EXHIBIT 10.21
AGREEMENT NO. PSC ▇▇-▇▇
▇▇▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇ ▇▇ ▇▇▇ ▇▇▇▇▇▇ HUMAN SERVICES DEPARTMENT
AND ▇▇▇▇▇▇▇▇ COMMUNITY HEALTH PLAN
Amendment No. 1 ("Amendment") is entered into by and between the New Mexico
Human Services Department (hereinafter referred to "HSD") and ▇▇▇▇▇▇▇▇ COMMUNITY
HEALTH PLAN (hereinafter referred to as "CONTRACTOR" OR "MCO").
WHEREAS, the parties have previously entered into Agreement PSC 02-05
Approved by the Department of Finance and Administration (DFA) on July 1, 2001
(the "Agreement") and
WHEREAS, Article 37 of the Agreement allows for amendment of the
Agreement; and
WHEREAS, the parties have determined that the term of the Agreement
should be extended for an additional year.
WHEREAS, the Balanced Budget Act of 1997 requires certain changes to
the Agreement; and
WHEREAS, based on the parties' experience since implementation of the
Agreement, the parties have agreed to certain changes in the Agreement
beneficial to the Agreement's goals;
NOW THEREFORE, the parties do amend the Agreement as follows:
1. All terms, definitions and conditions stated in the Agreement and
not modified by this Amendment shall remain in full force and effect. This
Amendment shall become effective July 1, 2003, provided it has been approved by
the Department of Finance and Administration, and the U.S. Department of Health
and Human Services, Center for Medicare/Medicaid Services (CMS). Any reference
to CMS in this document is a reference to the agency formerly known as Health
Care Financing Administration (HCFA);
2. This Agreement is extended to expire at midnight June 30, 2004.
3. In the event of a conflict between, on the one hand, the Agreement
as amended herein, and on the other hand, the regulations promulgated by the
Code of Federal Regulations (CFR) for Managed Care Organizations (MCOs) and the
Human Services Department, the federal and state regulations will prevail.
IN WITNESS WHEREOF, the parties have executed this Amendment No. 1 as
of the date of execution by the State Contracts Officer, below.
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ARTICLE 1 (RECITALS), SECTION 1.2.(6). IS AMENDED TO READ AS FOLLOWS:
1.2.(6). All applicable statutes, regulations and rules implemented by
the Federal Government, the State of New Mexico ("State"), and
HSD, concerning Medicaid services, managed care organizations,
health maintenance organizations, fiscal and fiduciary
responsibilities applicable under the Insurance Code of New
Mexico, NMSA 1978 ▇▇.▇▇. 59A-1-1 et. seq., and any other
applicable laws.
ARTICLE 1 (RECITALS), SECTION 1.7. IS ADDED TO READ AS FOLLOWS:
1.7. The parties to this contract acknowledge the need to work
cooperatively to address and resolve problems that may arise
in the administration and performance of this contract.
ARTICLE 1 (RECITALS), SECTION 1.8. IS ADDED TO READ AS FOLLOWS:
1.8 HSD may, in the administration of this contract, seek input on
health care related issues from any advisory group or steering
committee.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(1).A.V. IS AMENDED TO READ AS FOLLOWS:
2.1.(1).A.v. The CONTRACTOR shall provide potential members upon request
and enrolled members with a directory to include MCO addresses
and telephone numbers. The CONTRACTOR shall also provide upon
request a listing of primary care and specialty providers with
the identity, location, phone number and qualifications to
include area of specialty, board certification and any area of
special expertise that would be helpful to individuals
deciding to enroll with the CONTRACTOR. This material must be
available in a manner and format that may be easily
understood. At the option of the CONTRACTOR, the directory may
be limited to primary care and self-refer providers.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(1).▇.▇▇. IS AMENDED TO READ AS FOLLOWS:
2.1.(1).▇.▇▇. The CONTRACTOR shall provide potential members upon request
and enrolled members with a list of all items and services
that are available to members covered either directly or
through a method of referral and/or prior authorization. These
materials must be available in a manner and format that may be
easily understood.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(1).D. IS AMENDED TO READ AS FOLLOWS:
2.1.(1).D. MCO Enrollment Information
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Once a member is determined to be an MCO mandatory member, HSD
provides specific information about services included in the
benefit packages, MCOs from which the member can choose, and
enrollment of the member(s). The CONTRACTOR shall have written
policies and procedures regarding the utilization of
information on race, ethnicity, and primary language spoken,
as provided by HSD to the CONTRACTOR at the time of enrollment
in the MCO of each Medicaid member.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(1).E.II. IS AMENDED TO READ AS FOLLOWS:
2.1.(1).E.ii. The CONTRACTOR is responsible for providing members with a
member handbook and provider directory within a reasonable
time after the CONTRACTOR is notified by HSD of the member's
enrollment. The CONTRACTOR must notify all members at least
once per year of their right to request and obtain this
information. The member handbook shall include information
contained in 42 CFR, Section 438.10.F.2.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(1).E.III. IS AMENDED TO READ AS FOLLOWS:
2.1.(1).E.iii. The CONTRACTOR shall send a provider directory and member
handbook to members or potential members requesting a copy and
as requested by HSD. The CONTRACTOR may direct a person
requesting a member handbook or a provider directory to an
internet site. However, a specific request for a printed
document shall be met. The CONTRACTOR shall provide a one
page, two-sided summary of its benefits which may be
distributed by HSD at its discretion. The CONTRACTOR must
notify all members at least once per year of their right to
request and obtain this information.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(1).E.IV.A.B.C. ARE AMENDED TO READ AS
FOLLOWS:
2.1.(1).E.iv. Member handbooks shall be available in formats other than
English and in an appropriate manner that takes into
consideration the special needs of those who for example, are
visually limited or have limited reading proficiency, if, in
the CONTRACTOR'S or HSD's determination there is a prevalent
population of the CONTRACTOR'S Salud! members that are
conversant only in those other languages or require alternate
formats. In addition, oral interpretation must be made
available free of charge to potential members or members.
These oral interpretations must be available in all
non-English languages, not just those that are determined to
be prevalent by the CONTRACTOR and HSD. The CONTRACTOR must
notify potential members and members that oral interpretation
is
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available in any language and that written information is
available in prevalent languages and how to access this
information.
(1) The format for the written material shall:
a) Use easily understood language and format;
b) Be available in alternative formats and in
an appropriate manner that takes into
consideration the special needs of those
who, for example, are visually limited or
have limited reading proficiency.
(2) All potential members upon request and enrolled
members must be notified how to access these formats.
(3) The handbook shall include:
a) Limitations to the receipt of care from
non-participating providers;
b) Coordination of care by PCPs;
c) The CONTRACTOR demographic information
including the organization's toll-free
member phone number;
d) Services for which prior authorization or a
referral is required, and the method
of obtaining both;
e) The provider directory, which need not
physically be part of the handbook. This
provider directory shall include the names,
locations, telephone numbers of, and non-
English languages spoken by current
contracted providers in the member's service
area, including the identification of
providers who are not accepting new
patients. At a minimum, this information
shall include Primary Care Providers (PCPs),
self referral specialists, and hospitals.
f) Any restrictions on the member's freedom of
choice among network providers;
g) Notice to members on both the CONTRACTOR'S
internal grievance and appeal processes
and HSD's fair hearing process;
h) Information on how to obtain services, such
as after hours and emergency service,
including the 911 telephone system or its
local equivalent;
i) The member's rights, protections, and
responsibilities;
j) Information on obtaining care in emergency
or urgent conditions;
k) Information on accessing behavioral health
or other specialty services, including
but not limited to EPSDT and family planning
services, information regarding the member's
rights to self-refer to in-plan and
out-of-plan family planning providers; and a
female member's right to self-refer to a
women's health specialist within the network
for covered care
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necessary to provide women's routine and
preventive health care services. This is in
addition to the member's designated source
of primary care if that source is not a
women's health specialist.
l) Information on the member's rights to
terminate enrollment and the process for
voluntarily disenrolling from the plan;
m) Other information determined by HSD to be
essential during the member's initial
contact with the CONTRACTOR;
n) The CONTRACTOR'S policy on referrals for
specialty care and other benefits not
furnished by the member's primary care
provider;
o) Information regarding advanced directives.
p) Information on cost sharing if any;
q) Additional information upon request,
including information on how to obtain the
CONTRACTOR'S structure and operation and
physician incentive plans.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(1).F.III. IS ADDED TO READ AS FOLLOWS:
2.1.(1).F.iii. The CONTRACTOR shall provide for a second opinion from a
qualified health care professional within the network, or
arrange for the member to obtain one outside the network if
there is not another qualified provider in the network, at no
cost to the member.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(1).I.I.D). IS AMENDED TO READ AS FOLLOWS:
2.1.(1).I.i.d) The following information regarding the member's rights of
access to and coverage of emergency services shall include:
1. The fact that the member has a right to use
any hospital or other setting for emergency
care;
2. What constitutes emergency medical
condition, emergency services, and post
stabilization services;
3. That an emergency condition is a medical
condition manifesting itself by acute
symptoms of sufficient severity (including
severe pain) such that a prudent layperson,
who possesses an average knowledge of health
and medicine, could reasonably expect the
absence of immediate medical attention to
result in placing the individual's health
(or with respect to a pregnant woman, the
health of a woman or her unborn child) in
serious jeopardy, serious impairment to
bodily function or serious dysfunction of
any bodily organ or part;
4. That post stabilization care covers services
related to an emergency medical condition,
that are provided after the
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member is stabilized in order to maintain
the stabilized condition or, to improve or
resolve the member's condition;
5. The fact that prior authorization is not
required for emergency services in or out of
the network with all emergency services
reimbursed at least at the Medicaid network
rate and that the CONTRACTOR shall not
retroactively deny a claim for an emergency
screening examination because the condition,
which appeared to be an emergency medical
condition under the prudent layperson
standard (defined above), turned out to be
non-emergency in nature;
6. The locations of any emergency settings and
other locations at which providers and
hospital furnish emergency services and post
stabilization services furnished under the
contract.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(1).I.IV. IS AMENDED TO READ AS FOLLOWS:
2.1.(1).I.iv. The CONTRACTOR shall provide affected members and/or legal
guardians with written updated information within 30 days of
the intended effective date of any material change. In
addition, the CONTRACTOR must make a good faith effort to give
written notice of termination of a contracted provider, within
fifteen days after receipt or issuance of termination notice
to each who received his or her primary care from, or was seen
on a regular basis by, the terminated provider.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(1).K. IS AMENDED TO READ AS FOLLOWS:
2.1.(1).K. The CONTRACTOR shall be required to comply with the MAD
regulation 8.305.8.15. on Patient ▇▇▇▇ of Rights. The
CONTRACTOR shall provide each member with written information,
in English or prevalent language, as appropriate, found in the
MAD patient ▇▇▇▇ of Rights pursuant to MAD 8.305.8.15.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(1).K.II.A IS AMENDED TO READ AS FOLLOWS:
2.1.(1).K.ii.a Members and, as appropriate, their families and/or legal
guardians have a right to participate with practitioners in
decision making regarding all aspects of their health care,
including development of the course of treatment. The
CONTRACTOR'S policy shall contain procedures for obtaining
informed consent.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(1).K.XI. IS ADDED TO READ AS FOLLOWS:
2.1.(1).K.xi. Members have a right to be free from any form of restraint or
seclusion used as a means of coercion, discipline, convenience
or retaliation, as
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specified in other federal regulations on the use of
restraints and seclusion.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(1).L.II. IS AMENDED TO READ AS FOLLOWS:
2.1.(1).L.ii. The Consumer Advisory Board shall serve to advise the
CONTRACTOR on issues concerning service delivery and quality,
member rights and responsibilities, the process for resolving
member grievances, and the needs of the groups they represent
as they pertain to Medicaid managed care. The Board shall meet
on at least a quarterly basis. The CONTRACTOR shall conduct
outreach activities in the state's regions to ensure member
input. The CONTRACTOR is responsible for keeping a written
record of the board meetings.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(1).M.VII IS AMENDED TO READ AS FOLLOWS:
2.1.(1).M.vii. The CONTRACTOR shall comply with NCQA standards for
Utilization Management and follow NCQA timeliness standards
for routine, urgent and emergent situations. The
decision-making timeframes should accommodate the clinical
urgency of the situation and not delay the provision of
services to member for lengthy periods of time. These required
timeframes are not to be affected by "pend" decisions. A
possible extension of up to 14 additional calendar days may
apply if:
(i) the member, or the provider, requests extension; or
(ii) the CONTRACTOR justifies to HSD a need for additional
information and demonstrates how the extension is in
the member's interest.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(1).N. IS ADDED TO READ AS FOLLOWS:
A. Coverage and authorization of services.
The CONTRACTOR shall do the following:
(1) Identify, define, and specify the amount, duration, and scope
of each service that the CONTRACTOR is required to offer.
(2) Require that the services identified in paragraph (1) of this
section be furnished in an amount, duration, and scope that is
no less than the amount, duration, and scope for the same
services furnished to beneficiaries under fee-for-service
Medicaid as set forth in 42 CFR, Section 440.230.
(3) The CONTRACTOR:
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(i) shall ensure that the services are sufficient in
amount, duration, or scope to reasonably be expected
to achieve the purpose for which the services are
furnished.
(ii) may not arbitrarily deny or reduce the amount,
duration, or scope of a required service solely
because of diagnosis, type of illness, or condition
of the beneficiary;
(iii) may place appropriate limits on a service -
(a) on the basis of criteria applied under HSD,
such as medical necessity; or
(b) for the purpose of utilization control,
provided the services furnished can
reasonably be expected to achieve their
purpose, as required in paragraph
(A)(3)(i) of this section; and
(4) The CONTRACTOR shall specify what constitutes "medically
necessary services" in a manner that:
(i) Is no more restrictive than that used by HSD as
indicated in State statutes and regulations, the
State Plan, and other State policy and procedures;
and
(ii) Addresses the extent to which the CONTRACTOR is
responsible for covering services related to the
following:
(a) the prevention, diagnosis, and treatment of
health impairments;
(b) the ability to achieve age-appropriate
growth and development;
(c) the ability to attain, maintain, or regain
functional capacity.
(B) Authorization of Services
For the processing of requests for initial and continuing
authorizations of services, the CONTRACTOR must:
(1) Require that its subcontractors have in place, and follow,
written policies and procedures;
(2) Have in effect mechanisms to ensure consistent application of
review criteria for authorization decisions;
(3) Consult with the requesting provider when appropriate; and
(4) Require that any decision to deny a service authorization
request or to authorize a service in an amount, duration, or
scope that is less than requested, be made by a health care
professional who has appropriate
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clinical expertise in treating the member's condition or
disease, such as the CONTRACTOR'S Medical Director.
(C) Notice of adverse action.
The CONTRACTOR must notify the requesting provider, and give the member
written notice of any decision by the CONTRACTOR to deny a service
authorization request, or to authorize a service in an amount,
duration, or scope that is less than requested. The notice must meet
the requirement of 42 CFR Section 438.404, except that the notice to
the provider need not be in writing.
D. Compensation for utilization management activities.
Each contract must provide that, consistent with 42 CFR, Sections
438.6(h) and 422.208, compensation to individuals or entities that
conduct utilization management activities is not structured so as to
provide incentives for the individual or entity to deny, limit, or
discontinue medically necessary services to any member.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(1).N. (DENIALS) IS CHANGED TO
SECTION 2.1.(1).O.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(2).F.VIII. IS AMENDED TO READ AS
FOLLOWS:
2.1.(2).F.viii. The CONTRACTOR shall have written policies and procedures for
conducting member surveys.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(2).G.II. IS AMENDED TO READ AS FOLLOWS:
2.1.(2).G.ii. Ensure that the QI program is applied to the entire range of
health services provided through the CONTRACTOR by assuring
that all major population groups, care settings, and service
types are included in the scope of the review. A major
population group is one which represents at least five percent
of a CONTRACTOR'S enrollment.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(2).J.X. IS ADDED TO READ AS FOLLOWS:
2.1.(2).J.x. Ensure the delegate takes corrective action if the CONTRACTOR
identifies deficiencies.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(2).J.XI. IS ADDED TO READ AS FOLLOWS:
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2.1.(2).J.xi. Revoke delegation or impose other sanctions if the delegate's
performance is inadequate, in accordance with CONTRACTOR'S
policy and procedures.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(2).L.IV. IS AMENDED TO READ AS FOLLOWS:
2.1.(2).L.iv. Follow NCQA guidelines for the conduct of provider
satisfaction surveys; cooperate with HSD in conducting
provider satisfaction survey, including making available a
current, unduplicated provider file(s) available to HSD or its
EQRO upon request;
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(2).M.I. IS AMENDED TO READ AS FOLLOWS:
2.1.(2).M.i. HSD shall retain the services of an external quality review
organization in accordance with the Social Security Act,
Section 1902 (a) (30) [C], and the CONTRACTOR shall cooperate
fully with that organization and prove to that organization
the CONTRACTOR'S adherence to HSD's quality standards as set
forth in MAD Policy Section 8.305.8. HSD shall also contract
with an external review organization to audit a statistically
valid sample of the CONTRACTOR behavioral health UM decisions
including authorizations, reductions, terminations and
denials. This audit is intended to determine if authorized
service levels are appropriate with respect to accepted
standards of clinical care. The CONTRACTOR shall cooperate
fully with that organization.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(3). IS AMENDED TO READ AS FOLLOWS:
2.1.(3). Disease Management Indicators
A. Disease Management Programs and Performance Improvement
Projects are two of the tools that HSD has chosen to use to
measure a CONTRACTOR'S ability to identify problematic areas
within its operations and take actions which shall improve its
performance in those focus areas. Examples of these include
but, are not limited to, administrative functions (telephone
response rates), utilization management (timeliness of prior
authorizations), access to care, preventive care (improvement
of EPSDT screening rates), and care coordination.
B. The CONTRACTOR shall:
i. Participate in disease management
programs/performance improvement projects annually.
HSD will coordinate with CONTRACTOR to select
programs that meet the NCQA requirements. Fifty
percent of the disease management
programs/performance improvement projects shall
relate to behavioral health;
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ii. Adhere to timely and accurate collection of baseline
project indicator data (physical health, behavioral
health, administrative), which shall show the
CONTRACTOR'S performance rate for those indicators
identified for improvement by HSD;
iii. Identify specific interventions that the CONTRACTOR
intends to use to improve performance in a given
area;
iv. Demonstrate improvement in each quality indicator
within each calendar year of the contract; and
v. Perform subsequent measurement and written assessment
of the ongoing effectiveness of named interventions.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(3).C.I. AND II. IS AMENDED TO READ AS
FOLLOWS:
2.1.(3).C.i. Track, analyze, and report to HSD quarterly, certain
indicators identified specific to behavioral or physical
health that shall enable HSD to determine potential problems
areas within quality of care, access, or service delivery;
2.1.(3).C.ii. Collect the requested data quarterly, perform analysis on the
data for the purpose of determining completeness and validity,
and report results to HSD quarterly;
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(3).D. IS ADDED TO READ AS FOLLOWS:
2.1.(3).D. PHYSICAL AND BEHAVIORAL HEALTH PERFORMANCE MEASURES FOR FY
2004 MCO CONTRACTS.
A. Managed Care Performance Measures:
For capitation payments made on or after June 25, 2003, HSD
shall withhold one-half of one (0.5) percent of the
CONTRACTOR'S payments. The withhold funds shall be released to
the CONTRACTOR no sooner than July 1st and no later than July
31st of 2004 only if, in the judgment of HSD, performance
targets in the contract are achieved. Withhold funds shall be
released to the CONTRACTOR based on the following scoring
system for each of the ten performance measures listed below:
1. Dental Access to Care shall be worth 10
points;
2. Child Access to PCP shall be worth 10
points;
3. Diabetes Care shall be worth 10 points;
4. Consumer/Family Based Services shall be
worth 15 points;
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5. RTC Readmissions shall be worth 10 points;
6. Behavioral Health Discharge Follow-up after
7 days shall be worth 5 points;
7. Behavioral Health Discharge Follow-up after
30 days shall be worth 5 points;
8. Provider Payment Timeliness shall be worth
15 points;
9. Customer Support Services shall be worth 10
points; and
10. Encounter Data Reporting shall be worth 10
points.
The percentage of the CONTRACTOR'S withhold funds to be
released shall be calculated by summing all earned points,
dividing the sum by 100, and converting to a percentage. No
partial whole number of points will be assigned if the
CONTRACTOR fails to completely meet performance measures
described in one through ten above. Points assigned for the
performance measures will be all or none (e.g. 15 points or 0
points).
To the extent that the following performance measures are not
based on HEDIS measures, the parties agree that the measure
shall be evaluated based on the standard reports for such
measures already submitted to HSD by CONTRACTOR, provided that
HSD shall have the right to audit and validate the information
or results as reported by CONTRACTOR.
For the current contract amendment the CONTRACTOR shall submit
HEDIS scores for calendar year 2003 according to the required
HEDIS submission schedule for evaluation under this
performance measurement section.
B. Performance Measures Requirements:
The ten performance measures shall be evaluated using the
following criteria:
1. DENTAL ACCESS TO CARE:
The CONTRACTOR'S members between the ages of four and
twenty-one who were continuously enrolled with the
CONTRACTOR during the measurement period will have a
dental visit during the measurement year, as
evidenced by a minimum HEDIS score of 44.00.
2. CHILD ACCESS TO PCP:
The CONTRACTOR'S members between the age of twelve
months through twenty-four months who are
continuously enrolled with the CONTRACTOR during the
measurement period, will have a visit with a
pediatrician, family physician, or other CONTRACTOR'S
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primary care provider during the measurement year, as
evidenced by a minimum HEDIS score of 96.00.
3. DIABETES CARE, HbA1c:
Diabetic members who are continuously enrolled with
the CONTRACTOR during the measurement period will
have a glycohemoglobin (HbA1c) blood test during the
measurement year, as evidenced by a minimum HEDIS
score of 73.72.
4. CONSUMER/FAMILY BASED SERVICES:
At least one-half of one (0.5) percent of the Salud!
behavioral health expenditures for FY 04 will be
expended for non-profit family and/or member
controlled/operated organizations. These
organizations shall be member-centered and
recovery-driven. These organizations shall develop
and direct activities that provide support, education
and access to services to consumers and families. HSD
shall provide the reporting format to the CONTRACTOR.
The CONTRACTOR shall report to HSD on a quarterly
basis.
For all three CONTRACTORS the total minimum
expenditure will be $434,166.00 (0.5% of
$86,833,000.00).
Cimarron's minimum expenditure will be $117,225.00.
▇▇▇▇▇▇▇▇'▇ minimum expenditure will be $104,200.00.
Presbyterian's minimum expenditure will be
$212,741.00.
5. RTC RE-ADMISSIONS:
Nineteen percent or less of the CONTRACTOR'S members
who are discharged from a residential treatment
center (RTC) will be readmitted to the same level of
care or a higher level of care within thirty days of
discharge from the RTC.
6. BEHAVIORAL HEALTH DISCHARGE FOLLOW-UP:
The CONTRACTOR'S members who are discharged from an
acute psychiatric hospital setting will receive
follow-up care within seven days of discharge as
evidenced by a minimum HEDIS score of 34.56.
7. BEHAVIORAL HEALTH DISCHARGE FOLLOW-UP:
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The CONTRACTOR'S members who are discharged from an
acute psychiatric hospital setting will receive
follow-up care within thirty days of discharge as
evidenced by a minimum HEDIS score of 57.25.
8. PROVIDER PAYMENT TIMELINESS:
The CONTRACTOR shall pay ninety percent of all clean
claims for physical and behavioral health within
thirty days and ninety-nine percent of all physical
and behavioral health clean claims within ninety
days.
9. CUSTOMER SUPPORT SERVICES:
a. Ninety percent of the CONTRACTOR'S member
services calls shall be answered within
thirty seconds or less based on the reported
average.
b. The CONTRACTOR shall conduct a Consumer
Advisory Board meeting on a quarterly basis.
10. ENCOUNTER DATA REPORTING:
The CONTRACTOR shall submit 100 percent of all
required encounter data on a timely basis for
submissions and necessary re-submissions as set forth
in the contract, 2.12.(5).B. The submissions and
required re-submissions shall have an error rate of
five percent or less for at least seventy-five
percent of the files.
C. Retention and Release of Withhold Funds:
1. The retention of funds withheld shall be accomplished
as follows:
A. The CONTRACTOR shall place all funds to be
withheld by HSD, under part A. (Managed Care
Performance Measures) of this section, in a
separate account and shall provide to HSD a
monthly statement of the account in order to
verify that the withheld funds are being
maintained during the period of time
specified in this contract.
2. The release of the funds withheld shall be made as
follows:
A. The funds in the withheld funds account
shall be released for use by the CONTRACTOR
only after HSD has submitted in writing
that, in HSD's judgment, the performance
targets in the contract have been achieved
for the period of time
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specified in the contract. HSD shall provide
written confirmation no sooner than July 1st
and no later than July 31st of 2004.
3. The release of funds withheld shall be calculated as
follows:
A. The difference between the total FY 2004
capitation payments to the CONTRACTOR as of
June 30, 2004 divided by 0.995 (99.5
percent) and the total FY 2004 capitation
payments to the MCO as of June 30, 2004.
B. The difference calculated shall be
multiplied by the percentage determined in
Section A., Managed Care Withhold, above.
D. Challenge Pool Funding:
If the CONTRACTOR fails to earn any portion of its withheld
funds, these funds will immediately be placed in a challenge
pool. The challenge pool funds will be paid based upon the
performance across the average of the two HEDIS 2004 Use of
Services measurements.
A. Challenge Pool Measurement. For purposes of the challenge
pool funds, the percentage of the CONTRACTOR'S qualifying
members meeting each target measurement will be weighted
together pursuant to the following:
1. HEDIS WELL-CHILD VISITS IN THE THIRD,
FOURTH, FIFTH, AND SIXTH YEAR OF LIFE.
As annually reported to HSD, the percentage
of members who were three, four, five, or
six years old during the measurement year,
who were continuously enrolled with the
CONTRACTOR during the measurement year, and
who received at least one primary care
provider visit.
a. For this measurement, the
CONTRACTOR shall determine
continuous enrollment for a member
pursuant to the HEDIS technical
specifications.
b. The CONTRACTOR shall determine a
primary care provider visit
pursuant to the HEDIS technical
specifications for administrative
or hybrid methods.
2. HEDIS ADOLESCENT WELL-CHILD VISIT.
As annually reported to HSD, the year's
percentage of members who were twelve
through twenty-one years old
15
during the measurement year, who were
continuously enrolled with the CONTRACTOR
during the measurement year, and who
received at least one primary care provider
visit.
a. For this measurement, the
CONTRACTOR shall determine
continuous enrollment for a member
pursuant to the HEDIS technical
specifications.
b. The CONTRACTOR shall determine a
primary care provider visit
pursuant to the HEDIS technical
specifications for administrative
or hybrid methods.
3. For the purpose of weighting together the Use of
Service measurements, a CONTRACTOR who does not
submit data to HSD for either of the two target HEDIS
measurements above shall receive a zero score for any
unreported HEDIS target measurement.
B. Challenge Pool Payments
1. A CONTRACTOR that earns all withhold funds described in
Section A shall not be eligible for any Challenge Pool
payment.
2. The CONTRACTOR with the highest overall average of two
HEDIS 2004 measurements during the measurement year will
have released an amount that does not exceed one hundred
percent of the funds withheld from the CONTRACTOR.
3. All other CONTRACTORS will have returned a percentage of
their withheld funds not already returned calculated as:
the CONTRACTOR'S average performance divided by the
highest CONTRACTOR average performance, times the amount
of the CONTRACTOR'S withheld funds that were not earned
under Section A.
E. Tracking Measures That Are Not Subject to the Managed Care
Withhold or Challenge Pool:
The following measures are not subject to the managed care
withhold or challenge pool and shall be reported to HSD:
1. CERVICAL CANCER SCREENING:
Female members aged twenty-one to sixty-four who were
continuously enrolled with the CONTRACTOR during the
measurement year will receive one or more Pap tests
during the
16
measurement year or the two years prior to the
measurement year as evidenced by HEDIS reported data.
2. DISTRIBUTION OF BEHAVIORAL HEALTH PROVIDERS:
As demonstrated by a quarterly geo-access report,
ninety percent of CONTRACTOR members in urban areas
will have access to a licensed behavioral health
provider within thirty miles. Ninety percent of
CONTRACTOR members in rural areas will have access to
a licensed behavioral health provider within sixty
miles. Ninety percent of CONTRACTOR members in
frontier areas will have access to a licensed
behavioral health provider within ninety miles. The
behavioral health provider must be in active
practice. Telemedicine and circuit-riders can be
utilized to fulfill this requirement. Compliance
shall be averaged over a six-month measurement
period.
3. BEHAVIORAL HEALTH PENETRATION RATE:
The penetration rates for the following populations
shall be determined according to HEDIS methodology,
using appropriate encounter data:
a. CONTRACTOR members up to the age of
twenty-one who are continuously enrolled
during the measurement year, there will be a
behavioral health penetration rate of at
least 7.7 percent.
b. CONTRACTOR members ages nineteen through
twenty who are continuous enrolled during
the measurement year, there will be a
behavioral health penetration rate of at
least 10.5 percent.
4. COMMUNITY BASED BEHAVIORAL HEALTH SERVICES:
The CONTRACTOR shall increase its expenditures on the
following community based services by a total of ten
percent:
Assertive Community Treatment (ACT);
Behavior Management Services (BMS);
Case Management for children and adults (CM);
Non-Emergency Room Crisis Services;
Home Based Services;
Intensive Outpatient Services (IOP);
Psychosocial Rehabilitation Services (PSR);
Respite Services for children/adolescents and adults;
17
Shelter Care Services for children/adolescents;
Transitional Living Services for children/adolescents
and adults;
Day Treatment Program (DTP); and
Multi-Systemic Therapy (MST).
HSD shall provide a reporting format to the
CONTRACTOR. The CONTRACTOR shall report to HSD on a
quarterly basis using this format.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(4).C. IS AMENDED TO READ AS FOLLOWS:
2.1.(4).C. The CONTRACTOR shall meet time and distance standards for PCPs
and pharmacies as determined by HSD or as described in MAD
Policy 8.305.8.18. The CONTRACTOR shall have systems to track
and report this data and such data shall be available to HSD
upon request.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(4).D. IS AMENDED TO READ AS FOLLOWS:
2.1.(4).D. The CONTRACTOR shall meet provider appointment and pharmacy
in-person prescription fill time standards as described in MAD
Policy 8.305.8.18; shall approve or deny requests for DME
within seven (7) working days of the initial request. Members
shall be able to obtain prescribed medical supplies and
non-specialized DME within 24 hours, when needed on an urgent
basis. All new, customized, made-to-measure equipment shall be
delivered within 150 days of the request date. All repairs or
modifications shall be delivered within 60 days of the request
date.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(4).E.I. IS AMENDED TO READ AS FOLLOWS:
2.1.(4).E.i. Routine and non-specialized supplies
The CONTRACTOR shall:
a) Ensure supplies are delivered consistent with
clinical need;
b) Have an emergency response plan for medical equipment
or supplies needed on an emergent basis;
c) Ensure that members and/or their family receive
adequate instruction on use of the supplies or
equipment;
d) Be able to deliver the transportation benefit
statewide;
e) Have a sufficient transportation network available to
meet the transportation needs of members. This
includes requiring an appropriate number of handivans
for members who are wheelchair or
ventilator-dependent or have other equipment needs;
f) Require that all transportation vehicles be equipped
with a communication device for use in case of an
emergency;
18
g) Have CPR certified drivers to transport members whose
clinical needs dictate.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(4).I IS ADDED TO READ AS FOLLOWS:
2.1.(4).I The CONTRACTOR shall meet and require its providers to meet
State standards for timely access to care and services, taking
into account the urgency of the need for services; establish
mechanisms to ensure compliance by providers; monitor
providers regularly to determine compliance; and take
corrective action if there is a failure to comply.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(6).A.III IS AMENDED TO READ AS FOLLOWS:
2.1.(6).A.iii Develop and implement written policies and procedures, which
govern how members with multiple and complex special physical,
and behavioral health care needs shall be identified.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(6).A.IV. IS AMENDED TO READ AS FOLLOWS:
2.1.(6).A.iv Develop and implement written policies and procedures,
governing how care coordination shall be provided for members
with special health care needs. A member or family shall have
a right to refuse care coordination or case management.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.1.(6).B.VII IS AMENDED TO READ AS FOLLOWS:
2.1.(6).B.vii Coordination of Services with Children, Youth and Families
Department (CYFD). The CONTRACTOR shall have written policies
and procedures requiring coordination with the CYFD Protective
Services and Juvenile Justice Divisions to ensure that members
receive medically necessary services regardless of the
member's custody status. These policies and procedures shall
specifically address compliance with the current New Mexico
Children's Code. If Child Protective Services (CPS), Juvenile
Justice or Adult Protective Services (APS) has an open case on
a member, the CYFD social worker or Juvenile Probation Officer
assigned to the case shall be involved in the assessment and
planning for the course of treatment, including decisions
regarding the provision of services for the member. The
CONTRACTOR shall designate a single contact point for these
cases.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.1.(7).B. IS AMENDED TO READ AS FOLLOWS:
2.1.(7).B. Subsequent Change in PCP Initiated by Member. Members may
initiate a PCP change at any time, for any reason. The request
can be made in writing or by telephone. If a request is made
by the 20th of a month it becomes effective as of the first of
the following month. If a request is
19
made after the 20th of the month the change becomes effective
the first of the month after the following month.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.2.(3).A.IV. IS AMENDED TO READ AS FOLLOWS:
2.2.(3.).A. HSD shall determine eligibility for enrollment in the managed
care program. All Medicaid eligible members are required to
participate in the Medicaid managed care program except for
the following:
iv. Members participating in the Health Insurance Premium
(▇▇▇▇) Program or the Breast and Cervical Cancer
(BCC) Medicaid Program.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.2.(5).B. IS AMENDED TO READ AS FOLLOWS:
2.2.(5).B. Hospitalized Members
A member who is hospitalized in a general acute-care,
rehabilitation or freestanding psychiatric hospital at the
time he/she first enrolls with the CONTRACTOR may enroll with
the CONTRACTOR. However, the CONTRACTOR shall not be
responsible for the costs of such hospitalization, except
newborns born to a member mother, until the member is
discharged from the hospital or there is a change in the level
of care. Instead, HSD shall pay the appropriate provider(s) on
a fee-for-service basis for all provider-submitted claims
related to a member who is hospitalized in a general acute
care, rehabilitation or freestanding psychiatric hospital at
the time such member enrolls with the CONTRACTOR, until such
time as the member is discharged from the hospital.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.2.(5).C. IS AMENDED TO READ AS FOLLOWS:
2.2.(5).C. Members in Placement in Residential Treatment Centers
If a child or adolescent becomes Medicaid eligible or enrolls
with the CONTRACTOR while residing in an accredited or
non-accredited residential treatment center, he or she shall
be immediately eligible for enrollment and the CONTRACTOR
shall assume financial responsibility for the member as of the
effective date of enrollment.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.2.(5).D. IS AMENDED TO READ AS FOLLOWS:
2.2.(5).D. Members in Treatment ▇▇▇▇▇▇ Care Placements
If a child or adolescent was residing in a treatment ▇▇▇▇▇▇
care placement at the time managed care enrollment began, they
shall be exempt from enrolling in an MCO until he or she is
discharged from treatment ▇▇▇▇▇▇ care.
20
ARTICLE 2 (SCOPE OF WORK), SECTION 2.2.(6). IS AMENDED TO READ AS FOLLOWS:
2.2.(6). Enrollment Process for Members
Current members may request a change in MCOs during the first
ninety (90) days of a twelve (12) month enrollment period.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.2.(6).C. IS AMENDED TO READ AS FOLLOWS:
2.2.(6).C. Member Switch and Loss of Medicaid Eligibility
A current CONTRACTOR member has the opportunity to change
CONTRACTORS during the first ninety (90) days of a twelve (12)
month period. HSD shall notify the CONTRACTOR members of their
opportunity to select a new CONTRACTOR provider. A member is
limited to one ninety day switch period per CONTRACTOR. After
exercising the switching rights, and returning to a previously
selected CONTRACTOR, the member shall remain with the
CONTRACTOR until his/her twelve (12) month lock-in period
expires before being permitted to switch CONTRACTORS.
If a member loses Medicaid eligibility for a period of two
months or less, he/she will be automatically reenrolled with
the former CONTRACTOR. If the member misses the annual
disenrollment opportunity during this two month time, he/she
may request to be assigned to another CONTRACTOR.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.2.(6).E.II. IS AMENDED TO READ AS FOLLOWS:
2.2.(6).E.ii The CONTRACTOR shall develop a detailed plan for the
transition of an individual member, which includes member and
provider education about the CONTRACTOR, and the CONTRACTOR
process to assure any existing courses of treatment are
revised as necessary;
ARTICLE 2 (SCOPE OF WORK) SECTION 2.2.(6).E.X. IS AMENDED TO READ AS FOLLOWS:
2.2.(6).E.x. The CONTRACTOR is responsible for payment of all inpatient
services provided by a general acute-care, rehabilitation or
freestanding psychiatric hospital until discharge from the
hospital or transfer to a different level of care, if the
member is hospitalized in such a facility at the time the
member becomes exempt or switches enrollment;
ARTICLE 2 (SCOPE OF WORK) SECTION 2.2.(6).E.XI. IS AMENDED TO READ AS FOLLOWS:
2.2.(6).E.xi. The CONTRACTOR is responsible for payment until disenrollment
or switch enrollment, if an enrolled member is placed in a
residential treatment center or treatment ▇▇▇▇▇▇ care, or is
admitted to a nursing
21
facility or intermediate care facility for the mentally
retarded as a long term or permanent placement; and
ARTICLE 2 (SCOPE OF WORK), SECTION 2.2.(7).A.IV. IS AMENDED TO READ AS FOLLOWS:
2.2.(7).A.iv. The CONTRACTOR shall not request disenrollment because of an
adverse change in the member's health status, or because of
the member's utilization of medical services, diminished
mental capacity, or uncooperative or disruptive behavior
resulting from his or her special needs (except when his or
her continued enrollment with the CONTRACTOR seriously impairs
the CONTRACTOR'S ability to furnish services to either this
particular member or other members). The CONTRACTOR shall
provide adequate documentation that the CONTRACTOR'S request
for termination is proper;
ARTICLE 2 (SCOPE OF WORK), SECTION 2.2.(7).B. IS AMENDED TO READ AS FOLLOWS:
2.2.(7).B. Member Initiated Disenrollment
1. A member who is required to participate in managed
care may request to be disenrolled from the
CONTRACTOR "for cause" at anytime, even during a
lock-in period. The following are causes for
disenrollment:
i. The member moves out of the Contractor's
service area.
ii. The CONTRACTOR does not, because of moral or
religious objections, cover the service the
member seeks.
iii. The member needs related services (for
example, a caesarian section and a tubal
ligation) to be performed at the same time
and there is no network provider able to do
this and another provider determines that
receiving the services separately would
subject the member to unnecessary risk.
iv. Other reasons, including but not limited to,
poor quality of care, lack of access to
services covered under the contract, or lack
of access to providers experienced in
dealing with the member's health care needs.
2. This request shall be submitted in writing to HSD for
review. HSD shall complete the review and furnish a
written decision to the member and the CONTRACTOR.
The effective date of an approved disenrollment must
be no later than the first day of the second month
following the month in which the member files the
request. If HSD fails to make the determination
within this timeframe, the disenrollment is
considered approved. A member who is denied
disenrollment shall have access to the State fair
hearing process.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.2.(7).D. IS ADDED TO READ AS FOLLOWS:
22
2.2.(7).D Retroactive Reenrollment
A member who is no longer enrolled with the CONTRACTOR,
whether in error or otherwise, shall not be retroactively
reenrolled by the CONTRACTOR unless HSD submits its request
for re-enrollment to the CONTRACTOR within 30 days of the date
the CONTRACTOR received enrollment data from HSD indicating
that the member was no longer enrolled with the CONTRACTOR or
eligible for Medicaid Managed Care provided however that
nothing in this section shall restrict the appropriate
enrollment of newborns in accordance with the provision of
2.2.(5).A. The CONTRACTOR may not be obligated to accept
retroactive reenrollment.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.3, IS AMENDED TO READ AS FOLLOWS:
2.3 The CONTRACTOR shall establish and maintain a comprehensive network of
providers capable of serving all members who enroll in the MCO.
Pursuant to Section 1932(b)(7) of the Social Security Act, the
CONTRACTOR shall not discriminate against providers that serve
high-risk populations or specialize in conditions that require costly
treatment, and with respect to participation, reimbursement, or
indemnification for any provider acting within the scope of that
provider's license or certification under applicable state law solely
on the basis of the provider's license or certification. In addition,
the CONTRACTOR shall not discriminate against providers with respect to
participation, reimbursement, or indemnification for any provider
acting within the scope of that provider's license or certification
under applicable state law solely on the basis of the provider's
license or certification. If the CONTRACTOR declines to include
individual or groups of providers in its network, it must give the
affected providers written notice of the reason for its decision. The
CONTRACTOR shall not be required to contract with providers beyond the
number necessary to meet the needs of its members. The CONTRACTOR shall
be allowed to use different reimbursement amounts for different
specialties or for different practitioners in the same specialty. The
CONTRACTOR shall be allowed to establish measures that are designed to
maintain quality of services and control of costs and are consistent
with its responsibility to members.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.3(1).C IS ADDED TO READ AS FOLLOWS:
2.3.(1).C. The CONTRACTOR, in establishing and maintaining the network of
appropriate providers, shall consider its:
i. Anticipated Medicaid enrollment;
ii. Expected utilization of services, taking into
consideration the characteristics and health care
needs of specific Medicaid populations represented in
the CONTRACTOR'S population;
23
iii. Numbers and types (in terms of training, experience,
and specialization) of providers required to furnish
the contracted Medicaid services;
iv. Numbers of network providers who are not accepting
new Medicaid patients; and
v. Geographic location of providers and Medicaid
members, considering distance, travel time, the means
of transportation ordinarily used by Medicaid member,
and whether the location provides physical access for
Medicaid members with disabilities.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.3.(1).D. IS ADDED TO READ AS FOLLOWS:
2.3.(1).D The CONTRACTOR shall ensure that the network providers offer
hours of operation that are no less than the hours of
operation offered to commercial enrollees or comparable to
Medicaid fee-for-service, if the provider serves only Medicaid
enrollees.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.3.(11).A. IS AMENDED TO READ AS FOLLOWS:
2.3.(11).A. The CONTRACTOR shall contract with public health providers for
services as described in Section MAD 8.305.6.15 and those
defined as public health services under State law, ▇▇▇▇ ▇▇▇▇
▇▇.▇▇. 24-1-1, et. seq.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.3.(16).B IS AMENDED TO READ AS FOLLOWS:
2.3.(16).B. The CONTRACTOR shall give each member, including adolescents,
the opportunity to use his or her own primary care provider or
go to any family planning center for family planning services
without requiring a referral. Each female member shall also
have the right to self-refer to a women's health specialist
within the network for covered care necessary to provide
women's routine and preventive health care services. This is
in addition to the member's designated source of primary care
if that source is not a women's health specialist. Clinics and
providers, including those funded by Title X of the Public
Health Service Act, shall be reimbursed by the CONTRACTOR for
all family planning services regardless of whether they are a
participating or non-participating provider. Unless otherwise
negotiated, the CONTRACTOR shall reimburse providers of family
planning services at the Medicaid rate.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.3.(17).A.III. IS AMENDED TO READ AS FOLLOWS:
2.3.(17).A.iii. Build a statewide behavioral health provider network that
ensures access to all levels of behavioral health services,
across a continuum from the most to the least restrictive
setting. The network shall be sufficient to
24
ensure that the standards in MAD Policy 8.305 for access to
care providers who want to refer members for behavioral health
care and vice versa;
ARTICLE 2 (SCOPE OF WORK), SECTION 2.3.(17).B.II. IS AMENDED TO READ AS FOLLOWS:
2.3.(17).B.ii The CONTRACTOR shall provide care coordination for members
with multiple and complex special physical, mental,
neurobiological, emotional and/or behavioral health care needs
on an as needed basis, depending upon the clinical profile of
the member. The CONTRACTOR shall have written policies and
procedures, which govern how members with these multiple and
complex needs shall be identified and how these specific care
coordination services shall be provided.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.3.(17).C IS AMENDED TO READ AS FOLLOWS:
2.3.(17).C The CONTRACTOR shall provide care coordination for members
with multiple and complex special physical, mental,
neurobiological, emotional and/or behavioral health care needs
on an as needed basis, depending upon the clinical profile of
the member. The CONTRACTOR shall have written policies and
procedures, which govern how members with these multiple and
complex needs shall be identified and how these specific care
coordination services shall be provided.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.3.(20). IS AMENDED TO READ AS FOLLOWS:
2.3.(20) Recredentialing
The CONTRACTOR shall formally recredential its network
providers at least every three years.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.4.(1). IS AMENDED TO READ AS FOLLOWS:
2.4.(1). Inpatient Hospital Services
The benefit package includes hospital inpatient acute care,
procedures, and services asset forth in MAD Program Manual
section MAD-721, HOSPITAL SERVICES. The CONTRACTOR shall
comply with the maternity length of stay in the Health
Insurance Portability and Accounting Act of 1996. Coverage for
a hospital stay following a normal vaginal delivery may
generally not be limited to less than 48 hours for both the
mother and newborn child. Health coverage for a hospital stay
in connection with childbirth following a cesarean section may
generally not be limited to less than 96 hours for both mother
and newborn child.
ARTICLE 2, (SCOPE OF WORK), SECTION 2.4.(5).A. IS AMENDED TO READ AS FOLLOWS:
25
2.4.(5).A. The benefit package includes emergency and poststabilization
care services. Emergency services are covered inpatient and
outpatient services that are furnished by a provider that is
qualified to furnish these services and are needed to evaluate
or stabilize an emergency condition. An emergency condition
shall meet the definition of emergency as per NMAC
8.305.1.7.V. Emergency services shall be provided in
accordance with NMAC 8.305.7.11F. Poststabilization care
services are covered services related to an emergency
condition that are provided after a patient is stabilized in
order to maintain the stabilized condition or to improve or
resolve the patient's condition, such that within reasonable
medical probability, no material deterioration of the
patient's condition is likely to result from or occur during
discharge of the patient or transfer of the patient to another
facility.
ARTICLE 2, (SCOPE OF WORK), SECTION 2.4.(5).B.III. IS AMENDED TO READ AS
FOLLOWS:
2.4.(5).B.iii. The CONTRACTOR is required to pay for all emergency and
poststabilization care services that are medically necessary
until the emergency condition is stabilized and maintained.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.4.(23). IS AMENDED TO READ AS FOLLOWS:
2.4.(23). Reproductive Health Services
The benefit package includes reproductive health services as
set forth in MAD Program Policy, Section 762, REPRODUCTIVE
HEALTH SERVICES. The CONTRACTOR shall provide Medicaid members
with sufficient information to allow them to make informed
choices including: the types of family planning services
available; the member's right to access these services in a
timely and confidential manner; and the freedom to choose a
qualified family planning provider who participates in the
CONTRACTOR network or from a provider who does not participate
in the CONTRACTOR network. A female member shall have the
right to self-refer to a women's health specialist within the
network for covered care necessary to provide women's routine
and preventive health care services. This is in addition to
the member's designated source of primary care if that source
is not a women's health specialist.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.4.(28) IS AMENDED TO READ AS FOLLOWS:
2.4.(28).A. The benefit package includes prevention, screening,
diagnostics, ameliorative services, and other medically
necessary behavioral health care and substance abuse treatment
or services for Medicaid members under twenty-one (21) years
of age whose need for behavioral health services is identified
during an Early and Periodic Screening, Diagnostic, and
Treatment (EPSDT) screen.
26
ARTICLE 2 (SCOPE OF WORK), SECTION 2.4.(31).A. IS AMENDED TO ADD AS FOLLOWS:
2.4.(31).A. The CONTRACTOR shall implement written policies and
procedures with respect to advance directives. The CONTRACTOR
shall provide adult members with written information on
advance directives policies to include a description of
applicable state law. The information must reflect changes in
State law as soon as possible, but no later than 90 days after
effective date of the change.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.5.(1). IS AMENDED TO READ AS FOLLOWS:
2.5.(1). The CONTRACTOR shall develop and implement a Cultural
Competency/Sensitivity Plan, through which the CONTRACTOR
shall ensure that it provides, both directly and through its
health care providers and subcontractors, culturally competent
services to its SALUD! members. The CONTRACTOR shall
participate with the State's efforts to promote the delivery
of services in a culturally competent manner to all members,
including those with limited English proficiency and diverse
cultural ethnic backgrounds.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.5.(2).B.I IS AMENDED TO READ AS FOLLOWS:
2.5.(2).B.i Incorporate cultural competence into utilization management,
quality improvement and planning for the course of treatment.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.6 IS AMENDED IN ITS ENTIRETY TO READ AS
FOLLOWS:
2.6. INDIVIDUALS WITH SPECIAL HEALTH CARE NEEDS
2.6.(1) General Requirements
Individuals with special health care needs have ongoing health
conditions, high or complex service utilization, and low to
severe functional limitations. The primary purpose of the
definition is to identify these individuals so that the
CONTRACTOR can facilitate access to appropriate services. The
definition also allows for a flexible targeting of individuals
based on clinical justification and discontinuing targeted
efforts when such efforts are no longer needed.
2.6.(1).A. CONTRACTOR Requirements:
i. The CONTRACTOR shall produce a special handbook or
create an insert to include in its member services
handbook a description of
27
providers and programs available to individuals with
special health care needs.
ii. The CONTRACTOR shall identify from among its members
individuals with special health care needs, using the
criteria for identification and information provided
by the state to the MCO.
2.6.(1).B. The CONTRACTOR shall work with HSD to develop and implement
written policies and procedures which govern how members with
multiple and complex physical and behavioral health care needs
shall be identified. The CONTRACTOR shall have an internal
operational process, in accordance with policy and procedure,
to target members for the purpose of applying stratification
criteria to identify individuals with special health care
needs.
2.6.(1).C. SALUD! Enrollment for Individuals with Special Health Care
Needs
The CONTRACTOR shall have written policies and procedures to
facilitate a smooth transition of a member to another
CONTRACTOR, when a member chooses and is approved to switch to
another CONTRACTOR.
2.6.(2) Information and Education for Individuals with Special Health
Care Needs
2.6.(2)A. The CONTRACTOR shall develop and distribute, as appropriate,
information and materials specific to the needs of individuals
with special health care needs, and, in the case of children
with special health care needs, their caregivers. This
includes information, such as a list of items and services
that are in the SALUD! benefit package and those that are
carved out, how to plan for and arrange transportation, how to
access behavioral health care without going through the PCP,
how to present for care in an emergency room unfamiliar with
the individual's special health care needs, and the
availability of a care coordinator. This information could be
included in a special member handbook on individuals with
special needs or in an insert to the member handbook.
2.6.(2).B. The CONTRACTOR shall make available health education programs
to assist individuals with special health care needs, and, in
the case of children with special health care needs, the
caregiver(s), in understanding how to cope with the day-to-day
stress of living with the limitation or providing care.
2.6.(2).C. The CONTRACTOR shall provide a list of key CONTRACTOR resource
people and their phone numbers.
2.6.(2).D. The CONTRACTOR shall designate a single entity that can be
called for information during the enrollment process and after
becoming a member.
28
2.6.(3). Choice of Specialist as Primary Care Provider (PCP) for
Individuals with Special Health Care Needs
The CONTRACTOR shall develop and implement written policies
and procedures governing the process for member selection of a
PCP, including the right to choose a specialist as a PCP, if
warranted and agreed upon by the specialist provider.
2.6.(4). Specialty Providers for Individuals with Special Health Care
Needs
The CONTRACTOR shall have policies and procedures in place to
allow direct access to necessary specialty care, consistent
with SALUD! access appointment standards for clinical urgency.
2.6.(5). Transportation for Individuals with Special Health Care Needs
2.6.(5).A. The CONTRACTOR shall have written policies and procedures in
place to ensure that the appropriate level of transportation
is arranged based on the individual's clinical condition.
2.6.(5).B. The CONTRACTOR shall have past member and service data
available at the time services are requested to expedite
appropriate arrangements.
2.6.(5).C. The CONTRACTOR shall ensure that CPR-certified drivers
transport individuals with special health care needs whose
clinical need dictates.
2.6.(5).D The CONTRACTOR shall have written policies and procedures to
ensure that transportation mode is clinically appropriate,
including access to non-emergency ground ambulance carriers.
2.6.(5).E. The CONTRACTOR shall develop and implement written policies
and procedures to ensure that individuals can access and
receive authorization for needed transportation services under
certain unusual circumstances without the usual advance
notification.
2.6.(5).F. The CONTRACTOR shall develop and implement a written policy
regarding the transportation of minors if a parent or legal
guardian shall not be in attendance to ensure the minor's
safety.
2.6.(5).G. The CONTRACTOR shall distribute clear and detailed written
information to individuals with special health care needs and,
if needed, their caregivers on how to obtain transportation
services and also make this information available to network
providers.
2.6.(6). Care Coordination for Individuals with Special Needs
29
2.6.(6).A. The CONTRACTOR shall have an internal operational process, in
accordance with policy and procedure, to target Medicaid
members for purposes of applying stratification criteria to
identify those who are potential Individuals with Special
Health Care Needs. The CONTRACTOR will provide HSD with the
applicable policy and procedure describing the targeting and
stratification process.
2.6.(6).B. The CONTRACTOR shall have written policies and procedures for
accessing the need for care coordination.
2.6.(6).C. The CONTRACTOR shall have written policies and procedures for
educating individuals with special health care needs and, in
the case of children with special health care needs,
parent(s), legal guardians, that care coordination is
available and when it may be appropriate to their needs.
2.6.(6).D. The CONTRACTOR shall have written policies and procedures for
educating providers about the availability of care
coordination, its value as a resource in caring for
individuals with special health care needs, and how to access
it.
2.6.(7). Emergency, Inpatient and Outpatient Ambulatory Surgery
Hospital Requirements for Individuals with Special Health Care
Needs
2.6.(7).A. The CONTRACTOR shall develop and implement written policies
and procedures for educating individuals with special care
needs, and with complicated clinical histories, and their
caregivers, on how to utilize emergency room care, including
what clinical history to present when emergency care or
inpatient admission are needed.
2.6.(7).B The CONTRACTOR shall develop and implement written policies
and procedures governing how coordination with the PCP and
hospitalists shall occur when an individual with a special
health care need is hospitalized.
2.6.(7).C The CONTRACTOR shall develop and implement written policies
and procedures to ensure that the ER physician has access to
the individual's medical history.
2.6.(7).D. The CONTRACTOR shall develop and implement written policies
and procedures for obtaining any necessary referrals from PCPs
for hospitals that require in-house staff to examine or treat
individuals having outpatient or ambulatory surgical
procedures performed.
2.6.(8) Rehabilitation Therapy Services (Physical, Occupational,
Speech Therapy) for Individuals with Special Health Care Needs
30
2.6.(8).A. The CONTRACTOR shall develop and implement therapy clinical
practice guidelines specific to the chronic or long term
conditions of their individuals with special health care needs
population, based on Medicaid managed care policy on medical
necessity.
2.6.(8).B. The CONTRACTOR shall be informed about and coordinate with
other therapy services being delivered by: Special
Rehabilitation Services, the Home and Community Based Waiver
programs or by the schools to avoid unnecessary duplication.
2.6.(8).C. The CONTRACTOR shall involve families of members, physicians
and therapy providers to identify issues that should be
addressed in developing the new criteria.
2.6.(8).D. The CONTRACTOR shall develop and implement utilization prior
approval and continued stay criteria, including timeframes,
that are appropriate to the chronicity of the member 's status
and anticipated development process.
2.6.(9). Durable Medical Equipment (DME) and Supplies for Individuals
with Special Health Care Needs
2.6.(9).A. Subject to any requirements to procure a physician's order to
provide supplies to members, the CONTRACTOR shall develop and
implement a process to permit members utilizing supplies on an
ongoing basis to submit a list of supplies monthly. The
CONTRACTOR shall contact the member or the member's legal
guardian when requested supplies cannot be delivered (require
back-ordering, etc.) and make other arrangements, consistent
with clinical need.
2.6.(9).B. The CONTRACTOR shall develop and implement a system for
monitoring compliance with standards for DME and medical
supplies, and instituting corrective action, if the provider
is out of compliance.
2.6.(9).C. The CONTRACTOR shall have an emergency response plan for DME
and medical supplies needed on an emergent basis.
2.6.(10). Clinical Practice Guidelines for Provision of Care to
Individuals with Special Health Care Needs
The CONTRACTOR shall develop clinical practice guidelines,
practice parameters and/or other specific criteria that
consider the needs of individuals with special health care
needs and provide guidance in the provision of acute and
chronic medical and behavioral health care
31
services to this population. The guidelines should be
professionally accepted standards of practice and national
guidelines.
2.6.(11). Utilization Management (UM) for Services to Individuals with
Special Health Care Needs
The CONTRACTOR shall develop written policies and procedures
to exclude from prior authorization any item or service in the
course of treatment, and/or extend the authorization
periodicity, for services provided for a chronic condition.
There should be a process for review and periodic update of
the course of treatment, as indicated.
2.6.(12). Consumer Surveys Specific to Individuals with Special Health
Care Needs
The CONTRACTOR shall add questions about individuals with
special health care needs to the most current HEDIS CAHPS
survey.
2.6.(13). Individuals with Special Health Care Needs Performance
Improvement Project
The CONTRACTOR shall perform a performance improvement project
specific to individuals with special health care needs.
ARTICLE 2 (SCOPE OF WORK), SECTION 2.9 IS AMENDED IN ITS ENTIRETY TO READ AS
FOLLOWS:
2.9 GRIEVANCE SYSTEM
The CONTRACTOR shall have a grievance system in place for members that
includes a grievance process related to dissatisfaction, and an appeals
process related to a CONTRACTOR action, including the opportunity to
request an HSD fair hearing.
A grievance is a member's expression of dissatisfaction about any
matter or aspect of the CONTRACTOR or its operation other than a
CONTRACTOR action.
An appeal is a request for review by the CONTRACTOR of a CONTRACTOR
action. An action is the denial or limited authorization of a requested
service, including the type or level of service; the reduction,
suspension, or termination of a previously authorized service; the
denial, in whole or in part, of payment for a service; or the failure
to provide services in a timely manner. An untimely service
authorization constitutes a denial and is thus considered an action.
32
The member, legal guardian of the member for minors or incapacitated
adults, or a representative of the member as designated in writing to
the CONTRACTOR, has the right to file a grievance or an appeal of a
CONTRACTOR action on behalf of the member. A provider acting on behalf
of the member and with the member's written consent, may file a
grievance and/or an appeal of a CONTRACTOR action.
General Requirements for Grievance & Appeals
1. The CONTRACTOR shall implement written policies and procedures
describing how the member may register a grievance or an
appeal with the CONTRACTOR and how the CONTRACTOR resolves the
grievance or appeal.
2. The CONTRACTOR shall provide a copy of its policies and
procedures for resolution of a grievance and/or an appeal to
all service providers in the CONTRACTOR'S network.
3. The CONTRACTOR shall have available reasonable assistance in
completing forms and taking other procedural steps. This
includes, but is not limited to, providing interpreter
services and toll-free numbers that have adequate TTY/TTD and
interpreter capability.
4. The CONTRACTOR shall name a specific individual(s) designated
as the CONTRACTOR'S Medicaid member grievance coordinator with
the authority to administer the policies and procedures for
resolution of a grievance and/or an appeal, to review
patterns/trends in grievances and/or appeals, and to initiate
corrective action.
5. The CONTRACTOR shall ensure that the individuals who make
decisions on grievances and/or appeals are not involved in any
previous level of review or decision-making. The CONTRACTOR
shall also ensure that health care professionals with
appropriate clinical expertise will make decisions for the
following:
a) An appeal of a CONTRACTOR denial that is based on lack of
medical necessity;
b) A CONTRACTOR denial that is upheld in an expedited
resolution;
c) A grievance or appeal that involves clinical issues.
6. Upon enrollment, the CONTRACTOR shall provide members, at no
cost, with a member information sheet or handbook that
provides information on how they and/or their
representative(s) can file a grievance and/or an appeal, and
the resolution process. The member information shall also
advise members of their right to file a request for an
administrative hearing with the HSD Hearings Bureau, upon
notification of a CONTRACTOR action, or concurrent with or
following an appeal of the CONTRACTOR
33
action. The information shall meet the standards for
communication specified in MAD policy 8.305.8.15.(13).
7. The CONTRACTOR must ensure that punitive or retaliatory action
is not taken against a member or a provider that files a
grievance and/or an appeal, or a provider that supports a
member's grievance and/or appeal.
GRIEVANCE
A grievance is a member's expression of dissatisfaction about any
matter or aspect of the CONTRACTOR or its operation other than a
CONTRACTOR action.
1. A member may file a grievance either orally or in writing with
the CONTRACTOR within 90 calendar days of the date the
dissatisfaction occurred. The legal guardian of the member for
minors or incapacitated adults, a representative of the member
as designated in writing to the CONTRACTOR, or a provider
acting on behalf of the member and with the member's written
consent, has the right to file a grievance on behalf of the
member.
2. Within five (5) working days of receipt of the grievance, the
CONTRACTOR shall provide the grievant with written notice that
the grievance has been received and the expected date of its
resolution.
3. The investigation and final CONTRACTOR resolution process for
grievances shall be completed within thirty (30) calendar days
of the date the grievance is received by the CONTRACTOR and
shall include a resolution letter to the grievant.
4. The CONTRACTOR may request an extension from HSD of up to
fourteen (14) calendar days if the member requests the
extension, or the CONTRACTOR demonstrates to HSD that there is
need for additional information, and the extension is in the
member's interest. For any extension, not requested by the
member, the CONTRACTOR shall give the member written notice of
the reason for the extension within two (2) working days of
the decision to extend the timeframe.
5. Upon resolution of the grievance the CONTRACTOR shall mail a
resolution letter to the member. The resolution letter must
include but not be limited to the following:
(a) all information considered in investigating the
grievance;
(b) findings and conclusions based on the investigation;
and
(c) the disposition of the grievance.
APPEALS
34
An appeal is a request for review by the CONTRACTOR of a CONTRACTOR
action.
1. A member may file an appeal of a CONTRACTOR action within 90
calendar days of receiving the CONTRACTOR'S notice of action.
The legal guardian of the member for minors or incapacitated
adults, a representative of the member as designated in
writing to the CONTRACTOR, or a provider acting on behalf of
the member with the member's written consent, has the right to
file an appeal of an action on behalf of the member.
An "action" is defined as:
(a) the denial or limited authorization of a requested
service, including the type or level of service;
(b) the reduction, suspension, or termination of a
previously authorized service;
(c) the denial, in whole or in part, of payment for a
service;
(d) the failure of the CONTRACTOR to provide services in
a timely manner, as defined by HSD; or
(e) the failure of the CONTRACTOR to complete the
authorization request in a timely manner as defined
in 42 CFR Section 438.408.
2. The CONTRACTOR shall have a process in place that assures that
an oral inquiry from a member seeking to appeal an action is
treated as an appeal (to establish the earliest possible
filing date for the appeal). An oral appeal must be followed
by a written appeal that is signed by the member.
3. Within five (5) working days of receipt of the appeal, the
CONTRACTOR shall provide the grievant with written notice that
the appeal has been received and the expected date of its
resolution. The CONTRACTOR shall confirm in writing receipt of
oral appeals, unless the member or the provider requests an
expedited resolution.
4. The CONTRACTOR has thirty (30) calendar days from the date the
oral or written appeal is received by the CONTRACTOR to
resolve the appeal.
5. The CONTRACTOR may extend the thirty (30) day timeframe by 14
calendar days if the member requests the extension, or the
CONTRACTOR demonstrates to HSD that there is need for
additional information, and the extension is in the member's
interest. For any extension not requested by the member, the
CONTRACTOR must give the member written notice of the
extension and the reason for the extension within two (2)
working days of the decision to extend the timeframe.
35
6. The CONTRACTOR shall provide the member and/or the
representative a reasonable opportunity to present evidence,
and allegations of the fact or law, in person as well as in
writing.
7. The CONTRACTOR shall provide the member and/or the
representative the opportunity, before and during the appeals
process, to examine the member's case file, including medical
records, and any other documents and records considered during
the appeals process. The CONTRACTOR shall include as parties
to the appeal, the member and his or her representative, or
the legal representative of a deceased member's estate.
8. For all appeals, the CONTRACTOR shall provide written notice
within the thirty (30) calendar day timeframe of the appeal
resolution to the member and the provider, if the provider
filed the appeal.
a. The written notice of the appeal resolution must
include but not be limited to the following
information:
(i) the result(s) of the appeal resolution; and
(ii) the date it was completed.
b. The written notice of the appeal resolution for
appeals not resolved wholly in favor of the member
must include but not be limited to the following
information:
(i) the right to request an HSD fair hearing and
how to do so;
(ii) the right to request receipt of benefits
while the hearing is pending, and how to
make the request; and
(iii) that the member may be held liable for the
cost of those benefits if the hearing
decision upholds the CONTRACTOR'S action.
9. The CONTRACTOR may continue benefits while the appeal and/or
the HSD fair hearing process is pending.
a. The CONTRACTOR shall continue the member's benefits
if all of the following are met:
(i) The member or the provider files a timely
appeal of the CONTRACTOR action (within
10 days of the date the CONTRACTOR mails the
notice of action);
(ii) The appeal involves the termination,
suspension, or reduction of a previously
authorized course of treatment;
(iii) The services were ordered by an authorized
provider;
(iv) The time period covered by the original
authorization has not expired; and
(v) The member requests extension of the
benefits.
36
b. The CONTRACTOR shall provide benefits until one of
the following occurs:
(i) The member withdraws the appeal;
(ii) Ten days have passed since the date the
CONTRACTOR mailed the resolution letter,
providing the resolution of the appeal was
against the member and the member has
taken no further action;
(iii) An HSD Administrative Law Judge issues a
hearing decision adverse to the member;
(iv) The time period or service limits of a
previously authorized service has expired.
c. If the final resolution of the appeal is adverse to
the member, that is, the CONTRACTOR'S action is
upheld, the CONTRACTOR may recover the cost of the
services furnished to the member while the appeal was
pending to the extent that services were furnished
solely because of the requirements of this section,
and in accordance with the policy set forth in 42 CFR
Section 431.230(b).
d. If the CONTRACTOR or the HSD Administrative Law Judge
reverses a decision to deny, limit, or delay
services, and these services were not furnished while
the appeal was pending, the CONTRACTOR must authorize
or provide the disputed services promptly and as
expeditiously as the member's health condition
requires.
e. If the CONTRACTOR or the HSD Administrative Law Judge
reverses a decision to deny, limit or delay services
and the member received the disputed services while
the appeal was pending, the CONTRACTOR must pay for
these services.
EXPEDITED RESOLUTION OF APPEALS
An expedited resolution of an appeal is an expedited review by the
CONTRACTOR of a CONTRACTOR action.
1. The CONTRACTOR shall establish and maintain an expedited
review process for appeals when the CONTRACTOR determines that
taking the time for a standard resolution could seriously
jeopardize the member's life or health or ability to attain,
maintain, or regain maximum function. Such a determination is
based on:
(i) a request from the member;
(ii) a provider's support of the member's request;
(iii) a provider's request on behalf of the member; and
(iv) the CONTRACTOR'S independent determination.
37
2. The CONTRACTOR shall ensure that the expedited review process
is convenient and efficient for the member.
3. The CONTRACTOR shall resolve the appeal within three (3)
working days of receipt of the request for an expedited
appeal.
4. The CONTRACTOR may extend the timeframe by up to 14 calendar
days if the member requests the extension, or the CONTRACTOR
demonstrates to HSD that there is need for additional
information, and the extension is in the member's interest.
For any extension not requested by the member, the CONTRACTOR
shall make reasonable efforts to give the member prompt oral
notification and follow-up within two (2) days.
5. The CONTRACTOR shall ensure that punitive action is not taken
against a member or a provider who requests an expedited
resolution or supports a member's expedited appeal.
6. The CONTRACTOR shall provide expedited resolution of an appeal
in response to an oral or written request from the member or
provider on behalf of the member.
7. The CONTRACTOR shall inform the member of the limited time
available to present evidence and allegations in fact or law.
8. If the CONTRACTOR denies a request for an expedited resolution
of an appeal, it shall:
(i) transfer the appeal to the thirty (30) day timeframe
for standard resolution, in which the 30-day period
begins on the date the CONTRACTOR received the
request; and
(ii) make reasonable efforts to give the member prompt
oral notice of the denial, and follow up with a
written notice within two (2) calendar days;
(iii) inform the member in the written notice of the right
to file a grievance if the member is dissatisfied
with the CONTRACTOR'S decision to deny an expedited
resolution.
9. The CONTRACTOR shall document in writing all oral requests for
expedited resolution and shall maintain the documentation in
the case file.
Special Rule for Certain Expedited Service Authorization Decisions
In the case of certain expedited service authorization decisions that
deny or limit services, the CONTRACTOR shall, within 72 hours of
receipt of the request for service, automatically file an appeal on
behalf of the member, make a best effort to give the member oral notice
of the decision of the automatic appeal, and make a best effort to
resolve the appeal.
38
OTHER RELATED CONTRACTOR PROCESSES
1. Notice of CONTRACTOR Action (this also applies to Article 2
Section 2.1.(1).N. ii., Denials in the current contract and
renumbered in this Amendment as Section 2.1.(1).O.ii.)
a. The CONTRACTOR shall mail a notice of action to the
member or provider and all those parties affected by
the decision within 10 days of the date of an action.
The notice must contain but not be limited to the
following:
(i) The action the CONTRACTOR has taken or
intends to take;
(ii) The reasons for the action;
(iii) The member's or the provider's right to file
an appeal of the CONTRACTOR action through
the CONTRACTOR;
(iv) The member's right to request an HSD fair
hearing and what the process would be;
(v) The procedures for exercising the rights
specified;
(vi) The circumstances under which expedited
resolution of an appeal is available and how
to request it;
(vii) The member's right to have benefits continue
pending resolution of an appeal, how to
request the benefits be continued, and the
circumstances under which the member may be
required to pay the costs of these services.
2. Information About Grievance System to Providers and
Subcontractors
The CONTRACTOR must provide information specified in 42 CFR
Section, 438.10(g)(1) about the grievance system to all
providers and subcontractors at the time they enter into a
contract.
3. Grievance and/or Appeal Files
a. All grievance and/or appeal files shall be maintained
in a secure, designated area and be accessible to HSD
upon request, for review. Grievance and/or appeal
files shall be retained for six (6) years following
the final decision by the CONTRACTOR, HSD, an
Administrative Law Judge, judicial appeal, or closure
of a file, whichever occurs later.
b. The CONTRACTOR will have procedures for assuring that
files contain sufficient information to identify the
grievance and/or appeal, the date it was received,
the nature of the grievance and/or appeal, notice to
the member of receipt of the grievance and/or appeal,
all correspondence between the CONTRACTOR and the
member, the date the grievance and/or appeal is
resolved, the resolution, and notices of final
decision to the member and all other pertinent
information.
39
c. Documentation regarding the grievance shall be made
available to the member, if requested.
4. Reporting
a. The CONTRACTOR shall provide information requested or
required by the Centers for Medicare and Medicaid
Services.
b. The CONTRACTOR shall provide a quarterly report to
HSD of all grievances received from or about Medicaid
members, by the CONTRACTOR or its subcontractors in
compliance with the timelines and procedures set
forth in Section 2.12.(2).
SECTION 2 (SCOPE OF WORK), SECTION 2.10.(2). IS AMENDED TO READ AS FOLLOWS:
2.10.(2). The CONTRACTOR shall have and maintain adequate protections
against financial loss due to outlier (catastrophic) cases and
member utilization that is greater than expected. The
CONTRACTOR shall submit to HSD such documentation as is
necessary to prove the existence of this protection, which may
include policies and procedures of reinsurance. Information
provided to HSD on the CONTRACTOR's reinsurance must be
computed on an actuarially sound basis.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.10.(6).B. IS AMENDED TO READ AS FOLLOWS:
2.10.(6).B. Per Member Cash Reserve
The CONTRACTOR shall maintain three (3) percent of the monthly
capitated payments per member with an independent trustee
during each month of the first year of the Agreement;
provided, however, that if this Agreement replaces or extends
a previous agreement with HSD to provide Medicaid managed
care, then continued maintenance of the per member cash
reserve established and maintained by CONTRACTOR pursuant to
such previous agreement shall be deemed to satisfy this
requirement. The CONTRACTOR shall maintain this cash reserve
for the duration of the Agreement. HSD shall adjust this cash
reserve requirement annually, or as needed, based on the
number of the CONTRACTOR'S members. Each CONTRACTOR shall
maintain its own cash reserve account. This account may be
accessed solely for payment for services to that CONTRACTOR'S
members in the event that the CONTRACTOR becomes insolvent.
Money in the reserve account remains the property of the
CONTRACTOR and any interest earned (even if retained in the
account) shall be the property of the CONTRACTOR.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.10.(8).A. IS AMENDED TO READ AS FOLLOWS:
2.10.(8). Timely Payments
40
A. The CONTRACTOR shall make timely payments to both its
contracted and non-contracted providers.
i. The CONTRACTOR shall promptly pay for all
covered emergency services, including
medically necessary testing to determine if
a medical emergency exists, that are
furnished by providers that do not have
arrangements with the CONTRACTOR. This
includes all covered emergency services
provided by a nonparticipating provider,
including those when the time required to
reach the CONTRACTOR'S facilities or the
facilities of a provider with which the
CONTRACTOR has contracted, would mean risk
of permanent damage to the member's health.
ii. The CONTRACTOR shall pay 90 percent of all
clean claims from practitioners who are in
individual or group practice or who practice
in shared health facilities within 30 days
of date of receipt, and shall pay 99 percent
of all such clean claims within 90 days of
receipt. A "clean claim" means a manually or
electronically submitted claim from a
participating provider that: contains
substantially all the required data elements
necessary for accurate adjudication without
the need for additional information from
outside of the health plan's system. It does
not include a claim from a provider who is
under investigation for fraud or abuse, or a
claim under review for medical necessity, or
one that is not materially deficient or
improper, including lacking substantiating
documentation currently required by the
health plan; or one that has no particular
or unusual circumstances requiring special
treatment that prevent payment from being
made by the health plan within thirty days
of the date of receipt if submitted
electronically or forty-five days if
submitted manually.
iii. Consistent with the requirements of MAD Reg.
8.305.11.9.B(1), which applies to clean
claims submitted electronically, and NMSA
Section59A-2-9.2, the CONTRACTOR shall pay
interest at the rate of one and one-half
percent a month on:
(1) the amount of a clean claim
electronically submitted by a
contracted provider and not paid
within thirty days of the date of
receipt; and
(2) the amount of a clean claim
manually submitted by a contracted
provider and not paid within
forty-five days of the date of
receipt.
(3) Interest payments shall accrue and
begin on the 31st day for
electronic submissions and the 46th
day for hard copy.
41
ARTICLE 2 (FIDUCIARY RESPONSIBILITIES), SECTION 2.10.(11) IS ADDED TO READ AS
FOLLOWS:
2.10.(11) Special Contract Provisions As required by 42 CFR 438.6 (c
)(5): Pursuant to 42 CFR Section 438.6(c)(5), contract
provisions for reinsurance, stop-loss limits or other risk
sharing methodologies must be computed on an actuarially sound
basis.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.12.(4).A., B. AND C IS AMENDED TO READ AS
FOLLOWS:
2.12.(4).A. The CONTRACTOR is required to submit data to HSD. Subject to
the provisions of Section 4.2 of this Agreement, HSD shall
define the format and data elements after having consulted
with the CONTRACTOR on the definition of these elements.
2.12.(4).B. The CONTRACTOR is responsible for identifying and reporting to
HSD immediately upon discovery any inconsistencies in its
automated reporting, CONTRACTOR shall make necessary
adjustments to its reports at its own expense.
2.12.(4).C. HSD, in conjunction with its fiscal agent, intends to
implement electronic data interchange standards for
transactions related to managed health care. Subject to the
provisions of Section 4.2 of this Agreement, the CONTRACTOR
shall work with HSD to develop the technical components of
such an interface.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.12.(5).B. IS AMENDED TO READ AS FOLLOWS:
2.12.(5).B. Encounter Submission Time Frames
The CONTRACTOR shall submit encounters to HSD within 120 days
of the date of service or discharge, regardless of whether the
encounter is from a subcontractor or subcapitated arrangement.
Encounters that do not clear edit checks shall be returned to
the CONTRACTOR for correction and re-submission. The
CONTRACTOR shall correct and resubmit the encounter data to
HSD.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.12.(5).C IS AMENDED TO READ AS FOLLOWS:
2.12.(5).C. Encounter Data Elements
Encounter data elements are based on the Medicaid-Medicare
Common Data Initiative (McData Set) which is a minimum core
data set for states and MCOs developed by CMS and HSD for use
in managed care. Subject to the provisions of Section 4.2 of
this Agreement, HSD may
42
increase or reduce or make mandatory or optional, data
elements as it deems necessary.
ARTICLE 2 (SCOPE OF WORK) SECTION 2.13.(6).A. IS AMENDED TO READ AS FOLLOWS:
2.13.(6).A. Submitting to HSD encounters, according to the specifications
included in the SALUD! Systems Manual, within 120 days of the
date of service or discharge, regardless of whether the
encounter is from a subcontractor or subcapitated arrangement;
ARTICLE 2 (SCOPE OF WORK) SECTION 2.13.(6).E. IS AMENDED TO READ AS FOLLOWS:
2.13.(6).E. Including written contractual requirements for subcontractors
or providers that pay their own claims to submit encounters to
the CONTRACTOR on a timely basis to ensure that the CONTRACTOR
can submit encounters to HSD within 120 days of the date of
service or discharge;
ARTICLE 2 (SCOPE OF WORK), SECTION 2.14 IS ADDED TO READ:
2.14 CARE COORDINATION
(1) General Requirements
Care coordination is defined as a service that assists clients with
special health care needs. Care coordination is provided on an as
needed basis. Care coordination is member-centered, family-focused
(when appropriate), culturally competent and strength-based service.
Care coordination helps to ensure that the medical and behavioral
health needs of the Salud! population are identified and related
services are provided and coordinated with the individual member and
family as appropriate. Care coordination operates within the MCO by
means of a dedicated care coordination staff functioning independently
but is structurally linked to the other MCO systems, such as quality
assurance, member services and grievances. Clinical decisions shall be
based on the medically necessary covered services and not fiscal
considerations. If both physical and behavioral health conditions
exist, the care shall be coordinated between both physical and
behavioral health staff, and the responsibility for the care
coordination shall be based upon what is in the best interest of the
member.
(2) Primary Elements of Care Coordination
The CONTRACTOR shall use the following primary elements for care
coordination:
A. Identify proactively the eligible populations;
B. Identify proactively the needs of the eligible
population;
43
C. Designate an individual who has primary
responsibility for coordinating health services and
serves as the single point of contact for the member;
D. Inform the member regarding the care coordinator's
name and how to contact him/her;
E. Ensure access to a qualified provider who is
responsible for developing and implementing a
comprehensive treatment plan or plan of care as per
applicable provider regulation.
F. Ensure the provision of necessary services and
actively assist members and providers in obtaining
such services;
G. Ensure appropriate coordination between physical and
behavioral health services and non-Salud! services;
H. Coordinate with designated case managers and/or
medical/behavioral health service providers;
I. Monitor progress of the members to ensure that
services are received and assist in resolving
identified problems;
J. Be responsible for linking individuals to case
management when needed if a local case
manager/designated provider is not available.
ARTICLE 3 (LIMITATION OF COST) IS AMENDED TO READ AS FOLLOWS:
In no event shall capitation fees or other payments provided for in the
Agreement exceed the payment limits set forth in 42 C.F.R. Section 447.361 and
447.362. In no event shall HSD pay twice for the provision of services.
ARTICLE 4 (HSD RESPONSIBILITY) SECTION 4.1.(18). IS AMENDED TO READ AS FOLLOWS:
4.1.(18). Amend its fee-for-service and other provider agreements, or
take such other action as may be necessary to encourage health
care providers paid by HSD to enter into contracts with the
CONTRACTOR at the applicable Medicaid reimbursement rate for
the provider, absent other negotiated arrangements, and take
all available measures to have any Medicaid participating
provider who is not contracted with the CONTRACTOR accept the
applicable Medicaid reimbursement as payment in full for
covered services provided in an emergency to a member who is
enrolled with the CONTRACTOR. The applicable Medicaid
reimbursement rate is defined to exclude disproportionate
share and medical education payments.
ARTICLE 4 (HSD RESPONSIBILITY) SECTION 4.1.(20). IS ADDED TO READ AS FOLLOWS:
4.1.(20). Ensure that no requirement or specification established or
provided by HSD under this section conflicts with requirements
or specifications established pursuant to the federal Health
Insurance Portability and Accountability Act (HIPAA) and the
regulations promulgated thereunder.
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All requirements and specifications established or provided by
HSD under this section shall comply with the requirements of
Section 4.2 of this Agreement.
ARTICLE 4 (HSD RESPONSIBILITY) SECTION 4.1.(21). IS ADDED TO READ AS FOLLOWS:
4.1.(21). Cooperate with CONTRACTOR in CONTRACTOR'S efforts to achieve
compliance with HIPAA requirements.
ARTICLE 4 (HSD RESPONSIBILITY) SECTION 4.2. IS AMENDED TO READ AS FOLLOWS:
4.2.(1). HSD and/or its fiscal agent shall implement electronic data
standards for transactions related to managed health care. In
the event HSD and/or any of its agents are unable to accept
standard transactions on or after October 1, 2003, the
CONTRACTOR and HSD shall address any additional costs
associated with such an event through an amendment to this
contract.
4.2.(2). In the event that HSD and/or its fiscal agent requests that
the CONTRACTOR or its subcontractors deviate from or provide
information in addition to the information called for in
required and optional fields included in the standard
transaction code sets established under HIPAA, such request
shall be made by amendment to this Agreement in accordance
with the provisions of Article 37.
ARTICLE 5 (COMPENSATION & PAYMENT REIMBURSEMENT FOR MANAGED CARE), SECTION 5.1
IS AMENDED TO READ AS FOLLOWS:
5.1 HSD shall make payments under capitated risk contracts which
are actuarially sound. Rates shall be developed in accordance
with generally accepted actuarial principles and practices.
Rates must be appropriate for the populations to be covered,
the services to be furnished under the contract and be
certified as meeting the foregoing requirements by actuaries.
The actuaries must meet the qualification standards
established by the American Academy of Actuaries and follow
the practice standards established by the Actuarial Standards
Board. To the extent, if any, it is determined by the
appropriate taxing authority, that the performance of this
Agreement by the CONTRACTOR is subject to taxation, the
amounts paid by HSD to the CONTRACTOR under this Agreement,
shall include such tax(es). The CONTRACTOR is responsible for
reporting and remitting all applicable taxes to the
appropriate taxing agency.
ARTICLE 5 (COMPENSATION & PAYMENT REIMBURSEMENT FOR MANAGED CARE) SECTION 5.2.
IS AMENDED TO READ AS FOLLOWS:
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5.2 The monthly rates set forth in Attachments A and B shall be subject to
renegotiation during the Agreement if HSD determines that it is
necessary due to change in Federal or State law or in the
appropriations made available for these tasks as set forth in Article
14, Appropriations, and Article 12, Contract Modification. Rates shall
in all events be actuarially sound. In addition, in the event that HSD
implements a significant or material program change under this or any
other provision of this Agreement, such change including but not
limited to the rates paid hereunder and the costs associated with the
change, shall be adjusted appropriately pursuant to a mutually
agreeable amendment to this Agreement in accordance with the provisions
of Article 37.
ARTICLE 5 (COMPENSATION & PAYMENT REIMBURSEMENT FOR MANAGED CARE), SECTION
5.3.(1). IS AMENDED TO READ AS FOLLOWS:
5.3.(1). HSD shall pay a capitated amount to the CONTRACTOR for the
provision of the managed care benefit package at the rates
specified below. The monthly rate for each member is based on
actuarially sound capitation rate cells. Medicaid members
shall be held harmless against any liability for debts of a
CONTRACTOR that were incurred within the Agreement in
providing covered services to the Medicaid member.
ARTICLE 5 (COMPENSATION & PAYMENT REIMBURSEMENT FOR MANAGED CARE), SECTION
5.3.(4). IS ADDED TO READ AS FOLLOWS:
5.3.(4). 42 CFR Section 438.6(c), which regulates participation in the
Medicaid program, requires that all payments under risk
contracts and all risk-sharing mechanisms in contracts must be
actuarially sound and approved as such by the Centers for
Medicare and Medicaid Strategies (CMS) prior to
implementation. To meet the requirement for actuarial
soundness, all capitation rates must be certified by an
actuary meeting the qualification standards of the American
Academy of Actuaries following generally accepted actuarial
principles, as set forth in the standards of practice
established by the Actuarial Standards Board. Accordingly, the
State's offer of all capitation rates referred to in the
attached Schedule of this contract is contingent on both
certification by the State's actuary and final approval by
CMS, prior to becoming effective for payment purposes. In the
event such certification or approval is not obtained for any
or all capitation rates subject to this regulation, the State
reserves the right to renegotiate these rates. The state's
decision to renegotiate the rates under the circumstances
described above is binding on the CONTRACTOR.
ARTICLE 5 (COMPENSATION & PAYMENT REIMBURSEMENT FOR MANAGED CARE) SECTION
5.5.(1) IS AMENDED TO READ AS FOLLOWS:
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5.5.(1). The capitation rates shall remain in effect as referenced in
Attachments A and B for the first twenty-four (24) months
following the effective date of the original Agreement and
thereafter the capitation rates shall be effective for twelve
(12) months. Capitation rates may be reviewed if this
Agreement is extended with the CONTRACTOR pursuant to this
Agreement. Upon mutual agreement of the CONTRACTOR and HSD,
the capitation rates may be adjusted based on factors such as
changes in the scope of work, a Native American MCO is
established or a Navajo Medicaid Agency created, CMS requires
a modification of the state's waiver or new or amended federal
or state laws or regulations are implemented, inflation,
significant changes in the demographic characteristics of the
member population, or the disproportionate enrollment
selection of the CONTRACTOR by members in certain rate
cohorts. Any changes to the rates shall be actuarially sound
and negotiated and implemented pursuant to Articles 12
(Contract Modification) and 37 (Amendments) of this Agreement.
ARTICLE 5 (COMPENSATION & PAYMENT REIMBURSEMENT FOR MANAGED CARE) SECTION
5.6.(4) IS AMENDED TO READ AS FOLLOWS:
5.6.(4). HSD shall have the discretion to recoup payments for members
who are incorrectly enrolled with more than one CONTRACTOR
including members categorized as newborns or X5; payments made
for members who die prior to the enrollment month for which
payment was made; and/or payments for members whom HSD later
determines were not eligible for Medicaid during the
enrollment month for which payment was made. Notwithstanding
the foregoing, in the absence of fraud on the part of
CONTRACTOR, HSD shall not have the right to recoup any payment
made to the CONTRACTOR if either the CONTRACTOR (and/or its
subcontractors) provided any health care services to the
member during the relevant period of time or more than
twenty-four months have elapsed since the payments were made
unless HSD is required by a federal agency to go beyond the
twenty-four month period. To allow for claim submission lags,
HSD will not request a payment recoupment until 120 days has
elapsed from the date of which the enrollment error was made.
Any process that automates the recoupment procedures will be
mutually agreed upon in advance by HSD and the CONTRACTOR and
documented in writing. The CONTRACTOR has the right to dispute
any recoupment requests in accordance with Article 15
(DISPUTES).
ARTICLE 5 (COMPENSATION & PAYMENT REIMBURSEMENT FOR MANAGED CARE), SECTION
5.6.(8). IS AMENDED TO READ AS FOLLOWS:
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5.6.(8). On a periodic basis, HSD shall provide the CONTRACTOR with
coordination of benefits and third party liability information
for enrolled members. The CONTRACTOR shall:
ARTICLE 5 (COMPENSATION & PAYMENT REIMBURSEMENT FOR MANAGED CARE), SECTION
5.6.(8).B IS AMENDED TO READ AS FOLLOWS:
5.6.(8).B. Have the sole right of subrogation, and to recovery of and/or
to attempt to recover any third-party resources available to
Medicaid members but shall make records pertaining to Third
Party Collections (TPL) for members available to HSD for audit
and review.
ARTICLE 5 (COMPENSATION & PAYMENT REIMBURSEMENT FOR MANAGED CARE), SECTION
5.8.(3) IS AMENDED TO READ AS FOLLOWS:
5.8.(3). The CONTRACTOR is required to pay for all emergency and
poststabilization care services that are medically necessary
until the emergency medical condition is stabilized and
maintained such that within reasonable medical probability, no
material deterioration of the patient's condition is likely to
result from or occur during discharge of the patient or
transfer of the patient to another facility.
ARTICLE 5 (COMPENSATION & PAYMENT REIMBURSEMENT FOR MANAGED CARE), SECTION 5.9
IS ADDED TO READ AS FOLLOWS:
5.9. The CONTRACTOR shall accept the capitation rate paid each month by the
HSD as payment in full for all services to be provided pursuant to this
Agreement, including all administrative costs associated therewith. A
minimum of eighty-five percent (85%) of all the CONTRACTOR'S income
generated under this Agreement, including but not limited to Third
Party Recoupments and Interest, shall be expended on the medical and
related services required under this Agreement to be provided to the
CONTRACTOR'S Medicaid Members. If the CONTRACTOR does not expend a
minimum of eighty-five percent (85%) on medical and related services of
the Agreement, the HSD will withhold an amount so that the CONTRACTOR'S
ratio for service expenditures are eighty-five percent (85%). The HSD
will calculate the CONTRACTOR'S income at the end of the State Fiscal
Year to determine if eighty-five percent (85%) was expended on the
medical and related services required under the contract utilizing
reported information and the Department of Insurance Reports.
Administrative costs and other financial information will be monitored
on a regular basis by the HSD.
Members shall be entitled to receive all covered services for the
entire period for which payment has been made by the HSD. Any and all
costs incurred by the CONTRACTOR in excess of the capitation payment
will be borne in full by the CONTRACTOR. Interest generated through
investment of funds paid to the
48
CONTRACTOR pursuant to this Agreement shall be the property of the
CONTRACTOR.
ARTICLE 8 (ENFORCEMENT) SECTION 8.1.(2).B. IS AMENDED TO READ AS FOLLOWS:
8.1.(2).B. Directed Plans of Correction. The CONTRACTOR shall be
required to provide to HSD, within fourteen (14) days, a
response to the directed plan of correction as directed by
HSD.
ARTICLE 8 (ENFORCEMENT), SECTION 8.1.(2).C.III IS AMENDED TO READ AS FOLLOWS:
8.1.(2).C.iii. The limit on, or specific amount of, civil monetary penalties
that HSD may impose upon the CONTRACTOR varies depending upon
the nature and severity of the CONTRACTOR'S action or failure
to act, as specified below:
a. A maximum of $25,000 for each of the following
determinations: failure to provide medically
necessary services; misrepresentation or false
statements to members, potential members, or health
care provider(s); or failure to comply with physician
incentive plan requirements and marketing violations.
b. A maximum of $100,000 for each of the following
determinations: discrimination; or misrepresentation
or false statements to HSD or CMS.
c. A maximum of $15,000 for each member HSD determines
was not enrolled, or reenrolled, or enrollment was
terminated because of a discriminatory practice. This
is subject to an overall limit of $100,000 under (b.)
above.
d. A maximum of $25,000 or double the amount of excess
charges whichever is greater, for premiums or charges
in excess of the amount permitted under the Medicaid
program. HSD will deduct from the penalty the amount
of overcharge and return it to the affected
member(s).
ARTICLE 8. (ENFORCEMENT), SECTION 8.1.(2).L. IS AMENDED TO READ AS FOLLOWS:
8.1.(2).L. Temporary Management
1. Optional imposition of sanction. HSD may impose
temporary management to oversee the operations of the
CONTRACTOR upon a finding by the Secretary of HSD
that there is continued egregious behavior by the
CONTRACTOR, including but not limited to behavior
that is described in 42 CFR Section 438.700, or that
is contrary to any requirements of 42 USC, Sections
42 USC 1396b (m) or 1396u-2; there is substantial
risk to members health; or the sanction is necessary
to ensure the health of the CONTRACTOR'S members
while improvement is made to remedy violations under
42
49
CFR Section 438.700; or until there is an orderly
termination or reorganization of the CONTRACTOR.
2. The CONTRACTOR does not have the right to a
predetermination hearing prior to the appointment of
temporary management if the conditions above are not
met.
3. Required imposition of sanction. HSD shall impose
temporary management (regardless of any other
sanction that may be imposed) if it finds that the
CONTRACTOR has repeatedly failed to meet substantive
requirements in 42 USC, Section 1396b (m) or 1396u-2
or 42 CFR 438, Subpart I (Sanctions).
4. Hearing. HSD shall not delay imposition of temporary
management to provide a hearing before imposing this
sanction.
5. Duration of Sanction. HSD shall not terminate
temporary management until it determines that the
CONTRACTOR can ensure that the sanctioned behavior
will not recur.
ARTICLE 8. (ENFORCEMENT), SECTION 8.1.(2).M. IS AMENDED TO READ AS FOLLOWS:
8.1.(2).M. Terminate Enrollment
HSD shall grant members the right to terminate enrollment
without cause as described in 42 CFR Section 438.702 (a) (3),
and shall notify the affected members of their right to
terminate enrollment.
ARTICLE 8. (ENFORCEMENT), SECTION 8.1.(2).O. IS AMENDED TO READ AS FOLLOWS:
8.1.(2).O. Intermediate Sanctions
1. Basis for imposition of Sanctions: HSD will impose
the foregoing sanctions if HSD determines that the
CONTRACTOR acts or fails to act as follows:
(a) fails substantially to provide medically
necessary services and items that the
CONTRACTOR is required to provide, under law
or under its contract with HSD, to a member
covered under the contract;
(b) imposes on members premiums or charges that
are in excess of the premiums or charges
permitted under the Medicaid program;
(c) acts to discriminate among members on the
basis of their health status or need for
health care services. This includes
termination of enrollment or refusal to
reenroll a member, except as permitted by
the Medicaid program, or any practice that
would reasonably be expected to discourage
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enrollment by members whose medical
condition or history indicate probable need
for substantial future medical services;
(d) misrepresents or falsifies information that
it furnishes to HSD or CMS;
(e) misrepresents or falsifies information that
it furnishes to a member, potential member,
or health care provider;
(f) fails to comply with Federal requirements
for physician incentive plans, including
disclosures;
(g) has distributed directly, or becomes aware
of material distributed indirectly through
any agent or independent subcontractor,
marketing materials that have not been
approved by HSD or that contain false or
materially misleading information; or
(h) fails to perform in any other contract
areas.
2. HSD's determination of any of the above may be based
on findings from onsite reviews; surveys or audits;
member or other complaints; financial status; or any
other source.
3. HSD retains authority to impose additional sanctions
under state statutes or state regulations that
address areas of noncompliance specified in 42 CFR
Section 438.700, as well as additional areas of
noncompliance.
4. Intermediate Sanctions: The Secretary of HSD or
designee will impose upon the CONTRACTOR any of the
following intermediate sanctions:
(a) civil monetary penalties in the amounts
specified in the 42 CFR, Section 438.704;
(b) appointing temporary management for the
CONTRACTOR or a State Monitor as provided in
42 CFR Section 438.706;
(c) granting members the right to terminate
enrollment without cause (affected members
will be notified by HSD of their right to
disenroll);
(d) suspending all new enrollment, including
default enrollment after the effective date
of sanction;
(e) suspending of payment for members enrolled
after the effective date of the sanction
until HSD or CMS is satisfied that the
reason for imposing the sanction no longer
exists and is not likely to recur.
ARTICLE 8 (ENFORCEMENT) 8.1. (2).Q. IS AMENDED TO READ AS FOLLOWS:
8.1.(2).Q. The Secretary of HSD or the designee has the authority to
terminate the contract and enroll the CONTRACTOR'S members in
another MCO or
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other MCOs, or provide their Medicaid benefits through other
options included in the State plan, if HSD determines that the
CONTRACTOR has failed to do either of the following:
1. Carry out the substantive terms of its contract; or
2. Meet applicable requirements in Sections 1932,
1903(m), and 1905 of the Social Security Act.
ARTICLE 8 (ENFORCEMENT) 8.1.(2).R. IS ADDED TO READ AS FOLLOWS:
8.1.(2).R. Notice of sanction: Except as provided in this Article
regarding Temporary Management, before imposing any of the
intermediate sanctions specified, HSD must give the CONTRACTOR
timely written notice that explains the basis and nature of
the sanction and any other due process protections that HSD
elects to provide.
a. Pre-termination hearing: Before terminating the
contract, HSD must provide the CONTRACTOR a
pre-termination hearing, which consist of the
following procedures:
1. HSD shall give the CONTRACTOR written notice
of its intent to terminate, the reason for
the termination, and the time and place of
the hearing.
2. After the hearing, HSD shall give the
CONTRACTOR written notice of the decision
affirming or reversing the proposed
termination of the contract and, for an
affirming decision, the effective date of
termination.
3. For an affirming decision, give members of
the CONTRACTOR notice of the termination and
information, consistent with their options
for receiving Medicaid services following
the effective date of termination.
4. The pre-termination hearing procedures shall
proceed according to Section 15.3 (Dispute
Procedures) of the Agreement.
b. HSD will give the CMS Regional Office written notice
whenever it imposes or lifts a sanction for one of the
violations listed in Section 8.1.(2).O. of this Article.
The notice will be given no later than 30 days after HSD
imposes or lifts a sanction; and must specify the
affected CONTRACTOR, the kind of sanction, and the
reason for HSD's decision to impose or lift the
sanction.
ARTICLE 8 (ENFORCEMENT) SECTION 8.3 IS AMENDED TO READ AS FOLLOWS:
8.3. Notice and Cure
HSD shall provide reasonable written notice of its decision to impose
sanctions on the CONTRACTOR and, as HSD may deem necessary and proper,
subsequently to members and others who may be directly interested. Such
written notice shall set forth the effective date and the reason(s) for
the
52
sanctions. Prior to imposing sanctions, HSD shall afford the CONTRACTOR
a reasonable opportunity to cure, unless such opportunity would result
in immediate harm to members, or the improper diversion of Medicaid
program funds.
ARTICLE 9 (TERMINATION) SECTION 9.1.(17) IS AMENDED TO READ AS FOLLOWS:
9.1.(17). By the CONTRACTOR, on at least sixty (60) days prior written
notice in the event that HSD is unable to make future payments
of undisputed capitation payments due to a lack of a state
budget or legislative appropriation;
ARTICLE 9 (TERMINATION) SECTION 9.1.(18). IS ADDED TO READ AS FOLLOWS:
9.1.(18). By either party, upon 90 days written notice, in the event of
a material change in the Medicaid managed care program,
regardless of the cause of or reason for such change, if the
parties after negotiating in good faith are unable to agree on
the terms of an amendment to incorporate such change; and
ARTICLE 9 (TERMINATION) SECTION 9.1.(19). IS RENUMBERED TO READ AS FOLLOWS:
9.1.(19). By the CONTRACTOR on sixty (60) days prior written notice with
cause, or one hundred eighty (180) days written notice without
cause.
ARTICLE 10 (TERMINATION AGREEMENT), SECTION 10.3 IS ADDED TO READ AS FOLLOWS:
10.3. Dispute Procedure Involving Contract Termination Proceedings. In the
event HSD seeks to terminate this Agreement with the CONTRACTOR, the
CONTRACTOR may appeal the termination directly to the HSD Secretary
within ten (10) days of receiving HSD's termination notice.
(1) The HSD Secretary shall acknowledge receipt of the
CONTRACTOR'S appeal request within three (3) calendar days of
the date the appeal request is received.
(2) The HSD Secretary will conduct a formal hearing on the
contract termination issues raised by the CONTRACTOR.
(3) The CONTRACTOR and MAD, or its successor, shall be allowed to
present evidence in the form of documents and testimony.
(4) The parties to the hearing are the CONTRACTOR and MAD, or its
successor.
(5) The hearing shall be recorded by a court reporter paid for
equally by HSD and the CONTRACTOR. Copies of transcripts of
the hearing shall be paid by the party requesting the copy.
(6) The court reporter shall swear witnesses under oath.
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(7) The HSD Secretary shall determine which party presents its
issues first and shall allow both sides to question each
other's witnesses in the order determined by the Secretary.
(8) The HSD Secretary may, but is not required, to allow opening
statements from the parties before taking evidence.
(9) The HSD Secretary may, but it not required, to request written
findings of fact, conclusions of law and closing argument or
any combination thereof. Or, the Secretary may, but is not
required, to allow only oral closing argument.
(10) The HSD Secretary shall render a written decision and mail the
decision to the CONTRACTOR within sixty (60) days of the date
the request for a hearing is received.
(11) MAD, or its successor, and the CONTRACTOR may be represented
by counsel or another representative of choice at the hearing.
The legal or other representative shall submit a written
request for an appearance with the Secretary within fifteen
(15) days of the date of the hearing request.
(12) The civil rules of procedure and rules of evidence shall not
apply, but the Secretary may limit evidence that is redundant
or not relevant to the contract termination issues presented
for review.
(13) The Secretary's written decision shall be mailed by certified
mail, postage prepaid, to the CONTRACTOR. Another copy of the
decision shall be sent to the MAD director.
ARTICLE 14 (APPROPRIATIONS) SECTION 14.1 IS AMENDED TO READ AS FOLLOWS:
14.1 The terms of this Agreement are contingent upon sufficient
appropriations or authorizations being made by either the Legislature
of New Mexico, Health and Human Services (HHS)/Centers for Medicare and
Medicaid Services (CMS), or the U.S. Congress for the performance of
this Agreement. If sufficient appropriations and authorizations are not
made by either the Legislature, HHS/CMS or the Congress, this Agreement
shall be subject to termination or amendment. Subject to the provisions
of Article 27 of this Agreement, HSD's decision as to whether
sufficient appropriations or authorizations exist shall be accepted by
the CONTRACTOR and shall be final and binding. Any changes to the Scope
of Work and compensation to CONTRACTOR effected pursuant to this
Section 14.1 shall be negotiated, reduced to writing and signed by the
parties in accordance with Article 37 (Amendments) of this Agreement
and any other applicable state or federal rules, regulations or
statutes.
ARTICLE 14 (APPROPRIATIONS) SECTION 14.2 IS AMENDED TO READ AS FOLLOWS:
14.2 To the extent CMS, legislation or congressional action impacts the
amount of appropriation available for performance under this contract,
HSD has the right to amend the Scope of Work, in its discretion, which
shall be effected by HSD sending written notice to the CONTRACTOR. Any
changes to the Scope of Work and compensation to CONTRACTOR effected
pursuant to this Section
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14.2 shall be negotiated, reduced to writing and signed by the parties
in accordance with Article 37 (Amendments) of this Agreement and any
other applicable state or federal rules, regulations or statutes.
ARTICLE 15 (DISPUTES), SECTION 15.3.(1). IS AMENDED TO READ AS FOLLOWS:
15.3. Dispute Procedures for Other than Contract Termination Proceedings
(1) Except for contract termination (specified in Section 8.1.(2)
(Q), any dispute concerning sanctions imposed under this
Agreement shall be reported in writing to the MAD director
within fifteen (15) days of the date the reporting party
receives notice of the sanction. The decision of the Director
regarding the dispute shall be delivered to the parties in
writing within thirty (30) days of the date the Director
receives the written dispute. The decision shall be final and
conclusive unless, within fifteen (15) days from the date of
the decision, either party files with the HSD Secretary a
written appeal of the decision of the Director.
ARTICLE 26 (ERRONEOUS ISSUANCE OF PAYMENT OR BENEFITS) IS AMENDED TO READ AS
FOLLOWS:
In the event of an error which causes payment(s) to the CONTRACTOR to be issued
by HSD, the CONTRACTOR shall reimburse the State within thirty (30) days of
written notice of such error for the full amount of the payment, subject to the
provisions of Section 5.6(4) of this Agreement. Interest shall accrue at the
statutory rate on any amounts not paid and determined to be due after the
thirtieth (30th) day following the notice.
ARTICLE 27 (EXCUSABLE DELAYS) IS AMENDED TO READ AS FOLLOWS:
The CONTRACTOR shall be excused from performance hereunder for any period that
it is prevented from performing any services hereunder in whole or in part as a
result of an act of nature, war, civil disturbance, epidemic, court order, or
other cause beyond its reasonable control, and such nonperformance shall not be
a default hereunder or ground for termination of the Agreement.
In addition the CONTRACTOR shall be excused from performance hereunder during
any period for which the State of New Mexico has failed to enact a budget or
appropriate monies to fund the managed care program provided that the CONTRACTOR
notifies HSD, in writing, of its intent to suspend performance and HSD is unable
to resolve the budget or appropriation deficiencies within forty-five (45) days.
In addition, the CONTRACTOR shall be excused from performance hereunder for
insufficient payment by HSD provided that the CONTRACTOR notifies HSD in writing
of its intent to suspend performance and HSD is unable to remedy the monetary
shortfall within 45 days.
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ARTICLE 28 (MARKETING), SECTION 28.2. IS AMENDED IN ITS ENTIRETY TO READ AS
FOLLOWS:
28.2 HSD shall review and approve the content, comprehension level, and
language(s) of all marketing materials directed at members before use.
(1) The CONTRACTOR shall distribute its marketing materials to its
entire service area;
(2) The CONTRACTOR shall not seek to influence enrollment in
conjunction with the sale or offering of any private
insurance, not including public/private partnerships; and
(3) The CONTRACTOR shall specify the methods by which the entity
assures HSD that marketing materials are accurate and do not
mislead, confuse, or defraud the members or HSD. Statements
that will be considered inaccurate, false, or misleading
include, but are not limited to, any assertion or statement
(whether written or oral )that:
(a) the member must enroll in the MCO in order to obtain
benefits or in order not to lose benefits; or
(b) The MCO is endorsed by CMS, the Federal or State
Government, or similar entity.
ARTICLE 28 (MARKETING) SECTION 28.3.(1). IS AMENDED TO READ AS FOLLOWS:
28.3.(1). Marketing and/or outreach materials shall meet requirements
for all communication with Medicaid members, as set forth in
Section MAD 8.305.5.16, MEDICAID MANAGED CARE MARKETING
GUIDELINES.
ARTICLE 28 (MARKETING), SECTION 28.4.(1).G. IS AMENDED TO READ AS FOLLOWS:
28.4.(1).G. Directly or indirectly conducting door-to-door, telephonic or
other "Cold Call" marketing. "Cold Call" marketing is defined
as any unsolicited personal contact by the MCO with a
potential member for the purpose of marketing. Marketing means
any communication from an MCO to a Medicaid member who is not
enrolled in that entity, that can reasonably be interpreted as
intended to influence the member to enroll in that particular
MCO's Medicaid product, or either not to enroll in, or to
disenroll from, another MCO's Medicaid product. The CONTRACTOR
may send informational material regarding their benefit
package to potential members.
ARTICLE 28 (MARKETING), SECTION 28.8. IS AMENDED TO READ AS FOLLOWS:
28.8 Health Education and Outreach Materials may be distributed to
the CONTRACTOR'S members by mail or in connection with
exhibits or other organized events, including but not limited
to health fair, booths at
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community events and health plan hosted health improvement
events. Health Education means programs, services or
promotions that are designed or intended to inform the
CONTRACTOR'S actual or potential members upon request about
the issues related to health lifestyles, situations that
affect or influence health status or methods or modes of
medical treatment. Outreach is the means of educating or
informing the CONTRACTOR'S actual or potential members about
health issues. Health Education and Outreach materials include
but are not limited to general distribution brochures, member
newsletters, posters, member handbooks. HSD shall not approve
health education materials.
ARTICLE 32 (CONFIDENTIALITY), SECTION 32.1 IS AMENDED TO READ AS FOLLOWS:
32.1 Any confidential information, as defined in State or Federal law, code,
rules or regulations or otherwise applicable by the Code of Ethics,
regarding HSD's members or providers given to or developed by the
CONTRACTOR and its subcontractors shall not be made available to any
individual or organization by the CONTRACTOR and its subcontractors
without the prior written approval of HSD. Specifically the CONTRACTOR
shall ensure that medical records and any other health and enrollment
information that identifies a particular member, that the CONTRACTOR
uses and discloses such individually identifiable health information in
accordance with the privacy requirements in 45 CFR parts 160 and 164,
subparts A and E, to the extent that these requirements are applicable.
ARTICLE 32 (CONFIDENTIALITY) SECTION 32.5. IS ADDED TO READ AS FOLLOWS:
32.5 The CONTRACTOR and HSD shall each comply with all requirements
established under HIPAA regarding the privacy of individually
identifiable health information and notices.
ARTICLE 33 (COOPERATION WITH MEDICAID FRAUD CONTROL UNIT) SECTION 33.1. IS
AMENDED TO READ AS FOLLOWS:
33.1 The CONTRACTOR shall make an initial report to HSD within five working
days when, in CONTRACTOR'S professional judgment, suspicious activities
may have occurred. The CONTRACTOR shall then take steps to establish
whether or not, in its professional judgment, potential fraud has
occurred. The CONTRACTOR will then make a report to the HSD and submit
any applicable evidence in support of its findings. If HSD decides to
refer the matter to the New Mexico State Medicaid Fraud Control Unit of
the Attorney General's Office (MFCU), HSD will notify the CONTRACTOR
within five working days of making the referral. The CONTRACTOR shall
cooperate fully with any and all requests from MFCU for additional
documentation or other types of collaboration in accordance with
applicable law.
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CONTRACTOR
BY: /s/ ILLEGIBLE DATE: 6/12/03
-------------------------------
TITLE: PRESIDENT
STATE OF NEW MEXICO
BY: /s/ ILLEGIBLE DATE: 6/30/03
-------------------------------
SECRETARY
HUMAN SERVICES DEPARTMENT
APPROVED AS TO FORM AND LEGAL SUFFICIENCY:
BY: /s/ ILLEGIBLE DATE: 6/19/03
-------------------------------
GENERAL COUNSEL
HUMAN SERVICES DEPARTMENT
OFFICE OF THE ATTORNEY GENERAL
BY: /s/ ILLEGIBLE DATE: 8/5/03
-------------------------------
THE RECORDS OF THE TAXATION AND REVENUE DEPARTMENT REFLECT THAT THE CONTRACTOR
IS REGISTERED WITH THE TAXATION AND REVENUE DEPARTMENT OF THE STATE OF NEW
MEXICO TO PAY GROSS RECEIPTS AND COMPENSATING TAXES.
TAXATION AND REVENUE DEPARTMENT
ID NUMBER 02 02 1710002
BY: /s/ ▇▇▇▇▇ ▇▇▇▇ DATE: 6/23/03
-------------------------------
DEPARTMENT OF FINANCE AND ADMINISTRATION
BY: /s/ ILLEGIBLE DATE: 8/26/03
-------------------------------
STATE CONTRACTS OFFICER
58
