Exhibit 10.34
MEDICAL SERVICES CONTRACT
FLORIDA HEALTHY KIDS CORPORATION
and
PHYSICIANS HEALTHCARE PLANS, INC.
Pinellas County
Effective Date:
February 1,2000 - September 30,2001
Amendment #1 - Effective 12/01/01
Amendment #2 - Effective 12/01/02
FLORIDA HEALTHY KIDS CORPORATION
CONTRACT FOR MEDICAL SERVICES
TABLE OF CONTENTS
SECTION 1 GENERAL PROVISIONS
1-1 Definitions
SECTION 2 FLORIDA HEALTHY KIDS CORPORATION RESPONSIBILITIES
2-1 Participant Identification
2-2 Payments
2-3 Reduced Fee Arrangements
2-3-1 Specialty Fee Arrangements
2-3-2 Children's Medical Services
2-4 Quarterly Program Updates
2-5 Change in Benefit Schedule
2-6 Marketing
2-7 Forms and Reports
2-8 Coordination of Benefits
2-9 Entitlement to Reimbursement
SECTION 3 PHYSICIANS HEALTHCARE PLANS, INC. (PHP)
3-1 Benefits
3-2 Access to Care
3-3 Marketing Materials
3-4 Use of Name
3-5 Eligibility
3-6 Effective Date of Coverage
3-7 Termination of Participation
3-8 Continuation of Coverage Upon Termination of this Agreement
3-9 Individual Contracts
3-10 Refusal of Coverage
3-11 Extended Coverage
3-12 Grievances and Complaints
3-13 Claims Payment
3-14 Notification
3-15 Rates
3-16 Rate Modification
3-17 Conditions of Services
3-18 Medical Records Requirements
3-18-1 Medical Quality Review and Audit
3-19 Quality Enhancement
3-19-1 Authority
3-19-2 Staff
3-19-3 Peer Review
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3-19-4 Referrals
3-20 Availability of Records
3-21 Audits
3-21-1 Accessibility of Records
3-21-2 Financial Audit
3-21-3 Post-Contract Audit
3-21-4 Accessibility for Monitoring
3-22 Indemnification
3-23 Confidentiality of Information
3-24 Insurance
3-25 Lobbying Disclosure
3-26 Reporting Requirements
3-27 Participant Liability
3-28 Protection of Proprietary Information
3-29 Regulatory Filings
SECTION 4 TERMS AND CONDITIONS
4-1 Effective Date
4-2 Multi-year Agreement
4-3 Entire Understanding
4-4 Independent Contractor
4-5 Assignment
4-6 Notice
4-7 Amendments
4-8 Governing Law
4-9 Contract Variation
4-10 Attorney's Fees
4-11 Representatives
4-12 Termination
4-13 Contingency
SECTION 5 EXHIBITS
Exhibit A: Premium Payment and Rates
Exhibit B: Enrollment Dates
Exhibit C: Benefits
Exhibit D: Coordination of Benefits
Exhibit E: Access Standards
Exhibit F: Grievance Procedure
Exhibit G: Eligibility
Exhibit H: Reporting Requirements
Exhibit I: Certification Regarding Debarment, Suspension and
Involuntary Cancellation
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AGREEMENT TO PROVIDE
COMPREHENSIVE HEALTH CARE SERVICES
This agreement is made by and between the Florida Healthy Kids
Corporation, hereinafter referred to as "FHKC" and PHYSICIANS HEALTHCARE PLANS,
INC., hereinafter referred to as "PHP".
WHEREAS, FHKC has been specifically empowered in subsections
624.91 (3) (b) 4, 7, and 8, Florida Statutes, to enter into contracts with
HMO's, insurers, or any provider of health care services, meeting standards
established by FHKC, for the provision of comprehensive health insurance
coverage to participants; and
WHEREAS, Sections 641.2017 (1) and (2), Florida Statutes, allows PHP to
enter such a contractual arrangement on a prepaid per capita basis whereby PHP
assumes the risk that costs exceed the amount paid on a prepaid per capita
basis; and
WHEREAS, FHKC desires to increase access to health care services and
improve children's health; and
WHEREAS, FHKC did issue an Invitation to Participate in the FHKC School
Enrollment-Based Health Insurance Program inviting PHP as well as other
entities, to submit a proposal for the provision of those comprehensive health
care services set forth in the Invitation to Participate; and
WHEREAS, PHP's proposal in response to the Invitation to Participate was
selected through a competitive bid process as the one of the most responsive
bids; and
WHEREAS, PHP has assured FHKC of full compliance with the standards
established in this Agreement and agrees to promptly respond to any required
revisions or changes in the FHKC operating procedures which may be required by
law or implementing regulations; and
WHEREAS, FHKC is desirous of using PHP's provider network to deliver
comprehensive health care services to all eligible FHKC participants in Pinellas
County;
NOW, THEREFORE, in consideration of the premises and the mutual
covenants and promises contained herein, the parties agree as follows:
SECTION 1 GENERAL PROVISIONS
1-1 Definitions
As used in this agreement, the term:
A. "COMPREHENSIVE HEALTH CARE SERVICES" means those
services, medical equipment, and supplies to be provided
by PHP in accordance with standards set by FHKC and
further described in Exhibit C.
B. "THE PROGRAM" shall mean the project established by FHKC
pursuant to
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Section 624.91, Florida Statutes and specified herein.
C. "PARTICIPANT" means those individuals meeting FHKC
standards of eligibility and who have been enrolled in
the program.
D. "PHP PROVIDERS" shall mean those providers set forth in
the participant's handbook as from time to time amended.
E. "CO-PAYMENT" is the payment required of the participant
at the time of obtaining service. In the event the
participant fails to pay the required co-payment, PHP
may decline to provide non-emergency or non-urgently
needed care.
F. "FRAUD" shall mean:
1) Any FHKC participant or person who knowingly:
a) Fails, by any false statement,
misrepresentation, impersonation, or
other fraudulent means, to a disclose a
material fact used in making a
determination as to such person's
qualification to receive comprehensive
health care services coverage under the
FHKC program;
b) Fails to disclose a change in
circumstances in order to obtain or
continue to receive comprehensive health
care services coverage under the FHKC
program to which he or she is not
entitled or in an amount larger than
that which he or she is entitled;
c) Aids and abets another person in the
commission of any such act.
2) Any person or FHKC participant who:
a) Uses, transfers, acquires, traffics,
alters, forges, or possess, or
b) Attempts to use, transfer, acquire,
traffic, alter, forge or possess, or
c) Aids and abets another person in the
use, transfer, acquisition, traffic,
alteration, forgery or possession of
a FHKC identification card.
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SECTION 2 FLORIDA HEALTHY KIDS CORPORATION RESPONSIBILITIES
2-1 Participant Identification
FHKC shall promptly furnish to PHP information to sufficiently identify
participants in the Comprehensive Health Care Services plan authorized by this
agreement. Additionally, FHKC shall provide PHP a compatible computer tape, or
other computer-ready media, with the names of participants along with monthly
additions or deletions throughout the term of this contract in accordance with
the following:
A. With respect to participants who enroll during open enrollment,
such listing shall be furnished not less than seven (7) working
days prior to the effective date of coverage.
B. With respect to additions and deletions occurring after open
enrollment, such listing shall be furnished not less than seven
(7) working days prior to effective date of coverage.
C. With respect to both A and B above, furnish a supplemental list
of eligible participants by the third day after the effective
date of coverage. PHP shall adjust enrollment retroactively to
the 1st day of that month in accordance with the supplemental
list and as listed in Exhibit B.
D. FHKC may request PHP to accept additional participants after the
supplemental listing for enrollment retroactive to the 1st of
that coverage month. Such additions will be limited to those
participants who made timely payments but were not included on
the previous enrollment reports. If such additions exceed more
than one percent on that month's enrollment, PHP reserves the
right to deny FHKC's request.
2-2 Payments
FHKC will promptly forward the authorized premiums in accordance with Exhibit A
attached hereto and incorporated herein as part of this Agreement on or before
the 1st day of each month this Agreement is in force commencing with the 1st day
of February, 2000. Premiums are past due on the 15th day of each month.
In the case of non-payment of premiums by the 15th day of the month for that
month of coverage, PHP shall have the right to terminate coverage under this
contract, provided FHKC is given written notice prior to such termination.
Termination of coverage shall be retroactive to the last day for which premium
payment has been made.
2-3 Reduced Fee Arrangements
2-3-1 Specialty Service Fee Arrangements
Upon prior approval of PHP, FHKC shall have the right to
negotiate specialty service fee arrangements with non-PHP
affiliated providers and make such rates available to PHP. In
such cases if there is a material impact on the premium, the
premium in Exhibit A will be adjusted by PHP in a manner
consistent with sound actuarial practices.
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2-3-2 Children's Medical Services Network
If there is a material impact on the premium in Exhibit A due to
the implementation of the Children's Medical Services Network as
created in Chapter 391, Florida Statutes, PHP agrees to reduce
the premium in Exhibit A in an amount consistent with sound
actuarial practices.
2-4 Program Updates
FHKC shall provide PHP with updates on program highlights such as participant
demographics, profiles, newsletters, legislative or regulatory inquiries and
program directives.
2-5 Change in Benefit Schedule
FHKC agrees that any changes to the participant benefit schedule as set forth in
Exhibit C attached hereto and incorporated herein as part of this Agreement,
shall only be made as the parties hereto may mutually agree in writing.
2-6 Marketing
FHKC will market the program primarily through the Pinellas County school
district. FHKC agrees that PHP shall be allowed to participate in any scheduled
marketing efforts to include, but not be limited to, any scheduled open house
type activities. However, PHP is prohibited from any direct marketing to
applicants or the use of FHKC's logo, name or corporate identity unless such
activity has received prior written authorization from FHKC. Written
authorization must be received for every individual activity.
FHKC will have the right of approval or disapproval of all descriptive plan
literature and forms.
2-7 Forms and Reports
FHKC agrees that PHP shall participate in the development of any FHKC
eligibility report formats which may be required from time to time.
2-8 Coordination of Benefits
FHKC agrees that PHP shall be able to coordinate health benefits with other
insurers as provided for in Florida Statutes and the procedures contained in
Exhibit D attached hereto and incorporated herein as part of this Agreement.
If PHP identifies a participant covered through another health benefits program,
PHP shall notify FHKC. FHKC shall make the decision as to whether the
participant may continue coverage through FHKC in accordance with the
eligibility standards contained herein.
2-9 Entitlement to Reimbursement
In the event PHP provides medical services or benefits to participants who
suffer injury, disease or illness by virtue of the negligent act or omission of
a third party, PHP shall be entitled to reimbursement from the participant, at
the prevailing rate, for the reasonable value of the services or benefits
provided. PHP shall not be entitled to reimbursement in excess of the
participant's monetary recovery for medical expenses provided, from
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the third party.
SECTION 3 PHP RESPONSIBILITIES
3-1 Benefits
PHP agrees to make its provider network available to FHKC participants in
Pinellas County and to provide the comprehensive health care services as set
forth in Exhibit C attached hereto and by reference made a part hereof.
3-2 Access to Care
PHP agrees to meet or exceed the appointment and geographic access standards for
pediatric care existing in the community and as specifically provided for in
Exhibit E attached hereto and incorporated herein as a part of this Agreement.
In the event PHP's provider network is unable to provide those medically
necessary benefits specified in Exhibit C, for any reason, except force majeure,
PHP shall be responsible for those contract benefits obtained from providers
other than PHP for eligible FHKC participants. In the event PHP fails to meet
those access standards set forth in Exhibit E, FHKC may, after following
procedures set forth in Exhibit E, direct its participants to obtain such
contract benefit from other providers and may contract for such services. All
financial responsibility related to services received under these specific
circumstances shall be assumed by PHP.
3-3 Marketing Materials
PHP agrees that it shall not utilize the marketing materials, logos, trade
names, service marks or other materials belonging to FHKC without FHKC's consent
which shall not be unreasonably withheld.
PHP will be responsible for all preparation, cost and distribution of members
PHP handbooks, plan documents, materials, and orientation, for FHKC
participants. Materials will be appropriate to the population served and unique
to the program.
3-4 Use of Name
PHP consents to the use of its name in any marketing and advertising or media
presentations describing FHKC, which are developed and disseminated by FHKC to
participants, employees, employers, the general public or the Pinellas County
School System, provided however, PHP reserves the right to review and concur in
any such marketing materials prior to their dissemination.
3-5 Eligibility
PHP agrees to accept participants who meet the eligibility standards contained
in Exhibit G attached hereto and incorporated herein as a part of this
Agreement. Provided, PHP reserves the right upon reasonable notification to
periodically review certain eligibility determinations and FHKC shall ensure all
records and findings concerning a particular eligibility determination will be
made available with reasonable promptness.
3-6 Effective Date of Coverage
Coverage for every participant shall become effective at 12:01 a.m. EST/EDT, as
appropriate, and as indicated in Exhibit B.
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3-7 Termination of Participation
A participant's coverage under this program shall terminate on the last day of
the month in which the participant:
A. ceases to be eligible to participate in the program;
B. establishes residence outside the service area; or
C. is determined to have acted fraudulently pursuant to Section
l-l(F).
3-8 Continuation of Coverage Upon Termination of this Agreement
PHP agrees that, upon termination of this Agreement for any reason, unless
instructed otherwise by FHKC, it will continue to provide inpatient services to
FHKC participants who are then inpatients until such time as such participants
have been appropriately discharged. However, PHP shall not be required to
provide such extended benefits beyond 12 calendar months from the date the
Agreement is terminated.
If PHP terminates this Contract at its sole option and through no fault of the
FHKC and if on the date of termination a participant is totally disabled and
such disability commenced while coverage was in effect, that participant shall
continue to receive all benefits otherwise available under this contract for the
condition under treatment which caused such total disability until the earlier
of (1) the expiration of the contract benefit period for such benefits; (2)
determination by the Medical Director of PHP that treatment is no longer
medically necessary; (3) twelve (12) months from the date of termination of
coverage; (4) a succeeding carrier elects to provide replacement coverage
without limitation as to the disability condition; provided however, that
benefits will be provided only so long as the participant is continuously
totally disabled and only for the illness or injury which caused the total
disability.
For the purpose of this section, a participant who is "totally disabled" shall
mean a participant who is physically unable to work, as determined by the
Medical Director of PHP, due to an illness or injury at any gainful job for
which the participant is suited by education, training, experience or ability.
Pregnancy, childbirth or hospitalization in and of themselves do not constitute
"total disability". In the case of maternity coverage, when participant is
eligible for such coverage, when not covered by a succeeding carrier, a
reasonable period of extension of benefits shall be granted. The extension of
benefits shall be only for the period of pregnancy, and shall not be based on
total disability.
3-9 Participant Certificates and Handbooks
PHP will issue participant certificates and handbooks to all FHKC designated
participants. Except as specifically provided in Sections 3-8 and 3-11 hereof,
all participant rights and benefits shall terminate upon termination of this
Agreement or upon termination of participation in the program.
3-10 Refusal of Coverage
PHP shall not refuse to provide coverage to any participant on the basis of past
or present health status.
3-11 Extended Coverage
With regards to those participants who have been terminated pursuant to Section
3-7 A, PHP agrees to offer individual coverage to all participants without
regard to health condition or status.
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3-12 Grievances and Complaints
PHP agrees to provide all FHKC participants a Grievance Process and the
grievance and complaint procedures shall be governed by the following rules and
guidelines:
A. There must be sufficient support staff (clerical and
professional) available to process grievances.
B. Staff must be educated concerning the importance of the
procedure and the rights of the enrollee.
C. Someone with problem solving authority must be part of the
grievance procedure.
D. In order to initiate the grievance process, such grievance must
be filed in writing.
E. The parties will provide assistance to grievant during the
grievance process to the extent FHKC deems necessary.
F. Grievances shall be resolved within sixty days from initial
filing by the participant, unless information must be collected
from providers located outside the authorized service area or
from non-contract providers. In such exceptions, an additional
extension shall be authorized upon establishing good cause.
G. A record of informal complaints received which are not
grievances shall be maintained and shall include the date, name,
nature of the complaint and the disposition.
3-13 Claims Payment
PHP will pay any claims from its offices located at 000 Xxxxx Xxxxxx Xxxxxx
Xxxx., Xxxxx, Xxxxxxx 00000 (or any other designated claims office located in
its service area). PHP will pay clean claims filed within thirty (30) working
days or request additional information of the claimant necessary to process the
claim.
3-14 Notification
PHP shall immediately notify FHKC of:
A. Any judgment, decree, or order rendered by any court of any
jurisdiction or Florida Administrative Agency enjoining PHP from
the sale or provision of service under Chapter 641, Part II,
Florida Statutes.
B. Any petition by PHP in bankruptcy or for approval of a plan of
reorganization or arrangement under the Bankruptcy Act or
Chapter 631, Part I, Florida Statutes, or an admission seeking
the relief provided therein.
C. Any petition or order of rehabilitation or liquidation as
provided in Chapters 631 or 641, Florida Statutes.
D. Any order revoking the Certificate Of Authority granted to PHP.
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E. Any administrative action taken by the Department of Insurance
or Agency for Health Care Administration in regard to PHP.
F. Any medical malpractice action filed in a court of law in which
a FHKC participant is a party (or in whose behalf a
participant's allegations are to be litigated).
G. The filing of an application for change of ownership with the
Florida Department of Insurance.
H. On a monthly basis, inform FHKC of any changes to the provider
network that differ from the network presented in the original
bid proposal, including discontinuation of any primary care
providers or physician practice associations or groups with
Healthy Kids enrollees on their panels.
3-15 Rates
The rate charged for provision of Comprehensive Health Care Services shall be as
stated in Exhibit A.
3-16 Rate Modification
I. Annual Adjustment
Upon request by PHP, the Board of Directors of the FHKC may
approve an adjustment to the premium effective only on October
1, however each adjustment must meet the following minimum
conditions:
A. Any request to adjust the premium must be received by
the preceding April 1;
B. The request for an adjustment must be accompanied by a
supporting actuarial memorandum; and
C. The proposed premium shall not be excessive or
inadequate in accordance with the standards established
by the Department of Insurance for such determination.
D. In the event a mutually acceptable premium rate cannot
be agreed upon by FHKC and PHP, an independent actuary
may be retained to determine whether or not the proposed
rate is excessive or inadequate. The cost for such
review will be split between FHKC and PHP. The decision
of the independent actuary will be binding on FHKC and
PHP.
II. Coverage\Copayment Adjustment
In the event, FHKC requires a change in coverage or benefits to
be effective immediately, PHP shall have the right within ninety
(90) calendar days from the effective date of the such change to
propose in writing any adjustment to premium necessitated by
such change. Such proposed premium adjustments shall comply with
paragraph (d) of Section I above and upon approval of FHKC shall
be retroactive to the effective date of
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such change. The retroactive payment of the adjusted premium
shall apply only to non-subsidized participants. The proposed
premium increase shall not be excessive or inadequate as
determined by an independent actuary mutually acceptable to both
FHKC and PHP.
3-17 Conditions of Services
Services shall be provided by PHP under the following conditions:
A. Appointment. Participants shall first contact their assigned
primary care physician for an appointment in order to receive
non-emergency health services.
B. Provision of Services. Services shall be provided and paid for
by PHP only when PHP performs, prescribes, arranges or
authorizes the services. Services are available only from and
under the direction of PHP and neither PHP nor PHP Physicians
shall have any liability or obligation whatsoever on account of
any service or benefit sought or received by any member from any
other physician or other person, institution or organization,
unless prior special arrangements are made by PHP and confirmed
in writing except as provided for in Section 3-2.
C. Hospitalization. PHP does not guarantee the admission of a
participant to any specific hospital or other facility or the
availability of any accommodations or services therein.
Inpatient Hospital Service is subject to all rules and
regulations of the hospital or other medical facility to which
the member is admitted.
D. Emergency Services. Exceptions to Section 3-17 A, B and C are
services which are needed immediately for treatment of an injury
or sudden illness where delay means risk of permanent damage to
the participant's health. PHP shall provide and pay for
emergency services both inside and outside the service area.
3-18 Medical Records Requirements
PHP shall require providers to maintain medical records for each participant
under this contract in accordance with applicable state and federal law.
3-18-1 Medical Quality Review and Audit
FHKC shall conduct an independent medical quality review of PHP
at the conclusion of the first twelve months of coverage. The
independent auditor's report will include a written review and
evaluation of care provided to FHKC participants in Pinellas
County.
3-19 Quality Enhancement (Assurance)
The PHP shall have a quality enhancement program. If the PHP has an existing
program, it must satisfy the FHKC's quality enhancement standards. Approval will
be based on the PHP adherence to the minimum standards listed below.
3-19-1 Quality Enhancement Authority. The Plan shall have a quality
enhancement review authority which shall:
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(a) Direct and review all quality enhancement activities.
(b) Assure that quality enhancement activities take place in
all areas of the plan.
(c) Review and suggest new or improved quality enhancement
activities.
(d) Direct task forces/committees in the review of focused
concern.
(e) Designate evaluation and study design procedures.
(f) Publicize findings to appropriate staff and departments
within the plan.
(g) Report findings and recommendations to the appropriate
executive authority.
(h) Direct and analyze periodic reviews of enrollees'
service utilization patterns.
3-19-2 Quality Enhancement Staff. The plan shall provide for quality
enhancement staff which has the responsibility for:
(a) Working with personnel in each clinical and
administrative department to identify problems related
to quality of care for all covered professional
services.
(b) Prioritizing problem areas for resolution and designing
strategies for change.
(c) Implementing improvement activities and measuring
success.
(d) Performing a quarterly review of a random selection of
10 percent or 50 enrollee records, whichever is fewer.
Reviewing elements shall include management of specific
diagnosis, appropriateness and timeliness of care,
comprehensiveness of and compliance with the plan of
care, and evidence of special screening for high risk
individuals or conditions.
(e) Providing outcome of any Quality Enhancement activities
involving children 5-19 years of age to the FHKC.
3-19-3 Peer Review Authority. The plan's quality enhancement program
shall have a peer review component and a peer review authority.
Scope of Activities
(a) The review of the practice methods and patterns of
individual physicians and other health care
professionals.
(b) The ability and responsibility to evaluate the
appropriateness of care rendered by professionals.
(c) The authority to implement corrective action when deemed
necessary.
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(d) The responsibility to develop policy recommendations to
maintain or enhance the quality of care provided to plan
participants.
(e) A review process which includes the appropriateness of
diagnosis and subsequent treatment, maintenance of
medical record requirements, adherence to standards
generally accepted by professional group peers, and the
process and outcome of care.
(f) The maintenance of written minutes of the meetings and
provision of reports to FHKC of any activities related
to FHKC participants.
(g) Peer review must include examination of morbidity and
mortality.
3-19-4 Referrals To Peer Review Authority
(a) All written and/or oral allegations of inappropriate or
aberrant service must be referred to the Peer Review
Authority.
(b) Recipients and staff must be advised of the role of the
Peer Review Authority and the process to advise the
authority of situations or problems.
(c) All grievances related to medical treatment must be
presented to the Authority for examination and, when a
FHKC participant is involved, the outcome of the
grievance resolution reported to FHKC.
3-20 Availability of Records
PHP shall make all records available at its own expense for review, audit, or
evaluation by authorized federal, state and FHKC personnel. The location will be
determined by PHP subject to approval of FHKC. Access will be during normal
business hours and will be either through on-site review of records or through
the mail.
Copies of all records, will be sent to FHKC by certified mail within seven
working days of request. It is FHKC's responsibility to obtain sufficient
authority, as provided for by applicable statute or requirement, to provide for
the release of any patient specific information or records requested by the
FHKC, State or Federal agencies.
3-21 Audits
3-21-1 Accessibility of Records
PHP shall maintain books, records, documents, and other evidence
pertaining to the administrative costs and expenses of the
contract relating to the individual participants for the
purposes of audit requirements. These records, books, documents,
etc., shall be available for review by authorized federal, state
and FHKC personnel during the contract period and five (5) years
thereafter, except if an audit is in progress or audit findings
are yet unresolved in which case records shall be kept until all
tasks are completed. During the contract period these records
shall be available at PHP's offices at all reasonable times.
After the contract period and for five years following, the
records shall be available at PHP's chosen location subject to
the approval of FHKC. If the records need to be sent to FHKC,
PHP shall bear the expense of delivery. Prior approval of the
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disposition of PHP and subcontractor records must be requested
and approved if the contract or subcontract is continuous.
This agreement is subject to unilateral cancellation by FHKC if
PHP refuses to allow such public access.
3-21-2 Financial Audit
Upon reasonable notice by FHKC, PHP shall permit an independent
audit by FHKC of its financial condition or performance standard
in accordance with the provisions of this agreement and the
Florida Insurance Code and regulations adopted thereunder.
3-21-3 Post-Contract Audit
PHP agrees to cooperate with the post-contract audit
requirements of appropriate regulatory authorities and in the
interim will forward promptly PHP's annual audited financial
statements to the FHKC. In addition, PHP agrees to the
following:
PHP agrees to retain and make available upon request, all books,
documents and records necessary to verify the nature and extent
of the costs of the services provided under this Agreement, and
that such records will be retained and held available by PHP for
such inspection until the expiration of four (4) years after the
services are furnished under this Agreement. If, pursuant to
this Agreement and if PHP's duties and obligations are to be
carried out by an individual or entity subcontracting with PHP
and that subcontractor is, to a significant extent, owns or is
owned by or has control of or is controlled by PHP, each
subcontractor shall itself be subject to the access requirement
and PHP hereby agrees to require such subcontractors to meet the
access requirement.
PHP understands that any request for access must be in writing
and contain reasonable identification of the documents, along
with a statement as to the reason that the appropriateness of
the costs or value of the services in question cannot be
adequately or efficiently determined without access to its books
or records. PHP agrees that it will notify FHKC in writing
within ten (10) days upon receipt of a request for access.
3-21-4 Accessibility for Monitoring
PHP shall make available to all authorized federal, state and
FHKC personnel, records, books, documents, and other evidence
pertaining to the contract as well as appropriate personnel for
the purpose of monitoring under this contract. The monitoring
shall occur periodically during the contract period.
3-22 Indemnification
PHP agrees to indemnify and hold harmless FHKC from any losses resulting from
negligent, dishonest, fraudulent or criminal acts of PHP, its officers, its
directors, or its employees, whether acting alone or in collusion with others.
PHP shall indemnify, defend, and hold FHKC and its officers, employees and
agents harmless from all claims, suits, judgments or damages, including court
costs and attorney fees, arising out of any negligent or intentional
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torts by PHP.
PHP shall hold all enrolled participants harmless from all claims for payment of
covered services, except co-payments, including court costs and attorney fees
arising out of or in the course of this contract pertaining to covered services.
In no case will FHKC or program participants be liable for any debts of the PHP.
PHP agrees to indemnify, defend, and save harmless FHKC, its officers, agents,
and employees from:
A. Any claims or losses attributable to a service rendered by any
subcontractor, person, or firm performing or supplying services,
materials, or supplies in connection with the performance of the
contract regardless of whether FHKC knew or should have known of
such improper service, performance, materials or supplies.
B. Any failure of PHP, its officers, employees, or subcontractors
to observe Florida law, including but not limited to labor laws
and minimum wage laws, regardless of whether the FHKC knew or
should have known of such failure.
With respect to the rights of indemnification given herein, FHKC agrees to
provide to PHP, if known to FHKC, timely written notice of any loss or claim and
the opportunity to mitigate, defend and settle such loss or claim as a condition
to indemnification.
3-23 Confidentiality of Information
PHP shall treat all information, and in particular information relating to
participants which is obtained by or through its performance under the contract,
as confidential information to the extent confidential treatment is provided
under state and federal laws. PHP shall not use any information so obtained in
any manner except as necessary for the proper discharge of its obligations and
securement of its rights under the contract.
All information as to personal facts and circumstances concerning participants
obtained by PHP shall be treated as privileged communications, shall be held
confidential, and shall not be divulged without the written consent of FHKC or
the participant, provided that nothing stated herein shall prohibit the
disclosure of information in summary, statistical, or other form which does not
identify particular individuals. The use or disclosure of information concerning
participants will be limited to purposes directly connected with the
administration of the contract. It is expressly understood that substantial
evidence of PHP's refusal to comply with this provision shall constitute a
breach of contract.
3-24 Insurance
PHP shall not commit any work in connection with the contract until it has
obtained all types and levels of insurance required and approved by appropriate
state regulatory agencies. The insurance includes but is not limited to worker's
compensation, liability, fire insurance, and property insurance. Upon request,
FHKC shall be provided proof of coverage of insurance by a certificate of
insurance accompanying the contract documents.
FHKC shall be exempt from and in no way liable for any sums of money which may
represent a deductible in any insurance policy. The payment of such a deductible
shall be the sole responsibility of PHP and/or subcontractor holding such
insurance. The same holds true of any premiums paid on any insurance policy
pursuant to this contract. Failure to provide proof of coverage may result in
the contract being terminated.
3-25 Lobbying Disclosure
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PHP shall comply with applicable state and federal requirements for the
disclosure of information regarding lobbying activities of the firm,
subcontractors or any authorized agent. Certification forms shall be filed by
PHP certifying that no state or federal funds have been or will be used in
lobbying activities, and the disclosure forms shall be used by PHP to disclose
lobbying activities in connection with the Program that have been or will be
paid for with non-federal funds.
3-26 Reporting Requirements
PHP agrees to provide on a timely basis the quarterly statistical reports
detailed in Exhibit H to FHKC which FHKC must have to satisfy reporting
requirements.
3-27 Participant Liability
PHP hereby agrees that no FHKC participant shall be liable to PHP or any PHP
network providers for any services covered by FHKC under this Agreement. Neither
PHP or any representative of PHP shall collect or attempt to collect from an
FHKC participant any money for services covered by the program and neither PHP
nor representatives of PHP may maintain any action at law against a FHKC
participant to collect money owed to PHP by FHKC. FHKC participants shall not be
liable to PHP for any services covered by the participant's contract with FHKC.
This provision shall not prohibit collection of co-payments made in accordance
with the terms of this Agreement. Nor shall this provision prohibit collection
for services not covered by the contract between FHKC and the participants.
3-28 Protection of Proprietary Information
PHP and FHKC mutually agree to maintain the integrity of all proprietary
information, including but not limited to membership lists, including names,
addresses and telephone numbers. Neither parties will disclose or allow to be
disclosed proprietary information, by any means, to any person without the prior
written approval of the other party. All proprietary information will be so
designated.
This requirement does not extend to routine reports and membership disclosure
necessary for efficient management of the program.
3-29 Regulatory Filings
PHP will forward all regulatory filings, (i.e., documents, forms and rates)
relating to this contract to FHKC for their review and approval. Once such
regulatory filings are approved, FHKC will submit them to the Department of
Insurance on PHP's behalf.
SECTION 4 TERMS AND CONDITIONS
4-1 Effective Date
This Agreement shall be effective on the first (1st) day of February, 2000 and
shall remain in effect through September 30, 2001.
4-2 Multiple Year Agreement
Parties hereto agree this is a "Multiple Year Agreement" meaning this Agreement
which is effective as of February 1, 2000 shall extend through September 30,
2001, and shall thereafter be automatically renewed for no
Physicians Healthcare February 1, 2000 -
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more than (2) successive one year periods. Either party may elect not to renew
this Agreement and in that event shall give written notice to said effect to the
other party at least six (6) months prior to the expiration of the then current
term.
4-3 Entire Understanding
This Agreement embodies the entire understanding of the parties in relationship
to the subject matter hereof. No other agreement, understanding or
representation, verbal or otherwise, relative to the subject matter hereof
exists between the parties at the time of execution of this Agreement.
4-4 Independent Contractor
The relationship of PHP to the FHKC shall be solely that of an independent
contractor. As an independent contractor, PHP agrees to comply with the
following provisions:
a. Title VI of the Civil Rights Act of 1964, as amended, 42 U.S.C.
2000d et seq., which prohibits discrimination on the basis of
race, color, or national origin.
b. Section 504 of the Rehabilitation Act of 1973, as amended, 29
U.S.C. 794, which prohibits discrimination on the basis of
handicap.
c. Title IX of the Education Amendments of 1972, as amended 29
U.S.C. 601 et seq., which prohibits discrimination on the basis
of sex.
d. The Age Discrimination Act of 1975, as amended, 42 U.S.C. 6101
et seq., which prohibits discrimination on the basis of age.
e. Section 654 of the Omnibus Budget Reconciliation Act of 1981, as
amended, 42 U.S.C. 9848, which prohibits discrimination on the
basis of race, creed, color, national origin, sex, handicap,
political affiliation or beliefs.
f. The American with Disabilities Act of 1990, P.L. 101-336, which
prohibits discrimination on the basis of disability and requires
reasonable accommodation for persons with disabilities.
g. Section 274A (e) of the Immigration and Nationalization Act,
FHKC shall consider the employment by any contractor of
unauthorized aliens a violation of this Act. Such violation
shall be cause for unilateral cancellation of this contract.
h. OMB Circular A-l10 (Appendix A-4) which identifies procurement
procedures which conform to applicable federal law and
regulations with regard to debarment, suspension, ineligibility,
and involuntary exclusion of contracts and subcontracts and as
contained in Exhibit I of this contract. Covered transactions
include procurement contracts for services equal to or in excess
of $25,000 and all non-procurement transactions.
4-5 Assignment
This Agreement may not be assigned by PHP without the express prior written
consent of FHKC. Any purported assignment shall be deemed null and void.
Physicians Healthcare February 1, 2000 -
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This contract and the monies which may become due hereunder are not assignable
by PHP except with the prior written approval of FHKC.
4-6 Notice
Notice required or permitted under this Agreement shall be directed as follows:
For PHYSICIANS HEALTHCARE PLANS, INC.,
PHYSICIANS HEALTHCARE PLANS, INC.
0000 XXXXX XX XXXX XXXX., XXXXX 000
XXXXX XXXXXX, XXXXXXX 00000
For FHKC:
EXECUTIVE DIRECTOR
FLORIDA HEALTHY KIDS CORPORATION
POST OFFICE BOX 980
TALLAHASSEE, FL 32302
or to such other place or person as written notice
thereof may be given to the other party.
4-8 Amendment
Not withstanding anything to the contrary contained herein, this Agreement may
be amended by mutual written consent of the parties at any time.
4-9 Governing Law
This Agreement shall be construed and governed in accordance with the laws of
the State of Florida.
4-10 Contract Variation
If any provision of the contract (including items incorporated by reference) is
declared or found to be illegal, unenforceable, or void, then both FHKC and PHP
shall be relieved of all obligation arising under such provisions. If the
remainder of the contract is capable of performance, it shall not be affected by
such declaration or finding and shall be fully performed. In addition, if the
laws or regulations governing this contract should be amended or judicially
interpreted as to render the fulfillment of the contract impossible or
economically infeasible, both FHKC and PHP will be discharged from further
obligations created under the terms of the contract.
4-11 Attorneys Fees
In the event that either party deems it necessary to take legal action to
enforce any provision of this Agreement the court or hearing officer, in his
discretion, may award costs and attorneys' fees to the prevailing party. Legal
actions are defined to include administrative proceedings.
4-12 Representatives
Each party shall designate a representative to serve as the day to day
management of FHKC School Based Health Insurance Plan, helping to resolve
services questions, assuring proper arbitration in the event of a dispute, as
well
Physicians Healthcare February 1, 2000 -
Plans\Pinellas September 30, 2001 Page 19 of 44
as responding to general administrative and procedural problems. These
individuals will be the principal points of contact for all inquiries unless the
designated representatives specifically refer the inquiry to another party
within their respective organizations.
4-13 Termination
A. Termination for Cause
FHKC shall have the absolute right to terminate for cause, this
Agreement, and all obligations contained hereunder. Cause shall be
defined as any material breach of PHP's responsibilities as set forth
herein, which can not be cured by PHP within 30 days from the date of
written notice from FHKC but, if the default condition cannot be cured
within the 30 days, PHP may, if it has commenced reasonable efforts to
correct the condition within that 30 day period, have up to 90 days to
complete the required cure. Nothing in this Agreement shall extend this
90 day period except the mutual consent of the parties hereto.
PHP shall have the absolute right to terminate for cause this Agreement,
and all obligations contained hereunder. Cause shall be defined as any
material breach of FHKC's responsibilities as set forth herein, which
can not be cured by FHKC within 30 days from the date of written notice
from PHP but, if the default condition cannot be cured within the 30
days, FHKC may, if it has commenced reasonable efforts to correct the
condition within that 30 day period, have up to 90 days to complete the
required cure. Nothing in this Agreement shall extend this 90 day period
except the mutual consent of the parties hereto.
B. Change of Controlling Interest
FHKC shall have the absolute right to elect to continue or terminate
this Agreement, at its sole discretion, in the event of a change in the
controlling interest of PHP. PHP shall provide notice of regulatory
agency approval prior to any transfer or change in control, and FHKC
shall have ten (10) days thereafter to elect continuation or termination
of this Agreement.
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4-14 Contingency
This Agreement and all obligations created hereunder, are subject to
continuation and approval of funding of the FHKC by the appropriate
state and federal or local agencies.
IN WITNESS WHEREOF the parties hereto have executed this Agreement on
the 16th day of November, 1999.
PHYSICIANS HEALTHCARE PLANS, INC.
BY:
/s/ [ILLEGIBLE] /s/ Xxxxx Xxxxx
------------------------ -----------------------------------
Witness Name: Xxxxx Xxxxx
Title Government Programs Director
FLORIDA HEALTHY KIDS CORPORATION
BY:
/s/ [ILLEGIBLE] /s/ Xxxx X. Xxxx
------------------------ -----------------------------------
Witness Xxxx X. Xxxx
Executive Director
Physicians Healthcare February 1, 2000 -
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EXHIBIT A
HEALTH SERVICES AGREEMENT
The Comprehensive Health Care Services premium for participants in the Florida
Healthy Kids School Enrollment-Based Health Insurance Program for the coverage
period February 1, 2000 through September 30, 2001 shall be $81.51 per month for
each covered participant.
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EXHIBIT B
ENROLLMENT PROCEDURES
1 All FHKC eligible participants will be provided with necessary
enrollment materials and forms from FHKC or its assignee.
2. FHKC will provide PHP with eligible participants who have selected PHP
or who have been assigned by FHKC to PHP according to the provisions of
Section 2-1 via an enrollment tape, using a tape layout to be
specified by FHKC.
3. Upon receipt of such enrollment tape, PHP acting as an agent for FHKC
shall provide each participant with an enrollment package including:
A. A members PHP card displaying participants name, participation
number, and effective date of coverage.
B. Participants handbook.
C. Current listing of primary care and hospital providers.
4. All additions or deletions will be submitted in accordance with
referenced sections of this Agreement and Exhibit B.
5. Upon receipt of monthly tape from FHKC, PHP will process all new
enrollments and provide new participants with enrollment package
described above.
6. Deletions will be processed by PHP and participants will be notified in
writing by regular mail advising them of the effective date of deletion.
7. A waiting period of sixty days will be imposed on those participants who
voluntarily cancel their coverage by non-payment of the required monthly
premium. Canceled participants must request reinstatement from FHKC and
wait at least sixty days from the date of that request before coverage
can be reinstated.
Physicians Healthcare February 1, 2000 -
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EXHIBIT C
ENROLLEE BENEFIT SCHEDULE
The following health care benefits are included under this contract and PHP
shall pay an enrollee's covered expenses up to a lifetime maximum of $1 million
per covered enrollee.
BENEFIT LIMITATIONS CO-PAYMENT
A. Inpatient Hospital Services All admissions must be authorized by PHP. NONE
All covered services provided for the The length of the patient stay shall be
medical care and treatment of an determined based on the medical
enrollee who is admitted as an inpatient condition of the enrollee in relation to
to a hospital licensed under part 1 of the necessary and appropriate level of
Chapter 395. care.
Covered services include: physician's Room and board may be limited to
services; room and board; general semi-private accommodations, unless a
nursing care; patient meals; use of private room is considered medically
operating room and related facilities; necessary or semi-private accommodations
use of intensive care unit and services; are not available.
radiologic, laboratory and other
diagnostic tests; drugs; medications; Private duty nursing limited to
biologicals; anesthesia and oxygen circumstances where such care is
services; special duty nursing; medically necessary.
radiation and chemotherapy; respiratory
therapy; administration of whole blood Admissions for rehabilitation and
plasma; physical, speech and physical therapy are limited to 15 days
occupational therapy; medically per contract year.
necessary services of other health
professionals. Shall Not Include Experimental or
Investigational Procedures as defined
as a drug, biological product, device,
medical treatment or procedure that
meets any one of the following criteria,
as determined by the Plan:
1. Reliable Evidence shows the drug,
biological product, device, medical
treatment, or procedure when applied to
the circumstances of a particular
patient is the subject of ongoing phase
I, II or III clinical trials or
2. Reliable Evidence shows the drug,
biological product, device, medical
treatment or procedure when
Enrollee Benefit Schedule Page 24 of 44
applied to the circumstances of a
particular patient is under study with a
written protocol to determine maximum
Inpatient Services, (cont'd) tolerated dose, toxicity, safety,
efficacy, or efficacy in comparison to
conventional alternatives, or
3. Reliable Evidence shows the drug,
biological product, device, medical
treatment, or procedure is being
delivered or should be delivered subject
to the approval and supervision of an
Institutional Review Board (IRB) as
required and defined by federal
regulations, particularly those of the
U.S. Food and Drug Administration or the
Department of Health and Human Services.
B. Emergency Services Must use a PHP designated facility or $10 per visit
provider for emergency care unless the (waived if primary care
Covered Services include visits to an time to reach such facilities or physician authorizes or if admitted)
emergency room or other licensed providers would mean the risk of
facility if needed immediately due to an permanent damage to patient's health.
injury or illness and delay means risk
of permanent damage to the enrollee's
health.
C. Maternity Services and Newborn Care Infant is covered for up to three (3) NONE
days following birth or until the infant
Covered services include maternity and is transferred to another medical
newborn care; prenatal and postnatal facility, whichever occurs first.
care; initial inpatient care of
adolescent participants, including Coverage may be limited to the fee for
nursery charges and initial pediatric or vaginal deliveries.
neonatal examination.
D. Organ Transplantation Services Coverage is available for transplants NONE
and medically related services if deemed
Covered services include pretransplant, necessary and appropriate within the
transplant and postdischarge services guidelines set by the Organ Transplant
and treatment of complications after Advisory Council or the Bone Marrow
transplantation. Transplant Advisory Council.
Enrollee Benefit Schedule Page 25 of 44
C. Outpatient Services Services must be provided directly by No co-payment for well child care,
PHP or through pre-approved referrals. preventive care or for routine vision
Preventive, diagnostic, therapeutic, and hearing screenings.
palliative care, and other services Routine hearing and screening must be
provided to an enrollee in the provided by primary care physician. $3 per office visit
outpatient portion of a health facility
licensed under chapter 395. Family planning limited to one annual
visit and one supply visit each ninety
Covered services include Well-child days.
care, including services recommended in
the Guidelines for Health Supervision of Chiropractic services shall be provided
Children and Youth as developed by in the same manner as in the Florida
Academy of Pediatrics; immunizations and Medicaid program.
injections; health education counseling
and clinical services; family planning Podiatric services are limited to one
services, vision screening; hearing visit per day totaling two visits per
screening; clinical radiologic, month for specific foot disorders.
laboratory and other outpatient Routine foot care must be for conditions
diagnostic tests; ambulatory surgical that result in circulatory embarrassment
procedures; splints and casts; or desensitization.
consultation with and treatment by
referral physicians; radiation and Dental services must be provided to an
chemotherapy; chiropractic services; oral surgeon for medically necessary
podiatric services. reconstructive dental surgery due to
injury.
Treatment for temporomandibular joint
(TMJ) disease is specifically excluded.
Shall Not Include Experimental or
Investigational Procedures as defined as
a drug, biological product, device,
medical treatment or procedure that
meets any one of the following criteria,
as determined by the Plan:
1. Reliable Evidence shows the drug,
biological product, device, medical
treatment, or procedure when applied to
the circumstances of a particular
patient is the subject of ongoing phase
I, II or III clinical trials or
2. Reliable Evidence shows the drug,
biological product, device, medical
treatment or procedure when applied to
the circumstances of a particular
patient is under study with a written
protocol to determine maximum tolerated
dose, toxicity, safety, efficacy, or
efficacy in comparison to conventional
alternatives, or
Enrollee Benefit Schedule Page 26 of 44
3. Reliable Evidence shows the drug,
Outpatient Services, (cont'd) biological product, device, medical
treatment, or procedure is being
delivered or should be delivered subject
to the approval and supervision of an
Institutional Review Board (IRB) as
required and defined by federal
regulations, particularly those of the
U.S. Food and Drug Administration or the
Department of Health and Human Services.
D. Behavioral Health Services All services must be provided directly
by PHP or upon approved referral.
Covered services include inpatient and
outpatient care for psychological or Inpatient services are limited to not
psychiatric evaluation, diagnosis and more than thirty inpatient days per INPATIENT: NONE
treatment by a licensed mental health contract year for psychiatric
professional. admissions, or residential services in
lieu of inpatient psychiatric
admissions; however, a minimum of ten
of the thirty days shall be available
only for inpatient psychiatric services
when authorized by PHP physician.
Outpatient services are limited to a OUTPATIENT: $3 per visit
maximum of forty outpatient visits per
contract year.
E. Substance Abuse Services All services must be provided directly INPATIENT: NONE
by PHP or upon approved referral.
Includes coverage for inpatient and
outpatient care for drug and alcohol Inpatient services are limited to not
abuse including counseling and placement more than seven inpatient days per
assistance. contract year for medical detoxification
only and thirty days residential
Outpatient services include evaluation, services.
diagnosis and treatment by a licensed
practitioner. Outpatient visits are limited to a OUTPATIENT: $3 per visit
maximum of forty visits per contract
year.
Enrollee Benefit Schedule Page 27 of 44
F. Therapy Services All treatments must be performed $3 per visit
directly or as authorized by PHP.
Covered services include physical,
occupational, respiratory and speech Limited to up to twenty-four treatment
therapies for short-term rehabilitation sessions within a sixty day period per
where significant improvement in the episode or injury, with the sixty day
enrollee's condition will result. period beginning with the first
treatment.
I. Home Health Services Coverage is limited to skilled nursing $3 per visit
services only.
Includes prescribed home visits by both
registered and licensed practical nurses Meals, housekeeping and personal
to provide skilled nursing services on a comfort items are excluded.
part-time intermittent basis.
Services must be provided directly by
PHP.
J. Hospice Services Once a family elects to receive hospice $3 per visit
care for an enrollee, other services
Covered services include reasonable and that treat the terminal condition will
necessary services for palliation or not be covered.
management of an enrollee's terminal
illness. Services required for conditions totally
unrelated to the terminal condition are
covered to the extent that the services
are covered under this contract.
Enrollee Benefit Schedule Page 28 of 44
K. Nursing Facility Services All admissions must be authorized by PHP NONE
and provided by a PHP affiliated
Covered services include regular nursing facility.
services, rehabilitation services, drugs
and biologicals, medical supplies, and Participant must require and receive
the use of appliances and equipment skilled services on a daily basis as
furnished by the facility. ordered by PHP physician.
The length of the enrollee's stay shall
be determined by the medical condition
of the enrollee in relation to the
necessary and appropriate level of care,
but is no more than 100 days per
contract year.
Room and board is limited to
semi-private accommodations unless a
private room is considered medically
necessary or semi-private accommodations
are not available.
Specialized treatment centers and
independent kidney disease treatment
centers are excluded.
Private duty nurses, television, and
custodial care are excluded.
Admissions for rehabilitation and
physical therapy are limited to fifteen
days per contract year.
L. Durable Medical Equipment and Equipment and devices must be provided NONE
Prosthetic Devices by authorized PHP supplier.
Equipment and devices that are medically Covered prosthetic devices include
indicated to assist in the treatment of artificial eyes and limbs, braces, and
a medical condition and specifically other artificial aids.
prescribed as medically necessary by
enrollee's PHP physician. Low vision and telescopic lenses are not
included.
Hearing aids are covered only when
medically indicated to assist in the
treatment of a medical condition.
Enrollee Benefit Schedule Page 29 of 44
M. Refractions Enrollee must have failed vision $3 per visit
screening by primary care physician.
Examination by a PHP optometrist to
determine the need for and to prescribe Corrective lenses and frames are limited
corrective lenses as medically to one pair every two years unless head $10 for corrective lenses
indicated. size or prescription changes. Coverage
is limited to Medicaid frames with
plastic or SYL non-tinted lenses.
N. Pharmacy Covered drugs are limited to the Florida $3 per prescription for up to a 31-day
Medicaid formulary with generic supply
Prescribed drugs for the treatment of substitution.
illness or injury or injury.
Brand name products are covered if a
generic substitution is not available or
where the prescribing physician
indicates that a brand name is medically
necessary.
All medications must be dispensed
through PHP or a PHP designated
pharmacy.
All prescriptions must be written by the
participant's primary care physician,
PHP approved specialist or consultant
physician.
O. Transportation Services Must be in response to an emergency $10 per service
situation.
Emergency transportation as determined
to be medically necessary in response to
an emergency situation.
P. Dental Services PHP shall provide enrolles with the same No Co payment
dental benefits provided to its Medicaid
members.
EXHIBIT D
WORKER'S COMPENSATION, THIRD PARTY CLAIM
PERSONAL INJURY PROTECTION BENEFITS, AND
COORDINATION OF BENEFITS
A. WORKER'S COMPENSATION
Worker's compensation benefits are primary to all benefits which
may be provided pursuant to this contract. In the event PHP
provides services or benefits to a participant who is entitled
to worker's compensation benefits, PHP shall complete and submit
to the appropriate carrier, such forms, assignments, consents
and releases as are necessary to enable PHP to obtain payment,
or reimbursement, under the worker's compensation law.
B. THIRD PARTY CLAIMS
In the event PHP provides medical services or benefits to
participants who suffer injury, disease or illness by virtue of
the negligent act or omission of a third party, PHP shall be
entitled to reimbursement from the participant, at the
prevailing rate, for the reasonable value of the services or
benefits provided. PHP shall not be entitled to reimbursement in
excess of the participant's monetary recovery for medical
expenses provided, from the third party.
C. NO-FAULT, PERSONAL INJURY PROTECTION AND MEDICAL PAYMENTS
COVERAGE
As noted in the Florida Statutes (F.S. 641.31(8)), automobile
no-fault, personal injury protection, and medical payments
insurance, maintained by or for the benefit of the participant,
shall be primary to all services or benefits which may be
provided pursuant to this contract. In the event PHP provides
services or benefits to a participant who is entitled to the
aforesaid automobile insurance benefits, the parent/guardian or
participant shall complete and submit to PHP, or to the
automobile insurance carrier, such forms, assignments, consents
and releases as are necessary to enable PHP to obtain payment or
reimbursement from such automobile insurance carrier.
D. COORDINATION OF BENEFITS AMONG HEALTH INSURERS
PHP shall coordinate benefits in accordance with NAIC principles
as may be amended from time to time. If any benefits to which a
participant is entitled under this contract are also covered
under any other group health benefit plan or insurance policy,
the benefits hereunder shall be reduced to the extent that
benefits are available to participant under such other plan or
policy whether or not a claim is made for the same, subject to
the following:
PHP\Pinellas County Page 31 of 44
EXHIBIT D
(Continued)
1. The rules establishing the order of benefit determination
between this contract and other plan covering the participant on
whose behalf a claim is made are as follows:
(a) The benefits of a policy or plan which covers the
person as an employee, member, or subscriber, other
than as a dependent are determined before those of
the policy or plan which covers the person as a
dependent.
(b) Except as stated in paragraph C, when two or more
policies or plans cover the same child as a dependent
of different parents:
(1)The benefits of the policy or plan of the parent
whose birthday, excluding year of birth, falls
earlier in a year are determined before those of the
policy of the parent whose birthday, excluding year
of birth, falls later in that year; but
(2)If both parents have the same birthday, the
benefits of the policy or plan which covered the
parent for a longer period of time are determined
before those of the policy or plan which covered the
parent for shorter period of time. However, if a
policy or plan subject to the rule based on the
birthday of the parents as stated above coordinates
with an out-of-state policy or plan which contains
provisions under the benefits of a policy or a person
as a dependent of a male are determined before those
of a policy or plan which covers the person as a
dependent of a female and if, as a result, the
policies or plans do not agree in the order of
benefits, the provisions or the other policy or plan
shall determine the order of benefits.
(c) If two or more policies or plans cover a dependent
child of divorced or separated parents, benefits for
the child are determined in this order:
(1)First, the policy or plan of the parent with
custody of the child;
(2)Second, the policy or plan of the spouse of the
parent with custody of the child, and
PHP\Pinellas County Page 32 of 44
EXHIBIT D
(Continued)
(3)Third, the policy or plan of the parent not having
custody of the child. However, if the specific terms
of a court decree state that one of the parents is
responsible for the health care expenses of the child
and of the entity obliged to pay or provide the
benefits of the policy or plan or that parent has
actual knowledge of those terms, the benefits of that
policy are determined first. This does not apply with
respect to any claim determination period or plan or
policy year during which any benefits are actually
paid or provided before the entity has that
knowledge.
(d) The benefits of a policy or plan which covers a
person as an employee which is neither laid off nor
retired, or as that employee's dependent, are
determined before those of a policy or plan which
covers that person as a laid off or retired employee
or as that employee's dependent. If the other policy
or plan is not subject to this rule, and if, as
result, the policies or plans do not agree on the
order of benefits, this paragraph shall not apply.
(e) If none of the rules in paragraph a, paragraph b,
paragraph c, or paragraph d, determine the order of
benefits of the policy or plan which covered an
employee, member or subscriber for a longer period of
time are determined before those of the policy or
plan which covered that person for the shorter period
of time.
2. None of the above rules as to coordination of benefits shall
limit the participant's right to receive direct health services
hereunder.
3. Any participant claiming benefits under the contract shall
furnish to PHP all information deemed necessary by it to
implement this provision.
PHP\Pinellas County Page 33 of 44
EXHIBIT E
ACCESS AND CREDENTIALING STANDARDS
PHP shall maintain a medical staff, under contract, sufficient to permit
reasonably prompt medical service to all participants in accordance with the
following:
1. Primary Care Physician Standards
PHP shall include only board certified pediatricians and family
practice physicians or physician extenders working under the
direct supervision of a board certified practitioner to serve as
primary care physicians in its provider network for Pinellas
County. PHP may request that an individual physician be granted
an exception to this policy by making such a request in writing
to the Corporation and providing the physician's curriculum
vitae and a reason why the physician should be granted an
exception to the accepted standard. Such requests will be
reviewed by the Corporation on a case by case basis and a
written response will be made to PHP on the outcome of the
request.
2. Geographical Access:
Geographical access to board certified family practice
physicians, pediatric physicians, or ARNP's, experienced in
child health care, of approximately twenty (20) minutes driving
time from residence to provider, except that this driving time
limitation shall be reasonably extended in those areas where
such limitation with respect to rural residence is unreasonable.
In such instance, PHP shall provide access for urgent care
through contracts with nearest providers.
3. Timely Treatment:
Timely treatment by providers, such that the participant shall
be seen by a provider in accordance with the following:
A. Emergency care shall be provided immediately;
B. Urgently needed care shall be provided within
twenty-four (24) hours;
C. Routine care of patients who do not require emergency or
urgently needed care shall be provided within seven (7)
calendar days;
D. Physical examinations shall be provided within four (4)
weeks of request for appointment; and
E. Follow-up care shall be provided as medically
appropriate.
PHP\Pinellas County Page 34 of 44
EXHIBIT E
(Continued)
For the purposes of this section, the following definitions shall apply:
Emergency care is that required for the treatment of an injury
or acute illness which, if not treated immediately, could
reasonably result in serious or permanent damage to the
patient's health.
Urgently needed care is that required within a twenty-four (24)
hour period to prevent a condition from requiring emergency
care.
Routine care is that level of care which can be delayed without
anticipated deterioration in the patient's medical condition for
a period of seven (7) calendar days.
By utilization of the foregoing standards, FHKC does not intend to create
standards of care or access different from those which are deemed acceptable
within the PHP service area. Rather FHKC intends that the provider timely and
appropriately respond to patient care needs, as they are presented, in
accordance with standards of care existing within the service area. In applying
the foregoing standards, the provider shall give due regard to the level of
discomfort and anxiety of the patient and/or parent.
In the event FHKC determines that PHP, or its providers, has failed to meet the
access standards herein set forth, FHKC shall provide PHP with written notice of
non-compliance. Such notice can be provided via facsimile or other means,
specifying the failure in such detail as will reasonably allow PHP to
investigate and respond. Failure of PHP to obtain reasonable compliance or
acceptable community care under the following conditions shall constitute a
breach of this agreement:
A. immediately upon receipt of notice for emergency or
urgent problem; or
B. within ten (10) days of receipt of notice for routine
visit access.
Such breach shall entitle FHKC to such legal and equitable relief as may be
appropriate. In particular, FHKC may direct its participants to obtain such
services outside the PHP provider network. PHP shall be financially responsible
for all services under this provision.
PHP\Pinellas County Page 35 of 44
EXHIBIT F
GRIEVANCE, ARBITRATION AND LEGAL PROCESS
GRIEVANCE, ARBITRATION AND LEGAL PROCESS
X. XXXXXXXXX AND ARBITRATION
Complaints or disputes which do not involve allegations of
"medical negligence" against a health care provider as defined
in Chapter 768, Florida Statutes, shall be subject to grievance
and arbitration as hereinafter set forth:
1. Initiation of Complaint:
a. If a participant's complaint cannot be resolved
satisfactorily on an informal basis, the
participant shall complete and submit to PHP, a
grievance form recording the participant's name,
address, telephone number, client number and as
many facts as possible related to the problem
(date, time, people, circumstances, etc.). The
completed form shall be filed with the PHP
Member Relations Counselor (MRC) within sixty
(60) days from the date the problem occurred.
b. A written response shall be made acknowledging
receipt and filing of said form by the MRC
within two (2) working days from the date
written grievance was received.
c. The Executive Director and Medical Director of
PHP, or their designee(s) shall review the
written grievance, conduct a fact-finding
examination, and issue a decision in writing to
all parties concerned, within ten (10) working
days from date the written grievance was
received by the MRC.
2. Appeal to the Grievance Committee:
a. If any participant declines to accept the
decision of Executive Director and Medical
Director, that participant has fourteen (14)
working days within which to file a formal
written appeal to the Grievance Committee.
b. The composition of the Grievance Committee shall
comply with appropriate state and federal
regulations.
c. The Grievance Committee shall be convened within
thirty
PHP\Pinellas County Page 36 of 44
(30) days of receipt of the written appeal. The
complaining participant shall present, either in
person or in writing, his/her complaint. Upon
completion of the participant's presentation,
the Grievance Committee shall have seven (7)
days in which to deliberate and issue a formal
written decision. The deliberations of the
Grievance Committee shall be closed to both the
complaining participant and the public.
d. Any decision to resolve the complaint that
involves distribution of PHP monies is subject
to confirmation and ratification by PHP's
Executive Committee or the Board of Directors.
3. The participant always has the right to appeal to the
FHKC and/or the Statewide Subscriber Assistance Program
prior to entering arbitration or legal process.
4. Arbitration:
If a participant refuses to accept the decision of the
Grievance Committee, or the decision of the PHP
Executive Committee or the Board of Directors, or the
Statewide Subscriber Assistance Program as provided
above, such participant shall file a claim for binding
arbitration as follows:
a. Participant shall initiate the claim by serving
on PHP, by registered mail, a notice of the
existence and nature of claims, the remedy
sought, the amount claimed, and a demand for
arbitration. A copy of such letter shall be sent
to PHP at the address listed in Section 4-7.
Within thirty (30) calendar days after initial
notice to PHP, participant and PHP shall each
designate an arbitrator and notify the other of
that designation. Within thirty (30) days after
designation of the arbitrators and payments of
the initial deposits, the two arbitrators shall
select a neutral arbitrator, and the three
arbitrators shall hold a hearing within 210 days
from the date of initial designation, at a time
and place designated pursuant to paragraph g
below. If the claimant and respondent agree, in
writing, the arbitration may be conducted by a
single arbitrator.
EXHIBIT F
(Continued)
b. All claims based upon the same incident,
transaction or related circumstances shall be
arbitrated in one proceeding, and any claim
based upon the incident and not submitted to
PHP\Pinellas County Page 37 of 44
arbitration shall be waived and forever barred
to any claimant.
c. The arbitrators shall have jurisdiction only
over parties ("Respondent") actually served or
who submit voluntarily to their jurisdiction.
d. The arbitrators shall not have jurisdiction to
determine whether PHP is liable for the
professional negligence of any physician
providing services under the contract.
e. A claim shall be waived and forever barred if,
on the date notice thereof is received by the
party served, the claim, if it were asserted in
a civil action filed on that day, would be
barred by the applicable statute of limitations
of the state in which the cause for action
arose. Such determination shall be made by the
arbitrators.
f. Initial service shall be by registered mail,
postage prepaid. Any subsequent notices or other
papers required to be served in the course of
arbitration proceedings, shall be directed to
the arbitrators at the address or addresses
which they designate by written notice to the
other party.
g. The neutral arbitrator shall designate the time
and place for the hearing in a county in which
an alleged wrongful act or omission allegedly
occurred, except that if the claim involves both
parties, evidence or witnesses located in more
than one country or state, the arbitrators may
select a time and place of hearing to facilitate
presentation of evidence necessary or desirable
for arbitration.
h. Modifications of any matter herein provided for
may be made by mutual agreement of the parties
and the neutral arbitrator. With respect to any
matter not expressly provided for herein, the
arbitration shall be governed by Florida law.
PHP\Pinellas County Page 38 of 44
EXHIBIT F
(Continued)
i. The decision of the arbitrators shall be
enforceable in a court of competent
jurisdiction.
B. LEGAL PROCESS
Complaints or disputes which do involve allegations of "medical
negligence" against a "health care provider" as defined in
Chapter 768, Florida Statutes, shall be subject to the provision
of that chapter as may be amended from time to time.
PHP\Pinellas County Page 39 of 44
EXHIBIT G
ELIGIBILITY STANDARDS
PARTICIPANT ELIGIBILITY CRITERIA
The following eligibility criteria for participation in the Healthy Kids Program
must be met:
1. The participants must be children who are age 5 through 18.
Children between the ages of 3 and 5 who received coverage prior
to the effective date of this contract will be also be eligible
and children who received coverage prior to October 1, 1998 will
be eligible through their 19th birthday.
2. All enrolled participants must have had no comparable health
insurance coverage at the time of program enrollment.
3. Participants must not be enrolled in or eligible for Medicaid,
Medicare, the Children's Medical Services program or other
comparable governmental sponsored health benefits program.
4. In addition to the open enrollment period, new students
enrolling in the Pinellas School System may be eligible for the
School Enrollment Based Insurance Program. In order to become a
participant, a student must meet all other eligibility standards
and must apply for coverage within thirty (30) days of entry
into the Pinellas County School System.
5. In addition to the Open enrollment period otherwise eligible
participants may enroll in the program upon submission of proof
of involuntary termination of comparable health insurance
coverage, including termination of eligibility for Medicaid.
PHP\Pinellas County Page 40 of 44
EXHIBIT H
REPORTING REQUIREMENTS
PHP shall provide the following reports and data tapes to FHKC according to the
time schedules detailed below. This information shall include all services
provided by PHP's subcontractors.
I. Data Tape
A quarterly data tape shall be prepared that will contain the
following data fields. The tape shall reflect claims and
encounters entered during the quarter and shall be delivered to
FHKC according to the time table listed below. PHP shall also
provide quarterly tapes that reflect claims run-off once the
contract between PHP and FHKC terminates.
REQUIRED DATA FIELDS TO BE CAPTURED
. Provider's name, address and tax I.D. number (and
payee's group number if applicable)
. Patient's name, address, social security number, I.D.
number, birth date, and sex
. Third party payor information, including amount(s) paid
by other payor(s).
. Primary and secondary diagnosis code(s) and treatment(s)
related to diagnosis
. Date(s) of service
. Procedure code(s)
. Unit(s) of service
. Total charge(s)
. Total payment(s)
Additional required hospital fields include the following:
. Date and type of admission (emergency, outpatient,
inpatient, newborn, etc.)
. For inpatient care: covered days and date of discharge
PHP\Pinellas County Page 41 of 44
EXHIBIT H
(Continued)
Specific pharmacy fields include:
. Pharmacy name and tax I.D. number
. Other payor information
. Rx number and date filled
. National drug code, manufacturer number, item number,
package size, quantity, days supply
. Prescriber's Florida Department of Professional
Regulations number
REQUIRED TAPE FORMAT SPECIFICATIONS
The tape format is as follows:
. 1600 BPI
. EBCDIC
. 9 Track
. no labels
. each file not to exceed 100 megs in size
. fixed record length
TIME TABLE FOR DELIVERY OF TAPE
For encounters and claims processed during: Claims tape due to FHKC by:
------------------------------------------- ---------------------------
January 1 - March 31 April 15
April 1 - June 30 July 15
July 1 - September 30 October 15
October 1 - December 31 January 15
PHP\Pinellas County Page 42 of 44
EXHIBIT H
(Continued)
II. Utilization and Cost Information
The following information is to be 1) provided monthly for the
current month as well as year-to-date; and 2) delivered by the
last day of each month for services rendered during the prior
month.
. Member months
. Hospital admissions per 1000
. Hospital bed days per 1000
. Surgeries per 1000
. Primary care physician visits per 1000
. Specialist/referral visits per 1000
. Emergency room visits per 1000
. Average length of hospital stay
. Listing of hospital admissions, including admission and
discharge date, diagnosis, type of service, name of
hospital, and amount paid
. Listing of outpatient procedures, including date,
diagnosis, procedure, and name of hospital
. Average cost per hospital day
. Average cost per hospital admission
. Dental Visits per 1000
PHP\Pinellas County Page 43 of 44
EXHIBIT I
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY, AND
VOLUNTARY EXCLUSION
CONTRACTS AND SUBCONTRACTS
This certification is required by the regulations implementing Executive Order
12549, Debarment and Suspension, signed February 18, 1986. The guidelines were
published in the May 29, 1987, Federal Register (52 Fed. Reg., pages
20360-20369).
INSTRUCTIONS
A. Each Provider whose contract\subcontract equals or exceeds
$25,000 in federal monies must sign this certification prior to
execution of each contract\subcontract. Additionally, providers
who audit federal programs must also sign, regardless of the
contract amount. The Florida Healthy Kids Corporation cannot
contract with these types of providers if they are debarred or
suspended by the federal government.
B. This certification is a material representation of fact upon
which reliance is placed when this contract\subcontract is
entered into. If it is later determined that the signer
knowingly rendered an erroneous certification, the Federal
Government may pursue available remedies, including suspension
and/or debarment.
C. The provider shall provide immediate written notice to the
contract manager at any time the provider learns that its
certification was erroneous when submitted or has become
erroneous by reason of changed circumstances.
D. The terms "debarred," "suspended," "ineligible," "person,"
"principal," and "voluntarily excluded," as used in this
certification, have the meanings set out in the Definitions and
Coverage sections of rules implementing Executive Order 12549.
You may contact the contract manager for assistance in obtaining
a copy of those regulations.
X. The provider agrees by submitting this certification that, it
shall not knowingly enter into any subcontract with a person who
is debarred, suspended, declared ineligible, or voluntarily
excluded from participation in this contract/subcontract unless
authorized by the Federal Government.
F. The provider further agrees by submitting this certification
that it will require each subcontractor of this
contract/subcontract whose payment will equal or exceed $25,000
in federal monies, to submit a signed copy of this
certification.
G. The Florida Healthy Kids Corporation may rely upon a
certification of a provider that it is not debarred, suspended,
ineligible, or voluntarily excluded from
contracting\subcontracting unless it knows that the
certification is erroneous.
H. This signed certification must be kept in the contract manager's
file. Subcontractor's certifications must be kept at the
contractor's business location.
CERTIFICATION
1. The prospective provider certifies, by signing this
certification, that neither he nor his principals is presently
debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from participation in this
contract/subcontract by any federal agency.
2. Where the prospective provider is unable to certify to any of
the statements in this certification, such prospective provider
shall attach an explanation to this certification.
-------------------------------- ----------------
Signature Date
---------------------------------------------
Name and Title of Authorized Signee
PHP\Pinellas County Page 44 of 44
AMENDMENT #1
TO THE CONTRACT BETWEEN
THE FLORIDA HEALTHY KIDS CORPORATION
AND
PHYSICIANS HEALTH CARE PLANS
THIS AMENDMENT, entered into between the Florida Healthy Kids Corporation,
hereinafter referred to as "FHKC" and PHYSICIANS HEALTH CARE PLANS, hereinafter
referred to as "PHP", amends its contract dated November 16, 1999.
WHEREAS, the contract between FHKC and PHP allows for amendments to said
contract by mutual written consent of the parties;
WHEREAS, the federal regulations governing programs such as FHKC became
effective August 24,2001 and this Amendment will effectuate the changes required
by said federal regulations;
THEREFORE, be it resolved that the Parties agree to the following amendment of
their contract:
I. Section 1-1 is amended to read:
1-1 Definitions
As used in this agreement, the term:
A. "COMPREHENSIVE HEALTH CARE SERVICES" means those
services, medical equipment, and supplies to be provided
by PHP in accordance with standards set by FHKC and
further described in Exhibit C.
B. "THE PROGRAM" shall mean the project established by FHKC
pursuant to Section 624.91, Florida Statutes and
specified herein.
C. "PARTICIPANT" means those individuals meeting FHKC
standards of eligibility and who have been enrolled in
the program.
D. "PHP PROVIDERS" shall mean those providers set forth in
the participant's handbook as from time to time amended.
E. "CO-PAYMENT" or "COST SHARING" is the payment required
of the participant at the time of obtaining service. In
the event the participant fails to pay the required
co-payment, PHP may decline to provide non-emergency or
non-urgently needed care unless the participant meets
the conditions for waiver of co-payments described in
Exhibit C.
F. "FRAUD" shall mean:
1) Any FHKC participant or person who knowingly:
a) Fails, by any false statement,
misrepresentation, impersonation, or
other fraudulent means, to disclose a
material fact used in making a
PHP/Pinellas Page 1 of 19
Effective Date: December 1, 2001
determination as to such person's
qualification to receive comprehensive
health care services coverage under the
FHKC program;
b) Fails to disclose a change in
circumstances in order to obtain or
continue to receive comprehensive health
care services coverage under the FHKC
program to which he or she is not
entitled or in an amount larger than
that which he or she is entitled;
c) Aids and abets another person in the
commission of any such act.
2) Any person or FHKC participant who:
a) Uses, transfers, acquires, traffics,
alters, forges, or possess, or
b) Attempts to use, transfer, acquire,
traffic, alter, forge or possess, or
c) Aids and abets another person in the
use, transfer, acquisition, traffic,
alteration, forgery or possession of a
FHKC identification card.
G. "STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP)" OR
"TITLE XXI" shall mean the program created by the
federal Balanced Budget Act of 1997 as Title XXI of the
Social Security Act.
II. Section 3-2- Access to Care is amended to read:
3-2-1 Access and Appointment Standards
PHP agrees to meet or exceed the appointment and geographic access
standards for pediatric care existing in the community and as
specifically provided for in Exhibit E attached hereto and incorporated
herein as a part of this Agreement.
In the event PHP's provider network is unable to provide those medically
necessary benefits specified in Exhibit C, for any reason, except force
majeure, PHP shall be responsible for those contract benefits obtained
from providers other than PHP for eligible FHKC participants. In the
event PHP fails to meet those access standards set forth in Exhibit E,
FHKC may, after following procedures set forth in Exhibit E, direct its
participants to obtain such contract benefit from other providers and
may contract for such services. All financial responsibility related to
services received under these specific circumstances shall be assumed by
PHP.
3-2-2 Integrity of Professional Advice to Enrollees
PHP ensures no interference with the advice of health care professionals
to enrollees and that information about treatments will be provided to
enrollees and their families in the appropriate manner.
PHP/Pinellas Page 2 of 19
Effective Date: December 1, 2001
PHP agrees to comply with any federal regulations related to physician
incentive plans and any disclosure requirements related to such
incentive plans.
III. Section 3-3 is amended to read:
3-3 Fraud and Abuse (renumber subsequent sections)
PHP ensures that it has appropriate measures in place to ensure against
fraud and abuse. PHP shall report to FHKC any information on violations
by subcontractors or participants that pertain to enrollment or the
payment and provision of health care services under this Agreement.
IV. Section 3-9 is amended to read:
PHP will issue participant certificates, identification cards, provider
network listings and handbooks to all FHKC designated participants
within five business days of receipt of an eligibility tape. Except as
specifically provided in Sections 3-8 and 3-11 hereof, all participant
rights and benefits shall terminate upon termination of this Agreement
or upon termination of participation in the program. All participant
handbooks and member materials must be approved by FHKC prior to
distribution.
V. Section -3-12 is amended to read:
Grievances and Complaints
PHP agrees to provide all FHKC participants a Grievance Process and the
grievance and complaint procedures shall be governed by federal and
state regulations issued for SCHIP, and the following additional rules
and guidelines:
A. There must be sufficient support staff (clerical and
professional) available to process grievances.
B. Staff must be educated concerning the importance of the
procedure and the rights of the enrollee.
C. Someone with problem solving authority must be part of the
grievance procedure.
D. In order to initiate the grievance process, such grievance must
be filed in writing.
E. The parties will provide assistance to grievant during the
grievance process to the extent FHKC deems necessary.
F. Grievances shall be resolved within sixty days from initial
filing by the participant, unless information must be collected
from providers located outside the authorized service area or
from non-contract providers. In such exceptions, an additional
extension shall be authorized upon establishing good cause.
G. A record of informal complaints received that are not grievances
shall be maintained and shall include the date, name, nature of
the complaint and the disposition.
H. The grievance procedures must conform with the federal
regulations governing the State Children's Health Insurance
Program (SCHIP).
I. A quarterly report of all grievances involving FHKC participants
must be submitted to FHKC. The report should list the number of
grievances received during the quarter and the disposition of
those grievances. PHP
PHP/Pinellas Page 3 of 19
Effective Date: December 1, 2001
shall also inform FHKC of any grievances that are referred to
the Statewide Subscriber Assistance Panel prior to their
presentation at the panel.
VI. Section 3-14 is amended to read:
3-14 Notification
A. PHP shall immediately notify FHKC of:
1. Any judgment, decree, or order rendered by any court of
any jurisdiction or Florida Administrative Agency
enjoining PHP from the sale or provision of service
under Chapter 641, Part II, Florida Statutes.
2. Any petition by PHP in bankruptcy or for approval of a
plan of reorganization or arrangement under the
Bankruptcy Act or Chapter 631, Part I, Florida Statutes,
or an admission seeking the relief provided therein.
3. Any petition or order of rehabilitation or liquidation
as provided in Chapters 631 or 641, Florida Statutes.
4. Any order revoking the Certificate Of Authority granted
to PHP.
5. Any administrative action taken by the Department of
Insurance or Agency for Health Care Administration in
regard to PHP.
6. Any medical malpractice action filed in a court of law
in which a FHKC participant is a party (or in whose
behalf a participant's allegations are to be litigated).
7. The filing of an application for change of ownership
with the Florida Department of Insurance.
8. Any change in subcontractors who are providing services
to FHKC participants.
B. Monthly Notification Requirements
PHP shall inform FHKC monthly of any changes to the provider
network that differ from the network presented in the original
bid proposal, including discontinuation of any primary care
providers or physician practice associations or groups with
Healthy Kids enrollees on their panels. FHKC may require PHP to
provide FHKC with evidence that its provider network continues
to meet the access standards described in Exhibit E.
VII. Section 3-18 is amended to read:
3-18 Medical Records Requirements
PHP shall require providers to maintain medical records for each
participant under this Agreement in accordance with applicable state and
federal law.
3-18-1 Medical Quality Review and Audit
FHKC shall conduct an independent medical quality review of PHP
at the conclusion of the first twelve months of coverage. The
independent auditor's report will include a written review and
evaluation of care
PHP/Pinellas Page 4 of 19
Effective Date: December 1, 2001
provided to FHKC participants in Pinellas County. Additional
reviews may also be conducted after completion of the baseline
review at the discretion of FHKC. PHP agrees to cooperate in all
evaluation efforts conducted or authorized by FHKC.
3-18-2 Privacy of Medical Records
PHP will ensure that all individual medical records will be
maintained with confidentiality in accordance with state and
federal guidelines. PHP agrees to abide by all applicable state
and federal laws governing the confidentiality of minors and the
privacy of individually identifiable health information.
3-18-3 Requests by Participants for Medical Records
PHP will ensure that each participant may request and receive a
copy of records and information pertaining to that enrollee in a
timely manner. Additionally, the participant may request that
such records be corrected or supplemented.
VIII. Section 3-26 is amended to read:
3-26 Reporting Requirements
PHP agrees to provide on a timely basis the quarterly statistical
reports detailed in Exhibit H to FHKC that FHKC must have to satisfy
reporting requirements. PHP also agrees to attest to the accuracy,
completeness and truthfulness of claims and payment data that are
submitted to FHKC under penalty of perjury. Access to participant claims
data by FHKC, the State of Florida, the federal Centers for Medicaid
and Medicare Services, the Department of Health and Human Services
Inspector General will be allowed to the extent allowed under any state
privacy protections.
IX. A new section 4-4 is created and subsequent sections are renumbered as
follows:
4-4 Relation to Other Laws (renumber subsequent sections)
4-4-1 Health Insurance Portability and Accountability Act
(HIPAA) Coverage offered under this Agreement is considered
creditable coverage for the purposes of part 7 of subtitle B of
title II of ERISA, title XXVII of the Public Health Services Act
and subtitle K of the Internal Revenue Code of 1986.
Additionally, PHP agrees to comply with all other applicable
provisions of the HIPAA.
4-4-2 Mental Health Parity Act (MHPA)
PHP agrees to comply with the requirements of the Mental Health
Parity Act of 1996 regarding parity in the application of annual
and lifetime dollar limits to mental health benefits in
accordance with 45 CFR 146.136.
4-4-3 Newborns and Mothers Health Protection Act of 1996 (NMHPA)
PHP/Pinellas Page 5 of 19
Effective Date: December 1, 2001
PHP agrees to comply with the requirements of the NMHPA of 1996
regarding requirements for minimum hospital stays for mothers
and newborns in accordance with 45 CFR 146.130 and 148.170.
X. Section 4-4 is renumbered and amended to read:
4-4 Independent Contractor
The relationship of PHP to the FHKC shall be solely that of an
independent contractor. As an independent contractor, PHP agrees to
comply with the following provisions:
a. Title VI of the Civil Rights Act of 1964, as amended, 42
U.S.C. 2000d et seq., which prohibits discrimination on
the basis of race, color, or national origin.
b. Section 504 of the Rehabilitation Act of 1973, as
amended, 29 U.S.C. 794, which prohibits discrimination
on the basis of handicap.
c. Title IX of the Education Amendments of 1972, as amended
29 U.S.C. 601 et seq., which prohibits discrimination on
the basis of sex.
d. The Age Discrimination Act of 1975, as amended, 42
U.S.C. 6101 et seq., which prohibits discrimination on
the basis of age.
e. Section 654 of the Omnibus Budget Reconciliation Act of
1981, as amended, 42 U.S.C. 9848, which prohibits
discrimination on the basis of race, creed, color,
national origin, sex, handicap, political affiliation or
beliefs.
f. The American with Disabilities Act of 1990, P.L.
101-336, which prohibits discrimination on the basis of
disability and requires reasonable accommodation for
persons with disabilities.
g. Section 274A (e) of the Immigration and Nationalization
Act, FHKC shall consider the employment by any
contractor of unauthorized aliens a violation of this
Act. Such violation shall be cause for unilateral
cancellation of this Agreement.
h. OMB Circular A-l10 (Appendix A-4) which identifies
procurement procedures which conform to applicable
federal law and regulations with regard to debarment,
suspension, ineligibility, and involuntary exclusion of
contracts and subcontracts and as contained in Exhibit I
of this Agreement. Covered transactions include
procurement contracts for services equal to or in excess
of $100,000 and all non-procurement transactions.
i. The federal regulations implementing the State
Children's Health Insurance Program (SCHIP) as found in
42 CFR Parts 431,433,435,436 and 457 and any subsequent
revisions to the regulation.
PHP/Pinellas Page 6 of 19
Effective Date: December 1, 2001
XI. Section 4-8 is amended to read as follows:
4-8 Governing Law
This Agreement shall be construed and governed in accordance with the
laws of the State of Florida. In the event any action is brought to
enforce the provisions of this Agreement, venue shall be in Xxxx County,
Florida.
XII. Exhibits B, C, E and G are hereby amended as attached and incorporated
into the Agreement.
XIII. Exhibit F is removed from the Agreement and the remaining Amendments are
renumbered.
XIV. Exhibits I and J are new Exhibits to the existing Agreement between FHKC
and PHP and are hereby attached and incorporated into the Agreement.
XV. The effective date of this Amendment is December 1, 2001.
All provisions in the contract and any attachments thereto in conflict with this
amendment shall be and are hereby changed to conform with this amendment.
All provisions not in conflict with this amendment are still in effect and are
to be performed at the level specified in the contract. This amendment and all
of its attachments are hereby made a part of this contract.
IN WITNESS WHEREOF, the parties hereto have caused this 19 page amendment to be
executed by their officials thereunto duly authorized.
FLORIDA HEALTHY KIDS CORPORATION
/s/ Xxxx X. Xxxx
---------------------------------
Xxxx X. Xxxx, Executive Director
Date: 12/20/01
PHYSICIANS HEALTH CARE PLANS
/s/ Xxxxx X. Xxxxxxx
---------------------------------
Name: XXXXX X. XXXXXXX
Date: 11/26/01
PHP/Pinellas Page 7 of 19
Effective Date: December 1, 2001
EXHIBIT B
ENROLLMENT PROCEDURES
1. All FHKC eligible participants will be provided with necessary
enrollment materials and forms from FHKC or its assignee.
2. FHKC will provide PHP with eligible participants who have selected PHP
or who have been assigned by FHKC to PHP according to the provisions of
Section 2-1 via an enrollment tape, using a tape layout to be specified
by FHKC.
3. Upon receipt of such enrollment tape, PHP acting as an agent for FHKC
shall provide each participant with an enrollment package within five
business days of receipt of an enrollment tape that includes at a
minimum the following items:
A. A membership card displaying participant's name, participation number
and effective date of coverage.
B. Participant's handbook that complies with any federal requirements,
including at a minimum, a description of how to access services, a
listing of any copayment requirements, the grievance process and the
covered benefits.
C. Current listing of primary care physicians, specialists and hospital
providers.
4. All additions or deletions will be submitted in accordance with
referenced sections of this Agreement and Exhibit B.
5. Upon receipt of monthly tape from FHKC, PHP will process all new
enrollments and provide new participants with an enrollment package
within five business days of receipt of the enrollment tape.
6. Deletions will be processed by PHP and PHP will notify each cancelled
participant in writing by regular mail of the effective date of
deletion.
7. In accordance with state law, a waiting period of sixty days will be
imposed on those participants who voluntarily cancel their coverage by
non-payment of the required monthly premium. Cancelled participants must
request reinstatement from FHKC and wait at least sixty days from the
date of that request before coverage can be reinstated.
8. FHKC is the sole determiner of eligibility and effective dates of
coverage.
9. PHP must also comply with the guidance issued by the Office of Civil
Rights of the United States Department of Health and Human Services
("Policy Guidance on the Title VI Prohibition against National Origin
Discrimination as it Effects Persons with Limited English Proficiency")
regarding the availability of information and assistance for persons
with limited English proficiency.
PHP/Pinellas Page 8 of 19
Effective Date: December 1, 2001
EXHIBIT C
ENROLLEE BENEFIT SCHEDULE
I. Minimum Benefits; Statutory Requirements
PHP agrees to provide, at a minimum, those benefits that are
prescribed by state law under Section 409.815(2)(a-p) and
409.815(r-t). PHP shall pay an enrollee's covered expenses up to
a lifetime maximum of $1 million per covered enrollee.
The following health care benefits are included under this Agreement:
BENEFIT LIMITATIONS CO-PAYMENTS
--------------------------------------------------------------------------------
A. Inpatient Services All admissions must be authorized by NONE
All covered services PHP.
provided for the The length of the patient stay shall
medical care and be determined based on the medical
treatment of an condition of the enrollee in relation
enrollee who is to the necessary and appropriate level
admitted as an of care.
inpatient to a hospital Room and board may be limited to
licensed under part I semi-private accommodations, unless a
of Chapter 395. private room is considered medically
Covered services necessary or semi-private
include: physician's accommodations are not available.
services; room and Private duty nursing limited to
board; general nursing circumstances where such care is
care; patient meals; medically necessary.
use of operating room Admissions for rehabilitation and
and related facilities; physical therapy are limited to 15
use of intensive care days per contract year.
unit and services; Shall Not Include Experimental or
radiological, Investigational Procedures as defined
laboratory and other as a drug, biological product, device,
diagnostic tests; medical treatment or procedure that
drugs; medications; meets any one of the following
biologicals; anesthesia criteria, as determined by the Plan:
and oxygen services; 1. Reliable Evidence shows the drug,
special duty nursing; biological product, device, medical
radiation and treatment, or procedure when applied
chemotherapy; to the circumstances of a particular
respiratory therapy; patient is the subject of ongoing
administration of whole phase I, II or III clinical trials or
blood plasma; physical, 2. Reliable Evidence shows the drug,
speech and occupational biological product, device, medical
therapy, medically treatment or procedure when applied to
necessary services of the circumstances of a particular
other health patient is under study with a written
professionals. protocol to determine maximum
tolerated dose, toxicity, safety,
efficacy, or efficacy in comparison to
conventional alternatives, or
3. Reliable Evidence shows the drug,
biological product, device, medical
treatment, or procedure is being
delivered or should be delivered
subject to the approval and
supervision of an Institutional Review
Board (IRB) as required and defined by
federal regulations, particularly
those of the U.S. Food and Drug
Administration or the Department of
Health and Human Services.
PHP/Pinellas Page 9 of 19
Effective Date: December 1, 2001
BENEFIT LIMITATIONS CO-PAYMENTS
--------------------------------------------------------------------------------
B. Emergency Services Must use a PHP designated facility or $10 per visit
Covered Services provider for emergency care unless the waived if
include visits to an time to reach such facilities or admitted or
emergency room or other providers would mean the risk of authorized by
licensed facility if permanent damage to patient's health. primary care
needed immediately due physician
to an injury or illness
and delay means risk of
permanent damage to the
enrollee's health.
C. Maternity Services Infant is covered for up to three (3) NONE
and Newborn Care days following birth or until the
Covered services infant is transferred to another
include maternity and medical facility, whichever occurs
newborn care; prenatal first.
and postnatal care;
initial inpatient care
of adolescent Coverage may be limited to the fee for
participants, including vaginal deliveries.
nursery charges and
initial pediatric or
neonatal examination.
D. Organ Transplantation Coverage is available for transplants NONE
Services and medically related services if
Covered services deemed necessary and appropriate
include pretransplant, within the guidelines set by the Organ
transplant and Transplant Advisory Council or the
postdischarge services Bone Marrow Transplant Advisory
and treatment of Council.
complications after
transplantation.
E. Outpatient Services Services must be provided directly by No co-payment
Preventive, diagnostic, PHP or through pre-approved referrals. for well child
therapeutic, palliative care,
care, and other preventive care
services provided to an Routine hearing and screening must be or for routine
enrollee in the provided by primary care physician. vision and
outpatient portion of a hearing
health facility screenings.
licensed under chapter Family planning limited to one annual
395. visit and one supply visit each ninety $3 per office
days. visit
Covered services
include Well-child
care, including those Chiropractic services shall be
services recommended in provided in the same manner as in the
the Guidelines for Florida Medicaid program.
Health Supervision of
Children and Youth as
developed by Academy of Podiatric services are limited to one
Pediatrics; visit per day totaling two visits per
immunizations and month for specific foot disorders.
injections as Routine foot care must be for
recommended by the conditions that result in circulatory
Advisory Committee on embarrassment or desensitization.
Immunization Practices; Dental services must be provided to an
health education oral surgeon for medically necessary
counseling and clinical reconstructive dental surgery due to
services; family injury.
planning services,
vision screening;
hearing screening; Treatment for temporomandibular joint
clinical radiological, (TMJ) disease is specifically
laboratory and other excluded.
outpatient diagnostic
tests; ambulatory
surgical procedures; Shall Not Include Experimental or
splints and casts; Investigational Procedures as defined
consultation with and as a drug, biological product, device,
treatment medical treatment or procedure that
meets any one of the following
criteria, as determined by PHP:
1. Reliable Evidence shows the drug,
biological product,
PHP/Pinellas Page 10 of 19
Effective Date: December 1, 2001
BENEFIT LIMITATIONS CO-PAYMENTS
--------------------------------------------------------------------------------
by referral physicians; device, medical treatment, or
radiation and procedure when applied to the
chemotherapy; circumstances of a particular patient
chiropractic services; is the subject of ongoing phase I, II
podiatric services. or III clinical trials or
2. Reliable Evidence shows the drug,
biological product, device, medical
treatment or procedure when applied to
the circumstances of a particular
patient is under study with a written
protocol to determine maximum
tolerated dose, toxicity, safety,
efficacy, or efficacy in comparison to
conventional alternatives, or
3. Reliable Evidence shows the drug,
biological product, device, medical
treatment, or procedure is being
delivered or should be delivered
subject to the approval and
supervision of an Institutional Review
Board (IRB) as required and defined by
federal regulations, particularly
those of the U.S. Food and Drug
Administration or the Department of
Health and Human Services
E. Behavioral Health All services must be provided directly
Services by PHP or upon approved referral.
Covered services
include inpatient and
outpatient care for Inpatient services are limited to not INPATIENT:
psychological or more than thirty inpatient days per NONE
psychiatric evaluation, contract year for psychiatric
diagnosis and treatment admissions, or residential services in
by a licensed mental lieu of inpatient psychiatric
health professional. admissions; however, a minimum of ten
of the thirty days shall be available
only for inpatient psychiatric
services when authorized by PHP
physician.
Outpatient services are limited to a
maximum of forty outpatient visits per OUTPATIENT:$3
contract year. per visit
F. Substance Abuse All services must be provided directly INPATIENT:
Services by PHP or upon approved referral. NONE
Includes coverage for
inpatient and
outpatient care for Inpatient services are limited to not
drug and alcohol abuse more than seven inpatient days per
including counseling contract year for medical
and placement detoxification only and thirty days
assistance. residential services.
Outpatient services
include evaluation, Outpatient visits are limited to a
diagnosis and maximum of forty visits per contract OUTPATIENT:$3
treatment by a licensed year. per visit
practitioner
G. Therapy Services All treatments must be performed $3 per visit
Covered services directly or as authorized by PHP.
include physical,
occupational,
respiratory and speech Limited to up to twenty-four treatment
therapies for sessions within a sixty day period per
short-term episode or injury, with the sixty day
rehabilitation where period beginning with the first
significant improvement treatment.
in the enrollee's
condition will result.
H. Home Health Services Coverage is limited to skilled nursing $3 per visit
Includes prescribed services only. Meals, housekeeping and
home visits by both personal comfort items are excluded.
registered and licensed Services must be provided directly by
practical nurses to PHP.
provide skilled nursing
services on a part-time
intermittent basis.
PHP/Pinellas Page 11 of 19
Effective Date: December 1, 2001
BENEFIT LIMITATIONS CO-PAYMENTS
--------------------------------------------------------------------------------
I. Hospice Services Once a family elects to receive $3 per visit
Covered services hospice care for an enrollee, other
include reasonable and services that treat the terminal
necessary services for condition will not be covered.
palliation or
management of an
enrollee's terminal Services required for
illness. conditions totally unrelated to the
terminal condition are covered to the
extent that the services are covered
under this contract.
J.Nursing Facility All admissions must be authorized by NONE
Services PHP and provided by a PHP affiliated
facility.
Covered services Participant must require and receive
include regular nursing skilled services on a daily basis as
services, ordered by PHP physician.
rehabilitation The length of the enrollee's stay
services, drugs and shall be determined by the medical
biologicals, medical condition of the enrollee in relation
supplies, and the use to the necessary and appropriate level
of appliances and of care, but is no more than 100 days
equipment furnished by per contract year.
the facility.
Room and board is limited to
semi-private accommodations unless a
private room is considered medically
necessary or semi-private
accommodations are not available.
Specialized treatment centers and
independent kidney disease treatment
centers are excluded.
Private duty nurses, television, and
custodial care are excluded.
Admissions for rehabilitation and
physical therapy are limited to
fifteen days per contract year.
K. Durable Medical Equipment and devices must be provided NONE
Equipment and by authorized PHP supplier.
Prosthetic Devices
Equipment and devices
that are medically Covered prosthetic devices include
indicated to assist in artificial eyes and limbs, braces, and
the treatment of a other artificial aids.
medical condition and
specifically prescribed
as medically necessary Low vision and telescopic lenses are
by enrollee's PHP not included.
physician.
Hearing aids are covered only when
medically indicated to assist in the
treatment of a medical condition.
L. Refractions Enrollee must have failed vision $3 per visit
Examination by a PHP screening by primary care physician.
optometrist to
determine the need for
and to prescribe Corrective lenses and frames are
corrective lenses as limited to one pair every two years
medically indicated. unless head size or prescription $10 for
changes. corrective
lenses
Coverage is limited to Medicaid frames
with plastic or SYL non-tinted lenses.
M. Pharmacy Prescribed drugs covered under this $3 per
Prescribed drugs for Agreement shall include all prescribed prescription
the treatment of drugs covered under the Florida for up to a
illness or injury or Medicaid program. PHP may implement a 31-day supply
injury. pharmacy benefit management program if
FHKC so authorizes.
Brand name products are covered if a
generic substitution is not available
or where the prescribing physician
indicates that a brand name is
medically necessary.
All medications must be dispensed
through PHP or a PHP designated
pharmacy.
All prescriptions must be written by
the participant's
PHP/Pinellas Page 12 of 19
Effective Date: December 1, 2001
BENEFIT LIMITATIONS CO-PAYMENTS
--------------------------------------------------------------------------------
primary care physician, PHP approved
specialist or consultant physician.
N. Transportation Must be in response to an emergency $10 per
Services situation. service
Emergency
transportation as
determined to be
medically necessary in
response to an
emergency situation.
II. Cost Sharing Provisions
PHP agrees to comply with all cost sharing restrictions imposed on FHKC
participants by federal or state laws and regulations, including the following
specific provisions:
A. Special Populations
Enrollees identified by FHKC to PHP as Native Americans or
Alaskan Natives are prohibited from paying any cost sharing
amounts.
B. Cost Sharing Limited to No More than Five Percent of Family's
Income FHKC may identify to PHP other enrollees who have met
federal requirements regarding maximum out of pocket
expenditures. Enrollees identified by FHKC as having met this
threshold are not required to pay any further cost sharing for
covered services for a time specified by FHKC.
C. PHP is responsible for informing its providers of these
provisions and ensuring that enrollees under this section incur
no further out of pocket costs for covered services and are not
denied access to services. FHKC will provide these enrollees
with a letter indicating that they may not incur any cost
sharing obligations.
III. Other Benefit Provision
All requirements for prior authorizations must conform with
federal and state regulations and must be completed within
fourteen (14) days of request by the enrollee. Extensions to
this process may be granted in accordance with federal and/or
state regulations.
PHP/Pinellas Page 13 of 19
Effective Date: December 1, 2001
EXHIBIT E
ACCESS and CREDENTIALING STANDARDS
PHP shall maintain a medical staff, under contract, sufficient to permit
reasonably prompt medical service to all participants in accordance with the
following:
1. Physician and Medical Provider Standards
PHP shall provide include only board certified pediatricians and
family practice physicians or physician extenders working under
the direct supervision of a board certified practitioner to
serve as primary care physicians in its provider network for
Pinellas County.
Additionally, PHP shall identify a medical home, as defined by
the American Academy of Pediatrics, for each enrollee. The
enrollee shall be given the opportunity to select a primary care
physician and if a physician has not been selected, Insurer will
assign the enrollee to a provider meeting the primary medical
care standards above.
The PHP may request that an individual provider be granted an
exception to this policy by making such a request in writing to
the Corporation and providing the provider's curriculum vitae
and a reason why the provider should be granted an exception to
the accepted standard. Such requests will be reviewed by the
Corporation on a case by case basis and a written response will
be made to PHP on the outcome of the request.
2. Geographical Access:
Geographical access to board certified family practice
physicians, pediatric physicians, primary care dental providers
or ARNP's, experienced in child health care, of approximately
twenty (20) minutes driving time from residence to provider,
except that this driving time limitation shall be reasonably
extended in those areas where such limitation with respect to
rural residence is unreasonable. In such instance, PHP shall
provide access for urgent care through contracts with nearest
providers.
3. Timely Treatment:
Timely treatment by providers, such that the participant shall
be seen by a provider in accordance with the following:
A. Emergency care shall be provided immediately;
B. Urgently needed care shall be provided within
twenty-four (24) hours;
C. Routine care of patients who do not require
emergency or urgently needed care shall be
provided within seven (7) calendar days;
PHP/Pinellas Page 14 of 19
Effective Date: December 1, 2001
D. Physical examinations and appointments for
dental oral examinations and routine cleanings
shall be provided within four (4) weeks of
request for appointment; and
E. Follow-up care shall be provided as medically
appropriate.
For the purposes of this section, the following definitions shall apply:
Emergency care is that required for the treatment of an injury
or acute illness that, if not treated immediately, could
reasonably result in serious or permanent damage to the
patient's health.
Urgently needed care is that required within a twenty-four (24)
hour period to prevent a condition from requiring emergency
care.
Routine care is that level of care that can be delayed without
anticipated deterioration in the patient's medical condition for
a period of seven (7) calendar days.
By utilization of the foregoing standards, FHKC does not intend to create
standards of care or access different from those which are deemed acceptable
within the PHP service area. Rather FHKC intends that the provider timely and
appropriately respond to patient care needs, as they are presented, in
accordance with standards of care existing within the service area. In applying
the foregoing standards, the provider shall give due regard to the level of
discomfort and anxiety of the patient and/or parent.
In the event FHKC determines that PHP, or its providers, has failed to meet the
access standards herein set forth, FHKC shall provide PHP with written notice of
non-compliance. Such notice can be provided via facsimile or other means,
specifying the failure in such detail as will reasonably allow PHP to
investigate and respond. Failure of PHP to obtain reasonable compliance or
acceptable community care under the following conditions shall constitute a
breach of this agreement:
A. immediately upon receipt of notice for emergency
or urgent problem; or
B. within ten (10) days of receipt of notice for
routine visit access.
Such breach shall entitle FHKC to such legal and equitable relief as may be
appropriate. In particular, FHKC may direct its participants to obtain such
services outside the PHP provider network. PHP shall be financially responsible
for all services under this provision.
PHP/Pinellas Page 15 of 19
Effective Date: December 1, 2001
EXHIBIT F
GRIEVANCE, ARBITRATION AND LEGAL PROCESS
DELETE EXHIBIT FROM CONTRACT; RENUMBER
SUBSEQUENT EXHIBITS
PHP/Pinellas Page 16 of 19
Effective Date: December 1, 2001
EXHIBIT G
ELIGIBILITY STANDARDS
PARTICIPANT ELIGIBILITY CRITERIA
The following eligibility criteria for participation in the Healthy Kids Program
must be met:
1. The participants must be children who are age 5 through 18, and
the following groups are also eligible:
A. Children between the ages of 3 and 5 who applied for
coverage prior to the effective date of this Agreement
will be also be eligible; and,
B. Children who received coverage prior to October 1, 1998
will be eligible through their 19th birthday.
2. Participants must meet the eligibility criteria established
under Section 624.91, Florida Statutes and as implemented by
FHKC Board of Directors.
3. Eligible participants may enroll during time periods established
by FHKC Board of Directors and in accordance with
Section 624.91, Florida Statutes.
PHP/Pinellas Page 17 of 19
Effective Date: December 1, 2001
EXHIBIT I
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY,
AND VOLUNTARY EXCLUSION
CONTRACTS AND SUBCONTRACTS
This certification is required by the regulations implementing Executive Order
12549, Debarment and Suspension, signed February 18,1986. The guidelines were
published in the May 29, 1987, Federal Register (52 Fed. Reg., pages
20360-20369).
INSTRUCTIONS
A. Each Provider whose contract\subcontract equals or exceeds
$25,000 in federal monies must sign this certification prior to execution of
each contract\subcontract. Additionally, providers who audit federal programs
must also sign, regardless of the contract amount. The Florida Healthy Kids
Corporation cannot contract with these types of providers if they are debarred
or suspended by the federal government.
B. This certification is a material representation of fact upon
which reliance is placed when this contract\subcontract is entered into. If it
is later determined that the signer knowingly rendered an erroneous
certification, the Federal Government may pursue available remedies, including
suspension and/or debarment.
C. The provider shall provide immediate written notice to the
contract manager at any time the provider learns that its certification was
erroneous when submitted or has become erroneous by reason of changed
circumstances.
D. The terms "debarred," "suspended," "ineligible," "person,"
"principal," and "voluntarily excluded," as used in this certification, have the
meanings set out in the Definitions and Coverage sections of rules implementing
Executive Order 12549. You may contact the contract manager for assistance in
obtaining a copy of those regulations.
X. The provider agrees by submitting this certification that, it
shall not knowingly enter into any subcontract with a person who is debarred,
suspended, declared ineligible, or voluntarily excluded from participation in
this contract/subcontract unless authorized by the Federal Government.
F. The provider further agrees by submitting this certification
that it will require each subcontractor of this contract/subcontract whose
payment will equal or exceed $25,000 in federal monies, to submit a signed copy
of this certification.
G. The Florida Healthy Kids Corporation may rely upon a
certification of a provider that it is not debarred, suspended, ineligible, or
voluntarily excluded from contracting\subcontracting unless it knows that the
certification is erroneous.
H. This signed certification must be kept in the contract manager's
file. Subcontractor's certifications must be kept at the contractor's business
location.
CERTIFICATION
The prospective provider certifies, by signing this certification, that neither
he nor his principals is presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from participation in this
contract/subcontract by any federal agency.
Where the prospective provider is unable to certify to any of the statements in
this certification, such prospective provider shall attach an explanation to
this certification.
Signature Date
Name and Title of Authorized Signee
PHP/Pinellas Page 18 of 19
Effective Date: December 1, 2001
EXHIBIT J
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND
COOPERATIVE AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No federal appropriated funds have been paid or will be paid, by or on
behalf of the undersigned, to any person for influencing or attempting
to influence an officer or employee of any agency, a member of congress,
an officer or employee of congress, or an employee of a member of
congress in connection with the awarding of any federal contract, the
making of any federal grant, the making of any federal loan, the
entering into of any cooperative agreement, and the extension,
continuation, renewal, amendment, or modification of any federal
contract, grant, loan, or cooperative agreement.
(2) If any funds other than federal appropriated funds have been paid or
will be paid to any person for influencing or attempting to influence an
officer or employee of any agency, a member of congress, an officer or
employee of congress, or an employee of a member of congress in
connection with this federal contract, grant, loan, or cooperative
agreement, the undersigned shall complete and submit Standard Form-LLL,
"Disclosure Form to Report Lobbying," in accordance with its
instructions.
(3) The undersigned shall require that the language of this certification be
included in the award documents for all subawards at all tiers
(including subcontracts, subgrants, and contracts under grants, loans,
and cooperative agreements) and that all subrecipients shall certify and
disclose accordingly.
This certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction
imposed by section 1352, Title 31, U.S. Code. Any person who fails to file the
required certification shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.
/s/ XXXXX X. XXXXXXX 11/26/01
--------------------------------------------------------------------------------
Signature Date
XXXXX X. XXXXXXX
-----------------------------
Name of Authorized Individual
--------------------------------------------------------------------------------
Name and Address of Organization
PHP/Pinellas Page 19 of 19
Effective Date: December 1, 2001
STANDARD AMENDMENT TO HEALTH PLAN
AMENDMENT #2
TO THE CONTRACT BETWEEN
THE FLORIDA HEALTHY KIDS CORPORATION
AND
PHYSICIANS HEALTHCARE PLANS
THIS AMENDMENT, entered into between the Florida Healthy Kids Corporation,
hereinafter referred to as "FHKC" and PHYSICIANS HEALTHCARE PLANS, hereinafter
referred to as "PHP", amends its contract dated November 16, 1999.
WHEREAS, the contract between FHKC and PHP allows for amendments to said
contract by mutual written consent of the parties;
WHEREAS, FHKC conducts an annual review of its contracts in order to identify
any contract provisions that require modification in order to conform to changes
in the federal and state laws and regulations as well as to reflect programmatic
changes; and,
THEREFORE, be it resolved that the Parties agree to the following amendment of
their contract:
I. Section 3-19-2 is amended to insert the following after
"information.":
PHP's policies and procedures for handling medical records and
protected health information (PHI) shall be compliant with the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) and shall
include provisions for when an enrollee's PHI may be disclosed without
consent or authorization.
II. Section 3-20-2(d) is deleted from the contract.
III. Section 4-4-1 is amended to insert the following after "1986.":
PHP Insurer is responsible for issuing a certificate of creditable
coverage to those FHKC participants who disenroll from the Program.
IV. Exhibit C, Section E, "Outpatient Services" is amended to include the
following additional provision:
Immunizations are to be provided by the primary care physician.
V. Exhibit E, "Access and Credentialling Standards", Paragraph I, A. is
amended to include the following additional provision:
Primary care physicians must provide covered immunizations to
enrollees.
VI. Exhibit K is a new amendment to the Agreement between FHKC and Insurer
and is hereby attached and incorporated into this Agreement.
PHP - Pinellas Page 1 of 4
Effective Date: December 1,2002
VII. This contract amendment is effective December 1, 2002.
All provisions in the contract and any attachments thereto in conflict with this
amendment shall be and are hereby changed to conform with this amendment.
All provisions not in conflict with this amendment are still in effect and are
to be performed at the level specified in the contract. This amendment and all
of its attachments are hereby made a part of this contract.
IN WITNESS WHEREOF, the parties hereto have caused this four (4) page amendment
to be executed by their officials thereunto duly authorized.
FLORIDA HEALTHY KIDS CORPORATION
-------------------------------- -----------------------------------
Xxxx X. Xxxx, Executive Director Witness
Date:
PHYSICIANS HEALTHCARE PLANS
/s/ Xxxxx Xxxxx [ILLEGIBLE]
-------------------------------- -----------------------------------
NAME Xxxxx Xxxxx Witness
Date: 10/16/02
PHP - Pinellas Page 2 of 4
Effective Date: December 1, 2002
EXHIBIT K
CERTIFICATION
REGARDING HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY
ACT OF 1996 COMPLIANCE
This certification is required for compliance with the requirements of the
Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The undersigned Insurer certifies and agrees as to abide by the following:
1. Protected Health Information. For purposes of this Certification,
Protected Health Information shall have the same meaning as the term
"protected health information" in 45 C.F.R. Section 164.501, limited to
the information created or received by the Provider from or on behalf of
the FHKC.
2. Limits on Use and Disclosure of Protected Health Information. The Insurer
shall not use or disclose Protected Health Information other than as
permitted by this Contract or by federal and state law. The Insurer will
use appropriate safeguards to prevent the use or disclosure of Protected
Health Information for any purpose not in conformity with this Contract
and federal and state law. The Insurer will not divulge, disclose, or
communicate in any manner any Protected Health Information to any third
party without prior written consent from the FHKC. The Insurer will report
to the FHKC, within two (2) business days of discovery, any use or
disclosure of Protected Health Information not provided for in this
Contract of which the Insurer is aware. A violation of this paragraph
shall be a material violation of this Contract.
3. Use and Disclosure of Information for Management, Administration, and
Legal Responsibilities. The Insurer is permitted to use and disclose
Protected Health Information received from the Insurer for the proper
management and administration of the Insurer or to carry out the legal
responsibilities of the Insurer, in accordance with 45 C.F.R.
164.504(e)(4). Such disclosure is only permissible where required by law,
or where the Insurer obtains reasonable assurances from the person to whom
the Protected Health Information is disclosed that: (1) the Protected
Health Information will be held confidentially, (2) the Protected Health
Information will be used or further disclosed only as required by law or
for the purposes for which it was disclosed to the person, and (3) the
person notifies the Insurer of any instance of which it is aware in which
the confidentiality of the Protected Health Information has been breached.
4. Disclosure to Subcontractors or Agents. The Insurer agrees to enter into a
subcontract with any person, including a subcontractor or agent, to whom
it provides Protected Health Information received from, or created or
received by the Insurer on behalf of, the FHKC. Such subcontract shall
contain the same terms, conditions, and restrictions that apply to the
Insurer with respect to Protected Health Information.
5. Access to Information. The Insurer shall make Protected Health Information
available in accordance with federal and state law, including providing a
right of access to persons who are the subjects of the Protected Health
Information.
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Effective Date: December 1, 2002
6. Amendment and Incorporation of Amendments. The Insurer shall make
Protected Health Information available for amendment and to incorporate
any amendments to the Protected Health Information in accordance with 45
C.F.R. Section 164.526.
7. Accounting for Disclosures. The Insurer shall make Protected Health
Information available as required to provide an accounting of disclosures
in accordance with 45 C.F.R. Section 164.528.
8. Access to Books and Records. The Insurer shall make its internal
practices, books, and records relating to the use and disclosure of
Protected Health Information received from, or created or received by the
Insurer on behalf of, the FHKC to the Secretary of the Department of
Health and Human Services or the Secretary's designee for purposes of
determining compliance with the Department of Health and Human Services
Privacy Regulations.
9. Termination. At the termination of this contract, the Insurer shall return
all Protected Health Information that the Insurer still maintains in any
form, including any copies or hybrid or merged databases made by the
Insurer; or with prior written approval of the FHKC, the Protected Health
Information may be destroyed by the Insurer after its use. If the
Protected Health Information is destroyed pursuant to the FHKC's prior
written approval, the Insurer must provide a written confirmation of such
destruction to the FHKC. If return or destruction of the Protected Health
Information is determined not feasible by the FHKC, the Provider agrees to
protect the Protected Health Information and treat it as strictly
confidential.
CERTIFICATION
The Insurer and the Florida Healthy Kids Corporation have caused this
Certification to be signed and delivered by their duly authorized
representatives, as of the date set forth below.
Provider Name:
/s/ Xxxxx Xxxxx 10/16/02
--------------------------- -----------------
Signature Date
Xxxxx Xxxxx Dir Govt Prog.
----------------------------------------
Name and Title of Authorized Signee
PHP - Pinellas Page 4 of 4
Effective Date: December 1, 2002
