the other party for any purposes whatsoever. Neither party will assume any
liability for any injury (including death) to any persons, or any
property arising out of the acts or omissions of the agents, employees or
subcontractors of the other party.
The Contractor shall be responsible for providing all necessary
unemployment and worker compensation insurance for the Contractor's
employees.
V. Lobbying Activities. Pursuant to 31 U.S.C. 1352, and any regulations
promulgated thereunder, the Contractor hereby assures and certifies that
no federally appropriated funds have been paid, or will be paid, by or on
behalf of the Contractor, to any person for influencing or attempting to
influence an officer or employee of any agency, a member of Congress, an
officer or employee of Congress, or an employee of a member of Congress,
in connection with the awarding of any federal contract, the making of any
federal grant, the making of any federal loan, the entering into of any
cooperative contract, and the extension, continuation, renewal, amendment,
or modification of any federal contract, grant, loan or cooperative
contract. If any funds other than federally appropriated funds have been
paid or will be paid to any person for influencing or attempting to
influence an officer or employee of any agency, a member of Congress, an
officer or employee of Congress, or an employee of a member of Congress in
connection with this Contract, the Contractor shall complete and submit
Standard Form-LLL, "Disclosure Form to Report Lobbying", in accordance
with its instructions.
MCO Contract Harmony Health Plan
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W. Ownership of Documents and Materials. All documents, records, programs,
data, film, tape, articles, memoranda, and other materials developed under
this Contract will be the property of the State of Indiana. Use of these
materials other than related to contract performance by the Contractor
without the prior written consent of the State of Indiana is prohibited.
During the performance of the services specified herein, the Contractor
shall be responsible for any loss or damage to these materials developed
for or supplied by the State of Indiana and used to develop or assist in
the services provided herein, while they are in the possession of the
Contractor, and any loss or damage thereto shall be restored at the
Contractor's expense. Full, immediate and unrestricted access to the work
product of the Contractor during the term of this Contract shall be
available to the State of Indiana. The Contractor will give to the State
of Indiana, or the State of Indiana's designee, all records of other
materials described in this section, after termination of the Contract and
upon five (5) days notice of a request from the State of Indiana.
The parties acknowledge that it is in their interests for the Contractor
to develop new techniques and advances in managed care. Therefore, the
Offices hereby grant to the Contractor, subject to the confidentiality
obligations set forth in this Contract, as well as those imposed by
federal and state laws and regulations, a perpetual license to use
materials, models, methodologies and techniques developed under this
contract.
X. Penalties/Interest/Attorney's Fees. The State will in good faith perform
its required obligations hereunder and does not agree to pay any
penalties, liquidated damages, interest, or attorney's fees, except as
required by Indiana law, in part, I.C. 5-17-5-1 et seq., I.C. 34-54-8-2 et
seq., and I.C. 34-13-1-1 et seq.
Y. Severability. The invalidity in whole or in part of any provision of this
Contract shall not void or affect the validity of any other provision.
Z. Successors and Assignees. The Contractor binds its successors, executors,
assignees, and administrators, to all covenants of this Contract. Except
as set forth above, the Contractor shall not assign, sublet, or transfer
the Contractor's interest in this Contract without the prior written
consent of the Office.
AA. Termination. The Offices may, without cause, cancel and terminate this
Contract in whole or in part upon sixty (60) days' prior written notice.
The Contractor will be reimbursed for services performed prior to the date
of termination consistent with the terms of the Contract. The Offices will
not be liable for services performed after notice of termination, but
before the date of termination, without written authorization from the
Offices. In no event will the Offices be liable for services performed
after the termination date.
In the event that the Offices request that the Contractor perform any
additional services associated with the transition or turnover of this
Contract, the Offices agree to pay reasonable costs for those additional
services specifically requested by the Offices.
MCO Contract Harmony Health Plan
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BB. Termination by the Contractor. This Contract may be terminated by the
Contractor upon one hundred eighty (180) days prior written notice to the
Offices. The Contractor will be reimbursed for services performed prior to
the effective date of termination consistent with the terms of the
Contract. In no event will the Offices be liable for services performed
after the effective date of termination, without written authorization
from the Offices.
CC. Change in Scope of Work -- In the event the Offices require a major change
in scope, character or complexity of the work after the work has
commenced, adjustments in compensation to the Contractor shall be
determined by the Office, in the exercise of its honest and reasonable
judgment, and the Contractor shall not commence the additional work or
the change in the scope of work until authorized in writing by the
Offices. No claim for additional compensation shall be made in the absence
of a prior written approval executed by all signatories hereto.
DD. Waiver of Breach. No waiver of breach of any provision of this Contract
shall constitute a waiver of any other breach or of such provision.
Failure of the Office to enforce at any time any provision of this
Contract shall not be construed as a waiver thereof. The remedies herein
reserved shall be cumulative and additional to any other remedies in law
or equity.
EE. Work Standards. The Contractor agrees to execute its respective
responsibilities by following and applying at all times the highest
professional and technical guidelines and standards. If the State becomes
dissatisfied with the work product or the working relationship with those
individuals assigned to work on this Contract, the State may request in
writing the replacement of any or all such individuals.
FF. Non-Collusion and Acceptance. The undersigned attests, subject to the
penalties for perjury, that he is the contracting party, or that he is
the representative, agent, member or officer of the contracting party,
that he has not, nor has any other member employee, representative, agent
or officer of the firm, company, corporation or partnership represented by
him, directly or indirectly, to the best of his knowledge, entered into or
offered to enter into any combination, collusion or agreement to receive
or pay, and that he has not received or paid, any sum of money or other
consideration for the execution of this agreement other than that which
appears upon the face of the agreement.
/// The remainder of this page is intentionally left blank. ///
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IN WITNESS WHEREOF, Harmony Health Plan of Illinois, Inc. and the State of
Indiana have, through duly authorized representatives, entered into this
agreement. The parties having read and understand the foregoing terms of the
Contract do by their respective signatures dated below hereby agree to the terms
thereof.
For the Contractor: For the State of Indiana:
/s/ Xxxxxxx X. Xxxxx /s/ Xxxxxxxx X. Xxxxxxx
---------------------------------------- -------------------------------------
Xxxxxxx X. Xxxxx, President CEO Xxxxxxxx X. Xxxxxxx
Harmony Health Plan of Illinois, Inc. Assistant Secretary
Office of Medicaid Policy & Planning
Date: 12/19/00 Date: 12/12/2000
/s/ Xxxxx Xxxx
-------------------------------------
Xxxxx Xxxx, Director
Children's Health Insurance
Program
Date: 1/5/00
APPROVED: APPROVED
/s/ Xxxxx Xxxxxxx /s/ [ILLEGIBLE]
---------------------------------------- -------------------------------------
Xxxxx Xxxxxxx, Director Xxxxx X. Xxxxxxxx, Commissioner
State Budget Agency Department of Administration
Date: 01/10/01 Date: Jan 4, 2001
APPROVED AS TO FORM AND LEGALITY
/s/ [ILLEGIBLE]
----------------------------------------
[ILLEGIBLE]
Attorney General of Indiana
Date: 22/01
MCO Contract
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AMEND. 2
CONTRACT BETWEEN
THE OFFICE OF MEDICAID POLICY AND PLANNING,
THE OFFICE OF THE CHILDREN'S HEALTH INSURANCE PROGRAM
AND
HARMONY HEALTH PLAN OF ILLINOIS, INC.
This Contract is made and entered into by and between the State of Indiana
(hereinafter "State" or "State of Indiana"), through the Office of Medicaid
Policy and Planning and the Office of Children's Health Insurance Program
(hereinafter "the Offices"), of the Indiana Family and Social Services
Administration, 000 Xxxx Xxxxxxxxxx Xxxxxx, X000, Xxxxxxxxxxxx, Xxxxxxx, and
Harmony Health Plan of Illinois, Inc., 000 Xxxxx Xxxxxx Xxxxx, Xxxxx 0000,
Xxxxxxx, Xxxxxxxx, doing business as Harmony Health Plan of Indiana,
(hereinafter "Contractor").
WHEREAS, I.C. 12-15-30-1 and I.C. 12-17.6 authorize the Offices to enter
into contracts to assist in the administration of the Indiana Medicaid and the
Indiana Children's Health Insurance Program (CHIP), respectively;
WHEREAS, the State of Indiana desires to contract for services to arrange
for and to administer a risk-based managed care program (RBMC) for certain
Hoosier Healthwise enrollees in Packages A, B and C as procured through BAA
01-28;
WHEREAS this Contract contains the payment rates under which the
Contractor shall be paid and that these rates have been determined to be
actuarially sound for risk contracts, in accordance with applicable law;
WHEREAS, the Contractor is willing and able to perform the desired
services for Hoosier Healthwise Packages A, B and C;
WHEREAS, the Family and Social Services Administration (FSSA) is issuing
new contract documents in lieu of renewal or amendment documents so that FSSA
may move its contract data into a single contract database. The original
contract was issued for the contract term starting January 1, 2001, through
December 31, 2002 and provided a renewal clause, exercised at the option of the
State for two additional years. The State is hereby exercising this option and
renewing the contract.
THEREFORE, the parties to this Contract agree that the terms and
conditions specified below will apply to services in connection with this
contract, and such terms and conditions are as follows:
I. TERM AND RENEWAL OPTION
This Contract is effective from January 1, 2003 through December 31, 2004.
In no event shall the term exceed December 31, 2004.
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II. DEFINITIONS
For the purposes of this contract, terms not defined herein shall be
defined as they are in the documents incorporated in and attached to this
document, subject to the order of precedence spelled out in Section V of this
document.
"Contract" means this document and all documents or standards incorporated
herein, expressly including but not limited to the following documents appended
hereto and listed in chronological order and to be given precedence as described
in Section V of this document, entitled "Order of Precedence":
Attachment 1 - BAA 01-28, released July 31, 2000;
Attachment 2 - Contractor's response to BAA 01-28, submitted September
25, 2000, excluding the following sections: Section
5.3.8; Section 5.4.4; Appendices A, B, C, D, and H;
Exhibit 5.4.4I; Exhibit 5.4.4M; and Exhibit 5.4.4O.
Attachment 3 - First Amendment to the original contract, effective
April 1, 2002;
Any other documents, standards, laws, rules or regulations incorporated by
reference in the above materials, all of which are hereby incorporated by
reference.
"Covered Services" means all services required to be arranged, administered,
managed or provided by or on behalf of the Contractor under this contract.
"Effective Date of Enrollment" means:
- The first day of the birth month of a newborn that is determined by the
Offices to be an enrolled member;
- The fifteenth day of the current month for a member who has, between the
twenty-sixth day of the previous month and the tenth day of the current
month, been determined by the Offices to be an enrolled member; and,
- The first day of the following month for a member who has, between the
eleventh day and the twenty-fifth day of a month, been determined by the
Offices to be an enrolled member.
"Enrolled Member", or "Enrollee", means a Hoosier Healthwise-eligible member who
is listed by the Offices on the enrollment rosters to receive covered services
from the Contractor or its subcontractors, employees, agents, or providers, as
of the Effective Date of Enrollment, under this contract.
"Provider" means a physician, hospital, home health agency or any other
institution, or health or other professional person or entity, which
participates in the provision of services to an enrolled member under BAA 01-28,
whether as an independent contractor, a subcontractor, employee, or agent of the
Contractor.
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"Broad Agency Announcement", or "BAA", means BAA 01-28 for providers of managed
care services, released July 31, 2000.
III. DUTIES OF THE CONTRACTOR
A. The Contractor agrees to assume financial risk for developing and managing
a health care delivery system and for arranging or administering all
Hoosier Healthwise covered services except, as set out in section 3.4.3 of
the BAA, dental care, long-term institutional care, services provided as
part of an individualized education plan (IEP) pursuant to the Individuals
with Disabilities Education Act (IDEA) at 20 U.S.C. 1400 et seq.,
behavioral health, and hospice services, in exchange for a per-enrollee,
per-month fixed fee, to certain enrollees in Hoosier Healthwise Packages
A, B and C. Wards of the State, xxxxxx children and children receiving
adoption assistance may enroll on a voluntary basis and will not be
subject to auto-assignment into the Hoosier Healthwise program. The
Contractor must, at a minimum, furnish covered services up to the limits
specified by the Medicaid and CHIP programs. The Contractor may exceed
these limits. However, in no instance may any covered service's
limitations be more restrictive than those which exist in the Indiana
Medicaid fee-for-service program for Packages A and B, and the Children's
Health Insurance Program for Package C.
B. The Contractor agrees to perform all duties and arrange and administer the
provision of all services as set out herein and contained in the BAA as
attached and the Contractor's responses to the BAA as attached, all of
which are incorporated into this Contract by reference. In addition, the
Contractor shall comply with all policies and procedures defined in any
bulletin, manual, or handbook yet to be distributed by the State or its
agents insofar as those policies and procedures provide further
clarification and are no more restrictive than any policies and procedures
contained in the BAA and any amendments to the BAA. The Contractor agrees
to comply with all pertinent state and federal statutes and regulations in
effect throughout the duration of this Contract and as they may be amended
from time to time.
C. The Contractor agrees that it will not discriminate against individuals
eligible to be covered under this Contract on the basis of health status
or need for health services; and the Contractor may not terminate an
enrollee's enrollment, or act to encourage an enrollee to terminate
his/her enrollment, because of an adverse change in the enrollee's health.
The disenrollment function will be carried out by a State contractor who
is independent of the Contractor; therefore, any request to terminate an
enrollee's enrollment must be approved by the Offices.
D. The Contractor agrees that no services or duties owed by the Contractor
under this Contract will be performed or provided by any person or entity
other than the Contractor, except as contained in written subcontracts or
other legally binding agreements. Prior to entering into any such
subcontract or other legally binding agreement, the Contractor shall, in
each case, submit the proposed subcontract or other legally binding
agreement to the Offices for prior review and approval. Prior review and
approval of a subcontract or legally binding agreement shall not be
unreasonably delayed by the Offices. The Offices shall, in
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appropriate cases and as requested by the Contractor, expedite the review
and approval process. Under no circumstances shall the Contractor be
deemed to have breached its obligations under this Contract if such breach
was a result of the Offices' failure to review and approve timely any
proposed subcontract or other legally binding agreement. If the Offices
disapprove any proposed subcontract or other legally binding agreement,
the Offices shall state with reasonable particularity the basis for such
disapproval. No subcontract into which the Contractor enters with respect
to performance under this Contract shall in any way relieve the Contractor
of any responsibility for the performance of duties under this Contract.
All subcontracts and amendments thereto executed by the Contractor under
this Contract must meet the following requirements; any existing
subcontracts or legally binding agreements which fail to meet the
following requirements shall be revised to include the requirements within
ninety (90) days from the effective date of this Contract:
1. Be in writing and specify the functions of the subcontractor.
2. Be legally binding agreements.
3. Specify the amount, duration and scope of services to be provided by
the subcontractor.
4. Provide that the Offices may evaluate, through inspection or other
means, the quality, appropriateness, and timeliness of services
performed.
5. Provide for inspections of any records pertinent to the contract by
the Offices.
6. Require an adequate record system to be maintained for recording
services, charges, dates and all other commonly accepted information
elements for services rendered to recipients under the contract.
7. Provide for the participation of the Contractor and subcontractor in
any internal and external quality assurance, utilization review,
peer review, and grievance procedures established by the Contractor,
in conjunction with the Offices.
8. Provide that the subcontractor indemnify and hold harmless the State
of Indiana, its officers, and employees from all claims and suits,
including court costs, attorney's fees, and other expenses, brought
because of injuries or damage received or sustained by any person,
persons, or property that is caused by any act or omission of the
Contractor and/or the subcontractors. The State shall not provide
such indemnification to the subcontractor.
9. Identify and incorporate the applicable terms of this Contract and
any incorporated documents. The subcontract shall provide that the
subcontractor agrees to perform duties under the subcontract, as
those duties pertain to enrollees, in accordance with the applicable
terms and conditions set out in this Contract, any incorporated
documents, and all applicable state and federal laws, as amended.
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E. The Contractor agrees that, during the term of this Contract, it shall
maintain, with any in-network provider rendering health care services
under the BAA, provider service agreements which meet the following
requirements:
1. Identify and incorporate the applicable terms of this Contract and
any incorporated documents. Under the terms of the provider services
agreement, the provider shall agree that the applicable terms and
conditions set out in this Contract, any incorporated documents, and
all applicable state and federal laws, as amended, govern the duties
and responsibilities of the provider with regard to the provision of
services to enrollees.
2. Reference a written provider claim resolution procedure as set out
in section III.Q. below.
F. The Contractor agrees that all laboratory testing sites providing services
under this Contract must have a valid Clinical Laboratory Improvement
Amendments (CLIA) certificate and comply with the CLIA regulations at 42
C.F.R. Part 493.
G. The Contractor agrees that it shall:
1. Retain, at all times during the period of this Contract, a valid
Certificate of Authority under applicable State laws issued by the
State of Indiana Department of Insurance.
2. Ensure that, during the term of this Contract, each provider
rendering health care services under the BAA is authorized to do so
in accordance with the following:
a. The provider must maintain a current Indiana Health Coverage
Programs (IHCP) provider agreement and must be duly licensed
in accordance with the appropriate state licensing board and
shall remain in good standing with said board.
b. If a provider is not authorized to provide such services under
a current IHCP provider agreement or is no longer licensed by
said board, the Contractor is obligated to terminate its
contractual relationship authorizing or requiring such
provider to provide services under the BAA. The Contractor
must terminate its contractual relationship with the provider
as soon as the Contractor has knowledge of the termination of
the provider's license or the IHCP provider agreement.
3. Comply with the specific requirements for Health Maintenance
Organizations (HMOs) eligible to receive Federal Financial
Participation (FFP) under Medicaid, as listed in the State
Organization and General Administration Chapter of the Health Care
Financing Administration (HCFA) Medicaid Manual. These requirements
include, but are not limited to the following:
a. The Contractor shall meet the definition of HMO as specified
in the Indiana State Medicaid Plan.
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b. Throughout the duration of this Contract, the Contractor shall
satisfy the Chicago Regional Office of the Centers for
Medicare and Medicaid Policy (hereinafter called CMS) that
the Contractor is compliant with the Federal requirements for
protection against insolvency pursuant to 42 CFR 434.20(c)(3)
and 434.50(a), the requirement that the Contractor shall
continue to provide services to Contractor enrollees until the
end of the month in which insolvency has occurred, and the
requirement that the Contractor shall continue to provide
inpatient services until the date of discharge for an enrollee
who is institutionalized when insolvency occurs. The
Contractor shall meet this requirement by posting a
performance bond pursuant to Section [ILLEGIBLE] paragraph C,
of this Contract, and satisfying the statutory reserve
requirements of the Indiana Department of Insurance.
c. The Contractor shall comply with, and shall exclude from
participation as either a provider or subcontractor of the
Contractor, any entity or person that has been excluded under
the authority of Sections 1124A, 1128 or 1128A of the Social
Security Act or does not comply with the requirements of
Section 1128(b) of the Social Security Act.
d. In the event that the CMS determines that the Contractor has
violated any of the provisions of 42 CFR 434.67(a), CMS may
deny payment of FFP for new enrollees of the HMO under 42 USC
1396b(m)(5)(B)(ii). The Offices shall automatically deny State
payment for new enrollees whenever, and for so long as,
Federal payment for such enrollees has been denied.
H. The Contractor shall submit proof, satisfactory to the Offices, of
indemnification of the Contractor by the Contractor's parent corporation,
if applicable, and by all of its subcontractors.
I. The Contractor shall submit proof, satisfactory to the Offices, that all
subcontractors will hold the State harmless from liability under the
subcontract. This assurance in no way relieves the Contractor of any
responsibilities under the BAA or this Contract.
K. The Contractor shall establish and maintain a quality improvement program
that meets the requirements of 42 CFR 434.34, as well as other specific
requirements set forth in the BAA. The Offices and the CMS may evaluate,
through inspection or other means, including but not limited to, the
review of the quality assurance reports required under this Contract, and
the quality, appropriateness, and timeliness of services performed under
this Contract. The Contractor agrees to participate and cooperate, as
directed by the Offices, in the annual external quality review of the
services furnished by the Contractor.
Annual HEDIS rates must be submitted in a manner and timeline established
by the Office, including but not limited, to HEDIS rates that have been
audited by a HEDIS-certified audit firm within 30 days of receiving their
final audit report. The HEDIS rates which have completed the certified
audit may be submitted for 2003 HEDIS rates, but must be submitted for
2004 HEDIS rates and all other HEDIS rates in the future.
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L. In accordance with 42 CFR 434.28, the Contractor agrees that it and any of
its subcontractors shall comply with the requirements, if applicable, of
42 CFR 489, Subpart I, relating to maintaining and distributing written
policies and procedures respecting advance directives. The Contractor
shall distribute policies and procedures to adult individuals during the
enrollee enrollment process and whenever there are revisions to these
policies and procedures. The Contractor shall make available for
inspection, upon reasonable notice and request by the Offices,
documentation concerning its written policies, procedures and distribution
of such written procedures to enrollees.
M. Pursuant to 42 C.F.R. 417.479(a), the Contractor agrees that no specific
payment can be made directly or indirectly under a physician incentive
plan to a physician or physician group as an inducement to reduce or limit
medically necessary services furnished to an individual enrollee. The
Contractor must disclose to the State the information on provider
incentive plans listed in 42 C.F.R. 417.479(h)(1) and 417.479(i) at the
times indicated at 42 C.F.R. 434.70(a)(3), in order to determine whether
the incentive plan meets the requirements of 42 C.F.R. 417(d)-(g). The
Contractor must provide the capitation data required under paragraph
(h)(1)(vi) for the previous calendar year to the State by
application/contract renewal of each year. The Contractor will provide the
information on its physician incentive plan(s) listed in 42 C.F.R.
417.479(h)(3) to any enrollee upon request.
N. The Contractor must not prohibit or restrict a health care professional
from advising an enrollee about his/her health status, medical care, or
treatment, regardless of whether benefits for such care are provided under
this Contract, if the professional is acting within the lawful scope of
practice. However, this provision does not require the Contractor to
provide coverage of a counseling or referral service if the Contractor
objects to the service on moral or religious grounds and makes available
information on its policies to potential enrollees and enrollees within
ninety (90) days after the date the Contractor adopts a change in policy
regarding such counseling or referral service.
O. In accordance with 42 U.S.C. Section 1396u-2(b)(6), the Contractor agrees
that an enrollee may not be held liable for the following:
1. Debts of the Contractor, or its subcontractors, in the event of
any organization's insolvency;
2. Services provided to the enrollee in the event the Contractor fails
to receive payment from the Offices for such services or in the
event a provider fails to receive payment from the Contractor or
Offices; or
3. Payments made to a provider in excess of the amount that would be
owed by the enrollee if the Contractor had directly provided the
services.
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P. The Offices may from time to time request and the Contractor, and all of
its subcontractors, agree that the Contractor, or its subcontractors,
shall prepare and submit additional compilations and reports as requested
by the Offices. Such requests will be limited to situations in which the
desired data is considered essential and cannot be obtained through
existing Contractor reports. The Contractor, and all of its
subcontractors, agree that a response to the request shall be submitted
within thirty (30) days from the date of the request, or by the Offices'
requested completion date, whichever is earliest. The response shall
include the additional compilations and reports as requested, or the
status of the requested information and an expected completion date. When
such requests pertain to legislative inquiries or expedited inquiries from
the Office of the Governor, the additional compilations and reports shall
be submitted by the Offices' requested completion date. Failure by the
Contractor, or its subcontractors, to comply with response time frames
shall be considered grounds for the Offices to pursue the provisions
outlined in Section [ILLEGIBLE] of the BAA. In the event that delays in
submissions are a consequence of a delay by the Offices or the Medicaid
Fiscal Agent, the time frame for submission shall be extended by the
length of time of the delay.
Q. The Contractor shall establish a written claim resolution procedure
applicable to both in-network and out-of-network providers which shall be
distributed to all in-network providers and shall be available to out-
of-network providers upon request. The Contractor shall negotiate the
terms of a written claim resolution procedure with in-network providers
individually; but if the Contractor and an in-network provider are unable
to reach agreement on the terms of such procedure, the out-of-network
provider claims resolution procedure approved by the Offices under this
section shall govern the resolution of such in-network provider's claims
with the Contractor. The written claim resolution procedure must include,
at a minimum, the following elements:
1. A statement noting that providers objecting to determinations
involving their claims will be provided due process through the
Contractor's claim resolution procedure.
2. A description of both the informal and formal claim resolution
procedures that will be available to resolve a provider's objection
to a determination involving the provider's claim.
3. An informal claim resolution procedure which:
a. shall be available for the resolution of claims submitted to
the Contractor by the provider within 120 days after the date
on which services were rendered;
b. shall precede the formal claim resolution procedure;
c. shall be used to resolve a provider's objection to a
determination by the Contractor involving the provider's
claim, including a provider's objection to:
(1) any determination by the Contractor regarding payment for
a claim submitted by the provider, including the amount of
such payment; and
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(2) the Contractor's determination that a claim submitted by
the provider lacks sufficient supporting information, records,
or other materials;
d. may, at the election of a provider, be utilized to determine
the payment due for a claim in the event the Contractor fails,
within thirty (30) days after the provider submits the claim,
to notify the provider of:
(1) its determination regarding payment for the provider's
claim; or
(2) its determination that the provider's claim lacked
sufficient supporting information, records, or other
materials;
e. shall be commenced by a provider submitting to the Contractor:
(1) within sixty (60) days after the provider's receipt of
written notification of the Contractor's determination
regarding the provider's claim, the provider's written
objection to the Contractor's determination and an explanation
of the objection; or
(2) within sixty (60) days after the Contractor fails to make
a determination as described in subparagraph (d), a written
notice of the provider's election to utilize the informal
claims resolution procedure under subparagraph (d) above;
f. shall allow providers and the Contractor to make verbal
inquiries and to otherwise informally undertake to resolve the
matter submitted for resolution by the provider.
4. In the event the matter submitted for informal resolution is not
resolved to the provider's satisfaction within thirty (30) days
after the provider commenced the informal claim resolution
procedure, the provider shall have sixty (60) days from that point
to submit to the Contractor written notification of the provider's
election to submit the matter to the formal claim resolution
procedure. The provider's notice must specify the basis of the
provider's dispute with the Contractor. The Contractor's receipt of
the provider's written notice shall commence the formal claim
resolution procedure.
5. The formal claim resolution procedure shall be conducted by a panel
of one (1) or more individuals selected by the Contractor. Each
panel must be knowledgeable about the policy, legal, and clinical
issues involved in the matter that is the subject of the formal
claim resolution procedure. An individual who has been involved in
any previous consideration of the matter by the Contractor may not
serve on the panel. The Contractor's medical director, or another
licensed physician designated by the medical director, shall serve
as a consultant to the panel in the event the matter involves a
question of medical necessity or medical appropriateness.
6. The panel shall consider all information and material submitted to
it by the provider that bears directly upon an issue involved in the
matter that is the subject of the
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formal claim resolution procedure. The panel shall allow the
provider an opportunity to appear in person before the panel, or to
communicate with the panel through appropriate other means if the
provider is unable to appear in person, and question the panel in
regard to issues involved in the matter. The provider shall not be
required to be represented by an attorney for purposes of the formal
claim review procedure.
7. Within forty-five (45) days after the commencement of the formal
claim resolution procedure, the panel shall deliver to the provider
the panel's written determination of the matter before it. Such
determination shall be the Contractor's final position in regard to
the matter. The written determination shall include, as applicable,
a detailed explanation of the factual, legal, policy and clinical
basis of the panel's determination.
8. In the event the panel fails to deliver to the provider the panel's
written determination within forty-five (45) days after the
commencement of the formal claim resolution procedure, such failure
on the part of the panel shall have the effect of a denial by the
panel of the provider's claim.
9. The panel's written determination shall include notice to the
provider of the provider's right, within sixty (60) days after the
provider's receipt of the panel's written determination, to submit
to binding arbitration the matter that was the subject of the formal
claim resolution procedure. The provider shall also have the right
to submit the matter to binding arbitration if the panel has failed
to deliver its written determination to the provider within the
required forty-five (45) day period.
10. Any procedure involving binding arbitration must be conducted in
accordance with the rules and regulations of the American Health
Lawyers Association (AHLA), pursuant to the Uniform Arbitration Act
as adopted in the State of Indiana at I.C. 34-57-2, unless the
provider and Contractor mutually agree to some other binding
resolution procedure. However, any Contractor and provider that are
subject to statutorily imposed arbitration procedures for the
resolution of these claims shall be required to follow the
statutorily imposed arbitration procedures, but only to the extent
those procedures differ from, or are irreconcilable with, the rules
and regulations of the American Health Lawyers Association (AHLA),
pursuant to the Uniform Arbitration Act as adopted in the State of
Indiana at I.C. 34-57-2.
11. A provider may, within the requisite sixty (60) day time period,
include in a single arbitration proceeding matters from multiple
formal claim resolution procedures involving the Contractor and the
provider.
12. For claims disputed under Paragraph 3. c. (2) above:
a. a claim that is finally determined through the Contractor's
claim resolution procedure (including arbitration) not to lack
sufficient supporting documentation shall be processed by the
Contractor within thirty (30) days
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after such final determination. The processing of the claim
and the Contractor's determination involving the claim shall
be subject to Paragraph 3. c. and Paragraph 3. d. and the
Contractor's formal claim resolution procedure and binding
arbitration.
b. a claim that is finally determined through the Contractor's
claim resolution procedure (including arbitration) to lack
sufficient supporting documentation shall be processed by the
Contractor within thirty (30) days after the provider submits
to the Contractor the requisite supporting documentation. The
provider shall have thirty (30) days after written notice of
the final determination establishing that the claim lacked
sufficient supporting documentation is received by the
provider to submit the requisite supporting documentation. The
processing of the claim and the Contractor's determination
involving the claim shall be subject to Paragraph 3. c. and
Paragraph 3. d. and the Contractor's formal claim resolution
procedure and binding arbitration.
13. A Contractor may not include in its claim resolution procedures
elements that restrict or diminish the claim review procedures, time
periods or subject matter provided for in paragraphs 1 through 12
above.
14. A Contractor shall maintain a log of all informally and formally
filed provider objections to determinations involving claims. The
logged information shall include the provider's name, date of
objection, nature of the objection, and disposition. The Contractor
shall submit quarterly reports to the Offices regarding the number
and type of provider objections.
R. In accordance with the First Amendment to the original contract between
the parties dated April 1, 2002, Section 3.6.1.3 of the BAA is amended to
require the Contractor to submit the "Mandatory RBMC Transition Report"
(Attachment A) according the schedule set out in the "2002 Hoosier
Healthwise MCO Reporting Calendar for Mandatory RBMC Transition Report"
(Attachment B), unless the MCO has received written notification from OMPP
that the report, or certain data elements in the report, is/are no longer
required or may be reported less frequently. Pursuant to the reporting
calendar (Attachment B), the final submission shall be due on January
6, 2003.
S. In accordance with the First Amendment to the original contract between
the parties dated April 1, 2002, the parties agree that Section 3.6.3 of
the BAA is amended to require the Contractor to obtain written approval of
the State prior to closing its provider networks, which shall not be
unreasonably withheld or delayed.
T. In accordance with the First Amendment to the original contract between
the parties dated April 1, 2002, the parties agree that Sections 3.6.6 and
3.6.7.3 of the BAA are amended to require the Contractor to maintain a
monthly telephone abandonment rate equal to or less than five percent of
calls received each by the member helpline and provider helpline. The
parties agree that BAA Section 3.16 is amended to add a new section 3.16.8
to read as follows:
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Section 3.16.8. The MCO will comply with the call abandonment requirements
for the member and provider helplines described in Sections 3.6.6. and
3.6.7.3 of this BAA. Because actual damages caused by non-compliance are
not subject to exact determination, the State will assess the MCO, as
liquidated damages and not as a penalty, (a) two hundred dollars ($200.00)
for each business day the MCO fails to submit required documentation to
provide evidence of compliance with this requirement, or (b) two thousand
dollars ($2000.00) for each month the MCO fails to meet the requirement
after 2 consecutive months of non-compliance on the member helpline or (c)
two thousand dollars ($2000.00) for each month the MCO fails to meet the
requirement after 2 consecutive months of non-compliance on the provider
helpline.
U. In accordance with the First Amendment to the original contract between
the parties dated April 1, 2002, the parties agree that Section 3.5.3 of
the BAA is amended to allow OMPP to change, at OMPP's discretion, the
frequency of the MCO Enrollment Rosters generated by OMPP's fiscal agent
to once per month, upon reasonable and adequate prior written notice to
the Contractor.
V. In accordance with the First Amendment to the original contract between
the parties dated April 1, 2002, the parties agree that Section 3.6.3 of
the BAA is amended to require the Contractor to develop and adhere to a
plan for identifying and serving people with special needs. The plan must
satisfy any applicable federal requirements.
W. In accordance with the First Amendment to the original contract between
the parties dated April 1, 2002, the Contractor agrees to provide OMPP
with prior written notice at least ninety (90) days in advance of their
inability to maintain a sufficient Primary Medical Provider (PMP) network
in any of the counties where mandatory RBMC has been or will be
implemented, including Marion, Allen, Elkhart, St. Xxxxxx, Lake, Hamilton,
and Vanderburgh Counties, such that the program would not be able to
maintain the appropriate member choice of two (2) MCOs, pursuant to
federal requirements.
X. In accordance with the First Amendment to the original contract between
the parties dated April 1, 2002, the Contractor agrees that agreements
with PMPs in mandatory RBMC counties shall include a provision allowing
the PMP to terminate the agreement for any reason upon written notice to
the Contractor. The Contractor may require that the physician provide said
notice to the Contractor at least ninety (90) days prior to termination.
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IV. PAYMENT
A. In consideration of the services to be performed by the Contractor, the
Offices agree to pay the Contractor the following amounts per month per
enrolled member, as contained in the Offices' capitation payment listing,
based upon the capitation rates by category and benefit package as listed
below:
CAPITATION RATES
------------------------------------------------------------
CATEGORY PACKAGES A/B PACKAGE C
------------- ------------ ---------
Newborns $ 365.86 $ 119.11
Preschool $ 73.95 $ 76.59
Children $ 59.97 $ 64.10
Adolescents $ 90.21 $ 91.00
Adult Males $ 254.69
Adult Females $ 199.59
Deliveries $ 3,396.90/delivery $ 3410.09/delivery
B. The actuarial basis for computing the rates set forth above is as follows:
The capitation rates have been determined from historical Hoosier
Healthwise claim experience for the PCCM enrollees. The historical
experience has been adjusted to reflect anticipated trend in the Hoosier
Healthwise program, cost containment initiatives, morbidity variations
between the PCCM and RBMC enrollees, and anticipated managed care
utilization adjustments. The Offices may rely on self-report RBMC
experience to determine appropriate managed care utilization adjustments
and other morbidity variation adjustments.
C. The parties agree that the Offices have the option to adjust the
capitation rates annually. In the event that the Offices adjust the
fee-for-service (FFS) rates, the Offices may, in its sole discretion,
further adjust the capitation rates in accordance with the FFS adjustment.
If the Offices made such an adjustment, it shall apply only to the
specific service component of the capitation rate that corresponds to the
FFS adjustment. Any capitation rates adjusted due to a change in the FFS
program may be further adjusted to ensure actuarial soundness. All
adjustments are subject to federal regulations for risk contracts. Rates
revised under this provision shall be implemented only after a contract
amendment is executed and approved.
D. All payment obligations of the Offices are subject to the encumbrance of
monies and shall be paid to the Contractor on the first Wednesday after
the fifteenth of the month.
E. The capitation payment will be prospective, based upon the number of
enrollees assigned to the Contractor as of the first of the month. The
Offices will establish an administrative procedure to allow retroactive or
other payment adjustments as necessary to implement this contract.
F. The Contractor will be provided a capitation payment listing which
includes a detailed listing of all enrollees for which the Contractor is
receiving a capitation payment.
G. It is understood and agreed upon by the parties that all obligations of
the State of Indiana are contingent upon the availability and continued
appropriation of State and Federal funds, and
MCO Contract Extension Page 13 of 26 Harmony Health Plan
in no event shall the State of Indiana be liable for any payments in
excess of available appropriated funds.
H. When the Director of the State Budget Agency makes a written determination
that funds are not appropriated or otherwise available to support
continuation of performance of this Contract, the Contract shall be
cancelled. A determination by the State Budget Director that funds are not
appropriated or otherwise available to support continuation of performance
shall be final and conclusive.
V. ORDER OF PRECEDENCE
Any inconsistency or ambiguity in this Contract shall be resolved by giving
precedence in the following order:
1) The express terms of this contract;
2) Attachment 1 - BAA 01-28, released July 31, 2000 and First Amendment
dated April 1, 2002;
3) Attachment 2 - the Contractors; response to the BAA;
4) Any other documents, standards laws, rules or regulations
incorporated by reference in the above materials, all of which are
hereby incorporated by reference.
VI. NOTICE
A. Whenever notice is required to be given to the other party, it shall be
made in writing and delivered to that party. Delivery shall be deemed to
have occurred if a signed receipt is obtained when delivered by hand or
according to the date on the return receipt if sent by certified mail,
return receipt requested. Notices shall be addressed as follows:
In case of notice to the Contractor: In case of notice to the Offices:
Xxxx Xxxxx, MD, President/CEO Xxxx Xxxxx, Managed Care Director
Harmony Health Plan of Illinois, Inc. Office of Medicaid Policy and Planning
000 Xxxxx Xxxxxx Xxxxx, Xxxxx 0000 Family and Social Services Administration
Xxxxxxx, Xxxxxxxx 00000 000 X. Xxxxxxxxxx Xx., XXXX X000, MS07
Xxxxxxxxxxxx, Xxxxxxx 00000
B. Said notices shall become effective on the date of delivery or the date
specified within the notice, whichever comes later. Either party may
change its address for notification purposes by mailing a notice stating
the change and setting forth the new address.
MCO Contract Extension Page 14 of 26 Harmony Health Plan
VII. MISCELLANEOUS PROVISIONS
A. Entire Agreement. This Contract constitutes the entire agreement between
the parties with respect to the subject matter; all prior agreements,
representations, statements, negotiations, and undertakings are superseded
hereby.
B. Changes. Any changes to this Contract shall be by formal amendment of this
Contract signed by all parties required by Indiana law.
C. Termination. The Office may, without cause, cancel and terminate this
Contract in whole or in part upon sixty (60) days' prior written notice.
The Contractor will be reimbursed for services performed prior to the
effective date of termination consistent with the terms of the Contract.
The Office will not be liable for services performed after notice of
termination, but before the date of termination, without written
authorization from the Office. In no event will the Office be liable for
services performed after the effective date of termination.
In the event that the Office requests that the Contractor perform any
additional services associated with the transition or turnover of the
contract, the Office agrees to pay reasonable costs for those additional
services specifically requested by the Office. Any additional services and
costs must receive prior approval in writing by the Office.
D. Disputes. Should any disputes arise with respect to this Contract, the
Contractor and the State of Indiana agree to act immediately to resolve
any such disputes. Time is of the essence in the resolution of disputes.
The Contractor agrees that, the existence of a dispute notwithstanding, it
will continue without delay to carry out all of its responsibilities under
this Contract which are not affected by the dispute. Should the Contractor
fail to continue without delay to perform its responsibilities under this
Contract in the accomplishment of all non-disputed work, any additional
costs incurred by the Contractor or the State of Indiana as a result of
such failure to proceed shall be borne by the Contractor, and the
Contractor shall make no claim against the State of Indiana for such
costs. If the Contractor and the State of Indiana cannot resolve a dispute
within ten (10) working days following notification in writing by either
party of the existence of said dispute, then the following procedure shall
apply:
1. The parties agree to resolve such matters through submission of
their dispute to the Commissioner of the Indiana Department of
Administration who shall reduce a decision to writing and mail or
otherwise furnish a copy thereof to the Contractor and the State of
Indiana within ten (10) working days after presentation of such
dispute for decision. The Commissioner's decision shall be final and
conclusive unless either party mails or otherwise furnishes to the
Commissioner, within ten (10) working days after receipt of the
Commissioner's decision, a written appeal. Within ten (10) working
days of receipt by the Commissioner of a written request for appeal,
the decision may be reconsidered.
MCO Contract Extension Page 15 of 26 Harmony Health Plan
If no reconsideration is provided within ten (10) working days, the
Contractor may submit the dispute to an Indiana court of competent
jurisdiction.
2. The State of Indiana may with hold payments on disputed items
pending resolution of the dispute. The on-payment by the State of
Indiana to the Contractor of one or more invoices not in dispute
shall not constitute default, however, the Contractor may bring suit
to collect such monies without following the disputes procedure
contained herein.
E. Debarment and Suspension. Contractor certifies, by entering into this
agreement, that neither it nor its principals are presently debarred,
suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from entering into this agreement by any federal agency or
department, agency or political subdivision of the State of Indiana. The
term "principal" for the purposes of this agreement is defined as an
officer, director, owner, partner, key employee, or other person with
primary management or supervisory responsibilities or a person who has a
critical influence on or substantive control over the operations of the
Contractor.
F. Compliance with Laws. The Contractor shall comply with all applicable
federal, state, and local laws, rules, regulations, or ordinances, and all
provisions required thereby to be included herein are hereby incorporated
by reference. The enactment or amendment of any applicable state or
federal statute or the promulgation of any rules or regulations thereunder
after execution of this Contract shall be reviewed by the State and the
Contractor to determine whether the provisions of the Contract require
formal modification.
G. Indemnification. Contractor agrees to indemnify, defend, and hold harmless
the State of Indiana and its agents, officers, and employees from all
claims and suits including court costs, attorney's fees, and other
expenses caused by any act or omission of the Contractor and/or its
subcontractors, if any. The state shall not provide such indemnification
to the Contractor.
H. Nondiscrimination. Pursuant to IC 22-9-1-10 and the Civil Rights Act of
1964, Contractor and its subcontractors shall not discriminate against any
employee or applicant for employment in the performance of this contract.
The Contractor shall not discriminate with respect to the hire, tenure,
terms, conditions or privileges of employment or any matter directly or
indirectly related to employment, because of race, color, religion, sex,
disability, national origin or ancestry. Breach of this covenant may be
regarded as a material breach of contract. Acceptance of this Contract
also signifies compliance with applicable federal laws, regulations, and
executive orders prohibiting discrimination in the provision of services
based on race, color, national origin, age, sex, disability, or status as
a veteran. The Contractor understands that the State is a recipient of
federal funds. Pursuant to that understanding, the Contractor and its
subcontractor, if any, agree that if the Contractor employs fifty (50) or
more employees and does at least fifty-thousand dollars ($50,000.00) worth
of business with the State and is not exempt, the Contractor will comply
with the affirmative action reporting requirements of 41 C.F.R. Section
60-1.7, if applicable. The Contractor shall comply with Section 202 of
MCO Contract Extension Page 16 of 26 Harmony Health Plan
Executive Order 11246, as amended, 41 C.F.R. Section 60-250, and 41
C.F.R. Section 60-741, as amended, which are incorporated herein by
specific reference. Breach of this covenant may be regarded as a material
breach of contract.
I. Confidentiality of State of Indiana Information. The Contractor
understands and agrees that data, materials and information disclosed to
the Contractor may contain confidential and protected data; therefore, the
Contractor promises and assures that data, material, and information
gathered, based upon or disclosed to the Contractor for the purpose of
this Contract will not be disclosed to others or discussed with other
parties without the prior written consent of the State of Indiana.
J. Confidentiality of Data and Property Rights. The Contractor agrees that
all information, data, findings, recommendations, and proposals, by
whatever name described and by whatever form therein, secured developed,
written, or produced by the Contractor in furtherance of this Contract,
shall be the property of the State of Indiana and that the Contractor
shall take such action as is necessary under law to preserve such property
rights in and of the State of Indiana while such property is within the
control and/or custody of the Contractor.
By this Contract the Contractor specifically waives and/or releases to
the State of Indiana any cognizable property right in the Contractor to
copyright or patent such information, data, findings, recommendations,
and proposals, that are developed exclusively in furtherance of the
Contract and not developed by the Contractor for its other lines of
business and incidentally applied to its Hoosier Healthwise line of
business.
The parties acknowledge that it is in their interests for the Contractor
to develop new techniques and advances in managed care. Therefore, the
Offices hereby grant to the Contractor, subject to the confidentiality
obligations set forth in this Contract, as well as those imposed by
federal and state laws and regulations, a perpetual license to use
materials, models, methodologies and techniques developed under this
contract.
K. Ownership of Documents and Materials. All documents, records, programs,
data, film, tape, articles, memoranda, and other materials developed under
this Contract will be the property of the State of Indiana. Use of these
materials other than related to contract performance by the Contractor
without the prior written consent of the State of Indiana is prohibited.
During the performance of the services specified herein, the Contractor
shall be responsible for any loss or damage to these materials developed
for or supplied by the State of Indiana and used to develop or assist in
the services provided herein, while they are in the possession of the
Contractor, and any loss or damage thereto shall be restored at the
Contractor's expense. Full, immediate and unrestricted access to the work
product of the Contractor during the term of this Contract shall be
available to the State of Indiana. The Contractor will give to the State
of Indiana, or the State of Indiana's designee, all records of other
materials described in this section, after termination of the Contract and
upon five (5) days notice of a request from the State of Indiana.
The parties acknowledge that it is in their interests for the Contractor
to develop new techniques and advances in managed care. Therefore, the
Offices hereby grant to the
MCO Contract Extension Page 17 of 26 Harmony Health Plan
Contractor, subject to the confidentiality obligations set forth in this
Contract, as well as those imposed by federal and state laws and
regulations, a perpetual license to use materials, models, methodologies
and techniques developed under this contract.
L. Conveyance of Documents And Continuation of Existing Activity: Should the
Contract for whatever reason, (i.e. completion of a contract with no
renewal, or termination of service by either party), be discontinued and
the activities as provided for in the Contract for services cease, the
Contractor and any subcontractors employed by the terminating Contractor
in the performance of the duties of the Contract shall promptly convey to
the State of Indiana, copies of all vendor working papers, data collection
forms, reports, charts, programs, cost records and all other material
related to work performed on this Contract.
The Contractor and the Office shall convene immediately upon notification
of termination or non-renewal of the Contract to determine what work shall
be suspended, what work shall be completed, and the time frame for
completion and conveyance. The Office will then provide the Contractor
with a written schedule of the completion and conveyance activities
associated with termination. Documents/materials associated with suspended
activities shall be conveyed by the Contractor to the State of Indiana
upon five days' notice from the State of Indiana. Upon completion of those
remaining activities noted on the written schedule, the Contractor shall
also convey all documents and materials to the State of Indiana upon five
days' notice from the State of Indiana.
M. Independent Contractor. The Office and the Contractor acknowledge and
agree that in the performance of this contract, the Contractor is an
independent contractor and both parties will be acting in an individual
capacity and not an as agents, employees, partners, joint venturers,
officers, or associates of one another. The employees or agents of one
party shall not be deemed or construed to be the employees or agents of
the other party for any purposes whatsoever. Neither party will assume
any liability for any injury (including death) to any persons, or damage
to any property arising out of the acts or omissions of the agents,
employees or subcontractors of the other party.
The Contractor shall be responsible for providing all necessary
unemployment and worker compensation insurance for the Contractor's
employees.
N. Work Standards. The Contractor agrees to execute its respective
responsibilities by following and applying at all times the highest
professional and technical guidelines and standards. If the State becomes
dissatisfied with the work product or the working relationship with those
individuals assigned to work on this Contract, the State may request in
writing the replacement of any or all such individuals and the Contractor
shall grant such a request.
O. Governing Laws. This Contract shall be construed in accordance with and
governed by the laws of the State of Indiana and suit if any, must be
brought in the State of Indiana.
P. Severability. The invalidity in whole or in part of any provision of this
Contract shall not void or affect the validity of any other provision.
MCO Contract Extension Page 18 of 26 Harmony Health Plan
Q. Waiver of Rights. No right conferred on either party under this Contract
shall be deemed waived and no breach of this Contract deemed excused,
unless such waiver or excuse shall be in writing and signed by the party
claimed to have waived such right.
Failure of the Office to enforce at any time any provision of this
Contract shall not be construed as a waiver thereof. The remedies herein
reserved shall be cumulative and additional to any other remedies in law
or equity.
R. Taxes. The State of Indiana is exempt from all State, Federal and local
taxes. The State will not be responsible for any taxes levied on the
Contractor as a result of this Contract.
S. Force Majeure, Suspension and Termination. In the event either party is
unable to perform any of its obligations under this Contract or to enjoy
any of its benefits because of (or if failure to perform the service is
caused by) natural disaster, actions or decrees of governmental bodies, or
communication line failure not the fault of the affected party
(hereinafter referred to as a "Force Majeure Event"), the party who has
been so affected shall immediately give notice to the other party and
shall take reasonable measures to resume performance. Upon receipt of such
notice, all obligations under this Contract shall be immediately
suspended. If the period of non-performance exceeds thirty (30) days from
the receipt of notice of the Force Majeure Event, the party whose ability
to perform has not been so affected may, by giving written notice,
terminate this Contract.
T. Assignment. The Contractor shall not assign or subcontract the whole or
any part of this Contract without the State's prior written consent. The
Contractor may assign its right to receive payments to such third parties
a the Contractor may desire without the prior written consent of the
State, provided that the Contractor gives written notice (including
evidence of such assignment) to the State thirty (30) days in advance of
any payment so assigned. The assignment shall cover all unpaid amounts
under this Contract and shall not be made to more than one party.
U. Successors and Assignees. The Contractor binds its successors, executors,
assignees, and administrators, to all covenants of this Contract. Except
as set forth above, the Contractor shall not assign, sublet, or transfer
the Contractor's interest in this Contract without the prior written
consent of the Office.
V. Drug-Free Workplace Certification
The Contractor hereby covenants and agrees to make a good faith effort to
provide and maintain a drug-free workplace. Contractor will give written
notice to the State within ten (10) days after receiving actual notice
that the Contractor or an employee of the Contractor has been convicted of
a criminal drug violation occurring in the contractor's workplace.
False certification or violation of the certification may result in
sanctions including, but not limited to, suspension of contract payments,
termination of the contract or agreement
MCO Contract Extension Page 19 of 26 Harmony Health Plan
and/or debarment of contracting opportunities with the State of Indiana
for up to three (3) years.
In addition to the provisions of the above paragraphs, if the total
contract amount set forth in this agreement is in excess of $25,000.00,
Contractor hereby further agrees that this agreement is expressly subject
to the terms, conditions, and representations of the following
certification:
This certification is required by Executive Order No. 90-5, April 12,
1990, issued by the Governor of Indiana. Pursuant to its delegated
authority, the Indiana Department of Administration is requiring the
inclusion of this certification in all contracts with and grants from the
State of Indiana in excess of $25,000.00. No award of a contract shall be
made, and no contract, purchase order or agreement, the total amount of
which exceeds $25,000.00, shall be valid, unless and until this
certification has been fully executed by the Contractor and made a part of
the contract or agreement as part of the contract documents.
The Contractor certifies and agrees that it will provide a drug-free
workplace by:
1. Publishing and providing to all of its employees a statement notifying
employees that the unlawful manufacture, distribution, dispensing,
possession or use of a controlled substance is prohibited in the
Contractor's workplace and specifying the actions that will be taken
against employees for violations of such prohibition;
2. Establishing a drug-free awareness program to inform employees of (1)
the dangers of drug abuse in the workplace; (2) the Contractor's policy of
maintaining a drug-free workplace; (3) any available drug counseling,
rehabilitation, and employee assistance programs; and (4) the penalties
that may be imposed upon an employee for drug abuse violations occurring
in the workplace;
3. Notifying all employees in the statement required by subparagraph (1)
above that as a condition of continued employment the employee will (A)
abide by the terms of the statement; and (B) notify the Contractor of any
criminal drug statute conviction for a violation occurring in the
workplace no later than five (5) days after such conviction;
4. Notifying in writing the State within ten (10) days after receiving
notice from an employee under subdivision (3)(B) above, or otherwise
receiving actual notice of such conviction;
5. Within thirty (30) days after receiving notice under subdivision (3)(B)
above of a conviction, imposing the following sanctions or remedial
measures on any employee who is convicted of drug abuse violations
occurring in the workplace: (1) take appropriate personnel action against
the employee, up to and including termination; or (2) require such
employee to satisfactorily participate in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State or
local health, law enforcement, or other appropriate agency; and
MCO Contract Extension Page 20 of 26 Harmony Health Plan
Making a good faith effort to maintain a drug-free workplace through the
implementation of subparagraphs (1) through (5) above.
W. Lobbying Activities. Pursuant to 31 U S.C. Section 1352, and any
regulations promulgated thereunder, the Contractor hereby assures and
certifies that no federally appropriated funds have been paid, or will be
paid, by or on behalf of the Contractor, to any person for influencing or
attempting to influence in officer or employee of any agency, a member of
Congress, an officer or employee of Congress, or an employee of a member
of Congress, in connection with the awarding of any federal contract, the
making of any federal grant, the making of any federal loan, the entering
into of any cooperative contract, and the extension, continuation,
renewal, amendment, or modification of any federal contract, grant, loan
or cooperative contract. If any funds other than federally appropriated
funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a member of
Congress, an officer or employee of Congress, or an employee of a member
of Congress in connection with this Contract, the Contractor shall
complete and submit Standard Form-LLL, "Disclosure Form to Report
Lobbying", in accordance with its instructions.
X. Access to Records. The Contractor and any subcontractor shall maintain all
books, documents, papers, accounting records and any other evidence
pertaining to the cost incurred under this agreement. Contractor and any
subcontractors shall make such materials available at all reasonable times
during the contract period and for three (3) years from the date of final
payment under the Contract or until all pending matters are closed,
whichever date is later, for inspection by the Office, or any other duly
authorized representative of the State of Indiana or the Federal
government. Copies thereof shall be furnished at no cost to the State if
requested. To the extent that such records reveal information about
salaries/compensation of the Contractor's employees or financial statement
of the Contractor that are not directly pertinent to this Contract, the
Contractor may redact it.
Y. Environmental Standards. If the contract amount set forth in this Contract
is in excess of $100,000, the Contractor shall comply with all applicable
standards, orders, or requirements issued under section 306 of the Clean
Air Act (42 U.S.C. Section 7606), section 508 of the Clean Water Act (33
U.S.C. Section 1368), Executive Order 11738, and Environmental Protection
Agency regulations (40 C.F.R. Part 32), which prohibit the use under
non-exempt Federal contracts of facilities included on the EPA List of
Violating Facilities. The Contractor shall report any violations of this
paragraph to the State of Indiana and to the United States Environmental
Protection Agency Assistant Administrator for Enforcement.
Z. Conflict of Interest
1. As used in this section:
"Immediate family" means the spouse and the unemancipated
children of an individual.
MCO Contract Extension Page 21 of 26 Harmony Health Plan
"Interested party" means:
a. The individual executing this Contract;
b. An individual who has an interest of three percent (3%) or more
of the Contractor if the Contractor is not an individual; or
c. Any member of the immediate family of an individual specified
under subdivision a or b.
"Department" means the Indiana a Department of Administration.
"Commission" means the State Ethics Commission.
2. The Department may a cancel this Contract without recourse by the
Contractor if any interested party is an employee of the State of
Indiana.
3. The Department will not exercise its right of cancellation under
section 2 above if the Contractor gives the Department an opinion by
the Commission indicating that the existence of this Contract and
the employment by the State of Indiana of the interested party does
not violate any statute or code relating to ethical conduct of state
employ es. The Department may take action, including cancellation of
this Contract co consistent with an opinion of the Commission
obtained under this section.
4. The Contractor has an affirmative obligation under this Contract
to disclose to the Department when an interested party is or becomes
an employee of the State of Indiana. The obligation under this
section extends only to those facts which the Contractor knows or
reasonably could know.
AA. Assurance of Compliance with Civil Rights Act of 1964, Section 504 of the
Rehabilitation Act of 1973 and the Age Discrimination Act of 1975, the
Americans with Disabilities Act of 1990 and Title IX of the Education
Amendments of 1972: The Contractor agrees that it, and all of its
subcontractors and providers, will comply with the following:
1. Title VI of the Civil Rights Act of 1964 (Pub. L. 88-352), as
amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Health and Human Services (45 C.F.R.
Part 80), to the end that, in accordance with Title VI of that Act
and the Regulation, no person in the United States shall on the
ground of race, color, or national origin, be excluded from
participation in, be denied the benefits of, or be otherwise
subjected to discrimination under any program or activity for which
the Contractor receives Federal financial assistance under this
Contract.
2. Section 504 of the Rehabilitation Act of 1973 (Pub. L. 93-112),
as amended, and all requirements imposed by or pursuant to the
Regulation of the
MCO Contract Extension Page 22 of 26 Harmony Health Plan
Department of Health and Human Services (45 C.F.R. Part 84), to the
end that, in accordance with Section 504 of that Act and the
Regulation, no otherwise qualified handicapped individual in the
United States shall, solely by reason of his/her handicap, be
excluded from participation in, be denied the benefits of, or be
subjected to discrimination under any program or activity for which
the Contractor receives Federal financial assistance under this
Contract.
3. The Age Discrimination Act of 1975 (Pub. L. 94-135), as amended,
and all requirements imposed by or pursuant to the Regulation of the
Department of Health and Human Services (45 C.F.R. Part 91), to the
end that, in accordance with the Act and the Regulation, no person
in the United States shall, on the basis of age, be denied the
benefits of, be excluded from participation in, or be subjected to
discrimination under any program or activity for which the
Contractor receives Federal financial assistance under this
Contract.
4. The Americans with Disabilities Act of 1990 (Pub. L. 101-336), as
amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Justice (28 C.F.R. 35.101 et seq.),
to the end that in accordance with the Act and Regulation, no person
in the United States with a disability shall, on the basis of the
disability, be excluded from participation in, be denied the
benefits of, or otherwise be subjected to discrimination under any
program or activity for which the Contractor receives Federal
financial assistance under this Contract.
5. Title IX of the Education Amendments of 1972, as amended (20
U.S.C. Sections 1681-1683, and 1685-1686), an all requirements
imposed by or pursuant to regulation, to the end that, in accordance
with the Amendments, no person in the United States shall, on the
basis of sex, be excluded from participation in, be denied the
benefits of, or otherwise be subjected to discrimination under any
program or activity for which the Contractor receives Federal
financial assistance under this Contract.
The Contractor agrees that compliance with this assurance constitutes a
condition of continued receipt of Federal financial assistance, and that
it is binding upon the Contractor, its successors, transferees and
assignees for the period during which such assistance is provided. The
Contractor further recognizes that the United States shall have the right
to seek judicial enforcement of this assurance.
BB. Security and Privacy of Health Information. The Contractor agrees to
comply with all requirements of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA in all activities related to this
contract, to maintain compliance throughout the life of the contract, to
operate any systems used to fulfill the requirements of this contract in
full compliance with HIPAA and to take no action which adversely affects
the State's HIPAA compliance.
The parties acknowledge that the Department of Health and Human Services
has issued the Final Rule, as amended from time to time on the Standards
for Privacy of Individually
MCO Contract Extension Page 23 of 26 Harmony Health Plan
Identifiable Health Information, as required by the Administrative
Simplification Section of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). To the extent required by the
provisions of HIPAA and regulations promulgated thereunder, the
Contractor assures that it will appropriately safeguard Protected Health
Information (PHI), as defined by the regulations, which is made available
to or obtained by the Contractor in the course of its work under the
contract. The Contractor agrees to comply with applicable requirements of
law relating to PHI with respect to any task or other activity it performs
for the Office including, as required by the final regulations:
1. Not using or further disclosing PHI other than as permitted or
required by this Contract or by applicable law;
2. Using appropriate safeguards to prevent use or disclosure of PHI
other than as provided by this Contract or by applicable law;
3. Reporting to the Office any use or disclosure by the Contractor, its
agent, employees, subcontractors or third parties, of PHI obtained
under this Contract in a manner not provided for by this Contract or
by applicable law of which the Contractor becomes aware;
4. Ensuring that any subcontractors or agents to whom the Contractor
provides PHI received from, or created or received by the Contractor
on behalf of the Office agrees to the same restrictions, conditions
and obligations applicable to such party regarding PHI;
5. Making the Contractor's internal practices, books and records
related to the use of disclosure of PHI received from or created or
received by the Contractor on behalf of the Office available to the
Secretary of the United States Department of Health and Human
Services for purposes of determining the Office's compliance with
applicable law. The Contractor shall immediately notify the Office
upon receipt by the Contractor of any such request, and shall
provide the Office with copies of any materials made available in
response to such a request;
6. Making available the information required to provide an accounting
of disclosures pursuant to applicable law; and
7. At the termination of this Contract, returning or destroying all PHI
obtained under this Contract.
BB. Termination by the Contractor. This Contract may be terminated by the
Contractor upon one hundred eighty (180) days prior written notice to the
Offices. The Contractor will be reimbursed for services performed prior to
the effective date of termination consistent with the terms of the
Contract. In no event will the Offices be liable for services performed
after the effective date of termination, without written authorization
from the Offices.
CC. Change in Scope of Work -- In the event the Offices require a major change
in scope, character or complexity of the work after the work has
commenced, adjustments in compensation to the Contractor shall be
determined by the Office, in the exercise of its honest and reasonable
judgment, and the Contractor shall not commence the additional work or the
change in the scope of work until authorized in writing by the Offices. No
claim for additional compensation shall be made in the absence of a prior
written approval executed by all signatories her to.
MCO Contract Extension Page 24 of 26 Harmony Health Plan
DD. Substantial Performance. This Contract shall be deemed to be substantially
performed only when fully performed according to its terms and conditions
and any modification thereof.
EE. Penalties/Interest/Attorney's Fees. The State will in good faith perform
its required obligations hereunder and does not agree to pay any
penalties, liquidated damages, interest, or attorney's fees, except as
required by Indiana law, in part, IC 5-17-5, IC 34-54-8, and IC 34-13-1.
FF. Authority to Bind Contractor. Notwithstanding anything in the Contract to
the contrary, the signatory for the Contractor represents that he/she has
been duly authorized to execute contracts on behalf of the Contractor
designated herein and has obtained all necessary or applicable approval
from the home office of the Contractor, if applicable, to make this, the
contract, fully binding upon the Contractor when his/her signature is
affixed and is not subject to home office acceptance hereto when accepted
by the State of Indiana.
GG. Performance Bond. The Contractor agrees that a performance bond in the
amount of five hundred thousand dollars ($500,000.00) will be maintained
in the Indiana Department of Administration (IDOA). Said bond is in the
form of a cashier's check, a certified check, or a surety bond executed by
a surety company authorized to do business in the State of Indiana as
approved by the Insurance Department of State of Indiana. No other check
or surety will be accepted. The performance bond shall be made payable to
the IDOA and shall be effective for the duration of the contract and any
extensions thereof. The State reserves the right to increase the
performance bond amount if enrollment levels indicate the need for higher
liquidated damages.
HH. Non-Collusion and Acceptance. The undersigned attests, subject to the
penalties for perjury, that he/she is the contracting party, or that
he/she is the representative, agent, member or officer of the contracting
party, that he/she has not, nor has any other member, employee,
representative, agent, or officer of the firm, company, corporation, or
partnership represented by him/her, directly or indirectly, to the best of
his/her knowledge, entered into or offered to enter into any combination,
collusion, or agreement to receive or pay, and that he/she has not
received or paid, any sum of money or other consideration for the
execution of this agreement other than that which appears upon the face of
the agreement.
/// The remainder of this page is left intentionally blank. ///
MCO Contract Extension Harmony Health Plan
Page 25 of 26
IN WITNESS WHEREOF, [Contractor's Name] and the State of Indiana have, through
duly authorized representatives, entered into this agreement. The parties having
read and understand the foregoing terms of the Contract do by their respective
signatures dated below hereby agree to the terms thereof.
For the Contractor: For the State of Indiana:
/s/ Xxxx Xxxxx
______________________________________ _____________________________________
Xxxx Xxxxx, MD, President/CEO Xxxxxxx Bella, Assistant Secretary
Harmony Health Plan of Illinois, Inc. Office of Medicaid Policy & Planning
Date: 12/20/02 Date:________________________________
_____________________________________
Xxxxxxx X. Xxxxx, Director
Children's Health Insurance Program
Date:________________________________
APPROVED: APPROVED:
______________________________________ _____________________________________
Xxxxxxx Xxxxxxx, Director Xxxxx Xxxxxxx, Commissioner
State Budget Agency Department of Administration
Date:_________________________________ Date:________________________________
APPROVED AS TO FORM AND LEGALITY
______________________________________
Xxxxxxx Xxxxxx
Attorney General of Indiana
Date:_________________________________
MCO Contract Extension Harmony Health Plan
Page 26 of 26
[INDIANA FAMILY & SOCIAL SERVICES ADMINISTRATION LOGO ] Xxxxx X'Xxxxxx, Governor
State of Indiana
"People OFFICE OF MEDICAID POLICY AND PLANNING
helping people 000 X. XXXXXXXXXX XXXXXX, XXXX X000
help XXXXXXXXXXXX, XX 00000-0000
themselves"
Xxxx Xxxxxxxx, Secretary
June 13, 2002
Xxxxxx Xxxxxx, Executive Director
Harmony Health Plan
000 Xxxxxxxx, Xxxxx 000
Xxxx, Xxxxxxx 00000
RE: Hoosier Healthwise MCO Contract, First Amendment
Dear Xx. Xxxxxx:
Enclosed is your copy of the fully executed first amendment to Harmony's
contract with the State for the Hoosier Healthwise program. The amendmentis
effective April 1, 2002 through December 31, 2002.
This amendment was necessary due to the implementation of mandatory riskbased
managed care in several Indiana counties pursuant to IC 00-00-00-00. The
amendment adds new requirements and addresses changes to the capitation rates.
Some of the additional requirements include the following:
1. The submission of the "Mandatory RBMC Transition Report;
2. Written approval from OMPP prior to closing a provider network;
3. Monthly telephone abandonment rate of 5% for the member and provider
helplines;
4. Developing a plan for identifying and serving people with special
needs;
5. Ninety-day notice to OMPP of insufficient PMP network in a mandatory
county, and
6. Inclusion of a 90-day termination clause in PMP agreements.
Thank you for your commitment to the Hoosier Healthwise program If you have any
questions, please do not hesitate to contact me at 000-000-0000.
Sincerely,
/s/ Xxxxxx Xxxxxx
--------------------------------------
Xxxxxx Xxxxxx
Acting Co-Director of Operations- Managed Care
Enclosure
Equal Opportunity/Affirmative Action Employer [SEAL]
FIRST AMENDMENT
TO THE
CONTRACT BETWEEN
THE OFFICE OF MEDICAID POLICY AND PLANNING,
THE OFFICE OF THE CHILDREN'S HEALTH INSURANCE PROGRAM
AND
HARMONY HEALTH PLAN OF ILLINOIS, INC.
This FIRST AMENDMENT to the above-referenced Contract is made and entered
into by and between the State of Indiana [hereinafter "State" of "State of
Indiana"], through the Office of Medicaid Policy and Planning and Office of the
Children's Health Insurance Program [hereinafter called "Office"], of the
Indiana Family and Social Services Administration, 000 Xxxx Xxxxxxxxxx Xxxxxx,
Xxxx X000, Xxxxxxxxxxxx, Xxxxxxx 00000, and Harmony Health Plan of Illinois,
Inc., 000 Xxxxx Xxxxxx Xxxxx, Xxxxx 0000, Xxxxxxx, Xxxxxxxx, doing business as
Harmony Health Plan of Indiana, (hereinafter "Contractor").
WHEREAS, the State of Indiana and Contractor have previously entered into
a contract for a term beginning January 1, 2001 and ending December 31, 2002,
[hereinafter "the original contract"] for services to arrange for and to
administer a risk-based managed care (RBMC) program for certain Hoosier
Healthwise enrollees in packages A, B and C as procured through Broad Agency
Announcement (BAA) 01-28;
WHEREAS, the parties desire to further extend the duties to be performed
by the Contractor due to mandatory risk-based managed care (RBMC) in certain
counties pursuant to IC 00-00-00-00;
NOW THEREFORE, the parties enter into this FIRST AMENDMENT for the
consideration set out below, all of which is deemed to be good and sufficient
consideration in order to make this FIRST AMENDMENT a binding legal instrument.
1. The parties hereby ratify and incorporate herein each term and
condition set out in the original contract, as well as all written
matters incorporated therein except as specifically provided for by
this FIRST AMENDMENT.
2. The term of this amendment is from April 1, 2002, through December
31, 2002, subject to the termination and/or extension provisions as
provided for under the original contract.
3. The parties agree that the BAA is amended to add the following
additional Contractor Duties:
A. Section 3.6.1.3 of the BAA is amended to require the
Contractor to submit the "Mandatory RBMC Transition Report"
(Attachment A) according the schedule set out in the "2002
Hoosier Healthwise MCO Reporting Calendar for Mandatory RBMC
Transition Report" (Attachment B) unless the MCO has received
written notification from OMPP that the report, or certain
data elements in the report, is/are no longer required or may
be reported less frequently.
MCO Contract, First Amendment Harmony Health Plan of Indiana, Inc.
Page 1 of 4
B. The parties agree that Section 3.6.3 of the BAA is amended to
require the Contractor to obtain written approval of the State
prior to closing its provider networks, which shall not be
unreasonably withheld or delayed.
C. The parties agree that Sections 3.6.6 and 3.6.7.3 of the BAA
are amended to require the Contractor to maintain a monthly
telephone abandonment rate equal to or less than five percent
of calls received each by the member helpline and provider
helpline. The parties agree that BAA Section 3.16 is amended
to add a new section 3.16.8 to read as follows:
Section 3.16.8 The MCO will comply with the call
abandonment requirements for the member and provider
helplines described in Sections 3.6.6. and 3.6.7.3 of
this BAA. Because actual damages caused by
non-compliance are not subject to exact determination,
the State will assess the MCO, as liquidated damages and
not as a penalty, (a) two hundred dollars ($200.00) for
each business day the MCO fails to submit required
documentation to provide evidence of compliance with
this requirement, or (b) two thousand dollars ($2000.00)
for each month the MCO fails to meet the requirement
after 2 consecutive months of non-compliance on the
member helpline or (c) two thousand dollars ($2000.00)
for each month the MCO fails to meet the requirement
after 2 consecutive months of non-compliance on the
provider helpline.
D. The parties agree that Section 3.5.3 of the BAA is amended to
allow OMPP to change, at OMPP's discretion, the frequency of
the MCO Enrollment Rosters generated by OMPP's fiscal agent to
once per month, upon reasonable and adequate prior written
notice to the Contractor.
E. The parties agree that Section 3.6.3 of the BAA is amended to
require the Contractor to develop and adhere to a plan for
identifying and serving people with special needs. The plan
must satisfy any applicable federal requirements.
4. The parties agree that, in consideration of the services to be
performed by the Contractor as delineated in this First Amendment
and the original contract, the Offices' will adjust the capitation
rates, as contained in the Offices' capitation payment listing, as
the counties transition to mandatory MCO enrollment. The rate
adjustment factors shown in the following table will be applied to
the base rates for the entire region upon implementation of
mandatory enrollment for the specified county or county
combinations. The base rates for the region are the rates in effect
on January 1, 2002, without any adjustment for mandatory enrollment.
REGION COUNTY PACKAGE A/B PACKAGE C
------ ---------- ----------- ---------
North Xxxxx 0.9% 1.7%
North Elkhart 0.7% 0.9%
North St. Xxxxxx 1.4% 1.6%
North Lake 2.1% 2.1%
MCO Contract, First Amendment Harmony Health Plan of Indiana, Inc.
Page 2 of 4
North Xxxxx/Elkhart 1.4% 2.2%
North Xxxxx/St. Xxxxxx 1.9% 2.5%
North Xxxxx/Lake 2.4% 2.8%
North Elkhart/St. Xxxxxx 1.8% 2.1%
North Elkhart/Lake 2.6% 2.8%
North Lake/St. Xxxxxx 2.6% 2.8%
North Xxxxx/Elkhart/ St. Xxxxxx 2.2% 2.8%
North Xxxxx/Elkhart/Lake 2.7% 3.1%
North Elkhart/St. Xxxxxx/Lake 2.8% 3.0%
North Xxxxx/Elkhart/St. Xxxxxx/Lake 3.0% 3.4%
Central Xxxxxx 1.8% 2.1%
Central Xxxxxxxx 0.3% 0.6%
Central Xxxxxx/Hamilton 1.9% 2.3%
5. The Contractor agrees to provide OMPP with prior written notice at
least ninety (90) days in advance of their inability to maintain a
sufficient Primary Medical Provider (PMP) network in any of the
counties where mandatory RBMC has been or will be implemented,
including Marion, Allen, Elkhart, St. Xxxxxx, Lake, Hamilton, and
Vanderburgh Counties, such that the program would not be able to
maintain the appropriate member choice of two (2) MCOs, pursuant to
federal requirements.
6. The Contractor agrees that a contracted PMP in a mandatory RBMC
county may terminate his/her agreement for any reason upon written
notice to the Contractor. The Contractor may require that the
physician provide said notice to the Contractor up to ninety (90)
days prior to termination. The Contractor further agrees that any
existing PMP agreements that fail to meet this requirement shall be
amended to comply with this requirement within sixty (60) days of
the effective date of this amendment.
7. The parties agree that this First Amendment has been duly prepared
and executed pursuant to Section VII.B. of the original contract.
8. The undersigned attests, subject to the penalties for perjury, that
he is the contracting party, or that he is the representative,
agent, member or officer of the contracting party, that he has not,
nor has any other member employee, representative, agent or officer
of the firm, company, corporation or partnership represented by him,
directly or indirectly, to the best of his knowledge, entered into
or offered to enter into any combination, collusion or agreement to
receive or pay, and that he has not received or paid, any sum of
money or other consideration for the execution of this agreement
other than that which appears upon the face of the agreement.
MCO Contract, First Amendment Harmony Health Plan of Indiana, Inc.
Page 3 of 4
WHEREOF, the parties have executed this Contract.
For the Contractor: For the State of Indiana:
/s/ Xxxx Xxxxx MD /s/ Xxxxxxx Bella
-------------------------------------- ---------------------------------------
Xxxx Xxxxx, MD, President/CEO Xxxxxxx Bella, Assistant Secretary
Harmony Health Plan of Illinois, Inc. Office of Medicaid Policy and Planning
Date: 3/29/02 Date: 4/3/02
/s/ Xxxxxxx X. Xxxxx
---------------------------------------
Xxxxxxx X. Xxxxx, Director
APPROVED: Office of Children's Health Insurance
Program Date: 4/9/02
/s/ Xxxxx Xxxxxxx
--------------------------------------
Xxxxx Xxxxxxx, Director
State Budget Agency
Date:5/6/02
APPROVED AS TO FORM AND LEGALITY: APPROVED:
/s/ Xxxxxxx Xxxxxx /s/ Xxxxx X. Xxxxxxxx
-------------------------------------- ---------------------------------------
Xxxxxxx Xxxxxx Xxxxx X. Xxxxxxxx Commissioner
Attorney General of Indiana Department of Administration
Date: 6/7/02 Date : APR 22, 2002
MCO Contract, First Amendment Harmony Health Plan of Indiana, Inc.
Page 4 of 4
ATTACHMENT A
MANDATORY RBMC TRANSITION REPORT
Name of MCO Sample Template
Report Period Start Date XXXXX, 0000
Report Due Date XXXXX, 0000
PROVIDER ACCESS AND AVAILABILITY
Reporting Requirement Mandatory Risk Based Managed Care (RBMC) Counties
--------------------- -------------------------------------------------
XXXXX [ILLEGIBLE] ST. XXXXXX ELKHART XXXXXXXX LAKE VANDERBURGH
------- ----------- ---------- ------- -------- ------- -----------
Potential RBMC member enrollment 25,249 [ILLEGIBLE] 23,682 14,993 3,563 55,573 15,278
Current MCO member enrollment
PRIMARY MEDICAL PROVIDER*
OB-GYN contracts at beginning of period
Pediatrician contracts at beginning of period
Other PMP contracts at beginning of period
New-OB-GYN contracts this period
New-Pediatrician contracts this period
New-Other PMP contracts this period
All PMPs at end of period 0 0 0 0 0 0 0
Percent increase #DIV/0! #DIV/0! #DIV/0! #DIV/0! #VALUE! #DIV/0! #DIV/0!
PMP-to-member ratio at end of period #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
PMP contracts pending- high probability of
completion within 60 days of
scheduled transition date
SPECIALTY PROVIDERS
Specialty providers at beginning of period
Specialty providers at end of period
FACILITIES
Acute care hospitals beginning of period
Acute care hospitals end of period
Hospital contracts pending - high probability
of completion within 60 days of scheduled
transition date
ANCILLARY PROVIDERS
Ancillary providers beginning of period (please
describe in Comments section)
Ancillary providers end of period (please
describe in Comments section)
----------
INSTRUCTIONS: MCOs should complete cells highlighted in yellow only. Provider
and hospital disenrollments should be reported and described in the Comments
section.
"PMP contract" refers to a contract with an individual provider rather than a
delivery system
XXXXXX XXXX INC. - 1/16/02
1
ATTACHMENT A
MANDATORY RBMC TRANSITION REPORT
CLAIMS PROCESSING
Reporting Requirement Current Period Previous Period
----------------------------------------------- -------------- ---------------
Claims on-hand at beginning of period
Claims received this period
Claims paid this period*
Claims denied this period*
Claims on-hand end of period 0
Average length of time to pay or deny (in days)
*Claims paid are those claims for which some payment was made to the billing
provider, and those claims which were submitted as encounter claims. Claims
adjudicated but not paid should not be counted as paid claims. Denied claims are
those claims for which all payments were denied and no payment was made. Include
all claims without regard to type (UB 92 vs. HCFA 1500).
XXXXXX XXXX INC. - 1/16/02
2
ATTACHMENT A
MANDATORY RBMC TRANSITION REPORT
HELPLINE MEMBER SERVICES
Reporting Requirement Current Period Previous Period
----------------------------------------------- -------------- ---------------
MEMBER CALLS
Number FTEs
Member Calls received
Member calls answered live
Abandonment rate #DIV/0!
Three most frequent reasons for member calls,
as percent of all calls %
PROVIDER CALLS
Number FTEs
Provider calls received
Provider calls answered live
Abandonment rate #DIV/0!
Three most frequent reasons for provider
calls, as percent of all calls %
XXXXXX XXXX INC. - 1/16/02
3
ATTACHMENT A
MANDATORY RBMC TRANSITION REPORT
Report Comments
----------------------------------------------- --------------
PROVIDER ACCESS AND AVAILABILITY
CLAIMS PROCESSING
HELPLINE AND MEMBER SERVICES
XXXXXX XXXX INC. - 1/16/02
4
ATTACHMENT B
2002 HOOSIER HEALTHWISE MCO REPORTING CALENDAR
FOR MANDATORY RBMC TRANSITION REPORT
REPORTING PERIOD DATE DUE*
---------------------------------------- --------------------------------------
January 15th through January 31st Tuesday, February 5, 2002
February 1st through February 14th Tuesday, February 19, 2002
February 15th through February 28th Tuesday, March 5, 2002
March 1st through March 14th Tuesday, March 19, 2002
March 15th through March 31st Wednesday, April 3, 2002
April 1st through April 14th Wednesday, April 17, 2002
April 15th through April 30th Friday, May 3, 2002
May 1st through May 14th Friday, May 17, 2002
May 15th through May 31st Wednesday, June 5, 2002
June 1st through June 14th Wednesday, June 19, 2002
June 15th through June 30th Wednesday, July 3, 2002
July 1st through July 14th Wednesday, July 17, 2002
July 15th through July 31st Monday, August 5, 2002
August 1st through August 14th Monday, August 19, 2002
August 15th through August 31st Thursday, September 5, 2002
September 1st through September 14th Wednesday, September 18, 2002
September 15th through September 30th Thursday, October 3, 2002
October 1st through October 14th Thursday, October 17, 2002
October 15th through October 31st Tuesday, November 5, 2002
November 1st through November 14th Tuesday, November 19, 2002
November 15th through November 30th Wednesday, December 4, 2002
December 1st through December 14th Wednesday, December 18, 2002
December 15th through December 31st Monday, January 6, 2003
----------
* Date due is by the end of the third business day after the reporting
period..
XXXXXX XXXX INC. Page 1 of 1
01/14/02
CONTRACT BETWEEN
THE OFFICE OF MEDICAID POLICY AND PLANNING,
THE OFFICE OF THE CHILDREN'S HEALTH INSURANCE PROGRAM
AND
HARMONY HEALTH PLAN OF ILLINOIS, INC.
This Contract is made and entered into by and between the State of Indiana
(hereinafter "State" or "State of Indiana"), through the Office of Medicaid
Policy and Planning and the Office of Children's Health Insurance Program
(hereinafter "the Offices"), of the Indiana Family and Social Services
Administration, 000 Xxxx Xxxxxxxxxx Xxxxxx, X000, Xxxxxxxxxxxx, Xxxxxxx, and
Harmony Health Plan of Illinois, Inc., 000 Xxxxx Xxxxxx Xxxxx, Xxxxx 0000,
Xxxxxxx, Xxxxxxxx, doing business as Harmony Health Plan of Indiana,
(hereinafter "Contractor").
WHEREAS, I.C. 12-15-30-1 and I.C. 12-17.6 authorize the Offices to enter
into contracts to assist in the administration of the Indiana Medicaid and the
Indiana Children's Health Insurance Program (CHIP), respectively;
WHEREAS, the State of Indiana desires to contract for services to arrange
for and to administer a risk-based managed care program (RBMC) for certain
Hoosier Healthwise enrollees in Packages A, B and C as procured through BAA 01
-28;
WHEREAS this Contract contains the payment rates under which the
Contractor shall be paid and that these rates have been determined to be
actuarially sound and not in excess of the fee-for-service upper payment limit
(FFS-UPL) specified for risk contracts in 42 CFR 447.361;
WHEREAS, the Contractor is willing and able to perform the desired
services for Hoosier Healthwise Packages A, B and C;
THEREFORE, the parties to this Contract agree that the terms and
conditions specified below will apply to services in connection with this
contract, and such terms and conditions are as follows:
I. TERM AND RENEWAL OPTION
This Contract is effective from January 1, 2001 through December 31, 2002.
At the discretion of the Offices the term may be extended for up to two
additional years. In no event shall the term exceed December 31, 2004.
MCO Contract Harmony Health Plan
PAGE 1 of 24
II. DEFINITIONS
For the purposes of this contract, terms not defined herein shall be
defined as they are in the documents incorporated in and attached to this
document, subject to the order of precedence spelled out in Section V of this
document.
"Contract" means this document and all documents or standards incorporated
herein, expressly including but not limited to the following documents appended
hereto and listed in chronological order and to be given precedence as described
in Section V of this document, entitled "Order of Precedence":
Attachment 1 - BAA 01-28, released July 31, 2000;
Attachment 2 - Contractor's response to BAA 01-28, submitted
September 25, 2000, excluding the following sections:
Section 5.3.8,
Section 5.4.4, Appendices A, B, C, D, H; Exhibit 5.4.4I;
Exhibit 5.4.4M; Exhibit 5.4.4O;
and,
Any other documents, standards, laws, rules or regulations incorporated by
reference in the above materials, all of which are hereby incorporated by
reference.
"Covered Services" means all services required to be arranged, administered,
managed or provided by or on behalf of the Contractor under this contract.
"Effective Date of Enrollment" means:
- The first day of the birth month of a newborn that is determined by
the Offices to be an enrolled member;
- The fifteenth day of the current month for a member who has, between
the twenty-sixth day of the previous month and the tenth day of the
current month, been determined by the Offices to be an enrolled
member; and,
- The first day of the following month for a member who has, between
the eleventh day and the twenty-fifth day of a month, been
determined by the Offices to be an enrolled member.
"Enrolled Member", or "Enrollee", means a Hoosier Healthwise-eligible member who
is listed by the Offices on the enrollment rosters to receive covered services
from the Contractor or its subcontractors, employees, agents, or providers, as
of the Effective Date of Enrollment, under this contract.
"Provider" means a physician, hospital, home health agency or any other
institution, or health or other professional person or entity, which
participates in the provision of services to an enrolled
MCO Contract Harmony Health Plan
Page 2 of 24
member under BAA 01-28, whether as an independent contractor, a subcontractor,
employee, or agent of the Contractor.
"Broad Agency Announcement", or "BAA", means BAA 01-28 for providers of managed
care services, released July 31, 2000.
III. DUTIES OF THE CONTRACTOR
A. The Contractor agrees to assume financial risk for developing and managing
a health care delivery system and for arranging or administering all
Hoosier Healthwise covered services except, as set out in section 3.4.3 of
the BAA, dental care, long-term institutional care, services provided as
part of an individualized education plan (IEP) pursuant to the Individuals
with Disabilities Education Act (IDEA) at 20 U.S.C. 1400 et seq.,
behavioral health, and hospice services, in exchange for a per-enrollee,
per-month fixed fee, to certain enrollees in Hoosier Healthwise Packages
A, B and C. Wards of the State, xxxxxx children and children receiving
adoption assistance may enroll on a voluntary basis and will not be
subject to auto-assignment into the Hoosier Healthwise program. The
Contractor must, at a minimum, furnish covered services up to the limits
specified by the Medicaid and CHIP programs. The Contractor may exceed
these limits. However, in no instance may any covered service's
limitations be more restrictive than those which exist in the Indiana
Medicaid fee-for-service program for Packages A and B, and the Children's
Health Insurance Program for Package C.
B. The Contractor agrees to perform all duties and arrange and administer
the provision of all services as set out herein and contained in the BAA
as attached and the Contractor's responses to the BAA as attached, all of
which are incorporated into this Contract by reference. In addition, the
Contractor shall comply with all policies and procedures defined in any
bulletin, manual, or handbook yet to be distributed by the State or its
agents insofar as those policies and procedures provide further
clarification and are no more restrictive than any policies and procedures
contained in the BAA and any amendments to the BAA. The Contractor agrees
to comply with all pertinent state and federal statutes and regulations in
effect throughout the duration of this Contract and as they may be amended
from time to time.
C. The Contractor agrees that it will not discriminate against individuals
eligible to be covered under this Contract on the basis of health status
or need for health services; and the Contractor may not terminate an
enrollee's enrollment, or act to encourage an enrollee to terminate
his/her enrollment, because of an adverse change in the enrollee's health.
The disenrollment function will be carried out by a State contractor who
is independent of the Contractor; therefore, any request to terminate an
enrollee's enrollment must be approved by the Offices.
D. The Contractor agrees that no services or duties owed by the Contractor
under this Contract will be performed or provided by any person or entity
other than the Contractor, except as contained in written subcontracts or
other legally binding agreements. Prior to entering into
MCO Contract Harmony Health Plan
Page 3 of 24
any such subcontract or other legally binding agreement, the Contractor shall,
in each case, submit the proposed subcontract or other legally binding agreement
to the Offices for prior review and approval. Prior review and approval of a
subcontract or legally binding agreement shall not be unreasonably delayed by
the Offices. The Offices shall, in appropriate cases and as requested by the
Contractor, expedite the review and approval process. Under no circumstances
shall the Contractor be deemed to have breached its obligations under this
Contract if such breach was a result of the Offices' failure to review and
approve timely any proposed subcontract or other legally binding agreement. If
the Offices disapprove any proposed subcontract or other legally binding
agreement, the Offices shall state with reasonable particularity the basis for
such disapproval. No subcontract into which the Contractor enters with respect
to performance under this Contract shall in any way relieve the Contractor of
any responsibility for the performance of duties under this Contract. All
subcontracts and amendments thereto executed by the Contractor under this
Contract must meet the following requirements; any existing subcontracts or
legally binding agreements which fail to meet the following requirements shall
be revised to include the requirements within ninety(90) days from the effective
date of this Contract:
1. Be in writing and specify the functions of the subcontractor.
2. Be legally binding agreements.
3. Specify the amount, duration and scope of services to be provided by the
subcontractor.
4. Provide that the Offices may evaluate, through inspection or other means,
the quality, appropriateness, and timeliness of services performed.
5. Provide for inspections of any records pertinent to the contract by the
Offices.
6. Require an adequate record system to be maintained for recording services,
charges, dates and all other commonly accepted information elements for
services rendered to recipients under the contract.
7. Provide for the participation of the Contractor and subcontractor in any
internal and external quality assurance, utilization review, peer review,
and grievance procedures established by the Contractor, in conjunction
with the Offices.
8. Provide that the subcontractor indemnify and hold harmless the State of
Indiana, its officers, and employees from all claims and suits, including
court costs, attorney's fees, and other expenses, brought because of
injuries or damage received or sustained by any person, persons or
property that is caused by any act or omission of the Contractor and/or
the subcontractors. The State shall not provide such indemnification to
the subcontractor.
9. Identify and incorporate the applicable terms of this Contract and any
incorporated documents. The subcontract shall provide that the
subcontractor
MCO Contract Harmony Health Plan
Page 4 of 24
agrees to perform duties under the subcontract, as those duties
pertain to enrollees, in accordance with the applicable terms and
conditions set out in this Contract, any incorporated documents, and
all applicable state and federal laws, as amended.
E. The Contractor agrees that, during the term of this Contract, it shall
maintain, with any in-network provider rendering health care services
under the BAA, provider service agreements which meet the following
requirements; any existing provider service agreements which fail to meet
the following requirements shall be revised to include the requirements
within ninety (90) days from the effective date of this Contract. The
provider service agreements shall:
1. Identify and incorporate the applicable terms of this Contract and
any incorporated documents. Under the terms of the provider services
agreement, the provider shall agree that the applicable terms and
conditions set out in this Contract, any incorporated documents, and
all applicable state and federal laws, as amended, govern the duties
and responsibilities of the provider with regard to the provision of
services to enrollees.
2. Reference a written provider claim resolution procedure as set out
in section III.Q. below.
F. The Contractor agrees that all laboratory testing sites providing services
under this Contract must have a valid Clinical Laboratory Improvement
Amendments (CLIA) certificate and comply with the CLIA regulations at 42
C.F.R. Part 493.
G. The Contractor agrees that it shall:
1. Retain, at all times during the period of this Contract, a valid
Certificate of Authority under applicable State laws issued by the
State of Indiana Department of Insurance.
2. Ensure that, during the term of this Contract, each provider
rendering health care services under the BAA is authorized to do so
in accordance with the following:
a. The provider must maintain a current Indiana Health Coverage
Programs (IHCP) provider agreement and must be duly licensed
in accordance with the appropriate state licensing board and
shall remain in good standing with said board.
b. If a provider is not authorized to provide such services under
a current IHCP provider agreement or is no longer licensed by
said board, the Contractor is obligated to terminate its
contractual relationship authorizing or requiring such
provider to provide services under the BAA. The Contractor
must terminate its contractual relationship with the provider
as soon as the Contractor has knowledge of the termination of
the provider's license or the IHCP provider agreement.
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3. Comply with the specific requirements for Health Maintenance
Organizations (HMOs) eligible to receive Federal Financial
Participation (FFP) under Medicaid, as listed in the State
Organization and General Administration Chapter of the Health Care
Financing Administration (HCFA) Medicaid Manual. These requirements
include, but are not limited to the following:
a. The Contractor shall meet the definition of HMO as specified
in the Indiana State Medicaid Plan.
b. Throughout the duration of this Contract, the Contractor shall
satisfy the Chicago Regional Office of the Health Care
Financing Authority (hereinafter called HCFA) that the
Contractor is compliant with the Federal requirements for
protection against insolvency pursuant to 42 CFR 434.20(c)(3)
and 434.50(a), the requirement that the Contractor shall
continue to provide services to Contractor enrollees until the
end of the month in which insolvency has occurred, and the
requirement that the Contractor shall continue to provide
inpatient services until the date of discharge for an enrollee
who is institutionalized when insolvency occurs. The
Contractor shall meet this requirement by posting a
performance bond pursuant to Section VII, paragraph C, of this
Contract, and satisfying the statutory reserve requirements of
the Indiana Department of Insurance.
c. The Contractor shall comply with, and shall exclude from
participation as either a provider or subcontractor of the
Contractor, any entity or person that has been excluded under
the authority of Sections 1124A, 1128 or 1128A of the Social
Security Act or does not comply with the requirements of
Section 1128(b) of the Social Security Act.
d. In the event that the HCFA determines that the Contractor has
violated any of the provisions of 42 CFR 434.67(a), HCFA may
deny payment of FFP for new enrollees of the HMO under 42 USC
1396b(m)(5)(B)(ii). The Offices shall automatically deny
State payment for new enrollees whenever, and for so long
as, Federal payment for such enrollees has been denied.
H. The Contractor shall submit proof, satisfactory to the Offices, of
indemnification of the Contractor by the Contractor's parent corporation,
if applicable, and by all of its subcontractors.
I. The Contractor shall submit proof, satisfactory to the Offices, that all
subcontractors will hold the State harmless from liability under the
subcontract. This assurance in no way relieves the Contractor of any
responsibilities under the BAA or this Contract.
J. The Contractor agrees that, prior to initially enrolling any Hoosier
Healthwise Package A, B or C enrollees, it shall go through and
satisfactorily complete the readiness review as described in the BAA. The
required readiness review shall begin before the contract
MCO Contract Harmony Health Plan
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between the Contractor and the State is finalized and executed. Within
ninety (90) days from the effective date of this Contract, the Contractor
shall make a good faith effort to resolve, to the satisfaction of the
Offices, any outstanding issues brought to the Contractor's attention by
the Offices as a result of the readiness review.
K. The Contractor shall establish and maintain a quality improvement program
that meets the requirements of 42 CFR 434.34, as well as other specific
requirements set forth in the BAA. The Offices and the HCFA may evaluate,
through inspection or other means, including but not limited to, the
review of the quality assurance reports required under this Contract, and
the quality, appropriateness, and timeliness of services performed under
this Contract. The Contractor agrees to participate and cooperate, as
directed by the Offices, in the annual external quality review of the
services furnished by the Contractor.
L. In accordance with 42 CFR 434.28, the Contractor agrees that it and any of
its subcontractors shall comply with the requirements, if applicable, of
42 CFR 489, Subpart I, relating to maintaining and distributing written
policies and procedures respecting advance directives. The Contractor
shall distribute policies and procedures to adult individuals during the
enrollee enrollment process and whenever there are revisions to these
policies and procedures. The Contractor shall make available for
inspection, upon reasonable notice and request by the Offices,
documentation concerning its written policies, procedures and distribution
of such written procedures to enrollees.
M. Pursuant to 42 C.F.R. 417.479(a), the Contractor agrees that no specific
payment can be made directly or indirectly under a physician incentive
plan to a physician or physician group as an inducement to reduce or limit
medically necessary services furnished to an individual enrollee. The
Contractor must disclose to the State the information on provider
incentive plans listed in 42 C.F.R. 417.479(h)(1) and 417.479(i) at the
times indicated at 42 C.F.R. 434.70(a)(3), in order to determine whether
the incentive plan meets the requirements of 42 C.F.R. 417(d)-(g). The
Contractor must provide the capitation data required under paragraph
(h)(1)(vi) for the previous calendar year to the State by
application/contract renewal of each year. The Contractor will provide the
information on its physician incentive plan(s) listed in 42 C.F.R.
417.479(h)(3) to any enrollee upon request.
N. The Contractor must not prohibit or restrict a health care professional
from advising an enrollee about his/her health status, medical care, or
treatment, regardless of whether benefits for such care are provided under
this Contract, if the professional is acting within the lawful scope of
practice. However, this provision does not require the Contractor to
provide coverage of a counseling or referral service if the Contractor
objects to the service on moral or religious grounds and makes available
information on its policies to potential enrollees and enrollees within
ninety (90) days after the date the Contractor adopts a change in policy
regarding such counseling or referral service.
O. In accordance with 42 U.S.C. Section 1396u-2(b)(6), the Contractor
agrees that an enrollee may not be held liable for the following:
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1. Debts of the Contractor, or its subcontractors, in the event of any
organization's insolvency;
2. Services provided to the enrollee in the event the Contractor fails
to receive payment from the Offices for such services or in the
event a provider fails to receive payment from the Contractor or
Offices; or
3. Payments made to a provider in excess of the amount that would be
owed by the enrollee if the Contractor had directly provided the
services.
P. The Offices may from time to time request and the Contractor, and all of
its subcontractors, agree that the Contractor, or its subcontractors,
shall prepare and submit additional compilations and reports as requested
by the Offices. Such requests will be limited to situations in which the
desired data is considered essential and cannot be obtained through
existing Contractor reports. The Contractor, and all of its
subcontractors, agree that a response to the request shall be submitted
within thirty (30) days from the date of the request, or by the Offices'
requested completion date, whichever is earliest. The response shall
include the additional compilations and reports as requested, or the
status of the requested information and an expected completion date. When
such requests pertain to legislative inquiries or expedited inquiries from
the Office of the Governor, the additional compilations and reports
shall be submitted by the Offices' requested completion date. Failure by
the Contractor, or its subcontractors, to comply with response time frames
shall be considered grounds for the Offices to pursue the provisions
outlined in Section 3.16.5 of the BAA. In the event that delays in
submissions are a consequence of delay by the Offices or the Medicaid
Fiscal Agent, the time frame for submission shall be extended by the
length of time of the delay.
Q. The Contractor shall establish a written claim resolution procedure
applicable to both in-network and out-of-network providers which shall be
distributed to all in-network providers and shall be available to
out-of-network providers upon request. The Contractor shall negotiate the
terms of a written claim resolution procedure with in-network providers;
but if the Contractor and an in-network provider are unable to reach
agreement on the terms of such procedure, the out-of-network provider
claims resolution procedure approved by the Offices under this section
shall govern the resolution of such in-network provider's claims with the
Contractor. The written claim resolution procedure for out-of-network
providers (and in-network providers in the absence of an agreement) must
be submitted to the Offices for approval Within thirty (30) days from the
effective date of this Contract and must include, at a minimum, the
following elements:
1. A statement noting that providers objecting to determinations
involving their claims will be provided procedural due process
through the Contractor's claim resolution procedure.
2. A description of both the informal and formal claim resolution
procedures that will be available to resolve a provider's objection
to a determination involving the provider's claim.
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3. An informal claim resolution procedure which:
a. shall be available for the resolution of claims submitted to
the Contractor by the provider within the allowable claims
submission time limits under federal and state law;
b. shall precede the formal claim resolution procedure;
c. shall be used to resolve a provider's objection to a
determination by the Contractor involving the provider's
claim, including a provider's objection to:
(1) any determination by the Contractor regarding payment for
a claim submitted by the provider, including the amount of
such payment; and
(2) the Contractor's determination that a claim submitted by
the provider lacks sufficient supporting information, records,
or other materials;
d. may, at the election of a provider, be utilized to determine
the payment due for a claim in the event the Contractor fails,
within thirty (30) days after the provider submits the claim,
to notify the provider of:
(1) its determination regarding payment for the provider's
claim; or
(2) its determination that the provider's claim lacked
sufficient supporting information, records, or the materials;
e. shall be commenced by a provider submitting to the Contractor:
(1) within sixty (60) days after the provider's receipt of
written notification of the Contractor's determination
regarding the provider's claim, the provider's written
objection to the Contractor's determination and an explanation
of the objection; or
(2) within sixty (60) days after the Contractor fails to make
a determination as described in subparagraph (d), a written
notice of the provider's election to utilize the informal
claims resolution procedure under subparagraph (d) above;
f. shall allow providers and the Contractor to make verbal
inquiries and to otherwise informally undertake to resolve the
matter submitted for resolution by the provider pursuant to
Paragraph 3.e.
4. In the event the matter submitted for informal resolution is not
resolved to the provider's satisfaction within thirty (30) days
after the provider commenced the informal claim resolution
procedure, the provider shall have sixty (60) days from that point
to submit to the Contractor written notification of the provider's
election to submit the matter to the formal claim resolution
procedure. The
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provider's notice must specify the basis of the provider's dispute with
the Contractor. The Contractor's receipt of the provider's written notice
shall commence the formal claim resolution procedure.
5. The formal claim resolution procedure shall be conducted by a panel of one
(1) or more individuals selected by the Contractor. Each panel must be
knowledgeable about the policy, legal, and clinical issues involved in the
matter that is the subject of the formal claim resolution procedure. An
individual who has been involved in any previous consideration of the
matter by the Contractor may not serve on the panel. The Contractor's
medical director, or another licensed physician designated by the medical
director, shall serve as a consultant to the panel in the event the matter
involves a question of medical necessity or medical appropriateness.
6. The panel shall consider all information and material submitted to it by
the provider that bears directly upon an issue involved in the matter
that is the subject of the formal claim resolution procedure. The panel
shall allow the provider an opportunity to appear in person before the
panel, or to Communicate with the panel through appropriate other means if
the provider is unable to appear in person, and question the panel in
regard to issues involved in the matter. The provider shall not be
required to be represented by an attorney for purposes of the formal claim
review procedure.
7. Within forty-five (45) days after the Commencement of the formal claim
resolution procedure, the panel shall deliver to the provider the panel's
written determination of the matter before it. Such determination shall be
the Contractor's final position in regard the matter. The written
determination shall include, as applicable, a detailed explanation of the
factual, legal, policy and clinical basis of the panel's determination.
8. In the event the panel fails to deliver to the provider the panel's
written determination within forty-five (45) days after the after the
commencement of the formal claim resolution procedure, such failure on the
part of the panel shall have the effect of a denial by the panel of the
provider's claim.
9. The panel's written determination shall include notice to the provider of
the provider's right, within sixty (6) days after the provider's receipt
of the panel's written determination, to submit to binding arbitration the
matter that was the subject of the formal claim resolution procedure. The
provider shall also have the right to submit the matter to binding
arbitration if the panel has failed to deliver its written determination
to the provider within the required forty-five (45) day period.
10. Any procedure involving binding arbitration must be conducted in
accordance with the rules and regulations of the American Health Lawyers
Association (AHLA), pursuant to the Uniform Arbitration Act as adopted in
the State of Indiana at I.C. 34-57-2, unless the provider and Contractor
mutually agree to some other binding resolution procedure. However, any
Contractor and provider
MCO Contract Harmony Health Plan
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that are subject to statutorily imposed arbitration procedures for the
resolution of these claims shall be required to follow the statutorily
imposed arbitration procedures, but only to the extent those procedures
differ from, or are irreconcilable with, the rules and regulations of the
American Health Lawyers Association (AHLA), pursuant to the Uniform
Arbitration Act as adopted in the State of Indiana at I.C. 34-57-2. It is
the intent of the Offices that the fees and expenses of arbitration be
borne by the non-prevailing party.
11. The provider and Contractor may agree, within the requisite sixty (60) day
time period, to include in a single arbitration proceeding matters from
multiple formal claim resolution procedures involving the Contractor and
the provider. If the provider and Contractor are not able to agree, the
arbitrator, as selected in Paragraph 10 above, shall have the discretion
to include in a single arbitration proceeding matters from multiple formal
claim resolution procedures involving the Contractor and the provider.
12. For claims disputed under Paragraph 3.c.(2) above:
a. a claim that is finally determined through the Contractor's claim
resolution procedure (including arbitration) not to lack sufficient
supporting documentation shall be processed by the Contractor within
thirty (30) days after such final determination. The processing of
the claim and the Contractor's determination involving the. claim
shall be subject to Paragraph 3. c. and Paragraph 3.d and the
Contractor's formal claim resolution procedure and binding
arbitration.
b. a claim that is finally determined through the Contractor's claim
resolution procedure (including arbitration) to lack sufficient
supporting documentation shall be processed by the Contractor within
thirty (30) days after the provider submits to the Contractor the
requisite supporting documentation. The provider shall have thirty
(30) days after written notice of the final determination
establishing that the claim lacked sufficient supporting
documentation is received by the provider to submit the requisite
supporting documentation. The processing of the claim and the
Contractor's determination involving the claim shall be subject to
Paragraph 3. c. and Paragraph 3. d. and the Contractor's formal
claim resolution procedure and binding arbitration.
13. A Contractor may not include in its claim resolution procedures for
out-of-network providers (and in-network providers in the absence of an
agreement) elements that restrict or diminish the claim review procedures,
time periods or subject matter provided for in paragraphs 1 through 12
above.
14. A Contractor shall maintain a log of all informally and formally filed
provider objections to determinations involving claims. The logged
information shall include the provider's name, date of objection, nature
of the objection, and
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disposition. The Contractor shall submit quarterly reports to the
Offices regarding the number and type of provider objections.
IV. PAYMENT
A. In consideration of the services to be performed by the Contractor, the
Offices agree to pay the Contractor the following amounts per month per
enrolled member as contained in the Offices' capitation payment listing
based upon the capitation rates by category as listed below:
CAPITATION RATES
---------------------------------------------------------------
CATEGORY PACKAGES A AND B PACKAGE C
-------- ---------------- ---------
Newborns $ 355.20 $ 127.99
Preschool $ 71.80 $ 82.30
Children $ 58.22 $ 68.88
Adolescents $ 87.58 $ 97.79
Adult Males $ 247.27
Adult Females $ 193.78
Deliveries $3,297.96/delivery $3,297.96/delivery
These capitation rates will be adjusted by the medical component of the
Consumer Price Index. The initial adjustment will occur in January 2002,
with subsequent adjustments to occur annually thereafter. In the event
that the Offices adjust the fee-for-service (FFS) rates, the Offices
may, in its sole discretion, further adjust the capitation rates in
accordance with the FFS adjustment, based on the same methodology or
percentage change used for the FFS adjustment. If the Offices make such an
adjustment, it shall apply only to the specific service component of the
capitation rate that corresponds to the FFS adjustment. Any capitation
rates adjusted due to a change in the FFS program may be further adjusted
to ensure actuarial soundness. All adjustments are subject to federal
regulations that this Contract may not exceed the FFS Upper Payment Limit
(UPL).
B. All payment obligations of the Offices are subject to the encumbrance of
monies and shall be paid to the Contractor on the first Wednesday after
the fifteenth of the month.
C. The capitation payment will be prospective, based upon the number of
enrollees assigned to the Contractor as of the first of the month. The
Offices will establish an administrative procedure to allow retroactive or
other payment adjustments as necessary to implement this contract.
D. The Contractor will be provided a capitation payment listing which
includes a detailed listing of all enrollees for which the Contractor is
receiving a capitation payment.
E. The parties agree that the Offices have the option of renegotiating
actuarially sound capitation rates annually. Rates revised under this
provision shall be implemented only
MCO Contract Harmony Health Plan
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after a contract amendment is executed and approved. Contractor may submit
information for the Offices' review and consideration.
F. It is understood and agreed upon by the parties that all obligations of
the State of Indiana are contingent upon the availability and continued
appropriation of State and Federal funds, and in no event shall the State
of Indiana be liable for any payments in excess of available appropriated
funds.
G. When the Director of the State Budget Agency makes a written determination
that funds are not appropriated or otherwise available to support
continuation of performance of this Contract, the Contract shall be
cancelled. A determination by the State Budget Director that funds are not
appropriated or otherwise available to support continuation of performance
shall be final and conclusive.
V. ORDER OF PRECEDENCE
Any inconsistency or ambiguity in this Contract shall be resolved by giving
precedence in the following order:
1) The express terms of this document;
2) Attachment 1 - BAA 01-28, released July 31, 2000;
3) Attachment 2 - the Contractor's response to the BAA;
4) Any other documents, standards, laws, rules or regulations
incorporated by reference in the above materials, all of which are
hereby incorporated by reference.
VI. NOTICE
A. Whenever notice is required to be given to the other party, it shall be
made in writing and delivered to that party. Delivery shall be deemed to
have occurred if a signed receipt is obtained when delivered by hand or
according to the date on the return receipt if sent by certified mail,
return receipt requested. Notices shall be addressed as follows:
In case of notice to the Contractor: In case of notice to the Offices:
Xxxxxxx X. Xxxxx, President/CEO Xxxxxx Xxxxxxxx, Managed Care Director
Harmony Health Plan of Illinois, Inc. Office of Medicaid Policy and Planning
000 Xxxxx Xxxxxx Xxxxx, Xxxxx 0000 Family and Social Services Administration
Xxxxxxx, Xxxxxxxx 00000 000 X. Xxxxxxxxxx Xx., XXXX X000, MS07
Xxxxxxxxxxxx, Xxxxxxx 00000
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B. Said notices shall become effective on the date of delivery or the date
specified within the notice, whichever comes later. Either party may
change its address for notification purposes by mailing a notice stating
the change and setting forth the new address.
VII. MISCELLANEOUS PROVISIONS
A. Entire Agreement. This Contract constitutes the entire agreement between
the parties with respect to the subject matter; all prior agreements,
representations, statements, negotiations, and undertakings are superseded
hereby.
B. Changes. Any changes to this Contract shall be by formal amendment of this
Contract signed by all parties required by Indiana law.
C. Performance Bond. The Contractor agrees that a performance bond in the
amount of five hundred thousand dollars ($500,000.00) will be delivered to
the Indiana Department of Administration (IDOA) within ten (10) calendar
days of the execution of this contract. Said bond will be in the form of a
cashier's check, a certified check, or a surety bond executed by a surety
company authorized to do business in the State of Indiana as approved by
the Insurance Department of State of Indiana. No other check or surety
will be accepted. The performance bond shall be made payable to the IDOA
and shall be effective for the duration of the contract and any extensions
thereof. The State reserves the right to increase the performance bond
amount if enrollment levels indicate the need for higher liquidated
damages.
D. Access To Records. The Contractor and any subcontractor shall maintain all
books, documents, papers and records which are directly pertinent to this
Contract and shall make such materials available at all reasonable times
during the contract period and for three (3) years from the date of final
payment under the Contract or until all pending matters are closed,
whichever date is later, for inspection by the Office, or any other duly
authorized representative of the State of Indiana or the Federal
government. Copies thereof shall be furnished at no cost to the State if
requested.
E. Assignment. The Contractor shall not assign or subcontract the whole or
any part of this Contract without the State's prior written consent. Such
consent will not be unreasonably withheld. The Contractor may assign its
right to receive payments to such third parties as the Contractor may
desire without the prior written consent of the State, provided that the
Contractor gives written notice (including evidence of such assignment) to
the State thirty (30) days in advance of any payment so assigned. The
assignment shall cover all unpaid amounts under this Contract and shall
not be made to more than one party.
F. Authority to Bind Contractor. Notwithstanding anything in this Contract to
the contrary, the signatory for the Contractor represents that he/she has
been duly authorized to execute contracts on behalf of the Contractor
designed above, has filed proof of such authority with the Indiana
Department of Administration, 000 Xxxx Xxxxxxxxxx Xxxxxx, X000,
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Xxxxxxxxxxxx, Xxxxxxx 00000, and has obtained all necessary or applicable
approval from the home office of the Contractor to make this Contract
fully binding upon the Contractor when his/her signature is affixed and is
not subject to home office acceptance hereto and accepted by the State of
Indiana.
G. Compliance with Laws. The Contractor agrees to comply with all applicable
Federal, State, and local laws, rules, regulations, or ordinances, and all
provisions required thereby to be included herein are hereby incorporated
by reference. The enactment of any state or federal statute or the
promulgation of regulations thereunder after execution of this Contract
shall be reviewed by the State and the Contractor to determine whether the
provisions of this Contract require formal modification.
H. Compliance with Civil Rights Laws. The Contractor and its subcontractors
hereby assure that they will comply with all Federal and Indiana Civil
Rights Laws, including, but not limited to, I.C. 22-9-1-10 and the Civil
Rights Act of 1964, to the end that they shall not discriminate against
any employee or applicant for employment, to be employed in the
performance of this Contract, with respect to his/her hire, tenure, terms,
conditions or privileges of employment or any matter directly or
indirectly related to employment, because of his/her race, color,
religion, sex, disability, national origin, ancestry or status as a
veteran. The Contractor understands, that the State of Indiana is a
recipient of federal funds. Pursuant to that understanding,
the Contractor, and its subcontractors, if any, agree that if the
Contractor employs 50 or more employees and does at least $50,000 worth of
business with the State of Indiana and is not exempt, the Contractor will
comply with the reporting requirements of 41 CFR 60-1.7, if applicable.
Breach of this covenant may be regarded as a material breach of the
Contract. The State of Indiana shall comply with Section 202 of Executive
Order 11246, as amended and 41 CFR 60-741, as amended, which are
incorporated herein by specific reference.
I. Assurance of Compliance with Civil Rights Act of 1964, Section 504 of the
Rehabilitation Act of 1973 and the Age Discrimination Act of 1975, the
Americans with Disabilities Act of 1990 and Title IX of the Education
Amendments of 1972: The Contractor agrees that it, and all of its
subcontractors and providers, will comply with the following:
1. Title VI of the Civil Rights Act of 1964 (Pub. L. 88-352), as
amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Health and Human Services (45 C.F.R.
Part 80), to the end that, in accordance with Title VI of that Act
and the Regulation, no person in the United States shall on the
ground of race, color, or national origin, be excluded from
participation in, be denied the benefits of, or be otherwise
subjected to discrimination under any program or activity for which
the Contractor receives Federal financial assistance under this
Contract.
2. Section 504 of the Rehabilitation Act of 1973 (Pub. L. 93-112), as
amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Health and Human Services (45 C.F.R.
Part 84), to the end that, in accordance with Section 504 of that
Act and the Regulation, no otherwise qualified handicapped
individual in
MCO Contract Harmony Health Plan
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the United States shall, solely by reason of his/her handicap, be
excluded from participation in, be denied the benefits of, or be
subjected to discrimination under any program or activity for which
the Contractor receives Federal financial assistance under this
Contract.
3. The Age Discrimination Act of 1975 (Pub. L. 94-135), as amended, and
all requirements imposed by or pursuant to the Regulation of the
Department of Health and Human Services (45 C.F.R. Part 91), to the
end that, in accordance with the Act and the Regulation, no person
in the United States shall, on the basis of age, be denied the
benefits of, be excluded from participation in, or be subjected to
discrimination under any program or activity for which the
Contractor receives Federal financial assistance under this
Contract.
4. The Americans with Disabilities Act of 1990 (Pub. L. 101-336), as
amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Justice (28 C.F.R. 35.101)et
seq.), to the end that in accordance with the Act and Regulation, no
person in the United States with a disability shall, on the basis of
the disability, be excluded from participation in, be denied the
benefits of, or otherwise be subjected to discriminations under any
program or activity for which the Contractor receives Federal
financial assistance under this Contract.
5. Title IX of the Education Amendments of 1972, as amended (20
U.S.C. Sections 1681-1683, and 1685-1686), and all requirements
imposed by or pursuant to regulation, to the end that, in
accordance with the Amendments, no person in the United States
shall, on the basis Of sex, be excluded from participation in, be
denied the benefits of, or otherwise be subjected to discrimination
under any program or activity for which the Contractor receives
Federal financial assistance under this Contract.
The Contractor agrees that compliance with this assurance constitutes a
condition of continued receipt of Federal financial assistance, and that
it is binding upon the Contractor, its successors, transferees and
assignees for the period during which such assistance is provided. The
Contractor further recognizes that the United States shall have the right
to seek judicial enforcement of this assurance.
J. Conflict of Interest
1. As used in this section:
"Immediate family" means the spouse and the unemancipated children
of an individual.
"Interested party" means:
a. The individual executing this Contract;
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b. An individual who has an interest of three percent (3%) or
more of the Contractor if the Contractor is not an individual;
or
c. Any member of the immediate family of an individual specified
under subdivision a. or b.
"Department" means the Indiana Department of Administration.
"Commission" means the State [ILLEGIBLE]thics Commission.
2. The Department may cancel this Contract without recourse by the
Contractor if any interested party is an employee of the State of
Indiana.
3. The Department will not exercise its right of cancellation under
section 2 above if the Contractor gives the Department an opinion by
the Commission indicating that the existence of this Contract and
the employment by the State of Indiana of the interested party does
not violate any statute or code relating to ethical conduct of state
employees. The Department may take action, including cancellation of
this Contract consistent with an opinion of the Commission obtained
under this section.
4. The Contractor has an affirmative obligation under this Contract to
disclose to the Department when an interested party is or becomes an
employee of the State of Indiana. The obligation under this section
extends only to those facts which the Contractor knows or reasonably
could know.
K Confidentiality of Data and Property Rights. The Contractor further
agrees that all information, data, findings, recommendations, and
proposals, by whatever name described and by whatever form therein,
secured developed, written, or produced by the Contractor in furtherance
of this Contract, shall be the property of the State of Indiana and that
the Contractor shall take such action as is necessary under law to
preserve such property rights in and of the State of Indiana while such
property is within the control and/or custody of the Contractor.
By this Contract the Contractor specifically waives and/or releases to the
State of Indiana any cognizable property right in the Contractor to
copyright or patent such information, data, findings, recommendations, and
proposals, that are developed exclusively in furtherance of the Contract
and not developed by the Contractor for its other lines of business and
incidentally applied to its Hoosier Healthwise line of business.
The parties acknowledge that it is in their interests for the Contractor
to develop new techniques and advances in managed care. Therefore, the
Offices hereby grant to the Contractor, subject to the confidentiality
obligations set forth in this Contract, as well as those imposed by
federal and state laws and regulations, a perpetual license to use
materials, models, methodologies and techniques developed under this
contract.
MCO Contract Harmony Health Plan
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L. Confidentiality of State of Indiana Information. The Contractor
understands and agrees that data, materials and information disclosed to
the Contractor may contain confidential and protected data; therefore, the
Contractor promises and assures that data, material, and information
gathered, based upon or disclosed to the Contractor for the purpose of
this Contract will not be disclosed to others or discussed with other
parties without the prior written consent of the State of Indiana.
M. Conveyance of Documents And Continuation of Existing Activity: Should the
Contract for whatever reason, (i.e. completion of a contract with no
renewal, or termination of service by either party), be discontinued and
the activities as provided for in the Contract for services cease, the
Contractor and any subcontractors employed by the terminating Contractor
in the performance of the duties of the Contract shall promptly convey to
the State of Indiana, copies of all vendor working papers, data collection
forms, reports, charts, programs, cost records and all other material
related to work performed on this Contract.
The Contractor and the Office shall convene immediately upon notification
of termination or non-renewal of the Contract to determine what work
shall be suspended, what work shall be completed, and the timeframe for
completion and conveyance. The Office will then provide the Contractor
with a written schedule of the completion and conveyance activities
associated with termination. Documents/materials associated with suspended
activities shall be conveyed by the Contractor to the State of Indiana
upon five days' notice from the State of Indiana. Upon completion of those
remaining activities noted on the written schedule, the Contractor shall
also convey all documents and materials to the State of Indiana upon five
days' notice from the State of Indiana.
N. Disputes. Should any disputes arise with respect to this Contract, the
Contractor and the State of Indiana agree to act immediately to resolve
any such disputes. Time is of the essence in the resolution of disputes.
The Contractor agrees that, the existence of a dispute notwithstanding, it
will continue without delay to carry out all its responsibilities under
this Contract which are not affected by the dispute. Should the Contractor
fail to continue without delay to perform its responsibilities under this
Contract in the accomplishment of all non-disputed work, any additional
costs incurred by the Contractor or the State of Indiana as a result of
such failure to proceed shall be borne by the Contractor, and the
Contractor shall make no claim against the State of Indiana for such
costs. If the Contractor and the State of Indiana cannot resolve a dispute
within ten (10) working days following notification in writing by either
party of the existence of said dispute, then the following procedure shall
apply:
1. The parties agree to resolve such matters through submission of
their dispute to the Commissioner of the Indiana Department of
Administration who shall reduce her decision to writing and mail or
otherwise furnish a copy thereof to the Contractor and the State of
Indiana within ten (10) working days after presentation of such
dispute for her decision. Her decision shall be final and conclusive
unless the Contractor mails or otherwise furnishes to the
Commissioner of Administration within ten (10) working days after
receipt
MCO Contract Harmony Health Plan
Page 18 of 24
of the Commissioner's decision, a written appeal. Within ten (10)
working days of receipt by the Commissioner, she may reconsider her
decision. If no reconsideration is provided with in ten (10) working
days the Contractor may submit the dispute to an Indiana court of
competent jurisdiction.
2. The State of Indiana may withold payments on disputed items pending
resolution of the dispute. The non-payment by the State of Indiana
to the Contractor of one or more invoices not in dispute shall not
constitute default, however, the Contractor may bring suit to
collect such monies without following the disputes procedure
contained herein.
O. Drug-Free Workplace
1. The Contractor hereby covenants and agrees to make a good faith
effort to provide and maintain during the term of this Contract a
drug-free workplace. Contractor will give written notice to the
Office and the Indiana Department of Administration within ten (10)
days after receiving actual notice that an employee of the
Contractor has been convicted of a criminal drug violation occurring
in the Contractor's workplace.
2. In addition to subparagraph(1) if the total amount set forth in
this Contract is in excess of twenty-five thousand dollars
($25,000.00), the Contractor hereby further agrees that this
Contract is expressly subject to the terms, conditions, and
representations contained in the Drug-Free Workplace
Certification. The Certification is hereby executed by the
Contractor in conjunction with this Contract and set forth in this
Contract.
3. It is further expressly agreed that the failure of the Contractor
to in good faith comply with the terms of subparagraph (1) above, or
falsifying or otherwise violating the terms of the certification
referenced in subparagraph (2) above shall constitute a material
breach of this Contract, and shall entitle the State of Indiana to
impose sanctions against the Contractor including, but not limited
to, suspension of contract payment, termination of this Contract
and/or debarment of the Contractor from doing further business with
the State of Indiana for up to three (3) years.
P. Drug-Free Workplace Certification
This Certification is required by Executive Order No. 90-5, April 12,
1990, issued by the Governor of Indiana. Pursuant to its delegated
authority, the Indiana Department of Administration is requiring the
inclusion of this certification in all contracts with the State of Indiana
in excess of $25,000.00. No award of a contract shall be made, and no
contract, purchase order or agreement, the total amount of which exceeds
$25,000.00 shall be valid, unless and until this certification has been
fully executed by the Contractor and made a part of the Contract as part
of the Contract documents. False certification or violation of the
certification may result in sanctions including, but not limited to,
suspension of contract
MCO Contract Harmony Health Plan
Page 19 of 24
payment, termination of the contract and/or debarment of contracting
opportunities with the Contractor for up to three (3) years.
The Contractor certifies and agrees that it will provide a drug-free
workplace by:
1. Publishing and providing to all of its employees a statement
notifying them that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance is
prohibited in the Contractor's workplace and specifying the actions
that will be taken against employees for violations of such
prohibition.
2. Establishing a drug-free awareness program to inform employees of
(A) the dangers of drug abuse in the workplace (B) the Contractor's
policy of maintaining a drug-free workplace; (C) any available drug
counseling, rehabilitation, and employee assistance programs; and
(4) the penalties that may be imposed upon an employee for drug
abuse violations occurring in the workplace.
3. Notifying all employees in the statement required by subparagraph
(1) above that as a condition of continued employment the employee
will (A) abide by the terms of the statement; and (B) notify the
Contractor of any criminal drug statute conviction for a violation
occurring in the workplace no later than five (5) days after such
conviction.
4. Notify the State in writing within ten (10) days after receiving
notice from an employee under subdivision (3)(B) above, or otherwise
receiving actual notice of such conviction.
5. Within thirty (30)days after receiving notice under subdivision
(3)(B) above of a conviction, imposing the following sanctions or
remedial measures on any employee who is convicted of drug abuse
violations occurring in the workplace: (A) take appropriate
personnel action against the employee, up to and including
termination; or (B) require such employee to satisfactorily
participate in a drug abuse assistance or rehabilitation program
approved for such purposes by a Federal, State, or local health, law
enforcement, or other appropriate agency.
6. Making a good faith effort to maintain a drug-free workplace through
the implementation of subparagraphs (1) through (5).
Q. Environmental Standards. If the contract amount set forth in this Contract
is in excess of $100,000, the Contractor shall comply with all applicable
standards, orders, or requirements issued under section 305 of the Clean
Air Act (42 USC 7606), section 508 of the Clean Air Act (33 USC 1368),
Executive Order 11738, and Environmental Protection Agency regulations (40
CFR Part 15), which prohibit the use under non-exempt Federal contracts of
facilities included on the EPA List of Violating Facilities. The
Contractor shall report any violations of this paragraph to the State of
Indiana and to the United States Environmental Protection Agency Assistant
Administrator for Enforcement.
MCO Contract Harmony Health Plan
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R. Force Majeure; Suspension and Termination. In the event either party is
unable to perform any of its obligations under this Contract or to enjoy
any of its benefits because of (or if failure to perform the service is
caused by) natural disaster, actions or decrees of governmental bodies, or
communication line failure not the fault of the affected party
(hereinafter referred to as a "Force Majeure Event"), the party who has
been so affected shall immediately give notice to the other party and
shall take reasonable measures to resume performance. Upon receipt of such
notice, all obligations under this Contract shall be immediately
suspended. If the period of non-performance exceeds thirty (30) days from
the receipt of notice of the Force Majeure Event, the party whose ability
to perform has not been so affected may, by giving written notice,
terminate this Contract.
S. Governing Laws. This Contract shall be construed in accordance with and
governed by the laws of the State of Indiana and suit, if any, must be
brought in the State of Indiana.
T. Indemnification. The Contractor agrees to indemnify, defend, and hold
harmless the State of Indiana and its agents, officers, and employees from
all claims and suits including court costs, attorney's fees, and other
expenses caused by any act or omission of the Contractor and/or its
subcontractors, if any. The State shall not provide such indemnification
to the Contractor.
U. Independent Contractor. The Office and the Contractor acknowledge and
agree that in the performance of this contract, the Contractor is an
independent contractor and both parties will be acting in an individual
capacity and not an as agents, employees, partners, joint venturers,
officers, or associates of one another. The employees or agents of one
party shall not be deemed or construed to be the employees or agents of
the other party for any purposes whatsoever. Neither party will assume any
liability for any injury (including death) to any persons, or any property
arising out of the acts or omissions of the agents, employees or
subcontractors of the other party.
The Contractor shall be responsible for providing all necessary
unemployment and worker compensation insurance for the Contractor's
employees.
V. Lobbying Activities. Pursuant to 31 U.S.C. 1352, and any regulations
promulgated thereunder, the Contractor hereby assures and certifies that
no federally appropriated funds have been paid, or will be paid, by or on
behalf of the Contractor, to any person for influencing or attempting to
influence an officer or employee of any agency, a member of Congress, an
officer or employee of Congress, or an employee of a member of Congress,
in connection with the awarding of any federal contract, the making of any
federal grant, the making of any federal loan, the entering into of any
cooperative contract, and the extension, continuation, renewal, amendment,
or modification of any federal contract, grant, loan or cooperative
contract. If any funds other than federally appropriated funds have been
paid or will be paid to any person for influencing or attempting to
influence an officer or employee of any agency, a member of Congress, an
officer or employee of Congress, or an employee of a member of Congress in
connection with this Contract, the Contractor shall complete and submit
Standard Form-LLL, "Disclosure Form to Report Lobbying", in accordance
with its instructions.
MCO Contract Harmony Health Plan
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W. Ownership of Documents and Materials. All documents, records, programs,
data, film, tape, articles, memoranda, and other materials developed under
this Contract will be the property of the State of Indiana. Use of these
materials other than related to contract performance by the Contractor
without the prior written consent of the State of Indiana is prohibited.
During the performance of the services specified herein, the Contractor
shall be responsible for any loss or damage to these materials developed
for or supplied by the State of Indiana and used to develop or assist in
the services provided herein, while they are in the possession of the
Contractor, and any loss or damage thereto shall be restored at the
Contractor's expense. Full, immediate and unrestricted access to the work
product of the Contractor during the term of this Contract shall be
available to the State of Indiana. The Contractor will give to the State
of Indiana, or the State of Indiana's designee, all records of other
materials described in this section, after termination of the Contract and
upon five (5) days notice of a request from the State of Indiana.
The parties acknowledge that it is in their interests for the Contractor
to develop new techniques and advances in managed care. Therefore, the
Offices hereby grant to the Contractor, subject to the confidentiality
obligations set forth in this Contract, as well as those imposed by
federal and state laws and regulations, a perpetual license to use
materials, models, methodologies and techniques developed under this
contract.
X. Penalties/Interest/Attorney's Fees. The State will in good faith perform
its required obligations hereunder and does not agree to pay any
penalties, liquidated damages, interest, or attorney's fees, except as
required by Indiana law, in part, I.C. 5-17-5-1 et seq., IC. 34-54-8-2 et
seq., and I.C. 34-13-1-1 et seq.
Y. Severability. The invalidity in whole or in part of any provision of this
Contract shall not void or affect the validity of any other provision.
Z. Successors and Assignees. The Contractor binds its successors, executors,
assignees, and administrators, to all covenants of this contract. Except
as set forth above, the Contractor shall not assign, sublet, or transfer
the Contractor's interest in this Contract without the prior written
consent of the Office.
AA. Termination. The Offices may, without cause, cancel and terminate this
Contract in whole or in part upon sixty (60) days' prior written notice.
The Contractor will be reimbursed for services performed prior to the date
of termination consistent with the terms of the Contract. The Offices will
not be liable for services performed after notice of termination, but
before the date of termination, without written authorization from the
Offices. In no event will the Offices be liable for services performed
after the termination date.
In the event that the Offices request that the Contractor perform any
additional services associated with the transition or turnover of this
Contract, the Offices agree to pay reasonable costs for those additional
services specifically requested by the Offices.
MCO Contract Harmony Health Plan
Page 22 of 24
BB. Termination by the Contractor. This Contract may be terminated by the
Contractor upon one hundred eighty (180) days prior written notice to the
Offices. The Contractor will be reimbursed for services performed prior to
the effective date of termination consistent with the terms of the
Contract. In no event will the Offices be liable for services performed
after the effective date of termination, without written authorization
from the Offices.
CC. Change in Scope of Work -- In the event the Offices require a major change
in scope, character or complexity of the work after the work has
commenced, adjustments in compensation to the Contractor shall be
determined by the Office, in the exercise of its honest and reasonable
judgment, and the Contractor shall not commence the additional work or the
change in the scope of work until authorized in writing by the Offices. No
claim for additional compensation shall be made in the absence of a prior
written approval executed by all signatories hereto.
DD. Waiver of Breach. No waiver of breach of any provision of this Contract
shall constitute a waiver of any other breach or of such provision.
Failure of the Office to enforce at any time any provision of this
Contract shall not be construed as a waiver thereof. The remedies herein
reserved shall be cumulative and additional to any other remedies in law
or equity.
EE. Work Standards. The Contractor agrees to execute its respective
responsibilities by following and applying at all times the highest
professional and technical guidelines and standards. If the State becomes
dissatisfied with the work product or the working relationship with those
individuals assigned to work on this Contract, the State may request in
writing the replacement of any or all such individuals.
FF. Non-Collusion and Acceptance. The undersigned attests, subject to the
penalties for perjury, that he is the contracting party, or that he is the
representative, agent, member or officer of the contracting party, that he
has not, nor has any other member employee, representative, agent or
officer of the firm, company, corporation or partnership represented by
him, directly or indirectly, to the best of his knowledge, entered into or
offered to enter into any combination, collusion or agreement to receive
or pay, and that he has not received or paid, any sum of money or other
consideration for the execution of this agreement other than that which
appears upon the face of the agreement.
/// The remainder of this page is intentionally left blank. ///
MCO Contract Harmony Health Plan
Page 23 of 24
IN WITNESS WHEREOF, Harmony Health Plan of Illinois. Inc. and the State of
Indiana have through duly authorized representatives entered into this
agreement. The parties having read and understand the foregoing terms of the
Contract do by their respective signatures dated below hereby agree to the terms
thereof.
For the Contractor: For the State of Indiana:
/s/ Xxxxxxx X. Xxxxx /s/ Xxxxxxxx X. Xxxxxxx
----------------------------- ---------------------------------
Xxxxxxx X.Xxxxx, President CEO Xxxxxxxx X. Xxxxxxx
Harmony Health Plan of Illinois, Inc. Assistant Secretary
Office of Medicaid Policy &
Planning
Date: 12/19/00 Date: 12/21/2000
/s/ Xxxxx Xxxx
---------------------------------
Xxxxx Xxxx. Director
Children's Health Insurance Program
Date: [ILLEGIBLE]
APPROVED: APPROVED:
/s/ Xxxxx Xxxxxxx /s/ Xxxxx X. Xxxxxxxx
----------------------------- ---------------------------------
Xxxxx Xxxxxxx, Director Xxxxx X. Xxxxxxxx, Commissioner
State Budget Agency Department of Administration
Date: 01/10/01 Date: Jan 4, 2001
APPROVED AS TO FORM AND LEGALITY
/s/ Xxxxx Xxxxxxx-Xxxxxx
-----------------------------------
Xxxxx Xxxxxxx-Xxxxxx
Attorney General of Indiana
Date: 2/2/01
MCO Contract
Page 24 of 24
JUL 17 2003
Xxxxx X'Xxxxxx, Governor
State of Indiana
OFFICE OF MEDICAID POLICY AND PLANNING
000 X. XXXXXXXXXX XXXXXX, XXXX X000
XXXXXXXXXXXX, XX 00000-0000
Xxxx Xxxxxxxx, Secretary
[FSSA LOGO]
"People helping people help themselves"
July 15, 2003
Xxxx Xxxxx, MD, CEO
Harmony Health Plan of Illinois, Inc.
000 Xxxxx Xxxxxx Xxxxx, Xxxxx 0000
Xxxxxxx, XX 00000
RE: Hoosier Healthwise Contract, Third Amendment
Dear Dr. Blank,
Enclosed you will find the Third Amendment to the Indiana MCO contract for your
review and signature.
This amendment was necessary for the contract to be compliant with the federal
managed care regulations at 00 XXX 000, and includes new actuarially sound
capitation rates and a revised Scope of Work attachment (Exhibit 1). The
transition report for the second phase of mandatory RBMC is also included as
Exhibit 3 and provides for Harmony's expansion into the Central Region. The
amendment is effective August 1, 2003.
Please sign and return the enclosed amendment document at your earliest
convenience to Xxxxxx Xxxxxx of my staff. You will receive a copy of the fully
executed amendment once all other signatures have been obtained. Thank you for
your continued commitment to Hoosier Healthwise.
Sincerely,
/s/ Xxxx Xxxxx
------------------------------
Xxxx Xxxxx
Managed Care Director
Enclosure
Cc: Xxxxxx Xxxxxx
Xxxxxx Xxxxxx
Equal Opportunity / Affirmative Action Employer
[SEAL]
THIRD AMENDMENT
TO
CONTRACT BETWEEN
THE OFFICE OF MEDICAID POLICY AND PLANNING
AND
HARMONY HEALTH PLAN OF ILLINOIS, INC.
This THIRD AMENDMENT to the above-referenced Contract is made and entered
into by and between the State of Indiana [hereinafter "State" of "State of
Indiana"], through the Office of Medicaid Policy and Planning [hereinafter
called "State" or "Office"], of the Indiana Family and Social Services
Administration, 000 Xxxx Xxxxxxxxxx Xxxxxx, Xxxx X000, Xxxxxxxxxxxx, Xxxxxxx
00000, and Harmony Health Plan of Illinois, Inc., 000 Xxxxx Xxxxxx Xxxxx, Xxxxx
0000, Xxxxxxx, Xxxxxxxx, doing business as Harmony Health Plan of Indiana,
[hereinafter called "Contractor"].
WHEREAS, the State of Indiana and Contractor have previously entered into
a contract for a term beginning January 1, 2001, and ending December 31, 2004,
[hereinafter "the original contract"] for services to arrange for and to
administer a risk-based managed care program (RBMC) for certain Hoosier
Healthwise enrollees in Packages A, B and C as procured through BAA 01-28;
WHEREAS, the parties have previously entered into a First Amendment for
additional duties and the adjustment of capitation rates related to the
mandatory MCO enrollment of Hoosier Healthwise members residing in certain
Indiana counties;
WHEREAS, the Family and Social Services Administration (FSSA) issued new
contract documents in lieu of a Second Amendment document so that FSSA may move
its contract data into a single contract database. The original contract was
issued for the contract term starting January 1, 2001, through December 31,
2002, and provided for a renewal clause, exercised at the option of the State
for two additional years. The State exercised this option and renewed the
contract from January 1, 2003, through December 31, 2004;
WHEREAS, this Contract contains the payment rates under which the
Contractor shall be paid and that these rates have been determined to be
actuarially sound for risk contracts, in accordance with applicable law;
WHEREAS, the Office desires to further amend the contract with this THIRD
AMENDMENT in order to bring the contract into compliance with applicable new
federal regulations at 42 CFR 438 implementing the federal Balanced Budget Act
of 1997.
NOW THEREFORE, the parties enter into this THIRD AMENDMENT for the
consideration set out below, all of which is deemed to be good and sufficient
consideration in order to make this THIRD AMENDMENT a binding legal instrument.
1. The parties hereby ratify and incorporate herein each term and condition
set out in the original Contract, First Amendment, Second Amendment (i.e.,
renewal contract), as well
MCO Contract, Third Amendment Page 1 of 6 Harmony Health Plan
as all written matters incorporated therein except as specifically
provided for by this THIRD AMENDMENT.
2. The term of this amendment is August 1, 2003, through December 31, 2004.
3. The parties agree that BAA 01-28, Attachment A, Section 3.0, Requested
Services, is amended, as required by 00 XXX 000, and is replaced with BAA
01-28, Attachment A, Section 3.0, Requested Services, dated July 10, 2003,
which is incorporated herein by reference as Exhibit 1.
4. The parties agree that BAA 01-28, Appendix 2, Definition and
Abbreviations, is amended, as required by 00 XXX 000, and is replaced with
BAA 01-28, Appendix 2, Definitions and Abbreviations, dated July 10, 2003,
which is incorporated herein by reference as Exhibit 2.
5. Paragraph XXX.XX. of the Second Amendment (Renewal Contract) is deleted
and replaced with the following concerning Security and Privacy of Health
Information:
The Contractor agrees to comply with all requirements of the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) in all
activities related to this contract, to maintain compliance throughout the
life of the contract, to operate any systems used to fulfill the
requirements of this contract in full compliance with HIPAA and to take no
action which adversely affects the State's HIPAA compliance.
The parties acknowledge that the Department of Health and Human Services
has issued the Final Rule, as amended from time to time on the Standards
for Privacy of Individually Identifiable Health Information, as required
by the Administrative Simplification Section of the Health Insurance
Portability and Accountability Act of 1996 ("HIPAA"). The parties
acknowledge that the Office is a Covered Entity within the meaning of
HIPAA. To the extent required by the provisions of HIPAA and regulations
promulgated thereunder, the Contractor assures that it will appropriately
safeguard Protected Health Information (PHI), as defined by the
regulations, which is made available to or obtained by the Contractor in
the course of its work under the contract. The Contractor agrees to comply
with applicable requirements of law, as they may be amended from time to
time, relating to PHI with respect to any task or other activity it
performs for the Office including, as required by the final regulations:
A. Not using or further disclosing PHI other than as permitted or
required by this Contract or by applicable law;
B. Using appropriate safeguards to prevent use or disclosure of PHI
other than as provided by this Contract or by applicable law;
C. Mitigating, to the extent practicable, any harmful effect that is
known to the Contractor and reporting to the office any use or
disclosure by the Contractor, its agent, employees, subcontractors
or third parties, of PHI obtained under this Contract
MCO Contract, Third Amendment Page 2 of 6 Harmony Health Plan
in a manner not provided for by this Contract or by applicable law
of which the Contractor becomes aware;
D. Ensuring that any subcontractors or agents to whom the Contractor
provides PHI received from, or created or received by the Contractor
on behalf of the Office agree to the same restrictions, conditions
and obligations applicable to such party regarding PHI;
E. Making the Contractor's internal practices, books and records
related to the use of disclosure of PHI received from, or created or
received by the Contractor on behalf of the Office available to the
Secretary of the United States Department of Health and Human
Services for purposes of determining the Office's compliance with
applicable law. The Contractor shall immediately notify the Office
upon receipt by the Contractor of any such request, and shall
provide the Office with copies of any materials made available in
response to such a request;
F. In accordance with procedures established by the Office, documenting
and making available the information required to provide an
accounting of disclosures pursuant to applicable law, if the duties
of the Contractor include disclosures that must be accounted for;
G. In accordance with procedures established by the Office, making
available PHI for amendment and incorporating any amendments to PHI
in accordance with 45 CFR 164.526, if the Contractor maintains PHI
subject to amendment;
H. In accordance with procedures established by the Office, making PHI
available to individuals entitled to access and requesting access in
compliance with 45 CFR 164.524 and consistent with the duties of the
Contractor;
I. At the termination of this Contract, if feasible, return or destroy
all PHI received or created under this Contract. If the Office
determines return or destruction is not feasible, the protections in
this agreement shall continue to be extended to any PHI maintained
by the Contractor for as long as it is maintained.
In order to fulfill the terms of this Contract, Contractor will utilize
and interface with the State's electronic systems and will use them to
perform certain electronic transactions that contain health information,
and which are subject to the final rules for the Standards for Electronic
Transactions, dated August 17, 2000, under the Administrative
Simplification Section of HIPAA (the "Transaction Standards").
The Contractor shall comply with the Transaction Standards, as may be
amended from time to time, and shall provide documentation of its
compliance with them, including a summary of project plans for
remediation, status reports of remediation efforts, summary of text
results, copies of certifications, if any, and the Contractor's statement
affirming completion of all requirements. Such compliance shall be
maintained at no additional cost to the State.
MCO Contract, Third Amendment Page 3 of 6 Harmony Health Plan
Contractor will indemnify and hold the State harmless from any loss,
damage, costs, expense, judgment, sanction or liability including, but not
limited to, attorneys' fees and costs, that the State incurs or is subject
to, as a result of Contractor's breach of this Paragraph.
6. The parties agree that Article IV. Payment, paragraph A, of the Second
Amendment (renewal contract) is amended as follows:
CAPITATION RATES
CATEGORY PACKAGES A/B PACKAGE C
-------- ------------ ---------
NORTH REGION
Newborns $ 381.83 $ 208.22
Preschool $ 71.66 $ 78.20
Children $ 58.10 $ 63.25
Adolescents $ 87.40 $ 83.63
Adult Males $ 246.78
Adult Females $ 203.16
Deliveries $[ILLEGIBLE],356.03 $3,356.03
CENTRAL REGION
Newborns $ 390.49 $ 156.05
Preschool $ 77.35 $ 74.26
Children $ 55.04 $ 50.40
Adolescents $ 105.91 $ 64.08
Adult Males $ 234.59
Adult Females $ 206.70
Deliveries $[ILLEGIBLE] 482.86 $3,482.86
7. The parties agree that paragraph III.Q.3.a. of the renewal contract is
amended to read as follows:
An informal claim resolution procedure which shall be available for
the resolution of claims submitted to the Contractor by the provider
within the allowable claims submission time limits under federal and
state law.
8. The parties agree that Contractor's service area, as described in
Contractor's response to the BAA, has been amended to include, not only
the initial service area in the Northern Region, but also the Central
Region, including, but not limited to, the Phase II Mandatory MCO
Enrollment counties of Xxxxx, Xxxxxx, Madison and Delaware.
9. Contractor shall submit a network development plan to OMPP and to the
monitoring contractor for the counties identified for Phase II of
mandatory MCO enrollment by August 5, 2003.
MCO Contract, Third Amendment Page 4 of 6 Harmony Health Plan
10. The parties agree that Section 3.6.1.3 of the BAA is amended to require
the Contractor to submit the "Transition Report (Phase II )," attached as
Exhibit 3, monthly from August 2003 until August 2004, according to the
schedule in Exhibit 3, or until the MCO has received written notification
from OMPP that the report, or certain data elements in the report, is/are
no longer required or may be reported less frequently. If Contractor fails
to submit the Transition Report on time, or submits a Transition Report
with incomplete data, OMPP may assess, and the MCO shall pay, liquidated
damages in the amount of $200 per business day until a complete report is
received.
11. The Contractor certifies and warrants that federal funds have not been
used for lobbying.
12. The parties agree that this Third Amendment to the parties' original
Contract has been duly prepared and executed pursuant to Paragraph VII.B
of the original contract.
13. The undersigned attests, subject to the penalties for perjury, that he is
the contracting party, or that he is the representative, agent, member or
officer of the contracting party, that he has not, nor has any other
member employee, representative, agent or officer of the firm, company,
corporation or partnership represented by him, directly or indirectly, to
the best of his knowledge, entered into or offered to enter into any
combination, collusion or agreement to receive or pay, and that he has not
received or paid, any sum of money or other consideration for the
execution of this agreement other than that which appears upon the face of
the agreement.
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MCO Contract, Third Amendment Page 5 of 6 Harmony Health Plan
WHEREOF, the parties have, through duly authorized representatives, entered into
this agreement. The parties having read and understood the foregoing terms of
the contract do by their respective signatures dated below hereby agree to the
terms thereof.
For the Contractor: For the State of Indiana:
/s/ Xxxx Xxxxx
_____________________________________ ___________________________________
Xxxx Xxxxx, MD, President/CEO Xxxxxxx Bella, Assistant Secretary
Harmony Health Plan of Illinois, Inc. Office of Medicaid Policy Planning
Date: 7/29/03 Date:______________________________
___________________________________
Xxxxxxx X. Xxxxx, Director
Children's Health Insurance Program
Date:______________________________
APPROVED: APPROVED:
__________________________________ ___________________________________
Xxxxxxx Xxxxxxx, Director Xxxxx Xxxxxxx, Commissioner
Slate Budget Agency Department of Administration
Date:_____________________________ Date:______________________________
APPROVED AS TO FORM AND LEGALITY
__________________________________
Xxxxxxx Xxxxxx
Attorney General of Indiana
Date:_____________________________
MCO Contract, Third Amendment Page 6 of 6 Harmony Health Plan
EXHIBIT 1
BAA 01-28, ATTACHMENT A - SCOPE OF WORK
REVISED SECTION 3.0 REQUESTED SERVICES
3.0 REQUESTED SERVICES.................................................................................... 4
3.1 INTRODUCTION........................................................................................ 4
3.2 FEDERAL REQUIREMENTS................................................................................ 4
3.2.1 Capacity and Service............................................................................ 4
3.2.2 Federal Upper Payment Limit..................................................................... 5
3.2.3 Fiscal Soundness of the MCOs.................................................................... 5
3.2.4 Physician Incentive Plan(s)..................................................................... 6
3.2.5 Balance Billing................................................................................. 6
3.2.6 Debarred or Suspended Individuals............................................................... 6
3.2.7 Civil Rights Compliance......................................................................... 7
3.3 CONTRACT COMMUNICATION.............................................................................. 7
3.4 DESCRIPTION OF MANAGED CARE SERVICES................................................................ 7
3.4.1 Hoosier Healthwise MCO Covered Services......................................................... 7
3.4.2 Special Provisions.............................................................................. 11
3.4.2.1 Emergency Services and Post-Stabilization Services.......................................... 11
3.4.2.2 Out-of-Area Services........................................................................ 13
3.4.2.3 Out-of-Plan Services........................................................................ 13
3.4.2.4 MCO-Covered Self-Referral Services.......................................................... 13
3.4.2.4.1 Family Planning......................................................................... 14
3.4.2.4.2 Chiropractic, Eye Care and Podiatry Services............................................ 14
3.4.2.4.3 HIV/AIDS Targeted Case Management Services.............................................. 14
3.4.2.5 MCO-Covered Diabetes Self-Management Services............................................... 15
3.4.2.6 Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs).................. 15
3.4.2.7 Short-term placements in long-term care facilities.......................................... 16
3.4.2.8 Co-payments................................................................................. 16
3.4.3 Medicaid and Hoosier Healthwise Covered, But MCO Non-Covered, Services (Carved-Out Services).... 16
3.4.4 Enhanced Services............................................................................... 18
3.4.5 Drug Formularies................................................................................ 18
3.5 RESPONSIBILITIES OF OMPP AND CHIP................................................................... 18
3.5.1 Determination of Hoosier Healthwise Benefits and Hoosier Healthwise Managed Care Eligibility.... 18
3.5.2 Member Enrollment in Hoosier Healthwise Managed Care............................................ 19
3.5.2.1 Member Disenrollment From Hoosier Healthwise MCOs........................................... 20
3.5.2.2 Redetermination Enrollment In Hoosier Healthwise RBMC..........:............................ 22
3.5.3 MCO Enrollment Rosters.......................................................................... 22
3.5.4 Utilization Review.............................................................................. 23
3.5.5 Monitoring...................................................................................... 23
3.5.6 Capitation Payments............................................................................. 24
3.6 RESPONSIBILITIES OF MCO............................................................................. 24
3.6.1 Administration and Organizational Structure..................................................... 24
3.6.1.1 Administrative Requirements................................................................. 25
3.6.1.2 Meeting Requirements........................................................................ 27
3.6.1.3 Reporting Requirements...................................................................... 27
3.6.1.4 Subcontractor Review Requirements........................................................... 29
3.6.2 Provider Network Requirements................................................................... 30
3.6.3 Provider Network Access to Care Requirements.................................................... 32
3.6.4 Provider Payment Requirements................................................................... 34
3.6.5 Disclosure of Physician Incentive Plan.......................................................... 35
3.6.6 Advance Directives.............................................................................. 36
3.6.7 Member Services................................................................................. 36
3.6.7.1 Member Hotline.............................................................................. 36
3.6.7.2 Services for Newborns....................................................................... 37
3.6.7.3 Member Outreach for the Hoosier Healthwise RBMC............................................. 38
3.6.7.4 Member Education Requirements............................................................... 39
3.6.7.4.1 Member Materials........................................................................ 39
3.6.7.4.2 Alternate Format Requirements........................................................... 40
3.6.7.5 Member Grievance Procedures and Reporting Standards......................................... 40
Section 3.0 1 Revised July 10, 2003
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REVISED SECTION 3.0 REQUESTED SERVICES
3.6.7.6 Protection of Member-Provider Communications................................................ 43
3.6.7.7 Member Rights............................................................................... 43
3.6.7.8 Members With Special Needs.................................................................. 44
3.6.8 Provider Services............................................................................... 45
3.6.9 Provider Credentialing.......................................................................... 45
3.6.9.1 Provider Enrollment and Education........................................................... 50
3.6.9.2 Maintenance of Medical Records.............................................................. 50
3.6.9.3 MCO Communications with Providers........................................................... 50
3.6.10 Program Integrity Plan and Reporting Standard................................................... 51
3.6.10.1 MCO Communications With Indiana Medicaid Fraud Control Unit (IMFCU)..................... 52
3.6.11 Regional Network Development Requirement and Reporting Standard................................. 53
3.6.12 Quality Improvement and Utilization Review Program.............................................. 53
3.6.12.1 Quality Assessment and Performance Improvement Program and Reporting Standard........... 53
3.6.12.2 Utilization Review (UR) Requirement and UR Reporting Standard.......................... 56
3.6.13 Management Information Systems.................................................................. 60
3.6.13.1 Member Enrollment Data Exchange......................................................... 61
3.6.13.2 Claims Processing....................................................................... 62
3.6.13.3 Shadow Claims Reporting................................................................. 62
3.6.13.3.1 Shadow Claims Requirements and Submission Standards..................................... 63
3.6.13.4 Third-Party Liability Reporting............................................................. 64
3.6.13.4.1 MCO TPL Responsibilities - Cost Avoidance............................................... 65
3.6.13.4.2 Cost Avoidance Exceptions............................................................... 65
3.6.13.4.3 Coordination of Benefits................................................................ 66
3.6.13.4.4 Casualty Cases.......................................................................... 67
3.6.14 Financial Reporting Requirements................................................................ 67
3.6.15 Dispute Resolution Processes.................................................................... 68
3.7 REINSURANCE REQUIREMENTS............................................................................ 68
3.8 CHANGE IN SCOPE OF WORK............................................................................. 69
3.9 TERMINATION OF CONTRACT............................................................................. 69
3.9.1 Termination for Default......................................................................... 70
3.9.2 Termination for Convenience..................................................................... 71
3.9.3 Termination for Unavailable Funds............................................................... 71
3.9.4 Termination for Financial Instability........................................................... 71
3.9.5 Termination for Failure to Disclose Records..................................................... 72
3.9.6 Procedures for Termination...................................................................... 72
3.9.7 Refunds of Advanced Payments.................................................................... 73
3.9.8 Liability for Medical Claims.................................................................... 73
3.9.9 Termination Claims.............................................................................. 73
3.9.10 Right to Suspend Operations..................................................................... 74
3.10 INDEMNIFICATION..................................................................................... 74
3.11 KICKBACKS........................................................................................... 74
3.12 ASSIGNMENTS......................................................................................... 74
3.13 AUDIT OR EXAMINATION OF RECORDS..................................................................... 74
3.14 FINANCIAL ACCOUNTING REQUIREMENTS................................................................... 75
3.15 CONTRACT PERFORMANCE DISPUTES AND APPEALS........................................................... 76
3.16 LIQUIDATED DAMAGES AND OTHER REMEDIES FOR CONTRACT NON-COMPLIANCE................................... 76
3.16.1 Non-Compliance with Performing Requested Services............................................... 77
3.16.2 Non-Compliance with Shadow Claims Data Submission Requirements.................................. 77
3.16.3 Non-Compliance with Submission of Quality Improvement and Quarterly Reports..................... 78
3.16.4 Non-Compliance with Reporting Grievance Data.................................................... 79
3.16.5 Non-Compliance with all Other Reporting Requirements............................................ 79
3.16.6 Non-Compliance with General Contract Provisions................................................. 79
3.16.6.1 Right to Suspend Enrollment................................................................. 80
3.16.6.2 Right to Suspend Monthly Capitation Payments................................................ 80
3.16.7 Non-Compliance with Submission of Education/Outreach and Marketing Materials.................... 81
3.17 WARRANT AGAINST CONTINGENCY fees.................................................................... 81
3.18 INSURANCE........................................................................................... 81
3.18.1 Professional Liability Insurance................................................................ 81
3.18.2 Workers' Compensation........................................................................... 82
Section 3.0 2 Revised July 10, 2003
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REVISED SECTION 3.0 REQUESTED SERVICES
3.18.3 Minimum Liability and Property Damage Insurance................................................. 82
3.18.4 Errors and Omissions Insurance.................................................................. 82
3.18.5 Bonds........................................................................................... 82
3.18.6 Evidence of Coverage............................................................................ 83
3.19 FORCE MAJEURE...................................................................................... 83
Section 3.0 3 Revised July 10, 2003
BAA 01-28, ATTACHMENT A - SCOPE OF WORK
REVISED SECTION 3.0 REQUESTED SERVICES
3.0 REQUESTED SERVICES
3.1 INTRODUCTION
This section of the BAA provides a description of the general
characteristics of a fully-capitated prepayment managed care system and
sets out the minimum requirements of MCOs who are qualified to contract
with the State as an MCO for the Hoosier Healthwise RBMC delivery
system. In addition, this section includes an overview of other major
State functions and federal Medicaid managed care and CHIP
requirements, and provisions that must be considered when contracting
with OMPP as an MCO for the Hoosier Healthwise RBMC delivery system.
Please note that all descriptions of Federal and state statutes,
regulations or administrative procedures currently in effect are made
in good faith to provide MCOs relevant information available to the
State at this time. However, MCOs will be required to comply with any
statutes, regulations or administrative procedures that become
effective following release of the BAA. The State is not precluded by
any description contained in this BAA from implementing any lawful
changes in statutes, rules or administrative procedures that may become
effective following release of the BAA. Definitions for terms used
throughout this BAA are provided in Appendix 2.
3.2 FEDERAL REQUIREMENTS
Federal requirements governing contracts with risk-based managed care
plans are specified in Section 1903(m)of the Social Security Act
(including amendments made by the Balanced Budget Act of 1997 [P.L.
105-33]) and Part 434 and 438 of 42 CFR. The MCO procurement must also
comply with 45 CFR 74. In addition to these federal regulations and
statutes, federal civil rights laws will also govern the principles of
this procurement. The following regulations apply to Hoosier Healthwise
managed care.
3.2.1 CAPACITY AND SERVICE
Federal rule 42 CFR 438.207 requires a contracting MCO to provide the
State with adequate assurances and documentation that the MCO:
- Offers an appropriate range of services and access to
preventive and primary care services for the population
expected to be enrolled in the service area; and
- Maintains a sufficient number, mix and geographic distribution
of providers of services.
Section 3.0 4 Revised July 10, 2003
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REVISED SECTION 3.0 REQUESTED SERVICES
3.2.2 PAYMENT UNDER RISK CONTRACTS
In accordance with 42 CFR 438.6, all payments under risk contracts must
be actuarially sound. OMPP will comply with this requirement in setting
the capitation rates paid to the MCOs.
3.2.3 FISCAL SOUNDNESS OF THE MCOS
Federal regulations require that the MCO maintain a fiscally solvent
operation. OMPP has the right to evaluate the ability of the MCO to
bear the risk of potential financial losses, or to perform services
based on determinations of payable amounts under the contract. The
Department of Insurance maintains the primary responsibility for
regulating the MCO's solvency by requiring a minimum net worth and a
set reserve amount. MCOs or their subcontractors shall not hold members
liable for any payments that are not made by the State to the MCO or by
the MCO to its subcontractors in the event of an insolvency. MCOs or
their subcontractors are also prohibited from holding members liable
for any payments for covered services furnished under a contract,
referral or other arrangement, to the extent that those payments are in
excess of the amount that the enrollee would owe if the MCO provided
the services directly. The MCO is also prohibited from holding the
member liable for covered services provided to the member for which the
State does not pay the MCO or for which the MCO or the State does not
pay the provider.
In accordance with 42 CFR 438.116(b)(l) and 438.116(b)(2), MCOs must
meet the solvency standards established by the State for private health
maintenance organizations, or be licensed or certified by the State as
a risk-bearing entity except when the entity meets any one of the
following conditions:
- The entity does not provide both inpatient hospital services
and physician services.
- The entity is a public entity.
- The entity is (or is controlled by) one or more federally
qualified health centers and meets the solvency standards
established by the State for those centers.
Section 3.0 5 Revised July 10, 2003
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REVISED SECTION 3.0 REQUESTED SERVICES
3.2.4 PHYSICIAN INCENTIVE PLAN(S)
Federal regulations regarding physician incentive plans are provided in
42 CFR 422.208 and 42 CFR 438.6. Section 1876(i)(8) of the Social
Security Act prohibits MCOs from making specific payments, directly or
indirectly, to a physician or physician group as an inducement to
reduce or limit medically necessary services to members. Other types of
incentive arrangements are allowed, including those that place
physicians at substantial financial risk. MCOs that have physician
incentive plans placing a physician or physician group at substantial
financial risk for the cost of services the physician or physician
group does not furnish must assure that the physician or physician
group has adequate stop-loss protection and conducts annual enrollee
surveys. Survey results must be disclosed to the State and, upon
request, disclosed to the members.
In accordance with 42 CFR 422.208,422.210 and 417.479, MCOs must comply
with physician incentive plan requirements. The MCO must supply
information on its physician incentives plan as listed in 42 CFR
417.479(h)(l)(I) through (v) to the OMPP in sufficient detail to permit
the State to determine whether the plan complies with federal
requirements. This information must be supplied to OMPP upon request.
In addition, the MCO must provide information, upon request by a member
and in the marketing materials, about a physician incentive plan that
affects the use of referral services. The required disclosure to
members is detailed in the federal regulation.
3.2.5 BALANCE BILLING
The Balanced Budget Act (BBA) of 1997 (42 CFR 438.106(a)) provides that
Medicaid and CHIP members in an MCO cannot be held responsible for
payment liabilities incurred by the MCO. For example, if the MCO were
to become bankrupt, the member would not have to assume the
responsibility for the MCO's debts, or if the provider fails to receive
a payment from the MCO, the member cannot be held responsible for these
payments. An MCO cannot charge members for services at a rate in excess
of the rate specified in the MCO's contract.
3.2.6 DEBARRED OR SUSPENDED INDIVIDUALS
Section 1932(d)(l) of the Social Security Act provides that an MCO may
not knowingly have a director, officer, partner or person with
beneficial ownership of more than five percent of the entity's equity
who has been debarred or suspended by any federal agency. This
provision also prohibits an MCO from having an employment, consulting,
or any other agreement with a debarred or suspended person for the
provision of items or services that are significant and material to the
entity's contractual obligation with the State.
Section 3.0 6 Revised July 10, 2003
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REVISED SECTION 3.0 REQUESTED SERVICES
In accordance with 42 CFR 438.610, if OMPP finds that the MCO is in
violation of this portion of the contract OMPP will notify the
Secretary of noncompliance and determine if the agreement will continue
to exist. Unless the Secretary provides a written description of
compelling reasons for renewing or extending the agreement to the State
and to Congress, OMPP will not renew or extend the duration of existing
agreements with the MCO. Any action taken by the Secretary will be
taken in consultation with the Inspector General.
The General Services Administration (GSA) maintains a list of parties
excluded from federal programs. The "Exclude Parties Lists" (EPLS) and
any rules and/or restrictions pertaining to the use of EPLS data can be
found on GSA's homepage at the following Internet address:
xxx.xxxx.xxx.
3.2.7 CIVIL RIGHTS COMPLIANCE
The Centers for Medicare and Medicaid Services (CMS) has set forth a
Civil Rights Compliance Policy Statement, in addition to 42 CFR
438.6(f)(l), which expresses their commitment to eliminating
discrimination in the delivery of health care services through CMS
programs. As such, MCOs contracting with the OMPP and CHIP are required
to comply with the following laws:
- Title VI of the Civil Right Act, as amended
- Section 504 of the Rehabilitation Act, as amended
- Age Discrimination Act of 1975, as amended
- Americans with Disabilities Act of 1990, as amended
- Title IX of the Education Amendments of 1972
3.3 CONTRACT COMMUNICATION
The MCO shall direct all contract communications directly to the OMPP
Managed Care Program Director.
3.4 DESCRIPTION OF MANAGED CARE SERVICES
This section provides a summary of benefit packages encompassed by
Hoosier Healthwise, covered an non-covered services and Hoosier
Healthwise co-payment policies. Where applicable, pertinent Federal and
State regulations have been referenced.
PACKAGE A (Standard Coverage):
Full coverage for the following groups:
- Low income families, with children under 18 years, including
those receiving Temporary Assistance for Needy Families
(TANF).
Section 3.0 7 Revised July 10, 2003
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REVISED SECTION 3.0 REQUESTED SERVICES
- Children's Medicaid - Children whose families do not receive
TANF, but who are under age 21 and meet the eligibility
requirements.
- Pregnant women who meet the TANF income and resource criteria.
- Wards of the state and xxxxxx children. These children may
enroll in managed care on a voluntary basis.
- CHIP - Phase I - children under age 19 whose family's income
is up to 150% of federal poverty level.
PACKAGE B (Pregnancy Coverage):
Pregnancy-related coverage is provided to women whose income is below
150% of poverty without regard to their resources. Eligibility extends
up to 60 days postpartum.
PACKAGE C (CHIP Phase II):
Preventive, primary and acute care services for children under age 19
whose family's income is 150-200% of federal poverty level.
PACKAGE D (Reserved):
Formerly Hoosier Healthwise for People with Disabilities and Chronic
Illnesses. It provided full coverage with case management services.
PACKAGE E (Emergency Services):
Individuals enrolled in this package are eligible for emergency
services only. These individuals are considered Hoosier Healthwise
members; however, they are not enrolled in managed care.
For a complete comparison of the benefits available under each of
benefit package, see Appendix 3.
3.4.1 HOOSIER HEALTHWISE MCO COVERED SERVICES
Hoosier Healthwise MCO covered services are included in the MCO's
capitation rate and the MCO's responsibility. Hoosier Healthwise MCO
covered services include all Medicaid (Packages A and B), and CHIP
(Package C) covered services with the exception of carved out services
(refer to 3.4.3 for a listing of carved out services).
CHIP Package C has a benefit package similar to Medicaid, but has some
additional benefit limitations. 407 IAC 3-3-1 sets forth the CHIP
Package C covered services which can be found on the State's website.
The MCO must
Section 3.0 8 Revised July 10, 2003
BAA 01-28, ATTACHMENT A - SCOPE OF WORK
REVISED SECTION 3.0 REQUESTED SERVICES
arrange and assure the provision of all MCO covered services except
self-referral services. For additional information about self-referral
services, refer to Section 3.4.2.4 of this BAA. Detailed explanations
of the amount, duration and scope of Medicaid covered services and
limitations are cited in Title 405, Article 5 of the Indiana
Administrative Code, which can be found on the State's website at
xxx.xxxxx.xx.xx/xxxxxxxxxxx/xxx. Services delivered must be sufficient
in amount, duration or scope to reasonably expect that provision of
such services would achieve the purpose of the furnished services.
The following is a general list of Hoosier Healthwise covered services
that are MCO covered services, listed by general categories. If a
service is not a Hoosier Healthwise covered service under a particular
benefit package, then the MCO is not responsible for providing that
service to members enrolled in that benefit package. For a more
complete list of services covered in each of the Hoosier Healthwise
benefit packages, see Xxxxxxxx 0, Xxxxxxx Xxxxxxxxxx Benefit Package
Comparison.
- Emergency and poststabilization services
- Physician services
- Primary care services
- Preventive health services
- Therapeutic and rehabilitative services
- Specialty care services
- Nursing services
- Hospital services
- Inpatient care
- Outpatient services
- Therapy services
- Laboratory and x-ray services
- Diagnostic studies
- Sterilization, hysterectomy services
- Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT)
- Initial and periodic screenings
- Diagnosis and treatment
- Home health services
- Physical, occupational and respiratory therapy
- Speech pathology
- Renal dialysis
- Pharmacy services
- Legend drugs
- Non-legend drugs (selected over-the-counter drugs) as
identified in OMPP's over-the-counter formulary (the OTC
formulary can be found in the IHCP Provider Manual which can
be found at xxx.xxxxxxxxxxxxxxx.xxx)
- Medical supplies and equipment
- Durable medical equipment
- Braces and orthopedic shoes
Section 3.0 Revised July 10, 2003
9
BAA 01-28, ATTACHMENT A - SCOPE OF WORK
REVISED SECTION 3.0 REQUESTED SERVICES
- Prosthetic devices
- Hearing aids
- Preventive and diagnostic services
- Transportation services
- Emergency transportation
- Non-emergency transportation
- Transportation to and from excluded but covered services
- HIV/AIDS targeted case management
- Diabetes self-management training
- Smoking cessation
If the MCO elects not to provide, reimburse for, or provide coverage
of, a counseling or referral service because of an objection on moral
or religious grounds, it must furnish information about the services it
does not cover as follows, in accordance with 42 CFR 438.102(b):
- To the State with its application for a Hoosier Healthwise
contract;
- To the State if it adopts the policy during the term of the
contract;
- To potential members before and during enrollment; and
- To members within 90 days after adopting the policy with
respect to any particular service.
The MCO must comply with all member requests for a second opinion from
a qualified professional. If the provider network does not include a
provider who is qualified to give a second opinion, the MCO must
arrange for the member to obtain a second opinion from a provider
outside the network, at no cost to the member.
In accordance with 42 CFR 438.208(c), the MCO must allow members with
special needs who are determined to need a course of treatment or
regular care monitoring to directly access a specialist for treatment
via an established mechanism such as a standing referral from the
member's PMP or an approved number of visits. Treatment provided by the
specialist must be appropriate for the member's condition and
identified needs.
In accordance with 42 CFR 438.206(b)(2), the MCO must also provide
female enrollees with direct access to a women's health specialist
within the network for covered care necessary to provide women's
routine and preventive health care services. This is in addition to the
enrollee's designated source of primary care if that source is not a
woman's health specialist. Direct access must be permitted via an
established mechanism such as a standing referral from the member's PMP
or an approved number of visits.
Section 3.0 Revised July 10, 2003
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3.4.2 SPECIAL PROVISIONS
Specific managed care coverage and payment policies (described below)
apply to certain types of services and providers, including the
following:
- Emergency room services and poststabilization services
- Out-of-area services
- Out-of-plan providers
- Self-referral services
- Federally Qualified Health Centers (FQHCs)
- Rural Health Clinics (RHCs)
- Short-term placements in a long-term care facility
- Co-payments
3.4.2.1 EMERGENCY SERVICES AND POST-STABILIZATION SERVICES
The MCO must cover emergency services without regard to prior
authorization or the emergency care provider's contractual relationship
with the MCO. Thus, the MCO is responsible for coverage and payment of
all emergency services, including out-of-plan or out-of-area emergency
services. The MCO must ensure that emergency services are available 24
hours a day, seven days a week. The MCO must comply with emergency
services requirements specified in Indiana Code 12-15-12.
As specified in, Indiana Code 12-15-12 and 42 CFR 438.114, "Emergency
Services" are defined as covered inpatient and outpatient services
furnished by a qualified IHCP provider that are necessary to evaluate
or stabilize an emergency medical condition. "Emergency Medical
Condition" is defined as:
A medical condition manifesting itself by acute symptoms of
sufficient severity, including severe pain, that a prudent lay
person, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate
medical attention to result in placing the health of the
individual (or with respect to a pregnant woman, the health of
the woman or her unborn child) in serious jeopardy, serious
impairment to body functions or serious dysfunction of any
bodily organ or part.
The MCO will not be responsible for paying for services not meeting the
above "prudent layperson" definition and that are not authorized by the
MCO or by the PMP. The MCO may use its discretion in determining
whether to cover and reimburse non-emergency care provided in the
emergency room.
The MCO may not determine what constitutes an emergency on the basis of
lists of diagnoses or symptoms. The MCO may not deny payment for
treatment obtained when an enrollee had an emergency medical condition,
even if the outcomes, in the absence of immediate medical attention,
would not have been
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those specified in the above definition of emergency medical condition.
The MCO is prohibited from refusing to cover emergency services because
the emergency room provider, hospital, or fiscal agent does not notify
the member's PMP, MCO, or applicable State entity of the member's
screening and treatment within 10 calendar days of presentation for
emergency services. A member who has an emergency medical condition may
not be held liable for payment of subsequent screening and treatment
needed to diagnose the specific condition or stabilize the patient. The
attending emergency physician, or the provider actually treating the
enrollee, is responsible for determining when the enrollee is
sufficiently stabilized for transfer or discharge. The physician's
determination is binding and may not be challenged by the MCO.
The MCO must cover poststabilization services related to an emergency
medical condition that are provided after an enrollee is stabilized in
order to maintain the stabilized condition, or, under the circumstances
described in 42 CFR 438.114(e) to improve or resolve the enrollee's
condition. The MCO is financially responsible for post-stabilization
services obtained within or outside the MCO network that are
pre-approved by a plan provider or other MCO representative. In
addition, the MCO is also financially responsible for
post-stabilization care services obtained within or outside the MCO
network that are not pre-approved by a plan provider or other MCO
representative, but are administered to maintain the enrollee's
stabilized condition if:
- The MCO does not respond to a request for pre-approval within
1 hour;
- The MCO cannot be contacted; or
- The MCO representative and the treating physician cannot reach
an agreement concerning the enrollee's care and a plan
physician is not available for consultation. In this
situation, the MCO must give the treating physician the
opportunity to consult with a plan physician and the treating
physician may continue with care of the patient until a plan
physician is reached or one of the criteria of 422.133(c)(3)
is met.
The MCO must limit charges to enrollees for poststabilization care
services to an amount no greater than what the MCO would charge the
enrollee if services were obtained through the MCO network.
The MCO's financial responsibility for poststabilization care services
it has not pre-approved ends when:
- A plan physician with privileges at the treating hospital
assumes responsibility for the enrollee's care;
- A plan physician assumes responsibility for the enrollee's
care through transfer;
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- An MCO representative and the treating physician reach an
agreement concerning the enrollee's care; or
- The enrollee is discharged.
3.4.2.2 OUT-OF-AREA SERVICES
The MCO is responsible for payment of emergency services obtained
out-of-area. However, MCO members and/or providers must obtain
authorization from the PMP or MCO in order to obtain non-emergency
services out-of-area; otherwise, the MCO may deny payment to the
out-of-area rendering provider.
3.4.2.3 OUT-OF-PLAN SERVICES
In accordance with 42 CFR 438.206(b)(4), the MCO must authorize and pay
for out-of-network care if the MCO is unable to provide necessary
medical services covered under the contract to a particular enrollee.
Authorized out-of-network services must be provided in a timely manner
and adequately covered for as long as the entity is unable to provide
them.
The MCO shall reimburse out-of-plan claims for plan or PMP authorized
services provided to its members at a rate negotiated with the provider
or according to the lesser of the following:
- The usual and customary charge made to the general public by
the provider; or
- At established IHCP reimbursement rates in effect for
participating IHCP providers at the time the service was
rendered.
3.4.2.4 MCO-COVERED SELF-REFERRAL SERVICES
Capitation amounts include payment for the following services known as
self-referral services which include:
- Services rendered for the treatment of an emergency (See
Section 3.4.2.1 above);
- Family planning services;
- Chiropractic services;
- Podiatric services;
- Eye Care services (except eye care surgical services);
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- HIV/AIDS targeted case management services;
The MCO may negotiate reimbursement paid to self-referral service
providers who have contractual relationships with the MCO. However,
when members choose IHCP-enrolled providers for self-referral services
who do not have contractual relationships with the MCO, the MCO is
nevertheless responsible for payment to these providers at established
Hoosier Healthwise fees that currently exist for paying participating
Hoosier Healthwise providers. The current Hoosier Healthwise fee
schedule can be found on the IHCP web site at: xxx.xxxxxxxxxxxxxxx.xxx.
In addition, the MCO is responsible for ensuring that self-referral
services are covered and prior authorized in accordance with 405 IAC 5.
The MCO should encourage providers of self-referral services to
communicate with PMPs once any form of medical treatment is undertaken.
3.4.2.4.1 FAMILY PLANNING
Federal regulation requires, in 42 CFR 431.51 (b)(2), freedom of choice
of providers and access to family planning services and supplies.
Hoosier Healthwise members enrolled in an MCO may not be restricted in
choice of family planning service provider. Family planning services
are those services provided to individuals of childbearing age to
temporarily or permanently prevent or delay pregnancy. Refer to the
IHCP Provider Manual for a complete list of family planning services
which can be found at xxx.xxxxxxxxxxxxxxx.xxx.
CMS interprets family planning services to include birth control pills.
Therefore, the member must be allowed to obtain birth control pills on
a self-referral basis. The OMPP recognizes the need for appropriate
management of prescription medication in the interest of the member's
health. However, the OMPP also recognizes the importance of removing
barriers to family planning services. In order to reduce potential
barriers to obtaining birth control pills, which may include, but may
not be limited to transportation to pharmacies for periodic refills,
MCOs must, at a minimum, reimburse for the dispensation of up to a
90-day supply of birth control pills, per member, at one time, if
prescribed.
3.4.2.4.2 CHIROPRACTIC, EYE CARE AND PODIATRY SERVICES
The Indiana General Assembly has specifically provided that
chiropractic care (IC 12-15-12-1), eye care (IC 12-15-12-7), podiatry
(IC 12-15-12-8) are self-referral services. Hoosier Healthwise members
may self-refer these services to any IHCP provider.
3.4.2.4.3 HIV/AIDS TARGETED CASE MANAGEMENT SERVICES
Members with HIV/AIDS may self refer to case management services.
HIV/AIDS case management services are limited to no more than 60 hours
per quarter and are available to Package A and Package B members (as
the case management services relate to the pregnancy.) For more
detailed information
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concerning HIV/AIDS case management refer to the IHCP Provider Manual
available at xxx.xxxxxxxxxxxxxxx.xxx.
3.4.2.5 MCO-COVERED DIABETES SELF-MANAGEMENT SERVICES
Generally, diabetes self management (DSM) is not a self-referral
service. MCOs may limit the providers from whom members may receive
DSM. However, MCOs must permit members to self-refer to any
chiropractor, optometrist, podiatrist, or non-MCO covered service
provider with an IHCP provider agreement, who may provide DSM services.
Indiana Code (IC) 27-8-14.5-6 requires insurers, including IHCP, to
provide coverage for DSM training services. The statute also provides
that coverage for DSM is subject to the requirements of the health
insurance plan regarding the use of participating providers (IC
27-8-14.5-6(c)). However, state statutes also provide that chiropractic
care (IC 12-15-12-1), eye care (IC 12-15-12-7) and podiatry (IC
12-15-12-8) are self-referral services. This means that although the
MCOs may require members to receive DSM services from non self-referral
providers in the MCO's network, they must make allowances for members
who choose an IHCP chiropractor, optometrist, or podiatrist outside the
network for DSM related services.
3.4.2.6 FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS) AND RURAL HEALTH CENTERS
(RHCS)
Since FQHCs and RHCs are essential community providers, MCOs are
strongly encouraged to contract with FQHCs and RHCs. The MCO must
reimburse FQHCs and RHCs for services no less than the level and amount
of payment that the MCO would make to a non-FQHC or RHC provider for
the services. OMPP endorses the following two types of contractual
arrangements:
- The FQHC or RHC accepts a full capitation (i.e., for primary
care, specialty care, and hospital care); or
- The FQHC or RHC accepts a partial capitation or other method
of payment at less than full risk for patient care (i.e.,
primary care capitation, fee-for-service).
OMPP will provide a supplemental payment at least quarterly to the FQHC
and RHC to bring reimbursement up to 100% of reasonable costs. In order
to calculate the supplemental payment, the amount paid directly to the
FQHC or RHC by the MCO for services provided to members will be
subtracted from 100% of reasonable costs. The MCO must submit to OMPP,
or its designee, at least quarterly, the amount paid by the MCO to the
FQHC or RHC for services provided to MCO members, and/or in capitated
amounts, in order for OMPP to calculate the supplemental payment due to
the FQHC or RHC.
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The MCO shall identify to the State any performance incentives offered
to the FQHC or RHC. All such FQHC and RHC incentives which accrue
during the contract period that are related to the cost of providing
FQHC-covered or RHC-covered services to RBMC members shall be included
along with any fee-for-service and/or capitation payments in the
determination of the amount of direct reimbursement paid by the MCO to
the FQHC or RHC.
The MCO must provide assurances that it is paying the FQHC or RHC at a
rate that is not less than the level and amount of payment the MCO
would make for the services if the services were furnished by a
provider which is not a FQHC or RHC. The MCO shall provide supporting
documentation of its rates at OMPP's request. In addition, the FQHC or
RHC, and the MCO, are required to maintain and submit records
documenting the number and types of encounters provided to MCO members
and to provide these records at OMPP's request. Capitated FQHCs and
RHCs must also submit encounter data (e.g., in the form of shadow
claims to the MCOs). The number of encounters will be subject to audit
by OMPP or its representatives.
3.4.2.7 SHORT-TERM PLACEMENTS IN LONG-TERM CARE FACILITIES
Although long-term care facilities are not a Hoosier Healthwise
MCO-covered service, an MCO may allow its enrolled Hoosier Healthwise
members to obtain services in a nursing facility setting on a
short-term basis (no more than 30 days) if this setting is more cost
effective than other options and the member can obtain the care and
services needed.
3.4.2.8 CO-PAYMENTS
Hoosier Healthwise MCO members, with the exception of Package C
enrollees, may not be charged any co-payments or other cost-sharing
fees for MCO-covered services. For Package C members, certain services
such as transportation, non-emergency use of the emergency room, and
pharmacy may be subject to a member co-payment under the Hoosier
Healthwise program.
Following 407 IAC 3-10-3 and 407 IAC 3-9-3, members enrolled in Package
C may be charged co-payments for prescription drugs ($3.00 generic and
$10.00 brand name) and ambulance transportation ($10.00). Package C
members cannot be charged a co-payment for emergency room services, but
they may be required to pay for the entire visit if it is deemed a
non-emergency.
3.4.3 MEDICAID AND HOOSIER HEALTHWISE COVERED, BUT MCO NON-COVERED, SERVICES
(CARVED-OUT SERVICES)
Medicaid and Hoosier Healthwise services excluded from the MCO's
capitated payment amount, but still a covered benefit for Hoosier
Healthwise members, are
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known as "carved-out" services. The carved-out services, subject to the
benefit package limitations in which a member is enrolled, include:
- Long-term institutional care
- Hospice care
- Services provided by a school as part of a student's
Individualized Education Plan(IEP)
- Dental services rendered by providers enrolled in IHCP in a
dental specialty; the dental specialties are: endodontist,
general dentistry practitioner, oral surgeon, orthodontist,
pediatric dentist, periodontist, pedodontist, and
prosthodontist
- Behavioral health services, including mental health and
substance abuse and chemical dependency services, rendered by
providers enrolled in IHCP with a mental health specialty;
those provider specialties are listed below.
Behavioral health services rendered by providers enrolled in IHCP with
a mental health specialty can be accessed by members on a self-referral
basis. These services are reimbursed to the provider by the IHCP fiscal
agent on a fee-for-service basis. These provider specialties are:
psychiatric hospital, outpatient mental health clinic, community mental
health clinic, psychiatrist, psychologist, certified psychologist,
health services provider in psychology, certified social worker,
certified clinical social worker, psychiatric nurse, independent
practice school psychologist and advanced practice nurse under IC
25-23-1-1(b)(3), credentialed in psychiatric or mental health nursing
by the American Nurses Credentialing Center.
MCOs are fully responsible for payment for behavioral health services
rendered BY PROVIDERS OTHER THAN PROVIDERS IN THE MENTAL HEALTH
SPECIALTIES LISTED ABOVE. Behavioral health services rendered by
providers other than those in the above-specified mental health
specialties are not required to be rendered on a self-referral basis.
The MCOs are financially responsible for all facility, ancillary, and
professional services related to carved-out behavioral health services,
including services related to substance abuse and chemical dependency
diagnoses, when rendered in an acute care hospital, by the PMP, or by
another specialty not enrolled as one of the specialists listed in the
above paragraph. MCO member confinements in acute care hospitals with
primary diagnoses of substance abuse and chemical dependency are the
responsibility of the MCO. MCOs are financially responsible for
behavioral health services provided in an acute care hospital,
regardless of the admitting diagnoses. (The responsible party for claim
payment is based on billing provider type and specialty.)
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3.4.4 ENHANCED SERVICES
In conjunction with the provision of covered services, contracted MCOs
are strongly encouraged to develop and maintain programs that enhance
the general health and well-being of Hoosier Healthwise managed care
members, including programs that specifically address preventive health
and preventive risk factors. Wellness programs available to the MCO's
commercial population should be made available to Hoosier Healthwise
members. The MCO is encouraged to provide enhanced services, such as
health education classes which target the Hoosier Healthwise population
specifically. In addition to wellness and education services, it is
appropriate for an MCO to provide non-Hoosier Healthwise covered
services to members that are more clinically appropriate or
cost-effective than Hoosier Healthwise covered services. The MCO must
inform OMPP at least four weeks prior to implementing or providing any
enhanced services. Enhanced services must comply with the
education/outreach and other relevant guidelines set forth in this BAA.
3.4.5 DRUG FORMULARIES
The MCO can implement restrictions on prescribed drugs; however, before
a Hoosier Healthwise MCO implements a drug formulary, the MCO must
submit the formulary to OMPP at least 35 days before the MCO intends to
implement the formulary. OMPP will forward the formulary to the DUR
Board for review and recommendation. Based on the recommendation of the
DUR Board, OMPP will either approve, disapprove or require
modifications to the MCO's proposed formulary.
IC 00-00-00-00 provides that if a Hoosier Healthwise MCO removes one or
more drugs from the formulary or places new restrictions on one or more
drugs on the formulary, the MCO must submit the changes to OMPP for
review and recommendation by the DUR Board. More information regarding
the DUR Board is available at xxx.xxxxxxxxxxxxxxx.xxx.
3.5 RESPONSIBILITIES OF OMPP AND CHIP
Hoosier Healthwise managed care is funded by two separate sources:
Medicaid and CHIP. While MCO contractors are responsible to both OMPP
and the CHIP Office, the OMPP managed care unit is responsible for
administering Hoosier Healthwise MCO contracts, monitoring contractor
performance and performing certain quality assurance activities.
3.5.1 DETERMINATION OF HOOSIER HEALTHWISE BENEFITS AND HOOSIER HEALTHWISE
MANAGED CARE ELIGIBILITY
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Through the IFFSA Division of Family and Children, the State is
responsible for determining if persons are eligible for benefits and
enrollment in Hoosier Healthwise. The OMPP is responsible for
identifying and enrolling people who have been determined eligible for
benefits into Hoosier Healthwise managed care. Most people eligible for
Packages A, B and C are required to enroll in Hoosier Healthwise
managed care.
3.5.2 MEMBER ENROLLMENT IN HOOSIER HEALTHWISE MANAGED CARE
Initial applicants and re-applicants for Hoosier Healthwise will
receive a presentation by the enrollment broker on Hoosier Healthwise
managed care and assistance in selecting a PMP. Members are educated on
the benefits of primary and preventive care, the differences between
PrimeStep and the MCO networks, and the importance of choosing a PMP.
Additionally, members receive educational materials and may watch a
video describing Hoosier Healthwise.
Benefit Advocates (BAs), who are employed by the enrollment broker,
provide potential members with a list of their provider options and
explain that they have 30 days from the date they are determined
eligible for Hoosier Healthwise to choose a PMP. Whether the choice
leads to enrollment in PrimeStep or RBMC will depend on the PMP's
enrollment status at the time of selection. The education provided by
the BAs focuses on the choice of a physician, but the implications of
network choice are also discussed. MCOs are required to provide
information regarding their network, grievance procedures, and any
other information requested by the State, for use in member education
and enrollment. If a potential member fails to make a PMP selection
within thirty days, one will be made for him or her through an
auto-assignment enrollment mechanism processed by the IndianaAIM
system. Once a PMP is chosen, or when a PMP is assigned, the member is
linked to a Hoosier Healthwise PMP, and thereby enrolled in managed
care.
For members who apply for Hoosier Healthwise from an outstation
location (enrollment center), the same requirements apply to the MCO
and OMPP. OMPP will assure that those individuals are educated and
enrolled in Hoosier Healthwise.
If the member does not choose a PMP within 30 days, a PMP will be
assigned to the member through an auto-assignment process that complies
with Section 1932(a)(4)(D) of Title XIX of the Social Security Act.
This process automatically assigns a PMP to a member if he/she fails to
select a PMP. A detailed description of the auto-assignment logic is
contained in the MCO Policies and Procedures Manual.
Once a member is linked to a PMP, either by self-selection or
auto-assignment, the member will be informed by mail of the member's
PMP and plan enrollment. The PMP and the MCO are informed of the
enrollment on bi-monthly enrollment rosters, which are updated on the
first and fifteenth of each month.
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The MCO is prohibited from discriminating against individuals eligible
to enroll on the basis of race, color, national origin, health status
or the need for health care services, and will not use any policy or
practice that has the effect of discriminating on the basis of race,
color, national origin, health status or the need for health care
services, in accordance with 42 CFR 438.6(d). The MCO may neither
terminate enrollment nor encourage a member to disenroll because of a
patient's health care needs or a change in a patient's health care
status. Further, a patient's health care utilization patterns may not
serve as the basis for disenrollment from the MCO. A PMP may refuse a
member assignment only if he or she does not feel medically qualified
to accept the case. A new PMP selection for the member will then be
facilitated by the enrollment broker.
The member will be allowed at any time to change PMPs. Requests for a
PMP change are made through the Hoosier Healthwise Helpline department
(managed by the enrollment broker) and are documented, tracked, and
monitored.
3.5.2.1 MEMBER DISENROLLMENT FROM HOOSIER HEALTHWISE MCOS
The MCO must comply with all federal enrollment and disenrollment
requirements stated in 42 CFR Section 438.56, as applicable to the
Hoosier Healthwise program. Members may change PMPs at any time, for
any reason. However, members should be encouraged to establish a
relationship with their PMP.
In accordance with 42 CFR 438.56(d)(2), the following are typical
reasons for members to request to disenroll from the MCO:
- The member moves out of the MCO's service area.
- The MCO does not, because of moral or religious objections,
cover the service the member seeks.
- The member needs related services (for example a cesarean
section and a tubal ligation) to be performed at the same
time; not all related services are available within the
network; and the member's PMP another provider determines that
receiving the services separately would subject the member to
unnecessary risk.
- Other reasons, including but not limited to, poor quality of
care, lack of access to services covered under the contract,
or lack of access to providers experienced in dealing with the
member's health care needs.
For more information regarding acceptable reasons for a member
requesting a network change, refer to the MCO Policies and Procedures
Manual. The MCO may make PMP changes within its own network as
requested by its members; however, the MCO must notify the enrollment
broker of the change. If the member desires a change to a PMP in
another MCO, the MCO must direct the
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member to call the Hoosier Healthwise Helpline so the enrollment broker
can make this change.
Unless certain conditions are identified and approved for disenrollment
from the Hoosier Healthwise managed care program entirely, members may
be required to participate in the PrimeStep component of the program
upon MCO disenrollment.
Oral or written requests for disenrollment are made through the
enrollment broker and are documented, tracked, and monitored. OMPP has
the ultimate authority for allowing eligible members to disenroll from
the program. Members who disenroll and switch programs frequently will
be monitored and such activity will be discouraged. Disenrollment
determinations will be made and implemented no later than the first day
of the second month following the month in which the enrollee or the
MCO files the disenrollment request. If a disenrollment decision is not
made within this timeframe, the disenrollment will automatically be
considered approved, in accordance with 42 CFR Section 438.56(d)(3).
In accordance with 42 CFR 438.56(b), the MCO, a PMP, or both may, with
just cause, and following certain guidelines, choose to discontinue
their relationship with a Hoosier Healthwise member for the following
reasons:
- Missed appointments
- Member fraud
- Uncooperative or disruptive behavior resulting from the member
or the member's family
- Medical needs could be met by a different PMP
- Breakdown in physician and patient relationship
- Member access care from providers other than the selected or
assigned PMP
- Member insists on medically unnecessary medications
MCOs may not request to disenroll a member because of a change in the
member's health status, or because of the member's utilization of
medical services, diminished mental capacity, or uncooperative or
disruptive behavior resulting from his or her special needs (except
when the member's continued enrollment in the MCO seriously impairs the
entity's ability to furnish services to either this particular member
or other members).
To ensure that the MCO does not request member disenrollment for
reasons not permitted, the MCO must provide evidence to the enrollment
broker that one of the acceptable terms for disenrollment exists. The
enrollment broker may then disenroll the member from the MCO.
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Within Package C, there is a 60-day grace period for non-payment of
premiums after which a child is disenrolled. Families will be required
to pay any premiums owed from the previous twenty-four months before
they will be allowed to re-enroll their children in Package C. Families
will lose their benefits if they do not pay the premiums.
3.5.2.2 REDETERMINATION ENROLLMENT IN HOOSIER HEALTHWISE RBMC
Redetermination enrollment will occur no later than once every six
months for TANF members and once every 12 months for Pregnancy
Medicaid, Children's Medicaid, and Package C members. The redetermined
member will be given the opportunity to choose a PMP in either the
PrimeStep or RBMC delivery system. Redetermination is generally a
seamless process if there have been no gaps in coverage, but some
members lose eligibility upon redetermination, especially members in
Package B.
When there is a break in the member's eligibility, upon
redetermination, the individual will be instructed to participate in an
educational session and re-select a PMP. If a selection is not made by
the member 30 days from the date of eligibility, he/she will be
automatically re-enrolled in Hoosier Healthwise and assigned to the
previous PMP. If the reasons for reassignment to the previous PMP are
not appropriate, an assignment is made to an appropriate PMP.
3.5.3 MCO ENROLLMENT ROSTERS
OMPP's fiscal agent notifies each MCO of all members enrolled in the
MCO's network. The fiscal agent generates semi-monthly MCO Member
Enrollment Rosters using information obtained from the state's Indiana
Client Eligibility System (ICES) transmissions, PMP assignments entered
into the IndianaAIM system during member enrollment, and the
auto-assignment process. The MCO Member Enrollment Rosters provide the
MCO with a detailed listing of all members for whom the MCO is
responsible, including new and continuing members, newborns, and
members terminated since the previous listing. The enrollment roster
also includes deleted members who appeared as eligible members on the
previous roster, but whose eligibility was terminated prior to the
actual effective date with the MCO. The MCO enrollment rosters will
include Package C members and distinguish them from Package A and B.
The PMP enrollment rosters will also include Package C members but will
not distinguish them from Package A and B members. It is the MCO and
rendering provider's responsibility to check for eligibility.
If an MCO receives either eligibility information or capitation payment
for a member, the MCO is financially responsible for the member. While
the enrollment rosters are accurate at the time they are produced,
there may be discrepancies from real-time eligibility information. The
AVR/OMNI eligibility
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systems, which are updated daily, should be used in the event of any
discrepancies. MCOs who discover eligibility/capitation discrepancies
should notify OMPP or the fiscal agent within 30 days of discovering
the discrepancy.
Monthly member enrollments are provided to the MCO in two segments:
- On the 26 th of the month, MCOs are provided with managed care
enrollments entered into the IndianaAIM system from the 11th
through the 25th days of the month. Listed are members who are
effective on the first day of the following month.
- On the 11th day of the month, MCOs are provide with managed
care enrollments entered into the IndianaAIM system from the
26th day of the month through the 10th day of the following.
Listed are members who are effective on the 15th day of the
current month.
The MCO should note that the member data on enrollment rosters are
current as of the day the rosters are produced.
3.5.4 UTILIZATION REVIEW
OMPP and/or the CHIP Office may waive certain administrative
requirements, including prior authorization procedures, to the extent
that such waivers are allowed by law and are consistent with policy
objectives. The MCOs may be required to comply with such waivers and
will be provided with prior notice by the Office. Removal of prior
authorization requirements has no impact on the ability or
responsibility of the MCO to review claims for medical necessity.
3.5.5 Monitoring
OMPP and its MCO monitoring contractor will be responsible for
reviewing and monitoring the performance of the MCO and for identifying
violations of the requirements and performance standards outlined in
Section 3.6 of this BAA. OMPP and the monitoring contractor will
monitor contract compliance throughout the contract period. The MCO
shall also be subject to annual, external independent reviews of
quality outcomes, timeliness of, and access to, the services covered
under the contract. The CHIP Office will monitor the access, quality,
and cost-effectiveness of services provided to the CHIP members.
The contract monitoring process and policies undergo ongoing review by
OMPP. OMPP reserves the right to change or modify the reporting
requirements, evaluation instruments and enforcement policies as
necessary at any time during the contract period.
The MCO shall allow, during normal business hours, duly authorized
agents or representatives of the State or Federal government access to
the health plan's
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premises or health plan's subcontractor's premises to inspect, audit,
monitor, or otherwise evaluate the performance of the health plan or
its subcontractors.
3.5.6 CAPITATION PAYMENTS
OMPP will be responsible for the payment of capitation payments to the
MCO. Capitation payments are made on the first Wednesday after the
fifteenth of the month. Barring problems with the run, the files will
always be available for download from an electronic bulletin board
system during the early morning hours of the following day.
3.6 RESPONSIBILITIES OF MCO
The MCO will be responsible for arranging or administering the prompt
provision of all medically necessary MCO covered services as outlined
in this BAA and in accordance with all applicable state and federal
requirements. The MCO must notify OMPP when it makes significant
changes to the managed care program that affect capacity or services,
such as change in services, geographic area or payments. The MCO must
notify OMPP of the change at least 30-calendar days prior to the
effective date of change. If the MCO changes subcontractors, it must
notify OMPP 90 days before the contract effective date.
The MCO must adhere to all requirements and reporting standards
specified in this Section of the BAA. Any changes in the requirements
and reporting standards will be communicated to the MCO at least 60
days before they are effective, unless otherwise required by law.
In addition to the requirements outlined within this document, the MCO
must comply with all requirements stated within the MCO Policies and
Procedures Manual as well as any revised requirements, which OMPP may
specify in the future.
3.6.1 ADMINISTRATION AND ORGANIZATIONAL STRUCTURE
The MCO must maintain an administrative and organizational structure
that supports a high quality, comprehensive managed care program. The
MCO's management approach and organizational structure should ensure
effective linkages between administrative areas such as: provider
enrollment, member services, provider services, regional network
development, quality improvement and utilization review, management
information systems, and services provided through subcontractor
arrangements.
The MCO must also be organized in a manner that will facilitate
efficient and economic delivery of services conforming to acceptable
business practices within the State of Indiana. The MCO must clearly
demonstrate its corporate
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qualifications and experience as a managed care organization, and also
specifically as a Medicaid managed care organization, must employ
senior level managers with sufficient experience and expertise in
health care management, and must employ or contract with skilled
clinicians for medical management activities. Section 3.6.1.1 specifies
minimal requirements of managerial, technical, and operational
resources. The MCO must promptly provide written notification to OMPP
of any vacancies of key positions listed in section 3.6.1.1 and must
make every effort to fill vacancies in all key positions with qualified
persons approved by the OMPP.
3.6.1.1 ADMINISTRATIVE REQUIREMENTS
The MCO must have in place sufficient administrative staff and
organizational components to comply with all program requirements and
standards. In addition, all MCO key personnel must be accessible to
OMPP and other program contractors via voice-mail and electronic mail
systems. The MCO must contract or employ the following minimum staff
persons:
- CONTRACT MANAGER - The MCO must employ a management level staff
person (one dedicated, full-time equivalent or FTE) who is dedicated
to managing the MCO's Hoosier Healthwise members and is the primary
contact person with the State or its designee.
- MEDICAL DIRECTOR - The MCO must employ or contract the services of a
Medical Director. The Medical Director shall review any potential
quality of care problems and direct the Quality Assurance/Utilization
Review program.
- MEMBER RELATIONS MANAGER - The MCO must employ a full-time (one
dedicated FTE) Member Relations Manager and a sufficient number of
member representatives to coordinate communications between the MCO,
members, and OMPP.
- PROVIDER RELATIONS MANAGER - the MCO must employ a full-time (one
dedicated FTE) Provider Relations Manager and a sufficient number of
provider representatives to coordinate communications between the
MCO, providers, and OMPP.
- QUALITY IMPROVEMENT/UTILIZATION REVIEW MANAGER - The MCO must employ
a full-time (one dedicated FTE) Quality Improvement/Utilization
Control Manager and a sufficient number of staff dedicated to perform
QI/UR activities.
The MCO shall have in place organizational and administrative systems
capable of implementing contractual obligations that include, but are
not limited to the following:
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- A Grievance Coordinator to investigate member and provider complaints
and grievances against the MCO.
- A financial officer to oversee the budget and accounting systems of
the MCO.
- A systems coordinator to oversee MIS and serve as a liaison between
the MCO and the State's fiscal agent.
- A sufficient number of member service representatives to service the
special needs of the Hoosier Healthwise population.
- A sufficient number of claims examiners to process the timely and
accurate submission of claims, claims correction letters (CCL),
resubmission and overall disposition of all claims for the MCO.
- A sufficient number of staff to ensure the timely and accurate
submission of shadow claim data.
- Support services staff to ensure the timely and accurate processing
of support services reports/requests i.e. telephone systems, MIS,
etc.).
It is the MCO's responsibility to ensure that all staff have
appropriate training, education and experience to fulfill the
requirements of their position.
The MCO must submit to OMPP on an annual basis an updated
organizational chart including email addresses for staff. The MCO
organizational chart shall include at least the following positions:
- Executive management
- Support/administrative staff
- Medical director
- Quality improvement director, staff and committee
- Utilization management staff
- Member services staff
- Provider services staff
- Claims administrator/Management information systems staff
- Education/outreach staff (outreach staff is not required, but the MCO
must specify if the MCO or any of its subcontractors intend to
conduct outreach activities)
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The number of member and provider services staff must be sufficient to
satisfy the demand of members and providers.
3.6.1.2 MEETING REQUIREMENTS
The MCO must comply with all meeting and reporting requirements
detailed in the MCO Policies and Procedures Manual and Section 3.6 of
this BAA.
Quality improvement activities include both MCO meeting participation
and MCO reporting. The lists below are an outline of current meeting
and reporting requirements for the MCO.
Meetings
The MCO must attend and must participate in the following meetings:
- Managed Care Monthly Policy/Operations meeting
- Managed Care Technical meeting
- Quality Improvement Committee (QIC)
- Clinical Studies Workgroup
The MCO must attend and may participate in the following meetings:
- Clinical Advisory Committee (CAC)
- Drug Utilization Review (DUR) Board
The MCO may attend the following meetings:
- Medicaid Medical Policy meeting
- Medicaid Surveillance, Utilization Review (SUR) meeting
3.6.1.3 REPORTING REQUIREMENTS
MCOs are required to submit Quarterly Reports to OMPP and the
monitoring contractor according to a schedule established by OMPP,
specified in the Reporting Manual. The Quarterly Reports are composed
of seven sections:
- NETWORK DEVELOPMENT
PURPOSE: To identify what services are provided within the network
for assessment of how well the MCO is addressing the needs of the
program in terms of access/capacity. The MCO must identify current
enrollment, gaps, and the steps that will be taken to resolve any
potential problems relating to network development.
- MANAGEMENT INFORMATION SYSTEMS
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PURPOSE: To identify the collection of data and maintenance of
network information systems for MCO management of services accessed
and utilized by members and providers. The MCO must submit claims
processing and shadow claims processing/adjudication data. The MCO
must also identify specific cases and trends to prevent and respond
to any potential problems relating to timely and appropriate claims
processing, and shadow claim submission.
- QUALITY IMPROVEMENT
PURPOSE: To state the on going or future methods/processes used to
identify program and clinical improvements which are to be made to
enhance the appropriate access, quality, and utilization of program
services by members and providers.
- MEMBER EDUCATION AND OUTREACH
PURPOSE: To identify methods used to communicate to members about
preventive health care and program services.
- PROVIDER EDUCATION AND OUTREACH
PURPOSE: To identify methods used to communicate to providers about
clinical, technical, and quality improvement issues relating to the
program.
- SERVICE UTILIZATION/FINANCIAL REPORTING
PURPOSE: To identify utilization and financial trends, which includes
but is not limited to: capitation rate calculation sheets (CRCS),
Medicaid, Medicare, and commercial population enrollment, financial
stability indicators, stop loss or reinsurance information, and
financial statements required by Department of Insurance.
- OTHER REPORTING
PURPOSE: To state program-related issues that may not change on a
quarterly basis, but are necessary for program monitoring including,
but not limited to: MCO organizational chart and contact list, annual
summary of activities, annual workplan of future activities, annual
summary of program integrity activities specific to the Hoosier
Healthwise population, Physician Incentive Plan (PIP) disclosure
information, and annual member survey results.
The Quarterly Report Submission Schedule is presented in the Reporting
Manual.
Additional detail regarding specific reporting requirements for each
area can be found in the Reporting Manual, and/or the MCO Policies and
Procedures Manual.
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3.6.1.4 SUBCONTRACTOR REVIEW REQUIREMENTS
As used in this BAA, the term "subcontractor(s)" does not include
contractual agreements between MCOs and health care providers or other
ancillary medical providers. The term "subcontractor(s)" does include
contracts between one prepaid health care delivery plan and another
prepaid health care delivery plan or administrative entity not Involved
in the actual delivery of medical care.
The MCO is responsible for the performance of any obligations that may
result from this BAA. Subcontractor or agreements do not terminate the
legal responsibility of the MCO to the State to ensure that all
activities under the contract are carried out. The MCO must oversee
subcontractor activities. The MCO will be held accountable for any
functions and responsibilities that it delegates.
The MCO must comply with 42 CFR 438.230 and the following
subcontracting requirements:
- The MCO must obtain the approval of OMPP and IDOA before
subcontracting any portion of the project's requirements. THE MCO
MUST GIVE OMPP A WRITTEN REQUEST AT LEAST 30 DAYS PRIOR TO THE USE OF
A SUBCONTRACTOR. If the MCO makes changes to the subcontractor
contract, it must notify OMPP 60 days prior to the revised contract
effective date.
- The MCO must evaluate prospective subcontractors' abilities to
perform delegated activities prior to contracting with the
subcontractor to perform services associated with the Hoosier
Healthwise program.
- The MCO must have a written agreement in place that specifies the
subcontractor's responsibilities and provides an option for revoking
delegation or imposing other sanctions if performance is inadequate.
The written agreement must be in compliance with all State of Indiana
statutes, and will be subject to the provisions thereof.
- The MCO must monitor delegates' performance on an ongoing basis and
conduct formal, periodic and random reviews, as directed by OMPP.
- All subcontractors must fulfill all State and federal requirements
appropriate to the services or activities delegated under the
subcontract. In addition, all subcontractors must fulfill the
requirements of this BAA that are appropriate to the service or
activity delegated under the subcontract.
- The MCO must take corrective action if deficiencies are identified
during the review.
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All employment agreements, provider contracts, agreements or other
arrangements by which the MCO intends to deliver services required
under this BAA, whether or not characterized as a subcontract under
this BAA, shall be subject to review and approval by OMPP and must be
sufficient to assure the fulfillment of the requirements of 42 CFR
434.6(a) that are appropriate to the service or activity delegated
under such employment agreements, provider contracts, agreements or
other arrangements. In addition, MCOs must comply with all subcontract
requirements specified in 42 CFR 438.230.
3.6.2 PROVIDER NETWORK REQUIREMENTS
The MCO will be solely responsible for arranging for and administering
covered services to its members. Covered services shall be medically
necessary, and shall be administered by or arranged for by, a
designated PMP or the MCO. The MCO will assure that each member has PMP
who is responsible for providing an ongoing source of primary care
appropriate to his or her needs. PMPs coordinate each member's care and
make any referrals necessary.
The MCO must ensure that its network provides available, geographically
accessible and adequate numbers of facilities, medical providers,
ancillary providers, locations and personnel for the provision of
covered services within the MCO's service area, in accordance with 42
CFR 438.206. MCOs must arrange for laboratory services only through
those IHCP enrolled laboratories with Clinical Laboratory Improvement
Amendments (CLIA) certificates.
The MCO must ensure that all of its providers, including ancillary
providers, are enrolled as IHCP providers and that there are sufficient
providers to adequately serve the MCO's members. The MCO must have
policies and procedures detailing the process used to select and
maintain providers. Policies regarding provider availability are
referenced in the MCO Policies and Procedures Manual and the Hoosier
Healthwise Povider Manual.
In accordance with 42 CFR 438.206(b)(l), the MCO must consider the
following elements when developing and maintaining its provider
network:
- The anticipated Hoosier Healthwise enrollment;
- The expected utilization of services, taking into consideration the
characteristics and health care needs of specific Hoosier Healthwise
populations represented in the MCO;
- The numbers and types (in terms of training, experience, and
specialization) of providers required to furnish the contracted
Hoosier Healthwise services;
- The numbers of network providers who are not accepting new Hoosier
Healthwise patients;
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- The geographic location of providers and Hoosier Healthwise
enrollees, considering distance, travel time, the means of
transportation ordinarily used by Hoosier Healthwise enrollees, and
whether the location provides physical access for Hoosier Healthwise
enrollees with disabilities.
Provider enrollment activities will be governed by the following:
- PMP EDUCATION AND OUTREACH:
The MCO will educate its own network providers.
- PMP PANEL SIZE:
PMP maximum panel size is limited to a total of 2,000 members for
both delivery systems combined. Exceptions will be granted to allow
the PMP to accept former Hoosier Healthwise patients, new family
members of already enrolled individuals, and in designated medically
under-served areas as determined by OMPP. The number of PMP panel
slots must be stated in the PMP contract.
- PMP ENROLLMENT:
PMPs enroll directly with the MCO for the RBMC delivery system. PMPs
will be allowed to enroll in both PrimeStep and RBMC, although they
may only accept new members in one delivery system at a time. For
example, while the PMP's practice is open for PrimeStep member
enrollment, it will be closed for new RBMC member enrollment, and
vice versa. Within RBMC, PMPs may not be enrolled in more than one
MCO. In order for a PMP to change enrollment status, the PMP must
disenroll from one delivery system and enroll in the other delivery
system. The PMP must notify the fiscal agent no later than the 24th
day of the month prior to the month they wish to switch delivery
system enrollment.
- PMP DISENROLLMENT:
The MCO will provide the fiscal agent's Managed Care Unit with a list
of representatives who have been trained and authorized to submit PMP
disenrollments and keep it updated as responsibilities change.
The MCO will notify the fiscal agent of the intent to disenroll a PMP
within five working days of the receipt/issuance of the PMP's
disenrollment request. The fiscal agent will not process the
disenrollment until the disenrollment request is sent, but advance
notification will allow the opportunity to begin the coordination of
enrollment in another network, if necessary.
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The MCOs will submit completed requests for disenrollment to
the fiscal agent at least five working days prior to the 24th
day of the month for mandatory requests.
If a PMP disenrolls from the MCO, the MCO must ensure that the
PMP provides continuation of care for his/her Hoosier
Healthwise patients for a minimum of 30 days, or until another
PMP is chosen or assigned.
In the event of a provider termination, the MCO must make a
good faith effort to notify members in writing of the
termination within 15 calendar days of receipt of the provider
intent or issuance of the termination notice, in accordance
with 42 CFR 438.10(f). This notification applies to members
who received their primary care from, or were seen on a
regular basis by, the terminated provider. Please refer to the
MCO Policies and Procedures Manual for more details regarding
PMP disenrollment.
Requirements governing provider selection can be found at 42 CFR
438.214. The MCO shall not discriminate with respect to participation,
reimbursement, or indemnification as to any provider who is acting
within the scope of the provider's license or certification under
applicable State law, solely on the basis of such license or
certification. However, the MCO is not prohibited from including
providers only to the extent necessary to meet the needs of the MCO's
members or from establishing any measure designed to maintain quality
and control costs consistent with the responsibilities of the MCO.
Emphasis should be placed on the credentialing and re-credentialing
process to ensure that provision of quality care is maintained.
3.6.3 PROVIDER NETWORK ACCESS TO CARE REQUIREMENTS
The MCO must have a mechanism in place to ensure that emergency
services are available seven days a week, 24 hours per day without
prior approval. The MCO must maintain a network of sufficient size and
resources to offer quality care that can accommodate the needs of the
members within each enrollment area. The MCO must have a mechanism in
place to ensure that contracted PMPs are required to provide or arrange
for coverage of services 24 hours a day, seven days a week. The MCO
must also ensure that PMPs are available to see patients a minimum of
20 hours over a three day period per practice location per week. The
three day requirement can be fulfilled by more than one PMP in a group
practice. Each MCO must also assess the PMP's non-Hoosier Healthwise
practice to ensure that this segment of the population is receiving
accessible services on an equal basis with the Hoosier Healthwise
population.
The MCO must monitor compliance with access requirement regularly and
take corrective action if practitioners within the network fail to
comply with the established access requirements. The MCO must comply
with access standards selected and approved by the QIC (Appendix 5 of
the BAA).
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The MCO must establish and maintain provider networks in geographically
accessible locations for the populations to be served.
The MCO must provide OMPP, the enrollment broker and all Hoosier
Healthwise members with a network directory which lists PMPs and
specialists, including their name, specialty, willingness and/or
ability to provider services for members with special needs,
location(s), qualifications, whether or not they are accepting new
patients, and what languages, other than English, the provider speaks,
in accordance with 42 CFR 438.206. Hospital providers, pharmacists,
home care providers and all other network providers must also be listed
in the network directory. Office hours of physician and ancillary
providers must be stated. Office hours should include evening and
weekend hours of operation. An electronic data file of the network
directory must be provided to OMPP's enrollment broker, including
updates, for the purpose of providing a program comparison guide for
members and potential members, as required by federal law. The MCO must
certify that all provider network information submitted to OMPP is
timely and accurate.
- The MCO must update the network directory monthly using addenda
and/or through reprints, and make available for use by the enrollment
broker in each location where potential members are enrolled in the
Hoosier Healthwise program and any other location specified by the
State.
- Physician to member ratios for each geographic area must be
sufficient to handle network capacity.
- The MCO must have policies and procedures to allow members to change
their PMPs within timeframes appropriate to authorized disenrollment
and grievance procedures requirements.
- The MCO must track member disenrollments and reasons for
disenrollment.
- The MCO must have a reliable method and system for providing 24 hour
access to care and emergency services. Direct contact with a
qualified clinical staff person must be available through a toll-free
member services voice and telecommunication device for the deaf
telephone number.
- The MCO must ensure that PMPs in its network maintain office
locations sufficiently near members' homes so that members can reach
the PMP office within a reasonable amount of time, using available
and affordable means of transportation.
- Procedures must be in place for referrals to specialists.
- The following waiting times should be monitored. These standards are
included in the Reporting Manual:
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- Time to get an appointment with a provider.
- Time actually waiting to see a provider in his/her
office.
- For maternity care the MCO shall be able to provide
initial prenatal care appointments for enrolled
pregnant members according to standards developed
by the CAC and the QIC.
- For primary care services, the MCO shall provide
appointments according to standards developed by
the CAC and QIC.
- For children with special health care needs, the
MCO shall provide appointments acccording to the
standards developed by the CAC and QIC.
The MCO must submit documentation assuring adequate network capacity
and services, as specified by OMHP, as follows:
- At the time the MCO enters into contract with the
State
- At any time there has been a significant change in
the entity's operations that would affect adequate
capacity and services, including change in services
benefits, geographic service area or payments
- At the time of enrollment of a new population in
the MCO
The MCO and its PMPs and other network providers should have a
comprehensive system in place to respond to the cultural, racial and
linguistic needs of the Hoosier Healthwise population, including those
members with special health care needs.
3.6.4 PROVIDER PAYMENT REQUIREMENTS
The MCO must pay providers for covered medically necessary services
rendered to their members in accordance with the standards set forth in
I.C. 12-15-13-1.6 and 1.7, unless the MCO and provider agree to an
alternate payment schedule and method. The MCO must pay or deny
electronically filed claims within 21 days of receipt and clean paper
claims be paid within 30 days of receipt. If the MCO fails to pay or
deny a clean claim within these timeframes and subsequently pays the
claim, the MCO shall also pay the provider interest as required under
I.C. 12-15-13-1.7(d). "Clean claim" has the meaning set forth in I.C.
12-15-13-0.6. These standards will apply to out-of-network claims for
which the MCO is responsible and any other claims submitted by
providers that have not agreed to alternate payment arrangements.
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While the MCO may choose to subcontract claims processing functions, or
portions of those functions, with a State-approved subcontractor, the
MCO is expected to demonstrate that the use of such subcontractors is
invisible to providers, including out-of-network and self-referral, and
will not result in confusion to the provider community about where to
submit claims for payments. For example, the MCO may elect to establish
one post office box address for submission of all out-of-network
provider claims. If different subcontracting organizations are
responsible for processing those claims, it will be the MCO's
responsibility to ensure that the claims are forwarded to the
appropriate processing entity. Use of a method such as this will not
lengthen the timeliness standards discussed in this section. In this
example, date of receipt will be defined as the date the claim is
received at the post office box.
If the MCO has excessive claims liability with its providers and these
liabilities continue to increase, the State then has the option to
withhold capitation payments from the MCO until the timeliness
requirements are met.
3.6.5 DISCLOSURE OF PHYSICIAN INCENTIVE PLAN
The MCO may implement a physician incentive plan only if:
(1) no specific payment will be made directly or indirectly under the
plan to a physician or physician group as an inducement to reduce
or limit medically necessary services furnished to an individual
member; and
(2) the stop-loss protection, member survey, and disclosure
requirements under 42 CFR 417.479 are met.
The MCO must provide information concerning its physician incentive
plan in accordance with the disclosure requirements listed at 42 CFR
417.479(h)(l)(i)-(v), 422.208, 422.210, and 438.6. These requirements
are as follows:
- Whether services not furnished by a physician or physician group are
covered by the incentive plan. If only the services furnished by the
physician or physician group are covered by the incentive plan,
disclosure of other aspects of the plan need not be made.
- The type of incentive arrangement; for example, withhold, bonus,
capitation.
- If the incentive plan involves a withhold or bonus, the percent of
the withhold or bonus.
- Proof that the physician or physician group has adequate stop-loss
protection, including the amount and type of stop-loss protection.
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- The panel size and, if patients are pooled, the method used to
determine if substantial financial risk exists. The method used must
be permitted by federal regulation, 42 C.F.R. 417.479(h)(v).
- The annual member survey results and a copy of the survey instrument
used.
Similar requirements apply to subcontracting arrangements with
physician groups and intermediate entities. These requirements are
further detailed at 42 CFR 417.479(i).
3.6.6 ADVANCE DIRECTIVES
In accordance with 42 CFR 422.128,438.6 and 438.10, MCOs must maintain
written policies and procedures for advance directives relating to all
adult individuals receiving medical care by or through the MCO. The
policies and procedures must meet the advance directive requirements
stated in Subpart I of 42 CFR 489.
The MCO must provide written information to members regarding the MCO's
advance directive policies and the member's rights under State law. The
MCO must communicate to the member its policies for ensuring that
member rights in relation to advance directives are implemented and
respected. The MCO must provide a statement to the members outlining
any limitations associated with implementing advance directives as a
matter of conscience. The MCO must also inform individuals that
complaints against providers concerning noncompliance with the advance
directive requirements may be filed with the Indiana State Department
of Health by calling 1-800-246-8909. If changes are made to the State's
advance directive laws, the MCO must notify members in writing of the
change within 90 days of the effective date of change.
3.6.7 MEMBER SERVICES
3.6.7.1 MEMBER HOTLINE
The MCO must establish a single toll-free telephone number to assist
with questions that members may have about the MCO's providers or
benefits. In accordance with 42 CFR 438.10(c), the MCO must satisfy
each of the following requirements:
- Provide a description of the oral interpretation services offered to
members
- Notify members of the availability of free oral interpretation
services for all languages
- Make free oral interpretation services available for all languages
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- Explain the process for accessing interpretation services
- Notify members that written information is available to them in
prevalent languages upon request
- Explain to members the process for requesting written information in
non-English languages
3.6.7.2 SERVICES FOR NEWBORNS
The MCO must arrange for, and administer covered services to a newborn
child of a Package A or B MCO enrolled mother from the newborn's date
of birth. The MCO will receive the newborn's corresponding monthly
capitation rate from the newborn's date of birth. If the newborn
changes his/her PMP resulting in a change in network, the MCO remains
responsible for services from the newborn's date of birth until such
time as eligibility and enrollment in another network can be verified
through the Eligibility Verification System (EVS).
Newborns of women who were in Package C on the newborn's date of birth
are not enrolled in an MCO. New-borns of teenagers enrolled in Package
C are not automatically eligible for the benefits. If a teenager who is
enrolled in Package C becomes pregnant, an application must be
submitted for the newborn, the newborn must be found eligible for the
program, and the premium payment must be made before the newborn is
enrolled in the program. Once the first premium payment is received,
and the member is thus eligible for benefits, the newborn may be
assigned, prospectively, to managed care.
Pregnant women in Packages A or B are encouraged to select a doctor for
their newborn, prior to the birth. If the mother was in PrimeStep or
fee-for-service (not managed care) on the newborn's date of birth, and
there is a newborn PMP preselection assignment, the effective date with
the MCO or PrimeStep PMP is the next 1st or 15th of the month,
dependent on when the newborn's eligibility was initially established
in the IndianaAIM system. If a Package A or B mother is enrolled in an
MCO and she selects a PrimeStep PMP for her newborn, the system will
auto-assign the newborn to the mother's MCO and then the PrimeStep PMP
pre-selection will be entered as a PMP change when the newborn's
eligibility is established. The MCO will be financially responsible for
the newborn from birth until eligibility is established. The fiscal
agent produces a newborn pre-selection report monthly for the MCOs. The
MCOs are encouraged to use this report for outreach to expectant
mothers who have not yet pre-selected an MCO PMP for their children.
MCOs must accept as enrolled all individuals appearing on monthly
enrollment rosters and infants enrolled by virtue of the mother's
enrollment status, as described above, as well as those members for
whom capitation payment is received. MCOs may not discriminate against
Hoosier Healthwise managed care members on the basis of their Health
needs or health status.
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3.6.7.3 MEMBER OUTREACH FOR THE HOOSIER HEALTHWISE RBMC
The MCOs and their subcontractors are permitted and encouraged to
promote their services to the general community. However, direct
outreach to potential Hoosier Healthwise members and Hoosier Healthwise
members who are not members of the MCO is not permitted. For example,
MCOs cannot conduct, indirectly or directly, door-to-door, phone or
other "cold call" marketing practices. The prohibition on MCO outreach
to Hoosier Healthwise managed care members applies equally to members
who apply for the program at a County DFC office or at any other
outstation location.
The MCO must comply with the following provisions applicable to
marketing and all other marketing provisions in 42 CFR 438.104.
Outreach and any marketing activities (written and oral) shall be
presented and conducted in an easily understood manner and format, at a
fifth grade reading level, and shall not be misleading or designed to
confuse or defraud members and/or potential members. The MCO must
include in its workplan the methods it will use to assure that
materials are accurate and do not mislead. Examples of false or
misleading statements include, but are not limited to:
- Any assertion or statement that the member or potential member must
enroll in the MCO to obtain benefits or to avoid losing benefits
- Any assertion or statement that the MCO is endorsed by CMS, the
Federal or State government, or a similar entity
All outreach and marketing materials must be submitted to and approved
by OMPP at least 10 business days prior to distribution. OMPP's
decision on any material is final.
MCOs cannot entice a potential member to join the MCO by offering the
sale of any other type of insurance as a bonus for enrollment and MCOs
must ensure that a potential member can make his/her own decision as to
whether or not to enroll. Any type of incentives used to market an
outreach or education program must be prior-approved by the State, and
their value may not exceed ten dollars ($10) per event or $50 per year
per member. Under no circumstances are monetary incentives to be
offered or used.
All brochures, presentation materials and informational packets used by
education and outreach representatives should follow Quality Assurance
Reform Initiative (QUARI) standards. To the extent possible, all
material must be written at a fifth grade reading level or lower and
must be culturally appropriate. Materials submitted to the State for
approval must indicate the measurement used to assess the reading level
(i.e. SMOG, FOG or other method) and the level the method indicated.
Marketing materials must be distributed within the entire service area
served by the MCO.
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The MCO will send its education/outreach and marketing plans and
policies and procedures to OMPP and the AGO monitoring contractor on a
quarterly basis. The quarterly report is due on the last day of the
month following the reporting quarter. The MCO will update its plan
quarterly, including reporting on the status of previously projected
activities, and submit it to OMPP and the MCO monitoring contractor.
OMPP and the MCO monitoring contractor will review the
outreach/education and marketing plans and workplans. OMPP will respond
to the MCO with specific feed back to be used in improving the MCO's
performance.
3.6.7.4 MEMBER EDUCATION REQUIREMENTS
3.6.7.4.1 MEMBER MATERIALS
The MCO will be responsible for developing and maintaining member
education programs designed to provide the members with clear,
concise, and accurate information about the MCO. The MCO must provide
information requested by the State, or the State's disagree, for use
in member education and enrollment, upon request. Member education
materials must include, but are not limited to the following:
- MEMBER HANDBOOK which describes in full detail the terms and nature
of services offered by the MCO, including MCO covered and MCO
non-covered services and benefits, preventive services, limitations
and exclusions, provider network, self-referral services (specified
in Section 3.4.2.4 of this BAA), wellness programs and other enhanced
services, coordination of benefits, disenrollment, member rights and
responsibilities, grievance procedures, and any other terms and
conditions pertinent to the member.
- MCO BULLETINS OR NEWSLETTERS specific to the Hoosier Healthwise
population issued not fewer than three times a year which provide
updates related to covered services, access to providers, and updated
policies and procedures.
- LITERATURE REGARDING HEALTH/WELLNESS PROMOTION PROGRAMS offered by
the MCO are encouraged.
- NOTIFICATION OF COVERED SERVICES THE MCO DOES NOT ELECT TO COVER on
the basis of moral or religious grounds and guidelines for how and
where to obtain those services, in accordance with 42 CFR 438.102.
The MCO must provide this information to members before and during
enrollment and within 90 days after adopting the policy with respect
to any particular service.
- The MCO must inform the members that the following information is
available upon request:
- Information on the structure and operation of the MCO
- Physician incentive plans as set forth in 42 CFR 438.6(h)
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The MCO must provide the information listed under this section
within a reasonable timeframe, following the notification from OMPP
of the member's enrollment. In addition, the MCO must notify members
at least once a year of their right to request and obtain the
information listed in this section. If the MCO makes significant
changes to the information provided under this subsection, the MCO
must notify the member in writing of the intended change at least 30
calendar days prior to the intended effective date of the change, in
accordance with 42 CFR 438.10(f)(4). OMPP defines significant
changes as any changes that effect member accessibility of the MCO's
services and benefits. All materials must be approved by the OMPP
prior to distribution.
3.6.7.4.2 ALTERNATE FORMAT REQUIREMENTS
OMPP will identify prevalent languages spoken by Hoosier Healthwise
members. The MCO must make written information in each prevalent
non-English language, as identified by OMPP, available upon the
member's request. In addition, the MCO must identify additional
languages that are prevalent among the MCO's membership.
The MCO must inform members that information is available upon
request in alternative formats and explain how alternative formats
may be obtained. OMPP defines alternative formats as Braille, large
font letters, audiotape, prevalent languages, and verbal explanation
of written materials. To the extent possible, written materials must
be not exceed a fifth grade reading level.
3.6.7.5 MEMBER GRIEVANCE PROCEDURES AND REPORTING STANDARDS
As required by 42 CFR 438.228, the MCO shall have a formal grievance
system that is approved in writing by the OMPP for promptly
reviewing and resolving grievances and appeals registered by its
members.
At a minimum, the grievance system includes a grievance process, an
appeal process, as well as expedited review procedures and access to
the State's fair hearing system. The grievance system must comply
with Indiana Code 27-13-10 and 27-13-10.1 and 42 CFR 438, Subpart F,
and include the all elements outlined below. The MCO must comply
with all grievance and appeal reporting requirements provided in the
Reporting Manual.
In accordance with Subpart F of 42 CFR 438, the MCO's grievance and
appeal process must comply with each of the requirements stated
below.
- DECISIONS IMPLEMENTATION: Decisions must be implemented as
expeditiously as the member's health condition requires and no
later than the date the decision expires. If services were not
furnished while an appeal is pending and a decision to deny,
limit or delay services is overturned, the MCO must authorize
or provide the disputed services promptly.
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- MEMBER ASSISTANCE: The MCO shall treat oral inquiries seeking
to appeal an action as appeals and shall confirm those
inquiries in writing, unless an expedited resolution is
requested. The MCO must assist members in completing forms and
procedural steps, as needed.
- MEMBER REPRESENTATION: The MCO must provide members with a
reasonable opportunity to present their case in person and in
writing at each level of review. The MCO must recognize as
parties to the appeal members, member representatives and
legal representatives of deceased members' estates. The MCO
must allow the enrollee and representative opportunity to
examine the enrollee's case file before and during the appeals
process.
- PROVIDER INFORMATION AND RIGHTS: The MCO must provide
information about the member grievance system to all providers
and subcontractors at the time they enter into a contract. The
MCO may not take punitive action against a provider who
supports a member's appeal or requests an expedited
resolution.
- CONTINUATION OF BENEFITS: The MCO must continue the members
benefits during grievances, appeal, external reviews and State
fair hearings if:
- The member or provider files the appeal in a
timely manner
- The appeal involves termination, suspension or
reduction of previously authorized service
- The services were ordered by an authorized
provider
- The original services coverage period has not
expired, or
- The member requests a benefits extension.
If a benefits continuation is granted, the benefits must be
continued until:
- The member withdraws the review request
- The timeframe for requesting the next level of
review passes
- An adverse decision is made or the time period, or
- The service limits of a previously authorized
service has been met.
If the final resolution is adverse to the member, the MCO may
recover the cost of services furnished while the grievance, appeal,
external review or Medicaid hearing was pending. Services may be
recovered to the extent they were furnished solely because of the
requirements in this section. If a decision is made in favor of the
member, the MCO must pay for services received during the review
process.
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- UTILIZATION REVIEW STAFF: UR staff making determinations on
service cannot have been involved in previous levels of
review. Reviewers must possess the proper clinical expertise
to make decisions regarding denials based on medical
necessity, denials of expedited reviews and clinical
grievances and appeals.
- ISSUES TRACKING: The MCO must maintain a single toll-free
telephone number for members with inquiries and grievances.
The MCO must track and report inquiries, grievances and
appeals, as described in the Reporting Manual.
- MEMBER NOTIFICATION OF GRIEVANCE AND APPEALS PROCESS: The MCO
must provide members with a description of the grievance and
appeals procedures and timeframes after receiving notification
from OMPP of the member's enrollment. The materials must
include information regarding State fair hearings, the right
to file a grievance and appeal, allotted timeframes, the
availability of assistance in the filing process, toll-free
numbers enrollees can use to file an appeal over the phone, an
explanation of continued benefits and the members
responsibility to pay costs associated with an adverse
decision. The grievance policies and procedures provided to
the member must comply with 438.400 through 438.424. In
addition, the MCO must notify members at least once a year of
their right to request and obtain the information listed in
this section. If the MCO makes significant changes to the
information provided under this subsection, the MCO must
notify the member in writing of the intended change at least
30 calendar days prior to the intended effective date of the
change.
- MEMBER NOTICE OF RESOLUTION: The MCO must provide the member
with written notice of the resolution of the appeal. The
notice must include the following information:
- The results and date of the resolution
- For decisions not wholly in favor of the enrollee:
- The right to request a State fair hearing,
- How to request a State fair hearing,
- The member's right to continue to receive
benefits pending a hearing,
- How to request the continuation of
benefits, and
- If the MCO's action is upheld in the
hearing, the enrollee may be liable for
the cost of any continued benefits.
MCOs must submit a monthly report on inquiries, grievances and
appeals, as specified in the Reporting Manual, to the monitoring
contractor. The MCO must submit separate monthly reports of
inquires, grievances and appeals filed for children with special
health needs.
The MCO must submit a quarterly report of all external independent
reviews and Medicaid hearings to the Hoosier Healthwise monitoring
contractor. The MCO
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must submit separate quarterly reports of external reviews and
Medicaid hearings filed for children with special health needs.
Failure to submit the information on time, and/or in the format
required, may result in the assessment of liquidated damages by the
State, in accordance with Section 3.16 of this BAA.
Records for all formal inquires and grievances shall be maintained
for a period of three years after resolution. The record shall
include a complete description of the grievance (or a copy of the
original), the response to, and disposition of, such grievances. The
record shall also include sufficient information to demonstrate
timely attention to written grievances, including the date the
grievance was filed, the date reviewed, the date resolution was
proposed, the date any corrective action was initiated, and, if
applicable, the plan of correction to avoid such occurrences in the
future.
3.6.7.6 PROTECTION OF MEMBER-PROVIDER COMMUNICATIONS
The MCO must not prohibit or restrict a health care professional
from advising a member about his/her health status, medical care, or
treatment options, regardless of whether benefits for such care are
provided under the contract, if the professional is acting within
the lawful scope of practice. In accordance with 42 CFR 438.102(a),
the MCO must allow health professionals to advise the member on
alternative treatments that may be self administered and provide the
member with any information needed to decide among relevant
treatment options. Health professionals are free to advise members
on the risks, benefits and consequences of treatment or
nontreatment.
The MCO must not prohibit health professionals from advising members
of their right to participate in decisions regarding their health,
including the right to refuse treatment and express preferences for
future treatment methods. The MCO may not take punitive action
against a provider who requests an expedited resolution or supports
a member's appeal.
This provision does not require the MCO to provide coverage of a
counseling or referral service if it objects to the service on moral
or religious grounds. However, the MCO must makes it policies
regarding these services available to member and potential members
within 90 days after the date the MCO adopts a change in policy
regarding such a counseling or referral service.
Information provided must comply with 42 CFR 438.10, as specified in
Section 3.6.7.4 of this BAA.
3.6.7.7 MEMBER RIGHTS
In accordance with 42 CFR 438.100, the MCO must have written
policies and procedures regarding member rights. The MCO must ensure
that its staff and
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affiliates take member rights into consideration when delivering
services. The member rights policies and procedures must include the
member's right to:
- Receive enrollment notices, informational materials, and
instructional materials relating to members in an easily
understood manner and format.
- Be treated with respect and due consideration for his or her
dignity and privacy.
- Receive information on available treatment options and
alternatives presented in a manner appropriate to the member's
condition and ability to understand.
- Receive information regarding advance directive policies in
place.
- Participate in decisions regarding the member's health care,
including the right to refuse treatment.
- Be free from any form of restraint or seclusion used as a
means of coercion, discipline, convenience or retaliation, in
accordance with Federal regulations.
- Request a copy of the member's medical record and request
amendments or corrections, as provided for in 45 CFR 164.524
and 164.526.
- Be furnished with covered health care services.
- Exercise his or her rights, and that the exercise of those
rights will not adversely affect the way the MCO and its
providers or OMPP treat the member.
- Request a second opinion from a qualified professional. If the
provider network does not include a professional who is
qualified to give a second opinion, the member can request the
MCO to arrange for the member to obtain a second opinion from
a professional outside the network, at no cost to the member.
In addition to the rights stated above, the MCO's member rights
policies and procedures must comply with all Federal and State laws,
including the Health Insurance Portability and Accountability Act
(HIPAA), regarding a member's right to privacy and confidentiality.
3.6.7.8 MEMBERS WITH SPECIAL NEEDS
The MCO must also assist OMPP with identifying, assessing and
tracking its members with special needs, as required by OMPP and
pursuant to 42 CFR 438.208(c). The MCO must have procedures in place
to conduct assessments of each member identified as having potential
special health care needs in order to identify any ongoing special
conditions of the member that may require a course of treatment or
regular care monitoring. The assessment procedures must use
appropriate health care professionals. Grievances and appeals filed
by members with special needs must be reported separately in the
grievance reports.
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3.6.8 PROVIDER SERVICES
The MCO must provide enrollment and education services for the
provider network, ensure proper maintenance of medical records,
maintain proper staffing to respond to provider inquires and be able
to process provider disputes and appeals.
The MCO must have written policies and procedures for registering
and responding to provider disputes in a timely fashion. The MCOs
policies and procedures for informal claims disputes, formal claims
disputes and binding arbitration must be in compliance with the
requirements provided in the Claims Dispute Resolution process
outlined in the MCO's contract with the State.
3.6.9 PROVIDER CREDENTIALING
The MCO must have written credentialing and re-credentialing
policies and procedures for ensuring quality of care and assuring
that all providers rendering services to their members are licensed
by the State and qualified to perform their services as approved
IHCP providers. The MCO's credentialing and recredentialing policy
must, at a minimum, comply with the State's credentialing and
recredentialing policy as stated below.
3.6.9.1 PROVIDER CREDENTIALING AND RECREDENTIALING POLICIES AND PROCEDURES
The MCO must have written policies and procedures for credentialing
health care professionals it employs and with whom it contracts. The
MCO should refer to NCQA standards as a guideline for credentialing.
At a minimum, the requirements outlined in this policy must be met.
MCOs must credential PMPs, chiropractors and podiatrists, at a
minimum. The MCO must have documented plans to periodically review
and revise policies and procedures. If the MCO contracts with a
subcontractor that conducts the MCO's credentialing activity, the
MCO must have access to the subcontractor's credentialing files. At
minimum, the MCO must obtain and review verification of the
following:
- A current valid license to practice.
- Status of clinical privileges at the hospital designated by
the practitioner as the primary admitting facility.
- Current and valid Drug Enforcement Administration (DEA) or
controlled substance registration (CSR) certificate, as
applicable (DEA certificates are not applicable to
chiropractic settings).
- Proof of graduation from medical school and completion of a
residency, or board certification for medical doctors (MDs)
and doctors in osteopathy
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(DOs), as applicable since the last time the provider was
credentialed or recredentialed.
- Proof of graduation from chiropractic college for doctors of
chiropractic medicine (DC).
- Proof of graduation from podiatry school and completion of
residency program for doctors in podiatric medicine (DPMs).
- Work history that includes a minimum of five years on the
curriculum vitae (the MCO is not required to verify work
histories).
- Current, adequate malpractice insurance according to the MCO's
policies.
- History detailing any pending professional liability claims,
as well as claims resulting in settlements or judgments paid
by or on behalf of the practitioner.
- Proof of board certification if the practitioner states being
board certified.
- Verification of IHCP enrollment. If group enrollment, verify
that the provider is linked appropriately to the group, and
verify that the provider is enrolled at the appropriate
service locations.
The credentialing policies and procedures must specify the
professional criteria required to participate in the MCO. Each
practitioner file must contain sufficient documentation to
demonstrate that these criteria are evaluated. Primary sources used
by the MCO to verify credentialing information must be included in
its policies and can include use of external agencies such as county
medical societies, hospital associations, or private verification
services.
3.6.9.2 MECHANISMS FOR CREDENTIALING AND RECREDENTIALING
The MCO must document the mechanism for credentialing and
recredentialing MDs, DOs, DPMs, and DCs that fall under the MCO's
scope of authority and action, and with whom it contracts or employ
to treat members outside the inpatient setting. This documentation
includes but is not limited to the following:
- The scope of practitioners covered.
- The criteria and the primary source verification of
information used to meet these criteria.
- The process used to make decisions.
- The extent of any delegated credentialing or recredentialing
arrangements.
Policies and procedures must specify the requirements and the
process used to evaluate practitioners. Selection decisions must be
based on the network needs of the MCO, as well as practitioners'
qualifications. Selection decisions cannot be
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based solely on a practitioner's membership in another organization,
such as a hospital or medical group.
Policies and procedures must include physicians and other licensed
independent practitioners who are subject to these policies, as well
as criteria to reach a decision.
The MCO must have a process in place for receiving advice from
participating practitioners in credentialing and recredentialing to
ensure that procedures are followed consistently. MCOs must seek
practitioner expertise on current practice in the medical community
and advice on modifying the criteria, as appropriate. This expertise
can be obtained from a committee with participating practitioner
representation or from consultation with participating
practitioners.
Participating practitioners must complete an application for
membership on such a committee. Through the application process, the
practitioner discloses information about health status and any
history of issues with licensure or privileges that may require
additional follow-up. A signed attestation statement on the
application ensures that the practitioner has completed it in good
faith. Before making a credentialing decision, the MCO must have the
following information on the practitioner:
- Information from the National Practitioner Data Bank (NPDB).
NPDB is not applicable to chiropractors and podiatrists.
- Information about sanctions or limitations on licensure from
the State Board of Medical Examiners, Federation of State
Medical Boards, or the Department of Professional Regulations,
if available.
- Information from the State Board of Chiropractic Examiners or
the Federation of Chiropractic Licensing Boards.
- Information from the State Board of Podiatric Examiners.
- Previous sanction activity by Medicare and the IHCP.
Evidence indicating that the MCO has obtained information from the
previously designated organizations must be included in the
credentialing file.
3.6.9.3 CREDENTIALING - INITIAL VISIT
The MCO credentialing process must include an initial visit to the
offices of all potential primary medical providers including all
OB/GYNs. There must be a structured review that evaluates the site
against the MCO standards. The initial site visit must also include
documentation of the evaluation of the medical record-keeping
practices at each site to ensure conformity with the maintenance of
medical records. Section 5: MCO Education, Outreach, and Marketing
Activity outlines this documentation.
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3.6.9.4 RECREDENTIALING
The MCO must have a [ILLEGIBLE] recredentialing process that
verifies the credentialing information subject to change over time.
The recredentialing process must be organized to verify the
information through a primary source on the current standing of
items listed in this section, such as member complaints, quality
reviews, utilization management, and member satisfaction. The MCO
must recredential providers at least every three years. The
description of the recredentialing process must include data from at
least three of the following six sources:
- Member complaints
- Quality reviews (practice-specific)
- Utilization management (profile of utilization)
- Member satisfaction (practice-specific)
- Medical record review
- Practice site reviews
The recredentialing evaluation process must use this data as
objective evidence in the reappraisal of professional performance,
judgment, and clinical competence. There must be evidence that the
MCO has taken action based on the data. Examples of action taken
include continuation in the MCO, required participation in
continuing education, required supervision, a clear plan for
improvement with the practitioner, evidence of changes in the scope
of practice, or termination of the practitioner from the MCO.
3.6.9.5 RECREDENTIALING PRACTICE SITE VISIT
The MCO must conduct an on-site visit at the time of recredentialing
to determine if there have been any changes in the facility,
equipment, staffing, or medical record-keeping practices that would
affect the quality of care or services provided to members of the
MCO. Primary medical providers, OB/GYNs, and other high- volume
specialists must be included in this site visit. The MCO is
responsible for determining which high-volume specialists are
subject to this visit, based on its own experience with the
specialist.
3.6.9.6 ALTERING CONDITIONS OF PROVIDER PARTICIPATION
MCOs must have plans for developing and implementing policies and
procedures for altering conditions of a provider's participation
with the MCO due to issues of quality of care and service. These
policies and procedures need to specify actions the MCO may take
before terminating the provider's participation with the MCO.
Policies and procedures must have mechanisms in place for reporting
serious quality deficiencies to the OMPP that could result in a
provider's suspension or termination. These policies and procedures
must specify how reporting will occur and the individual staff
members responsible for reporting deficiencies.
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The policies and procedures must include a well-defined appeals
process for instances in which the MCO decides to alter the
provider's condition of participation as a result of quality of care
or service issues. The MCO must ensure providers are aware of the
appeals process. Policies and procedures must include mechanisms to
ensure that providers are treated fairly and uniformly.
3.6.9.7 CREDENTIALING PROVIDER HEALTH CARE DELIVERY ORGANIZATIONS
The MCO must have policies and procedures for credentialing health
care delivery organizations, including but not limited to,
hospitals, home health agencies, freestanding surgical centers,
laboratories, and subcontracted networks of providers.
Every three years after the effective date of the initial contract
the MCO must confirm the following:
- That the organizations are in good standing with state and
federal regulatory bodies.
- That the organizations have been reviewed and approved by an
accreditation body before contracting with the MCO.
- That the organizations conform to the previously mentioned
requirements.
The MCO must also develop standards of participation and assess
these providers accordingly if the provider has not received
accreditation.
The MCO is prohibited from contracting with or paying (except in the
case of emergency situations) providers that are excluded from
participation in Federal health care programs. The MCO must
credential and recredential all providers. The MCO is required to
report on the credentialing status of its providers, as required in
the Reporting Manual.
In accordance with 42 CFR 438.214, the credentialing and
re-credentialing policies and procedures must be uniformly applied
to all contracted providers. The MCO may not discriminate against
providers serving high-risk populations or specializing in
conditions requiring costly treatment. If the MCO declines to
include an individual or group of providers in its network, the MCO
must furnish written notice to the provider of the reason for its
decision. The health plan must have written policies and procedures
for monitoring its providers and for sanctioning providers who are
out of compliance with the plan's medical management standards.
In accordance with 42 CFR 438.12, the MCO is not required to
contract with providers beyond the number necessary to meet the
needs of its member. The MCO may choose to use different
reimbursement amounts for different specialties or for different
practitioners in the same specialty. The MCO is also permitted to
establish measures that are designed to maintain quality of services
and control
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costs as long as they are consistent with the MCO's responsibilities
to its members. Agreements with participating providers must include
provisions to hold the State harmless and ensure continuation of
benefits.
The MCO must have a process in place to review and authorize all
network provider contracts and review and authorize contracts
established for reinsurance and third-party liability, if
applicable.
3.6.9.8 PROVIDER ENROLLMENT AND EDUCATION
All education/outreach materials designed for distribution to
enrolled providers must be submitted to OMPP for review and approval
at least 10 working days prior to distribution. The MCO must
receive approval from OMPP prior to distribution of materials.
OMPP's decision on any material is final.
3.6.9.9 MAINTENANCE OF MEDICAL RECORDS
As required by Indiana Code [ILLEGIBLE], the MCO must assure that
its participating providers maintain health records of all medical
services received by the member from the MCO and its providers in
accordance with 42 CFR 431.305 and 405 IAC 1-5-1. The medical record
must include, at a minimum, a record of outpatient and emergency
care, specialist referrals, ancillary care, laboratory and x-ray
tests and findings, prescription for medications, inpatient
discharge summaries, histories (including immunization) and
physicals and a list of smoking and chemical dependencies.
Medical records shall be maintained in a detailed and comprehensive
manner which conforms to good professional medical practice, permits
effective professional medical review and medical audit processes,
and which facilitates an accurate system for follow-up treatment.
Health records must be legible, signed and dated, and maintained for
at least seven years as required by state and federal regulations.
Confidentiality of medical records must be maintained in accordance
with State and Federal regulations, include HIPPA.
3.6.9.10 MCO COMMUNICATIONS WITH PROVIDERS
The MCO must establish and maintain a regular means of communicating
and providing information on changes in policies, procedures and
other network changes to its providers. This may include guidelines
for answering written correspondence to providers, offering
provider-dedicated phone lines, or a regular provider newsletter.
The MCO must give 60-day advance notice to providers of significant
changes that may affect the providers procedures (e.g. changes in
subcontractors). In addition, the MCO must notify the State of
significant changes at least 30 days prior to provision of the
provider notification.
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MCOs must provide a staff of sufficient size to respond timely to
provider inquiries, questions and concerns regarding the MCO's
Hoosier Healthwise delivery system.
3.6.10 PROGRAM INTEGRITY PLAN AND REPORTING STANDARD
Pursuant to 42 CFR 438.601 and 438.610, the MCO must have a written
program integrity plan that describes in detail the manner in which
fraud and abuse will be detected. The plan should include, but not
be limited to:
- Written policies, procedures and standards of conduct that
articulate the organization's commitment to comply with all
applicable Federal and State standards.
- A description of the safeguards the MCO will implement in
order to avoid and detect fraud (i.e., process for verifying
services are actually provided).
- Designation of a compliance officer and a compliance
committee who will be responsible for detecting fraud and
monitoring the contracting process between the MCO and its
subcontractors. The compliance officer and compliance
committee will be accountable to senior management.
- Training and education for the compliance officer and the
organization's employees that will be provided to detect
fraud.
- Methods of establishing effective lines of communication
between the compliance officer and the organization's
employees.
- A process for enforcing standards through well-publicized
disciplinary guidelines.
- An internal monitoring and auditing process.
- The manner (how, when, and to whom) in which fraud will be
reported. The reporting guidelines must include mechanisms for
reporting the following to the state regarding all
complaints of fraud and abuse that warrant investigation:
- Number of complaints of fraud and abuse made to
State that warrant preliminary investigation
- Name
- Provider ID number (each provider is required to
have a unique identifier)
- Source of complaint
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- Type of provider
- Nature of complaint
- Approximate dollars involved
- Legal and administrative disposition of the case
- Provision for prompt response to detected offenses, and for
development of corrective action initiative relating to the
MCO's contract.
An annual summary of program integrity activities specific to the
program must be submitted to OMPP and the MCO monitoring contractor
within 60 days of the end of the contract year. The OMPP may assess
liquidated damages, as specified in Section 3.16 of this BAA, for
MCO non-compliance with this reporting standard.
3.6.10.1 MCO COMMUNICATIONS WITH INDIANA MEDICAID FRAUD CONTROL UNIT (IMFCU)
The MCO shall immediately report to the IMFCU and OMPP any suspicion
or knowledge of fraud and/or abuse, including but not limited to the
false or fraudulent filings of claims and/or the acceptance or
failure to return monies allowed or paid on claims known to be false
or fraudulent. The reporting entity shall not attempt to investigate
or resolve the reported suspicion, knowledge or action without
informing the IMFCU and must cooperate fully in any investigation by
the IMFCU or subsequent legal action that may result from such an
investigation.
If subsequent investigation or legal action results in a monetary
recovery to the OMPP, the reporting MCO shall be entitled to share
in such recovery following final resolution of the matter settlement
agreement/final court judgment) and following payment of recovered
funds to the State of Indiana. The MCO's share of recovery shall be
as follows:
From the recovery, the State (including the IMFCU) shall retain its
costs of pursing the action, and its actual documented loss (if
any). The State shall pay to the MCO the remainder of the recovery,
not to exceed the MCO's actual documented loss. Actual documented
loss of the parties will be determined by paid false or fraudulent
claims, canceled checks or other similar documentation which
objectively verifies the dollar amount of loss.
If the State determines it is in its best interests to resolve the
matter under a settlement agreement, the State has final authority
concerning the offer, or acceptance, and terms of a settlement. The
State shall exercise its best efforts to consult with the MCO about
potential settlement. The MCO's preferences or
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opinions about acceptance, rejection, or the terms of a settlement
may be considered, but are not binding on the State.
If final resolution of a matter does not occur until after the
contract has expired, the preceding terms concerning disposition of
any recovery and consultation with the MCO shall survive expiration
of the contract and remain in effect until final resolution of a
matter referred to the IMFCU by the MCO under this section.
If the State makes a recovery in a matter where the MCO has
sustained a documented loss but the case did not result from a
referral made by the MCO, the recovery shall be distributed in
accordance with the terms of this section.
3.6.11 REGIONAL NETWORK DEVELOPMENT REQUIREMENT AND REPORTING STANDARD
OMPP recognizes the difficulty MCOs may have in developing networks
outside of the urban areas of the state. Instead of requiring MCOs
to concentrate on expanding networks into rural areas, MCOs
contracting with the State should focus their efforts on providing
quality health care to Hoosier Healthwise managed care members in
geographical areas where the MCOs believe they can most effectively
provide care However, MCOs are encouraged, but not required, to
develop networks in rural areas of the state.
The MCOs must maintain a comprehensive network in the service area
where the MCO is contracted to provide services.
3.6.12 QUALITY IMPROVEMENT AND UTILIZATION REVIEW PROGRAM
The MCO must monitor, evaluate, and take effective action to
identify and address any needed improvements in the quality of care
delivered to members by all providers in all types of settings. In
addition, the MCO must have a utilization review program in place
that meets the requirements specified in this BAA.
3.6.12.1 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM AND REPORTING
STANDARD
The MCO must have a quality improvement (QI) program that meets the
requirements of 42 CFR 438.240. The activities of the QI program are
to be designed in such a way that they lead to improvements in the
MCO's functioning and delivery of health care to its Hoosier
Healthwise members, and, to the extent possible, in the health
outcomes of the members.
The MCO will be required to submit quality improvement data that
includes the status and results of performance improvement projects,
as specified in the Reporting Manual. If the MCO does not comply
with the submission of the quality improvement reporting
requirements, OMPP will notify the MCO of the
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noncompliance and will designate a period of time not less than ten
(10) days in which the MCO must provide a written response to the
notification or the OMPP reserves the right to assess liquidated
damages in accordance with Section 3.16 of this BAA.
The MCO Medical Director shall be responsible for the coordination
and implementation of the QI program. The MCO shall establish an
internal committee to monitor and evaluate quality improvement
activities. The committee shall be representative of key management
staff, MCO departments, and subcontractors, if appropriate. The MCO
must send the Medical Director and/or any other appropriate
personnel to the Hoosier Healthwise Quality Improvement Committee
meetings to report on QI activities and to update OMPP on internal
activities and outcomes. The MCO must send the Medical Director
and/or any other appropriate personnel to the Clinical Advisory
Committee (CAC) meetings and to the Drug Utilization Review (DUR)
Board meetings.
OMPP reserves the right to review the qualifications of individuals
whom the MCO wishes to place in positions key to the operation of
the QI program and related functions.
The MCO must meet the following performance requirements:
- The MCO must have an internal system for monitoring services,
including clinical appropriate data collection and management
for focused studies, internal quality improvement activities,
and other quality improvement activities requested by the
OMPP.
- The MCO must conduct performance improvement projects that are
designed to achieve, through ongoing measurements and
intervention, significant improvement, sustained over time, in
clinical care and nonclinical care areas that are expected to
have a favorable effect on health outcomes and enrollee
satisfaction. The performance improvement projects must
involve the following:
- Measurement of performance using objective quality
indicators.
- Implementation of system interventions to achieve
improvement in quality.
- Evaluation of the effectiveness of the
interventions.
- Planning and initiation of activities for
increasing or sustaining improvement.
- The MCO's performance improvement projects must be completed
in a reasonable time period so as to generally allow
information on the success of
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performance improvement projects in the aggregate and to
produce new information on quality of care every year. .
- The MCO must report the status and results of each quality
improvement project to the State as requested.
- The MCO must have staff with expertise and skill sets in
quality assurance and improvement, and in data collection and
management.
- The MCO must have written policies and procedures for quality
improvement. Policies and procedures must include methods,
timelines, and individuals responsible for completing each
task.
- The MCO must have mechanisms in place for detecting over-and
under-utilization to be used in conjunction with its quality
assessment and improvement program.
- The MCO must participate appropriately in focused studies and
in other studies requested by the OMPP.
- The MCO must demonstrate an effort toward implementing
member-targeted or PMP-targeted programs that result from
areas for improvement identified through readiness review,
focused studies, and internal quality improvement efforts.
- The quality improvement program must include an assessment of
quality and appropriateness of care provided to members with
special needs, in accordance with 42 CFR 438.240(b)(4).
- The MCO must report an national performance measures developed
by CMS. The MCO must develop an approach for meeting the
desired performance levels established by CMS upon release of
the national performance measures, in accordance with 42 CFR
438.240(a)(2).
- The MCO must participate in the Hoosier Healthwise Quality
Improvement Committee (QIC), Managed Care Policy/Operations
meetings, MCO Technical meetings, and Clinical Studies
meetings. See Section 3.6.1.2.
- The MCO must submit quarterly reports, as described in the
Reporting Manual, on its QI program and activities and
performance.
- The MCO must be able to demonstrate that its QI program is
integrated throughout the organization, and by any
subcontractors, if appropriate, for the purposes of
assessment, evaluation and implementation of modifications and
changes.
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- The MCO should conduct a quality of care chart audit at least
bi-annually of providers of services, including service
providers of its subcontractors. Methods for conducting the
chart audit should be described within the quality improvement
plan.
- The MCO must participate in measuring indicators related to
areas of clinical priority and quality of care. The CAC and
the QIC will establish areas of clinical priority and
indictors of care. These may vary from one year to the next
and they will reflect the needs of the Indiana Hoosier
Healthwise population. Examples of areas of clinical priority
for which measures have been studied include:
- Immunization rates;
- EPSDT;
- Prenatal care initiation;
- Cervical cancer screening; and
- Access to care.
The MCO will be required to conduct focused studies and other
quality measures such as Medicaid HEDIS measures. Focused
studies and quality measures activities will be coordinated
with the OMPP and its designated contractor. The MCO is
expected to attend clinical studies meetings held for the
purposes of developing study design and for coordination of
related activities.
- The MCO must have procedures to measure various quality
indicators. These indicators may be modified or vary at the
discretion of the Quality Improvement Committee or Clinical
Advisory Committee. The MCO must have in place a quality
improvement process that uses at least these indicators to
refine and develop MCO policies and procedures.
- The MCO must have procedures in place to conduct performance
feedback to providers that discusses clinical and facility
indicators and ways to improve performance.
3.6.12.2 UTILIZATION REVIEW (UR) REQUIREMENT AND UR REPORTING STANDARD
The MCO must maintain an efficient utilization review program that:
- Identifies instances of over-and under-utilization
- Identifies aberrant provider practice patterns
- Ensures active participation of a normal review committee
- Evaluates efficiency and appropriateness of service delivery
- Facilitates program management and long-term quality
- Identifies critical quality of care issues.
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The MCO is encouraged to monitor utilization through retrospective
reviews. As part of the utilization review, the MCO must monitor
utilization of preventive care services by members and access to
preventive care, specifically to identify members who are not
accessing preventive care services, as appropriate, and in
accordance with preventive care standards, during their enrollment
period with the MCO. The MCO is responsible for conducting follow-up
education to the identified members to ensure that preventive care
services are accessed appropriately and in accordance with
preventive care standards.
The major components of the MCO's utilization review (UR) program
should encompass, at a minimum, the following:
- A utilization review committee directed by the MCO's Medical
Director to oversee the utilization review process.
- Sufficient resources to regularly review the effectiveness of
the utilization review process, and to make changes to the
process as needed.
- The MCO must have written policies and procedures for
utilization management and authorization of service that
conform with industry standards. Policies and procedures must
include methods, timelines, and individuals responsible for
completing each task. The MCO must require that all
subcontractors comply with these policies and procedures.
In accordance with 42 CFR 438.210, the MCO's utilization review
program must comply with the following requirements:
- The MCO must adopt practice guidelines that are based on valid
and reliable clinical evidence or consensus among clinical
professionals, and consider the needs of members. Guidelines
must be selected upon consultation with contracting
professionals and must be reviewed and updated periodically.
The MCO must distribute the guidelines to all providers and
make the guidelines available to all members and potential
members upon request.
- The MCO must consistently apply review criteria and consult
with requesting providers, as appropriate.
- Clinical professionals who have appropriate clinical expertise
in the treating member's condition or disease must make all
decisions to deny a service authorization request or to
authorize a service in an amount, duration or scope that is
less than requested.
- The MCO must define service authorizations in a manner that at
least includes a member's request for the provision of a
service.
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- The MCO must provide a notice of action to members in writing,
which notifies members of decisions to deny a service
authorization request or to authorize a service in an amount,
duration or scope that is less than requested. Notices must be
mailed a least 10 days prior to the effective date of the
action. The notifications must meet all requirements stated
within 3.6.7.4.1 and 3.6.7.4.2 regarding non-prevalent
languages, oral interpretation and format. The form letters
used must be approved by OMPP. In addition, the MCO must also
provide written notification to the requesting provider. The
member notification must clearly explain:
- The action the MCO has or intends to take (i.e.,
deny or reduce services)
- The reason for the action
- The member's or the provider's right to file an
appeal
- The procedures for exercising the member's right
to file an appeal or grievance
- The circumstances under which the member may file
an expedited grievance or appeal and the process
for requesting and expedited resolution
- The enrollee's right to have benefits continue
pending the resolution of an appeal and the
process for requesting continued benefits
- The circumstances under which a member may be
required to pay the costs of continued benefits
- The enrollee's right to represent himself or use
legal counsel, a relative, a friend or other
spokesman
- The specific regulations that support the action
- If the member has exhausted the MCO's appeal
process, an explanation of the enrollee's right to
request a FSSA Hearing.
- The MCO must notify members of standard authorization
decisions as expeditiously as required by the member's health
condition, not to exceed 14 calendar days after the request
for services. Extensions of up to 14 calendar days are
permitted if the member or provider requests an extension or
if the MCO justifies to the State a need for more information
and explains how the extension is in the member's best
interest. If the MCO does not make a decision within the
timeframe, the MCO must notify the member on the last day of
the decision timeframe that is has not made a decision. OMPP
considers untimely decisions to be denials.
- The MCO must make and notify enrollees of decisions to
terminate, suspend, or reduce previously authorized Hoosier
Healthwise-covered services at least 10 days before the date
of action, with the following exceptions:
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- Notice is shortened to five days if probable member fraud has
been verified
- Notice may occur no late than the date of the action in the
event of:
- The death of a member;
- The MCO's receipt of a signed written statement
from the member requesting service termination or
giving information requiring termination or
reduction of services (the member must understand
the result of supplying this information);
- The member's admission to an institution and
consequential ineligibility for further services;
- The member's inaccessibility via mail in the event
that the member's address is unknown and mail
directed to the member him has no forwarding
address;
- The member's acceptance for Medicaid services by
another local juriscdiction;
- A prescribed change in the level of medical care
by the member's physician;
- An adverse determination made with regard to the
preadmission screening requirements for NF
admissions on or after January 1, 1989; or
- Endangered safety or health of the individuals in
the facility;
- Sufficient improvement in the resident's health
that allows a more immediate transfer or
discharge
- An immediate transfer or discharge required by the
member's urgent medical needs
- A member's residency in the nursing home of less
than 30 days
- The MCO must notify the member of a decision to deny payment
on the day of the MCO's decision.
- The MCO makes expedited review decisions as expeditiously as
required by the member's condition, but no later than three
business days after the request, when appropriate. The
expedited review period may be extended up to 14 calendar days
if requested by the member. If the MCO does not make a
decision within the timeframe, the MCO must notify the member
on the last day of the decision timeframe that is has not made
a decision. OMPP considers untimely decisions to be denials.
- The MCO must not provide incentives for denying, limiting or
discontinuing medically necessary services to individuals that
conduct utilization management
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- The services provided under this contract must be no less than
the amount, duration, and scope for the same services furnished
under Traditional Medicaid. Pursuant to 42 CFR 438.210(a)(3), the
MCO may place appropriate limits on coverage on the basis of
medical necessity or utilization control criteria, provided the
services furnished can reasonably be expected to achieve their
purpose. The MCO is prohibited from arbitrarily denying or
reducing the amount, duration or scope of required services solely
because of diagnosis, type of illness or condition.
A written UR plan detailing how the MCO's UR program works, and how
it relates to PMPs and other providers via individual feedback, must
be submitted to the OMPP with the first quarterly report of 2001.
OMPP may assess liquidated damages, as specified in Section 3.16,
for MCO non-compliance with this reporting standard.
3.6.13 MANAGEMENT INFORMATION SYSTEMS
In accordance with 42 CFR 438.242, the MCO must have available a
claims processing and management information system sufficient to
support network provider claims payments and data reporting between
the MCO and the State or its designee, including but not limited to
utilization, grievances and appeals. The MCO must demonstrate and
maintain the capability to control, process, and pay providers for
services rendered to plan members in accordance with Indiana Code
12-15-13.
The MCO will receive detailed claims submissions from both network
and out-of-network providers. The MCO shall have the capability to
collect and generate service-specific procedures and diagnosis data
on a per member basis, to price specific procedures or encounters
(depending on the agreement between the provider and the MCO), and
to maintain detailed records of remittances to providers. The MCO is
responsible for annual 1099 reporting of provider earnings. The MCO
must have written policies, procedures and an operational plan in
place for information systems that will transmit shadow claims to
the State no later than one year from the date of services. The MCO
is expected to meet a shorter time frame for a specified percentage
of claims. See Section 3.6.13.3 for the shadow claims requirements.
Management information systems capabilities are necessary to
collect, analyze, integrate and report data for the following areas:
- Member data exchange
- Provider data exchange
- Member and provider grievances and appeals
- MCO provider network data, including additions, changes, and
deletions
- Shadow claim/encounter data reporting
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- Third party liability
- Claims processing
- internal quality improvement measures
- Utilization monitoring, including tracking and monitoring members
with special needs
The MCO must make all collected information available to OMPP and
upon request to CMS.
OMPP requirements in each of the areas listed above are described in
the following subsections. The MCO must also meet the quarterly
reporting requirements listed in the Reporting Manual.
3.6.13.1 MEMBER ENROLLMENT DATA CHANGE
As stated in Section 3.5.3, OMPP will maintain enrollment data and
notify the MCOs of members who are enrolled with the MCO. OMPP will
maintain an updated enrollment roster as a part of the Indiana
eligibility file for MCOs. This eligibility file will determine the
monthly capitation payment for the MCO.
The MCO must verify member eligibility and the capitation received
for each eligible member. The MCO is financially responsible for any
member for whom it receives eligibility or capitation. The MCO must
have a process to reconcile their eligibility and capitation records
monthly. The MCO must identify eligibility/capitation discrepancies
and notify OMPP or EDS within 30 days of discovering the
discrepancy.
The MCO must accept enrollment data via cartridge or bulletin board
access as directed by OMPP. The MCO must load the eligibility
information into their claims system within five days of receipt.
Because the enrollment rosters are produced semi-monthly and the
IndianaAIM system is updated with daily ICES transmissions, changes
in enrollment may occur during the interim period between the
production of the roster and the effective date. For example, a
member who is auto-assigned to an MCO on the 20th day of the month
with an effective date on the first day of the following month
appears on the MCO enrollment roster produced on the 26th of the
month. If that member loses eligibility in the Hoosier Healthwise
program, and that loss is reported between the 26th day and the end
of the month, this deletion is included on the second enrollment
roster of the month. Because the member lost eligibility prior to
the effective date in the MCO network, he or she is reported as a
deleted member on the next enrollment roster. An automated
eligibility reconciliation process is currently in development. When
completed, this process will assist MCOs in the reconciliation of
membership records at quarterly intervals.
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3.6.13.2 CLAIMS PROCESSING
MCOs must have a detailed approach to claims processing, including
electronic claims submission (ECS), for both in and out-of-network
providers that submit claims. The approach should address all claim
types (CMS 1500, UB92, and Pharmacy). The MCO must comply with the
claims processing standards under Indiana Code 12-15-13-1.6 and
12-15-13-1.7.
The approach should also take into account communication with
providers, particularly out-of-network providers, and ensure that
submission requirements are efficient and not burdensome for all
providers. For example, the MCO could establish a central claims
submission point for all out-of-network and self-referral providers.
The MCO must adhere to any federally mandated electronic claims
submission standards and any other standards as directed by OMPP.
3.6.13.3 SHADOW CLAIMS REPORTING
It is OMPP's goal to improve the quality of, and access to, Hoosier
Healthwise services. In order to ensure that these goals are being
met in Hoosier Healthwise, OMPP must track expenditures and service
utilization on an ongoing and regular basis.
The State must collect information that is sufficient to calculate
future capitation rates. Information must also be collected that
enables the calculation of reimbursement rates for the
fee-for-service reimbursement system. This information is gathered
in the form of shadow claims (or encounter data). Shadow claims are
reports of individual patient encounters with an MCO's healthcare
network. These claims contain fee-for-service equivalent detail as
to procedures, diagnoses, place of service, billed amounts, and
rendering/billing providers, as well as detailed claims data for
utilization analysis, quality improvement program analysis, and
future capitation rate adjustments.
The MCO must collect shadow claims/encounter data in standard
formats and verify that the data is accurate, complete and timely.
The MCO is responsible for ensuring the timely receipt of shadow
claims from its capitated providers. The MCO is also responsible for
the timely provision of shadow claims to OMPP. The MCO must have
policies for using incentives, sanctions, or other sanction-like
programs to ensure timely receipt of shadow claims from its
capitated providers.
Shadow claims will be reviewed for, at least, four elements:
timeliness, completeness, correctness and accuracy. See Section
3.6.13.3.1 below for the specifics of what is expected for each of
these named elements. The State will assess liquidated damages, in
accordance with Section 3.16 of this BAA, for failure to comply with
these requirements.
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3.6.13.3.1 SHADOW CLAIMS REQUIREMENTS AND SUBMISSION STANDARDS
MCOs must submit shadow claims data in an electronic format that
adheres to the data specification in the Electronic Claims
Submission Manual and any other federally mandated electronic claims
submission standard. The MCO must submit at least one batch of
shadow claims for UB-92, CMS 1500 and pharmacy claims each month.
More than one submission is acceptable, but an overall average of
calendar monthly submissions will be assessed for compliance with
requirements below and will be subject to liquidated damages
assessments for non-compliance.
A shadow claim must be submitted to the State's fiscal agent for
every service rendered to an MCO member MCOs must meet requirements
for shadow claims submissions for the elements of timeliness,
completeness, correctness, and accuracy as follows:
TIMELINESS: The MCO must file a shadow claim within 365 days from
the first date of service
The OMPP will conduct an annual review to determine MCO compliance
with the submission schedule and liquidated damages will be
assessed, in accordance with Section 3.16 of this BAA.
COMPLETENESS: Each shadow claim will be assessed for its compliance
with pre-cycle edits. For each batch of shadow claims submitted, 98
percent of the batch must pass all pre-cycle edits. The remaining
two (2) percent must be corrected and resubmitted until a 100
percent accuracy rate is achieved. Each time the batch is
resubmitted, it is treated as a new submission and checked for
compliance with the 98 percent standard. As batches are resubmitted,
these batches will be included in the overall average of calendar
monthly submissions. Liquidated damages will be assessed, per claim
type, in accordance with the schedule in Section 3.16 of this BAA,
for submissions that fall below the 98 percent standard.
CORRECTNESS: For each claim type submitted in shadow claims, 85
percent of those claims must adjudicate with a paid status in a
calendar month. Each resubmission will be included in the overall
average of calendar monthly submissions for the calculation of
paid/denied status. Eighty-five percent of all shadow claims must be
adjudicated in IndianaAIM with a paid status within 365 days of the
first date of service on the claim. Liquidated damages will be
assessed, by claim type, in accordance with the schedule in Section
3.16 of this BAA, for submissions that fall below the 85 percent
compliance standard. The OMPP recognizes that certain claims will be
denied appropriately, so it may not be possible at any time to
attain 100 percent paid claims. However, the remaining 15 percent
must be corrected and resubmitted with a goal of achieving as close
to 100 percent paid status as possiible.
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ACCURACY: In addition, the MCO must ensure that shadow claims
submissions are accurate. The MCO must submit to OMPP its internal
criteria for determining claims payment accuracy, their internal
standard for an acceptable level of accuracy, as well as its
monitoring plan for determining levels of accuracy. The monitoring
plan must include a description of any liquidated damages, sanctions
or sanction-like provisions employed to ensure accuracy of claims,
and how often the MCO conducts its claims accuracy audits. The OMPP
will regularly monitor MCO shadow claims for accuracy. The OMPP
reserves the right to assess liquidated damages, similar to that
described in the MCO monitoring plan for non compliance. The MCO
must submit the status and results of its internal Hoosier
Healthwise claims audit to OMPP. OMPP reserves the right to re-audit
claims or perform a random sample audit of all claims.
The MCO shall report problem(s) with shadow claims submissions at
the monthly MCO technical meeting. The purpose of the meeting is
to provide a forum for MCO technical support staff to ask questions
related to data exchange issues and shadow claims issues. In
addition, the MCO must report on the measures it is taking to
correct any shadow claims submission problem(s) that have been
identified. The MCO must include a discussion of the quarter's
claims submission problem(s) and its corrective action plan and
progress in the quarterly quality report submitted to OMPP.
3.6.13.4 THIRD-PARTY LIABILITY REPORTING
Federal regulations require that OMPP's contract with risk-based
managed care entities specify any activities to be performed by the
MCO relating to third party liability (TPL) requirements in 42 CFR
433.138, Subpart D. MCOs will be responsible for identifying and
collecting third party liability information, and may retain third
party liability collections.
The State's fiscal agent will provide each MCO with a monthly
listing, on tape, of the known TPL resources for its members. The
tape will be produced monthly and will report information relating
to:
- Member name/RID/SSN
- Carrier name/Address/Phone number/Contact person
- Policyholder name/Address/SSN/Relationship to member
- Policy number/Effective date/Coverage type
The MCO will provide the same categories of information to the
fiscal agent each month for those members where it identifies newly
discovered health insurance, a change in an member's health
insurance coverage, or casualty insurance coverage available to an
member that has not been included in the fiscal agent's monthly
listing.
The MCO shall notify the local county DFC office within 30 days of
the date it becomes aware of the death of one of its Hoosier
Healthwise members, giving the
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member's full name, address, Social Security Number, member
identification (RID) number, and date of death. The MCO will have no
authority to pursue recovery against the estate of a deceased
Medicaid member.
As TPL information is a component of capitation rate development,
MCOs must maintain records regarding TPL collections sufficient to
comply with the financial reporting requirements described in this
BAA. TPL recovery information will be reported to OMPP annually.
3.6.13.4.1 MCO TPL RESPONSIBILITIES - COST AVOIDANCE
When the MCO is aware of health or casualty insurance coverage prior
to paying for a health care service for a member, it shall avoid
payment by rejecting a provider's claim and direct that the claim be
submitted first to the appropriate third party.
If insurance coverage is not available, or if one of the exceptions
to the cost avoidance rule discussed in Section 3.6.13.4.2 applies,
then payment must be made and a claim made against the third party,
if it is determined that the third party is or may be liable.
The MCO must ensure that its cost avoidance efforts do not prevent a
member from receiving medically necessary services in a timely
manner.
3.6.13.4.2 COST AVOIDANCE EXCEPTIONS
In the following situations, the MCO must first pay the provider and
then coordinate with the liable third party:
- The coverage is derived from a parent whose obligation to pay
support is being enforced by the State Title IV-D Agency and the
provider of service has not received payment from the third party
within 30 days after the date of service.
- The claim is for prenatal care for a pregnant woman or for
preventive pediatric services (including EPSDT) that are covered
by the Medicaid program.
- The claim is for labor, delivery and post-partum care, and does
not involve hospital costs associated with the inpatient hospital
stay.
If any other third party payor fails to respond within 90 days of
the date of the provider's attempt to xxxx, the MCO must pay the
claim upon submission by the provider of the claim and documentation
supporting the billing provider's persistent attempts to obtain
payment. Such documentation can include copies of unpaid bills or
statements sent to the third party or copies of complaints filed
with the Department of Insurance. A written explanation from the
billing provider of
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attempts to xxxx, dates of contracts, and response of third party
should also be included. The MCO can propose other documentation
requirements, but must assure that any additional requirements do
not serve only to further delay payment.
If the MCO was not aware of third party coverage at the time
services were rendered or paid for, the MCO shall pursue
reimbursement from potentially liable third parties, if it is
cost-effective to do so.
The OMPP has a cost avoidance waiver for pharmacy claims. This means
that pharmacy providers, unlike other Medicaid providers, are not
required to xxxx potentially liable third parties before filing
claims for Medicaid payment. The MCO may negotiate agreements with
its contracted pharmacy providers to cost avoid; however, if there
are situations where the MCO is responsible for payment of an
out-of-network or out-of-area claim to a non-contracted pharmacy
provider, the MCO must follow fee-for service policy by paying the
claim, including any co-payments, and then pursuing reimbursement
from the liable third party.
3.6.13.4.3 COORDINATION OF BENEFITS
If a Hoosier Healthwise member enrolled with the MCO is also
enrolled or covered by a health or casualty insurer, the MCO is
fully responsible for coordinating benefits so as to maximize the
utilization of third party coverage. The MCO must share information
on its members with special health care needs, with other MCOs, as
specified by OMPP and in accordance with 42 CFR 438.208(b). In the
process of coordinating care, the MCO must protect each member's
privacy in accordance with the confidentiality requirements stated
in 45 CFR 160 and 164. The MCO shall be responsible for payment of
the member's coinsurance, deductibles, co-payments, and other
cost-sharing expenses, but the MCO's total liability shall not
exceed what the MCO would have paid in the absence of TPL, after
subtracting the amount paid by the primary payor. There is one
exception to this general rule because of the cost avoidance waiver
discussed in the previous section. Co-payments imposed by a primary
payor for pharmacy services remain the responsibility of the MCO,
regardless of the amount paid for the service by the primary
insurer. This exception does not apply to deductibles or coinsurance
amounts for pharmacy services or co-payments, deductibles or
coinsurance amount for any other service.
The MCO shall coordinate benefits and payments with the health or
casualty insurer for services authorized by the MCO, but provided
outside the MCO's plan. Such authorization may occur prior to
provision of service but any authorization requirements imposed on
the member or provider of service by the MCO must not prevent or
unduly delay a member from receiving medically necessary services.
MCOs must include in their responses a detailed explanation of any
authorization procedures they propose as part of their coordination
of benefits efforts. The MCO remains responsible for the costs
incurred by the member with respect to
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care and services which are included in the MCO's capitation rate,
but which are not covered or payable under the health or casualty
insurer's plan.
If the Hoosier Healthwise member's primary insurer is a commercial
HMO and the MCO cannot efficiently coordinate benefits because of
conflicts between the primary HMO's rules and the MCO's rules, the
MCO may submit a written request for disenrollment to the enrollment
broker. The request must provide the specific description of the
conflicts and explain why benefits cannot be coordinated. The
enrollment broker will consult with the OMPP and the request for
disenrollment will be considered and acted upon promptly.
3.6.13.4.4 CASUALTY CASES
The MCO may exercise any independent subrogation rights it may have
under Indiana law in pursuit or collection of payments it has made
when a legal cause of action for damages is instituted by the member
or on behalf of the member. Any recoveries made may be retained by
the MCO, but must be reported to the OMPP.
3.6.14 FINANCIAL REPORTING REQUIREMENTS
The MCO must submit financial information including:
- Department of Insurance quarterly audited statements
- Certified annual audits
- The final management letter provided by the independent certified
public accountants shall be provided to OMPP along with the
required financial statements
- Insurance and re-insurance coverage
- Health Employer Data Information Set (HEDIS(R)) Financial
Stability Indicators
- Utilization rates by category of service
Please see Appendix 4 for financial reporting requirements.
If the MCO does not meet the financial requirements, the State will
notify the MCO of the non-compliance and designate a period of time,
not less than ten days in which the MCO must provide a written
response to the notification. OMPP will reserve the right to assess
liquidated damages in accordance with Section 3.16 of this BAA.
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3.6.15 DISPUTE RESOLUTION PROCESSES
A contract between the MCO and another entity for the provision of
services under the Hoosier Healthwise managed care program must
include a contract clause outlining a dispute resolution procedure
for all disputed claims. The MCO also must develop and maintain a
dispute resolution process to resolve disputed claims between the
MCO and any provider not contracted with the MCO. The dispute
resolution process must be in compliance with the Claims Dispute
Resolution process outlined in the MCO's contract with the State.
3.7 REINSURANCE REQUIREMENTS
The MCO must purchase reinsurance from a commercial reinsurer and
must establish reinsurance agreerments meeting the requirements
listed below. These agreements must be reviewed and approved by the
State prior to their effective date.
- The attachment point must be equal to or less than $75,000.
- Reinsurance agreements must transfer risk from the ceding company
to the reinsurer.
- The reinsurer's payment to the ceding company must depend on and
vary directly with the amount and timing of claims settled under
the reinsured contract. Contractual features that delay timely
reimbursement are not acceptable.
- The MCO must follow the National Association of Insurance
Commissioners' (NAIC) Reinsurance Accounting Standards and
document its compliance with NAIC.
- Subcontractors' reinsurance coverage requirements must be clearly
defined in the reinsurance agreement.
- If subcontractors do not obtain reinsurance on their own, the MCOs
should be required to forward appropriate recoveries from
stop-loss coverage to applicable subcontractors.
- MCOs must receive reinsurance coverage of at least
$2,000,000/member/year.
- If the MCO elects to self-insure, it must provide audited
financial information on its insurance subsidiary and obtain
Xxxxx'x or Standard and Poor's bond and claims-paying ability
ratings for its insurance subsidiary.
- MCOs must obtain continuation of Coverage (Insolvency Insurance)
to cover members who are in an acute care hospital/nursing
facility setting until their
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discharge and to continue plan benefits for members until the end
of the period for which premiums have been paid.
- Subcontractors should be encouraged to obtain their own stop-loss
coverage with the above-mentioned terms.
- MCOs are required to obtain reinsurance from insurance
organizations that have S&P claims-paying ability ratings of "AA"
or higher.
- MCOs are required to obtain reinsurance from insurance
organizations that also have Xxxxx'x bond ratings of "A1" or
higher.
3.8 CHANGE IN SCOPE OF WORK
An approved contract amendment is required whenever a change affects
the payment provisions, the term or scope of the contract. Formal
contract amendments may be negotiated by the State with the MCO on
an annual basis to address changes to the terms and conditions, or
the cost of the scope of work included under the contract which may
result from new federal or state legislative requirements or medical
policy mandates. An approved contract amendment is defined as one
approved by OMPP, the MCO, and all other applicable State and
Federal agencies prior to the effective date of such change.
IFSSA/OMPP may use contract amendments to reduce or increase the
scope of services in MCO contracts prior to their expiration to
comply with changes in federal mandates for the Medicaid and/or CHIP
Program or other circumstances as deemed necessary by the State. The
State will establish processes for notifying MCOs of such changes
when they occur and may adjust MCO capitation payments as determined
by the State's actuaries.
3.9 TERMINATION OF CONTRACT
The contract between the parties may be terminated on the following
bases listed below:
- By mutual written agreement of the State and MCO.
- By the State, in whole or in part, whenever the State determines
that the MCO has failed to satisfactorily perform its contracted
duties and responsibilities and is unable to cure such failure
within 60 days after receipt of a notice specifying those
conditions.
- By the State, in whole or in part, whenever, for any reason, the
State shall determine that such termination is in the best
interest of the State, with sufficient prior notice to the MCO as
defined by Section 3.9.2.
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- By the State, in whole or in part, whenever funding from
State, Federal, or other sources are withdrawn, reduced, or
limited, with sufficient prior notice to the MCO.
- By the State, in whole or in part, whenever the State
determines that the instability of the MCO's financial
conditions threatens delivery of Medicaid services and
continued performance of MCO responsibilities.
Each of these circumstances is incorporated in the following sections.
The State will provide the MCO with a hearing prior to contract
termination in accordance with the 42 CFR Section 438.708. The notice
of termination will include appeal rights. After the State notifies an
MCO that it intends to terminate the contract, the State may give the
MCO's members written notice of the State's intent to terminate the
contract and allow the members to disenroll immediately.
3.9.1 TERMINATION FOR DEFAULT
The State may terminate the Contract, in whole or in part, whenever the
State determines that the MCO or subcontractor has failed to
satisfactorily perform its contracted duties and responsibilities and
is unable to cure such failure within a reasonable period of time as
specified in writing by the State, taking into consideration the
gravity and nature of the default. Such termination shall be referred
to herein as "Termination for Default."
Upon determination by the State that the MCO has failed to
satisfactorily perform its contracted duties and responsibilities, the
MCO shall be notified in writing, by either certified or registered
mail, of the failure and of the time period of sixty (60) days which
has been established to cure such failure. If the MCO is unable to cure
the failure within the specified time period, the State will notify the
MCO that the Contract, in full or in part, has been terminated for
default.
If, after notice of termination for default, it is determined by the
State or by a court of law that the MCO was not in default or that the
MCO's failure to perform or make progress in performance was due to
causes beyond the control of, and without error or negligence on the
part of, the MCO or any of its subcontractors, the notice of
termination shall be deemed to have been issued as a termination for
the convenience of the State, and the rights and obligations of the
parties shall be governed accordingly.
In the event of termination for default, in full or in part, as
provided under this clause, the State may procure, upon such terms and
in such manner as is deemed appropriate by the State, supplies or
services similar to those terminated, and the MCO shall be liable for
any costs for such similar supplies and services and all other damages
allowed by law. In addition, the MCO shall be liable to the State for
administrative costs incurred to procure such similar supplies or
services as are needed to continue operations.
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In the event of a termination for default prior to the start of
operations, any claim the MCO may assert shall be governed by the
procedures defined in Section 3.9.6 of this BAA.
In the event of a termination for default during ongoing operations,
the MCO shall be paid for any outstanding capitation payments due, less
any assessed damages.
The rights and remedies of the State provided in this clause shall not
be exclusive and are in addition to any other rights and remedies
provided by law or under the Contract.
3.9.2 TERMINATION FOR CONVENIENCE
The State may terminate performance of work under the Contract, in
whole or in part, whenever, for any reason, the State shall determine
that such termination is the most appropriate action for the State of
Indiana. The provisions of this clause may also be applied to a
termination of mutual agreement.
In the event that the contract is terminated pursuant to this
provision, the MCO shall be notified in writing by either certified or
registered mail either sixty (60) days prior to or such other
reasonable period of time prior to the effective date, of the basis and
extent of termination. Termination shall be effective as of the close
of business on the date specified in the notice.
3.9.3 TERMINATION FOR UNAVAILABLE FUNDS
When the Director of the State Budget Agency makes a written
determination that funds are not appropriated or otherwise available to
support continuance of performance of this Contract, the Contract shall
be canceled. A determination by the Budget Director that funds are not
appropriated or otherwise available to support continuation of
performance shall be final and conclusive.
3.9.4 TERMINATION FOR FINANCIAL INSTABILITY
In the event that the MCO becomes financially unstable to the point of
threatening the ability of the State to obtain the services provided
for under the Contract, ceases to conduct business in normal course,
makes a general assignment for the benefit of creditors, or suffers or
permits the appointment of a receiver for its business or assets, the
State may, at its option, immediately terminate this Contract effective
at the close of business on the date specified. In the event the State
elects to terminate the contract under this provision, the MCO shall be
notified in writing, by either certified or registered mail, specifying
the date of termination. The MCO shall submit a written waiver of the
MCO's rights under the federal bankruptcy laws. In the event of the
filing of a petition in bankruptcy by or against a principal
subcontractor, the MCO shall immediately so advise the Contract
Administrator as specified in the contract between the State and the
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MCO. The MCO shall ensure that all tasks related to the subcontract are
performed in accordance with the terms of this Contract.
3.9.5 TERMINATION FOR FAILURE TO DISCLOSE RECORDS
The State may terminate the Contract, in whole or in part, whenever the
State determines that the MCO has failed to make available to any
authorized representative of the State, any administrative, financial
and medical records relating to the delivery of times or services for
which State Medicaid and CHIP program dollars have been expended.
In the event that the Contract is terminated pursuant to this
provision, the MCO shall be notified in writing, either by certified or
registered mail, either sixty (60) days prior to or such other
reasonable period of time prior to the effective date, of the basis and
extent of the termination. Termination shall be effective as of the
close of business on the date specified in the notice.
3.9.6 PROCEDURES FOR TERMINATION
Upon delivery by certified mail or registered mail to the MCO of a
Notice of Termination, specifying the nature of the termination and the
date upon which such termination becomes effective, the MCO shall:
- Stop work under the Contract on the date, and to the extent
specified in the Notice of Termination.
- Place no further orders or subcontracts for materials,
services or facilities.
- Notify all of the MCO's members regarding the date of
termination and the process by which members will continue to
receive medical care.
- Terminate all orders and subcontracts to the extent that they
relate to the performance of work terminated by the Notice of
Termination.
- Assign to the State in the manner, and to the extent that they
relate to the performance of work terminated by the Notice of
Termination.
- Assign to the State in the manner, and to the extent directed,
all of the rights, titles, and interests of the MCO under the
orders or subcontracts so terminated.
- With the approval of the State, settle outstanding liabilities
and all claims arising out of such termination of orders and
subcontracts.
- Within ten working days from the effective date of the
termination, transfer title to the State of Indiana (to the
extent that title has not already been transferred) and
deliver, in the manner and to the extent directed, all data,
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other information and documentation, in any form that relates
to the work terminated by the Notice of Termination.
- Complete the performance of such part of the work as has not
been specified for termination by the Notice of Termination.
- Take such action as may be necessary, or as the State may
direct, for the protection and preservation of the property
related to the Contract which is in the possession of the MCO
and in which the State has or may acquire an interest.
- Assist the State in taking the necessary steps to ensure a
smooth transition of Requested Services after receipt of the
Notice of Termination.
The MCO acknowledges that any failure or unreasonable delay on its part
in affecting a smooth transition will cause irreparable injury to the
State, which may not be adequately compensable in damages. The MCO
accordingly agrees that the State may, in such event, seek and obtain
injunctive relief, as well as monetary damages. Any payments made by
the State pursuant to this section may also constitute an element of
damages in any action in which MCO default is alleged.
The MCO shall proceed immediately with the performance of the above
obligations. Upon termination of this Contract in full, the State shall
require the MCO to return to the State any property made available for
its use during the Contract term.
3.9.7 REFUNDS OF ADVANCED PAYMENTS
The MCO shall, within thirty (30) days of receipt, return any funds
advanced for coverage of members for periods after the date of
termination of the contract.
3.9.8 LIABILITY FOR MEDICAL CLAIMS
The MCO shall be liable for all medical claims incurred up to the date
of termination. This shall include the relevant portion of hospital
inpatient claims incurred for members hospitalized at the time of
terminating.
3.9.9 TERMINATION CLAIMS
If the Contract is terminated under this section, the MCO shall be
entitled to be paid a prorated capitation amount, determined by the
State based on available information, for the month in which notice of
termination was received for the service days prior to the effective
date of termination. The MCO shall have the right of appeal, as stated
under the subsection on Disputes, of any such determination. The MCO
shall not be entitled to be paid for any services performed after the
effective date of termination.
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3.9.10 RIGHT TO SUSPEND OPERATIONS
If, at any time during the operations phase of the Contract, the state
determines that it is in its best interest to temporarily suspend
enrollment, reassign all or some members to another health plan,
terminate payments, or any part thereof, the State may do so by
providing the MCO with written notice to that effect. The MCO shall,
immediately upon receipt of such notice, cease providing services for
the period specified in such notice. The MCO shall be responsible for
any administrative costs incurred by the State as a result of
suspending operations.
3.10 INDEMNIFICATION
The MCO, its subcontractors and its providers shall indemnify and hold
harmless the State, its officers, and employees from all suits,
actions, or claims of any character brought because of injuries or
damage received or sustained by any person, persons, or property. The
contracting MCO also undertakes to indemnify and hold the State
harmless from all losses, costs, damages, and all fees arising out of
or in any manner connected with the MCO's performance of managed care
services under the contract. The State shall not provide such
indemnification to the contractor.
3.11 KICKBACKS
Each MCO must certify and warrant that no gratuities, kickbacks, or
contingency fees were paid in connection with the contract, nor were
any fees, commissions, gifts, or other considerations made contingent
upon the award of the contract.
3.12 ASSIGNMENTS
MCOs shall not sell, transfer, assign, or otherwise dispose of the
contract or any portion thereof or of any right, title, or interest
therein without the prior written consent of the state. Such consent,
if granted, shall not relieve the MCO of its responsibilities under the
contract. This provision includes reassignment of the contract due to
change in ownership of the organization.
3.13 AUDIT OR EXAMINATION OF RECORDS
Throughout the duration of the contract term, or until all other
pending matters are closed, whichever is later, and for a period of
three years after termination of the contract, each MCO, in accordance
with 45 CFR, 92.36(i), shall agree that the State Board of Accounts or
any authorized representative of the State, and where Federal funds are
involved, the Comptroller General of the United States or any other
authorized representative of the United States Government, shall have
access to, and the right to examine, audit, excerpt, and transcribe any
pertinent books, documents, paper, and records of the contractor
related to order, invoices, or payments under the contract. The
contractor further expressly agrees to provide full cooperation and
access to such records and personnel and to provide
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such information as shall be requested by the state Insurance
Commissioner or her designee.
3.14 FINANCIAL ACCOUNTING REQUIREMENTS
Each MCO shall maintain accounting records relating directly to
performance of the contract. Accounting records shall be maintained in
accordance with generally accepted Federal cost accounting standards
and principles and in accordance with NAIC. The MCO must provide
documentation that it is in compliance with NAIC standards. In
accordance with 42 CFR 455.100-104, the MCO must notify OMPP of any
person or corporation with five percent or more of ownership or
controlling interest in the MCO and must submit financial statements
for these individuals or corporations. Financial records should include
matters of ownership, organization, and operation of the MCO's
financial, medical, and other record keeping systems.
Authorized representatives or agents of the State and the Federal
government shall have access to the MCO's accounting records and the
accounting records of its subcontractors upon reasonable notice and at
reasonable times during the performance and/or retention period of this
contract for purposes of review, analysis, inspection, audit, and/or
reproduction. In addition, each MCO shall file with the State Insurance
Commissioner under oath and on a form prescribed by the State Insurance
Commissioner, the financial and other information required.
Non-federally qualified MCO's must report a description of certain
transactions with parties of interest.
Copies of any accounting records pertaining to the contract shall be
made available by the MCO within ten days of receiving a written
request from the State for specified records. If such original
documentation is not made available as requested, the MCO agrees to
provide transportation, lodging, and subsistence at no cost, for all
State and/or Federal representatives to carry out their audit functions
at the principal offices of the MCO or other locations of such records.
The Family and Social Services Administration, The Indiana Department
of Insurance, and other State and Federal agencies and their respective
authorized representatives or agents shall have access to all
accounting and financial records of any individual, partnership, firm,
or corporation insofar as they relate to transactions with any
department, board, commission, institution, or other State or Federal
agency connected with the contract.
Financial records pertaining to the contract, including all claims
records, shall be maintained for three years following the end of the
Federal fiscal year during which the contract is terminated, or when
all State and Federal audits of the contract have been completed,
whichever is later, in accordance with 45 CFR 74.53. However,
accounting records pertaining to the contract shall be retained until
final resolution of all pending audit questions and for one year
following the terminating of any litigation relating to the contract if
the litigation has not
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terminated within the three year period. Accounting records and
procedures shall be subject to State and Federal approval.
In addition to the above, the MCO shall be subject to the applicable
suspension, revocation and penalty provisions imposed by the State
Insurance Commissioner.
3.15 CONTRACT PERFORMANCE DISPUTES AND APPEALS
The Assistant Secretary of OMPP shall be authorized to resolve contract
disputes between Contractors and OMPP upon the submission of a request
in writing from either party. The request shall provide:
- A description of the problem, including all appropriate
citations and references from the contract in question
- A clear statement by the party requesting the decision of his
interpretation of the contract
- A proposed course of action to resolve the dispute
The Assistant Secretary of OMPP shall determine whether:
- The interpretation provided is appropriate
- The proposed solution is feasible
- Another solution may be negotiable
The Contractor agrees that, the existence of a dispute notwithstanding,
it will continue without delay to carry out all its responsibilities
under this contract which are not affected by the dispute. Should the
Contractor fail to continue without delay to perform its
responsibilities under this contract in the accomplishment of all
nondisputed work, any additional costs incurred by the Contractor or
the State as a result of such failure to proceed shall be borne by the
Contractor, and the Contractor shall make no claim against the State of
Indiana for such costs. If the Contractor and the OMPP cannot resolve a
dispute within ten working days following notification in writing by
either party of the existence of said dispute, then the procedures
outlined in the contract between the MCO and the State shall apply.
3.16 LIQUIDATED DAMAGES AND OTHER REMEDIES FOR CONTRACT NON-COMPLIANCE
In the event that the MCO fails to meet performance requirements or
reporting standards set forth in this BAA, the contract, or reporting
requirements schedule, it is agreed that damages shall be sustained by
the State and the MCO shall pay to the State its actual or liquidated
damages according to the following subsections and subject to the
limitations provided in Section 1932(e) of the Balanced Budget
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Act of 1997 and 42 CFR 438, Subpart I. The State may also impose any of
the sanctions specified in 42 CFR 438, Subpart I, including the
assessment of monetary penalties, and the appointment of temporary
management. In accordance with 42 CFR 438, 708(a)(3), the State will
impose temporary management if it finds that an MCO has repeatedly
failed to meet substantive requirements in Section 1903(m) or Section
1932 of the Act. In the event that the State assumes temporary
management of the MCO, the State will grant enrollees the right to
terminate without cause and will notify enrollees of this right.
It is agreed that in the event of a failure to meet specified
performance or reporting requirements subject to liquidated damages, it
is and will be impractical and difficult to ascertain and determine the
actual damages which the State will sustain in the event of, and by
reason of, such failure; and it is therefore agreed that the MCO will
pay the State for such failures according to the following subsections.
No punitive intention is inherent in the following liquidated damages
provisions.
Written notice of failure to perform will be provided to the MCO within
thirty days of the State's discovery of such failure.
If the OMPP elects not to exercise a damage clause contained anywhere
in the BAA or contract in a particular instance, this decision shall
not be construed as a waiver of the State's right to pursue future
assessment of that performance requirement and associated damages,
including damages that, under the terms of the BAA or contract, may be
retroactively assessed.
3.16.1 NON-COMPLIANCE WITH PERFORMING REQUESTED SERVICES
Damages resulting from failure of the MCO to provide the requested
services will vary depending on the nature of the deficiency. Damages
will include, but not be limited to, the costs incurred by the State to
ensure adequate service delivery to the affected members. If
non-compliance results in a transfer of members to another health plan,
damages will include the following: the difference between the
capitated rates that would have been paid to the originally contracted
MCO and the actual rates paid to the replacement health plan; and costs
incurred by the State to accomplish the transfer of members.
3.16.2 NON-COMPLIANCE WITH SHADOW CLAIMS DATA SUBMISSION REQUIREMENTS
The MCO must comply with the shadow claims submission standards under
Section 3.6.13.3.1 of this BAA. Liquidated damages will be assessed on
three elements of shadow claims submissions, as follows.
TIMELINESS: An annual review of the MCO's rate of compliance with the
established schedule for submitting shadow claims within 90, 180, and
270 days increments will be performed. Liquidated damages in the amount
of $200.00 per claim type, per percentage point of non-compliance will
be assessed. For example, if the established schedule indicated that 50
percent of claims would be
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submitted within 180 days and the MCO's actual performance was 48
percent compliance, then liquidated damages of $400.00 would be
assessed. Damages will be assessed for each of the three time frames.
COMPLETENESS: Each shadow claim must pass pre-cycle edits. For each
batch submitted, a 98 percent compliance rate is required. Liquidated
damages will be assess based on an overall average of calendar monthly
submissions. For compliance levels lower than 98 percent, the following
schedule of liquidated damages will be assessed:
Percent of Claims Accepted Liquidated Damages Amount
-------------------------- -------------------------
93.0 - 97.9 $ 100
88.0 - 92.9 $ 300
83.0 - 87.9 $ 500
78.0 - 82.9 $ 700
76.0 - 77.9 $ 900
0.0 - 75.9 $1000
Failure to submit all claim types per month will result in an
assessment of liquidated damages of $2,000.00 for each claim type not
submitted during that month.
CORRECTNESS: Each claim must pass paid/denied edits and audits. For
each claim type of shadow claims submitted, a minimum of 85 percent of
details must adjudicate with a paid status in a calendar month. For
compliance levels lower than 85 percent, the following schedule of
liquidated damages will be assessed:
Percent of Details Accepted Liquidated Damages Amount
--------------------------- -------------------------
80.0 - 84.9 $ 100
75.0 - 79.9 $ 300
70.0 - 74.9 $ 500
65.0 - 69.9 $ 700
60.0 - 64.9 $ 900
0.0 - 59.9 $1000
3.16.3 NON-COMPLIANCE WITH SUBMISSION OF QUALITY IMPROVEMENT PLAN AND
QUARTERLY REPORTS
The MCO must comply with the timely submission requirements and OMPP
approval of the quality improvement plan, which is due within 90 days
of the execution of the contract date. Because actual damages caused by
non-compliance is not subject to exact determination, the State will
assess the MCO, as liquidated damages, $200.00 for each business day
that the plan is not delivered after the date it was due. In addition,
$200.00 will be applied for each
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business day that the quarterly report and/or readiness review
responses are not delivered after the date it was due.
3.16.4 NON-COMPLIANCE WITH REPORTING GRIEVANCE DATA
Each MCO will be expected to report complaints and grievances data, as
required in Section 3.6.7.5 of this BAA. Failure to report the data
within the allotted time frame and in the appropriate format will
constitute non-compliance. Because actual damages caused by
non-compliance is not subject to exact determination, the State will
assess the MCO, as liquidated damages, $200.00 for each business day
the MCO is out of compliance with either or both time frame and format
requirements.
3.16.5 NON-COMPLIANCE WITH ALL OTHER REPORTING REQUIREMENTS
Liquidated damages under this Subsection 3.16 of this BAA apply to non-
compliance with all other reporting requirements for which liquidated
damages are not separately addressed in Section 3.16 of this BAA.
The MCO will comply with the education/outreach, marketing, network
development/access to services, quality improvement, utilization and
financial reporting requirements described in this BAA. Because actual
damages caused by non-compliance is not subject to exact determination,
the State will assess the MCO, as liquidated damages and not as a
penalty, $200.00 for each business day the MCO is out of compliance.
The MCO will be responsible for the timely reporting of utilization and
financial data to keep OMPP and the Department of Insurance informed of
the latest developments. If any non-compliance negatively impacts the
ability of the State to monitor the MCO's solvency position, and
changes in the MCO's financial position would have required the State
to transfer members to another health plan, actual damages for which
the MCO will be responsible in addition to the liquidated amounts
above, will include the following: the difference between the capitated
rates that would have been paid to the originally contracted MCO and
the actual rates paid to the replacement health plan as a result of
member transfer; and costs incurred by the State to accomplish the
transfer of members. Further, OMPP may withhold all capitation payments
until satisfactory financial data is provided.
3.16.6 NON-COMPLIANCE WITH GENERAL CONTRACT PROVISIONS
The objective of this requirement is to provide the State with an
administrative procedure to address issues where the MCO is out of
compliance with the Contract. Examples of noncompliance include:
- Fails to provide medically necessary services that the MCO is
required to provide by law or under this contract.
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- Imposing premiums or charges on members that are in
excess of the premiums or charges permitted under the
Hoosier Healthwise program.
- Discriminating among enrollees on the basis of their
health status or need for health care services.
- Misrepresenting or falsifying information furnished to
CMS or to the State.
- Misrepresenting or falsifying information furnished to a
member, potential member, or health care provider.
- Failing to comply with the requirements for physician
incentive plans, as set forth (for Medicare) in 42 CFR
422.208 and 422.210.
- Distributing, either 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.
- Violating any of the other applicable requirements of
sections 1903(m), or 1932 of the Balanced Budget Act of
1997 and any implementing regulations.
Through routine monitoring, the State may identify contract
non-compliance issues resulting from non-performance. If this
occurs, the Assistant Secretary of the OMPP or his/her designee will
notify the MCO in writing of the nature of the non-performance
issue, the basis and nature of the sanction, and the required
timeframe for correction. The State will establish a reasonable
period of time, not less than ten business days, in which the MCO
must provide a written response to the notification. If the
noncompliance is not corrected within the specified time, the State
may enforce any of the remedies listed below or as allowed under 42
CFR 438 Subpart I.
3.16.6.1 RIGHT TO SUSPEND ENROLLMENT
Whenever the State determines that the managed care organization is
out of compliance with this contract the State may suspend the MCO's
right to enroll new participants under this contract. The State must
notify the MCO in writing of its intent to suspend new enrollment
ten business days before the beginning of the suspension period. The
suspension period may be for any length of time specified by the
State.
3.16.6.2 RIGHT TO SUSPEND MONTHLY CAPITATION PAYMENTS
The State may suspend capitation payments for the following month or
subsequent months when the State determines that the MCO is out of
compliance with this contract. The managed care organization shall
be given written notice ten business days prior to the suspension of
capitation payments and specific reasons for non-compliance that
results in suspension of payments. The OMPP may continue to suspend
all capitation payments until non-compliance issues are corrected.
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In addition, payments provided for under the contract will be denied
for new enrollees when, and for so long as, payment for those
enrollees is denied by CMS in accordance with the requirements in 42
CFR 438.730.
3.16.7 NON-COMPLIANCE WITH SUBMISSION OF EDUCATION/OUTREACH AND MARKETING
MATERIALS
The MCO must submit all education/outreach materials, including
materials developed by subcontractors, to the State for approval,
prior to distribution, in accordance with Section 3.6.7.3 and
3.6.7.4. If the OMPP becomes aware of the failure of the MCO to
comply with these requirements, the OMPP may assess liquidated
damages in the amount of $200.00 for every piece of material
distributed, without OMPP approval, to either members or enrolled
providers.
3.17 WARRANT AGAINST CONTINGENCY FEES
Each MCO warrants that no person or selling agency has been employed
or retained to solicit and secure the MCO contract upon an agreement
or understanding for commission, percentage, brokerage, or
contingency excepting bona fide employees or selling agents
maintained by the MCO for the purpose of securing the business. For
breach or violation of this warranty, the State of Indiana will have
the right to cancel the contract without liability, or in its
discretion, to deduct from the contract price or to otherwise
recover, the full amount of such commission, percentage, brokerage,
or contingency.
3.18 INSURANCE
Before delivering services under the contract, MCOs will obtain from
an insurance company duly authorized to do business in the State of
Indiana, at least the minimum coverage levels as listed below for
the following types of insurance:
- Professional Liability Insurance for the MCO Medical
Director
- Workers' Compensation
- Comprehensive Liability Insurance
- Property Damage Insurance
- Errors and Omissions Insurance
Each MCO must be in compliance with all applicable insurance laws of
the State of Indiana and the federal government throughout the term
of the contract.
3.18.1 PROFESSIONAL LIABILITY INSURANCE
Professional liability insurance in the amount of at least one
million dollars ($ 1,000,000.00) for each occurrence shall be
maintained for the MCO Medical Director.
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3.18.2 WORKERS' COMPENSATION
The Contractor shall obtain and maintain, for the duration of this
Contract, workers' compensation insurance for all of its employees
working in the State of Indiana. In the event any work is
subcontracted, the Contractor shall require the subcontractor
similarly to provide workers' compensation insurance for all the
latter's employees working in the state, unless such subcontractor's
employees are covered by the workers' compensation protection
afforded by the Contractor. Any subcontract executed with a firm not
having the requisite workers' compensation coverage will be
considered void by the Sate of Indiana.
3.18.3 MINIMUM LIABILITY AND PROPERTY DAMAGE INSURANCE
The Contractor shall obtain, pay for, and keep in force, general
liability insurance (including, but not limited to automobile and
broad form contractual coverage) against bodily injury or death of
any person in the amount of one-million dollars ($1,000,000.00) for
each occurrence; and insurance against liability for property
damages, as well as first-party fire insurance, including contents
coverage for all records maintained pursuant to this contract, in
the amount of five-hundred thousand dollars ($500,000.00) for each
occurrence; and such insurance coverage that will protect the State
against liability from other types of damages, for up to
five-hundred thousand dollars ($500,000.00) for each occurrence.
3.18.4 ERRORS AND OMISSIONS INSURANCE
The Contractor shall obtain, pay for, and keep in force for the
duration of the Contract, Error and Omissions Insurance in the
amount of one-million dollars ($1,000,000.00).
3.18.5 BONDS
There must also be a willingness on the part of the MCO to furnish
to the IDOA a performance bond of five hundred thousand dollars
($500,000.00). The performance bond, which is due within ten
calendar days after the execution of the renewed contract, shall be
in the form of a cashier's check, a certified check, or a surety
bond. No other check or surety will be accepted. If a surety bond is
executed, the surety company must be authorized to do business in
the State of Indiana as approved by the Insurance Department of the
State of Indiana. The Performance Bond shall be made payable to the
IDOA of the State of Indiana and shall be effective for the duration
of the contract and any extensions thereof.
The State reserves the right to increase required bond amounts if
enrollment levels indicate the need for higher liquidated damages.
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3.18.6 EVIDENCE OF COVERAGE
The Contractor shall furnish to the State upon request, a
certificate or certificates evidencing that required insurance is in
effect, for what amounts, and applicable policy numbers and
expiration dates, prior to start of work under the Contract. In the
event of cancellation of any insurance coverage, the Contractor
shall immediately notify the State of such cancellation. The
Contractor shall provide the State with written notice at least ten
days prior to any change in the insurance required under this
subsection.
The Contractor shall also require that each of its subcontractors
maintain insurance coverage as specified above or provide coverage
for each subcontractor's liability and employees. The provisions of
this clause shall not be deemed to limit the liability or
responsibility of the Contractor or any of its subcontractors
hereunder.
3.19 FORCE MAJEURE
Neither the MCO nor the State will be liable for any damages or
excess costs for failure to perform their contract responsibilities
if such failure arises from causes beyond their reasonable control
and without fault or neglect by the MCO or the State. Such causes
may include, but are not restricted to, fires, earthquakes,
tornadoes, floods, unusually severe weather, or other catastrophic
natural events or acts of God; quarantine restrictions; explosions;
subsequent legislation by the State of Indiana or the Federal
government; strikes by other than the MCOs' employees; and freight
embargoes. In all cases, the failure to perform must be beyond the
reasonable control of, and without fault or negligence of, either
party.
Within 48 hours of the occurrence of such an event, the MCO will
initiate disaster recovery and/or back-up procedures to provide
alternate services for the resumption of business operations. During
such period, the MCO will be responsible for all costs and expenses
related to provision of the alternate services. Each MCO will notify
OMPP prior to initiation of alternate services as to the extent of
the disaster and/or emergency and the expected duration of alternate
services within 24 hours from onset of the problem.
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EXHIBIT 2
BAA 1-28, APPENDIX 2, REVISED
DEFINITIONS AND ABBREVIATIONS
Following are explanations of terms and abbreviations appearing throughout the
BAA. These terms will apply in the interpretation of the BAA.
ACTION - The denial or limited authorization of a requested service, including
the type or level of service; reduction, suspension, or termination of a
previously authorized service; denial, in whole or in part, of payment for a
service; failure to provide services in a timely manner; or failure of an MCO or
PIHP to act within the timeframes.
AMBULATORY-SENSITIVE CONDITIONS - Chronic diseases or conditions that are
amenable to timely office-based management and, therefore, can result in
improved patient status and decrease in high cost of care (e.g. reduced
inpatient stays and decrease in Emergency Room utilization). Examples of
ambulatory-sensitive conditions are diabetes, asthma, congestive heart failure,
and pregnancy.
AUTOMATED VOICE RESPONSE (AVR) SYSTEM - A system that helps providers obtain
pertinent information about Traditional Medicaid and Hoosier Healthwise member
eligibility, benefit limitation, Hoosier Healthwise managed care membership,
including delivery system and Primary Medical Provider information, as well as
information about prior authorization. Enrollee information obtained through AVR
is confidential.
BALANCED BUDGET ACT OF 1997 - Public Law 105-33 that makes numerous changes to
various titles of the Social Security Act and creates a new Title XXI, the State
Children's Health Insurance Program (CHIP).
BIDDER OR OFFEROR - A qualified, "eligible organization" that submits a bid
under this BAA, meets the Criteria for Selection in Section 4.3 of this BAA, and
can perform the scope of services outlined in this BAA.
BROAD AGENCY ANNOUNCEMENT (BAA) - This document.
CAPITATION MODEL - A set of fixed rates that is comprised of individual rate
components for each type of covered service category (e.g., inpatient hospital,
outpatient hospital, physician, home health, etc.).
CAPITATION RATE - The fixed fee that OMPP and CHIP pay monthly to a contracted
managed care organization (MCO) for each Hoosier Healthwise member enrolled with
that MCO for the provision of covered medical and health services whether or not
the member received services during the month for which the fee is intended.
These rates vary by age/sex and pregnancy delivery..
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BAA 1-28 Appendix 2
CASUALTY INSURANCE - Includes, but is not limited to, no fault auto insurance,
worker's compensation benefits, and medical payments coverage through a
homeowner's insurance policy.
CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP) - As part of the Balance Budget Act
of 1997, Congress created CHIP as a way to encourage states to provide health
insurance to uninsured children. The federal CHIP program gave states the option
to develop a children's health insurance program that was: 1) a Medicaid
expansion; 2) a private health insurance program; or 3) a combination of a
Medicaid expansion and a private program. The Indiana program is a combination
program.
CHILDREN'S MEDICAID - Children whose families do not receive Temporary
Assistance to Needy Families (TANF), but who are under age 21 and meet the
eligibility requirements.
CHIP COVERED SERVICES - A service provided or authorized by a CHIP provider for
a CHIP Package C enrollee for which payment is available under IHCP as set forth
407 IAC 3-3-1.
CLINICAL ADVISORY COMMITTEE (CAC) - The committee established by the OMPP
comprised of actively participating medical providers enrolled in Hoosier
Healthwise. The CAC's mission is to advise the OMPP concerning its policies by
making recommendations that support the quality, accessibility, appropriateness,
and cost-effectiveness of health and medical care provided to Indiana's Hoosier
Healthwise managed care members.
COLD-CALL MARKETING - Any unsolicited personal contact with a potential enrollee
by an employee or agent of an MCO for the purpose of influencing the individual
to enroll with the MCO.
CONTRACT - A binding agreement between OMPP and CHIP and the successful offeror
for arranging delivery of medical and health services to Hoosier Healthwise
managed care program enrollees in which the eligible organization assumes a risk
as defined in the contract. The terms of any contract issued pursuant to this
BAA shall be construed to be consistent with the Code of Federal Regulations 42
CFR, Part 434.
CONTRACTOR - Any successful offeror or organization selected as a result of the
procurement process and contracted to deliver the products/services requested by
this BAA.
COST AVOIDANCE - When Medicaid payment is denied or reduced because coverage is
available from a liable third party.
CULTURALLY APPROPRIATE - The ability of individuals or organizations to
effectively identify and address health practices and behaviors of target
populations.
DISEASE MANAGEMENT - An approach to patient care that emphasizes coordinated
comprehensive care along the continuum of disease and across health care
services. It includes coordination of educational, promotive, preventive,
diagnostic and therapeutic services and decisions.
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BAA 1-28 Appendix 2
DRUG UTILIZATION REVIEW BOARD - The Indiana Drug Use Review Board is appointed
by the governor to serve in an advisory capacity to Indiana Medicaid with regard
to the prescription and dispensing of drugs by Medicaid providers and the use of
drugs by Medicaid recipients. The board, composed of representatives of the
pharmacy, medical, and scientific community has a responsibility to establish
criteria for both retrospective review and prospective surveillance of drug
prescription and dispensing for and use by Medicaid recipients.
EARLY PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) SERVICES - Those
services described at 405 IAC 5-15 as required by Federal law pursuant to 42
U.S.C. 1396d(r), which include certain preventive services to children under 21
years of age.
ELIGIBILITY VERIFICATION SYSTEM (EVS) - There are three eligibility verification
systems available to providers. They are Automated Voice Response System (AVR),
OMNI 380 Terminal (OMNI), and electronic claims software such as National
Electronic Claims Submission (NECS) or Provider Electronic Solutions (PES).
EMERGENCY MEDICAL CONDITION - A medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) such that a prudent
layperson, who possesses an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to result in
placing the health of the individual (or with respect to a pregnant woman, the
health of the woman or her unborn child) in serious jeopardy, serious impairment
to bodily functions, or serious dysfunction of any bodily organ or part.
EMERGENCY SERVICES - With respect to an individual enrolled with a managed care
organization, covered inpatient and outpatient services that are furnished by a
provider that is qualified to furnish such services and are needed to evaluate
or stabilize an emergency medical condition.
EPSDT - Early and Periodic Screening, Diagnosis and Treatment
ENROLLMENT BROKER - The contractor that is responsible for educating potential
Hoosier Healthwise enrollees about and enrolling them in Hoosier Healthwise.
This contractor is also responsible for enrolling providers in the Hoosier
Healthwise PCCM delivery system and maintaining the Hoosier Healthwise Help-
line.
EXPERIMENTAL SERVICE/TREATMENT - Medical technology or a new application of
existing medical technology, including medical procedures, drugs, and devices
for treating a medical condition, illness or diagnosis that: (1) is not
generally accepted by informed health care professionals in the United States as
effective, or (2) has not been proven by scientific testing or evidence to be
effective in treating the medical condition, illness, or diagnosis for which its
use is proposed. Experimental services/treatments are not covered by the Indiana
Medicaid and CHIP programs and Federal Financial Participation is not available
for experimental services.
FQHC - Federally Qualified Health Center.
FISCAL AGENT - The contractor that is responsible for managing all of the
information systems related to the processing and reporting of enrollment,
claims, and utilization data. This
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BAA 1-28 Appendix 2
contractor is responsible for making capitated payments and for reimbursing
fee-for-service providers on behalf of OMPP.
HCFA - Health Care Financing Administration.
HEALTH MAINTENANCE ORGANIZATION (HMO) - An entity that operates a prepaid health
care delivery plan that is licensed by the Indiana Department of Insurance as an
HMO.
HEALTH INSURANCE - Includes, but is not limited to, coverage by any health care
insurer, MCO, Medicare, or an employer-administered ERISA plan.
HOOSIER HEALTHWISE - Hoosier Healthwise was the name for Indiana's Medicaid
managed care program. With the CHIP program's influence, and an extensive
marketing campaign, Hoosier Healthwise is now the program name for Medicaid and
CHIP sponsored health care coverage to eligible children, pregnant women and
low-income families. The two delivery systems of Hoosier Healthwise are primary
care case management (PCCM), risk-based managed care (RBMC).
INDIANAAIM - The Indiana Advanced Information Management System; another name
for the State's Medicaid Management Information System (MMIS).
INDIANA DEPARTMENT OF ADMINISTRATION (IDOA) - The State of Indiana Department
of Administration.
INDIANA DEPARTMENT OF INSURANCE (IDOI) - The State of Indiana Department of
Insurance.
INDIANA FAMILY AND SOCIAL SERVICES ADMINISTRATION (IFSSA) - The umbrella agency
administering many of Indiana's social service programs, including those
administered by the Office of Medicaid Policy and Planning, and the Office of
the Children's Health Insurance Program.
INDIANA HEALTH COVERAGE PROGRAMS -- Includes three distinct programs: 590,
Traditional Medicaid, and Hoosier Healthwise (which also includes CHIP).
MCO ENROLLEE OR MCO MEMBER - A Hoosier Healthwise Package A, B or C enrollee who
is eligible to participate in managed care, and is enrolled with a Hoosier
Healthwise contracted MCO.
MANAGED CARE - Any effort to influence the utilization and efficiency of
medical/health care through the restructuring and integration of both financing
and health care delivery systems.
MANAGED CARE ENTITY (MCE) - Following the Balanced Budget Act, it refers to both
PCCM and contracted MCOs.
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MANAGED CARE ORGANIZATION (MCO) - A contracting organization that assumes
financial risk for arranging or administering a health care delivery system for
Hoosier Healthwise enrollees and paying for covered health care services.
MANAGED CARE ENTITY MONITORING CONTRACTOR - An entity under contract with the
State to evaluate the quality of services under the Hoosier Healthwise program
and assist the State in monitoring the performance of the Managed Care
Organization (MCO) under the MCO contract with the State and the PCCM component
of the program.
MANAGED CARE MEMBER - An individual linked to a PMP and a plan within the
Hoosier Healthwise program.
MARKETING - Communication from an MCO to a Medicaid recipient who is not
enrolled in that entity, that can reasonably be interpreted as intended to
influence the recipient to enroll in that particular MCO's Medicaid product, or
either to not enroll in, or to disenroll from, another MCO's Medicaid product.
MARKETING MATERIALS - Materials that are produced in any medium, by or on behalf
of an MCO that can reasonably be interpreted as intended to market to potential
enrollees.
MEDICAID OR MEDICAL ASSISTANCE PROGRAM - Medicaid is a federal-state funded
medical assistance program administered by the State to provide reasonable and
necessary medical care for persons meeting both medical and financial
eligibility requirements pursuant to federal law, 42 U.S.C. 1396 and state law,
IC 12-15.
MEDICAID COVERED SERVICE - A service provided or authorized by a Medicaid
provider for a Medicaid enrollee for which payment is available under the
Indiana Medicaid program as set forth in 405 IAC 5. A list of covered services
is referenced in IC 12-15-5-1.
MEDICAID MANAGEMENT INFORMATION SYSTEM (MMIS) - The new medical assistance and
payment information system of the Indiana Family and Social Services
Administration; also known as IndianaAIM.
MEDICAID ENROLLEE - A person who is Medicaid-eligible, enrolled and receives
health services covered by Medicaid. Enrollees are divided into the following
eligibility categories: Traditional Medicaid (Aged; Blind and Disabled); and
Hoosier Healthwise (TANF; Pregnancy Medicaid and Children's Medicaid).
MEDICALLY NECESSARY - Medically necessary services covered by the Indiana
Medicaid and CHIP are specified in 405 IAC 5.
MEMBER IDENTIFICATION NUMBER - The member identification number may also be
called recipient identification (RID) number. This number is on the enrollee's
Hoosier Health Card. See the IHCP Provider Manual for a picture of the card.
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NON-COVERED SERVICE - Service not covered, arranged or provided for under the
Indiana Medicaid or CHIP program.
OFFICE OF MEDICAID POLICY AND PLANNING (OMPP) - The office within IFSSA that is
the designated single state agency that administers the Indiana Health Coverage
Programs. OMPP is responsible for developing the policies and procedures for
Hoosier Healthwise.
OUT-OF-AREA SERVICES - Services provided outside of the MCO contracted region.
OUT-OF-PLAN SERVICES (also referred to as "OUT-OF-NETWORK" SERVICES) - Services
provided outside of the established MCO network.
PACKAGE A - Full Medicaid coverage for low income families, with children under
18 years, including those receiving Temporary Assistance for Needy Families
(TANF); children whose families do not receive TANF, but who are under age 21
and meet the eligibility requirements; pregnant women who meet the TANF income
and resource criteria; wards of the state and xxxxxx children (on a voluntary
basis); and CHIP Phase I, children under age 19 whose family's income is up to
150% of federal poverty level.
PACKAGE B - Pregnancy-related coverage is provided to women whose income is
below 150% of poverty without regard to their resources. Eligibility extends up
to 60 days postpartum.
PACKAGE C - Preventive, primary and acute care services for children under age
19 whose family's income is 150-200% of federal poverty level.
PACKAGE D - Formerly Hoosier Healthwise for People with Disabilities and Chronic
Illnesses. It provided full coverage with case management services.
PACKAGE E - Individuals enrolled in this package are eligible for emergency
services only. These individuals are considered Hoosier Healthwise enrollees,
however, they are no enrolled in managed care.
PARTICIPATING PROVIDER - The healthcare practitioner who is either employed by,
or has executed an agreement with an MCO, to service Indiana Medicaid and
Hoosier Healthwise managed care members.
POST-STABILIZATION SERVICES - Covered services, related to an emergency medical
condition that are provided after an enrollee is stabilized in order to maintain
the stabilized condition, or, under the circumstances described in 42 CFR
438.114(e) to improve or resolve the enrollee's condition.
PRIMARY CARE CASE MANAGEMENT (PCCM) - One of the delivery systems of Hoosier
Healthwise, in which members are linked to a Primary Medical Provider (PMP) who
contracts directly with the State of Indiana. The PMP is responsible for
coordinating designated covered services and is reimbursed on a fee-for-service
basis.
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PRIMARY MEDICAL PROVIDER (PMP) - Those contracted physicians who are responsible
for providing primary and preventive care, and for authorizing other Medicaid
and CHIP covered services as needed, and within the scope of their contracts to
authorize, for members of Hoosier Healthwise.
PRIMESTEP - This is the name of the Hoosier Healthwise PCCM network. PCCM and
PrimeStep are often used interchangeably.
QUALITY ASSURANCE/QUALITY CONTROL (QA/QC)- QA/QC are interrelated methods of
monitoring the services that MCOs arrange or administer for their members.
QUALITY IMPROVEMENT COMMITTEE (QIC) - The committee established by the OMPP that
serves to provide oversight for the appropriateness and quality of care provided
to members by establishing standards and guidelines for the provision of care.
The QIC is responsible for integrating the quality improvement process and
serves as a coordinating and advisory body. ,
RHC - Rural Health Clinic.
REDETERMINATION - A process performed by the County Office of the Division of
Family and Children (DFC) caseworkers, to determine whether a currently eligible
member continues to be eligible to receive benefits.
RISK-BASED MANAGED CARE (RBMC) FOR HOOSIER - A fully capitated prepayment plan
where MCOs are at risk to arrange for and administer the provision of a
comprehensive set of covered services to Hoosier Healthwise members. Members are
linked to a Primary Medical Provider (PMP) who contracts directly with the MCO.
SELF-REFERRAL SERVICES - Services that enrolled members may receive from any
IHCP-enrolled provider qualified to render the service. These are: emergency
services; family planning services; behavioral health services rendered by
providers in a Medicaid mental health specialty; podiatric services;
chiropractic services; eye care services (except for eye-care surgical
services); and HIV/AIDS targeted case management services.
SERVICE AREA - The counties and municipalities in which an MCO is authorized by
the State of Indiana pursuant to a contract under this BAA to operate as a
Medicaid MCO and in which service capability exists as defined by the State.
SERVICES - Work to be performed as specified in this BAA.
SHADOW CLAIMS - Reports of individual patient encounters with an MCO's
healthcare delivery system which contain fee-for-service equivalent detail as to
procedures, diagnoses, place of service, billed amounts, and rendering/billing
providers.
STATE - The State of Indiana.
Revision date: 7/10/2003 Page 7
BAA 1-28 Appendix 2
SUBCONTRACTOR - A state-approved entity that contracts with the MCO, or one of
the MCO's approved subcontractors, to perform a specific part of the MCO's
obligations under the provisions of the Contract between the State and the MCO.
For purposes of this BAA, the definition of subcontractors is limited to parties
not involved in the actual delivery of health care services.
TANF (TEMPORARY ASSISTANCE FOR NEEDY FAMILIES) - A cash assistance program for
families (caretakers and children under 18 years). TANF replaces the
cash-assistance program, Aid to Families with Dependent Children.
THIRD PARTY - Any person or entity who is or may be liable to pay for health
care and services rendered to a Medicaid beneficiary. Some examples of "third
parties" include a beneficiary's health insurer, casualty insurer, a managed
care organization (MCO), or an employer-administered ERISA plan.
UPPER PAYMENT LIMIT - A federal regulation which requires that the maximum
payments to the MCO, for a defined scope of services delivered to a defined
number of members, may not exceed the cost to the Medicaid program of paying for
those same services on a fee-for-service basis, for an actuarially equivalent
non-enrolled population group.
UTILIZATION REVIEW (UR) - A process by which the MCO performs ongoing monitoring
of the services arranged for and administered by the MCO and provided by its
participating providers to ensure that members receive appropriate and medically
necessary health care services.
Revision date: 7/10/2003 Page 8
TRANSITION REPORT
NAME OF MCO MCO A
REPORTING PERIOD START DATE JULY 1, 2003
REPORT DUE DATE AUGUST 7, 2003
PROVIDER NETWORK DEVELOPMENT
REPORTING REQUIREMENT MANDATORY RISK BASED MANAGED CARE (RBMC) COUNTIES
XXXXXX XXXXXXX XXXXXX XXXXXXX XXXXXX XXXXX MADISON DELAWARE
------ ------- ------ ------- ------ ----- ------- --------
Total member enrollment
Current MCO member enrollment
PRIMARY MEDICAL PROVIDER
OB-GYN contracts at beginning of period
Pediatricians at beginning of period
Other PMPs at beginning of period
New - OB-GYN contracts this period
New - Pediatrician contracts this period
New - Other PMP contracts this period
All PMPs at end of period 0 0 0 0 0 0 0 0
PMP contracts pending ***
SPECIALISTS
Specialists at beginning of period
New specialist contracts this period**
Specialists at end of period
FACILITIES
Acute care hospitals beginning of period
Acute care hospitals end of period
Hospital contracts pending***
ANCILLARY PROVIDERS
Pharmacies beginning of period
Pharmacies end of period
Home Health Providers beginning
Home Health end of period
Transportation providers beginning
Transportation end of period
Other - Beginning of period
Other - End of period**
INSTRUCTIONS: For the first reporting period, MCOs should complete all cells
highlighted in blue and yellow.
For all subsequent reporting periods, MCOs should complete cells highlighted in
yellow only. Disenrollments should be reported and described should be reported
and described in the Comments section.
* "PMP contract" refers to a contract with an individual provider rather than a
group or delivery system
** Give provider type in Comments section
*** high probability of completing contract negotiations within 60 days after
end of period
EXHIBIT 3
MCO Transition Report for Mandatory MCO Counties (Phase II)
PROVIDER CLAIMS
NETWORK STATISTICS DATE DUE
REPORT PERIOD REPORT PERIOD (5TH BUSINESS DAY AFTER MONTH END)
------------- ------------- ----------------------------------
July-03 June-03 August 7, 2003
August-03 July-03 September 8, 2003
September-03 August-03 October 7, 2003
October-03 September-03 November 7, 2003
November-03 October-03 December 5, 2003
December-03 November-03 January 7, 2004
January-04 December-03 February 6, 2004
February-04 Xxxxxxx-00 Xxxxx 0, 0000
Xxxxx-00 February-04 April 7, 2004
April-04 Xxxxx-00 Xxx 0, 0000
Xxx-00 Xxxxx-00 June 7, 2004
June-04 May-04 July 7, 2004
July-04 June-04 August 6, 2004
Submissions are due to Xxxxxx Xxxxxxxxxx by 5:00 PM on the date listed
XxxxxxxxxxXX@xxxx.xxxxx.xx.xx
TRANSITION REPORT
NAME OF MCO MCO A
REPORTING PERIOD START DATE JUNE 1, 2003
REPORT DUE DATE AUGUST 7, 2003
CLAIMS PROCESSING
REPORTING REQUIREMENT CURRENT PERIOD PREVIOUS PERIOD
--------------------- -------------- ---------------
Claims on-hand at beginning of period
Claims received this period
Claims paid this period*
Claims denied this period*
Claims on-hand end of period 0 0
Average length of time to pay or deny (in days)
* Claims paid are those claims for which some payment was made to the billing
provider, and those
TRANSITION REPORT
NAME OF MCO MCO A
REPORTING PERIOD START DATE JULY 1, 2003
REPORT DUE DATE August 7, 2003
REPORT COMMENTS
------ --------
PROVIDER ACCESS AND AVAILABILITY
CLAIMS PROCESSING
Xxxxxx X. Xxxxxx, Governor
State of Indiana
[INDIANA FAMILY & "People OFFICE OF MEDICAID POLICY AND PLANNING
SOCIAL SERVICES helping people 000 X. XXXXXXXXXX XXXXXX, XXXX X000
ADMINISTRATION LOGO] help XXXXXXXXXXXX, XX 00000-0000
themselves"
March 2, 2004
Xxxx Xxxxx, MD, CEO
Harmony Health Plan of Illinois, Inc.
000 Xxxxx Xxxxxx Xxxxx, Xxxxx 0000
Xxxxxxx, XX 00000
RE: Hoosier Healthwise Contract, Fourth Amendment
Dear Dr. Blank,
Enclosed is your copy of the fully executed Fourth Amendment to the Hoosier
Healthwise MCO contract.
The amendment is effective January 1, 2004, and adjusts the capitation rates.
OMPP and Milliman USA discussed the adjusted rates with representatives of the
MCOs on December 19, 2003.
OMPP appreciates Harmony's continued partnership in the Hoosier Healthwise
program.
Sincerely,
/s/ Xxxx Xxxxx
-------------------------------------
Xxxx Xxxxx
Director of Managed Care
Enclosure
Cc: Xxxxxx Xxxxxx, Harmony
Xxxxxx Xxxxxx
Equal Opportunity / Affirmative Action Employer [SEAL]
MAR - 8 2004
FOURTH AMENDMENT
TO
CONTRACT BETWEEN
THE OFFICE OF MEDICAID POLICY AND PLANNING,
THE OFFICE OF THE CHILDREN'S HEALTH INSURANCE PROGRAM
AND
HARMONY HEALTH PLAN OF ILLINOIS, INC.
This FOURTH AMENDMENT to the above-referenced Contract is made and entered
into by and between the State of Indiana [hereinafter "State" of "State of
Indiana"], through the Office of Medicaid Policy and Planning and Office of the
Children's Health Insurance Program [hereinafter called "State" or "Office"], of
the Indiana Family and Social Services Administration, 000 Xxxx Xxxxxxxxxx
Xxxxxx, Xxxx X000, Xxxxxxxxxxxx, Xxxxxxx 00000, and Harmony Health Plan of
Illinois, Inc., doing business as Harmony Health Plan of Indiana, [hereinafter
called "Contractor"], 000 Xxxxx Xxxxxx Xxxxx, Xxxxx 0000, Xxxxxxx, Xxxxxxxx,
00000.
WHEREAS, the State of Indiana and Contractor have previously entered into
a contract for a term beginning January 1, 2001, and ending December 31, 2002,
[hereinafter "the original contract"] for services to arrange for and to
administer a risk-based managed care program (RBMC) for certain Hoosier
Healthwise enrollees in Packages A, B and C as procured through BAA 01-28;
WHEREAS, the parties have previously entered into a First Amendment for
additional duties and the adjustment of capitation rates related to the
mandatory MCO enrollment of Hoosier Healthwise members residing in certain
Indiana counties;
WHEREAS, the Family and Social Services Administration (FSSA) issued new
contract documents in lieu of a Second Amendment document so that FSSA may move
its contract data into a single contract database. The original contract was
issued for the contract term starting January 1, 2001, through December 31,
2002, and provided for a renewal clause, exercised at the option of the State
for two additional years. The State exercised this option and renewed the
contract from January 1, 2003, through December 31, 2004;
WHEREAS, the parties have previously entered into a Third Amendment in
order to bring the contract into compliance with applicable new federal
regulations at 42 CFR 438 implementing the federal Balanced Budget Act of 1997;
WHEREAS, the Office desires to further amend the contract with this FOURTH
AMENDMENT to adjust the capitation rates under which the Contractor shall be
paid and these rates have been determined to be actuarially sound for risk
contracts, in accordance with applicable law and federal regulations at 42 CFR
438.6(c), and to update state contract language;
NOW THEREFORE, the parties enter into this FOURTH AMENDMENT for the
consideration set out below, all of which is deemed to be good and sufficient
consideration in order to make this FOURTH AMENDMENT a binding legal instrument.
MCO Contract, Fourth Amendment Page 1 of 4 Harmony Health Plan
1. The parties hereby ratify and incorporate herein each term and condition
set out in the original Contract and the first, second, and third
amendments, as well as all written matters incorporated therein except as
specifically provided for by this FOURTH AMENDMENT.
2. The effective date of this amendment is January 1, 2004.
3. The parties agree that Article IV. Payment, paragraph A, of the Second
Amendment (renewal contract) is amended as follows:
CAPITATION RATES
CATEGORY PACKAGES A/B PACKAGE C
-------- ------------ ---------
NORTH REGION
Newborns $ 397.38 $ 217.38
Preschool $ 73.69 $ 78.20
Children $ 58.10 $ 63.25
Adolescents $ 91.72 $ 83.63
Adult Males $ 246.78
Adult Females $ 214.49
Deliveries $ 3406.34 $ 3406.34
CENTRAL REGION
Newborns $ 406.30 $ 162.90
Preschool $ 82.21 $ 78.39
Children $ 58.89 $ 53.63
Adolescents $ 113.13 $ 67.91
Adult Males $ 247.25
Adult Females $ 217.85
Deliveries $ 3535.12 $ 3535.12
4. Insurance Coverage.
a. The Contractor shall secure and keep in force during the term of this
agreement, the following insurance coverage, covering the Contractor for
any and all claims of any nature, which may in any manner arise out of or
result from this agreement:
1) Commercial general liability, including contractual coverage,
and products or completed operations coverage (if applicable),
with minimum liability limits of $500,000 per person and
$1,0000,000 per occurrence unless additional coverage is
required by the State.
2) (Reserved)
3) (Reserved)
4) Workers compensation coverage meeting all statutory
requirements of IC 22-3-2. In addition, an "all states
endorsement" covering claims occurring outside the state of
Indiana if any of the services provided under this agreement
involve work outside the state of Indiana. The Contractor
shall provide proof of such insurance coverage by tendering to
the undersigned State representative, a certificate of
insurance prior to the commencement of this agreement.
b. The Contractor's insurance coverage must meet the following additional
requirements:
1) Any deductible or self-insured retention amount or other
similar obligation
MCO Contract, Fourth Amendment Page 2 of 4 Harmony Health Plan
under the insurance policies shall be the sole obligation of
the Contractor.
2) The State will be defended, indemnified, and held harmless to
the full extent of any coverage actually secured by the
contractor in excess of the minimum requirements set forth
above. The duty to indemnify the State under this agreement
shall not be limited by the insurance required in this
agreement.
3) The insurance required in this agreement, through a policy or
endorsement, shall included a provision that the policy and
endorsements may not be canceled or modified without thirty
(30) days prior written notice to the undersigned State
representative.
4) Failure to provide insurance as required in this agreement is
a material breach of contract entitling the State to
immediately terminate this agreement.
c. The Contractor shall furnish a certificate of insurance and all
endorsements to the undersigned State representative prior to the
commencement of this agreement.
5. The Contractor agrees to comply fully with the provisions of the
Contractor's MBE/WBE participation plans, and agrees to comply with all
Minority and Women Business Enterprise statutory and administrative code
requirement and obligations, including IC 4-13-16.5 and 25 IAC 5.
The Contractor further agrees to cooperate fully with the minority and
women's business enterprises division to facilitate the promotion,
monitoring, and enforcement of the policies and goals of the MBE/WBE
program, including any and all assessments, compliance reviews and audits
that may be required.
6. The Contractor certifies that, if it is a non-domestic entity, it is
registered with the Indiana Secretary of State to do business in the State
of Indiana.
7. The parties agree that this Fourth Amendment to the parties' original
Contract has been duly prepared and executed pursuant to Paragraph VII.B
of the original contract.
8. The undersigned attests, subject to the penalties for perjury, that he is
the contracting party, or that he is the representative, agent, member or
officer of the contracting party, that he has not, nor has any other
member employee, representative, agent or officer of the firm, company,
corporation or partnership represented by him, directly or indirectly, to
the best of his knowledge, entered into or offered to enter into any
combination, collusion or agreement to receive or pay, and that he has not
received or paid, any sum of money or other consideration for the
execution of this agreement other than that which appears upon the face of
the agreement.
//THE REST OF THIS PAGE IS INTENTIONALLY LEFT BLANK.//
MCO Contract, Fourth Amendment Page 3 of 4 Harmony Health Plan
WHEREOF, the parties have, through duly authorized representatives, entered into
this agreement. The parties having read and understood the foregoing terms of
the contract do by their respective signatures dated below hereby agree to the
terms thereof.
For the Contractor: For the State of Indiana:
/s/ Xxxx Xxxxx /s/ Xxxxxxx X. Bella
------------------------------------- ------------------------------------
Xxxx Xxxxx, MD Xxxxxxx X. Bella
President/CEO Assistant Secretary
Harmony Health Plan of Illinois, Inc. Office of Medicaid Policy & Planning
Date: 1/8/04 Date: 1/13/04
APPROVED:
/s/ [ILLEGIBLE] /s/ Xxxxxxxxx X. Xxxx
------------------------------------- ------------------------------------
Xxxxxxx Xxxxxxx, Director Xxxxxxxxx X. Xxxx, Director
State Budget Agency Children's Health Insurance Program
Date: 1-26-04 Date: 1-14-04
APPROVED AS TO FORM AND LEGALITY: APPROVED:
/s/ Xxxxxxx Xxxxxx /s/ A. Xxxxxxx Xxxxxxx (for)
------------------------------------- ------------------------------------
Xxxxxxx Xxxxxx Xxxxxxx X. Xxxxxxxxxx, Commissioner
Attorney General of Indiana Department of Administration
Date: 2/25/04 Date: 1/16/04
MCO Contract, Fourth Amendment Page 4 of 4 Harmony Health Plan
