Exhibit 10.37
HEALTHCHOICES LEHIGH/CAPITAL PHYSICAL HEALTH AGREEMENT
BETWEEN
COMMONWEALTH OF PENNSYLVANIA
AND
HRM HEALTH PLANS (PA), INC.
HEALTHCHOICES LEHIGH/CAPITAL PHYSICAL HEALTH AGREEMENT
THIS AGREEMENT made effective as of the 1st day of April 2001 by and
between the Commonwealth of Pennsylvania, acting through its Department of
Public Welfare (the "Department") and HRM Health Plans (PA), Inc., (the
"Contractor").
WITNESSETH:
WHEREAS, the Pennsylvania Medical Assistance Program ("MA Program") is
organized under Title XIX of the Social Security Act, 42 U.S.C.A. 1396 et seq.
and under the Public Welfare Code, 62 P.S. 101 et seq. to provide payment for
medical services to persons eligible for medical assistance; and
WHEREAS, Section 443.5 of the Public Welfare Code (62 P.S. 443.5)
authorizes the Department to provide prepaid capitation payments for services
provided under contracts with Physical Health Maintenance Organizations; and
WHEREAS, the Hearth Care Financing Administration ("HCFA") approved the
Department's waiver request under Section 1915(b) of the Social Security Act,
42 U.S.C.A. 1396n, to implement a mandatory managed care program, under the name
HealthChoices Lehigh/Capital (the "HC-L/C Program") for Medical Assistance (MA)
consumers in Adams, Berks, Cumberland, Dauphin, Lancaster, Lebanon, Lehigh,
Northampton, Perry and York Counties (the "HC-L/C Counties"); (see Appendix 3)
and
WHEREAS, the Department issued Request for Proposal Number 11-00 (the
"RFP") containing the participation requirements and the terms and conditions of
the HC-L/C Physical Health Program and soliciting proposals from Physical Health
Managed Care Organizations (PH-MCOs) to participate in the program (including
all technical amendments, appendices and exhibits attached thereto); and
WHEREAS, the Contractor submitted a proposal in response to the RFP and
such Proposal was selected by the Department as responsive to the requirements
of the RFP. (The proposal submitted by the Contractor, including all appendices
and exhibits attached thereto, shall be referred to as the "Proposal"); and
WHEREAS, the Department and the Contractor desire to enter into this
Agreement for the time period April 01, 2001 through December 31, 2005.
NOW, THEREFORE, the parties intending to be legally bound hereby agree as
follows:
LEHIGH/CAPITAL PHYSICAL HEALTH AGREEMENT
SECTION I: INCORPORATION OF DOCUMENTS ....................................2
A. Operative Documents ...................................................2
SECTION II: DEFINITIONS ...................................................2
AGREEMENT AND RFP ACRONYMS ...................................20
SECTION III: RELATIONSHIP OF PARTIES ......................................23
A. Basic Relationship ...................................................23
B. Nature of Contract ...................................................23
SECTION IV: APPLICABLE LAWS AND REGULATIONS ..............................23
A. Certification and Licensing ..........................................23
B. Specific to MA Program ...............................................24
C. General Laws and Regulations .........................................24
D. Limitation on the Department's Obligations ...........................25
SECTION V: PROGRAM REQUIREMENTS .........................................25
A. In-Plan Services .....................................................25
1. Amount, Duration and Scope .......................................25
2. Program Exception ................................................26
3. Expanded Benefits ................................................26
4. Referrals ........................................................27
5. Self Referral/Direct Access ......................................27
6. Behavioral Health Services .......................................28
7. Pharmacy Services ................................................28
8. EPSDT Services ...................................................31
9. Emergency Room (ER) Services .....................................32
10. Post-Stabilization Services ......................................33
11. Examinations to Determine Abuse or Neglect .......................33
12. Hospice Services .................................................34
13. Organ Transplants ................................................34
14. Transportation ...................................................34
15. Waiver Services/State Plan Amendments ............................35
16. Nursing Facility Services ........................................36
B. Prior Authorization of Services ......................................37
1. General Prior Authorization Requirements .........................37
2. Prior Authorization for Outpatient Prescription Drugs ............39
C. Continuity of Care ...................................................40
D. Coordination of Care .................................................40
1. Nursing Facility Care ............................................41
2. Special Services .................................................41
3. Out-of-Plan Services .............................................41
4. Coordination of Care/Letters of Agreement ........................42
5. PH-MCO and BH-MCO Coordination ...................................43
E. Contractor Responsibility for Reportable Conditions ..................44
F. Member Enrollment and Disenrollment ..................................44
1. General ..........................................................44
2. Contractor Outreach Materials ....................................45
3. Contractor Outreach Activities ...................................46
4. Alternative Language Requirement .................................48
5. Contractor Enrollment Procedures .................................49
6. Enrollment of Newborns ...........................................49
7. Transitioning Members Between PH-MCOs ............................49
8. Change in Status .................................................50
9. Monthly Membership ...............................................50
10. Enrollment and Disenrollment Updates .............................50
11. Services for New Members .........................................51
12. New Member Orientation ...........................................52
13. Eligibility Verification System (EVS) ............................53
14. Contractor Identification Cards ..................................53
15. Member Handbook ..................................................53
16. Provider Directories .............................................54
17. HC-L/C Member Disenrollment ......................................55
G. Member Services ......................................................55
1. General ..........................................................55
2. Contractor Internal Member Dedicated Hotline .....................56
3. Education and Outreach Health Education Advisory Committee .......57
4. Informational Materials ..........................................57
5. Member Encounter Listings ........................................58
H. Additional Addressee .................................................59
I. Member Complaint, Grievance and DPW Fair Hearing Process ............59
1. Member Complaint, Grievance and DPW Fair Hearing Process .........59
2. DPW Fair Hearing Process for Members .............................60
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J. Clinical Sentinel ....................................................60
K. Provider Dispute Resolution System ...................................61
L. Certification of Authority ...........................................62
M. Executive Management .................................................62
N. Other Administrative Components ......................................64
O. Administration .......................................................65
1. Responsibility to Employ MA Consumers ............................66
2. Recipient Restriction Program ....................................66
3. Contracts and Subcontracts .......................................66
4. Lobbying Disclosure ..............................................67
5. Records Retention ................................................67
6. Fraud and Abuse ..................................................67
7. Information Systems and Encounter Data ...........................69
8. Department Access and Availability ...............................71
P. Special Needs Unit (SNU) .............................................72
1. Establishment of Special Needs Unit ..............................72
2. Special Needs Coordinator ........................................73
3. Responsibilities of Special Needs Unit Staff .....................73
Q. Assignment of PCPs.. .................................................74
R. Provider Services ....................................................75
1. Provider Manual ..................................................76
2. Provider Education ...............................................76
S. Provider Network/Services Access .....................................77
1. Network Composition ..............................................78
2. Provider Agreements ..............................................82
3. Cultural Competence ..............................................85
4. Primary Care Practitioner (PCP) Responsibilities .................85
5. Specialists as PCPs ..............................................86
6. Any Willing Pharmacy .............................................87
7. Hospital Related Party ...........................................88
8. Mainstreaming ....................................................88
9. Network Changes ..................................................89
10. Other Provider Enrollment Standards ..............................89
11. Twenty-Four Hour Coverage ........................................90
12. Appointment Standards ............................................90
13. Policies and Procedures for Appointment Standards ................93
14. Compliance with Access Standards .................................93
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T. QM and UM Program Requirements .......................................94
1. Overview .........................................................94
2. General ..........................................................95
3. Additional Utilization Management Program Requirements ...........95
4. Healthplan Employer Data Information Set (HEDIS) .................96
5. External Quality Review (EQR) ....................................97
6. QM and UM Program Reporting Requirements .........................97
7. Collaboration Between Contractor QM and UM Departments
and Special Needs Unit ...........................................98
8. Delegated Quality Management and Utilization Management
Functions ........................................................98
9. Consumer Involvement in the Quality Management and
Utilization Management Programs ..................................99
10. Confidentiality ..................................................99
11. Department Oversight .............................................99
SECTION VI: PROGRAM OUTCOMES AND DELIVERABLES ...........................100
SECTION VII: FINANCIAL REQUIREMENTS ......................................100
A. Financial Standards .................................................100
1. Risk Protection Reinsurance for High Cost Cases .................100
2. Equity Requirements and Insolvency Protection ...................101
3. Secondary Liability .............................................103
4. Limitation of Liability .........................................103
5. Medical Cost Accruals ...........................................103
6. Claims Processing and MIS .......................................104
7. DSH/GME Payment for Disproportionate Share Hospitals
(DSH)/Graduate Medical Education (GME) ..........................104
8. Member Liability ................................................104
B. Commonwealth Capitation Payments ....................................105
1. Payments for In-Plan Services ...................................105
2. Voluntary Risk Adjustment .......................................107
3. Maternity Care Payment ..........................................107
4. Program Changes .................................................108
5. Supplemental Payments ...........................................108
C. HIV/AIDS Risk Pool ..................................................109
D. Claims Processing Standards, Monthly Report and Penalties ...........109
1. Timeliness Standards ............................................109
2. Sanctions .......................................................111
3. Physician Incentive Arrangements ................................112
4. Retroactive Eligibility Period ..................................114
5. In-Network Services .............................................114
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6. Payments for Out-of-Network Providers ...........................114
7. Payments to FQHCs and Rural Health Centers (RHCs) ...............115
8. Liability During an Active Grievance or Appeal ..................115
9. Financial Responsibility for Dual Eligibles .....................115
10. Third Party Liability (TPL) .....................................116
11. Health Insurance Premium Payment (XXXX) Program .................119
12. Requests for Additional Data ....................................120
13. Accessibility to TPL Data .......................................120
14. Damage Liability ................................................120
15. Estate Recovery .................................................120
16. Audits ..........................................................121
17. Restitution .....................................................121
SECTION VIII: REPORTING REQUIREMENTS ......................................121
A. General .............................................................121
B. Systems Reports .....................................................121
1. Encounter Data and Subcapitation Data Reports ...................121
2. Federalizing GA Data Reporting ..................................124
3. Third Party Resource Identification .............................125
C. Operations Reports ..................................................125
1. Continuous Quality Improvement ..................................125
2. Federal Waiver Reporting Requirements ...........................125
3. Complaint, Grievance and DPW Fair Hearing Data ..................125
4. EPSDT Reports ...................................................126
5. Healthy Beginnings Plus Reporting ...............................126
6. Member Hotline Activities Report ................................127
7. Fraud and Abuse .................................................127
8. Provider Network ................................................127
9. Provider Dispute Resolution Process .............................127
10. Reports Submission Schedule .....................................127
11. HEDIS including CAHPS ...........................................128
12. SERB ............................................................128
D. Financial Reports ...................................................128
E. Equity ..............................................................128
F. Claims Processing Reports ...........................................129
G. Presentation of Findings ............................................129
H. Reference Information ...............................................129
I. Sanctions ...........................................................130
J. Non-Duplication of Financial Penalties ..............................131
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SECTION IX: REPRESENTATIONS AND WARRANTIES OF THE CONTRACTOR ............132
A. Accuracy of Proposal ................................................132
B. Disclosure of Interests .............................................132
C. Disclosure of Change in Circumstances ...............................132
D. SERB Commitment .....................................................133
SECTION X: DURATION OF AGREEMENT AND RENEWAL ...........................134
A. Initial Term ........................................................134
B. Renewal .............................................................134
SECTION XI: TERMINATION AND DEFAULT .....................................134
A. Termination by the Department .......................................134
1. Termination for Convenience Upon Notice .........................134
2. Termination for Cause ...........................................135
3. Termination Due to Unavailability of Funds/Approvals ............135
B. Termination by the Contractor .......................................136
C. Responsibilities of the Contractor Upon Termination .................136
1. Continuing Obligations ..........................................136
2. Notice to Members ...............................................136
3. Submission of Invoices ..........................................136
4. Failure to Perform ..............................................136
D. Transition at Expiration and/or Termination of Agreement ............138
SECTION XII: RECORDS .....................................................138
A. Financial Records Retention .........................................138
B. Operational Data Reports ............................................139
C. Medical Records Retention ...........................................139
D. Review of Records ...................................................139
SECTION XIII: SUBCONTRACTUAL RELATIONSHIPS ................................140
A. Compliance with Program Standards ...................................140
B. Consistency with Policy Statements ..................................141
SECTION XIV: CONFIDENTIALITY .............................................141
SECTION XV: INDEMNIFICATION AND INSURANCE ...............................142
A. Indemnification .....................................................142
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B. Insurance ...........................................................143
SECTION XVI: DISPUTES ....................................................143
SECTION XVII: FORCE MAJEURE ...............................................144
SECTION XVIII: GENERAL .....................................................144
A. Suspension From Other Programs ......................................144
B. Rights of the Department and the Contractor .........................145
C. Waiver ..............................................................145
D. Invalid Provisions ..................................................145
E. Governing Law .......................................................145
F. Expansion of the Zone ...............................................145
G. Notice ..............................................................146
H. Counterparts ........................................................146
I. Headings ............................................................146
J. Assignment ..........................................................147
K. No Third Party Beneficiaries ........................................147
L. News Releases .......................................................147
M. Entire Agreement: Modification ......................................147
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SECTION I: INCORPORATION OF DOCUMENTS
A. Operative Documents
The RFP, a copy of which is attached hereto as Appendix 1, and the
Proposal, a copy of which is attached hereto as Appendix 2, are
incorporated herein and are made a part of this Agreement. With
regard to the governance of such documents, it is agreed that:
1. In the event that any of the terms of this Agreement conflict
with, are inconsistent with, or are in addition to the terms
of the RFP, the terms of this Agreement shall govern;
2. In the event that any of the terms of this Agreement conflict
with, are inconsistent with, or are in addition to the terms
of the Proposal, the terms of this Agreement shall govern;
3. In the event that any of the terms of the RFP conflict with,
are inconsistent with, or are in addition to the terms of the
Proposal, the terms of the RFP shall govern.
SECTION II: DEFINITIONS
Abuse - Any Provider practices that are inconsistent with sound fiscal,
business, or medical practices, and result in an unnecessary cost to the MA
Program, or in reimbursement for services that are not medically necessary or
that fail to meet professionally recognized standards or contractual obligations
(including the terms of the RFP, Agreement, and the requirements of state or
federal regulations) for health care in a managed care setting. The abuse can be
committed by the Contractor, subcontractor, Provider, State employee, or a
Member, among others. Abuse also includes enrollee practices that result in
unnecessary cost to the MA Program, the Contractor, a subcontractor, or
Provider.
ACCESS Card - Medical Assistance Identification (MAID) Card. The individual card
issued to enrolled consumers in the MA Program.
ACCESS Program - A system used by school districts, intermediate units,
state-owned schools or approved private schools to xxxx Medicaid for services
for special education students who are enrolled in the MA Program.
Adjudicated Claim - A claim that has been processed to payment or denial.
Affiliate - Any individual, corporation, partnership, joint venture, trust,
unincorporated organization or association, or other similar organization
(hereinafter "Person"), controlling, controlled by or under common control with
the Contractor or its parent(s), whether such common control be direct or
indirect. Without limitation, all officers, or persons, holding
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five percent (5%) or more of the outstanding ownership interests of Contractor
or its parent(s), directors or subsidiaries of Contractor or parent(s) shall be
presumed to be affiliates for purposes of the RFP and Agreement. For purposes of
this definition, "control" means the possession, directly or indirectly, of the
power (whether or not exercised) to direct or cause the direction of the
management or policies of a person, whether through the ownership of voting
securities, other ownership interests, or by contract or otherwise including but
not limited to the power to elect a majority of the directors of a corporation
or trustees of a trust, as the case may be.
Alternate Payment Name - The person to whom benefits are issued on behalf of an
MA Consumer.
Amended Claim - A Provider request to adjust the payment of a previously
adjudicated claim.
Area Agency on Aging (AAA) - The single local agency designated by the
Pennsylvania Department of Aging within each planning and service area to
administer the delivery of a comprehensive and coordinated plan of social and
other services and activities.
Behavioral Health Managed Care Organization (BH-MCO) - An entity, operated by
county government or licensed by the Commonwealth as a risk-bearing Health
Maintenance Organization (HMO) or Preferred Provider Organization (PPO), which
manages the purchase and provision of behavioral health services under a
contract with the Department.
Behavioral Health Rehabilitation Services for Children and Adolescents (formerly
EPSDT "Wraparound") - Individualized, therapeutic mental health, substance abuse
or behavioral interventions/services developed and recommended by an interagency
team and prescribed by a physician or licensed psychologist.
Behavioral Health (BH) Services - Mental health and/or drug and alcohol
services which are provided by the BH-MCO.
Business Days - A business day includes Monday through Friday except for those
days recognized as federal holidays and/or Pennsylvania State holidays.
Capitation - A fee the Department pays periodically to a Contractor for each MA
Consumer enrolled under a contract for the provision of medical services,
whether or not the MA Consumer receives the services during the period covered
by the fee.
Case Management Services - Services which will assist individuals in gaining
access to necessary medical, social, educational and other services.
Case Payment Name - The person in whose name benefits are issued.
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Certificate of Authority - A document issued jointly by the Departments of
Health and Insurance authorizing a corporation to establish, maintain and
operate an HMO in Pennsylvania.
Certified Nurse Midwife - An individual licensed under the laws within the scope
of Chapter 6 of Professions & Occupations, 63 P.S. 171-176.
Certified Registered Nurse Practitioner (CRNP) - A registered nurse licensed in
the Commonwealth of Pennsylvania who is certified by the boards in a particular
clinical specialty area and who, while functioning in the expanded role as a
professional nurse, performs acts of medical diagnosis or prescription of
medical therapeutic or corrective measures in collaboration with and under the
direction of a physician licensed to practice medicine in Pennsylvania.
Children in Substitute Care - Children who have been adjudicated dependent or
delinquent and who are in the legal custody of a public agency and/or under the
jurisdiction of the juvenile court and are living outside their homes, in any of
the following settings: shelter homes, xxxxxx homes, group homes, supervised
independent living, and Residential Treatment Facilities for Children (RTFs).
Claim - A xxxx from a provider of a medical service or product that is assigned
a unique identifier (i.e. claim reference number). A Claim does not include an
encounter form for which no payment is made or only a nominal payment is made.
Clean Claim - A Claim that can be processed without obtaining additional
information from the Provider of the service or from a third party. A Clean
Claim includes a Claim with errors originating in the Contractor's claims
system. Claims under investigation for fraud or abuse or under review to
determine if they are Medically Necessary are not clean claims.
Client Information System (CIS) - The Department's database of MA Consumers. The
database contains demographic and eligibility information for all MA Consumers.
Complaint - A dispute or objection regarding a participating health care
provider or the coverage, operations, or management policies of a managed care
plan, which has not been resolved by the managed care plan and has been filed
with the plan or with the Department of Health or the Insurance Department of
the Commonwealth. The term does not include a Grievance.
Concurrent Review - A review conducted by the Contractor during a course of
treatment to determine whether the prescribed services should continue in
amount, duration and scope or whether a modification is necessary.
Contractor - A successful proposer or its successor approved by the Department.
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County Assistance Office (CAO) - The county offices of the Department that
administer all benefit programs, including MA, on the local level. Department
staff in these offices perform necessary functions such as determining and
maintaining MA Consumer eligibility.
Cultural Competency - The ability of individuals, as reflected in personal and
organizational responsiveness, to understand the social, linguistic, moral,
intellectual and behavioral characteristics of a community or population, and
translate this understanding systematically to enhance the effectiveness of
healthcare delivery to diverse populations.
Daily Membership File - An electronic file generated by the Department using CIS
on a daily basis, exclusive of weekends and Department holidays, that is
transmitted to the Contractor. The Daily Membership File contains information on
changes made to MA Consumer records on CIS, and may include retroactive, current
or prospective MA eligibility, and PH-MCO coverage information.
Deliverables - Those documents, records and reports required to be furnished to
the Department for review and/or approval pursuant to the terms of the RFP and
this Agreement.
Denial of Services - Any determination made by the Contractor in response to a
provider's request for approval to provide MA covered services of a specific
duration and scope which: disapproves the request completely; approves provision
of the requested service(s), but for a lesser scope or duration than requested
by the Provider; or disapproves provision of the requested service(s), but
approves provision of an alternative service(s). An approval of a requested
service which includes a requirement for a concurrent review by the Contractor
during the authorized period does not constitute a denial of service.
Denied Claim - An Adjudicated Claim that does not result in a payment to a
Provider.
Department - The Department of Public Welfare (DPW) of the Commonwealth of
Pennsylvania.
Deprivation Qualifying Code - The code specifying the condition which determines
an MA Consumer to be eligible in nonfinancial criteria.
Developmental Disability - A severe, chronic disability of an individual that
is:
o Attributable to a mental or physical impairment or combination of
mental or physical impairments.
o Manifested before the individual attains age 22.
o Likely to continue indefinitely.
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o Manifested in substantial functional limitations in three or more of
the following areas of life activity:
- Self care;
- Receptive and expressive language;
- Learning;
- Mobility:
- Capacity for independent living; and
- Economic self-sufficiency.
o Reflective of the individual's need for special, interdisciplinary
or generic services, supports, or other assistance that is of
lifelong or extended duration, except in the cases of infants,
toddlers, or preschool children who have substantial developmental
delay or specific congenital or acquired conditions with a high
probability of resulting in developmental disabilities if services
are not provided.
Disease Management - An integrated treatment approach that includes the
collaboration and coordination of patient care delivery systems and that focuses
on measurably improving clinical outcomes for a particular medical condition
through the use of appropriate clinical resources such as preventive care,
treatment guidelines, patient counseling, education and outpatient care; and
that includes evaluation of the appropriateness of the scope, setting and level
of care in relation to clinical outcomes and cost of a particular condition.
DPW Fair Hearing - A hearing conducted by the Department of Public Welfare.
Bureau of Hearings and Appeals or its subcontractor, based on a PH-MCO Member's
filing of an appeal from a termination, suspension or a reduction in MA
eligibility or MA covered services.
Drug Efficacy Study Implementation (DESI) -Drug products that have been
classified as less-than-effective by the Food and Drug Administration (FDA).
Dual Eligibles - An individual who is eligible to receive services through both
Medicare and the MA Program (Medicaid).
Early Intervention Program -The provision of specialized services through
family-centered intervention for a child, birth to age three (3), who has been
determined to have a developmental delay of twenty-five percent (25%) of the
child's chronological age or has documented test performance of 1.5 standard
deviation below the mean in standardized tests in one or more areas: cognitive
development; physical development, induding vision and hearing; language and
speech development; psycho-social development; or self-help skills or has a
diagnosed condition which may result in developmental delay.
Eligibility Period - A period of time during which a consumer is eligible to
receive MA benefits. An eligibility period is indicated by the eligibility start
and end dates on CIS. A blank eligibility end date signifies an open-ended
eligibility period.
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Eligibility Verification System (EVS) - An automated system available to
Providers and other specified organizations for on-line verification of MA
eligibility, prepaid capitation, PH-MCO or BH-MCO enrollment, third party
resources, and the applicable benefit package under the MA Fee-for-Service (FFS)
Program.
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: (a)
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, (b) serious
impairment to bodily functions, or (c) serious dysfunction of any bodily organ
or part.
Emergency Member Issue - A problem of a PH-MCO Member (including problems
related to whether an individual is a Member), the resolution of which should
occur immediately or before the beginning of the next business day in order to
prevent a denial or significant delay in care to the Member that could
precipitate a Medical Emergency Condition or need for urgent care.
Emergency Services - Covered inpatient and outpatient services that: (a) are
furnished by a Provider that is qualified to furnish such service under Title
XIX of the Social Security Act and (b) are needed to evaluate or stabilize an
Emergency Medical Condition.
Encounter Data - Any health care service provided to a PH-MCO Member. Encounters
whether reimbursed through capitation, fee-for-service, or another method of
compensation must result in the creation and submission of an encounter record
to the Department. The information provided on these records represents the
encounter data provided by the MCO.
Enrollee - A person eligible to receive services under the MA Program in the
Commonwealth of Pennsylvania and who is mandated to be enrolled in the
HealthChoices Lehigh/Capital (HC-L/C) Program.
Enrollment - The process by which a Member's entitlement tb receive services
from a PH-MCO is initiated.
Enrollment Specialist - The individual responsible to assist MA Consumers with
selecting a PH-MCO and PCP as well as providing information regarding physical
and behavioral health services and service providers under the HealthChoices
Program.
EPSDT - Early and Periodic Screening, Diagnosis and Treatment. Items and
services which must be made available to persons age twenty-one (21) and under
upon a determination of medical necessity and required by federal law at 42
U.S.C. ss.1396d(r).
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Expanded Services - Any Medically Necessary service, covered under Title XIX of
the Social Security Act, 42 U.S.C.A. 1396 et seq., but not included in the
State's Medicaid Plan, which is provided to an enrollee.
Expedited Grievance - A process for reviewing and resolving Grievances within
forty-eight (48) hours.
Experimental Treatment - A course of treatment, procedure, device or other
medical intervention that is not yet recognized by the professional medical
community as an effective, safe and proven treatment for the condition for which
it is being used.
External Quality Review (EQR) - A requirement under Section 1902(a)(30)(C) of
Title XIX of the Social Security Act, 42 U.S.C.A. 1396a(a)(30)(C) for states to
obtain an independent, external review body to perform an annual review of the
quality of services furnished under state contracts with managed care
organizations, including the evaluation of quality outcomes, timeliness and
access to services.
Family Planning Services - Services which enable individuals voluntarily to
determine family size, to space children and to prevent or reduce the incidence
of unplanned pregnancies. They are made available without regard to marital
status, age, sex or parenthood.
Federally Qualified Health Center (FQHC) - An entity which is receiving a grant
as defined under the Social Security Act, 42 U.S.C.A. 1396d(I) or is receiving
funding from such a grant under a contract with the recipient of such a grant,
and meets the requirements to receive a grant under the above-mentioned sections
of the Act.
Fee-for-Service (FFS) - Payment by the Department to providers on a per-service
basis for health care services provided to MA Consumers.
Formulary - An exclusive list of drug products for which the Contractor will
provide coverage to its Members, as approved by the Department.
Fraud - Any type of intentional deception or misrepresentation made by an entity
or person with the knowledge that the deception could result in some
unauthorized benefit to the entity, him/herself, or some other person in a
managed care setting. The fraud can be committed by many entities, including the
Contractor, a subcontractor, a State employee, or a Member, among others.
Generally Accepted Accounting Principles (GAAP) - A technical term in financial
accounting. It encompasses the conventions, rules, and procedures necessary to
define accepted accounting practice at a particular time.
Government Liaison - The Department's primary point of contact within the
PH-MCO. This individual acts as the day-to-day manager of contractual and
operational issues and works within PH-MCO and with DPW to facilitate
compliance, solve problems, and
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implement corrective action. The Government Liaison negotiates internal plan,
policy and operational issues.
Grievance - A request by an enrollee or a health care provider, with written
consent of the enrollee, to have the managed care plan or utilization review
entity reconsider a decision solely concerning medical necessity and
appropriateness of health care services. If the managed care plan is unable to
resolve the matter, a Grievance may be filed regarding a decision that: (1)
disapproves full or partial payment for requested health care services; (2)
approves a provision of a requested health care service for a lesser scope or
duration than requested; or (3) disapproves payment for provisions of a
requested health care service but approves payment for provision of an
alternative health care service. The term does not include a Complaint.
Health Care Financing Administration (HCFA) - The federal agency within the
Department of Health and Human Services responsible for oversite of MA programs.
Health Care Professional - A physician or other health care
provider/practitioner whose professional services are covered and provided for
under the professional scope of practice, and are included under the contract
for the services of the professional. This term includes, but is not limited
to: podiatrist, optometrist, chiropractor, psychologist, dentist, pharmacist,
physician assistant, physical or occupational therapist and therapy assistant,
speech-language pathologist, audiologist, registered or licensed practical nurse
(including nurse practitioner, clinical nurse specialist, certified registered
nurse anesthetist and certified nurse-midwife), licensed certified social
worker, registered respiratory therapist and certified respiratory therapy
technician.
Health Maintenance Organization (HMO) - A Commonwealth licensed risk-bearing
entity which combines delivery and financing of health care and which provides
basic health services to enrolled Members for a fixed, prepaid fee.
HealthChoices Disenrollment - Action taken by the Department to remove a
Member's name from the monthly Enrollment Report following the Department's
receipt of a determination that the Member is no longer eligible for enrollment
in HealthChoices.
HealthChoices Lehigh/Capital (HC-L/C) Program - The mandatory Medical Assistance
managed care program in Adams, Berks, Cumberland, Dauphin, Lancaster, Lebanon,
Lehigh, Northampton, Perry and York counties.
HealthChoices Proposers' Library - A collection of reference documents and
materials, relevant to the HC-L/C Program, available for use by proposers.
HealthChoices Program - The name of Pennsylvania's 1915(b)-waiver program to
provide mandatory managed health care to MA Consumers.
HIV/AIDS Waiver Program - A home and community based waiver that provides for
expanded services to MA Consumers who are diagnosed with Acquired
Immunodeficiency
9
Syndrome (AIDS) or symptomatic Human Immunodeficiency Virus (HIV) as a
cost-effective alternative to inpatient care.
Home and Community Based Services - Necessary and cost effective services, not
otherwise furnished under the State's Medicaid Plan, or services already
furnished under the State's Medicaid Plan but in expanded amount, duration, or
scope which are furnished to an individual in his/her home or community in order
to prevent institutionalization.
Immediate Need - A situation in which, in the professional judgment of the
dispensing registered pharmacist and/or prescriber, the dispensing of the drug
at the time when the prescription is presented is necessary to reduce or prevent
the occurrence or persistence of a serious adverse health condition.
Independent Enrollment Assistance Program (IEAP) - The program that provides
enrollment specialists to assist MA Consumers in selecting the PH-MCO and
Primary Care Practitioner (PCP) and obtaining information regarding
HealthChoices physical and behavioral health services and service providers.
In-Plan Services - Services which are the payment responsibility of the
Contractor under the HC-L/C Program.
Inquiry - Any Member's request for administrative service, information or to
express an opinion.
Interagency Team for Adults - A multi-system planning team consisting of the
individual, family member(s), legal guardian, advocate(s), county mental
health/mental retardation and/or drug and alcohol case manager(s), PCP, treating
specialist(s), residential and/or day service provider(s) and any other
participant(s) necessary and appropriate to assess the needs and strengths of
the individual, formulate treatment and service goals, approaches and methods,
recommend and monitor services and develop discharge plans. Representation on
the team is based on expertise necessary to determine and meet each individual's
needs and, therefore, is developed on a case-by-case basis.
Interagency Team for Individuals Under the Age of Twenty-One (21) - A
multi-system planning team comprised of the child, when appropriate, at least
one (1) accountable family member, a representative of the County Mental Health
and/or Drug and Alcohol Program, the case manager, the prescribing physician or
psychologist, and as applicable, the County Children and Youth, Juvenile
Probation, Mental Retardation, and Drug and Alcohol agencies, a representative
of the school district, BH-MCO, PH-MCO and/or PCP, other agencies that are
providing services to the child, and other community resource persons identified
by the family. The purpose of the interagency team is to collaboratively assess
the needs and strengths of the child and family, formulate the measurable goals
for treatment, recommend the services, treatment approaches and methods,
intensity and frequency of interventions and develop the discharge goals and
plans.
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intermediate Care Facility for the Mentally Retarded and Other Related
Conditions (ICF/MR/ORC) - An institution (or distinct part of an institution)
that 1) is primarily for the diagnosis, treatment or rehabilitation for persons
with mental retardation or persons with other related conditions; and 2)
provides, in a residential setting, ongoing evaluation, planning, twenty-four
(24) hour supervision, coordination and integration of health or rehabilitative
services to help each individual function at his/her maximum capacity.
Issuing Office - The Department's Division of Procurement.
Juvenile Detention Center - A publicly or privately administered, secure
residential facility for:
o Children alleged to have committed delinquent acts who are awaiting
a court hearing;
o Children who have been adjudicated delinquent and are awaiting
disposition or awaiting placement; and
o Children who have been returned from some other form of disposition
and are awaiting a new disposition (i.e., court order regarding
custody of child, placement of child, or services to be provided to
the child upon discharge from the Juvenile Detention Center).
Lock-In - If a MA Consumer is identified as abusing services provided under the
MA Program, they are restricted (locked-in) to a specific Provider(s) to obtain
all of his/her services to ensure they receive comprehensiveness of care.
MA Consumer - A person enrolled to receive services under the MA Program in the
Commonwealth of Pennsylvania.
Managed Care Organization (MCO) - An entity which manages the purchase and
provision of physical or behavioral health services under the HC-L/C Program.
Market Share - The percentage of members enrolled with a particular PH-MCO when
compared to the total of members enrolled in all the PH-MCOs within a zone.
Medical Assistance (MA) - The Medical Assistance Program authorized by Title XIX
of the federal Social Security Act, 42 U.S.C.A 1396 et seq., and regulations
promulgated thereunder, and 62 P.S. 101 et seq.
Medical Assistance Transportation Program (MATP) - A non-emergency medical
transportation service provided to eligible persons who need to make trips
to/from a MA reimbursable service for the purpose of receiving treatment,
medical evaluation, or purchasing prescription drugs or medical equipment.
11
Medically Necessary - A service or benefit is medically necessary if it is
compensable under the MA Program and if it meets any one of the following
standards:
o The service or benefit will, or is reasonably expected to, prevent
the onset of an illness, condition or disability.
o The service or benefit will, or is reasonably expected to, reduce or
ameliorate the physical, mental or developmental effects of an
illness, condition, injury or disability.
o The service or benefit will assist the Member to achieve or maintain
maximum functional capacity in performing daily activities, taking
into account both the functional capacity of the Member and those
functional capacities that are appropriate for members of the same
age.
Determination of medical necessity for covered care and services, whether made
on a prior authorization, concurrent review, post-utilization, or exception
basis, must be in writing.
The determination is based on medical information provided by the Member, the
member's family/caretaker and the primary care practitioner, as well as any
other providers, programs, agencies that have evaluated the Member.
All such determinations must be made by qualified and trained providers.
Member - An individual who is enrolled with a PH-MCO under the HC-L/C Program
and for whom the PH-MCO is responsible to provide physical health services
under the provisions of the HealthChoices Program.
Member Record - A record contained on the Daily Membership File or the Monthly
Membership File that contains information on MA eligibility, managed care
coverage, and the category of assistance, which help establish the covered
services for which a MA Consumer is eligible.
Mental Retardation - An impairment in intellectual functioning which is lifelong
and originates during the developmental period (birth to 22 years). It results
in substantial limitations in three or more of the following areas: learning,
self-direction; self care; expressive and/or receptive language; mobility;
capacity for independent living; and economic self-sufficiency.
Xxxxxxx Dallas Waiver (MOW) - A program operating under a federal waiver that
provides essential home care services to technology-dependent individuals.
Midwifery Practice - Management of the care of essentially healthy women and
their healthy neonates (initial twenty-eight [28] day period). This includes
intrapartum, postpartum and gynecological care.
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Minority Business Enterprise - A business concern that is:
o A sole proprietorship, owned and controlled by a minority;
o A partnership or joint venture controlled by minorities in which
fifty-one percent (51%) of the beneficial ownership interest is
held by minorities; or
o A corporation or other entity controlled by minorities in which
fifty-one percent (51%) of the voting interest and fifty-one percent
(51%) of the beneficial ownership interest are held by minorities.
Monthly Membership File - An electronic file generated by the Department using
CIS that is transmitted to the Contractor. The Monthly Membership File lists
retroactive, current and prospective members, specifying for each Member the
corresponding eligibility period, PH-MCO coverage and BH-MCO coverage.
Network - All contracted or employed providers in the PH-MCO who are providing
covered services to Members.
Network Provider - A health care professional who has a written Provider
Agreement with a HC-L/C PH-MCO and is credentialed by and who participates in
the PH-MCO's provider network to serve HealthChoices members.
Net Worth (Equity) - The residual interest in the assets of an entity that
remains after deducting its liabilities.
Nursing Facility - A facility licensed by the DOH as a MA provider type 35 or
type 36 or a facility licensed by DOH as such and certified for Medicare
participation.
Ongoing Medication - A medication that has been previously dispensed to the
Member for the treatment of an illness that is chronic in nature or for an
illness for which the medication is required for a length of time to complete a
course of treatment, until the medication is no longer considered necessary by
the physician/prescriber. If the current prescription is for a higher dosage
than previously prescribed, the prescription is for an ongoing medication at
least to the extent of the previous dosage.
Open-ended - A period of time that has a start date but no definitive end date.
OPTIONS - The long-term care pre-admission assessment program operated by the
Department of Aging under contract with the Department of Public Welfare.
Other Related Conditions (ORC) - A physical disability such as cerebral palsy,
epilepsy, xxxxx bifida or similar conditions which occur before the age of
twenty-two (22), is likely to continue indefinitely and results in three (3) or
more substantial functional limitations.
13
Other Resources - All other resources include, but are not limited to,
recoveries from personal injury claims, liability insurance, first-party
automobile medical insurance, accident-indemnity insurance, and the assigned
claims plan.
Out-of-Area Covered Services - Medical services provided to MA Consumers that
meet one (1) or more of the following criteria:
o An emergency medical condition that occurs while outside the zone;
o The health of the MA consumer would be endangered if the MA consumer
returned to the zone for needed services;
o The provider is located outside the zone, but is nonetheless a
subcontractor regularly providing medical services to MA consumers
at the request of the PH-MCO; or
o The needed medical services are not available in the zone.
Out-of-Network Provider - A health care professional who has not been
credentialed by and does not have a signed Provider Agreement with a HC-L/C
PH-MCO.
Out-of-Plan Services - Services which are non-plan, non-capitated and are not
the responsibility of the Contractor under the HC-L/C Program comprehensive
benefit package.
Physical Health Managed Care Organization (PH-MCO) -A risk bearing entity, also
referred to as the "plan", which has contracted with the Department to manage
the purchase and provision of physical health services under the HC-L/C Program.
Physician Incentive Plan - Any compensation arrangement between an MCO and a
physician or physician group that may directly or indirectly have the effect of
reducing or limiting services furnished to Medicaid recipients enrolled in the
MCO.
PH-MCO Coverage Period - A period of time during which an individual is eligible
for MA coverage and a PH-MCO coverage period exists on CIS.
PH-MCO Disenrollment - The process by which a Member's ability to receive
services from a PH-MCO is terminated.
Physical Health (PH) Services - Medical and other related services which the
Contractor is responsible to provide to its Members.
Physician Incentive Plan-Any compensation arrangement between an MCO and a
physician or physician group that may directly or indirectly have the effect of
reducing or limiting services furnished to Medicaid recipients enrolled in the
MCO.
14
POSNet - The Pennsylvania Open Systems Network (POSNet) which is a peer-to-peer
network based on open systems products and protocols.
Post-Stabilization Services - Medically necessary non-emergency services
furnished to a Member after the Member is stabilized following an Emergency
Medical Condition.
Preferred Provider Organization (PPO) - A Commonwealth licensed person,
partnership, association or corporation which establishes, operates, maintains
or underwrites in whole or in part a preferred provider arrangement as defined
in 31 Pa. Code 152.2.
Primary Care Case Management (PCCM) - A program under which the Department
contracts directly with primary care providers who agree to be responsible for
the provision and/or coordination of medical services to MA Consumers under
their care.
Primary Care Practitioner (PCP) - A specific physician, physician group or a
CRNP operating under the scope of his/her licensure who has received an
exception from the Department of Health, and who is responsible for supervising,
prescribing, and providing primary care services; locating, coordinating and
monitoring other medical care and rehabilitative services and maintaining
continuity of care on behalf of an MA Consumer.
Prior Authorization - A determination made by a Contractor to approve or deny a
Provider's request to provide a service or course of treatment of a specific
duration and scope to a member prior to the Provider's initiating provision of
the requested service.
Prior Authorization Review Panel (PARP) - A panel of representatives from within
the Department who have been assigned organizational responsibility for the
review, approval and denial of all PH-MCO prior authorization policies and
procedures.
Prior Authorized Services - In-plan services for which a physical health service
Provider must obtain, pursuant to Department-approved PH-MCO policies and
procedures, the PH-MCO's approval in advance of the Provider's initiating
provision of the service.
Provider - A person, firm or corporation, enrolled in the Pennsylvania MA
Program, which provides services or supplies to MA Consumers.
Provider Agreement - Any Department-approved written agreement between the
Contractor and a Provider to provide medical or professional services to MA
Consumers to fulfill the requirements of this Agreement.
Provider Appeal - A request from a Provider for reversal of a denial by the
Contractor, with regard to the three (3) major types of issues that are to be
addressed in a provider appeal system as outlined in this Agreement at Section
V.K, Provider Dispute Resolution System. The three (3) types of Provider appeals
issues are:
15
1. Provider credentialing denial by the PH-MCO
2. Claims denied by the PH-MCO for Providers participating in the
PH-MCOs network. This includes payment denied for services already
rendered by the Provider to the Member; and
3. Provider termination by the PH-MCO.
Provider Dispute - A written communication to a PH-MCO, made by a Provider,
expressing dissatisfaction with a PH-MCO decision that directly impacts the
Provider. This does not include decisions concerning medical necessity.
Quality Management - An ongoing, objective and systematic process of monitoring,
evaluating and improving the quality, appropriateness and effectiveness of care.
Recipient - A person eligible to receive physical and/or behavioral health
services under the MA Program of the Commonwealth of Pennsylvania.
Recipient Month - One MA Consumer covered by the HC-L/C Program for one (1)
calendar month.
Rejected Claim - A non-HealthChoices Claim or a Claim that has erroneously been
assigned a unique identifier and is removed from the claims processing system
prior to adjudication.
Related Parties - Any entity that is related to the Contractor or subcontracting
PH-MCO by common ownership or control, (see definition of "Affiliate"), and (1)
performs some of the Contractor or subcontracting PH-MCO's management functions
under contract or delegation; (2) furnishes services to Members under a written
agreement; or (3) leases real property or sells materials to the Contractor or
subcontracting PH-MCO at a cost of more than $2,500.00 during any year of a
HC-L/C physical health contract with the Department.
Residential Treatment Facility (RTF) - A facility licensed by the Department of
Public Welfare that provides twenty-four (24) hour out-of-home care, supervision
and medically necessary mental health services for individuals under twenty-one
(21) years of age with a diagnosed mental illness or severe emotional disorder.
Retrospective Review - A review conducted by the Contractor to determine whether
services were delivered as prescribed and consistent with the Contractor's
payment policies and procedures.
Rural - Consists of territory, persons and housing units in areas throughout the
Commonwealth which are designated as having less than 2,500 persons.
16
School-Based Health Center - A health care site located on school building
premises which provides, at a minimum, on-site, age-appropriate primary and
preventive health services with parental consent, to children in need of primary
health care and which participate in the MA Program and adhere to EPSDT
standards and periodicity schedule.
School-Based Health Services - An array of Medically Necessary health services
performed by licensed professionals that may include, but are not limited to,
immunization, well child care and screening examinations in a school-based
setting.
Socially/Economically Restricted Business (SERB) - A business whose economic
growth and development has been restricted based on social and economic bias.
Special Needs - The circumstances for which a Member will be classified as
having a special need will be based on a non-categorical or generic perspective
that identifies key attributes of physical, developmental, emotional or
behavioral conditions, as determined by DPW and as described in this Agreement
at Section V.P, Special Needs Unit (SNU) and Exhibit NN, Special Needs Unit.
Spend-down - A process of establishing eligibility for MA whereby consumers
spend their excess net income on certain incurred or paid medical expenses.
Eligibility may need to be redetermined monthly.
Start Date - The first date on which MA Consumers are eligible for medical
services under this Agreement, and on which the Contractors are operationally
responsible and financially liable for providing Medically Necessary services to
MA Consumers.
Stop-Loss Protection - Coverage designed to limit the amount of financial loss
experienced by a health care provider.
Subcapitation - A fixed per capita amount that is paid by the PH-MCO to a
network provider for each Member identified as being in their capitation group,
whether or not the Member received medical services.
Subcontract - Any contract between the PH-MCO and an individual, business,
university, governmental entity, or nonprofit organization to perform part or
all of the PH-MCO's responsibilities under this Agreement. Exempt from this
definition are salaried employees, utility agreements and Provider Agreements,
which are not considered Subcontracts for the purpose of this Agreement and,
unless otherwise specified herein, are not subject to the provisions governing
Subcontracts.
Sustained Improvement - Improvement in performance documented through continued
measurement of quality indicators after the performance project/study/quality
initiative is completed.
Substantial Financial Risk- Financial risk set at greater than 25% of potential
payments for covered services, regardless of the frequency of assessment (i.e.,
collection) or
17
distribution of payments. The term "potential payments" means simply the maximum
anticipated total payments that the physician or physician group could receive
if the use or cost of referral services were significantly low. The cost of
referrals, then, must not exceed that 25% level, or else the financial
arrangement is considered to put the physician or group at substantial financial
risk.
Targeted Case Management (TCM) Program -- A case management program for MA
Consumers who are diagnosed with AIDS or symptomatic HIV.
Third Party Liability (TPL) -- The financial responsibility for all or part of a
Member's healthcare expenses of an individual entity or program (e.g., Medicare)
other than the Contractor.
Third Party Resource (TPR) -- Any individual, entity or program that is liable
to pay all or part of the medical cost of injury, disease or disability of a MA
Consumer. Examples of third party resources include: government insurance
programs such as Medicare or CHAMPUS (Civilian Health and Medical Program of the
Uniformed Services); private health insurance companies, or carriers; liability
or casualty insurance; and court-ordered medical support.
Title XVIII (Medicare) -- A federally-financed health insurance program
administered by the Health Care Financing Administration (HCFA) pursuant to 42
U.S.C.A. 1395 et seq., covering almost all Americans sixty-five (65) years of
age and older and certain individuals under sixty-five (65) who are disabled or
have chronic kidney disease.
Transitional Care Home -- A tertiary care center which provides medical and
personal care services to children upon discharge from the hospital who require
intensive medical care for an extended period of time. This transition allows
for the caregiver to be trained in the care of the child, so that the child can
eventually be placed in the caregiver's home.
Urban -- Consists of territory, persons and housing units in places which are
designated as 2,501 persons or more. These places must be in close proximity to
one another.
Urgent Medical Condition -- Any illness, injury or severe condition which under
reasonable standards of medical practice, would be diagnosed and treated within
a twenty-four (24) hour period and if left untreated, could rapidly become a
crisis or Emergency Medical Condition. The terms also include situations where a
person's discharge from a hospital will be delayed until services are approved
or a person's ability to avoid hospitalization depends upon prompt approval of
services.
Utilization Management -- An objective and systematic process for planning,
organizing, directing and coordinating health care resources to provide
Medically Necessary, timely and quality health care services in the most
cost-effective manner.
Utilization Review Criteria -- Detailed standards, guidelines, decision
algorithms, models, or informational tools that describe the clinical factors to
be considered relevant to
18
making determinations of medical necessity including, but not limited to, level
of care, place of service, scope of service, and duration of service.
Ventilator Dependent -- A person who requires respiratory support through the
use of a mechanical ventilator in order to replace or support normal
musculo-skeletal respiratory function to support the adequate exchange of oxygen
and carbon dioxide. A Member is considered ventilator dependent if he/she:
(1) Demonstrates an inability to maintain adequate respiratory function
without the assistance of a mechanical ventilator and therefore the
mechanical ventilator is needed for its cyclic mechanical support or
replacement of the inspiratory phase of respiration,
(2) Requires more than twelve hours per day of continuous support from
the mechanical ventilator to sustain life in order to prevent
significant abnormalities in the physiologic parameters associated
with respiration, and
(3) Is maintained on a mechanical ventilatory support via a
tracheostomy.
Voided Member Record -- A Member Record used by the Department to advise the
Contractor that a certain related Member Record previously submitted by the
Department to the Contractor should be voided. A Voided Member Record can be
recognized by its illogical sequence of PH-MCO membership start and end dates
with the end date preceding the Start Date.
Women's Business Enterprise -- A business concern that is:
o A sole proprietorship, owned and controlled by a woman;
o A partnership or joint venture controlled by women in which
fifty-one percent (51%) of the beneficial ownership interest is held
by women; or
o A corporation or other entity controlled by women in which fifty-one
percent (51%) of the voting interest and fifty-one percent (51%) of
the beneficial ownership interest are held by women.
19
AGREEMENT and RFP ACRONYMS:
For the purpose of this Agreement and RFP, the acronyms set forth shall apply.
AAA -- Area Agency on Aging.
AIDS -- Acquired Immunodeficiency Syndrome.
ADA -- Americans with Disabilities Act.
BBS -- Bulletin Board System.
BCABD -- Bureau of Contract Administration and Business Development.
BH -- Behavioral Health.
BHA -- Bureau of Hearings and Appeals.
BH-MCO -- Behavioral Health Managed Care Organization.
CAHPS -- Consumer Assessment of Health Plans Study.
CAO -- County Assistance Office.
CASSP -- Children and Adolescent Support Services Program.
CDC -- Centers for Disease Control (and Prevention).
CFO -- Chief Financial Officer.
CFR -- Code of Federal Regulations.
CIS -- Client Information System.
CLIA -- Clinical Laboratory Improvement Amendment.
CLPPP -- Childhood Lead Poisoning Prevention Project.
COB -- Coordination of Benefits.
CSP -- Community Support Program.
CRNP -- Certified Registered Nurse Practitioner.
CRR -- Community Residential Rehabilitation.
DEA -- Drug Enforcement Agency.
DESI -- Drug Efficacy Study Implementation.
DSH -- Disproportionate Share.
DME -- Durable Medical Equipment.
DOH -- Department of Health (of the Commonwealth of Pennsylvania).
DOI -- Department of Insurance (Pennsylvania Insurance Department).
DUR -- Drug Utilization Review.
EMS -- Emergency Medical Services.
EQR -- External Quality Review.
EVS -- Eligibility Verification System.
EPSDT -- Early and Periodic Screening, Diagnosis and Treatment.
ER -- Emergency Room.
ERISA -- Employees Retirement Income Security Act of 1974.
FDA -- Food and Drug Administration.
FFS -- Fee-for-Service.
FQHC -- Federally Qualified Health Center.
FTE -- Full Time Equivalent.
FTP -- File Transfer Protocol.
GA -- General Assistance.
GAAP -- Generally Accepted Accounting Principles.
GME -- Graduate Medical Education.
20
HBP -- Healthy Beginnings Plus.
HCFA -- Health Care Financing Administration.
HEDIS -- Healthplan Employer Data and Information Set.
HC-L/C -- HealthChoices Lehigh/Capital (Program).
HIPAA -- Health Insurance Portability and Accountability Act.
XXXX -- Health Insurance Premium Payment.
HIV -- Human Immunodeficiency Virus.
HMO -- Health Maintenance Organization.
IBNP -- Incurred But Not Paid.
ICF/MR -- Intermediate Care Facility for the Mentally Retarded.
ICF/ORC -- Intermediate Care Facility/Other Related Conditions.
lEAP -- Independent Enrollment Assistance Program.
JCAHO -- Joint Commission for the Accreditation of Healthcare Organizations.
JDC -- Juvenile Detention Center.
LAAM -- Levo-Alpha-acetyl-Methadol, now known as Levomethadyl Acetate
Hydrochloride.
LTCCAP -- Long Term Care Capitation.
MA -- Medical Assistance.
MAAC -- Medical Assistance Advisory Committee.
MAID -- Medical Assistance Identification Number.
MATP -- Medical Assistance Transportation Program.
MBE -- Minority Business Enterprise.
MCO -- Managed Care Organization.
MDW -- Xxxxxxx Dallas Waiver.
MIS -- Management Information System.
NCQA -- National Committee for Quality Assurance.
NPDB -- National Practitioner Data Bank.
OBRA -- Omnibus Budget Reconciliation Act.
OCYF -- Office of Children, Youth and Families.
OIP -- Other Insurance Paid.
OMAP -- Office of Medical Assistance Programs.
OMHSAS -- Office of Mental Health and Substance Abuse Services.
OMR -- Office of Mental Retardation.
ORC -- Other Related Conditions.
OSP -- Office of Social Programs.
PARP -- Prior Authorization Review Panel.
PBM -- Pharmacy Benefit Manager.
PCP -- Primary Care Practitioner.
PDA -- Pennsylvania Department of Aging.
PERT -- Program Evaluation and Review Technique.
PH -- Physical Health.
PH-MCO -- Physical Health Managed Care Organization.
PMPM -- Per Member, Per Month.
QARI -- Quality Assurance Reform Initiative.
QM -- Quality Management.
QMC -- Quality Management Committee.
21
QM/UMP -- Quality Management and Utilization Management Program.
RBUC -- Reported But Unpaid Claim.
RFP -- Request for Proposal.
RPAA -- Risk Pool Allocation Amount.
RTF -- Residential Treatment Facility.
SAP -- Statutory Accounting Principles.
SERB -- Socially/Economically Restricted Business.
SNU -- Special Needs Unit.
SPR -- Systems Performance Review.
SSA -- Social Security Act.
SSI -- Supplemental Security Income.
STD -- Sexually Transmitted Disease.
TANF -- Temporary Assistance for Needy Families.
TCM -- Targeted Case Management.
TPL -- Third Party Liability.
TTY -- Text Telephone Typewriter.
UM -- Utilization Management.
URCAP -- Utilization Review Criteria Assessment Process.
U.S. DHHS -- United States Department of Health and Human Services.
WBE -- Women's Business Enterprise.
WIC -- Women's, Infants' and Children (Program).
22
SECTION III: RELATIONSHIP OF PARTIES
A. Basic Relationship
The relationship between the Department and the Contractor is that
of independent contracting parties. The Contractor, its employees,
servants, agents, and representatives shall not be considered and
shall not hold themselves out as the employees, servants, agents or
representatives of the Department or the Commonwealth of
Pennsylvania. The Contractor, its employees, servants, agents and
representatives do not have the authority to bind the Department or
the Commonwealth of Pennsylvania and they shall not make any claim
or demand for any right or privilege applicable to an officer or
employee of the Department or the Commonwealth of Pennsylvania. In
furtherance of the foregoing, the Contractor acknowledges that no
workers' compensation or unemployment insurance coverage shall be
provided by the Department to the Contractor's employees, servants,
agents and representatives. The Contractor shall be responsible for
maintaining for its employees, and for requiring of its agents and
representatives, malpractice, workers' compensation and unemployment
compensation insurance in such amounts as required by law.
The Contractor acknowledges and agrees that it shall have full
responsibility for all taxes and withholdings of all of its
employees. In the event that any employee or representative of the
Contractor is deemed an employee of the Department by any taxing
authority or other governmental agency, the Contractor agrees to
indemnify the Department for any taxes, penalties or interest
imposed upon the Department by such taxing authority or other
governmental agency.
B. Nature of Contract
Pursuant to this Agreement, the Contractor shall arrange for the
provision of medical and related services to MA Consumers through
qualified health care Providers in accordance with the terms and
conditions of this Agreement. In administering the HealthChoices
Program, the Contractor shall comply fully with the terms and
conditions set forth in this Agreement, including but not limited
to, the operational and financial standards.
SECTION IV: APPLICABLE LAWS AND REGULATIONS
A. Certification and Licensing
During the term of this Agreement, the Contractor shall require that
each of the health care professionals with which it contracts comply
with all certification and licensing laws and regulations applicable
to the profession. The Contractor agrees not to employ or enter into
a contractual relationship
23
with a Provider or practitioner who is precluded from participation
in the MA program.
B. Specific to MA Program
The Contractor agrees to participate in the MA Program and to
arrange for the provision of those medical and related services
essential to the medical care of those individuals being served, and
to comply with all federal and Pennsylvania laws generally and
specifically governing participation in the MA Program. The
Contractor agrees that all services provided hereunder shall be
provided in the manner prescribed by 42 U.S.C.A. 300e(b), and
warrants that the organization and operation of the Contractor is in
compliance with 42 U.S.C.A. 300e(c). The Contractor agrees to comply
with all applicable rules, regulations, and Bulletins promulgated
under such laws including, but not limited to, 42 U.S.C.A. 300e,
1396 et seq.; 62 P.S. 101 et. seq.; 42 C.F.R. Parts 431 through 481
and 45 C.F.R. Parts 74, 80, and 84, and the Department of Public
Welfare regulations as specified in Exhibit A of this Agreement,
General Guidelines for Managed Care Regulatory Review, and, the
HealthChoices Proposers' Library, Exhibit C of this Agreement for a
list of applicable regulations.
C. General Laws and Regulations
The Contractor must comply with Tifles VI and VII of the Civil
Rights Act of 1964, 42 U.S.C.A. Section 2000d et seq. and 2000e et
seq.; Section 504 of the Rehabilitation Act of 1973, 29 U.S.C.A.
Section 701 et seq.; the Age Discrimination Act of 1975, 42 U.S.C.A.
6101 et seq.; the Americans with Disabilities Act, 42 US.C.A. 12101
et seq.; and the Pennsylvania Human Relations Act of 1955, 71 P.S.
941 et seq.; and Article XXI of the Insurance Company Law of 1921,
as amended, 40 P.S. 991.2102 et seq.
The Contractor must comply with the Commonwealth's Contract
Compliance Regulations that are set forth at 16 Pa. Code 49.191 and
on file with the Contractor.
The Contractor must comply with the Standard Contract Terms and
Conditions found in Exhibit D of this Agreement, Standard Contract
Terms and Conditions for Services.
The Contractor must comply with all applicable laws, regulations,
and policies of the Pennsylvania Department of Health and the
Pennsylvania Insurance Department.
In addition, the Contractor and its subcontractors must respect the
conscience rights of individual providers and provider
organizations, and comply with the current Pennsylvania laws
prohibiting discrimination on the
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basis of the refusal or willingness to participate in certain
abortion and sterilization-related activities as outlined in 43 P.S.
955.2 and 18 Pa. C.S.A. 3213(d).
Nothing in this Agreement shall be construed to permit or require
the Department to pay for any services or items which are not or
have ceased to be compensable under the laws, rules and regulations
governing the MA Program at the time such services are provided.
The Contractor shall maintain the highest standards of integrity in
the performance of this Agreement and shall take no action in
violation of state or federal laws, regulations, or other
requirements that govern contracting with the Commonwealth. The
requirements regarding Contractor Integrity Provisions, are
contained in Exhibit D of this Agreement, Standard Contract Terms
and Conditions for Services.
D. Limitation on the Department's Obligations
The obligations of the Department under this Agreement are limited
and subject to the availability of funds appropriated by the General
Assembly of the Commonwealth of Pennsylvania, and certified by the
Comptroller for Public Health and Human Services.
SECTION V: PROGRAM REQUIREMENTS
A. In-Plan Services
The Contractor must ensure that all services provided are Medically
Necessary.
1. Amount, Duration and Scope
At a minimum, In-Plan Services shall be provided in the
amount, duration and scope set forth in the MA FFS Program and
be based on the MA Consumer's benefit package, unless
otherwise specified by the Department. If new services or
eligible consumers are added to the Pennsylvania MA Program,
or if covered services or eligible consumers are expanded or
eliminated, implementation by the Contractor shall be on the
same day as the Department's, unless the Contractor is
notified by the Department of an alternative implementation
date. When new services are added, the Department shall
conduct an actuarial analysis including appropriate input by
the Contractor, to determine if there is a need for a rate
change and if necessary, adjust the rates to appropriately
reflect the addition of the new services.
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The Department has established benefit packages based on
category of assistance, program status code, age, and, for
some packages, the existence of Medicare coverage or a
deprivation qualifying code. In cases where the Member
benefits are determined by the benefit package, the most
comprehensive package is to be honored.
2. Program Exception
The Contractor is also required to establish a process,
reviewed and approved by the Department, whereby a Provider
may request coverage for items or services, which while
included under the MA Consumer's benefit package, are not
currently listed on the MA Program Fee Schedule. These
requests are recognized by the Department as a Program
Exception and described in 55 Pa. Code 1150.63.
3. Expanded Benefits
The Contractor may provide expanded benefits subject to
advance written approval by the Department. These must be
benefits that are generally considered to have a direct
relationship to the maintenance or enhancement of a Member's
health status. Examples of potentially approvable benefits
include various seminars and educational programs promoting
healthy living or illness prevention, memberships in health
clubs and/or facilities promoting physical fitness and
expanded eyeglass or eye care benefits. These benefits must be
generally available to all Members and must be made available
at all appropriate Contractor Network Providers. Such benefits
cannot be tied to specific Member performance. However, the
Department may grant exceptions in areas where it believes
that such tie-ins shall produce significant health
improvements for Members.
In order for information about expanded benefits to be
included in any Member information provided by the Contractor,
the expanded benefits must apply for a minimum of one full
year or until the Member information is revised, whichever is
later. Upon approval by the Department, the Contractor may
modify or eliminate any expanded benefits, which exceed the
benefits provided for under the MA FFS Program. Such
benefit(s) as modified or eliminated shall supersede those
specified in the Proposal. The Contractor must send written
notice to Members and affected Providers at least thirty (30)
days prior to the effective date of the change in covered
benefits and shall simultaneously amend all written materials
describing its covered benefit or provider network. A change
in covered benefits
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includes any reduction in benefits or a substantial change to
the Provider network.
For information to be included in materials to be used by the
Independent Enrollment Assistance Program (IEAP), the expanded
benefits must be in effect for the full calendar year for
which the IEAP information applies. IEAP information will be
updated annually on a calendar year basis.
4. Referrals
The Contractor is required to establish and maintain a
referral process to effectively utilize and manage the care of
its Members. The Contractor may require a referral for any
medical services, which cannot be provided by the PCP except
where specifically provided for in this Agreement.
5. Self Referral/Direct Access
There are some services, which can be accessed without a
referral from the PCP. Vision, dental care, obstetrical and
gynecological (OB/GYN) services and chiropractor services may
be self-referred, providing the Member obtains the services
from the PH-MCO's Provider Network.
The referral authorization process must not apply to the
delivery of family planning services. The right of the Member
to choose a provider for family planning services shall not be
restricted. Members may access at a minimum, health education
and counseling necessary to make an informed choice about
contraceptive methods, pregnancy testing and counseling,
breast cancer screening services, basic contraceptive supplies
such as oral birth control pills, diaphragms, foams, creams,
jellies, condoms (male and female), Norplant, injectibles,
intrauterine devices, and other family planning procedures as
described in Exhibit F of this Agreement, Family Planning
Services Procedures, and the Contractor must pay for the
Out-of-Plan Services.
Under Section 2111(7) of the Insurance Company Law of 1921, as
amended, 40 P.S. 991.72111(7), Members are to be provided
direct access to OB/GYN services. The Contractor must have a
system in place that does not erect barriers to care for
pregnant women and does not involve a time-consuming
authorization process or unnecessary travel.
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Members must be permitted to select a healthcare Provider,
including nurse midwives participating in the PH-MCO's
Network, to obtain maternity and gynecological care without
prior approval from a PCP. This includes selecting a
healthcare Provider to provide Medically Necessary follow-up
care, an annual well-woman gynecological visit, primary and
preventive gynecology care, including a PAP smear and
referrals for diagnostic testing related to maternity and
gynecological care.
In situations where a new (and pregnant) enrollee is already
receiving care from an out-of-network OB-GYN specialist at the
time of enrollment, the member may continue to receive
services from that specialist throughout the pregnancy and
postpartum care related to the delivery.
6. Behavioral Health Services
The Contractor is not responsible to provide any services as
set forth in the Behavioral Health RFP and/or in the contracts
between the Department and the Behavioral Health Managed Care
Organizations (BH-MCOs).
7. Pharmacy Services
a. General
The Contractor must cover, at a minimum, those
therapeutic categories currently covered by the
Department's FFS Pharmaceutical Services Program.
Under no circumstances will the Contractor permit the
therapeutic substitution of a prescription drug by a
pharmacist without explicit authorization from the
licensed prescriber.
The Contractor must also comply with the requirements
for Prior Authorization for Outpatient Prescription
Drugs, Section V. B.2 of this Agreement.
b. Formularies
Formulary guidelines and approval criteria are listed in
Exhibit G of this Agreement, Drug Formulary Guidelines.
The Contractor may use a formulary as long as it meets
the clinical needs of the MA population and allows
access to all other MA FFS drug products not on the
formulary through
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some exception process such as prior authorization in
accordance with Exhibit H of this Agreement, Prior
Authorization Guidelines. The Contractor must submit the
request for advance written approval by the Department
of the exception or prior authorization process related
to pharmacy services together with the request for
formulary approval. Pharmacy prior authorization
policies and procedures must be submitted to the Prior
Authorization Review Panel (PARP) for review and
approval prior to implementation. Clinical guidelines to
prior authorize non-formulary drugs require advance
written approval under the Department's Utilization
Review Criteria Assessment Process (URCAP) process which
can be found in the HealthChoices Proposers' Library.
All formularies must conform to the formulary guidelines
and approval criteria established by the Department and
may not be implemented prior to receiving advance
written approval from the Department. For additional
clarification on formulary guidelines, see Exhibit G of
this Agreement, Drug Formulary Guidelines.
c. Coverage Exclusions
In accordance with Section 1927 of the Social Security
Act, 42 U.S.C.A. 1396r-8, the Contractor must exclude
coverage for any drug marketed by a drug company (or
labeler) who does not participate in the MA FFS Medicaid
Drug Rebate Program. Therefore, the Contractor is not
permitted to provide coverage for any drug product,
brand name or generic, legend or non-legend, sold or
distributed by a company that did not sign an agreement
with the federal government to provide rebates to the
Medicaid agency.
In addition, the Contractor must allow access to all
drug products covered by the MA FFS Program. This
includes brand name and generic products, as well as all
outpatient legend drugs, sold or distributed by
companies that participate in the rebate program for all
medically accepted indications, as described in Section
1927(k)(6) of the Social Security Act, 42 U.S.C.A.
1396r-8(k)(6). The Contractor must include coverage for
non-legend drugs as required under formulary guidelines
and covered by the MA FFS Program. This includes any use
which is approved under the Federal Food, Drug, and
Cosmetic Act, 21 U.S.C.A. 301 et seq. or, whose use is
supported by the American Hospital Formulary Service -
Drug Information, American Medical Association Drug
Evaluations, United States Pharmacopoeia -- Drug
Information, and
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DRUGDEX.
d. DESI Drugs
The Contractor shall not provide coverage for Drug
Efficacy Study Implementation (DESI) drugs under any
circumstances. DESI drugs are those drug products that
have been classified as less-than-effective by the Food
and Drug Administration (FDA).
e. Pharmacy Rebate Program
Under the provisions of Section 1927 of the Social
Security Act 42 U.S.C.A. 1396r-8, drug companies that
wish to have their products covered through the MA
Program (both fee-for-service and managed care) must
sign an agreement with the federal government to provide
rebates to the State. Any drug company that does not
sign a rebate agreement may not have their products
covered through the MA Program.
The Contractor must negotiate with drug companies to
collect rebates for pharmaceutical products.
f. Drug Utilization Review (DUR) Program
The Contractor must have written polices and procedures
to adhere to a DUR Program prior approved by the
Department. This system must be based on federal law and
regulation at Section 1927 of the Social Security Act,
42 U.S.C.A. 1396r-8 and 42 C.F.R. 456 and state
guidelines adopted from the existing MA FFS DUR Program.
DUR state guidelines can be found in Exhibit I of this
Agreement, Drug Utilization Review Guidelines.
The Contractor must have a procedure to compare pharmacy
encounter data use against predetermined therapeutic
drug criteria standards consistent with the official
compendia and the peer-reviewed medical literature. The
official compendia shall consist of the American
Hospital Formulary Service Drug Information, the United
States Pharmacopoeia - Drug Information, the DRUGDEX
Information System, and the American Medical Association
Drug Evaluations. These standards must be consistent
with medical practices that have been developed by
unbiased, independent experts through an open
professional consensus process. This procedure must also
include an ongoing review for current drug criteria
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standards. All drug criteria standards must be submitted
to the Department for advance written approval before
its usage by the Contractor, under the Utilization
Review Criteria Assessment Process (URCAP). The URCAP
manual may be found in the HealthChoices Proposers'
Library.
The Contractor must have a process for the communication
of counseling for Members based on standards established
by state pharmacy law related to patient counseling and
to the maintenance of patient profiles.
The Contractor must have procedures for retrospective
DUR through mechanized drug claims processing and an
information retrieval system in accordance with Exhibit
I of this Agreement, Drug Utilization Review Guidelines.
In no case shall the Contractor's DUR Program provide
any financial or other incentive to a pharmacist for
encouraging the physician to change his/her prescription
order. A change to a prescription order is only
acceptable when warranted by clinical reasons of Member
safety and approved efficacy.
g. Pharmacy Benefit Manager (PBM)
The Contractor may use a PBM to process prescription
claims only if the PBM Subcontract has received advance
written approval by the Department. The Contractor must
indicate the intent to use a PBM, identify the proposed
PBM Subcontract and the ownership of the proposed PBM
subcontractor. If the PBM is owned wholly or in part by
a retail pharmacy Provider, chain drug store or
pharmaceutical manufacturer, the Contractor will submit
a written description of the assurances and procedures
that shall be put in place under the proposed PBM
Subcontract, such as an independent audit, to assure
confidentiality of proprietary information. These
assurances and procedures must be submitted and receive
advance written approval by the Department prior to
initiating the PBM Subcontract. The Department will
allow the continued operation of pre-existing PBM
subcontracts while the Department is reviewing such
pre-existing contracts.
8. EPSDT Services
The Contractor must comply with the requirements regarding
EPSDT services as set forth in Exhibit J of this Agreement,
EPSDT Guidelines.
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The Contractor must also adhere to specific Department
regulations at 55 Pa. Code Chapters 3700 and 3800 as they
relate to EPSDT examination for individuals under the age of
21 and entering substitute care or a child residential
facility placement.
9. Emergency Room (ER) Services
The Contractor agrees to comply with the program standards
regarding Emergency Room (ER) Services that are set forth in
Exhibit K of this Agreement, Emergency Room Services.
The Contractor must comply with the provisions of the Balanced
Budget Act of 1997 (BBA) and Sections 2102 & 2116 of the
Insurance Company Law of 1921 as amended, 40 P.S. 991.2102 &
991.2116, pertaining to coverage and payment of Medically
Necessary Emergency Services. In addition:
o Emergency Providers may initiate the necessary
intervention to stabilize an Emergency Medical Condition
of the patient without seeking or receiving prospective
authorization by the Contractor.
o The Contractor shall be responsible for all ER services
including those categorized as mental health or drug and
alcohol. Exception: ER evaluations for voluntary and
involuntary commitments pursuant to the Mental Health
Procedures Act of 1976, 50 P.S. 7101 et seq. shall be
the responsibility of the BH-MCO.
Nothing in the above section shall be construed to imply that
the Contractor shall not:
o track, trend and profile ER utilization;
o retrospectively review and where appropriate, deny
payment for inappropriate ER use; or
o use all appropriate methods to encourage members to use
PCPs rather than ERs for minor acute conditions;
o use a recipient restriction methodology for members with
a history of significant inappropriate ER usage.
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10. Post-Stabilization Services
The Contractor must cover Post-Stabilization Services,
pursuant to 42 C.F.R. 422.100(b)(iv).
The Contractor must cover Post-Stabilization Services without
requiring authorization, and regardless of whether the Member
obtains the services within or outside the Contractor's
Provider Network if any of the following situations exist:
a. The Post-Stabilization Services were pre-approved by the
Contractor.
b. The Post-Stabilization Services were not pre-approved by
the Contractor because the Contractor did not respond to
the Provider's request for these Post-Stabilization
Services within one (1) hour of the request.
c. The Post-Stabilization Services were not pre-approved by
the Contractor because the Contractor could not be
reached by the Provider to request pre-approval for
these Post-Stabilization Services.
11. Examinations to Determine Abuse or Neglect
a. The Contractor must ensure that Members who are MA
Consumers under evaluation for suspected child abuse or
neglect by the County Children and Youth Agency system,
and who present for physical examinations for
determination of abuse or neglect, shall receive such
services. These services must be performed by trained
examiners in a timely manner according to the Child
Protective Services Law, 23 Pa. C.S.A. 6301 et seq. and
Department regulations.
b. The Contractor is responsible to ensure that ER staff
and physicians know the procedures for reporting
suspected abuse and neglect in addition to performing
exams for the county. This requirement must be included
in all applicable Provider Agreements.
c. Should the PCP determine that a mental health assessment
is needed, s/he must inform the MA consumer or the
County Children and Youth Agency representative how to
access these mental health services and coordinate
access to these services, when necessary.
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12. Hospice Services
The Contractor must provide hospice care and use certified
hospice providers in accordance with the provisions outlined
at 42 C.F.R. 418.1 et seq.
MA Consumers who are enrolled in the Department's Hospice
Program and were not previously enrolled in the HC L/C Program
will not be enrolled in HC-L/C. However, if a PH-MCO Member is
determined eligible for the Department's Hospice Program after
being enrolled in the PH-MCO, the Member will remain the
responsibility of the PH-MCO and will not be disenrolled from
HC-L/C.
13. Organ Transplants
The Contractor is responsible to pay for transplants to the
extent that the MA FFS Program pays for such transplants. When
Medically Necessary, the following transplants shall be the
responsibility of the Contractor: Kidney (cadaver and living
donor), kidney/pancreas, cornea, heart, heart/lung, single
lung, double lung, liver (cadaver and living donor),
liver/pancreas, small bowel, pancreas/small bowel, bone
marrow, stem cell, pancreas, liver/small bowel transplants,
and multi-visceral transplants.
14. Transportation
The Contractor is responsible to provide all Medically
Necessary emergency transportation. In addition, all ambulance
costs, which include emergency and non-emergency Medically
Necessary transportation, are the responsibility of the PH-MCO
even when the service is provided by the BH-MCO.
Regulations set forth at 55 Pa. Code 1150.6 and 1245.52(l)
outline the conditions required for ambulance transportation
to be considered Medically Necessary.
Any non-emergency transportation (excluding Medically
Necessary non-emergency ambulance) for Members to and from MA
compensable services must be arranged through the Medical
Assistance Transportation Program (MATP). A complete
description of MATP responsibilities can be found in Exhibit L
of this Agreement, Transportation.
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15. Waiver Services/State Plan Amendments
a. HIV/AIDS Waiver Program
The Contractor must arrange for and provide services to
persons with AIDS or symptomatic HIV the same as those
provided under the Department's AIDS Waiver Program.
Individuals enrolled in the Department's AIDS Waiver
Program who would not otherwise be eligible for MA, are
included in HealthChoices. The Contractor shall be
responsible for tracking these Members in accordance
with federal reporting requirements. A full description
of the AIDS Waiver Program can be found in the
HealthChoices Proposers' Library.
b. HIV/AIDS Targeted Case Management (TCM) Program
The Contractor must ensure the provision of TCM services
for persons with AIDS or symptomatic HIV, including
access to needed medical and social services using the
existing TCM program standards of practice followed by
the Department or comparable standards approved by the
Department. In addition, individuals within the PH-MCO
who provide the TCM services must meet the same
qualifications as those under the Department's TCM
Program. A full description of the TCM Program including
practice standards for case managers, can be found in
the HealthChoices Proposers' Library.
c. Michael Dallas Waiver (MDW) Program
The Contractor must arrange for and provide enhanced
medical benefits to technology-dependent individuals
under age twenty-one (21), equal or in addition to that
provided under the Department's MDW Program, to minimize
hospitalization/institutionalization of the child. MA
Consumers currently receiving services through the MDW
Program and deemed MA eligible solely through the MDW in
the future are exempt from the HC-L/C Program.
MA Consumers age 21 years and older currently receiving
home and community based services through the MDW, will
be enrolled in HealthChoices but all waiver services
will be covered under the MA FFS delivery system.
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d. Healthy Beginnings Plus (HBP) Program
The Contractor must provide services that meet or exceed
HBP standards in effect as defined in current MA
Bulletins. The Contractor must also assure that the
coordinated prenatal activities of the HBP Program
continue by utilizing enrolled HBP Providers or
developing comparable resources. Such comparable
programs will be subject to review and approval by the
Department based on the likelihood that such programs
will be of greater effectiveness in meeting the goals of
the HBP Program. The Contractor must provide a full
description of its plan to provide prenatal care for
pregnant women and infants in fulfillment of the HBP
Program objectives for review and advance written
approval by the Department. This plan must include
comprehensive postpartum care.
e. Pennsylvania Department of Aging (PDA) Waivers
The Department reserves the right to expand the scope of
services to include MA Consumers in the PDA Waiver in
HealthChoices. Please refer to Section VII.B.4 of this
Agreement for further information on program changes.
16. Nursing Facility Services
The PH-MCO is responsible for payment for up to thirty (30)
days of nursing home care (including hospital reserve or bed
hold days) if a Member is admitted to a Nursing Facility.
Members are disenrolled from HealthChoices thirty (30) days
following the admission date to the nursing facility as long
as the Member has not been discharged (from the nursing
facility).
A PH-MCO may not deny or otherwise limit Medically Necessary
services, such as home health services, on the grounds that
the Member needs, but is not receiving, a higher level of
care. A PH-MCO may not offer financial or other incentives to
obtain or expedite a Member's admission to a nursing facility
except as short-term nursing care, not to exceed thirty (30)
days.
The PH-CMO must abide by the decision of the OPTIONS
assessment process determination letter related to the need
for nursing facility services.
MA Consumers who are placed into a nursing facility from a
hospital and who were not previously enrolled in the HC-L/C
Program or individuals who enter a nursing facility from a
hospital
36
and are then determined eligible for MA will not be enrolled
in HC-L/C. However, should an individual leave the nursing
facility to reside in the HC-L/C Zone and then be determined
eligible for enrollment into HC-L/C, they will then be
required to enroll into the HC-L/C Program.
Individuals who are residing in nursing facilities and are
subsequently found eligible for MA will not be enrolled in the
HealthChoices Program. individuals eligible for MA, but not
mandated into the HC-L/C Program when they enter nursing
facilities, or MA Consumers who are placed in nursing
facilities inside the HC-L/C Zone, who previously resided
outside the HC-L/C Zone, will not be enrolled in the HC-L/C
Program.
B. Prior Authorization of Services
1. General Prior Authorization Requirements
The Contractor must provide Emergency Services without regard
to prior authorization or the emergency care provider's
contractual relationship with the Contractor.
If the Contractor wishes to require prior authorization of any
services which are not required to be prior authorized under
the MA FFS Program, the Contractor must establish and maintain
written policies and procedures which must have advance
written approval by the Department. In addition, the
Contractor must include a list and scope of services for
referral and prior authorization, which must be included in
the Contractor's Provider Manual and Member Handbook.
Contractors must receive advance written approval of the list
and scope of services to be referred or prior authorized by
the Department as outlined in Exhibit H of this Agreement,
Prior Authorization Guidelines and Exhibit M(1) of this
Agreement, Quality Management and Utilization Management
Program Requirements. Prior authorization policies and
procedures approved under previous HealthChoices contracts
will be considered approved under this Agreement.
The Contractor shall not implement prior authorization
policies without having sought and obtained advance written
approval by the Department. Denials issued under unapproved
prior authorization policies may be subject to retrospective
review and reversal at the Department's sole discretion. The
Department may, at its discretion, impose sanctions and/or
corrective action plans in the event that the Contractor
improperly implements any prior authorization policy or
procedure.
37
The Department will make its best efforts to review and
provide feedback to the Contractor (e.g., written approval,
request for corrective action plan, denial, etc.) within sixty
(60) days from the date the Department receives the request
for review by the Contractor. For minor updates to existing
approved prior authorization plans, the Department will make
its best efforts to review updates within forty-five (45) days
from the date the Department receives the request for review
by the Contractor.
The Contractor is required to process each request for prior
authorization of a covered service and ensure that the Member
is notified of the decision within two (2) business days of
receiving the request. If the Member does not receive written
notification of a decision on a request for a covered service
or item within twenty-one (21) days of the date the Contractor
received the request, the service or item is automatically
approved. To satisfy the twenty-one (21) day time period, the
Contractor must mail to the Member, the Member's PCP, and the
prescribing Provider a notice of partial approval or denial of
the request on or before the eighteenth (18th) day from the
date the request is received. If the notice is not mailed by
the eighteenth (18th) day after the request is received, the
request is automatically authorized (i.e., deemed approved).
If additional information is needed to review the request, the
Contractor must request such information from the appropriate
Provider within forty-eight (48) hours of receiving the
request for prior authorization of a covered service. If the
Contractor requests additional information, the request may be
pended for a reasonable time period. However, a prospective
utilization review decision must be communicated to the Member
within two (2) business days of the receipt of all supporting
information reasonably necessary to complete the review.
The Contractor may waive the prior authorization requirements
for services, which are required by the Department to be prior
authorized.
If a HCFA determination that an HMO has committed a violation
described in paragraph (a) of 42 C.F.R. Chapter IV Subsection
434.67 (Sanctions Against HMOs with Risk Comprehensive
Contracts) is affirmed on review of paragraph (d) (Informal
Reconsideration), or is not timely contested by the HMO under
paragraph (c) (Notice of Sanction), HCFA, based upon this
recommendation of the agency, may deny payment for new
enrollees of the HMO under Section 1903 (m)(5)(B)(ii) of the
Act. Under Subsections 434.22 and 434.42, HCFA's denial of
payment for new enrollees automatically results in a denial of
agency
38
payments to the HMO for the same enrollees. A new enrollee is
an enrollee that applies for enrollment after the effective
date as found in 42 C.F.R. Section 434.67(f)(l).
2. Prior Authorization for Outpatient Prescription Drugs
The Contractor may require prior authorization as a condition
of coverage or payment for an outpatient prescription drug
provided that 1) a decision whether to approve or deny the
prescription is made within twenty-four (24) hours, and 2) if
a Member's prescription for a medication is not filled when a
prescription is presented to the pharmacist, the PH-MCO must
allow the pharmacist to dispense either a seventy-two (72)
hour supply for a new medication, or a fifteen (15) day supply
for an ongoing medication if there is an Immediate Need for
the medication. Immediate Need is a situation in which, in the
professional judgment of the dispensing registered pharmacist
and/or prescriber, the dispensing of the drug at the time when
the prescription is presented is necessary to reduce or
prevent the occurrence or persistence of a serious adverse
health condition. The Contractor must issue a written denial
notice, in the form attached as Exhibit N of this Agreement,
Denial Notices, within twenty-four (24) hours from the time
that the prescription is presented at the pharmacy. In the
event that the Contractor cannot issue a written denial notice
within twenty-four (24) hours, the Contractor must have
procedures in place so as to permit the Member to receive a
supply of the new medication such that the supply will not be
exhausted prior to receipt of the notice. For drugs not able
to be divided and dispensed into individual doses, the
Contractor will make provisions to allow the pharmacist to
dispense the smallest amount that will provide at least a
seventy-two (72) hour or fifteen (15) day supply, whichever is
applicable. The Department will waive the seventy-two (72)
hour supply requirement for medications and treatments under
concurrent clinical review and treatments that are outside the
parameter of use approved by the FDA or accepted standards of
care.
The Contractor must have procedures in place to assure that if
a prescription for an Ongoing Medication is not authorized
when presented at the pharmacy, the pharmacist shall dispense
a fifteen (15) day supply of the prescription, unless the
Contractor or its designated subcontractor issued a proper
written notice of benefit reduction or termination at least
ten (10) days prior to the end of the period for which the
medication was previously authorized and a Grievance or DPW
Fair Hearing request has not been filed. If the Member files a
Grievance or DPW Fair Healing request from a denial of an
Ongoing Medication, the Contractor must authorize the
39
medication until the Grievance or DPW Fair Hearing request is
resolved. When medication is authorized due to the
Contractor's obligation to continue services while a member's
grievance or fair hearing is pending, and the final binding
decision is in favor of the Contractor, a request for
subsequent refill of the prescribed medication does not
constitute an ongoing medication.
The requirement that the Member be given at least a
seventy-two (72) hour supply for a new medication or a fifteen
(15) day supply for an Ongoing Medication does not apply when
a pharmacist determines that the taking of the prescribed
medication, either alone or along with other medication that
the Member may be taking, would jeopardize the health or
safety of the Member. In such event, the Contractor and/or its
subcontractor must require that its participating pharmacist
make good faith efforts to contact the prescriber. In such
instances, however, the requirement that the Contractor issue
a written denial notice within twenty-four (24) hours still
applies.
C. Continuity of Care
The Contractor must comply with the procedures outlined in MA
Bulletin #99-96-01, Continuity of Prior Authorized Services Between
FFS and Managed Care Plans and Between Managed Care Plans for
Individuals Under Twenty-one (21), to ensure continuity of prior
authorized services whenever an individual under the age of
twenty-one (21) transfers from one PH-MCO to another, from a PH-MCO
to the MA FFS Program, or from the MA FFS Program to a PH-MCO.
The PH-MCO must comply with Section 2117 of Article XXI of the
Insurance Company Law of 1921, as amended, 40 P.S. 991.2117
regarding continuity of care requirements. A bulletin detailing the
continuity of care requirements applicable to prior authorized
services to adult members, as well as continuity of treatment for
non-prior authorized services for all Members will be issued by the
Department in the near future. A draft of this bulletin can be found
in the HealthChoices Proposers' Library.
D. Coordination of Care
The PH-MCO is responsible for coordination of care for individuals
enrolled in HC-L/C. The PH-MCO must ensure seamless and continuous
coordination of care across a continuum of services for the
individual member with a focus on improving health care outcomes.
The continuum of services may include the in-plan comprehensive
benefits package, out-of-plan benefits, and non-MA covered services
provided by other community resources such as:
40
1. Nursing Facility Care
The PH-MCO must ensure the decisions related to placement in
Nursing Facilities are coordinated with the Member and, where
appropriate, the Member's family.
2. Special Services
Through a variety of mechanisms including Quality Management
and Utilization Management (QM/UM) and Special Needs Unit
(SNU) functions, the PH-MCO is responsible to coordinate
special In-Plan Services.
Special In-Plan Services include but are not limited to:
o ICF/MR/ORC Intermediate Care Facility for the Mentally
Retarded/Other Related Conditions
o Residential Treatment Facility (RTF)
o Acute and Extended Acute Psychiatric Facility
o Non-Hospital Residential Detoxification, Rehabilitation,
and Half-Way House Facilities for Drug/Alcohol
Dependence/Addiction
o Area Agencies on Aging (AAA)/Options Assessment and
Pre-admission Screening Requirements
o Pennsylvania Department of Aging (PDA) Waiver
o Members Admitted to Juvenile Detention Centers (JDCs)
o Children in Substitute Care Transition
o Adoption Assistance Children/Adolescents
o Dual Eligibles (Medicare/Medicaid)
The HealthChoices Program requirements covering special
services are outlined In Exhibit O of this Agreement,
Description of Special Services.
3. Out-of-Plan Services
The PH-MCO is responsible to interact/coordinate with the
entity responsible for the Out-of-Plan Services to promote a
seamless
41
continuum of care coordination.
Out-of-Plan Services include, but are not limited to:
o Transitional Care Homes
o Medical Xxxxxx Care Services
o Early Intervention Services
o The Home and Community Based Waiver Program for Nursing
Facility Residents with other related conditions
(OSP/OBRA Waiver)
o The Home and Community Based Waiver Program for Nursing
Facility Applicants with other related conditions
(OSP/lndependence Waiver)
o Home and Community Based Waiver for Attendant Care
Services (OSP/AC Waiver)
o Home and Community Based Waiver for Persons with Mental
Retardation
Out-of-Plan Services are described in Exhibit P of this
Agreement, Out-of-Plan Services.
4. Coordination of Care/Letters of Agreement
The Contractor is responsible to coordinate the comprehensive
in-plan package of services with entities providing
Out-of-Plan Services. To clearly define the roles of the
entities involved in the coordination of services, the
Contractor must enter into coordination of care letters of
agreement with all school districts. County Children and Youth
Agencies (CCYAs) and Juvenile Probation Offices (refer to
Sample Model Agreement, Exhibit Q of this Agreement), and the
BH-MCOs (refer to Exhibit R of this Agreement, Coordination
with BH-MCOs). The Department encourages the Contractor to
make a good faith effort to enter into coordination of care
letters of agreement with other public, governmental, county,
and community-based service providers.
Should the Contractor be unable to enter into coordination of
care letters of agreement as required under this Agreement,
the Contractor must submit wntten justification to the
Department. Justification must include all the steps taken by
the Contractor to attempt to secure coordination of care
letters of agreement, or must demonstrate an existing,
ongoing, and cooperative relationship with the entity. The
Department will then determine whether or not this requirement
will be deemed met.
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All written coordination documents developed and maintained by the
Contractor must have advance written approval by the Department and
must be reviewed/revised at least annually by the Contractor.
Coordination documents must be available for review by the
Department at the time of Readiness Review and upon request
thereafter. The written coordination documents must be submitted to
the Department for final review and approval at least thirty (30)
days prior to the initial transition in the HC-L/C Program. All
written coordination documents entered into between a service
Provider and the Contractor after implementation must also be
approved by the Department. These written coordination documents,
including operational procedures, must be submitted for final review
and approval at least thirty (30) days prior to the initial
transition in HC-L/C.
Any written coordination documents entered into between the
Contractor and service Providers must contain, but are not limited
to, the provisions outlined in Exhibit S of this Agreement, Written
Agreements Between PH-MCO and Service Providers. Under no
circumstances may these coordination documents contain any
definition of Medically Necessary other than the definition found in
this Agreement.
5. PH-MCO and BH-MCO Coordination
The HC-L/C PH-MCOs and the BH-MCOs are required to develop and
implement written agreements regarding the interaction and
coordination of services provided to MA Consumers enrolled in the
HC-L/C Program. These agreements must be submitted and approved by
the Department. The PH Contractors and BH Contractors in the HC-L/C
Zone are encouraged to develop uniform coordination agreements to
promote consistency in the delivery and administration of services.
Program requirements covering PH/BH Provider Agreements are outlined
in Exhibit T of this Agreement, PH/BH Provider Agreements. The
HealthChoices Program requirements covering behavioral health
services requirements are outlined in Exhibit U of this Agreement,
Behavioral Health Services.
The Contractor agrees to comply with the requirements regarding
Coordination with Out-of-Plan Services, which are set forth in
Section V.D.3 of this Agreement, including those pertaining to
behavioral health.
a. The Contractor agrees, and the Department will use its best
43
efforts to require HC-L/C BH-MCOs to agree, to submit to a
binding independent arbitration process in the event of a
dispute between the Contractor and any such BH-MCOs concerning
their respective obligations pursuant to this Agreement and a
Behavioral HC-L/C contract. The mutual agreement of the
Contractor and a BH-MCO to such an arbitration process must be
evidenced by and included in the written agreement between the
Contractor and the BH-MCO.
b. All pharmacy services are the payment responsibility of the
Member's PH-MCO. The only exception is that the BH-MCO is
responsible for the payment of methadone and Levomethadyl
Acetate Hydrocchloride (LAAM). All prescribed medications are
to be dispensed through the Contractor's Network pharmacies.
This includes drugs prescribed by both the PH-MCO and the
BH-MCO Providers. The Contractor must follow the PH/BH
Pharmacy Services guidelines in Exhibit V of this Agreement,
PH-MCO Pharmacy Guidelines. The Department will issue a list
of BH-MCO Providers to the Contractor prior to the effective
date of this Agreement. Should the Contractor receive a
request to dispense medication from a BH Provider not listed
on the BH-MCO's Provider file, the Contractor must work
through the appropriate BH-MCO to identify the Provider. The
Contractor is prohibited from denying prescribed medications
solely in cases where the BH-MCO Provider is not clearly
identified on the BH-MCO Provider file.
E. Contractor Responsibility for Reportable Conditions
The Contractor will work with State Department of Health (DOH) State
and District Office Epidemiologists in partnership with the
designated county/municipal health department staffs to ensure that
reportable conditions are appropriately reported in accordance with
Department regulations, in accordance with 28 Pa. Code 27.1 et seq.
The Contractor will designate a single contact person to facilitate
the implementation of this requirement.
The Contractor is not responsible for the payment of Environmental
Lead Investigations.
F. Member Enrollment and Disenrollment
1. General
The Contractor is prohibited from restricting its Members from
44
changing PH-MCOs for any reason. The MA Consumer has the right
to initiate a change in PH-MCOs at any time.
The Contractor is prohibited from offering or exchanging
financial payments, incentives, commissions, etc., to any
other PH-MCO (not receiving a contract to operate under the
HC-L/C Program or not choosing to continue a contractual
relationship with the Department) for the exchange of
information on the terminating PH-MCO's membership. This
includes offering incentives to a terminating PH-MCO to
recommend that its membership join the PH-MCO offering the
incentives.
The Department may disenroll members from a PH-MCO when there
is a change in residence which places the member outside the
HC Zone, as indicated on the individual county file maintained
by the Department's Office of Income Maintenance.
2. Contractor Outreach Materials
The Contractor must develop outreach materials such as
pamphlets and brochures which can be used by the IEAP
contractor to assist MA Consumers in choosing a PH-MCO and
PCP. These materials must be developed in the form and context
required by the Department. The Department must approve of
such materials in writing prior to their use. The Department's
review will be conducted within thirty (30) days and approval
will not be unreasonably withheld. The Contractor is required
to print and provide to the IEAP contractor an adequate supply
of previously approved materials within five (5) business days
from the request of the IEAP contractor. The Contractor
brochure must follow the guidelines outlined in Exhibit W of
this Agreement, PH-MCO Guidelines for Outreach Materials.
The Contractor is prohibited from distributing directly or
through any agent or independent contractor, outreach
materials without advance written approval of the Department.
In addition, the Contractor must comply with the following
guidelines and/or restrictions.
a. The Contractor may not seek to influence an individual's
enrollment with the PH-MCO in conjunction with the sale
of any other insurance.
b. The Contractor must comply with the enrollment
procedures established by the Department in order to
ensure that, before the individual is enrolled with the
PH-MCO, the individual is provided accurate oral and
written information sufficient to make an informed
decision on whether to enroll.
45
c. In accordance with the federal Balanced Budget Act of
1997, Section 1 932(d)(2)(E), the Contractor shall not
directly or indirectly conduct door-to-door, telephone
or other cold-call marketing activities.
d. The Contractor must ensure that all outreach plans,
procedures and materials are accurate and do not
mislead, confuse or defraud either the MA Consumer or
the Department.
3. Contractor Outreach Activities
The Contractor must comply with the following principles for
all Contractor outreach activities:
a. Due to the Department's use of HealthChoices Enrollment
Specialists, the Contractor will be prohibited from
engaging In any marketing activities associated with
enrollment into a PH-MCO in any HealthChoices Zone. The
Contractor will be prohibited from engaging in any
marketing activities associated with enrollment into
their PH-MCO program upon notification by the Department
prior to commencement of this Agreement, but in no case
after the IEAP contractor commences enrollment
activities.
The Contractor is also prohibited from subcontracting
with an outside entity to engage in marketing activities
associated with any form of enrollment to eligible or
potential MA Consumers. The Contractor must not engage
in marketing activities associated with enrollments,
which include but are not limited to, the following
locations and activities:
o County Assistance Offices (CAOs)
o Providers' offices
o Malls/Commercial or retail establishments
o Hospitals
o Check cashing establishments
o Door-to-door visitations
o Telemarketing
o Community Centers
o Churches
o Direct Mail
b. The Contractor may use but not be limited to commonly
accepted media methods to advertise. These include
46
television, radio, billboard, the Internet and printed
media. All such advertising is subject to advance
written approval by the Department.
c. The Contractor may participate in or sponsor health
fairs or community events. The Department reserves the
right to set limits on contributions and/or payments
made to non-profit groups in connection with health
fairs or community events. Advance written approval is
required for contributions of $2,000.00 or more. The
Department will make every reasonable effort to respond
to the Contractor's request for advance written approval
within ten (10) business days. All contributions are
subject to financial audit by the Department
d. Items of little or no intrinsic value (i.e., trinkets
with promotional Contractor logos), may be offered at
health fairs or other approved community events. Such
items must be made available to the general public, not
to exceed $3.00 in retail value and must not be
connected in any way to Contractor enrollment activity.
All such items are subject to advance written approval
by the Department.
e. The Contractor will be permitted to offer Members
health-related benefits in excess of those required by
the Department, and are permitted to feature such
expanded benefits in approved marketing materials. All
such expanded benefits are subject to advance written
approval by the Department and must meet the
requirements of Section V.A.3 of this Agreement,
Expanded Benefits.
f. Contractors may not offer Member coupons for products of
value.
g. Unless approved by the Department, Contractors are not
permitted to directly provide products of value unless
they are health related and are prescribed by a licensed
Provider.
h. The PH-MCO will be responsible for bearing the cost of
reprinting HealthChoices outreach materials, if a major
change involving content is made prior to the IEAP's
annual revision of materials. These changes include, but
are not limited to, change in product names, program
benefits and services.
i. The Department reserves the right to review any and all
outreach activities and advertising materials and
procedures used by the Contractor for its personnel. In
addition to any
47
other sanctions, the Department may impose monetary or
restricted enrollment penalties should the Contractor be
found to be using marketing materials or engaging in
marketing practices. The Department reserves the right
to suspend all outreach activities and the completion of
applications for new Members. Such suspensions may be
imposed for a period of sixty (60) days from
notification by the Department to the Contractor citing
the violation.
j. The Contractor is prohibited from distributing, directly
or through any agent or independent Contractor,
marketing materials that contain false or misleading
information.
k. The Contractor must not, under any conditions use the
Department's Client Information System (CIS) to identify
and market to MA Consumers participating in the MA FFS
Program or enrolled in another PH-MCO. The Contractor
shall not share or sell MA Consumer lists with other
organizations for any purpose.
l. The Contractor must submit a plan for advertising,
sponsorship and outreach procedures to the Department
for advance written approval in accordance with the
guidelines outlined in Exhibit X of this Agreement,
HealthChoices PH-MCO Guidelines for Advertising,
Sponsorship and Outreach.
4. Alternative Language Requirement
During the enrollment process, the Department and/or its
HealthChoices Enrollment Specialists shall seek to identify
program Members who speak a language other than English as
their first language. The Department and/or its HealthChoices
Enrollment Specialists shall notify the Contractor when it
knows of Members who do not speak English as a first language
and who have either selected or been assigned to the
Contractor.
If five percent (5%) or more of MA Consumers in a County
Assistance/District Office speak a language other than English
as a first language, the Contractor must make available in
that language all information that is disseminated to English
speaking Members. This information includes, but is not
limited to, member handbooks, hardcopy provider directories,
education and outreach materials, written notifications, etc.
Materials must include appropriate instructions on how to
access or receive assistance with accessing desired materials
in an alternate language or format.
48
5. Contractor Enrollment Procedures
The Contractor must have in effect written administrative
policies and procedures for newly enrolled Members. The
Contractor must also provide written policies and procedures
for coordinating enrollment information with the Department's
lEAP contractor. The Contractor must receive advance written
approval from the Department regarding these policies and
procedures.
The Contractor must take necessary administrative steps
consistent with the Enrollment/Disenrollment Dating Rules that
are determined by and provided by the Department in Exhibit Y
of this Agreement, Managed Care Enrollment/Disenrollment
Dating Rules.
The Contractor must enroll any eligible MA Consumer who
selects the Contractor or is assigned in accordance with
Exhibit Z of this Agreement, Automatic Assignment, to the
Contractor regardless of the MA Consumer's race, color, creed,
religion, age, sex, national origin, ancestry, marital status,
sexual orientation, income status, program membership,
grievance status, MA category status, health status,
pre-existing condition, physical or mental handicap or
anticipated need for health care. See Exhibit AA of this
Agreement, Category/Program Status Coverage Chart.
6. Enrollment of Newborns
The Contractor must have written administrative policies and
procedures to enroll and provide all necessary services to
newborn infants of members, effective from the time of birth,
without delay, in accordance with to Section V.F.11, Services
for New Members, and Exhibit BB of this Agreement, PH-MCO
Recipient Coverage Document. The Contractor must receive
advance written approval from the Department regarding these
policies and procedures.
The Contractor is not responsible for the payment of newborn
metabolic screenings.
7. Transitioning Members Between PH-MCOs
It may be necessary to transition a Member between PH-MCOs.
Members with special needs should be assisted by the SNU(s) to
facilitate a seamless transition. The Contractor must follow
the Department's established procedures as outlined in Exhibit
BB of this Agreement, PH-MCO Recipient Coverage Document.
49
8. Change in Status
The Contractor must report to the Department on a weekly
enrollment/disenrollment file the following:
o Pregnancies not on CIS;
o Newborns not on CIS; and
o Return mail
The Contractor must report to the appropriate CAO any changes
in the status of families or individual Members within ten
(10) business days of their becoming known, including changes
in family size and residence, and new phone numbers.
9. Monthly Membership
The Department will provide an electronic file, on a monthly
basis, that lists program eligibles who are prior, current or
future Contractor Members. The Contractor agrees to reconcile
this membership list against its internal membership
information and notify the Department of any discrepancies
found within the data on the file within thirty (30) business
days, in order to resolve problems.
MA Consumers not included on this file with an indication of
prospective coverage will not be the responsibility of the
PH-MCO unless a subsequent Daily Membership File indicates
otherwise. Those with an indication of future month coverage
will not be the responsibility of the PH-MCO if a Daily
Membership File received by the PH-MCO prior to the beginning
of the future month Indicates otherwise.
10. Enrollment and Disenrollment Updates
a. Daily File
The Department will provide to the Contractor by
electronic file transmission, a daily file that lists
demographic changes, eligibility changes, enrollment
changes and Members enrolled through the automatic
assignment process.
The Contractor must reconcile this file against its
internal membership information and notify the
Department within thirty (30) business days in order to
resolve problems.
50
b. Weekly Enrollment/Disenrollment Reconciliation File
The Department will provide, every week by electronic
file transmission, information on Members voluntarily
enrolled or disenrolled. This file also provides
dispositions on alerts submitted by the Contractor.
c. Disenrollment Effective Dates
Member disenrollments will become effective on the date
specified by the Department. The Contractor must have
written policies and procedures for complying with
Department disenrollment orders.
d. Discharge/Transition Planning
When any Member is disenrolled from the PH-MCO because
of:
o admission to or length of stay in a facility,
o a waiver program eligibility, or
o a child's placement in substitute care outside the
HC-L/C Zone,
the Contractor from which the Member disenrolled must
remain responsible for participating in
discharge/transition planning for up to six (6) months
from the initial date of disenrollment. The Contractor
will remain the MA Consumer's PH-MCO upon discharge
(upon returning to the HC-L/C Zone), unless the MA
Consumer chooses a different PH-MCO or is determined to
no longer be eligible for participation in
HealthChoices.
If the MA Consumer chooses a different PH-MCO, that
PH-MCO must participate in the discharge/transition
planning upon notification that the MA Consumer is
enrolled.
11. Services for New Members
The Contractor must make available the full scope of benefits
to which a Member is entitled from the effective enrollment
date provided by the Department. Detailed descriptions of
those services can be found in the HealthChoices Proposers'
Library in the materials describing the MA FFS Program for
those services.
51
The Contractor must ensure that pertinent demographic
information about the MA Consumer, i.e., special needs data
collected through the IEAP or directly indicated to the
Contractor by the MA Consumer after enrollment, will be used
by the Contractor upon the new Member's effective enrollment
date in the PH-MCO. If a special need is indicated, the
Contractor is required to place a special needs indicator on
the Member's record and must outreach to that Member to
identify their special need or circumstance. For any Member
with a special needs indicator, the Contractor must perform a
health needs assessment within forty-five (45) days; provide
results of the same to the assigned PCP; and track and
follow-up outcomes to assure the Member's needs are adequately
addressed.
The Contractor must comply with access standards as required
in Section V.S. of this Agreement, Provider Network/Services
Access and follow the appointment standards described in
Section V.S.12 of this Agreement, Appointment Standards, when
an appointment is requested by a Member.
12. New Member Orientation
The Contractor must have written policies and procedures for:
o Orienting new Members to their benefits (e.g., prenatal
care, dental care, and specialty care),
o Educational and preventative care programs,
o The proper use of the PH-MCO identification card and the
Department's ACCESS card,
o The role of the PCP,
o What to do in an emergency or urgent medical situation,
o How to utilize services in other circumstances, and
o How to register a Complaint, file a Grievance or request
a DPW Fair Hearing.
These policies and procedures must receive advance written
approval by the Department.
The Contractor is prohibited from contacting a potential
enrollee who is identified on the daily file with an automatic
assignment indicator (either an "A" auto assigned or "M"
member assigned) until ten (10) business days before the
effective date of the Member enrollment, unless it is the
Contractor responsibility under this Agreement.
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13. Eligibility Verification System (EVS)
The Contractor must provide a file, via the Department's
Pennsylvania Open Systems Network (POSNet), to the
Department's EVS contractor of PCP assignments for all its
Members. The Contractor must provide this file at least weekly
or more frequently if requested by the Department. The
Contractor must ensure that the PCP assignment information is
consistent with all requirements specified by the Department.
The file layout and data dictionary for this file are located
in the Exhibit CC of this Agreement, Data Support for PH-MCOs.
14. Contractor Identification Cards
The Contractor may issue its own identification card to
enrolled Members. However, the Department issues an
identification card, called an ACCESS card, to each MA
Consumer, which the Member is required to use when accessing
services. Providers must use this card to access the
Department's EVS and to verify the Members eligibility. The
ACCESS card shall allow the Provider the capacity to access
the most current eligibility information without contacting
the Contractor directly.
15. Member Handbook
The Contractor agrees to mail a member handbook, or other
written materials, with information on how to access services,
in the appropriate language or alternate format to Members
within five (5) business days of being notified of a Member's
enrollment. The Contractor must maintain documentation
verifying that the member handbook is reviewed for accuracy at
least once a year, and that all necessary modifications have
been made and all Members notified.
a. Member Handbook Requirements
The Contractor must ensure that the member handbook is
written at no higher than a fourth grade level and
include, at a minimum, the information outlined in
Exhibit DD of this Agreement, HealthChoices PH-MCO
Member Handbook.
b. Department Approval
The Contractor must submit member handbook language to
the Department for advance written approval prior to
distribution to Members. The Contractor must make
modifications in the language contained in the member
53
handbook if ordered by the Department so as to comply
with the requirements described in a., Member Handbook
Requirements, above.
c. Languages Other than English
The Contractor must follow the Member access standards
for member handbooks outlined in Section V.F.4 of this
Agreement, Alternative Language Requirement.
16. Provider Directories
Directories must be available for all types of Providers in
the Contractors Network, including, but not limited to: PCPs,
hospitals, specialists, providers of ancillary services,
nursing facilities, etc. The Contractor must provide the IEAP
contractor with an adequate supply of hardcopy provider
directories (including updates) on a continual basis. Hardcopy
provider directories must be updated annually.
The Contractor must provide the IEAP contractor with an
updated electronic version of their provider directory on a
weekly basis beginning with the IEAP contractor's voluntary
conversion outreach education campaign. This will provide
information regarding terminations, additions, PCPs and
specialists not accepting new assignments, and other
information determined by the Department to be necessary. The
Contractor must provide the file layout and format specified
by the Department. The format shall include, but not be
limited to the following:
o Correct Provider Medical Assistance Identification
(MAID) number
o All providers in the Contractor's network
o Wheel chair accessibility of provider sites
o Language indicators
To comply with this provision, the Contractor must submit a
test file to the IEAP contractor and receive advanced written
approval by the Department prior to the end of the Readiness
Reviews. A Contractor will not be certified as "ready" without
the completion of the electronic provider directory component.
See Exhibit EE of this Agreement, Online Provider Directory
File Layout.
The Contractor must provide its Members with directories for
PCPs, dentists, specialists and providers of ancillary
services, upon request, which include, at a minimum, the
information listed in Exhibit FF of this Agreement, PCP,
Dentists, Specialists and Providers of
54
Ancillary Services Directories. The Contractor must submit
PCP, specialists, and provider of ancillary services
directories to the Department for advance written approval
before distribution to its Members. The Contractor must submit
provider directories to the Department for review and approval
thirty (30) days prior to the initial transition or as
determined by the Department. The Contractor also agrees to
make modifications to its provider directories if ordered by
the Department to do so.
17. HC-L/C Member Disenrollment
The PH-MCO may not reassign or remove Members involuntarily
from Network Providers who are willing and able to serve the
Member.
G. Member Services
1. General
The Contractor's Member services functions shall be
operational at least during regular business hours (9:00 a.m.
to 5:00 p.m., Monday through Friday) and one (1) evening per
week (5:00 p.m. to 8:00 p.m.) or one (1) weekend per month to
address non-emergency problems encountered by members.
Arrangements must be made to receive, identify, and resolve
Emergency Member Issues, including prior authorization and
medical necessity determinations for urgent/Emergency Services
on a twenty-four (24) hour, seven (7) day-a-week basis. The
Contractor's Member services functions shall include, but are
not limited to, the following Member services standards:
o Explaining the operation of the Contractor and assisting
Members in the selection of a PCP.
o Assisting Members with making appointments and obtaining
services.
o Assist with arranging transportation for members through
the MATP. See Section V.A.14 of this Agreement,
Transportation and Exhibit L of this Agreement,
Transportation.
o Receiving, identifying and resolving Emergency Member
Issues.
o Under no circumstances will unlicensed members services
staff provide health-related advice to members
requesting clinical information. The Contractor must
ensure that all such inquires
55
are addressed by clinical personnel acting within the
scope of their licensure to practice a health related
profession.
2. Contractor Internal Member Dedicated Hotline
The Contractor must maintain and staff a twenty-four (24)
hour, seven (7) day-a-week toll-free dedicated hotline to
respond to Members' inquiries, Complaints and problems raised
regarding services. The Contractor internal Member hotline
staff are required to ask the caller whether or not they are
satisfied with the response given to their call. All calls
must be documented and if the caller is not satisfied, the
Contractor must ensure that the call is referred to the
appropriate individual within the PH-MCO for follow-up and/or
resolution. This referral must take place within forty-eight
(48) hours of the call. The Contractor must provide the
Department with the capability to monitor the Contractor's
Member services and internal Member dedicated hotline from
both the Department's headquarters and at each of the
Contractor's offices The Contractor is not permitted to
utilize electronic call answering methods, as a substitute for
staff persons, to perform this service. The Contractor must
ensure that its dedicated hotline meets the following Member
services performance standards:
o Provide for a dedicated phone line for its Members.
o Provide for necessary translation assistance including
provisions for Members who have hearing impairments.
o Be staffed by individuals trained in:
-- cultural competence;
-- addressing the needs of special populations;
-- the availability of the functions of the SNU;
-- the services which the Contractor is required to
make available to children; and
-- the availability of social services within the
community.
o Be staffed with representatives familiar with accessing
medical transportation.
o Be staffed with adequate service representatives to
accommodate a delay in answering no greater than five
(5) rings and three (3) minutes hold time.
o Provide for TTY and/or Pennsylvania Telecommunication
Relay Service availability.
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3. Education and Outreach Health Education Advisory Committee
The Contractor must develop and implement effective Member
education and outreach programs which may include health
education programs focusing on the leading causes of
hospitalization and emergency room use and health initiatives
which target members with special needs including but not
limited to: HIV/AIDS, mental retardation/developmental
disabilities, eligibility (Medicare/ Medicaid), etc.
The Contractor must establish and maintain a Health Education
Advisory Committee that includes MA Consumers and Providers of
the community to advise on the health education needs of
managed care members. Representation on this Committee shall
include, but not be limited to, women, minorities, persons
with special needs and at least one (1) person with expertise
on the medical needs of children with special needs.
The Contractor must provide for and document coordination of
health education materials, activities and programs with
public health entities, particularly as they relate to public
health priorities and population-based interventions. The
Contractor must also work with the Department to ensure that
its Health Education Advisory Committees are provided with an
effective means to consult with each other and, when
appropriate, coordinate efforts and resources for the benefit
of the entire HC-L/C population or populations with special
needs. Provider representation includes physical health,
behavioral health, and dental health providers on the
Contractor's Health Education Advisory Committees.
The Contractor must provide the Department with a written
description of all planned health education activities and
targeted implementation dates on an annual basis.
4. Informational Materials
All information given to Members and potential Members must be
easily understood and must comply with all requirements
outlined in the RFP and Agreement and the provisions of
Section 2136 of the Insurance Company Law of 1921, as amended,
40 P.S. 991.2136. Informational material distributed to
HealthChoices Members, including but not limited to provider
directories and member handbooks, shall be available, upon
request, in Braille, large print, and audio tape and must be
provided in the format requested by the person with a visual
impairment. The information contained in the provider
directories may cover only those zip codes or other
57
geographic locations that the person with a visual impairment
requests. The Contractor must pay particular attention for the
provision of the following items:
o Identity, location, qualifications and availability of
health care providers within the organization.
o Members' rights and responsibilities.
o Complaint, Grievances, and DPW Fair Hearing procedures.
o Instructions for Members to access or receive assistance
in accessing materials in an alternate language or
format. Instructions should include both phone and TTY
numbers.
o Information on services covered directly or through
referral and prior authorization.
o Information regarding how an individual who is deaf can
access interpreter services for medical appointments.
The Contractor must obtain advance written approval from the
Department of all Member newsletters. In addition, the
Contractor must send Member newsletters to all Members.
The Contractor must obtain advance written approval from the
Department to use Member related HealthChoices information, on
their electronic web sites and bulletin boards.
5. Member Encounter Listings
The Contractor must include, in its PCP Provider Agreements,
language which requires PCPs to contact new Members Identified
in the quarterly encounter lists who have not had an encounter
during the first six (6) months of enrollment, or who have not
complied with the scheduling requirements outlined in the RFP
and this Agreement. The Contractor must require the PCP to
contact Members identified in the quarterly encounter lists as
not complying with EPSDT periodicity and immunization
schedules for children. The PCP must be required to identify
to the Contractor any such Members who have not come into
compliance with the EPSDT periodicity and immunization
schedules within one (1) month of such notification to the
site by the Contractor. The PCP must also be required to
document the reasons for non-compliance, and to document its
efforts to bring the Member's care into compliance with the
standards.
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The Contractor must distribute quarterly lists to each PCP in
Its Provider networks which identify new Members and Members
who have not had an encounter during the previous six (6)
months or within the time frames set forth in Section V.F.11
of this Agreement, Services for New Members, or Members who
have not complied with EPSDT periodicity and immunization
schedules for children. PCPs shall be required to contact
these Members to arrange appointments. The Contractor is
responsible for contacting such Members, documenting the
reasons for noncompliance and documenting its efforts for
bringing the Member's care into compliance.
H. Additional Addressee
The Contractor must have administrative mechanisms for sending
copies of information, notices and other written materials to
a third party upon the request and signed consent of the
Member. The Contractor must develop plans to process such
individual requests and for obtaining the necessary releases
signed by the Member to ensure that the Member's rights
regarding confidentiality are maintained.
I. Member Complaint. Grievance and DPW Fair Hearing Process
1. Member Complaint, Grievance and DPW Fair Hearing Process
The Contractor must develop, implement, and maintain a
Complaint and Grievance process that provides for
settlement of Members' Complaints and Grievances and the
processing of requests for DPW Fair Hearings as outlined
in Exhibit GG of this Agreement. Complaints, Grievances,
and DPW Fair Hearing Process. The Contractor must have
written policies and procedures approved by the
Department, for resolving Member Complaints and for
processing Grievances and DPW Fair Hearing requests,
that meet the requirements established by the Department
and the provisions of Article XXI of the Insurance
Company Law of 1921, as amended by the Act of June 17,
1998, (P.L. 464, No. 68), 40 P.S. 991.2101-991.2361)
known as Act 68 and corresponding Act 68 regulations and
and 42 C.F.R. 431.200 et seq of the Federal Regulations.
The Contractor must also comply with 55 Pa. Code 275
regarding DPW Fair Hearing Requests.
The Contractor must require each of its subcontractors
to comply with the Member Complaint, Grievance, and DPW
Fair Hearing Process. This includes reporting
requirements established by the Contractor, which have
received advance written approval by the Department. The
Contractor must provide to the Department for
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approval, its written procedures governing the
resolution of Complaints and Grievances and the
processing of DPW Fair Hearing requests.
The standard notice required and outlined in Exhibit N
of this Agreement, Denial Notices, must be used in the
Contractor's Complaint, Grievance and DPW Fair Hearing
process and must be in accessible formats for
individuals with vision impairments. In addition, the
notice must be available for persons who do not speak
English.
For children in substitute care, notices must be sent to
the County Children and Youth Agency with legal custody
of a child or to the court authorized juvenile probation
office with primary supervision of a juvenile, provided
the PH-MCO knows that the child is in substitute care
and the address of the custodian of the child.
The Contractor must abide by the final decision of the
Departments of Health or Insurance (as applicable) when
a Member has filed an external appeal of a second level
complaint decision. When a Member files an external
appeal of a second level grievance decision, the
Contractor must abide by the decision of the Department
of Health certified utilization review entity (URE),
which was assigned to conduct the independent external
review, unless appealed to the court of competent
jurisdiction. The Contractor must abide by the final
decision of the Department of Public Welfare's Bureau of
Hearings and Appeals for those cases when an MA Consumer
has requested a DPW Fair Hearing, unless requesting
reconsideration by the Secretary of the Department of
Public Welfare or appealing to the court of competent
jurisdiction.
2. DPW Fair Hearing Process for Members
During all phases of the PH-MCO Complaint/Grievance
process, the Member has the right to request a Fair
Hearing with the Department. The Contractor must comply
with the DPW Fair Hearing Process requirements defined
in Exhibit GG of this Agreement, Complaints, Grievances
and DPW Fair Hearing Process.
A request for a DPW Fair Hearing does not prevent a
Member from also utilizing the plan's Grievance process.
J. Clinical Sentinel
The Contractor agrees to cooperate with the functions of the
Department's Clinical Sentinel Hotline which is designed to
address clinically related
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systems issues encountered by MA Consumers and their advocates
or Providers. The Clinical Sentinel Hotline facilitates
resolution according to Contractor policies and procedures and
does not impose additional obligations on the Contractor.
K. Provider Dispute Resolution System
The Contractor shall develop, implement, and maintain a
Provider Dispute Resolution Process, which provides for
informal settlement of Providers' disputes at the lowest level
and a formal process for appeal. The resolution of all issues
regarding the interpretation of Department approved provider
PH-MCO contracts shall be handled between the two entities and
shall not involve the Department. The Department's Bureau of
Hearings and Appeals or its designee is not an appropriate
forum for dispute decisions with PH-MCO.
Prior to implementation, the PH-MCO shall submit to the
Department, their policies and procedures relating to the
resolution of Provider disputes/appeals for approval. Any
changes made to the Provider disputes/appeals policies and
procedures shall be submitted to the Department for approval
prior to implementation of the changes.
The PH-MCO's policies and procedures shall include at a
minimum:
o Informal and formal processes for settlement of
Provider disputes;
o Acceptance and usage of the Department's
definition/delineation of disputes;
o Submission and resolution of timeframes for
disputes/appeals;
o Processes to ensure equitability for all
Providers;
o Mechanisms and time-frames for reporting Provider
appeal decisions to PH-MCO administration, QM
Provider Relations and the Department; and
o Establishment of a PH-MCO Committee to process
Provider formal disputes/appeals which shall
include:
o At least one-fourth (1/4") of the membership of
the Committee shall be composed of
providers/peers;
o Committee members who have the authority,
training, and expertise to address and resolve
Provider dispute/appeal issues;
o Access to data necessary to assist committee
members in making decisions; and
o Documentation of meetings and decisions of the
Committee.
In addition to Provider Dispute Resolution System covering
contractual issues between the Provider and the managed care
plan, Article XXI of the Insurance Company Law of 1921, as
amended, 40 P.S. 991.2101 et seq.
61
and the regulations promulgated by the Pennsylvania Insurance
Department, 31 Pa. Code Chapters 154 and 301 to afford
Providers the opportunity to file Clean Claim disputes with
the Insurance Department.
L. Certification of Authority
The Contractor will be required to maintain operating
authority in all HC-L/C counties throughout the term of this
Agreement. The Contractor must provide to the Department a
copy of Certificates of Authority verifying the counties in
which it is licensed to operate, upon request.
M. Executive Management
The Contractor must provide the following management
personnel:
o Designated administrator/program manager empowered to
make day-to-day decisions about the administration of
the program.
o Member services supervisor/manager and adequate
qualified member service staff to interact by phone or
in person with MA Consumers.
o Qualified medical personnel to oversee QA, UM, Special
Needs, Maternal Health/EPSDT functions.
o Personnel with access to the MIS system and the ability
to produce ad hoc reports to assist in the
administration of the program.
The Contractor must document minority participation in
executive level decision making positions within its corporate
structure. In addition, the Contractor's staffing should
represent the cultural and ethnic diversity of the Program and
comply with all requirements of Exhibit D of this Agreement,
Standard Contract Terms and Conditions for Services. Cultural
competency may be reflected by the Contractor's pursuit to:
o Identify and value differences;
o Acknowledge the interactive dynamics of cultural
differences;
o Continually expand cultural knowledge and resources with
regard to the populations served;
o Recruit minority staff in proportion to the populations
served;
o Collaborate with the community regarding service
provisions and delivery; and
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o Commit to cross-cultural training of staff and the
development of policies to provide relevant, effective
programs for the diversity of people served.
The Contractor must have in place sufficient administrative
staff and organizational components to comply with the
requirements of this Agreement. The Contractor must include in
its organizational structure, the components outlined below.
The functions must be staffed by qualified persons in numbers
appropriate to the PH-MCO's size of enrollment. The Department
has the right to make the final determination regarding
whether or not the Contractor is in compliance.
The Contractor may combine functions or split the
responsibility for a function across multiple departments,
unless otherwise indicated, as long as it can demonstrate that
the duties of the function are being carried out. Similarly,
the Contractor may contract with a third party to perform one
(1) or more of these functions, subject to the subcontractor
conditions described in Section XIII of this Agreement,
Subcontractual Relationships. The Contractor is required to
keep the Department informed at all times of the management
individual(s) whose duties include each of the
responsibilities outlined in this section.
The Contractor must include in its Executive Management
structure:
o A full-time Administrator with authority over the entire
operation of the PH-MCO.
o A full-time HC-L/C Program Manager to oversee the
operation of the Agreement, if different than the
Administrator of the PH-MCO.
o A full-time Medical Director who is a current
Pennsylvania-licensed physician. The Medical Director
must be actively involved in all major clinical program
components of the PH-MCO and directly accountable within
the organization for management of the QM Department, UM
Department, and Special Needs Unit. The Medical Director
and his/her staff/consultant physicians shall devote
sufficient time to the PH-MCO to ensure timely medical
decisions, including after-hours consultation, as
needed.
o A full-time Chief Financial Officer (CFO) to oversee the
budget and accounting systems implemented by the PH-MCO.
The CFO must ensure the timeliness and accurateness of
all financial reports.
o A full-time Information Systems (IS) Coordinator, who
would be the single point of contact for all information
systems issues with the Department. The IS Coordinator
must have a good working knowledge of the PH-MCO's
entire program and operation, as well as the technical
63
expertise to answer questions related to the operation
of the information system.
o Clerical and support staff to ensure appropriate
functioning of the PH-MCO's operation.
N. Other Administrative Components
The Contractor must address each of the administrative
functions listed below. These functions may be combined or
split as long as the Contractor can demonstrate that the
duties of these functions will conform to the work statement
described herein.
o A QM Coordinator who is a Pennsylvania-licensed
physician, registered nurse or physician's assistant
with past experience or education in quality management
systems. The Department may consider other advanced
degrees relevant to quality management in lieu of
professional licensure.
o A UM Coordinator who is a Pennsylvania-licensed
physician, registered nurse or physician's assistant
with past experience or education in utilization
management systems. The Department may consider other
advanced degrees relevant to utilization management in
lieu of professional licensure.
o A full-time SNU Coordinator who is a
Pennsylvania-licensed or certified medical professional,
social worker, teacher or psychologist with a minimum of
three (3) years past experience in dealing with special
needs populations similar to those served by Medicaid
and in implementing the principles of case management.
o A full-time Government Liaison who will serve as the
Department's primary point of contact with the PH-MCO
for the day-to-day management of contractual and
operational issues.
o A Maternal Health/EPSDT Coordinator who is a
Pennsylvania-licensed physician, registered nurse or
physician's assistant; or has a Master's degree in
Health Services, Public Health, or Health Care
Administration to coordinate maternity and prenatal care
services.
o A Member Services Manager who will oversee staff to
coordinate communications with Members and act as Member
advocates. There must be sufficient Member Services
staff to enable Members to receive prompt resolution to
their complaints, problems or inquiries.
o A Provider Services Manager who will oversee staff to
coordinate communications between the Contractor and its
Providers. There shall
64
be sufficient Provider Services staff to enable
Providers to receive prompt resolution to their
complaints, problems or inquiries.
o A Grievance Coordinator whose qualifications demonstrate
the ability to manage and facilitate Member Grievances.
o A Member Advocate or Ombudsman whose qualifications
demonstrate the ability to exercise independent judgment
to assist Members in navigating the Grievance and DPW
Fair Hearing process.
o A Claims Administrator who will oversee staff to ensure
the timely and accurate processing of claims, encounter
forms and other information necessary for meeting
contract requirements and the efficient management of
the PH-MCO.
The Contractor must ensure that all staff has appropriate
training, education, experience and orientation to fulfill the
requirements of the position.
O. Administration
The Contractor agrees to comply with the program standards
regarding PH-MCO Administration, which are set forth in this
Agreement and in Exhibit D of this Agreement, Standard
Contract Terms and Conditions for Services and in Exhibit E of
this Agreement, DPW Addendum to Standard Contract Terms and
Conditions. In addition, it is agreed that the Department must
approve the location of the Contractor's administrative
offices. Once approved, the Contractor will not relocate such
administrative offices without the Department's advance
written approval, which approval will not be unreasonably
withheld.
The Contractor must have an administrative office within the
zone from which the HC-L/C Program is operated. However,
exceptions to this requirement will be considered on an
individual basis if the Contractor has administrative offices
elsewhere in Pennsylvania and the Contractor is in compliance
with all standards set forth by the Departments of Health and
Insurance.
The Contractor must submit for approval by the Department its
organizational structure listing the function of each
executive as well as administrative staff members. Staff
positions outlined in this Agreement must be maintained in
accordance with the Department's requirements. The
HealthChoices Program Manager must be accessible to the
Department and may not be reassigned without advance approval
by the Department, which approval shall not be unreasonably
withheld.
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1. Responsibility to Employ MA Consumers
The Contractor must provide a plan approved by the CAO
Employment Unit Coordinator for the recruitment and hiring of
MA Consumers as described in Exhibit HH of this Agreement,
Contractor Responsibility to Employ MA Consumers.
2. Recipient Restriction Program
The Contractor agrees to maintain a recipient restriction
program to interface with the Department's recipient
restriction program and provide for appropriate professional
resources to identify and monitor Member abuse and perform the
necessary administrative activities to maintain accurate
records and comply with state and federal requirements.
A centralized recipient restriction process is in place for
the MA FFS Program and the managed care programs and is
managed by the Department. The Department maintains a lock-in
database that is accessible to all PH-MCOs. The Contractor
will cooperate with the Department in all procedures necessary
to restrict Members who are misutilizing medical services or
pharmacy benefits and to provide the appropriate resources to
enforce and monitor the restrictions.
3. Contracts and Subcontracts
In fulfilling its obligations hereunder, the Contractor has
the right to utilize the services of persons or entities by
means of subcontractual relationships. The Contractor
acknowledges and agrees that the execution of Subcontracts
does not diminish or alter the Contractor's responsibilities
under this Agreement.
The Contractor must make all Subcontracts available to the
Department within five (5) days of a request by the
Department. Contracts and Subcontracts entered into by the
Contractor does not terminate the Contractor's obligations
under this Agreement. All contracts and Subcontracts must be
in writing and must include, at a minimum, the provisions
contained in Exhibit II of this Agreement, Required Contract
Terms for Subcontractors.
Subcontracts which must be submitted to the Department for
advance written approval are:
o Any subcontract between the Contractor and any
individual, firm, corporation or any other entity to
perform part or all of the selected Contractor's
responsibilities under this Agreement. This
66
provision includes, but is not limited to, contracts for
vision services, dental services, claims processing,
member services, pharmacy services and lobbying
activities. This provision does not include, for
example, purchase orders.
o Any transaction with a related party, regardless of its
stated purpose, including, but not limited to, loans,
advances and/or lease arrangements. The Contractor must
inform the Department that the subcontractor is a
related party at the time approval is requested.
4. Lobbying Disclosure
The Contractor agrees to the terms and conditions for lobbying
disclosure defined in Exhibit D of this Agreement, Standard
Contract Terms and Conditions for Services.
The Contractor will be required to complete and return a
"Lobbying Certification Form" and a "Disclosure of Lobbying
Activities Form" found in Exhibit JJ of this Agreement,
Lobbying Certification and Disclosure of Lobbying Activities
Forms.
5. Records Retention
The Contractor agrees to comply with the program standards
regarding records retention, which are set forth in Exhibit D,
Standard Terms and Conditions of Services, of this Agreement.
Upon thirty (30) days notice from the Department, the
Contractor must provide copies of all records to the
Department at the Contractor's site, if requested, so long as
the Department requests access to those records during the
retention period prescribed by this Agreement. This thirty
(30) days notice does not apply to records requested by the
state or federal government for purposes of fiscal audits or
fraud and/or abuse. The retention requirements in this section
do not apply to DPW-generated Remittance Advices.
6. Fraud and Abuse
The Contractor shall be required to establish written policies
and procedures for the detection and prevention of fraud and
abuse in its program. Such written policies and procedures
must be reviewed and approved by the Department.
Within the Contractor's written policies and procedures, the
Contractor shall identify the corporate officer responsible
for the proactive detection, prevention and elimination of
fraud or abuse in its
67
program. The designated corporate officer must have direct
access to the CEO and be granted independent authority to
refer instances of suspected fraud and abuse directly to the
Department.
The Contractor and its employees shall cooperate fully with
centralized oversight agencies responsible for fraud and abuse
detection and prospecution activities. Such agencies include,
but are not limited to, the Departments Bureau of Program
Integrity, the Governor's Office of the Budget, the Office of
the Attorney General's Medicaid Fraud Control Section, the
Pennsylvania State Inspector General, the HCFA Office of
Inspector General, and the United States Justice Department.
Such cooperation may include participating in periodic fraud
and abuse training sessions and joint reviews of subcontracted
providers or members.
The Contractor must also ensure that the Department's
toll-free fraud and abuse hotline and accompanying explanatory
statement (which will be established in the near future) is
distributed to its Members and Providers through its Member
and Provider handbooks. Notwithstanding this requirement, the
Contractor will not be required to re-print handbooks for the
sole purpose of revising them to include fraud and abuse
hotline information. The Contract must, however, include such
information in any new version of these documents to be
distributed to Members and Providers.
The Contractor, including the designated corporate officer,
shall have an affirmative responsibility to refer suspected
fraud or abuse to relevant oversight agencies.
Contractors who do not report such information are subject to
sanctions, penalties, or other actions. A standardized
referral process is outlined in Exhibit II of this Agreement,
Standardized Referrals, to expedite information for
appropriate disposition. The requirements of the standardized
referral process are incorporated by reference into this
Agreement.
The Department shall provide the Contractor with immediate
notice via electronic transmission or access to Medicheck
listings or upon request if a provider with whom the
Contractor has entered into an agreement is subsequently
suspended or terminated from participation in the Medicaid or
Medicare Programs. Such notification will not include the
basis for the departmental action, due to confidentiality
issues. Upon notification from the Department that a provider
with whom the Contractor has entered into an agreement is
suspended or terminated from participation in the Medicaid or
Medicare Programs, the Contractor shall immediately act to
terminate
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the provider from participation. Terminations for loss of
licensure and criminal convictions must coincide with the MA
effective date of the action.
The Contractor must immediately notify the Department, in
writing, if a provider or subcontractor with whom the
Contractor has entered into an agreement is subsequently
suspended, terminated or voluntarily withdraws from
participation in the program as a result of suspected or
confirmed fraud or abuse. The Contractor must also immediately
notify the Department, in writing, if it terminates or
suspends an employee as a result of suspected or confirmed
fraud or abuse. The Contractor shall inform the Department, in
writing, of the specific underlying conduct that lead to the
suspensions, or voluntary withdrawal. Provider agreements
shall carry notification of the prohibition and sanctions for
submission of false claims and statements. Contractors who
fail to report such information are subject to sanctions,
penalties, or other actions. The Department's enforcement
guidelines are outlined in Exhibit JJ of this Agreement,
Guidelines for Sanctions Regarding Fraud and Abuse in the
HealthChoices Program.
The Department reserves the right to impose sanctions,
penalties, or take other actions when it identifies fraud and
abuse within a Contractors program.
The Contractor agrees to ensure that all of the health care
providers and others with whom it subcontracts agree to comply
with the Program Standards regarding Fraud and Abuse.
7. Information Systems and Encounter Data
The Contractor must have a comprehensive, automated and
integrated health management information system (MIS) that is
capable of meeting the requirements listed below and
throughout this Agreement.
a. The Contractor must ensure that its data system is
linked throughout all of its internal departments. In
addition, the Contractor must have an authorization
system that links with claims processing.
b. The membership management system must have the
capability to receive, update and maintain the
Contractor's membership files consistent with
information provided by the Department. The Contractor
must have the capability to provide daily updates of
membership information to subcontractors or Providers
with responsibility for processing
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claims or authorizing services based on membership
information.
c. The Contractor's claims processing system must have the
capability to process claims consistent with timeliness
and accuracy requirements identified in this Agreement.
Claims history must be maintained with sufficient detail
to meet all Department reporting and encounter
requirements.
d. The Contractor's provider management system must have
the capability to receive, store, analyze, and report on
provider specific data sufficient to meet the Provider
credentialing, auditing, quality improvement, and
profiling requirements of this Agreement.
e. The Contractor's Provider file must be maintained with
detailed information on each Provider sufficient to meet
the Department's reporting and encounter data
requirements.
f. The Contractor must have sufficient telecommunication
capabilities, including electronic mail, to meet the
requirements of this Agreement.
g. The Contractor must have the capability to
electronically transfer data files with the Department
and the IEAP contractor.
h. The encounter data system must be bi-directionally
linked to the other operational systems listed in this,
in order to ensure that data captured in encounter
records accurately matches data in member, provider and
claims files, and in order to enable encounter data to
be utilized for member profiling, provider profiling,
claims validation, and fraud and abuse monitoring
activities.
i. The Contractor's MIS must be compatible with the
Department's POSNet system. The Contractor must comply
with the policies and procedures governing the operation
of the Department's POSNet system, as defined in the
POSNet Interface Specifications and Data Exchange
Guidelines, which can be found in the HealthChoices
Proposers' Library. In addition, the Contractor must
comply with changes made to the POSNet Interface
Specifications and the Data Exchange Guidelines of the
Department. The Contractor must make changes to their
MIS system, in order to remain compatible with the
Department's data system. Whenever possible, the
70
Department will provide advance notice of at least sixty
(60) days prior to the implementation of changes. For
more complex changes, every effort will be made to
provide additional notice.
j. The Contractor must have a claims processing system and
MIS sufficient to support the Provider payment and data
reporting requirements specified in this Agreement. See
Exhibit MM of this Agreement, Management Information
System and System Performance Review Standards, for MIS
and Systems Performance Review (SPR) standards. The
Contractor must be prepared to document its ability to
expand claims processing or MIS capacity should either
or both are exceeded through the enrollment of program
Members.
k. The Contractor will designate appropriate staff to
participate in DPW directed development and
implementation activities. The Contractor will make all
necessary systems changes to migrate to the new EPSDT
reporting system consistent with timeframes to be
established by the Department to the extent possible, to
be consistent with federal reporting/claims formats and
to avoid duplication of data collection.
l. Subcontractors must meet the same MIS requirements as
the Contractor and the Contractor will be held
responsible for MIS errors or noncompliance resulting
from the action of a subcontractor.
m. The Contractor's MIS shall be subject to review and
approval during the Department's HC-L/C Readiness Review
process as referenced in Section VI of this Agreement,
Program Outcomes and Deliverables.
8. Department Access and Availability
The Contractor is responsible for providing Department staff
with access to appropriate on-site private office space and
equipment including, but not limited to, the following:
o Two (2) desks and two (2) chairs;
o Two (2) telephones, one (1) of which has speaker phone
capabilities;
o One (1) personal computer and printer with on-line
access to the Contractor's MIS;
o FAX machine; and
o Bookcase.
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The Contractor must ensure Department access to administrative
policies and procedures, including, but not limited to;
o Personnel policies and procedures
o Procurement policies and procedures
o Public relations policies and procedures
o Operations policies and procedures
o Policies and procedures developed to ensure compliance
with requirements under this Agreement.
P. Special Needs Unit (SNU)
1. Establishment of Special Needs Unit
a. The Contractor must develop, train, and maintain a
"special" dedicated unit within its organizational
structure to deal with issues relating to Members with
special needs ("Special Needs Unit" (SNU)). The purpose
of the SNU is to ensure that each Member with special
needs receives access to PCPs, dentists, and specialists
trained and skilled in the special needs of the Member;
information about the access to a specialist, as
appropriate; information about and access to all covered
services appropriate to the Member's condition or
circumstance, including pharmaceuticals and Durable
Medical Equipment (DME); access to sign language
interpreter services; and access to needed community
services. The Contractor must show evidence they can
execute agreements with individuals who have expertise
in the treatment of special needs to provide
consultation to the SNU staff, as needed.
b. The Contractor agrees to comply with the Department's
requirements and determination of whether a Member shall
be classified as having a special need, which
determination will be based on criteria set forth in
Exhibit NN of this Agreement, Special Needs Unit.
c. It is the responsibility of the SNU to arrange for and
ensure coordination between the PH-MCO and other health,
education, and human service systems for Members with
special needs. See Exhibit OO of this Agreement,
Coordination of Care Entities, for an example but not an
all-inclusive list. The Contractor is responsible to
coordinate the comprehensive in-plan package of services
with entities providing Out-of-Plan Services.
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d. The Contractor must assure that outpatient case
management for services for Members under age twenty-one
(21) are not provided through any individual employed by
the Contractor or through a subcontractor of the
Contractor if the individual's responsibilities include
outpatient utilization review or otherwise include
reviews of requests for authorization of outpatient
benefits. In addition, if the Contractor provides case
management services to members under the age of
twenty-one (21) through the SNU, the Contractor must
assure that the SNU assists individuals in gaining
access to necessary medical, social, education, and
other services in accordance with Medical Assistance
Bulletin #1239-94-01 Medical Assistance Case Management
Services for Recipients Under the Age of 21.
e. The Contractor must comply with SNU reporting
requirements as specified by the Department and
described in Exhibit NN of this Agreement, Special Needs
Unit.
2. Special Needs Coordinator
The Contractor must employ a full-time SNU Coordinator whose
qualifications include, among other things; experience with
special needs populations similar to those served by Medicaid.
The SNU Coordinator must report directly and be accountable to
the Contractor's Medical Director and be responsible for the
management and supervision of the SNU and SNU staff. The
Contractor agrees to notify the Department within thirty (30)
days of a change in the SNU Coordinator. See also Section V.M
of this Agreement, Executive Management.
3. Responsibilities of Special Needs Unit Staff
a. The Contractor agrees that the staff members which it
employs within the SNU must assist MA Consumers in
accessing services and benefits and act as liaisons with
various government offices, providers, public entities,
and county entities which shall include, but shall not
be limited to the list of Providers in Exhibit OO of
this Agreement, Coordination of Care Entities.
b. The staff members of this unit must work in close
collaboration with the SNU operated by the Department
and the IEAP contractor's SNU.
c. The Contractor must demonstrate to the Department that
its
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SNU staff is qualified to perform the functions outlined
in Exhibit NN of this Agreement, Special Needs Unit.
Q. Assignment of PCPs
The Contractor must have written policies and procedures for
Members, including parents and guardians, or attending staff for
special needs populations, who require assistance in the selection
of a PCP. The Contractor must receive advance written approval by
the Department regarding these policies and procedures. The
Contractor must ensure that the process includes at a minimum the
following features:
o The Contractor must ensure that a Member's selection of a PCP
through the IEAP contractor is honored upon commencement of
PH-MCO coverage. If the Contractor is not able to honor the
selection, the Contractor is required to follow the guidelines
described further under this provision.
o Should the Contractor permit selection of a PCP group and the
Member has selected a PCP group in the PH-MCO's Network
through the Enrollment Specialist, the PH-MCO must ensure that
upon commencement of the PH-MCO coverage, the Member's
selection is honored. In addition, the PH-MCO will have three
(3) months to outreach to this Member to make an individual
PCP selection within the PCP group. If the Member does not
make a selection within the three (3) month period, the PH-MCO
must ensure that the Member is assigned to a PCP within that
PCP group the Member initially selected. The PH-MCO must then
notify the Member by telephone or in writing of his/her PCP's
name, location and office telephone number. In addition, at no
time is the Contractor permitted to assign a PCP group to a
Member if the Member has not selected a PCP or a PCP group at
the time of enrollment.
o If the Member has not selected a PCP--through the Enrollment
Specialist, the PH-MCO must make contact with the Member
within seven (7) business days of his or her enrollment and
provide information on options for selecting a PCP, unless the
PH-MCO has information that the Member should be immediately
contacted due to a medical condition requiring immediate care.
To the extent practical, the PH-MCO must offer freedom of
choice to Members in making a PCP selection.
o If a Member does not select a PCP within fourteen (14)
business days of enrollment, the PH-MCO must make an automatic
assignment. The Contractor must consider such factors (to the
extent they are known), as current Provider relationships,
need of children to be followed by a
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pediatrician, special medical needs, physical disabilities of
the Member, language needs, area of residence and access to
transportation. The PH-MCO must then notify the Member by
telephone or in writing of his/her PCP's name, location and
office telephone number. The PH-MCO must make every effort to
determine PCP choice and confirm this with the Member prior to
the commencement of the PH-MCO coverage in accordance with
Section V.F so that new Members do not go without a PCP for a
period of time after enrollment begins.
o The Contractor must take into consideration, language and
cultural compatibility between the Member and the PCP.
o If a Member requests a change in his or her PCP selection
following the initial visit, the Contractor must promptly
grant the request and process the change timely.
o The Contractor must have written policies and procedures for
allowing Members to select or be assigned to a new PCP
whenever requested by the Member, when a PCP is terminated
from the Contractor's network or when a PCP change is ordered
as part of the resolution to a Grievance proceeding. The
policies and procedures must receive advance written approval
by the Department.
o In cases where a PCP has been terminated, the Contractor must
immediately inform Members assigned to that PCP in order to
allow them to select another PCP prior to the PCP's
termination effective date. In cases where an MA Consumer
fails to select a new PCP, reassignment must take place prior
to the PCP's termination effective date.
o The Contractor must consider that a Member with special needs
can request a specialist as a PCP. Denial of such requests are
appealable.
Should the Contractor choose to implement a process for the
assignment of a primary dentist, the Contractor must submit the
process for advance written approval from the Department prior to
its implementation.
R. Provider Services
Provider services functions shall be required to be operated at
least during regular business hours (9:00 am. to 5:00 p.m., Monday
through Friday). Provider services functions include, but are not
limited to, the following:
o Assisting Providers with questions concerning Member
eligibility status.
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o Assisting Providers with Contractor prior authorization and
referral procedures.
o Assisting Providers with claims payment procedures and
handling Provider complaints.
o Facilitating transfer of Member medical records among medical
Providers, as necessary.
o Providing to PCPs a monthly list of Members who are under
their care, including identification of new and deleted
Members. An explanation guide detailing use of the list must
also be provided to PCPs.
o Developing a process to respond to Provider inquiries
regarding current enrollment.
o Coordinating the administration of Out-of-Plan Services.
1. Provider Manual
The Contractor must keep its Network Providers up-to-date with
the latest policy and procedures changes as they affect the MA
Program. The key to maintaining this level of communication is
the publication of a provider manual. Copies of the provider
manual shall be distributed in a manner that makes them easily
accessible to all participating practitioners. The Contractor
may specifically delegate this responsibility to large
providers in its Provider Agreement. The provider manual must
be updated annually. The Department may grant an exception to
this annual requirement upon written request from the PH-MCO
provided there are no major changes to the manual. For a
complete description of the provider manual contents and
information requirements, refer to Exhibit PP of this
Agreement, Provider Manuals.
2. Provider Education
The Contractor must demonstrate that its Provider Network is
knowledgeable and experienced in treating Members with special
needs. The Contractor must submit a plan to the Department
that outlines its plans to educate and train Providers. This
training plan can be done in conjunction with the SNU training
requirements as outlined in Section V.P of this Agreement,
Special Needs Unit, and must also include special needs MA
Consumers, advocates and family members in developing the
design and implementation of the training plan.
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The Contractor must submit its plan for measuring training
outcomes including the tracking of training schedules and
Provider attendance to the Department for approval at least
annually.
At a minimum, the Provider training must be conducted for PCPs
and dentists as appropriate, and include the following areas:
a. EPSDT training for any Providers who serve Members under
age twenty-one (21).
b. Identification and appropriate referral for mental
health, drug and alcohol and substance abuse services.
c. Sensitivity training on diverse and special needs
populations such as persons who are deaf and hard of
hearing.
d. Cultural competence.
e. Treating special needs populations, including the right
to treatment for individuals with disabilities.
f. Administrative processes that include, but are not
limited to: coordination of benefits, dual eligibles,
and encounter reporting.
The Contractor may submit an alternate Provider training and
education plan should the Contractor wish to combine its
activities with other Contractors operating in the HC-L/C zone
or wish to develop and implement new and innovative methods
for Provider training and education. However, this alternative
plan must have advance written approval by the Department.
Should the Department approve an alternative plan, the
Contractor must have the ability to track and report on the
components included in the Contractor's alternative Provider
training and education plan.
S. Provider Network/Services Access
The Contractor must establish and maintain adequate Provider
networks to serve all of the eligible HC-L/C populations. Provider
networks must include, but not be limited to: hospitals, children's
tertiary care hospitals, specialty clinics, trauma centers,
facilities for high-risk deliveries and neonates, specialists,
dentists orthodontists, physicians, pharmacies, emergency
transportation services, long-term care facilities, rehab
facilities, home health agencies and DME suppliers in sufficient
numbers to make available all services in a timely manner.
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1. Network Composition
The Contractor must ensure that its Provider network is
adequate to provide its Members in the HC-L/C zone with access
to quality Member care through participating professionals, in
a timely manner, and without the need to travel excessive
distances. Upon request from the Department, the Contractor
must supply geographic access maps detailing the number,
location and specialties of their Provider network to the
Department in order to verify accessibility of Providers
within their network. The Department may require additional
numbers of specialists and ancillary providers should it be
determined that geographic access is not adequate.
The Contractor must make all reasonable efforts to honor a
Member's choice of Providers who are credentialed in the
network.
Additional requirements for establishing and maintaining an
acceptable Provider network are as follows:
a. The Contractor must ensure the provision of services to
persons who have special health needs or who face access
barriers to health care. If the Contractor does not have
at least two (2) specialists or sub-specialists
qualified to meet the particular needs of the
individuals, then the Contractor must allow Members to
pick an Out-of-Network Provider if not satisfied with
the Network Provider. The Contractor must develop a
system to determine prior authorization for Out-of-Plan
Services, including provisions for informing the MA
Consumer of how to request this authorization for
Out-at-Plan Services. For children with special health
needs, the Contractor must offer at least two (2)
pediatric specialists or pediatric sub-specialists.
b. The Contractor must ensure and must demonstrate its
ability to:
i. Make available to every Member a choice of at
least two (2) appropriate PCPs whose offices are
located within a travel time no greater than
thirty (30) minutes (urban) and sixty (60) minutes
(rural). This travel time is measured via public
transportation, where available. Members may, at
their discretion, select PCPs located further from
their homes.
ii. Ensure an adequate number of pediatricians to
permit all Members who want a pediatrician as a
PCP to
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have a choice of two (2) for their children within
the travel time limits (30 minutes urban, 60
minutes rural).
iii. Demonstrate its attempts to contract in good faith
with a sufficient number of Certified Registered
Nurse Practitioners (CRNP) to ensure access to
CRNP services. While the Contractor may contract
with a primary care practice in which the majority
of primary care services are performed by CRNP's,
the number of CRNPs in such practices may not
exceed 10 percent of the total number of PCPs in
the Contractor's network.
iv. Limit its PCP network to appropriately qualified
Providers. The PH-MCO's PCP network must meet the
following:
o Seventy-five to one hundred percent
(75-100%) of the Network consists of PCPs
who have completed an approved primary care
residency in family medicine, osteopathic
general medicine, internal medicine or
pediatrics;
o No more than twenty-five percent (25%) of
the Network consists of PCPs without
appropriate residencies but who have, within
the past seven (7) years, five (5) years of
post-training clinical practice experience
in family medicine, osteopathic general
medicine, internal medicine or pediatrics.
Post-training experience is defined as
having practiced at least as a 0.5 full-time
equivalent in the practice areas described;
and
o No more than ten percent (10%) of the
Network consists of PCPs who were previously
trained as specialist physicians and changed
their areas of practice to primary care, and
who have completed Department-approved
primary care retraining programs.
c. The Contractor must ensure a choice of at least two (2)
pharmacies (excluding mail-order entities) within the
travel time limits (30 minutes urban, 60 minutes rural).
d. The Contractor must ensure a choice of at least two
hospitals within the Provider Network, at least one (1)
of
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which must be within the travel limits (30 minutes
urban, 60 minutes rural).
e. The Contractor must ensure a choice of at least two (2)
home health agencies within the HC-L/C zone.
f. The Contractor must ensure a choice of at least two (2)
DME suppliers within the zone.
g. The Contractor must ensure a choice of at least two (2)
rehabilitation facilities within the Provider network,
at least one (1) of which must be located within the
zone.
h. The Contractor must ensure a choice of at least two (2)
nursing facilities within the Provider network.
i. The Contractor must ensure a choice of at least two (2)
general practice dentists within the Provider Network.
For members needing anesthesia for dental care, the
Contractor must ensure a choice of at least two (2)
dentists within the Provider Network with privileges or
certificates to perform specialized dental procedures
under general anesthesia.
j. The Contractor must ensure access to Certified Nurse
Midwives (CNMs) and CRNPs.
k. The Contractor must demonstrate its ability to offer its
Members freedom of choice in selecting a PCP. At a
minimum, the Contractor must have or provide one (1)
full-time equivalent (FTE) PCP who serves no more than
one thousand (1,000) MA Consumers (cumulative across all
HC-L/C PH-MCO plans) and PCP sites which serve no more
than five thousand (5,000) MA Consumers (cumulative
across all HC-L/C PH-MCO plans). The Department will
develop a system to notify the Contractor of a Provider
reaching maximum panel limits. The number of Members
assigned to a PCP may be decreased by the Contractor if
necessary to maintain the appointment availability
standards.
l. The Contractor and the Department will work together to
avoid the PCP having a caseload or medical practice
composed predominantly of HC-L/C Members. In addition,
the Contractor must organize its PCP sites so as to
ensure continuity of care to Members and must identify a
specific PCP within the site for each Member. The
Contractor may
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apply to the Department for a waiver of these
requirements on a site-specific basis. The Department
may waive these requirements for good cause demonstrated
by the Contractor.
m. The Contractor must demonstrate its ability to provide
adequate access to physician specialists for PCP
referrals, and must employ or contract with adult and
pediatric specialists in sufficient numbers to ensure
that specialty services are made available in a timely,
geographically, and physically accessible manner,
particularly for those Members in special needs
populations. The Contractor must ensure Members a choice
of at least two (2) appropriate specialists.
n. The Contractor must contract with a sufficient number of
Federally Qualified Health Centers (FQHCs) to ensure
access to FQHC services, provided FQHC services are
available, within a travel time of thirty (30) minutes
(urban) and sixty (60) minutes (rural). If the
Contractor's primary care network includes FQHCs, these
sites may be designated as PCP sites. A listing of FQHCs
for the HC-L/C project area is included in Exhibit QQ of
this Agreement, HealthChoices Federally Qualified Health
Centers (FQHCs) and Rural Health Clinics. If a
Contractor cannot contract with a sufficient number of
FQHCs, the Contractor must demonstrate in writing it has
attempted to reasonably contract in good faith.
o. The Contractor must comply with the provisions of Act
112 of 1996 (H.B. 1415, P.N. 3853, signed July 11,
1996), The Balanced Budget Reconciliation Act of 1997
and Act 68 or 1998, the Quality Health Care
Accountability and Protection Provisions, 40 P.S.
991.2101 et seq., pertaining to coverage and payment of
medically necessary emergency services. The definition
of such services is set forth herein at Section II.
p. The Contractor must inspect the office of any PCP or
dentist who seeks to participate in Contractor's
provider network (excluding offices located in
hospitals) to determine whether the office is
architecturally accessible to persons with mobility
impairments. Architectural accessibility means
compliance with ADA accessibility guidelines with
reference to parking (if any), path of travel to an
entrance, and the entrance to both the building and the
office of the provider, if different from the building
entrance. If the office or facility is
81
not accessible, the PCP or dentist may not participate
in the Contractor's provider network until the barrier
has been removed and the office or facility is
accessible to persons with mobility impairments or the
provider presents proof of an exemption under Title III
of the ADA.
q. The Department shall notify the Contractor and the
Provider of the office of any PCP or dentist that the
Department has determined is not architecturally
accessible to persons with mobility impairments. Such
Provider shall have ninety (90) days from the date of
notification that a barrier exists to remove the barrier
unless the Department expressly agrees to extend the
time for compliance. If the PCP or dentist falls to
remove the barrier, the Contractor shall initiate
appropriate action to promptly terminate the Provider's
participation in the Contractor's Network unless
notified by the Department that termination is not
necessary.
r. The PH-MCO must ensure that all laboratory testing sites
providing services have either a Clinical Laboratory
Improvement Amendment (CLIA) certificate of waiver or a
certificate of registration along with a CLIA
identification number in accordance with CLIA 1988.
Those laboratories with certificates of waiver will
provide only the eight types of tests permitted under
the terms of their waiver. Laboratories with
certificates of registration may perform a full range of
laboratory tests. The PCP must provide all required
demographics to the laboratory when submitting a
specimen for analysis.
2. Provider Agreements
The Contractor is required to have written Provider Agreements
with a sufficient number of Providers to ensure Member access
to all Medically Necessary services covered by the
HealthChoices Program.
The Contractor's Provider Agreements must include the
following provisions:
a. A requirement that the Contractor will not exclude or
terminate a Provider from participation in the
Contractor's provider network due to the fact that the
Provider has a practice that includes a substantial
number of patients with expensive medical conditions.
b. A requirement that the Contractor will not exclude a
Provider
82
from the Contractor's Provider network because the
Provider advocated on behalf of a Member for Medically
Necessary and appropriate health care consistent with
the degree of learning and skill ordinarily possessed by
a reputable health care Provider practicing according to
the applicable legal standard of care.
c. A provision that prohibits the Provider from denying
services to an MA Consumer during the MA FFS eligibility
window prior to the effective date of the PH-MCO
enrollment.
d. Notification of the prohibition and sanctions for
submission of false claims and statements.
e. The definition of Medically Necessary as defined in
Section II of this Agreement, Definitions.
j. A requirement that the Contractor cannot prohibit or
restrict a health care professional from discussing
Medically Necessary and appropriate care with or on
behalf of an enrollee, including information regarding
the nature of treatment; risks of treatment; alternative
treatments; or the availability of alternative
therapies, consultation or tests.
g. A requirement that the Contractor cannot terminate a
contract or employment with a health care Provider for
filing a Grievance on a Member's behalf.
h. A clause which specifies that the agreement will not be
construed as requiring the Contractor to provide,
reimburse for, or provide coverage of, a counseling or
referral service if the Provider objects to the
provision of such services on moral or religious
grounds.
i. A requirement securing cooperation with the QM/UM
Program standards outlined in Exhibit M(1) of this
Agreement, Quality Management & Utilization Management
Program Requirements.
j. A requirement for cooperation for the submission of
encounter data for all services provided within the
timeframes required in Section VIII of this Agreement,
Reporting Requirements, no matter whether reimbursement
for these services is made by the Contractor either
directly or indirectly through capitation.
83
k. A continuation of benefits provision which states that
the Provider agrees that in the event of the
Contractor's insolvency or other cessation of
operations, the Provider must continue to provide
benefits to the Contractor's Members through the period
for which the premium has been paid, including Members
in an inpatient setting.
l. A continuation of benefits provision which states the
Provider must continue to provide benefits to the
Contractor's Members through the period for which the
premium has been paid, including Members in an inpatient
facility.
m. A requirement that the PCPs who serve Members under the
age of twenty-one (21) are responsible for conducting
all EPSDT screens for individuals on their panel under
the age of twenty-one (21). Should the PCP be unable to
conduct the necessary EPSDT screens, the PCP is
responsible for arranging to have the necessary EPSDT
screens conducted by another Network Provider and ensure
that all relevant medical information, including the
results of the EPSDT screens, are incorporated into the
Member's PCP medical record. For details on access
requirements, see Section V.S.1 of this Agreement,
Network Composition.
n. A requirement that PCPs who serve Members under the age
of twenty-one (21) report encounter data associated with
EPSDT screens, using a format approved by the
Department, to the Contractor within ninety (90) days
from the date of service.
o. A requirement that the Contractor include in all
capitated Provider Agreements a clause which requires
that should the Provider terminate its agreement with
the Contractor, for any reason, that the Provider
provide services to the contracted Members up to the end
of the month in which the effective date of termination
falls.
p. A requirement that the Contractor must 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. This paragraph must not be
construed to prohibit an organization from including
Providers only to the extent necessary to meet the needs
of the organization's enrollees or from establishing any
measure designed to maintain quality and
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control costs consistent with the responsibilities of
the organization.
q. A requirement that ensures each physician providing
services to enrollees eligible for medical assistance
under the State Plan to have a unique identifier in
accordance with the system established under section
1173(b) of the Balanced Budget Act.
The Contractor must make all necessary revisions to its
Provider Agreements to be in compliance with the requirements
set forth in this Section. Revisions may be completed as
Provider Agreements become due for renewal provided that all
Provider Agreements are amended within one (1) year of the
effective date of this Agreement with the exception of the
encounter data requirements which must be amended immediately,
if necessary, to ensure that all Providers are submitting
encounter data to the Contractor within the timeframes
specified in Section VIII.B.1 of this Agreement, Encounter
Data and Subcapitation Data Reports.
3. Cultural Competence
Both the Contractor and Providers must demonstrate cultural
competency and must understand that cultural differences
between Provider and Member cannot be permitted to present
barriers to accessing and receiving quality health care; must
demonstrate the willingness and ability to make the necessary
distinctions between traditional treatment methods and/or
non-traditional treatment methods that are consistent with the
Member's cultural background and which may be equally or more
effective and appropriate for the particular Member; and
demonstrate consistency in providing quality care across a
variety of cultures. For example, language, religious beliefs,
cultural norms, social-economic conditions, diet, etc., may
make one treatment method more palatable to a member of a
particular culture than to another of a differing culture.
4. Primary Care Practitioner (PCP) Responsibilities
The Contractor must have written policies and procedures for
assigning every Member to a PCP. The PCP must serve as the
Member's initial and most important point of contact regarding
health care needs. As such, PCP responsibilities include at a
minimum:
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a. Providing primary and preventive care and acting as the
Member's advocate, providing, recommending and arranging
for care.
b. Documenting all care rendered in a complete and accurate
encounter record that meets or exceeds the DPW data
specifications.
c. Maintaining continuity of each Member's health care.
d. Making referrals for specialty care and other Medically
Necessary services, both in and out-of-plan.
e. Maintaining a current medical record for the Member,
including documentation of all services provided to the
member by the PCP, as well as any specialty or referral
services.
f. Arranging for behavioral health services in accordance
with Exhibit U of this Agreement, Behavioral Health
Services.
The Contractor agrees to retain responsibility for monitoring
PCP actions to ensure they comply with the provisions of this
Agreement.
5. Specialists as PCPs
A Member may qualify to select a specialist to act as PCP if
s/he has a disease or condition that is life threatening,
degenerative, or disabling.
The PH-MCO must adopt and maintain procedures by which an
enrollee with a life-threatening, degenerative or disabling
disease or condition shall, upon request, receive an
evaluation and, if the Contractor's established standards are
met, be permitted to receive:
a. A standing referral to a specialist with clinical
expertise in treating the disease or condition; or
b. The designation of a specialist to provide and
coordinate the enrollee's primary and specialty care.
The referral to or designation of a specialist must be
pursuant to a treatment plan approved by the Contractor, in
consultation with the PCP, the enrollee and, as appropriate,
the specialist. When possible,
86
the specialist must be a health care Provider participating in
the Contractor's Network.
Information for MA Consumers must include a description of the
procedures that a Member with a life-threatening, degenerative
or disabling disease or condition shall follow and satisfy to
be eligible for:
o A standing referral to a specialist with clinical
expertise in treating the disease or condition; or
o The designation of a specialist to provide and
coordinate the enrollee's primary and specialty care.
It is the responsibility of the Contractor to ensure adequate
Network capacity of qualified specialists as PCPs. These
physicians may be predetermined and listed in the directory
but may also be determined on an as needed basis. All
determinations must comply with specifications set out by DOH
in Exhibit SS of this Agreement, HMO Technical Advisory
#96-1. The Contractor must establish and maintain its own
credentialing and recredentialing policies and procedures to
ensure compliance with these specifications.
The Contractor must ensure that Providers credentialed as
specialists and as PCPs agree to meet all of the Contractor's
standards for credentialing PCPs and specialists, including
compliance with record keeping standards, the Department's
access and availability standards and other QM/UM Program
standards. The specialist as a PCP must agree to provide or
arrange for all primary care, consistent with Contractor
preventive care guidelines, including routine preventive care,
and to provide those specialty medical services consistent
with the Member's "special need" in accordance with the
Contractor's standards and within the scope of the specialty
training and clinical expertise. In order to accommodate the
full spectrum of care, the specialist as a PCP also must have
admitting privileges at a hospital in the Contractor's
Network.
6. Any Willing Pharmacy
The Contractor must contract on an equal basis with any
pharmacy qualified to participate in the MA FFS Program that
is willing to comply with the Contractor's payment rates and
terms and to adhere to quality standards established by the
Contractor as required by 62 P.S. 449.
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7. Hospital Related Party
The Department requires that a hospital that is a Related
Party to a Contractor shall be willing to negotiate in good
faith with other contractors regarding the provision of
services to MA Consumers. The Department reserves the right to
terminate this Agreement with the Contractor if it determines
that a hospital related to the Contractor has refused to
negotiate in good faith with other contractors.
8. Mainstreaming
The Contractor must ensure that Network Providers do not
intentionally segregate their Members in any way from other
persons receiving services.
The Contractor must investigate complaints and take
affirmative action so that Members are provided covered
services without regard to race, color, creed, sex, religion,
age, national origin, ancestry, marital status, sexual
orientation, language. MA status, health status, disease or
pre-existing condition, anticipated need for health care or
physical or mental handicap, except where medically indicated.
Example of prohibited practices include, but are not limited
to, the following:
o Denying or not providing a Member any MA covered service
or availability of a facility within the Contractor's
Network. The Contractor must have explicit policies to
provide access to complex interventions such as
cardiopulmonary resuscitations, intensive care,
transplantation and rehabilitation when medically
indicated and must educate its Providers on these
policies. Health care and treatment necessary to
preserve life shall be provided to all persons who are
not terminally ill or permanently unconscious, except
where a competent Member objects to such care on his/her
own behalf.
o Subjecting a Member to segregated, separate, or
different treatment, including a different place or time
from that provided to other members, public or private
patients, in any manner related to the receipt of any MA
covered service, except where Medically Necessary.
o The assignment of times or places for the provision of
services on the basis of the race, color, creed,
religion, age, sex, national origin, ancestry, marital
status, sexual orientation, income status, program
membership, language, MA status, health status, disease
or pre-existing condition, anticipated need for
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health care or physical or mental disability of the
participants to be served.
If the Contractor knowingly executes an agreement with a
Provider with the intent of allowing or permitting the
Provider to implement barriers to care (i.e. the terms of the
Provider Agreement are more restrictive than this Agreement),
the Contractor shall be in breach of this Agreement.
9. Network Changes
The Contractor must notify the Department promptly of any
changes to the composition of its Provider Network that
materially affects the Contractor's ability to make available
all services covered by this Agreement in a timely manner. The
Contractor also must have procedures to address changes in its
Network that negatively affect the ability of Members to
access services. Material changes in network composition that
negatively affect Member access to services may be grounds for
termination of this Agreement.
a. For PCP terminations, the Contractor must provide thirty
(30) days advance written notice to Members assigned to
the PCP and must provide for or assist with those
assignments of the Member to another PCP. The Contractor
must ensure the timely and complete transfer of medical
records to the new PCP.
b. For hospital terminations, the Contractor must provide
thirty (30) days advance notice to Members assigned to
any PCPs or PCP groups that will be terminated as a
result of the hospital termination. In addition, the
Department may require notification to all Members of a
hospital change.
c. The Department will work with the Contractor to identify
those situations in which advance notification to
Members of an ancillary Provider termination is
necessary, with special consideration given to Members
with special needs.
d. The advance notice requirement will not apply to
terminations by the Contractor due to quality of care or
other "for cause" reasons.
10. Other Provider Enrollment Standards
The Contractor agrees to comply with the program standards
regarding Provider enrollment that are set forth in this
Agreement.
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All Providers operating within the Contractor's network who
provide services to MA Consumers must be enrolled in the
Commonwealth's MA Program and possess an active Medical
Assistance Identification (MAID) number.
The Contractor must enroll a sufficient number of Providers
qualified to conduct the specialty evaluations necessary for
conducting alleged physical and/or sexual abuse
investigations.
The Department encourages the use of providers currently
contracting with the County Children and Youth Agencies who
have experience with the xxxxxx care population and who have
been providing services to children and youth MA Consumers for
many years.
11. Twenty-Four Hour Coverage
It is the responsibility of the Contractor to have coverage
available directly or through its PCPs either directly or
through on-call arrangements with other qualified Providers
for Urgent or Emergency Care on a twenty-four (24) hour, seven
(7) day-a-week basis. The Contractor shall not use central
services without knowledge of the Member in lieu of the above
PCP emergency coverage requirements. For Emergency or Urgent
Medical Conditions, the Contractor must have written policies
and procedures on how Members and Providers can make contact
to receive instruction or prior authorization for treatment.
If it is determined that emergency care is not required by the
PCP or the Contractor, the PCP must immediately arrange to see
the Member or refer the Member to an urgent care clinic which
can immediately see the Member in accordance with Section
V.S.12 of the Agreement, Appointment Standards.
12. Appointment Standards
The Contractor agrees to require the PCP, dentist, or
specialist to conduct affirmative outreach whenever a Member
misses an appointment and to document this in the medical
record. Such an effort shall be deemed to be reasonable if it
includes three (3) attempts to contact the Member. Such
attempts may include, but are not be limited to: written
attempts, telephone calls and home visits. At least one (1)
such attempt must be written.
a. General
PCP scheduling procedures must ensure that:
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i. Emergency cases must be seen immediately or
referred to an emergency facility. If it is
determined that Emergency Medical Condition care
is not required, the Member must be seen at once
by the PCP or referred to an open urgent care
clinic.
ii. Urgent Medical Condition cases must be scheduled
within twenty-four (24) hours.
iii. Routine appointments must be scheduled within ten
(10) business days.
iv. Health assessment/general physical examinations
and first examinations must be scheduled within
three (3) weeks of enrollment.
v. The Contractor must provide the Department with
its protocol for ensuring that a Member's average
office waiting time is no more than twenty (20)
minutes or at any time no more than up to one (1)
hour when the physician encounters an
unanticipated Urgent Medical Condition visit or is
treating a Member with a difficult medical need.
The Member will be informed of scheduling time
frames through educational outreach efforts.
vi. The Contractor must monitor the adequacy of its
appointment processes and reduce the unnecessary
use of emergency room visits.
b. Persons with HIV/AIDS
The Contractor must have adequate PCP scheduling
procedures in place to ensure that an appointment with a
PCP or specialist must be scheduled within seven (7)
days from the effective date of enrollment for any
person known to the Contractor to be HIV positive or
diagnosed with AIDS (e.g. self-identification), unless
the enrollee is already in active care with a PCP or
specialist.
c. SSI
The Contractor must make a reasonable effort to schedule
an appointment with a PCP or specialist within
forty-five (45) days of enrollment for any Member who is
an SSI or SSI-related consumer unless the member is
already in active
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care with a PCP or specialist.
d. Specialty Referrals
For specialty referrals, the Contractor must be able to
provide:
i. Emergency Medical Condition appointments
immediately upon referral.
ii. Urgent Medical Condition care appointments within
twenty-four (24) hours of referral.
iii. Routine appointments within ten (10) business days
of referral.
e. Pregnant Women
Should the IEAP contractor or Member notify the
Contractor that a new Member is pregnant or there is a
pregnancy indication on the files transmitted to the
Contractor by the Department, the Contractor must
contact the Member within five (5) days of the effective
date of enrollment to assist the woman in obtaining an
appointment with an OB/GYN or Nurse Midwife. For
maternity care, the Contractor must be able to provide
initial prenatal care appointments for enrolled pregnant
members as follows:
i. First trimester -- within ten (10) business days
of the Member being identified as being pregnant.
ii. Second trimester -- within five (5) business days
of the Member being identified as being pregnant.
iii. Third trimester -- within four (4) business days
of the Member being identified as being pregnant.
iv. High-risk pregnancies -- within twenty-four (24)
hours of identification of high risk to the
Contractor or maternity care provider, or
immediately if an emergency exists.
f. EPSDT
EPSDT screens for any new enrollee under the age of
twenty-one (21) must be scheduled within forty-five (45)
days from the effective date of enrollment unless the
child is
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already under the care of a PCP and the child is current
with screens and immunizations.
The Contractor must ensure that PCPs follow-up with those
Members described in the above Section V.S.12 for any missed
appointments. The PCP or specialist must send two (2) notices
of missed appointments and make a follow-up telephone call to
the Member for any missed appointments and the PCP or
specialist must document these in the medical record.
13. Policies and Procedures for Appointment Standards
The Contractor agrees to comply with the program standards
regarding service accessibility standards that are set forth
in Section V.S. of this Agreement, Provider Network/Services
Access.
The Contractor must have written policies and procedures for
disseminating its appointment standards to all Members through
its member handbook and through other means. In addition, the
Contractor must have written policies and procedures to
educate its Provider Network about appointment standard
requirements. The Contractor must monitor compliance with
appointment standards and shall have a corrective action plan
when appointment standards are not met.
14. Compliance with Access Standards
a. Mandatory Compliance
The Contractor must comply with the access standards in
accordance with Section V.S of this Agreement, Provider
Network/Services Access. If the Contractor fails to meet
any of the access standards by the dates specified by
the Department, the Department may terminate this
Agreement.
b. Reasonable Efforts and Assurances
The Contractor must make reasonable efforts to honor a
Member's choice of Providers among Network Providers as
long as:
i. The PH-MCO's agreement with the Network Provider
covers the services required by the Member; and
ii. The Contractor has not determined that the
Member's choice is clinically inappropriate.
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The Contractor must provide the Department adequate
assurances that the Contractor, with respect to the
HC-L/C zone, has the capacity to serve the expected
enrollment in the HC-L/C zone by providing assurances
that the Contractor offers the full scope of covered
services as set forth in this Agreement and access to
preventive and primary care services and maintains a
sufficient number, mix and geographic distribution of
Providers and services in accordance with the standards
set forth in Section V.S of this Agreement, Provider
Network/Services Access.
c. Contractor's Corrective Action
The Contractor must take all necessary steps to resolve,
in a timely manner, its failure to comply with the
access standards. Prior to a termination action or other
sanction by the Department, the Contractor will be given
the opportunity to institute a corrective action plan.
The Contractor must submit a corrective action plan to
the Department for approval within thirty (30) days of
notification of such failure to comply, unless
circumstances warrant and the Department demands a
shorter response time. The Department's approval of the
Contractor's corrective action plan will not be
unreasonably withheld. The Department will make its best
effort to respond to the Contractor within thirty (30)
days from the submission date of the corrective action
plan. If the Department rejects the corrective action
plan, the Contractor shall be notified of the
deficiencies of the corrective action plan. In such
event, the Contractor shall submit a revised corrective
action plan within fifteen (15) days of notification. If
the Department does not receive an acceptable corrective
action plan, the Department may impose sanctions against
the Contractor, in accordance with Section VIII.I of
this Agreement, Sanctions. Failure to implement the
corrective action plan may result in the imposition of a
sanction as provided in this Agreement.
T. QM and UM Program Requirements
1. Overview
The Contractor must comply with the Department's QM and UM
program standards and requirements described in Exhibit M(1)
of this Agreement, Quality Management and Utilization
Management Program Requirements. The Department retains the
right of advance written approval and to review on an ongoing
basis all aspects of the
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Contractor QM and UM programs, including subsequent changes.
The Contractor must comply with all QM and UM program
reporting requirements and must submit data in formats to be
determined by the Department.
2. General
The QM and UM programs must include a written program
description and annual work plan with a timetable of all
activities and performance improvement initiatives for the
coming year. The Department, in collaboration with the
Contractor, retains the right to determine and prioritize QM
and UM activities and initiatives based on areas identified as
being of importance to the Department and areas identified
through its analysis of external quality review (EQR)
findings, Health Plan Employer Data and Information Set
(HEDIS) measures, and encounter data submitted by the
Contractor. The Contractor must implement and abide by the
program description and work plan or amended plan as approved
by the Department. The QM and UM programs must:
a. Include methodologies that allow for statistically valid
performance based monitoring of the QM and UM programs
and include documentation that all QM and UM activities
and initiatives undertaken by the plan are selected
through clinical and financial analysis of encounter,
Member demographic and other data.
b. Provide evidence of evaluation and re-measurement of the
Contractor QM and UM activities and initiatives in order
to determine sustained improvement or the need for
further action.
c. Address development, implementation, and performance
measurement of disease management programs that are
intended for selected conditions among targeted
populations in order to improve outcomes through the
quality of care provided while effectively managing
utilization.
3. Additional Utilization Management Program Requirements
The Contractor agrees to provide twenty-four (24) hour staff
availability to authorize emergency/weekend services,
including but not limited to: home health care, pharmacy, DME,
and medical supplies. The Contractor must have written
policies and procedures that address how Members and Providers
can make
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contact with the plan to receive instruction or prior
authorization, as necessary.
The Contractor must ensure that all utilization review
decisions are made using the HealthChoices definition of
Medically Necessary. In addition, the Contractor must take
steps to ensure that determinations made by individual
clinical reviewers on whether or not requested care and
services are Medically Necessary are consistent with
determinations for care and services that would be found to be
Medically Necessary consistent with the HealthChoices
definition of Medically Necessary.
The Contractor must develop polices and procedures that allow
for prospective, concurrent, and retrospective determination
of medical necessity, which are based on the HealthChoices
Program's definition of Medically Necessary and meet
HealthChoices Program's timeframes for the processing of
requests, for elective, urgent and Emergency Services as
outlined in Exhibit H of this Agreement, Prior Authorization
Guidelines.
In addition, the Contractor must submit utilization review
criteria and policies/procedures that contain utilization
review criteria used to determine medical necessity to the
Department for evaluation under the Utilization Review
Criteria Assessment Process (URCAP).
4. Healthplan Employer Data Information Set (HEDIS)
The Contractor must submit data to the Department by June 15th
of the current year. The calendar year is the standard
measurement year for HEDIS data. HEDIS measures are specified
for one of three data collection methodologies:
administrative, hybrid or survey. The administrative
methodology requires that contractors identify the denominator
and numerator using transaction data or other administrative
databases. The denominator includes all eligible Members.
The Contractor will report a rate based on all Members who
meet the criteria who are found through administrative data to
have received the service identified in the numerator data.
The hybrid methodology requires that the Contractor identify
the denominator and the numerator through both administrative
and medical record data. The denominator consists of a
systematic sample of members drawn from the measure's eligible
population.
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The Contractor will report a rate based on those Members in
the sample who are found through either administrative or
medical record data to have received the service identified in
the numerator. The Contractor may not report a measure using
the hybrid method when the numerator is derived solely from
administrative data.
5. External Quality Review (EQR)
The Contractor agrees to cooperate fully with any external
evaluations and assessments of its performance authorized by
the Department under this Agreement. Independent assessments
will include, but not be limited to, any independent
evaluation required or allowed by federal or state statute or
regulation. See Exhibit M(2) of this Agreement, External
Quality Review.
The Contractor agrees to cooperate fully with external
clinical record reviews that assess the Contractor's quality
of care, access to care, and timeliness of care i.e., any
studies as determined by the Department.
The Contractor agrees to assist in the identification and
collection of any data or clinical records to be reviewed by
the independent evaluation team members. In addition, the
Contractor must provide to the External Quality Review
Organization (EQRO) complete medical records in the timeframe
allowed by the EQRO.
The Contractor must ensure that data, clinical records and
workspace located at the Contractor's work site are available
to the independent review team and to the Department, upon
request.
The Contractor must demonstrate how the results of the EQR are
incorporated into the overall Quality and Utilization
Management Programs.
6. QM and UM Program Reporting Requirements
The Contractor agrees to:
a. Provide the Department with uniform QM, UM, and Member
satisfaction/complaint data, in a format to be
determined by the Department, on a regular basis;
b. Collaborate with the Department in carrying out data
validation steps;
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c. Maintain and make available to the Department, upon
request, studies, reports, protocols, standards,
worksheets, minutes or other such documentation as may
be appropriate; and
d. Submit reports based on the most current version of
HEDIS measures.
The Contractor agrees to comply with all QM and UM program
reporting requirements and time frames outlined in Exhibit
M(1) or this Agreement, Quality Management & Utilization
Management Program Requirements. The Department will, on a
periodic basis, review the required reports and make changes
to the information/data and/or formats requested based on the
changing needs of the HealthChoices Program. The Contractor
must comply with all requested changes to the report
information and formats as deemed necessary by the Department.
Copies of current QM and UM reporting requirements can be
found in the HealthChoices Proposers' Library.
7. Collaboration Between Contractor QM and UM Departments and
Special Needs Units
The Contractor must provide evidence of ongoing collaboration
and coordination between its QM and UM Departments and its SNU
regarding quality initiatives, case management and/or disease
management activities directed toward or involving care of
special needs populations. Collaboration must include, but not
be limited to, quality improvement studies; UM referrals;
discharge planning/case management, identification of and
outreach to MA Consumers with special needs and special needs
populations.
8. Delegated Quality Management and Utilization Management
Functions
The Contractor must demonstrate that it retains accountability
for all QM and UM programs functions, including those that are
delegated to other entities. The Contractor must make
available to the Department, any records, documents, and data
detailing its oversight of delegated QM and UM program
functions. In addition, the Contractor must ensure that
delegated entities make available to the Department, any
records, documents, and data detailing the delegated QM and UM
program functions undertaken by the entity of behalf of the
Contractor.
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9. Consumer Involvement in the Quality Management and Utilization
Management Programs
The Contractor agrees to participate and cooperate in the work
and review of the Department's formal advisory body through
participation in the Medical Assistance Advisory Committee
(MAAC) and its subcommittees.
10. Confidentiality
The Contractor must have written policies and procedures for
maintaining the confidentiality of data that addresses medical
records, Member information and Provider information and is in
compliance with the provisions set forth in Section 2131 of
the Insurance Company Law of 1921, as amended, 40 P.S.
991.2131 and 55 Pa. Code 105.
The Contractor must ensure that Provider offices/sites have
implemented mechanisms that guard against unauthorized or
inadvertent disclosure of confidential information to persons
outside the Contractor.
All clinical data related to HealthChoices Members is the
property of the Department. Release of data by the Contractor
to third parties, except for the purpose of individual care
and coordination among Providers as consented to by Members,
requires the Department's advance written approval.
11. Department Oversight
The Contractor and its subcontractor(s) agree to make
available to the Department upon request, data, clinical and
other records and reports for review of quality of care,
access and utilization issues including but not limited to
EQRO, HEDIS, Encounter Data Validation, and other related
activities.
The Contractor must submit a plan, as determined by the
Department, and within time frames established by the
Department, to resolve any performance or quality of care
deficiencies identified by the Department's ongoing monitoring
activities and any independent assessments or evaluations
requested by the Department.
The Contractor must obtain advance written approval from the
Department before releasing or sharing data, correspondence
and/or improvements from the Department regarding the
Contractor's
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internal QM and UM programs with any of the other
HealthChoices PH-MCOs or any external entity.
The Contractor must obtain advance written approval from the
Department before participating in or providing letters of
support for QM or UM data studies and/or any data related
external research projects related to HealthChoices with any
entity.
SECTION VI: PROGRAM OUTCOMES AND DELIVERABLES
All deliverables must receive advance written approval by the
Department prior to the implementation of the HC-L/C Program unless
otherwise specified by the Department. Deliverables include, but are
not limited to, operational policies and procedures; required
materials; letters of agreement; provider agreements; reimbursement
methodology and rates; coordination agreements; reports; tracking
systems; required files; QM/UM documents (See Exhibit M(3) of this
Agreement, Quality Management/Utilization Management Deliverables),
and referral systems.
The Department may conduct on-site Readiness Reviews as needed to
document the Contractor's compliance with this Agreement. Upon
request by the Department, as part of the Readiness Review, the
Contractor must provide detailed written descriptions of how the
Contractor is complying with Agreement requirements and standards.
The Department retains the right to continue development of
Readiness Review elements, program standards and forms prior to
scheduling the actual on-site Readiness Review visits.
SECTION VII: FINANCIAL REQUIREMENTS
A. Financial Standards
1. Risk Protection Reinsurance for High Cost Cases
The Contractor must have a risk protection arrangement during
the term of this Agreement. This risk protection arrangement
must include reinsurance that covers, at a minimum, 80% of
inpatient costs incurred by one (1) Member in one (1) year in
excess of $150,000. The Department may alter or waive the
reinsurance requirement if the Contractor proposes an
alternative risk protection arrangement that the Department
determines is acceptable.
The Contractor may not change or discontinue the risk
protection arrangement without advance written approval from
the Department, which approval shall not be unreasonably
withheld. The Contractor
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must notify the Department thirty (30) days prior to any
change in the risk protection arrangement. The Department
reserves the right to review such risk protection arrangements
and require changes based on the Department's assessment of
the Contractor's overall financial condition.
The reinsurance threshold requirement shall be $75,000,
instead of $150,000, if any of the following criteria is met:
a. The Contractor has been operational (providing medical
benefits to any type of consumer) for less than 3
(three) years; or,
b. The Contractor's Statutory Accounting Principles (SAP)
basis equity is less than 4.2 percent of MA premiums
earned during the most recent calendar year for which
the due date has passed for submission of the unaudited
annual reports filed by the Contractor with the
insurance Department (DOI); or,
c. The Contractor did not earn cumulative net surplus over
the previous three (3) years.
2. Equity Requirements and Insolvency Protection
The Contractor must meet, during the term of this Agreement,
the equity requirements set forth below. The Contractor shall
comply with all financial requirements included in this
Agreement in addition to those of the Pennsylvania Departments
of Health and Insurance. The Department reserves the right to
review such equity and financial requirements and require
changes based on the Department's assessment of the
Contractor's overall financial condition.
The Contractor must maintain SAP-basis equity equal to the
highest of the amounts determined by the following "Three (3)
Part Test":
o $1.5 million.
o 4.2% of MA premiums earned during the most recent four
(4) calendar quarters.
o 4.2% of MA premiums earned during the current quarter
multiplied by three (3).
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The amount of the requirement for equity shall be phased in as
follows:
====================================================================
Equity as of the last day of the 50% of the amount determined
first contract calendar quarter. by the Three (3) Part Test, but
not less than $1.5 million.
--------------------------------------------------------------------
Equity as of the last day of the 66% of the amount determined
second contract calendar by the Three (3) Part Test, but
quarter. not less than $1.5 million.
--------------------------------------------------------------------
Equity as of the last day of the 80% of the amount determined
third contract calendar quarter. by the Three (3) Part Test, but
not less than $1.5 million.
--------------------------------------------------------------------
Equity as of the last day of the 100% of the amount fourth
contract calendar quarter. determined by the Three (3)
Part Test.
====================================================================
MA premiums are defined as all revenue received from the
Commonwealth for any and all Managed Care Medical Assistance
contracts.
For the purpose of this requirement, equity amounts, as of the
last day of each calendar quarter shall be determined in
accordance with statutory accounting principles as specified
or accepted by DOI. The Department shall accept DOI
determinations of equity amounts, and in the absence of such
determination, shall rely on required financial statements
filed by the Contractor with DOI to determine equity amounts.
The Contractor shall provide the Department with reports as
specified in Section VIII.D of this Agreement, Financial
Reports.
In addition to the Department's general sanction authority
specified in Section VIII.I of this Agreement, Sanctions, if
the Contractor fails to comply with the requirements of this
Section, the Department may take any or all of the following
actions:
o Discuss fiscal plans with the Contractor's management.
o Require the Contractor to submit and implement a
corrective action plan.
o Suspend some or all enrollment of MA Consumers into the
Contractor's plan.
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o Terminate this agreement effective the last day of the
calendar month after the Department notifies the
Contractor of termination.
3. Secondary Liability
The Contractor must have in place an acceptable plan to
provide for payment to Providers by a secondary liable party
after default in payment to Providers resulting from
bankruptcy or insolvency. The secondary liability must ensure
payment for all services performed by providers through the
last day for which the Department paid a capitation premium to
the Contractor. The requirements may be met by submission of
one or more of the following arrangements:
a. Insolvency insurance.
b. An irrevocable, unconditional, and automatically
renewable letter of credit for the benefit of the
Department which is in place for the entire term of
this Agreement.
c. A guarantee from an entity acceptable to the Department,
with sufficient financial strength and creditworthiness
to assume the payment obligations of the Contractor in
the event of a default in payment resulting from
bankruptcy or insolvency.
d. Other arrangements satisfactory to the Department, that
are sufficient to insure payment to Providers in the
event of default in payment resulting from bankruptcy or
insolvency.
The Department must approve all arrangements for secondary
liability. Such approval shall include approval of the
financial strength of the secondary liable parties and
approval of all legal forms for secondary liability.
4. Limitation of Liability
In accordance with 42 C.F.R. 434.20, the Contractor must
assure that MA Consumers shall not be liable for the
Contractor's debts if the Contractor becomes insolvent.
5. Medical Cost Accruals
As part of its accounting and budgeting function, the
Contractor must establish and maintain an actuarially sound
process for estimating and tracking Incurred But Not Paid
(IBNP) amounts. The Contractor must reserve funds by major
categories of service to cover IBNP
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amounts. As part of its reserving methodology, the Contractor
must conduct annual reviews to assess its reserving
methodology and make adjustments, as necessary.
6. Claims Processing and MIS
The Contractor must have a claims processing system and MIS
sufficient to support the Provider payment and data reporting
requirements specified in Section VIII of this Agreement,
Reporting Requirements. See also Exhibit MM of this Agreement,
Management Information System and System Performance Review
Standards, for MIS and Systems Performance Review (SPR)
standards. The Contractor shall be prepared to document its
ability to expand claims processing or MIS capacity should
either or both be exceeded through the enrollment of program
Members.
7. DSH/GME Payment for Disproportionate Share Hospitals (DSH)/
Graduate Medical Education (GME)
The Department shall make direct payments of DSH/GME to
hospitals. DSH and GME amounts shall not be included in
fee-for-service cost equivalent projections or in capitation
payments paid by the Department to the Contractor.
8. Member Liability
The Contractor is prohibited from holding the Member liable
for the following:
a. Debts of the Contractor in the event of the Contractor's
insolvency.
b. Services provided to the Member in the event of the
Contractor failing to receive payment from the
Department for such services.
c. Services provided to the Member in the event of a health
care Provider with a contractual, referral or other
arrangement with the Contractor failing to receive
payment from the Department or the Contractor for such
services.
d. Payments to a Provider that furnishes covered services
under a contractual, referral or other arrangement with
the Contractor in excess of the amount that would be
owed by the Member if the Contractor had directly
provided the services.
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B. Commonwealth Capitation Payments
1. Payments For In-Plan Services
The obligation of the Department to make payments shall be
limited to capitation payments, maternity care payments, and
any other payments provided by this Agreement.
a. Capitation Payments
i. The Contractor shall receive capitated payments
for In-Plan Services as defined in Section VII.B.1
of this Agreement. Capitation rates and maternity
care rates, applicable to the agreement year
beginning October 1, 2001, are set forth in
Exhibit B of this Agreement, Capitated Rates. This
agreement year, for capitation purposes, begins
October 1, 2001, and extends 15 months to December
31. 2002.
For the agreement year beginning January 1, 2003,
and for each subsequent agreement year, the
Department will provide an initial schedule of
capitation rates, maternity care rates, and Risk
Pool Allocation Amounts (RPAAs), not later than
July 1 of the previous year. The Department will
provide the Contractor with information on
methodology and data used to develop the initial
schedule of rates. The Department will provide
the Contractor with the opportunity of a meeting,
in which the Department will consider questions
from the Contractor on development of the initial
schedule of rates. The Department will provide
the Contractor with a final schedule of
capitation rates; maternity care rates, and
RPAAs, by September 30 of the year prior to the
effective date of the rates. If the Contractor
does not notify the Department of its acceptance
of the final schedule of rates by October 15 of
the same year, the Department will, at its sole
discretion, decide on a schedule of rates for the
subsequent agreement year that will consist of
one of the following:
1. The final schedule of capitation
rates, maternity care rates and
RPAAs, applicable to the
subsequent agreement year,
previously provided by the
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Department; or
2. The schedule of capitation rates,
maternity care rates and RPAAs
applicable to the prior agreement
year.
ii. The Department shall make a pre-paid capitation
payment, referenced in Section VII.B.1.a above,
for each Member whose enrollment on the first day
of the month is indicated on the Department's CIS
on the first day of the month. If the Contractor
is responsible to provide benefits to a MA
Consumer who does not appear on CIS on the first
day of the month, the Department shall initiate a
capitation payment on the first day of the first
subsequent month on which said enrollment appears
on CIS. The Department will compute capitation
payments using per diem rates. The Department will
make a monthly payment to the PH-MCO for each MA
Consumer enrolled in the PH-MCO, for the first day
in the month the MA Consumer is enrolled in the
PH-MCO and for each subsequent day through, and
including the last day of the month.
iii. The Department shall make each monthly capitation
payment by the fifteenth of the month. The
Department shall seek to make arrangements for
payment by wire transfer or electronic funds
transfer. If such arrangements are not in place,
payment shall be made by U.S. Mail.
iv. The Department shall not make a capitation payment
for a Recipient Month if it notifies the
Contractor before the first of the month that the
individual's MA eligibility or PH-MCO enrollment
ends prior to the first of the month.
v. This Agreement provides for rates for SSI
consumers who have Medicare Part A benefits that
are distinct from rates for SSI consumers who do
not have Medicare Part A benefits. If the
Department's Third Party Liability (TPL) file is
updated to indicate Medicare Part A coverage
within four (4) months prior to the current month
for a MA Consumer at an SSI Without Medicare rate,
the Department shall adjust the payment to reflect
the rating group appropriate to the MA Consumer,
provided the TPL file indicates
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Medicare Part A coverage as of the first day of
coverage by the Contractor for this MA Consumer
during the month for which payment was made. If
the Department's TPL file is updated to adjust or
delete indication of Medicare Part A coverage
within four (4) months of a payment to the
Contractor for a MA consumer at an SSI with
Medicare or Healthy Horizons rate, the Department
shall adjust the payment to reflect the rating
group appropriate to the MA Consumer, provided the
TPL file does not indicate Medicare Part A
coverage as of the first day of coverage by the
Contractor for this MA Consumer during the month
for which payment was made. The Department shall
provide information to the Contractor on this type
of payment adjustment on an electronic file. The
Contractor shall utilize this information to
adjust its payments to Providers and instruct its
Providers to xxxx Medicare.
vi. The Department will recover capitation payments
made for Members who were later determined to be
ineligible for managed care for up to twelve (12)
months after the service month for which payment
was made. The Department will recover capitation
payments made for deceased recipients for up to
eighteen (18) months after the service month for
which payment was made. See Exhibit BB of this
Agreement, PH-MCO Recipient Coverage Document.
2. Voluntary Risk Adjustment
Exhibit B provides capitation rates and maternity care rates,
for the agreement year beginning October 1, 2001. Exhibit B
includes a distinct schedule of rates applicable to the first
six (6) months the Contractor is responsible to provide
medical benefits to recipients. These rates are computed to
reflect a voluntary risk adjustment. The voluntary risk
adjustment reflects the lesser financial risk associated with
voluntary enrollment in a managed care program.
3. Maternity Care Payment
For each live birth, the Department shall make a one-time
maternity care payment to the Contractor with whom the mother
is enrolled on the date of birth; however, if the mother is
admitted to a hospital and a change in the PH-MCO coverage
occurs during the hospital admission, the PH-MCO responsible
for the hospital stay at the
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time of birth shall receive the maternity care payment. The
amount of the maternity care payment for the agreement year
beginning October 1, 2001 is shown in Exhibit B of this
Agreement, Capitated Rates. The payment is a global fee to
cover all maternity expenses, including prenatal care,
delivery fees and post-partum care for the mother and all
services mandated by Act 85 of 1996 ("The Health Security
Act").
If required by the Department, the Contractor must submit
invoices or Data Files to the Department to receive maternity
care payments, consistent with specifications determined by
the Department.
4. Program Changes
Amendments, revisions, or additions to the State Medicaid Plan
or to state or federal regulations, laws, guidelines, or
policies shall, insofar as they affect the scope or nature of
benefits available to eligible persons, amend the Contractor's
obligations as specified herein, unless the Department
notifies the Contractor otherwise. The Department shall inform
the Contractor of any changes, amendments, revisions, or
additions to the State Medicaid Plan or changes in the
Department's regulations, guidelines, or policies in a timely
manner.
The Department shall adjust rates, as necessary, to maintain
the actuarial soundness of the rates to reflect the impact on
costs of program changes. If the Department makes an
adjustment to the rates, as provided by this paragraph, the
Department will provide information to the Contractor on the
methodology used to determine the amount of the rate
adjustment.
5. Supplemental Payments
Exhibit B provides capitation rates and maternity care rates
for the agreement year beginning October 1, 2001. The
Department will review pharmacy cost trends and changes to the
Medical Assistance program to determine whether any supplement
to the rates in Exhibit B is warranted. This determination
will be at the sole discretion of the Department. If the
Department determines a supplement is warranted, the
Department will make each capitation or maternity care payment
to the PH-MCO at the applicable rate included in Exhibit B, as
adjusted by the amount of the supplement. On or about July 1,
2001, the Department will notify the PH-MCO if the Department
has determined that any supplement is warranted.
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C. HIV/AIDS Risk Pool
The Department shall withhold the portion of each capitation payment
that is designated as a Risk Pool Allocation Amount on each rate
schedule. Funds so withheld shall be allocated to an HIV/AIDS Risk
Pool and distributed to PH-MCOs in accordance with Exhibit VV of
this Agreement, HIV/AIDS Risk Pool.
D. Claims Processing Standards, Monthly Report and Penalties
1. Timeliness Standards
The Contractor will adjudicate Provider claims consistent with
the requirements below. These requirements apply collectively
to claims processed by the Contractor and any subcontractor.
Subcapitation payments are excluded from these requirements.
The adjudication timeliness standards follow for each of three
categories of claims:
a. Claims received from a hospital for inpatient admissions
("Inpatient")
o 90.0% of Clean Claims must be adjudicated within
thirty (30) days of receipt.
o 100.0% of Clean Claims must be adjudicated within
forty-five (45) days of receipt.
o 100.0% of all claims must be adjudicated within
ninety (90) days of receipt.
b. Drug claims
o 90.0% of Clean Claims must be adjudicated within
thirty (30) days of receipt.
o 100.0% of Clean Claims must be adjudicated within
forty-five (45) days of receipt.
o 100.0% of all claims must be adjudicated within
ninety (90) days of receipt.
c. All claims other than inpatient and drug:
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o 90.0% of Clean Claims must be adjudicated within
thirty (30) days of receipt.
o 100.0% of Clean Claims must be adjudicated within
forty-five (45) days of receipt.
o 100.0% of all claims must be adjudicated within
ninety (90) days of receipt.
The adjudication timeliness standards do not apply to claims
submitted by Providers under investigation for fraud or abuse
from the date of service to the date of adjudication of the
claims, Providers can be under investigation by a governmental
agency or the Contractor; however, if under investigation by
the Contractor, the Department must have immediate written
notification of the investigation.
Every claim entered into the Contractor's computer information
system that is not a Rejected Claim must be adjudicated. The
Contractor must maintain an electronic file of rejected
claims, inclusive of a reason or reason code for rejection.
The amount of time required to adjudicate a paid claim is
computed by comparing the date the claim was received with the
check date or the transmission date of an electronic payment.
The check date is the date printed on the check. The amount of
time required to adjudicate a denied claim is computed by
comparing the date the claim was received with the date the
denial notice was created or the transmission date of an
electronic denial notice. For an amended claim, the date the
Contractor received the request to adjust the payment from the
Provider must be recorded and counted as the date the claim
was received. Amended claims do not include provider appeals.
Checks must be mailed not later than three (3) working days
from the check creation date.
The Contractor must record, on every claim processed, the date
the claim was received. A date of receipt imbedded in a claim
reference number is acceptable for this purpose. This date
must be carried on claims records in the claims processing
computer system. Each hardcopy claim received by the
Contractor, or the electronic image thereof, must be
date-stamped with the date of receipt no later than the first
work day after the date of receipt. The Contractor must add a
date of receipt to each claim received in the form of an
electronic record or file within one work day of receipt.
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If responsibility to receive claims is subcontracted, the date
of initial receipt by the subcontractor determines the date of
receipt applicable to these requirements.
2. Sanctions
The Department will utilize the monthly report that is due
five (5) months and five (5) days after the end of the month
in which claims are received to determine claims processing
penalties. For example, the Department shall utilize the
monthly report that is due April 5, 2002, to determine claims
processing penalties for claims received in October 2001. The
Department shall utilize the monthly report that is due May 5,
2002, to determine claims processing penalties for claims
received in November 2001. The Department shall utilize the
monthly report that is due June 5, 2002, to determine claims
received in December 2001, and so on.
All claims received during the month, for which a penalty is
being computed, that remain unadjudicated at the time the
sanction is being determined, shall be considered a Clean
Claim.
If a Commonwealth audit, or an audit required or paid for by
the Commonwealth, determines claims processing timeliness data
that are different than data submitted by the Contractor, or
if the Contractor has not submitted required claims processing
data, the Department shall use the audit results to determine
the penalty amount.
The penalties included in the charts below shall apply
separately to:
a. Inpatient claims.
b. Claims other than inpatient and drug.
The penalties provided by this Section apply to all claims
included in each of the two (2) claim categories specified
above, including claims processed by any subcontractor.
Penalties in the charts below shall be reduced by one-third if
the Contractor has 25,000-50,000 MA Consumers. Penalties in
the charts below shall be reduced by two-thirds if the
Contractor has less than 25,000 MA Consumers.
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CLAIMS ADJUDICATION MONTHLY PENALTY CHART
This chart is used to compute any applicable penalty for
failure to adjudicate inpatient claims timely. This chart is
also used to compute any applicable penalty for failure to
adjudicate claims other than inpatient or drug.
--------------------------------------------------------------
Percentage of Clean Claims Penalty
Adjudicated in 30 Days
--------------------------------------------------------------
88.0 - 89.9 $1,000
80.0 - 87.9 $5,000
70.0 - 79.9 $10,000
60.0 - 69.9 $30,000
50.0 - 59.9 $50,000
40.0 - 49.9 $70,000
30.0 - 39.9 $90,000
Less than 30.0 $100,000
--------------------------------------------------------------
Percentage of Clean Claims
Adjudicated in 45 Days Penalty
--------------------------------------------------------------
98.0 - 99.9 $1,000
90.0 - 97.9 $5,000
80.0 - 89.9 $10,000
70.0 - 79.9 $30,000
60.0 - 69.9 $50,000
50.0 - 59.9 $70,000
40.0 - 49.9 $90,000
Less than 40.0 $100,000
--------------------------------------------------------------
Percentage of All Claims Penalty
Adjudicated in 90 Days
--------------------------------------------------------------
98.0 - 99.9 $1,000
90.0 - 97.9 $5,000
80.0 - 89.9 $10,000
70.0 - 79.9 $30,000
60.0 - 69.9 $50,000
50.0 - 59.9 $70,000
40.0 - 49.9 $90,000
Less than 40.0 $100,000
--------------------------------------------------------------
3. Physician Incentive Arrangements
a) Federal financial participation is only available for
payments to Medicaid MCOs that are in compliance with
the Physician
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Incentive Plan (PIP) requirements included under 42
C.F.R. 417.479.
b) 42 C.F.R. 417.479(a) permits MCOs to operate PIPs only
if: 1) no specific payment is made directly or
indirectly to a physician or physician group as an
inducement to reduce or limit Medically Necessary
services furnished to an enrollee; and 2) the
disclosure, computation of Substantial Financial Risk,
Stop-Loss Protection, and enrollee survey requirements
of this section are met.
c) MCOs must provide information specified in the
regulations to the Department and HCFA, upon request. In
addition, MCOs must provide the information on their
physician incentive plans to any Medicaid client, upon
request. MCOs that have PIPs 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. MCOs that have
PIPs placing a physician or physician group at
Substantial Financial Risk for the cost of service the
physician or physician group does not furnish must also
conduct surveys of enrollees and disenrollees addressing
their satisfaction with the quality of services and
their degree of access to the services.
d) MCOs must provide the following disclosure information
concerning its PIPs to the Department prior to approval
of the initial contract:
o whether referral services are included in the PIP
plan,
o the type of incentive arrangement used, i.e.
withhold bonus, capitation,
o a determination of the percent of payment under
the contract that is based on the use of referral
services to determine if Substantial Financial
Risk exists,
o panel size, and if patients are pooled, pooling
method used to determine if Substantial Financial
Risk exists,
o assurance that the physician or physician group
has adequate stop-loss protection and the type of
coverage, if this requirement applies.
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Where enrollee/disenrollee survey requirements exist,
MCOs must provide the survey results. In addition, all
MCOs must subsequently provide the above disclosure
information annually to the Department.
e) These PIP regulations apply to all MCOs and any of their
subcontracting arrangements that utilize a PIP in their
payment arrangements with individual physicians or
physician groups. PIP regulations require that
physicians and physician groups be protected from risk
beyond the stop-loss threshold.
4. Retroactive Eligibility Period
The Contractor shall not be responsible for any payments owed
to Providers for services that were rendered prior to the
effective date of a Member's enrollment into the PH-MCO.
5. In-Network Services
The Contractor shall be responsible for making timely payment
for Medically Necessary, covered services rendered by Network
Providers when:
a. Services were rendered to treat a medical emergency;
b. Services were rendered under the terms of the
Contractor's agreement with the Provider;
c. Services were prior authorized; or
d. It is determined by the Department, after a hearing,
that the services should have been authorized.
The Contractor will not be financially liable for services
rendered to treat a non-emergency condition in a hospital
emergency room (except to the extent required elsewhere by
law), unless the services were prior authorized or otherwise
conformed to the terms of the Contractor's agreement with the
Provider.
6. Payment for Out-of-Network Providers
The Contractor will be responsible for making timely payments
to Out-of-Network Providers for Medically Necessary, covered
services when:
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a. Services were rendered to treat a medical emergency;
b. Services were prior authorized;
c. It is determined by the Department, after a hearing,
that the services should have been authorized; or
d. A child enrolled in its plan is placed in emergency
substitute care and the county placement agency cannot
identify the child nor verify MA coverage See Exhibit O
of this Agreement, Description of Special Services.
The Contractor shall not be financially liable for services
rendered to treat a non-emergency condition in a hospital
emergency room (except to the extent required elsewhere in
law), unless the services were prior authorized.
The Contractor must assume financial responsibility and
provide reasonable reimbursement for emergency room services
and urgently needed services as defined in 42 C.F.R. Section
417.401 that are obtained by its Members from Providers and
suppliers outside the Contractor's Provider network even in
the absence of the Contractor's prior approval.
7. Payments to FQHCs and Rural Health Centers (RHCs)
The Contractor agrees to negotiate and pay rates to FQHCs and
RHCs comparable to other Providers who provide comparable
services in the Contractor's Provider network.
The Contractor may require that an FQHC comply with case
management procedures that apply to other entities that
provide similar benefits or services.
8. Liability During an Active Grievance or Appeal
The Contractor shall not be liable to pay claims to Providers
if the validity of the claim is being challenged by the
Contractor through a grievance or appeal, unless the
Contractor is obligated to pay the claim or a portion of the
claim through its agreement with the Provider.
9. Financial Responsibility for Dual Eligibles
The Contractor must pay Medicare deductibles and coinsurance
amounts relating to any Medicare-covered service for qualified
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Medicare beneficiaries in accordance with Section 4714 of the
Balanced Budget Act or 1997.
If no contracted PH-MCO rate exists or if the Provider of the
service is an Out-of-Network Provider, the Contractor must pay
deductibles and coinsurance up to the applicable MA fee
schedule for the service.
For Medicare services that are not covered by either MA or the
PH-MCO, the Contractor must pay cost-sharing to the extent
that the payment made under Medicare for the service and the
payment made by the PH-MCO do not exceed 80% of the
Medicare-approved amount.
The Contractor, its subcontractors and Providers are
prohibited from balance billing Members for Medicare
deductibles or coinsurance. The Contractor must ensure that a
Member who is eligible for both Medicaid and Medicare benefits
has the right to access a Medicare product or service from the
Medicare Provider of his/her choice. The Contractor is
responsible to pay any Medicare coinsurance and deductible
amount, whether or not the Medicare provider is included in
the Contractor's Provider network and whether or not the
Medicare provider has complied with the authorization
requirements of the Contractor.
10. Third Party Liability (TPL)
The Contractor must comply with the third party liability
procedures defined by Section 1902(a)(25) of the Social
Security Act, 42 U.S.C.A. 1396(a)(25) and implemented by the
Department. Under this Agreement, the third party liability
responsibilities of the Department will be allocated between
the Department and the Contractor.
a. Cost Avoidance Activities
i. The Contractor will have primary responsibility
for cost avoidance through the Coordination of
Benefits (COB) relative to federal and private
health insurance-type resources including, but
not limited to, Medicare, private health
insurance, Employees Retirement Income Security
Act of 1974 (ERISA), 29 U.S.C.A. 1396a(a)(25)
plans, and workers compensation. The Contractor
must attempt to avoid initial payment of claims,
whenever possible, where federal or private health
insurance-type resources are available. All
cost-avoided funds must be reported to the
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Commonwealth via encounter data submissions and
financial report 8A-D. The use of the COB flag,
Medicare fields, and the Other Insurance Paid
(OIP) field shall indicate that TPL has been
pursued and the amount which has been
cost-avoided. The Contractor shall not be held
responsible for any TPL errors in the Department's
Eligibility Verification System (EVS) or the
Department's TPL file.
ii. The Contractor agrees to pay, and to require that
its subcontractors pay, all Clean Claims for
prenatal or preventive pediatric care (including
EPSDT services to children), and services to
children having medical coverage under a Title
IV-D child support order to the extent the
Contractor is notified by the Department of such
support orders or to the extent the Contractor
becomes aware of such orders, and then seek
reimbursement from liable third parties. The
Contractor recognizes that cost avoidance of these
claims is prohibited with the exception of
hospital delivery claims, which may be
cost-avoided.
iii. The Contractor may not deny or delay approval of
otherwise covered treatment or services based upon
third party liability considerations. The
Contractor may neither unreasonably delay payment
nor deny payment of claims unless the probable
existence of third party liability is established
at the time the claim is filed.
b. Post-Payment Recoveries
i. Post-payment recoveries are categorized by (a)
health-related insurance resources and (b) other
resources. Health-related insurance resources are
ERISA health benefit plans, Blue Cross/Blue Shield
subscriber contracts, Medicare, private health
insurance, workers compensation, and health
insurance contracts.
ii. The Department's TPL Section retains the sole and
exclusive right to investigate, pursue, collect,
and retain all "Other Resources" as defined in
Section II of this Agreement, Definitions. Any
correspondence or inquiry forwarded to the
Contractor (by an attorney, provider of service,
insurance carrier, etc.) relating to
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a personal injury accident or trauma-related
medical service, or which in any way indicates
that there is, or may be, legal involvement
regarding the MA Consumer and the services which
were provided, must be immediately forwarded to
the Department's TPL Section. The Contractor may
neither unreasonably delay payment nor deny
payment of claims because they involved an injury
stemming from an accident such as a motor vehicle
accident, where the services are otherwise
covered. Those funds recovered by the Commonwealth
under the scope of these "Other Resources" shall
be retained by the Commonwealth.
iii. Due to potential time constraints involving cases
subject to litigation, the Department must ensure
that it identifies these cases and establishes its
claim before a settlement has been negotiated.
Should the Department fail to identify and
establish a claim prior to settlement due to the
Contractor's untimely submission of notice of
legal involvement where the Contractor has
received such notice, the amount of the
Department's actual loss of recovery shall be
assessed against the Contractor. The Department's
actual loss of recovery shall not include the
attorney's fees or other costs, which would not
have been retained by the Department.
iv. The Contractor has the sole and exclusive right to
pursue, collect and retain all health-related
insurance resources for a period of nine (9)
months from the date of service or six (6) months
after the date of payment, whichever is later. The
Department's TPL Section may pursue, collect, and
retain recoveries of all health-related insurance
cases which are outstanding after the earlier of
nine (9) months from the date of service or six
(6) months after the date of payment. However, in
those cases subject to this paragraph where
payment is being pursued by the Contractor but,
for whatever reason, has not been collected by the
earlier of nine (9) months from the date of
service or six (6) months after the date of
payment, the Contractor shall notify the
Department if action to recover has been initiated
by the Contractor. In such cases, the Contractor
shall retain exclusive responsibility for the
cases while they are being
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actively pursued.
v. Should the Department lose recovery rights to any
claim due to late or untimely filing of a claim
with the liable third party, and the untimeliness
in billing that specific claim is directly related
to untimely submission of encounter data or
additional records under special request, or
inappropriate denial of claims for accidents or
emergency care in casualty related situations. The
amount of the unrecoverable claim shall be
assessed against the Contractor.
vi. Encounter data that is not submitted to the
Department in accordance with the data
requirements and/or timeframes identified in this
Agreement can possibly result in a loss of revenue
to the Department. Strict compliance with these
requirements and timeframes shall therefore be
enforced by the Department and could result in the
assessment of sanctions against the Contractor.
vii. As part of its authority under paragraph iv.
above, the Contractor is responsible for pursuing,
collecting, and retaining recoveries of
health-related insurance resources where the
liable party has improperly denied payment based
upon either lack of a Medically Necessary
determination or lack of coverage. The Contractor
is encouraged to develop and implement
cost-effective procedures to identify and pursue
cases which are susceptible to collection through
either legal action or traditional subrogation and
collection procedures.
11. Health Insurance Premium Payment (XXXX) Program
The XXXX Program pays for employment-related health insurance
for MA Consumers when it is determined to be cost effective.
The cost effectiveness determination involves the review of
group health insurance benefits offered by employers to their
employees to determine if the anticipated expenditures in MA
payments are likely to be greater than the cost of paying the
premiums under a group plan for those services.
The Department shall not purchase Medigap policies for equally
eligible MA Consumers in the Zone.
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12. Requests for Additional Data
The Contractor must provide, at the Department's request, such
information not included in the encounter data submissions
that may be necessary for the administration of TPL activity.
The Contractor shall use its best efforts to provide this
information within fifteen (15) calendar days of the
Department's request. There are certain urgent requests
involving cases for minors that require information within
forty-eight (48) hours. Such information may include, but is
not limited to, individual medical records for the express
purpose of determining TPL for the services rendered.
Confidentiality of the information shall be maintained as
required by federal and state regulations.
13. Accessibility to TPL Data
The Department shall provide the Contractor with access to
data maintained on the TPL file.
14. Damage Liability
Liability for damages is identified in Section VII.D.10 of
this Agreement, Third Party Liability, due to the large dollar
value of many claims which are potentially recoverable by the
Department's TPL Section.
15. Estate Recovery
Section 1412 of the Public Welfare Code, 62 P.S. 1412,
requires the Department to recover MA costs paid on behalf of
certain deceased individuals. Individuals age fifty-five (55)
and older who were receiving MA benefits for any of the
following services are affected:
a. Public or private Nursing Facility services;
b. Residential care at home or in a community setting; or
c. Any hospital care and prescription drug services
provided while receiving Nursing Facility services or
residential care at home or in a community setting.
The applicable MA costs are recovered from the assets of the
individual's probate estate. The Department's TPL Section is
solely responsible for administering the Estate Recovery
Program.
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16. Audits
The Contractor is responsible to comply with audit
requirements as specified in Exhibit WW of this Agreement,
HealthChoices Audit Clause.
17. Restitution
The Contractor shall make full and prompt restitution to the
Department, as directed by the Department, for any payments
received in excess of amounts due to the Contractor under this
Agreement whether such overpayment is discovered by the
Contractor, the Department, or other third party.
SECTION VIII: REPORTING REQUIREMENTS
A. General
The Contractor must comply with state and federal reporting
requirements that are set forth in this section and throughout this
Agreement.
B. Systems Reports
The Contractor must submit electronic files and data as specified by
the Department. To the extent possible, the Department shall provide
reasonable advance notice of such reports. These reports include,
but are not limited to, the following (Refer to Exhibit CC of this
Agreement, Data Support for PH-MCOs):
1. Encounter Data and Subcapitation Data Reports
The Contractor must record for internal use and submit to the
Department a separate record each time a Member has an
encounter with a Provider. A service rendered under this
Agreement is considered an encounter regardless of whether or
not it has an associated claim. Every record that is provided
is considered to be an encounter and will require the
Contractor to submit a separate encounter data record for each
service received by a Member. The Provider's MAID number must
be used when submitting required encounter data.
The Contractor must maintain appropriate systems and
mechanisms to obtain all necessary data from its health care
Providers to ensure its ability to comply with the encounter
data reporting requirements. The failure of a health care
Provider to provide the Contractor with
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necessary encounter data shall not excuse the Contractor's
noncompliance with this requirement.
Effective on a date to be determined by the Department, the
Contractor must submit separate subcapitation records for each
advance payment made to a Contractor responsible for all or
part of a Member's medical care. If the payment is a
capitation payment, a separate record is required to report
the amount paid on behalf of each Member. Prior to the
effective date of this requirement, the Contractor must
provide a periodic report with summary information on
subcapitation payments, consistent with the content, format
and due date requirements specified by the Department.
The Contractor will be given a minimum of sixty (60) days
notification of any new edits or changes that DPW intends to
implement regarding encounter data.
a. Data Format
The Contractor must submit encounter and subcapitation
data electronically over POSNet using file transfer
protocol (FTP). Subcapitation data reporting currently
being submitted via paper reports will, at a future
date, be required to be transmitted electronically.
Encounter data files must be provided in ASCII text
format using the appropriate format for the five
different record types.
b. Timing of Data Submittal
Claims must be submitted by Providers to the Contractor
within one hundred and eighty (180) days after the date
of service. It is acceptable for the Contractor to
include a requirement for more prompt submissions of
claims or encounter records in Provider Agreements.
Claims adjudicated by a third party vendor must be
provided to the Contractor by the end of the month
following the month of adjudication.
An encounter must be submitted and found acceptable by
the Department on or before the last calendar day of the
third month after the encounter's Contractor
payment/adjudication calendar month in which the
Contractor paid/adjudicated the encounter. References to
"accepted by the Department" refer to encounter records
send to DPW by the Contractor that have passed all
Department edits: records that fail any Department
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edits are returned to the Contractor and must be
corrected, resubmitted to the Department, and pass all
edits before they are accepted by the Department.
One "initial" file and one "correction" file may be
submitted each weekday. If a file is received at the DPW
mainframe computer before 6 p.m. (Eastern Time), it will
be processed that weekday. If a file is received at the
DPW mainframe computer after 6 p.m. (Eastern Time), it
will be processed on the next weekday. Files received at
the DPW mainframe computer after 6 p.m. on Friday are
not processed until the following Monday.
Acceptable subcapitation data must be submitted to the
Department within thirty (30) days after the end of the
month of the subcapitation payment data.
c. Data Completeness
The Contractor shall monitor the completeness and
accuracy of the encounter data from all Providers and
shall initiate corrective action, as necessary.
d. Financial Penalties
The Contractor is required to provide complete,
accurate, and timely encounter data to the Department,
and to maintain complete medical records. The Department
may withhold a portion of the monthly capitation payment
as reimbursement for financial penalties assessed.
Financial penalties shall be calculated monthly.
Assessment of financial penalties is based on the
identification of penalty occurrences. Encounter Data
Penalty occurrences/assessments of financial penalties
are outlined in Exhibit XX of this Agreement, Encounter
and Subcapitation Data Penalty Occurrences.
e. Data Validation
The Contractor agrees to assist the Department in its
validation of encounter data by making available medical
records and a sample of its claims data. The validation
may be completed by Department staff and/or independent,
external review organizations.
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f. Secondary Release of Encounter Data
All encounter data recorded to document services
rendered to MA Consumers under this Agreement are the
property of the Department. Access to these data is
provided to the Contractor and its agents for the sole
purpose of operating the HealthChoices Program under
this Agreement. The Contractor and its agents are
prohibited from releasing any data resulting from this
Agreement to any third party without the advance written
approval of the Department. This prohibition does not
apply to internal quality improvement or disease
management activities undertaken by the Contractor or
its agents in the routine operation of a managed care
plan.
2. Federalizing GA Data Reporting
The Contractor shall be required to submit a properly
formatted monthly file to the Department regarding payments
applicable to state-only general assistance (GA) consumers.
The file shall include data on hospital claims paid by the
Contractor during the reporting month. The files shall include
data for three types of hospital services that are paid on a
capitated basis, as listed below:
o Admissions to acute care hospitals
o Admissions to rehabilitation hospitals
o Outpatient hospital services, defined by the Department
The following types of information shall be included in each
record on the file:
o Contractor
o Provider
o Consumer
o Claim
o Additional data elements as required.
Failure to comply with this requirement shall result in a
penalty equal to three (3) times the amount that applies to
other reporting requirements.
Additional Federalizing GA Data Reporting requirements can be
found in Exhibit CC of this Agreement, Data Support for
PH-MCOs.
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3. Third Party Resource Identification
Third party resources identified by the Contractor, which do
not appear on the Department's TPL database, must be supplied
to the Department's TPL Section by the Contractor on a monthly
basis. The method of reporting shall be electronic submission
or hardcopy document, whichever is deemed most convenient and
efficient by the Contractor for its individual use. For
electronic submissions, the Contractor must follow the
required report format, data elements, and tape specifications
supplied by the Department. For hardcopy submissions, the
Contractor must use an exact replica of the TPL resource
referral form supplied by the Department.
C. Operations Reports
The Contractor is required to submit such reports as specified by
the Department to enable the Department to monitor the Contractor's
internal operations and service delivery. These reports include, but
are not limited to, the following:
1. Continuous Quality Improvement
The Contractor agrees to provide the Department with uniform
data on services, QM, UM and Member satisfaction/complaint
data on a regular basis. All quality reports must be submitted
according to specifications defined by the Department. The
Contractor also agrees to cooperate with the Department in
carrying out data validation steps.
2. Federal Waiver Reporting Requirements
As a condition of approval of the Waiver for the operation of
HealthChoices in Pennsylvania, the Health Care Financing
Administration has imposed specific reporting requirements
related to the AIDS Home and Community Based Waiver and
special needs population, particularly related to special
needs services provided to children. The Contractor must
provide the information necessary to meet these reporting
requirements. To the extent possible the Department will
provide reasonable advance notice of such reports.
3. Complaint, Grievance and DPW Fair Hearing Data
The Contractor agrees to requirements governing the submission
of Complaint, Grievance and DPW Fair Hearing process data
found at
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Section VIII.C.3 of this Agreement, Complaint, Grievance and
DPW Fair Hearing Data.
The Contractor agrees to submit a quarterly Complaint,
Grievance and DPW Fair Hearing process report no later than
forty-five (45) days from the end of the quarter that conforms
to the Department's and DOH's specifications and includes at a
minimum:
o Total informal Complaints and Member informal Complaint
rate by medical nature of Complaint (quality of care,
days to appointment, specialist referral, request for
interpreter, denial of ER claim, etc.); and by
non-medical nature of Complaint (PH-MCO office staff,
office waiting time, etc.).
o Total Grievances and Grievance rate using the indicators
in the bullet above.
o Total Provider appeals by nature of grievance (quality
of care, denial of referral request, denial of claim,
lack of timely payment, etc.) and resolution.
The Contractor agrees to report its Provider appeal data and
utilization management outcomes to the Department utilizing
the standardized report form specified by the Department.
4. EPSDT Reports
The Contractor must submit EPSDT reports in the time and
manner prescribed by the Department. The Contractor shall be
responsible for maintaining appropriate systems and mechanisms
to obtain all necessary encounter data from its health care
Providers to ensure its ability to comply with the EPSDT
reporting requirements. The failure of a health care Provider
to provide the Contractor with necessary EPSDT encounter data
shall not excuse the Contractor's compliance with this
requirement.
The Contractor must submit reports providing all data
regarding children in substitute care (e.g., the number of
children enrolled in substitute care who have received
comprehensive EPSDT screens, the number who have received
blood level assessments, etc.).
5. Healthy Beginnings Plus Reporting
The Contractor must report certain Healthy Beginnings Plus
(HBP) statistics to the Department. HBP reporting periods are
January 1 through June 30, and July 1 through December 31.
The Contractor
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must submit a semi-annual report to the Department within
sixty (60) days from the end of the six-month service period.
See Exhibit YY of this Agreement, HMO Obstetrical Reporting
Form.
6. Member Hotline Activities Report
The Contractor's Member services function shall: provide
reports/analyses of hotline activity in a format and frequency
to be established by the Department.
7. Fraud and Abuse
The Contractor must submit to the Department quarterly and
annual statistical reports which relate to its Fraud and Abuse
detection and sanctioning activities, as well as an annual
update in the aggregate.
8. Provider Network
The Contractor must report the composition of its Provider
network to the Department and receive advance written approval
from the Department prior to the end of the Readiness Review.
Updates to the Provider file must be provided to the
Department monthly. A list of Network composition requirements
are found in Section V.S.1 of this Agreement, Network
Composition. The file layout for the provider file can be
found in the HealthChoices Proposers' Library.
9. Provider Dispute Resolution Process
The Contractor must submit to the Department copies of the
completed Provider Dispute Resolution System Quarterly and
Annual Reports relating to Provider specific disputes and
resolutions.
10. Reports Submission Schedule
Reports as defined by the Department must be submitted
according to the following schedule:
Quarterly Reports:
Quarter Ending Report Due
-------------- -----------
March 31 May 15
June 30 August 15
September 30 November 15
December 31 February 15
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Annual Reports:
The Annual Report is to be submitted ninety (90) days
after the end of the calendar year.
11. HEDIS including CAHPS
The Contractor must submit annual reports based on the
Medicaid HEDIS outcome measures, as outlined in the most
current version of the Medicaid HEDIS applicable to the
reporting year. See Exhibit M(4) of this Agreement, HEDIS. The
Consumer Assessment of Health Plan Satisfaction (CAHPS) 2.0H
surveys (Adult and Child) are part of the HEDIS required by
the Department. Those HEDIS measures related to behavioral
health issues are not the responsibility of the Contractor. In
addition, the Contractor's voluntary population is not
included in these reports since the HealthChoices Program does
not encompass the voluntary plans.
12. SERB
The Contractor's Quarterly Utilization Report (or similar type
document containing the same information) must be completed
and submitted to the Contracting Officer and the Bureau of
Contract Administration and Business Development within ten
(10) business days at the end of each quarter the contract is
in force. If there was no activity, the form must also be
completed, stating "No activity in this quarter."
D. Financial Reports
The Contractor agrees to submit such reports as specified by the
Department to assist the Department in assessing the Contractor's
financial viability and to ensure compliance with this Agreement.
The Department shall distribute financial data reporting
requirements to the Contractor. The Contractor will furnish all
financial reports timely and accurately, with content in the format
prescribed by the Department.
E. Equity
Not later than May 15, August 15, and November 15 of each agreement
year, the Contractor shall provide the Department with:
o A copy of quarterly reports filed with DOI, for the quarter
ending the last day of the second previous month.
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o A statement that its equity is in compliance with the equity
requirements or is not in compliance with the equity
requirements.
o If equity is not in compliance with the equity requirements,
the Contractor shall supply a report that provides an analysis
of its fiscal health and steps that management plans to take,
if any, to improve fiscal health.
Not later than March 10 of each agreement year, the Contractor shall
provide the Department with:
o A copy of unaudited annual reports flied with DOI.
o A statement that its equity is in compliance with the equity
requirements or is not in compliance with the equity
requirements.
o If equity is not in compliance with the equity requirements,
the Contractor shall supply a report that provides an analysis
of its fiscal health and steps that management plans to take,
if any, to improve fiscal health.
F. Claims Processing Reports
The Contractor shall provide the Department with monthly claims
processing reports with content and in a format specified by DPW.
The reports are due on the 5th calendar day of the second subsequent
month.
Failure to submit a claims processing report timely that is accurate
and fully compliant with the reporting requirements shall result in
the following penalties: $200 per day for the first 10 calendar days
from the date that the report is due and $1,000 per day for each
calendar day thereafter.
G. Presentation of Findings
The Contractor must obtain advance written approval from the
Department before publishing or making formal public presentations
of statistical or analytical material based on its HC-L/C
membership.
H. Reference Information
The Department will make files available to the Contractor on a
routine basis that allow the Contractor to effectively meet its
obligation to provide services and record information consistent
with this Agreement. See Exhibit CC of this Agreement, Data Support
for PH-MCOs, for information on the data files the Department will
provide to the Contractor.
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I. Sanctions
1. The Department may impose sanctions for non-compliance with
the requirements under this Agreement in addition to any
penalties described in Exhibit D of this Agreement, Standard
Contract Terms and Conditions for Services and in Exhibit E of
this Agreement, DPW Addendum to Standard Contract Terms and
Conditions. The sanctions which can be imposed shall depend on
the nature and severity of the breach, which the Department,
in its reasonable discretion, shall determine as follows:
a. Imposing civil monetary penalties of a minimum of
$1,000.0O per day for non-compliance;
b. Requiring the submission of a corrective action plan;
c. Limiting enrollment of new MA Consumers;
d. Suspension of payments:
e. Temporary management subject to applicable federal or
state law; and/or
f. Termination of the Agreement.
2. Where this Agreement provides for a specific sanction for a
defined infraction, the Department may, at its discretion,
apply the specific sanction provided for the non-compliance or
apply any of the general sanctions set forth in Section VIII.I
of this Agreement, Sanctions. Specific sanctions contained in
this Agreement include the following:
a. Claims Processing: Sanctions related to claims
processing are provided in Section VIII.I of this
Agreement, Sanctions.
b. Report or File, exclusive of Audit Reports: If the
Contractor fails to provide any report or file that is
specified by this Agreement by the applicable due date,
or if the Contractor provides any report or file
specified by this Agreement that does not meet
established criteria, a subsequent payment to the
Contractor may be reduced by the Department. The
reduction shall equal the number of days that elapse
between the due date and the day that the Department
receives a report or file that meets established
criteria, multiplied by the average Per-Member-Per-Month
capitation rate that applies to the first month of the
agreement year. If
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the Contractor provides a report or file on or before
the due date, and if the Department notifies the
Contractor after the 15th calendar day after the due
date that the report or file does not meet established
criteria, no reduction in payment shall apply to the
16th day after the due date through the date that the
Department notifies the Contractor.
c. Federalizing GA Data Reporting: The penalty for failure
to comply with the Federalizing GA Data Reporting
requirement is defined in Section VIII.B.2 of this
Agreement, Federalizing GA Data Reporting.
d. Encounter Data Reporting: The penalty for late reporting
of encounter data is set forth in Section VIII.B of this
Agreement, Systems Reports, and Exhibit XX of this
Agreement, Encounter and Subcapitation Data Penalty
Occurrences.
e. Marketing: The sanctions for engaging in unapproved
marketing practices are set forth in Section V.F.3 of
this Agreement, Contractor Outreach Activities.
f. Access Standard: The sanction for non-compliance with
the access standard is set forth in Section V.S.14 of
this Agreement, Compliant with Access Standards.
g. Subcontractor Prior Approval: The Contractor's failure
to obtain advance written approval of a subcontract will
result in the application a penalty of one (1) month's
capitation rate for a categorically needy adult female
TANF consumer for each day that the subcontractor was in
effect without the Department's approval.
J. Non-Duplication of Financial Penalties
If the Department assesses a financial penalty pursuant to one of
the provisions of Section VIII.I, of this Agreement, Sanctions, it
shall not impose a financial sanction pursuant to Section VIII.I
with respect to the same infraction.
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SECTION IX: REPRESENTATIONS AND WARRANTIES OF THE CONTRACTOR
A. Accuracy of Proposal
The Contractor represents and warrants that the representations made
to the Department in the Proposal are true and correct. The
Contractor further represents and warrants that all of the
information submitted to the Department in or with the Proposal is
accurate and complete in all material respects. The Contractor
agrees that such representations shall be continuing ones, and that
it is the Contractor's obligation to notify the Department within
ten (10) business days, of any material fact, event, or condition
which arises or is discovered subsequent to the date of the
Contractor's submission of the Proposal, which affects the truth,
accuracy, or completeness of such representations.
B. Disclosure of Interests
The Contractor must disclose to the Department, in writing, the name
of any person or entity having a direct or indirect ownership or
control interest of five percent (5%) or more in the Contractor. The
Contractor must inform the Department, in writing, of any change in
or addition to the ownership or control of the Contractor. Such
disclosure shall be made within thirty (30) days of any change or
addition. The Contractor acknowledges and agrees that any failure to
comply with this provision in any material respect, or making of any
misrepresentation which would cause the Contractor's application to
be precluded from participation in the MA Program, shall entitle the
Department to recover all payments made to the Contractor subsequent
to the date of the misrepresentation.
C. Disclosure of Change in Circumstances
The Contractor agrees to report to the Department, as well as the
Departments of Health and Insurance, within ten (10) business days
of the Contractor's notice of same, any change in circumstances that
may have a material adverse affect upon Contractor's or Contractor's
parent(s)' financial or operational conditions. Such reporting shall
be triggered by and include, by way of example and without
limitation, the following events, any of which shall be presumed to
be material and adverse:
1. Suspension or debarment of Contractor. Contractor's parent(s),
or any Affiliate or Related Party of either, by any state or
the federal government;
2. The Contractor may not knowingly have a person act as a
director, officer, partner or person with beneficial ownership
of more than five percent (5%) of the Contractor's equity who
has been debarred
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from participating in procurement activities under federal
regulations.
3. Notice of suspension or debarment or notice of an intent to
suspend/debar issued by any state or the federal government to
Contractor, Contractor's parent(s), or any Affiliate or
Related Party of either; and
4. Any new or previously undisclosed lawsuits or investigations
by any federal or state agency involving Contractor,
Contractor's parent(s), or any affiliate or related party of
either, which would have a material impact upon the
Contractor's financial condition or ability to perform under
this Agreement.
D. SERB Commitment
Contractor's SERB commitment as set forth in Exhibit CCC of this
Agreement, Contractor SERB Commitment, is hereby incorporated as a
contractual obligation during the term of this Agreement. The
Contractor shall make every reasonable effort to utilize SERB
services. The Contractor shall submit quarterly reports to the
Department outlining SERB utilization.
All contracts containing SERB participation must also include a
provision requiring the Contractor to meet and maintain those
commitments made to SERBs at the time of submittal or contract
negotiation, unless a change in the commitment is approved by the
contracting Commonwealth agency upon recommendation by the Bureau of
Contract Administration and Business Development (BCABD). All
contracts containing SERB participation must include a provision
requiring SERB subcontractors and SERBs in a joint venture to incur
at least 50% of the cost of the subcontract or SERB portion of the
joint venture, not including materials.
Commitments to Minority Business Enterprise (MBE) and Women's
Business Enterprise (WBE) firms made at the time of bidding must be
maintained throughout the term of the contract. Any proposed change
must be submitted to BCABD which will make a recommendation as to a
course of action to the contracting officer.
If a contract is assigned to another contractor, the new contractor
must maintain the SERB participation of the original contract.
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SECTION X: DURATION OF AGREEMENT AND RENEWAL
A. Initial Term
This Agreement shall have an initial term of [to be determined]
commencing on April 1, 2001 (the "Initial Term"), unless sooner
terminated in accordance with Section XI of this Agreement,
Termination and Default; provided that no court order,
administrative decision, or action by any other instrumentality of
the United States Government or the Commonwealth of Pennsylvania is
outstanding which prevents implementation of this Agreement.
B. Renewal
The Department shall have the option to renew this Agreement for an
additional three (3) year period after the expiration of the Initial
Term. The Department shall give written notice to the Contractor one
hundred twenty (120) days prior to the expiration of the Initial
Term as to whether it wishes to renew this Agreement. If the
Department exercises its option to renew this Agreement, rate
discussions shall commence promptly after notice of the same.
Upon expiration of the Initial Term, the Agreement currently in
effect will continue to be effective for a period of one hundred and
twenty (120) days if the Contractor and the Department agree to a
renewal term, but cannot reach resolution of renewal contract terms,
or if the parties have not proceeded to terminate the Agreement in
accordance with Section XI of this Agreement, Termination and
Default.
SECTION XI: TERMINATION AND DEFAULT
A. Termination by the Department
This Agreement may be terminated by the Department upon the
happening of any of the following events and upon compliance with
the notice provisions set forth below:
1. Termination for Convenience Upon Notice
The Department may terminate this Agreement at any time for
convenience upon giving one hundred twenty (120) days advance
written notice to the Contractor. The effective date of the
termination shall be the last day of the month in which the
120th day falls.
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2. Termination for Cause
The Department may terminate this Agreement for cause upon
forty-five (45) days written notice, which notice shall set
forth the grounds for termination and, with the exception of
termination under Section VI.A.2.b below, shall provide the
Contractor with forty-five (45) days in which to implement
corrective action and cure the deficiency. If corrective
action is not implemented to the satisfaction of the
Department within the forty-five (45) day cure period, the
termination shall be effective at the expiration of the
forty-five (45) day cure period. "Cause" shall mean the
following for the purposes of termination under this
Agreement:
a. The Contractor defaults in the performance of any
material duties or obligations hereunder or is in
material breach of any provision of this Agreement; or
b. The Contractor commits an act of theft or Fraud against
the Department, any state agency, or the Federal
Government; or
c. An adverse material change in circumstances as described
in Section IX.C of this Agreement, Disclosure of Change
in Circumstances.
3. Termination Due to Unavailability of Funds/Approvals
The Department may terminate this Agreement immediately upon
the happening of any of the following events:
a. Notification by the United States Department of Health
and Human Services of the withdrawal of federal
financial participation in all or part of the cost
hereof for covered services/contracts; or
b. Notification that there shall be an unavailability of
funds available for the HC-L/C Program; or
c. Notification that the federal approvals necessary to
operate the HC-L/C Program shall not be retained; or
d. Notification by the Pennsylvania Insurance Department or
Health Department that the authority under which the
Contractor operates is subject to suspension or
revocation proceedings or sanctions, has been suspended,
limited, or curtailed to any extent, or has been
revoked, or has expired
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and shall not be renewed.
B. Termination by the Contractor
The Contractor may terminate this Agreement at any time upon giving
one hundred twenty (120) days advance written notice to the
Department. The effective date of the termination shall be the last
day of the month in which the 120th day falls.
C. Responsibilities of the Contractor Upon Termination
1. Continuing Obligations
Termination or expiration of this Agreement shall not
discharge the obligations of the Contractor with respect to
services or items furnished prior to termination, including
retention of records and verification of overpayments or
underpayments. Termination or expiration shall not discharge
the Department's payment obligations to the Contractor or the
Contractor's payment obligations to its subcontractors.
2. Notice to Members
In the event that this Agreement is terminated pursuant to
Sections XIII.A or XIII.B above, or expires without a new
contract in place, the Contractor shall notify all Members of
such termination or such expiration at least forty-five (45)
days in advance of the effective date of termination, if
practical. The Contractor shall be responsible for
coordinating the continuation of care for Members who are
undergoing treatment for an acute condition.
3. Submission of Invoices
Upon termination, the Contractor shall submit to the
Department all outstanding invoices for allowable services
rendered prior to the date of termination in the form
stipulated by the Department. Such invoices shall be submitted
promptly but in no event later than forty-five (45) days from
the effective date of termination. Invoices submitted later
than forty-five (45) days from the effective date of
termination shall not be payable.
4. Failure to Perform
If the Department terminates a contract due to failure to
perform, the Department may add that PH-MCO's responsibility
to the responsibilities of one (1) or more different PH-MCOs
who are also
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operating within the context of the HC-L/C Program, subject to
consent by the PH-MCO which would gain that responsibility.
The Department will develop a transition plan should it choose
to terminate or not extend a contract with one (1) or more
PH-MCOs operating the HC-L/C Program.
During the final quarter of this Agreement, the Contractor
will work cooperatively with, and supply program information
to, any subsequent contractors. Both the program information
and the working relationship among the PH-MCOs will be defined
by the Department.
Upon termination or expiration of this Agreement, the
Contractor must:
a. Provide the Department with all information deemed
necessary by the Department within thirty (30) days of
the request;
b. Be financially responsible for MA claims with dates of
service through the day of termination, except as
provided in c. below, including those submitted within
established time limits after the day of termination;
c. Be financially responsible for hospitalized patients
through the date of discharge or thirty-one (31) days
after termination or expiration of this Agreement,
whichever is earlier;
d. Be financially responsible for services rendered through
11:59 p.m. on the day of termination, except as provided
in c. above, for which payment is denied by the
Contractor and subsequently approved upon appeal by the
Provider;
e. Be financially responsible for MA Consumer appeals of
adverse decisions rendered by the Contractor concerning
treatment of services requested prior to termination
which are subsequently overturned at a DPW Fair Hearing
or Grievance proceeding; and
f. Arrange for the orderly transfer of patient care and
patient records to those Providers who will be assuming
care for the Member. For those Members in a course of
treatment for which a change of providers could be
harmful, the Contractor must continue to provide
services on a FFS basis until that treatment is
concluded or appropriate transfer of care can be
arranged.
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D. Transition at Expiration and/or Termination of Agreement
A transition period shall begin prior to the last day the Contractor
awarded this Agreement is responsible for operating under this
Agreement, if no new contract is in place. During the transition
period, the Contractor shall work cooperatively with any subsequent
contractor and the Department. Both the program information and the
working relationship between to the two contractors shall be defined
by the Department. The length of the transition period shall be no
less than three (3) months and no more than six (6) months in
duration.
All reasonable costs relating to the transfer of materials and
responsibilities will be paid by the Contractor as a normal part of
doing business with the Department.
The Contractor shall be responsible for the provision of necessary
information to the new contractor and/or the Department during the
transition period to ensure a smooth transition of responsibility.
The Department shall define the information required during this
period and time frames for submission.
SECTION XII: RECORDS
A. Financial Records Retention
1. The Contractor shall maintain and shall cause its
subcontractors to maintain all books, records, and other
evidence pertaining to revenues, expenditures, and other
financial activity pursuant to this Agreement in accordance
with the standards and procedures specified in Section V.O.5
of this Agreement, Records Retention.
2. The Contractor agrees to submit to the Department or to the
Secretary of Health and Human Services or their designees,
within thirty-five (35) days of a request, information related
to the Contractor's business transactions which are related to
the provision of services for the HC-L/C Program pursuant to
this Agreement which shall include full and complete
information regarding:
a. The Contractor's ownership of any subcontractor with
whom the Contractor has had business transactions
totaling more than $25,000 during the twelve (12) month
period ending on the date of the request; and
b. Any significant business transactions between the
Contractor and any wholly-owned supplier or between the
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Contractor and any subcontractor during the five (5)
year period ending on the date of the request.
3. The Contractor agrees to include the requirements set forth in
Section XIII in this Agreement, Subcontractual Relationships,
in all contracts it enters with subcontractors under the
HealthChoices Program, and to ensure that all persons and/or
entities with whom it so contracts agree to comply with said
provisions.
B. Operational Data Reports
The Contractor shall maintain and shall cause its subcontractors to
maintain all source records for data reports in accordance with the
procedures specified in Section V.O.5 of this Agreement, Records
Retention.
C. Medical Records Retention
The Contractor shall maintain and shall cause its subcontractors to
maintain all medical records in accordance with the procedures
outlined in Section V.O.5 of this Agreement, Records Retention.
The Contractor must provide a MA Consumer's medical records to the
Department or its contractor(s) within fifteen (15) business days of
the Department's request.
D. Review of Records
1. The Contractor shall make all records relating to the HC-L/C
Program, including but not limited to, the records referenced
in this Section, available for audit, review, or evaluation by
the Department, or federal agencies. Such records shall be
made available on site at the Contractor's chosen location,
subject to the Department's approval, during normal business
hours or through the mail. The Department shall, to the
extent required by law, maintain as confidential any
confidential information provided by the Contractor.
2. In the event that the Department, or federal agencies request
access to records after the expiration or termination of this
Agreement or at such time that the records no longer are
required by the terms of this Agreement to be maintained at
the Contractor's location, but in any case, before the
expiration of the period for which the Contractor is required
to retain such records, the Contractor, at its own expense,
shall send copies of the requested records to the requesting
entity within thirty (30) days of such request.
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SECTION XIII: SUBCONTRACTUAL RELATIONSHIPS
A. Compliance with Program Standards
As part of its contracting or subcontracting, with the exception of
Provider Agreements which are outlined in Section V.S.2 of this
Agreement, Provider Agreements, the Contractor agrees that it shall
comply with the procedures set forth in Section V.O.3 of this
Agreement, Contracts and Subcontracts.
The written information that must be provided to the Department
prior to the awarding of any contract or Subcontract must provide
disclosure of ownership interests of five percent (5%) or more in
any entity or subcontractor.
All contracts and Subcontracts must be in writing and must contain
all items set forth in this Agreement and Exhibit AAA, Internal
Operations Contract Monitoring Guidelines.
The Contractor shall require its subcontractors to provide written
notification of a denial, partial approval, reduction, or
termination of service or coverage, or a change in the level of
care, using the standard form notice outlined in Exhibit M(1) of
this Agreement, Quality Management and Utilization Management
Program Requirements.
In addition, all contracts or Subcontracts that cover the provision
of medical services to the Contractor's Members must include the
following provisions:
1. A requirement for cooperation for the submission of all
encounter data for all services provided within the timeframes
required in Section VIII of this Agreement, Reporting
Requirements, no matter whether reimbursement for these
services is made by the Contractor either directly or
indirectly through capitation.
2. Language which ensures compliance with all applicable federal
and state laws.
3. Language which prohibits gag clauses which would limit the
subcontractor from disclosure of Medically Necessary or
appropriate health care information or alternative therapies
to members, other health care professionals, or to the
Department.
4. A requirement that ensures that the Department has ready
access to any and all documents and records of transactions
pertaining to the provision of services to MA Consumers.
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5. The definition of Medically Necessary as outlined in Section
II, of this Agreement, Definitions.
6. The Contractor must ensure, if applicable, that its
Subcontracts adhere to the standards for Network composition
and adequacy.
7. Should the Contractor use a subcontracted utilization review
entity, the Contractor must ensure that its subcontractors
process each request for benefits in accordance with Section
V.B.1 of this Agreement, General Prior Authorization
Requirements.
8. Should the Contractor subcontract with an entity to provide
any information systems services, the Subcontract must include
provisions for a transition plan in the event that the
Contractor terminates the Subcontract or enters into a
Subcontract with a different entity. This transition plan must
include information on how the data shall be converted and
made available to the new subcontractor. The data must include
all historical claims and service data.
The Contractor must make all necessary revisions to its contracts
and Subcontracts to be in compliance with the requirements set forth
in Section XIII.A of this Agreement, Compliance with Program
Standards. Revisions may be completed as contracts and Subcontracts
become due for renewal provided that all contracts and Subcontracts
are amended within one (1) year of execution of this Agreement with
the exception of the encounter data requirements, which must be
amended immediately, if necessary, to ensure that all subcontractors
are submitting encounter data to the Contractor within the
timeframes specified in Section VIII.B of this Agreement, Systems
Reports.
B. Consistency with Policy Statements
The Contractor agrees that its agreements with all Providers shall
be consistent, as may be applicable, with the policy statements
governing HMO Contracting with Integrated Delivery Systems issued by
the Pennsylvania Department of Health on April 6, 1996 and those
issued by the Pennsylvania Department of Insurance on April 6, 1996.
(26 Pa. Bulletin 1629, et seq. (04/06/96)).
SECTION XIV: CONFIDENTIALITY
A. The Contractor shall comply with all applicable federal and state
laws regarding the confidentiality of medical records. The
Contractor shall also cause each of its subcontractors to comply
with all applicable federal and state laws regarding the
confidentiality of medical records. The Contractor
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shall comply with Exhibit M(1), of this Agreement, Quality
Management & Utilization Management Program Requirements, regarding
maintaining confidentiality of data. The federal and state laws with
regard to confidentiality of medical records include, but are not
limited to: Mental Health Procedures Act, 50 P.S. 7101 et seq.;
Confidentiality of HIV-Related Information Act, 35 P.S. 7601 et
seq.; and the Pennsylvania Drug and Alcohol Abuse Contract Act, 71
P.S. 1690.101 et seq., 42 U.S.C. 1396a(a) (7); P.S. 404(a): 55 Pa.
Code 105.1 et seq.; and 42 C.F.R. 431.300.
B. The Contractor shall be liable for any state or federal fines,
financial penalties, or damages levied upon the Department for a
breach of confidentiality due to the negligent or intentional
conduct of the Contractor in relation to the Contractor's systems,
staff, or other area of responsibility.
C. The Contractor agrees to return all data and material obtained in
connection with this Agreement and the implementation thereof,
including confidential data and material, at the Department's
request. No material can be used by the Contractor for any purpose
after the expiration or termination of this Agreement. The
Contractor also agrees to transfer all such information to a
subsequent contractor at the direction of the Department.
D. The Contractor considers its financial reports and information,
marketing plans, provider rates, trade secrets, information or
materials relating to the Contractor's software, databases or
technology, and information or materials licensed from, or otherwise
subject to contractual nondisclosure rights of third parties, which
would be harmful to the Contractor's competitive position to be
confidential information. This information shall not be disclosed by
the Department to other parties except as required by law or except
as may be determined by the Department to be related to the
administration and operation of the HealthChoices Program.
E. The Contractor is entitled to receive all information relating to
the health status of its members in accordance with applicable
confidentiality laws.
SECTION XV: INDEMNIFICATION AND INSURANCE
A. Indemnification
1. The Contractor shall indemnify and hold the Department and the
Commonwealth of Pennsylvania, their respective employees,
agents, and representatives free and harmless against any and
all liabilities, losses, settlements, claims, demands, and
expenses of any kind (including, but not limited to,
attorneys' fees) which may result or arise out of any dispute
of any kind by and between the
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Contractor and its subcontractors with Members, agents,
clients, or any defamation, malpractice, fraud, negligence, or
intentional misconduct caused or alleged to have been caused
by the Contractor or its agents, subcontractors, employees, or
representatives in the performance or omission of any act or
responsibility assumed by the Contractor pursuant to this
Agreement.
2. The Contractor shall indemnify and hold harmless the
Department and the Commonwealth of Pennsylvania from any audit
disallowance imposed by the federal government resulting from
the Contractor's failure to follow state or federal rules,
regulations, or procedures unless prior authorization was
given by the Department. The Department shall provide timely
notice of any disallowance to the Contractor and allow the
Contractor an opportunity to participate in the disallowance
appeal process and any subsequent judicial review to the
extent permitted by law. Any payment required under this
provision shall be due from the Contractor upon notice from
the Department. The indemnification provision hereunder shall
not extend to disallowances which result from a determination
by the federal government that the terms of this Agreement are
not in accordance with federal law. The obligations under this
paragraph shall survive any termination or cancellation of
this Agreement.
B. Insurance
The Contractor shall maintain for itself, each of its employees,
agents, and representatives, general liability and all other types
of insurance in such amounts as reasonably required by the
Department and all applicable laws. In addition, the Contractor
shall require that each of the health care professionals with which
the Contractor contracts maintains professional malpractice and all
other types of insurance in such amounts as required by all
applicable laws. The Contractor shall provide to the Department,
upon the Department's request, certificates evidencing such
insurance coverage.
SECTION XVI: DISPUTES
A. In the event that a dispute arises between the parties relating to
any matter regarding this Agreement, the Contractor shall send
written notice of an initial level dispute to the Contracting
Officer for this Agreement, who shall make a determination in
writing of his/her interpretation and shall send the same to the
Contractor within thirty (30) days of the Contractor's written
request for same. That interpretation shall be final, conclusive,
and binding on the Contractor, and unreviewable in all respects
unless the Contractor within twenty (20) days of its receipt of said
interpretation, delivers a written appeal to the Secretary of Public
Welfare. Unless the
143
Contractor consents to extend the time for disposition by the
Secretary, the decision of the Secretary shall be released within
thirty (30) days of the Contractor's written appeal and shall be
final, conclusive, and binding, and the Contractor shall thereafter
with good faith and diligence, render such performance in compliance
with the Secretary's determination; subject to the provisions of
Section XVIII.B below. Notice of initial level dispute shall be sent
to:
Xx. Xxxxxxxxx X. Xxxxxx
Director, Bureau of Managed Care Operations
X.X. Xxx 0000
Xxxxxxxxxx, Xxxxxxxxxxxx 00000-0000
B. All claims against the Department relating to any matter regarding
this Agreement may be filed by the Contractor in the Board of Claims
pursuant to 72 P.S. 4651-1 et seq., but only after first complying
with Section XVI.A above. Resolution of disputes under this
provision must occur prior to any final payment of a disputed amount
to the Contractor.
SECTION XVII: FORCE MAJEURE
In the event of a major disaster or epidemic as declared by the
Governor of the Commonwealth of Pennsylvania or an act of any
military or civil authority, outage of communications, power, or
other utility, the Contractor shall cause its employees and all
Providers to render all services provided for in the RFP and herein
as is practical within the limits of Providers' facilities and
available staff. The Contractor, however, shall not be liable nor
deemed to be in default for any Provider's failure to provide
services or for any delay in the provision of services when such a
failure or delay is the direct or proximate result of the depletion
of staff or facilities by the major disaster or epidemic, or act of
any military or civil authority, outage of communications, power, or
other utility; provided, however, in the event that the provision of
services is substantially interrupted, the Department shall have the
right to terminate this Agreement upon ten (10) days written notice
to the Contractor.
SECTION XVIII: GENERAL
A. Suspension From Other Programs
In the event that the Contractor learns that a Health Care
Professional with whom the Contractor contracts is suspended or
terminated from participation in the MA Program of another state or
from the Medicare Program, the Contractor shall promptly notify the
Department, in writing, of such suspension or termination.
144
No payment shall be made to any Health Care Professional for any
services rendered by a health care practitioner during the period
the Contractor knew, or should have known, such practitioner was
suspended or terminated from the Medical Assistance Program of this
or another state, or the Medicare Program.
B. Rights of the Department and the Contractor
The rights and remedies of the Department provided herein shall not
be exclusive and are in addition to any rights and remedies provided
by law.
Except as otherwise stated in Section XVI of this Agreement,
Disputes, the rights and remedies of the Contractor provided herein
shall not be exclusive and are in addition to any rights and
remedies provided by law.
C. Waiver
No waiver by either party of a breach or default of this Agreement
shall be considered as a waiver of any other or subsequent breach or
default.
D. Invalid Provisions
Any provision of this Agreement which is in violation of any state
or federal law or regulation shall be deemed amended to conform with
such law or regulation, pursuant to the terms of this Agreement,
except that if such change would materially and substantially alter
the obligations of the parties under this Agreement, any such
provision shall be renegotiated by the parties. The invalidity or
unenforceability of any terms or provisions hereof shall in no way
affect the validity or enforceability of any other terms or
provisions hereof.
E. Governing Law
This Agreement shall be governed by and construed in accordance with
the laws of the Commonwealth of Pennsylvania.
F. Expansion of the Zone
The Department reserves the right to expand the required geographic
coverage area of the Zone to include additional counties under this
Agreement. Expansion of the Zone will be solely at the discretion of
the Department.
145
G. Notice
Any notice, request, demand, or other communication required or
permitted hereunder, with the exception of initial level disputes
submitted to the Contracting Officer pursuant to Section XVI of this
Agreement, Disputes, shall be given in writing by certified mail,
communication charges prepaid, to the party to be notified. All
communications shall be deemed given and received upon delivery or
attempted delivery to the address specified herein, as from time to
time amended. The addresses for the parties for the purposes of such
communication are:
To the Department:
Department of Public Welfare
Office of Medical Assistance Programs
Bureau of Managed Care Operations
Box 0000
Xxxxxxxxxx Xxxxx Xxxxxxxx
Xxxxxxxxxx, Xxxxxxxxxxxx 00000
With a Copy to:
Department of Public Welfare
Office of Legal Counsel
3rd Floor West, Health and Welfare Building
Xxxxxxx and 0xx Xxxxxx
Xxxxxxxxxx, Xxxxxxxxxxxx 00000
Attention: Chief Counsel
To the Contractor- See Exhibit BBB of this Agreement, Contractor
Information, for name and address
H. Counterparts
This Agreement may be executed in counterparts, each of which shall
be deemed an original for all purposes, and all of which, when taken
together shall constitute but one and the same instrument.
I. Headings
The section headings used herein are for reference and convenience
only, and shall not enter into the interpretation of this Agreement.
146
J. Assignment
Neither this Agreement nor any of the parties' rights hereunder
shall be assignable by either party hereto without the advance
written approval of the other party hereto, which approval shall not
be unreasonably withheld.
K. No Third Party Beneficiaries
This Agreement does not, nor is it intended to, create any rights,
benefits, or interest to any third party, person, or organization.
L. News Releases
News releases pertaining to the HC-L/C Program may not be made
without advance written approval by the Department, and then only in
conjunction with the Issuing Office.
M. Entire Agreement: Modification
This Agreement constitutes the entire understanding of the parties
hereto and supersedes any and all written or oral agreements,
representations, or understandings. No modifications, discharges,
amendments, or alterations shall be effective unless evidenced by an
instrument in writing signed by both parties. Furthermore, neither
this Agreement nor any modifications, discharges, amendments or
alterations thereof shall be considered executed by or binding upon
the Department or the Commonwealth of Pennsylvania unless and until
signed by a duly authorized officer of the Department or
Commonwealth of Pennsylvania.
147
IN WITNESS WHEREOF, the parties hereto have caused this Grant Agreement to be
executed by its duly authorized officials.
GRANTEE
/s/ Xxxxxx X. Xxxxx /s/ Xxxxxx X. XxXxxxx
--------------------------------------- ---------------------------------------
SIGNATURE SIGNATURE
PRINT OR TYPE NAME AND TITLE PRINT OR TYPE NAME AND TITLE
Xxxxxx X. Xxxxx, President Xxxxxx X. XxXxxxx, CFO
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
Program Deputy Secretary Secretary
/s/ Xxxxxxxx Xxxxxxxx /s/ Xxxxxx X. Xxxx
--------------------------------------- ---------------------------------------
SIGNATURE SIGNATURE
COMPTROLLER - DEPARTMENT OF PUBLIC WELFARE
I hereby certify that funds in the amount shown are available under the
Appropriation Symbols shown
================================================================================
APPROPRIATION
AMOUNT SOURCE SYMBOL PROGRAM
--------------------------------------------------------------------------------
See attached rates
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
================================================================================
/s/ Xxxxxxx X. Xxxxx 4/3/01
---------------------------
SIGNATURE
COMPTROLLER FOR BUDGET SECRETARY
N/A
---------------------------
SIGNATURE
Approved as to Legality and Form:
MAR 20 2001
/s/ Xxxxxxxx Xxxxxx /s/ Xxxx X. Xxxx /s/ Xxxxxxx X. Xxxxxxxx
----------------------- ------------------------- -----------------------
OFFICE OF LEGAL COUNSEL DEPUTY ATTORNEY GENERAL DEPUTY GENERAL COUNSEL
DEPARTMENT OF PUBLIC OFFICE OF ATTORNEY OFFICE OF GENERAL
WELFARE GENERAL COUNSEL
Copy I.D.: Grant Number
------------------ ------------------
VENDOR ME 01200017
------------------ ------------------
PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
GRANT AGREEMENT
PURPOSE OF
THE GRANT:
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To provide Mandatory Managed Care services to Medicaid consumers in the
following counties: Adams, Berks, Cumberland, Dauphin, Lancaster,
Lebanon, Lehigh, Northampton, Perry, and York
--------------------------------------------------------------------------------
AWARD TO:
--------------------------------------------------------------------------------
HRM Health Plans (PA), Inc.
0000 Xxxxxx Xxxxxx, 00xx Xxxxx
Xxxxxxxxxxxx, Xxxxxxxxxxxx 00000
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
FEDERAL I.D. NUMBER: 00-0000000
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