EXHIBIT 10.5a
AMENDMENT NO. 10
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
THE HEALTH AND HUMAN SERVICES COMMISSION AND HMO
This Amendment No. 10 is entered into between the Health and Human Services
Commission (HHSC) and Superior Health Plan, Inc. (HMO) in Xxxxxx Service Area,
to amend the 1999 Contract for Services between the Health and Human Services
Commission and HMO. The effective date of this Amendment is the date HHSC Signs
this Amendment. All other contract provisions remain in full force and effect.
The Parties agree to amend the Contract as follows:
1. ARTICLE XVIII IS AMENDED TO READ AS FOLLOWS:
15.2 AMENDMENT AND CHANGE REQUEST PROCESS
15.2.1 HHSC and HMO may amend this contract if reductions in funding or
appropriations make full performance by either party impracticable or
impossible, and amendment could provide a reasonable alternative to
termination. If HMO does not agree to the amendment, the contract may
be terminated under Article XVIII.
15.2.2 This contract must be amended if either party discovers a material
omission of a negotiated or required term, which is essential to the
successful performance or maintaining compliance with the terms of the
contract. The party discovering the omission must notify the other
party of the omission in writing as soon as possible after discovery.
If there is a disagreement regarding whether the omission was intended
to be a term of the contract, the parties must submit the dispute to
dispute resolution under Article 15.9.
15.2.3 This contract may be amended at any time by mutual agreement.
15.2.4 All amendments to this contract must be in writing and signed by both
parties.
15.2.5 Any change in either party's obligations under this contract
("Change") requires a written amendment to the contract that is
negotiated using the process outlined in Article 15.2.6.
15.2.6 Change Request Process.
October 30, 2001 1 of 3
15.2.6.1 If federal or state laws, rules, regulations, policies or
guidelines are adopted, promulgated, judicially interpreted
or changed, or if contracts are entered into or changed, the
effect of which is to alter the ability of either party to
fulfill its obligations under this contract, the parties will
promptly negotiate in good faith, using the process outlined
in Article 15.2.6, appropriate modifications or alterations
to the contract and any appendix (appendices) or
attachments(s) made a part of this contract.
15.2.6.2 Change Order Approval Procedure
15.2.6.2.1 During the term of this contract, HHSC or HMO may propose
changes in the services, deliverables, or other aspects of
this contract ("Changes"), pursuant to the procedures set
forth in this article.
15.2.6.2.2 If HHSC proposes a Change, it shall deliver to the HMO a
written notice describing the proposed Change which includes
the State's estimated fiscal impact on the HMO, if available
("Change Order Request"). HMO must respond to such proposal
within 30 calendar days of receipt by preparing and
delivering to HHSC, at no additional cost to HHSC a written
document (a "Change Order Response"), that specifies:
15.2.6.2.2.1 The financial impact, if any, of the Change Order Request on
the HMO and the manner in which such impact was calculated;
15.2.6.2.2.2 The effect, if any, of the Change Order Request on HMO's
performance of its obligations under this contract, including
the effect on the services or deliverables;
15.2.6.2.2.3 The anticipated time schedule for implementing the Change
Order Request; and
15.2.6.2.2.4 Any other information requested in the Change Order Request
or which is reasonably necessary for HHSC to make an informed
decision regarding the proposal.
15.2.6.2.3 If HMO proposes a Change, it must deliver a HMO Change Order
Request to HHSC that includes the proposed Change and
information described in Articles 15.2.6.2.2.1 - 15.2.6.2.2.4
for a Change Order Response. HHSC must respond to HMO within
30 calendar days of receipt of this information.
15.2.6.2.4 Upon HHSC's receipt of a Change Order Request or a Change
Order Response, the Parties shall negotiate a resolution of
the requested Change in good faith. The parties will exchange
information in good faith in an attempt to agree upon the
requested Change.
October 30, 2001 2 of 3
15.2.6.3 No Change to the services or deliverables or any other aspect
of this contract will become effective without the written
approval and execution of a mutually agreeable written
amendment to this contract by HHSC and the HMO. Under no
circumstances will the HMO be entitled to payment for any
work or services rendered under a Change Order that has not
been approved by HHSC in accordance with the Change Order
Procedures.
15.2.7 The implementation of an amendment to this contract is
subject to the approval of the Centers for Medicare and
Medicaid Services (CMS, formerly called HCFA).
2. APPENDIX C: Appendix C is deleted in its entirety and is replaced by a
new Appendix C which is Attachment No. 1 to this amendment. This
amendment provides for the removal of "Special Programs for Illness"
and the modification of the "Prenatal Program with Gifts" services.
AGREED AND SIGNED by an authorized representative of the parties on December 13,
2001.
Health and Human Services Commission Superior Health Plan, Inc.
By: /s/ Xxx X. Xxxxxxx By: /s/ Xxxxxxx Xxxxxxxx
-------------------------- -----------------------------
Don. A Xxxxxxx Xxxxxxx Xxxxxxxx
President & CEO, Centene
Approved as to Form:
-----------------------------
Office of General Counsel
October 30, 2001 3 of 3
AMENDMENT NO. 11
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
HEALTH AND HUMAN SERVICES COMMISSION AND HMO
This Amendment No. 11 is entered into between the Health and Human Services
Commission (HHSC) and Superior Health Plan, Inc. (HMO), to amend the Contract
for Services between the Health and Human Services Commission and HMO in the
Xxxxxx Service Area. The effective date of this amendment is January 1, 2002.
The Parties agree to amend the Contract as follows:
1. Article XIII is amended to read as follows:
ARTICLE XIII PAYMENT PROVISIONS
13.1 CAPITATION AMOUNTS
13.1.2 HMO capitation rates listed below reflect program increases
appropriated by the 76th and 77th legislatures for physician services
(to include THSteps providers) and outpatient facility services. Rates
will be increased starting January 1, 2002, to reflect increases in
traditional fee-for-service payments for 1) Evaluation and Management
Level 3 services (procedure code 99213), and 2) high-volume providers.
The methodology for determining high-volume providers will be
distributed to HMO by HHSC ("High-volume Provider Methodology"). The
first rate increase will be effective January 1, 2002, and will
reflect increases for procedure code 99213. Rate increases for high
volume providers will be effective the first day of the month after
the "High-volume Provider Methodology" is released by HHSC. The
Methodology will state the amount of each increase (99213 and
high-volume provider). Final rates with all increases included are
shown in the table below.
13.1.2. HMO must submit reports to HHSC indicating the methodology used and
must certify that the funds provided to the HMO for the pass through
have been passed through to providers. HMO must use the reporting
format specified by HHSC and follow the reporting schedule indicated
on the HHSC deliverables matrix.
PPAC Rate Increase Amendment
12/12/01
13.1.2.2 Capitation Rates
Risk Group Monthly Capitation Amounts
TANF Adults $165.30
TANF Children > 12 Months of Age $ 75.07
Expansion Children > 12 Months
of Age $ 61.17
Newborns ( <12 Months of Age) $357.27
TANF Children <1 2 Months of Age $357.27
Expansion Children < 12 Months
of Age $357.27
Federal Mandate Children $ 59.14
CHIP Phase I $ 71.69
Pregnant Women $270.52
Disabled/Blind Administration $ 14.00
13.1.2.3 Delivery Supplemental Payment. A one-time per pregnancy supplemental
payment for each delivery shall be paid to HMO in the following
amount: $2.817.00. HMO will receive a DSP for each live or still
birth. The one-time payment is made regardless of whether there is a
single or multiple births at time of delivery. A delivery is the birth
of a liveborn infant, regardless of the duration of the pregnancy, or
a stillborn (fetal death) infant of 20 weeks or more gestation. A
delivery does not include a spontaneous or induced abortion,
regardless of the duration of the pregnancy.
13.1.2.4 For an HMO Member who is classified in the Pregnant Women, TANF
Adults, TANF Children >12 months, Expansion Children >12 months,
Federal Mandate Children, or CHIP risk group, HMO will be paid the
monthly capitation amount identified in Article 13.1.2 for each month
of classification, plus the DSP amount identified in Article 13.1.2.
13.1.2.5 HMO must submit a monthly DSP Report (report) that includes the data
elements specified by TDH. TDH will consult with contracted HMOs prior
to revising the report data elements and requirements. The reports
must be submitted to TDH in the format and time specified by TDH. The
report must include only unduplicated deliveries. The report must
include
PPAC Rate Increase Amendment
12/12/01
only deliveries for which HMO has made a payment for the delivery, to
either a hospital or other provider. No DSP will be made for
deliveries which are not reported by HMO to TDH within 210 days after
the date of delivery, or within 30 days from the date of discharge
from the hospital for the stay related to the delivery, whichever is
later.
13.1.2.6 HMO must maintain complete claims and adjudication disposition
documentation, including paid and denied amounts for each delivery.
HMO must submit the documentation to TDH within five (5) days from the
date of a TDH request for documents.
13.1.2.7 The DSP will be made by TDH to HMO within twenty (20) state working
days after receiving an accurate report from HMO.
13.1.2.8 All infants of age equal to or less than twelve months (Newborns) in
the TANF Children, Expansion Children, and Newborns risk groups will
be capitated at the Newborns classification capitation amount in
Article 13.1.2.
AGREED AND SIGNED by an authorized representative of the parties on
_____________________ 2001.
Health and Human Services Commission Health Plan Name
By: By:
--------------------------------- ---------------------------------
Xxx X. Xxxxxxx Xxxxxxx Xxxxxxxx
President & CEO, Centene
Approved as to Form:
-------------------------
Office of General Counsel
PPAC Rate Increase Amendment
12/12/01
AMENDMENT 12
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
SUPERIOR HEALTH PLAN, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR PROGRAM
IN THE
XXXXXX SERVICE DELIVERY AREA
AMENDMENT 12
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
SUPERIOR HEALTH PLAN, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR PROGRAM EM THE XXXXXX SDA
ARTICLE 1. PURPOSE...............................................................................................1
SECTION 1.01 AUTHORIZATION...................................................................................1
SECTION 1.02 GENERAL EFFECTIVE DATE OF CHANGES...............................................................1
ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES...........................................................1
SECTION 2.01 GENERAL.........................................................................................1
SECTION 2.02 MODIFICATION OF SECTION 1.4, RENEWAL REVIEWS....................................................1
SECTION 2.03 MODIFICATION OF ARTICLE 2, DEFINITIONS..........................................................2
SECTION 2.04 MODIFICATION OF SECTION 3.4, PLAN MATERIALS AND DISTRIBUTION OF PLAN MATERIALS..................3
SECTION 2.05 MODIFICATION OF SECTION 3.5, RECORDS REQUIREMENT AND RECORDS RETENTION..........................3
SECTION 2.06 MODIFICATION OF SECTION 3.7, HMO TELEPHONE ACCESS REQUIREMENTS..................................3
SECTION 2.07 MODIFICATION OF SECTION 4.3, PERFORMANCE BOND...................................................4
SECTION 2.08 MODIFICATION OF SECTION 4.6, AUDIT..............................................................4
SECTION 2.09 MODIFICATION OF SECTION 4.9, THIRD PARTY RECOVERY...............................................4
SECTION 2.10 MODIFICATION OF SECTION 4.10, CLAIMS PROCESSING REQUIREMENTS....................................4
SECTION 2.11 MODIFICATION TO SECTION 5.4, SAFEGUARDING INFORMATION...........................................5
SECTION 2.12 MODIFICATION OF SECTION 5.6, HISTORICALLY UNDERUTILIZED BUSINESSES (HUBS).......................5
SECTION 2.13 MODIFICATION OF SECTION 5.10, NOTICE AND APPEAL.................................................6
SECTION 2.14 MODIFICATION OF SECTION 6.3, SPAN OF ELIGIBILITY................................................6
SECTION 2.15 MODIFICATION OF SECTION 6.4, CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS....................7
SECTION 2.16 MODIFICATION OF SECTION 6.5, EMERGENCY SERVICES.................................................8
SECTION 2.17 MODIFICATION OF SECTION 6.6, BEHAVIORAL HEALTH CARE SERVICES - SPECIFIC REQUIREMENTS............8
SECTION 2.18 MODIFICATION TO SECTION 6.16, BLIND AND DISABLED MEMBERS........................................9
SECTION 2.19 MODIFICATION OF SECTION 8.4, MEMBER ID CARDS....................................................9
SECTION 2.20 MODIFICATION OF SECTION 10.1, MODEL MIS REQUIREMENTS............................................9
SECTION 2.21 MODIFICATION OF SECTION 10.4, PROVIDER SUBSYSTEM................................................9
SECTION 2.22 MODIFICATION OF SECTION 10.9, DATA INTERFACE SUBSYSTEM..........................................9
SECTION 2.23 MODIFICATION OF SECTION 10.11, YEAR 2000 (Y2K) COMPLIANCE......................................10
SECTION 2.24 ADDITION OF SECTION 10.12, HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
(HIP AA) COMPLIANCE.......................................................................................10
SECTION 2.25 MODIFICATION OF SECTION 12.1., FINANCIAL REPORTS...............................................10
SECTION 2.26 MODIFICATION OF SECTION 12.4, SUMMARY REPORT OF PROVIDER COMPLAINTS............................11
SECTION 2.27 MODIFICATION OF SECTION 12.6, MEMBER COMPLAINTS................................................12
SECTION 2.28 MODIFICATION OF SECTION 12.13, EXPEDITED PRENATAL OUTREACH REPORT..............................12
SECTION 2.29 ADDITION OF SECTION 12.14, MEMBER HOTLINE PERFORMANCE REPORT...................................12
SECTION 2.30 ADDITION OF SECTION 12.15, SUBMISSION OF STAR DELIVERABLES/REPORTS.............................12
SECTION 2.31 MODIFICATIONS TO SECTION 13.1, CAPITATION AMOUNTS..............................................13
SECTION 2.32 MODIFICATION OF SECTION 13.2, EXPERIENCE REBATE TO THE STATE...................................14
SECTION 2.33 SECTION 13.3, PERFORMANCE OBJECTIVES...........................................................15
SECTION 2.34 MODIFICATION OF SECTION 13.5, NEWBORN AND PREGNANT WOMEN PAYMENT PROVISIONS....................15
SECTION 2.35 MODIFICATION OF SECTION 14.3, NEWBORN ENROLLMENT...............................................16
SECTION 2.36 MODIFICATION OF SECTION 15.12, NOTICES.........................................................16
SECTION 2.37 MODIFICATION OF SECTION 18.1.6, TERMINATION BY HMO.............................................16
SECTION 2.38 MODIFICATION OF SECTION 18.10, REVIEW OF REMEDY OR REMEDIES TO BE IMPOSED......................16
SECTION 2.39 MODIFICATION OF SECTION 19.1, CONTRACT TERM....................................................17
SECTION 2.40 MODIFICATIONS TO CONTRACT APPENDICES...........................................................17
ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES.........................................................17
i
STATE OF TEXAS HHSC CONTRACT NO. 000-00-000
COUNTY OF XXXXXX
AMENDMENT 12
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
SUPERIOR HEALTH PLAN, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR PROGRAM
IN THE
XXXXXX SERVICE DELIVERY AREA
THIS CONTRACT AMENDMENT (the "Amendment") is entered into between the
HEALTH & HUMAN SERVICES COMMISSION ("HHSC"), an administrative agency within
the executive department of the State of Texas, and Superior Health Plan, Inc.
("HMO"), a health maintenance organization organized under the laws of the
State of Texas, possessing a certificate of authority issued by the Texas
Department of Insurance to operate as a health maintenance organization, and
having its principal office at: 0000 X. XX-00, Xxxxx 000, Xxxxxx, XX 00000.
HHSC and HMO may be referred to in this Amendment individually as a "Party" and
collectively as the "Parties."
The Parties hereby agree to amend their Agreement as set forth in
Article 2 of this Amendment.
ARTICLE 1. PURPOSE.
SECTION 1.01 AUTHORIZATION.
This Amendment is executed by the Parties in accordance with Section
15.2 of the Agreement.
SECTION 1.02 GENERAL EFFECTIVE DATE OF CHANGES.
This Amendment is effective SEPTEMBER 1, 2002, and terminates on
August 31, 2003, unless extended or terminated sooner in accordance with the
Agreement.
ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES
SECTION 2.01 GENERAL
The Health Care Financing Administration (HCFA) has had a name change
to the Centers for Medicare and Medicaid Services (CMS). All references to HCFA
in the Agreement should be replaced with CMS.
SECTION 2.02 MODIFICATION OF SECTION 1.4, RENEWAL REVIEWS
Section 1.4 is replaced with the following language:
"Renewal Review. At its sole discretion, HHSC may choose to
conduct a renewal review of HMO's performance and compliance with this
contract as a condition for retention and renewal."
HHSC Contract 000-00-000 Page 1 of 17
SECTION 2.03 MODIFICATION OF ARTICLE 2, DEFINITIONS
(a) The following terms amend and modify the definitions set
forth in Article 2:
"CMS means the Centers for Medicare and Medicaid Services,
formerly known as the Health Care Financing Administration (HCFA),
which is the federal agency responsible for administering Medicare and
overseeing state administration of Medicaid.
EMERGENCY MEDICAL CONDITION means a medical condition
manifesting itself by acute symptoms of recent onset and 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 care could result
in:
(a) placing the patient's health in serious jeopardy;
(b) serious impairment to bodily functions;
(c) serious dysfunction of any bodily organ or part;
(d) serious disfigurement; or
(e) in the case of a pregnant woman, serious jeopardy to
the health of the fetus.
FAIR HEARING means the process adopted and implemented by the
Texas Health and Human Services Commission, 25 TAG Chapter 1, in
compliance with federal regulations and state rules relating to
Medicaid Fair Hearings.
HEDS means the HMO/EPO/Dental Services Division of the Texas
Health and Human Services Commission.
HHSC means the Texas Health and Human Services Commission or
its designees.
THIRD PARTY LIABILITY (TPL) means the legal responsibility of
another individual or entity to pay for all or part of the services
provided to Members under this contract (see 1 TAG, Subchapter
354.2301 et seq., relating to Third Party Resources).
TP 40 means Type Program 40, which is a TDHS Medicaid program
eligibility type assigned to pregnant women under 185% of the federal
poverty level (FPL).
TP 45 means Type Program 45, which is a TDHS Medicaid program
eligibility code assigned to newborns (under 12 months) who are born
to mothers who are Medicaid eligible at the time of the child's birth.
TEXMEDNET means Texas Medical Network, which is the State's
information system that processes claims and encounters. TexMedNet's
functions include, but are not limited to eligibility verification,
claims and encounters submissions, e-mail communications, and
electronic funds transfers."
(b) The term "HHSCS" is deleted and replaced with "TDHS" as
defined in Article 2 of the Contract.
(c) The term "THHSC" is deleted and replaced with "HHSC" as
defined above.
HHSC Contract 000-00-000 Page 2 of 17
SECTION 2.04 MODIFICATION OF SECTION 3.4, PLAN MATERIALS AND
DISTRIBUTION OF PLAN MATERIALS
Section 3.4.3 is replaced with the following language:
"3.4.3 All plan materials regarding the STAR Program,
including Member education materials, must be submitted to HHSC for
approval prior to distribution. HHSC has fifteen (15) working days to
review the materials and recommend any suggestions or required
changes. If HHSC has not responded to HMO by the fifteenth (15th) day,
HMO may print and distribute these materials. HHSC reserves the right
to request HMO to modify plan materials that are deemed approved and
have been printed or distributed. These modifications can be made at
the next printing unless substantial non-compliance exists. An
exception to the fifteen (15) working day timeframe may be requested
in writing by HMO, for written provider materials that require a quick
turn-around time (e.g., letters). These materials will generally be
reviewed by HHSC within five (5) working days. HHSC reserves the right
to require revisions to materials if inaccuracies are discovered or if
changes are required by changes in policy or law. These changes can be
made at the next printing unless substantial non-compliance exists, as
determined by HHSC.
SECTION 2.05 MODIFICATION OF SECTION 3.5, RECORDS REQUIREMENT AND RECORDS
RETENTION
Section 3.5.1 is replaced with the following language:
"3.5.1 HMO must keep all records required to be created and
retained under this Agreement in accordance with the standards set
forth herein. Records related to Members served in the HMO's service
area(s) must be made available in HMO's local office when requested by
HHSC.
Original records, except paper claims, must be kept in the
form they were created in the regular course of business for a minimum
of three (3) years following the expiration of the contract period,
including any extensions. Paper claims may be digitally copied from
the time of initial receipt, if the HMO: 1) receives HHSC prior
written approval; 2) certifies that an unaltered copy of the original
claim received can be produced upon request; 3) the retention system
is reliable and supported by a retrieval system that allows reasonable
accurate records. HHSC may require the HMO to retain the records for
an additional period if an audit, litigation or administrative action
involving the records exists."
SECTION 2.06 MODIFICATION OF SECTION 3.7, HMO TELEPHONE ACCESS
REQUIREMENTS
Section 3.7.1 is replaced with the following language:
3.7.1 For all HMO telephone access (including Behavioral
Health telephone services), HMO must ensure adequately-staffed
telephone lines. Telephone personnel must receive customer service
telephone training. HMO must ensure that telephone staffing is
adequate to fulfill the standards of promptness and quality listed
below:
1. 80% of all telephone calls must be answered within
an average of 30 seconds;
2. The lost (abandonment) rate must not exceed 10%;
HHSC Contract 000-00-000 Page 3 of 17
3. HMO cannot impose maximum call duration limits but
must allow calls to be of sufficient length to ensure adequate
information is provided to the Member or Provider.
4. Telephone services must meet cultural competency
requirements (see Article 8.8) and provide "linguistic access" to all
members as defined in Article II. This would include the provision of
interpretive services required for effective communication for Members
and providers.
SECTION 2.07 MODIFICATION OF SECTION 4.3. PERFORMANCE BOND
Section 4.3 is replaced with the following language:
"4.3 HMO has furnished HHSC with a performance bond in
the form prescribed by HHSC and approved by TDI, naming HHSC as
Obligee, securing HMO's faithful performance of the terms and
conditions of this Agreement. The performance bond must be issued in
the amount of $100,000 for the Contract Period, plus an additional 12
months after the expiration of the Contract Period. If the Contract
Period is renewed or extended pursuant to Article 15, the HMO must
replace the performance bond with a separate bond covering performance
during the renewal or extension period, plus an additional 12 months.
The bond must be issued by a surety licensed by TDI, and specify cash
payment as the sole remedy. HMO must deliver the bond to HHSC at the
same time the signed HMO contract, renewal or extension is delivered
to HHSC."
SECTION 2.08 MODIFICATION OF SECTION 4.6. AUDIT
Section 4.6.2 is replaced with the following language:
"4.6.2 HHSC or its designee will conduct an audit of HMO at
least once every two years. HMO is responsible for paying the costs of
an audit conducted under this Article. The costs of the audit paid by
HMO are allowable costs under this Agreement."
SECTION 2.09 MODIFICATION OF SECTION 4.9. THIRD PARTY RECOVERY
Section 4.9.2 is replaced with the following language:
"4.9.2 Identification. HMO must develop and implement
systems and procedures to identify potential third parties who may be
liable for payment of all or part of the costs for providing medical
services to Members under this contract. Potential third parties must
include any of the sources identified in 42 C.F.R. 433.138, relating
to identifying third parties, except workers' compensation, uninsured
and underinsured motorist insurance, first and third party liability
insurance and tortfeasors. HMO must coordinate with HHSC to obtain
information from other state and federal agencies and HMO must
cooperate with HHSC in obtaining information from commercial third
party resources. HMO must require all providers to comply with the
provisions of 1 TAC ss.354.2301, et seq., relating to Third Party
Recovery in the Medicaid program."
SECTION 2.10 MODIFICATION OF SECTION 4.10. CLAIMS PROCESSING REQUIREMENTS
Section 4.10.8 is replaced with the following language:
HHSC Contract 000-00-000 Page 4 of 17
"4.10.8 HMO must comply with the standards adopted by the
U.S. Department of Health and Human Services under the Health
Insurance Portability and Accountability Act of 1996 (HIPAA), Public
Law 104-191, regarding submitting and receiving claims information
through electronic data interchange (EDI) that allows for automated
processing and adjudication of claims within two or three years, as
applicable, from the date the rules promulgated under HIPAA are
adopted (see 45 CFR parts 160 through 164).
SECTION 2.11 MODIFICATION TO SECTION 0.X, XXXXXXXXXXXX INFORMATION
Section 5.4.1 is replaced with the following language:
"5.4.1 The use and disclosure of all Member information,
records, and data (Member Information) collected or provided to HMO by
HHSC or another state agency is protected by state and federal law and
regulations, including, but not limited to, the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), Public law
104-191, and 45 CFR parts 160 through 164. HMO agrees to ensure that
any of its agents, including subcontractors, to whom HMO discloses
Member Information agrees to the same restrictions and conditions that
apply to HMO with respect to Member Information.
SECTION 2.12 MODIFICATION OF SECTION 5.6, HISTORICALLY UNDERUTILIZED
BUSINESSES (HUBS)
Sections 5.6.1 through 5.6.3 are replaced with the following language:
"5.6.1 In accordance with Texas Government Code Chapter
2161 and 1 TAC ss.111.11 et seq. and ss.392.100 state agencies are
required to make a good faith effort to assist Historically
Underutilized Businesses (HUBs) in receiving contract awards issued by
the State. The goal of this program is to promote full and equal
business opportunity for all businesses in contracting with the state.
It is HHSC's intent that all contractors make a good faith effort to
subcontract with HUBs during the performance of their contracts.
IMPORTANT NOTE: The Health and Human Services Commission has
concluded that HUB subcontracting opportunities may exist in
connection with this contract. See Appendix B to the Agreement for the
following instructions and form: "Grant/Contract Applicants Client
Services HUB Subcontracting Plan Instructions" (C-IGA), and
Determination of Good Faith Effort for Grant Contracts (C-DGFE). If an
approved HUB subcontracting plan is not already on file with HHSC, the
HMO shall submit a completed C-DGFE Form along with the signed
contract or renewal.
If HMO responds, 'yes' to question two on Form C-DGFE, HMO
shall document good faith efforts to develop a HUB Subcontracting Plan
by completing and documenting the steps on form C-DGFE. Additionally,
quarterly reports on HUB subcontracting are required according to the
schedule on Form C-QSR. Quarterly Report forms are included in
Appendix B of this amendment.
HHSC Contract 000-00-000 Page 5 of 17
If HMO decides after the award to subcontract any part of the
contract, the HMO shall notify the contract manager prior to entering
into any subcontract. The HMO shall comply with the good faith effort
requirements relating to developing and submitting a subcontracting
plan.
5.6.2 HMO is required to submit HUB
quarterly reports to HHSC as required in Article
12.11.
5.6.3 HHSC will assist HMO in meeting the contracting and
reporting requirements of this Article."
SECTION 2.13 MODIFICATION OF SECTION 5.10, NOTICE AND APPEAL
Section 5.10 is replaced with the following:
"5.10 HMO must comply with the notice requirements
contained in 1 TAG ss.354.2211, and the maintaining benefits and
services contained in 1 TAG ss.354.2213, whenever HMO intends to take
an action affecting the Member benefits and services under this
contract. Also see the Member appeal requirements contained in Article
8.6 of this Agreement."
SECTION 2.14 MODIFICATION OF SECTION 6.3, SPAN OF ELIGIBILITY
Section 6.3 and its subparts are replaced with the following language"
"6.3 The following outlines HMO's responsibilities for
payment of hospital and freestanding psychiatric facility (facility)
admissions:
6.3.1 The payor responsible for the hospital/facility
charges at the start of an inpatient stay remains responsible for
hospital/facility charges until the time of discharge, or until such
time that there is a loss of Medicaid eligibility.
6.3.2 HMO is responsible for professional charges during
every month for which the payor receives a full capitation payment.
6.3.3 HMO is not responsible for any services after
effective date of loss of Medicaid eligibility
6.3.4 Plan Change. A Member cannot change from one STAR
health plan to another STAR health plan during an inpatient hospital
stay.
6.3.5 Hospital/Facility Transfer. Discharge from one acute
care hospital/facility and readmission to another acute care
hospital/facility within 24 hours for continued treatment is not a
discharge under this contract.
6.3.6 HMO insolvency or receivership. HMO is responsible
for payment of all services provided to a person who was a Member on
the date of insolvency or receivership to the same extent they would
otherwise be responsible under this Article 6.3.
HHSC Contract 000-00-000 Page 6 of 17
6.3.7 For purposes of this Section 6.3, a Member "loses
Medicaid eligibility" when:
6.3.7.1 Medicaid eligibility is terminated and never
regained under one Medicaid Type Program with no subsequent transfer
of eligibility to another Medicaid Type Program; or
6.3.7.2 Medicaid eligibility is terminated and there is a
lapse of at least one month in regular Medicaid coverage. The term
"regular Medicaid coverage" refers to either traditional
fee-for-service Medicaid or Medicaid managed care coverage; or
6.3.7.3 A client re-applies for Medicaid eligibility and is
certified for prior Medicaid coverage, as defined by TDHS, for any
month(s) prior to the month of application. The term "prior Medicaid
coverage" refers to Applicants who are eligible for Medicaid coverage
during the three-month period before the month they apply for TANF or
Medical Programs. Prior Medicaid coverage may be continuous or there
may be interrupted periods of eligibility involving all or some of the
certified Members.
Administrative process limitations within the State's
application and recertification process do not constitute a "loss of
Medicaid eligibility".
SECTION 2.15 MODIFICATION OF SECTION 6.4, CONTINUITY OF CARE AND OUT-OF-
NETWORK PROVIDERS
Section 6.4.3 is replaced with the following language:
"6.4.3 HMO must pay a Member's existing out-of-network
providers for covered services until the Member's records, clinical
information and care can be transferred to a network provider. Payment
must be made within the time period required for network providers.
This Article does not extend the obligation of HMO to reimburse the
Member's existing out-of-network providers for on-going care for more
than 90 days after Member enrolls in HMO or for more than nine months
in the case of a Member who at the time of enrollment in HMO has been
diagnosed with and receiving treatment for a terminal illness. The
obligation of HMO to reimburse the Member's existing out-of-network
provider for services provided to a pregnant Member with 12 weeks or
less remaining before the expected delivery date extends through
delivery of the child, immediate postpartum care, and the follow-up
checkup within the first six weeks of delivery.
6.4.3.1 HMO will pay reasonable and customary rates for all
out-of-network provider claims with dates of service between
September 1, 2002 and November 30, 2002. HMO must forward any
complaints submitted by out-of-network providers during this time to
HHSC. HHSC will review all complaints and determine whether payments
were reasonable and customary. HHSC will direct the HMO to pay a
reasonable and customary amount, as determined by HHSC, if it
concludes that the payments were not reasonable and customary for the
provider. Failure to comply with this provision constitutes a default
under Article XVI, Default and Remedies.
6.4.3.2 For all out-of-network provider claims with dates of
service on or after December 1, 2002, HMO must pay providers a
reasonable and
HHSC Contract 000-00-000 Page 7 of 17
customary amount consistent with a methodology approved by HHSC. HMO
must submit its methodology, along with any supporting documentation,
to HHSC by September 30, 2002. HHSC will review and respond to the
information by November 15, 2002. HMO must forward any complaints by
out-of-network providers submitted after December 1, 2002 to HHSC,
which will review all complaints. If HHSC determines that payment is
not consistent with the HMO's approved methodology, the HMO must pay
the provider a rate, using the approved reasonable and customary
methodology, as determined by HHSC. Failure to comply with this
provision constitutes a default under Article XVI, Default and
Remedies.
SECTION 2.16 MODIFICATION OF SECTION 6.5, EMERGENCY SERVICES
Section 6.5.1 is replaced with the following language:
"6.5.1 HMO must pay for the professional, facility, and
ancillary services that are medically necessary to perform the medical
screening examination and stabilization of HMO Member presenting as an
emergency medical condition or an emergency behavioral health
condition to the hospital emergency department, 24 hours a day, 7 days
a week, rendered by either HMO's in-network or out-of-network
providers.
6.5.1.1 For all out-of-network providers, HMO will pay a
reasonable and customary amount for emergency services.
HMO will pay a reasonable and customary amount for services
for all out-of-network emergency services provider claims with dates
of service between September 1, 2002 and November 30, 2002. HMO must
forward any complaints submitted by out-of-network emergency services
providers during this time to HHSC. HHSC will review all complaints
and determine whether payments were reasonable and customary. HHSC
will direct the HMO to pay a reasonable and customary amount, as
determined by HHSC, if it concludes that the payments were not
reasonable and customary for the provider.
6.5.1.2 For all out-of-network emergency services provider
claims with dates of service on or after December 1, 2002, HMO must
pay providers a reasonable and customary amount consistent with a
methodology approved by HHSC. HMO must submit its methodology, along
with any supporting documentation, to HHSC by September 30, 2002. HHSC
will review and respond to the information by November 15, 2002. HMO
must forward any complaints by out-of-network emergency services
providers submitted after December 1, 2002 to HHSC, which will review
all complaints. If HHSC determines that payment is not consistent with
the HMO's approved methodology, the HMO must pay the emergency
services provider a rate, using the approved reasonable and customary
methodology, as determined by HHSC. Failure to comply with this
provision constitutes a default under Article XVI, Default and
Remedies.
SECTION 2.17 MODIFICATION OF SECTION 6.6, BEHAVIORAL HEALTH CARE SERVICES
-- SPECIFIC REQUIREMENTS
Section 6.6.5 is replaced with the following language:
HHSC Contract 000-00-000 Page 8 of 17
"6.6.5 When assessing Members for behavioral health care
services, HMO and network behavioral health providers must use the DSM-IV
multi-axial classification. HHSC may require use of other assessment
instrument/outcome measures in addition to the DSM-IV. Providers must document
DSM-IV and assessment/outcome information in the Member's medical record."
SECTION 2.18 MODIFICATION TO SECTION 6.16, BLIND AND DISABLED MEMBERS
Section 6.16.1 is replaced with the following language:
"6.16.1 Blind and disabled Members' SSI status is effective
the date of State's eligibility system, SAVERR, identifies the Member
as Type Program 13 (TP13). On this effective date, the Member becomes
a voluntary STAR enrollee.
The State is responsible for updating the State's eligibility
system within 45 days of official notice of the Members' federal SSI
eligibility by the Social Security Administration (SSA).
SECTION 2.19 MODIFICATION OF SECTION 8.4, MEMBER ID CARDS
Section 8.4.1 is replaced with the following language:
"8.4.1 A Medicaid Identification Form (Form 3087) is issued
monthly by the TDHS. The form includes the "STAR" Program logo and the
name and toll free number of the Member's health plan. A Member may
have a temporary Medicaid Identification (Form 1027-A), which will
include a STAR indicator."
SECTION 2.20 MODIFICATION OF SECTION 10.1, MODEL MIS REQUIREMENTS
Section 10.1.3.6 is replaced with the following language:
"10.1.3.6 HMO is required to provide representation to attend
and participate in the HHSC Systems Workgroup as a part of the Systems
Scan Call."
SECTION 2.21 MODIFICATION OF SECTION 10.4, PROVIDER SUBSYSTEM
Subparts 7 and 8 of Section 10.4 are replaced with the following
language:
"7. Support national provider number format (UPIN, NPIN,
CLIA, TPI, etc., as required by HHSC).
8. Provide Provider Network and Affiliation files 90
days prior to implementation and updates monthly. Format will be
provided by HHSC to contracted entities."
SECTION 2.22 MODIFICATION OF SECTION 10.9, DATA INTERFACE SUBSYSTEM
Section 10.9.3 is replaced with the following language:
HHSC Contract 000-00-000 Page 9 of 17
"10.9.3 Provider Network and Affiliation Files. The HMO will
supply network provider data to the Enrollment Broker and Claims
Administrator. This data will consist of a Provider Network File and a
Provider Affiliation File. The HMO will submit the Provider Network
File to the Enrollment Broker and the Provider Affiliation File to the
Claims Administrator. Both files shall accomplish the following
objectives:
1. Provide identifying information for all managed care
providers (e.g. name, address, etc.).
2. Maintain history on provider
enrollment/disenrollment.
3. Identify PCP capacity.
4. Identify any restrictions (e.g., age, sex, etc.).
5. Identify number and types of specialty providers
available to Members.
6. Provide other (Master Provider File) information
identified by HHSC."
SECTION 2.23 MODIFICATION OF SECTION 10.11, YEAR 2000 (Y2K) COMPLIANCE
Section 10.11 is deleted in its entirety.
SECTION 2.24 ADDITION OF SECTION 10.12, HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT (HIPAA) COMPLIANCE.
Section 10.12 is added as follows:
"10.12 Health Insurance Portability and Accountability Act
(HIPAA) Compliance. HMO's system must comply with applicable
certificate of coverage and data specification and reporting
requirements promulgated pursuant to the Health Insurance Portability
and Accountability Act (HIPPA) of 1996, P.L. 104-191 (August 21,
1996), as amended or modified.
SECTION 2.25 MODIFICATION OF SECTION 12.1. FINANCIAL REPORTS
Sections 12.1.4, 12.1.11, and 12.13 are replaced with the following
language, and Section 12.14 is added. Sections 12.1.2, 12.1.3, 12.1.7 and
12.1.10 are deleted in their entirety.
12.1.2 [Deleted]
12.1.3 [Deleted]
12.1.4 Final MCFS Reports. HMO must file two final MCFS
Reports for each of the following:
- The initial two-year contract period (SFY
2000-2001),
- The first one-year contract extension period (SFY
2002), and
HHSC Contract 000-00-000 Page 10 of 17
- This second one-year contract extension period (SFY
2003).
The first final report must reflect expenses incurred during
each contract period and paid through the 90th day after the end of
the contract period. The first final report must be filed on or before
the 120th day after the end of each contract period. The second final
report must reflect expenses incurred during each contract period and
paid through the 334th day after the end of the contract period. The
second final report must be filed on or before the 365th day after the
end of each contract period.
. . . .
12.1.7 [Deleted]
. . . .
12.1.10 [Deleted]
12.1.11 IBNR Plan. HMO must furnish a written IBNR Plan to
manage incurred-but-not-reported (IBNR) expenses, and a description of
the method of insuring against insolvency, including information on
all existing or proposed insurance policies. The Plan must include the
methodology for estimating IBNR. The plan and description must be
submitted to HHSC no later than 60 days after the effective date of
this contract. Changes to the IBNR plan and description must be
submitted to HHSC no later than 30 days before changes to the plan are
implemented by HMO.
. . . .
12.1.13 Each report required under this Article must be
mailed to: Medicaid HMO Contract Deliverables Manager, HEDS Division,
Texas Health and Human Services Commission, X.X. Xxx 00000, Xxxxxx,
Xxxxx 00000-0000 (Exception: The MCFS Report may be submitted to HHSC
via E-mail to xxxxxxx@xxxx.xxxxx.xx.xx).
12.1.14 Bonus and/or Incentive Payment Plan. The HMO must
furnish a written Bonus and/or Incentive Payments Plan to HHSC to
determine whether such payments are allowable administrative expenses
in accordance with Appendix L, "Cost Principles for Administrative
Expenses, 11. Compensation for Personnel Services, i. Bonuses and
Incentive Payments." The written plan must include a description of
the plan's criteria for establishing bonus and/or incentive payments,
the methodology to calculate bonus and/or incentive payments, and the
timing as to when these bonus and/or incentive payments are to be
paid. The plan and description must be submitted to HHSC for approval
no later than 30 days after the execution of the contract and any
contract renewal. If the HMO revises the Bonus and/or Incentive
Payment Plan, the HMO must submit the revised plan to HHSC for
approval prior to implementing the plan."
SECTION 2.26 MODIFICATION OF SECTION 12.4, SUMMARY REPORT OF PROVIDER
COMPLAINTS
Section 12.4 is replaced with the following language:
HHSC Contract 000-00-000 Page 11 of 17
"12.4 HMO must submit a Summary Report of Provider
Complaints. HMO must also reports complaints submitted to its
subcontracted risk groups (e.g., IPAs). The complaint report format
must be submitted not later than 45 days following the end of the
state fiscal quarter in a format specified by HHSC."
SECTION 2.27 MODIFICATION OF SECTION 12.6, MEMBER COMPLAINTS
Section 12.6 is replaced with the following language:
"12.6 HMO must submit a quarterly summary report of Member
complaints. HMO must also report complaints submitted to its
subcontracted risk groups (e.g., IPAs). The complaint report must be
submitted not later than 45 days following the end of the state fiscal
quarter in a format specified by HHSC."
SECTION 2.28 MODIFICATION OF SECTION 12.13, EXPEDITED PRENATAL OUTREACH
REPORT
Section 12.13 is deleted in its entirety.
SECTION 2.29 ADDITION OF SECTION 12.14, MEMBER HOTLINE PERFORMANCE REPORT
Section 12.14 is added as follows:
"12.14 MEMBER HOTLINE PERFORMANCE REPORT
HMO must submit, on a monthly basis, a Member Hotline
Performance Report that contains all required elements set out in
Article 3.7 of this Agreement in a formant approved by HHSC. The
report is due on the 30th of the month following the end of each
month."
SECTION 2.30 ADDITION OF SECTION 12.15, SUBMISSION OF STAR DELIVERABLES/REPORTS
Section 12.15 is added as follows:
"12.15 SUBMISSION OF STAR DELIVERABLES/REPORTS
12.15.1 Electronic Mail. STAR deliverables and reports
should be submitted to HHSC via electronic mail unless HHSC expressly
provides that they must be submitted in a different manner. Reports
and deliverables that may not be submitted electronically include, but
are not limited to: Encounter Data, Supplemental Delivery Payment
data, UDT data, and certain Member Materials.
12.15.1.1 The e-mail address for deliverables submission is
xxxxxxx@xxxx.xxxxx.xx.xx.
12.15.1.2 Electronic Mail Restrictions:
File Size: E-mail file size is limited to 2.5 MB. Files
larger than that will need to be compressed (zip file) or split into
multiple files for submission.
HHSC Contract 000-00-000 Page 12 of 17
Confidentiality: Routine STAR deliverables/reports should not
contain any member specific data that would be considered
confidential.
12.15.2 FQHC and RHC Deliverables. HMO may submit FQHC and
RHC deliverables by uploading the required information to the Claims
Administrator's Bulleting Board System (BBS). The uploaded data must
contain a unique 8-digit control number. HMO should format the 8-digit
control number as follows:
- 2 digit plan code identification number;
- Julian date; and then
- HMO's 3-digit report number (i.e., HMO's first
report will be 001).
After uploading the data to the BBS, the HMO must notify HHSC
via e-mail that it has uploaded the data, and include the name of the
file and recipient directory. HMO must also mail signed original
report summaries, including the corresponding 8-digit control number,
to HHSC within three (3) business days after uploading the data to the
BBS.
12.15.3 Special Submission Needs. In special cases where
other submission methods are necessary, HMO must contact the assigned
Health Plan Manager for authorization and instructions.
12.15.4 Deliverables due via Mail. HMO should mail reports
and deliverables that must be submitted by mail to the following
address:
General Mail:
Texas Health & Human Services Commission
HEDS Contract Deliverables
X.X. Xxx 00000
Xxxxxx, Xxxxx 00000-0000
Overnight Mail:
Texas Health & Human Services Commission
HEDS Contract Deliverables
00000 Xxxxx Xxxxx Xxxxxx
Xxxxxx, XX 00000
12.15.5 Texas Department of Insurance (TDI). The submission
of deliverables/reports to HHSC does not relieve the Plan of any
reporting requirements/responsibility with TDI. The Plan should
continue to report to TDI as they have in the past."
SECTION 2.31 MODIFICATIONS TO SECTION 13.1, CAPITATION AMOUNTS
Section 13.1.7.1 is added:
"13.1.7.1 HMO rates for FY 2002 and FY 2003 include pass
through funds for providers, as appropriated by the 77th Texas
Legislature. HMO must file reports on pass through methodology
expenditures as requested by HHSC."
HHSC Contract 000-00-000 Page 13 of 17
SECTION 2.32 MODIFICATION OF SECTION 13.2, EXPERIENCE REBATE TO THE STATE
Sections 13.2.1, 13.2.2.1, 13.2.3, and 13.2.5 are replaced with the
following language:
"13.2.1 For the Contract Period, HMO must pay to HHSC an
experience rebate calculated in accordance with the tiered rebate
method listed below based on the excess of allowable HMO STAR revenues
over allowable HMO STAR expenses as set forth in Appendix I, as
reviewed and confirmed by HHSC. HHSC reserves the right to have an
independent audit performed to verify the information provided by HMO.
GRADUATED REBATE METHOD
NET INCOME BEFORE
TAXES AS A
PERCENTAGE OF
REVENUES HMO SHARE STATE SHARE
0% - 3% 100% 0%
OVER 3% - 7% 75% 25%
OVER 7% -10% 50% 50%
OVER 10% - 15% 25% 75%
OVER 15% 0% 100%
13.2.2.1 The experience rebate for the HMO shall be
calculated by applying the experience rebate formula in Article 13.2.1
to the sum of the net income before taxes for all STAR Medicaid
service areas contracted between the State and HMO.
13.2.3 Experience rebate will be based on a pre-tax basis.
Expenses for value-added services are excluded from the determination
of Net Income Before Taxes reported in the Final MCFS Report; however,
HMO may subtract from Net Income Before Taxes, expenses incurred for
value added services for the experience rebate calculations.
13.2.5 There will be two settlements for payment(s) of the
experience rebate for SFY 2000-2001, two settlements for payment(s)
for the experience rebate for SFY 2002, and two settlements for
payment(s) for the experience rebate for SFY 2003. The first settlement
for the specified contract period shall equal 100 percent of the
experience rebate as derived from Net Income Before Taxes less the
value-added services expenses in the first final MCFS Report and shall
be paid on the same day the first final MCFS Report is submitted to
HHSC for the specified time period. The second settlement shall be an
adjustment to the first settlement and shall be paid to HHSC on the
same day that the second final MCFS Report is submitted to HHSC for
that specified time period if the adjustment is a payment from HMO to
HHSC. If the adjustment is a payment from HHSC to HMO, HHSC shall pay
such adjustment to HMO within thirty (30) days of receipt of the
second final MCFS Report. HHSC or its agent may audit the MCFS report.
If HHSC determines that corrections to the MCFS reports are required,
based on a audit of other documentation acceptable to HHSC, to
determine an adjustment to the amount of the second settlement, then
HHSC Contract 000-00-000 Page 14 of 17
final adjustment shall be made within three years from the date that
HMO submits the second final MCFS report. HMO must pay the first and
second settlements on the due dates for the first and second final
MCFS reports respectively as identified in Article 12.1.4. HHSC may
adjust the experience rebate if HHSC determines HMO has paid
affiliates amounts for goods or services that are higher than the fair
market value of the goods and services in the service area. Fair
market value may be based on the amount HMO pays a non-affiliate(s) or
the amount another HMO pays for the same or similar service in the
service area. HHSC has final authority in auditing and determining the
amount of the experience rebate."
SECTION 2.33 SECTION 13.3, PERFORMANCE OBJECTIVES
Section 13.3.9 is replaced with the following language:
"13.3.9 The performance objective allocation for HMO shall
be assigned to each performance objective, described in Appendix K, in
accordance with the following percentages:
PERCENT OF
PERFORMANCE
OBJECTIVE
EPSDT SCREENS INCENTIVE FUND
1.<12 MONTHS 12%
2. 12 TO 24 MONTHS 12%
3. 25 MONTHS - 20 YEARS 20%
PERCENT OF
PERFORMANCE
OBJECTIVE
IMMUNIZATIONS INCENTIVE FUND
4. <12 MONTHS 17%
5. 12 TO 24 MONTHS 12%
PERCENT OF
PERFORMANCE
PREGNANCY OBJECTIVE
VISITS INCENTIVE FUND
6. INITIAL PRENATAL EXAM 15%
7. POSTPARTUM VISIT 12%
SECTION 2.34 MODIFICATION OF SECTION 13.5, NEWBORN AND PREGNANT WOMEN
PAYMENT PROVISIONS
Sections 13.5.1.1, 13.5.3 and 13.5.6 are replaced with the following
language:
"13.5.1.1 The mother of the newborn Member may request that
the newborn's health plan coverage be changed to another HMO during
the first 90 days following the date of birth, but may only do so
through the Medicaid managed care Enrollment Broker.
HHSC Contract 000-00-000 Page 15 of 17
13.5.3 All non-TP45 newborns whose mothers are HMO Members
at the time of the birth will be retroactively enrolled into the HMO
by TDHS Data Control except as outlined in Article 13.5.4.
13.5.6 HMO is responsible for payment for all covered
services provided to TP40 members by in-network or out-of-network
providers from the date of enrollment in HMO, but prior to HMO
receiving TP40 Member on monthly capitation file. HMO must waive
requirement for prior authorization (or grant retroactive prior
authorization) for medically necessary services provided from the date
of enrollment in HMO, but prior to HMO receiving TP40 member on
monthly capitation file."
SECTION 2.35 MODIFICATION OF SECTION 14.3, NEWBORN ENROLLMENT
Section 14.3.1.1 is replaced with the following language:
"14.3.1.1 A mother of a newborn Member may request a plan
change for her newborn during the first 90 days by contacting the
Enrollment Broker. If a change is approved, the Enrollment Broker will
notify both plans involved in the process. If no alternative to the
plan change can be reached, the Enrollment Broker will notify the HMO
of the newborn plan change request received from the mother."
SECTION 2.36 MODIFICATION OF SECTION 15.12, NOTICES
Section 15.12 is replaced with the following language:
"Notice may be given by registered mail, facsimile, and/or
hand delivery. All notices to HHSC shall be addressed to: Medicaid HMO
Contract Deliverables Manager, HEDS Division, Texas Health and Human
Services Commission, X.X. Xxx 00000, Xxxxxx, Xxxxx 00000-0000, with a
copy to the Contract Administrator. Notices to HMO shall be addressed
to President/CEO, 0000 X. XX-00, Xxxxx 000, Xxxxxx, XX 00000."
SECTION 2.37 MODIFICATION OF SECTION 18.1.6, TERMINATION BY HMO
Section 18.1.6 is replaced with the following language:
"18.1.6 HMO may terminate this contract if HHSC fails to pay
HMO as required under Article 13 of this contract or otherwise
materially defaults in its duties and responsibilities under this
contract, or by giving notice no later than 30 days after receiving
the capitation rates for the Contract Period. Retaining premium,
recoupment, sanctions, or penalties that are allowed under this
contract or that result from HMO's failure to perform or HMO's default
under the terms of this contract is not cause for termination."
SECTION 2.38 MODIFICATION OF SECTION 18.10, REVIEW OF REMEDY OR REMEDIES
TO BE IMPOSED
Section 18.10 is replaced with the following language:
"18.10.2 HMO and HHSC must attempt to informally resolve a
dispute. If HMO and HHSC are unable to informally resolve a dispute,
HHSC Contract 000-00-000 Page 16 of 17
HMO must notify the HEDS Manager and Director of Medicaid/CHIP
Operations that HMO and HHSC cannot agree. The Director of
Medicaid/CHIP Operations will refer the dispute to the State Medicaid
Director who will appoint a committee to review the dispute under
HHSC's dispute resolution procedures. The decision of the dispute
resolution committee will be HHSC's final administrative decision."
SECTION 2.39 MODIFICATION OF SECTION 19.1, CONTRACT TERM
Section 19.1 is replaced with the following language:
"19.1 The effective date of this contract is August 31,
1999. This contract will terminate on August 31, 2003 unless extended
or terminated earlier as provided for elsewhere in this contract."
SECTION 2.40 MODIFICATIONS TO CONTRACT APPENDICES.
The following appendices are replaced with the versions attached to
this Amendment:
- Appendix B, HUB
- Appendix C, Value-added Services (for certain HMOs)
- Appendix F, Texas Trauma Facilities
- Appendix G, Texas Hemophilia Centers
- Appendix I, Financial Statistical Report
- Appendix K, Preventive Health Performance Objectives
ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES
The Parties contract and agree that the terms of the Agreement will
remain in effect and continue to govern except to the extent modified in this
Amendment.
By signing this Amendment, the Parties expressly understand and agree
that this Amendment is hereby made a part of the Agreement as though it were
set out word for word in the Agreement.
IN WITNESS HEREOF, HHSC AND THE HMO HAVE EACH CAUSED THIS AMENDMENT TO
BE SIGNED AND DELIVERED BY ITS DULY AUTHORIZED REPRESENTATIVE.
SUPERIOR HEALTH PLAN, INC. HEALTH & HUMAN SERVICES COMMISSION
By: By:
-------------------------------- -------------------------------
Xxxxxxxxxxx Xxxxxx Xxx Xxxxxxx
President & CEO Commissioner
Date: Date:
------------------------------ -----------------------------
HHSC Contract 000-00-000 Page 17 of 00
XXXXX XX XXXXX XXXX XXXXXXXX XX. 000-00-000
XXXXXX OF XXXXXX
AMENDMENT 13
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
SUPERIOR HEALTH PLAN, INC.
FOR HEALTH SERVICES
TO THE
MEDICAI STAR PROGRAM
IN THE
XXXXXX SERVICE DELIVERY AREA
THIS CONTRACT AMENDMENT (the "Amendment") is entered into between the
HEALTH & HUMAN SERVICES COMMISSION ("HHSC"). an administrative agency within
the executive department of the State of Texas, and SUPERIOR HEALTH PLAN, INC.
("CONTRACTOR"), a health maintenance organization organized under the laws of
the State of Texas, possessing a certificate of authority issued by the Texas
Department of Insurance to operate as a health maintenance organization, and
having its principal office at 0000 X. XX-00, Xxxxx 000, Xxxxxx, Xxxxx 00000.
HHSC and CONTRACTOR may be referred to in this Amendment individually as a
"Party" and collectively as the "Parties."
The Parties hereby agree to amend their Agreement as set forth in
Article 2 of this Amendment.
ARTICLE 1. PURPOSE.
SECTION 1.01 AUTHORIZATION.
This Amendment is executed by the Parties in accordance with Article
15.2 of the Agreement.
SECTION 1.02 GENERAL EFFECTIVE DATE OF CHANGES.
This Amendment is effective November 1,2002.
ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES
SECTION 2.01 MODIFICATION OF ARTICLE 2 DEFINITIONS
The following term is added to amend the definitions set forth in
Article 2:
"EXPERIENCE REBATE PERIOD means each period within the
Contract Period related to the calculations and settlements of
Experience Rebates to HHSC described in Section 13.2. The Contract
Period consists of the following Experience Rebate Periods:
- September 1, 1999 through August 31, 2001 (1st Experience
Rebate Period)
- September 1, 2001 through August 31, 2002 (2nd Experience
Rebate Period)
- September 1, 2002 through August 31, 2003 (3rd Experience
Rebate Period)"
HHSC Contract 000-00-000 Page 1 of 4
SECTION 2.02 MODIFICATION TO SECTION 13.2, EXPERIENCE REBATE TO STATE
Section 13.2 is replaced with the following language:
"13.2.1 HMO must pay to HHSC an experience rebate for each
Experience Rebate Period. HMO will calculate the experience rebate in
accordance with the tiered rebate formula listed below based on Net
Income Before Taxes (excess of allowable revenues over allowable
expenses) as set forth in Appendix I. The HMO's calculations are
subject to HHSC approval, and HHSC reserves the right to have an
independent audit performed to verify the information provided by HMO.
GRADUATED REBATE FORMULA
NET INCOME
BEFORE TAXES AS
A PERCENTAGE OF
TOTAL REVENUES HMO SHARE HHSC SHARE
0% - 3% 100% 0%
OVER 3% - 7% 75% 25%
OVER 7% -10% 50% 50%
OVER 10% - 15% 25% 75%
OVER 15% 0% 100%
13.2.2 Carry Forward of Prior Experience Rebate Period
Losses: Losses incurred for one Experience Rebate Period can only be
carried forward as an offset to Net Income Before Taxes in the next
Experience Rebate Period.
13.2.2.1 HMO shall calculate the experience rebate by
applying the experience rebate formula in Article 13.2.1 as follows:
For the 1st Experience Rebate Period, to the Net Income
Before Taxes for each STAR Medicaid service area contracted between
HHSC and HMO. The HMO will separately calculate the experience rebate
for each service area, and losses in one service area cannot be used
to offset Net Income Before Taxes in another service area. Losses from
the 1st Experience Rebate Period can be carried forward to the 2nd
Experience Rebate Period for the same service area.
For the 2nd Experience Rebate Period, to the sum of the Net
Income Before Taxes for all STAR Medicaid service areas contracted
between HHSC and HMO. Losses from the 2nd Experience Rebate Period can
be carried forward to the 3rd Experience Rebate Period.
For the 3rd Experience Rebate Period, to the sum of the Net
Income Before Taxes for all CHIP, STAR Medicaid, and STAR+PLUS
Medicaid service areas contracted between HHSC or TDHS and HMO.
13.2.3 Experience rebate will be based on a pre-tax basis.
Expenses for value-added services are excluded from the determination
HHSC Contract 000-00-000 Page 2 of 4
of Net Income Before Taxes reported in the Final MCFS Report; however,
HMO may subtract from Net Income Before Taxes, expenses incurred for
value added services for the experience rebate calculations.
13.2.4 Population-Based Initiatives (PBIs) and Experience
Rebates: HMO may subtract from an experience rebate owed to HHSC,
expenses for population-based health initiatives that have been
approved by HHSC. A PBI is a project or program designed to improve
some aspect of quality of care, quality of life, or health care
knowledge for the Medicaid population that may also benefit the
community as a whole. Value-added service does not constitute a PBI.
Contractually required services and activities do not constitute a
PBI.
13.2.5 There will be two settlements for payment(s) of the
experience rebate for the 1st Experience Rebate Period, two
settlements for payment(s) of the experience rebate for the 2nd
Experience Rebate Period, and two settlements for payments) of the
experience rebate for the 3rd Experience Rebate Period. Settlement
payments are payable to HHSC. The first settlement for the specified
Experience Rebate Period shall equal 100 percent of the experience
rebate as derived from Net Income Before Taxes reduced by any
value-added services expenses in the first Final MCFS Report and shall
be paid on the same day that the first Final MCFS Report is submitted
to HHSC for the specified time period. The second settlement shall be
an adjustment to the first settlement and shall be paid on the same
day that the second Final MCFS Report is submitted to HHSC for that
specified time period if the adjustment is a payment from HMO to HHSC.
If the adjustment is a payment from HHSC to HMO, HHSC shall pay such
adjustment to HMO within thirty (30) days of receipt of the second
Final MCFS Report. HHSC or its agent may audit the MCFS Reports. If
HHSC determines that corrections to the MCFS Reports are required,
based on an audit of other documentation acceptable to HHSC, to
determine an adjustment to the amount of the second settlement, then
final adjustment shall be made within three (3) years from the date
that HMO submits the second Final MCFS Report. HMO must pay the first
and second settlements on the due dates for the first and second Final
MCFS Reports, respectively, as identified in Article 12.1.4. HHSC may
adjust the experience rebate if HHSC determines HMO has paid (an)
affiliate(s) amounts for goods or services that are higher than the
fair market value of the goods and services in the service area. Fair
market value may be based on the amount HMO pays (a) non-affiliate(s)
or the amount another HMO pays for the same or similar goods and
services in the service area. HHSC has final authority in auditing and
determining the amount of the experience rebate."
ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES
The Parties contract and agree that the terms of the Agreement will
remain in effect and continue to govern except to the extent modified in this
Amendment.
By signing this Amendment, the Parties expressly understand and agree
that this Amendment is hereby made a part of the Agreement as though it were
set out word for word in the Agreement.
HHSC Contract 000-00-000 Page 3 of 4
IN WITNESS HEREOF, HHSC AND THE CONTRACTOR HAVE EACH CAUSED THIS
AMENDMENT TO BE SIGNED AND DELIVERED BY ITS DULY AUTHORIZED REPRESENTATIVE.
SUPERIOR HEALTH PLAN, INC. HEALTH & HUMAN SERVICES COMMISSION
By: By:
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Xxxxxxxxxxx Xxxxxx Xxx X. Xxxxxxx
President and CEO Commissioner
Date: Date:
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HHSC Contract 000-00-000 Page 4 of 4
