Contract
Exhibit
10.1
Part
1: Parties to the Contract:
|
This
Contract Amendment (the “Amendment”) is between the Texas Health and Human
Services Commission (HHSC), an administrative agency within the
executive
department of the State of Texas, having its principal office at
0000
Xxxxx Xxxxx Xxxxxxxxx, Xxxxxx, Xxxxx 00000, and Superior HealthPlan,
Inc.
(HMO) a corporation organized under the laws of the State of Texas,
having
its principal place of business at: 0000 Xxxxx XX-00, Xxxxx 000,
Xxxxxx,
Xxxxx 00000. HHSC and HMO may be referred to in this Amendment
individually as a “Party” and collectively as the
“Parties.”
The
Parties hereby agree to amend their original contract, HHSC contract
number 529-06-0280-00014 (the “Contract”) as set forth
herein. The Parties agree that the terms of the Contract will
remain in effect and continue to govern except to the extent modified
in
this Amendment.
This
Amendment is executed by the Parties in accordance with the authority
granted in Attachment A to the HHSC Managed Care Contract document,
“HHSC
Uniform Managed Care Contract Terms & Conditions,” Article 8,
“Amendments and Modifications.”
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Part
2: Effective Date of Amendment:
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Part
3: Contract Expiration Date
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Part
4: Operational Start Date:
|
September
1, 2007
|
August
31, 2008
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STAR
and CHIP HMOs: September 1, 2006 STAR+PLUS
HMOs: February 1, 2007 CHIP Perinatal HMOs: January
1, 2007
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Part
5: Project Managers:
|
||
HHSC:
Xxxxx Xxxxxxxxx Director of Medicaid/CHIP Health Plan Operations
00000
Xxxxxx Xxxxxxxxx, Xxxxxxxx X Xxxxxx, Xxxxx 00000 Phone: 000-000-0000
Fax:
000-000-0000
HMO:
Xxxxxx Xxxx Vice President of Regulatory Affairs 0000 Xxxxx XX-00,
Xxxxx
000 Xxxxxx, Xxxxx 00000 Phone: 000-000-0000 Fax: 000-000-0000 E-mail:
xxxxx@xxxxxxx.xxx
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||
Part
6: Deliver Legal Notices to:
|
||
HHSC:
General Counsel 0000 Xxxxx Xxxxx Xxxxxxxxx, 0xx Xxxxx Xxxxxx,
Xxxxx
00000 Fax: 000-000-0000
HMO:
Superior HealthPlan 0000 Xxxxx XX-00, Xxxxx 000 Xxxxxx, Xxxxx 00000
Fax:
000-000-0000
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Part
7: HMO Programs and Service
Areas:
|
This
Contract applies to the following HHSC HMO Programs and Service
Areas
(check all that apply). All references in the Contract
Attachments to HMO Programs or Service Areas that are not checked
are
superfluous and do not apply to the HMO.
x
Medicaid STAR HMO
Program
Service
Areas:
x
Bexar
x
Lubbock
o Dallas x
Nueces
x
El
Paso oTarrant
o
Harris x
Travis
See
Attachment B-6, “Map of Counties with HMO Program Service Areas,” for
listing of counties included within the STAR Service
Areas.
|
x
Medicaid
STAR+PLUS HMO Program
Service
Areas:
xBexar
x
Nueces
oHarris oTravis
See
Attachment B-6.1, “Map of Counties with STAR+PLUS HMO Program Service
Areas,” for listing of counties included within the STAR+PLUS Service
Areas.
|
xCHIP
HMO Program
Core
Service Areas:
x
Bexar x
Nueces
o
Dallas oTarrant
x
El
Paso x Xxxxxx
x
Xxxxxx x
Xxxx
x
Lubbock
Optional
Service Areas:
x
Bexar x Lubbock
x
El
Paso xNueces
x
Xxxxxx xTravis
See Attachment B-6, “Map of Counties with HMO Program Service Areas,” for
listing of counties included within the CHIP Core Service Areas
and CHIP
Optional Service Areas.
|
xCHIP Perinatal
Program
Core
Service Areas:
xBexar x
Nueces
o
Dallas oTarrant
xEl
Paso x Xxxxxx
xXxxxxx oWebb
xLubbock
Optional
Service Areas:
xBexar x Lubbock
xEl
Paso xNueces
oHarris xTravis
See Attachment B-6.2, “Map of Counties with CHIP Perinatal HMO Program
Service Areas,” for a list of counties included within the CHIP Perinatal
Service Areas.
|
Part
8 of the HHSC Managed Care Contract document, “Payment,” is modified to
add the capitation rates for Rate Period
2.
|
xMedicaid
STAR HMO
PROGRAM
Capitation:
See Attachment A, “HHSC Uniform Managed Care Contract Terms and
Conditions,” Article 10, for a description of the Capitation Rate-setting
methodology and the Capitation Payment requirements for the STAR Program. The
following Rate Cells and Capitation Rates will apply to Rate Period
2:
Service
Area: BEXAR
|
|||
Rate
Cell
|
|
Rate
Period 2 Capitation Rates
|
|
1
|
TANF
Adult
|
$
345.82
|
|
2
|
TANF
Child>12 months
|
$
102.97
|
|
3
|
Expansion
Child>12 months
|
$
108.32
|
|
4
|
Newborn
< 12 months
|
$
705.42
|
|
5
|
TANF
child < 12 months
|
$
225.72
|
|
6
|
Expansion
child < 12 months
|
$
236.12
|
|
7
|
Federal
Mandate child
|
$
83.88
|
|
8
|
Pregnant
Woman
|
$463.85
|
|
9
|
Delivery
Supplemental Payment
|
$3,266.59
|
Service
Area: EL PASO
|
|||
Rate
Cell
|
|
Rate
Period 2 Capitation Rates
|
|
1
|
TANF
Adult
|
$
270.85
|
|
2
|
TANF
Child>12 months
|
$
88.14
|
|
3
|
Expansion
Child>12 months
|
$
104.55
|
|
4
|
Newborn
< 12 months
|
$
584.53
|
|
5
|
TANF
child < 12 months
|
$
360.60
|
|
6
|
Expansion
child < 12 months
|
$
212.40
|
|
7
|
Federal
Mandate child
|
$
81.89
|
|
8
|
Pregnant
Woman
|
$443.70
|
|
9
|
Delivery
Supplemental Payment
|
$3,443.04
|
Service
Area: LUBBOCK
|
|||
Rate
Cell
|
|
Rate
Period 2 Capitation Rates
|
|
1
|
TANF
Adult
|
$
292.63
|
|
2
|
TANF
Child>12 months
|
$
96.20
|
|
3
|
Expansion
Child>12 months
|
$
99.81
|
|
4
|
Newborn
< 12 months
|
$
437.14
|
|
5
|
TANF
child < 12 months
|
$
183.18
|
|
6
|
Expansion
child < 12 months
|
$
262.61
|
|
7
|
Federal
Mandate child
|
$
89.39
|
|
8
|
Pregnant
Woman
|
$
542.76
|
|
9
|
Delivery
Supplemental Payment
|
$3,230.39
|
Service
Area: NUECES
|
|||
Rate
Cell
|
|
Rate
Period 2 Capitation Rates
|
|
1
|
TANF
Adult
|
$
321.57
|
|
2
|
TANF
Child>12 months
|
$
123.41
|
|
3
|
Expansion
Child>12 months
|
$
128.78
|
|
4
|
Newborn
< 12 months
|
$936.09
|
|
5
|
TANF
child < 12 months
|
$
450.28
|
|
6
|
Expansion
child < 12 months
|
$
450.28
|
|
7
|
Federal
Mandate child
|
$
93.82
|
|
8
|
Pregnant
Woman
|
$
407.48
|
|
9
|
Delivery
Supplemental Payment
|
$3,203.82
|
Service
Area: XXXXXX
|
|||
Rate
Cell
|
|
Rate
Period 2 Capitation Rates
|
|
1
|
TANF
Adult
|
$
230.91
|
|
2
|
TANF
Child>12 months
|
$
81.64
|
|
3
|
Expansion
Child>12 months
|
$
98.68
|
|
4
|
Newborn
< 12 months
|
$
760.37
|
|
5
|
TANF
child < 12 months
|
$
229.19
|
|
6
|
Expansion
child < 12 months
|
$
290.55
|
|
7
|
Federal
Mandate child
|
$
77.94
|
|
8
|
Pregnant
Woman
|
$
464.58
|
|
9
|
Delivery
Supplemental Payment
|
$3,247.49
|
STAR
SSI Administrative Fee: HHSC will pay a STAR HMO a monthly
Administrative Fee of $14.00 per SSI Beneficiary who voluntarily enrolls in
the
HMO in accordance with Attachment A, “HHSC Uniform Managed Care Contract Terms
and Conditions,” Article 10.
Delivery
Supplemental Payment: See Attachment A, “HHSC
Uniform Managed Care Contract Terms and Conditions,” Article 10, for a
description of the methodology for establishing the Delivery Supplemental
Payment for the STAR Program.
x Medicaid
STAR+PLUS HMO Program
Capitation:
See Attachment A, “HHSC Uniform Managed Care Contract Terms and Conditions,”
Article 10, for a description of the Capitation Rate-setting methodology and
the
Capitation Payment requirements for the STAR+PLUS Program. The
following Rate Cells and Capitation Rates will apply to Rate Period
2:
STAR+PLUS
Service Area: BEXAR
|
||
Rate
Cell
|
Rate
Period 2 Capitation Rates
|
|
1.
|
Medicaid
Only Standard Rate
|
$
462.72
|
2.
|
Medicaid
Only 1915(C) Nursing Facility Waiver Rate
|
$
3,138.64
|
3.
|
Dual
Eligible Standard Rate
|
$
270.37
|
4.
|
Dual
Eligible 1915(C) Nursing Facility Waiver Rate
|
$
1,931.47
|
5.
|
Nursing
Facility – Medicaid Only
|
$
462.72
|
6.
|
Nursing
Facility – Dual Eligible
|
$
270.37
|
STAR+PLUS
Service Area: NUECES
|
||
Rate
Cell
|
Rate
Period 2 Capitation Rates
|
|
1.
|
Medicaid
Only Standard Rate
|
$
533.57
|
2.
|
Medicaid
Only 1915(C) Nursing Facility Waiver Rate
|
$
3,062.58
|
3.
|
Dual
Eligible Standard Rate
|
$
337.13
|
4.
|
Dual
Eligible 1915(C) Nursing Facility Waiver Rate
|
$
1,887.61
|
5.
|
Nursing
Facility – Medicaid Only
|
$
533.57
|
6.
|
Nursing
Facility – Dual Eligible
|
$
337.13
|
x CHIP
HMO
PROGRAM
Capitation:
See Attachment A, “HHSC Uniform Managed Care Contract Terms and Conditions,”
Article 10, for a description of the Capitation Rate-setting methodology and
the
Capitation Payment requirements for the CHIP Program. The following Rate Cells
and Capitation Rates will apply to Rate Period 2:
Service
Area: BEXAR
|
|||
Rate
Cell
|
|
Rate
Period 2 Capitation Rates
|
|
1
|
<
Age 1
|
$
89.60
|
|
2
|
Ages
1 through 5
|
$
93.96
|
|
3
|
Ages
6 through 14
|
$
60.55
|
|
4
|
Ages
15 through 18
|
$
78.04
|
Service
Area: EL PASO
|
|||
Rate
Cell
|
|
Rate
Period 2 Capitation Rates
|
|
1
|
<
Age 1
|
$
67.70
|
|
2
|
Ages
1 through 5
|
$
67.69
|
|
3
|
Ages
6 through 14
|
$
58.59
|
|
4
|
Ages
15 through 18
|
$
64.24
|
Service
Area: LUBBOCK
|
|||
Rate
Cell
|
|
RatePeriod
2 Capitation Rates
|
|
1
|
<
Age 1
|
$
80.56
|
|
2
|
Ages
1 through 5
|
$
78.16
|
|
3
|
Ages
6 through 14
|
$
62.30
|
|
4
|
Ages
15 through 18
|
$
89.83
|
Service
Area: NUECES
|
|||
Rate
Cell
|
|
Rate
Period 2 Capitation Rates
|
|
1
|
<
Age 1
|
$
62.31
|
|
2
|
Ages
1 through 5
|
$
97.40
|
|
3
|
Ages
6 through 14
|
$
84.79
|
|
4
|
Ages
15 through 18
|
$
116.44
|
Service
Area: XXXXXX
|
|||
Rate
Cell
|
|
Rate
Period 2 Capitation Rates
|
|
1
|
<
Age 1
|
$
129.53
|
|
2
|
Ages
1 through 5
|
$
99.35
|
|
3
|
Ages
6 through 14
|
$
86.64
|
|
4
|
Ages
15 through 18
|
$
117.02
|
Delivery
Supplemental Payment: See Attachment A, “HHSC
Uniform Managed Care Contract Terms and Conditions,” Article 10, for a
description of the methodology for establishing the Delivery Supplemental
Payment for the CHIP Program. The CHIP Delivery Supplemental Payment is
$3,100.00 for all Service Areas.
x CHIP
Perinatal Program
Capitation:
See Attachment A, “HHSC Uniform Managed Care Contract Terms and Conditions,”
Article 10, for a description of the Capitation Rate-setting methodology and
the
Capitation Payment requirements for the CHIP Perinatal Program.
Service
Area: BEXAR
|
|||
Rate
Cell
|
|
Rate
Period 2 Capitation Rates
|
|
1
|
Perinate
0% - 185%
|
$
539.19
|
|
2
|
Perinate
186% - 200%
|
$
175.04
|
|
3
|
Perinate
Newborn 0% - 185%
|
$
394.44
|
|
4
|
Perinate
Newborn 186% - 200%
|
$
741.26
|
Service
Area: EL PASO
|
|||
Rate
Cell
|
|
Rate
Period 2 Capitation Rates
|
|
1
|
Perinate
0% - 185%
|
$
539.19
|
|
2
|
Perinate
186% - 200%
|
$
175.04
|
|
3
|
Perinate
Newborn 0% - 185%
|
$
323.76
|
|
4
|
Perinate
Newborn 186% - 200%
|
$
608.42
|
Service
Area: LUBBOCK
|
|||
Rate
Cell
|
|
Rate
Period 2 Capitation Rates
|
|
1
|
Perinate
0% - 185%
|
$
539.19
|
|
2
|
Perinate
186% - 200%
|
$
175.04
|
|
3
|
Perinate
Newborn 0% - 185%
|
$
244.43
|
|
4
|
Perinate
Newborn 186% - 200%
|
$
459.35
|
Service
Area: NUECES
|
|||
Rate
Cell
|
|
Rate
Period 2 Capitation Rates
|
|
1
|
Perinate
0% - 185%
|
$
539.19
|
|
2
|
Perinate
186% - 200%
|
$
175.04
|
|
3
|
Perinate
Newborn 0% - 185%
|
$
523.42
|
|
4
|
Perinate
Newborn 186% - 200%
|
$
983.65
|
Service
Area: XXXXXX
|
|||
Rate
Cell
|
|
Rate
Period 2 Capitation Rates
|
|
1
|
Perinate
0% - 185%
|
$
539.19
|
|
2
|
Perinate
186% - 200%
|
$
175.04
|
|
3
|
Perinate
Newborn 0% - 185%
|
$
434.23
|
|
4
|
Perinate
Newborn 186% - 200%
|
$
816.04
|
Delivery
Supplemental Payment: See Attachment A, “HHSC
Uniform Managed Care Contract Terms and Conditions,” Article 10, for a
description of the methodology for establishing the Delivery Supplemental
Payment for the CHIP Perinatal Program. The CHIP Perinatal Delivery
Supplemental Payment is $3,100.00 for Perinates between 186% and 200% of the
Federal Poverty Level for all Service Areas.
Modifications
to Part 9 of the HHSC Managed Care Contract document, “Contract Attachments,”
are italicized below:
A:
HHSC
Uniform Managed Care Contract Terms & Conditions - Version 1.7 is
replaced with Version 1.8
B:
Scope
of Work/Performance Measures – Version 1.7 is replaced with Version 1.8 for
all attachments, except if noted.
B-1:
HHSC RFP
000-00-000, Sections 6-9
B-2:
Covered
Services
B-2.1
STAR+PLUS
Covered Services
B-2.2
CHIP Perinatal
Program Covered Services
B-3:
Value-added Services
B-3.1
STAR+PLUS Value-added Services
B-3.2
CHIP Perinatal Program Value-added Services
B-4:
Performance Improvement Goals
B-4.1
SFY 2008
Performance Improvement Goals
B-5:
Deliverables/Liquidated Damages Matrix
B-6:
Map of
Counties with STAR and CHIP HMO Program Service Areas
B-6.1
STAR+PLUS
Service Areas
B-6.2
CHIP Perinatal
Program Service Areas
B-7:
STAR+PLUS Attendant Care Enhanced Payment Methodology
C:
HMO’s
Proposal and Related Documents
C-1:
HMO’s
Proposal
C-2:
HMO
Supplemental Responses
C-3:
Agreed
Modifications to HMO’s Proposal
Part
10: Special Provisions for Nueces Service Area
|
||
|
Attachment
A, Section 10.04 is amended to include sub-part (b) as
follows:
(b)
In
addition to the reasons set forth in Section 10.04(a), the Parties expressly
understand and agree that HHSC may, at any time, unilaterally adjust the Rate
Period 2 STAR Program Capitation Rates for the Nueces Service
Area. HHSC is entitled to unilaterally adjust such rates,
prospectively and/or retrospectively, if it determines
that: (1) the cumulative Rate Period 2 Encounter Data for all HMOs in the Nueces
Service Area does not
support the Capitation Rates; or (2) economic factors in the Nueces Service
Area
significantly and measurably
impact providers or the delivery of Covered Services to Members. For
adjustments made pursuant to this Section 10.04(b), HHSC will provide written
notice at least ten (10) Business Days before: (1) the effective date of a
prospective adjustment; (2) offsetting Capitation Payments to recover
retrospective adjustments. Any adjustments to the Rate Period 2
Capitation Rates must meet the actuarial soundness requirements of Attachment
A,
Section 10.03, “Certification of Capitation Rates.”
The
Parties have executed this Contract Amendment in their capacities
as
stated below with authority to bind their organizations on the dates
set
forth by their signatures. By signing this Amendment, the
Parties expressly understand and agree that this Amendment is hereby
made
part of the Contract as though it were set out word for word in the
Contract.
Texas
Health and Human Services Commission
/s/
X. X. Xxxx, MD
Xxxxxxx
X. Xxxx, M.D.
Deputy
Executive Commissioner for Health Services
Date:
9/05/07
Superior
HealthPlan, Inc.
/s/
Xxxxxxxxxxx X.
Xxxxxx
By: Xxxxxxxxxxx
Xxxxxx
Title:
President and CEO
Date:
8/22/07
|
Responsible
Office: HHSC Office of General Counsel (OGC) Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8
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Texas
Health & Human Services Commission
Uniform
Managed Care Contract Terms & Conditions
Version
1.8
Responsible
Office: HHSC Office of General Counsel (OGC)
Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version of the Uniform Managed Care Contract Terms &
Conditions
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
version of the Uniform Managed Care Contract Terms & Conditions that
includes provisions applicable to MCOs participating in the STAR+PLUS
Program.
Article
2, “Definitions,” is amended to add or modify the following
definitions: 1915(c) Nursing Facility Waiver; Community-based
Long Term Care Services; Court-ordered Commitment; Default Enrollment;
Dual Eligibles; Eligibles; Functionally Necessary Covered Services;
HHSC
Administrative Services Contractor; HHSC HMO Programs or HMO Programs;
Medicaid HMOs; Medical Assistance Only; Member; Minimum Data Set
For Home
Care (MSD-HC); Nursing Facility Cost Ceiling; Nursing Facility Level
of
Care; Outpatient Hospital Service; Qualified and Disabled Working
Individual (QDWI); Qualified Medicare Beneficiary; Service Coordination;
Service Coordinator; Specified Low-income Medicare Beneficiary (SMBL);
STAR+PLUS or STAR+PLUS Program; STAR+PLUS HMO; Supplemental Security
Income (SSI).
Article
4, “Contract Administration and Management,” is amended to add Sections
4.02(a)(12) and 4.04.1, relating to the STAR+PLUS Service Coordinator.
Article
8, “Amendments and Modifications,” Section 8.06 is amended to clarify that
CMS must approve all amendments to STAR and STAR+PLUS HMO contracts.
Article
10, “Terms and Conditions of Payment,” Section 10.05.1 is added to include
the Capitation Rate structure provisions relating to STAR+PLUS. Section
10.11 is modified to apply only to STAR and CHIP. Section
10.11.1 is added to include the Experience Rebate provisions relating
to
STAR+PLUS.
|
Revision
|
1.2
|
September
1, 2006
|
Revised
version of the Uniform Managed Care Contract Terms & Conditions that
includes provisions applicable to MCOs participating in the STAR
and CHIP
Programs.
Section
4.04(a) is amended to change the reference from “Texas Board of Medical
Examiners” to “Texas Medical Board”.
Article
5 is amended to clarify the following sections: 5.02(e)(5), regarding
disenrollment of Members; 5.02(i), regarding disenrollment of xxxxxx
care
children; and 5.04(b), regarding CHIP eligibility and enrollment
for
babies of CHIP Members
Article
10 is amended to clarify the following sections: 10.01(d), regarding
the
fixed monthly Capitation Rate components; 10.10(c), regarding updating
the
state
|
Responsible
Office: HHSC Office of General Counsel (OGC)
Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8
system
for Members who become eligible for SSI. Section 10.17 is added
regarding recoupment for federal disallowance.
Article
17 is amended to clarify the following section: 17.01, naming HHSC
as an
additional insured.
|
|||
Revision
|
1.3
|
September
1, 2006
|
Article
2 is amended to modify and add the following definitions to include
the
CHIP Perinatal Program- Appeal, CHIP Perinatal Program, CHIP Perinatal
HMO, CHIP Perinate, CHIP Perinate Newborn, Covered Services, Complaint,
Delivery Supplemental Payment, Eligibles, Experience Rebate, HHSC
Administrative Services Contractor, Major Population Group, Member,
Optional Service Area, and Service Management. Article 5 is amended
to add
the following sections: 5.04.1 CHIP Perinatal eligibility and enrollment;
5.05(c) CHIP Perinatal HMOs.
Article
10 is amended to apply to the CHIP Perinatal Program. Section 10.06(a)
is
amended to add the Capitation Rates Structure for CHIP Perinates
and CHIP
Perinate Newborns. Section 10.06(e) is added to include a
description of the rate-setting methodology for the CHIP Perinatal
Program. 10.09(b) is modified to include CHIP Perinatal Program;
Section
10.11 is amended to add the CHIP Perinatal Program to the STAR and
CHIP
Experience Rebate. Section 10.12(c) amended to clarify cost
sharing for the CHIP Perinatal Program.
|
Revision
|
1.4
|
September,
1 2006
|
Contract
amendment did not revise Attachment A HHSC Uniform Managed Care Terms
and
Conditions
|
Revision
|
1.5
|
January
1, 2007
|
Revised
version of the Uniform Managed Care Contract Terms & Conditions that
includes provisions applicable to MCOs participating in the STAR,
STAR+PLUS, CHIP, and CHIP Perinatal Programs.
Section
5.04(a) is amended to clarify the period of CHIP continuous coverage.
Section
5.04.1 is amended to clarify the process for a CHIP Perinatal Newborn
to
move into CHIP at the end of the 12-month CHIP Perinatal Program
eligibility.
Section
5.08 is added to include STAR+PLUS special default language.
Section
10.06.1 is amended to correct the FPL percentages for CHIP Perinates
and
CHIP Perinate Newborns.
Section
17.01 is amended to clarify the insurance requirements for the HMOs
and
Network Providers and to remove the insurance requirements for
Subcontractors.
Section
17.02(b) is added to clarify that a separate Performance Bond is
not
needed for the CHIP Perinatal Program.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment A HHSC Uniform Managed Care Terms
and
Conditions
|
Revision
|
1.7
|
July
1, 2007
|
Article
2 is modified to correct and align definition for “Clean Claim” with the
UMCM.
Section
4.08(c) is modified to add a cross-reference
to
|
Responsible
Office: HHSC Office of General Counsel (OGC)
Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8
new
Attachment B-1, Section 8.1.1.2.
Section
5.05(a), Medicaid HMOs, is amended to clarify provisions regarding
enrollment into Medicaid Managed Care from Medicaid Fee-for-Service
while
in the hospital, changing HMOs while in the hospital, and addressing
which
HMO is responsible for professional and hospital charges during the
hospital stay.
New
Section 10.05.1 (c) is added to clarify capitation payments (delays
in
payment and levels of capitation) for Members certified to receive
STAR+PLUS Waiver Services.
Section
10.06.1 is modified to include the CHIP Perinatal pass through for
delivery physician services for women under 185% FPL.
Section
10.11 is modified to include treatment of the new Incentives and
Disincentives (within the Experience Rebate
determination); additionally, several clarifications are added
with respect to the continuing accrual of any unpaid interest, etc.
Section
10.11.1 is modified to include treatment of the new Incentives and
Disincentives (within the Experience Rebate determination); additionally,
several clarifications are added with respect to the continuing accrual
of
any unpaid interest, etc.
|
|||
Revision
|
1.8
|
September
1, 2007
|
Article
2 is modified to add definitions for Migrant Farmworker and FWC as
a
result of the Xxxx litigation corrective action plans.
Article
2 is modified to reflect legislative changes required by SB 10 to
the
definition for Value-added Services. New
Section
5.03.1 is added to clarify the enrollment process for infants born
to
pregnant women in STAR+PLUS.
Section
5.04 is modified to reflect legislative changes required by HB 109.
Section
10.18 is added to clarify the required pass through of physician
rate
increases for all programs to comply with HHSC
directives.
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn versions
2Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3 Brief
description of the changes to the document made in the
revision.
|
Responsible
Office: HHSC Office of General Counsel (OGC) Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8
TABLE
OF CONTENTS
Article
1.
Introduction...................................................................................................................................
2
Section
1.01
Purpose......................................................................................................................................
2
Section
1.02 Risk-based contract.
..................................................................................................................
2
Section
1.03
Inducements...............................................................................................................................
2
Section
1.04 Construction of the Contract.
.....................................................................................................
2
Section
1.05 No implied authority.
..................................................................................................................
3
Section
1.06 Legal Authority.
..........................................................................................................................
3
Article
2. Definitions
.....................................................................................................................................
3
Article
3. General Terms &
Conditions.......................................................................................................15
Section
3.01 Contract
elements.....................................................................................................................15
Section
3.02 Term of the Contract.
................................................................................................................15
Section
3.03 Funding.
....................................................................................................................................15
Section
3.04 Delegation of authority.
.............................................................................................................15
Section
3.05 No waiver of sovereign immunity.
.............................................................................................15
Section
3.06 Force
majeure...........................................................................................................................15
Section
3.07
Publicity.....................................................................................................................................16
Section
3.08 Assignment.
..............................................................................................................................16
Section
3.09 Cooperation with other vendors and prospective vendors.
.......................................................16
Section
3.10 Renegotiation and reprocurement rights.
..................................................................................16
Section
3.11 RFP errors and
omissions.........................................................................................................16
Section
3.12 Attorneys’ fees.
.........................................................................................................................17
Section
3.13 Preferences under service
contracts.........................................................................................17
Section
3.14 Time of the
essence..................................................................................................................17
Section
3.15
Notice........................................................................................................................................17
Article
4. Contract Administration & Management
..................................................................................17
Section
4.01 Qualifications, retention and replacement of HMO employees.
................................................17
Section
4.02 HMO’s Key
Personnel...............................................................................................................17
Section
4.03 Executive
Director.....................................................................................................................18
Section
4.04 Medical Director.
.......................................................................................................................18
Section
4.04.1 STAR+PLUS Service Coordinator
.........................................................................................18
Section
4.05 Responsibility for HMO personnel and
Subcontractors.............................................................19
Section
4.06 Cooperation with HHSC and state administrative agencies.
.....................................................19
Section
4.07 Conduct of HMO
personnel.......................................................................................................19
Section
4.08
Subcontractors..........................................................................................................................20
Section
4.09 HHSC’s ability to contract with Subcontractors.
........................................................................21
Section
4.10 HMO Agreements with Third
Parties.........................................................................................21
Article
5. Member Eligibility &
Enrollment.................................................................................................21
Section
5.01 Eligibility
Determination.............................................................................................................21
Section
5.02 Member Enrollment &
Disenrollment.........................................................................................21
Section
5.03 STAR enrollment for pregnant women and
infants....................................................................22
Section
5.04 CHIP eligibility and enrollment.
.................................................................................................22
Section
5.05 Span of Coverage
.....................................................................................................................23
Section
5.06 Verification of Member Eligibility.
..............................................................................................23
Section
5.07 Special Temporary STAR Default Process
...............................................................................24
Section
5.08 Special Temporary STAR+PLUS Default
Process....................................................................24
Article
6. Service Levels & Performance Measurement
...........................................................................24
Section
6.01 Performance
measurement.......................................................................................................24
Article
7. Governing Law &
Regulations....................................................................................................24
Section
7.01 Governing law and venue.
........................................................................................................24
Section
7.02 HMO responsibility for compliance with laws and
regulations...................................................24
Responsible
Office: HHSC Office of General Counsel (OGC)
Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8
Section
7.03 TDI licensure/ANHC certification and
solvency.........................................................................25
Section
7.04 Immigration Reform and Control Act of 1986.
...........................................................................25
Section
7.05 Compliance with state and federal anti-discrimination laws.
.....................................................25
Section
7.06 Environmental protection laws.
.................................................................................................26
Section
7.07 HIPAA.
......................................................................................................................................26
Section
8.01 Mutual agreement.
....................................................................................................................26
Section
8.02 Changes in law or
contract........................................................................................................26
Section
8.03 Modifications as a remedy.
.......................................................................................................26
Section
8.04 Modifications upon renewal or extension of
Contract................................................................26
Section
8.05 Modification of HHSC Uniform Managed Care Manual.
............................................................26
Section
8.06 CMS approval of Medicaid amendments
..................................................................................27
Section
8.07 Required compliance with amendment and modification procedures.
......................................27
Section
9.01 Financial record retention and
audit..........................................................................................27
Section
9.02 Access to records, books, and
documents................................................................................27
Section
9.03 Audits of Services, Deliverables and
inspections......................................................................27
Section
9.04 SAO Audit
.................................................................................................................................28
Section
9.05 Response/compliance with audit or inspection findings.
...........................................................28
Article
10. Terms & Conditions of
Payment...............................................................................................28
Section
10.01 Calculation of monthly Capitation
Payment.............................................................................28
Section
10.02 Time and Manner of
Payment.................................................................................................29
Section
10.03 Certification of Capitation
Rates..............................................................................................29
Section
10.04 Modification of Capitation
Rates..............................................................................................29
Section
10.05 STAR Capitation
Structure......................................................................................................29
Section
10.05.1STAR+PLUS Capitation Structure.
.......................................................................................30
Section
10.06 CHIP Capitation Rates
Structure.............................................................................................30
Section
10.07 HMO input during rate setting
process....................................................................................31
Section
10.08 Adjustments to Capitation Payments.
.....................................................................................31
Section
10.09 Delivery Supplemental Payment for CHIP, CHIP Perinatal and STAR HMOs.
.......................32
Section
10.10 Administrative Fee for SSI
Members.......................................................................................32
Section
10.11 STAR, CHIP, and CHIP Perinatal Experience
Rebate............................................................33
Section
10.11.1 STAR+PLUS Experience
Rebate.........................................................................................34
Section
10.12 Payment by Members.
............................................................................................................36
Section
10.13 Restriction on assignment of fees.
..........................................................................................36
Section
10.14 Liability for taxes.
....................................................................................................................37
Section
10.15 Liability for employment-related charges and benefits.
...........................................................37
Section
10.16 No additional
consideration.....................................................................................................37
Section
10.17 Federal
Disallowance..............................................................................................................37
Section
10.18 Required Pass Through of Physician Rate Increases
.............................................................37
Article
11. Disclosure & Confidentiality of Information
...........................................................................37
Section
11.01
Confidentiality..........................................................................................................................38
Section
11.02 Disclosure of HHSC’s Confidential
Information.......................................................................38
Section
11.03 Member
Records.....................................................................................................................38
Section
11.04 Requests for public
information...............................................................................................39
Section
11.05 Privileged Work
Product..........................................................................................................39
Section
11.06 Unauthorized acts.
..................................................................................................................39
Section
11.07 Legal
action.............................................................................................................................39
Section
12.01 Understanding and
expectations.............................................................................................39
Section
12.02 Tailored remedies.
..................................................................................................................40
Section
12.03 Termination by HHSC.
............................................................................................................42
Section
12.04 Termination by
HMO...............................................................................................................43
Responsible
Office: HHSC Office of General Counsel (OGC)
Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8
Section
12.05 Termination by mutual
agreement...........................................................................................44
Section
12.06 Effective date of
termination....................................................................................................44
Section
12.07 Extension of termination effective date.
..................................................................................44
Section
12.08 Payment and other provisions at Contract
termination............................................................44
Section
12.09 Modification of Contract in the event of remedies.
..................................................................44
Section
12.10 Turnover
assistance................................................................................................................44
Section
12.11 Rights upon termination or expiration of Contract.
..................................................................44
Section
12.12 HMO responsibility for associated costs.
................................................................................44
Section
12.13 Dispute resolution.
..................................................................................................................44
Section
12.14 Liability of
HMO.......................................................................................................................45
Article
13. Assurances & Certifications
.....................................................................................................45
Section
13.01 Proposal certifications.
............................................................................................................45
Section
13.02 Conflicts of
interest..................................................................................................................45
Section
13.03 Organizational conflicts of interest.
.........................................................................................46
Section
13.04 HHSC personnel recruitment
prohibition.................................................................................46
Section
13.05 Anti-kickback
provision............................................................................................................46
Section
13.06 Debt or back taxes owed to State of
Texas.............................................................................46
Section
13.07 Certification regarding status of license, certificate, or permit.
................................................46
Section
13.08 Outstanding debts and
judgments...........................................................................................47
Section
14.01 Authorization.
..........................................................................................................................47
Section
14.02 Ability to perform.
....................................................................................................................47
Section
14.03 Minimum Net Worth.
...............................................................................................................47
Section
14.04 Insurer
solvency......................................................................................................................47
Section
14.05 Workmanship and performance.
.............................................................................................47
Section
14.06 Warranty of deliverables.
........................................................................................................47
Section
14.07 Compliance with Contract.
......................................................................................................48
Section
14.08 Technology Access
.................................................................................................................48
Section
15.01 Infringement and
misappropriation..........................................................................................48
Section
15.02
Exceptions...............................................................................................................................48
Section
15.03 Ownership and
Licenses.........................................................................................................48
Article
16. Liability
.......................................................................................................................................49
Section
16.01 Property
damage.....................................................................................................................49
Section
16.02 Risk of
Loss.............................................................................................................................50
Section
16.03 Limitation of HHSC’s Liability.
.................................................................................................50
Article
17. Insurance &
Bonding.................................................................................................................50
Section
17.01 Insurance
Coverage................................................................................................................50
Section
17.02 Performance Bond.
.................................................................................................................51
Section
17.03 TDI Fidelity
Bond.....................................................................................................................51
Article
1. Introduction
Section
1.01 Purpose.
The
purpose of this Contract is to set forth the terms and conditions for the HMO’s
participation as a managed care organization in one or more of the HMO Programs
administered by HHSC. Under the terms of this Contract, HMO will
provide comprehensive health care services to qualified Program recipients
through a managed care delivery system.
Section
1.02 Risk-based contract.
This
is a
Risk-based contract.
Section
1.03 Inducements.
In
making
the award of this Contract, HHSC relied on HMO’s assurances of the
following:
(1)
HMO
is an established health maintenance organization that arranges for the delivery
of health care services, is currently licensed as such in the State of Texas
and
is fully authorized to conduct business in the Service Areas;
(2)
HMO
and the HMO Administrative Service Subcontractors have the skills,
qualifications, expertise, financial resources and experience necessary to
provide the Services and Deliverables described in the RFP, HMO’s Proposal, and
this Contract in an efficient, cost-effective manner, with a high degree of
quality and responsiveness, and has performed similar services for other public
or private entities;
(3)
HMO
has thoroughly reviewed, analyzed, and understood the RFP, has timely raised
all
questions or objections to the RFP, and has had the opportunity to review and
fully understand HHSC’s current program and operating environment for the
activities that are the subject of the Contract and the needs and requirements
of the State during the Contract term;
(4)
HMO
has had the opportunity to review and understand the State’s stated objectives
in entering into this Contract and, based on such review and understanding,
HMO
currently has the capability to perform in accordance with the terms and
conditions of this Contract;
(5)
HMO
also has reviewed and understands the risks associated with the HMO Programs
as
described in the RFP, including the risk of non-appropriation of
funds.
Accordingly,
on the basis of the terms and conditions of this Contract, HHSC desires to
engage HMO to perform the Services and provide the Deliverables described in
this Contract under the terms and conditions set forth in this
Contract.
Section
1.04 Construction of the
Contract.
(a)
Scope of Introductory Article.
The
provisions of any introductory article to the Contract are intended to be a
general introduction and are not intended to expand the scope of the Parties’
obligations under the Contract or to alter the plain meaning of the terms and
conditions of the Contract.
(b)
References to the “State.” References in the Contract to the “State” shall mean
the State of Texas unless otherwise specifically indicated and shall be
interpreted, as appropriate, to mean or include HHSC and other agencies of
the
State of Texas that may participate in the administration of the HMO Programs,
provided, however, that no provision will be interpreted to include
any entity other than HHSC as the contracting agency.
(c)
Severability. If any provision of this Contract is construed to be
illegal or invalid, such interpretation will not affect the legality or validity
of any of its other provisions. The illegal or invalid provision will be deemed
stricken and deleted to the same extent and effect as if never incorporated
in this Contract, but all other provisions will remain in full force and
effect.
(d)
Survival of terms. Termination or expiration of this Contract for
any
reason
will not release either Party from any liabilities or obligations set forth
in
this Contract that:
(1)
The
Parties have expressly agreed shall survive any such termination or expiration;
or
(2)
Arose
prior to the effective date of termination and remain to be performed or by
their nature would be intended to be applicable following any such termination
or expiration.
(e)
Headings. The article, section and paragraph headings in this Contract are
for
reference and convenience only and
may
not be considered in the interpretation of this Contract.
(f)
Global drafting conventions.
(1)
The
terms “include,” “includes,” and “including” are terms of inclusion, and where
used in this Contract, are deemed to be followed by the words “without
limitation.”
(2)
Any
references to “sections,” “appendices,” “exhibits” or “attachments” are deemed
to be references to sections, appendices, exhibits or attachments to this
Contract.
(3)
Any
references to laws, rules, regulations, and manuals in this Contract are deemed
references to these documents as amended, modified, or supplemented from time
to
time during the term of this Contract.
Section
1.05 No implied authority.
The
authority delegated to HMO by HHSC is limited to the terms of this Contract.
HHSC is the state agency designated by the Texas Legislature to administer
the
HMO Programs, and no other agency of the State grants HMO any authority related
to this program unless directed through HHSC. HMO may not rely upon
implied authority, and specifically is not delegated authority under this
Contract to:
(1)
make
public policy;
(2)
promulgate, amend or disregard administrative regulations or program policy
decisions made by State and federal agencies responsible for administration
of
HHSC Programs; or
(3)
unilaterally communicate or negotiate with any federal or state agency or the
Texas Legislature on behalf of HHSC regarding the HHSC Programs.
HMO
is
required to cooperate to the fullest extent possible to assist HHSC in
communications and negotiations with state and federal governments and agencies
concerning matters relating to the scope of the Contract and the HMO Program(s),
as directed by HHSC.
Section
1.06 Legal Authority.
(a)
HHSC
is authorized to enter into this Contract under Chapters 531 and 533, Texas
Government Code; Section 2155.144, Texas Government Code; and/or Chapter 62,
Texas Health & Safety Code. HMO is authorized to enter into this Contract
pursuant to the authorization of its governing board or controlling owner or
officer.
(b)
The
person or persons signing and executing this Contract on behalf of the Parties,
or representing themselves as signing and executing this Contract on behalf
of
the Parties, warrant and guarantee that he, she, or they have been duly
authorized to execute this Contract and to validly and legally bind the Parties
to all of its terms, performances, and provisions.
Article
2. Definitions
As
used
in this Contract, the following terms and conditions shall have the meanings
assigned below:
1915(c)
Nursing Facility Waiver means the HHSC waiver program that provides
home and community based services to aged and disabled adults as cost-effective
alternatives to institutional care in nursing homes.
Abuse
means provider practices that are inconsistent with sound fiscal, business,
or
medical practices and result in an unnecessary cost to the Medicaid or CHIP
Program, or in reimbursement for services that are not Medically Necessary
or
that fail to meet professionally recognized standards for health care. It also
includes Member practices that result in unnecessary cost to the Medicaid or
CHIP Program.
Account
Name means the name of the individual who lives with the child(ren)
and who applies for the Children’s Health Insurance Program coverage on behalf
of the child(ren).
Action
(Medicaid only) means:
(1)
the
denial or limited authorization of a requested Medicaid service, including
the
type or level of service;
(2)
the
reduction, suspension, or termination of a previously authorized
service;
(3)
the
denial in whole or in part of payment for service;
(4)
the
failure to provide services in a timely manner;
(5)
the
failure of an HMO to act within the timeframes set forth in the Contract and
42
C.F.R.
§438.408(b); or
(6)
for a
resident of a rural area with only one HMO, the denial of a Medicaid Members’
request to obtain services outside of the Network.
An
Adverse Determination is one type of Action.
Acute
Care means preventive care, primary care, and other medical care
provided under the direction of a physician for a condition having a relatively
short duration.
Acute
Care Hospital means a hospital that
provides
acute care services
Adjudicate
means to deny or pay a clean claim.
Administrative
Services see HMO Administrative
Services.
Administrative
Services Contractor see HHSC Administrative Services Contractor.
Adverse
Determination means a determination by an HMO or Utilization Review
agent that the Health Care Services furnished, or proposed to be furnished
to a
patient, are not Medically Necessary or not appropriate.
Affiliate
means any individual or entity owning or holding more than a five percent (5%)
interest in the HMO or in which the HMO owns or holds more than a five percent
(5%) interest; any parent entity; or subsidiary entity of the HMO, regardless
of
the organizational structure of the entity.
Agreement
or Contract means this formal, written, and
legally enforceable contract and amendments thereto between the Parties.
Allowable
Expenses means all expenses related to the Contract between HHSC
and the HMO that are incurred during the Contract Period, are not reimbursable
or recovered from another source, and that conform with the HHSC Uniform Managed
Care Manual’s “Cost Principles for Administrative Expenses.”
AAP
means the American Academy of Pediatrics.
Approved
Non-Profit Health Corporation (ANHC) means an organization formed
in compliance with Chapter 844 of the Texas Insurance Code and licensed by
TDI.
See also HMO.
Appeal
(Medicaid only) means the formal process by which a Member or his
or her representative request a review of the HMO’s Action, as defined
above.
Appeal
(CHIP and CHIP Perinatal Program only) means the formal process by
which a Utilization Review agent addresses Adverse Determinations.
Auxiliary
Aids and Services includes:
(1)
qualified interpreters or other effective methods of making aurally delivered
materials understood by persons with hearing impairments;
(2)
taped
texts, large print, Braille, or other effective methods to ensure visually
delivered materials are available to individuals with visual impairments;
and
(3)
other
effective methods to ensure that materials (delivered both aurally and visually)
are available to those with cognitive or other Disabilities affecting
communication.
Behavioral
Health Services means Covered Services for the treatment of mental,
emotional, or chemical dependency disorders.
Benchmark
means a target or standard based on historical data or an
objective/goal.
Business
Continuity Plan or BCP means a plan that provides for a quick and
smooth restoration of MIS operations after a disruptive event. BCP
includes business impact analysis, BCP development, testing, awareness,
training, and maintenance. This is a day-to-day plan.
Business
Day means any day other than a Saturday, Sunday, or a state or
federal holiday on which HHSC’s offices are closed, unless the context clearly
indicates otherwise.
CAHPS
means the Consumer Assessment of Health Plans Survey. This survey
is conducted annually by the EQRO.
Call
Coverage means arrangements made by a facility or an attending
physician with an appropriate level of health care provider who agrees to be
available on an as-needed basis to provide medically appropriate services for
routine, high risk, or Emergency Medical Conditions or Emergency Behavioral
Health Conditions that present without being scheduled at the facility or when
the attending physician is unavailable.
Capitation
Rate means a fixed predetermined fee paid by HHSC to the HMO each
month in accordance with the Contract, for each enrolled
Member
in
a defined Rate Cell, in exchange for the HMO arranging for or providing a
defined set of Covered Services to such a Member, regardless of the amount
of
Covered Services used by the enrolled Member.
Capitation
Payment means the aggregate amount paid by HHSC to the HMO on a
monthly basis for the provision of Covered Services to enrolled Members in
accordance with the Capitation Rates in the Contract.
Case
Head means the head of the household that is applying for
Medicaid.
C.F.R.
means the Code of Federal Regulations.
Chemical
Dependency Treatment means treatment provided for a chemical
dependency condition by a Chemical Dependency Treatment facility, chemical
dependency counselor or hospital.
Children’s
Health Insurance Program or
CHIPmeans
the
health insurance program authorized and funded pursuant to Title XXI, Social
Security Act (42U.S.C.
§§
1397aa-1397jj) and administered by HHSC.
Child
(or Children) with Special Health Care Needs
(CSHCN) means a child (or children)
who:
(1)
ranges in age from birth up to age nineteen (19) years;
(2)
has a
serious ongoing illness, a complex chronic condition, or a disability that
has
lasted or is anticipated to last at least twelve (12) continuous months or
more;
(3)
has
an illness, condition or disability that results (or without treatment would
be
expected to result) in limitation of function, activities, or social roles
in
comparison with accepted pediatric age-related milestones in the general areas
of physical, cognitive, emotional, and/or social growth and/or
development;
(4)
requires regular, ongoing therapeutic intervention and evaluation by
appropriately trained health care personnel; and
(5)
has a
need for health and/or health-related services at a level significantly above
the usual for the child’s age.
CHIP
HMO Program, or CHIP Program, means the State of Texas program in
which HHSC contracts with HMOs to provide, arrange for, and coordinate Covered
Services for enrolled CHIP Members.
CHIP
HMOs means HMOs participating in the CHIP HMO Program.
CHIP
Perinatal HMOs means HMOs participating in the CHIP Perinatal
Program.
CHIP
Perinatal Program means the State of Texas program in which HHSC
contracts with HMOs to provide, arrange for, and coordinate Covered Services
for
enrolled CHIP Perinate and CHIP Perinate Newborn Members. Although
the CHIP Perinatal
Program is part of the CHIP Program, for Contract administration purposes it
is
identified independently in this Contract. An HMO must specifically contract
with HHSC as a CHIP Perinatal HMO in order to participate in this part of the
CHIP Program.
CHIP
Perinate means a CHIP Perinatal Program Member identified prior to
birth.
CHIP
Perinate Newborn means a CHIP Perinate who has been born
alive.
Chronic
or Complex Condition means a physical, behavioral, or developmental
condition which may have no known cure and/or is progressive and/or can be
debilitating or fatal if left untreated or under-treated.
Clean
Claim means a claim submitted by a physician or provider for
medical care or health care services rendered to a Member, with the data
necessary for the MCO or subcontracted claims processor to adjudicate and
accurately report the claim. A Clean Claim must meet all requirements for
accurate and complete data as defined in the appropriate 837-(claim type)
encounter guides as follows:
(1)
837
Professional Combined Implementation Guide
(2)
837
Institutional Combined Implementation Guide
(3)
837
Professional Companion Guide
(4)
837
Institutional Companion Guide
The
HMO
may not require a physician or provider to submit documentation that conflicts
with the requirements of Texas Administrative Code, Title 28, Part 1, Chapter
21, Subchapters C and T.
CMS
means the Centers for Medicare and Medicaid Services, formerly known as the
Health Care Financing Administration (HCFA), which is the federal agency
responsible for administering Medicare and overseeing state administration
of
Medicaid and CHIP.
COLA
means the Cost of Living Adjustment.
Community-based
Long Term Care Services means services provided to STAR+PLUS
Members in their home or other community based settings necessary to provide
assistance with activities of daily living to allow the Member to remain in
the
most integrated setting possible. Community-based Long-term Care includes
services available to all STAR+PLUS Members as well as those services available
only to STAR+PLUS Members who qualify under the 1915(c) Nursing Facility Waiver
services.
Community
Resource Coordination Groups (CRCGs) means a statewide system of
local interagency groups, including both public and private
providers,
which coordinate services for ”multi-need” children and youth. CRCGs develop
individual service plans for children and adolescents whose needs can be met
only through interagency cooperation. CRCGs address Complex Needs in a model
that promotes local decision-making and ensures that children receive the
integrated combination of social, medical and other services needed to address
their individual problems.
Complainant
means a Member or a treating provider or other individual
designated to act on behalf of the Member who filed the Complaint.
Complaint
(CHIP and CHIP Perinatal Programs only) means any dissatisfaction,
expressed by a Complainant, orally or in writing to the HMO, with any aspect
of
the HMO’s operation, including, but not limited to, dissatisfaction with plan
administration, procedures related to review or Appeal of an Adverse
Determination, as defined in Texas Insurance Code, Chapter 843, Subchapter
G;
the denial, reduction, or termination of a service for reasons not related
to
medical necessity; the way a service is provided; or disenrollment
decisions. The term does not include misinformation that is resolved
promptly by supplying the appropriate information or clearing up the
misunderstanding to the satisfaction of the CHIP Member.
Complaint
(Medicaid only) means an expression of dissatisfaction expressed by
a Complainant, orally or in writing to the HMO, about any matter related to
the
HMO other than an Action. As provided by 42 C.F.R. §438.400, possible subjects
for Complaints include, but are not limited to, the quality of care of services
provided, and aspects of interpersonal relationships such as rudeness of a
provider or employee, or failure to respect the Medicaid Member’s
rights.
Complex
Need means a condition or situation resulting in a need for
coordination or access to services beyond what a PCP would normally provide,
triggering the HMO's determination that Care Coordination is
required.
Comprehensive
Care Program: See definition for Texas Health Steps.
Confidential
Information means any communication or record (whether oral,
written, electronically stored or transmitted, or in any other form) consisting
of:
(1)
Confidential Client information, including HIPAA-defined protected health
information;
(2)
All
non-public budget, expense, payment and other financial
information;
(3)
All
Privileged Work Product;
(4)
All
information designated by HHSC or any other State agency as confidential, and
all information designated as confidential under the Texas Public Information
Act, Texas Government Code, Chapter 552;
(5)
The
pricing, payments, and terms and conditions of the Contract, unless disclosed
publicly by HHSC or the State; and
(6)
Information utilized, developed, received, or maintained by HHSC, the HMO,
or
participating State agencies for the purpose of fulfilling a duty or obligation
under this Contract and that has not been disclosed publicly.
Consumer-Directed
Services means the Member or his legal guardian is the employer of
and retains control over the hiring, management, and termination of an
individual providing personal assistance or respite.
Continuity
of Care means care provided to a Member by the same PCP or
specialty provider to ensure that the delivery of care to the Member remains
stable, and services are consistent and unduplicated.
Contract
or Agreement means this formal, written, and legally
enforceable contract and amendments thereto between the Parties.
Contract
Period or Contract Term means the Initial
Contract Period plus any and all Contract extensions.
Contractor
or HMO means the HMO that is a party to this Contract
and is an insurer licensed by TDI as an HMO or as an ANHC formed in compliance
with Chapter 844 of the Texas Insurance Code.
Core
Service Area (CSA) means the core set Service Area counties defined
by HHSC for the STAR and/or CHIP HMO Programs in which Eligibles will be
required to enroll in an HMO. (See Attachment B-6 to the HHSC Managed Care
Contract document for detailed information on the Service Area
counties.)
Copayment
(CHIP only) means the amount that a Member is required to pay when
utilizing certain benefits within the health care plan. Once the
copayment is made, further payment is not required by the Member.
Corrective
Action Plan means the detailed written plan that may be required by
HHSC to correct or resolve a deficiency or event causing the assessment of
a
remedy or damage against HMO.
Court-Ordered
Commitment means a commitment of a STAR, STAR+PLUS or CHIP Member
to a psychiatric facility for treatment ordered by a court of law pursuant
to
the Texas Health and Safety Code, Title VII Subtitle C.
Covered
Services means Health Care Services the HMO must arrange to provide
to Members, including all services required by the Contract and state and
federal law, and all Value-added Services negotiated by the Parties (see
Attachments B-2, B2.1, B-2.2 and B-3 of the HHSC
Managed Care Contract
relating to “Covered Services” and “Valueadded
Services”). Covered Services include Behavioral Health
Services.
Credentialing
means the process of collecting, assessing, and validating
qualifications and other relevant information pertaining to a health care
provider to determine eligibility and to deliver Covered Services.
Cultural
Competency means the ability of individuals and systems to provide
services effectively to people of various cultures, races, ethnic backgrounds,
and religions in a manner that recognizes, values, affirms, and respects the
worth of the individuals and protects and preserves their dignity.
Date
of Disenrollment means the last day of the last month for which HMO
receives payment for a Member.
Day
means a calendar day unless specified otherwise.
Default
Enrollment means the process established by HHSC to assign a
mandatory STAR, STAR+PLUS, or CHIP Perinate enrollee who has not selected an
MCO
to an MCO.
Deliverable
means a written or recorded work product or data prepared, developed, or
procured by HMO as part of the Services under the Contract for the use or
benefit of HHSC or the State of Texas.
Delivery
Supplemental Payment means a onetime per pregnancy
supplemental payment for STAR, CHIP and CHIP Perinatal HMOs.
DADS
means the Texas Department of Aging and Disability Services or
its
successor agency (formerly Department of Human Services).
DSHS
means the Texas Department of State Health Services or its successor agency
(formerly Texas Department of Health and Texas Department of Mental Health
and
Mental Retardation).
Disease
Management means a system of coordinated healthcare interventions
and communications for populations with conditions in which patient self-care
efforts are significant.
Disproportionate
Share Hospital (DSH) means a hospital that serves
a higher than average number of Medicaid and other low-income patients and
receives additional reimbursement from the State.
Disabled
Person or Person with Disability means a person under sixty-five
(65) years of age, including a child, who qualifies for Medicaid services
because of a disability.
Disability
means a physical or mental impairment that substantially limits one or more
of
an individual’s major life activities, such as caring for oneself, performing
manual tasks, walking, seeing,
hearing,
speaking, breathing, learning, and/or working.
Disability-related
Access means that facilities are readily accessible to and usable
by individuals with disabilities, and that auxiliary aids and services are
provided to ensure effective communication, in compliance with Title III of
the
Americans with Disabilities Act.
Disaster
Recovery Plan means the document developed by the HMO that outlines
details for the restoration of the MIS in the event of an emergency or
disaster.
DSM-IV
means the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, which is the American Psychiatric Association’s official
classification of behavioral health disorders.
Dual
Eligibles means Medicaid recipients who are also eligible for
Medicare.
ECI
means Early Childhood Intervention, a federally mandated program for infants
and
children under the age of three with or at risk for developmental delays and/or
disabilities. The federal ECI regulations are found at 34 §C.F.R. 303.1 et
seq. The State ECI rules are found at 25 TAC §621.21 et
seq.
EDI
means electronic data interchange.
Effective
Date means the effective date of this Contract, as specified in the
HHSC Managed Care Contract document.
Effective
Date of Coverage means the first day of the month for which the HMO
has received payment for a Member.
Eligibles
means individuals residing in one of the Service Areas and eligible to enroll
in
a STAR, STAR+PLUS, CHIP, or CHIP Perinatal HMO, as applicable.
Emergency
Behavioral Health Condition means any condition, without regard to
the nature or cause of the condition, which in the opinion of a prudent
layperson possessing an average knowledge of health and medicine:
(1)
requires immediate intervention and/or medical attention without which Members
would present an immediate danger to themselves or others, or
(2)
which
renders Members incapable of controlling, knowing or understanding the
consequences of their actions.
Emergency
Services means covered inpatient and outpatient services furnished
by a provider that is qualified to furnish such services under the Contract
and
that are needed to evaluate or stabilize an Emergency Medical Condition and/or
an Emergency Behavioral Health Condition, including Post-stabilization Care
Services.
Emergency
Medical Condition means a medical condition manifesting itself by
acute symptoms of recent onset and sufficient severity (including severe pain),
such that a prudent layperson, who possesses an average knowledge of health
and
medicine, could reasonably expect the absence of immediate medical care could
result in:
(1)
placing the patient’s health in serious jeopardy;
(2)
serious impairment to bodily functions;
(3)
serious dysfunction of any bodily organ or part;
(4)
serious disfigurement; or
(5)
in
the case of a pregnant women, serious jeopardy to the health of
a woman or her unborn child.
Encounter
means a Covered Service or group of Covered Services delivered by a Provider
to
a Member during a visit between the Member and Provider. This also includes
Value-added Services.
Encounter
Data means data elements from Fee-for-Service claims or capitated
services proxy claims that are submitted to HHSC by the HMO in accordance with
HHSC’s required format for Medicaid and CHIP HMOs.
Enrollment
Report/Enrollment File means the daily or monthly list of Eligibles
that are enrolled with an HMO as Members on the day or for the month the report
is issued.
EPSDT
means the federally mandated Early and Periodic Screening,
Diagnosis and Treatment program contained at 42 U.S.C. 1396d(r). The name has
been changed to Texas Health Steps (THSteps) in the State of Texas.
Exclusive
Provider Organization (EPO) means the vendor contracted with HHSC
to operate the CHIP EPO in Texas.
Expansion
Area means a county or Service Area that has not previously
provided healthcare to HHSC’s HMO Program Members utilizing a managed care
model.
Expansion
Children means children who are generally at least one, but under
age 6, and live in a family whose income is at or below 133 percent of the
federal poverty level (FPL). Children in this coverage group have
either elected to bypass TANF or are not eligible for TANF in
Texas.
Experience
Rebate means the portion of the HMO’s net income before taxes that
is returned to the State in accordance with Section 10.11 for the STAR, CHIP
and
CHIP Perinatal Programs and 10.11.1 for the STAR+PLUS Program (“Experience
Rebate”).
Expedited
Appeal means an appeal to the HMO in which the decision is required
quickly based on the Member's health status, and the amount of time
necessary
to participate in a standard appeal could jeopardize the Member's life or health
or ability to attain, maintain, or regain maximum function.
Expiration
Date means the expiration date of this Contract, as specified in
HHSC’s Managed Care Contract document.
External
Quality Review Organization (EQRO) means the entity that contracts
with HHSC to provide external review of access to and quality of healthcare
provided to Members of HHSC’s HMO Programs.
Fair
Hearing means the process adopted and implemented by HHSC in 25
T.A.C. Chapter 1, in compliance with federal regulations and state rules
relating to Medicaid Fair Hearings.
Farmworker
Child (FWC) means a child under age 21 of a Migrant
Farmworker.
Fee-for-Service
means the traditional Medicaid Health Care Services payment system
under which providers receive a payment for each unit of service according
to
rules adopted pursuant to Chapter 32, Texas Human Resources Code.
Force
Majeure Event means any failure or delay in performance of a duty
by a Party under this Contract that is caused by fire, flood, hurricane,
tornadoes, earthquake, an act of God, an act of war, riot, civil disorder,
or
any similar event beyond the reasonable control of such Party and without the
fault or negligence of such Party.
FQHC
means a Federally Qualified Health Center, certified by CMS to meet the
requirements of §1861(aa)(3) of the Social Security Act as a federally qualified
health center, that is enrolled as a provider in the Texas Medicaid
program.
FPL
means the Federal Poverty Level.
Fraud
means an intentional deception or misrepresentation made by a person with the
knowledge that the deception could result in some unauthorized benefit to
himself or some other person. It includes any act that constitutes fraud
under
applicable
federal or state law.
FSR
means Financial Statistical Report.
Functionally
Necessary Covered Services means Community-based Long Term Care
services provided to assist STAR+PLUS Members with activities of daily living
based on a functional assessment of the Member’s activities of daily living and
a determination of the amount of supplemental supports necessary for the
STAR+PLUS Member to remain independent or in the most integrated setting
possible.
Habilitative
and Rehabilitative Services means Health Care Services described in
Attachment B-2 that may be required by children who fail to
reach (habilitative) or have lost (rehabilitative) age appropriate developmental
milestones.
Health
Care Services means the Acute Care, Behavioral Health Care and
health-related services that an enrolled population might reasonably require
in
order to be maintained in good health.
Health
and Human Services Commission or HHSC means
the administrative agency within the executive department of Texas state
government established under Chapter 531, Texas Government Code, or its
designee, including, but not limited to, the HHS Agencies.
Health-related
Materials are materials developed by the HMO or obtained from a
third party relating to the prevention, diagnosis or treatment of a medical
condition.
HEDIS,
the Health Plan Employer Data and Information Set, is a registered
trademark of NCQA. HEDIS is a set of standardized performance measures designed
to reliably compare the performance of managed health care plans. HEDIS is
sponsored, supported and maintained by NCQA.
HHS
Agency means the Texas health and human service agencies subject to
HHSC’s oversight under Chapter 531, Texas Government Code, and their successor
agencies.
HHSC
Administrative Services Contractor (ASC) means an entity performing
HMO administrative services functions, including member enrollment functions,
for STAR, STAR+PLUS, CHIP, or CHIP Perinatal HMO Programs under contract
with
HHSC.
HHSC
HMO Programs or HMO Programs mean the STAR, STAR+PLUS, CHIP, and
CHIP Perinatal HMO Programs.
HHSC
Uniform Managed Care Manual means the manual published by or on
behalf of HHSC that contains policies and procedures required of all HMOs
participating in the HHSC Programs.
HIPAA
means the Health Insurance Portability and Accountability Act
of
1996, P.L. 104-191 (August 21, 1996), as amended or modified.
HMO
or Contractor means the HMO that is a party to this
Contract, and is either:
(1)
an
insurer licensed by TDI as a Health Maintenance Organization in accordance
with
Chapter 843 of the Texas Insurance Code, or
(2)
a
certified Approved Non-Profit Health Corporation (ANHC) formed in compliance
with Chapter 844 of the Texas Insurance Code.
HMO
Administrative Services means the performance of services or
functions, other than the direct delivery of Covered Services, necessary for
the
management of the delivery of and payment for Covered Services, including but
not limited to Network, utilization, clinical and/or quality management, service
authorization, claims
processing,
management information systems operation and reporting.
HMO’s
Service Area means all the counties included in any HHSC-defined
Core or Optional Service Area, as applicable to each HMO Program and within
which the HMO has been selected to provide HMO services.
Home
and Community Support Services Agency or HCSS means an entity
licensed to provide home health, hospice, or personal assistance services
provided to individuals in their own home or independent living environment
as
prescribed by a physician or individualized service plan. Each HCSS must provide
clients with a plan of care that includes specific services the agency agrees
to
perform. The agencies are licensed and monitored by DADS or its
successor.
Hospital
means a licensed public or private institution as defined by Chapter 241, Texas
Health and Safety Code, or in Subtitle C, Title 7, Texas Health and Safety
Code.
ICF-MR
means an intermediate care facility for the mentally retarded.
Individual
Family Service Plan (IFSP) means the plan for services required by
the Early Childhood Intervention (ECI) Program and developed by an
interdisciplinary team.
Initial
Contract Period means the Effective Date of the Contract through
August 31, 2008.
Inpatient
Stay means at least a 24-hour stay in a facility licensed to
provide hospital care.
JCAHO
means Joint Commission on Accreditation of Health Care
Organizations.
Joint
Interface Plan (JIP) means a document used to communicate basic
system interface information. This information includes: file structure, data
elements, frequency, media, type of file, receiver and sender of the file,
and
file I.D. The JIP must include each of the HMO’s interfaces required to conduct
business under this Contract. The JIP must address the coordination with each
of
the HMO’s interface partners to ensure the development and maintenance of the
interface; and the timely transfer of required data elements between contractors
and partners.
Key
HMO Personnel means the critical management and technical positions
identified by the HMO in accordance with Article
4.
Linguistic
Access means translation and interpreter services, for written and
spoken language to ensure effective communication. Linguistic access includes
sign language interpretation, and the provision of other auxiliary aids and
services to persons with disabilities.
Local
Health Department means a local health department established
pursuant to Health and Safety
Code,
Title 2, Local Public Health Reorganization Act §121.031.
Local
Mental Health Authority (LMHA) means an entity within a specified
region responsible for planning, policy development, coordination, and resource
development and allocation and for supervising and ensuring the provision of
mental health care services to persons with mental illness in one or more local
service areas.
Major
Population Group means any population, which represents at least
10% of the Medicaid, CHIP, and/or CHIP Perinatal Program population in any
of
the counties in the Service Area served by the HMO.
Material
Subcontractor or Major Subcontractor means
any entity that contracts with the HMO for all or part of the HMO Administrative
Services, where the value of the subcontracted HMO Administrative Service(s)
exceeds $100,000, or is reasonably expected to exceed $100,000, per State Fiscal
Year. Providers in the HMO’s Provider Network are not Material
Subcontractors.
Mandated
or Required Services means services that a state is required to
offer to categorically needy clients under a state Medicaid plan.
Marketing
means any communication from the HMO to a Medicaid or CHIP Eligible who is
not
enrolled with the HMO that can reasonably be interpreted as intended to
influence the Eligible to:
(1)
enroll with the HMO; or
(2)
not
enroll in, or to disenroll from, another MCO.
Marketing
Materials means materials that are produced in any medium by or on
behalf of the HMO and can reasonably be interpreted as intending to market
to
potential Members. Health-related Materials are not Marketing
Materials.
MCO
means managed care organization. Medicaid means the
medical assistance entitlement program authorized and funded pursuant to Title
XIX, Social Security Act (42 U.S.C. §1396 et seq.) and administered by
HHSC. Medicaid HMOs means contracted HMOs participating
in STAR and/or STAR+PLUS. Medical Assistance
Only (MAO) means a person that does not receive SSI
benefits but qualifies financially and functionally for limited Medicaid
assistance. Medical Home means a PCP or specialty care
Provider who has accepted the responsibility for providing accessible,
continuous, comprehensive and coordinated care to Members participating in
a
HHSC HMO Program. Medically Necessary
means:
(1)
Non-behavioral health related Health Care Services that are:
(a)
reasonable and necessary to prevent illnesses or medical conditions, or provide
early screening, interventions, and/or treatments for conditions that cause
suffering or pain, cause physical deformity or limitations in function, threaten
to cause or worsen a handicap, cause illness or infirmity of a Member, or
endanger life;
(b)
provided at appropriate facilities and at the appropriate levels of care for
the
treatment of a Member’s health conditions;
(c)
consistent with health care practice guidelines and standards that are endorsed
by professionally recognized health care organizations or governmental
agencies;
(d)
consistent with the diagnoses of the conditions;
(e)
no
more intrusive or restrictive than necessary to provide a proper balance of
safety, effectiveness, and efficiency;
(f)
are
not experimental or investigative; and
(g)
are
not primarily for the convenience of the Member or Provider; and
(2)
Behavioral Health Services that are:
(a)
are
reasonable and necessary for the diagnosis or treatment of a mental health
or
chemical dependency disorder, or to improve, maintain, or prevent deterioration
of functioning resulting from such a disorder;
(b)
are
in accordance with professionally accepted clinical guidelines and standards
of
practice in behavioral health care;
(c)
are
furnished in the most appropriate and least restrictive setting in which
services can be safely provided;
(d)
are
the most appropriate level or supply of service that can safely be
provided;
(e)
could
not be omitted without adversely affecting the Member’s mental and/or physical
health or the quality of care rendered;
(f)
are
not experimental or investigative; and
(g) are not primarily for the convenience of the Member or Provider.
Member
means a person who:
(1)
is
entitled to benefits under Title XIX of the Social Security Act and Medicaid,
is
in a Medicaid eligibility category included in the STAR or STAR+PLUS Program,
and is enrolled
in
the
STAR or STAR+PLUS Program and the
HMO’s
STAR or STAR+PLUS HMO;
(2)
is
entitled to benefits under Title XIX of the Social Security Act and Medicaid,
is
in a Medicaid eligibility category included as a voluntary participant in the
STAR or STAR+PLUS Program, and is enrolled in the STAR or STAR+PLUS Program
and
the HMO’s STAR or STAR+PLUS HMO;
(3)
has met
CHIP eligibility criteria and is enrolled in the HMO’s CHIP HMO; or
(4)
has met
CHIP Perinatal Program eligibility criteria and is enrolled in the HMO’s CHIP
Perinatal Program.
Member
Materials means all written materials produced or authorized by the
HMO and distributed to Members or potential members containing information
concerning the HMO Program(s). Member Materials include, but are not
limited to, Member ID cards, Member handbooks, Provider directories, and
Marketing Materials.
Member
Month means one Member enrolled with the HMO during any given
month. The total Member Months for each month of a year comprise the annual
Member Months.
Member(s)
with Special Health Care Needs (MSHCN) includes a
Child or Children with a Special Health Care Need (CSHCN) and any adult Member
who:
(1)
has a
serious ongoing illness, a Chronic or Complex Condition, or a Disability that
has lasted or is anticipated to last for a significant period of time,
and
(2)
requires regular, ongoing therapeutic intervention and evaluation by
appropriately trained health care personnel.
Migrant
Farmworker means a migratory agricultural worker, generally defined
as an individual whose principal employment is in agriculture on a seasonal
basis, who has been so employed within the last twenty-four months, and who
establishes for the purposes of such employment a temporary abode.
Minimum
Data Set for Home Care (MDS-HC) means the assessment instrument
included in the Uniform Managed Care Manual that is used to
collect data such as health, social support and service use information on
persons receiving long term care services outside of an institutional
setting.
MIS
means Management Information System.
National
Committee for Quality Assurance (NCQA) means the independent
organization that accredits HMOs, managed behavioral health organizations,
and
accredits and certifies disease management programs. HEDIS and the Quality
Compass are registered trademarks of NCQA.
Net
Income before Taxes means an aggregate excess of Revenues over
Allowable Expenses.
Network
or Provider Network means all Providers that have a contract with
the HMO, or any Subcontractor, for the delivery of Covered Services to the
HMO’s
Members under the Contract.
Network
Provider or Provider means an appropriately credentialed and
licensed individual, facility, agency, institution, organization or other
entity, and its employees and subcontractors, that has a contract with the
HMO
for the delivery of Covered Services to the HMO’s Members.
Non-capitated
Services means those Medicaid services identified in Attachment
B-1, Section 8.2.2.8.
Non-provider
Subcontracts means contracts between the HMO and a third party that
performs a function, excluding delivery of health care services, that the HMO
is
required to perform under its Contract with HHSC.
Nursing
Facility Cost Ceiling means the annualized cost of serving a client
in a nursing facility. A per diem cost is established for each Medicaid nursing
facility resident based on the level of care needed. This level of
care is referred to as the Texas Index for Level of Effort or the TILE
level. The per diem cost is annualized to achieve the nursing
facility ceiling.
Nursing
Facility Level of Care means the determination that the level of
care required to adequately serve a STAR+PLUS Member is at or above the level
of
care provided by a nursing facility.
OB/GYN
means obstetrician-gynecologist.
Open
Panel means Providers who are accepting new patients for the HMO
Program(s) served.
Operational
Start Date means the first day on which an HMO is responsible for
providing Covered Services to Members of an HMO Program in a Service Area in
exchange for a Capitation Payment under the Contract. The Operational
Start Date may vary per HMO Program and Service Area. The Operational
Start Date(s) applicable to this Contract are set forth in the HHSC
Managed Care Contract document.
Optional
Service Area (OSA) means an HHSC defined county or counties,
contiguous to a CSA, in which CHIP or CHIP Perinatal HMOs provide health care
coverage to CHIP Eligibles. The CHIP or CHIP Perinatal HMO must serve the
associated Core Service Area in order to provide coverage in the OSA. The
HHSC Managed Care Contract document includes OSAs, if
applicable.
Operations
Phase means the period of time when HMO is responsible for
providing the Covered Services and all related Contract functions for a Service
Area. The Operations Phase begins on the
Operational
Start Date, and may vary by HMO Program and Service Area.
Outpatient
Hospital Services means diagnostic, therapeutic, and rehabilitative
services that are provided to Members in an organized medical facility, for
less
than a 24-hour period, by or under the direction of a physician. To distinguish
between the types of services being billed, hospitals must indicate a
three-digit type of xxxx (TOB) code in block 4 of the UB-92 claim form. Most
commonly for hospitals, this code will be 131 for an outpatient hospital
claims.
Out-of-Network
(OON) means an appropriately licensed individual, facility, agency,
institution, organization or other entity that has not entered into a contract
with the HMO for the delivery of Covered Services to the HMO’s
Members.
Parties
means HHSC and HMO, collectively.
Party
means either HHSC or HMO, individually.
Pended
Claim means a claim for payment, which requires additional
information before the claim can be adjudicated as a clean claim.
Population
Risk Group means a distinct group of members identified by age, age
range, gender, type of program, or eligibility category.
Post-stabilization
Care Services means Covered Services, related to an Emergency
Medical Condition that are provided after a Medicaid Member is stabilized in
order to maintain the stabilized condition, or, under the circumstances
described in 42 §§C.F.R. 438.114(b)&(e) and 42 C.F.R. §422.113(c)(iii) to
improve or resolve the Medicaid Member’s condition.
Primary
Care Physician or Primary Care Provider (PCP) means a physician or
provider who has agreed with the HMO to provide a Medical Home to Members and
who is responsible for providing initial and primary care to patients,
maintaining the continuity of patient care, and initiating referral for
care.
Provider
types that can be PCPs are from any of the following practice areas: General
Practice, Family Practice, Internal Medicine, Pediatrics, Obstetrics/Gynecology
(OB/GYN), Pediatric and Family Advanced Practice Nurses (APNs) and Physician
Assistants (when practicing under the supervision of a physician specializing
in
Family Practice, Internal Medicine, Pediatrics or Obstetrics/Gynecology who
also
qualifies as a PCP under this contract), , Federally Qualified Health Centers
(FQHCs), Rural Health Clinics (RHCs) and similar community clinic s; and
specialist physicians who are willing to provide a Medical Home to selected
Members with special needs and conditions.
Proposal
means the proposal submitted by the HMO in response to the
RFP.
Provider
or Network Provider means an appropriately credentialed and
licensed individual, facility, agency, institution, organization or other
entity, and its employees and subcontractors, that has a contract with the
HMO
for the delivery of Covered Services to the HMO’s Members.
Provider
Contract means a contract entered into by a direct provider of
health care services and the HMO or an intermediary entity.
Provider
Network or Network means all Providers that have contracted with
the HMO for the applicable HMO Program.
Proxy
Claim Form means a form submitted by Providers to document services
delivered to Members under a capitated arrangement. It is not a claim for
payment.
Public
Health Entity means a HHSC Public Health Region, a Local Health
Department, or a hospital district.
Public
Information means information that:
(1)
Is
collected, assembled, or maintained under a law or ordinance or in connection
with the transaction of official business by a governmental body or for a
governmental body; and
(2)
The
governmental body owns or has a right of access to.
Qualified
and Disabled Working Individual (QDWI) means an individual whose
only Medicaid benefit is payment of the Medicare Part A premium.
Qualified
Medicare Beneficiary (QMB) means a Medicare
beneficiary whose only Medicaid benefits are payment of Medicare premiums,
deductibles, and coinsurance for individuals who are entitled to Medicare Part
A, whose income does not exceed 100% of the federal poverty level, and whose
resources do not exceed twice the resource limit of the SSI
program.
Quality
Improvement means a system to continuously examine, monitor and
revise processes and systems that support and improve administrative and
clinical functions.
Rate
Cell means a Population Risk Group for which a Capitation Rate has
been determined.
Rate
Period 1 means the period of time beginning on the Operational
Start Date and ending on August 31, 2007.
Rate
Period 2 means the period of time beginning on September 1, 2007
and ending on August 31, 2008.
Real-Time
Captioning (also known as CART, Communication Access Real-Time
Translation) means a process by which a trained individual uses a shorthand
machine, a computer, and real-time translation software to type and
simultaneously translate spoken language into text on a computer
screen.
Real Time Captioning is provided for individuals who are deaf, have hearing
impairments, or have unintelligible speech. It is usually used to interpret
spoken English into text English but may be used to translate other spoken
languages into text.
Readiness
Review means the assurances made by a selected HMO and the
examination conducted by HHSC, or its agents, of HMO’s ability, preparedness,
and availability to fulfill its obligations under the Contract.
Request
for Proposals or RFP means the procurement
solicitation instrument issued by HHSC under which this Contract was awarded
and
all RFP addenda, corrections or modifications, if any.
Revenue
means all managed care revenue received by the HMO pursuant to this Contract
during the Contract Period, including retroactive adjustments made by HHSC.
This
would include any funds earned on Medicaid or CHIP managed care funds such
as
investment income, earned interest, or third party administrator earnings from
services to delegated Networks.
Risk
means the potential for loss as a result of expenses and costs of the HMO
exceeding payments made by HHSC under the Contract.
Routine
Care means health care for covered preventive and medically
necessary Health Care Services that are non-emergent or non-urgent.
Rural
Health Clinic (RHC) means an entity that meets all of the
requirements for designation as a rural health clinic under 1861(aa)(1) of
the
Social Security Act and approved for participation in the Texas Medicaid
Program.
Service
Coordination means a specialized care management service that is
performed by a Service Coordinator and that includes but is not limited
to:
(1)
identification of needs, including physical health, mental health services
and
for STAR+PLUS Members, long term support services,
(2)
development of a Service Plan to address those identified needs;
(3)
assistance to ensure timely and a coordinated access to an array of providers
and Covered Services;
(4)
attention to addressing unique needs of Members; and
(5)
coordination of Plan services with social and other services delivered outside
the Plan, as necessary and appropriate.
Service
Coordinator means the person with primary responsibility for
providing service coordination and care management to STAR+PLUS
Members.
Scope
of Work means the description of Services and Deliverables
specified in this Contract, the RFP, the HMO’s Proposal, and any agreed
modifications to these documents.
SDX
means State Data Exchange.
SED
means severe emotional disturbance as determined by a Local Mental Health
Authority.
Service
Area means the counties included in any HHSC-defined Core and
Optional Service Area as applicable to each HMO Program.
Service
Management is an administrative service in the STAR, CHIP and CHIP
Perinatal Programs performed by the HMO to facilitate development of a Service
Plan and coordination of services among a Member’s PCP, specialty providers and
non-medical providers to ensure Members with Special Health Care Needs and/or
Members needing high-cost treatment have access to, and appropriately utilize,
Medically Necessary Covered Services, Noncapitated Services, and other
services and supports.
Service
Plan (SP) means an individualized plan developed with and for
Members with Special Health Care Needs, including persons with disabilities
or
chronic or complex conditions. The SP includes, but is not limited
to, the following:
(1)
the
Member’s history;
(2)
summary of current medical and social needs and concerns;
(3)
short
and long term needs and goals;
(4)
a
list of services required, their frequency, and
(5)
a
description of who will provide such services.
The
Service Plan should incorporate as a component of the plan the Individual Family
Service Plan (IFSP) for members in the Early Childhood Intervention (ECI)
Program
The
Service Plan may include information for services outside the scope of covered
benefits such as how to access affordable, integrated housing.
Services
means the tasks, functions, and responsibilities assigned and
delegated to the HMO under this Contract.
Significant
Traditional Provider or STP (for Medicaid) means primary care
providers and long-term care providers, identified by HHSC as having provided
a
significant level of care to Fee-for-Service clients. Disproportionate Share
Hospitals (DSH) are also Medicaid STPs.
Significant
Traditional Provider or STP (for CHIP) means primary care providers
participating in the CHIP HMO Program prior to May 2004, and Disproportionate
Share Hospitals (DSH).
Skilled
Nursing Facility Services (CHIP only) Services provided in a
facility that provides nursing or rehabilitation services and Medical supplies
and use of appliances and equipment furnished by the facility.
Software
means all operating system and applications software used by the HMO to provide
the Services under this Contract.
SPMI
means severe and persistent mental illness as determined by the
Local Mental Health Authority.
Specialty
Hospital means any inpatient hospital that is not a general Acute
Care hospital.
Specialty
Therapy means physical therapy, speech therapy or occupational
therapy.
Specified
Low-Income Medicare Beneficiary (SLMB) means a Medicare beneficiary
whose only Medicaid benefit is payment of the Medicare Part B
premium.
SSA
means the Social Security Administration.
SSI
Administrative Fee means the monthly per member per month fee paid
to an HMO to provide administrative services to manage the healthcare of the
HMO’s voluntary SSI beneficiaries. These services are described in more detail
under Section
10.10
of
this document. Stabilize means to
provide such medical care as to assure within reasonable medical probability
that no deterioration of the condition is likely to result from, or occur from,
or occur during discharge, transfer, or admission of the Member.
STAR+PLUS or STAR+PLUS Program means the State of Texas
Medicaid managed care program in which HHSC contracts with HMOs to provide,
arrange, and coordinate preventive, primary, acute and long term care Covered
Services to adult persons with disabilities and elderly persons age 65 and
over
who qualify for Medicaid through the SSI program and/or the MAO program.
Children under age 21, who qualify for Medicaid through the SSI
program,
may voluntarily participate in the STAR+PLUS program.
STAR+PLUS
HMOs means contracted HMOs participating in the STAR+PLUS
Program.
State
Fiscal Year (SFY) means a 12-month period beginning on September 1
and ending on August 31 the following year.
Subcontract
means any agreement between the HMO and other party to fulfill the requirements
of the Contract.
Subcontractor
means any individual or entity, including an Affiliate, that has
entered into a Subcontract with HMO.
Subsidiary
means an Affiliate controlled by such person or entity directly
or
indirectly through one or more intermediaries.
Supplemental
Security Income (SSI) means a Federal income supplement program
funded by general tax revenues (not Social Security taxes) designed to help
aged, blind and disabled people with little or no income by providing cash
to
meet basic needs for food, clothing and shelter.
T.A.C.
means Texas Administrative Code. TDD means
telecommunication device for the deaf. It is interchangeable with the term
Teletype
machine
or TTY.
TDI
means the Texas Department of Insurance.
Temporary
Assistance to Needy Families (TANF) means the federally funded
program that provides assistance to single parent families with children who
meet the categorical requirements for aid. This program was formerly known
as
the Aid to Families with Dependent Children (AFDC) program.
Texas
Health Network (THN) is the name of the Medicaid primary care case
management program in Texas.
Texas
Health Steps (THSteps) is the name adopted by the State of Texas
for the federally mandated Early and Periodic Screening, Diagnosis and Treatment
(EPSDT) program. It includes the State’s Comprehensive Care Program extension to
EPSDT, which adds benefits to the federal EPSDT requirements contained in 42
U.S.C. §1396d(r), and defined and codified at 42 C.F.R. §§440.40 and 441.56-62.
HHSC’s rules are contained in 25 T.A.C., Chapter 33 (relating to Early and
Periodic Screening, Diagnosis and Treatment).
Texas
Medicaid Bulletin means the bi-monthly update to the Texas Medicaid
Provider Procedures Manual.
Texas
Medicaid Provider Procedures Manual means the policy and procedures
manual published by or on behalf of HHSC that contains policies and procedures
required of all health care providers who participate in the Texas Medicaid
program. The manual is published annually and is updated bimonthly by the
Texas Medicaid Bulletin.
Texas
Medicaid Service Delivery Guide means an attachment to the Texas
Medicaid Provider Procedures Manual.
Third
Party Liability (TPL) means the legal responsibility of another
individual or entity to pay for all or part of the services provided to Members
under the Contract (see 1 TAC §354.2301 et seq., relating to Third
Party Resources).
Third
Party Recovery (TPR) means the recovery of payments on behalf of a
Member by HHSC or the HMO from an individual or entity with the legal
responsibility to pay for the Covered Services.
TP
40 means Type Program 40, which is a Medicaid program eligibility
type assigned to pregnant women under 185% of the federal poverty level
(FPL).
TP
45 means Type Program 45, which is a Medicaid program eligibility
code assigned to newborns (under 12 months of age) who are born to mothers
who
are Medicaid eligible at the time of the child’s birth.
Transition
Phase includes all activities the HMO is required to perform
between the Contract Effective Date and the Operational Start Date for a Service
Area.
Turnover
Phase includes all activities the HMO is required to perform in
order to close out the Contract and/or transition Contract activities and
operations for a Service Area to HHSC or a subsequent contractor.
Turnover
Plan means the written plan developed by HMO, approved by
HHSC, to be employed during the Turnover Phase. The Turnover Plan describes
HMO’s policies and procedures that will assure:
(1)
The
least disruption in the delivery of Health Care Services to those Members who
are enrolled with the HMO during the transition to a subsequent health
plan;
(2)
Cooperation with HHSC and the subsequent health plan in notifying Members of
the
transition and of their option to select a new plan, as requested and in the
form required or approved by HHSC; and
(3)
Cooperation with HHSC and the subsequent health plan in transferring information
to the subsequent health plan, as requested and in the form required or approved
by HHSC.
URAC
/American Accreditation Health Care Commission means the
independent organization that accredits Utilization Review functions and offers
a variety of other accreditation and certification programs for health care
organizations.
Urgent
Behavioral Health Situation means a behavioral health condition
that requires attention and assessment within twenty-four (24) hours but which
does not place the Member in immediate danger to himself or herself or others
and the Member is able to cooperate with treatment.
Urgent
Condition means a health condition including an Urgent Behavioral
Health Situation that is not an emergency but is severe or painful enough to
cause a prudent layperson, possessing the average knowledge of medicine, to
believe that his or her condition requires medical treatment evaluation or
treatment within twenty-four (24) hours by the Member’s PCP or PCP designee to
prevent serious deterioration of the Member’s condition or health.
Utilization
Review means the system for retrospective, concurrent, or
prospective review of the medical necessity and appropriateness of Health Care
Services provided, being provided, or proposed to be provided to a
Member. The term does not include elective requests for clarification
of coverage.
Value-added
Services means additional services for coverage beyond those
specified in Attachments B-2, B-2.1, and B-2.2. Value-added Services
may be actual Health Care Services, benefits, or positive incentives
that HHSC determines will promote healthy lifestyles and improve health outcomes
among Members. Value-added Services that promote healthy lifestyles
should target specific weight loss, smoking cessation, or other programs
approved by HHSC. Temporary phones, cell phones, additional transportation
benefits, and extra home health services may be Value-added Services, if
approved by HHSC. Best practice approaches to delivering Covered
Services are not considered Value-added Services.
Waste
means practices that are not cost-efficient.
Article
3. General Terms & Conditions
Section
3.01 Contract elements.
(a)
Contract documentation. The Contract between the Parties will consist
of
the
HHSC
Managed Care Contract document and all attachments and amendments.
(b)
Order
of documents. In the event of any conflict or contradiction between or among
the
contract documents, the
documents
shall control in the following order of precedence:
(1)
The
final executed HHSC Managed Care Contract document, and all
amendments thereto;
(2)
HHSC
Managed Care Contract Attachment A – “HHSC’s Uniform Managed
Care Contract Terms and Conditions,” and all amendments thereto;
(3)
HHSC
Managed Care Contract Attachment B – “Scope of Work/Performance
Measures,” and all attachments and amendments thereto;
(4)
The
HHSC Uniform Managed Care Manual, and all attachments and
amendments thereto;
(5)
HHSC
Managed Care Contract Attachment C-3– “Agreed Modifications to
HMO’s Proposal;”
(6)
HHSC
Managed Care Contract Attachment C-2, “HMO Supplemental
Responses,” and
(7)
HHSC
Managed Care Contract
Attachment
C-1 – “HMO’s Proposal.”
Section
3.02 Term of the Contract.
The
term
of the Contract will begin on the Effective Date and will conclude on the
Expiration Date. The Parties may renew the Contract for an additional period
or
periods, but the Contract Term may not exceed a total of eight (8)
years. All reserved contract extensions beyond the Expiration Date
will be subject to good faith negotiations between the Parties and mutual
agreement to the extension(s).
Section
3.03 Funding.
This
Contract is expressly conditioned on the availability of state and federal
appropriated funds. HMO will have no right of action against HHSC in the event
that HHSC is unable to perform its obligations under this Contract as a result
of the suspension, termination, withdrawal, or failure of funding to HHSC or
lack of sufficient funding of HHSC for any activities or functions contained
within the scope of this Contract. If funds become unavailable, the provisions
of Article 12 (“Remedies and Disputes”) will apply. HHSC will
use all reasonable efforts to ensure that such funds are available, and will
negotiate in good faith with HMO to resolve any HMO claims for payment that
represent accepted Services or Deliverables that are pending at the time funds
become unavailable. HHSC shall make best efforts to provide
reasonable written advance notice to HMO upon learning that funding for this
Contract may be unavailable.
Section
3.04 Delegation of authority.
Whenever,
by any provision of this Contract, any right, power, or duty is imposed or
conferred on HHSC, the right, power, or duty so imposed or conferred is
possessed and exercised by the Commissioner unless any such right, power, or
duty is specifically delegated to the duly appointed agents or employees of
HHSC. The Commissioner will reduce any such delegation of authority to writing
and provide a copy to HMO on request.
Section
3.05 No waiver of sovereign immunity.
The
Parties expressly agree that no provision of this Contract is in any way
intended to constitute a waiver by HHSC or the State of Texas of any immunities
from suit or from liability that HHSC or the State of Texas may have by
operation of law.
Section
3.06 Force majeure.
Neither
Party will be liable for any failure or delay in performing its obligations
under the Contract if such failure or delay is due to any cause beyond the
reasonable control of such Party, including, but not limited to, unusually
severe weather, strikes, natural disasters, fire, civil disturbance, epidemic,
war, court order, or acts of God. The existence of such causes of
delay or failure will extend the period of
performance
in the exercise of reasonable diligence until after the causes of delay or
failure have been removed. Each Party must inform the other in
writing with proof of receipt within five (5) Business Days of the existence
of
a force majeure event or otherwise waive this right as a defense.
Section
3.07 Publicity.
(a)
HMO
may use the name of HHSC, the State of Texas, any HHS Agency, and the name
of
the HHSC HMO Program in any media release, public announcement, or public
disclosure relating to the Contract or its subject matter only if, at least
seven (7) calendar days prior to distributing the material, the HMO submits
the
information to HHSC for review and comment. If HHSC has not responded within
seven (7)
calendar days, the HMO may use the submitted information. HHSC
reserves the right to object to and require changes to the publication if,
at
HHSC’s sole discretion, it determines that the publication does not accurately
reflect the terms of the Contract or the HMO’s performance under the Contract.
.
(b)
HMO
will provide HHSC with one (1) electronic copy of any information described
in
Subsection 3.07(a) prior to public release. HMO will provide
additional copies, including hard copies, at the request of HHSC.
(c)
The
requirements of Subsection 3.07(a) do not apply to:
(1)
proposals or reports submitted to HHSC, an administrative agency of the State
of
Texas, or a governmental agency or unit of another state or the federal
government;
(2)
information concerning the Contract’s terms, subject matter, and estimated
value:
(a)
in
any report to a governmental body to which the HMO is required by law to report
such information, or
(b)
that
the HMO is otherwise required by law to disclose; and
(3)
Member Materials (the HMO must comply with the Uniform Managed Care
Manual’s provisions regarding the review and approval of Member
Materials).
Section
3.08 Assignment.
(a)
Assignment by HMO. HMO shall not assign all or any portion of its rights under
or interests in the Contract or delegate any of its duties without prior written
consent of HHSC. Any written request for assignment or delegation must be
accompanied by written acceptance of the assignment or delegation by the
assignee or delegation by the delegate. Except where otherwise agreed
in writing by HHSC, assignment or delegation will not release HMO
from
its
obligations pursuant to the Contract. An HHSC-approved Material Subcontract
will
not be considered to
be an
assignment or delegation for purposes of this section.
(b)
Assignment by HHSC. HMO understands and agrees HHSC may in one or more
transactions assign, pledge, transfer, or hypothecate the
Contract. This assignment will only be
made
to another State agency or a non-State agency that is contracted to perform
agency support.
(c)
Assumption. Each party to whom a transfer is made (an "Assignee") must assume
all or any part of HMO’S or HHSC's interests in the Contract, the product, and
any documents executed with respect to the Contract,
including,
without limitation, its obligation for all or any portion of the purchase
payments, in whole or in part.
Section
3.09 Cooperation with other vendors and prospective
vendors.
HHSC
may
award supplemental contracts for work related to the Contract, or any portion
thereof. HMO will reasonably cooperate with such other vendors, and
will not commit or permit any act that may interfere with the performance of
work by any other vendor.
Section
3.10 Renegotiation and reprocurement rights.
(a)
Renegotiation of Contract terms. Notwithstanding anything in the Contract to
the
contrary, HHSC may at any time during the term of the Contract exercise the
option to notify HMO that HHSC has elected to renegotiate certain terms of
the
Contract. Upon HMO’s receipt of any notice pursuant to this Section, HMO and
HHSC will undertake good faith negotiations of the subject terms of the
Contract,
and
may
execute an amendment to the Contract in accordance with Article
8.
(b)
Reprocurement of the services or procurement of additional
services.
Notwithstanding
anything in the Contract to the contrary, whether or not HHSC has accepted
or
rejected HMO’s Services and/or Deliverables provided during any period of the
Contract, HHSC may at any time issue requests for proposals or offers to other
potential contractors for performance of any portion of the Scope of Work
covered by the Contract or Scope of Work similar or comparable to the Scope
of
Work performed by HMO under the Contract.
(c)
Termination rights upon reprocurement. If HHSC elects to procure the Services
or
Deliverables or any portion of the Services or Deliverables from another vendor
in accordance with this
Section, HHSC will have the termination rights set forth in Article
12 (“Remedies and Disputes”).
Section
3.11 RFP errors and
omissions.
HMO
will
not take advantage of any errors and/or omissions in the RFP or the resulting
Contract. HMO must promptly notify HHSC of any such errors and/or omissions
that
are discovered.
Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8
Section
3.12 Attorneys’ fees.
In
the
event of any litigation, appeal, or other legal action to enforce any provision
of the Contract, HMO agrees to pay all reasonable expenses of such action,
including attorneys' fees and costs, if HHSC is the prevailing
Party.
Section
3.13 Preferences under service contracts.
HMO
is
required in performing the Contract to purchase products and materials produced
in the State of Texas when they are available at a price and time comparable
to
products and materials produced outside the State.
Section
3.14 Time of the essence.
In
consideration of the need to ensure uninterrupted and continuous HHSC HMO
Program performance, time is of the essence in the performance of the Scope
of
Work under the Contract.
Section
3.15 Notice
(a)
Any
notice or other legal communication required or permitted to be made or given
by
either Party pursuant to the Contract will be in writing and in English, and
will be deemed to have been given:
(1)
Three
(3) Business Days after the date of mailing if sent by registered or certified
U.S. mail, postage prepaid, with return receipt requested;
(2)
When
transmitted if sent by facsimile, provided a confirmation of transmission is
produced by the sending machine; or
(3)
When
delivered if delivered personally or sent by express courier
service.
(b)
The
notices described in this Section may not be sent by electronic
mail.
(c)
All
notices must be sent to the Project Manager identified in the HHSC
Managed Care Contract document. In addition, legal notices
must be sent to the Legal Contact identified in the HHSC Managed Care
Contract document.
(d)
Routine communications that are administrative in nature will be provided in
a
manner agreed to by the Parties.
Article
4. Contract Administration & Management
Section
4.01 Qualifications, retention and replacement
of HMO employees.
HMO
agrees to maintain the organizational and administrative capacity and
capabilities to carry out all duties and responsibilities under this
Contract. The personnel HMO assigns to perform the duties and
responsibilities under this Contract will be properly trained and qualified
for
the functions they are to perform. Notwithstanding transfer or turnover of
personnel,
HMO remains obligated to perform all duties and responsibilities under this
Contract without degradation and in accordance with the terms of this
Contract.
Section
4.02 HMO’s Key Personnel.
(a)
Designation of Key Personnel. HMO must designate key management and technical
personnel who will be assigned to the Contract. For the purposes of this
requirement, Key Personnel are those with management responsibility or principal
technical responsibility for the following functional
areas for each HMO Program included within the scope of the
Contract:
(1)
Member Services;
(2)
Management Information Systems;
(3)
Claims Processing,
(4)
Provider Network Development and Management;
(5)
Benefit Administration and Utilization and Care Management;
(6)
Quality Improvement;
(7)
Behavioral Health Services;
(8)
Financial Functions;
(9)
Reporting;
(10)
Executive Director(s) for applicable HHSC HMO Program(s) as defined in
Section 4.03 (“Executive Director”);
(11)
Medical Director(s) for applicable HHSC HMO
Program(s) as defined in Section 4.04 (“Medical Director”);
and
(12)
STAR+PLUS Service Coordinators for STAR+PLUS HMOs as defined in Section
4.04.1 (“STAR+PLUS Service Coordinator.”)
(b)
Support and Replacement of Key Personnel. The HMO must maintain, throughout
the
Contract Term, the ability to supply its Key Personnel with the required
resources necessary to meet Contract requirements and comply with applicable
law. The HMO must ensure project continuity by timely replacement of Key
Personnel, if necessary, with a sufficient number of persons having the
requisite skills, experience and other qualifications. Regardless of
specific personnel changes, the HMO must maintain the overall level of
expertise, experience, and skill reflected in the Key HMO Personnel
job descriptions and qualifications included in the HMO’s proposal.
(c)
Notification of replacement of Key Personnel. HMO must notify HHSC within
fifteen (15) Business Days of any change in Key Personnel. Hiring or replacement
of Key Personnel must conform to all Contract requirements. If HHSC determines
that a
satisfactory working relationship cannot be established between certain Key
Personnel and HHSC,
it
will notify the HMO in writing. Upon receipt of HHSC’s notice, HHSC
and HMO will attempt to resolve HHSC’s concerns on a mutually agreeable
basis.
Section
4.03 Executive Director.
(a)
The
HMO must employ a qualified individual to serve as the Executive Director for
its HHSC HMO Program(s). Such Executive Director must be employed full-time
by
the HMO, be primarily dedicated to HHSC HMO Program(s), and must hold a Senior
Executive or Management position in the HMO’s organization, except that the HMO
may propose an alternate structure for the Executive Director position, subject
to HHSC’s prior review and written approval.
(b)
The
Executive Director must be authorized and empowered to represent the HMO
regarding all matters pertaining to the Contract prior to such representation.
The Executive Director must act as liaison between the HMO and the HHSC and
must
have responsibilities that include, but are not limited to, the
following:
(1)
ensuring the HMO’s compliance with the terms of the Contract, including securing
and coordinating resources necessary for such compliance;
(2)
receiving and responding to all inquiries and requests made by HHSC related
to
the Contract, in the time frames and formats specified by HHSC. Where
practicable, HHSC must consult with the HMO to establish time frames and formats
reasonably acceptable to the Parties;
(3)
attending and participating in regular HHSC HMO Executive Director meetings
or
conference calls;
(4)
attending and participating in regular HHSC Regional Advisory Committees (RACs)
for managed care (the Executive Director may designate key personnel to attend
a
RAC if the Executive Director is unable to attend);
(5)
making best efforts to promptly resolve any issues identified either by the
HMO
or HHSC that may arise and are related to the Contract;
(6)
meeting with HHSC representative(s) on a periodic or as needed basis to review
the HMO’s performance and resolve issues, and
(7)
meeting with HHSC at the time and place requested by HHSC, if HHSC determines
that the HMO is not in compliance with the requirements of the
Contract.
Section 4.04 Medical
Director
(a)
The
HMO must have a qualified individual to serve as the Medical Director for its
HHSC HMO Program(s). The Medical Director must be currently licensed in Texas
under the Texas Medical Board as an
M.D.
or D.O. with no restrictions or other licensure limitations. The Medical
Director must comply with the requirements of 28 T.A.C. §11.1606 and all
applicable federal and state statutes and regulations.
(b)
The
Medical Director, or his or her physician designee meeting the same Contract
qualifications that apply to the Medical Director, must be available by
telephone 24 hours a day, seven days a week, for Utilization Review decisions.
The Medical Director, and his/her designee, must either possess expertise with
Behavioral Health Services, or ready access to such expertise to ensure timely
and appropriate medical decisions for Members, including after regular business
hours.
(c)
The
Medical Director, or his or her physician designee meeting the same Contract
qualifications that apply to the Medical Director, must be authorized and
empowered to represent the HMO regarding clinical issues, Utilization Review
and
quality of care inquiries. The Medical Director, or his or her physician
designee, must exercise independent medical judgment in all decisions relating
to medical necessity. The HMO must ensure that its decisions relating to medical
necessity are not adversely influenced by fiscal management decisions. HHSC
may
conduct reviews of decisions relating to medical necessity upon reasonable
notice.
Section
4.04.1 STAR+PLUS Service Coordinator
(a)
STAR+PLUS HMOs must employ as Service Coordinators persons experienced in
meeting the needs of people with disabilities, old and young, and vulnerable
populations who have Chronic or Complex Conditions. A Service Coordinator must
have an undergraduate and/or graduate degree in social work or a related field,
or be a Registered Nurse, Licensed Vocational Nurse, Advanced Nurse
Practitioner, or a Physician Assistant.
(b)
The
STAR+PLUS HMO must monitor the Service Coordinator’s workload and performance to
ensure that he or she is able to perform all necessary Service Coordination
functions for the STAR+PLUS Members in a timely manner.
(c)
The
Service Coordinator must be responsible for working with the Member or his
or
her representative, the PCP and other Providers to develop a seamless package
of
care in which primary, Acute Care, and long-term care service needs are met
through a single, understandable, rational plan. Each Member’s Service Plan must
also be well coordinated with the Member’s family and community support systems,
including Independent Living Centers, Area Agencies on Aging and Mental
Retardation Authorities. The Service Plan should be agreed to and signed by
the
Member or the Member’s representative to indicate agreement with the plan. The
plan should promote consumer direction and self-determination and may include
information for services
outside the scope of Covered Services such as how to access affordable,
integrated housing. For dual eligible Members, the STAR+PLUS HMO is responsible
for meeting the Member’s Community Long- term Care Service needs.
(d)
The
STAR+PLUS HMO must empower its Service Coordinators to authorize the provision
and delivery of Covered Services, including Community Long-term Care Covered
Services.
Section
4.05 Responsibility for HMO personnel and
Subcontractors.
(a)
HMO’s
employees and Subcontractors will not in any sense be considered employees
of
HHSC or the State of Texas, but will be considered for all purposes as the
HMO’s
employees or its Subcontractor’s employees, as applicable.
(b)
Except as expressly provided in this Contract, neither HMO nor any of HMO’s
employees or Subcontractors may act in any sense as agents or representatives
of
HHSC or the State of Texas.
(c)
HMO
agrees that anyone employed by HMO to fulfill the terms of the Contract is
an
employee of HMO and remains under HMO’s sole direction and control. HMO assumes
sole and full responsibility for its acts and the acts of its employees and
Subcontractors.
(d)
HMO
agrees that any claim on behalf of any person arising out of employment or
alleged employment by the HMO (including, but not limited to, claims
of discrimination against HMO, its officers, or its agents) is the sole
responsibility of HMO and not the responsibility of HHSC. HMO will
indemnify and hold harmless the State from any and all claims asserted against
the State arising out of such employment or alleged employment by the
HMO. HMO understands that any person who alleges a claim arising out
of employment or alleged employment by HMO will not be entitled to any
compensation, rights, or benefits from HHSC (including, but not limited to,
tenure rights, medical and hospital care, sick and annual/vacation leave,
severance pay, or retirement benefits).
(e)
HMO
agrees to be responsible for the following in respect to its
employees:
(1)
Damages incurred by HMO’s employees within the scope of their duties under the
Contract; and
(2)
Determination of the hours to be worked and the duties to be performed by HMO’s
employees.
(f)
HMO
agrees and will inform its employees and Subcontractor(s) that there is no
right
of subrogation, contribution, or indemnification against HHSC for any duty
owed
to them by HMO pursuant to this Contract or any judgment rendered against the
HMO. HHSC’s liability to the HMO’s employees, agents
and Subcontractors, if any, will be governed by the Texas Tort Claims Act,
as
amended or modified (TEX.
CIV. PRACT.
&
REM.
CODE§101.001et
seq.).
(g)
HMO
understands that HHSC does not assume liability for the actions of, or judgments
rendered against, the HMO, its employees, agents or
Subcontractors. HMO agrees that it has no right to indemnification or
contribution from HHSC for any such judgments rendered against HMO or its
Subcontractors.
Section
4.06 Cooperation with HHSC and stateadministrative
agencies.
(a)
Cooperation with Other MCOs. HMO agrees to reasonably cooperate with and work
with the other MCOs in the HHSC HMO Programs, Subcontractors, and third-party
representatives as requested by HHSC. To the extent permitted by HHSC’s
financial and personnel resources, HHSC agrees to reasonably cooperate with
HMO
and to use its best efforts to ensure that other
HHSC contractors reasonably cooperate with the HMO.
(b)
Cooperation with state and federal administrative agencies. HMO
must
ensure that HMO personnel will cooperate with HHSC or other state or federal
administrative agency personnel at no charge to HHSC for purposes relating
to
the administration of HHSC programs including, but not limited to the following
purposes:
(1)
The
investigation and prosecution of fraud, abuse, and waste in the HHSC
programs;
(2)
Audit, inspection, or other investigative purposes; and
(3)
Testimony in judicial or quasi-judicial proceedings relating to the Services
and/or Deliverables under this Contract or other delivery of information to
HHSC
or other agencies’ investigators or legal staff.
Section
4.07 Conduct of HMO personnel.
(a)
While
performing the Scope of Work, HMO’s personnel and Subcontractors
must:
(1)
Comply with applicable State rules and regulations and HHSC’s requests regarding
personal and professional conduct generally applicable to the service locations;
and
(2)
Otherwise conduct themselves in a businesslike and professional
manner.
(b)
If
HHSC determines in good faith that a particular employee or Subcontractor is
not
conducting himself or herself in accordance with this Contract, HHSC may provide
HMO with notice and documentation concerning such conduct. Upon
receipt of such notice, HMO must promptly investigate the
matter and take appropriate action that may include:
(1)
Removing the employee from the project;
(2)
Providing HHSC with written notice of such removal; and
(3)
Replacing the employee with a similarly qualified individual acceptable to
HHSC.
(c)
Nothing in the Contract will prevent HMO, at the request of HHSC, from replacing
any personnel who are not adequately performing their assigned responsibilities
or who, in the reasonable opinion of HHSC’s Project Manager, after consultation
with HMO, are unable to work effectively with the members of the HHSC’s staff.
In such event, HMO will provide replacement personnel with equal or greater
skills and qualifications as soon as reasonably
practicable. Replacement of Key Personnel will be subject to HHSC
review. The Parties will work together in the event of any such replacement
so
as not to disrupt the overall project schedule.
(d)
HMO
agrees that anyone employed by HMO to fulfill the terms of the Contract remains
under HMO’s sole direction and control.
(e)
HMO
shall have policies regarding disciplinary action for all employees who have
failed to comply with federal and/or state laws and the HMO’s standards of
conduct, policies and procedures, and Contract requirements. HMO
shall have policies regarding disciplinary action for all employees who have
engaged in illegal or unethical conduct.
Section
4.08 Subcontractors.
(a)
HMO
remains fully responsible for the obligations, services, and functions performed
by its Subcontractors to the same extent as if such obligations, services,
and
functions were performed by HMO’s employees, and for purposes of this Contract
such work will be deemed work performed by HMO. HHSC reserves the
right to require the replacement of any Subcontractor found by HHSC to be
unacceptable and unable to meet the requirements of the Contract, and to object
to the selection of a Subcontractor.
(b)
HMO
must:
(1)
actively monitor the quality of care and services, as well as the quality of
reporting data, provided under a Subcontract;
(2)
notify HHSC in writing at least 60 days prior to reprocurement of services
provided by any Material Subcontractor;
(3)
notify HHSC in writing within three (3) Business Days after making a
decision to terminate a Subcontract with a Material Subcontractor or
upon receiving notification from the Material Subcontractor of its intent to
terminate such Subcontract;
(4)
notify HHSC in writing within one (1) Business Day of making a decision to
enter
into a Subcontract with a new Material Subcontractor, or a new Subcontract
for
newly procured services of an existing Material Subcontractor; and
(5)
provide HHSC with a copy of TDI filings of delegation agreements.
(c)
During the Contract Period, Readiness Reviews by HHSC or its designated agent
may occur if:
(1)
a new
Material Subcontractor is employed by HMO;
(2)
an
existing Material Subcontractor provides services in a new Service
Area;
(3)
an
existing Material Subcontractor provides services for a new HMO
Program;
(4)
an
existing Material Subcontractor changes locations or changes its MIS and or
operational functions;
(5)
an
existing Material Subcontractor changes one or more of its MIS subsystems,
claims processing or operational functions; or
(6)
a
Readiness Review is requested by HHSC.
The
HMO must submit information required by HHSC for each proposed Material
Subcontractor as indicated in Attachment B-1, Section 7. Refer
to Attachment B-1, Sections 8.1.1.2 and
8.1.18
for additional information regarding HMO Readiness Reviews during
the
Contract Period.
(d)
HMO
must not disclose Confidential Information of HHSC or the State of Texas to
a
Subcontractor unless and until such Subcontractor has agreed in writing to
protect the confidentiality of such Confidential Information in the manner
required of HMO under this Contract.
(e)HMO
must identify any Subcontractor that is a subsidiary or entity formed after
the
Effective Date of the Contract, whether or not an Affiliate of HMO, substantiate
the proposed Subcontractor’s ability to perform the subcontracted Services, and
certify to HHSC that no loss of service will occur as a result of the
performance of such Subcontractor. The HMO will assume responsibility
for all contractual responsibilities whether or not the HMO performs them.
Further, HHSC considers the HMO to be the sole point of contact with regard
to
contractual matters, including payment of any and all charges resulting from
the
Contract.
(f)
Except as provided herein, all Subcontracts must be in writing and must provide
HHSC the right to examine the Subcontract and all Subcontractor records relating
to the Contract and the Subcontract. This requirement does not apply
to agreements with utility or mail service providers.
(g)
A
Subcontract whereby HMO receives rebates, recoupments, discounts, payments,
or
other consideration from a Subcontractor (including without limitation
Affiliates) pursuant to or related to the execution of this Contract must be
in
writing and must provide HHSC the right to examine the Subcontract and all
records relating to such consideration.
(h)
All
Subcontracts described in subsections (f) and (g) must show the dollar amount,
the percentage of money, or the value of any consideration that HMO pays to
or
receives from the Subcontractor.
(i)
HMO
must submit a copy of each Material Subcontract executed prior to the Effective
Date of the Contract to HHSC no later than thirty (30) days after the Effective
Date of the Contract. For Material Subcontracts executed after the
Effective Date of the Contract, HMO must submit a copy to HHSC no later than
five (5) Business Days after execution.
(j)
Network Provider Contracts must include the mandatory provisions included in
the
HHSC Uniform Managed Care Manual.
(k)
HHSC
reserves the right to reject any Subcontract or require changes to any
provisions that do not comply with the requirements or duties and
responsibilities of this Contract or create significant barriers for HHSC in
monitoring compliance with this Contract.
Section
4.09 HHSC’s ability to contract
withSubcontractors.
The
HMO
may not limit or restrict, through a covenant not to compete, employment
contract or other contractual arrangement, HHSC’s ability to contract with
Subcontractors or former employees of the HMO.
Section
4.10 HMO Agreements with Third Parties
(a)
If
the HMO intends to report compensation paid to a third party (including without
limitation an Affiliate) as an Allowable Expense under this Contract, and the
compensation paid to the third party exceeds $100,000, or is reasonably
anticipated to exceed $100,000, in a State Fiscal Year, then the HMO’s agreement
with the third party must be in writing. The agreement must provide
HHSC the right to examine the agreement and all records relating to the
agreement.
(b)
All
agreements whereby HMO receives rebates, recoupments, discounts, payments,
or
other consideration from a third party (including without limitation Affiliates)
pursuant to or related to the execution of this Contract, must be in writing
and
must provide HHSC the right to examine the agreement and all records relating
to
such consideration. .
(c)
All
agreements described in subsections (a) and (b) must show the dollar amount,
the
percentage
of
money,
or the value of any consideration that HMO pays to or receives from the third
party.
(d)
HMO
must submit a copy of each third party agreement described in subsections (a)
and (b) to HHSC. If the third party agreement is entered into prior to the
Effective Date of the Contract, HMO must submit a copy no later than thirty
(30)
days after the Effective Date of the Contract. If the third party
agreement is executed after the Effective Date of the Contract, HMO must submit
a copy no later than five
(5)
Business Days after execution. (e) For third party agreements valued under
$100,000 per State Fiscal Year that are reported as Allowable Expenses, the
HMO
must maintain financial records and data sufficient to verify the accuracy
of
such expenses in accordance with the requirements of Article
9.
(f)
HHSC
reserves the right to reject any third party agreement or require changes to
any
provisions that do not comply with the requirements or duties and
responsibilities of this Contract or create significant barriers for HHSC in
monitoring compliance with this Contract.
(g)
This
section shall not apply to Provider Contracts, or agreements with utility or
mail service providers.
Section
5.01 Eligibility Determination
The
State
or its designee will make eligibility determinations for each of the HHSC HMO
Programs.
Section
5.02 Member Enrollment & Disenrollment.
(a)
The
HHSC Administrative Services Contractor will enroll and disenroll eligible
individuals in the HMO Program. To enroll in an HMO, the Member’s permanent
residence must be located within the HMO’s Service Area. The HMO is not allowed
to induce or accept disenrollment from a Member. The HMO must refer the Member
to the HHSC Administrative Services Contractor.
(b)
HHSC
makes no guarantees or representations to the HMO regarding the number of
eligible Members who will ultimately be enrolled into the HMO or the length
of
time any such enrolling Members remain enrolled with the HMO beyond the minimum
mandatory enrollment periods established for each HHSC HMO Program.
(c)
The
HHSC Administrative Services Contractor will electronically transmit to the
HMO
new Member information and change information applicable to active
Members.
(d)
As
described in the following Sections, depending on the HMO Program, special
conditions may also apply to enrollment and span of coverage for the
HMO.
(e)
HMO
has a limited right to request a Member be disenrolled from HMO without the
Member’s consent. HHSC must approve any HMO request for disenrollment of a
Member for cause. HHSC may permit disenrollment of a Member under the following
circumstances:
(1)
Member misuses or loans Member’s HMO membership card to another person to obtain
services.
(2)
Member is disruptive, unruly, threatening or uncooperative to the extent that
Member’s membership seriously impairs HMO’s or Provider’s ability to provide
services to Member or to obtain new Members, and Member’s behavior is not caused
by a physical or behavioral health condition.
(3)
Member steadfastly refuses to comply with managed care restrictions (e.g.,
repeatedly using emergency room in combination with refusing to allow HMO to
treat the underlying medical condition).
(4)
HMO
must take reasonable measures to correct Member behavior prior to requesting
disenrollment. Reasonable measures may include providing education and
counseling regarding the offensive acts or behaviors.
(5)
For
STAR+PLUS HMOs, under limited conditions, the HMO may request disenrollment
of
members who are totally dependent on a ventilator or who have been diagnosed
with End Stage Renal Disease.
(f)
HHSC
must notify the Member of HHSC’s decision to disenroll the Member if all
reasonable measures have failed to remedy the problem.
(g)
If
the Member disagrees with the decision to disenroll the Member from HMO, HHSC
must notify the Member of the availability of the Complaint procedure and,
for
Medicaid Members, HHSC’s Fair Hearing process.
(h)
HMO
cannot request a disenrollment based on adverse change in the member’s health
status or utilization of services that are Medically Necessary for treatment
of
a member’s condition.
(i)
Upon implementation of the
Comprehensive Healthcare Program for Xxxxxx Care, STAR and CHIP Members taken
into conservatorship by the Department of Family and Protective Services (DFPS)
will be disenrolled effective the date of conservatorship.
Section
5.03 STAR enrollment for pregnant women and
infants.
(a)
The
HHSC Administrative Services Contractor will retroactively enroll some pregnant
Members in a Medicaid HMO based on their date of eligibility.
(b)
The
HHSC Administrative Services Contractor will enroll newborns born to Medicaid
eligible mothers who are enrolled in a STAR HMO in the same HMO for 90 days
following the date of birth, unless the mother requests a plan change as a
special exception. The Administrative Service Contractor will
consider such requests on a case-bycase basis. The HHSC Administrative
Services Contractor will retroactively, to date of birth, enroll newborns in
the
applicable STAR HMO.
Section
5.03.1 Enrollment for infants born to pregnant women in
STAR+PLUS.
If
a
newborn is born to a Medicaid-eligible mother enrolled in a STAR+PLUS HMO,
the
HHSC Administrative Service Contractor will enroll the newborn into that HMO’s
STAR HMO product, if one exists. All rules related to STAR newborn enrollment
will apply to the newborn. If the STAR+PLUS HMO does not have a STAR product
but
the newborn is eligible for STAR, the newborn will be enrolled in traditional
Fee-for-Service Medicaid, and given the opportunity to select a STAR
HMO.
Section
5.04 CHIP eligibility and enrollment.
(a)
Term
of coverage. The Administrative Services Contractor determines CHIP
eligibility on behalf of HHSC. The Administrative Services
Contractor will enroll and disenroll eligible individuals into and out of
CHIP. CHIP Members with an Effective Date of Coverage on or
after
September 1, 2007 will have twelve (12) months of coverage. CHIP
Members with an Effective Date of Coverage prior to September 1, 2007 will
be
required to re-enroll in the CHIP Program at the end of their six month coverage
period, at which point they will have a new Effective Date of Coverage and
twelve (12) months of coverage.
(b)
Pregnant Members and Infants.
(1)
The
HHSC Administrative Contractor will refer pregnant CHIP Members, with the
exception of Legal Permanent Residents and other legally qualified aliens barred
from Medicaid due to federal eligibility restrictions, to Medicaid for
eligibility determinations. Those CHIP Members who are determined to be Medicaid
Eligible will be disenrolled from HMO’s CHIP plan. Medicaid coverage will be
coordinated to begin after CHIP eligibility ends to avoid gaps in health care
coverage.
(2)
In
the event the HMO remains unaware of a Member’s pregnancy until delivery, the
delivery will be covered by CHIP. Babies are automatically enrolled
in the mother’s CHIP health plan at birth with CHIP eligibility and
re-enrollment following the timeframe as that of the mother. The HHSC
Administrative Services Contractor will then set the Member’s eligibility
expiration date at the later of (1) the end of the second month following the
month of the baby’s birth
or
(2) the Member’s original eligibility expiration date.
Section
5.04.1 CHIP Perinatal eligibility, enrollment, and
disenrollment
(a)
The
HHSC Administrative Contractor will electronically transmit to the HMO new
CHIP
Perinate Member information based on the appropriate CHIP Perinate or CHIP
Perinate Newborn Rate Cell. There is no waiting period for CHIP
Perinatal Program Members.
(b)
CHIP
Perinate Newborns are eligible for 12 months continuous enrollment, beginning
with the month of enrollment as a CHIP Perinate (month of enrollment plus 11
months). A CHIP Perinate Newborn will maintain coverage in his or her
CHIP Perinatal health plan.
(c)
If
only one CHIP Perinatal HMO operates in a Service Area, HHSC will automatically
enroll a prospective member in that CHIP Perinatal HMO. If multiple
CHIP Perinatal HMOs offer coverage in the Service Area, HHSC will send an
enrollment packet to the prospective Member’s household. If the
household of a prospective member does not make a selection within 15 calendar
days, the HHSC Administrative Services Contractor will notify the household
that
the prospective member has been assigned to a CHIP Perinatal HMO (“Default
Enrollment”). When this occurs the household has 30 calendar days to
select another CHIP Perinatal HMO for the Member.
(d)
HHSC’s Administrative Services Contractor will assign prospective members to
CHIP Perinatal HMOs in a Service Area in a rotational basis. Should HHSC
implement one or more administrative rules governing the Default Enrollment
processes, such administrative rules will take precedence over the Default
Enrollment process set forth herein.
(e)
When
a member of a household enrolls in the CHIP Perinatal Program, all traditional
CHIP members in the household will be disenrolled from their current health
plans and prospectively enrolled in the CHIP Perinatal Program Member’s health
plan. All members of the household must remain in the same health
plan through the end of the CHIP Perinatal Program Member’s enrollment
period.
(f)
In
the 10th month
of the CHIP Perinate Newborn’s coverage, the family will receive a CHIP renewal
form. The family must complete and submit the renewal form, which
will be pre-populated to include the CHIP Perinate Newborn’s and the CHIP
Program Members’ information. Once the child’s CHIP Perinatal Program
coverage expires, the child will be added to his or her siblings’ existing CHIP
program case.
Section
5.05 Span of Coverage
(a)
Medicaid HMOs.
(1)
HHSC
will conduct continuous open enrollment for Medicaid Eligibles and the HMO
must
accept all persons who choose to enroll as Members in the HMO or who are
assigned as Members in the HMO by HHSC, without regard to the Member’s health
status, inpatient status, or any other factor.
(2)
Members who are disenrolled because they are temporarily ineligible for Medicaid
will be automatically re-enrolled into the same health plan, if
available. Temporary loss of eligibility is defined as a period of
six months or less.
(3)
A
Member cannot change from one Medicaid HMO to another Medicaid HMO during an
inpatient hospital stay. Medicaid HMOs are responsible for
professional charges during every month for which the HMO receives a full
capitation for a Member.
(4)
The
payor responsible for the hospital charges at the start of an Inpatient Stay
remains responsible for hospital charges until the time of discharge, or until
such time that there is a loss of Medicaid eligibility. Medicaid HMOs
are not responsible for any services after the effective date of loss of
Medicaid eligibility.
(b)
CHIP
HMOs. If a CHIP Member’s Effective Date of Coverage occurs while the CHIP Member
is confined in a hospital, HMO is responsible for the CHIP Member’s costs of
Covered Services beginning on the Effective Date of Coverage. If a
CHIP Member is disenrolled while the CHIP Member is confined in a hospital,
HMO’s responsibility for the CHIP Member’s costs of Covered
Services terminates on the Date of Disenrollment.
(c)
CHIP
Perinatal HMOs. If a CHIP Perinate’s Effective Date of Coverage occurs while the
CHIP Perinate is confined in a Hospital, HMO is responsible for the CHIP
Perinate’s costs of Covered Services beginning on the Effective Date of
Coverage. If a CHIP Perinate is disenrolled while the CHIP Perinate is confined
in a Hospital, the HMO’s responsibility for the CHIP Perinate’s costs
of
Covered
Services terminates on the Date of Disenrollment.
Section
5.06 Verification of Member Eligibility.
Medicaid
MCOs are prohibited from entering into an agreement to share information
regarding their Members with an external vendor that provides verification
of
Medicaid recipients’ eligibility to Medicaid providers. All such
external vendors must contract with the State and obtain eligibility information
from the State.
Section
5.07 Special Temporary STAR Default Process
(a)
STAR
HMOs that did not contract with HHSC prior to the Effective Date of the Contract
to provide Medicaid Health Care Services will be assigned a limited number
of
Medicaid-eligibles, who have not actively made a STAR HMO choice, for a finite
period. The number will vary by Service Area as set forth
below. To the extent possible, the special default assignment will be
based on each eligible’s prior history with a PCP and geographic proximity to a
PCP.
(b)
For
the Bexar, Dallas, El Paso, Harris, Tarrant, and Xxxxxx Service Areas, the
special default process will begin with the Operational Start Date and conclude
when the HMO has achieved an enrollment of 15,000 mandatory STAR members, or
at
the end of six months, whichever comes first.
(c)
For
the Lubbock Service Area, the special default process will begin with the
Operational Start Date and conclude when the HMO has achieved an enrollment
of
5,000 mandatory STAR members, or at the end of six months, whichever comes
first.
(d)
Special default periods may be extended for one or more Service Areas if
consistent with HHSC administrative rules.
(e)
This
Section does not apply to the Nueces Service Area.
Section 5.08 Special Temporary STAR+PLUS
Default Process
(a)
STAR+PLUS HMOs that did not contract with HHSC to provide STAR+PLUS services
in
Xxxxxx County prior to the Effective Date of the Contract will be assigned
a
limited number of STAR+PLUS Medicaid-eligibles in Xxxxxx County, who have not
actively made a STAR+PLUS HMO choice, for a finite period. To the extent
possible, the special default assignment will be based on each eligible's prior
history with a PCP and geographic proximity to a PCP.
(b)
For
the Xxxxxx Service Area, the special default process will begin on the
Operational Start Date. All defaults for Xxxxxx County will be awarded to the
new HMO during the special default process. The special default process will
conclude at the end of the first 6-month period following the Operational Start
Date, or when the HMO has achieved a total enrollment of 8,000 STAR+PLUS Members
for the entire Xxxxxx Service Area (includes Xxxxxx and Xxxxxx Contiguous
counties), whichever comes first.
(c)
The
special default process will apply to Xxxxxx County only. The Xxxxxx Contiguous
counties will follow the standard default process.
(d)
This
Section does not apply to the Bexar, Nueces or Xxxxxx Service Areas for
STAR+PLUS.
Section
6.01 Performance measurement.
Satisfactory
performance of this Contract will be measured by:
(a)
Adherence to this Contract, including all representations and
warranties;
(b)
Delivery of the Services and Deliverables described in Attachment
B;
(c)
Results of audits performed by HHSC or its representatives in accordance with
Article 9 (“Audit and Financial Compliance”);
(d)
Timeliness, completeness, and accuracy of required reports; and
(e)
Achievement of performance measures developed by HMO and HHSC and as modified
from time to time by written agreement during the term of this
Contract.
Section
7.01 Governing law and venue.
This
Contract is governed by the laws of the State of Texas and interpreted in
accordance with Texas law. Provided HMO first complies with the
procedures set forth in Section 12.13 (“Dispute Resolution,”)
proper venue for claims arising from this Contract will be in the State District
Court of Xxxxxx County, Texas.
Section
7.02 HMO responsibility for compliance with
laws and regulations.
(a)
HMO
must comply, to the satisfaction of HHSC, with all provisions set forth in
this
Contract, all applicable provisions of state and federal laws, rules,
regulations, federal waivers, policies and guidelines, and any court-ordered
consent decrees, settlement agreements, or other court orders that govern the
performance of the Scope of Work including, but not limited to:
(1)
Titles XIX and XXI of the Social Security Act;
(2)
Chapters 62 and 63, Texas Health and Safety Code;
(3)
Chapters 531 and 533, Texas Government Code;
(4)
42
C.F.R. Parts 417 and 457, as applicable;
(5)
45
C.F.R. Parts 74 and 92;
(6)
48
C.F.R. Part 31, or OMB Circular A-122, based on whether the entity is for-profit
or nonprofit;
(7)
1
T.A.C. Part 15, Chapters 361, 370, 391, and 392; and
(8)
all
State and Federal tax laws, State and Federal employment laws, State and Federal
regulatory requirements, and licensing provisions.
(b)
The
Parties acknowledge that the federal and/or state laws, rules, regulations,
policies, or guidelines, and court-ordered consent decrees, settlement
agreements, or other court orders that affect the performance of the Scope
of
Work may change from time to time or be added, judicially interpreted, or
amended by competent authority. HMO acknowledges that the HMO
Programs will be subject to continuous change during the term of the Contract
and, except as provided in Section 8.02, HMO has provided for or will provide
for adequate resources, at no additional charge to HHSC, to reasonably
accommodate such changes. The Parties further acknowledge that HMO
was selected, in part, because of its expertise, experience, and knowledge
concerning applicable Federal and/or state laws, regulations, policies, or
guidelines that affect the performance of the Scope of Work. In
keeping with HHSC’s reliance on this knowledge and expertise, HMO is responsible
for identifying the impact of changes in applicable Federal or state legislative
enactments and regulations that affect the performance of the Scope of Work
or
the State’s use of the Services and Deliverables. HMO must timely notify HHSC of
such changes and must work with HHSC to identify the impact of such changes
on
how the State uses the Services and Deliverables.
(c)
HHSC
will notify HMO of any changes in applicable law, regulation, policy, or
guidelines that HHSC becomes aware of in the ordinary course of its
business.
(d)
HMO
is responsible for any fines, penalties, or disallowances imposed on the State
or HMO arising from any noncompliance with the laws and regulations relating
to
the delivery of the Services or Deliverables by the HMO, its Subcontractors
or
agents.
(e)
HMO
is responsible for ensuring each of its employees, agents or Subcontractors
who
provide Services under the Contract are properly licensed, certified, and/or
have proper permits to perform any activity related to the
Services.
(f)
HMO
warrants that the Services and Deliverables will comply with all applicable
Federal, State, and County laws, regulations, codes, ordinances, guidelines,
and
policies. HMO will indemnify HHSC from and against any losses,
liability, claims, damages, penalties, costs, fees, or expenses arising from
or
in connection with HMO’s failure to comply with or violation of any such law,
regulation, code, ordinance, or policy.
Section
7.03 TDI licensure/ANHC certification and
solvency.
(a)
Licensure HMO must be either licensed by the TDI as an HMO or a certified ANHC
in all counties for the
Service
Areas included within the scope of the Contract.
(b)
Solvency HMO must maintain compliance with the Texas Insurance Code and rules
promulgated and administered by the TDI requiring a fiscally sound
operation. HMO must have a plan and take appropriate measures to
ensure adequate provision against the risk of insolvency as required by
TDI.
Such
provision must be adequate to provide for the following in the event of
insolvency:
(1)
continuation of benefits, until the time of discharge, to Members who are
confined on the date of insolvency in a Hospital or other inpatient
facility;
(2)
payment to unaffiliated health care providers and affiliated health care
providers whose agreements do not contain member “hold harmless” clauses
acceptable to TDI, and
(3)
continuation of benefits for the duration of the Contract period for which
HHSC
has paid a Capitation Payment.
Provision
against the risk of insolvency must be made by establishing adequate reserves,
insurance or other guarantees in full compliance with all financial requirements
of TDI.
Section
7.04 Immigration Reform and Control Act of
1986.
HMO
shall
comply with the requirements of the Immigration Reform and Control Act of 1986
and the Immigration Act of 1990 (8 X.X.X. §0000, et seq.) regarding
employment verification and retention of verification forms for any
individual(s) hired on or after November 6, 1986, who will perform any labor
or
services under this Contract.
Section
7.05 Compliance with state and federal anti-discrimination
laws.
HMO
shall
comply with Title VI of the Civil Rights Act of 1964, Executive Order 11246
(Public Law 88352), Section 504 of the Rehabilitation Act of 1973 (Public
Law 93-112), the Americans with Disabilities Act of 1990 (Public Law 101-336),
and all amendments to each, and all requirements imposed by the regulations
issued pursuant to these Acts. In addition, HMO shall comply with
Title 40, Chapter 73 of the Texas Administrative Code, “Civil Rights,” to the
extent applicable to this Contract. These provide in part that no
persons in the United States must, on the grounds of race, color, national
origin, sex, age, disability, political beliefs, or religion, be excluded from
participation in, or denied, any aid, care, service or
other
benefits provided by Federal or State funding, or otherwise be subjected to
any
discrimination.
Section
7.06 Environmental protection laws.
HMO
shall
comply with the applicable provisions of federal environmental protection laws
as described in this Section:
(a)
Pro-Children Act of 1994. HMO shall comply with the Pro-Children Act of 1994
(20
X.X.X. §0000 et seq.), as applicable, regarding
the provision of a smoke-free workplace and promoting the non-use of all tobacco
products.
(b)
National Environmental Policy Act of 1969. HMO shall comply with any applicable
provisions relating to the institution of environmental quality control measures
contained in the National Environmental Policy Act of 1969 (42 X.X.X. §0000
et seq.)
and Executive Order 11514 (“Protection and Enhancement of Environmental
Quality”).
(c)
Clean
Air Act and Water Pollution Control Act regulations. HMO
shall
comply with any applicable provisions relating to required notification of
facilities violating the requirements of Executive Order 11738 (“Providing for
Administration of the Clean Air Act and the Federal Water Pollution Control
Act
with Respect to Federal Contracts, Grants, or Loans”).
(d)
State
Clean Air Implementation Plan. HMO shall comply with any applicable provisions
requiring conformity of federal actions to State (Clean Air)
Implementation Plans under §176(c) of the Clean Air Act of 1955, as amended (42
U.S.C. §740 et seq.).
(e)
Safe
Drinking Water Act of 1974. HMO shall comply with applicable provisions relating
to the protection of underground sources of drinking water under the Safe
Drinking Water Act of 1974,
as
amended (21 U.S.C. § 349; 42 U.S.C. §§ 300f to 300j-9).
Section
7.07 HIPAA.
HMO
shall
comply with applicable provisions of HIPAA. This includes, but is not limited
to, the requirement that the HMO’s MIS system comply with applicable certificate
of coverage and data specification and reporting requirements promulgated
pursuant to HIPAA. HMO must comply with HIPAA EDI requirements.
Section
8.01 Mutual agreement.
This
Contract may be amended at any time by mutual agreement of the
Parties. The amendment must be in writing and signed by individuals
with authority to bind the Parties.
Section
8.02 Changes in law or contract.
If
Federal or State laws, rules, regulations, policies or guidelines are adopted,
promulgated, judicially interpreted or changed, or if contracts are entered
or
changed, the effect of which is to alter the ability of either Party to fulfill
its obligations under this Contract, the Parties will promptly negotiate in
good
faith appropriate modifications or alterations to the Contract and any
schedule(s) or attachment(s) made a part of this Contract. Such modifications
or
alterations must be in writing and signed by individuals with authority to
bind
the parties, equitably adjust the terms and conditions of this Contract, and
must be limited to those provisions of this Contract affected by the
change.
Section
8.03 Modifications as a remedy.
This
Contract may be modified under the terms of Article 12 (
“Remedies and Disputes”).
Section
8.04 Modifications upon renewal or extension of
Contract.
(a)
If
HHSC seeks modifications to the Contract as a condition of any Contract
extension, HHSC’s notice to HMO will specify those modifications to the Scope of
Work, the Contract pricing terms, or other Contract terms and
conditions.
(b)
HMO
must respond to HHSC’s proposed modification within the timeframe specified by
HHSC, generally within thirty (30) days of receipt. Upon receipt of
HMO’s response to the proposed modifications, HHSC may enter into negotiations
with HMO to arrive at mutually agreeable Contract amendments. In the event
that
HHSC determines that the Parties will be unable to reach agreement on mutually
satisfactory contract modifications, then HHSC will provide written notice
to
HMO of its intent not to extend the Contract beyond the Contract Term then
in
effect.
Section
8.05 Modification of HHSC Uniform Managed Care
Manual.
(a)
HHSC
will provide HMO with at least thirty (30)
days
advance written notice before implementing a substantive and material change
in
the HHSC Uniform Managed Care Manual (a change that materially and substantively
alters the HMO’s ability to fulfill its obligations under the
Contract). The Uniform Managed Care Manual, and all modifications
thereto made during the Contract Term, are incorporated by reference into this
Contract. HHSC will provide HMO with a reasonable amount of time to
comment on such changes, generally at least ten (10) Business
Days. HHSC is not required to provide advance written notice of
changes that are not material and substantive in nature, such as corrections
of
clerical errors or policy clarifications.
(b)
The
Parties agree to work in good faith to resolve disagreements concerning material
and substantive
changes to the HHSC Uniform Managed Care Manual. If the Parties are
unable to resolve issues relating to material and substantive changes, then
either Party may terminate the agreement in accordance with Article
12 (“Remedies and Disputes”).
(c)
Changes will be effective on the date specified in HHSC’s written notice, which
will not be earlier than the HMO’s response deadline, and such changes will be
incorporated into the HHSC Uniform Managed Care Manual. If the HMO
has raised an objection to a material and substantive change to the HHSC Uniform
Managed Care Manual and submitted a notice of termination in accordance with
Section 12.04(d), HHSC will not enforce the policy change
during the period of time between the receipt of the notice and the date of
Contract termination.
Section
8.06 CMS approval of Medicaid amendments
The
implementation of amendments, modifications, and changes to STAR and STAR+PLUS
HMO contracts is subject to the approval of the Centers for Medicare and
Medicaid Services (“CMS.”)
Section
8.07 Required compliance with amendment and modification
procedures.
No
different or additional services, work, or products will be authorized or
performed except as authorized by this Article. No waiver of any
term, covenant, or condition of this Contract will be valid unless executed
in
compliance with this Article. HMO will not be entitled to payment for
any services, work or products that are not authorized by a properly executed
Contract amendment or modification.
Section
9.01 Financial record retention and audit.
HMO
agrees to maintain, and require its Subcontractors to maintain, supporting
financial information and documents that are adequate to ensure that payment
is
made and the Experience Rebate is calculated in accordance with applicable
Federal and State requirements, and are sufficient to ensure the accuracy and
validity of HMO invoices. Such documents, including all original claims forms,
will be maintained and retained by HMO or its Subcontractors for a period of
five (5) years after the Contract Expiration Date or until the resolution of
all
litigation, claim, financial management review or audit pertaining to this
Contract, whichever is longer.
Section
9.02 Access to records, books, and documents.
(a)
Upon
reasonable notice, HMO must provide, and cause its Subcontractors to provide,
the officials and entities identified in this Section with prompt, reasonable,
and adequate access to any records,
books,
documents, and papers that are related to the performance of the Scope of
Work.
(b)
HMO
and its Subcontractors must provide the access described in this Section upon
HHSC’s request. This request may be for, but is not limited to, the
following purposes:
(1)
Examination;
(2)
Audit;
(3)
Investigation;
(4)
Contract administration; or
(5)
The
making of copies, excerpts, or transcripts.
(c)
The
access required must be provided to the following officials and/or
entities:
(1)
The
United States Department of Health and Human Services or its
designee;
(2)
The
Comptroller General of the United States or its designee;
(3)
HMO
Program personnel from HHSC or its designee;
(4)
The
Office of Inspector General;
(5)
Any
independent verification and validation contractor or quality assurance
contractor acting on behalf of HHSC;
(6)
The
Office of the State Auditor of Texas or its designee;
(7)
A
State or Federal law enforcement agency;
(8)
A
special or general investigating committee of the Texas Legislature or its
designee; and
(9)
Any
other state or federal entity identified by HHSC, or any other entity engaged
by
HHSC.
(d)
HMO
agrees to provide the access described wherever HMO maintains such books,
records, and supporting documentation. HMO further agrees to provide
such access in reasonable comfort and to provide any furnishings, equipment,
and
other conveniences deemed reasonably necessary to fulfill the purposes described
in this Section. HMO will require its Subcontractors to provide
comparable access and accommodations.
Section
9.03 Audits of Services, Deliverables and
inspections.
(a)
Upon
reasonable notice from HHSC, HMO will provide, and will cause its Subcontractors
to provide, such auditors and inspectors as HHSC may from time to time
designate, with access to:
(1)
HMO
service locations, facilities, or installations; and
(2)
HMO
Software and Equipment.
(b)
The
access described in this Section will be for the purpose of examining, auditing,
or investigating:
(1)
HMO’s
capacity to bear the risk of potential financial losses;
(2)
the
Services and Deliverables provided;
(3)
a
determination of the amounts payable under this Contract;
(4)
detection of fraud, waste and/or abuse; or
(5)
other
purposes HHSC deems necessary to perform its regulatory function and/or enforce
the provisions of this Contract.
(c)
HMO
must provide, as part of the Scope of Work, any assistance that such auditors
and inspectors reasonably may require to complete such audits or
inspections.
(d)
If,
as a result of an audit or review of payments made to the HMO, HHSC discovers
a
payment error or overcharge, HHSC will notify the HMO of such error or
overcharge. HHSC will be entitled to recover such funds as an offset
to future payments to the HMO, or to collect such funds directly from the HMO.
HMO must return funds owed to HHSC within thirty (30) days after receiving
notice of the error or overcharge, or interest will accrue on the amount
due. HHSC will calculate interest at the Department of Treasury’s
Median Rate (resulting from the Treasury’s auction of 13-week bills) for the
week in which liability is assessed. In the event that an audit reveals that
errors in reporting by the HMO have resulted in errors in payments to the HMO
or
errors in the calculation of the Experience Rebate, the HMO will indemnify
HHSC
for any losses resulting from such errors, including the cost of
audit.
Section
9.04 SAO Audit
The
HMO
understands that acceptance of funds under this Contract acts as acceptance
of
the authority of the State Auditor’s Office (“SAO”), or any successor agency, to
conduct an investigation in connection with those funds. The HMO
further agrees to cooperate fully with the SAO or its successor in the conduct
of the audit or investigation, including providing all records
requested. The HMO will ensure that this clause concerning the
authority to audit funds received indirectly by Subcontractors through HMO
and
the requirement to cooperate is included in any Subcontract it awards, and
in
any third party agreements described in Section 4.10
(a-b).
Section
9.05 Response/compliance with audit orinspection
findings.
(a)
HMO
must take action to ensure its or a Subcontractor’s compliance with or
correction of any finding of noncompliance with any law, regulation, audit
requirement, or generally accepted accounting principle relating to the Services
and Deliverables or any
other
deficiency contained in any audit, review, or inspection conducted under this
Article. This action will include HMO’S delivery to HHSC, for HHSC’S
approval, a Corrective Action Plan that addresses deficiencies identified in
any
audit(s), review(s), or inspection(s) within thirty (30) calendar days of the
close of the audit(s), review(s), or inspection(s).
(b)
HMO
must bear the expense of compliance with any finding of noncompliance under
this
Section that is:
(1)
Required by Texas or Federal law, regulation, rule or other audit requirement
relating to HMO's business;
(2)
Performed by HMO as part of the Services or Deliverables; or
(3)
Necessary due to HMO's noncompliance with any law, regulation, rule or audit
requirement imposed on HMO.
(c)
As
part of the Scope of Work, HMO must provide to HHSC upon request a copy of
those
portions of HMO's and its Subcontractors' internal audit reports relating to
the
Services and Deliverables provided to HHSC under the Contract.
Section
10.01 Calculation of monthly Capitation
Payment.
(a)
This
is a Risk-based contract. For each applicable HMO Program, HHSC will
pay the HMO fixed monthly Capitation Payments based on the number of eligible
and enrolled Members. HHSC will calculate the monthly Capitation Payments by
multiplying the number of Members by each applicable Member Rate
Cell. In consideration of the Monthly Capitation Payment(s), the HMO
agrees to provide the Services and Deliverables described in this
Contract.
(b)
HMO
will be required to provide timely financial and statistical information
necessary in the Capitation Rate determination process. Encounter
Data provided by HMO must conform to all HHSC requirements. Encounter Data
containing noncompliant information, including, but not limited to,
inaccurate client or member identification numbers, inaccurate provider
identification numbers, or diagnosis or procedures codes insufficient to
adequately describe the diagnosis or medical procedure performed, will not
be
considered in the HMO’s experience for rate-setting purposes.
(c)
Information or data, including complete and accurate Encounter Data, as
requested by HHSC for rate-setting purposes, must be provided to HHSC: (1)
within thirty (30) days of receipt of the letter from HHSC requesting the
information or data; and (2) no later than March 31st of each
year.
(d)
The
fixed monthly Capitation Rate consists of the following components:
(1)
an
amount for Health Care Services performed
during the month;
(2)
an
amount for administering the program,
(3)
an
amount for the HMO’s Risk margin, and
(4)
with
respect to the Medicaid program, pass
through funds for high-volume providers. Capitation Rates for each HMO Program
may vary by Service Area and MCO. HHSC will employ or retain
qualified actuaries to perform data analysis and calculate the Capitation Rates
for each Rate Period.
(e)
HMO
understands and expressly assumes the risks associated with the performance
of
the duties and responsibilities under this Contract, including the failure,
termination or suspension of funding to HHSC, delays or denials of required
approvals, and cost overruns not reasonably attributable to HHSC.
Section
10.02 Time and Manner of Payment.
(a)
During the Contract Term and beginning after the Operational Start Date, HHSC
will pay the monthly Capitation Payments by the 10th Business Day of each
month.
(b)
The
HMO must accept Capitation Payments by direct deposit into the HMO’s
account.
(c)
HHSC
may adjust the monthly Capitation Payment to the HMO in the case of an
overpayment to the HMO, for Experience Rebate amounts due and unpaid, and if
money damages are assessed in accordance with Article 12
(“Remedies and Disputes”).
(d)
HHSC’s payment of monthly Capitation Payments is subject to availability of
federal and state appropriations. If appropriations are not available to pay
the
full monthly Capitation Payment, HHSC may:
(1)
equitably adjust Capitation Payments for all participating Contractors, and
reduce scope of service requirements as appropriate in accordance with
Article 8, or
(2)
terminate the Contract in accordance with Article
12 (“Remedies and Disputes”).
Section
10.03 Certification of Capitation
Rates.
HHSC
will
employ or retain a qualified actuary to certify the actuarial soundness of
the
Capitation Rates contained in this Contract. HHSC will also employ or
retain a qualified actuary to certify all revisions or modifications to the
Capitation Rates.
Section
10.04 Modification of Capitation Rates.
The
Parties expressly understand and agree that the agreed Capitation Rates are
subject to modification in accordance with Article 8
(“Amendments and Modifications,”) if changes in state
or
federal laws, rules, regulations or policies affect the rates or the actuarial
soundness of the rates. HHSC will provide the HMO notice of a
modification to the Capitation Rates 60 days prior to the effective date of
the
change, unless HHSC determines that circumstances warrant a shorter notice
period. If the HMO does not accept the rate change, either Party may
terminate the Contract in accordance with Article 12 (“Remedies
and Disputes”).
Section
10.05 STAR Capitation Structure.
(a)
STAR
Rate Cells. STAR Capitation Rates are defined on a per Member
per month basis by Rate Cells and Service Areas. STAR Rate Cells
are:
(1)
TANF
adults;
(2)
TANF
children over 12 months of age;
(3)
Expansion children over 12 months of age;
(4)
Newborns less than or equal to 12 months of age;
(5)
TANF
children less than or equal to 12 months of age;
(6)
Expansion children less than or equal to 12 months of age;
(7)
Federal mandate children; and
(8)
Pregnant women.
(b)
STAR
Capitation Rate development:
(1)
Capitation Rates for Rate Periods 1 and 2 for Service Areas with historical
STAR
Program participation.
For
Service Areas where HHSC operated the STAR Program prior to the Effective Date
of this Contract, HHSC will develop base Capitation Rates by analyzing
historical STAR Encounter Data and financial data for the Service
Area. This analysis will apply to all MCOs in the Service Area,
including MCOs that have no historical STAR Program participation in the Service
Area. The analysis will include a review of historical enrollment and
claims experience information; any changes to Covered Services and covered
populations; rate changes specified by the Texas Legislature; and any other
relevant information. If the HMO participated in the STAR Program in the Service
Area prior to the Effective Date of this Contract, HHSC may modify the Service
Area base Capitation Rates using diagnosis-based risk adjusters to yield the
final Capitation Rates.
(2)
Capitation Rates for Rate Periods 1 and 2 for Service Areas with no historical
STAR Program participation.
For
Service Areas where HHSC has not operated the STAR Program prior to
the
Effective
Date of this Contract, HHSC will establish base Capitation Rates for Rate
Periods 1 and 2 by analyzing Fee-for-Service claims data for the Service
Area. This analysis will include a review of historical enrollment
and claims experience information; any changes to Covered Services and covered
populations; rate changes specified by the Texas Legislature; and any other
relevant information.
(3)
Capitation Rates for subsequent Rate Periods for Service Areas with no
historical STAR Program participation.
For
Service Areas where HHSC has not operated the STAR Program prior to the
Effective Date of this Contract, HHSC will establish base Capitation Rates
for
the Rate Periods following Rate Period 2 by analyzing historical STAR Encounter
Data and financial data for the Service Area. This analysis will
include a review of historical enrollment and claims experience information;
any
changes to Covered Services and covered populations; rate changes specified
by
the Texas Legislature; and any other relevant information.
(c)
Acuity adjustment. HHSC may evaluate and implement an acuity adjustment
methodology, or alternative reasonable methodology, that appropriately
reimburses the HMO for acuity and cost differences that deviate from that of
the
community average, if HHSC in its sole discretion determines that such a
methodology is reasonable and appropriate. The community average is a
uniform rate for all HMOs in a Service Area, and is determined by combining
all
the experience for all HMOs
in a
Service Area to get an average rate for the Service Area. Value-added Services
will not be included in the rate-
setting
process.
(a)
STAR+PLUS Rate Cells. STAR+PLUS Capitation Rates are defined on a per
Member per month basis by Rate Cells. STAR+PLUS
Rate Cells are based on client category as follows:
(1)
Medicaid Only Standard Rate
(2)
Medicaid Only 1915 (c) Nursing Facility Waiver Rate
(3)
Dual
Eligible Standard Rate
(4)
Dual
Eligible 1915(c) Nursing Facility Waiver Rate
(5)
Nursing Facility – Medicaid only
(6)
Nursing Facility - Dual Eligible
These
Rate Cells are subject to change after Rate Period 2.
(b)
STAR+PLUS Capitation Rates For All Service Areas, HHSC will establish
base Capitation Rates by Service Area based on fee-forservice experience in
the counties included in the Service Area. For the base Capitation Rate in
the
Xxxxxx Service Area, the encounter data from existing STAR+PLUS plans in Xxxxxx
County will be blended with the fee-for-service experience from the balance
of
counties in the Xxxxxx Service Area. HHSC may adjust the base Capitation Rate
by
the HMO’s Case Mix Index to yield the final Capitation Rates. HHSC reserves the
right to trend forward these rates
until sufficient Encounter Data is available to base Capitation Rates on
Encounter Data.
(c)
Delay
in Increased Capitation Level for Certain Members Receiving Waiver
Services
Once
a
current HMO Member has been certified to receive STAR+PLUS Waiver (SPW)
services, there is a two-month delay before the HMO will begin receiving the
higher capitation payment.
Non-Waiver
Members who qualify for STAR+PLUS based on eligibility for SPW services and
Waiver recipients who transfer from another region will not be subject to this
two-month delay in the increased capitation payment.
All
SPW
recipients will be registered into Service Authorization System Online
(SASO). The Premium Payment System (PPS) will process data from the
SASO system in establishing a Member’s correct capitation payment.
Section
10.06 CHIP Capitation Rates Structure.
(a)
CHIP
Rate Cells. CHIP Capitation Rates are defined on a per Member per month basis
by
the Rate Cells applicable
to
a
Service Area. CHIP Rate Cells are based on the Member’s age group as
follows:
(1)
under
age one (1);
(2)
ages
one (1) through five (5);
(3)
ages
six (6) through fourteen (14); and
(4)
ages
fifteen (15) through eighteen (18).
(b)
CHIP
Capitation Rate development: HHSC will establish base
Capitation Rates by analyzing Encounter Data and financial data for each Service
Area. This analysis will include a review of historical enrollment
and claims experience information; any changes to Covered Services and covered
populations; rate changes specified by the Texas Legislature; and any other
relevant information. HHSC may modify the Service Area base
Capitation
Rate
using diagnosis based risk adjusters to yield the final Capitation
Rates.
(c)
Acuity adjustment. HHSC may evaluate and implement an acuity adjustment
methodology, or alternative reasonable methodology, that appropriately
reimburses the HMO for acuity and cost differences that deviate from that of
the
community average, if HHSC in its sole discretion determines that such a
methodology is reasonable and appropriate. The community average is a
uniform rate for all HMOs in a Service Area, and is determined by combining
all
the experience for all HMOs
in a
Service Area to get an average rate for the Service Area.
(d)
Value-added Services will not be included in the rate-setting
process.
Section 10.06.1 CHIP Perinatal Program
Capitation Structure.
(a)
CHIP
Perinatal Program Rate Cells. CHIP Perinatal Capitation Rates are defined on
a
per Member per month basis by the Rate Cells applicable to a Service
Area. CHIP Perinatal Rate Cells
are
based on the Member’s birth status and household income as follows:
(1)
CHIP
Perinate 0% - 185% of FPL;
(2)
CHIP
Perinate 186% - 200% of FPL;
(3)
CHIP
Perinate Newborn 0% - 185% of FPL;and
4)
CHIP
Perinate Newborn 186% - 200% of FPL.
(b)
CHIP
Perinatal Program Capitation Rate Development
(1)
Until
such time as adequate encounter data is available to set rates, CHIP Perinatal
Program capitation rates will be established based on experience from comparable
populations in the Medicaid Fee-for-Service and STAR programs. This
analysis will include: a review of historical enrollment and claims experience
information; changes to Covered Services and covered populations; rate changes
specified by the Texas Legislature; and any other relevant
information. HHSC may modify the Service Area based Capitation Rate
using diagnosis-based risk adjusters to yield the final Capitation
Rates.
(2)
Effective 4/1/07, on a prospective basis, the monthly premium rate for Perinatal
expectant mothers at or below 185% of FPL has been increased. The rate increase
is to be passed on to all physicians involved in the labor with delivery for
members at or below 185% FPL. The average increase for the fee schedule for
the
procedure codes related to labor with delivery is 26.1%.
(c)
Value-added Services will not be included in the rate-setting
process.
Section
10.07 HMO input during rate setting process.
(1)
In
Service Areas with historical STAR or CHIP Program participation, HMO must
provide certified Encounter Data and financial data as prescribed in
HHSC’s Uniform Managed Care Manual. Such information may
include, without limitation: claims lag information by Rate Cell, capitation
expenses, and stop loss reinsurance expenses. HHSC may request
clarification or for additional financial information from the
HMO. HHSC will notify the HMO of the deadline for submitting a
response, which will include a reasonable amount of time for
response.
(2)
HHSC
will allow the HMO to review and comment on data used by HHSC to determine
base
Capitation Rates. In Service Areas with no historical STAR Program
participation, this will include Fee-for-Service data for Rate Periods 1 and
2. HHSC will notify the HMO of deadline for submitting comments,
which will include a reasonable amount of time for response. HHSC
will not consider comments received after the deadline in its rate
analysis.
(3)
During the rate setting process, HHSC will conduct at least two (2) meetings
with the HMO. HHSC may conduct the meetings in person, via
teleconference, or by another method deemed appropriate by
HHSC. Prior to the first meeting, HHSC will provide the HMO with
proposed Capitation Rates. During the first meeting, HHSC will describe the
process used to generate the proposed Capitation Rates, discuss major changes
in
the rate setting process, and receive input from the HMO. HHSC will
notify the HMO of the deadline for submitting comments, which will include
a
reasonable amount of time to review and comment on the proposed Capitation
Rates
and rate setting process. After reviewing such comments, HHSC will
conduct a second meeting to discuss the final Capitation Rates and changes
resulting from HMO comments, if any.
Section
10.08 Adjustments to CapitationPayments.
(a)
Recoupment. HHSC
may
recoup a payment made to the HMO for a Member if:
(1)
the
Member is enrolled into the HMO in error, and the HMO provided no Covered
Services to the Member during the month for which the payment was
made;
(2)
the
Member moves outside the United States, and the HMO has not provided Covered
Services to the Member during the month for which the payment was
made;
(3)
the
Member dies before the first day of the month for which the payment was made;
or
(4)
a
Medicaid Member’s eligibility status or program type is changed, corrected as a
result of error, or is retroactively adjusted.
(b)
Appeal of recoupment. The HMO may appeal the recoupment or adjustment of
capitations in the above circumstances using
the
HHSC dispute resolution process set forth in Section 12.13,
(“Dispute Resolution”).
Section
10.09 Delivery Supplemental Payment for
CHIP,
CHIP Perinatal and STAR HMOs.
(a)
The
Delivery Supplemental Payment (DSP) is a function of the average delivery cost
in each Service Area. Delivery costs include facility and
professional charges.
(b)
CHIP
and STAR HMOs will receive a Delivery Supplemental Payment (DSP) from HHSC
for
each live or stillbirth by a Member. CHIP Perinatal HMOs will receive a DSP
from
HHSC for each live or stillbirth by a mother of a CHIP Perinatal Program Member
in the 186% to 200% FPL (measured at the time of enrollment in the CHIP
Perinatal Program). CHIP Perinatal HMOs will not receive a DSP
from HHSC for a live or stillbirth by the mother of a CHIP Perinatal Program
Member in the 100%-185% FPL. For STAR, CHIP and CHIP Perinatal
Program HMOs, the one-time DSP payment is made in the amount identified in
the
HHSC Managed Care Contract document regardless of whether there
is a single birth or there are multiple births at time of delivery. A
delivery is the birth of a live born infant, regardless of the duration of
the
pregnancy, or a stillborn (fetal death) infant of twenty (20) weeks or more
of
gestation. A delivery does not include a spontaneous or induced
abortion, regardless of the duration of the pregnancy.
(c)
HMO
must submit a monthly DSP Report as described in Attachment B-1, Section
8 to the HHSC Managed Care Contract document, in the
format prescribed in HHSC’s Uniform Managed Care
Manual.
(d)
HHSC
will pay the Delivery Supplemental Payment within twenty (20) Business Days
after receipt of a complete and accurate report from the HMO.
(e)
The
HMO will not be entitled to Delivery Supplemental Payments for deliveries that
are not reported to HHSC within 210 days after the date of delivery, or within
thirty (30) days from the date of discharge from the hospital for the stay
related to the delivery, whichever is later.
(f)
HMO
must maintain complete claims and adjudication disposition documentation,
including paid and denied amounts for each delivery. The HMO must submit the
documentation to HHSC within five
(5)
Business Days after receiving a request for such information from
HHSC.
Section
10.10 Administrative Fee for SSI Members
(a)
Administrative Fee. STAR HMOs will receive a monthly fee for administering
benefits to each SSI Beneficiary who voluntarily enrolls in the HMO (a
“Voluntary SSI Member”), in the amount identified in the HHSC Managed
Care Contract document. The HHSC will pay for Health Care Services for
such Voluntary SSI Members under the Medicaid Fee-for-Services
program. SSI Beneficiaries in all Service Areas except Nueces may
voluntarily participate in the
STAR
Program; however, HHSC reserves the right to discontinue such voluntary
participation.
(b)
Administrative services and functions.
(1)
HMO
must perform the same administrative services and functions for Voluntary SSI
Members as are performed for other Members under this contract. These
administrative services and functions include, but are not limited
to:
(i)
prior
authorization of services;
(ii)
all
Member services functions, including linguistic services and Member materials
in
alternative formats for the blind and disabled;
(iii)
health education;
(iv)
utilization management using HHSC Administrative Services Contractor encounter
data to provide service management and appropriate interventions;
(v)
quality assessment and performance improvement activities;
(vi)
coordination to link Voluntary SSI Members with applicable community resources
and Noncapitated services.
(2)
HMO
must require Network Providers to submit claims for health and health-related
services to the HHSC Administrative Services Contractor for claims adjudication
and payment.
(3)
HMO
must provide services to Voluntary SSI Members within the HMO’s Network unless
necessary services are unavailable within Network. HMO must also allow referrals
to Out-of-Network providers if necessary services are not available within
the
HMO’s Network. Records must be forwarded
to Member’s PCP following a referral visit.
(c)
Members who become eligible for SSI A Member’s SSI status is effective the date
the State’s eligibility system identifies the Member as Type Program 13 (TP13).
On this effective date, the Member becomes a voluntary STAR
enrollee. The State is responsible for updating the State's
eligibility system within 45 days of official notice of theMember’s
Federal SSI eligibility by the Social Security Administration
(SSA).
Section 10.11STAR, CHIP , and CHIP Perinatal Experience Rebate
(a)
HMO’s
duty to pay. At the end of each Rate Year beginning with Rate Year 1, the HMO
must pay an Experience Rebate for the STAR, CHIP, and CHIP Perinatal Programs
to
HHSC if the HMO’s Net Income before Taxes is greater than 3% of the total
Revenue for the period. The Experience Rebate is calculated in
accordance with the tiered rebate method set forth below based on the
consolidated Net Income before Taxes for all of the HMO’s STAR, CHIP, and CHIP
Perinatal Service Areas included within the scope of the Contract, as measured
by any positive amount on the
Financial-Statistical Report (FSR) as reviewed and confirmed by
HHSC.
(b)
Graduated Experience Rebate Sharing Method.
Experience
Rebate as a % of Revenues
|
HMO
Share
|
HHSC
Share
|
<
3%
|
100%
|
0%
|
>
3% and < 7%
|
75%
|
25%
|
>
7% and < 10%
|
50%
|
50%
|
>
10% and < 15%
|
25%
|
75%
|
>
15%
|
0%
|
100%
|
HHSC
and
the HMO will share the Net Income before Taxes for the STAR, CHIP, and CHIP
Perinatal Programs as follows, unless HHSC provides the HMO an Experience Rebate
Reward in accordance with Section 6 of Attachment B-1 to
the HHSC Managed Care Contract document and HHSC’s
Uniform Managed Care Manual:
(1)
The
HMO will retain all Net Income before Taxes that is equal to or less than 3%
of
the total Revenues received by the HMO.
(2)
HHSC
and the HMO will share that portion of the Net Income before Taxes that is
over
3% but less than or equal to 7% of the total Revenues received with 75% to
the
HMO and 25% to HHSC.
(3)
HHSC
and the HMO will share that portion of the Net Income before Taxes that is
over
7% but less than or equal to 10% of the total Revenues received with 50% to
the
HMO and 50% to HHSC.
(4)
HHSC
and the HMO will share that portion of the Net Income before Taxes that is
over
10% but less than or equal to 15% of the total Revenues received with 25% to
the
HMO and 75% to HHSC.
(5)
HHSC
will be paid the entire portion of the Net Income before Taxes that exceeds
15%
of the total Revenues.
(c)
Net
income before taxes.
(1)
The
HMO must compute the Net Income before Taxes in accordance with the HHSC
Uniform Managed Care Manual’s “Cost Principles for Administrative Expenses”
and“FSR Instructions for Completion” and applicable
federal regulations. The Net Income before Taxes will be confirmed by HHSC
or
its agent for the Rate Year relating to all revenues and expenses incurred
pursuant to the Contract. HHSC reserves the right to modify the “Cost
Principles for Administrative Expenses” and“FSR Instructions
for Completion” found in HHSC’s Uniform Managed Care
Manual in accordance with Section 8.05.
(2)
For
purposes of calculating Net Income before Taxes, the following items are not
Allowable Expenses:
(i)
the
payment of an Experience Rebate;
(ii)
any
interest expense associated with late or underpayment of the Experience
Rebate;
(iii)
financial incentives, including without limitation the Quality Challenge Award
described in Attachment B-1, Section 6.3.2.3; and
(iv)
financial disincentives, including without limitation: the Performance-based
Capitation Rate described in Attachment B-1, Section 6.3.2.2; and the liquidated
damages described in Attachment B-5.
(3)
Financial incentives are true net bonuses and shall not be reduced by the
potential increased Experience Rebate payments. Financial
disincentives are true net disincentives, and shall not be offset in whole
or
part by potential decreases in Experience Rebate payments.
(4)
For
FSR reporting purposes, financial incentives incurred shall not be reported
as
an increase in Revenues or as an offset to costs, and any award of such will
not
increase reported income. Financial disincentives incurred shall not
be included as reported expenses, and shall not reduce reported
income. The reporting or recording of any of these incurred items
will be done on a memo basis, which is below the income line, and will be listed
as separate items.
(d)
Carry
forward of prior Rate Year losses. Losses incurred by a STAR, CHIP, or CHIP
Perinatal HMO for one Rate Year may be carried forward to the next Rate Year,
and applied as an offset against a STAR, CHIP, or CHIP Perinatal Experience
Rebate. Prior losses may be carried forward for only one Rate Year for this
purpose. If the HMO offsets a loss against another STAR, CHIP, or
CHIP Perinatal Service Area, only that portion of the loss
that
was not used as an offset may be carried forward to the next Rate Year. Losses
incurred by a STAR,
CHIP, CHIP Perinatal HMO cannot be offset against the STAR+PLUS
Program.
(e)
Settlements for payment.
(1)
There
will be at least two
settlements for HMO payment(s) of the State share of the Experience Rebate
for
the STAR, CHIP, and CHIP Perinatal Programs. The first scheduled settlement
shall equal 100% of the State share of the Experience Rebate as derived from
the
FSR, and shall be paid on the same day the 90-day FSR Report is submitted to
HHSC, accompanied by an actuarial opinion certifying the reserve.
(2)
The
second scheduled settlement shall be an adjustment to the first settlement
and
shall be paid by the HMO to HHSC on the same day that the 334-day FSR Report
is
submitted to HHSC if the adjustment is a payment from the HMO to
HHSC.
(3)
HHSC
or its agent may audit or review the FSRs. If HHSC determines that corrections
to the FSRs are required, based on an HHSC audit/review or other documentation
acceptable to HHSC, to determine an adjustment to the amount of the second
settlement, then final adjustment shall be made by HHSC within three years
from
the date that the HMO submits the 334-day FSR. Any settlement payment
resulting from an audit or final adjustment shall be due from the HMO within
30
days of the earlier of:
(i)
the
date of the management representation letter resulting from the audit;
or
(ii)
the
date of any invoice issued by HHSC. Payment within the 30-day timeframe will
not
relieve
the HMO of any interest payment obligation that may exist under Section
10.11(f).
(4)
HHSC
may offset any Experience Rebates and/or corresponding interest payments owed
to
the State from any future Capitation Payments, or collect such sums directly
from the HMO. HHSC must receive the settlements by their due dates or HHSC
will
assess interest on the amounts due at the current prime interest rate as set
forth below. HHSC may adjust the Experience Rebate if HHSC determines the HMO
has paid amounts for goods or services that are not reasonable, necessary,
and
allowable in accordance with the HHSC Uniform Managed Care Manual’s
“Cost Principles for Administrative Expenses” and“FSR
Instructions for Completion” and applicable federal regulations. HHSC
has final authority in auditing and determining the amount of the Experience
Rebate.
(f)
Interest on Experience Rebate.
(1)
Interest on any Experience Rebate owed to HHSC shall be charged beginning thirty
(30) days after the due date for each settlement, as described in Section
10.11(e). In addition, if any adjusted amount is owed to HHSC at the
final settlement date, then interest will be charged on the adjusted amount
owed
beginning
thirty (30) days after the second settlement date to the date of the final
settlement payment. HHSC will calculate interest at the Department of
Treasury’s Median Rate (resulting from the Treasury’s auction of 13-week bills)
for the week in which the liability is assessed.
(2)
If an
audit or adjustment determines a downward revision of income after an interest
payment has previously been required for the same State Fiscal Year, then HHSC
will recalculate the interest and, if necessary, issue a full or partial refund
or credit to the HMO.
(3)
Any
interest obligations that are incurred pursuant to Section 10.11 that are not
timely paid will be subject to accumulation of interest as well, at the same
rate as applicable to the underlying Experience Rebate.
(4)
All
interest assessed pursuant to Section 10.11
will continue to accrue until such point as a payment is received by HHSC,
at
which point interest on the amount received will stop accruing. If a
balance remains at that point that is subject to interest, then the balance
shall continue to accrue interest. If interim payments are made, such as between
the first and second settlements, then any interest that may be due will only
be
charged on amounts for the time period during which they remained
unpaid. By way of example only, if $100,000 is subject to interest
commencing on a given day, and a payment is received for $75,000 35 days after
the start of interest, then the $75,000 will be subject to 35 days of interest,
and the $25,000 balance will continue to accrue interest until
paid.
Section
10.11.1 STAR+PLUS Experience Rebate
(a)
HMO’s
duty to pay. At the end of each Rate Year beginning with Rate Year 1, the HMO
must pay an Experience Rebate to HHSC for the STAR+PLUS Program if the HMO
produces a positive Net Income in STAR+PLUS. The STAR+PLUS Experience Rebate
is
calculated in accordance with the tiered rebate method set forth below based
on
the consolidated Net Income before Taxes for all of the HMO’s STAR+PLUS Service
Areas included within the scope of the Contract, as measured by any positive
amount on
the
Financial-Statistical Report (FSR) as reviewed and confirmed by
HHSC.
(b)
Graduated STAR+PLUS Experience Rebate Sharing Method.
Experience
Rebate as a % of Revenues
|
HMO
Share
|
HHSC
Share
|
<
3%
|
50%
|
50%
|
>
3%
|
75%
|
25%
|
HHSC
and
the HMO will share the Net Income before Taxes for the STAR+PLUS Program as
follows,
unless HHSC provides the HMO an Experience Rebate Reward in accordance with
Section 6 of Attachment B-1 to the HHSC Managed Care
Contract document and HHSC’s Uniform Managed Care
Manual:
(1)
HHSC
and the STAR+PLUS HMO will share that portion of the Net Income before Taxes
that is equal to or less than 3% of the total STAR+PLUS Revenues received with
50% to the HMO and 50% to HHSC.
(2)
HHSC
and the STAR+PLUS HMO will share that portion of the Net Income before Taxes
that is over 3% of the total STAR+PLUS Revenues received with 75% to the HMO
and
25% to HHSC.
(c)
Net
income before taxes. 1) The HMO must compute the Net Income before Taxes in
accordance with the HHSC Uniform Managed Care Manual’s “Cost Principles
for Administrative Expenses” and“FSR Instructions for
Completion” and applicable federal regulations. The Net Income before
Taxes will be confirmed by HHSC or its agent for the Rate Year relating to
all
revenues
and expenses incurred pursuant to the Contract. HHSC reserves the right to
modify the “Cost
Principles for Administrative Expenses” and“FSR Instructions
for Completion” found in HHSC’s Uniform Managed Care
Manual in accordance with Section 8.05.
(2)
For
purposes of calculating Net Income before Taxes, the following items are not
Allowable Expenses:
(i)
the
payment of an Experience Rebate;
(ii)
any
interest expense associated with late or underpayment of the Experience
Rebate;
(iii)
financial incentives, including without limitation the Quality Challenge Award
described in Attachment B-1, Section 6.3.2.3, and the STAR+PLUS Hospital
Inpatient Incentive Shared Savings Award described in Attachment B-1, Section
6.3.2.5.2; and
(iv)
financial disincentives, including without limitation: the Performance-based
Capitation Rate described in Attachment B-1, Section 6.3.2.2; the STAR+PLUS
Hospital Inpatient Disincentive Administrative Fee at Risk described in
Attachment B-1, Section 6.3.2.5.1; and the liquidated damages described in
Attachment B-5.
(3)
Financial incentives are true net bonuses and shall not be reduced by the
potential increased Experience Rebate payments. Financial
disincentives are true net disincentives, and shall not be offset in whole
or
part by potential decreases in Experience Rebate payments.
(4)
For
FSR reporting purposes, financial incentives incurred shall not be reported
as
an increase
in Revenues or as an offset to costs, and any award of such will not increase
reported income. Financial disincentives incurred shall not be
included as reported expenses, and shall not reduce reported
income. The reporting or recording of any of these incurred items
will be done on a memo basis, which is below the income line, and will be listed
as separate items.
(d)
Carry
forward of prior Rate Year losses. Losses incurred by a STAR+PLUS HMO for one
Rate Year may be carried forward to the next Rate Year, and applied as an offset
against a STAR+PLUS Experience Rebate. Prior losses may be carried
forward for only one Rate Year for this purpose. If the HMO offsets a
loss against another STAR+PLUS Service Area, only that portion of the loss
that
was not used as an offset may be carried forward to the next Rate
Year. Losses incurred by a STAR+PLUS HMO cannot be offset against the STAR
or
CHIP Programs.
(e)
Settlements for payment.
(1)
There
will be at least two settlements for HMO payment(s) of the State share of the
Experience Rebate for the STAR, CHIP, and CHIP Perinatal Programs. The first
scheduled settlement shall equal 100% of the State share of the Experience
Rebate as derived from the FSR, and shall be paid on the same day the 90-day
FSR
Report is submitted to HHSC, accompanied by an actuarial opinion certifying
the
reserve.
(2)
The
second scheduled settlement shall be an adjustment to the first settlement
and
shall be paid by the HMO to HHSC on the same day that the 334-day FSR Report
is
submitted to HHSC if the adjustment is a payment from the HMO to
HHSC.
(3)
HHSC
or its agent may audit or review the FSRs. If HHSC determines that corrections
to the FSRs are required, based on an HHSC audit/review or other documentation
acceptable to HHSC, to determine an adjustment to the amount of the second
settlement, then final adjustment shall be made by HHSC within three years
from
the date that the HMO submits the 334-day FSR. Any settlement payment
resulting from an audit or final adjustment shall be due from the HMO within
30
days of the earlier of:
(i)
the
date of the management representation letter resulting from the audit;
or
(ii)
the
date of any invoice issued by HHSC. Payment within the 30-day timeframe will
not
relieve
the HMO of any interest payment obligation that may exist under Section
10.11.1(f).
(4)
HHSC
may offset any Experience Rebates and/or corresponding interest payments owed
to
the State from any future Capitation Payments, or collect such sums directly
from the HMO. HHSC must receive settlements by their due dates or
HHSC will assess interest on the amounts due at the current prime
interest rate as set forth below. HHSC may adjust the Experience Rebate if
HHSC
determines the HMO has paid amounts for goods or services that are not
reasonable, necessary, and allowable in accordance with the HHSC Uniform
Managed Care Manual’s “Cost Principles for Administrative Expenses”
and“FSR Instructions for Completion” and applicable
federal regulations. HHSC has final authority in auditing and determining the
amount of the Experience Rebate.
(f)
Interest on Experience Rebate.
(1)
Interest on any Experience Rebate owed to HHSC shall be charged beginning thirty
(30) days after the due date for each settlement, as described in Section
10.11.1(e). In addition, if any adjusted amount is owed to HHSC at
the final settlement date, then interest will be charged on the adjusted amount
owed beginning thirty (30) days after the second settlement date to the date
of
the final settlement payment. HHSC will calculate interest at the
Department of Treasury’s Median Rate (resulting from the Treasury’s auction of
13-week bills) for the week in which the liability is assessed.
(2)
If an
audit or adjustment determines a downward revision of income after an interest
payment has previously been required for the same State Fiscal Year, then HHSC
will recalculate the interest and, if necessary, issue a full or partial refund
or credit to the HMO.
(3)
Any
interest obligations that are incurred pursuant to Section 10.11.1 that are
not
timely paid will be subject to accumulation of interest as well, at the same
rate as applicable to the underlying Experience Rebate.
(4)
All
interest assessed pursuant to Section 10.11.1
will continue to accrue until such point as a payment is received by HHSC,
at
which point interest on the amount received will stop accruing. If a
balance remains at that point that is subject to interest, then the balance
shall continue to accrue interest. If interim payments are made, such as between
the first and second settlements, then any interest that may be due will only
be
charged on amounts for the time period during which they remained
unpaid. By way of example only, if $100,000 is subject to interest
commencing on a given day, and a payment is received for $75,000 35 days after
the start of interest, then the $75,000 will be subject to 35 days of interest,
and the $25,000 balance will continue to accrue interest until
paid.
Section
10.12 Payment by Members.
(a)
Medicaid HMOs Medicaid HMOs and their Network Providers are prohibited from
billing or collecting any amount from a Member
for Health Care Services covered by this Contract. HMO must inform Members
of
costs for
non-covered
services, and must require its Network Providers to:
(1)
inform Members of costs for non-covered services prior to rendering such
services; and
(2)
obtain a signed Private Pay form from such Members.
(1)
Families that meet the enrollment period cost share limit requirement must
report it to the HHSC Administrative Services Contractor. The HHSC
Administrative Service Contractor notifies the HMO that a family’s cost share
limit has been reached. Upon notification from the HHSC Administrative Services
Contractor that a family has reached its cost-sharing limit for the term of
coverage, the HMO will generate and mail to the CHIP Member a new Member ID
card
within five days, showing that the CHIP Member’s cost-sharing obligation for
that term of coverage has been met. No cost-sharing may be collected
from these CHIP Members for the balance of their term of coverage.
(2)
Providers are responsible for collecting all CHIP Member co-payments at the
time
of service. Co-payments that families must pay vary according to their income
level. No co-payments apply, at any income level, to well-child or well-baby
visits or immunizations. Except for costs associated with unauthorized
non-emergency services provided to a Member by Out-of-Network providers and
for
non-covered services, the co-payments outlined in the CHIP Cost Sharing table
in
the HHSC Uniform Managed Care Manual are the only amounts that
a provider may collect from a CHIP-eligible family.
(3)
Federal law prohibits charging cost-sharing or deductibles to CHIP Members
of
Native Americans or Alaskan Natives. The HHSC Administrative Services Contractor
will notify the HMO of CHIP Members who are not subject to cost-sharing
requirements. The HMO is responsible for educating Providers
regarding the cost-sharing waiver for this population.
(4)
An
HMO’s monthly Capitation Payment will not be reduced for a family’s failure to
make its CHIP premium payment. There is no relationship between the
per Member/per month amount owed to the HMO for coverage provided during a
month
and the family’s payment of its CHIP premium obligation for that
month.
(c)
CHIP
Perinatal HMOs Cost-sharing does not apply to CHIP Perinatal Program
Members. The exemption from cost-sharing applies
through the end of the original 12-month enrollment period.
Section
10.13 Restriction on assignment of fees.
During
the term of the Contract, HMO may not, directly or indirectly, assign to any
third party any beneficial or legal interest of the HMO in or to
any
payments
to be made by HHSC pursuant to this Contract. This restriction does not apply
to
fees paid to Subcontractors.
Section
10.14 Liability for taxes.
HHSC
is
not responsible in any way for the payment of any Federal, state or local taxes
related to or incurred in connection with the HMO’s performance of this
Contract. HMO must pay and discharge any and all such taxes, including any
penalties and interest. In addition, HHSC is exempt from Federal excise taxes,
and will not pay any personal property taxes or income taxes levied on HMO
or
any taxes levied on employee wages.
Section
10.15 Liability for employment-related charges and
benefits.
HMO
will
perform work under this Contract as an independent contractor and not as agent
or representative of HHSC. HMO is solely and exclusively liable for payment
of
all employment-related charges incurred in connection with the performance
of
this Contract, including but not limited to salaries, benefits, employment
taxes, workers compensation benefits, unemployment insurance and benefits,
and
other insurance or fringe benefits for Staff.
Section
10.16 No additional consideration.
(a)
HMO
will not be entitled to nor receive from HHSC any additional consideration,
compensation, salary, wages, charges, fees, costs, or any other type of
remuneration for Services and Deliverables provided under the Contract, except
by properly authorized and executed Contract amendments.
(b)
No
other charges for tasks, functions, or activities that are incidental or
ancillary to the delivery of the Services and Deliverables will be sought from
HHSC or any other state agency, nor will the failure of HHSC or any other party
to pay for such incidental or ancillary services entitle the HMO to withhold
Services and Deliverables due under the Agreement.
(c)
HMO
will not be entitled by virtue of the Contract to consideration in the form
of
overtime, health insurance benefits, retirement benefits, disability retirement
benefits, sick leave, vacation time, paid holidays, or other paid leaves of
absence of any type or kind whatsoever.
Section
10.17 Federal Disallowance
If
the
federal government recoups money from the state for expenses and/or costs that
are deemed unallowable by the federal government, the state has the right to,
in
turn, recoup payments made to the HMOs for these same expenses and/or costs,
even if they had not been previously disallowed by the state and were incurred
by the HMO, and any such expenses and/or costs would then be deemed unallowable
by the state. If the state retroactively recoups money from the HMOs
due to a federal
disallowance,
the state will recoup the entire amount paid to the HMO for the federally
disallowed expenses and/or costs, not just the federal portion.
Section
10.18 Required Pass Through of Physician Rate
Increases
(a)
Effective September 1, 2007, all HMOs participating in the STAR, STAR+PLUS,
CHIP
and CHIP Perinatal Programs are required to adjust their physician fee schedules
to reflect the physician rate increases funded through Legislative
Appropriations during the 80th Regular
Legislative Session. The HMOs are required to pass on all
appropriated targeted physician rate increases to physicians serving their
Members.
(b)
The
Medicaid Fee Schedule in effect on September 1, 2007 (the “updated Medicaid Fee
Schedule”) will include the legislatively-mandated physician rate increases
based on the age of the Member, under 21 and over 21. The HMO must pay the
appropriate rate for the age of the Member on the date of service.
(c)
If,
under the terms of a Network Provider contract in place prior to September
1,
2007, the HMO pays for physician services based on the Medicaid Fee Schedule,
then the HMO must pay for physician services provided on or after September
1,
2007 based on the updated Medicaid Fee Schedule.
(d)
If,
under the terms of a Network Provider contract in place prior to September
1,
2007, the HMO pays for physician services based on a percentage of the Medicaid
Fee Schedule, then the HMO must pay for physician services provided on or after
September 1, 2007 based on the same percentage of the updated Medicaid Fee
Schedule. By way of example only, if prior to September 1, 2007, the
HMO paid for physician services at110% of the Medicaid Fee Schedule, then the
HMO will pay for physician services provided on or after September 1, 2007
at
110% of the updated Medicaid Fee Schedule.
(e)
If,
under the terms of a Network Provider contract in place prior to September
1,
2007, the HMO uses benchmarks other than the Medicaid Fee Schedule (e.g. rates
that are a percentage of Medicare) to pay for physician services, then for
physician services provided on or after September 1, 2007, the HMO must increase
its rates by 25% for services to Members under 21 and by 10% for Members age
21
and over. The HMO must provide HHSC with a copy of both the prior and
new Network Provider agreements and demonstrate how the new rates are 125%
or
110%, depending on the age of the Member, of the former rates.
(f)
The
HMO’s Chief Executive Officer will attest that the HMO has appropriately
increased physician reimbursements as required above. HHSC will
perform
sample audits to verify payments to physicians are in accordance with this
Contract requirement.
(a)
HMO
and all Subcontractors, consultants, or agents under the Contract must treat
all
information that is obtained through performance of the Services under the
Contract, including, but not limited to, information relating to applicants
or
recipients of HHSC Programs as Confidential Information to the extent that
confidential treatment is provided under law and regulations.
(b)
HMO
is responsible for understanding the degree to which information obtained
through performance of this Contract is confidential under State and Federal
law, regulations, or administrative rules.
(c)
HMO
and all Subcontractors, consultants, or agents under the Contract may not use
any information obtained through performance of this Contract in any manner
except as is necessary for the proper discharge of obligations and securing
of
rights under the Contract.
(d)
HMO
must have a system in effect to protect all records and all other documents
deemed confidential under this Contract maintained in connection with the
activities funded under the Contract. Any disclosure or transfer of Confidential
Information by HMO, including information required by HHSC, will be in
accordance with applicable law. If the HMO receives a request for information
deemed confidential under this Contract, the HMO will immediately notify HHSC
of
such request, and will make reasonable efforts to protect the information from
public disclosure.
(e)
In
addition to the requirements expressly stated in this Section, HMO must comply
with any policy, rule, or reasonable requirement of HHSC that relates to the
safeguarding or disclosure of information relating to Members, HMO’S operations,
or HMO’s performance of the Contract.
(f)
In
the event of the expiration of the Contract or termination of the Contract
for
any reason, all Confidential Information disclosed to and all copies thereof
made by the HMOI shall be returned to HHSC or, at HHSC’s option, erased or
destroyed. HMO shall provide HHSC certificates evidencing such
destruction.
(g)
The
obligations in this Section shall not restrict any disclosure by the HMO
pursuant to any applicable law, or by order of any court or government agency,
provided that the HMO shall give prompt notice to HHSC of such
order.
(h)
With
the exception of confidential Member information, Confidential Information
shall
not be afforded the protection of the Contract if such data was:
(1)
Already known to the receiving Party without restrictions at the time of its
disclosure by the furnishing Party;
(2)
Independently developed by the receiving Party without reference to the
furnishing Party’s Confidential Information;
(3)
Rightfully obtained by the other Party without restriction from a third party
after its disclosure by the furnishing Party;
(4)
Publicly available other than through the fault or negligence of the other
Party; or
(5)
Lawfully released without restriction to anyone.
Section
11.02 Disclosure of HHSC’s Confidential
Information.
(a)
HMO
will immediately report to HHSC any and all unauthorized disclosures or uses
of
HHSC’s Confidential Information of which it or its Subcontractor(s),
consultant(s), or agent(s) is aware or has knowledge. HMO
acknowledges that any publication or disclosure of HHSC’s Confidential
Information to others may cause immediate and irreparable harm to HHSC and
may
constitute a violation of State or federal laws. If HMO, its
Subcontractor(s), consultant(s), or agent(s) should publish or disclose such
Confidential Information to others without authorization, HHSC will immediately
be entitled to injunctive relief or any other remedies to which it is entitled
under law or equity. HHSC will have the right to recover from HMO all
damages and liabilities caused by or arising from HMO’s, its Subcontractors’,
consultants’, or agents’ failure to protect HHSC’s Confidential
Information. HMO will defend with counsel approved by HHSC, indemnify
and hold harmless HHSC from all damages, costs, liabilities, and expenses
(including without limitation reasonable attorneys’ fees and costs) caused by or
arising from HMO’s or its Subcontractors’, consultants’ or agents’ failure to
protect HHSC’s Confidential Information. HHSC will not unreasonably
withhold approval of counsel selected by the HMO.
(b)
HMO
will require its Subcontractor(s), consultant(s), and agent(s) to comply with
the terms of this provision.
Section
11.03 Member Records
(a)
HMO
must comply with the requirements of state and federal laws, including the
HIPAA
requirements set forth in Section 7.07, regarding the transfer
of Member Records.
(b)
If at
any time during the Contract Term this Contract is terminated, HHSC may require
the transfer of Member Records, upon written notice to HMO,
to
another entity, as consistent with federal and state laws and applicable
releases.
(c)
The
term “Member Record” for this Section means only those administrative,
enrollment, case management and other such records maintained by HMO and is
not
intended to include patient records maintained by participating Network
Providers.
Section
11.04 Requests for public information.
(a)
HHSC
agrees that it will promptly notify HMO of a request for disclosure of
information filed in accordance with the Texas Public Information Act, Chapter
552 of the Texas Government Code, that consists of the HMO’S confidential
information, including without limitation, information or data to which HMO
has
a proprietary or commercial interest. HHSC will deliver a copy of the
request for public information to HMO.
(b)
With
respect to any information that is the subject of a request for disclosure,
HMO
is required to demonstrate to the Texas Office of Attorney General the specific
reasons why the requested information is confidential or otherwise excepted
from
required public disclosure under law. HMO will provide HHSC with
copies of all such communications.
(c)
To
the extent authorized under the Texas Public Information Act, HHSC agrees to
safeguard from disclosure information received from HMO that the HMO believes
to
be confidential information. HMO must clearly xxxx such information
as confidential information or provide written notice to HHSC that it considers
the information confidential.
Section
11.05 Privileged Work Product.
(a)
HMO
acknowledges that HHSC asserts that privileged work product may be prepared
in
anticipation of litigation and that HMO is performing the Services with respect
to privileged work product as an agent of HHSC, and that all matters related
thereto are protected from disclosure by the Texas Rules of Civil Procedure,
Texas Rules of Evidence, Federal Rules of Civil Procedure, or Federal Rules
of
Evidence.
(b)
HHSC
will notify HMO of any privileged work product to which HMO has or may have
access. After the HMO is notified or otherwise becomes aware that
such documents, data, database, or communications are privileged work product,
only HMO personnel, for whom such access is necessary for the purposes of
providing the Services, may have access to privileged work product.
(c)
If
HMO receives notice of any judicial or other proceeding seeking to obtain access
to HHSC’s privileged work product, HMO will:
(1)
Immediately notify HHSC; and
(2)
Use
all reasonable efforts to resist providing such access.
(d)
If
HMO resists disclosure of HHSC’s privileged work product in accordance with this
Section, HHSC will, to the extent authorized under Civil Practices and Remedies
Code or other applicable State law, have the right and duty to:
(1)
represent HMO in such resistance;
(2)
to
retain counsel to represent HMO; or
(3)
to
reimburse HMO for reasonable attorneys' fees and expenses incurred in resisting
such access.
(e)
If a
court of competent jurisdiction orders HMO to produce documents, disclose data,
or otherwise breach the confidentiality obligations imposed in the Contract,
or
otherwise with respect to maintaining the confidentiality, proprietary nature,
and secrecy of privileged work product, HMO will not be liable for breach of
such obligation.
Section
11.06 Unauthorized acts.
Each
Party agrees to:
(1)
Notify the other Party promptly of any unauthorized possession, use, or
knowledge, or attempt thereof, by any person or entity that may become known
to
it, of any HHSC Confidential Information or any information identified by the
HMO as confidential or proprietary;
(2)
Promptly furnish to the other Party full details of the unauthorized possession,
use, or knowledge, or attempt thereof, and use reasonable efforts to assist
the
other Party in investigating or preventing the reoccurrence of any unauthorized
possession, use, or knowledge, or attempt thereof, of Confidential
Information;
(3)
Cooperate with the other Party in any litigation and investigation against
third
Parties deemed necessary by such Party to protect its proprietary rights;
and
(4)
Promptly prevent a reoccurrence of any such unauthorized possession, use, or
knowledge such information.
Section
11.07 Legal action.
Neither
party may commence any legal action or proceeding in respect to any unauthorized
possession, use, or knowledge, or attempt thereof by any person or entity of
HHSC’s Confidential Information or information identified by the HMO as
confidential or proprietary, which action or proceeding identifies the other
Party such information without such Party’s consent.
Section
12.01 Understanding and expectations.
The
remedies described in this Section are directed to HMO’s timely and responsive
performance of the Services and production of Deliverables, and the creation
of
a flexible and responsive relationship
between
the Parties. The HMO is expected to meet or exceed all HHSC
objectives and standards, as set forth in the Contract. All areas of
responsibility and all Contract requirements will be subject to performance
evaluation by HHSC. Performance reviews may be conducted at the
discretion of HHSC at any time and may relate to any responsibility and/or
requirement. Any and all responsibilities and/or requirements not
fulfilled may be subject to remedies set forth in the Contract.
Section
12.02 Tailored remedies.
(a)
Understanding of the Parties. HMO agrees and understands that HHSC may pursue
tailored contractual remedies for noncompliance with the Contract. At
any time and at its discretion, HHSC may impose or pursue one or more remedies
for each item of noncompliance and will determine remedies on a case-by-case
basis. HHSC’s pursuit or non-pursuit of a tailored
remedy
does
not
constitute a waiver of any other remedy that HHSC may have at law or
equity.
(b)
Notice and opportunity to cure for non-material breach.
(1)
HHSC
will notify HMO in writing of specific areas of HMO performance that fail to
meet performance expectations, standards, or schedules set forth in the
Contract, but that, in the determination of HHSC, do not result in a material
deficiency or delay in the implementation or operation of the
Services.
(2)
HMO
will, within five (5) Business Days (or another date approved by HHSC) of
receipt of written notice of a non-material deficiency, provide the HHSC Project
Manager a written response that:
(A)
Explains the reasons for the deficiency, HMO’s plan to address or cure the
deficiency, and the date and time by which the deficiency will be cured;
or
(B)
If
HMO disagrees with HHSC’s findings, its reasons for disagreeing with HHSC’s
findings.
(3)
HMO’s
proposed cure of a non-material deficiency is subject to the approval of HHSC.
HMO’s repeated commission of non-material deficiencies or repeated failure to
resolve any such deficiencies may be regarded by HHSC as a material deficiency
and entitle HHSC to pursue any other remedy provided in the Contract or any
other appropriate remedy HHSC may have at law or equity.
(c)
Corrective action plan.
(1)
At
its option, HHSC may require HMO to submit to HHSC a written plan (the
“Corrective Action Plan”) to correct or resolve a material breach of this
Contract, as determined by HHSC.
(2)
The
Corrective Action Plan must provide:
(A)
A
detailed explanation of the reasons for the cited deficiency;
(B)
HMO’s
assessment or diagnosis of the cause; and
(C)
A
specific proposal to cure or resolve the deficiency.
(3)
The
Corrective Action Plan must be submitted by the deadline set forth in HHSC’s
request for a Corrective Action Plan. The Corrective Action Plan is
subject to approval by HHSC, which will not unreasonably be
withheld.
(4)
HHSC
will notify HMO in writing of HHSC’s final disposition of HHSC’s
concerns. If HHSC accepts HMO’s proposed Corrective Action Plan, HHSC
may:
(A)
Condition such approval on completion of tasks in the order or priority that
HHSC may reasonably prescribe;
(B)
Disapprove portions of HMO’s proposed Corrective Action Plan; or
(C)
Require additional or different corrective action(s).
Notwithstanding
the submission and acceptance of a Corrective Action Plan, HMO remains
responsible for achieving all written performance criteria.
(5)
HHSC’s acceptance of a Corrective Action Plan under this Section will
not:
(A)
Excuse HMO’s prior substandard performance;
(B)
Relieve HMO of its duty to comply with performance standards; or
(C)
Prohibit HHSC from assessing additional tailored remedies or pursuing other
appropriate remedies for continued substandard performance.
(1)
At
its discretion, HHSC may impose one or more of the following remedies for each
item of material noncompliance and will determine the scope and severity of
the
remedy on a case-by-case basis:
(A)
Assess liquidated damages in accordance with Attachment B-5 to
the HHSC Managed Care Contract, “Liquidated Damages
Matrix;”
(B)
Conduct accelerated monitoring of the HMO. Accelerated monitoring includes
more
frequent or more extensive monitoring by HHSC or its agent;
(C)
Require additional, more detailed, financial and/or programmatic reports to
be
submitted by HMO;
(D)
Decline to renew or extend the Contract;
(E)
Appoint temporary management;
(F)
Initiate disenrollment of a Member or Members;
(G)
Suspend enrollment of Members;
(H)
Withhold or recoup payment to HMO;
(I)
Require forfeiture of all or part of the HMO’s bond; or
(J)
Terminate the Contract in accordance with Section 12.03,
(“Termination by HHSC”).
(2)
For
purposes of the Contract, an item of material noncompliance means a specific
action of HMO that:
(A)
Violates a material provision of the Contract;
(B)
Fails
to meet an agreed measure of performance; or
(C)
Represents a failure of HMO to be reasonably responsive to a reasonable request
of HHSC relating to the Services for information, assistance, or support within
the timeframe specified by HHSC.
(3)
HHSC
will provide notice to HMO of the imposition of an administrative remedy in
accordance with this Section, with the exception of accelerated monitoring,
which may be unannounced. HHSC may require HMO to file a written
response in accordance with this Section.
(4)
The
Parties agree that a State or Federal statute, rule, regulation, or Federal
guideline will prevail over the provisions of this Section unless the statute,
rule, regulation, or guidelines can be read together with this Section to give
effect to both.
(e)
Damages.
(1)
HHSC
will be entitled to actual and consequential damages resulting from the HMO’S
failure to comply with any of the terms of the Contract. In some
cases, the actual damage to HHSC or State of Texas as a result of HMO’S failure
to meet any aspect of the responsibilities of the Contract and/or to meet
specific performance standards set forth in the Contract are difficult or
impossible to determine with precise accuracy. Therefore, liquidated
damages will be assessed in writing against and paid by the HMO in accordance
with and for failure to meet any aspect of the responsibilities of the Contract
and/or to meet the specific performance standards identified by the HHSC in
Attachment B-5 to the HHSC Managed Care Contract,
“Deliverables/Liquidated Damages Matrix.” Liquidated damages will be
assessed if HHSC determines such failure is the fault of the HMO (including
the
HMO’S Subcontractors and/or consultants) and is not materially caused or
contributed to by HHSC or its agents. If at any time,
HHSC
determines the HMO has not met any aspect of the responsibilities of the
Contract and/or the specific performance standards due to mitigating
circumstances, HHSC reserves the right to waive all or part of the liquidated
damages. All such waivers must be in writing, contain the reasons for
the waiver, and be signed by the appropriate executive of HHSC.
(2)
The
liquidated damages prescribed in this Section are not intended to be in the
nature of a penalty, but are intended to be reasonable estimates of HHSC’s
projected financial loss and damage resulting from the HMO’s nonperformance,
including financial loss as a result of project delays. Accordingly,
in the event HMO fails to perform in accordance with the Contract, HHSC may
assess liquidated damages as provided in this Section.
(3)
If
HMO fails to perform any of the Services described in the Contract, HHSC may
assess liquidated damages for each occurrence of a liquidated damages event,
to
the extent consistent with HHSC's tailored approach to remedies and Texas
law.
(4)
HHSC
may elect to collect liquidated damages:
(A)
Through direct assessment and demand for payment delivered to HMO;
or
(B)
By
deduction of amounts assessed as liquidated damages as set-off against payments
then due to HMO or that become due at any time after assessment of the
liquidated damages. HHSC will make deductions until the full amount payable
by
the HMO is received by HHSC.
(f)
Equitable Remedies
(1)
HMO
acknowledges that, if HMO breaches (or attempts or threatens to breach) its
material obligation under this Contract, HHSC may be irreparably
harmed. In such a circumstance, HHSC may proceed directly to court to
pursue equitable remedies.
(2)
If a
court of competent jurisdiction finds that HMO breached (or attempted or
threatened to breach) any such obligations, HMO agrees that without any
additional findings of irreparable injury or other conditions to injunctive
relief, it will not oppose the entry of an appropriate order compelling
performance by HMO and restraining it from any further breaches (or attempted
or
threatened breaches).
(g)
Suspension of Contract
(1)
HHSC
may suspend performance of all or any part of the Contract if:
(A)
HHSC
determines that HMO has committed a material breach of the
Contract;
(B)
HHSC
has reason to believe that HMO has committed, assisted in the commission of
Fraud, Abuse, Waste, malfeasance,
misfeasance, or nonfeasance by any party concerning the Contract;
(C)
HHSC
determines that the HMO knew, or should have known of, Fraud, Abuse, Waste,
malfeasance, or nonfeasance by any party concerning the Contract, and the HMO
failed to take appropriate action; or
(D)
HHSC
determines that suspension of the Contract in whole or in part is in the best
interests of the State of Texas or the HHSC Programs.
(2)
HHSC
will notify HMO in writing of its intention to suspend the Contract in whole
or
in part. Such notice will:
(A)
Be
delivered in writing to HMO;
(B)
Include a concise description of the facts or matter leading to HHSC’s decision;
and
(C)
Unless HHSC is suspending the contract for convenience, request a Corrective
Action Plan from HMO or describe actions that HMO may take to avoid the
contemplated suspension of the Contract.
Section
12.03 Termination by HHSC.
This
Contract will terminate upon the Expiration Date. In addition, prior to
completion of the Contract Term, all or a part of this Contract may be
terminated for any of the following reasons:
(a)
Termination in the best interest of HHSC. HHSC may terminate the Contract
without cause at any time when, in its sole discretion, HHSC determines that
termination is in the best interests of the State of Texas. HHSC will
provide reasonable advance written notice of the termination, as it deems
appropriate under the circumstances. The
termination
will be effective on the date specified in HHSC’s notice of
termination.
(b)
Termination for cause. HHSC reserves the right to terminate this
Contract,
in whole or in part, upon the following conditions:
(1)
Assignment for the benefit of creditors,
appointment
of receiver, or inability to pay debts. HHSC may terminate this Contract at
any time if HMO:
(A)
Makes
an assignment for the benefit of its creditors;
(B)
Admits in writing its inability to pay its debts generally as they become due;
or
(C)
Consents to the appointment of a receiver, trustee, or liquidator of HMO or
of
all or any part of its property.
(2)
Failure to adhere to laws, rules, ordinances, or orders.HHSC
may
terminate this Contract if a court of competent jurisdiction finds HMO failed
to
adhere to any laws, ordinances, rules, regulations or orders of any public
authority having jurisdiction and such violation prevents or substantially
impairs performance of HMO’s duties under this Contract. HHSC will
provide at least thirty (30) days advance written notice of such
termination.
(3)
Breach of confidentiality. HHSC may terminate this Contract at any time
if HMO breaches confidentiality laws with respect
to the Services and Deliverables provided under this Contract.
(4)
Failure to maintain adequate personnel or resources.HHSC
may
terminate this Contract if, after providing notice and an opportunity to
correct, HHSC determines that HMO has failed to supply personnel or resources
and such failure results in HMO’s inability to fulfill its duties under this
Contract. HHSC will provide at least thirty (30) days advance written notice
of
such termination.
(5)
Termination for gifts and gratuities.
(A)
HHSC
may terminate this Contract at any time following the determination by a
competent judicial or quasi-judicial authority and HMO’s exhaustion of all legal
remedies that HMO, its employees, agents or representatives have either offered
or given any thing of value to an officer or employee of HHSC or the State
of
Texas in violation of state law.
(B)
HMO
must include a similar provision in each of its Subcontracts and shall enforce
this provision against a Subcontractor who has offered or given any thing of
value to any of the persons or entities described in this Section, whether
or
not the offer or gift was in HMO’s behalf.
(C)
Termination of a Subcontract by HMO pursuant to this provision will not be
a
cause for termination of the Contract unless:
(1)
HMO
fails to replace such terminated Subcontractor within a reasonable time;
and
(2)
Such
failure constitutes cause, as described in this Subsection
12.03(b).
(D)
For
purposes of this Section, a “thing of value” means any item of tangible or
intangible property that has a monetary value of more than $50.00 and includes,
but is not limited to, cash, food, lodging, entertainment,
and charitable contributions. The term does not include contributions
to holders of public office or candidates for public office that are paid and
reported in accordance with State and/or Federal law.
(6)
Termination for non-appropriation of funds. Notwithstanding any other
provision of this Contract, if funds for the continued fulfillment of this
Contract by HHSC are at any time not forthcoming or are insufficient, through
failure of any entity to appropriate funds or otherwise, then HHSC will have
the
right to terminate this Contract at no additional cost and with no penalty
whatsoever by giving prior written notice documenting the lack of
funding. HHSC will provide at least thirty (30) days advance written
notice of such termination. HHSC will use
reasonable efforts to ensure appropriated funds are available.
(7)
Judgment and execution.
(A)
HHSC
may terminate the Contract at any time if judgment for the payment of money
in
excess of $500,000.00 that is not covered by insurance, is rendered by any
court
or governmental body against HMO, and HMO does not:
(1)
Discharge the judgment or provide for its discharge in accordance with the
terms
of the judgment;
(2)
Procure a stay of execution of the judgment within thirty (30) days from the
date of entry thereof; or
(3)
Perfect an appeal of such judgment and cause the execution of such judgment
to
be stayed during the appeal, providing such financial reserves as may be
required under generally accepted accounting principles.
(B)
If a
writ or warrant of attachment or any similar process is issued by any court
against all or any material portion of the property of HMO, and such writ or
warrant of attachment or any similar process is not released or bonded within
thirty (30) days after its entry, HHSC may terminate the Contract in accordance
with this Section.
(8)
Termination for insolvency.
(A)
HHSC
may terminate the Contract at any time if HMO:
(1)
Files
for bankruptcy;
(2)
Becomes or is declared insolvent, or is the subject of any proceedings related
to its liquidation, insolvency, or the appointment of a receiver or similar
officer for it;
(3)
Makes
an assignment for the benefit of all or substantially all of its creditors;
or
(4)
Enters into an Contract for the composition, extension, or readjustment of
substantially all of its obligations.
(B)
HMO
agrees to pay for all reasonable expenses of HHSC including the cost of counsel,
incident to:
(1)
The
enforcement of payment of all obligations of the HMO by any action or
participation in, or in connection with a case or proceeding under Chapters
7,
11, or 13 of the United States Bankruptcy Code, or any successor
statute;
(2)
A
case or proceeding involving a receiver or other similar officer duly appointed
to handle the HMO's business; or
(3)
A
case or proceeding in a State court initiated by HHSC when previous collection
attempts have been unsuccessful.
(9)
Termination for HMO’S material breach of the Contract. HHSC
will
have the right to terminate the Contract in whole or in part if HHSC determines,
at its sole discretion, that HMO has materially breached the
Contract. HHSC will provide at least thirty (30) days advance written
notice of such termination.
Section
12.04 Termination by HMO.
(a)
Failure to pay. HMO may terminate this Contract if HHSC fails to pay the HMO
undisputed charges when due as required under this
Contract. Retaining premium, recoupment, sanctions, or penalties that
are allowed under this Contract or that result from the HMO’s failure to perform
or the HMO’s default under the terms of this Contract is not cause for
termination. Termination for failure to pay does not release HHSC
from the obligation to pay undisputed charges for services provided prior to
the
termination date. If HHSC fails to pay undisputed charges when due, then the
HMO
may submit a notice of intent to terminate for failure to pay in accordance
with
the requirements of Subsection 12.04(d). If HHSC pays all
undisputed amounts then due within thirty (30)days after receiving the
notice of intent to terminate,
the
HMO
cannot proceed with termination of the Contract under this Article.
(b)
Change to HHSC Uniform Managed Care Manual. HMO
may
terminate this agreement if the Parties are unable to resolve a dispute
concerning a material and substantive change to the HHSC Uniform Managed Care
Manual (a change that materially and substantively alters the HMO’s ability to
fulfill its obligations
under the Contract). HMO must submit a notice of intent to terminate
due to a material and substantive change in the HHSC Uniform Managed Care Manual
no later than thirty (30) days after the effective date of the policy
change. HHSC will not enforce the policy change during the period of
time between the receipt of the notice of intent to terminate and the effective
date of termination.
(c)
Change to Capitation Rate. If HHSC proposes a modification to the Capitation
Rate that is unacceptable to the HMO, the HMO may terminate the
Contract. HMO must submit a written notice of intent to terminate due
to a change in the Capitation Rate no later than thirty (30) days after HHSC’s
notice of the proposed change. HHSC will not enforce the rate change during
the
period of time
between the receipt of the notice of intent to terminate and the effective
date
of termination.
(d)
Notice of intent to terminate. In
order
to terminate the Contract pursuant to this Section, HMO must give HHSC at least
ninety (90)
days
written notice of intent to terminate. The termination date will be
calculated as the last day of the month following ninety (90) days from the
date
the notice of intent to terminate is received by HHSC.
Section
12.05 Termination by mutual agreement.
This
Contract may be terminated by mutual written agreement of the
Parties.
Section
12.06 Effective date of termination.
Except
as
otherwise provided in this Contract, termination will be effective as of the
date specified in the notice of termination.
Section
12.07 Extension of termination effective
date.
The
Parties may extend the effective date of termination one or more times by mutual
written agreement.
Section
12.08 Payment and other provisions at Contract
termination.
(a)
In
the event of termination pursuant to this Article, HHSC will pay the Capitation
Payment for Services and Deliverables rendered through the effective date of
termination. All pertinent provisions of the Contract will form the
basis of settlement.
(b)
HMO
must provide HHSC all reasonable access to records, facilities, and
documentation as is required to efficiently and expeditiously close out the
Services and Deliverables provided under this Contract.
(c)
HMO
must prepare a Turnover Plan, which is acceptable to and approved by
HHSC. The Turnover Plan will be implemented during the time period
between receipt of notice and the termination date.
Section
12.09 Modification of Contract in the event of
remedies.
HHSC
may propose a modification of this Contract in response to the imposition of
a
remedy under this Article. Any modifications under this Section must be
reasonable, limited to the matters causing the exercise of a remedy, in writing,
and executed in accordance with Article 8. HMO must negotiate
such proposed modifications in good faith.
Section
12.10 Turnover assistance.
Upon
receipt of notice of termination of the Contract by HHSC, HMO will provide
any
turnover assistance reasonably necessary to enable HHSC or its designee to
effectively close out the Contract and move the work to another vendor or to
perform the work itself.
Section
12.11 Rights upon termination or expiration of
Contract.
In
the
event that the Contract is terminated for any reason, or upon its expiration,
HHSC will, at HHSC's discretion, retain ownership of any and all associated
work
products, Deliverables and/or documentation in whatever form that they
exist.
Section
12.12 HMO responsibility for associated
costs.
If
HHSC
terminates the Contract for Cause, the HMO will be responsible to HHSC for
all
reasonable costs incurred by HHSC, the State of Texas, or any of its
administrative agencies to replace the HMO. These costs include, but
are not limited to, the costs of procuring a substitute vendor and the cost
of
any claim or litigation that is reasonably attributable to HMO’s failure to
perform any Service in accordance with the terms of the Contract
Section
12.13 Dispute resolution.
(a)
General agreement of the Parties. The Parties mutually agree that the interests
of fairness, efficiency, and good business practices are best served when the
Parties employ all reasonable and informal means to resolve any dispute under
this Contract. The Parties express their mutual commitment to using all
reasonable and informal means
of
resolving disputes prior to invoking a remedy provided elsewhere in this
Section.
(b)
Duty
to negotiate in good faith. Any dispute that in the judgment of any Party to
this Contract may materially or substantially affect the performance of any
Party will be reduced to writing and delivered to the other Party. The Parties
must then negotiate in good faith and use every reasonable effort to resolve
such dispute and the Parties shall not resort to any formal proceedings unless
they have reasonably determined that a negotiated resolution is
not
possible. The resolution of any dispute disposed of by Contract between the
Parties shall be reduced to
writing and delivered to all Parties within ten (10) Business Days.
(c)
Claims for breach of Contract.
(1)
General requirement. HMO’s claim for breach of this Contract will be
resolved in accordance with the dispute resolution process established by HHSC
in accordance with Chapter 2260, Texas Government Code.
(2)
Negotiation of claims. The Parties expressly agree that the HMO’s claim
for breach of this Contract that the Parties cannot resolve in the ordinary
course of business or through the use of all reasonable and informal means
will
be submitted to the negotiation process provided in Chapter 2260, Subchapter
B,
Texas Government Code.
(A)
To
initiate the process, HMO must submit written notice to HHSC that specifically
states that HMO invokes the provisions of Chapter 2260, Subchapter B, Texas
Government Code. The notice must comply with the requirements of
Title 1, Chapter 392, Subchapter B of the Texas Administrative
Code.
(B)
The
Parties expressly agree that the HMO’s compliance with Chapter 2260, Subchapter
B, Texas Government Code, will be a condition precedent to the filing of a
contested case proceeding under Chapter 2260, Subchapter C, of the Texas
Government Code.
(3)
Contested case proceedings. The contested case process provided in
Chapter 2260, Subchapter C, Texas Government Code, will be HMO’s sole and
exclusive process for seeking a remedy for any and all alleged breaches of
contract by HHSC if the Parties are unable to resolve their disputes under
Subsection (c)(2) of this Section. The
Parties expressly agree that compliance with the contested case process provided
in Chapter 2260, Subchapter C, Texas Government Code, will be a condition
precedent to seeking consent to xxx from the Texas Legislature under Chapter
107, Civil Practices & Remedies Code. Neither the execution of this Contract
by HHSC nor any other conduct of any representative of HHSC relating to this
Contract shall be considered a waiver of HHSC’s sovereign immunity to
suit.
(4)
HHSC rules. The submission, processing and resolution of HMO’s claim is
governed by the rules adopted by HHSC pursuant to Chapter 2260, Texas Government
Code, found at Title 1, Chapter 392, Subchapter B of the Texas Administrative
Code.
(5)
HMO’s duty to perform. Neither the occurrence of an event constituting
an alleged breach of contract nor the pending status of any claim for breach
of
contract is grounds for the suspension of performance, in whole or in part,
by
HMO of any duty or obligation with respect to the performance of this
Contract.
Any changes to the Contract as a result of a dispute resolution will be
implemented in accordance with Article 8 (“Amendments and
Modifications”).
Section
12.14 Liability of HMO.
(a)
HMO
bears all risk of loss or damage to HHSC or the State due to:
(1)
Defects in Services or Deliverables;
(2)
Unfitness or obsolescence of Services or Deliverables; or
(3)
The
negligence or intentional misconduct of HMO or its employees, agents,
Subcontractors, or representatives.
(b)
HMO
must, at the HMO’s own expense, defend with counsel approved by HHSC, indemnify,
and hold harmless HHSC and State employees, officers, directors, contractors
and
agents from and against any losses, liabilities, damages, penalties, costs,
fees, including without limitation reasonable attorneys' fees, and expenses
from
any claim or action for property damage, bodily injury or death, to the extent
caused by or arising from the negligence or intentional misconduct of the HMO
and its employees, officers, agents, or Subcontractors. HHSC will not
unreasonably withhold approval of counsel selected by HMO.
(c)
HMO
will not be liable to HHSC for any loss, damages or liabilities attributable
to
or arising from the failure of HHSC or any state agency to perform a service
or
activity in connection with this Contract.
Section
13.01 Proposal certifications.
HMO
acknowledges its continuing obligation to comply with the requirements of the
following certifications contained in its Proposal, and will immediately notify
HHSC of any changes in circumstances affecting these
certifications:
(1)
Federal lobbying;
(2)
Debarment and suspension;
(3)
Child
support; and
(4)
Nondisclosure statement.
Section
13.02 Conflicts of interest.
(a)
Representation. HMO agrees to comply with applicable state and federal laws,
rules, and regulations regarding conflicts of interest in the performance of
its
duties under this Contract. HMO warrants that it has no interest and will not
acquire any direct or indirect interest that would
conflict in any manner or degree with its performance under this
Contract.
(b)
General duty regarding conflicts of interest. HMO will establish safeguards
to
prohibit employees from using their positions for a purpose that constitutes
or
presents the appearance of personal or organizational conflict of interest,
or
personal gain. HMO will operate with complete independence and objectivity
without actual, potential or apparent conflict of interest with respect to
the
activities
conducted under this Contract with the State of Texas.
Section
13.03 Organizational conflicts of interest.
(a)
Definition. An organizational conflict of interest is a set of facts or
circumstances, a relationship, or other situation under which a HMO, or a
Subcontractor has past, present, or currently planned personal or
financial
activities or interests that either directly or indirectly:
(1)
Impairs or diminishes the HMO’s, or Subcontractor’s ability to render impartial
or objective assistance or advice to HHSC; or
(2)
Provides the HMO or Subcontractor an unfair competitive advantage in future
HHSC
procurements (excluding the award of this Contract).
(b)
Warranty. Except as otherwise disclosed and approved by HHSC prior to the
Effective Date of the Contract, HMO warrants that, as of the Effective Date
and
to the best of its knowledge and belief, there are no relevant facts or
circumstances that could give rise to an organizational conflict of interest
affecting this Contract. HMO affirms that it has neither given, nor intends
to
give, at any time hereafter, any economic opportunity, future employment, gift,
loan, gratuity, special discount, trip, favor, or service to a public servant
or
any employee or representative of same, at any time during the procurement
process or in connection
with the procurement process except as allowed under relevant state and federal
law.
(c)
Continuing duty to disclose.
(1)
HMO
agrees that, if after the Effective Date, HMO discovers or is made aware of
an
organizational conflict of interest, HMO will immediately and fully disclose
such interest in writing to the HHSC project manager. In addition,
HMO must promptly disclose any relationship that might be perceived or
represented as a conflict after its discovery by HMO or by HHSC as a potential
conflict. HHSC reserves the right to make a final determination
regarding the existence of conflicts of interest, and HMO agrees to abide by
HHSC’s decision.
(2)
The
disclosure will include a description of the action(s) that HMO has taken or
proposes to take to avoid or mitigate such conflicts.
(d)
Remedy. If HHSC determines that an organizational conflict of interest exists,
HHSC may, at its discretion, terminate the Contract pursuant to
Subsection 12.03(b)(9). If HHSC determines that HMO was aware
of an organizational conflict of interest before the award of this Contract
and
did not disclose the conflict to the contracting officer, such nondisclosure
will be considered a material breach of the Contract. Furthermore,
such breach may be submitted to the Office of the Attorney General, Texas Ethics
Commission,
or appropriate State or Federal law enforcement officials for further
action.
(e)
Flow
down obligation. HMO must include the provisions of this Section in all
Subcontracts for work to be performed similar to the service provided by HMO,
and the terms "Contract,"
"HMO," and "project manager" modified appropriately to preserve the State's
rights.
Section
13.04 HHSC personnel recruitment prohibition.
HMO
has
not retained or promised to retain any person or company, or utilized or
promised to utilize a consultant that participated in HHSC’s development of
specific criteria of the RFP or who participated in the selection of the HMO
for
this Contract. Unless
authorized in writing by HHSC, HMO will not recruit or employ any HHSC
professional or technical personnel who have worked on projects relating to
the
subject matter of this Contract, or who have had any influence on decisions
affecting the subject matter of this Contract, for two (2) years following
the
completion of this Contract.
Section
13.05 Anti-kickback provision.
HMO
certifies that it will comply with the Anti-Kickback Act of 1986, 41 U.S.C.
§51-58 and Federal Acquisition Regulation 52.203-7, to the extent
applicable.
Section
13.06 Debt or back taxes owed to State of
Texas.
In
accordance with Section 403.055 of the Texas Government Code, HMO agrees that
any payments due to HMO under the Contract will be first applied toward any
debt
and/or back taxes HMO owes State of Texas. HMO further agrees that
payments will be so applied until such debts and back taxes are paid in
full.
Section
13.07 Certification regarding status of license, certificate, or
permit.
Article
IX, Section 163 of the General Appropriations Act for the 1998/1999 state fiscal
biennium prohibits an agency that receives an appropriation under either Article
II or V of the General Appropriations Act from awarding a contract with the
owner, operator, or administrator of a facility that has had a license,
certificate, or permit revoked by
another Article II or V agency. HMO certifies it is not ineligible for an award
under this provision.
Section
13.08 Outstanding debts and judgments.
HMO
certifies that it is not presently indebted to the State of Texas, and that
HMO
is not subject to an outstanding judgment in a suit by State of Texas against
HMO for collection of the balance. For purposes of this Section, an indebtedness
is any amount sum of money that is due and owing to the State of Texas and
is
not currently under dispute. A false statement regarding HMO’s status will be
treated as a material breach of this Contract and may be grounds for termination
at the option of HHSC.
(a)
The execution, delivery and performance of this Contract has been duly
authorized by HMO and no additional approval, authorization or consent of any
governmental or regulatory agency is required to be obtained in order for HMO
to
enter into this Contract and perform its obligations under this
Contract.
(b)
HMO
has obtained all licenses, certifications, permits, and authorizations necessary
to perform the Services under this Contract and currently is in good standing
with all regulatory agencies that regulate any or all aspects of HMO’s
performance of this Contract. HMO will maintain all required certifications,
licenses, permits, and authorizations during the term of this
Contract.
Section
14.02 Ability to perform.
HMO
warrants that it has the financial resources to fund the capital expenditures
required under the Contract without advances by HHSC or assignment of any
payments by HHSC to a financing source.
Section
14.03 Minimum Net Worth.
The
HMO
has, and will maintain throughout the life of this Contract, minimum net worth
to the greater of (a) $1,500,000; (b) an amount equal to the sum of twenty-five
dollars ($25) times the number of all enrollees including Members; or (c) an
amount that complies with standards adopted by TDI. Minimum net worth means
the
excess total admitted assets over total liabilities, excluding liability for
subordinated debt issued in compliance with Chapter 843 of the Texas Insurance
Code.
Section
14.04 Insurer solvency.
(a)
The
HMO must be and remain in full compliance with all applicable state and federal
solvency requirements for basic-service health maintenance organizations,
including but not limited to, all reserve requirements, net worth standards,
debt-to-equity ratios, or other debt limitations. In the event the HMO fails
to
maintain such compliance, HHSC, without limiting any other rights it may have
by
law
or
under the Contract, may terminate the Contract.
(b)
If
the HMO becomes aware of any impending changes to its financial or business
structure that could adversely impact its compliance with the requirements
of
the Contract or its ability to pay its debts as they come due, the HMO must
notify HHSC immediately in writing.
(c)
The
HMO must have a plan and take appropriate measures to ensure adequate provision
against the risk of insolvency as required by TDI. Such provision must be
adequate to provide for the following in the event of insolvency:
(1)
continuation of Covered Services, until the time of discharge, to Members who
are confined on the date of insolvency in a hospital or other inpatient
facility;
(2)
payments to unaffiliated health care providers and affiliated healthcare
providers whose Contracts do not contain Member “hold harmless” clauses
acceptable to the TDI;
(3)
continuation of Covered Services for the duration of the Contract Period for
which a capitation has been paid for a Member;
(4)
provision against the risk of insolvency must be made by establishing adequate
reserves, insurance or other guarantees in full compliance with all financial
requirements of TDI and the Contract.
Should
TDI determine that there is an immediate risk of insolvency or the HMO is unable
to provide Covered Services to its Members, HHSC, without limiting any other
rights it may have by law, or under the Contract, may terminate the
Contract.
Section
14.05 Workmanship and performance.
(a)
All
Services and Deliverables provided under this Contract will be provided in
a
manner consistent with the standards of quality and integrity as outlined in
the
Contract.
(b)
All
Services and Deliverables must meet or exceed the required levels of performance
specified in or pursuant to this Contract.
(c)
HMO
will perform the Services and provide the Deliverables in a workmanlike manner,
in accordance with best practices and high professional standards used in
well-managed operations performing services similar to the services described
in
this Contract.
Section
14.06 Warranty of deliverables.
HMO
warrants that Deliverables developed and delivered under this Contract will
meet
in all material respects the specifications as described in the Contract during
the period following its acceptance by HHSC, through the term of the Contract,
including any subsequently negotiated by HMO and HHSC. HMO will
promptly repair or replace any such Deliverables not in compliance with this
warranty at no charge to HHSC.
Section
14.07 Compliance with Contract.
HMO
will
not take any action substantially or materially inconsistent with any of the
terms and conditions set forth in this Contract without the express written
approval of HHSC.
Section
14.08 Technology Access
(a)
HMO
expressly acknowledges that State funds may not be expended in connection with
the purchase of an automated information system unless that system meets certain
statutory requirements relating to accessibility by persons with visual
impairments. Accordingly, HMO represents and warrants to HHSC that
this technology is capable, either by virtue of features included within the
technology or because it is readily adaptable by use with other technology,
of:
(1)
Providing equivalent access for effective use by both visual and non-visual
means;
(2)
Presenting information, including prompts used for interactive communications,
in formats intended for non-visual use; and
(3)
Being
integrated into networks for obtaining, retrieving, and disseminating
information used by individuals who are not blind or visually
impaired.
(b)
For
purposes of this Section, the phrase "equivalent access" means a substantially
similar ability to communicate with or make use of the technology, either
directly by features incorporated within the technology or by other reasonable
means such as assistive devices or services that would constitute reasonable
accommodations under the Americans with Disabilities Act or similar State or
Federal laws. Examples of methods by which equivalent access may be
provided include, but are not limited to, keyboard alternatives to mouse
commands and other means of navigating graphical displays, and customizable
display appearance.
(c)
In
addition, all technological solutions offered by the HMO must comply with the
requirements of Texas Government Code §531.0162. This
includes, but is not limited to providing technological solutions that meet
federal accessibility standards for persons with disabilities, as
applicable.
Section
15.01 Infringement and misappropriation.
(a)
HMO
warrants that all Deliverables provided by HMO will not infringe or
misappropriate any right of, and will be free of any claim of, any third person
or entity based on copyright, patent, trade secret, or other intellectual
property rights.
(b)
HMO
will, at its expense, defend with counsel approved by HHSC, indemnify, and
hold
harmless HHSC, its employees, officers, directors, contractors, and agents
from
and against any losses, liabilities, damages, penalties, costs, fees, including
without limitation reasonable attorneys’ fees and expenses, from any claim or
action against HHSC that is based on a claim of breach of the warranty set
forth
in the preceding paragraph. HHSC will promptly notify HMO in writing
of the claim, provide HMO a copy of all information received by HHSC with
respect to the claim, and cooperate with HMO in defending or settling the
claim. HHSC will not unreasonably withhold, delay or condition
approval of counsel selected by the HMO.
(c)
In
case the Deliverables, or any one or part thereof, is in such action held to
constitute an infringement or misappropriation, or the use thereof is enjoined
or restricted or if a proceeding appears to HMO to be likely to be brought,
HMO
will, at its own expense, either:
(1)
Procure for HHSC the right to continue using the Deliverables; or
(2)
Modify or replace the Deliverables to comply with the Specifications and to
not
violate any intellectual property rights.
If
neither of the alternatives set forth in (1) or (2) above are available to
the
HMO on commercially reasonable terms, HMO may require that HHSC return the
allegedly infringing Deliverable(s) in which case HMO will refund all amounts
paid for all such Deliverables.
Section
15.02 Exceptions.
HMO
is
not responsible for any claimed breaches of the warranties set forth in Section
15.01 to the extent caused by:
(a)
Modifications made to the item in question by anyone other than HMO or its
Subcontractors, or modifications made by HHSC or its contractors working at
HMO’s direction or in accordance with the specifications; or
(b)
The
combination, operation, or use of the item with other items if HMO did not
supply or approve for use with the item; or
(c)
HHSC’s failure to use any new or corrected versions of the item made available
by HMO.
Section
15.03 Ownership and Licenses
For
purposes of this Section 15.03, the following terms have the meanings set forth
below:
(1)
“Custom Software” means any software developed by the
HMO: for HHSC; in connection with the Contract; and with funds received from
HHSC. The term does not include HMO Proprietary Software or Third
Party Software.
(2)
“HMO Proprietary Software” means software:
(i)
developed by the HMO prior to the Effective Date of the Contract, or (ii)
software developed by the HMO after the Effective Date of the Contract that
is
not developed: for HHSC; in connection with the Contract; and with funds
received from HHSC.
(3)
“Third Party Software” means software that is: developed
for general commercial use; available to the public; or not developed for
HHSC. Third Party Software includes without limitation: commercial
off-the-shelf software; operating system software; and application software,
tools, and utilities.
(b)
Deliverables. The Parties agree that any Deliverable, including without
limitation the Custom Software, will be the exclusive property of
HHSC.
(c)
Ownership rights.
(1)
HHSC
will own all right, title, and interest in and to its Confidential Information
and the Deliverables provided by the HMO, including without limitation the
Custom Software and associated documentation. For purposes of this
Section 15.03, the Deliverables will not include HMO Proprietary Software or
Third Party Software. HMO will take all actions necessary and
transfer ownership of the Deliverables to HHSC, including, without limitation,
the Custom Software and associated documentation prior to Contract
termination.
(2)
HMO
will furnish such Deliverables, upon request of HHSC, in accordance with
applicable State law. All Deliverables, in whole and in part, will be deemed
works made for hire of HHSC for all purposes of copyright law, and copyright
will belong solely to HHSC. To the extent that any such Deliverable does not
qualify as a work for hire under applicable law, and to the extent that the
Deliverable includes materials subject to copyright, patent, trade secret,
or
other proprietary right protection, HMO agrees to assign, and hereby assigns,
all right, title, and interest in and to Deliverables, including without
limitation all copyrights, inventions, patents, trade secrets, and other
proprietary rights therein (including renewals thereof) to HHSC.
(3)
HMO
will, at the expense of HHSC, assist HHSC or its nominees to obtain copyrights,
trademarks, or patents for all such Deliverables in the United States and any
other countries. HMO agrees to execute all papers and to give all
facts known to it necessary to secure United States or foreign country
copyrights and patents, and to transfer or cause to transfer to HHSC all the
right, title, and interest in and to such Deliverables. HMO also agrees not
to
assert any moral rights under applicable copyright law with regard to such
Deliverables.
(d)
License Rights HHSC will have a royalty-free and non-exclusive license to access
the HMO Proprietary Software and associated documentation during the term of
the
Contract. HHSC will also have ownership and unlimited rights to use, disclose,
duplicate, or publish all information and data developed, derived, documented,
or furnished by HMO under or resulting from the Contract. Such data
will include all results, technical information, and materials developed for
and/or obtained by HHSC from HMO in the performance of the Services hereunder,
including but not limited to all reports, surveys, plans, charts, recordings
(video and/or sound), pictures, drawings, analyses, graphic representations,
computer printouts, notes and memoranda, and documents whether finished or
unfinished, which result from or are
prepared in connection with the Services performed as a result of the
Contract.
(e)
Proprietary Notices HMO will reproduce and include HHSC’s copyright and other
proprietary notices and product identifications
provided by HMO on such copies, in whole or in part, or on any form of the
Deliverables.
(f)
State
and Federal Governments In accordance with 45 C.F.R. §95.617, all appropriate
State and Federal agencies will have a royalty-free, nonexclusive, and
irrevocable license to reproduce, publish, translate, or otherwise use, and
to
authorize others to use for Federal Government purposes all materials, the
Custom Software and modifications thereof, and associated documentation
designed, developed, or installed with federal financial participation under
the
Contract, including but not limited to those materials covered by copyright,
all
software
source and object code, instructions, files, and documentation.
Section
16.01 Property damage.
(a)
HMO
will protect HHSC’s real and personal property from damage arising from HMO’s,
its agent’s, employees’ and Subcontractors’ performance of the Contract, and HMO
will be responsible for any loss, destruction, or damage to HHSC’s
property that results from or is caused by HMO’s, its agents’, employees’ or
Subcontractors’ negligent or wrongful acts or omissions. Upon the
loss of, destruction of, or damage to any property of HHSC, HMO will notify
the
HHSC Project Manager thereof and, subject to direction from the Project Manager
or her or his designee, will take all reasonable steps to protect that property
from further damage.
(b)
HMO
agrees to observe and encourage its employees and agents to observe safety
measures and proper operating procedures at HHSC sites at all
times.
(c)
HMO
will distribute a policy statement to all of its employees and agents that
directs the employee or agent to promptly report to HHSC or to HMO any special
defect or unsafe condition encountered while on HHSC premises. HMO
will promptly report to HHSC any special defect or an unsafe condition it
encounters or otherwise learns about.
Section
16.02 Risk of Loss.
During
the period Deliverables are in transit and in possession of HMO, its carriers
or
HHSC prior to being accepted by HHSC, HMO will bear the risk of loss or damage
thereto, unless such loss or damage is caused by the negligence or intentional
misconduct of HHSC. After HHSC accepts a Deliverable, the risk of loss or damage
to the Deliverable will be borne by HHSC, except loss or damage attributable
to
the negligence or intentional misconduct of HMO’s agents, employees or
Subcontractors.
Section
16.03 Limitation of HHSC’s Liability.
HHSC
WILL
NOT BE LIABLE FOR ANY INCIDENTAL, INDIRECT, SPECIAL, OR CONSEQUENTIAL DAMAGES
UNDER CONTRACT, TORT (INCLUDING NEGLIGENCE), OR OTHER LEGAL
THEORY. THIS WILL APPLY REGARDLESS OF THE CAUSE OF ACTION AND EVEN IF
HHSC HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. HHSC’S
LIABILITY TO HMO UNDER THE CONTRACT WILL NOT EXCEED THE TOTAL CHARGES TO BE
PAID
BY HHSC TO HMO UNDER THE CONTRACT, INCLUDING CHANGE ORDER PRICES AGREED TO
BY
THE PARTIES OR OTHERWISE ADJUDICATED. HMO’s
remedies are governed by the provisions in Article 12.
Section
17.01 Insurance Coverage.
(a)
Statutory and General Coverage
HMO
will
maintain the following insurance coverage.
(1)
Standard Worker's Compensation Insurance coverage;
(2)
Automobile Liability;
(3)
Comprehensive Liability Insurance including Bodily Injury coverage of
$100,000.00 per each occurrence and Property Damage Coverage of $25,000.00
per
each occurrence; and
(4)
General Liability Insurance of at least $1,000,000.00 per occurrence and
$5,000,000.00 in the aggregate.
If
HMO’s
current Comprehensive General Liability insurance coverage does not meet the
above stated requirements,
HMO will obtain excess liability insurance to compensate for the difference
in
the coverage amounts.
(1)
HMO
must maintain, or cause its Network Providers to maintain, Professional
Liability Insurance for each Network Provider of $100,000.00 per occurrence
and
$300,000.00 in the aggregate, or the limits required by the hospital at which
the Network Provider has admitting privileges.
(2)
HMO
must maintain an Umbrella Professional Liability Insurance Policy for the
greater of $3,000,000.00 or an amount (rounded to the nearest $100,000.00)
that
represents the number of Members enrolled in the HMO in the first month of
the
applicable State Fiscal Year multiplied by $150.00, not to exceed
$10,000,000.00.
(1)
Except as provided herein, all exceptions to the Contract’s insurance
requirements must be approved in writing by HHSC. HHSC’s written approval is not
required in the following situations:
(A)
An
HMO or a Network Provider is not required to obtain the insurance coverage
described in Section 17.01 if the HMO or Network Provider qualifies as a state
governmental unit or municipality under the Texas Tort Claims Act, and is
required to comply with, and subject to the provisions of, the Texas Tort Claims
Act.
(B)
An
HMO may waive the Professional Liability Insurance requirement described in
Section 17.01(b)(1) for a Network Provider of Community-based Long Term Care
Services. An HMO may not waive this requirement if the Network
Provider provides other Covered Services in addition to Community-based Long
Term Care Services, or if a Texas licensing entity requires the Network Provider
to carry such Professional Liability coverage. An HMO that
waives the Professional Liability Insurance requirement for a Network Provider
pursuant to this provision is not required to obtain such coverage on behalf
of
the Network Provider.
(2)
HMO
or the Network Provider is responsible for any and all deductibles stated in
the
insurance policies.
(3)Insurance
coverage must be issued by insurance companies authorized to conduct business
in
the State of Texas.
(4)
Insurance coverage must name HHSC as an additional insured with the following
exceptions: Standard Workers’ Compensation Insurance maintained by the HMO, and
Professional Liability Insurance maintained by Network Providers.
(5)
Insurance coverage kept by the HMO must be maintained throughout the Term of
the
Contract, and until HHSC’s final acceptance of all Services and Deliverables.
Failure to maintain such insurance coverage will constitute a material breach
of
this Contract.
(6)
With
the exception of Professional Liability Insurance maintained by Network
Providers, the insurance policies described in this Section must have extended
reporting periods of two years. When policies are renewed or
replaced, the policy retroactive date must coincide with, or precede, the
Contract Effective Date.
(7)
With
the exception of Professional Liability Insurance maintained by Network
Providers, the insurance policies described in this Section must provide that
prior written notice to be given to HHSC at least thirty (30) calendar days
before coverage is substantially changed, canceled, or
non-renewed. HMO must submit a new coverage binder to HHSC to ensure
no break in coverage.
(8)
The
Parties expressly understand and agree that any insurance coverages and limits
furnished by HMO will in no way expand or limit HMO’s liabilities and
responsibilities specified within the Contract documents or by applicable
law.
(9)
HMO
expressly understands and agrees that any insurance maintained by HHSC will
apply in excess of and not contribute to insurance provided by HMO under the
Contract.
(10)
If
HMO, or its Network Providers, desire additional coverage, higher limits of
liability, or other modifications for its own protection, HMO or its Network
Providers will be responsible for the acquisition and cost of such additional
protection. Such additional protection will not be an Allowable
Expense under this Contract.
(d)
Proof
of Insurance Coverage
(1)
Except as provided in Section 17.01(d)(2), the HMO must furnish the HHSC Project
Manager original Certificates of Insurance evidencing the required insurance
coverage on or before the Effective Date of the Contract. If
insurance coverage is renewed during the Term of the Contract, the HMO must
furnish the HHSC Project Manager renewal certificates of insurance, or such
similar evidence, within five (5) Business Days of renewal. The
failure of HHSC to obtain such evidence
from HMO will not be deemed to be a waiver by HHSC and HMO will remain under
continuing obligation to maintain and provide proof of insurance
coverage.
(2)
The
HMO is not required to furnish the HHSC Project Manager proof of Professional
Liability Insurance maintained by Network Providers on or before the Effective
Date of the Contract, but must provide such information upon HHSC’s request
during the Term of the Contract.
Section
17.02 Performance Bond.
(a)
Beginning on the Operational Start Date of the Contract, and each year
thereafter, the HMO must obtain a performance bond with a one (1) year
term. The performance bond must continue to be in effect for one (1)
year following the expiration of the one (1) year term. HMO must
obtain and maintain the annual performance bonds in the form prescribed by
HHSC
and approved by TDI, naming HHSC as Obligee, securing HMO’s faithful performance
of the terms and conditions of this Contract. The annual performance bonds
must
comply with Chapter 843 of the Texas Insurance Code and 28 T.A.C.
§11.1805. The annual performance bond(s) must be issued in the amount
of $100,000.00 for each applicable HMO Program within each Service Area that
the
HMO covers under this Contract. All performance bonds must be issued by a surety
licensed by TDI, and specify cash payment as the sole remedy. HMO
must deliver the initial performance bond to HHSC prior to the Operational
Start
Date of the Contract, and each renewal performance bond prior to the first
day
of the State Fiscal Year.
(b)
Since
the CHIP Perinatal Program is a subprogram of the CHIP Program, neither a
separate performance bond for the CHIP Perinatal Program nor a combined
performance bond for the CHIP and CHIP Perinatal Programs is
required. The same bond that the HMO obtains for its CHIP Program
within a particular Service Area also will cover the HMO’s CHIP Perinatal
Program, if applicable, in that same Service Area.
Section
17.03 TDI Fidelity Bond
The
HMO
will secure and maintain throughout the life of the Contract a fidelity bond
in
compliance with Chapter 843 of the Texas Insurance Code and 28 T.A.C.
§11.1805. The HMO must promptly provide HHSC with copies of the bond
and any amendments or renewals thereto.
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 6
Version 1.8
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version Attachment B-1, Section 6
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
version of the Attachment B-1, Section 6, that includes provisions
applicable to MCOs participating in the STAR+PLUS Program.
Section
6.3.2.1, Experience Rebate Reward, is modified to delete references
to the
selected performance indicators and the Quality Challenge Pool.
Section
6.3.2.2, Performance-Based Capitation Rate, is modified to include
STAR+PLUS and to add Additional STAR+PLUS Performance Indicators.
Section
6.3.2.3, Quality Challenge Award, is modified to include STAR+PLUS.
Section 6.3.2.5, STAR+PLUS Hospital Inpatient Performance Based
Capitation
Rate: Hospital Inpatient Stay Cost Incentives and Disincentives,
is added.
Section
6.3.2.5.1, STAR+PLUS Hospital Inpatient Disincentive – Administrative Fee
at Risk, is added.
Section
6.3.2.5.2, STAR+PLUS Hospital Inpatient Incentive – Shared Savings Award,
is added.
|
Revision
|
1.2
|
September
1, 2006
|
Revised
version of the Attachment B-1, Section 6, that includes provisions
applicable to MCOs participating in the STAR and CHIP Programs.
Section
6.3.2.2, Performance-Based Capitation Rate, modifies the standard
performance indicator for the Behavioral Health Hotline to change
the
maximum abandonment rate from 5% to 7% (except in the Dallas
Core Service
Area).
Section
6.3.2.3, Quality Challenge Award, is modified to reflect the
new start
date for the Quality Challenge Award, which will not be implemented
until
State Fiscal Year 2008.
|
Revision
|
1.3
|
September
1, 2006
|
Revised
version of the Attachment B-1, Section 6, that includes provisions
applicable to MCOs participating in the CHIP Perinatal Program.
Section
6.3.2.1 modified to clarify that the Experience Rebate Reward
incentive
may apply to the CHIP Perinatal Program at a later
date.
Section
6.3.2.2 modified to clarify that the Performance-based Capitation
Rate
will not apply for the CHIP Perinatal Program in SFY
2007.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-1 Section 6 – Premium Payment,
Incentives, and Disincentives
|
Subject:
Attachment
B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 6 Version
1.8
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-1 Section 6 – Premium Payment,
Incentives, and Disincentives
|
Revision
|
1.6
|
February
1, 2007
|
Revised
version of the Attachment B-1, Section 6, that includes provisions
applicable to MCOs participating in the STAR+PLUS Program.
Section
6.3.2.5 is modified to clarify the months included in Rate Period
1.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-1 Section 6 – Premium Payment,
Incentives, and Disincentives
|
Revision
|
1.8
|
September
1, 2007
|
Section
6.3 is modified as a result of SB 10 legislation and the Xxxx
litigation
to prohibit HMOs from passing down financial disincentives or
sanctions to
providers.
Section
6.3.1.1 is modified as a result of the Xxxx litigation to allow
HHSC to
post information regarding poor HMO performance on the HHSC website.
Section
6.3.2.2 is modified to clarify language regarding the Performance
Indicator Dashboard and the reapportionment of points for the
1% at-risk
premium.
Section
6.3.2.3 is modified as a result of the Xxxx litigation to clarify
language.
New
Section 6.3.2.6 is added as a result of the Xxxx litigation to
clarify
requirements for additional incentives and
disincentives.
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn versions
2Revisions
should be numbered in accordance according to the version of
the issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3 Brief
description of the changes to the document made in the
revision.
|
This
section documents how the Capitation Rates are developed and describes
performance incentives and disincentives related to HHSC’s value-based
purchasing approach. For further information, HMOs should refer to
the HHSC Uniform Managed Care Contract Terms and
Conditions.
Under
the
HMO Contracts, health care coverage for Members will be provided on a fully
insured basis. The HMO must provide the Services and Deliverables, including
Covered Services to enrolled Members in order for monthly Capitation Payments
to
be paid by HHSC. Attachment B1, Section 8 includes the
HMO’s financial responsibilities regarding out-of-network Emergency Services
and
Medically Necessary Covered Services not available through Network
Providers.
6.1
Capitation Rate Development
Refer
to
Attachment A, HHSC Uniform Managed Care Contract Terms
& Conditions, Article 10, “Terms & Conditions of Payment,” for
information concerning Capitation Rate development.
6.2
Financial Payment Structure and Provisions
HHSC
will
pay the HMO monthly Capitation Payments based on the number of eligible
and
enrolled Members. HHSC will calculate the monthly Capitation Payments by
multiplying the number of Member Months times the applicable monthly Capitation
Rate by Member Rate Cell. The HMO must provide the Services and Deliverables,
including Covered Services to Members, described in the Contract for monthly
Capitation Payments to be paid by HHSC.
The
HMO
must understand and expressly assume the risks associated with the performance
of the duties and responsibilities under the Contract, including the failure,
termination, or suspension of funding to HHSC, delays or denials of required
approvals, cost of claims incorrectly paid by the HMO, and cost overruns
not
reasonably attributable to HHSC. The HMO must further agree that no other
charges for tasks, functions, or activities that are incidental or ancillary
to
the delivery of the Services and Deliverables will be sought from HHSC
or any
other state agency, nor will the failure of HHSC or any other party to
pay for
such incidental or ancillary services entitle the HMO to withhold Services
or
Deliverables due under the Contract.
6.2.1
Capitation Payments
The
HMO
must refer to the HHSC Uniform Managed Care Contract Terms &
Conditions for information and Contract requirements on
the:
1)
Time
and Manner of Payment,
2)
Adjustments to Capitation Payments,
3)
Delivery Supplemental Payment, and
4)
Experience Rebate.
6.3
Performance Incentives and Disincentives
HHSC
introduces several financial and non-financial performance incentives and
disincentives through this Contract. These incentives and disincentives
are
subject to change by HHSC over the course of the Contract Period. The
methodologies required to implement these strategies will be refined by
HHSC
after collaboration with contracting HMOs through a new incentives workgroup
to
be established by HHSC. HMO is prohibited from passing down financial
disincentives and/or sanctions imposed on the HMO to health care providers,
except on an individual basis and related to the individual provider’s
inadequate performance.
6.3.1
Non-financial Incentives
HHSC
intends to distribute information on key performance indicators to HMOs
on a
regular basis, identifying an HMO’s performance, and comparing that performance
to other HMOs, and HHSC standards and/or external Benchmarks. HHSC will
recognize HMOs that attain superior performance and/or improvement by
publicizing their achievements. For example, HHSC may post information
concerning exceptional performance on its website, where it will be available
to
both stakeholders and members of the public. Likewise, HHSC may post its
final
determination regarding poor performance or HMO peer group performance
comparisons on its website, where it will be available to both stakeholders
and
members of the public.
HHSC
may
also revise its auto-assignment methodology during the Contract Period
for new
Medicaid Members who do not select an HMO (Default Members). The new assignment
methodology would reward those HMOs that demonstrate superior performance
and/or
improvement on one or more key dimensions of performance. In establishing
the
assignment methodology, HHSC will employ a subset of the performance indicators
contained within the Performance Indicator Dashboard. At
present, HHSC intends to recognize those HMOs that exceed the minimum geographic
access standards defined within Attachment B-1, Section 8 and the
Performance Indicator Dashboard.
HHSC
may
also use its assessment of HMO performance on annual quality improvement
goals
(described in Attachment B-1, Section 8) in developing the
assignment methodology. The methodology would disproportionately assign
Default
Members to the HMO(s) in a given Service Area that performed comparably
favorably on the selected performance indicators.
HHSC
anticipates that it will not implement a performance-based auto-assignment
algorithm before September 1, 2007. HHSC will invite HMO comments on potential
approaches prior to implementation of the new performance-based auto-assignment
algorithm.
6.3.2
Financial Incentives and Disincentives
HHSC
historically has required HMOs to provide HHSC with an Experience Rebate
(see
the Uniform Managed Care Contract Terms and Conditions, Article 10.11)
when there has been an aggregate excess of Revenues over Allowable
Expenses. During the Contract Period, should the HMO experience an aggregate
excess of Revenues over Allowable Expenses across STAR and CHIP HMO Programs
and
Service Areas, HHSC will allow the HMO to retain that portion of the aggregate
excess of Revenues over Allowable Expenses that is equal to or less than
3.5% of
the total Revenue for the period should the HMO demonstrate superior performance
on selected performance indicators. The retention of 3.5% of revenue
exceeds the retention of 3.0% of revenue that would otherwise be afforded
to a
HMO without demonstrated superior performance on these performance indicators
relative to other HMOs. HHSC will develop the methodology for determining
the
level of performance necessary for an HMO to retain the additional 0.5%
of
revenue after consultation with HMOs. The finalized methodology will be
added to
the Uniform Managed Care Manual.
HHSC
will
calculate the Experience Rebate Reward after it has calculated the HMO’s at-risk
Capitation Rate payment, as described below in Section 6.3.2.2.
HHSC will calculate whether a HMO is eligible for the Experience Rebate
Reward
prior to the 90-day Financial Statistical Report (FSR) filing.
HHSC
anticipates that it will not implement the incentive for Rate Period 1
of the
Contract. HHSC will invite HMO comments on potential approaches prior
to implementation of the new performance-based Experience Rebate
Reward. HHSC may also implement this incentive option for the
STAR+PLUS and CHIP Perinatal programs in the future.
Beginning
in State Fiscal Year 2007 of the Contract, HHSC will place each STAR and
CHIP
HMO at risk for 1% of the Capitation Rate(s). Beginning in State Fiscal
Year
2008 of the Contract, HHSC will also place each STAR+PLUS HMO at risk for
1% of
the Capitation Rate(s). HHSC retains the right to vary the percentage
of the Capitation Rate placed at risk in a given Rate Period. HHSC will
not
place CHIP Perinatal HMOs at risk for 1% of the Capitation Rate(s) in State
Fiscal Year 2007, but reserves this right in subsequent State Fiscal
Years.
As
noted
in Section 6.2, HHSC will pay the HMO monthly Capitation Payments based
on the
number of eligible and enrolled Members. HHSC will calculate the monthly
Capitation Payments by multiplying the number of Member months times the
applicable monthly Capitation Rate by Member rate cell. At the end of
each Rate Period, HHSC will evaluate if the HMO has demonstrated that it
has
fully met the performance expectations for which the HMO is at
risk. Should the HMO fall short on some or all of the performance
expectations, HHSC will adjust a future monthly Capitation Payment by an
appropriate portion of the 1% at-risk amount. HMOs will be able to
earn variable percentages up to 100% of the 1% at-risk Capitation Rate.
HHSC’s
objective is that all HMOs achieve performance levels that enable them
to
receive the full at-risk amount.
HHSC
will
determine the extent to which the HMO has met the performance expectations
by
assessing the HMO’s performance for each applicable HMO Program relative to
performance targets for the rate period. HHSC will conduct separate accounting
for each HMO Program’s at-risk Capitation Rate amount.
HHSC
will
identify no more than 10 at-risk performance indicators for each HMO Program.
Some of the performance indicators will be standard across the HMO Programs
while others may apply to only one of the HMO Programs.
HHSC’s
at-risk performance indicators may include some or all of the following
measures. The specific performance indicators, periods of data collection,
and
associated points are detailed in the HHSC Uniform Managed Care Manual.
The minimum percentage targets identified in this section
were
developed based, in part, on the HHSC HMO Program objective of ensuring
access
to care and quality of care, past performance of the HHSC HMOs, and performance
of Medicaid and CHIP HMOs nationally on HEDIS and CAHPS measures of plan
performance. The Performance Indicator Dashboard includes a
more detailed listing of performance indicators by Program and is included
in
the HHSC Uniform Managed Care Manual.
Standard
Performance Indicators:
1 98%
of
Clean Claims are properly Adjudicated within 30 calendar days.
2 The
Member Services Hotline abandonment rate does not exceed 7%.
3 The
Behavioral Health Hotline abandonment rate does not exceed 7%.1
4 The
Provider Services Hotline abandonment rate does not exceed 7%.
Additional
STAR Performance Indicators
1 90%
of
child Members have access to at least one child-appropriate PCP with an
Open
Panel within 30 miles travel distance.
2 90%
of
adult Members have access to at least one adult-appropriate PCP with an
Open
Panel within 30 miles travel distance.
3 36%
of
age-qualified child Members receive six or more well-child visits (in the
first
15 months of life.
4 56%
of
age-qualified child Members receive at least one well-child visit in the
3rd,
4th, 5th, or 6th year of life.
5 72%
of
pregnant women Members receive a prenatal care visit in the first trimester
or
within 42 days of enrollment.
Additional
CHIP Performance Indicators
1. 90%
of child Members have access to at least one child-appropriate PCP with
an Open
Panel within 30 miles travel distance.
2. 90%
of child Members have access to at least one otolaryngologist (ENT) within
75
miles travel distance.
3. 56%
of age-qualified child Members receive at least one well-child visit in
the 3rd,
4th, 5th, or 6th year of life
4. 38%
of adolescents receive an annual well visit.
1
Will not apply in
the Dallas Core Service Area. Points will be allocated
proportionately over the remaining standard performance indicators.
Additional
STAR+PLUS Performance Indicators
1 57%
of
adult Members report no problem with delays in getting approval from the
HMO
2 90%
of
adult Members have access to at least one adult-appropriate PCP with an
Open
Panel within 30 miles travel distance
3 62%
of
adult Members report no problem in getting a referral to a Specialty
Physician
4 47%
of
adult Members report no problem getting needed Special Therapy (physical
therapy, occupational therapy, and speech therapy) from the HMO
5 57%
of
adult Members report no problem getting needed Behavioral Health Services
from
the HMO
Failure
to timely provide HHSC with necessary data related to the calculation of
the
performance indicators will result in HHSC’s assignment of a zero percent
performance rate for each related performance indicator.
For
any
Member survey-based indicators that are included in the 1% at-risk premium
that
yield response rates deemed by HHSC to be too low to yield credible data,
HHSC
will reapportion points across the remaining measures.
Actual
plan rates will be rounded to the nearest whole number. HHSC will calculate
performance assessment for the at-risk portion of the capitation payments
by
summing all earned points and converting them to a percentage. For
example, an HMO that earns 92 points will earn 92% of the at-risk Capitation
Rate. HHSC will apply the premium assessment of 8% of the at-risk Capitation
Rate as a reduction to the monthly Capitation Payment ninety days after
the end
of the contract period.
HMOs
will
report actual Capitation Payments received on the Financial Statistical
Report
(FSR). Actual Capitation Payments received include all of the at-risk Capitation
Payment paid to the HMO. Any performance assessment based on performance
for a
contract period will appear on the second final (334-day) FSR for that
contract
period.
HHSC
will
evaluate the performance-based Capitation Rate methodology annually in
consultation with HMOs. HHSC may then modify the methodology it deems necessary
and appropriate to motivate, recognize, and reward HMOs for
performance. The methodologies for Rate Periods 1 and 2 will be
included in the HHSC Uniform Managed Care Manual.
Data
collection for the Quality Challenge Award will begin on September 1, 2006;
however, the Quality Challenge Award will not be implemented until State
Fiscal
Year 2008. Should one or more HMOs be unable to earn the full amount of
the
performance-based at-risk portion of the Capitation Rate, HHSC will reallocate
the funds through the HMO Program’s Quality Challenge
Award.
HHSC will use these funds to reward HMOs that demonstrate superior clinical
quality, service delivery, access to care, and/or Member satisfaction,
HHSC will
determine the number of HMOs that will receive Quality Challenge Award
funds
annually based on the amount of the funds to be reallocated. Separate
Quality Challenge Award payments will be made for each of the HMO Programs.
As
with the performance-based Capitation Rate, each HMO will be evaluated
separately for each HMO Program. HHSC intends to evaluate HMO
performance annually on some combination of performance indicators in order
to
determine which HMOs demonstrate superior performance. In no event
will a distribution from the Quality Challenge Award, plus any other incentive
payments made in accordance with the HMO Contract, when combined with the
Capitation Rate payments, exceed 105% of the Capitation Rate payments to
an
HMO.
Information
about the data collection period to be used and each indicator that will
be
considered for any specific time period can be found in the HHSC Uniform
Managed Care Manual.
All
areas
of responsibility and all requirements in the Contract will be subject
to
performance evaluation by HHSC. Any and all responsibilities or requirements
not
fulfilled may have remedies and HHSC will assess either actual or liquidated
damages. Refer to Attachment A, HHSC Uniform Managed Care Contract Terms
and Conditions and Attachment B-5 for performance
standards that carry liquidated damage values.
6.3.2.5 STAR+PLUS
Hospital Inpatient Performance-Based Capitation Rate: Hospital Inpatient
Stay
Cost Incentives & Disincentives
Effective
as of the STAR+PLUS Operational Start Date, HHSC will place at-risk a portion
of
the HMO’s Medicaid-Only Capitation Rate. Settlements for Inpatient Stay costs
will be calculated by the State after the end of each State Fiscal Year
(SFY)
using three (3) months of completed Hospital paid data for the preliminary
settlement and 11 months of completed data for the final settlement. The
SFY
2006 Fee-for-Service (FFS) Inpatient Hospital per-member-per-month (PMPM)
rate
will be projected for Rate Period 1 (February 1, 2007 through August 31,
2007)
for the first settlement. Adjustments for the projection will include trending
and risk adjustment. The base and final inpatient hospital PMPM rate
will be calculated separately for each HMO, Service Area, and Rate Cell.
Xxxxxx
County is excluded from the Xxxxxx Service Area calculations.
6.3.2.5.1 STAR+PLUS
Hospital Inpatient Disincentive - Administrative Fee at
Risk
HHSC
has
assumed that STAR+PLUS HMOs will achieve a 22% reduction in projected FFS
Hospital Inpatient Stay costs, for the Medicaid-Only population, through
the
implementation of the STAR+PLUS model. HMOs achieving savings beyond
22% will be eligible for the STAR+PLUS Shared Savings Award described in
Section 6.3.2.5.2. The HMO will be at-risk for savings less
than 22%.
The
maximum risk to the HMO will be equal to 50% of the difference between
15%
Hospital inpatient savings and 22% Hospital inpatient savings. The disincentive
for savings above 15%, but still less than 22% will be equal to 50% of
the
difference between the level of achieved savings
and 22%. HHSC retains the right to vary the disincentive percentage in
a given
Rate Period by Contract amendment.
HMOs
that
exceed the 22% reduction in Inpatient Stay costs incurred by STAR+PLUS
Members
specified in Section 6.3.2.5.1 will be eligible to obtain a 20%
share of the savings achieved beyond the 22% target. HHSC will determine
the
extent to which the HMO has met and exceeded the performance expectation
in the
manner described within Section 6.3.2.5. Should HHSC determine
that the HMO exceeded the 22% target, HHSC will adjust a future monthly
Capitation Payment upward by 20% of the calculated savings. This shared
savings
award is limited to 5% of the HMO’s capitation in accordance with Federal
Balance Budget Act requirements and is calculated off of total of STAR+PLUS
Capitation Payment. An HMO will be subject to contractual remedies and
determined ineligible for the award, if a HHSC audit reveals that the HMO
has
inappropriately averted Medically Necessary Inpatient Stay admissions and
potentially endangered Member safety.
HHSC
will
evaluate all performance-based incentives and disincentive methodologies
annually and in consultation from the HMOs. HHSC may then modify the
methodologies as needed, as funds become available, or as mandated by court
decree, statute, or rule in an effort to motivate, recognize, and reward
HMOs
for performance.
Information
about the data collection period to be used, performance indicators selected
or
developed, or HMO ranking methodologies used for any specific time period
will
be found in the HHSC Uniform Managed Care
Manual.
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 7
Version 1.8
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version Attachment B-1, Section 7
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
version of the Attachment B-1, Section 7, that includes provisions
applicable to MCOs participating in the STAR+PLUS Program. Sections
7.1 to
7.3 modified to include STAR+PLUS.
|
Revision
|
1.2
|
September
1, 2006
|
Revised
version of the Attachment B-1, Section 7, that includes provisions
applicable to MCOs participating in the STAR and CHIP Programs.
Section
7.3.1.7, Operations Readiness, changes reference from “Operational Date”
to “Effective Date.”
|
Revision
|
1.3
|
September
1, 2006
|
Revised
version of the Attachment B-1, Section 7, that includes provisions
applicable to MCOs participating in the CHIP Perinatal Program.
Sections
7.2, 7.3, and 7.3.1.2 through 7.3.1.7 modified to include the
CHIP
Perinatal Program.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-1 Section 7 – Transition Phase
Requirements
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-1 Section 7 – Transition Phase
Requirements
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-1 Section 7 – Transition Phase
Requirements
|
Revision
|
1.7
|
July
1, 2007
|
Section
7.3.1.9 is modified to add a cross-reference to Attachment B-1,
Sections
8.1.1.2 and 8.1.18.
|
Revision
|
1.8
|
September
1, 2007
|
Contract
amendment did not revise Attachment B-1 Section 7 – Transition Phase
Requirements
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn versions
2
Revisions
should be numbered in accordance according to the version of
the issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3 Brief
description of the changes to the document made in the
revision.
|
This
Section presents the scope of work for the Transition Phase of the Contract,
which includes those activities that must take place between the time of
Contract award and the Operational Start Date.
The
Transition Phase will include a Readiness Review of each HMO, which must
be
completed successfully prior to a HMO’s Operational Start Date for each
applicable HMO Program. HHSC may, at its discretion, postpone the Operational
Start Date of the Contract for any such HMO that fails to satisfy all Transition
Phase requirements.
If
for
any reason, a HMO does not fully meet the Readiness Review prior to the
Operational Start Date, and HHSC has not approved a delay in the Operational
Start Date or approved a delay in the HMO’s compliance with the applicable
Readiness Review requirement, then HHSC shall impose remedies and either
actual
or liquidated damages. If the HMO is a current HMO Contractor, HHSC may
also
freeze enrollment into the HMO’s plan for any of its HMO Programs. Refer to
the HHSC Uniform Managed Care Contract Terms and Conditions (Attachment
A) and the Liquidated Damages Matrix (Attachment B-5)
for additional information.
7.2
Transition Phase Scope for HMOs
STAR,
STAR+PLUS and CHIP HMOs must meet the Readiness Review requirements established
by HHSC no later than 90 days prior to the Operational Start Date for each
applicable HMO Program. CHIP Perinatal HMOS must meet the Readiness Review
requirements established by HHSC not later than 60 days prior to the Operational
Start Date for the CHIP Perinatal Program. HMO agrees to provide all
materials required to complete the readiness review by the dates established
by
HHSC and its Contracted Readiness Review Vendor.
The
Transition Phase will begin after both Parties sign the Contract. The
start date for the STAR and CHIP Transition Phase is November 15,
2005. The start date for the STAR+PLUS Transition Phase is June 30,
2006. The start date for the CHIP Perinate Transition Phase is September
1,
2006.
The
Transition Phase must be completed no later than the agreed upon Operational
Start Date(s) for each HMO Program and Service Area. The HMO may be
subject to liquidated damages for failure to meet the agreed upon Operational
Start Date (see Attachment B-5).
The
HMO
has overall responsibility for the timely and successful completion of
each of
the Transition Phase tasks. The HMO is responsible for clearly specifying
and
requesting information needed from HHSC, other HHSC contractors, and Providers
in a manner that does not delay the schedule or work to be
performed.
HHSC
and
the HMO will work together during the initial Contract start-up phase
to:
• define
project management and reporting standards;
• establish
communication protocols between HHSC and the HMO;
• establish
contacts with other HHSC contractors;
• establish
a schedule for key activities and milestones; and
• clarify
expectations for the content and format of Contract Deliverables.
The
HMO
will be responsible for developing a written work plan, referred to as
the
Transition/Implementation Plan, which will be used to monitor progress
throughout the Transition Phase. An updated and detailed Transition
/Implementation Plan will be due to HHSC.
No
later
than the Effective Date of the Contract, the HMO must designate and identify
Key
HMO Personnel that meet the requirements in HHSC Uniform Managed Care
Contract Terms & Conditions, Article 4. The HMO will
supply HHSC with resumes of each Key HMO Personnel as well as organizational
information that has changed relative to the HMO’s Proposal, such as updated job
descriptions and updated organizational charts, (including updated Management
Information System (MIS) job descriptions and an updated MIS staff
organizational chart), if applicable. If the HMO is using a Material
Subcontractor(s), the HMO must also provide the organizational chart for
such
Material Subcontractor(s).
No
later
than the Contract execution date, STAR+PLUS HMOs must update the information
above and provide any additional information as it relates to the STAR+PLUS
Program.
No
later
than the Contract execution date, CHIP Perinatal HMOs must update the
information above and provide any additional information as it relates
to the
CHIP Perinatal Program.
In
order
to complete a Financial Readiness Review, HHSC will require that HMOs update
information submitted in their proposals. Note: STAR+PLUS and/or CHIP
Perinatal HMOs who have already submitted proposal updates for HHSC’s review for
STAR and/or CHIP, must either verify that the information has not changed
and
that it applies to STAR+PLUS and/or the CHIP Perinatal
Program or provide updated information for STAR+PLUS by July 10, 2006 and
for
the CHIP Perinatal Program by September 1, 2006. This information will
include
the following:
Contractor
Identification and Information
1 The
Contractor’s legal name, trade name, or any other name under which the
Contractor does business, if any.
2 The
address and telephone number of the Contractor’s headquarters
office.
3 A
copy of
its current Texas Department of Insurance Certificate of Authority to provide
HMO or ANHC services in the applicable Service Area(s). The
Certificate of Authority must include all counties in the Service Area(s)
for
which the Contractor is proposing to serve HMO Members.
4 Indicate
with a “Yes-HMO”, “Yes-ANHC” or “No” in the applicable cell(s) of the Column B
of the following chart whether the Contractor is currently certified by
TDI as
an HMO or ANHC in all counties in each of the CSAs in
which the Contractor proposes to participate in one or more of the HHSC
HMO
Programs. If the Contractor is not proposing to serve a CSA for a particular
HMO
Program, the Contractor should leave the applicable cells in the table
empty.
Table
2: TDI Certificate of Authority in Proposed HMO Program
CSAs
Column
A
|
Column
B
|
Column
C
|
Core
Service Area (CSA)
|
TDI
Certificate of Authority
|
Counties/Partial
Counties without a TDI Certificate of
Authority
|
Bexar
|
||
Dallas
|
||
El
Paso
|
||
Xxxxxx
|
||
Lubbock
|
||
Nueces
|
||
Tarrant
|
||
Xxxxxx
|
||
Xxxx
|
If
the
Contractor is not currently certified by TDI as an HMO
or ANHC in any one or more counties in a proposed CSA, the Contractor must
identify such entire counties in Column C for each CSA. For each county
listed
in Column C, the Contractor must document that it applied to TDI for such
certification of authority prior to the submission of a Proposal for this
RFP.
The Contractor shall indicate the date that it applied for such certification
and the status of its application to get TDI certification in the relevant
counties in this section of its submission to HHSC.
5. For
Contractors serving any CHIP and CHIP Perinatal OSAs, indicate with a “Yes-HMO”,
“Yes-ANHC” or “No” in the applicable cell(s) of the Column C of the following
chart whether the Contractor is currently certified by TDI as an HMO or
ANHC in
the entire county in the OSA. If the Contractor is not proposing to serve
an
OSA, the Contractor should leave the applicable cells in the table
empty.
Table
3: TDI Certificate of Authority in Proposed HMO Program
OSAs
CHIP
Program
|
||
Column
A
|
Column
B
|
Column
C
|
Core
Service Area (CSA)
|
Affiliated
CHIP OSA
|
TDI
Certificate of Authority
|
Bexar
|
||
El
Paso
|
||
Xxxxxx
|
||
Lubbock
|
||
Nueces
|
||
Travis
|
CHIP
Perinatal Program
|
||
Column
A
|
Column
B
|
Column
C
|
Core
Service Area (CSA)
|
Affiliated
CHIP OSA
|
TDI
Certificate of Authority
|
Bexar
|
||
El
Paso
|
||
Xxxxxx
|
||
Lubbock
|
||
Nueces
|
||
Xxxxxx
|
For
each
county listed in Column C, the Contractor must document that it applied
to TDI
for such certification of authority prior to the submission of a Proposal
for
this RFP. The Contractor shall indicate the date that it applied for such
certification and the status of its application to get TDI certification
in the
relevant counties in this section of its submission to HHSC.
6. If
the Contractor proposes to participate in STAR or STAR+PLUS and seeks to
be
considered as an organization meeting the requirements of Section §533.004(a) or
(e) of the Texas Government Code, describe how the Contractor meets the
requirements of §§533.004(a)(1), (a)(2), (a)(3), or (e) for each proposed
Service Areas.
7. The
type of ownership (proprietary, partnership, corporation).
8. The
type of incorporation (for profit, not-for-profit, or non-profit) and whether
the Contractor is publicly or privately owned.
9. If
the Contractor is an Affiliate or Subsidiary, identify the parent
organization.
10.
If
any change of ownership of the Contractor’s company is anticipated during the 12
months following the Proposal due date, the Contractor must describe the
circumstances of such change and indicate when the change is likely to
occur.
11.
The
name and address of any sponsoring corporation or others who provide financial
support to the Contractor and type of support, e.g., guarantees, letters
of
credit, etc. Indicate if there are maximum limits of the additional financial
support.
12.
The
name and address of any health professional that has at least a five percent
financial interest in the Contractor and the type of financial
interest.
13.
The
names of officers and directors.
14.
The
state in which the Contractor is incorporated and the state(s) in which
the
Contractor is licensed to do business as an HMO. The Contractor must also
indicate the state where it is commercially domiciled, if
applicable.
15.
The
Contractor’s federal taxpayer identification number.
16.
The
Contractor’s Texas Provider Identifier (TPI) number if the Contractor is
Medicaid-enrolled in Texas.
17.
Whether the Contractor had a contract terminated or not renewed for
non-performance or poor performance within the past five years. In such
instance, the Contractor must describe the issues and the parties involved,
and
provide the address and telephone number of the principal terminating party.
The
Contractor must also describe any corrective action taken to prevent any
future
occurrence of the problem leading to the termination.
18.
A
current Certificate of Good Standing issued by the Texas Comptroller of
Public
Accounts, or an explanation for why this form is not applicable to the
Contractor.
19.
Whether the Contractor has ever sought, or is currently seeking, National
Committee for Quality Assurance (NCQA) or American Accreditation HealthCare
Commission (URAC) accreditation status, and if it has or is,
indicate:
• its
current NCQA or URAC accreditation status;
• if
NCQA
or URAC accredited, its accreditation term effective dates; and
• if
not
accredited, a statement describing whether and when NCQA or URAC accreditation
status was ever denied the Contractor.
Material
Subcontractor Information
A
Material Subcontractor means any entity retained by the HMO to provide
all or
part of the HMO Administrative Services where the value of the subcontracted
HMO
Administrative Service(s) exceeds $100,000 per fiscal year. HMO Administrative
Services are those services or functions other than the direct delivery
of
Covered Services necessary to manage the delivery of and payment for Covered
Services. HMO Administrative Services include but are not limited to
Network, utilization, clinical and/or quality management, service authorization,
claims processing, Management Information System (MIS) operation and
reporting. The term Material Subcontractor does not include Providers
in the HMO’s Provider Network.
Contractors
must submit the following for each proposed Material Subcontractor, if
any:
1. A
signed letter of commitment from each Material Subcontractor that states
the
Material Subcontractor’s willingness to enter into a Subcontractor agreement
with the Contractor and a statement of work for activities to be subcontracted.
Letters of Commitment must be provided on the Material Subcontractor’s official
company letterhead and signed by an official with the authority to bind
the
company for the subcontracted work. The Letter of Commitment must state,
if
applicable, the company’s certified HUB status.
2. The
Material Subcontractor’s legal name, trade name, or any other name under which
the Material Subcontractor does business, if any.
3. The
address and telephone number of the Material Subcontractor’s headquarters
office.
4. The
type of ownership (e.g., proprietary, partnership, corporation).
5. The
type of incorporation (i.e., for profit, not-for-profit, or non-profit)
and
whether the Material Subcontractor is publicly or privately owned.
6. If
a Subsidiary or Affiliate, the identification of the parent
organization.
7. The
name and address of any sponsoring corporation or others who provide financial
support to the Material Subcontractor and type of support, e.g., guarantees,
letters of credit, etc. Indicate if there are maximum limits of the additional
financial support.
8. The
name and address of any health professional that has at least a five percent
(5%) financial interest in the Material Subcontractor and the type of financial
interest.
9. The
state in which the Material Subcontractor is incorporated, commercially
domiciled, and the state(s) in which the organization is licensed to do
business.
10.
The
Material Subcontractor’s Texas Provider Identifier if Medicaid-enrolled in
Texas.
11.
The
Material Subcontractor’s federal taxpayer identification number.
12.
Whether the Material Subcontractor had a contract terminated or not renewed
for
nonperformance or poor performance within the past five
years. In such instance, the Contractor must describe the issues and
the parties involved, and provide the address and telephone number of the
principal terminating party. The Contractor must also describe any corrective
action taken to prevent any future occurrence of the problem leading to
the
termination.
13.
Whether the Material Subcontractor has ever sought, or is currently seeking,
National Committee for Quality Assurance (NCQA) or American Accreditation
HealthCare Commission (URAC) accreditation or certification status, and
if it
has or is, indicate:
• its
current NCQA or URAC accreditation or certification status;
• if
NCQA
or URAC accredited or certified, its accreditation or certification term
effective dates; and
• if
not
accredited, a statement describing whether and when NCQA or URAC accreditation
status was ever denied the Material Subcontractor.
Organizational
Overview
1. Submit
an
organizational chart (labeled Chart A), showing the corporate structure
and
lines of responsibility and authority in the administration of the Bidder’s
business as a health plan.
2. Submit
an
organizational chart (labeled Chart B) showing the Texas organizational
structure and how it relates to the proposed Service Area(s), including
staffing
and functions performed at the local level. If Chart A represents the entire
organizational structure, label the submission as Charts A and B.
3. Submit
an
organizational chart (labeled Chart C) showing the Management Information
System
(MIS) staff organizational structure and how it relates to the proposed
Service
Area(s) including staffing and functions performed at the local
level.
4. If
the
Bidder is proposing to use a Material Subcontractor(s), the Bidder shall
include
an organizational chart demonstrating how the Material Subcontractor(s)
will be
managed within the Bidder’s Texas organizational structure, including the
primary individuals at the Bidder’s organization and at each Material
Subcontractor organization responsible for overseeing such Material Subcontract.
This information may be included in Chart B, or in a separate organizational
chart(s).
5. Submit
a
brief narrative explaining the organizational charts submitted, and highlighting
the key functional responsibilities and reporting requirements of each
organizational unit relating to the Bidder’s proposed management of the HMO
Program(s), including its management of any proposed Material
Subcontractors.
Other
Information
1. Briefly
describe any regulatory action, sanctions, and/or fines imposed by any
federal
or Texas regulatory entity or a regulatory entity in another state within
the
last 3 years, including a description of any letters of deficiencies, corrective
actions, findings of noncompliance, and/or sanctions. Please indicate which
of these actions or fines, if any, were related to Medicaid or CHIP programs.
HHSC may, at its option, contact these clients or regulatory agencies and
any
other individual or organization whether or not identified by the
Contractor.
2. No
later
than ten (10) days after the Contract Effective Date, submit documentation
that
demonstrates that the HMO has secured the required insurance and bonds
in
accordance with TDI requirements and Attachment B-1, Section 8.
3. Submit
annual audited financial statement for fiscal years 2004 and 2005 (2005
to be
submitted no later than six months after the close of the fiscal
year).
4. Submit
an
Affiliate Report containing a list of all Affiliates and for HHSC’s prior review
and approval, a schedule of all transactions with Affiliates that, under
the
provisions of the Contract, will be allowable as expenses in the FSR Report
for
services provided to the HMO by the Affiliate. Those should include financial
terms, a detailed description of the services to be provided, and an estimated
amount that will be incurred by the HMO for such services during the Contract
Period.
The
HMO
must have hardware, software, network and communications systems with the
capability and capacity to handle and operate all MIS systems and subsystems
identified in Attachment B-1, Section 8.1.18. For example, the
HMO’s MIS system must comply with the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) as indicated in
Section
8.1.18.4.
During
this Readiness Review task, the HMO will accept into its system any and
all
necessary data files and information available from HHSC or its
contractors. The HMO will install and test all hardware, software,
and telecommunications required to support the Contract. The HMO will
define and test modifications to the HMO’s system(s) required to support the
business functions of the Contract.
The
HMO
will produce data extracts and receive all electronic data transfers and
transmissions. STAR and CHIP HMOs must be able to demonstrate the ability
to
produce an EQRO (currently, Institute for Child Health Policy (ICHP)) encounter
file by April 1, 2006, and the 837-encounter file by August 1,
2006. STAR+PLUS HMOs must be able to demonstrate the ability to
produce the STAR+PLUS encounter file by the STAR+PLUS Operational Start
Date and
the 837- encounter file by September 1, 2007. CHIP Perinatal HMOs who have
already demonstrated the ability to produce an EQRO encounter file and
837-encounter file for the CHIP Program are not required to produce separate
files for the CHIP Perinatal Program.
If
any
errors or deficiencies are evident, the HMO will develop resolution procedures
to address problems identified. The HMO will provide HHSC, or a
designated vendor, with test data files for systems and interface testing
for
all external interfaces. This includes testing of the required
telephone
lines for Providers and Members and any necessary connections to the HHSC
Administrative Services Contractor and the External Quality Review
Organization. The HHSC Administrative Services Contractor will
provide enrollment test files to new HMOs that do not have previous HHSC
enrollment files. The HMO will demonstrate its system capabilities and
adherence
to Contract specifications during readiness review.
The
HMO
must assure that systems services are not disrupted or interrupted during
the
Operations Phase of the Contract. The HMO must coordinate with HHSC and
other
contractors to ensure the business and systems continuity for the processing
of
all health care claims and data as required under this contract.
The
HMO
must submit to HHSC, descriptions of interface and data and process flow
for
each key business processes described in Section 8.1.18.3,
System-wide Functions.
The
HMO
must clearly define and document the policies and procedures that will
be
followed to support day-to-day systems activities. The HMO must develop,
and
submit for State review and approval, the following information by December
14,
2005 for STAR and CHIP, by July 31, 2006 for STAR+PLUS:
1.
Joint
Interface Plan.
2.
Disaster Recovery Plan
3.
Business Continuity Plan
4.
Risk
Management Plan, and
5.
Systems Quality Assurance Plan.
Separate
plans are not required for CHIP Perinatal HMOs.
The
HMO
must provide documentation on systems and facility security and provide
evidence
or demonstrate that it is compliant with HIPAA. The HMO shall also provide
HHSC
with a summary of all recent external audit reports, including findings
and
corrective actions, relating to the HMO’s proposed systems, including any SAS70
audits that have been conducted in the past three years. The HMO shall
promptly
make additional information on the detail of such system audits available
to
HHSC upon request.
In
addition, HHSC will provide to the HMO a test plan that will outline the
activities that need to be performed by the HMO prior to the Operational
Start
Date of the Contract. The HMO must be prepared to assure and demonstrate
system
readiness. The HMO must execute system readiness test cycles to include
all
external data interfaces, including those with Material
Subcontractors.
HHSC,
or
its agents, may independently test whether the HMO’s MIS has the capacity to
administer the STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO business,
as
applicable to the HMO. This Readiness Review of a HMO’s MIS may include a desk
review and/or an onsite
review. HHSC may request from the HMO additional documentation to support
the
provision of STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO Services,
as
applicable to the HMO. Based in part on the HMO’s assurances of systems
readiness, information contained in the Proposal, additional documentation
submitted by the HMO, and any review conducted by HHSC or its agents, HHSC
will
assess the HMO’s understanding of its responsibilities and the HMO’s capability
to assume the MIS functions required under the Contract.
The
HMO
is required to provide a Corrective Action Plan in response to any Readiness
Review deficiency no later than ten (10) calendar days after notification
of any
such deficiency by HHSC. If the HMO documents to HHSC’s satisfaction that the
deficiency has been corrected within ten
(10)
calendar days of such deficiency notification by HHSC, no Corrective Action
Plan
is required.
The
HMO
must clearly define and document the policies and procedures that will
be
followed to support day-to-day business activities related to the provision
of
STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO Services, including
coordination with contractors. The HMO will be responsible for
developing and documenting its approach to quality assurance.
Readiness
Review. Includes all plans to be implemented in one or more Service
Areas on the anticipated Operational Start Date. At a minimum, the HMO
shall,
for each HMO Program:
1. Develop
new, or revise existing, operations procedures and associated documentation
to
support the HMO’s proposed approach to conducting operations activities in
compliance with the contracted scope of work.
2. Submit
to HHSC, a listing of all contracted and credentialed Providers, in a HHSC
approved format including a description of additional contracting and
credentialing activities scheduled to be completed before the Operational
Start
Date.
3. Prepare
and implement a Member Services staff training curriculum and a Provider
training curriculum.
4. Prepare
a Coordination Plan documenting how the HMO will coordinate its business
activities with those activities performed by HHSC contractors and the
HMO’s
Material Subcontractors, if any. The Coordination Plan will include
identification of coordinated activities and protocols for the Transition
Phase.
5. Develop
and submit to HHSC the draft Member Handbook, draft Provider Manual, draft
Provider Directory, and draft Member Identification Card for HHSC’s review and
approval. The materials must at a minimum meet the requirements specified
in
Section 8.1.5
and include the Critical Elements to be defined in the HHSC
Uniform Managed Care Manual.
6. Develop
and submit to HHSC the HMO’s proposed Member complaint and appeals processes for
Medicaid, CHIP, and CHIP Perinatal as applicable to the HMO’s Program
participation.
7. Provide
sufficient copies of the final Provider Directory to the HHSC Administrative
Services Contractor in sufficient time to meet the enrollment
schedule.
8. Demonstrate
toll-free telephone systems and reporting capabilities for the Member Services
Hotline, the Behavioral Health Hotline, and the Provider Services
Hotline.
9. Submit
a written Fraud and Abuse Compliance Plan to HHSC for approval no later
than 30
days after the Contract Effective Date. See Section
8.1.19, Fraud and Abuse, for the requirements of the plan, including
new requirements for special investigation units. As part of the Fraud
and Abuse
Compliance Plan, the HMO shall:
• designate
executive and essential personnel to attend mandatory training in fraud
and
abuse detection, prevention and reporting. Executive and essential fraud
and
abuse personnel means HMO staff persons who supervise staff in the following
areas: data collection, provider enrollment or disenrollment, encounter
data,
claims processing, utilization review, appeals or grievances, quality assurance
and marketing, and who are directly involved in the decision-making and
administration of the fraud and abuse detection program within the
HMO. The training will be conducted by the Office of Inspector
General, Health and Human Services Commission, and will be provided free
of
charge. The HMO must schedule and complete training no later than 90
days after the Effective Date.
• designate
an officer or director within the organization responsible for carrying
out the
provisions of the Fraud and Abuse Compliance Plan.
• The
HMO
is held to the same requirements and must ensure that, if this function
is
subcontracted to another entity, the subcontractor also meets all the
requirements in this section and the Fraud and Abuse section as stated
in
Attachment B-1, Section 8.
• Note:
STAR+PLUS HMOs who have already submitted and received HHSC’s approval for their
Fraud and Abuse Compliance Plans must submit acknowledgement that the HMO’s
approved Fraud and Abuse Compliance Plan also applies to the STAR+PLUS
program,
or submit a revised Fraud and Abuse Compliance Plan for HHSC’s approval, with an
explanation of changes to be made to incorporate the STAR+PLUS program
into the
plan, by July 10, 2006.
• CHIP
Perinatal HMOs who have already submitted and received HHSC’s approval for their
Fraud and Abuse Compliance Plans must submit acknowledgement that the HMO’s
approved Fraud and Abuse Compliance Plan also applies to the CHIP Perinatal
Program, or submit a revised Fraud and Abuse Compliance Plan for HHSC’s
approval, with an explanation of changes to be made to incorporate the
CHIP
Perinatal program into the plan, by September 15, 2006.
• Complete
hiring and training of STAR+PLUS Service Coordination staff, no later than
45
days prior to the STAR+PLUS Operational Start Date.
During
the Readiness Review, HHSC may request from the HMO certain operating procedures
and updates to documentation to support the provision of STAR, STAR+PLUS,
CHIP,
and/or CHIP Perinatal HMO Services. HHSC will assess the HMO’s
understanding of its responsibilities and the HMO’s capability to assume the
functions required under the Contract, based in part on the HMO’s assurances of
operational readiness, information contained in the Proposal, and in Transition
Phase documentation submitted by the HMO.
The
HMO
is required to promptly provide a Corrective Action Plan and/or Risk Mitigation
Plan as requested by HHSC in response to Operational Readiness Review
deficiencies identified by the HMO or by HHSC or its agent. The HMO
must promptly alert HHSC of deficiencies, and must correct a deficiency
or
provide a Corrective Action Plan and/or Risk Mitigation Plan no later than
ten
(10) calendar days after HHSC’s notification of deficiencies. If the Contractor
documents to HHSC’s satisfaction that the deficiency has been corrected within
ten (10) calendar days of such deficiency notification by HHSC, no Corrective
Action Plan is required.
7.3.1.8
Assurance of System and Operational Readiness
In
addition to successfully providing the Deliverables described in Section
7.3.1, the HMO must assure HHSC that all processes, MIS systems, and
staffed functions are ready and able to successfully assume responsibilities
for
operations prior to the Operational Start Date. In particular, the HMO
must
assure that Key HMO Personnel, Member Services staff, Provider Services
staff,
and MIS staff are hired and trained, MIS systems and interfaces are in
place and
functioning properly, communications procedures are in place, Provider
Manuals
have been distributed, and that Provider training sessions have occurred
according to the schedule approved by HHSC.
The
HMO
will work with HHSC, Providers, and Members to promptly identify and resolve
problems identified after the Operational Start Date and to communicate
to HHSC,
Providers, and Members, as applicable, the steps the HMO is taking to resolve
the problems.
If
a HMO
makes assurances to HHSC of its readiness to meet Contract requirements,
including MIS and operational requirements, but fails to satisfy requirements
set forth in this Section, or as otherwise required pursuant to the Contract,
HHSC may, at its discretion do any of the following in accordance with
the
severity of the non-compliance and the potential impact on Members and
Providers:
1. freeze
enrollment into the HMO’s plan for the affected HMO Program(s) and Service
Area(s);
2. freeze
enrollment into the HMO’s plan for all HMO Programs or for all Service Areas of
an affected HMO Program;
3. impose
contractual remedies, including liquidated damages; or
4. pursue
other equitable, injunctive, or regulatory relief.
Refer
to
Attachment B-1, Sections 8.1.1.2 and 8.1.18
for additional information regarding HMO Readiness Reviews during the Operations
Phase.
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8
Version 1.8
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version Attachment B-1, Section 8
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
version of the Attachment B-1, Section 8, that includes provisions
applicable to MCOs participating in the STAR+PLUS Program. Section
8.1.1.1, Performance Evaluation, is modified to include STAR+PLUS
Performance Improvement Goals. Section 8.1.2, Covered Services,
is modified to include Functionally Necessary Community Long-term
Care
Services for STAR+PLUS. Section 8.1.2.1 Value-Added Services, is
modified
to add language allowing for the HMO to distinguish between the Dual
Eligible and non-Dual Eligible populations. Section 8.1.2.2 Case-by-Case
Added Services, is modified to clarify for STAR+Plus members it is
based
on functionality. Section 8.1.3, Access to Care, is modified to include
STAR+PLUS Functional Necessity and 1915(c) Nursing Facility Waiver
clarifications. Section 8.1.4, Provider Network, is modified to include
STAR+PLUS. Section 8.1.4.2, Primary Care Providers, is modified
to include STAR+PLUS Section 8.1.4.8, Provider Reimbursement, is
modified
to include Functionally Necessary Long-term care services for STAR+PLUS.
Section 8.1.7.7, Provider Profiling, is modified to include STAR+PLUS.
Sections 8.1.12 and 8.1.12.2, Services for People with Special Health
Care
Needs, are modified to include STAR+PLUS. Section 8.1.13, Service
Management for Certain Populations, is modified to include STAR+PLUS.
Section 8.1.14, Disease Management, is modified to include STAR+PLUS.
Section 8.2, Additional Medicaid HMO Scope of Work, is modified to
include
STAR+PLUS. Section 8.3, Additional STAR+PLUS Scope of Work, is
added.
|
Revision
|
1.2
|
September
1, 2006
|
Revised
version of Attachment B-1, Section 8, that includes provisions applicable
to MCOs participating in the STAR and CHIP Programs. Section 8.1.1.1,
Performance Evaluation, is modified to clarify that the HMOs goals
are
Service Area and Program specific; when the percentages for Goals
1 and 2
are to be negotiated; and when Goal 3 is to be
negotiated.
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8
Version 1.8
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Section
8.1.2.1, Value-Added Services, is modified to add language allowing
for
the addition of two Value-added Services during the Transition Phase
of
the Contract and to clarify the effective dates for Value Added Services
for the Transition Phase and the Operation Phase of the Contract.
Section
8.1.3.2, Access to Network Providers, is modified to delete references
to
Open Panels. Section 8.1.4, Provider Network, is modified to clarify
that
“Out-of-Network reimbursement arrangements” with certain providers must be
in writing. Section 8.1.5.1, Member Materials, is modified to clarify
the
date that the member ID card and the member handbook are to be sent
to
members. Section 8.1.5.6, Member Hotline, is modified to clarify
the
hotline performance requirements. Section 8.1.17.2, Financial Reporting
Requirements, is modified to clarify that the Bonus Incentive Plan
refers
to the Employee Bonus Incentive Plan. It has also been modified to
clarify
the reports and deliverable due dates and to change the name of the
Claims
Summary Lag Report and clarify that the report format has been moved
to
the Uniform Managed Care Manual. Section 8.1.18.5, Claims Processing
Requirements, is modified to revise the claims processing requirements
and
move many of the specifics to the Uniform Managed Care Manual. Section
8.1.20, Reporting Requirements, is modified to clarify the reports
and
deliverable due dates. Section 8.1.20.2, Reports, is modified
to delete the Claims Data Specifications Report, amend the All Claims
Summary Report, and add two new provider-related reports to the contract.
Section 8.2.2.10, Cooperation with Immunization Registry, is added
to
comply with legislation, SB 1188 sec. 6(e)(1), 79th Legislature,
Regular
Session, 2005. Section 8.2.2.11, Case Management for Children and
Pregnant
Women, is added. Section 8.2.5.1, Provider Complaints, is modified
to
include the 30day resolution requirement. Section 8.2.10.2,
Non-Reimbursed Arrangements with Local Public Health Entities, is
modified
to update the requirements and delete the requirement for an MOU.
Section
8.2.11, Coordination with Other State Health and Human Services (HHS)
Programs, is modified to update the requirements and delete the
requirement for an MOU. Section 8.4.2, CHIP Provider Complaint and
Appeals, is modified to include the 30-day resolution
requirement.
|
|||
Revision
|
1.3
|
September
1, 2006
|
Revised
version of Attachment B-1, Section 8, that includes provisions applicable
to MCOs participating in the CHIP Perinatal
Program.
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8
Version 1.8
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Section
8.1.1.1, Performance Evaluation, is modified to clarify that HHSC
will
negotiate and implement Performance Improvement Goals for the first
full
State Fiscal Year following the CHIP Perinatal Operational Start
Date
Section 8.1.2, Covered Services is amended to: (a) clarify that Fee
For
Service will pay the Hospital costs for CHIP Perinate Newborns; (b)
add a
reference to new Attachment B-2.2 concerning covered services; (c)
add
CHIP Perinate references where appropriate. Section 8.1.2.2
Case-by-Case Added Services, is modified to clarify that this does
not
apply to the CHIP Perinatal Program. Section 8.1.3, Access to
Care, is amended to include emergency services limitations. Section
8.1.3.2, Access to Network Providers, is amended to include the Provider
access standards for the CHIP Perinatal Program. Section
8.1.4.2 Primary Care Providers, is modified to clarify the development
of
the PCP networks between the CHIP Perinates and the CHIP Perinate
Newborns. Section 8.1.4.6 Provider Manual, Materials and Training,
modified to include the CHIP Perinatal Program Section 8.1.4.9 Termination
of Provider Contracts modified to include the CHIP Perinatal Program.
Section 8.1.5.2 Member Identification (ID) Card, modified to include
the
CHIP Perinatal Program. Section 8.1.5.3 Member Handbook, modified
to
include the CHIP Perinatal Program. Section 8.1.5.4 Provider Directory,
modified to include the CHIP Perinatal Program. Section 8.1.5.6 Member
Hotline, modified to include the CHIP Perinatal Program. Section
8.1.5.7
Member Education, modified to include the CHIP Perinatal Program.
Section
8.1.5.9 Member Complaint and Appeal Process, modified to include
the CHIP
Perinatal Program. Section 8.1.7.7, Provider Profiling, is modified
to
include the CHIP Perinatal Program. Section 8.1.12, Services for
People
with Special Health Care Needs, modified to clarify between CHIP
Perinatal
Program and CHIP Perinatal Newborn. Section 8.1.13, Service Management
for
Certain Populations, modified to clarify the CHIP Perinatal Program.
Section 8.1.15, Behavioral Health (BH) Network and Services, modified
to
clarify between CHIP Perinatal and Perinate members. Section 8.1.17.2,
Financial Reporting Requirements, modified to include the CHIP Perinatal
Program. Section 8.1.18.3, System-wide Functions, modified to include
the
CHIP Perinatal Program. Section 8.1.18.5, Claims Processing Requirements,
modified to include the CHIP Perinatal
Program.
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8
Version 1.8
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Section
8.1.19, Fraud and Abuse, modified to include the CHIP Perinatal Program
Section 8.1.20.2, Provider Termination Report and Provider Network
Capacity Report, is modified to include the CHIP Perinatal Program.
Section 8.5, Additional Scope of Work for CHIP Perinatal Program
HMOs, is
added to Attachment B-1.
|
|||
Revision
|
1.4
|
September
1, 2006
|
|
Revision
|
1.5
|
January
1, 2007
|
Revised
version of the Attachment B-1, Section 8, that includes provisions
applicable to MCOs participating in the STAR and STAR+PLUS Program.
Section 8.1.2 is modified to include a reference to STAR and STAR+PLUS
covered services. Section 8.1.20.2 is modified to update the
references to the Uniform Managed Care Manual for the “Summary Report of
Member Complaints and Appeals” and the “Summary Report of Provider
Complaints.” Section 8.2.2.5 is modified to require the Provider to
coordinate with the Regional Health Authority. Section 8.2.4 is amended
to
clarify cost settlements and encounter rates for Federally Qualified
Health Centers (FQHCs) and Rural Health Clinics (RHCs) for STAR and
STAR+PLUS service areas. Section 8.3.2.4 is amended to clarify
the timeframe for initial STAR+PLUS assessments. Section 8.3.3 is
amended
to: (1) clarify the use of the DHS Form 2060; (2) require the HMO
to
complete the Individual Service Plan (ISP), Form 3671 for each Member
receiving 1915(c) Nursing Facility Waiver Services; (3) require HMOs
to
complete Form 3652 and Form 3671annually at reassessment; (4) allow
the
HMOs to administer the Minimum Data Set for Home Care (MDS-HC) instrument
for nonwaiver STAR+PLUS Members over the course of the first year of
operation; (5) allow HMOs to submit other supplemental assessment
instruments. Section 8.3.4 is modified to include the criteria
for participation in 1915(c) nursing facility waiver
services. Section 8.3.4.3 is amended to remove the six-month
timeframe for Nursing Facility Cost Ceiling. Deletes provision
stating DADS Commissioner may grant exceptions in individual cases.
Section 8.3.5 is amended to delete the requirement that HMOs use
the
Consumer Directed Services option for the delivery of Personal Attendant
Services. The new language provides HMOs with three options for delivering
these services. The options are described in the following new
subsections: 8.3.5.1, Personal Attendant Services Delivery Option
–
Self-Directed Model; 8.3.5.2, Personal Attendant Services Delivery
Option
– Agency Model, Self-Directed; and 8.3.5.3, Personal Attendant Services
Delivery Option – Agency Model. Section 8.3.7.3 is modified to reflect the
changes made by the HMO workgroup regarding enhanced payments for
attendant care. The section also includes a reference to new
Attachment B-7, which
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8
Version 1.8
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
contains
the HMO’s methodology for implementing and paying the enhanced
payments.
|
|||
Revision
|
1.6
|
February
1, 2007
|
Revised
version of the Attachment B-1, Section 8, that includes provisions
applicable to MCOs participating in the STAR+PLUS and CHIP Perinatal
Programs. Section 8.1 is modified to clarify the Operational Start
Date of
the STAR+PLUS Program. Section 8.1.3.2 is modified to allow exceptions
to
hospital access standards on a case-by-case basis only for HMOs
participating in the CHIP Perinatal Program. Section 8.3.3 is modified
to
clarify when the 12-month period begins for the STAR+PLUS HMOs to
complete
the MDS-HC instruments for non-1915(c) Nursing Facility Waiver Members
who
are receiving Community-based Long-term Care Services.
|
Revision
|
1.7
|
July
1, 0000
|
Xxx
Xxxxxxx 8.1.1.2 is added to require the HMOs to pay for any additional
readiness reviews beyond the original ones conducted before the
Operational Start Date. Section 8.1.5.5 is modified to add a requirement
that all HMOs must list Home Health Ancillary providers on their
websites,
with an indicator for Pediatric services. Section 8.1.17.2 is modified
to
remove the requirement that the Claims Lag Report separate claims
by
service categories. Section 8.1.18 is modified to update the
cross-references to sections of the contract addressing remedies
and
damages and to add cross-references to sections of the contract addressing
Readiness Reviews. Section 8.1.18.5 is modified to require the HMO
to make
an electronic funds transfer payment process available when processing
claims for Medically Necessary covered STAR+PLUS services. Section
8.1.19
is modified to comply with a new federal law that requires entities
that
receive or make Medicaid payments of at least $5 million annually
to
educate employees, contractors and agents and to implement policies
and
procedures for detecting and preventing fraud, waste and
abuse. Section 8.1.20.2 is modified to require Provider
Termination Reports for STAR+PLUS as required by the Dashboard. The
amendment also requires Claims Summary Reports be submitted by
claim type. Section 8.2.7.5 is modified to comply with the
settlement agreement in the Xxxxxxx X. litigation. Section
8.3.4.3 is modified to remove references to the cost cap for 1915(c)
Nursing Facility Waiver services.
|
Revision
|
1.8
|
September
1, 2007
|
Section
8.1.2.1 is modified to reflect legislative changes required by SB
10.
Section 8.1.3.2 is modified to reflect legislative changes required
by SB
10. Section 8.1.5.6 is modified to comply with the Xxxx litigation
corrective action plans. New Section 8.1.5.6.1 is added to comply
with the
Xxxx litigation corrective action plans. Section 8.1.5.7 is modified
to
comply with the Xxxx litigation corrective action
plans.
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8
Version 1.8
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
|
Section
8.1.11 is modified to delete language included in error and to clarify
the
coverage for children in xxxxxx care. Section 8.1.13 is
added to comply with the Xxxx litigation corrective action plans.
Section
8.1.17.2 is modified to reflect legislative changes required by SB
10.
Section 8.1.20.2 is modified to comply with the Xxxx litigation corrective
action plans by adding two new reports: Medicaid Medical Check-ups
Report
and Medicaid FWC Report. Section 8.2.2.3 is modified to comply with
Xxxx
litigation correction action plans. New Section 8.2.2.12 is added
to
comply with the Xxxx litigation correction action plans to enhance
care
for children of Migrant Farmworkers. Section 8.2.4 is modified to
clarify
cost settlement requirements and encounter and payment reporting
requirements for the Nueces Service Area and the STAR+PLUS Service
Areas.
Section 8.2.7.4 is amended to reflect the new fair hearings process
for
Medicaid Members that will be effective 9/1/07. Section
8.2.11 is modified to comply with the Xxxx litigation corrective
action
plans.
|
||||
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn versions
.
2Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision— e.g., “1.2” refers to the first
version of the document and the second revision.
3 Brief
description of the changes to the document made in the
revision.
|
This
Section is designed to provide HMOs with sufficient information to understand
the HMOs' responsibilities. This Section describes scope of work requirements
for the Operations Phase of the Contract.
Section
8.1 includes the general scope of work that applies to the STAR,
STAR+PLUS, CHIP, and CHIP Perinatal HMO Programs.
Section
8.2 includes the additional Medicaid scope of work that applies only
to
the STAR and STAR+PLUS HMOs.
Section
8.3 includes the additional scope of work that applies only to
STAR+PLUS HMOs.
Section
8.4 includes the additional scope of work that applies only to CHIP
HMOs.
Section
8.5 includes the additional scope of work that applies only to CHIP
Perinatal HMOs.
The
Section does not include detailed information on the STAR, STAR+PLUS, CHIP,
and
CHIP Perinatal HMO Program requirements, such as the time frame and format
for
all reporting requirements. HHSC has included this information in the
Uniform Managed Care Contract Terms and Conditions
(Attachment A) and the Uniform Managed Care
Manual. HHSC reserves the right to modify these documents as it deems
necessary using the procedures set forth in the Uniform Managed Care
Contract Terms and Conditions.
In
each
HMO Program Service Area, HHSC will select HMOs for each HMO Program to provide
health care services to Members. The HMO must be licensed by the Texas
Department of Insurance (TDI) as an HMO or an ANHC in all zip codes in the
respective Service Area(s).
Coverage
for benefits will be available to enrolled Members effective on the Operational
Start Date. The Operational Start Date is September 1, 2006 for STAR and CHIP
HMOs, January 1, 2007 for CHIP Perinatal HMOs, and February 1, 2007 for the
STAR+PLUS HMOs.
The
HMO
must comply, to the satisfaction of HHSC, with (1) all provisions set forth
in
this Contract, and (2) all applicable provisions of state and federal laws,
rules, regulations, and waivers.
The
HMO
must identify and propose to HHSC, in writing, no later than May 1st of each
State
Fiscal Year (SFY) after the Operational Start Date, annual HMO Performance
Improvement Goals for the next fiscal year, as well as measures and time frames
for demonstrating that such goals are being met. Performance
Improvement Goals must be based on HHSC priorities and identified opportunities
for improvement (see Attachment B-4, Performance Improvement
Goals). The Parties will negotiate such Performance Improvement Goals,
the measures that will be used to assess goal achievement, and the time frames
for completion, which will be incorporated into the Contract. If HHSC and the
HMO cannot agree on the Performance Improvement Goals, measures, or time frames,
HHSC will set the goals, measures, or time frames.
For
State
Fiscal Year 2007, HHSC has established three overarching goals for each Program.
These overarching goals are as follows:
Goal
1 (STAR and CHIP) Improve Access to Primary Care Services for
Members
Goal
2 (STAR and CHIP) Improve Access to Behavioral Health Services for
Members,
Goal
3 (STAR Only) Improve Access to Clinically Appropriate Alternatives
to Emergency Room Services Outside of Regular Office Hours (CHIP
Only) Improve Current Member Understanding About the CHIP Benefit
Renewal Processes
Note: The
HMO is required to propose customized sub-goals specific to the HMO’s Service
Areas and Programs for all overarching goals. The sub-goals must be
approved by HHSC as part of the negotiation process.
The
specific percentages of expected achievement for each sub-goal will be
negotiated by HHSC and the HMO before the Operational Start Date.
For
STAR+PLUS HMOs, HHSC will negotiate and implement Performance Improvement Goals
for the first full fiscal year following the STAR+PLUS Operational Start
Date. One standard STAR+PLUS goal will relate to Consumer-Directed
Services. STAR+PLUS improvement goals for SFY2008 will be included in
Attachment B-4.1.
For
CHIP
Perinatal HMOs, HHSC will negotiate and implement Performance Improvement Goals
for the first full State Fiscal Year following the CHIP Perinatal Operational
Start Date.
The
HMO
must participate in semi-annual Contract Status Meetings (CSMs) with HHSC for
the primary purpose of reviewing progress toward the achievement of annual
Performance Improvement Goals and Contract requirements. HHSC may
request additional CSMs, as it deems necessary to address areas of
noncompliance. HHSC will provide the HMO with reasonable advance
notice of additional CSMs, generally at least five (5) business
days.
The
HMO
must provide to HHSC, no later than 14 business days prior to each semi-annual
CSM, one electronic copy of a written update, detailing and documenting the
HMO’s progress toward meeting the annual Performance Improvement Goals or other
areas of noncompliance.
HHSC
will
track HMO performance on Performance Improvement Goals. It will also
track other key facets of HMO performance through the use of a
Performance Indicator Dashboard (see HHSC’s Uniform Managed Care
Manual). HHSC will compile the Performance Indicator Dashboard based on
HMO submissions, data from the External Quality Review Organization (EQRO),
and
other data available to HHSC. HHSC will share the Performance
Indicator Dashboard with the HMO on a quarterly basis.
During
the Operations Phase, a HMO that chooses to make a change to any operational
system or undergo any major transition may be subject to an additional Readiness
Review(s). HHSC will determine whether the proposed changes will
require a desk review and/or an onsite review. The HMO is responsible
for all costs incurred by HHSC or its authorized agent to conduct an onsite
Readiness Review.
Refer
to
Attachment X-0, Xxxxxxx 0 xxx Xxxxxxxxxx X-0, Section
8.1.18 for additional information regarding HMO Readiness Reviews.
Refer to Attachment A, Section 4.08(c) for information
regarding Readiness Reviews of the HMO’s Material Subcontractors.
The
HMO
is responsible for authorizing, arranging, coordinating, and providing Covered
Services in accordance with the requirements of the Contract. The HMO must
provide Medically Necessary Covered Services to all Members beginning on the
Member’s date of enrollment regardless of pre-existing conditions, prior
diagnosis and/or receipt of any prior health care services. STAR+PLUS HMOs
must
also provide Functionally Necessary Community Long-term Care Services to all
Members beginning on the Member’s date of enrollment regardless of
preexisting conditions, prior diagnosis and/or receipt of any prior health
care services. The HMO must not impose any pre-existing condition limitations
or
exclusions or require Evidence of Insurability to provide coverage to any
Member.
The
HMO
must provide full coverage for Medically Necessary Covered Services to all
Members and, for STAR+PLUS Members, Functionally Necessary Community Long-term
Care Services, without regard to the Member’s:
1.
previous coverage, if any, or the reason for termination of such
coverage;
2.
health
status;
3.
confinement in a health care facility; or
4.
for
any other reason.
(STAR
HMOs): A Member cannot change from one STAR HMO to another STAR HMO during
an
inpatient hospital stay. The STAR HMO responsible for the hospital charges
for
STAR Members at the start of an Inpatient Stay remains responsible for hospital
charges until the time of discharge or until such time that there is a loss
of
Medicaid eligibility. STAR HMOs are responsible for professional charges during
every month for which the HMO receives a full capitation for a
Member.
(STAR+PLUS
HMOs): A Member cannot change from one STAR+PLUS HMO to another STAR+PLUS HMO
during an inpatient hospital stay. The STAR+PLUS HMO is responsible for
authorization and management of the inpatient hospital stay until the time
of
discharge, or until such time that there is a loss of Medicaid
eligibility. STAR+PLUS HMOs are responsible for professional charges
during every month for which the HMO receives a full capitation for a
Member.
A
Member
cannot change from one STAR+PLUS HMO to another STAR+PLUS HMO during a nursing
facility stay.
(CHIP
HMOs): If a CHIP Member’s Effective Date of Coverage occurs while the CHIP
Member is confined in a hospital, HMO is responsible for the CHIP Member’s costs
of Covered Services beginning on the Effective Date of Coverage. If a
CHIP Member is disenrolled while the CHIP Member is confined in a hospital,
HMO’s responsibility for the CHIP Member’s costs of Covered Services terminates
on the Date of Disenrollment.
(CHIP
Perinatal HMOs): If a CHIP Perinate’s Effective Date of Coverage occurs while
the CHIP Perinate is confined in a Hospital, HMO is responsible for the CHIP
Perinate’s costs of Covered Services beginning on the Effective Date of
Coverage. If a CHIP Perinate is disenrolled while the CHIP Perinate is confined
in a Hospital, HMO’s responsibility for the CHIP Perinate’s costs of Covered
Services terminates on the Date of Disenrollment.
The
HMO
must not practice discriminatory selection, or encourage segregation among
the
total group of eligible Members by excluding, seeking to exclude, or otherwise
discriminating against any group or class of individuals.
Covered
Services for all Medicaid HMO Members are listed in Attachments B-2 and
B-2.1 of the Contract (STAR and STAR+PLUS Covered Services). As noted
in Attachments B-2 and B-2.1, all Medicaid HMOs must provide
Covered Services described in the most recent Texas Medicaid Provider
Procedures Manual (Provider Procedures Manual), the THSteps
Manual (a supplement to the Provider Procedures Manual), and in all
Texas Medicaid Bulletins, which update the Provider Procedures
Manual except for those services identified in Section 8.2.2.8
as non-capitated services. A description of CHIP Covered Services and exclusions
is provided in Attachment B-2 of the Contract. A description of
CHIP Perinatal Program Covered Services and exclusions is provided in
Attachment B-2.2 of the Contract. Covered Services are subject
to change due to changes in federal and state law, changes in Medicaid, CHIP
or
CHIP Perinatal Program policy, and changes in medical practice, clinical
protocols, or technology.
HMOs
may
propose additional services for coverage. These are referred to as “Value-added
Services.” Value-added Services may be actual Health Care Services, benefits, or
positive incentives that HHSC determines will promote healthy lifestyles and
improved health outcomes among Members. Value-added Services that
promote healthy lifestyles should target specific weight loss, smoking
cessation, or other programs approved by HHSC. Temporary phones, cell phones,
additional transportation benefits, and extra home health services may be
Value-added Services, if approved by HHSC. Best practice approaches
to delivering Covered Services are not considered Value-added
Services.
If
offered, Value-added Services must be offered to all mandatory STAR, and CHIP
and CHIP Perinatal HMO Members within the applicable HMO Program and Service
Area. For STAR+PLUS Acute Care services, the HMO may distinguish between the
Dual Eligible and non-Dual Eligible populations. Value-added Services do not
need to be consistent across more than one HMO Program or across more than
one
Service Area. Value-added Services that are approved by HHSC during the
contracting process will be included in the Contract’s scope of
services.
The
HMO
must provide Value-added Services at no additional cost to HHSC. The HMO must
not pass on the cost of the Value-added Services to Providers. The HMO must
specify the conditions and parameters regarding the delivery of the Value-added
Services in the HMO’s Marketing Materials and Member Handbook, and must clearly
describe any limitations or conditions specific to the Value-added
Services.
Transition
Phase. During the Transition Phase, HHSC will offer a
one-time opportunity for the HMO to propose two additional Value-added Services
to its list of current, approved Value-added Services. (See Attachment
B-3, Value-Added Services). HHSC will establish the requirements and
the timeframes for submitting the two additional proposed Value-added
Services.
During
this HHSC-designated opportunity, the HMO may propose either to add new
Value-added Services or to enhance its current, approved Value-added
Services. The HMO may propose two additional Value-added Services per
HMO Program, and the services do not have to be the same for each HMO
Program. HHSC will review the proposed additional services and, if
appropriate, will approve the additional Value-added Services, which will be
effective on the Operational Start Date. The HMO’s Contract will be amended to
reflect the additional, approved Value-added Services.
The
HMO
does not have to add Value-added Services during the HHSC-designated
opportunity, but this will be the only time during the Transition Phase for
the
HMO to add Value-added Services. At no time during the Transition Phase will
the
HMO be allowed to delete, limit or restrict any of its current, approved
Value-added Services.
Operations
Phase. During the Operations Phase, Value-added Services can be added
or removed only by written amendment of the Contract one time per fiscal year
to
be effective September 1 of the fiscal year, except when services are amended
by
HHSC during the fiscal year. This will allow HHSC to coordinate with
annual revisions to HHSC’s HMO Comparison Charts for Members. A HMO’s request to
add or delete a Value-added Service must be submitted
to
HHSC
by May 1 of each year to be effective September 1 for the following contract
period. (For STAR and CHIP, see Attachment B-3, Value-Added
Services. For STAR+PLUS, see Attachment B-3.1, STAR+PLUS
Value-Added Services. For CHIP Perinatal, see Attachment B-3.2,
CHIP Perinatal Value-Added Services.)
A
HMO’s
request to add a Value-added Service must:
a Define
and describe the proposed Value-added Service;
b Specify
the Service Areas and HMO Programs for the proposed Value-added
Service;
c Identify
the category or group of mandatory Members eligible to receive the Value-added
Service if it is a type of service that is not appropriate for all mandatory
Members;
d Note
any
limits or restrictions that apply to the Value-added Service;
e Identify
the Providers responsible for providing the Value-added Service;
f Describe
how the HMO will identify the Value-added Service in administrative (Encounter)
data;
g Propose
how and when the HMO will notify Providers and mandatory Members about the
availability of such Value-added Service;
h Describe
how a Member may obtain or access the Value-added Service; and
i Include
a
statement that the HMO will provide such Value-added Service for at least 12
months from the September 1 effective date.
A
HMO
cannot include a Value-added Service in any material distributed to mandatory
Members or prospective mandatory Members until the Parties have amended the
Contract to include that Value-added Service. If a Value-added Service is
deleted by amendment, the HMO must notify each mandatory Member that the service
is no longer available through the HMO. The HMO must also revise all materials
distributed to prospective mandatory Members to reflect the change in
Value-added Services.
Except
as
provided below, the HMO may offer additional benefits that are outside the
scope
of services to individual Members on a case-by-case basis, based on Medical
Necessity, cost-effectiveness, the wishes of the Member/Member’s family, the
potential for improved health status of the Member, and for STAR+PLUS Members
based on functional necessity.
Section
8.1.2.2, Case-by-Case Added Services, does not apply to the CHIP Perinatal
Program.
8.1.3
Access to Care
All
Covered Services must be available to Members on a timely basis in accordance
with medically appropriate guidelines, and consistent with generally accepted
practice parameters, requirements in this Contract. The HMO must comply with
the
access requirements as established by the Texas Department of Insurance (TDI)
for all HMOs doing business in Texas, except as otherwise required by this
Contract. Medicaid HMOs must be responsive to the possibility of increased
Members due to the phase-out of the PCCM model in Service Areas where adequate
HMO coverage exists.
The
HMO
must provide coverage for Emergency Services to Members 24 hours a day and
7
days a week, without regard to prior authorization or the Emergency Service
provider’s contractual relationship with the HMO. The HMO’s policy and
procedures, Covered Services, claims adjudication methodology, and reimbursement
performance for Emergency Services must comply with all applicable state and
federal laws and regulations, whether the provider is in-network or
Out-of-Network. A HMO is not responsible for payment for unauthorized
non-emergency services provided to a Member by Out-of-Network
providers.
The
HMO
must also have an emergency and crisis Behavioral Health Services Hotline
available 24 hours a day, 7 days a week, toll-free throughout the Service Area.
The Behavioral Health Services Hotline must meet the requirements described
in
Section 8.1.15. For Medicaid Members, a HMO must provide
coverage for Emergency Services in compliance with 42 C.F.R. §438.114, and as
described in more detail in Section 8.2.2.1. The HMO may
arrange Emergency Services and crisis Behavioral Health Services through mobile
crisis teams.
For
CHIP
Members, Emergency Services, including emergency Behavioral Health Services,
must be provided in accordance with the Texas Insurance Code and TDI
regulations.
For
the
CHIP Perinatal Program, refer to Attachment B-2.2 for description of emergency
services for CHIP Perinates and CHIP Perinate Newborns.
For
the
STAR, STAR+PLUS, and CHIP Programs, and for CHIP Perinate Newborns, HMO must
require, and make best efforts to ensure, that PCPs are accessible to Members
24
hours a day, 7 days a week and that its Network Primary Care Providers (PCPs)
have after-hours telephone availability that is consistent with, Section
8.1.4. CHIP Perinatal HMOs are not required to establish PCP Networks
for CHIP Perinates.
The
HMO
must provide that if Medically Necessary Covered Services are not available
through Network physicians or other Providers, the HMO must, upon the request
of
a Network physician or other Provider, within the time appropriate to the
circumstances relating to the delivery of the services and the condition of
the
patient, but in no event to exceed five business days after receipt of
reasonably requested documentation, allow a referral to a non-network physician
or provider. The HMO must fully reimburse the non-network provider in accordance
with the Out-of-Network methodology for Medicaid as defined by HHSC, and for
CHIP, at the usual and customary rate defined by TDI in 28 T.A.C. Section
11.506.
The
Member will not be responsible for any payment for Medically Necessary Covered
Services, including Functionally Necessary Covered Services, other
than:
(1)
HHSC-specified co-payments for CHIP Members, where applicable; and
(2)
STAR+PLUS Members who qualify for 1915(c) Nursing Facility Waiver services
and
enter a 24-hour setting will be required to pay the provider of care room and
board costs and any income in excess of the personal needs allowance, as
established by HHSC. If the HMO provides Members who do not qualify
for the 1915(c) Nursing Facility Waiver services
in a 24-hour setting as an alternative to nursing facility or hospitalization,
the Member will be required to pay the provider of care room and board costs
and
any income in excess of the personal needs allowance, as established by
HHSC.
Through
its Provider Network composition and management, the HMO must ensure that
appointments for the following types of Covered Services are provided within
the
time frames specified below. In all cases below, “day” is defined as a calendar
day.
1 Emergency
Services must be provided upon Member presentation at the service delivery
site,
including at non-network and out-of-area facilities;
2 Urgent
care, including urgent specialty care, must be provided within 24 hours of
request.
3 Routine
primary care must be provided within 14 days of request;
4 Initial
outpatient behavioral health visits must be provided within 14 days of
request;
5 Routine
specialty care referrals must be provided within 30 days of
request;
6 Pre-natal
care must be provided within 14 days of request, except for high-risk
pregnancies or new Members in the third trimester, for whom an appointment
must
be offered within five days, or immediately, if an emergency
exists;
7 Preventive
health services for adults must be offered to a Member within 90 days of
request; and
8 Preventive
health services for children, including well-child check-ups should be offered
to Members in accordance with the American Academy of Pediatrics (AAP)
periodicity schedule. Please note that for Medicaid Members, HMOs should use
the
THSteps Program modifications to the AAP periodicity schedule. For newly
enrolled Members under age 21, overdue or upcoming well-child checkups,
including THSteps medical checkups, should be offered as soon as practicable,
but in no case later than 14 days of enrollment for newborns, and no later
than
60 days of enrollment for all other eligible child Members.
The
HMO’s
Network shall have within its Network, PCPs in sufficient numbers, and with
sufficient capacity, to provide timely access to regular and preventive
pediatric care and THSteps services to all child Members in accordance with
the
waiting times for appointments in Section
8.1.3.1
PCP
Access: At a minimum, the HMO must ensure that all Members have access
to an age-appropriate PCP in the Provider Network with an Open Panel within
30
miles of the Member’s residence. For the purposes of assessing compliance with
this requirement, an internist who provides primary care to adults only is
not
considered an age-appropriate PCP choice for a Member under age 21, and a
pediatrician is not considered an age-appropriate choice for a Member age 21
and
over. Note: This provision does not apply to CHIP Perinates,
but it does apply to CHIP Perinate Newborns.
OB/GYN
Access and CHIP Perinatal Program Provider Access: STAR, STAR+PLUS and
CHIP Program Network: at a minimum, STAR, STAR+PLUS and CHIP HMOs
must ensure that all female Members have access to an OB/GYN in the Provider
Network within 75 miles of the
Member’s
residence. (If the OB/GYN is acting as the Member’s PCP, the HMO must follow the
access requirements for the PCP.) The HMO must allow female Members to select
an
OB/GYN within its Provider Network. A female Member who selects an OB/GYN must
be allowed direct access to the OB/GYN’s health care services without a referral
from the Member’s PCP or a prior authorization. A pregnant Member with 12 weeks
or less remaining before the expected delivery date must be allowed to remain
under the Member’s current OB/GYN care though the Member’s post-partum checkup,
even if the OB/GYN provider is, or becomes, Out-of-Network.
CHIP
Perinatal Program Network: At a minimum, CHIP Perinatal HMOs must
ensure that CHIP Perinates have access to a Provider of perinate services within
75 miles of the Member’s residence if the Member resides in an urban area and
within 125 miles of the Member’s residence if the Member resides in a rural
area.
Outpatient
Behavioral Health Service Provider Access: At a minimum, the HMO must
ensure that all Members except CHIP Perinates have access to an outpatient
Behavioral Health Service Provider in the Network within 75 miles of the
Member’s residence. Outpatient Behavioral Health Service Providers must include
Masters and Doctorate-level trained practitioners practicing independently
or at
community mental health centers, other clinics or at outpatient hospital
departments. A Qualified Mental Health Provider (QMHP), as defined and
credentialed by the Texas Department of State Health Services standards (T.A.C.
Title 25, Part I, Chapter 412), is an acceptable outpatient behavioral health
provider as long as the QMHP is working under the authority of an MHMR entity
and is supervised by a licensed mental health professional or
physician.
Other
Specialist Physician Access: At a minimum, the HMO must ensure that all
Members except CHIP Perinates have access to a Network specialist physician
within 75 miles of the Member’s residence for common medical specialties. For
adult Members, common medical specialties shall include general surgery,
cardiology, orthopedics, urology, and ophthalmology. For child Members, common
medical specialties shall include orthopedics and otolaryngology. In addition,
all Members must be allowed to: 1) select an in-network opthalmologist or
therapeutic optometrist to provide eye Health Care Services, other than surgery,
and 2) have access without a PCP referral to eye Health Care Services from
a
Network specialist who is an ophthalmologist or therapeutic optometrist for
non-surgical services.
Hospital
Access: The HMO must ensure that all Members have access to an Acute
Care hospital in the Provider Network within 30 miles of the Member’s
residence. For HMOs participating in the CHIP Perinatal Program,
exceptions to this access standard may be requested on a case-bycase basis
and must have HHSC approval.
All
other Covered Services, except for services provided in the Member’s
residence: At a minimum, the HMO must ensure that all Members have
access to at least one Network Provider for each of the remaining Covered
Services described in Attachment B-2, within 75 miles of the
Member’s residence. This access requirement includes, but is not limited to,
specialists, specialty hospitals, psychiatric hospitals, diagnostic and
therapeutic services, and single or limited service health care physicians
or
Providers, as applicable to the HMO Program.
The
HMO
is not precluded from making arrangements with physicians or providers outside
the HMO’s Service Area for Members to receive a higher level of skill or
specialty than the level
available
within the Service Area, including but not limited to, treatment of cancer,
xxxxx, and cardiac diseases. HHSC may consider exceptions to the above
access-related requirements when an HMO has established, through utilization
data provided to HHSC, that a normal pattern for securing health care services
within an area does not meet these standards, or when an HMO is providing care
of a higher skill level or specialty than the level which is available within
the Service Area such as, but not limited to, treatment of cancer, xxxxx, and
cardiac diseases.
The
HMO
is required to systematically and regularly verify that Covered Services
furnished by Network Providers are available and accessible to Members in
compliance with the standards described in Sections 8.1.3.1 and
8.1.3.2, and for Covered Services furnished by PCPs, the standards
described in Section 8.1.4.2.
The
HMO
must enforce access and other Network standards required by the Contract and
take appropriate action with Providers whose performance is determined by the
HMO to be out of compliance.
8.1.4
Provider Network
The
HMO
must enter into written contracts with properly credentialed Providers as
described in this Section. The Provider contracts must comply with the
Uniform Managed Care Manual’s requirements.
The
HMO
must maintain a Provider Network sufficient to provide all Members with access
to the full range of Covered Services required under the Contract. The HMO
must
ensure its Providers and subcontractors meet all current and future state and
federal eligibility criteria, reporting requirements, and any other applicable
rules and/or regulations related to the Contract.
The
Provider Network must be responsive to the linguistic, cultural, and other
unique needs of any minority, elderly, or disabled individuals, or other special
population in the Service Areas and HMO Programs served by the HMO, including
the capacity to communicate with Members in languages other than English, when
necessary, as well as with those who are deaf or hearing impaired.
The
HMO
must seek to obtain the participation in its Provider Network of qualified
providers currently serving the Medicaid and CHIP Members in the HMO’s proposed
Service Area(s).
NOTE:
The following Provider descriptions do not require STAR+PLUS HMOs to contract
with Hospital providers for Inpatient Stay services. STAR+PLUS HMOs are
required, however, to contract with Hospitals for Outpatient Hospital
Services.
All
Providers: All Providers must be licensed in the State of Texas to
provide the Covered Services for which the HMO is contracting with the Provider,
and not be under sanction or exclusion from the Medicaid program. All Acute
Care
Providers serving Medicaid Members must be enrolled as Medicaid providers and
have a Texas Provider Identification Number (TPIN). Long-term Care Providers
are
not required to have a TPIN but must have a LTC Provider
number. Providers
must also have a National Provider Identifier (NPI) in accordance with the
timelines established in 45 C.F.R. Part 162, Subpart D (for most Providers,
the
NPI must be in place by May 23, 2007.)
Inpatient
hospital and medical services: The HMO must ensure that Acute Care
hospitals and specialty hospitals are available and accessible 24 hours per
day,
seven days per week, within the HMO’s Network to provide Covered Services to
Members throughout the Service Area.
Children’s
Hospitals/hospitals with specialized pediatric services: The HMO must
ensure Members access to hospitals designated as Children’s Hospitals by
Medicare and hospitals with specialized pediatric services, such as teaching
hospitals and hospitals with designated children’s wings, so that these services
are available and accessible 24 hours per day, seven days per week, to provide
Covered Services to Members throughout the Service Area. The HMO must make
Out-of-Network reimbursement arrangements with a designated Children’s Hospital
and/or hospital with specialized pediatric services in proximity to the Member’s
residence, and such arrangements must be in writing, if the HMO does not include
such hospitals in its Provider Network. Provider Directories, Member materials,
and Marketing materials must clearly distinguish between hospitals designated
as
Children’s Hospitals and hospitals that have designated children’s
units.
Trauma:
The HMO must ensure Members access to Texas Department of State Health Services
(TDSHS) designated Level I and Level II trauma centers within the State or
hospitals meeting the equivalent level of trauma care in the HMO’s Service Area,
or in close proximity to such Service Area. The HMO must make Out-of-Network
reimbursement arrangements with the DSHS-designated Level I and Level II trauma
centers or hospitals meeting equivalent levels of trauma care, and such
arrangements must be in writing, if the HMO does not include such a trauma
center in its Provider Network.
Transplant
centers: The HMO must ensure Member access to HHSC-designated
transplant centers or centers meeting equivalent levels of care. A list of
HHSC-designated transplant centers can be found in the Procurement Library
in
Attachment H. The HMO must make Out-of-Network reimbursement arrangements with
a
designated transplant center or center meeting equivalent levels of care in
proximity to the Member’s residence, and such arrangements must be in writing,
if the HMO does not include such a center in its Provider Network.
Hemophilia
centers: The HMO must ensure Member access to hemophilia centers
supported by the Centers for Disease Control (CDC). A list of these hemophilia
centers can be found at xxxx://xxx.xxx.xxx/xxxxxx/xxx/xxx_xxxx.xxx. The HMO
must
make Out-of-Network reimbursement arrangements with a CDC-supported hemophilia
center, and such arrangements must be in writing, if the HMO does not include
such a center in its Provider Network.
Physician
services: The HMO must ensure that Primary Care Providers are available
and accessible 24 hours per day, seven days per week, within the Provider
Network. The HMO must contract with a sufficient number of participating
physicians and specialists within each Service Area to comply with the access
requirements throughout Section 8.1.3 and meet the needs of
Members for all Covered Services.
The
HMO
must ensure that an adequate number of participating physicians have admitting
privileges at one or more participating Acute Care hospitals in the Provider
Network to ensure that necessary admissions are made. In no case may
there be less than one in-network PCP with admitting privileges available and
accessible 24 hours per day, seven days per week for each Acute Care hospital
in
the Provider Network.
The
HMO
must ensure that an adequate number of participating specialty physicians have
admitting privileges at one or more participating hospitals in the HMO’s
Provider Network to ensure necessary admissions are made. The HMO
shall require that all physicians who admit to hospitals maintain hospital
access for their patients through appropriate call coverage.
Laboratory
services: The HMO must ensure that in-network reference laboratory
services must be of sufficient size and scope to meet the non-emergency and
emergency needs of the enrolled population and the access requirements
in Section 8.1.3. Reference laboratory specimen procurement
services must facilitate the provision of clinical diagnostic services for
physicians, Providers and Members through the use of convenient reference
satellite labs in each Service Area, strategically located specimen collection
areas in each Service Area, and the use of a courier system under the management
of the reference lab. For Medicaid Members, THSteps requires that laboratory
specimens obtained as part of a THSteps medical checkup visit must be sent
to
the TDSHS Laboratory.
Diagnostic
imaging: The HMO must ensure that diagnostic imaging services are
available and accessible to all Members in each Service Area in accordance
with
the access standards in Section 8.1.3. The HMO must ensure that
diagnostic imaging procedures that require the injection or ingestion of
radiopaque chemicals are performed only under the direction of physicians
qualified to perform those procedures.
Home
health services: The HMO must have a contract(s) with a home health
Provider so that all Members living within the HMO’s Service Area will have
access to at least one such Provider for home health Covered Services. (These
services are provided as part of the Acute Care Covered Services, not the
Community Long-term Care Services.)
Community
Long-term Care services: STAR+PLUS HMOs must have contracts with
Community Long-term Care service Providers, so that all Members living within
the Contractor’s Service Area will have access to Medically Necessary and
Functionally Necessary Covered Services.
The
HMO
is prohibited from requiring a provider or provider group to enter into an
exclusive contracting arrangement with the HMO as a condition for participation
in its Provider Network.
The
HMO’s
contract with health care Providers must be in writing, must be in compliance
with applicable federal and state laws and regulations, and must include minimum
requirements specified in the Uniform Managed Care Contract Terms and
Conditions (Attachment A) and HHSC’s Uniform Managed Care
Manual.
The
HMO
must submit model Provider contracts to HHSC for review during Readiness
Review. HHSC retains the right to reject or require changes to any
model Provider contract that does not comply with HMO Program requirements
or
the HHSC-HMO Contract.
The
HMO’s
PCP Network may include Providers from any of the following practice areas:
General Practice; Family Practice; Internal Medicine; Pediatrics;
Obstetrics/Gynecology (OB/GYN); Certified Nurse Midwives (CNM) and Physician
Assistants (PAs) practicing under the supervision of a physician; Federally
Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and similar
community clinics; and specialist physicians who are willing to provide a
Medical Home to selected Members with special needs and conditions. Section
533.005(a)(13), Government Code, requires the HMO to use Pediatric and Family
Advanced Practice Nurses practicing under the supervision of a physician as
PCPs
in its Provider Network for STAR and STAR+PLUS.
CHIP
Perinatal HMOs are not required to develop PCP Networks for CHIP Perinates.
CHIP
Perinatal HMOs may use the same PCP Network for CHIP Members and CHIP Perinatal
Newborns.
An
internist or other Provider who provides primary care to adults only is not
considered an age-appropriate PCP choice for a Member under age 21. An internist
or other Provider who provides primary care to adults and children may be a
PCP
for children if:
1 the
Provider assumes all HMO PCP responsibilities for such Members in a specific
age
group under age 21,
2 the
Provider has a history of practicing as a PCP for the specified age group as
evidenced by the Provider’s primary care practice including an established
patient population under age 20 and within the specified age range,
and
3 the
Provider has admitting privileges to a local hospital that includes admissions
to pediatric units.
A
pediatrician is not considered an age-appropriate choice for a Member age 21
and
over.
The
PCP
for a Member with disabilities, Special Health Care Needs, or Chronic or Complex
Conditions may be a specialist physician who agrees to provide PCP services
to
the Member. The specialty physician must agree to perform all PCP duties
required in the Contract and PCP duties must be within the scope of the
specialist’s license. Any interested person may initiate the request through the
HMO for a specialist to serve as a PCP for a Member with disabilities, Special
Health Care Needs, or Chronic or Complex Conditions. The HMO shall handle such
requests in accordance with 28 T.A.C. Part 1, Chapter 11, Subchapter
J.
PCPs
who
provide Covered Services for STAR, CHIP, and CHIP Perinatal Newborns must either
have admitting privileges at a Hospital that is part of the HMO’s Provider
Network or make referral arrangements with a Provider who has admitting
privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting
privileges at a Medicaid Hospital or make referral arrangements with a Provider
who has admitting privileges to a Medicaid Hospital.
The
HMO
must require, through contract provisions, that PCPs are accessible to Members
24 hours a day, 7 days a week. The HMO is encouraged to include in its Network
sites that offer primary care services during evening and weekend hours. The
following are acceptable and unacceptable telephone arrangements for contacting
PCPs after their normal business hours.
Acceptable
after-hours coverage:
1 The
office telephone is answered after-hours by an answering service, which meets
language requirements of the Major Population Groups and which can contact
the
PCP or another designated medical practitioner. All calls answered by
an answering service must be returned within 30 minutes;
2 The
office telephone is answered after normal business hours by a recording in
the
language of each of the Major Population Groups served, directing the patient
to
call another number to reach the PCP or another provider designated by the
PCP.
Someone must be available to answer the designated provider’s telephone. Another
recording is not acceptable; and
3 The
office telephone is transferred after office hours to another location where
someone will answer the telephone and be able to contact the PCP or another
designated medical practitioner, who can return the call within 30
minutes.
Unacceptable
after-hours coverage:
1 The
office telephone is only answered during office hours;
2 The
office telephone is answered after-hours by a recording that tells patients
to
leave a message;
3 The
office telephone is answered after-hours by a recording that directs patients
to
go to an Emergency Room for any services needed; and
4 Returning
after-hours calls outside of 30 minutes.
The
HMO
must require PCPs, through contract provisions or Provider Manual, to provide
children under the age of 21 with preventive services in accordance with the
AAP
recommendations for CHIP Members and CHIP Perinate Newborns, and the THSteps
periodicity schedule published in the THSteps Manual for Medicaid Members.
The
HMO must require PCPs, through contract provisions or Provider Manual, to
provide adults with preventive services in accordance with the U.S. Preventive
Services Task Force requirements. The HMO must make best efforts to ensure
that
PCPs follow these periodicity requirements for children and adult Members.
Best
efforts must include, but not be limited to, Provider education, Provider
profiling, monitoring, and feedback activities.
The
HMO
must require PCPs, through contract provisions or Provider Manual, to assess
the
medical needs of Members for referral to specialty care providers and provide
referrals as needed. PCPs must coordinate Members’ care with specialty care
providers after referral. The HMO must make best efforts to ensure that PCPs
assess Member needs for referrals and make such referrals. Best efforts must
include, but not be limited to, Provider education activities and review of
Provider referral patterns.
The
HMO
must furnish each PCP with a current list of enrolled Members enrolled or
assigned to that Provider no later than five (5) working days after the HMO
receives the Enrollment File from the HHSC Administrative Services Contractor
each month. The HMO may offer and provide such enrollment information in
alternative formats, such as through access to a secure Internet site, when
such
format is acceptable to the PCP.
The
HMO
must review, approve and periodically recertify the credentials of all
participating physician Providers and all other licensed Providers who
participate in the HMO’s Provider Network. The HMO may subcontract with another
entity to which it delegates such credentialing activities if such delegated
credentialing is maintained in accordance with the National Committee for
Quality Assurance (NCQA) delegated credentialing requirements and any comparable
requirements defined by HHSC.
At
a
minimum, the scope and structure of a HMO’s credentialing and re-credentialing
processes must be consistent with recognized HMO industry standards such as
those provided by NCQA and relevant state and federal regulations including
28
T.A.C. §11.1902, relating to credentialing of providers in HMOs, and as an
additional requirement for Xxxxxxxx XXXx, 00 C.F.R. §438.214(b). The initial
credentialing process, including application, verification of information,
and a
site visit (if applicable), must be completed before the effective date of
the
initial contract with the physician or Provider. The re-credentialing process
must occur at least every three years.
The
re-credentialing process must take into consideration Provider performance
data
including, but not be limited to, Member Complaints and Appeals, quality of
care, and utilization management.
The
HMO
must maintain a policy with respect to Board Certification for PCPs and
specialty physicians that encourage participation of board certified PCPs and
specialty physicians in the Provider Network. The HMO must make information
on
the percentage of Board-certified PCPs in the Provider Network and the
percentage of Board-certified specialty physicians, by specialty, available
to
HHSC upon request.
The
HMO
must prepare and issue a Provider Manual(s), including any necessary specialty
manuals (e.g., behavioral health) to all existing Network
Providers. For newly contracted Providers, the HMO must issue copies
of the Provider Manual(s) within five (5) working days from inclusion of the
Provider into the Network. The Provider Manual must contain sections relating
to
special requirements of the HMO Program(s) and the enrolled populations in
compliance with the requirements of this Contract.
HHSC
or
its designee must approve the Provider Manual, and any substantive revisions
to
the Provider Manual, prior to publication and distribution to
Providers. The Provider Manual must contain the critical elements
defined in the
Uniform
Managed Care Manual. HHSC’s initial review of the Provider Manual is
part of the Operational Readiness Review described in Attachment B-1,
Section 7.
The
HMO
must provide training to all Providers and their staff regarding the
requirements of the Contract and special needs of Members. The HMO’s Medicaid,
CHIP and/or CHIP Perinatal Program training must be completed within 30 days
of
placing a newly contracted Provider on active status. The HMO must provide
on-going training to new and existing Providers as required by the HMO or HHSC
to comply with the Contract. The HMO must maintain and make available upon
request enrollment or attendance rosters dated and signed by each attendee
or
other written evidence of training of each Provider and their
staff.
The
HMO
must establish ongoing Provider training that includes, but is not limited
to,
the following issues:
1 Covered
Services and the Provider’s responsibilities for providing and/or coordinating
such services. Special emphasis must be placed on areas that vary from
commercial coverage rules (e.g., Early Intervention services, therapies and
DME/Medical Supplies); and for Medicaid, making referrals and coordination
with
Non-capitated Services;
2 Relevant
requirements of the Contract;
3 The
HMO’s
quality assurance and performance improvement program and the Provider’s role in
such a program; and
4 The
HMO’s
policies and procedures, especially regarding in-network and Out-of-Network
referrals.
Provider
Materials produced by the HMO, relating to Medicaid Managed Care, the CHIP
Program, and/or the CHIP Perinatal Program must be in compliance with State
and
Federal laws and requirements of the HHSC Uniform Managed Care Contract
Terms and Conditions. HMO must make available any provider materials to
HHSC upon request.
The
HMO
must operate a toll-free telephone line for Provider inquiries from 8 a.m.
to 5
p.m. local time for the Service Area, Monday through Friday, except for
State-approved holidays. The Provider Hotline must be staffed with personnel
who
are knowledgeable about Covered Services and each applicable HMO Program, and
for Medicaid, about Non-capitated Services.
The
HMO
must ensure that after regular business hours the line is answered by an
automated system with the capability to provide callers with operating hours
information and instructions on how to verify enrollment for a Member with
an
Urgent Condition or an Emergency Medical Condition. The HMO must have a process
in place to handle after-hours inquiries from Providers seeking to verify
enrollment for a Member with an Urgent Condition or an Emergency Medical
Condition, provided, however, that the HMO and its Providers must not require
such verification prior to providing Emergency Services.
The
HMO
must ensure that the Provider Hotline meets the following minimum performance
requirements for all HMO Programs and Service Areas:
1.
99% of
calls are answered by the fourth ring or an automated call pick-up system is
used;
2.
no
more than one percent of incoming calls receive a busy signal;
3.
the
average hold time is 2 minutes or less; and
4.
the
call abandonment rate is 7% or less.
The
HMO
must conduct ongoing call quality assurance to ensure these standards are met.
The Provider Hotline may serve multiple HMO Programs if Hotline staff is
knowledgeable about all of the HMO’s Programs. The Provider Hotline may serve
multiple Service Areas if the Hotline staff is knowledgeable about all such
Service Areas, including the Provider Network in such Service
Areas.
The
HMO
must monitor its performance regarding Provider Hotline standards and submit
performance reports summarizing call center performance for the Hotline as
indicated in Section
8.1.20.
If the HMO subcontracts with a Behavioral Health Organization (BHO) that is
responsible for Provider Hotline functions related to Behavioral Health
Services, the BHO’s Provider Hotline must meet the requirements in
Section 8.1.4.7.
8.1.4.8
Provider Reimbursement
The
HMO
must make payment for all Medically Necessary Covered Services provided to
all
Members for whom the HMO is paid a capitation. A STAR+PLUS HMO must
also make payment for all Functionally Necessary Covered Services provided
to
all Members for whom the HMO is paid a capitation. The HMO must ensure that
claims payment is timely and accurate as described in Section 8.1.18.5.
The HMO must require tax identification numbers from all
participating
Providers. The HMO is required to do back-up withholding from all payments
to
Providers who fail to give tax identification numbers or who give incorrect
numbers.
Unless
prohibited or limited by applicable law, at least 15 days prior to the effective
date of the HMO’s termination of contract of any participating Provider the HMO
must notify the HHSC Administrative Services Contractor and notify affected
current Members in writing. Affected Members include all Members in a
PCP’s panel and all Members who have been receiving ongoing care from the
terminated Provider, where ongoing care is defined as two or more visits for
home-based or office-based care in the past 12 months.
For
the
CHIP and CHIP Perinatal Programs, the HMO’s process for terminating Provider
contracts must comply with the Texas Insurance Code and TDI
regulations.
8.1.5
Member Services
The
HMO
must maintain a Member Services Department to assist Members and Members’ family
members or guardians in obtaining Covered Services for Members. The HMO must
maintain employment standards and requirements (e.g., education, training,
and
experience) for Member
Services Department staff and provide a sufficient number of staff for the
Member Services Department to meet the requirements of this Section, including
Member Hotline response times, and Linguistic Access capabilities, see 8.1.5.6
Member Hotline Requirements.
The
HMO
must design, print and distribute Member identification (ID) cards and a Member
Handbook to Members. Within five business days following the receipt
of an Enrollment File from the HHSC Administrative Services Contractor, the
HMO
must mail a Member’s ID card and Member Handbook to the Case Head or Account
Name for each new Member. When the Case Head or Account Name is on behalf of
two
or more new Members, the HMO is only required to send one Member Handbook.
The
HMO is responsible for mailing materials only to those Members for whom valid
address data are contained in the Enrollment File.
The
HMO
must design, print and distribute a Provider Directory to the HHSC
Administrative Services Contractor as described in Section
8.1.5.4.
Member
materials must be at or below a 6th grade reading level as measured by the
appropriate score on the Xxxxxx reading ease test. Member materials must be
available in English, Spanish, and the languages of other Major Population
Groups making up 10% or more of the managed care eligible population in the
HMO’s Service Area, as specified by HHSC. HHSC will provide the HMO
with reasonable notice when the enrolled population reaches 10% within the
HMO’s
Service Area. All Member materials must be available in a format accessible
to
the visually impaired, which may include large print, Braille, and
audiotapes.
The
HMO
must submit member materials to HHSC for approval prior to use or
mailing. HHSC will identify any required changes to the Member
materials within 15 business days. If HHSC has not responded to the
Contractor by the fifteenth day, the Contractor may proceed to use the submitted
materials. HHSC reserves the right to require discontinuation of any
Member materials that violate the terms of the Uniform Managed Care
Terms and Conditions, including but not limited to “Marketing Policies
and Procedures” as described in the Uniform Managed Care
Manual.
8.1.5.2
Member Identification (ID) Card
All
Member ID cards must, at a minimum, include the following
information:
1 the
Member’s name;
2 the
Member’s Medicaid, CHIP or CHIP Perinatal Program number;
3 the
effective date of the PCP assignment (excluding CHIP Perinates);
4 the
PCP’s
name, address (optional for all products), and telephone number (excluding
CHIP
Perinates);
5 the
name
of the HMO;
6 the
24-hour, seven (7) day a week toll-free Member services telephone number and
BH
Hotline number operated by the HMO; and
7 any
other
critical elements identified in the Uniform Managed Care
Manual.
The
HMO
must reissue the Member ID card if a Member reports a lost card, there is a
Member name change, if the Member requests a new PCP, or for any other reason
that results in a change to the information disclosed on the ID
card. CHIP Perinatal HMOs must issue Member ID cards to both CHIP
Perinates and CHIP Perinate Newborns.
HHSC
must
approve the Member Handbook, and any substantive revisions, prior to publication
and distribution. As described in Attachment B-1, Section 7,
the HMO must develop and submit to HHSC the draft Member Handbook for approval
during the Readiness Review and must submit a final Member Handbook
incorporating changes required by HHSC prior to the Operational Start
Date.
The
Member Handbook for each applicable HMO Program must, at a minimum, meet the
Member materials requirements specified by Section 8.1.5.1
above and must include critical elements in the Uniform Managed Care
Manual. CHIP Perinatal HMOs must issue Member Handbooks to both CHIP
Perinates and CHIP Perinate Newborns. The Member Handbook for CHIP
Perinate Newborns may be the same as that used for CHIP.
The
HMO
must produce a revised Member Handbook, or an insert informing Members of
changes to Covered Services upon HHSC notification and at least 30 days prior
to
the effective date of such change in Covered Services. In addition to modifying
the Member materials for new Members, the HMO must notify all existing Members
of the Covered Services change during the time frame specified in this
subsection.
The
Provider Directory for each applicable HMO Program, and any substantive
revisions, must be approved by HHSC prior to publication and distribution.
The
HMO is responsible for submitting draft Provider directory updates to HHSC
for
prior review and approval if changes other than PCP information or clerical
corrections are incorporated into the Provider Directory.
As
described in Attachment B-1, Section 7, during the Readiness
Review, the HMO must develop and submit to HHSC the draft Provider Directory
template for approval and must submit a final Provider Directory incorporating
changes required by HHSC prior to the Operational Start Date. Such draft and
final Provider Directories must be submitted according to the deadlines
established in Attachment B-1, Section 7.
The
Provider Directory for each applicable HMO Program must, at a minimum, meet
the
Member Materials requirements specified by Section 8.1.5.1
above and must include critical elements in the Uniform Managed Care
Manual. The Provider Directory must include only Network Providers
credentialed by the HMO in accordance with Section 8.1.4.4. If
the HMO contracts with limited Provider Networks, the Provider Directory must
comply with the requirements of 28 T.A.C.
§11.1600(b)(11), relating to the disclosure and notice of limited Provider
Networks.
CHIP
Perinatal HMOs must develop Provider Directories for both CHIP Perinates and
CHIP Perinate Newborns. The Provider Directory for CHIP Perinate Newborns may
be
the same as that used for the CHIP Program.
The
HMO
must update the Provider Directory on a quarterly basis. The HMO must make
such
update available to existing Members on request, and must provide such update
to
the HHSC Administrative Services Contractor at the beginning of each state
fiscal quarter. HHSC will consult with the HMOs and the HHSC Administrative
Services Contractors to discuss methods for reducing the HMO’s administrative
costs of producing new Provider Directories, including considering submission
of
new Provider Directories on a semi-annual rather than a quarterly basis if
a HMO
has not made major changes in its Provider Network, as determined by HHSC.
HHSC
will establish weight limits for the Provider Directories. Weight limits may
vary by Service Area. HHSC will require HMOs that exceed the weight limits
to
compensate HHSC for postage fees in excess of the weight limits.
The
HMO
must send the most recent Provider Directory, including any updates, to Members
upon request. The HMO must, at least annually, include written and verbal offers
of such Provider Directory in its Member outreach and education
materials.
The
HMO
must develop and maintain, consistent with HHSC standards and Section 843.2015
of the Texas Insurance Code and other applicable state laws, a website to
provide general information about the HMO’s Program(s), its Provider Network,
its customer services, and its Complaints and Appeals process. The HMO may
develop a page within its existing website to meet the requirements of this
section. The HMO must maintain a Provider Directory for its HMO Program(s)
on
the HMO’s website with designation of open versus closed panels. All HMOs must
list Home Health Ancillary providers on their websites, with an indicator for
Pediatric services if provided. The HMO’s website must comply with the Marketing
Policies and Procedures for each applicable HHSC HMO Program.
The
website’s HMO Program content must be:
1 Written
in Major Population Group languages (which under this contract include only
English and Spanish);
2 Culturally
appropriate;
3 Written
for understanding at the 6th grade reading level; and
4 Be
geared
to the health needs of the enrolled HMO Program population.
To
minimize download and “wait times,” the website must avoid tools or techniques
that require significant memory or disk resources or require special
intervention on the customer side to install plug-ins or additional software.
Use of proprietary items that would require a specific browser are not
allowed. HHSC strongly encourages the use of tools that take
advantage of efficient data access methods and reduce the load on the server
or
bandwidth.
The
HMO
must operate a toll-free hotline that Members can call 24 hours a day, seven
(7)
days a week. The Member Hotline must be staffed with personnel who are
knowledgeable about its HMO Program(s) and Covered Services, between the hours
of 8:00 a.m. to 5:00 p.m. local time for the Service Area, Monday through
Friday, excluding state-approved holidays.
The
HMO
must ensure that after hours, on weekends, and on holidays the Member Services
Hotline is answered by an automated system with the capability to provide
callers with operating hours and instructions on what to do in cases of
emergency. All recordings must be in English and in Spanish. A voice mailbox
must be available after hours for callers to leave messages. The HMO’s Member
Services representatives must return member calls received by the automated
system on the next working day.
If
the
Member Hotline does not have a voice-activated menu system, the HMO must have
a
menu system that will accommodate Members who cannot access the system through
other physical means, such as pushing a button.
The
HMO
must ensure that its Member Service representatives treat all callers with
dignity and respect the callers’ need for privacy. At a minimum, the HMO’s
Member Service representatives must be:
1. Knowledgeable
about Covered Services;
2. Able
to answer non-technical questions pertaining to the role of the PCP, as
applicable;
3. Able
to answer non-clinical questions pertaining to referrals or the process for
receiving authorization for procedures or services;
4. Able
to give information about Providers in a particular area;
5. Knowledgeable
about Fraud, Abuse, and Waste and the requirements to report any conduct that,
if substantiated, may constitute Fraud, Abuse, or Waste in the HMO
Program;
6. Trained
regarding Cultural Competency;
7. Trained
regarding the process used to confirm the status of persons with Special Health
Care Needs;
8. For
Medicaid members, able to answer non-clinical questions pertaining to accessing
Non-capitated Services.
9. For
Medicaid Members, trained regarding: a) the emergency prescription process
and
what steps to take to immediately address problems when pharmacies do not
provide a 72-hour supply of emergency medicines; and b) DME processes for
obtaining services and how to address common problems.
10.
For
CHIP Members, able to give correct cost-sharing information relating to
premiums, co-pays or deductibles, as applicable. (Cost-sharing does not apply
to
CHIP Perinates or CHIP Perinate Newborns.)
Hotline
services must meet Cultural Competency requirements and must appropriately
handle calls from non-English speaking (and particularly, Spanish-speaking)
callers, as well as calls from individuals who are deaf or hard-of-hearing.
To
meet these requirements, the HMO must employ bilingual Spanish-speaking Member
Services representatives and must secure the services of other contractors
as
necessary to meet these requirements.
The
HMO
must process all incoming Member correspondence and telephone inquiries in
a
timely and responsive manner. The HMO cannot impose maximum call duration limits
but must allow calls to be of sufficient length to ensure adequate information
is provided to the Member. The HMO must ensure that the toll-free Member Hotline
meets the following minimum performance requirements for all HMO Programs and
Service Areas:
1 99%
of
calls are answered by the fourth ring or an automated call pick-up
system;
2 no
more
than one percent (1%) of incoming calls receive a busy signal;
3 at
least
80% of calls must be answered by toll-free line staff within 30 seconds measured
from the time the call is placed in queue after selecting an option;
and
4 the
call
abandonment rate is 7% or less.
The
HMO
must conduct ongoing quality assurance to ensure these standards are
met.
The
Member Services Hotline may serve multiple HMO Programs if Hotline staff is
knowledgeable about all of the HMO’s Medicaid and/or CHIP Programs. The Member
Services Hotline may serve multiple Service Areas if the Hotline staff is
knowledgeable about all such Service Areas, including the Provider Network
in
each Service Area.
The
HMO
must monitor its performance regarding HHSC Member Hotline standards and submit
performance reports summarizing call center performance for the Member Hotline
as indicated in Section 8.1.20 and the Uniform Managed
Care Manual.
HMO
is
encouraged to train staff at its 24-hour nurse hotline about: a) emergency
prescription process and what steps to take to immediately address Medicaid
Members’ problems when pharmacies do not provide a 72-hour supply of emergency
medicines; and b) DME processes for obtaining services and how to address common
problems. The 24-hour nurse hotline will attempt to respond
immediately to problems concerning emergency medicines by means at its disposal,
including explaining the rules to Medicaid Members so that they understand
their
rights and, if need be, by offering to contact the pharmacy that is refusing
to
fill the prescription to explain the 72-hour supply policy and DME
processes.
The
HMO
must, at a minimum, develop and implement health education initiatives that
educate Members about:
1. How
the HMO system operates, including the role of the PCP;
2. Covered
Services, limitations and any Value-added Services offered by the
HMO;
3. The
value of screening and preventive care, and
4. How
to obtain Covered Services, including:
a Emergency
Services;
b Accessing
OB/GYN
and specialty care;
c Behavioral
Health Services;
d Disease
Management programs;
e Service
Coordination, treatment for pregnant women, Members with Special Health Care
Needs, including Children with Special Health Care Needs; and other special
populations;
f Early
Childhood Intervention (ECI) Services;
g Screening
and preventive services, including well-child care (THSteps medical checkups
for
Medicaid Members);
h For
CHIP
Members, Member co-payments
i Suicide
prevention;
j Identification
and health education related to Obesity; and
k Obtaining
72 hour supplies of emergency prescriptions from pharmacies enrolled with HHSC
as Medicaid providers.
The
HMO
must provide a range of health promotion and wellness information and activities
for Members in formats that meet the needs of all Members. The HMO must propose,
implement, and assess innovative Member education strategies for wellness care
and immunization, as well as general health promotion and prevention. The HMO
must conduct wellness promotion programs to improve the health status of its
Members. The HMO may cooperatively conduct health education classes for all
enrolled Members with one or more HMOs also contracting with HHSC in the Service
Area. The HMO must work with its Providers to integrate health education,
wellness and prevention training into the care of each Member.
The
HMO
also must provide condition and disease-specific information and educational
materials to Members, including information on its Service Management and
Disease Management programs described in Section 8.1.13 and Section
8.1. Condition- and disease-specific information must be
oriented to various groups within the managed care eligible population, such
as
children, the elderly, persons with disabilities and non-English speaking
Members, as appropriate to the HMO’s Medicaid, CHIP and/or CHIP Perinatal
Program(s).
The
HMO
must have a comprehensive written Cultural Competency Plan describing how the
HMO will ensure culturally competent services, and provide Linguistic Access
and
Disability-related Access. The Cultural Competency Plan must describe how the
individuals and systems within the HMO will effectively provide services to
people of all cultures, races, ethnic backgrounds, and religions as well as
those with disabilities in a manner that recognizes, values, affirms, and
respects the worth of the individuals and protects and preserves the dignity
of
each. The HMO must submit the Cultural Competency Plan to HHSC for Readiness
Review. Modifications and amendments to the plan must be submitted to HHSC
no
later than 30 days prior to implementation. The Plan must also be made available
to the HMO’s Network of Providers.
The
HMO
must develop, implement and maintain a system for tracking, resolving, and
reporting Member Complaints regarding its services, processes, procedures,
and
staff. The HMO must ensure that Member Complaints are resolved within 30
calendar days after receipt. The HMO is subject to remedies, including
liquidated damages, if at least 98 percent of Member Complaints are not resolved
within 30 days of receipt of the Complaint by the HMO. Please see the
Uniform Managed Care Contract Terms & Conditions and
Attachment B-5, Deliverables/Liquidated Damages
Matrix.
The
HMO
must develop, implement and maintain a system for tracking, resolving, and
reporting Member Appeals regarding the denial or limited authorization of a
requested service, including the type or level of service and the denial, in
whole or in part, of payment for service. Within this
process,
the HMO must respond fully and completely to each Appeal and establish a
tracking mechanism to document the status and final disposition of each
Appeal.
The
HMO
must ensure that Member Appeals are resolved within 30 calendar days, unless
the
HMO can document that the Member requested an extension or the HMO shows there
is a need for additional information and the delay is in the Member's interest.
The HMO is subject to liquidated damages if at least 98 percent of Member
Appeals are not resolved within 30 days of receipt of the Appeal by the HMO.
Please see the Uniform Managed Care Contract Terms & Conditions
and Attachment B-5, Deliverables/Liquidated Damages
Matrix.
Medicaid
HMOs must follow the Member Complaint and Appeal Process described in
Section .2.6.
CHIP and CHIP Perinatal HMOs must comply with the CHIP Complaint and Appeal
Process described in Sections 8.4.2 and 8.5.2,
respectively.
8.1.6
Marketing and Prohibited Practices
The
HMO
and its Subcontractors must adhere to the Marketing Policies and Procedures
as
set forth by HHSC in the Contract, and the HHSC Uniform Managed Care
Manual.
8.1.7
Quality Assessment and Performance Improvement
The
HMO
must provide for the delivery of quality care with the primary goal of improving
the health status of Members and, where the Member’s condition is not amenable
to improvement, maintain the Member’s current health status by implementing
measures to prevent any further decline in condition or deterioration of health
status. The HMO must work in collaboration with Providers to actively improve
the quality of care provided to Members, consistent with the Quality Improvement
Goals and all other requirements of the Contract. The HMO must provide
mechanisms for Members and Providers to offer input into the HMO’s quality
improvement activities.
The
HMO
must develop, maintain, and operate a quality assessment and performance
improvement (QAPI) Program consistent with the Contract, and TDI requirements,
including 28
T.A.C.
§11.1901(a)(5) and §11.1902. Medicaid HMOs must also meet the requirements of
42
C.F.R.
§438.240.
The
HMO
must have on file with HHSC an approved plan describing its QAPI Program,
including how the HMO will accomplish the activities required by this section.
The HMO must submit a QAPI Program Annual Summary in a format and timeframe
specified by HHSC or its designee. The HMO must keep participating physicians
and other Network Providers informed about the QAPI Program and related
activities. The HMO must include in Provider contracts a requirement securing
cooperation with the QAPI.
The
HMO
must approach all clinical and non-clinical aspects of quality assessment and
performance improvement based on principles of Continuous Quality Improvement
(CQI)/Total Quality Management (TQM) and must:
1 Evaluate
performance using objective quality indicators;
2 Xxxxxx
data-driven decision-making;
3 Recognize
that opportunities for improvement are unlimited;
4 Solicit
Member and Provider input on performance and QAPI activities;
5 Support
continuous ongoing measurement of clinical and non-clinical effectiveness and
Member satisfaction;
6 Support
programmatic improvements of clinical and non-clinical processes based on
findings from on-going measurements; and
7 Support
re-measurement of effectiveness and Member satisfaction, and continued
development and implementation of improvement interventions as
appropriate.
The
HMO
must maintain a well-defined QAPI structure that includes a planned systematic
approach to improving clinical and non-clinical processes and outcomes. The
HMO
must designate a senior executive responsible for the QAPI Program and the
Medical Director must have substantial involvement in QAPI Program activities.
At a minimum, the HMO must ensure that the QAPI Program structure:
1 Is
organization-wide, with clear lines of accountability within the
organization;
2 Includes
a set of functions, roles, and responsibilities for the oversight of QAPI
activities that are clearly defined and assigned to appropriate individuals,
including physicians, other clinicians, and non-clinicians;
3 Includes
annual objectives and/or goals for planned projects or activities including
clinical and non-clinical programs or initiatives and measurement activities;
and
4 Evaluates
the effectiveness of clinical and non-clinical initiatives.
The
HMO
must engage in the collection of clinical indicator data. The HMO must use
such
clinical indicator data in the development, assessment, and modification of
its
QAPI Program.
If
the
HMO subcontracts any of the essential functions or reporting requirements
contained within the QAPI Program to another entity, the HMO must maintain
a
file of the subcontractors. The file must be available for review by HHSC or
its
designee upon request.
If
the
HMO provides Behavioral Health Services within the Covered Services as defined
in Attachments B-2, B-2.1, and B-2.2, it must integrate
behavioral health into its QAPI Program and include a systematic and on-going
process for monitoring, evaluating, and improving the
quality
and appropriateness of Behavioral Health Services provided to Members. The
HMO
must collect data, and monitor and evaluate for improvements to physical health
outcomes resulting from behavioral health integration into the Member’s overall
care.
The
HMO
must adopt not less than two evidence-based clinical practice guidelines for
each applicable HMO Program. Such practice guidelines must be based on valid
and
reliable clinical evidence, consider the needs of the HMO’s Members, be adopted
in consultation with contracting health care professionals, and be reviewed
and
updated periodically, as appropriate. The HMO must develop practice guidelines
based on the health needs and opportunities for improvement identified as part
of the QAPI Program.
The
HMO
may coordinate the development of clinical practice guidelines with other HHSC
HMOs to avoid providers in a Service Area receiving conflicting practice
guidelines from different HMOs.
The
HMO
must disseminate the practice guidelines to all affected Providers and, upon
request, to Members and potential Members.
The
HMO
must take steps to encourage adoption of the guidelines, and to measure
compliance with the guidelines, until such point that 90% or more of the
Providers are consistently in compliance, based on HMO measurement findings.
The
HMO must employ substantive Provider motivational incentive strategies, such
as
financial and non-financial incentives, to improve Provider compliance with
clinical practice guidelines. The HMO’s decisions regarding utilization
management, Member education, coverage of services, and other areas included
in
the practice guidelines must be consistent with the HMO’s clinical practice
guidelines.
The
HMO
must conduct PCP and other Provider profiling activities at least annually.
As
part of its QAPI Program, the HMO must describe the methodology it uses to
identify which and how many Providers to profile and to identify measures to
use
for profiling such Providers.
Provider
profiling activities must include, but not be limited to:
1 Developing
PCP and Provider-specific reports that include a multi-dimensional assessment
of
a PCP or Provider’s performance using clinical, administrative, and Member
satisfaction indicators of care that are accurate, measurable, and relevant
to
the enrolled population;
2 Establishing
PCP, Provider, group, Service Area or regional Benchmarks for areas profiled,
where applicable, including STAR, STAR+PLUS, CHIP and CHIP Perinatal
Program-specific Benchmarks, where appropriate; and
3 Providing
feedback to individual PCPs and Providers regarding the results of their
performance and the overall performance of the Provider Network.
The
HMO
must:
1 Use
the
results of its Provider profiling activities to identify areas of improvement
for individual PCPs and Providers, and/or groups of Providers;
2 Establish
Provider-specific quality improvement goals for priority areas in which a
Provider or Providers do not meet established HMO standards or improvement
goals;
3 Develop
and implement incentives, which may include financial and non-financial
incentives, to motivate Providers to improve performance on profiled measures;
and
4 At
least
annually, measure and report to HHSC on the Provider Network and individual
Providers’ progress, or lack of progress, towards such improvement
goals.
The
HMO
will collaborate with HHSC’s external quality review organization (EQRO) to
develop studies, surveys, or other analytical approaches that will be carried
out by the EQRO. The purpose of the studies, surveys, or other
analytical approaches is to assess the quality of care and service provided
to
Members and to identify opportunities for HMO improvement. To facilitate this
process, the HMO will supply claims data to the EQRO in a format identified
by
HHSC in consultation with HMOs, and will supply medical records for focused
clinical reviews conducted by the EQRO. The HMO must also work collaboratively
with HHSC and the EQRO to annually measure selected HEDIS measures that require
chart reviews. During the first year of operations, HHSC anticipates that the
selected measures will include, at a minimum, well-child visits and
immunizations, appropriate use of asthma medications, measures related to
Members with diabetes, and control of high blood pressure.
8.1.8
Utilization Management
The
HMO
must have a written utilization management (UM) program description, which
includes, at a minimum:
1 Procedures
to evaluate the need for Medically Necessary Covered Services;
2 The
clinical review criteria used, the information sources, the process used to
review and approve the provision of Covered Services;
3 The
method for periodically reviewing and amending the UM clinical review criteria;
and
4 The
staff
position functionally responsible for the day-to-day management of the UM
function.
The
HMO
must make best efforts to obtain all necessary information, including pertinent
clinical information, and consult with the treating physician as appropriate
in
making UM determinations.
The
HMO
must issue coverage determinations, including adverse determinations, according
to the following timelines:
• Within
three (3) business days after receipt of the request for authorization of
services;
• Within
one (1) business day for concurrent hospitalization decisions; and
• Within
one (1) hour for post-stabilization or life-threatening conditions, except
that
for Emergency Medical Conditions and Emergency Behavioral Health Conditions,
the
HMO must not require prior authorization.
The
HMO’s
UM Program must include written policies and procedures to ensure:
1. Consistent
application of review criteria that are compatible with Members’ needs and
situations;
2. Determinations
to deny or limit services are made by physicians under the direction of the
Medical Director;
3. Appropriate
personnel are available to respond to utilization review inquiries 8:00 a.m.
to
5:00
p.m., Monday through Friday, with a telephone system capable of accepting
utilization review inquiries after normal business hours. The HMO must respond
to calls within one business day;
4. Confidentiality
of clinical information; and
5. Quality
is not adversely impacted by financial and reimbursement-related processes
and
decisions.
For
HMOs
with preauthorization or concurrent review programs, qualified medical
professionals must supervise preauthorization and concurrent review
decisions.
The
HMO
UM Program must include polices and procedures to:
1 Routinely
assess the effectiveness and the efficiency of the UM Program;
2 Evaluate
the appropriate use of medical technologies, including medical procedures,
drugs
and devices;
3 target
areas of suspected inappropriate service utilization;
4 Detect
over- and under-utilization;
5 Routinely
generate Provider profiles regarding utilization patterns and compliance with
utilization review criteria and policies;
6 Compare
Member and Provider utilization with norms for comparable
individuals;
7 Routinely
monitor inpatient admissions, emergency room use, ancillary, and out-of-area
services;
8 Ensure
that when Members are receiving Behavioral Health Services from the local mental
health authority that the HMO is using the same UM guidelines as those
prescribed for use by Local Mental Health Authorities by MHMR which are
published at: xxxx://xxx.xxxx.xxxxx.xx.xx/xxxxxxxxxxxxx/xxxxxxxxxxxxxxxxxxxxxxxx/XXXXxxxXxxxx.xxxx
;
and
9. Refer
suspected cases of provider or Member Fraud, Abuse, or Waste to the Office
of
Inspector General (OIG) as required by Section
8.1.19.
8.1.9
Early Childhood Intervention (ECI)
The
HMO
must ensure that Network Providers are educated regarding their responsibility
under federal laws (e.g., 20 U.S.C. §1435 (a)(5); 34 C.F.R. §303.321(d)) to
identify and refer any Member age three (3) or under suspected of having a
developmental disability or delay, or who is at risk of delay, to the designated
ECI program for screening and assessment within two (2) working days from the
day the Provider identifies the Member. The HMO must use written
educational materials developed or approved by the Department of Assistive
and
Rehabilitative Services – Division for Early Childhood Intervention Services for
these “child find” activities. Eligibility for ECI services will be determined
by the local ECI program using the criteria contained in 40 T.A.C.
§108.25.
The
HMO
must contract with qualified ECI Providers to provide ECI services to Members
under age three who have been determined eligible for ECI services. The HMO
must
permit Members to self refer to local ECI Service Providers without requiring
a
referral from the Member’s PCP. The HMO’s policies and procedures, including its
Provider Manual, must include written policies and procedures for allowing
such
self-referral to ECI providers.
The
HMO
must coordinate and cooperate with local ECI programs in the development and
implementation of the Individual Family Service Plan (IFSP), including on-going
case management and other non-capitated services required by the Member’s IFSP.
The IFSP is an agreement developed by the interdisciplinary team that consists
of the ECI Case Manager/Service Coordinator, the Member/family, and other
professionals who participated in the Member’s evaluation or are providing
direct services to the Member, and may include the Member’s Primary Care
Physician (PCP) with parental consent. The IFSP identifies the Member’s present
level of development based on assessment, describes the services to be provided
to the child to meet the needs of the child and the family, and identifies
the
person or persons responsible for each service required by the plan. The IFSP
shall be transmitted by the ECI Provider to the HMO and the PCP with parental
consent to enhance coordination of the plan of care. The IFSP may be included
in
the Member’s medical record.
Cooperation
with the ECI program includes covering medical diagnostic procedures and
providing medical records required to perform developmental assessments and
developing the IFSP within the 45-day timeline established in federal rule
(34
C.F.R. §303.342(a)). The HMO must require compliance with these requirements
through Provider contract provisions. The HMO must not withhold authorization
for the provision of such medical diagnostic procedures. The HMO must promptly
provide to the ECI program, relevant medical records available to the
HMO.
The
interdisciplinary team will determine Medical Necessity for health and
Behavioral Health Services as approved by the Member’s PCP. The HMO must
require, through contract provisions, that all Medically Necessary health and
Behavioral Health Services contained in the Member’s IFSP are provided to the
Member in the amount, duration, scope and service setting established by the
IFSP. The HMO must allow services to be provided by a non-network provider
if a
Network Provider is not available to provide the services in the amount,
duration, scope and service setting as required by the IFSP. The HMO cannot
modify the plan of care or alter the amount, duration, scope, or service setting
required by the Member’s IFSP. The HMO cannot create unnecessary barriers for
the Member to obtain IFSP services, including requiring prior
authorization
for the ECI assessment or establishing insufficient authorization periods for
prior authorized services.
8.1.10
Special Supplemental Nutrition Program for Women, Infants, and
Children
(WIC)
- Specific Requirements
The
HMO
must, by contract, require its Providers to coordinate with the Special
Supplemental Nutrition Program for Women, Infants, and Children (WIC) to provide
medical information necessary for WIC eligibility determinations, such as
height, weight, hematocrit or hemoglobin. The HMO must make referrals to WIC
for
Members potentially eligible for WIC. The HMO may use the nutrition education
provided by WIC to satisfy certain health education requirements of the
Contract.
8.1.11
Coordination with Texas Department of Family and Protective
Services
The
HMO
must cooperate and coordinate with the Texas Department of Family and Protective
Services (TDFPS) (formerly the Department of Protective and Regulatory Services)
for the care of a child who is receiving services from or has been placed in
the
conservatorship of TDFPS.
The
HMO
must comply with all provisions related to Covered Services, including
Behavioral Health Services, in the following documents:
• A
court
order (Order) entered by a Court of Continuing Jurisdiction placing a child
under the protective custody of TDFPS.
• A
TDFPS
Service Plan entered by a Court of Continuing Jurisdiction placing a child
under
the protective custody of TDFPS.
• A
TDFPS
Service Plan voluntarily entered into by the parents or person having legal
custody of a Member and TDFPS.
The
HMO
cannot deny, reduce, or controvert the Medical Necessity of any health or
Behavioral Health Services included in an Order. The HMO may participate in
the
preparation of the medical and behavioral care plan prior to TDFPS submitting
the health care plan to the Court. Any modification or termination of
court-ordered services must be presented and approved by the court having
jurisdiction over the matter.
A
Member
or the parent or guardian whose rights are subject to an Order or Service Plan
cannot use the HMO’s Complaint or Appeal processes, or the HHSC Fair Hearing
process to Appeal the necessity of the Covered Services.
The
HMO
must include information in its Provider Manuals and training materials
regarding:
1 Providing
medical records to TDFPS;
2 Scheduling
medical and Behavioral Health Services appointments within 14 days unless
requested earlier by TDFPS; and
3 Recognition
of abuse and neglect, and appropriate referral to TDFPS.
The
HMO
must continue to provide all Covered Services to a Member receiving services
from, or in the protective custody of, TDFPS until the Member has been;(1)
disenrolled from the HMO due to loss of Medicaid managed care eligibility;
or
(2) enrolled in HHSC’s managed care program for children in xxxxxx care, once
the program is implemented.
8.1.12
Services for People with Special Health Care Needs
This
section applies to STAR, STAR+PLUS, CHIP HMOs. It applies to CHIP Perinatal
HMOs
with respect to their Perinate Newborn Members only.
The
HMO
must develop and maintain a system and procedures for identifying Members with
Special Health Care Needs (MSHCN), including people with disabilities or chronic
or complex medical and behavioral health conditions and Children with Special
Health Care Needs (CSHCN)1.
The
HMO
must contact Members pre-screened by the HHSC Administrative Services Contractor
as MSHCN to determine whether they meet the HMO’s MSHCN assessment criteria, and
to determine whether the Member requires special services described in this
section. The HMO must provide information to the HHSC Administrative Services
Contractor that identifies Members who the HMO has assessed to be MSHCN,
including any Members pre-screened by the HHSC Administrative Services
Contractor and confirmed by the HMO as a MSHCN. The information must be
provided, in a format and on a timeline to be specified by HHSC in the
Uniform Managed Care Manual, and updated with newly identified
MSHCN by the 10th day of each month. In the event that a MSHCN changes HMOs,
the
HMO must provide the receiving contractor information concerning the results
of
the HMO’s identification and assessment of that Member’s needs, to prevent
duplication of those activities.
Once
identified, the HMO must have effective systems to ensure the provision of
Covered Services to meet the special preventive, primary Acute Care, and
specialty health care needs appropriate for treatment of the individual Member’s
condition(s). All STAR+PLUS Members are considered to be
MSHCN.
The
HMO
must provide access to identified PCPs and specialty care Providers with
experience serving MSHCN. Such Providers must be board-qualified or
board-eligible in their specialty. The HMO may request exceptions from HHSC
for
approval of traditional providers who are not board-qualified or board-eligible
but who otherwise meet the HMO’s credentialing requirements.
For
services to CSHCN, the HMO must have Network PCPs and specialty care Providers
that have demonstrated experience with CSHCN in pediatric specialty centers
such
as children’s hospitals, teaching hospitals, and tertiary care
centers.
The
HMO
is responsible for working with MSHCN, their families and legal guardians if
applicable, and their health care providers to develop a seamless package of
care in which primary, Acute Care, and specialty service needs are met through
a
Service Plan that is understandable to the Member, or, when applicable, the
Member’s legal guardian.
The
HMO
is responsible for providing Service Management to develop a Service Plan and
ensure MSHCN, including CSHCN, have access to treatment by a multidisciplinary
team when the Member’s PCP determines the treatment is Medically Necessary, or
to avoid separate and fragmented evaluations and service plans. The team must
include both physician and non-physician providers determined to be necessary
by
the Member’s PCP for the comprehensive treatment of the Member. The team
must:
1 Participate
in hospital discharge planning;
2 Participate
in pre-admission hospital planning for non-emergency
hospitalizations;
3 Develop
specialty care and support service recommendations to be incorporated into
the
Service Plan; and
4 Provide
information to the Member, or when applicable, the Member’s legal guardian
concerning the specialty care recommendations.
MSHCN,
their families, or their health providers may request Service Management from
the HMO. The HMO must make an assessment of whether Service Management is needed
and furnish Service Management when appropriate. The HMO may also recommend
to a
MSHCN, or to a CSHCN’s family, that Service Management be furnished if the HMO
determines that Service Management would benefit the Member.
The
HMO
must provide information and education in its Member Handbook and Provider
Manual about the care and treatment available in the HMO’s plan for Members with
Special Health Care Needs, including the availability of Service
Management.
The
HMO
must have a mechanism in place to allow Members with Special Health Care Needs
to have direct access to a specialist as appropriate for the Member’s condition
and identified needs, such as a standing referral to a specialty physician.
The
HMO must also provide MSHCN with access to non-primary care physician
specialists as PCPs, as required by 28 T.A.C. §11.900 and Section
8.1.
The
HMO
must implement a systematic process to coordinate Non-capitated Services, and
enlist the involvement of community organizations that may not be providing
Covered Services but are otherwise important to the health and wellbeing of
Members. The HMO also must make a best effort to establish relationships with
State and local programs and community organizations, such as those listed
below, in order to make referrals for MSHCN and other Members who need community
services:
• Community
Resource Coordination Groups (CRCGs);
• Early
Childhood Intervention (ECI) Program;
• Local
school districts (Special Education);
• Texas
Department of Transportation’s Medical Transportation Program
(MTP);
• Texas
Department of Assistive and Rehabilitative Services (DARS) Blind Children’s
Vocational Discovery and Development Program;
• Texas
Department of State Health (DSHS) services, including community mental health
programs, the Title V Maternal and Child Health and Children with Special Health
Care Needs (CSHCN) Programs, and the Program for Amplification of Children
of
Texas (PACT);
• Other
state and local agencies and programs such as food stamps, and the Women,
Infants, and Children’s (WIC) Program;
• Civic
and religious organizations and consumer and advocacy groups, such as United
Cerebral Palsy, which also work on behalf of the MSHCN population.
__________________________
1
CSHCN is a term
often used to refer to a services program for children with special health
care
needs administered by DSHS, and described in 25 TAC, Part 1, Section 38.1.
Although children served through this program may also be served by Medicaid
or
CHIP, the reference to “CSHCN” in this Contract does not refer to children
served through this program.
8.1.13
Service Management for Certain Populations
The
HMO
must have service management programs and procedures for the following
populations, as applicable to the HMO’s Medicaid and/or CHIP Program(s) (See
CHIP Perinatal Program Covered Services, Attachment B-2.2, for
the applicability of these services to the CHIP Perinatal Program):
1 High-cost
catastrophic cases;
2 Women
with high-risk pregnancies (STAR and STAR+PLUS Programs only);
3 Individuals
with mental illness and co-occurring substance abuse; and
4 FWC
(STAR
and STAR+PLUS Programs only).
8.1.14
Disease Management (DM)
The
HMO
must provide, or arrange to have provided to Members, comprehensive disease
management services consistent with state statutes and regulations. Such DM
services must be part of person-based approach to DM and holistically address
the needs of persons with multiple chronic conditions. The HMO must develop
and
implement DM services that relate to chronic conditions that are prevalent
in
HMO Program Members. In the first year of operations, STAR, STAR+PLUS and CHIP
HMOs must have DM Programs that address Members with chronic conditions to
be
identified by HHSC and included within the Uniform Managed Care
Manual. HHSC will not identify the Members with chronic
conditions. The HMO must implement policies and procedures to ensure
that Members that require DM services are identified and enrolled in a program
to provide such DM services. The HMO must develop and maintain screening and
evaluation procedures for the early detection, prevention, treatment, or
referral of participants at risk for or diagnosed with chronic conditions
identified by HHSC and included within the Uniform Managed Care
Manual. The HMO must ensure that all Members identified for DM are
enrolled into a DM Program with the opportunity to opt out of these services
within 30 days while still maintaining access to all other Covered
Services.
The
DM
Program(s) must include:
1. Patient
self-management education;
2. Provider
education;
3. Evidence-based
models and minimum standards of care;
4. Standardized
protocols and participation criteria;
5. Physician-directed
or physician-supervised care;
6. Implementation
of interventions that address the continuum of care;
7. Mechanisms
to modify or change interventions that are not proven effective;
and
8. Mechanisms
to monitor the impact of the DM Program over time, including both the clinical
and the financial impact.
The
HMO
must maintain a system to track and monitor all DM participants for clinical,
utilization, and cost measures.
The
HMO
must provide designated staff to implement and maintain DM Programs and to
assist participating Members in accessing DM services. The HMO must educate
Members and Providers about the HMO’s DM Programs and activities. Additional
requirements related to the HMO’s Disease Management Programs and activities are
found in the HHSC Uniform Managed Care Manual.
At
a
minimum, the HMO must:
1 Implement
a system for Providers to request specific DM interventions;
2 Give
Providers information, including differences between recommended prevention
and
treatment and actual care received by Members enrolled in a DM Program, and
information concerning such Members’ adherence to a service plan;
and
3 For
Members enrolled in a DM Program, provide reports on changes in a Member’s
health status to their PCP.
8.1.14.2
HMO DM Evaluation
HHSC
or
its EQRO will evaluate the HMO’s DM Program.
8.1.15
Behavioral Health (BH) Network and Services
The
requirements in this sub-section pertain to all HMOs except: (1) the STAR HMOs
in the Dallas CSA, whose Members receive Behavioral Health Services through
the
NorthSTAR Program, and (2) the CHIP Perinatal Program HMOs with respect to
their
Perinate Members.
The
HMO
must provide, or arrange to have provided, to Members all Medically Necessary
Behavioral Health (BH) Services as described in Attachments B-2, B-2.1,
and B-2.2. All BH Services must be provided in conformance with the
access standards included in Section 8.1.3. For Medicaid HMOs,
BH Services are described in more detail in the Texas Medicaid Provider
Procedures Manual and the Texas Medicaid Bulletins.
When assessing Members for BH Services, the HMO and its Network Behavioral
Health Service Providers must use the DSM-IV multi-axial classification. HHSC
may require use of other assessment instrument/outcome
measures
in addition to the DSM-IV. Providers must document DSM-IV and assessment/outcome
information in the Member’s medical record.
The
HMO
must maintain a Behavioral Health Services Provider Network that includes
psychiatrists, psychologists, and other Behavioral Health Service Providers.
The
Provider Network must include Behavioral Health Service Providers with
experience serving special populations among the HMO Program(s)’ enrolled
population, including, as applicable, children and adolescents, persons with
disabilities, the elderly, and cultural or linguistic minorities, to ensure
accessibility and availability of qualified Providers to all Members in the
Service Area.
8.1.15.2
Member Education and Self-referral for Behavioral Health
Services
The
HMO
must maintain a Member education process to help Members know where and how
to
obtain Behavioral Health Services.
The
HMO
must permit Members to self refer to any in-network Behavioral Health Services
Provider without a referral from the Member’s PCP. The HMOs’ policies and
procedures, including its Provider Manual, must include written policies and
procedures for allowing such self- referral to BH services.
The
HMO
must permit Members to participate in the selection of the appropriate
behavioral health individual practitioner(s) who will serve them and must
provide the Member with information on accessible in-network Providers with
relevant experience.
This
Section includes Hotline functions pertaining to Members. Requirements for
Provider Hotlines are found in Section 8.1.4.7. The HMO must
have an emergency and crisis Behavioral Health Services Hotline staffed by
trained personnel 24 hours a day, 7 days a week, toll-free throughout the
Service Area. Crisis hotline staff must include or have access to
qualified Behavioral Health Services professionals to assess behavioral health
emergencies. Emergency and crisis Behavioral Health Services may be arranged
through mobile crisis teams. It is not acceptable for an emergency intake line
to be answered by an answering machine.
The
HMO
must operate a toll-free hotline as described in Section 8.1.5.6
to handle Behavioral Health-related calls. The HMO may operate
one
hotline to handle emergency and crisis calls and routine Member calls. The
HMO
cannot impose maximum call duration limits and must allow calls to be of
sufficient length to ensure adequate information is provided to the Member.
Hotline services must meet Cultural Competency requirements and provide
linguistic access to all Members, including the interpretive services required
for effective communication.
The
Behavioral Health Services Hotline may serve multiple HMO Programs Hotline
staff
is knowledgeable about all of the HMO Programs. The Behavioral Health Services
Hotline may serve multiple Service Areas if the Hotline staff is knowledgeable
about all such Service Areas, including the Behavioral Health Provider Network
in each Service Area. The HMO must ensure
that
the
toll-free Behavioral Health Services Hotline meets the following minimum
performance requirements for all HMO Programs and Service Areas:
1 99%
of
calls are answered by the fourth ring or an automated call pick-up
system;
2 No
incoming calls receive a busy signal;
3 At
least
80% of calls must be answered by toll-free line staff within 30 seconds measured
from the time the call is placed in queue after selecting an option;
and
4 The
call
abandonment rate is 7% or less.
The
HMO
must conduct on-going quality assurance to ensure these standards are
met.
The
HMO
must monitor the HMO’s performance against the Behavioral Health Services
Hotline standards and submit performance reports summarizing call center
performance as indicated in Section 8.1.20 and the
Uniform Managed Care Manual.
8.1.15.4
Coordination between the BH Provider and the PCP
The
HMO
must require, through contract provisions, that PCPs have screening and
evaluation procedures for the detection and treatment of, or referral for,
any
known or suspected behavioral health problems and disorders. PCPs may provide
any clinically appropriate Behavioral Health Services within the scope of their
practice.
The
HMO
must provide training to network PCPs on how to screen for and identify
behavioral health disorders, the HMO’s referral process for Behavioral Health
Services and clinical coordination requirements for such services. The HMO
must
include training on coordination and quality of care such as behavioral health
screening techniques for PCPs and new models of behavioral health
interventions.
The
HMO
shall develop and disseminate policies regarding clinical coordination between
Behavioral Health Service Providers and PCPs. The HMO must require that
Behavioral Health Service Providers refer Members with known or suspected and
untreated physical health problems or disorders to their PCP for examination
and
treatment, with the Member’s or the Member’s legal guardian’s consent.
Behavioral Health Providers may only provide physical health care services
if
they are licensed to do so. This requirement must be specified in all Provider
Manuals.
The
HMO
must require that behavioral health Providers send initial and quarterly (or
more frequently if clinically indicated) summary reports of a Members’
behavioral health status to the PCP, with the Member’s or the Member’s legal
guardian’s consent. This requirement must be specified in all Provider
Manuals.
8.1.15.5
Follow-up after Hospitalization for Behavioral Health
Services
The
HMO
must require, through Provider contract provisions, that all Members receiving
inpatient psychiatric services are scheduled for outpatient follow-up and/or
continuing treatment prior to discharge. The outpatient treatment must occur
within seven (7) days from the date of
discharge.
The HMO must ensure that Behavioral Health Service Providers contact Members
who
have missed appointments within 24 hours to reschedule
appointments.
The
HMO
must comply with 28 T.A.C. §3.8001 et seq., regarding utilization
review for Chemical Dependency Treatment. Chemical Dependency Treatment must
conform to the standards set forth in 28 T.A.C. Part 1, Chapter 3, Subchapter
HH.
“Court-Ordered
Commitment” means a commitment of a Member to a psychiatric facility for
treatment that is ordered by a court of law pursuant to the Texas Health and
Safety Code, Title VII, Subtitle C.
The
HMO
must provide inpatient psychiatric services to Members under the age of 21,
up
to the annual limit, who have been ordered to receive the services by a court
of
competent jurisdiction under the provisions of Chapters 573 and 574 of the
Texas
Health and Safety Code, relating to Court-Ordered Commitments to psychiatric
facilities. The HMO is not obligated to cover placements as a condition of
probation, authorized by the Texas Family Code.
The
HMO
cannot deny, reduce or controvert the Medical Necessity of inpatient psychiatric
services provided pursuant to a Court-ordered Commitment for Members under
age
21. Any modification or termination of services must be presented to the court
with jurisdiction over the matter for determination.
A
Member
who has been ordered to receive treatment under the provisions of Chapter 573
or
574 of the Texas Health and Safety Code can only Appeal the commitment through
the court system.
The
HMO
must coordinate with the Local Mental Health Authority (LMHA) and state
psychiatric facility regarding admission and discharge planning, treatment
objectives and projected length of stay for Members committed by a court of
law
to the state psychiatric facility.
Medicaid
HMOs are required to comply with additional Behavioral Health Services
requirements relating to coordination with the LMHA and care for special
populations. These Medicaid HMO requirements are described in Section
8.2.8.
8.1.16
Financial Requirements for Covered Services
The
HMO
must pay for or reimburse Providers for all Medically Necessary Covered Services
provided to all Members. The HMO is not liable for cost incurred in connection
with health care rendered prior to the date of the Member’s Effective Date of
Coverage in that HMO. A Member may receive collateral health benefits
under a different type of insurance such as workers compensation or personal
injury protection under an automobile policy. If a Member is entitled to
coverage for specific services payable under another insurance plan and the
HMO
paid for such
Covered
Services, the HMO may obtain reimbursement from the responsible insurance entity
not to exceed 100% of the value of Covered Services paid.
8.1.17
Accounting and Financial Reporting Requirements
The
HMO’s
accounting records and supporting information related to all aspects of the
Contract must be accumulated in accordance with Generally Accepted Accounting
Principles (GAAP) and the cost principles contained in the Cost Principles
Document in the Uniform Managed Care Manual. The State will not
recognize or pay services that cannot be properly substantiated by the HMO
and
verified by HHSC.
The
HMO
must:
1 Maintain
accounting records for each applicable HMO Program separate and apart from
other
corporate accounting records;
2 Maintain
records for all claims payments, refunds and adjustment payments to providers,
capitation payments, interest income and payments for administrative services
or
functions and must maintain separate records for medical and administrative
fees, charges, and payments;
3 Maintain
an accounting system that provides an audit trail containing sufficient
financial documentation to allow for the reconciliation of xxxxxxxx, reports,
and financial statements with all general ledger accounts; and
4 Within
60
days after Contract execution, submit an accounting policy manual that includes
all proposed policies and procedures the HMO will follow during the duration
of
the Contract. Substantive modifications to the accounting policy manual must
be
approved by HHSC.
The
HMO
agrees to pay for all reasonable costs incurred by HHSC to perform an
examination, review or audit of the HMO’s books pertaining to the
Contract.
The
HMO
must provide authorized representatives of the Texas and federal government
full
access to all financial and accounting records related to the performance of
the
Contract.
The
HMO
must:
1. Cooperate
with the State and federal governments in their evaluation, inspection, audit,
and/or review of accounting records and any necessary supporting
information;
2. Permit
authorized representatives of the State and federal governments full access,
during normal business hours, to the accounting records that the State and
the
Federal government determine are relevant to the Contract. Such access is
guaranteed at all times during the performance and retention period of the
Contract, and will include both announced and unannounced inspections, on-site
audits, and the review, analysis, and reproduction of reports produced by the
HMO;
3. Make
copies of any accounting records or supporting documentation relevant to the
Contract available to HHSC or its agents within ten (10) business days of
receiving a
written
request from HHSC for specified records or information. If such documentation
is
not made available as requested, the HMO agrees to reimburse HHSC for all costs,
including, but not limited to, transportation, lodging, and subsistence for
all
State and federal representatives, or their agents, to carry out their
inspection, audit, review, analysis, and reproduction functions at the
location(s) of such accounting records; and
4. Pay
any and all additional costs incurred by the State and federal government that
are the result of the HMO’s failure to provide the requested accounting records
or financial information within ten (10) business days of receiving a written
request from the State or federal government.
HHSC
will
require the HMO to provide financial reports by HMO Program and by Service
Area
to support Contract monitoring as well as State and Federal reporting
requirements. HHSC will consult with HMOs regarding the format and frequency
of
such reporting. All financial information and reports that are not
Member-specific are property of HHSC and will be public record. Any deliverable
or report in Section 8.1.17.2 without a specified due date is due quarterly
on
the last day of the month. Where the due date states 30 days, the HMO is to
provide the deliverable by the last day of the month following the end of the
reporting period. Where the due date states 45 days, the HMO is to
provide the deliverable by the 15th day of the second month following the end
of
the reporting period.
CHIP
Perinatal Program data must be reported, and the data will be integrated into
existing CHIP Program financial reports. Except for the Financial
Statistical Report, no separate CHIP Perinatal Program reports are
required. For all other CHIP financial reports, where appropriate,
HHSC will designate specific attributes within the CHIP Program financial
reports that the CHIP Perinatal HMOs must complete to allow HHSC to extract
financial data particular to the CHIP Perinatal Program.
HHSC’s
Uniform Managed Care Manual will govern the timing, format and
content for the following reports.
Audited
Financial Statement –The HMO must provide the annual audited financial
statement, for each year covered under the Contract, no later than June 30.
The
HMO must provide the most recent annual financial statements, as required by
the
Texas Department of Insurance for each year covered under the Contract, no
later
than March 1.
Affiliate
Report – The HMO must submit an Affiliate Report to HHSC if this
information has changed since the last report submission. The report must
contain the following:
1 A
list of
all Affiliates, and
2 For
HHSC’s prior review and approval, a schedule of all transactions with Affiliates
that, under the provisions of the Contract, will be allowable as expenses in
the
FSR Report for services provided to the HMO by the Affiliate. Those should
include financial terms, a detailed description of the services to be provided,
and an estimated amount that will be incurred by the HMO for such services
during the Contract Period.
Employee
Bonus and/or Incentive Payment Plan – If a HMO intends to include
Employee Bonus or Incentive Payments as allowable administrative expenses,
the
HMO must furnish a written Employee Bonus and/or Incentive Payments Plan to
HHSC
so it may determine whether such payments are allowable administrative expenses
in accordance with Cost Principles Document in the Uniform Managed Care
Manual. The written plan must include a description of the HMO’s
criteria for establishing bonus and/or incentive payments, the methodology
to
calculate bonus and/or incentive payments, and the timing of bonus and/or
incentive payments. The Bonus and/or Incentive Payment Plan and description
must
be submitted to HHSC for approval no later than 30 days after the Effective
Date
of the Contract and any Contract renewal. If the HMO substantively revises
the
Employee Bonus and/or Incentive Payment Plan, the HMO must submit the revised
plan to HHSC for prior review and approval.
Claims
Lag Report - The HMO must submit Claims Lag Report as a Contract
year-to-date report. The report must be submitted quarterly by the last day
of
the month following the reporting period. The report must be submitted to HHSC
in a format specified by HHSC. The report format is contained in the
Uniform Managed Care Manual Chapter 5, Section
5.6.2. The report must disclose the amount of incurred claims each
month and the amount paid each month.
DSP
Report - The HMO must submit a monthly Delivery Supplemental Payment
(DSP) Report that includes the data elements specified by HHSC in the format
specified by HHSC. HHSC will consult with contracted HMOs prior to revising
the
DSP Report data elements and requirements. The DSP Report must include only
unduplicated deliveries and only deliveries for which the HMO has made a
payment, to either a hospital or other provider.
Form
CMS-1513 - The HMO must file an original Form CMS-1513 prior to
beginning operations regarding the HMO’s control, ownership, or affiliations. An
updated Form CMS-1513 must also be filed no later than 30 days after any change
in control, ownership, or affiliations.
FSR
Reports – The HMO must file quarterly and annual Financial-Statistical
Reports (FSR) in the format and timeframe specified by HHSC. HHSC will include
FSR format and directions in the Uniform Managed Care Manual.
The HMO must incorporate financial and statistical data of delegated networks
(e.g., IPAs, ANHCs, Limited Provider Networks), if any, in its FSR Reports.
Administrative expenses reported in the FSRs must be reported in accordance
with
the Cost Principles Document in the Uniform Managed Care
Manual. Quarterly FSR reports are due no later than 30 days after the
end of the quarter and must provide information for the current quarter and
year-to-date information through the current quarter. The first annual FSR
report must reflect expenses incurred through the 90th day after the end of
the
fiscal year. The first annual report must be filed on or before the
120th day after the end of each fiscal year and accompanied by an actuarial
opinion by a qualified actuary who is in good standing with the American Academy
of Actuaries. Subsequent annual reports must reflect data completed through
the
334th day after the end of each fiscal year and must be filed on or before
the
365th day following the end of each fiscal year.
HHSC
will
post all FSRs on the HHSC website.
CHIP
Perinatal HMOs are required to submit separate FSRs for the CHIP Perinatal
Program following the instructions outlined above and in the Uniform
Managed Care Manual.
Out-of-Network
Utilization Reports – The HMO must file quarterly Out-of Network
Utilization Reports in the format and timeframe specified by
HHSC. HHSC will include the report format and directions in the
Uniform Managed Care Manual. Quarterly reports are due 30 days
after the end of each quarter.
HUB
Reports – Upon contract award, the HMO must attend a post award meeting
in Austin, Texas, at a time specified by HHSC, to discuss the development and
submission of a Client Services HUB Subcontracting Plan for inclusion and the
HMO’s good faith efforts to notify HUBs of subcontracting opportunities. The HMO
must maintain its HUB Subcontracting Plan and submit monthly reports documenting
the HMO’s Historically Underutilized Business (HUB) program efforts and
accomplishments to the HHSC HUB Office. The report must include a narrative
description of the HMO’s program efforts and a financial report reflecting
payments made to HUBs. HMOs must use the formats included in HHSC’s
Uniform Managed Care Manual for the HUB monthly reports. The
HMO must comply with HHSC’s standard Client Services HUB Subcontracting Plan
requirements for all subcontractors.
IBNR
Plan -The HMO must furnish a written IBNR Plan to manage
incurred-but-not-reported (IBNR) expenses, and a description of the method
of
insuring against insolvency, including information on all existing or proposed
insurance policies. The Plan must include the methodology for estimating IBNR.
The plan and description must be submitted to HHSC no later than 60 days after
the Effective Date of the Contract. Substantive changes to a HMO’s IBNR plan and
description must be submitted to HHSC no later than 30 days before the HMO
implements changes to the IBNR plan.
Medicaid
Disproportionate Share Hospital (DSH) Reports – Medicaid HMOs must file
preliminary and final Medicaid DSH reports, required by HHSC to identify and
reimburse hospitals that qualify for Medicaid DSH funds. The preliminary and
final DSH reports must include the data elements and be submitted in the form
and format specified by HHSC in the Uniform Managed Care
Manual. The preliminary DSH reports are due on or before June 1 of the
year following the state fiscal reporting year. The final DSH reports are due
no
later than July 15 of the year following the state fiscal reporting year. This
reporting requirement does not apply to CHIP or CHIP Perinatal Program HMOs.
For
STAR+PLUS, HMOs will include only outpatient services in the DSH
report.
TDI
Examination Report - The HMO must furnish a copy of any TDI Examination
Report, including the financial, market conduct, target exam, quality of care
components, and corrective action plans and responses, no later than 10 days
after receipt of the final report from TDI.
TDI
Filings – The HMO must submit annual figures for controlled risk-based
capital, as well as its quarterly financial statements, both as required by
TDI.
Registration
Statement (also known as the “Form B”) - If the HMO is a part of an
insurance holding company system, the HMO must submit to HHSC a complete
registration statement, also known as Form B, and all amendments to this form,
and any other information filed by such insurer with the insurance regulatory
authority of its domiciliary jurisdiction.
Section
1318 Financial Disclosure Report - The HMO must file an original CMS
Public Health Service (PHS) Section 1318 Financial Disclosure Report prior
to
the start of Operations and an
updated
CMS PHS Section 1318 Financial Disclosure Report no later than 30 days after
the
end of each Contract Year and no later than 30 days after entering into,
renewing, or terminating a relationship with an affiliated party.
Third
Party Recovery (TPR) Reports - The HMO must file TPR Reports in
accordance with the format developed by HHSC in the Uniform Managed Care
Manual. HHSC will require the HMO to submit TPR reports no more often
than quarterly. TPR reports must include total dollars recovered from
third party payers for each HMO Program for services to the HMO’s Members, and
the total dollars recovered through coordination of benefits, subrogation,
and
worker’s compensation. For CHIP HMOs, the TPR Reports only apply if the HMO
chooses to engage in TPR activities.
8.1.18
Management Information System Requirements
The
HMO
must maintain a Management Information System (MIS) that supports all functions
of the HMO’s processes and procedures for the flow and use of HMO data. The HMO
must have hardware, software, and a network and communications system with
the
capability and capacity to handle and operate all MIS subsystems for the
following operational and administrative areas:
1.
Enrollment/Eligibility Subsystem;
2.
Provider Subsystem;
3.
Encounter/Claims Processing Subsystem;
4.
Financial Subsystem;
5.
Utilization/Quality Improvement Subsystem;
6.
Reporting Subsystem;
7.
Interface Subsystem; and
8.
TPR
Subsystem, as applicable to each HMO Program.
The
MIS
must enable the HMO to meet the Contract requirements, including all applicable
state and federal laws, rules, and regulations. The MIS must have the capacity
and capability to capture and utilize various data elements required for HMO
administration.
HHSC
will
provide the HMO with pharmacy data on the HMO’s Members on a weekly basis
through the HHSC Vendor Drug Program, or should these services be outsourced,
through the Pharmacy Benefit Manager. HHSC will provide a sample format of
pharmacy data to contract awardees.
The
HMO
must have a system that can be adapted to changes in Business Practices/Policies
within the timeframes negotiated by the Parties. The HMO is expected to cover
the cost of such systems modifications over the life of the
Contract.
The
HMO
is required to participate in the HHSC Systems Work Group.
The
HMO
must provide HHSC prior written notice of major systems changes, generally
within 90 days, and implementations, including any changes relating to Material
Subcontractors, in accordance with the requirements of this Contract and the
Uniform Managed Care Terms and Conditions.
The
HMO
must provide HHSC any updates to the HMO’s organizational chart relating to MIS
and the description of MIS responsibilities at least 30 days prior to the
effective date of the change. The HMO must provide HHSC official points of
contact for MIS issues on an on-going basis.
HHSC,
or
its agent, may conduct a Systems Readiness Review to validate the HMO’s ability
to meet the MIS requirements as described in Attachment B-1, Section
7. The System Readiness Review may include a desk review and/or an
onsite review and must be conducted for the following events:
1 A
new
plan is brought into the HMO Program;
2 An
existing plan begins business in a new Service Area;
3 An
existing plan changes location;
4 An
existing plan changes its processing system, including changes in Material
Subcontractors performing MIS or claims processing functions; and
5 An
existing plan in one or two HHSC HMO Programs is initiating a Contract to
participate in any additional HMO Programs.
If
for
any reason, a HMO does not fully meet the MIS requirements, then the HMO must,
upon request by HHSC, either correct such deficiency or submit to HHSC a
Corrective Action Plan and Risk Mitigation Plan to address such deficiency
as
requested by HHSC. Immediately upon identifying a deficiency, HHSC may impose
remedies and either actual or liquidated damages according to the severity
of
the deficiency. HHSC may also freeze enrollment into the HMO’s plan for any of
its HMO Programs until such deficiency is corrected. Refer to Attachment
A, Article 12 and Attachment B-5 for additional
information regarding remedies and damages. Refer to
Attachment X-0, Xxxxxxx 0 xxx Xxxxxxxxxx X-0, Section 8.1.1.2
for additional information regarding HMO Readiness Reviews. Refer to
Attachment A, Section 4.08(c) for information regarding
Readiness Reviews of the HMO’s Material Subcontractors.
The
HMO
must provide complete Encounter Data for all Covered Services, including
Value-added Services. Encounter Data must follow the format, and data elements
as described in the HIPAA-compliant 837 format. HHSC will specify the method
of
transmission, and the submission schedule, in the Uniform Managed Care
Manual. The HMO must submit monthly Encounter Data transmissions, and
include all Encounter Data and Encounter Data adjustments processed by the
HMO.
Encounter Data quality validation must incorporate assessment standards
developed jointly by the HMO and HHSC. The HMO must make original records
available for inspection by HHSC for validation purposes. Encounter Data that
do
not meet quality standards must be corrected and returned within a time period
specified by HHSC.
In
addition to providing Encounter Data in the 837 format described above, HMOs
must submit an Encounter Data file to HHSC's EQRO, in the format provided in
the
Uniform Managed Care Manual. This additional submission
requirement is time-limited and may not be required for the entire term of
the
Contract.
For
reporting Encounters and fee-for-service claims to HHSC, the HMO must use the
procedure codes, diagnosis codes, and other codes as directed by HHSC. Any
exceptions will be considered
on
a
code-by-code basis after HHSC receives written notice from the HMO requesting
an
exception. The HMO must also use the provider numbers as directed by HHSC for
both Encounter and fee-for-service claims submissions, as
applicable.
At
the
beginning of each state fiscal year, the HMO must submit for HHSC’s review and
approval any modifications to the following documents:
1 Joint
Interface Plan;
2 Disaster
Recovery Plan;
3 Business
Continuity Plan;
4 Risk
Management Plan; and
5 Systems
Quality Assurance Plan.
The
HMO
must submit such modifications to HHSC according to the format and schedule
identified the HHSC Uniform Managed Care Manual.
The
HMO’s
MIS system must include key business processing functions and/or features,
which
must apply across all subsystems as follows:
1. Process
electronic data transmission or media to add, delete or modify membership
records with accurate begin and end dates;
2. Track
Covered Services received by Members through the system, and accurately and
fully maintain those Covered Services as HIPAA-compliant Encounter
transactions;
3. Transmit
or transfer Encounter Data transactions on electronic media in the HIPAA format
to the contractor designated by HHSC to receive the Encounter Data;
4. Maintain
a history of changes and adjustments and audit trails for current and
retroactive data;
5. Maintain
procedures and processes for accumulating, archiving, and restoring data in
the
event of a system or subsystem failure;
6. Employ
industry standard medical billing taxonomies (procedure codes, diagnosis
codes) to describe services delivered and Encounter transactions
produced;
7. Accommodate
the coordination of benefits;
8. Produce
standard Explanation of Benefits (EOBs);
9. Pay
financial transactions to Providers in compliance with federal and state laws,
rules and regulations;
10.
Ensure that all financial transactions are auditable according to GAAP
guidelines.
11.
Relate and extract data elements to produce report formats (provided within
the
Uniform Managed Care Manual) or otherwise required by
HHSC;
12.
Ensure that written process and procedures manuals document and describe all
manual and automated system procedures and processes for the MIS;
13.
Maintain and cross-reference all Member-related information with the most
current Medicaid, CHIP or CHIP Perinatal Program Provider number;
and
14.
Ensure that the MIS is able to integrate pharmacy data from HHSC’s Drug Vendor
file (available through the Virtual Private Network (VPN)) into the HMO’s Member
data.
The
HMO’s
MIS system must comply with applicable certificate of coverage and data
specification and reporting requirements promulgated pursuant to the Health
Insurance Portability and Accountability Act (HIPAA) of 1996, P.L. 104-191
(August 21, 1996), as amended or modified. The HMO must comply with HIPAA EDI
requirements. HMO’s enrollment files must be in the 834 HIPAA-compliant format.
Eligibility inquiries must be in the 270/271 format and all claims and
remittance transactions in the 837/835 format.
The
HMO
must provide its Members with a privacy notice as required by HIPAA. The HMO
must provide HHSC with a copy of its privacy notice for filing.
The
HMO
must process and adjudicate all provider claims for Medically Necessary Covered
Services that are filed within the time frames specified in the Uniform
Managed Care Manual. The HMO is subject to remedies, including
liquidated damages and interest, if the HMO does not process and adjudicate
claims within the timeframes listed in the Uniform Managed Care
Manual.
The
HMO
must administer an effective, accurate, and efficient claims payment process
in
compliance with federal laws and regulations, applicable state laws and rules,
the Contract, and the Uniform Managed Care Manual. In addition,
a Medicaid HMO must be able to accept and process provider claims in compliance
with the Medicaid Provider Procedures Manual and The Texas Medicaid
Bulletin.
The
HMO
must maintain an automated claims processing system that registers the date
a
claim is received by the MCO, the detail of each claim transaction (or action)
at the time the transaction occurs, and has the capability to report each claim
transaction by date and type to include interest payments. The claims
system must maintain information at the claim and line detail
level. The claims system must maintain adequate audit trails and
report accurate claims performance measures to HHSC.
The
HMO’s
claims system must maintain online and archived files. The HMO must keep online
automated claims payment history for the most current 18 months. The
HMO must retain other financial information and records, including all original
claims forms, for the time period established in Attachment A, Section
9.01. All claims data must be easily sorted and produced in formats as
requested by HHSC.
The
HMO
must offer its Providers/Subcontractors the option of submitting and receiving
claims information through electronic data interchange (EDI) that allows for
automated processing and adjudication of claims. EDI processing must be offered
as an alternative to the filing of paper claims. Electronic claims must use
HIPAA-compliant electronic formats.
The
HMO
must make an electronic funds transfer (EFT) payment process (for direct
deposit) available to in-network providers when processing claims for Medically
Necessary covered STAR+PLUS services.
The
HMO
may deny a claim submitted by a provider for failure to file in a timely manner
as provided for in the Uniform Managed Care Manual. The HMO
must not pay any claim submitted by a provider excluded or suspended from the
Medicare, Medicaid, CHIP or CHIP Perinatal programs for Fraud, Abuse, or
Waste. The HMO must not pay any claim submitted by a Provider that is
on payment hold under the authority of HHSC or its authorized agent(s), or
who
has pending accounts receivable with HHSC.
The
HMO
is subject to the requirements related to coordination of benefits for secondary
payors in the Texas Insurance Code Section 843.349 (e) and (f).
The
HMO
must notify HHSC of major claim system changes in writing no later than 90
days
prior to implementation. The HMO must provide an implementation plan and
schedule of proposed changes. HHSC reserves the right to require a desk or
on-site readiness review of the changes.
The
HMO
must inform all Network Providers about the information required to submit
a
claim at least 30 days prior to the Operational Start Date and as a provision
within the HMO/Provider contract. The HMO must make available to Providers
claims coding and processing guidelines for the applicable provider type.
Providers must receive 90 days notice prior to the HMO’s implementation of
changes to claims guidelines.
8.1.19
Fraud and Abuse
A
HMO is
subject to all state and federal laws and regulations relating to Fraud, Abuse,
and Waste in health care and the Medicaid and CHIP programs. The HMO must
cooperate and assist HHSC and any state or federal agency charged with the
duty
of identifying, investigating, sanctioning or prosecuting suspected Fraud,
Abuse
or Waste. The HMO must provide originals and/or copies of all records and
information requested and allow access to premises and provide records to the
Inspector General for the Texas Health and Human Services System, HHSC or its
authorized agent(s), the Centers for Medicare and Medicaid Services (CMS),
the
U.S. Department of Health and Human Services (DHHS), Federal Bureau of
Investigation, TDI, or other units of state government. The HMO must provide
all
copies of records free of charge.
The
HMO
must submit a written Fraud and Abuse compliance plan to the Office of Inspector
General at HHSC for approval (See Attachment B-1, Section 7 for
requirements regarding timeframes for submitting the original plan.) The plan
must ensure that all officers, directors, managers and employees know and
understand the provisions of the HMO’s Fraud and Abuse compliance plan. The plan
must include the name, address, telephone number, electronic mail address,
and
fax number of the individual(s) responsible for carrying out the
plan.
The
written Fraud and Abuse compliance plan must:
1 Contain
procedures designed to prevent and detect potential or suspected Abuse, Fraud
and Waste in the administration and delivery of services under the
Contract;
2 Contain
a
description of the HMO’s procedures for educating and training personnel to
prevent Fraud, Abuse, or Waste;
3 Include
provisions for the confidential reporting of plan violations to the designated
person within the HMO’s organization and ensure that the identity of an
individual reporting violations is protected from retaliation;
4 Include
provisions for maintaining the confidentiality of any patient information
relevant to an investigation of Fraud, Abuse, or Waste;
5 Provide
for the investigation and follow-up of any allegations of Fraud, Abuse, or
Waste
and contain specific and detailed internal procedures for officers, directors,
managers and employees for detecting, reporting, and investigating Fraud and
Abuse compliance plan violations;
6 Require
that confirmed violations be reported to the Office of Inspector General (OIG);
and
7 Require
any confirmed violations or confirmed or suspected Fraud, Abuse, or Waste under
state or federal law be reported to OIG.
If
the
HMO contracts for the investigation of allegations of Fraud, Abuse, or Waste
and
other types of program abuse by Members or Providers, the plan must include
a
copy of the subcontract; the names, addresses, telephone numbers, electronic
mail addresses, and fax numbers of the principals of the subcontracted entity;
and a description of the qualifications of the subcontracted
entity. Such subcontractors must be held to the requirements stated
in this Section.
The
HMO
must designate executive and essential personnel to attend mandatory training
in
Fraud and Abuse detection, prevention and reporting. Designated executive and
essential personnel means the HMO staff persons who supervise staff in the
following areas: data collection, provider enrollment or disenrollment,
encounter data, claims processing, utilization review, appeals or grievances,
quality assurance and marketing, and who are directly involved in the
decision-making and administration of the Fraud and Abuse detection program
within the HMO. The training will be conducted by the OIG free of charge. The
HMO must schedule and complete training no later than 90 days after the
Effective Date of the Contract. If the HMO updates or modifies its written
Fraud
and Abuse compliance plan, the HMO must train its executive and essential
personnel on these updates or modifications no later than 90 days after the
effective date of the updates or modifications.
The
HMO
must designate an officer or director in its organization with responsibility
and authority to carry out the provisions of the Fraud and Abuse compliance
plan. A HMO’s failure to report potential or suspected Fraud or Abuse may result
in sanctions, cancellation of the Contract, and/or exclusion from participation
in the Medicaid, CHIP or CHIP Perinatal HMO Programs. The HMO must allow the
OIG, HHSC, its agents, or other governmental units to conduct private interviews
of the HMO’s personnel, subcontractors and their personnel, witnesses, and
Members with regard to a confirmed violation. The HMO’s personnel and it
subcontractors must reasonably cooperate, to the satisfaction of HHSC, by being
available in person for interviews, consultation, grand jury proceedings,
pre-trial conferences, hearings, trials and in any other process, including
investigations, at the HMO’s and subcontractors’ own expense.
Additional
Requirements for STAR and STAR+PLUS HMOs:
In
accordance with Section 1902(a)(68) of the Social Security Act, STAR and
STAR+PLUS HMOs that receive or make annual Medicaid payments of at least $5
million must:
1 Establish
written policies for all employees, managers, officers, contractors,
subcontractors, and agents of the HMO, which provide detailed information about
the False Claims Act, administrative remedies for false claims and statements,
any state laws pertaining to civil or criminal penalties for false claims,
and
whistleblower protections under such laws, as described in Section
1902(a)(68)(A).
2 Include
as part of such written policies, detailed provisions regarding the HMO’s
policies and procedures for detecting and preventing fraud, waste, and
abuse.
3 Include
in any employee handbook a specific discussion of the laws described in Section
1902(a)(68)(A), the rights of employees to be protected as whistleblowers,
and
the HMO’s policies and procedures for detecting and preventing fraud, waste, and
abuse.
8.1.20
Reporting Requirements
The
HMO
must provide and must require its subcontractors to provide:
1 All
information required under the Contract, including but not limited to, the
reporting requirements or other information related to the performance of its
responsibilities hereunder as reasonably requested by the HHSC; and
2 Any
information in its possession sufficient to permit HHSC to comply with the
Federal Balanced Budget Act of 1997 or other Federal or state laws, rules,
and
regulations. All information must be provided in accordance with the timelines,
definitions, formats and instructions as specified by HHSC. Where practicable,
HHSC may consult with HMOs to establish time frames and formats reasonably
acceptable to both parties.
Any
deliverable or report in Section 8.1.20 without a specified due date is due
quarterly on the last day of the month following the end of the reporting
period. Where the due date states 30 days, the HMO is to provide the deliverable
by the last day of the month following the end of the reporting
period. Where the due date states 45 days, the HMO is to provide the
deliverable by the 15th day of the second month following the end of the
reporting period.
The
HMO’s
Chief Executive and Chief Financial Officers, or persons in equivalent
positions, must certify that financial data, Encounter Data and other
measurement data has been reviewed by the HMO and is true and accurate to the
best of their knowledge after reasonable inquiry.
The
HMO
must provide to HHSC or its designee all information necessary to analyze the
HMO’s provision of quality care to Members using measures to be determined by
HHSC in consultation with the HMO. Such measures must be consistent with HEDIS
or other externally based measures or measurement sets, and involve collection
of information beyond that present in Encounter Data. The Performance
Indicator Dashboard, found in the Uniform Managed Care
Manual provides additional information on the role of the HMO and the
EQRO in the collection and calculation of HEDIS, CAHPS, and other performance
measures.
The
HMO
must provide the following reports, in addition to the Financial Reports
described in Section 8.1.17 and those reporting requirements
listed elsewhere in the Contract. The HHSC Uniform Managed Care
Manual will include a list of all required reports, and a description
of the format, content, file layout and submission deadlines for each
report.
For
the
following reports, CHIP Perinatal Program data will be integrated into existing
CHIP Program reports. Generally, no separate CHIP Perinatal Program
reports are required. Where appropriate, HHSC will designate specific attributes
within the CHIP Program reports that the CHIP Perinatal HMOs must complete
to
allow HHSC to extract data particular to the CHIP Perinatal
Program.
Claims
Summary Report - The HMO must submit quarterly Claims Summary Reports
to HHSC by HMO Program, Service Area and claim type by the 30th day following
the
end of the reporting period unless otherwise specified. Claim Types include
facility and/or professional services for Acute Care, Behavioral Health, Vision,
and Long Term Services and Supports. Within each claim type, claims data must
be
reported separately on the UB and CMS 1500 claim forms. The format
for the Claims Summary Report is contained in Chapter 5, Section 5.6.1 of the
Uniform Managed Care Manual.
QAPI
Program Annual Summary Report - The HMO must submit a QAPI Program
Annual Summary in a format and timeframe as specified in the Uniform Managed
Care Manual.
Fraudulent
Practices Report - Utilizing the HHSC-Office of Inspector General (OIG)
fraud referral form, the HMO’s assigned officer or director must report and
refer all possible acts of waste, abuse or fraud to the HHSC-OIG within 30
working days of receiving the reports of possible acts of waste, abuse or fraud
from the HMO’s Special Investigative Unit (SIU). The report and
referral must include: an investigative report identifying the allegation,
statutes/regulations violated or considered, and the results of the
investigation; copies of program rules and regulations violated for the time
period in question; the estimated overpayment identified; a summary of the
interviews conducted; the encounter data submitted by the provider for the
time
period in question; and all supporting documentation obtained as the result
of
the investigation. This requirement applies to all reports of possible acts
of
waste, abuse and fraud.
Additional
reports required by the Office of the Inspector General relating to waste,
abuse
or fraud are listed in the HHSC Uniform Managed Care
Manual.
Provider
Termination Report: (CHIP (including integrated CHIP Perinatal Program data),
STAR, and STAR+PLUS)
MCO
must
submit a quarterly report that identifies any providers who cease to participate
in MCO's provider network, either voluntarily or involuntarily. The report
must
be submitted to HHSC in the format specified by HHSC, no later than 30 days
after the end of the reporting period.
PCP
Network & Capacity Report: (CHIP only (including integrated CHIP Perinatal
Program data))
For
the
CHIP Program, MCO must submit a quarterly report listing all unduplicated PCPs
in the MCO's Provider Network. For the CHIP Perinatal Program, the
Perinatal Newborns are assigned PCPs that are part of the CHIP PCP Network.
The
report must be submitted to HHSC in the format specified by HHSC, no later
than
30 days after the end of the reporting quarter.
Summary
Report of Member Complaints and Appeals - The HMO must submit quarterly
Member Complaints and Appeals reports. The HMO must include in its reports
Complaints and Appeals submitted to its subcontracted risk groups (e.g., IPAs)
and any other subcontractor that provides Member services. The HMO must submit
the Complaint and Appeals reports electronically on or before 45 days following
the end of the state fiscal quarter, using the format specified by HHSC in
the
HHSC Uniform Managed Care Manual, Chapter 5.4.2.
HHSC
may
direct the CHIP Perinatal HMOs to provide segregated Member Complaints and
Appeals reports on an as-needed basis.
Summary
Report of Provider Complaints - The HMO must submit Provider complaints
reports on a quarterly basis. The HMO must include in its reports complaints
submitted by providers to its subcontracted risk groups (e.g., IPAs) and any
other subcontractor that provides Provider services. The complaint reports
must
be submitted electronically on or before 45 days following the end of the state
fiscal quarter, using the format specified by HHSC in the HHSC
Uniform
Managed Care Manual, Chapter 5.4.2.
HHSC
may
direct the CHIP Perinatal HMOs to provide segregated Provider Complaints and
Appeals reports on an as-needed basis.
Hotline
Reports - The HMO must submit, on a quarterly basis, a status report
for the Member Hotline, the Behavioral Health Services Hotline, and the Provider
Hotline in comparison with the performance standards set out in Sections
8.1.5.6,
8.1.14.3, and 8.1.4.7. The HMO shall submit such reports using a format
to be prescribed by HHSC in consultation with the HMOs.
If
the
HMO is not meeting a hotline performance standard, HHSC may require the HMO
to
submit monthly hotline performance reports and implement corrective actions
until the hotline performance standards are met. If a HMO has a single hotline
serving multiple Service Areas, multiple HMO Programs, or multiple hotline
functions, (i.e. Member, Provider, Behavioral Health Services hotlines), HHSC
may request on an annual basis that the HMO submit certain hotline response
information by HMO Program, by Service Area, and by hotline function, as
applicable to the HMO. HHSC may also request this type of hotline information
if
a HMO is not meeting a hotline performance standard.
The
HMO
must follow all applicable Joint Interface Plans (JIPs) and all required file
submissions for HHSC’s Administrative Services Contractor, External Quality
Review Organization (EQRO) and HHSC Medicaid Claims
Administrator. The JIPs can be accessed through the Uniform Managed
Care Manual.
Medicaid
Medical Check-ups Report – Medicaid HMOs must submit an annual report
that identifies:
(1)
the
total number of new Members under the age of 21 who are still enrolled with
the
HMO after 90 days;
(2)
the
number and percent of new Members under the age of 21 still enrolled with the
HMO after 90 days who get medical check-ups within 90 days of enrollment into
the HMO;
(3)
the
total number of Members under the age of 21 who have been enrolled
continuously with the HMO for 90 days or more (excluding the new Members);
and
(4)
the
number and percent of Members under the age of 21 who have been enrolled
continuously for 90 days or more with the HMO (excluding the new
Members) who get timely, age-appropriate medical
check-ups.
HMOs
must
also document and report those Members refusing to obtain the
check-ups. The documentation must include the reason the Member
refused the check-up or the reason the checkup was not received. For
purposes of the Medicaid Medical Check-ups Report, “new Members” are Members who
have not previously been enrolled in the HMO that is preparing the
report.
The
timeframe, format, and details of the report will be described in the
Uniform Managed Care Manual.
Medicaid
FWC Report – Beginning in September 2008, Medicaid HMOs must submit an
annual report, in the timeframe and format described in the Uniform Managed
Care
Manual, about the identification of and delivery of services to children of
Migrant Farmworkers (FWC). The report will include a description and
results of the each of the following:
(1)
the
HMO’s efforts to identify as many community and statewide groups that work with
FWC as possible within its Service Areas;
(2)
the
HMO’s efforts to coordinate and cooperate with as many of such groups as
possible; and
(3)
the
HMO’s efforts to encourage the community groups to assist in the identification
of FWC.
The
HMO
will maintain accurate, current lists of all identified FWC
Members.
The
following provisions apply to any HMO participating in the STAR or STAR+PLUS
HMO
Program.
8.2.1
Continuity of Care and Out-of-Network Providers
The
HMO
must ensure that the care of newly enrolled Members is not disrupted or
interrupted. The HMO must take special care to provide continuity in the care
of
newly enrolled Members whose health or behavioral health condition has been
treated by specialty care providers or whose health could be placed in jeopardy
if Medically Necessary Covered Services are disrupted or
interrupted.
The
HMO
must allow pregnant Members with 12 weeks or less remaining before the expected
delivery date to remain under the care of the Member’s current OB/GYN through
the Member’s postpartum checkup, even if the provider is Out-of-Network. If a
Member wants to change her OB/GYN to one who is in the Network, she must be
allowed to do so if the Provider to whom she wishes to transfer agrees to accept
her in the last trimester of pregnancy.
The
HMO
must pay a Member’s existing Out-of-Network providers for Medically Necessary
Covered Services until the Member’s records, clinical information and care can
be transferred to a Network Provider, or until such time as the Member is no
longer enrolled in that HMO, whichever is shorter. Payment to Out-of-Network
providers must be made within the time period required for Network
Providers. The HMO must comply with out-of-network provider
reimbursement rules as adopted by HHSC.
This
Article does not extend the obligation of the HMO to reimburse the Member’s
existing Outof-Network providers for on-going care for:
1 More
than
90 days after a Member enrolls in the HMO’s Program, or
2 For
more
than nine (9) months in the case of a Member who, at the time of enrollment
in
the HMO, has been diagnosed with and receiving treatment for a terminal illness
and remains enrolled in the HMO.
The
HMO’s
obligation to reimburse the Member’s existing Out-of-Network provider for
services provided to a pregnant Member with 12 weeks or less remaining before
the expected delivery date extends through delivery of the child, immediate
postpartum care, and the follow-up checkup within the first six weeks of
delivery.
The
HMO
must provide or pay Out-of-Network providers who provide Medically Necessary
Covered Services to Members who move out of the Service Area through the end
of
the period for which capitation has been paid for the Member.
The
HMO
must provide Members with timely and adequate access to Out-of-Network services
for as long as those services are necessary and covered benefits not available
within the network, in accordance with 42 C.F.R. §438.206(b)(4). The HMO will
not be obligated to provide a Member with access to Out-of-Network services
if
such services become available from a Network Provider.
The
HMO
must ensure that each Member has access to a second opinion regarding the use
of
any Medically Necessary Covered Service. A Member must be allowed access to
a
second opinion from a Network Provider or Out-of-Network provider if a Network
Provider is not available, at no cost to the Member, in accordance with 42
C.F.R. §438.206(b)(3).
8.2.2
Provisions Related to Covered Services for Medicaid
Members
8.2.2.1
Emergency Services
HMO
policy and procedures, Covered Services, claims adjudication methodology, and
reimbursement performance for Emergency Services must comply with all applicable
state and
federal
laws, rules, and regulations including 42 C.F.R. §438.114, whether the provider
is in-network or Out-of-Network. HMO policies and procedures must be consistent
with the prudent layperson definition of an Emergency Medical Condition and
the
claims adjudication processes required under the Contract and 42 C.F.R.
§438.114.
The
HMO
must pay for the professional, facility, and ancillary services that are
Medically Necessary to perform the medical screening examination and
stabilization of a Member presenting with an Emergency Medical Condition or
an
Emergency Behavioral Health Condition to the hospital emergency department,
24
hours a day, 7 days a week, rendered by either the HMO's Network or
Out-of-Network providers.
The
HMO
cannot require prior authorization as a condition for payment for an Emergency
Medical Condition, an Emergency Behavioral Health Condition, or labor and
delivery. The HMO cannot limit what constitutes an Emergency Medical Condition
on the basis of lists of diagnoses or symptoms. The HMO cannot refuse to cover
Emergency Services based on the emergency room provider, hospital, or fiscal
agent not notifying the Member’s PCP or the HMO of the Member’s screening and
treatment within 10 calendar days of presentation for Emergency Services. The
HMO may not hold the Member who has an Emergency Medical Condition liable for
payment of subsequent screening and treatment needed to diagnose the specific
condition or stabilize the patient. The HMO must accept the emergency physician
or provider’s determination of when the Member is sufficiently stabilized for
transfer or discharge.
A
medical
screening examination needed to diagnose an Emergency Medical Condition must
be
provided in a hospital based emergency department that meets the requirements
of
the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 C.F.R.
§§489.20, 489.24 and 438.114(b)&(c)). The HMO must pay for the emergency
medical screening examination, as required by 42 U.S.C. §1395dd. The HMO must
reimburse for both the physician's services and the hospital's Emergency
Services, including the emergency room and its ancillary services.
When
the
medical screening examination determines that an Emergency Medical Condition
exists, the HMO must pay for Emergency Services performed to stabilize the
Member. The emergency physician must document these services in the Member's
medical record. The HMO must reimburse for both the physician's and hospital's
emergency stabilization services including the emergency room and its ancillary
services.
The
HMO
must cover and pay for Post-Stabilization Care Services in the amount, duration,
and scope necessary to comply with 42 C.F.R. §438.114(b)&(e) and 42 C.F.R.
§422.113(c)(iii). The HMO is financially responsible for post-stabilization
care
services obtained within or outside the Network that are not pre-approved by
a
Provider or other HMO representative, but administered to maintain, improve,
or
resolve the Member’s stabilized condition if:
1 The
HMO
does not respond to a request for pre-approval within 1 hour;
2 The
HMO
cannot be contacted; or
3 The
HMO
representative and the treating physician cannot reach an agreement concerning
the Member’s care and a Network physician is not available for consultation. In
this situation, the HMO must give the treating physician the opportunity to
consult with a Network physician and the treating physician may continue with
care of the patient until an HMO physician is reached. The HMO’s financial
responsibility ends as follows:
the
HMO
physician with privileges at the treating hospital assumes responsibility for
the Member’s care; the HMO physician assumes responsibility for the Member’s
care through transfer; the HMO representative and the treating physician reach
an agreement concerning the Member’s care; or the Member is
discharged.
8.2.2.2
Family Planning - Specific Requirements
The
HMO
must require, through Provider contract provisions, that Members requesting
contraceptive services or family planning services are also provided counseling
and education about the family planning and family planning services available
to Members. The HMO must develop outreach programs to increase community support
for family planning and encourage Members to use available family planning
services.
The
HMO
must ensure that Members have the right to choose any Medicaid participating
family planning provider, whether the provider chosen by the Member is in or
outside the Provider Network. The HMO must provide Members access to information
about available providers of family planning services and the Member’s right to
choose any Medicaid family planning provider. The HMO must provide access to
confidential family planning services.
The
HMO
must provide, at minimum, the full scope of services available under the Texas
Medicaid program for family planning services. The HMO will reimburse family
planning agencies the Medicaid fee-for service amounts for family planning
services, including Medically Necessary medications, contraceptives, and
supplies not covered by the Vendor Drug Program and will reimburse
Out-of-Network family planning providers in accordance with HHSC’s
administrative rules.
The
HMO
must provide medically approved methods of contraception to Members, provided
that the methods of contraception are Covered Services. Contraceptive methods
must be accompanied by verbal and written instructions on their correct use.
The
HMO must establish mechanisms to ensure all medically approved methods of
contraception are made available to the Member, either directly or by referral
to a subcontractor.
The
HMO
must develop, implement, monitor, and maintain standards, policies and
procedures for providing information regarding family planning to Providers
and
Members, specifically regarding State and federal laws governing Member
confidentiality (including minors). Providers and family planning agencies
cannot require parental consent for minors to receive family planning services.
The HMO must require, through contractual provisions, that subcontractors have
mechanisms in place to ensure Member’s (including minor’s) confidentiality for
family planning services.
8.2.2.3
Texas Health Steps (EPSDT)
The
HMO
must develop effective methods to ensure that children under the age of 21
receive THSteps services when due and according to the recommendations
established by the AAP and the THSteps periodicity schedule for children. The
HMO must arrange for THSteps services for all eligible Members except when
a
Member knowingly and voluntarily declines or refuses services after receiving
sufficient information to make an informed decision.
HMO
must
have mechanisms in place to ensure that all newly enrolled newborns receive
an
appointment for a THSteps checkup within 14 days of enrollment and all other
eligible child Members receive a THSteps checkup within 60 days of enrollment,
if one is due according to the AAP periodicity schedule.
The
HMO
must ensure that Members are provided information and educational materials
about the services available through the THSteps Program, and how and when
they
may obtain the services. The information should tell the Member how they can
obtain dental benefits, transportation services through the Texas Department
of
Transportation’s Medical Transportation Program, and advocacy assistance from
the HMO. The HMO will encourage Medicaid-enrolled pharmacies to also become
Medicaid-enrolled durable medical equipment (DME) providers.
The
HMO
must provide appropriate training to all Network Providers and Provider staff
in
the Providers’ area of practice regarding the scope of benefits available and
the THSteps Program. Training must include:
1 THSteps
benefits,
2 The
periodicity schedule for THSteps medical checkups and
immunizations,
3 The
required elements of THSteps medical checkups,
4 Providing
or arranging for all required lab screening tests (including lead screening),
and Comprehensive Care Program (CCP) services available under the THSteps
program to Members under age 21 years.
HMO
must
also educate and train Providers regarding the requirements imposed on HHSC
and
contracting HMOs under the Consent Decree entered in Xxxx x. Xxxxxxx, et.
al., Civil Action No. 3:93CV65, in the United States District Court for the
Eastern District of Texas, Paris Division. Providers should be educated and
trained to treat each THSteps visit as an opportunity for a comprehensive
assessment of the Member.
The
HMO
must provide outreach to Members to ensure they receive prompt services and
are
effectively informed about available THSteps services. Each month, the HMO
must
retrieve from the HHSC Administrative Services Contractor Bulletin Board System
a list of Members who are due and overdue THSteps services. Using these lists
and its own internally generated list, the HMO will contact such Members to
obtain the service as soon as possible. The HMO outreach staff must coordinate
with DSHS THSteps outreach staff to ensure that Members have access to the
Medical Transportation Program, and that any coordination with other agencies
is
maintained.
The
HMO
must cooperate and coordinate with the State, outreach programs and THSteps
regional program staff and agents to ensure prompt delivery of services to
children of migrant farm workers and other migrant populations who may
transition into and out of the HMO’s Program more rapidly and/or unpredictably
than the general population.
The
HMO
must have mechanisms in place to ensure that all newborn Members have an initial
newborn checkup before discharge from the hospital and again within two weeks
from the time of birth. The HMO must require Providers to send all THSteps
newborn screens to the DSHS Bureau of Laboratories or a DSHS certified
laboratory. Providers must include detailed identifying information for all
screened newborn Members and the Member’s mother to allow
DSHS
to
link the screens performed at the hospital with screens performed at the
two-week follow-up.
All
laboratory specimens collected as a required component of a THSteps checkup
(see
Medicaid Provider Procedures Manual for age-specific requirements) must be
submitted to the DSHS Laboratory for analysis. The HMO must educate Providers
about THSteps Program requirements for submitting laboratory tests to the DSHS
Bureau of Laboratories.
The
HMO
must make an effort to coordinate and cooperate with existing community and
school-based health and education programs that offer services to school-aged
children in a location that is both familiar and convenient to the Members.
The
HMO must make a good faith effort to comply with Head Start’s requirement that
Members participating in Head Start receive their THSteps checkup no later
than
45 days after enrolling into either program.
The
HMO
must educate Providers on the Immunization Standard Requirements set forth
in
Chapter 161, Health and Safety Code; the standards in the ACIP Immunization
Schedule; the AAP Periodicity Schedule for CHIP Members; and the DSHS
Periodicity Schedule for Medicaid Members. The HMO shall educate Providers
that
Medicaid Members under age 21 must be immunized during the THSteps checkup
according to the DSHS routine immunization schedule. The HMO shall also educate
Providers that the screening provider is responsible for administration of
the
immunization and should not refer children to Local Health Departments to
receive immunizations.
The
HMO
must educate Providers about, and require Providers to comply with, the
requirements of Chapter 161, Health and Safety Code, relating to the Texas
Immunization Registry (ImmTrac), to include parental consent on the Vaccine
Information Statement.
The
HMO
must require all THSteps Providers to submit claims for services paid (either
on
a capitated or fee-for service basis) on the HCFA 1500 claim form and use the
HIPAA compliant code set required by HHSC.
Encounter
Data will be validated by chart review of a random sample of THSteps eligible
enrollees against monthly Encounter Data reported by the HMO. HHSC or its
designee will conduct chart reviews to validate that all screens are performed
when due and as reported, and that reported data is accurate and timely.
Substantial deviation between reported and charted Encounter Data could result
in the HMO and/or Network Providers being investigated for potential Fraud,
Abuse, or Waste without notice to the HMO or the Provider.
8.2.2.4
Perinatal Services
The
HMO’s
perinatal health care services must ensure appropriate care is provided to
women
and infant Members of the HMO from the preconception period through the infant’s
first year of life. The HMO’s perinatal health care system must comply with the
requirements of the Texas Health and Safety Code, Chapter 32 (the Maternal
and
Infant Health Improvement Act) and administrative rules codified at 25 T.A.C.
Chapter 37, Subchapter M.
The
HMO
must have a perinatal health care system in place that, at a minimum, provides
the following services:
1 Pregnancy
planning and perinatal health promotion and education for reproductive- age
women;
2 Perinatal
risk assessment of non-pregnant women, pregnant and postpartum women, and
infants up to one year of age;
3 Access
to
appropriate levels of care based on risk assessment, including emergency
care;
4 Transfer
and care of pregnant women, newborns, and infants to tertiary care facilities
when necessary;
5 Availability
and accessibility of OB/GYNs, anesthesiologists, and neonatologists capable
of
dealing with complicated perinatal problems; and
6 Availability
and accessibility of appropriate outpatient and inpatient facilities capable
of
dealing with complicated perinatal problems.
The
HMO
must have a process to expedite scheduling a prenatal appointment for an
obstetrical exam for a TP40 Member no later than two weeks after receiving
the
daily Enrollment File verifying the Member’s enrollment into the
HMO.
The
HMO
must have procedures in place to contact and assist a pregnant/delivering Member
in selecting a PCP for her baby either before the birth or as soon as the baby
is born.
The
HMO
must provide inpatient care and professional services relating to labor and
delivery for its pregnant/delivering Members, and neonatal care for its newborn
Members at the time of delivery and for up to 48 hours following an
uncomplicated vaginal delivery and 96 hours following an uncomplicated Caesarian
delivery.
The
HMO
must Adjudicate provider claims for services provided to a newborn Member in
accordance with HHSC’s claims processing requirements using the proxy ID number
or State-issued Medicaid ID number. The HMO cannot deny claims based on a
provider’s non-use of State-issued Medicaid ID number for a newborn Member. The
HMO must accept provider claims for newborn services based on mother’s name
and/or Medicaid ID number with accommodations for multiple births, as specified
by the HMO.
The
HMO
must notify providers involved in the care of pregnant/delivering women and
newborns (including Out-of-Network providers and hospitals) of the HMO’s prior
authorization requirements. The HMO cannot require a prior authorization for
services provided to a pregnant/delivering Member or newborn Member for a
medical condition that requires Emergency Services, regardless of when the
emergency condition arises.
8.2.2.5
Sexually Transmitted Diseases (STDs) and Human Immunodeficiency Virus
(HIV)
The
HMO
must provide STD services that include STD/HIV prevention, screening,
counseling, diagnosis, and treatment. The HMO is responsible for implementing
procedures to ensure that Members have prompt access to appropriate services
for
STDs, including HIV. The HMO must allow Members access to STD services and
HIV
diagnosis services without prior authorization or referral by a
PCP.
The
HMO
must comply with Texas Family Code Section 32.003, relating to consent to
treatment by a child. The HMO must provide all Covered Services required to
form
the basis for a diagnosis by the Provider as well as the STD/HIV treatment
plan.
The
HMO
must make education available to Providers and Members on the prevention,
detection and effective treatment of STDs, including HIV.
The
HMO
must require Providers to report all confirmed cases of STDs, including HIV,
to
the local or regional health authority according to 25 T.A.C. §§97.131 - 97.134,
using the required forms and procedures for reporting STDs. The HMO must require
the Providers to coordinate with the HHSC regional health authority to ensure
that Members with confirmed cases of syphilis, chancroid, gonorrhea, chlamydia
and HIV receive risk reduction and partner elicitation/notification
counseling.
The
HMO
must have established procedures to make Member records available to public
health agencies with authority to conduct disease investigation, receive
confidential Member information, and provide follow up activities.
The
HMO
must require that Providers have procedures in place to protect the
confidentiality of Members provided STD/HIV services. These procedures must
include, but are not limited to, the manner in which medical records are to
be
safeguarded, how employees are to protect medical information, and under what
conditions information can be shared. The HMO must inform and require its
Providers who provide STD/HIV services to comply with all state laws relating
to
communicable disease reporting requirements. The HMO must implement policies
and
procedures to monitor Provider compliance with confidentiality
requirements.
The
HMO
must have policies and procedures in place regarding obtaining informed consent
and counseling Members provided STD/HIV services.
8.2.2.6
Tuberculosis (TB)
The
HMO
must implement policies and procedures requiring Providers to report all
confirmed or suspected cases of TB to the local TB control program within one
working day of identification, using the most recent DSHS forms and procedures
for reporting TB. The HMO must provide access to Member medical records to
DSHS
and the local TB control program for all confirmed and suspected TB cases upon
request.
The
HMO
must coordinate with the local TB control program to ensure that all Members
with confirmed or suspected TB have a contact investigation and receive Directly
Observed Therapy (DOT). The HMO must require, through contract provisions,
that
Providers report to DSHS or the local TB control program any Member who is
non-compliant, drug resistant, or who is or may be posing a public health
threat. The HMO must cooperate with the local TB control program in enforcing
the control measures and quarantine procedures contained in Chapter 81 of the
Texas Health and Safety Code.
The
HMO
must have a mechanism for coordinating a post-discharge plan for follow-up
DOT
with the local TB program. The HMO must coordinate with the DSHS South Texas
Hospital and Texas Center for Infectious Disease for voluntary and court-ordered
admission, discharge plans, treatment objectives and projected length of stay
for Members with multi-drug resistant TB.
8.2.2.7
Objection to Provide Certain Services
In
accordance with 42 C.F.R. §438.102, the HMO may file an objection to providing,
reimbursing for, or providing coverage of, a counseling or referral service
for
a Covered Service based on moral or religious grounds. The HMO must work with
HHSC to develop a work plan to complete the necessary tasks and determine an
appropriate date for implementation of the requested changes to the requirements
related to Covered Services. The work plan will include timeframes for
completing the necessary Contract and waiver amendments, adjustments to
Capitation Rates, identification of the HMO and enrollment materials needing
revision, and notifications to Members.
In
order
to meet the requirements of this section, the HMO must notify HHSC of grounds
for and provide detail concerning its moral or religious objections and the
specific services covered under the objection, no less than 120 days prior
to
the proposed effective date of the policy change.
8.2.2.8
Medicaid Non-capitated Services
The
following Texas Medicaid programs and services have been excluded from HMO
Covered Services. Medicaid Members are eligible to receive these Non-capitated
Services on a Fee-for-Service basis from Texas Medicaid providers. HMOs should
refer to relevant chapters in the Provider Procedures Manual
and the Texas Medicaid Bulletins for more
information.
1. THSteps
dental (including orthodontia);
2. Early
Childhood Intervention (ECI) case management/service coordination;
3. DSHS
targeted case management;
4. DSHS
mental health rehabilitation;
5. DSHS
case management for Children and Pregnant Women;
6. Texas
School Health and Related Services (SHARS);
7. Department
of Assistive and Rehabilitative Services Blind Children’s Vocational Discovery
and Development Program;
8. Tuberculosis
services provided by DSHS-approved providers (directly observed therapy and
contact investigation);
9. Vendor
Drug Program (out-of-office drugs);
11.
DADS
hospice services (all Members are disenrolled from their health plan upon
enrollment into hospice except STAR+PLUS members receiving 1915(c) Nursing
Facility Waiver services that are not covered by the Hospice
Program);
12.
Audiology services and hearing aids for children (under age 21) (hearing
screening services are provided through the THSteps Program and are capitated)
through PACT (Program for Amplification for Children of Texas).
13.
For
STAR+PLUS, Inpatient Stays are Non-capitated Services.
8.2.2.9
Referrals for Non-capitated Services
Although
Medicaid HMOs are not responsible for paying or reimbursing for Non-capitated
Services, HMOs are responsible for educating Members about the availability
of
Non-capitated Services, and for providing appropriate referrals for Members
to
obtain or access these services. The HMO is responsible for informing Providers
that bills for all Non-capitated Services must be submitted to HHSC’s Claims
Administrator for reimbursement.
8.2.2.10
Cooperation with Immunization Registry
The
HMO
must work with HHSC and health care providers to improve the immunization rate
of Medicaid clients and the reporting of immunization information for inclusion
in the Texas Immunization Registry, called “ImmTrac.”
8.2.2.11
Case Management for Children and Pregnant Women
The
HMO
must educate Members and Providers on the services available through Case
Management for Children and Pregnant Women (CPW) as described on the program’s
website at xxxx://xxx.xxxx.xxxxx.xx.xx/xxxxxxx/xxxxxxx.xxxx. An HMO may
provide information about CPW’s website and basic information about CPW services
in order to meet this requirement. CPW information and materials must be
included in the HMO’s Provider Manual, Member Handbook and Provider
orientations. The information and materials must also inform
Providers that the disclosure of medical records or information between
Providers, HMO’s and CPW case managers does not require a medical release form
from the Member.
The
HMO
must coordinate services with CPW regarding a Member’s health care needs that
are identified by CPW and referred to the HMO. Upon receipt of a
referral or assessment from a CPW case manager, the HMO’s designated staff are
required to review the assessment and determine, based on the HMO’s policies,
the appropriate level of health care and services. The HMO’s staff
must also coordinate with the Member’s family, Member’s Primary Care Provider
(PCP), in and Out-of-Network Providers, agencies, and the HMO’s utilization
management staff to ensure that the health care and services identified are
properly referred, authorized, scheduled and provided within a timely
manner.
The
HMO
must ensure that access to medically necessary health care needed by the Member
is available within the standards established by HHSC for respective
care. HMOs are not required to arrange or provide for any covered or
non-covered services identified in the CPW assessment. The decision
whether to authorize these services is made by the HMO. Within five
(5) business days of identifying any non-covered health care services or other
services that the Member may need, the HMO’s staff must report to the CPW case
manager which items/services will not be
performed
by the HMO. Additionally, within ten (10) business days after all of the
authorized services have been provided, the HMO’s staff must follow-up with CPW
case manager to report the provision of services. The HMO’s staff
must ensure that all services provided to a Member by an HMO Provider are
reported to the Member’s PCP.
The
CPW
program requires its contracted case managers to coordinate with the HMO and
the
HMO’s PCPs. The HMO should report problems regarding CPW referrals, assessments
or coordination activities to HHSC for follow-up with CPW program
staff.
8.2.2.12
Children of Migrant Farmworkers (FWC)
The
HMO
must cooperate and coordinate with the State, outreach programs, and THSteps
regional program staff and agents to ensure prompt delivery of services, in
accordance with the timeframes in this Contract, to FWC Members and other
migrant populations who may transition into and out of the HMO more rapidly
and/or unpredictably than the general population.
The
HMO
must provide accelerated services to FWC Members. For purposes of
this section, “accelerated services” are services that are provided to a child
of a migrant farm worker prior to their leaving Texas to work in other
states. Accelerated services include the provision of
preventive Health Care Services that will be due during the time the FWC Member
is out of Texas. The need for accelerated services must be determined on a
case-by-case and according to the FWC Member’s age, periodicity schedule and
health care needs.
The
HMO
must develop a plan annually for the process it will use to identify FWC and
for
the methods that will be used to provide accelerated services and submit an
annual certification that the HMO will comply with the plan. The plan
for FY2008 must be submitted for HHSC approval no later than December 1, 2007
and implemented by February 1, 2008. The plan must include at a
minimum:
• Identification
of community and statewide groups that work with FWC Members within the HMO’s
Service Areas;
• Participation
of the community groups in assisting with the identification of FWC
Members;
• Appropriate
aggressive efforts to reach each identified FWC to provide timely medical
checkups and follow up care if needed;
• Methods
to maintain accurate, current lists of all identified FWC Members;
• Methods
that the HMO and its Subcontractors will implement to maintain the
confidentiality of information about the identity of FWC; and
• Methods
to provide accelerated services to FWC.
8.2.3
Medicaid Significant Traditional Providers
In
the
first three (3) years of a Medicaid HMO Program operating in a Service Area,
the
HMO must seek participation in its Network from all Medicaid Significant
Traditional Providers (STPs) defined by HHSC in the applicable Service Area
for
the applicable HMO Program. For STAR
HMOs,
the
Medicaid STP requirements only apply in the Nueces Service Area. For
STAR+PLUS HMOs, the Medicaid STP requirements apply to all Service Areas, except
Xxxxxx County within the Xxxxxx Service Area.
Medicaid
STPs are defined as PCPs and, for STAR+PLUS, Community-based Long Term Care
providers in a county, that, when listed by provider type by county in
descending order by unduplicated number of clients, served the top 80% of
unduplicated clients. Hospitals receiving Disproportionate Share Hospital (DSH)
funds are also considered STPs in the Service Area in which they are
located. Note that STAR+PLUS HMOs are not required to contract with
Hospitals for Inpatient Stays, but are required to contract with Hospitals
for
Outpatient Hospital Services. The HHSC website includes a list of Medicaid
STPs
by Service Area.
Because
the STP lists were produced in FY2005, HHSC has developed an updated list for
Long Term Care Providers. The list will be provided to HMOs and posted on HHSC’s
website.
The
STP
requirement will be in place for three years after the program has been
implemented. During that time, providers who believe they meet the STP
requirements may contact HHSC request HHSC’s consideration for STP
status. STAR+PLUS HMOs will be notified when Providers are added to
the list of STPs for a Service Area.
The
HMO
must give STPs the opportunity to participate in its Network for at least three
(3) years commencing on the implementation date of Medicaid managed care in
the
Service Area. However, the STP provider must:
1 Agree
to
accept the HMO’s Provider reimbursement rate for the provider type;
and
2 Meet
the
standard credentialing requirements of the HMO, provided that lack of board
certification or accreditation by the Joint Commission on Accreditation of
Health Care Organizations (JCAHO) is not the sole grounds for exclusion from
the
Provider Network.
8.2.4
Federally Qualified Health Centers (FQHCs) and Rural Health Clinics
(RHCs)
The
HMO
must make reasonable efforts to include FQHCs and RHCs (freestanding and
hospital-based) in its Provider Network. The HMO must reimburse FQHCs and RHCs
for health care services provided outside of regular business hours, as defined
by HHSC in rules, including weekend days or holidays, at a rate that is equal
to
the allowable rate for those services as determined under Section 32.028, Human
Resources Code, if the Member does not have a referral from their PCP. FQHCs
or
RHCs will receive a cost settlement from HHSC and must agree to accept initial
payments from the HMO in an amount that is equal to or greater than the HMO’s
payment terms for other Providers providing the same or similar services. Prior
to September 1, 2007, cost settlements do not apply to the Nueces Service Area
and the STAR+PLUS Service Areas. The HMOs serving those Service Areas
must pay the full encounter rates to the FQHCs and RHCs for claims accruing
before September 1, 2007. Cost settlements will apply to all STAR and
STAR+PLUS Services Areas for claims accruing on or after September 1,
2007.
The
HMO
must submit monthly FQHC and RHC encounter and payment reports to all contracted
FQHCs and RHCs, and FQHCs and RHCs with which there have been encounters, not
later than
21
days
from the end of the month for which the report is submitted. The format will
be
developed by HHSC and provided in the Uniform Managed Care
Manual. The FQHC and RHC must validate the encounter and payment
information contained in the report(s). The HMO and the FQHC/RHC must both
sign
the report(s) after each party agrees that it accurately reflects encounters
and
payments for the month reported. The HMO must submit the signed FQHC and RHC
encounter and payment reports to HHSC not later than 45 days from the end of
the
reported month. Encounter and payment reports will not be necessary
for the Nueces Service Area and the STAR+PLUS Service Areas for claims accruing
before September 1, 2007, since the HMOs in those Areas will be paying the
full
encounter rates to the FQHCs and RHCs. Encounter and payment reports
are necessary for these Service Areas for claims accruing on or after September
1, 2007.
8.2.5
Provider Complaints and Appeals
8.2.5.1
Provider Complaints
Medicaid
HMOs must develop, implement, and maintain a system for tracking and resolving
all Medicaid Provider complaints. Within this process, the HMO must respond
fully and completely to each complaint and establish a tracking mechanism to
document the status and final disposition of each Provider
complaint. The HMO must resolve Provider Complaints within 30 days
from the date the Complaint is received.
8.2.5.2
Appeal of Provider Claims
Medicaid
HMOs must develop, implement, and maintain a system for tracking and resolving
all Medicaid Provider appeals related to claims payment. Within this process,
the Provider must respond fully and completely to each Medicaid Provider’s
claims payment appeal and establish a tracking mechanism to document the status
and final disposition of each Medicaid Provider’s claims payment
appeal.
Medicaid
HMOs must contract with physicians who are not Network Providers to resolve
claims disputes related to denial on the basis of medical necessity that remain
unresolved subsequent to a Provider appeal. The determination of the physician
resolving the dispute must be binding on the HMO and the Provider. The physician
resolving the dispute must hold the same specialty or a related specialty as
the
appealing Provider. HHSC reserves the right to amend this process to include
an
independent review process established by HHSC for final determination on these
disputes.
8.2.6
Member Rights and Responsibilities
In
accordance with 42 C.F.R. §438.100, all Medicaid HMOs must maintain written
policies and procedures for informing Members of their rights and
responsibilities, and must notify their Members of their right to request a
copy
of these rights and responsibilities. The Member Handbook must include
notification of Member rights and responsibilities.
8.2.7
Medicaid Member Complaint and Appeal System
The
HMO
must develop, implement, and maintain a Member Complaint and Appeal system
that
complies with the requirements in applicable federal and state laws and
regulations, including 42
C.F.R.
§431.200, 42 C.F.R. Part 438, Subpart F, “Grievance System,” and the provisions
of 1
T.A.C.
Chapter 357 relating to Medicaid managed care organizations.
The
Complaint and Appeal system must include a Complaint process, an Appeal process,
and access to HHSC’s Fair Hearing System. The procedures must be the same for
all Members and must be reviewed and approved in writing by HHSC or its
designee. Modifications and amendments to the Member Complaint and
Appeal system must be submitted for HHSC’s approval at least 30 days prior to
the implementation.
8.2.7.1
Member Complaint Process
The
HMO
must have written policies and procedures for receiving, tracking, responding
to, reviewing, reporting and resolving Complaints by Members or their authorized
representatives. For purposes of this Section 8.2.7, an
“authorized representative” is any person or entity acting on behalf of the
Member and with the Member’s written consent. A Provider may be an authorized
representative.
The
HMO
must resolve Complaints within 30 days from the date the Complaint is received.
The HMO is subject to remedies, including liquidated damages, if at least 98
percent of Member Complaints are not resolved within 30 days of receipt of
the
Complaint by the HMO. Please see the Uniform Managed Care Contract Terms
& Conditions and Attachment B-5, Deliverables/Liquidated
Damages Matrix. The Complaint procedure must be the same for all
Members under the Contract. The Member or Member’s authorized representative may
file a Complaint either orally or in writing. The HMO must also inform Members
how to file a Complaint directly with HHSC, once the Member has exhausted the
HMO’s complaint process.
The
HMO
must designate an officer of the HMO who has primary responsibility for ensuring
that Complaints are resolved in compliance with written policy and within the
required timeframe. For purposes of Section 8.2.7.2, an
“officer” of the HMO means a president, vice president, secretary,
treasurer, or
chairperson of the board for a corporation, the sole proprietor, the managing
general partner of a partnership, or a person having similar executive authority
in the organization.
The
HMO
must have a routine process to detect patterns of Complaints. Management,
supervisory, and quality improvement staff must be involved in developing policy
and procedure improvements to address the Complaints.
The
HMO’s
Complaint procedures must be provided to Members in writing and through oral
interpretive services. A written description of the HMO’s Complaint procedures
must be available in prevalent non-English languages for Major Population Groups
identified by HHSC, at no more than a 6th grade reading level.
The
HMO
must include a written description of the Complaint process in the Member
Handbook. The HMO must maintain and publish in the Member Handbook, at least
one
local and one toll
free
telephone number with TeleTypewriter/Telecommunications Device for the Deaf
(TTY/TDD) and interpreter capabilities for making Complaints.
The
HMO’s
process must require that every Complaint received in person, by telephone,
or
in writing must be acknowledged and recorded in a written record and logged
with
the following details:
1.
Date;
2.
Identification of the individual filing the Complaint;
3.
Identification of the individual recording the Complaint;
4.
Nature
of the Complaint;
5.
Disposition of the Complaint (i.e., how the HMO resolved the
Complaint);
6.
Corrective action required; and
7.
Date
resolved.
The
HMO
is prohibited from discriminating or taking punitive action against a Member
or
his or her representative for making a Complaint.
If
the
Member makes a request for disenrollment, the HMO must give the Member
information on the disenrollment process and direct the Member to the HHSC
Administrative Services Contractor. If the request for disenrollment includes
a
Complaint by the Member, the Complaint will be processed separately from the
disenrollment request, through the Complaint process.
The
HMO
will cooperate with the HHSC’s Administrative Services Contractor and HHSC or
its designee to resolve all Member Complaints. Such cooperation may include,
but
is not limited to, providing information or assistance to internal Complaint
committees.
The
HMO
must provide designated Member Advocates to assist Members in understanding
and
using the HMO’s Complaint system as described in Section
8.2.7.9. The HMO’s Member Advocates must assist Members in writing or
filing a Complaint and monitoring the Complaint through the HMO’s Complaint
process until the issue is resolved.
8.2.7.2
Medicaid Standard Member Appeal Process
The
HMO
must develop, implement and maintain an Appeal procedure that complies with
state and federal laws and regulations, including 42 C.F.R.§ 431.200 and 42
C.F.R. Part 438, Subpart F, “Grievance System.” An Appeal is a disagreement with
an HMO Action as defined in HHSC’s Uniform Contract Terms and
Conditions. The Appeal procedure must be the same for all
Members. When a Member or his or her authorized representative
expresses orally or in writing any dissatisfaction or disagreement with an
Action, the HMO must regard the expression of dissatisfaction as a request
to
Appeal an Action.
A
Member
must file a request for an Appeal with the HMO within 30 days from receipt
of
the notice of the Action. The HMO is subject to remedies, including liquidated
damages, if at least 98 percent of Member Appeals are not resolved within 30
days of receipt of the Appeal by the HMO. Please see the Uniform Managed
Care Contract Terms & Conditions and Attachment B-5, Deliverables/Liquidated
Damages Matrix. To ensure continuation of currently authorized
services, however, the Member must file the Appeal on or before the later of
10
days following
the
HMO’s
mailing of the notice of the Action, or the intended effective date of the
proposed Action. The HMO must designate an officer who has primary
responsibility for ensuring that Appeals are resolved in compliance with written
policy and within the 30-day time limit.
The
provisions of Article 21.58A, Texas Insurance Code, (to be recodified as Texas
Insurance Code, Title 14, Chapter 4201), relating to a Member’s right to Appeal
an Adverse Determination made by the HMO or a utilization review agent to an
independent review organization, do not apply to a Medicaid recipient. Article
21.58A is pre-empted by federal Fair Hearings requirements.
The
HMO
must have policies and procedures in place outlining the Medical Director’s role
in an Appeal of an Action. The Medical Director must have a significant role
in
monitoring, investigating and hearing Appeals. In accordance with 42 C.F.R.§
438.406, the HMO’s policies and procedures must require that individuals who
make decisions on Appeals are not involved in any previous level of review
or
decision-making, and are health care professionals who have the appropriate
clinical expertise in treating the Member’s condition or disease.
The
HMO
must provide designated Member Advocates, as described in Section
8.2.7.9, to assist Members in understanding and using the Appeal
process. The HMO’s Member Advocates must assist Members in writing or filing an
Appeal and monitoring the Appeal through the HMO’s Appeal process until the
issue is resolved.
The
HMO
must have a routine process to detect patterns of Appeals. Management,
supervisory, and quality improvement staff must be involved in developing policy
and procedure improvements to address the Appeals.
The
HMO’s
Appeal procedures must be provided to Members in writing and through oral
interpretive services. A written description of the Appeal procedures must
be
available in prevalent non-English languages identified by HHSC, at no more
than
a 6th grade reading level. The HMO must include a written description of the
Appeals process in the Member Handbook. The HMO must maintain and publish in
the
Member Handbook at least one local and one toll-free telephone number with
TTY/TDD and interpreter capabilities for requesting an Appeal of an
Action.
The
HMO’s
process must require that every oral Appeal received must be confirmed by a
written, signed Appeal by the Member or his or her representative, unless the
Member or his or her representative requests an expedited resolution. All
Appeals must be recorded in a written record and logged with the following
details:
1)
Date
notice is sent;
2)
Effective date of the Action;
3)
Date
the Member or his or her representative requested the
Appeal;
4)
Date
the Appeal was followed up in writing;
5)
Identification of the individual filing;
7)
Disposition of the Appeal, and notice of disposition to Member.
The
HMO
must send a letter to the Member within five (5) business days acknowledging
receipt of the Appeal request. Except for the resolution of an Expedited Appeal
as provided in Section 8.2.7.3, the HMO must complete the
entire standard Appeal process within 30 calendar days after receipt of the
initial written or oral request for Appeal. The timeframe for a standard Appeal
may be extended up to 14 calendar days if the Member or his or her
representative requests an extension; or the HMO shows that there is a need
for
additional information and how the delay is in the Member’s interest. If the
timeframe is extended, the HMO must give the Member written notice of the reason
for delay if the Member had not requested the delay. The HMO must designate
an
officer who has primary responsibility for ensuring that Appeals are resolved
within these timeframes and in accordance with the HMO’s written
policies.
During
the Appeal process, the HMO must provide the Member a reasonable opportunity
to
present evidence and any allegations of fact or law in person as well as in
writing. The HMO must inform the Member of the time available for providing
this
information and that, in the case of an expedited resolution, limited time
will
be available.
The
HMO
must provide the Member and his or her representative opportunity, before and
during the Appeal process, to examine the Member’s case file, including medical
records and any other documents considered during the Appeal process. The HMO
must include, as parties to the Appeal, the Member and his or her representative
or the legal representative of a deceased Member’s estate.
In
accordance with 42 C.F.R.§ 438.420, the HMO must continue the Member’s benefits
currently being received by the Member, including the benefit that is the
subject of the Appeal, if all of the following criteria are met:
1 The
Member or his or her representative files the Appeal timely as defined in this
Contract:
2 The
Appeal involves the termination, suspension, or reduction of a previously
authorized course of treatment;
3 The
services were ordered by an authorized provider;
4 The
original period covered by the original authorization has not expired;
and
5 The
Member requests an extension of the benefits.
If,
at
the Member’s request, the HMO continues or reinstates the Member’s benefits
while the Appeal is pending, the benefits must be continued until one of the
following occurs:
1 The
Member withdraws the Appeal;
2 Ten
(10)
days pass after the HMO mails the notice resolving the Appeal against the
Member, unless the Member, within the 10-day timeframe, has requested a Fair
Hearing with continuation of benefits until a Fair Hearing decision can be
reached; or
3 A
state
Fair Hearing officer issues a hearing decision adverse to the Member or the
time
period or service limits of a previously authorized service has been
met.
In
accordance with 42 C.F.R.§ 438.420(d), if the final resolution of the Appeal is
adverse to the Member and upholds the HMO’s Action, then to the extent that the
services were furnished to comply with the Contract, the HMO may recover such
costs from the Member.
If
the
HMO or State Fair Hearing Officer reverses a decision to deny, limit, or delay
services that were not furnished while the Appeal was pending, the HMO must
authorize or provide the disputed services promptly and as expeditiously as
the
Member’s health condition requires.
If
the
HMO or State Fair Hearing Officer reverses a decision to deny authorization
of
services and the Member received the disputed services while the Appeal was
pending, the HMO is responsible for the payment of services.
The
HMO
is prohibited from discriminating or taking punitive action against a Member
or
his or her representative for making an Appeal.
8.2.7.3
Expedited Medicaid HMO Appeals
In
accordance with 42 C.F.R. §438.410, the HMO must establish and maintain an
expedited review process for Appeals, when the HMO determines (for a request
from a Member) or the provider indicates (in making the request on the Member’s
behalf or supporting the Member’s request) that taking the time for a standard
resolution could seriously jeopardize the Member’s life or health. The HMO must
follow all Appeal requirements for standard Member Appeals as set forth in
Section 8.2.7.2), except where differences are specifically
noted. The HMO must accept oral or written requests for Expedited
Appeals.
Members
must exhaust the HMO’s Expedited Appeal process before making a request for an
expedited Fair Hearing. After the HMO receives the request for an Expedited
Appeal, it must hear an approved request for a Member to have an Expedited
Appeal and notify the Member of the outcome of the Expedited Appeal within
3
business days, except that the HMO must complete investigation and resolution
of
an Appeal relating to an ongoing emergency or denial of continued
hospitalization: (1) in accordance with the medical or dental immediacy of
the
case; and (2) not later than one (1) business day after receiving the Member’s
request for Expedited Appeal is received.
Except
for an Appeal relating to an ongoing emergency or denial of continued
hospitalization, the timeframe for notifying the Member of the outcome of the
Expedited Appeal may be extended up to 14 calendar days if the Member requests
an extension or the HMO shows (to the satisfaction of HHSC, upon HHSC’s request)
that there is a need for additional information and how the delay is in the
Member’s interest. If the timeframe is extended, the HMO must give the Member
written notice of the reason for delay if the Member had not requested the
delay.
If
the
decision is adverse to the Member, the HMO must follow the procedures relating
to the notice in Section 8.2.7.5. The HMO is responsible for
notifying the Member of his or her right to access an expedited Fair Hearing
from HHSC. The HMO will be responsible for providing documentation to the State
and the Member, indicating how the decision was made, prior to HHSC’s expedited
Fair Hearing.
The
HMO
is prohibited from discriminating or taking punitive action against a Member
or
his or her representative for requesting an Expedited Appeal. The HMO
must ensure that punitive action is neither taken against a provider who
requests an expedited resolution or supports a Member’s request.
If
the
HMO denies a request for expedited resolution of an Appeal, it
must:
(1)
Transfer the Appeal to the timeframe for standard resolution, and
(2)
Make
a reasonable effort to give the Member prompt oral notice of the denial, and
follow up within two (2) calendar days with a written notice.
8.2.7.4
Access to Fair Hearing for Medicaid Members
The
HMO
must inform Members that they have the right to access the Fair Hearing process
at any time during the Appeal system provided by the HMO. In the case of an
expedited Fair Hearing process, the HMO must inform the Member that he or she
must first exhaust the HMO’s internal Expedited Appeal process prior to filing
an Expedited Fair Hearing. The HMO must notify Members that they may be
represented by an authorized representative in the Fair Hearing
process.
If
a
Member requests a Fair Hearing, the HMO will assist the Member in the completion
of the request for Fair Hearing, and will submit the form electronically to
the
appropriate Fair Hearings office, within five business days of the Member's
request.
Upon
notification that the Fair Hearing is set, the HMO will prepare an evidence
packet for submission to the HHSC Fair Hearings staff and send a copy of the
packet to the Member, in accordance with HHSC Fair Hearings
requirements.
8.2.7.5
Notices of Action and Disposition of Appeals for Medicaid
Members
The
HMO
must notify the Member, in accordance with 1 T.A.C. Chapter 357, whenever the
HMO takes an Action. The notice must, at a minimum, include any information
required by 1
T.A.C.
Chapter 357 that relates to a managed care organization’s notice of Action and
any information required by 42 C.F.R. §438.404 as directed by HHSC, including
but not limited to:
1.
The
dates, types and amount of service requested;
2.
The
Action the HMO has taken or intends to take;
3.
The
reasons for the Action (If the Action taken is based upon a determination that
the requested service is not medically necessary, the HMO must provide an
explanation of the medical basis for the decision, application of policy or
accepted standards of medical practice to the individuals medical circumstances,
in it’s notice to the member.);
4.
The
Member’s right to access the HMO’s Appeal process.
5.
The
procedures by which the Member may Appeal the HMO’s Action;
6.
The
circumstances under which expedited resolution is available and how to request
it;
7.
The
circumstances under which a Member may continue to receive benefits pending
resolution of the Appeal, how to request that benefits be continued, and the
circumstances under which the Member may be required to pay the costs of these
services;
8.
The
date the Action will be taken;
9.
A
reference to the HMO policies and procedures supporting the HMO’s
Action;
10.
An
address where written requests may be sent and a toll-free number that the
Member can call to request the assistance of a Member representative, file
an
Appeal, or request a Fair Hearing;
11.
An
explanation that Members may represent themselves, or be represented by a
provider, a friend, a relative, legal counsel or another
spokesperson;
12.
A
statement that if the Member wants a Fair Hearing on the Action, the Member
must
make the request for a Fair Hearing within 90 days of the date on the notice
or
the right to request a hearing is waived;
13.
A
statement explaining that the HMO must make its decision within 30 days from
the
date the Appeal is received by the HMO, or 3 business days in the case of an
Expedited Appeal; and
14.
A
statement explaining that the hearing officer must make a final decision within
90 days from the date a Fair Hearing is requested.
8.2.7.6
Timeframe for Notice of Action
In
accordance with 42 C.F.R.§ 438.404(c), the HMO must mail a notice of Action
within the following timeframes:
1. For
termination, suspension, or reduction of previously authorized Medicaid-covered
services, within the timeframes specified in 42 C.F.R.§§ 431.211, 431.213, and
431.214;
2. For
denial of payment, at the time of any Action affecting the claim;
3. For
standard service authorization decisions that deny or limit services, within
the
timeframe specified in 42 C.F.R.§ 438.210(d)(1);
4. If
the HMO extends the timeframe in accordance with 42 C.F.R. §438.210(d)(1), it
must:
5. give
the Member written notice of the reason for the decision to extend the timeframe
and inform the Member of the right to file an Appeal if he or she disagrees
with
that decision; and
6. issue
and carry out its determination as expeditiously as the Member’s health
condition requires and no later than the date the extension
expires;
7. For
service authorization decisions not reached within the timeframes specified
in
42 C.F.R.§ 438.210(d) (which constitutes a denial and is thus an adverse
Action), on the date that the timeframes expire; and
8.
For
expedited service authorization decisions, within the timeframes specified
in
42
C.F.R.
438.210(d).
8.2.7.7
Notice of Disposition of Appeal
In
accordance with 42 C.F.R.§ 438.408(e), the HMO must provide written notice of
disposition of all Appeals including Expedited Appeals. The written resolution
notice must include the results and date of the Appeal resolution. For decisions
not wholly in the Member’s favor, the notice must contain:
1 The
right
to request a Fair Hearing;
2 How
to
request a Fair Hearing;
3 The
circumstances under which the Member may continue to receive benefits pending
a
Fair Hearing;
4 How
to
request the continuation of benefits;
5 If
the
HMO’s Action is upheld in a Fair Hearing, the Member may be liable for the cost
of any services furnished to the Member while the Appeal is pending;
and
6 Any
other
information required by 1 T.A.C. Chapter 357 that relates to a managed care
organization’s notice of disposition of an Appeal.
8.2.7.8
Timeframe for Notice of Resolution of Appeals
In
accordance with 42 C.F.R.§ 438.408, the HMO must provide written notice of
resolution of Appeals, including Expedited Appeals, as expeditiously as the
Member’s health condition requires, but the notice must not exceed the timelines
as provided in this Section for Standard or Expedited Appeals. For expedited
resolution of Appeals, the HMO must make reasonable efforts to give the Member
prompt oral notice of resolution of the Appeal, and follow up with a written
notice within the timeframes set forth in this Section for Expedited Appeals.
If
the HMO denies a request for expedited resolution of an Appeal, the HMO must
transfer the Appeal to the timeframe for standard resolution as provided in
this
Section, and make reasonable efforts to give the Member prompt oral notice
of
the denial, and follow up within two calendar days with a written
notice.
8.2.7.9
Medicaid Member Advocates
The
HMO
must provide Member Advocates to assist Members. Member Advocates must be
physically located within the Service Area unless an exception is approved
by
HHSC. Member Advocates must inform Members of the following:
1 Their
rights and responsibilities,
2 The
Complaint process,
3 The
Appeal process,
4 Covered
Services available to them, including preventive services, and
5 Non-capitated
Services available to them.
Member
Advocates must assist Members in writing Complaints and are responsible for
monitoring the Complaint through the HMO’s Complaint process.
Member
Advocates are responsible for making recommendations to management on any
changes needed to improve either the care provided or the way care is delivered.
Member Advocates are also responsible for helping or referring Members to
community resources available to meet Member needs that are not available from
the HMO as Medicaid Covered Services.
8.2.8
Additional Medicaid Behavioral Health Provisions
8.2.8.1
Local Mental Health Authority (LMHA)
Assessment
to determine eligibility for rehabilitative and targeted DSHS case management
services is a function of the LMHA. Covered Services must be provided to Members
with severe and persistent mental illness (SPMI) and severe emotional
disturbance (SED), when Medically Necessary, whether or not they are also
receiving targeted case management or rehabilitation services through the
LMHA.
The
HMO
must enter into written agreements with all LMHAs in the Service Area that
describe the process(es) that the HMO and LMHAs will use to coordinate services
for Medicaid Members with SPMI or SED. The agreements will:
1. Describe
the Behavioral Health Services indicated in detail in the Provider
Procedures Manual and in the Texas Medicaid Bulletin,
include the amount, duration, and scope of basic and Value-added Services,
and
the HMO’s responsibility to provide these services;
2. Describe
criteria, protocols, procedures and instrumentation for referral of Medicaid
Members from and to the HMO and the LMHA;
3. Describe
processes and procedures for referring Members with SPMI or SED to the LMHA
for
assessment and determination of eligibility for rehabilitation or targeted
case
management services;
4. Describe
how the LMHA and the HMO will coordinate providing Behavioral Health Services
to
Members with SPMI or SED;
5. Establish
clinical consultation procedures between the HMO and LMHA including consultation
to effect referrals and on-going consultation regarding the Member’s
progress;
6. Establish
procedures to authorize release and exchange of clinical treatment
records;
7. Establish
procedures for coordination of assessment, intake/triage, utilization
review/utilization management and care for persons with SPMI or
SED;
8. Establish
procedures for coordination of inpatient psychiatric services (including Court-
ordered Commitment of Members under 21) in state psychiatric facilities within
the LMHA’s catchment area;
9. Establish
procedures for coordination of emergency and urgent services to
Members;
10.
Establish procedures for coordination of care and transition of care for new
Members who are receiving treatment through the LMHA; and
11.
Establish that when Members are receiving Behavioral Health Services from the
Local Mental Health Authority that the HMO is using the same UM guidelines
as
those prescribed for use by local mental health authorities by DSHS which are
published at:
xxxx://xxx.xxxx.xxxxx.xx.xx/xxxxxxxxxxxxx/xxxxxxxxxxxxxxxxxxxxxxxx/XXXXxxxXxxxx.xxxx.
The
HMO
must offer licensed practitioners of the healing arts (defined in 25 T.A.C.,
Part 2, Chapter 419, Subchapter L), who are part of the Member’s treatment team
for rehabilitation services, the opportunity to participate in the HMO’s
Network. The practitioner must agree to accept the HMO’s Provider reimbursement
rate, meet the credentialing requirements, and comply with all the terms and
conditions of the HMO’s standard Provider contract.
HMOs
must
allow Members receiving rehabilitation services to choose the licensed
practitioners of the healing arts who are currently a part of the Member’s
treatment team for rehabilitation services to provide Covered Services. If
the
Member chooses to receive these services from licensed practitioners of the
healing arts who are part of the Member’s rehabilitation services treatment team
but are not part of the HMO’s Network, the HMO must reimburse the Local Mental
Health Authority through Out-of-Network reimbursement arrangements.
Nothing
in this section diminishes the potential for the Local Mental Health Authority
to seek best value for rehabilitative services by providing these services
under
arrangement, where possible, as specified is 25 T.A.C. §419.455.
8.2.9
Third Party Liability and Recovery
Medicaid
HMOs are responsible for establishing a plan and process for recovering costs
for services that should have been paid through a third party in accordance
with
State and Federal law and regulations. To recognize this requirement, capitation
payments to the HMOs are reduced by the projected amount of TPR that the HMO
is
expected to recover.
The
HMOs
must provide required reports as stated in Section 8.1.17.2,
Financial Reporting Requirements.
After
120-days from the date of service on any claim, encounter, or other Medicaid
related payment by the HMO subject to Third Party Recovery, HHSC may attempt
recovery independent of any HMO action. HHSC will retain, in full,
all funds received as a result of the state initiated recovery or subrogation
action.
HMOs
shall provide a Member quarterly file, which contains the following information
if available to the HMO: the Member name, address, claim submission address,
group number, employer's mailing address, social security number, and date
of
birth for each subscriber or policyholder and each dependent of the subscriber
or policyholder covered by the insurer. The file shall be used for
the purpose of matching the Texas Medicaid eligibility file against the HMO
Member file to identify Medicaid clients enrolled in the HMO, which may not
be
known the Medicaid Program.
8.2.10
Coordination With Public Health Entities
8.2.10.1
Reimbursed Arrangements with Public Health Entities
The
HMO
must make a good faith effort to enter into a subcontract for Covered Services
with Public Health Entities. Possible Covered Services that could be provided
by
Public Health Entities include, but are not limited to, the following
services:
1 Sexually
Transmitted Diseases (STDs) services;
2 Confidential
HIV testing;
3 Immunizations;
4 Tuberculosis
(TB) care;
5 Family
Planning services;
6 THSteps
medical checkups, and
7 Prenatal
services.
These
subcontracts must be available for review by HHSC or its designated agent(s)
on
the same basis as all other subcontracts. If the HMO is unable to enter into
a
contract with Public Health Entities, the HMO must document efforts to contract
with Public Health Entities, and make such documentation available to HHSC
upon
request.
HMO
Contracts with Public Health Entities must specify the scope of responsibilities
of both parties, the methodology and agreements regarding billing and
reimbursements, reporting responsibilities, Member and Provider educational
responsibilities, and the methodology and agreements regarding sharing of
confidential medical record information between the Public Health Entity and
the
HMO or PCP.
The
HMO
must:
1 Identify
care managers who will be available to assist public health providers and PCPs
in efficiently referring Members to the public health providers, specialists,
and health-related service providers either within or outside the HMO’s Network;
and
2 Inform
Members that confidential healthcare information will be provided to the PCP,
and educate Members on how to better utilize their PCPs, public health
providers, emergency departments, specialists, and health-related service
providers.
8.2.10.2
Non-Reimbursed Arrangements with Local Public Health
Entities
The
HMO
must coordinate with Public Health Entities in each Service Area regarding
the
provision of essential public health care services. In addition to the
requirements listed above in Section 8.2.2, or otherwise required under state
law or this contract, the HMO must meet the following requirements:
1 Report
to
public health entities regarding communicable diseases and/or diseases that
are
preventable by immunization as defined by state law;
2 Notify
the local Public Health Entity, as defined by state law, of communicable disease
outbreaks involving Members;
3 Educate
Members and Providers regarding WIC services available to Members;
and
4 Coordinate
with local public health entities that have a child lead program, or with DSHS
regional staff when the local public health entity does not have a child lead
program, for follow-up of suspected or confirmed cases of childhood lead
exposure.
The
HMO
must coordinate with other state HHS Programs in each Service Area regarding
the
provision of essential public health care services. In addition to
the requirements listed above in Section 8.2.2. or otherwise required under
state law or this contract, the HMO must meet the following
requirements:
1 Require
Providers to use the DSHS Bureau of Laboratories for specimens obtained as
part
of a THSteps medical checkup, including THSteps newborn screens, lead testing,
and hemoglobin/hematocrit tests;
2 Notify
Providers of the availability of vaccines through the Texas Vaccines for
Children Program;
3 Work
with
HHSC and Providers to improve the reporting of immunizations to the statewide
ImmTrac Registry;
4 Educate
Providers and Members about the Department of State Health Services (DSHS)
Case
Management for Children and Pregnant Women (CPW) services
available;
5 Coordinate
services with CPW specifically in regard to an HMO Member’s health care needs
that are identified by CPW and referred to the HMO;
6 Participate,
to the extent practicable, in the community-based coalitions with the
Medicaid-funded case management programs in the Department of Assistive and
Rehabilitative Services (DARS), the Department of Aging and Disability Services
(DADS), and DSHS;
7 Cooperate
with activities required of state and local public health authorities necessary
to conduct the annual population and community based needs
assessment;
8 Report
all blood lead results, coordinate and follow-up of suspected or confirmed
cases
of childhood lead exposure with the Childhood Lead Poisoning Prevention Program
in DSHS; and
9 Coordinate
with THSteps.
8.2.12
Advance Directives
Federal
and state law require HMOs and providers to maintain written policies and
procedures for informing all adult Members 18 years of age and older about
their
rights to refuse, withhold or withdraw medical treatment and mental health
treatment through advance directives (see Social Security Act §1902(a)(57) and
§1903(m)(1)(A)). The HMO’s policies and procedures must include written
notification to Members and comply with provisions contained in 42 C.F.R.
§434.28 and 42 C.F.R. § 489, Subpart I, relating to advance directives for all
hospitals, critical access hospitals, skilled nursing facilities, home health
agencies, providers of home health care, providers of personal care services
and
hospices, as well as the following state laws and rules:
1. A
Member’s right to self-determination in making health care
decisions;
2. The
Advance Directives Act, Chapter 166, Texas Health and Safety Code, which
includes:
a. A
Member’s right to execute an advance written directive to physicians and family
or surrogates, or to make a non-written directive to administer, withhold or
withdraw life-sustaining treatment in the event of a terminal or irreversible
condition;
b. A
Member’s right to make
written and non-written out-of-hospital do-notresuscitate (DNR)
orders;
c. A
Member’s right to execute a Medical Power of Attorney to appoint an agent to
make health care decisions on the Member’s behalf if the Member becomes incompetent;
and
3. The
Declaration for Mental Health Treatment, Chapter 137, Texas Civil Practice
and
Remedies Code, which includes: a Member’s right to execute a Declaration for
Mental Health Treatment in a document making a declaration of preferences or
instructions regarding mental health treatment.
The
HMO
must maintain written policies for implementing a Member’s advance directive.
Those policies must include a clear and precise statement of limitation if
the
HMO or a Provider cannot or will not implement a Member’s advance
directive.
The
HMO
cannot require a Member to execute or issue an advance directive as a condition
of receiving health care services. The HMO cannot discriminate against a Member
based on whether or not the Member has executed or issued an advance
directive.
The
HMO’s
policies and procedures must require the HMO and subcontractors to comply with
the requirements of state and federal law relating to advance directives. The
HMO must provide education and training to employees and Members on issues
concerning advance directives.
All
materials provided to Members regarding advance directives must be written
at a
7th - 8th
grade
reading
comprehension level, except where a provision is required by state or federal
law and the provision cannot be reduced or modified to a 7th - 8th
grade reading
level because it is a reference to the law or is required to be included “as
written” in the state or federal law.
The
HMO
must notify Members of any changes in state or federal laws relating to advance
directives within 90 days from the effective date of the change, unless the
law
or regulation contains a specific time requirement for
notification.
8.3
Additional STAR+PLUS Scope of Work
The
HMO
must ensure that STAR+PLUS Members needing Community Long-term Care Services
are
identified and that services are referred and authorized in a timely manner.
The
HMO must ensure that Providers of Community Long-term Care Services are licensed
to deliver the service they provide. The inclusion of Community Long-term Care
Services in a managed care model presents challenges, opportunities and
responsibilities.
Community
Long-term Care Services may be necessary as a preventative service to avoid
more
expensive hospitalizations, emergency room visits, or institutionalization.
Community Long-term Care Services should also be made available to Members
to
assure maintenance of the highest level of functioning possible in the least
restrictive setting. A Member’s need for Community Long-term Care Services to
assist with the activities of daily living must be considered as
important
as needs related to a medical condition. HMOs must provide Functionally
Necessary Covered Services to Community Long-term Care Service
Members.
The
HMO
shall enter into written contracts with Providers of Personal Assistance
Services and Day Activity and Health Services (DAHS) to make them available
to
all STAR+PLUS Members. These Providers must at a minimum, meet all of
the following state licensure and certification requirements for providing
the
services in Attachment B-2.1, Covered Services.
Community
Long-Term Care Services Available to All
Members
|
||
Service
|
Licensure
and Certification Requirements
|
|
Personal
Attendant Services
|
The
Provider must be licensed by the Texas Department of Human Services
as a
Home and Community Support Services Agency. The level of licensure
required depends on the type of service delivered. NOTE: For primary
home
care and client managed attendant care, the agency may have only
the
Personal Assistance Services level of licensure.
|
|
Day
Activity and Health Services (DAHS)
|
The
Provider must be licensed by the Texas Department of Human Services,
Long
Term Care Regulatory Division, as an adult day care provider. To
provide
DAHS, the Provider must provide the range of services required for
DAHS.
|
8.3.1.2 1915(c)
Nursing Facility Waiver Services Available to Members Who Qualify for 1915
(c)
Nursing Facility Waiver Services
The
1915(c) Nursing Facility Waiver provides Community Long-term Care Services
to
Medicaid Eligibles who are elderly and to adults with disabilities as a
cost-effective alternative to living in a nursing facility. These Members must
be age 21 or older, be a Medicaid recipient or be otherwise financially eligible
for waiver services. To be eligible for 1915(c) Nursing Facility Waiver
Services, a Member must meet income and resource requirements for Medicaid
nursing facility care, and receive a determination from HHSC on the medical
necessity of the nursing facility care. The HMO must make available to STAR+PLUS
Members who meet the eligibility requirements the array of services allowable
through HHSC’s CMS-approved 1915(c) Nursing Facility Waiver (see
Appendix B-2.1, STAR+PLUS Covered Services).
Community
Long-Term Care Services Under the 1915(c) Nursing Facility
Waiver
|
||
Service
|
Licensure
and Certification Requirements
|
|
Personal
Attendant Services
|
The
Provider must be licensed by the Texas Department of Human Services
as a
Home and Community Support Services Agency. The level of licensure
required depends on the type of service delivered. For Primary Home
Care
and Client Managed Attendant Care, the agency may have only the Personal
Assistance Services level of licensure.
|
Community
Long-Term Care Services Under the 1915(c) Nursing Facility
Waiver
|
||
Service
|
Licensure
and Certification Requirements
|
|
Assisted
Living
|
The
Provider must be licensed by the Texas Department of Aging and Disability
Services, Long Term Care Regulatory Division. The type of licensure
determines what services may be provided.
|
|
Emergency
Response Service Provider
|
Texas
Department of Aging and Disability Services (DADS) Standards for
Emergency
Response Services at 40 T.A.C. §52.201(a), and be licensed by the Texas
Board of Private Investigators and Private Security Agencies, unless
exempt from licensure.
|
|
Adult
Xxxxxx Home
|
TDSHS
Provider standards for Adult Xxxxxx Care and TDSHS Rules at 40 T.A.C.
§48.6032. Four bed homes also licensed under TDSHS Rules at 40 T.A.C.
§481.8906. DFPS licensure in accordance with 24-hour Care Licensing
requirements found in T.A.C., Title 40, Part 19, Chapter
720.
|
|
Home
Delivered Meals
|
T.A.C.,
Title 40, Part 1, Chapter 55.
|
|
Physical
Therapy
|
Licensed
Physical Therapist through the Texas Board of Physical Therapy Examiners,
Chapter 453.
|
|
Occupational
Therapy
|
Licensed
Occupational Therapist through the Texas Board of Occupational Therapy
Examiners, Chapter 454.
|
|
Speech
Therapy
|
Licensed
Speech Therapist Through the Department of State Health
Services.
|
|
Consumer
Directed Services
|
Home
and Community Support Services Agency (HCSSA)
|
|
Transition
Assistance Services
|
No
licensure or certification requirements.
|
|
Minor
Home Modification
|
No
licensure or certification requirements.
|
|
Adaptive
Aids and Medicaid Equipment
|
No
licensure or certification requirements.
|
|
Medical
supplies
|
No
licensure or certification requirements.
|
The
HMO
must furnish a Service Coordinator to all STAR+PLUS Members who request one.
The
HMO should also furnish a Service Coordinator to a STAR+PLUS Member when the
HMO
determines one is required through an assessment of the Member’s health and
support needs. The HMO must ensure that each STAR+PLUS Member has a qualified
PCP who is responsible for overall clinical direction and, in conjunction with
the Service Coordinator, serves as a central
point
of
integration and coordination of Covered Services, including primary, Acute
Care,
long-term care and Behavioral Health Services.
The
Service Coordinator must work as a team with the PCP, and coordinate all
STAR+PLUS Covered Services and any applicable Non-capitated Services with the
PCP. This requirement applies whether or not the PCP is in the HMO’s
Network, as some STAR+PLUS Members dually eligible for Medicare may have a
PCP
that is not in the HMO’s Provider Network. In order to integrate the Member’s
Acute Care and primary care, and stay abreast of the Member’s needs and
condition, the Service Coordinator must also actively involve and coordinate
with the Member’s primary and specialty care providers, including Behavioral
Health Service providers, and providers of Non-capitated Services.
STAR+PLUS
Members dually eligible for Medicare will receive most prescription drug
services through Medicare rather than Medicaid. The Texas Vendor Drug
Program will pay for a limited number of medications not covered by
Medicare.
The
HMO
must identify and train Members or their families to coordinate their own care,
to the extent of the Member’s or the family’s capability and willingness to
coordinate care.
The
HMO
must employ as Service Coordinators persons experienced in meeting the needs
of
vulnerable populations who have Chronic or Complex Conditions. Such Service
Coordinators are Key HMO Personnel as described in Attachment
A, HHSC’s Uniform Managed Care Contract Terms and Conditions,
Section 4.02, and must meet the requirements set forth in
Section 4.04.1 of HHSC’s Uniform Managed Care Contract
Terms and Conditions.
The
HMO
must provide information about and referral to community organizations that
may
not be providing STAR+PLUS Covered Services, but are otherwise important to
the
health and well being of Members. These organizations include, but are not
limited to:
1 State/federal
agencies (e.g., those agencies with jurisdiction over aging, public health,
substance abuse, mental health/retardation, rehabilitation, developmental
disabilities, income support, nutritional assistance, family support agencies,
etc.);
2 social
service agencies (e.g., Area Agencies on Aging, residential support agencies,
independent living centers, supported employment agencies, etc.);
3 city
and
county agencies (e.g., welfare departments, housing programs,
etc.);
4 civic
and
religious organizations; and
5 consumer
groups, advocates, and councils (e.g., legal aid offices, consumer/family
support groups, permanency planning, etc.).
The
HMO
must have a protocol for quickly assessing the needs of Members discharged
from
a Hospital or other care or treatment facility.
The
HMO’s
Service Coordinator must work with the Member’s PCP, the hospital discharge
planner(s), the attending physician, the Member, and the Member’s family to
assess and plan for the Member’s discharge. When long-term care is needed, the
HMO must ensure that the Member’s discharge plan includes arrangements for
receiving community-based care whenever possible. The HMO must ensure that
the
Member, the Member’s family, and the Member’s PCP are all well informed of all
service options available to meet the Member’s needs in the
community.
The
HMO
must provide a transition plan for Members enrolled in the STAR+PLUS
Program. HHSC, and/or the previous STAR+PLUS HMO contractor, will
provide the HMO with detailed Care Plans, names of current providers, etc.,
for
newly enrolled Members already receiving long-term care services at the time
of
enrollment. The HMO must ensure that current providers are paid for Medically
Necessary Covered Services that are delivered in accordance with the Member’s
existing treatment/long-term care services plan after the Member has become
enrolled in the HMO and until the transition plan is developed.
The
transition planning process must include, but is not limited to, the
following:
1 review
of
existing DADS long-term care services plans;
2 preparation
of a transition plan that ensures continuous care under the Member’s existing
Care Plan during the transfer into the HMO’s Network while the HMO conducts an
appropriate assessment and development of a new plan, if needed;
3 if
durable medical equipment or supplies had been ordered prior to enrollment
but
have not been received by the time of enrollment, coordination and
follow-through to ensure that the Member receives the necessary supportive
equipment and supplies without undue delay; and
4 payment
to the existing provider of service under the existing authorization until
the
HMO has completed the assessment and service plans and issued new
authorizations.
The
HMO
must review any existing care plan and develop a transition plan within 30
days
of receiving the Member’s enrollment. The transition plan will remain in place
until the HMO contacts the Member and coordinates modifications to the Member’s
current treatment/long-term care services plan. The HMO must ensure that the
existing services continue and that there are no breaks in services. For initial
implementation of the STAR+PLUS program in a Service Area, the HMO must complete
this process within 90-days of the Member’s enrollment.
The
HMO
must ensure that the Member is involved in the assessment process and fully
informed about options, is included in the development of the care plan, and
is
in agreement with the plan when completed.
The
Service Coordinator shall be responsible for maintaining a centralized record
related to Member contacts, assessments and service authorizations. The HMO
shall ensure that the organization of and documentation included in the
centralized Member record meets all applicable professional standards ensuring
confidentiality of Member records, referrals, and documentation of
information.
The
HMO
must have a systematic process for generating or receiving referrals and sharing
confidential medical, treatment, and planning information across
providers.
Nursing
facility care, although a part of the care continuum, presents a challenge
for
managed care. Because of the process for becoming eligible for Medicaid
assistance in a nursing facility, there is frequently a significant time gap
between entry into the nursing home and determination of Medicaid
eligibility. During this gap from entry to Medicaid eligibility, the
resident has “nested” in the facility and many of the community supports are no
longer available. To require participation of all nursing facility residents
would result in the HMO maintaining a Member in the nursing facility without
many options for managing their health. For this reason, persons who qualify
for
Medicaid as a result of nursing facility residency are not enrolled in
STAR+PLUS.
The
STAR+PLUS HMO must participate in the Promoting Independence initiative for
such
individuals. Promoting Independence (PI) is a philosophy that aged and disabled
individuals remain in the most integrated setting to receive long-term care
services. PI is Texas' response to the U.S. Supreme Court ruling in Xxxxxxxx
v. X.X. that requires states to provide community-based services for
persons with disabilities who would otherwise be entitled to institutional
services, when:
• the
state's treatment professionals determine that such placement is
appropriate;
• the
affected persons do not oppose such treatment; and
• the
placement can be reasonably accommodated, taking into account the resources
available to the state and the needs of others who are receiving state supported
disability services.
In
accordance with legislative direction, the HMO must designate a point of contact
to receive referrals for nursing facility residents who may potentially be
able
to return to the community through the use of 1915(c) Nursing Facility Waiver
services. To be eligible for this option, an individual must reside in a nursing
facility until a written plan of care for safely moving the resident back into
a
community setting has been developed and approved.
A
STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member
for a total of four months. The nursing facility will xxxx the state directly
for covered nursing facility services delivered while the Member is in the
nursing facility. See Section 8.3.2.7 for further
information.
If
the
initial review does not support a return to the community, the Service
Coordinator will conduct a second assessment 90 days after the initial
assessment to determine any changes in the individual’s condition or
circumstances that would allow a return to the community. The Service
Coordinator will develop and implement the transition plan.
The
HMO
will provide these services as part of the Promoting Independence initiative.
The HMO must maintain the documentation of the assessments completed and make
them available for state review at any time.
It
is
possible that the STAR+PLUS HMO will be unaware of the Member’s entry into a
nursing facility. It is the responsibility of the nursing facility to review
the
Member’s Medicaid card upon entry into the facility and notify the HMO. The
nursing facility is also required to notify HHSC of the entry of a new
resident.
A
STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member
for a total of four months. The four months do not have to be
consecutive. Upon completion of four months of nursing facility care, the
individual will be disenrolled from the STAR+PLUS Program and the Medicaid
Fee-for-Service program will provide Medicaid benefits. A STAR+PLUS Member
may
not change HMOs while in a nursing facility.
Tracking
the four months of liability is done through a counter system. The four-month
counter starts with the Medicaid admission or on the 21st day of a Medicare
stay. A partial month counts as a full month. In other words, the month in
which
the Medicaid admission occurs or the month on which the 21st day of the Medicare
stay occurs, is counted as one of the four months.
An
amount
will be included in the capitation rates to cover the cost of four months of
nursing facility services (based upon experience from STAR+PLUS in Xxxxxx
County) for the historical average number of admissions to nursing facilities.
Nursing facility costs for STAR+PLUS in Xxxxxx County have accounted for less
than one percent of premiums in recent years. HHSC believes that these costs
will not deviate substantially from this experience.
The
HMO
will be liable for the cost of care in a nursing facility care and, for
Medicaid-only Members, the cost of all other Covered Services. The HMO will
not
maintain nursing facilities in its Network and will not reimburse the nursing
facilities directly. Nursing facilities will use the traditional Fee-for-Service
system of billing HHSC rather than billing the HMO. The HMO's liability will
be
established based on the amount paid through the Fee-for-Service billing system
on behalf of the Member. HHSC will recoup those costs from the HMO by an offset
to the monthly Capitation Payment. The offset will be recognized as a nursing
facility expense.. The HMO will record the nursing facility liability recoupment
as nursing facility expense on its
Financial-Statistical
Reports (FSR). The HMO will be responsible for direct payment of all non-nursing
facility Medicaid expenses on behalf of the Member.
The
HMO
must have and use functional assessment instruments to identify Members with
significant health problems, Members requiring immediate attention, and Members
who need or are at risk of needing long-term care services. The HMO, a
subcontractor, or a Provider may complete assessment instruments, but the HMO
remains responsible for the data recorded.
HMOs
must
use the DHS Form 2060, as amended or modified, to assess a Member’s need for
Functionally Necessary Personal Attendant Services. The HMO may adapt the form
to reflect the HMO’s name or distribution instructions, but the elements must be
the same and instructions for completion must be followed without
amendment.
The
DHS
Form 2060 must be completed if a need or a change in Personal Attendant Services
is warranted at the initial contact, at the annual reassessment, and anytime
a
Member requests the services or requests a change in services. The DHS Form
2060
must also be completed if the HMO determines the Member requires the services
or
requires a change in the Personal Attendant Services that are
authorized.
For
Members and applicants seeking or needing the 1915(c) Nursing Facility Waiver
services, the HMOs must use the DADS CARE Form 3652, as amended or modified,
to
assess Members and to supply current medical information for Medical Necessity
determinations. The HMO must also complete the Individual Service
Plan (ISP), Form 3671 for each Member receiving 1915(c) Nursing Facility Waiver
Services. The ISP is established for a one-year period. After the
initial ISP is established, the ISP must be completed on an annual basis and
the
end date or expiration date does not change. Both of these forms
(Form 3652 and Form 3671) must be completed annually at
reassessment. The HMO is responsible for tracking the end dates of
the ISP to ensure that the Member is reassessed prior to the expiration
date. Note that the DADS CARE Form 3652 cannot be submitted earlier
than 90 days prior to the expiration date of the ISP.
HHSC
has
adopted a Minimum Data Set for Home Care (MDS-HC), which can be found in the
HHSC Uniform Managed Care Manual. HHSC may adopt new versions of this
instrument as appropriate or as directed by CMS. The MDS-HC instrument must
be
completed and electronically submitted to HHSC in the specified format within
30
days of enrollment for every Member receiving Community-based Long-term Care
Services, and then each year by the anniversary of the Member’s date of
enrollment.
The
MDS-HC instrument must be completed and electronically submitted to HHSC in
the
specified format within 30 days of enrollment for every Member receiving
Community-based Long-term Care Services. Because of the large number
of Members the HMOs will be receiving initially during the implementation period
of the STAR+PLUS Program, HHSC is allowing the following:
• For
the
1915(c) Nursing Facility Waiver Members, the MDS-HC instrument must be completed
in conjunction with the annual reassessment. The MDS-HC instrument
must be completed annually at the time of reassessment for these
Members.
• For
the
non-1915(c) Nursing Facility Waiver Members that are receiving Community-based
Long-term Care Services, the HMO must submit a schedule for HHSC’s approval that
provides a plan of how the MDS-HC instruments will be completed for these
Members over a twelve-month period beginning on February 1, 2007.
In
addition to submitting the MDS-HC instrument to HHSC, the HMO may also submit
other supplemental assessment instruments it elects to use. As
specialized MDS instruments are developed or adopted by HHSC for other living
arrangements (e.g., assisted living), HHSC will notify HMO of the availability
of the instrument and the date the HMO is required to begin using such
instrument in the HHSC Uniform Managed Care Manual. Any additional
assessment instruments used by the HMO must be approved by HHSC.
8.3.4
1915(c) Nursing Facility Waiver Service Eligibility
Recipients
of 1915(c) Nursing Facility Waiver services must meet nursing facility criteria
for participation in the waiver and must have a plan of care at initial
determination of eligibility in which the plan’s annualized cost is equal to or
less than the annualized cost of care if the individual were to enter a nursing
facility.
The
HMO
must notify HHSC when it initiates 1915(c) Nursing Facility Waiver eligibility
testing on a STAR+PLUS Member. The HMO must apply risk criteria, complete the
Form 3652 for Medical Necessity determination, complete the assessment
documentation, and prepare a 1915(c) Nursing Facility Waiver Individual Service
Plan (ISP) for each Member requesting 1915(c) Nursing Facility Waiver services
and for Members the HMO has identified as needing 1915(c) Nursing Facility
Waiver services. The HMO must provide HHSC the results of the assessment
activities within 45 days of initiating the assessment process.
HHSC
will
notify the Member and the HMO of the eligibility determination, which will
be
based on the information provided by the HMO. If the STAR+PLUS Member is
eligible for 1915(c) Nursing Facility Waiver services, HHSC will notify the
Member of the effective date of eligibility. If the Member is not eligible
for
1915(c) Nursing Facility Waiver services, HHSC will provide the Member
information on right to Appeal the Adverse Determination. Regardless of the
1915(c) Nursing Facility Waiver eligibility determination, HHSC will send a
copy
of the Member notice to the HMO.
Non-Member
persons who are not eligible for Medicaid in the community may apply for
participation in the 1915(c) Nursing Facility Waiver program under the financial
and functional eligibility requirements for MAO. HHSC will inform the applicant
that services are provided through an HMO and allow the applicant to select
the
HMO. HHSC will authorize the selected HMO to initiate pre-enrollment assessment
services required under the 1915(c) Nursing Facility Waiver
for the non-member. The HMO must complete Form 3652 for Medical Necessity
determination, complete the assessment documentation, and prepare a 1915(c)
Nursing Facility Waiver service plan for each applicant referred by HHSC. The
initial home visit with the applicant must occur within 14 days of the receipt
of the referral. The HMO must provide HHSC the results of the assessment
activities within 45 days of the receipt of the referral.
HHSC
will
notify the applicant and the HMO of the results of its eligibility
determination. If the applicant is eligible, HHSC will notify the applicant
and
the HMO will be notified of the effective date of eligibility, which will be
the
first day of the month following the determination of eligibility. The HMO
must
initiate the Individual Service Plan (ISP) on the date of
enrollment.
If
the
applicant is not eligible, the HHSC notice will provide information on the
applicant’s right to Appeal the Adverse Determination. HHSC will also
send notice to the HMO if the applicant is not eligible for 1915(c) Nursing
Facility Waiver services.
Prior
to
the end date of the annual ISP, the HMO must initiate an annual reassessment
to
determine and validate continued eligibility for 1915(c) Nursing Facility Waiver
services for each Member receiving such services. The HMO will be expected
to
complete the same activities for the annual reassessment as required for the
initial eligibility determination, with the following exception: the HMO does
not need to obtain a physician’s signature on the Form 3652 for the annual
reassessment. Existing 1915(c) Nursing Facility Waiver clients may not be denied
1915(c) Nursing Facility Waiver services solely on the basis that the proposed
cost of the ISP will exceed the cost of care if the Member were in a nursing
home if the following conditions are met:
1 those
services are required for that individual to live in the most integrated setting
appropriate to his or her needs; and
2 HHSC
continues to comply with the cost-effectiveness requirements from the
CMS.
Individuals
receiving waiver services through the Medically Dependent Children Program
are
covered by the provisions in this Section when they apply for transition to
the
1915(c) waiver program at age 21.
• at
initial assessment;
• at
annual
reassessment or annual contact with the STAR+PLUS Member;
• at
any
time when a STAR+PLUS Member receiving PAS requests the information;
and
• in
the
Member Handbook.
The
HMO
must contract with providers who are able to offer PAS and must also
educate/train the HMO Network Providers regarding the three PAS options. To
participate as a PAS Network Provider, the Provider must have a contract with
DADS for the delivery of PAS. The HMO must assure compliance with the
Texas Administrative Code in Title 40, Part 1, Chapter 41, Sections 41.101,
41.103, and 41.105. The HMO must include the requirements in the
Provider Manual and in the STAR+PLUS Provider training.
In
the
Self-Directed Model, the Member or the Member’s legal guardian is the employer
of record and retains control over the hiring, management, and termination
of an
individual providing Personal Attendant Services. The Member is
responsible for assuring that the employee meets the requirements for Personal
Attendant Services, including the criminal history check. The Member uses a
Home
and Community Support Services (HCSS) agency to handle the employer-related
administrative functions such as payroll, substitute (back-up), and filing
tax-related reports of Personal Attendant Services.
In
the
Agency Model, Self-Directed, the Member or the Member’s legal guardian chooses a
Home and Community Support Services (HCSS) agency in the HMO Provider Network
who is the employer of record. In this model, the Member selects the
personal attendant from the HCSS agency’s personal attendant
employees. The personal attendant’s schedule is set up based on the
Member input, and the Member manages the Personal Attendant
Services. The Member retains the right to supervise and train the
personal attendant. The Member may request a different personal
attendant and the HCSS agency would be expected to honor the
request. The HCSS agency establishes the payment rate, benefits, and
provides all administrative functions such as payroll, substitute (back-up),
and
filing tax-related reports of personal attendant services.
In
the
Agency Model, the Member chooses a Home and Community Support Services (HCSS)
agency to hire, manage, and terminate the individual providing Personal
Attendant Services. The HCSS agency is selected by the Member from
the HCSS agencies in the HMO Provider Network. The Service
Coordinator and Member develop the schedule and send it to the HCSS agency.
The
Member retains the right to supervise and train the personal
attendant. The Member may request a different personal attendant and
the HCSS agency would be expected to honor the request. The HCSS
agency establishes the payment rate, benefits, and provides all administrative
functions such as payroll, substitute (back-up), and filing tax-related reports
of personal attendant services.
The
HMO
must comply with Section 8.1.4.6 regarding Provider Manual and Provider training
specific to the STAR+PLUS Program. The HMO must train all Community Long-term
Care Service Providers regarding the requirements of the Contract and special
needs of STAR+PLUS
Members.
The HMO must establish ongoing STAR+PLUS Provider training addressing the
following issues at a minimum:
1 Covered
Services and the Provider’s responsibilities for providing such services to
STAR+PLUS Members and billing the HMO for such services. The HMO must place
special emphasis on Community Long-term Care Services and STAR+PLUS
requirements, policies, and procedures that vary from Medicaid Fee-for-Service
and commercial coverage rules, including payment policies and
procedures.
2 Inpatient
Stay hospital services and the authorization and billing of such services for
STAR+PLUS Members.
3 Relevant
requirements of the STAR+PLUS Contract, including the role of the Service
Coordinator;
4 Processes
for making referrals and coordinating Non-capitated Services;
5 The
HMO’s
quality assurance and performance improvement program and the Provider’s role in
such programs; and
6 The
HMO’s
STAR+PLUS policies and procedures, including those relating to Network and
Out-of-Network referrals.
8.3.7.2
LTC Provider Billing
Long-term
care providers are not required to utilize the billing systems that most medical
facilities use on a regular basis. For this reason, the HMO must make
accommodations to the claims processing system for such providers to allow
for a
smooth transition from traditional Medicaid to Managed Care
Medicaid.
HHSC
will
meet with HMOs to develop a standardized method long-term care
billing. All STAR+PLUS HMOs will be required to utilize the
standardized method, which will be incorporated into the HHSC Uniform
Managed Care Manual.
All
HMOs
participating in the STAR+PLUS program must allow their Long-term Support
Services (LTSS) Providers to participate in the STAR+PLUS Attendant Care
Enhancement Program if the providers are currently participating in the enhanced
payment program with the Department of Aging and Disability Services
(DADS). HMOs may choose not to offer participation to DADS-contracted
providers who do not currently participate in the enhancement
program. Additionally, HMOs may choose to include Providers in the
network who do not participate in the enhanced payment program.
Attachment
B-7, STAR+PLUS Attendant Care Enhanced Payment Methodology explains the
methodology that the STAR+PLUS HMO will use to implement and pay the enhanced
payments, including a description of the timing of the payments, in accordance
with the requirements in the Uniform Managed Care Manual and
the intent of the 2000-01 General Appropriations Act (Rider 27, House Xxxx
1,
76th
Legislature, Regular Session, 1999) and T.A.C. Title 1, Part 15, Chapter
355.
Disenrolled
Members: Occasionally, the Social Security Administration will place
SSI recipients on hold for a short period of time, usually due failure to
provide timely updates required for the continuation of SSI benefits. During
this period, the recipients will not appear to be eligible for Medicaid or
1915(c) Nursing Facility Waiver services. Often the Social Security
Administration reinstates these Medicaid Eligibles retroactively without a
break
in Medicaid coverage. To deal with this situation, for at least thirty (30)
days
after disenrollment, the HMO will continue to authorize and pay for 1915(c)
Nursing Facility Waiver services for disenrolled STAR+PLUS Members who appear
to
lose eligibility due to an administrative problem related to SSI. If at the
end
of the thirty (30) days, the Medicaid Eligible’s 1915(c) Nursing Facility Waiver
eligibility is reinstated, the Medicaid Eligible will be manually enrolled
into
the STAR+PLUS HMO back to the date of disenrollment and the retroactive
adjustment system will properly reimburse the HMO. If after thirty (30) days,
the former STAR+PLUS Member continues to be ineligible for Medicaid, the
individual will not be retroactively enrolled, and the HMO will xxxx HHSC for
1915(c) Nursing Facility Waiver services rendered during this time.
The
following provisions only apply to HMOs participating in CHIP.
In
each
Service Area, the HMO must seek to obtain the participation in its Provider
Network of CHIP Significant Traditional Providers (STPs), defined by HHSC as
PCP
Providers currently serving the CHIP population and DSH hospitals. The
Procurement Library includes CHIP STPs by Service Area.
The
HMO
must give STPs the opportunity to participate in its Network if the
STPs:
1 Agree
to
accept the HMO’s Provider reimbursement rate for the provider type;
and
2 Meet
the
standard credentialing requirements of the HMO, provided that lack of board
certification or accreditation by the Joint Commission on Accreditation of
Health Care Organizations (JCAHO) is not the sole grounds for exclusion from
the
Provider Network.
CHIP
Provider Complaints and Appeals are subject to disposition consistent with
the
Texas Insurance Code and any applicable TDI regulations. The HMO must
resolve Provider Complaints within 30 days from the date the Complaint is
received.
CHIP
Member Complaints and Appeals are subject to disposition consistent with the
Texas Insurance Code and any applicable TDI regulations. HHSC will
require the HMO to resolve Complaints and Appeals (that are not elevated to
TDI)
within 30 days from the date the Complaint or Appeal is received. The HMO is
subject to remedies, including liquidated damages, if at least 98 percent of
Member Complaints or Member Appeals are not resolved within 30 days of receipt
of the Complaint or Appeal by the HMO. Please see the Uniform Managed
Care Contract Terms & Conditions and Attachment B-5,
Deliverables/Liquidated Damages Matrix. Any person, including those
dissatisfied with a HMO’s resolution of a Complaint or Appeal, may report an
alleged violation to TDI.
The
HMO
is not responsible for reimbursing dental providers for preventive and
therapeutic dental services obtained by CHIP Members. However, medical and/or
hospital charges, such as anesthesia, that are necessary in order for CHIP
Members to access standard therapeutic dental services, are Covered Services
for
CHIP Members. The HMO must provide access to facilities and physician services
that are necessary to support the dentist who is providing dental services
to a
CHIP Member under general anesthesia or intravenous (IV) sedation.
The
HMO
must inform Network facilities, anesthesiologists, and PCPs what authorization
procedures are required, and how Providers are to be reimbursed for the
preoperative evaluations by the PCP and/or anesthesiologist and for the facility
services. For dental-related medical Emergency Services, the HMO must reimburse
in-network and Out-of-Network providers in accordance with federal and state
laws, rules, and regulations.
The
following provisions only apply to HMOs participating in CHIP Perinatal
Program.
In
each
Service Area, the CHIP Perinatal HMO must seek to obtain the participation
of
Providers for CHIP Perinate Members. CHIP Perinatal HMOs are
encouraged to obtain the participation of Obstetricians/Gynecologists (OB/GYNs),
Family Practice Physicians with experience in prenatal care, or other qualified
health care Providers as CHIP Perinate Providers.
See
Sections 8.1.3.2, Access to Network Providers, and 8.1.4.2, Primary Care
Providers, regarding distinctions in the provider networks for CHIP Perinates
and CHIP Perinate Newborns.
CHIP
Perinatal Program Provider Complaints and Appeals are subject to disposition
consistent with the Texas Insurance Code and any applicable TDI
regulations. The HMO must resolve Provider Complaints within 30 days
from the date the Complaint is received.
CHIP
Perinatal Program Member Complaints and Appeals are subject to disposition
consistent with the Texas Insurance Code and any applicable TDI
regulations. HHSC will require the HMO to resolve Complaints and
Appeals (that are not elevated to TDI) within 30 days from the date the
Complaint or Appeal is received. Any person, including those dissatisfied with
a
HMO’s resolution of a Complaint or Appeal, may report an alleged violation to
TDI.
Contractual
Document (CD)
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version Attachment B-1, Section 7
|
|
Revision
|
1.1
|
June
30, 2006
|
Contract
amendment to include STAR+PLUS program. No change to this
Section.
|
Revision
|
1.2
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-1 Section 9 – Turnover
Requirements
|
Revision
|
1.3
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-1 Section 9 – Turnover
Requirements
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-1 Section 9 – Turnover
Requirements
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-1 Section 9 – Turnover
Requirements
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-1 Section 9 – Turnover
Requirements
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-1 Section 9 – Turnover
Requirements
|
Revision
|
1.8
|
September
1, 2007
|
Contract
amendment did not revise Attachment B-1 Section 9 – Turnover
Requirements
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn versions
2Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3 Brief
description of the changes to the document made in the
revision.
|
Contractual
Document (CD)
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 9 Version
1.8
This
section presents the Turnover Requirements to which the HMO must agree. Turnover
is defined as those activities that are required for the HMO to perform upon
termination of the Contract in situations in which the HMO must transition
Contract operations to HHSC or a subsequent Contractor.
The
HMO
must transfer all data regarding the provision of Covered Services to Members
to
HHSC or a new HMO, at the sole discretion of HHSC and as directed by HHSC.
All
transferred data must be compliant with HIPAA.
All
relevant data must be received and verified by HHSC or the subsequent
Contractor. If HHSC determines that not all of the data regarding the provision
of Covered Services to Members was transferred to HHSC or the subsequent
Contractor, as required, or the data is not HIPAA compliant, HHSC reserves
the
right to hire an independent contractor to assist HHSC in obtaining and
transferring all the required data and to ensure that all the data are HIPAA
compliant. The reasonable cost of providing these services will be the
responsibility of the HMO.
Six
months prior to the end of the Contract Period, including any extensions to
such
Period, the HMO must propose a Turnover Plan covering the possible turnover
of
the records and information maintained to either the State or a successor HMO.
The Turnover Plan must be a comprehensive document detailing the proposed
schedule, activities, and resource requirements associated with the turnover
tasks. The Turnover Plan must be approved by HHSC.
As
part
of the Turnover Plan, the HMO must provide HHSC with copies of all relevant
Member and service data, documentation, or other pertinent information
necessary, as determined by the HHSC, for HHSC or a subsequent Contractor to
assume the operational activities successfully. This includes correspondence,
documentation of ongoing outstanding issues, and other operations support
documentation. The plan will describe the HMO’s approach and schedule for
transfer of all data and operational support information, as applicable. The
information must be supplied in media and format specified by the State and
according to the schedule approved by the State.
HHSC
is
not limited or restricted in the ability to require additional information
from
the HMO or modify the turnover schedule as necessary.
Thirty
(30) days following turnover of operations, the HMO must provide HHSC with
a
Turnover Results report documenting the completion and results of each step
of
the Turnover Plan. Turnover will not be considered complete until this document
is approved by HHSC.
If
the
HMO does not provide the required relevant data and reference tables,
documentation, or other pertinent information necessary for HHSC or the
subsequent Contractor to assume the operational activities successfully, the
HMO
agrees to reimburse the State for all reasonable costs, including, but not
limited
to, transportation, lodging, and subsistence for all state and federal
representatives, or their agents, to carry out their inspection, audit, review,
analysis, reproduction and transfer functions at the location(s) of such
records.
The
HMO
also agrees to pay any and all additional costs incurred by the State that
are
the result of the HMO’s failure to provide the requested records, data or
documentation within the time frames agreed to in the Turnover
Plan.
The
HMO
must maintain all files and records related to Members and Providers for five
years after the date of final payment under the Contract or until the resolution
of all litigation, claims, financial management review or audit pertaining
to
the Contract, whichever is longer. The HMO agrees to repay any valid, undisputed
audit exceptions taken by HHSC in any audit of the Contract.
Subject:
Attachment B-2 – Covered Services Version 1.8
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version Attachment B-2, Covered Services
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
Covered Services.
|
Revision
|
1.2
|
September
1. 2006
|
Revised
Attachment B-2 to include provisions applicable to MCOs participating
in
the STAR and CHIP Programs. STAR Covered Services, Services Included
under
the HMO Capitation Payment, is modified to clarify the STAR covered
services related to “optometry” and “vision.” CHIP Covered Services is
modified to correct services related to artificial aids including
surgical
implants.
|
Revision
|
1.3
|
September
1, 2006
|
Contract
amendment did not revise Attachment B2, Covered
Services.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment did not revise Attachment B2, Covered
Services.
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B2, Covered
Services.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B2, Covered
Services.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B2, Covered
Services.
|
Revision
|
1.8
|
September
1, 2007
|
CHIP
Covered Services are modified to comply with legislative changes
required
by HB 109 to eliminate the 6 month enrollment period effective
9/1/07.
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn versions
2Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3 Brief
description of the changes to the document made in the
revision.
|
STAR
Covered Services
The
following is a non-exhaustive, high-level listing of Acute Care Covered Services
included under the STAR Medicaid managed care program.
Medicaid
HMO Contractors are responsible for providing a benefit package to Members
that
includes all medically necessary services covered under the traditional,
fee-for-service Medicaid programs except for Non-capitated Services provided
to
STAR Members outside of the HMO capitation and listed in Attachment B-1,
Section 8.2.2.8. Medicaid HMO Contractors must coordinate care
for Members for these Non-capitated Services so that Members have access to
a
full range of medically necessary Medicaid services, both capitated and
non-capitated. A Contractor may elect to offer additional acute care Value-added
Services.
The
STAR
Members are provided with three enhanced benefits compared to the traditional,
fee-for
service
Medicaid coverage:
1) waiver
of the three-prescription per month limit;
2) waiver
of the 30-day spell-of-illness limitation under fee-for-services;
and
3) inclusion
of an annual adult well check for patients 21 years of age and
over.
Medicaid
HMO Contractors are responsible for providing a benefit package to Members
that
includes the waiver of the 30-day spell-of-illness limitation under
fee-for-service and the inclusion of an annual adult well check for patients
21
years of age and over. Prescription drug benefits to Medicaid HMO
Members are provided outside of the HMO capitation.
Bidders
and Contractors should refer to the current Texas Medicaid Provider
Procedures Manual and the bi-monthly Texas Medicaid
Bulletin for a more inclusive listing of limitations and
exclusions that apply to each Medicaid benefit category. (These documents can
be
accessed online at: xxxx://xxx.xxxx.xxx.)
The
services listed in this Attachment are subject to modification based on Federal
and State laws and regulations and Programs policy updates.
Services
included under the HMO capitation payment
• Ambulance
services
• Audiology
services, including hearing aids for adults (hearing aids for children are
provided through the PACT program and are a non-capitated service)
• Behavioral
Health Services, including:
Inpatient
and
outpatient mental health services for children (under age
21)
Outpatient
chemical
dependency services for children (under age 21)
Detoxification
services
Psychiatry
services
Counseling
services
for adults (21 years of age and over)
• Birthing
center services
• Chiropractic
services
• Dialysis
• Durable
medical equipment and supplies
• Emergency
Services
• Family
planning services
• Home
health care services
• Hospital
services, including inpatient and outpatient
• Laboratory
• Medical
check-ups and Comprehensive Care Program (CCP) Services for children (under
age
21) through the Texas Health Steps Program
• Podiatry
• Prenatal
care
• Primary
care services
• Radiology,
imaging, and X-rays
• Specialty
physician services
• Therapies
– physical, occupational and speech
•
Transplantation
of
organs and tissues
• Vision
(Includes optometry and glasses. Contact lenses are only covered if
they are medically necessary for vision correction, which can not be
accomplished by glasses.)
Subject:
Attachment B-2 – Covered Services Version 1.8
CHIP
Covered Services
Covered
CHIP services must meet the CHIP definition of Medically Necessary Covered
Services as defined in this Contract. There is no lifetime
maximum on benefits; however, 12-month period or lifetime limitations do apply
to certain services, as specified in the following chart. Co-pays
apply until a family reaches its specific cost-sharing maximum.
Inpatient
General Acute and Inpatient Rehabilitation Hospital
Services
|
Services
include, but are not limited to, the following:
Hospital-provided
Physician or Provider services
Semi-private
room and board (or private if medically necessary as certified by
attending)
General
nursing care
Special
duty nursing when medically necessary
ICU
and services
Patient
meals and special diets
Operating,
recovery and other treatment rooms
Anesthesia
and administration (facility technical component)
Surgical
dressings, trays, casts, splints
Drugs,
medications and biologicals
Blood
or blood products that are not provided free-of-charge to the patient
and
their administration
X-rays,
imaging and other radiological tests (facility technical
component)
Laboratory
and pathology services (facility technical component)
Machine
diagnostic tests (EEGs, EKGs, etc.)
Oxygen
services and inhalation therapy
Radiation
and chemotherapy
Access
to DSHS-designated Level III perinatal centers or Hospitals meeting
equivalent levels of care
In-network
or out-of-network facility and Physician services for a mother and
her
newborn(s) for a minimum of 48 hours following an uncomplicated vaginal
delivery and 96 hours following an uncomplicated delivery by caesarian
section.
Hospital,
physician and related medical services, such as anesthesia, associated
with dental care
Surgical
implants
Other
artificial aids including surgical implants
Implantable
devices are covered under Inpatient and Outpatient services and do
not
count towards the DME 12-month period limit
|
Skilled
Nursing
|
Services
include, but are not limited to, the following:
|
Facilities
|
Semi-private room and board
|
(Includes
Rehabilitation
|
Regular
nursing services
|
Hospitals)
|
Rehabilitation
services
Medical
supplies and use of appliances and equipment furnished by the
facility
|
Outpatient
Hospital,
|
Services
include, but are not limited to, the following services provided
in
a
|
Comprehensive
Outpatient
|
hospital
clinic or emergency room, a clinic or health center,
hospital-based
|
Rehabilitation
Hospital, Clinic
|
emergency
department or an ambulatory health care setting:
|
(Including
Health Center) and
|
X-ray,
imaging, and radiological tests (technical component)
|
Ambulatory
Health Care
|
Laboratory
and pathology services (technical component)
|
Center
|
Machine
diagnostic tests
Ambulatory
surgical facility services
Drugs,
medications and biologicals
|
Subject:
Attachment B-2 – Covered Services Version 1.8
Covered
Benefit
|
Description
|
Casts,
splints, dressings
Preventive
health services
Physical,
occupational and speech therapy
Renal
dialysis
Respiratory
services
Radiation
and chemotherapy
Blood
or blood products that are not provided free-of-charge to the patient
and
the administration of these products
Facility
and related medical services, such as anesthesia, associated with
dental
care, when provided in a licensed ambulatory surgical
facility.
Surgical
implants
Other
artificial aids including surgical implants
Implantable
devices are covered under Inpatient and Outpatient services and do
not
count towards the DME 12-month period limit
|
|
Physician/Physician
Extender Professional Services
|
Services
include, but are not limited to, the following:
American
Academy of Pediatrics recommended well-child exams and preventive
health
services (including, but not limited to, vision and hearing screening
and
immunizations)
Physician
office visits, in-patient and out-patient services
Laboratory,
x-rays, imaging and pathology services, including technical component
and/or professional interpretation
Medications,
biologicals and materials administered in Physician’s
office
Allergy
testing, serum and injections
Professional
component (in/outpatient) of surgical services, including: -Surgeons
and
assistant surgeons for surgical procedures including appropriate
follow-up
care -Administration of anesthesia by Physician (other than surgeon)
or
CRNA -Second surgical opinions -Same-day surgery performed in a Hospital
without an over-night stay -Invasive diagnostic procedures such as
endoscopic examinations
Hospital-based
Physician services (including Physician-performed technical and
interpretive components)
In-network
and out-of-network Physician services for a mother and her newborn(s)
for
a minimum of 48 hours following an uncomplicated vaginal delivery
and 96
hours following an uncomplicated delivery by caesarian
section.
Physician
services medically necessary to support a dentist providing dental
services to a CHIP member such as general anesthesia or intravenous
(IV)
sedation.
|
Durable
Medical Equipment (DME), Prosthetic Devices and Disposable Medical
Supplies
|
$20,000
12-month period limit for DME, prosthetics, devices and disposable
medical
supplies (diabetic supplies and equipment are not counted against
this
ccap). Services include DME (equipment which can withstand
repeated use and is primarily and customarily used to serve a medical
purpose, generally is not useful to a person in the absence of Illness,
Injury, or Disability, and is appropriate for use in the home), including
devices and supplies that are medically necessary and necessary for
one or
more activities of daily living and appropriate to assist in the
treatment
of a medical condition, including:
Orthotic
braces and orthotics
Prosthetic
devices such as artificial eyes, limbs, and
braces
Prosthetic
eyeglasses and contact lenses for the management of severe ophthalmologic
disease
Hearing
aids
|
Covered
Benefit
|
Description
|
Diagnosis-specific
disposable medical supplies, including diagnosis-specific prescribed
specialty formula and dietary supplements. (See Attachment
A)
|
|
Home
and Community Health Services
|
Services
that are provided in the home and community, including, but not limited
to:
Home
infusion
Respiratory
therapy
Visits
for private duty nursing (R.N., L.V.N.)
Skilled
nursing visits as defined for home health purposes (may include R.N.
or
L.V.N.).
Home
health aide when included as part of a plan of care during a period
that
skilled visits have been approved.
Speech,
physical and occupational therapies.
Services
are not intended to replace the CHILD'S caretaker or to provide relief
for
the caretaker
Skilled
nursing visits are provided on intermittent level and not intended
to
provide 24-hour skilled nursing services
Services
are not intended to replace 24-hour inpatient or skilled nursing
facility
services
|
Inpatient
Mental Health Services
|
Mental
health services, including for serious mental illness, furnished
in a
freestanding psychiatric hospital, psychiatric units of general acute
care hospitals and state-operated facilities, including, but not
limited
to:
Neuropsychological
and psychological testing.
Inpatient
mental health services are limited to:
45
days 12-month inpatient limit
Includes
inpatient psychiatric services, up to 12-month period limit, ordered
by a
court of competent jurisdiction under the provisions of Chapters
573 and
574 of the Texas Health and Safety Code, relating to court ordered
commitments to psychiatric facilities. Court order serves as binding
determination of medical necessity. Any modification or termination
of
services must be presented to the court with jurisdiction over the
matter
for determination
25
days of the inpatient benefit can be converted to residential treatment,
therapeutic xxxxxx care or other 24-hour therapeutically planned
and
structured services or sub-acute outpatient (partial hospitalization
or
rehabilitative day treatment) mental health services on the basis
of
financial equivalence against the inpatient per diem
cost
20
of the inpatient days must be held in reserve for inpatient use
only
Does
not require PCP referral
|
Outpatient
Mental Health Services
|
Mental
health services, including for serious mental illness, provided on
an
outpatient basis, including, but not limited to:
Medication
management visits do not count against the outpatient visit
limit.
The
visits can be furnished in a variety of community-based settings
(including school and home-based) or in a state-operated
facility
Up
to 60 days 12-month period limit for rehabilitative day
treatment
60
outpatient visits 12-month period limit
60
rehabilitative day treatment days can be converted to outpatient
visits on
the basis of financial equivalence against the day treatment per
diem
cost
60
outpatient visits can be converted to skills training (psycho educational
skills development) or rehabilitative day treatment on the basis
of
financial equivalence against the outpatient visit cost
Includes
outpatient psychiatric services, up to 12-month period limit, ordered
by a
court of competent jurisdiction under the provisions
of
|
Subject:
Attachment B-2 – Covered Services Version 1.8
Covered
Benefit
|
Description
|
Chapters
573 and 574 of the Texas Health and Safety Code, relating to court
ordered
commitments to psychiatric facilities. Court order serves as binding
determination of medical necessity. Any modification or termination
of
services must be presented to the court with jurisdiction over the
matter
for determination
Inpatient
days converted to sub-acute outpatient services are in addition to
the
outpatient limits and do not count towards those limits
A
Qualified Mental Health Professional (QMHP), as defined by and
credentialed through Texas Department of State Health Services (DSHS)
standards (TAC Title 25, Part II, Chapter 412), is a Local Mental
Health
Authorities provider. A QMHP must be working under the authority
of an
DSHS entity and be supervised by a licensed mental health professional
or
physician. QMHPs are acceptable providers as long as the services
would be
within the scope of the services that are typically provided by QMHPs.
Those services include individual and group skills training (which
can be
components of interventions such as day treatment and in-home services),
patient and family education, and crisis services
Does
not require PCP referral
|
|
Inpatient
Substance Abuse Treatment Services
|
Services
include, but are not limited to:
Inpatient
and residential substance abuse treatment services including
detoxification and crisis stabilization, and 24-hour residential
rehabilitation programs
Does
not require PCP referral
Medically
necessary detoxification/stabilization services, limited to 14 days
per
12-month period.
24-hour
residential rehabilitation programs, or the equivalent, up to 60
days per
12-month period
30
days may be converted to partial hospitalization or intensive outpatient
rehabilitation, on the basis of financial equivalence against the
inpatient per diem cost
30
days must be held in reserve for inpatient use only.
|
Outpatient
Substance Abuse Treatment Services
|
Services
include, but are not limited to, the following:
Prevention
and intervention services that are provided by physician and non-physician
providers, such as screening, assessment and referral for chemical
dependency disorders.
Intensive
outpatient services is defined as an organized non-residential service
providing structured group and individual therapy, educational services,
and life skills training which consists of at least 10 hours per
week for
four to 12 weeks, but less than 24 hours per day
Outpatient
treatment service is defined as consisting of at least one to two
hours
per week providing structured group and individual therapy, educational
services, and life skills training
Outpatient
treatment services up to a maximum of:
Intensive
outpatient program (up to 12 weeks per 12-month period)
Outpatient
services (up to six-months per 12-month period)
Does
not require PCP referral
|
Rehabilitation
Services
|
Services
include, but are not limited to, the following:
Habilitation
(the process of supplying a child with the means to reach age-appropriate
developmental milestones through therapy or treatment) and rehabilitation
services include, but are not limited to the following:
Physical,
occupational and speech therapy
Developmental
assessment
|
Hospice
Care Services
|
Services
include, but are not limited to:
|
Subject:
Attachment B-2 – Covered Services Version 1.8
Covered
Benefit
|
Description
|
Palliative
care, including medical and support services, for those children
who have
six months or less to live, to keep patients comfortable during the
last
weeks and months before death
Treatment
for unrelated conditions is unaffected
Up
to a maximum of 120 days with a 6 month life expectancy
Patients
electing hospice services waive their rights to treatment related
to their
terminal illnesses; however, they may cancel this election at
anytime
Services
apply to the hospice diagnosis
|
|
Emergency
Services, including Emergency Hospitals, Physicians, and Ambulance
Services
|
HMO
cannot require authorization as a condition for payment for emergency
conditions or labor and delivery. Covered services include, but are
not
limited to, the following:
Emergency
services based on prudent lay person definition of emergency health
condition
Hospital
emergency department room and ancillary services and physician services
24
hours a day, 7 days a week, both by in-network and out-ofnetwork
providers
Medical
screening examination
Stabilization
services
Access
to DSHS designated Xxxxx 0 and Level II trauma centers or hospitals
meeting equivalent levels of care for emergency
services
Emergency
ground, air and water transportation
Emergency
dental services, limited to fractured or dislocated jaw, traumatic
damage
to teeth, and removal of cysts.
|
Transplants
|
Services
include, but are not limited to, the following:
Using
up-to-date FDA guidelines, all non-experimental human organ and tissue
transplants and all forms of non-experimental corneal, bone marrow
and
peripheral stem cell transplants, including donor medical
expenses.
|
Vision
Benefit
|
The
health plan may reasonably limit the cost of the
frames/lenses. Services include:
One
examination of the eyes to determine the need for and prescription
for
corrective lenses per 12-month period, without
authorization
One
pair of non-prosthetic eyewear per 12-month period
|
Chiropractic
Services
|
Services
do not require physician prescription and are limited to spinal
subluxation
|
Tobacco
Cessation Program
|
Covered
up to $100 for a 12- month period limit for a plan- approved
program
Health
Plan defines plan-approved program.
May
be subject to formulary requirements.
|
[Value-added
services]
|
See
Attachment B-3
|
CHIP
EXCLUSIONS FROM COVERED SERVICES
Inpatient
and outpatient infertility treatments or reproductive services other than
prenatal care, labor and delivery, and care related to disease, illnesses,
or
abnormalities related to the reproductive system
Personal
comfort items including but not limited to personal care kits provided on
inpatient admission, telephone, television, newborn infant photographs, meals
for guests of patient, and other articles which are not required for the
specific treatment of sickness or injury
Experimental
and/or investigational medical, surgical or other health care procedures or
services which are not generally employed or recognized within the medical
community
Treatment
or evaluations required by third parties including, but not limited to, those
for schools, employment, flight clearance, camps, insurance or
court
Private
duty nursing services when performed on an inpatient basis or in a skilled
nursing facility.
Mechanical
organ replacement devices including, but not limited to artificial
heart
Hospital
services and supplies when confinement is solely for diagnostic testing
purposes, unless otherwise pre-authorized by Health Plan
Prostate
and mammography screening
Elective
surgery to correct vision
Gastric
procedures for weight loss
Cosmetic
surgery/services solely for cosmetic purposes
Out-of-network
services not authorized by the Health Plan except for emergency care and
physician services for a mother and her newborn(s) for a minimum of 48 hours
following an uncomplicated vaginal delivery and 96 hours following an
uncomplicated delivery by caesarian section
Services,
supplies, meal replacements or supplements provided for weight control or the
treatment of obesity, except for the services associated with the treatment
for
morbid obesity as part of a treatment plan approved by the Health
Plan
Acupuncture
services, naturopathy and hypnotherapy
Immunizations
solely for foreign travel
Routine
foot care such as hygienic care
Diagnosis
and treatment of weak, strained, or flat feet and the cutting or removal of
corns, calluses and toenails (this does not apply to the removal of nail roots
or surgical treatment of conditions underlying corns, calluses or ingrown
toenails)
Replacement
or repair of prosthetic devices and durable medical equipment due to misuse,
abuse or loss when confirmed by the Member or the vendor
Corrective
orthopedic shoes
Convenience
items
Orthotics
primarily used for athletic or recreational purposes
Custodial
care (care that assists a child with the activities of daily living, such as
assistance in walking, getting in and out of bed, bathing, dressing, feeding,
toileting, special diet preparation, and medication supervision that is usually
self-administered or provided by a parent. This care does not require the
continuing attention of trained medical or paramedical personnel.) This
exclusion does not apply to hospice services.
Housekeeping
Public
facility services and care for conditions that federal, state, or local law
requires be provided in a public facility or care provided while in the custody
of legal authorities
Services
or supplies received from a nurse, which do not require the skill and training
of a nurse
Vision
training and vision therapy
Reimbursement
for school-based physical therapy, occupational therapy, or speech therapy
services are not covered except when ordered by a Physician/PCP
Donor
non-medical expenses
Charges
incurred as a donor of an organ when the recipient is not covered under this
health plan
Subject:
Attachment B-2 – Covered Services Version 1.8
CHIP
DME/SUPPLIES
SUPPLIES
|
COVERED
|
EXCLUDED
|
COMMENTS/MEMBER
CONTRACT PROVISIONS
|
Ace
Bandages
|
X
|
Exception:
If provided by and billed through the clinic or home care agency
it is
covered as an incidental supply.
|
|
Alcohol,
rubbing
|
X
|
Over-the-counter
supply.
|
|
Alcohol,
swabs (diabetic)
|
X
|
Over-the-counter
supply not covered, unless RX provided at time of
dispensing.
|
|
Alcohol,
swabs
|
X
|
Covered
only when received with IV therapy or central line
kits/supplies.
|
|
Xxx
Kit Epinephrine
|
X
|
A
self-injection kit used by patients highly allergic to bee
stings.
|
|
Arm
Sling
|
X
|
Dispensed
as part of office visit.
|
|
Attends
(Diapers)
|
X
|
Coverage
limited to children age 4 or over only when prescribed by a physician
and
used to provide care for a covered diagnosis as outlined in a treatment
care plan
|
|
Bandages
|
X
|
||
Basal
Thermometer
|
X
|
Over-the-counter
supply.
|
|
Batteries
– initial
|
X
|
.
|
For
covered DME items
|
Batteries
– replacement
|
X
|
For
covered DME when replacement is necessary due to normal
use.
|
|
Betadine
|
X
|
See
IV therapy supplies.
|
|
Books
|
X
|
||
Clinitest
|
X
|
For
monitoring of diabetes.
|
|
Colostomy
Bags
|
See
Ostomy Supplies.
|
||
Communication
Devices
|
X
|
||
Contraceptive
Jelly
|
X
|
Over-the-counter
supply. Contraceptives are not covered under the plan.
|
|
Cranial
Head Mold
|
X
|
||
Diabetic
Supplies
|
X
|
Monitor
calibrating solution, insulin syringes, needles, lancets, lancet
device,
and glucose strips.
|
|
Diapers/Incontinent
Briefs/Chux
|
X
|
Coverage
limited to children age 4 or over only when prescribed by a physician
and
used to provide care for a covered diagnosis as outlined in a treatment
care plan
|
|
Diaphragm
|
X
|
Contraceptives
are not covered under the plan.
|
|
Diastix
|
X
|
For
monitoring diabetes.
|
|
Diet,
Special
|
X
|
||
Distilled
Water
|
X
|
||
Dressing
Supplies/Central Line
|
X
|
Syringes,
needles, Tegaderm, alcohol swabs, Betadine swabs or ointment,
tape. Many times these items are dispensed in a kit when
includes all necessary items for one dressing site
change.
|
|
Dressing
Supplies/Decubitus
|
X
|
Eligible
for coverage only if receiving covered home care for wound
care.
|
|
Dressing
Supplies/Peripheral IV Therapy
|
X
|
Eligible
for coverage only if receiving home IV therapy.
|
|
Dressing
Supplies/Other
|
X
|
||
Dust
Mask
|
X
|
||
Ear
Molds
|
X
|
Custom
made, post inner or middle ear surgery
|
|
Electrodes
|
X
|
Eligible
for coverage when used with a covered DME.
|
|
Enema
Supplies
|
X
|
Over-the-counter
supply.
|
|
Enteral
Nutrition
|
X
|
Necessary
supplies (e.g., bags, tubing, connectors, catheters, etc.)
are
|
Subject:
Attachment B-2 – Covered Services Version 1.8
SUPPLIES
|
COVERED
|
EXCLUDED
|
COMMENTS/MEMBER
CONTRACT PROVISIONS
|
Supplies
|
eligible
for coverage. Enteral nutrition products are not covered except
for those prescribed for hereditary metabolic disorders, a non-function
or
disease of the structures that normally permit food to reach the
small
bowel, or malabsorption due to disease
|
||
Eye
Patches
|
X
|
Covered
for patients with amblyopia.
|
|
Formula
|
X
|
Exception:
Eligible for coverage only for chronic hereditary metabolic disorders
a
non-function or disease of the structures that normally permit food
to
reach the small bowel; or malabsorption due to disease (expected
to last
longer than 60 days when prescribed by the physician and authorized
by
plan.) Physician documentation to justify prescription of formula
must
include: • Identification of a metabolic disorder, dysphagia that results
in a medical need for a liquid diet, presence of a gastrostomy, or
disease
resulting in malabsorption that requires a medically necessary nutritional
product Does not include formula: • For members who could be sustained on
an age-appropriate diet. • Traditionally used for infant feeding • In
pudding form (except for clients with documented oropharyngeal motor
dysfunction who receive greater than 50 percent of their daily caloric
intake from this product) • For the primary diagnosis of failure to
thrive, failure to gain weight, or lack of growth or for infants
less than
twelve months of age unless medical necessity is documented and other
criteria, listed above, are met. Food thickeners, baby food, or other
regular grocery products that can be blenderized and used with an
enteral
system that are not medically necessary, are not covered,
regardless of whether these regular food products are taken orally
or
parenterally.
|
|
Gloves
|
X
|
Exception:
Central line dressings or wound care provided by home care
agency.
|
|
Hydrogen
Peroxide
|
X
|
Over-the-counter
supply.
|
|
Hygiene
Items
|
X
|
||
Incontinent
Pads
|
X
|
Coverage
limited to children age 4 or over only when prescribed by a physician
and
used to provide care for a covered diagnosis as outlined in a treatment
care plan
|
|
Insulin
Pump (External) Supplies
|
X
|
Supplies
(e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible
for coverage if the pump is a covered item.
|
|
Irrigation
Sets, Wound Care
|
X
|
Eligible
for coverage when used during covered home care for wound
care.
|
|
Irrigation
Sets, Urinary
|
X
|
Eligible
for coverage for individual with an indwelling urinary
catheter.
|
|
IV
Therapy Supplies
|
X
|
Tubing,
filter, cassettes, IV pole, alcohol swabs, needles, syringes and
any other
related supplies necessary for home IV therapy.
|
|
K-Y
Jelly
|
X
|
Over-the-counter
supply.
|
|
Lancet
Device
|
X
|
Limited
to one device only.
|
|
Lancets
|
X
|
Eligible
for individuals with diabetes.
|
|
Med
Ejector
|
X
|
||
Needles
and
|
See
Diabetic Supplies
|
Subject:
Attachment B-2 – Covered Services Version 1.8
SUPPLIES
|
COVERED
|
EXCLUDED
|
COMMENTS/MEMBER
CONTRACT PROVISIONS
|
Syringes/Diabetic
|
|||
Needles
and Syringes/IV and Central Line
|
See
IV Therapy and Dressing Supplies/Central Line.
|
||
Needles
and Syringes/Other
|
X
|
Eligible
for coverage if a covered IM or SubQ medication is being administered
at
home.
|
|
Normal
Saline
|
See
Saline, Normal
|
||
Novopen
|
X
|
||
Ostomy
Supplies
|
X
|
Items
eligible for coverage include: belt, pouch, bags, wafer, face plate,
insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape,
skin
prep, adhesives, drain sets, adhesive remover, and pouch deodorant.
Items
not eligible for coverage include: scissors, room deodorants,
cleaners, rubber gloves, gauze, pouch covers, soaps, and
lotions.
|
|
Parenteral
Nutrition/Supplies
|
X
|
Necessary
supplies (e.g., tubing, filters, connectors, etc.) are eligible for
coverage when the Health Plan has authorized the parenteral
nutrition.
|
|
Saline,
Normal
|
X
|
Eligible
for coverage: a) when used to dilute medications for nebulizer treatments;
b) as part of covered home care for wound care; c) for indwelling
urinary
catheter irrigation.
|
|
Xxxxx
Sleeve
|
X
|
||
Xxxxx
Socks
|
X
|
||
Suction
Catheters
|
X
|
||
Syringes
|
See
Needles/Syringes.
|
||
Tape
|
See
Dressing Supplies, Ostomy Supplies, IV Therapy
Supplies.
|
||
Tracheostomy
Supplies
|
X
|
Cannulas,
Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for
coverage.
|
|
Under
Pads
|
See
Diapers/Incontinent Briefs/Chux.
|
||
Unna
Boot
|
X
|
Eligible
for coverage when part of wound care in the home setting. Incidental
charge when applied during office visit.
|
|
Urinary,
External Catheter & Supplies
|
X
|
Exception:
Covered when used by incontinent male where injury to the urethra
prohibits use of an indwelling catheter ordered by the PCP and approved
by
the plan
|
|
Urinary,
Indwelling Catheter & Supplies
|
X
|
Cover
catheter, drainage bag with tubing, insertion tray, irrigation set
and
normal saline if needed.
|
|
Urinary,
Intermittent
|
X
|
Cover
supplies needed for intermittent or straight
catherization.
|
|
Urine
Test Kit
|
X
|
When
determined to be medically necessary.
|
|
Urostomy
supplies
|
See
Ostomy Supplies.
|
Subject:
Attachment B-2.1 – STAR+PLUS Covered Services Version 1.8
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version of Attachment B-2, Covered Services.
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
Covered Services. This is the initial version of Attachment B-2.1,
STAR+PLUS Covered Services, which lists the Acute Care Services and
the
Community Based Long Term Care Services.
|
Revision
|
1.2
|
September
1, 2006
|
Contract
Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
Services.
|
Revision
|
1.3
|
September
1, 2006
|
Contract
Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
Services.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
Services.
|
Revision
|
1.5
|
January
1, 2007
|
Revised
Attachment B-2.1, STAR+PLUS Covered Services, to include inpatient
and
outpatient mental health services for adults.
|
Revision
|
1.6
|
February
1, 2007
|
|
Revision
|
1.7
|
June
1, 2007
|
Revised
Attachment B-2.1, STAR+PLUS Covered Services, to include inpatient
mental
health services for adults and children and to include effective
dates by
service area.
|
Revision
|
1.8
|
September
1, 2007
|
Contract
Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
Services.
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn versions
2Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3 Brief
description of the changes to the document made in the
revision.
|
STAR+PLUS
Covered Services
Acute
Care Services
The
following is a non-exhaustive, high-level listing of Acute Care Covered Services
included under the STAR+PLUS Medicaid managed care program.
Medicaid
HMO Contractors are responsible for providing a benefit package to Members
that
includes all medically necessary services covered under the traditional,
fee-for-service Medicaid programs except for Non-capitated Services provided
to
Medicaid Members outside of the HMO capitation and listed in Attachment B-1,
Section 8.2.2.8. In addition to the non-capitated services listed in Attachment
B-1, Section 8.2.2.8, Hospital Inpatient Stays are excluded from the capitation
payment to STAR+PLUS HMOs and are paid through HHSC’s Administrative Contractor
responsible for payment of Traditional Medicaid fee-for-service claims. Medicaid
HMO Contractors must coordinate care for Members for these Non-capitated
Services so that Members have access to a full range of medically necessary
Medicaid services, both capitated and non-capitated. A Contractor may elect
to
offer additional acute care Value-added Services.
The
STAR+PLUS Members are provided with two enhanced benefits compared to the
traditional, fee-for
service
Medicaid coverage:
1) waiver
of the three-prescription per month limit, for members not covered by
Medicare;
2) inclusion
of an annual adult well check for patients 21 years of age and
over.
Medicaid
HMO Contractors are responsible for providing a benefit package to Members
that
includes an annual adult well check for patients 21 years of age and
over. Prescription drug benefits to HMO Members are provided outside
of the HMO capitation.
STAR+PLUS
HMO Contractors should refer to the current Texas Medicaid Provider
Procedures Manual and the bi-monthly Texas Medicaid
Bulletin for a more inclusive listing of limitations and
exclusions that apply to each Medicaid benefit category. (These documents can
be
accessed online at: xxxx://xxx.xxxx.xxx.)
The
services listed in this Attachment are subject to modification based on Federal
and State laws and regulations and Programs policy updates.
Services
included under the HMO capitation payment
• Ambulance
services
• Audiology
services, including hearing aids for adults (hearing aids for children are
provided through the PACT program and are a non-capitated service)
•
• Behavioral
Health Services, including:
• Inpatient
mental health services for Adults and Children (Effective 6/01/07 in the Xxxxxx
Service Area; and effective 9/01/07 in the Bexar, Nueces and Xxxxxx Service
Areas.)
• Outpatient
mental health services for Adults and Children
• Outpatient
chemical dependency services for children (under age 21)
• Detoxification
services
• Psychiatry
services
• Counseling
services for adults (21 years of age and over)
•
• Birthing
center services
• Chiropractic
services
• Dialysis
• Durable
medical equipment and supplies
• Emergency
Services
• Family
planning services
• Home
health care services
• Hospital
services, outpatient
• Laboratory
• Medical
check-ups and Comprehensive Care Program (CCP) Services for children (under
age
21) through the Texas Health Steps Program
• Optometry,
glasses, and contact lenses, if medically necessary
• Podiatry
• Prenatal
care
• Primary
care services
• Radiology,
imaging, and X-rays
• Specialty
physician services
• Therapies
– physical, occupational and speech
• Transplantation
of organs and tissues
• Vision
The
following is a non-exhaustive, high-level listing of Community Based Long Term
Care Covered Services included under the STAR+PLUS Medicaid managed care
program.
• Personal
Attendant Services – All Members of a STAR+PLUS HMO may receive medically and
functionally necessary personal attendant services (PAS).
• 1915
(c) Nursing Facility Waiver Services for those Members who qualify for such
services The state provides an enriched array of services to clients who
would otherwise qualify for nursing facility care through a Home and Community
Based Medicaid Waiver. In traditional Medicaid, this is known as the
Community Based Alternatives (CBA) waiver. The STAR+PLUS HMO must
also provide the services that are available to clients through the CBA waiver
in traditional Medicaid to those clients that meet the functional and financial
eligibility for the 1915 (c)
Nursing Facility Waiver Services.
• Personal
Attendant Services (including the three service delivery options: Self-Directed;
Agency Model, Self-Directed; and Agency Model)
•
Nursing
Services (in
home)
•
Emergency
Response Services (Emergency
call button)
• Home
Delivered Meals
• Minor
Home Modifications
•
Adaptive
Aids and Medical
Equipment
•
Medical
Supplies
•
Physical
Therapy, Occupational
Therapy, Speech Therapy
• Adult
Xxxxxx Care
•
Assisted Living
• Transition
Assistance Services (These services are limited to a maximum of
$2,500.00. If the HMO determines that no other resources are
available to pay for the basic services/items needed to assist a Member, who
is
leaving a nursing facility, with setting up a household, the HMO may authorize
up to $2,500.00 for Transition Assistance Services (TAS). The
$2,500.00 TAS benefit is part of the expense ceiling when determining the Total
Annual Individual Service Plan (ISP) Cost.)
Subject:
Attachment B-2.2 – CHIP Perinatal Covered Services
DOCUMENT
HISTORY LOG
|
|||
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version of Attachment B-2, Covered Services
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
Covered Services.
|
Revision
|
1.2
|
September
1, 2006
|
Revised
Attachment B-2, Covered Services, by updating provisions applicable
to
MCOs participating in the STAR and CHIP Programs.
|
Revision
|
1.3
|
September
1, 2006
|
Revised
Attachment B-2, Covered Services, by adding Attachment B-2.2, CHIP
Perinatal Covered Services. This is the initial version of
Attachment B-2.2, which lists the CHIP Perinatal Covered Services,
exclusions and DME/Supplies.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
Services.
|
Revision
|
1.5
|
January
1, 2007
|
Contract
Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
Services.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
Services.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
Services.
|
Revision
|
1.8
|
September
1, 2007
|
Contract
Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
Services.
|
1
Status should be represented as “Baseline” for initial issuances,
“Revision” for changes to the Baseline version, and “Cancellation” for
withdrawn versions
2
Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3 Brief
description of the changes to the document made in the
revision.
|
CHIP
Perinatal Program Covered Services
Covered
CHIP Perinatal Program services must meet the definition of Medically Necessary
Covered Services as defined in this Contract. There
is no lifetime maximum on benefits; however, 12-month enrollment period or
lifetime limitations do apply to certain services, as specified in the following
chart. Co-pays do not apply to CHIP Perinatal Program
Members. CHIP Perinatal Program Members are eligible for 12-months
continuous coverage following enrollment in the program.
Covered
Benefit
|
CHIP
Perinate Newborn
|
CHIP
Perinate
|
Inpatient
General Acute and Inpatient Rehabilitation Hospital
Services
|
For
CHIP Perinate Newborns in families with incomes at or below 185%
of the
Federal Poverty Level, the facility charges are not a covered benefit
for
the initial Perinate Newborn admission; however, facility charges
are a
covered benefit after the initial Perinate Newborn admission. "Initial
Perinate Newborn admission" means the hospitalization associated
with the
birth.
For
CHIP Perinate Newborns in families with incomes at or below 185%
of the
Federal Poverty Level, professional service charges are a covered
benefit
for the initial Perinate Newborn admission and subsequent admissions.
"Initial Perinate Newborn admission" means the hospitalization associated
with the birth.
Services
include, but are not limited to, the following:
Hospital-provided
Physician or Provider services
Semi-private
room and board (or private if medically necessary as certified by
attending)
General
nursing care
Special
duty nursing when medically necessary
ICU
and services
Patient
meals and special diets
Operating,
recovery and other treatment rooms
Anesthesia
and administration (facility technical component)
Surgical
dressings, trays, casts, splints
Drugs,
medications and biologicals
Blood
or blood products that are not provided free-of-charge to the patient
and
their administration
X-rays,
imaging and other radiological tests (facility technical
component)
Laboratory
and pathology services (facility technical component)
Machine
diagnostic tests (EEGs, EKGs, etc.)
Oxygen
services and inhalation therapy
Radiation
and chemotherapy
Access
to DSHS-designated Level III perinatal centers or Hospitals meeting
equivalentlevels of care
In-network
or out-of-network facility and Physician services for a mother and
her
newborn(s) for a minimum of 48 hours following an uncomplicated vaginal
delivery and 96 hours following an uncomplicated delivery by caesarian
section.
Hospital,
physician and related medical services, such as anesthesia, associated
with dental care
Surgical
implants
Other
artificial aids including surgical implants
Implantable
devices are covered under Inpatient and Outpatient services and do
not
count towards the DME 12-month period limit
|
For
CHIP Perinates in families with incomes at or below 185% of the Federal
Poverty Level, the facility charges are not a covered benefit; however,
professional services charges associated with labor with delivery
are a
covered benefit.
For
CHIP Perinates in families with incomes between 186% and 200% of
the
Federal Poverty Level, benefits are limited to professional service
charges and facility charges associated with labor with
delivery.
Covered
medically necessary Hospital-provided services are limited to labor
with
delivery until birth.
Services
include:
Operating,
recovery and other treatment rooms
Anesthesia
and administration (facility technical component
Medically
necessary surgical services are limited to services that directly
relate
to the delivery of the unborn child.
|
Skilled
Nursing
Facilities
(Includes
Rehabilitation
Hospitals)
|
Services
include, but are not limited to, the following:
Semi-private
room and board
Regular
nursing services
Rehabilitation
services
Medical
supplies and use of appliances and equipment furnished by the
facility
|
Not
a covered benefit.
|
Outpatient
Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic
(Including Health Center) and Ambulatory Health Care
Center
|
Services
include, but are not limited to, the following services provided
in a
hospital clinic or emergency room, a clinic or health center,
hospital-based emergency department or an ambulatory health care
setting:
X-ray,
imaging, and radiological tests (technical component)
Laboratory
and pathology services (technical component)
Machine
diagnostic tests
Ambulatory
surgical facility services
Drugs,
medications and biologicals
Casts,
splints, dressings
Preventive
health services
Physical,
occupational and speech therapy
Renal
dialysis
Respiratory
services
Radiation
and chemotherapy
Blood
or blood products that are not provided free-of-charge to the patient
and
the administration of these products
Facility
and related medical services, such as anesthesia, associated with
dental
care, when provided in a licensed ambulatory surgical
facility.
Surgical
implants
Other
artificial aids including surgical implants
Implantable
devices are covered under Inpatient and Outpatient services and do
not
count towards the DME 12-month period limit.
|
Services
include, the following services provided in a hospital clinic or
emergency
room, a clinic or health center, hospital-based emergency department
or an
ambulatory health care setting:
X-ray,
imaging, and radiological tests (technical component)
Laboratory
and pathology services (technical component)
Machine
diagnostic tests
Drugs,
medications and biologicals that are medically necessary prescription
and
injection drugs.
(1)
Laboratory and radiological services are limited to services that
directly
relate to ante partum care and/or the delivery of the covered CHIP
Perinate until birth.
(2)
Ultrasound of the pregnant uterus is a covered benefit when medically
indicated. Ultrasound may be indicated for suspected genetic
defects, high-risk pregnancy, fetal growth retardation, or gestational
age
confirmation.
(3)
Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion (FIUT)
and
Ultrasonic Guidance for Cordocentesis, FIUT are covered benefits
with an
appropriate diagnosis.
(4)
Laboratory tests are limited to: nonstress testing,
contraction, stress testing, hemoglobin or hematocrit repeated once
a
trimester and at 32-36 weeks of pregnancy; or complete blood count
(CBC),
urinanalysis for protein and glucose every visit, blood type and
RH
antibody screen; repeat antibody screen for Rh negative women at
28 weeks
followed by RHO immune globulin
administration
if indicated; rubella antibody titer, serology for syphilis, hepatitis
B
surface antigen, cervical cytology, pregnancy test, gonorrhea test,
urine
culture, sickle cell test, tuberculosis (TB) test, human immunodeficiency
virus (HIV) antibody screen, Chlamydia test, other laboratory tests
not
specified but deemed medically necessary, and multiple marker screens
for
neural tube defects (if the client initiates care between 16 and
20
weeks); screen for gestational diabetes at 24-28 weeks of pregnancy;
other
lab tests as indicated by medical condition of client.
|
Physician/
Physician
Extender
Professional Services
|
Services
include, but are not limited to, the following:
American
Academy of Pediatrics recommended well-child exams and preventive
health
services (including, but not limited to, vision and hearing screening
and
immunizations)
Physician
office visits, in-patient and out-patient services
Laboratory,
x-rays, imaging and pathology services, including technical component
and/or professional interpretation
Medications,
biologicals and materials administered in Physician’s office
Allergy
testing, serum and injections
Professional
component (in/outpatient) of surgical services, including:
- Surgeons
and assistant surgeons for surgical procedures including appropriate
follow-up care
- Administration
of anesthesia by Physician (other than surgeon) or CRNA
- Second
surgical opinions
- Same-day
surgery performed in a Hospital without an over-night stay
- Invasive
diagnostic procedures such as endoscopic examinations
Hospital-based
Physician services (including Physician-performed technical and
interpretive components)
In-network
and out-of-network Physician services for a mother and her newborn(s)
for
a minimum of 48 hours following an uncomplicated vaginal delivery
and 96
hours following an uncomplicated delivery by caesarian
section.
Physician
services medically necessary to support a dentist providing dental
services to a CHIP member such as general anesthesia or intravenous
(IV)
sedation.
|
Services
include, but are not limited to the following:
Medically
necessary physician services are limited to prenatal and postpartum
care
and/or the delivery of the covered unborn child until birth
Physician
office visits, in-patient and out-patient services
Laboratory,
x-rays, imaging and pathology services including technical component
and
/or professional interpretation
Medically
necessary medications, biologicals and materials administered in
Physician’s office
Professional
component (in/outpatient) of surgical services, including:
o Surgeons
and assistant surgeons for surgical procedures directly related to
the
labor with delivery of the covered unborn child until birth.
o Administration
of anesthesia by Physician (other than surgeon) or CRNA
o Invasive
diagnostic procedures directly related to the
labor
Hospital-based
Physician services (including Physician performed technical and
interpretive components)
Professional
component of the ultrasound of the pregnant uterus when medically
indicated for suspected genetic defects, high-risk pregnancy, fetal
growth
retardation, or gestational age confirmation.
Professional
component of Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion
(FIUT) and Ultrasonic Guidance for Amniocentesis, Cordocentrsis,
and
FIUT.
|
Prenatal
Care and Pre-Pregnancy Family Services and Supplies
|
Not
a covered benefit.
|
Services
are limited to an initial visit and subsequent prenatal (ante partum)
care
visits that include:
(1)
One visit every four weeks for the first 28 weeks or
pregnancy;
(2)
one visit every two to three weeks from 28 to 36 weeks of pregnancy;
and
(3)
one visit per week from 36 weeks to delivery.
More
frequent visits are allowed as Medically Necessary. Benefits are
limited
to:
Limit
of 20 prenatal visits and 2 postpartum visits (maximum within 60
days)
without documentation of a complication of pregnancy. More
frequent visits may be necessary for high-risk
pregnancies. High-risk prenatal visits are not limited to 20
visits per pregnancy. Documentation supporting medical
necessity must be maintained in the physician’s files and is subject to
retrospective review.
Visits
after the initial visit must include:
interim
history (problems, marital status, fetal status);
physical
examination (weight, blood pressure, fundalheight, fetal position
and
size, fetal heart rate, extremities) and
laboratory
tests (urinanalysis for protein and glucose every visit; hematocrit
or
hemoglobin repeated once a trimester and at 32-36 weeks of pregnancy;
multiple marker screen for fetal abnormalities offered at 16-20 weeks
of
pregnancy; repeat antibody screen for Rh negative women at 28 weeks
followed by Rho immune globulin administration if indicated; screen
for
gestational diabetes at 24-28 weeks of pregnancy; and other lab tests
as
indicated by medical condition of client).
|
Durable
Medical Equipment (DME), Prosthetic Devices and
Disposable
Medical Supplies
|
$20,000
12-month period limit for DME, prosthetics, devices and disposable
medical
supplies (diabetic supplies and equipment are not counted against
this
cap). Services include DME (equipment which can withstand
repeated use and is primarily and customarily used to serve a medical
purpose, generally is not useful to a person in the absence of Illness,
Injury, or Disability, and is appropriate for use in the home), including
devices and supplies that are medically necessary and necessary for
one or
more activities of daily living and appropriate to assist in the
treatment
of a medical condition, including:
Orthotic
braces and orthotics
Prosthetic
devices such as artificial eyes, limbs, and braces
Prosthetic
eyeglasses and contact lenses for the management of severe ophthalmologic
disease
Hearing
aids
Diagnosis-specific
disposable medical supplies, including diagnosis-specific prescribed
specialty formula and dietary supplements. (See Attachment
A)
|
Not
a covered benefit.
|
Home
and Community Health Services
|
Services
that are provided in the home and community, including, but not limited
to:
Home
infusion
Respiratory
therapy
Visits
for private duty nursing (R.N., L.V.N.)
Skilled
nursing visits as defined for home health purposes (may include R.N.
or
L.V.N.).
Home
health aide when included as part of a plan of care during a period
that
skilled visits have been approved.
Speech,
physical and occupational therapies.
Services
are not intended to replace the CHILD'S caretaker or to provide relief
for
the caretaker
Skilled
nursing visits are provided on intermittent level and not intended
to
provide 24-hour skilled nursing services
Services
are not intended to replace 24-hour inpatient or skilled nursing
facility
services
|
Not
a covered benefit.
|
Inpatient
Mental Health Services
|
Mental
health services, including for serious mental illness, furnished
in a
free-standing psychiatric hospital, psychiatric units of general
acute
care hospitals and state-operated facilities, including, but not
limited
to:
Neuropsychological
and psychological testing.
Inpatient
mental health services are limited to:
45
days 12-month inpatient limit
Includes
inpatient psychiatric services, up to 12-month period limit, ordered
by a
court of competent jurisdiction under the provisions of Chapters
573 and
574 of the Texas Health and Safety Code, relating to court ordered
commitments to psychiatric facilities. Court order serves as binding
determination of medical necessity. Any modification or termination
of
services must be presented to the court with jurisdiction over the
matter
for determination
25
days of the inpatient benefit can be converted to residential treatment,
therapeutic xxxxxx care or other 24-hour therapeutically planned
and
structured services or sub-acute outpatient (partial hospitalization
or
rehabilitative day treatment) mental health services on the basis
of
financial equivalence against the inpatient per diem cost
20
of the inpatient days must be held in reserve for inpatient use
only
Does
not require PCP referral
|
Not
a covered benefit.
|
Outpatient
Mental Health Services
|
Mental
health services, including for serious mental illness, provided on
an
outpatient basis, including, but not limited to:
Medication
management visits do not count against the outpatient visit
limit.
The
visits can be furnished in a variety of community-based settings
(including school and home-based) or in a state-operated
facility
Up
to 60 days 12-month period limit for rehabilitative day
treatment
60
outpatient visits 12-month period limit
60
rehabilitative day treatment days can be converted to outpatient
visits on
the basis of financial equivalence against the day treatment per
diem
cost
60
outpatient visits can be converted to skills training (psycho educational
skills development) or rehabilitative day treatment on the basis
of
financial equivalence against the outpatient visit cost
Includes
outpatient psychiatric services, up to 12-month period limit, ordered
by a
court of competent jurisdiction under the provisions of Chapters
573 and
574 of the Texas Health and Safety Code, relating to court ordered
commitments to psychiatric facilities. Court order serves as binding
determination of medical necessity. Any modification or termination
of
services must be presented to the court with jurisdiction over the
matter
for determination
Inpatient
days converted to sub-acute outpatient services are in addition to
the
outpatient limits and do not count towards those limits
A
Qualified Mental Health Professional (QMHP), as defined by and
credentialed through Texas Department of State Health Services (DSHS)
standards (TAC Title 25, Part II, Chapter 412), is a Local Mental
Health
Authorities provider. A QMHP must be working under the authority
of an
DSHS entity and be supervised by a licensed mental health professional
or
physician. QMHPs are acceptable providers as long as the services
would be
within the scope of the services that are typically provided by QMHPs.
Those services include individual and group skills training (which
can be
components of interventions such as day treatment and in-home services),
patient and family education, and crisis services
Does
not require PCP referral
|
Not
a covered benefit.
|
Inpatient
Substance Abuse Treatment Services
|
Services
include, but are not limited to:
Inpatient
and residential substance abuse treatment services including
detoxification and crisis stabilization, and 24-hour residential
rehabilitation programs
Does
not require PCP referral
Medically
necessary detoxification/stabilization services, limited
to 14 days per 12-month period.
24-hour
residential rehabilitation programs, or the equivalent, up to 60
days per
12-month period
30
days may be converted to partial hospitalization or intensive outpatient
rehabilitation, on the basis of financial equivalence against the
inpatient per diem cost
30
days must be held in reserve for inpatient use only.
|
Not
a covered benefit.
|
Outpatient
Substance Abuse Treatment Services
|
Services
include, but are not limited to, the following:
Prevention
and intervention services that are provided by physician and non-physician
providers, such as screening, assessment and referral for chemical
dependency disorders.
Intensive
outpatient services is defined as an organized non-residential service
providing structured group and individual therapy, educational services,
and life skills training which consists of at least 10 hours per
week for
four to 12 weeks, but less than 24 hours per day
Outpatient
treatment service is defined as consisting of at least one to two
hours
per week providing structured group and individual therapy, educational
services, and life skills training
Outpatient
treatment services up to a maximum of:
Intensive
outpatient program (up to 12 weeks per 12-month period)
Outpatient
services (up to six-months per 12-month period)
Does
not require PCP referral
|
Not
a covered benefit.
|
Rehabilitation
Services
|
Services
include, but are not limited to, the following:
Habilitation
(the process of supplying a child with the means to reach age-appropriate
developmental milestones through therapy or treatment) and rehabilitation
services include, but are not limited to the following:
Physical,
occupational and speech therapy
Developmental
assessment
|
Not
a covered benefit.
|
Hospice
Care Services
|
Services
include, but are not limited to:
Palliative
care, including medical and support services, for those children
who have
six months or less to live, to keep patients comfortable during the
last
weeks and months before death
Treatment
for unrelated conditions is unaffected
Up
to a maximum of 120 days with a 6 month life expectancy
Patients
electing hospice services waive their rights to treatment related
to their
terminal illnesses; however, they may cancel this election at
anytime
Services
apply to the hospice diagnosis
|
Not
a covered benefit.
|
Emergency
Services, including Emergency Hospitals, Physicians, and Ambulance
Services
|
HMO
cannot require authorization as a condition for payment for emergency
conditions labor and
delivery.
Covered
services include, but are not limited to, the following:
Emergency
services based on prudent lay person definition of emergency health
condition
Hospital
emergency department room and ancillary services and physician services
24
hours a day, 7 days a week, both by in-network and out-of-network
providers
Medical
screening examination
Stabilization
services
Access
to DSHS designated Xxxxx 0 and Level II trauma centers or hospitals
meeting equivalent levels of care for emergency services
Emergency
ground, air and water transportation
Emergency
dental services, limited to fractured or dislocated jaw, traumatic
damage
to teeth, and removal of cysts.
|
HMO
cannot require authorization as a condition for payment for emergency
conditions related to labor with delivery.
Covered
services are limited to those emergency services that are directly
related
to the delivery of the unborn child until birth.
Emergency
services based on prudent lay person definition of emergency health
condition
Medical
screening examination to determine emergency when directly related
to the
delivery of the covered unborn child.
Stabilization
services related to the labor with delivery of the covered unborn
child.
Emergency
ground, air and water transportation for labor and threatened labor
is a
covered benefit
Benefit
limits: Post-delivery services or complications resulting in
the need for emergency services for the mother of the CHIP Perinate
are
not a covered benefit.
|
Transplants
|
Services
include, but are not limited to, the following:
Using
up-to-date FDA guidelines, all non-experimental human organ and tissue
transplants and all forms of non-experimental corneal, bone marrow
and
peripheral stem cell transplants, including donor medical
expenses.
|
Not
a covered benefit.
|
Vision
Benefit
|
The
health plan may reasonably limit the cost of the
frames/lenses.
Services
include:
One
examination of the eyes to determine the need for and prescription
for
corrective lenses per 12-month period, without authorization
One
pair of non-prosthetic eyewear per 12-month period
|
Not
a covered benefit.
|
Chiropractic
Services
|
Services
do not require physician prescription and are limited to spinal
subluxation.
|
Not
a covered benefit.
|
Tobacco
Cessation
Program
|
Covered
up to $100 for a 12- month period limit for a plan- approved
program
Health
Plan defines plan-approved program.
May
be subject to formulary requirements.
|
Not
a covered benefit.
|
Case
Management and Care Coordination Services
|
These
services include outreach informing, case management, care coordination
and community referral.
|
Covered
benefit.
|
Value-added
services
|
See
Attachment B-3.2
|
CHIP
PERINATAL PROGRAM EXCLUSIONS FROM COVERED SERVICES FOR CHIP
PERINATES
•
|
For
CHIP Perinates in families with incomes at or below 185% of the Federal
Poverty Level, inpatient facility charges are not a covered benefit
for
the initial Perinatal Newborn admission. "Initial Perinatal Newborn
admission" means the hospitalization associated with the birth.
|
•
|
Inpatient
and outpatient treatments other than prenatal care, labor with delivery,
and postpartum care related to the covered unborn child until
birth.
|
•
|
Inpatient
mental health services.
|
•
|
Outpatient
mental health services.
|
•
|
Durable
medical equipment or other medically related remedial
devices.
|
•
|
Disposable
medical supplies.
|
•
|
Home
and community-based health care
services.
|
•
|
Nursing
care services.
|
•
|
Dental
services.
|
•
|
Inpatient
substance abuse treatment services and residential substance abuse
treatment services.
|
•
|
Outpatient
substance abuse treatment services.
|
•
|
Physical
therapy, occupational therapy, and services for individuals with
speech,
hearing, and language disorders.
|
•
|
Hospice
care.
|
•
|
Skilled
nursing facility and rehabilitation hospital
services.
|
•
|
Emergency
services other than those directly related to the labor with delivery
of
the covered unborn child.
|
•
|
Transplant
services.
|
•
|
Tobacco
Cessation Programs.
|
•
|
Medical
transportation not directly related to the labor or threatened labor
and/or delivery of the covered unborn
child.
|
•
|
Personal
comfort items including but not limited to personal care kits provided
on
inpatient admission, telephone, television, newborn infant photographs,
meals for guests of patient, and other articles which are not required
for
the specific treatment related to labor with delivery or post partum
care.
|
•
|
Experimental
and/or investigational medical, surgical or other health care procedures
or services which are not generally employed or recognized within
the
medical community
|
•
|
Treatment
or evaluations required by third parties including, but not limited
to,
those for schools, employment, flight clearance, camps, insurance
or
court
|
•
|
Private
duty nursing services when performed on an inpatient basis or in
a skilled
nursing facility.
|
•
|
Mechanical
organ replacement devices including, but not limited to artificial
heart
|
•
|
Hospital
services and supplies when confinement is solely for diagnostic testing
purposes and not a part of labor with
delivery
|
•
|
Prostate
and mammography screening
|
•
|
Elective
surgery to correct vision
|
•
|
Gastric
procedures for weight loss
|
•
|
Cosmetic
surgery/services solely for cosmetic
purposes
|
•
|
Out-of-network
services not authorized by the Health Plan except for emergency care
related to the labor with delivery of the covered unborn
child.
|
•
|
Services,
supplies, meal replacements or supplements provided for weight control
or
the treatment of obesity
|
•
|
Acupuncture
services, naturopathy and
hypnotherapy
|
•
|
Immunizations
solely for foreign travel
|
•
|
Routine
foot care such as hygienic care
|
•
|
Diagnosis
and treatment of weak, strained, or flat feet and the cutting or
removal
of corns, calluses and toenails (this does not apply to the removal
of
nail roots or surgical treatment of conditions underlying corns,
calluses
or ingrown toenails)
|
•
|
Corrective
orthopedic shoes
|
•
|
Convenience
items
|
•
|
Orthotics
primarily used for athletic or recreational
purposes
|
•
|
Custodial
care (care that assists with the activities of daily living, such
as
assistance in walking, getting in and out of bed, bathing, dressing,
feeding, toileting, special diet preparation, and medication supervision
that is usually self-administered or provided by a caregiver. This
care
does not require the continuing attention of trained medical or
paramedical personnel.)
|
•
|
Housekeeping
|
•
|
Public
facility services and care for conditions that federal, state, or
local
law requires be provided in a public facility or care provided while
in
the custody of legal authorities
|
•
|
Services
or supplies received from a nurse, which do not require the skill
and
training of a nurse
|
•
|
Vision
training, vision therapy, or vision
services
|
•
|
Reimbursement
for school-based physical therapy, occupational therapy, or speech
therapy
services are not covered
|
•
|
Donor
non-medical expenses
|
•
|
Charges
incurred as a donor of an organ
|
CHIP
PERINATAL PROGRAM EXCLUSIONS FROM
COVERED SERVICES FOR CHIP PERINATE NEWBORNS
With
the
exception of the first bullet, all the following exclusions match those found
in
the CHIP Program.
•
|
For
CHIP Perinate Newborns in families with incomes at or below 185%
of the
Federal Poverty Level, inpatient facility charges are not a covered
benefit for the initial Perinate Newborn admission. "Initial
Perinate Newborn admission" means the hospitalization associated
with the
birth.
|
•
|
Inpatient
and outpatient infertility treatments or reproductive services other
than
prenatal care, labor and delivery, and care related to disease, illnesses,
or abnormalities related to the reproductive
system
|
•
|
Personal
comfort items including but not limited to personal care kits provided
on
inpatient admission, telephone, television, newborn infant photographs,
meals for guests of patient, and other articles which are not required
for
the specific treatment of sickness or
injury
|
•
|
Experimental
and/or investigational medical, surgical or other health care procedures
or services which are not generally employed or recognized within
the
medical community
|
•
|
Treatment
or evaluations required by third parties including, but not limited
to,
those for schools, employment, flight clearance, camps, insurance
or
court
|
•
|
Private
duty nursing services when performed on an inpatient basis or in
a skilled
nursing facility.
|
•
|
Mechanical
organ replacement devices including, but not limited to artificial
heart
|
•
|
Hospital
services and supplies when confinement is solely for diagnostic testing
purposes, unless otherwise pre-authorized by Health
Plan
|
•
|
Prostate
and mammography screening
|
•
|
Elective
surgery to correct vision
|
•
|
Gastric
procedures for weight loss
|
•
|
Cosmetic
surgery/services solely for cosmetic
purposes
|
•
|
Out-of-network
services not authorized by the Health Plan except for emergency care
and
physician services for a mother and her newborn(s) for a minimum
of 48
hours following an uncomplicated vaginal delivery and 96 hours following
an uncomplicated delivery by caesarian
section
|
•
|
Services,
supplies, meal replacements or supplements provided for weight control
or
the treatment of obesity, except for the services associated with
the
treatment for morbid obesity as part of a treatment plan approved
by the
Health Plan
|
•
|
Acupuncture
services, naturopathy and
hypnotherapy
|
•
|
Immunizations
solely for foreign travel
|
•
|
Routine
foot care such as hygienic care
|
•
|
Diagnosis
and treatment of weak, strained, or flat feet and the cutting or
removal
of corns, calluses and toenails (this does not apply to the removal
of
nail roots or surgical treatment of conditions underlying corns,
calluses
or ingrown toenails)
|
•
|
Replacement
or repair of prosthetic devices and durable medical equipment due
to
misuse, abuse or loss when confirmed by the Member or the vendor
|
•
|
Corrective
orthopedic shoes
|
•
|
Convenience
items
|
•
|
Orthotics
primarily used for athletic or recreational
purposes
|
•
|
Custodial
care (care that assists a child with the activities of daily living,
such
as assistance in walking, getting in and out of bed, bathing, dressing,
feeding, toileting, special diet preparation, and medication supervision
that is usually self-administered or provided by a parent. This care
does
not require the continuing attention of trained medical or paramedical
personnel.) This exclusion does not apply to hospice
services.
|
•
|
Housekeeping
|
•
|
Public
facility services and care for conditions that federal, state, or
local
law requires be provided in a public facility or care provided while
in
the custody of legal authorities
|
•
|
Services
or supplies received from a nurse, which do not require the skill
and
training of a nurse
|
•
|
Vision
training and vision therapy
|
•
|
Reimbursement
for school-based physical therapy, occupational therapy, or speech
therapy
services are not covered except when ordered by a
Physician/PCP
|
•
|
Donor
non-medical expenses
|
•
|
Charges
incurred as a donor of an organ when the recipient is not covered
under
this health plan
|
CHIP
&
CHIP
PERINATAL PROGRAM
DME/SUPPLIES
Note: DME/SUPPLIES
are not a covered benefit for CHIP Perinate Members but are a benefit for CHIP
Perinate Newborns.
SUPPLIES
|
COVERED
|
EXCLUDED
|
COMMENTS/MEMBER
CONTRACT
PROVISIONS
|
Ace
Bandages
|
X
|
Exception:
If provided by and billed through the clinic or home care agency
it is
covered as an incidental supply.
|
|
Alcohol,
rubbing
|
X
|
Over-the-counter
supply.
|
|
Alcohol,
swabs (diabetic)
|
X
|
Over-the-counter
supply not covered, unless RX provided at time of
dispensing.
|
|
Alcohol,
swabs
|
X
|
Covered
only when received with IV therapy or central line
kits/supplies.
|
|
Xxx
Kit Epinephrine
|
X
|
A
self-injection kit used by patients highly allergic to bee
stings.
|
|
Arm
Sling
|
X
|
Dispensed
as part of office visit.
|
|
Attends
(Diapers)
|
X
|
Coverage
limited to children age 4 or over only when prescribed by a physician
and
used to provide care for a covered diagnosis as outlined in a treatment
care plan.
|
|
Bandages
|
X
|
||
Basal
Thermometer
|
X
|
Over-the-counter
supply.
|
|
Batteries
– initial
|
X
|
.
|
For
covered DME items
|
Batteries
– replacement
|
X
|
For
covered DME when replacement is necessary due to normal
use.
|
|
Betadine
|
X
|
See
IV therapy supplies.
|
|
Books
|
X
|
||
Clinitest
|
X
|
For
monitoring of diabetes.
|
|
Colostomy
Bags
|
See
Ostomy Supplies.
|
||
Communication
Devices
|
X
|
||
Contraceptive
Jelly
|
X
|
Over-the-counter
supply. Contraceptives are not covered under the plan.
|
|
Cranial
Head Mold
|
X
|
||
Diabetic
Supplies
|
X
|
Monitor
calibrating solution, insulin syringes, needles, lancets, lancet
device,
and glucose strips.
|
|
Diapers/Incontinent
Briefs/Chux
|
X
|
Coverage
limited to children age 4 or over only when prescribed by a physician
and
used to provide care for a covered diagnosis as outlined in a treatment
care plan
|
|
Diaphragm
|
X
|
Contraceptives
are not covered under the plan.
|
|
Diastix
|
X
|
For
monitoring diabetes.
|
|
Diet,
Special
|
X
|
||
Distilled
Water
|
X
|
||
Dressing
Supplies/Central Line
|
X
|
Syringes,
needles, Tegaderm, alcohol swabs, Betadine swabs or ointment,
tape. Many times these items are dispensed in a kit when
includes all necessary items for one dressing site
change.
|
|
Dressing
Supplies/Decubitus
|
X
|
Eligible
for coverage only if receiving covered home care for wound
care.
|
|
Dressing
Supplies/Peripheral IV Therapy
|
X
|
Eligible
for coverage only if receiving home IV therapy.
|
|
Dressing
Supplies/Other
|
X
|
||
Dust
Mask
|
X
|
||
Ear
Molds
|
X
|
Custom
made, post inner or middle ear surgery
|
|
Electrodes
|
X
|
Eligible
for coverage when used with a covered DME.
|
|
Enema
Supplies
|
X
|
Over-the-counter
supply.
|
|
Enteral
Nutrition Supplies
|
X
|
Necessary
supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible
for coverage. Enteral nutrition products are not covered except
for those prescribed for hereditary metabolic disorders, a non-function
or
disease of the structures that normally permit food to reach the
small
bowel, or malabsorption due to disease
|
|
Eye
Patches
|
X
|
Covered
for patients with amblyopia.
|
|
Formula
|
X
|
Exception:
Eligible for coverage only for chronic hereditary metabolic disorders
a
non-function or disease of the structures that normally permit food
to
reach the small bowel; or malabsorption due to disease (expected
to last
longer than 60 days when prescribed by the physician and authorized
by
plan.) Physician documentation to justify prescription of
formula must include:
• Identification
of a metabolic disorder, dysphagia that results in a medical need
for a
liquid diet, presence of a gastrostomy, or disease resulting in
malabsorption that requires a medically necessary nutritional
product
Does
not include formula:
• For
members who could be sustained on an age-appropriate diet.
• Traditionally
used for infant feeding
• In
pudding form (except for clients with documented oropharyngeal motor
dysfunction who receive greater than 50 percent of their daily caloric
intake from this product)
• For
the primary diagnosis of failure to thrive, failure to gain weight,
or
lack of growth or for infants less than twelve months of age unless
medical necessity is documented and other criteria, listed above,
are
met.
Food
thickeners, baby food, or other regular grocery products that can
be
blenderized and used with an enteral system that are not
medically necessary, are not covered, regardless of whether these
regular
food products are taken orally or parenterally.
|
|
Gloves
|
X
|
Exception: Central
line dressings or wound care provided by home care
agency.
|
|
Hydrogen
Peroxide
|
X
|
Over-the-counter
supply.
|
|
Hygiene
Items
|
X
|
||
Incontinent
Pads
|
X
|
Coverage
limited to children age 4 or over only when prescribed by a physician
and
used to provide care for a covered diagnosis as outlined in a treatment
care plan
|
|
Insulin
Pump (External) Supplies
|
X
|
Supplies
(e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible
for coverage if the pump is a covered item.
|
|
Irrigation
Sets, Wound Care
|
X
|
Eligible
for coverage when used during covered home care for wound
care.
|
|
Irrigation
Sets, Urinary
|
X
|
Eligible
for coverage for individual with an indwelling urinary
catheter.
|
|
IV
Therapy Supplies
|
X
|
Tubing,
filter, cassettes, IV pole, alcohol swabs, needles, syringes and
any other
related supplies necessary for home IV therapy.
|
|
K-Y
Jelly
|
X
|
Over-the-counter
supply.
|
|
Lancet
Device
|
X
|
Limited
to one device only.
|
|
Lancets
|
X
|
Eligible
for individuals with diabetes.
|
|
Med
Ejector
|
X
|
||
Needles
and Syringes/Diabetic
|
See
Diabetic Supplies
|
||
Needles
and Syringes/IV and Central Line
|
See
IV Therapy and Dressing Supplies/Central Line.
|
||
Needles
and Syringes/Other
|
X
|
Eligible
for coverage if a covered IM or SubQ medication is being administered
at
home.
|
|
Normal
Saline
|
See
Saline, Normal
|
||
Novopen
|
X
|
||
Ostomy
Supplies
|
X
|
Items
eligible for coverage include: belt, pouch, bags, wafer, face plate,
insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape,
skin
prep, adhesives, drain sets, adhesive remover, and pouch
deodorant.
Items
not eligible for coverage include: scissors, room deodorants,
cleaners, rubber gloves, gauze, pouch covers, soaps, and
lotions.
|
|
Parenteral
Nutrition/Supplies
|
X
|
Necessary
supplies (e.g., tubing, filters, connectors, etc.) are eligible for
coverage when the Health Plan has authorized the parenteral
nutrition.
|
|
Saline,
Normal
|
X
|
Eligible
for coverage:
a)
when used to dilute medications for nebulizer treatments;
b)
as part of covered home care for wound care;
c)
for indwelling urinary catheter irrigation.
|
|
Xxxxx
Sleeve
|
X
|
||
Xxxxx
Socks
|
X
|
||
Suction
Catheters
|
X
|
||
Syringes
|
See
Needles/Syringes.
|
||
Tape
|
See
Dressing Supplies, Ostomy Supplies, IV Therapy
Supplies.
|
||
Tracheostomy
Supplies
|
X
|
Cannulas,
Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for
coverage.
|
|
Under
Pads
|
See
Diapers/Incontinent Briefs/Chux.
|
||
Unna
Boot
|
X
|
Eligible
for coverage when part of wound care in the home
setting. Incidental charge when applied during office
visit.
|
|
Urinary,
External Catheter & Supplies
|
X
|
Exception: Covered
when used by incontinent male where injury to the urethra prohibits
use of
an indwelling catheter ordered by the PCP and approved by the
plan
|
|
Urinary,
Indwelling Catheter & Supplies
|
X
|
Cover
catheter, drainage bag with tubing, insertion tray, irrigation set
and
normal saline if needed.
|
|
Urinary,
Intermittent
|
X
|
Cover
supplies needed for intermittent or straight
catherization.
|
|
Urine
Test Kit
|
X
|
When
determined to be medically necessary.
|
|
Urostomy
supplies
|
See
Ostomy Supplies.
|
Contractual
Document (CD)
Responsible
Office: HHSC Office of General Counsel (OGC)
Subject:
Attachment B-3 – Value-added Services
Version
1.8
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version of Attachment B-3, Value-added Services.
|
|
Revision
|
1.1
|
June
30, 2006
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.2
|
September
1. 2006
|
Revised
Physical Health Value-added Services to include Home Visits to
New
Mothers. Revised the certification provision by changing the start
date
for the 12-month provision of services.
|
Revision
|
1.3
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment removed the separate signature requirement for Attachment
B-3,
Value-added Services. By signing the Contract and/or Contract Amendment,
the HMO certifies that it will provide the Value-added Services
from
September 1, 2006 through August 31, 2007.
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.8
|
September
1, 2007
|
Revised
Attachment B-3, Value-added Services, to reflect newly negotiated
Value-added Services for FY 2008.
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn versions
2Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3
Brief
description of the changes to the document made in the
revision.
|
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3 – Value-added Services
Version
1.8
ATTACHMENT
B-3: VALUE-ADDED SERVICES
September
1, 2007 – August 31, 2008
HMO:
Superior HealthPlan, Inc. HMO
PROGRAM:
CHIP
SERVICE
AREA(S):Bexar, El Paso, Lubbock, Nueces, and Xxxxxx
Physical
Health Value-added Services
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Vision
|
20%
discount off of Upgraded Hardware- The Member will receive a 20%
discount
on upgraded hardware.
|
There
is no limitation on the number of times the discount can be
utilized.
|
TVHP
contracted providers.
|
Pharmacy
|
Provides
members with a $15.00 per household per quarter credit toward over
the
counter medications and supplies.
|
Services
must be sought from contracted pharmacies only. Items eligible
for
purchase under this benefit are over-the-counter, health related
items
only.
|
Pharmacy
Data Management contracted providers.
|
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3 – Value-added Services
Version
1.8
Physical
Health Value-added Services
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Transportation
|
For
Members in need of transportation that cannot access transportation
in a
timely manner, Superior will provide bus tokens to ensure that
Members
have a means of accessing their provider appointment.
|
Members
in the Nueces Service Area.
The transportation Authority
in this area will not agree
to allow the plan to purchase
bus vouchers or tokens.
The
bus tokens must be requested
in advance of a
provider
visit and authorized by Superior’s
Member Services Department.
|
Transit
Authorities in appliable Service Area.
|
NurseWise
|
Twenty-four hour nurse advice line |
Available
to all members by calling the Member Services toll-free
number
|
NurseWise,
an affiliate
of Centene
Corporation
|
Home
Visits to New Mothers
|
Superior
Social Work and/or CONNECTIONS staff will make
home visits to any Member with a new baby. This visit
provides for resource and education coordination as identified
in the visit,[what does this mean?] and ensures Members
and the new babies are keeping all post natal
and
newborn doctor visits. This benefit is available to all
Superior
Members who have delivered a baby.
|
Only
that a member consent to the home visit.
|
Superior's
CONNECTIONS and Social Work staff provide this service.
|
|
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3 – Value-added Services
Version
1.8
Behavioral
Health Value-added Services for Members Under 21
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Behavioral
Health Value-added Services for Members 21 and
Over
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
ADDITIONAL
INFORMATION:
1.
Explain how and when Providers and Members will be notified about the
availability of the value-added services to be provided.
Value
Added Services information will be included in the Superior Provider Manual
and
also during training sessions. Members will receive this information via
the
Plan Comparison Chart, in the Member Handbook, with New Member Packets and
during orientations. Periodically, Superior will also highlight Value
Added Services in the Provider and Member Newsletters.
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3 – Value-added Services
Version
1.8
2.
Describe how a Member may obtain or access the value-added services to be
provided.
See
explanations provided above for accessing services.
A
Member
may access the Home Visits to New Mothers service by accepting a home visit
appointment from a Superior Social Work or CONNECTIONS staff
member.
3.
Describe how the HMO will identify the Value-added Service in administrative
(encounter) data.
Superior
will track the value added services through our claims system for those
value-adds that HIPAA-compliant procedural codes are available (vision,
behavioral health, flu shots). Superior will create a specific
benefit category to track and report the value added services 'separately'
from
our 'capitated' service data. In addition, Superior will have the
ability to pass this information to the State utilizing the encounter submission
process, as long as the State is able to segregate the value adds data from
the
capitated services data.
For
pharmacy services, Superior will receive a data file from the pharmacy vendor
to
capture all utilization of the pharmacy value-add benefit.
For
transportation services, Superior will maintain an electronic file of
transportation services provided for Superior’s
membership.
Home
visits to new mothers are tracked through Superior’s case management
system. Each staff member logs each member visit and the
outcome/findings of the visit in Superior’s computer system. Superior
will work with HHSC to establish the most efficient transmission of the
data.
4.
By signing the Contract and/or Contract Amendment HMO certifies that it
will provide the approved Value-added Services described herein from September
1, 2007 through August 31, 2008.
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3 – Value-added Services
Version
1.8
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version of Attachment B-3, Value-added Services.
|
|
Revision
|
1.1
|
June
30, 2006
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.2
|
September
1, 2006
|
Revised
the Physical Health Value-added Services to include Home Visits
to New
Mothers. Revised the certification provision by changing the start
date
for the 12-month provision of services.
|
Revision
|
1.3
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment removed the separate signature requirement for Attachment
B-3,
Value-added Services. By signing the Contract and/or Contract Amendment,
the HMO certifies that it will provide the Value-added Services
from
September 1, 2006 through August 31, 2007.
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.8
|
September
1, 2007
|
Revised
Attachment B-3, Value-added Services, to reflect newly negotiated
Value-added Services for FY 2008.
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn versions
2Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3
Brief
description of the changes to the document made in the
revision.
|
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3 – Value-added Services
Version
1.8
ATTACHMENT
B-3: VALUE-ADDED SERVICES September 1, 2007 – August 31,
2008
HMO:
Superior HealthPlan, Inc.
HMO
PROGRAM: Medicaid
SERVICE
AREA(S):Bexar, El Paso, Lubbock, Nueces, and Xxxxxx
Physical
Health Value-added Services
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Vision
|
Members
are allowed to purchase any prescription eyewear and apply a $100
allowance toward the purchase of that eyewear.
|
Members
are responsible for any charges that exceed the $100 allowance.
Disposable
contact lenses are excluded from this $100 allowance. This Value-Added
benefit is only allowed one time per benefit period (i.e.
24-months).
|
TVHP
contracted providers.
|
Pharmacy
|
Provides
members with a $15.00 per household per quarter credit toward over
the
counter medications and supplies.
|
Services
must be sought from contracted pharmacies only. Items eligible
for
purchase under this benefit are over-the-counter, health related
items
only.
|
Pharmacy
Data Management contracted
providers.
|
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3 – Value-added Services
Version
1.8
Physical
Health Value-added Services
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Transportation
|
HMO
will offer tokens or vouchers for bus services
to
HMO members that have trouble accessing the
State's
Medical Transportation Program in a
timely
manner to ensure access to their provider
appointments.
In addition, HMO will provide
transportation
to non-medical services such as
health
education programs, nutrition classes, and
birth
preparation classes. HMO's member service
staff
will approve and coordinate the
transportation
service".
|
Members
in the Nueces Service Area.
The transportation Authority
in this area will not agree
to allow the plan to purchase
bus vouchers or tokens.
The
bus tokens must be requested
in advance of a
provider
visit and authorized by Superior’s
Member Services Department.
|
Transit
Authorities in appliable Service Area.
|
NurseWise | Twenty-four hour nurse advice line | Available to all members by calling the Member Services toll-free number | NurseWise,
an affiliate
of Centene
Corporation
|
Home
Visits to New Mothers
|
Superior
Social Work and/or CONNECTIONS staff will make
home visits to any Member with a new baby. This visit
provides for resource and education coordination as identified
in the visit, and ensures Members
and the new babies are keeping all post natal
and
newborn doctor visits. This benefit is available to all
Superior
Members who have delivered a baby.
|
Only
that a member consent to the home visit.
|
Superior's
CONNECTIONS and Social Work staff provide this service.
|
|
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3 – Value-added Services
Version
1.8
Behavioral
Health Value-added Services for Members Under 21
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Behavioral
Health
|
Rehabilitation/skills
training. These are services provided to pregnant and parenting
substance
abusers at MHMR centers or in other treatment settings, focusing
both on
substance abuse and parenting issues. An augmentation of standard
substance abuse treatment to focus on the special needs of this
population. Authorized in increments of 15 minutes, with amount,
duration,
and scope based on medical necessity. This benefit is available
to all
Members. It is geared to pregnant women and parenting
Members.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
In addition, the service will be authorized for15minute increments.
The amount, duration, and scope are based on medical
necessity.
|
It
is anticipated that Superior’s contracted MHMR providers specializing in
Rehabilitation/Skills training in each Service Area will render
this
service.
|
Behavioral
Health
|
Superior’s
Behavioral Health Subcontractor will authorize Behavioral Health
practitioners in medical settings to provide health psychology
interventions focused on the effective management of chronic medical
conditions. These might include psycho-educational groups for chronic
conditions, individual coaching for patients with chronic disease
states,
or skills training activities.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
The authorization will be tied to medical necessity.
|
It
is anticipated that these services will be rendered by Superior’s
behavioral health practitioners located in Superior’s contracted Federally
Qualified Health Centers.
|
Behavioral
Health
|
Partial
Hospitalization/Extended Day Treatment-An alternative to, or a
step down
from, inpatient care.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
Services are authorized for a minimum of five hours, but for less
than
24-hours per day. The amount, duration, and scope will be based
on medical
necessity.
|
It
is anticipated that Superior’s contracted Behavioral Health Providers such
as its’ MHMR facilities and other contracted facilities in each Service
Area will render this service.
|
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3 – Value-added Services
Version
1.8
Behavioral
Health Value-added Services for Members Under 21
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Behavioral
Health
|
Intensive
Outpatient Treatment/Day Treatment (IOP)- Used as an alternative
to or
step down from more restrictive levels of care.
|
These
services must be authorized by Superior’s Behavioral Health Material
Subcontractor. In addition, the service will be authorized for
greater
than one and one half hours, but less than five hours per day.
Amount,
duration, and scope are based on medical necessity.
|
It
is anticipated that Superior’s contracted Behavioral Health Providers such
as the MHMR or other facilities in each Service Area will render
this
service.
|
Behavioral
Health Value-added Services for Members 21 and
Over
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Behavioral
Health
|
Rehabilitation/skills
training. These are services provided to pregnant and parenting
substance
abusers at MHMR centers or in other treatment settings, focusing
both on
substance abuse and parenting issues. An augmentation of standard
substance abuse treatment to focus on the special needs of this
population. This benefit is available to all Members. It is geared
to
pregnant women and parenting Members.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
In addition, the service will be authorized for15minute increments.
The amount, duration, and scope are based on medical
necessity.
|
It
is anticipated that Superior’s contracted MHMR providers specializing in
Rehabilitation/Skills training in each Service Area will render
this
service.
|
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3 – Value-added Services
Version
1.8
Behavioral
Health Value-added Services for Members 21 and
Over
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Behavioral
Health
|
Partial
Hospitalization/Extended Day Treatment-An alternative to, or a
step down
from, inpatient care.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
Services are authorized for a minimum of five hours, but for less
than
24-hours per day. The amount, duration, and scope will be based
on medical
necessity.
|
It
is anticipated that Superior’s contracted Behavioral Health Providers such
as its’ MHMR facilities and other contracted facilities in each Service
Area will render this service.
|
Behavioral
Health
|
Superior’s
Behavioral Health Subcontractor, will authorize Behavioral Health
practitioners in medical settings to provide health psychology
interventions focused on the effective management of chronic medical
conditions. These might include psycho-educational groups for chronic
conditions, individual coaching for patients with chronic disease
states,
or skills training activities.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
The authorization will be tied to medical necessity.
|
It
is anticipated that these services will be rendered by Superior’s
behavioral health practitioners located in Superior’s contracted Federally
Qualified Health Centers.
|
Behavioral
Health
|
Intensive
Outpatient Treatment/Day Treatment (IOP)- Used as an alternative
to or
step down from more restrictive levels of care.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
In addition, the service will be authorized for greater than one
and one
half hours, but less than five hours per day. Amount, duration,
and scope
are based on medical necessity.
|
It
is anticipated that Superior’s contracted Behavioral Health Providers such
as the MHMR or other facilities in each Service Area will render
this
service.
|
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3 – Value-added Services
Version
1.8
Behavioral
Health Value-added Services for Members 21 and
Over
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Behavioral
Health
|
Off-site
Services such as home-based services, , mobile crisis, intensive
case
management. It should be noted that staff must go off-site to provide
such
services. These services are provided to Members to help reduce
or avoid
inpatient admissions by a community based, mobile, multi-disciplinary
team
of licensed clinicians and trained, unlicensed workers working
under the
direction of a licensed professional.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
The amount, duration and scope are based on medical
necessity.
|
It
is anticipated that Superior’s contracted Behavioral Health Providers such
as the MHMR in each Service Area will render this
service.
|
1.
Explain how and when Providers and Members will be notified about the
availability of the value-added services to be provided.
Value
Added Services information will be included in the Superior Provider Manual
and
also during training sessions. Members will receive this information via
the
Plan Comparison Chart, in the Member Handbook, with New Member Packets and
during orientations. Periodically, Superior will also highlight Value
Added Services in the Provider and Member Newsletters.
2.
Describe how a Member may obtain or access the value-added services to be
provided.
See
explanations provided above for accessing services.
A
Member
may access the Home Visits to New Mothers service by accepting a home visit
appointment from a Superior Social Work or CONNECTIONS staff
member.
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3 – Value-added Services
Version
1.8
3.
Describe how the HMO will identify the Value-added Service in administrative
(encounter) data.
Superior
will track the value added services through our claims system for those
value-adds that HIPAA-compliant procedural codes are available (vision,
behavioral health). Superior will create a specific benefit category to track
and report the value added services 'separately' from our 'capitated' service
data. In addition, Superior will have the ability to pass this information
to
the State utilizing the encounter submission process, as long as the State
is
able to segregate the value adds data from the capitated services data. For
pharmacy services, Superior will receive a data file from the pharmacy vendor
to
capture all utilization of the pharmacy value-add benefit.
For
transportation services, Superior will maintain an electronic file of
transportation services provided for Superior’s membership.
Home
visits to new mothers are tracked through Superior’s case management
system. Each staff member logs each member visit and the
outcome/findings of the visit in Superior’s computer system. Superior
will work with HHSC to establish the most efficient transmission of the
data.
4.
By
signing the Contract and/or Contract Amendment HMO certifies that it will
provide the approved Value-added Services described herein from September
1,
2007 through August 31, 2008.
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3.1 – STAR+PLUS Value-added Services
Version
1.8
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
1.0
|
Initial
version of Attachment B-3, Value-added Services
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
Attachment B-3, Value Added Services, by adding Attachment B-3.1,
STAR+PLUS Value Added Services. This is the initial version of
Attachment
B-3.1, STAR+PLUS Value Added Services.
|
Revision
|
1.2
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-3.1, STAR+PLUS Value Added
Services
|
Revision
|
1.3
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-3.1, STAR+PLUS Value Added
Services
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment removed the separate signature requirement for Attachment
B-3.1,
STAR+PLUS Value-added Services. By signing the Contract and/or
Contract
Amendment, the HMO certifies that it will provide the Value-added
Services
from January 1, 2007 through August 31, 2007.
|
Revision
|
1.5
|
January
1, 2007
|
Revised
Attachment B-3.1, STAR+PLUS Value Added Services to state that
only
non-dual members are eligible for dental benefits and to clarify
description of Out-of-Home Respite.
|
Revision
|
1.6
|
February
1, 2007
|
Revised
Attachment B-3.1, STAR+PLUS Value Added Services, to clarify the
coverage
period for the VAS.
|
Revision
|
1.7
|
July
1, 2007
|
Revised
Attachment B-3.1, STAR+PLUS Value Added Services, to clarify the
coverage
period for the VAS.
|
Revision
|
1.8
|
September
1, 2007
|
Revised
Attachment B-3-1, STAR+PLUS Value-added Services, to reflect newly
negotiated Value-added Services for FY 2008.
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn versions
2Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3
Brief
description of the changes to the document made in the
revision.
|
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3.1 – STAR+PLUS Value-added Services
Version
1.8
ATTACHMENT
B-3.1: STAR+PLUS VALUE-ADDED SERVICES
September
1, 2007 – August 31, 2008
HMO:
Superior HealthPlan, Inc.
SERVICE
AREA(S): Bexar & Nueces
Physical
Health Value-added Services
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Pharmacy
|
Provides
members with a $15.00 per household
quarter
credit toward over the counter
medications
and supplies.
|
Services
must be sought from
contracted
pharmacies only. Items
eligible
for purchase under this
benefit
are over-the-counter health
related
items only.
|
Pharmacy
Data
Management
contracted
providers.
|
Dental |
Basic
dental coverage, which includes the
following
CPT codes: 0140- Emergency
Evaluation;
0120- Periodic Oral Evaluation;
0220-
Intra-oral Periapaical First Film; 0230-
Intraoral
Periapical- Each Additional; 0240- Intraoral
Occlusal
Film; 0270- Bitewings- single film;
0272-
Bitewings- two films; 07110- Extraction-
Single
Tooth/Routine to Difficult; and 07120
Extraction-
Each Additional.
|
If
a Member receives services that
are
outside of the scope of the CPT
Codes
listed, the Member will be
subject
to a co-payment of 75% of
the
dentists’ usual and customary
charges
for those services.
Only
non-dual members are eligible
for
dental benefits.
|
OraQuest
Dental Network
|
Nursewise |
Twenty-four
hour nurse advice line
|
Available
to all members by calling
the
Member Services toll-free
numberTwenty-four
hour nurse advice line
|
NurseWise,
an affiliate of
Centene
Corporation
|
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this
service
|
Out-of-Home
Respit
|
Respite
services for a caretaker who needs relief
from
their care-giving responsibilities because of
severe
physical or mental stress or who is
temporarily
unable to provide care because of
illness,
hospitalization, family emergency or other
obligation.
Services will be provided in the setting
most
appropriate to the Member's needs
including
assisted living facilities, adult xxxxxx
care
homes, or adult day activity centers.
|
This
benefit is limited to non-dual
Adult
non-Waiver Members age 21
and
over. Must be prior authorized.
Limited
to up to ten hours per
month
of in home respite services.
|
Network
providers.
|
|
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3.1 – STAR+PLUS Value-added Services
Version
1.8
Behavioral
Health Value-added Services for Members 21 and
Over
|
||||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
|
Behavioral
Health
|
Health
Psychology Interventions provided by a behavioral health practitioner
in a
medical setting that focuses on the effective management of chronic
medical conditions. This might include psycho-educational groups
for
chronic conditions, individual coaching for patients with chronic
disease
states, or skills training activities.
|
Limited
to non-dual Members only. Services must be authorized and is based
on
medical necessity.
|
Network
Federally Qualified Health Centers (FQHCs)
|
|
Behavioral
Health
|
Intensive
Outpatient Treatment/Day Treatment (IOP)- Used as an alternative
to step
down from more restrictive levels of care.
|
Limited
to non-dual Members only. Services must be authorized and is based
on
medical necessity. Services will be authorized for greater than
one and
one half hours, but less than five hours per day.
|
It
is anticipated that behavioral health providers such as the MHMR
or other
facilities within the Service Area will render this
service.
|
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3.1 – STAR+PLUS Value-added Services
Version
1.8
Behavioral
Health Value-added Services for Members 21 and
Over
|
||||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
|
Behavioral
Health
|
Partial
Hospitalization/Extended Day Treatment-An alternative to, or a
step down
from, inpatient care.
|
Limited
to non-dual Members only. Services must be authorized and is based
on
medical necessity. Services will be authorized for a minimum of
five
hours, but for less than 24-hours per day.
|
It
is anticipated that behavioral health providers such as the MHMR
or other
facilities within the Service Area will render this
service.
|
|
Behavioral
Health
|
Off-site
services such as intensive case management. It should be noted
that staff
must go off-site to provide such services. These services are provided
to
Members to help reduce or avoid inpatient admissions by a community
based,
mobile, multi-disciplinary team of licensed clinicians and trained,
unlicensed workers working under the direction of a licensed
professional.
|
Limited
to non-dual Members only. Services must be authorized and is based
on
medical necessity.
|
It
is anticipated that behavioral health providers such as the MHMR
or other
facilities within the Service Area will render this
service.
|
1.
Explain how and when Providers and Members will be notified about the
availability of the value-added services to be provided.
Value
added services information will be included in the Superior Provider Manual
and
also during training sessions. Members will receive this information
via the Plan Comparison Chart, in the Member Handbook, with New Member Packets
and during orientations. Periodically, Superior will also highlight
Value Added Services in the Provider and member Newsletters.
2.
Describe how a Member may obtain or access the value-added services to be
provided.
See
explanations provided above for accessing services.
Contractual
Document (CD) Responsible Office: HHSC Office of General Counsel
(OGC)
Subject:
Attachment B-3.1 – STAR+PLUS Value-added Services
Version
1.8
3.
Describe how the HMO will identify the Value-added Service in administrative
(encounter) data.
Superior
will track value added services through our claims system for those value
–adds
that are IIPAA-compliant procedural codes are available (podiatry,
etc.). Superior will create specific benefit categories to track and
report the value added services “separately” from our “capitated” service data.
In addition, Superior will have the ability to pass this information to the
State utilizing the encounter submission process, as long as the Sate is
able to
segregate the value adds data from the capitated services
data. For pharmacy services, Superior will receive a data file
from the pharmacy vendor to capture all utilization of pharmacy value added
benefits. The same is true for dental services.
4.
By
signing the Contract and/or Contract Amendment HMO certifies that it will
provide the approved Value-added Services
described herein from September 1, 2007 – August 31,
2008.
Subject:
Attachment B-3.2 – CHIP Perinatal Program Value-added
Services
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
1.0
|
Initial
version of Attachment B-3, Value-added Services
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
Attachment B-3, Value Added Services, by adding Attachment B-3.1,
STAR+PLUS Value Added Services.
|
Revision
|
1.2
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-3, Value Added
Services
|
Revision
|
1.3
|
September
1, 2006
|
Revised
Attachment B-3, Value Added Services, by adding Attachment B-3.2,
CHIP
Perinatal Program Value Added Services. This is the initial version
of
Attachment B-3.2, CHIP Perinatal Program Value Added
Services.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment removed the separate signature requirement for Attachment
B-3.2,
CHIP Perinatal Program Value-added Services. By signing the Contract
and/or Contract Amendment, the HMO certifies that it will provide
the
Value-added Services from January 1, 2007 through August 31,
2007.
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-3.2, CHIP Perinatal Program
Value
Added Services.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-3.2, CHIP Perinatal Program
Value
Added Services.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-3.2, CHIP Perinatal Program
Value
Added Services.
|
Revision
|
1.8
|
September
1, 2007
|
Revised
Attachment B-3.2, CHIP Perinatal Program Value-added Services,
to reflect
newly negotiated Value-added Services for FY 2008.
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn versions
2Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3
Brief
description of the changes to the document made in the
revision.
|
ATTACHMENT
B-3.2: CHIP PERINATAL PROGRAM VALUE-ADDED SERVICES September 1, 2007 – August
31, 2008
HMO:
_________________________________________________________________________________
SERVICE
AREA(S):
______________________________________________________________________
Physical
Health Value-added Services
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Behavioral
Health Value-added Services for Members Under 21
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Behavioral
Health Value-added Services for Members 21 and
Over
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
1.
Explain how and when Providers and Members will be notified about the
availability of the value-added services to be provided.
2.
Describe how a Member may obtain or access the value-added services to be
provided.
3.
Describe how the HMO will identify the Value-added Service in administrative
(encounter) data.
4.
By
signing the Contract and/or Contract Amendment HMO certifies that it will
provide the approved Value-added Services described herein from September
1,
2007 through August 31, 2008.
Subject: Attachment B-4 – Performance Improvement Goals Version 1.8
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version Attachment B-4, Performance Improvement Goals.
|
|
Revision
|
1.1
|
June
30, 2006
|
Contract
amendment to include STAR+PLUS Program. Revised Attachment B-4,
Performance Improvement Goals Template, by adding Attachment B-4.1,
FY2008
Performance Improvement Goals Template. No change to this
Section.
|
Revision
|
1.2
|
September
1, 2006
|
Revised
version of Attachment B-4 that includes provisions applicable to
MCOs
participating in the STAR and CHIP Programs. Updates the attachment
to
reflect the changes made in Attachment B-1, Section
8.1.1.1.
|
Revision
|
1.3
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-4, Performance Improvement
Goals.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amended to include Attachment B-4 Performance Improvement Goals
for
SFY2007 and format change
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-4, Performance Improvement
Goals.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-4, Performance Improvement
Goals.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-4, Performance Improvement
Goals.
|
Revision
|
1.8
|
September
1, 2007
|
Revised
Attachment B-4, to replace FY2007 Performance Improvement Goals
with newly
negotiated FY2008 Performance Improvement Goals by Program and
by Service
Area. Attachment B-4.1, FY2008 Performance Improvement Goals
Template, is deleted as duplicative.
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn versions
2Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision— e.g., “1.2” refers to the first
version of the document and the second revision.
3 Brief
description of the changes to the document made in the
revision.
|
Subject:
Attachment B-4 – Performance Improvement Goals Version 1.8
Texas
Health and Human Services
Commission
HMO
Performance Improvement Goal
Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
2008)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program:
CHIP
HMO
Service
Delivery Area: Bexar SDA
|
|
||||
B.
Overarching Goal
|
C.
Sub Goals:
|
||||
Goal
1:
|
|
|
|||
Improve
Access to Primary Care
Services
for Members
|
90%
of initial credentialing of PCPs will be finalized within
75 days of receipt of application.
|
||||
|
|
The
percentage of Family Practitioners with open panels will increase
by 10
percentage points over baseline.
|
|||
Goal
2: Improve Access to Behavioral Health Services for
Members
|
|
Increase
Behavioral Health Urgent Care Appointment Availability by 5 percentage
points over the baseline. Increase
Behavioral Health Routine Care Appointment Availability by 5 percentage
points over the baseline.
|
|||
Goal
3:
|
|
|
|||
Increase
Utilization of New Member Medical Check-Ups
within
90 days of Enrollment
|
90%
of new members will receive a reminder/insert in the new member
packets to remind members to schedule a new patient
check-up.
|
||||
|
|
100%
of new members with working phone numbers and with default or no
PCP will
have a new PCP assignment within 60 days of
enrollment.
|
Additional information related to the Performance Improvement Goals can
be
found in Attachment B-1, Section 8.1.1.1, to the Contract.
Subject:
Attachment B-4 – Performance Improvement Goals Version 1.8
HMO
Performance Improvement Goal
Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
2008)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: CHIP
HMO
Service
Delivery Area: El Paso SDA
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1:
|
|
Improve
Access to Primary Care
|
90%
of initial credentialing of PCPs will be finalized within 75 days
of
receipt of application.
|
Services
for Members
|
The
percentage of Family Practitioners with open panels will increase
by four
percentage points over baseline.
|
Goal
2: Improve Access to Behavioral Health Services for
Members
|
Increase
Behavioral Health Urgent Care Appointment Availability by 5 percentage
points over the baseline.
Increase
Behavioral Health Routine Care Appointment Availability by 5 percentage
points over the baseline.
|
Goal
3:
|
|
Increase
Utilization of New Member Medical Check-Ups
|
90%
of initial credentialing of PCPs will be finalized new member packets
to
remind members to schedule a new patient check-up.
|
within
90 days of Enrollment
|
100%
of new members with working phone numbers and with default or no
PCP will
have a new PCP assignment within 60 days of
enrollment.
|
Subject:
Attachment B-4 – Performance Improvement Goals Version 1.8
HMO
Performance Improvement Goal
Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
2008)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: CHIP
HMO
Service
Delivery Area: Lubbock SDA
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1:
|
|
Improve
Access to Primary Care
|
90%
of initial credentialing of PCPs will be finalized within 75 days
of
receipt of application.
|
Services
for Members
|
The
percentage of Family Practitioners with open panels will increase
by four
percentage points over baseline.
|
Goal
2: Improve Access to Behavioral Health Services for
Members
|
Increase
Behavioral Health Urgent Care Appointment Availability by 5 percentage
points over the baseline.
Increase
Behavioral Health Routine Care Appointment Availability by 5 percentage
points over the baseline.
|
Goal
3:
|
|
Increase
Utilization of New Member Medical Check-Ups
|
90%
of initial credentialing of PCPs will be finalized new member packets
to
remind members to schedule a new patient check-up.
|
within
90 days of Enrollment
|
100%
of new members with working phone numbers and with default or no
PCP will
have a new PCP assignment within 60 days of
enrollment.
|
Subject:
Attachment B-4 – Performance Improvement Goals Version 1.8
HMO
Performance Improvement Goal
Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
2008)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: CHIP
HMO
Service Delivery Area: Nueces SDA
|
|
B.
Overarching Goal
|
|
Goal
1:
|
|
Improve
Access to Primary Care
|
90%
of initial credentialing of PCPs will be finalized within 75
days of receipt of application.
|
Services
for Members
|
The
percentage of Family Practitioners with open panels will increase
by four
percentage points over baseline.
|
Goal
2: Improve Access to Behavioral Health Services for
Members
|
Increase
Behavioral Health Urgent Care Appointment Availability by 5 percentage
points over the baseline.
Increase
Behavioral Health Routine Care Appointment Availability by 5 percentage
points over the baseline.
|
Goal
3:
|
|
Increase
Utilization of New Member Medical Check-Ups
|
90%
of initial credentialing of PCPs will be finalized new member
packets to remind members to schedule a new patient
check-up.
|
within
90 days of Enrollment
|
100%
of new members with working phone numbers and with default or no
PCP will
have a new PCP assignment within 60 days of
enrollment.
|
Subject:
Attachment B-4 – Performance Improvement Goals Version 1.8
HMO
Performance Improvement Goal
Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
2008)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: CHIP
HMO
Service
Delivery Area: Xxxxxx SDA
|
|
||||
B.
Overarching Goal
|
C.
Sub Goals:
|
||||
Goal
1:
|
|
|
|||
Improve
Access to Primary Care
|
90%
of initial credentialing of PCPs will be finalized within 75 days
of receipt of application.
|
||||
Services
for Members
|
|
The
percentage of Family Practitioners with open panels will increase
by 10
percentage points over baseline.
|
|||
Goal
2: Improve Access to Behavioral Health Services for
Members
|
|
Increase
Behavioral Health Urgent Care Appointment Availability by 5 percentage
points over the baseline.
Increase
Behavioral Health Routine Care Appointment Availability by 5 percentage
points over the baseline.
|
|||
Goal
3:
|
|
|
|||
Increase
Utilization of New Member Medical Check-Ups
|
90%
of new members will receive a reminder/insert in the new member
packets to remind members to schedule a new patient
check-up.
|
||||
within
90 days of Enrollment
|
|
100%
of new members with working phone numbers and with default or no
PCP will
have a new PCP assignment within 60 days of
enrollment.
|
Subject:
Attachment B-4 – Performance Improvement Goals Version 1.8
HMO
Performance Improvement Goal
Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
2008)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: STAR
HMO
Service
Delivery Area: Bexar SDA
|
|
||||
Goal
1:
|
|
90%
of initial credentialing of PCPs will be finalized
|
|||
Improve
Access to Primary Care
|
within
75 days of receipt of application.
|
||||
Services
for Members
|
|
The
percentage of Family Practitioners with open panels will increase
by 10
percentage points over baseline.
|
|||
Goal
2: Improve Access to Behavioral Health Services for
Members
|
|
Increase
Behavioral Health Urgent Care Appointment Availability by 5 percentage
points over the baseline. Increase Behavioral Health Routine Care
Appointment Availability by 5 percentage points over the
baseline.
|
|||
Goal
3:
|
|
90%
of new members will receive a reminder/insert in the
|
|||
Increase
Utilization of New Member Medical Check-Ups
|
new
member packets to remind members to schedule a new patient
check-up.
|
||||
within
90 days of Enrollment
|
|
100%
of new members with working phone numbers and with default or no
PCP will
have a new PCP assignment within 60 days of
enrollment.
|
Subject:
Attachment B-4 – Performance Improvement Goals Version 1.8
HMO
Performance Improvement Goal
Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
2008)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: STAR
HMO
Service
Delivery Area: El Paso SDA
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1:
|
|
Improve
Access to Primary Care
|
90%
of initial credentialing of PCPs will be finalizedwithin 75 days
of
receipt of application.
|
Services
for Members
|
The
percentage of Family Practitioners with open panels will increase
by four
percentage points over baseline.
|
Goal
2: Improve Access to Behavioral Health Services for
Members
|
Increase
Behavioral Health Urgent Care Appointment Availability by 5 percentage
points over the baseline.
Increase
Behavioral Health Routine Care Appointment Availability by 5 percentage
points over the baseline.
|
Goal
3:
|
|
Increase
Utilization of New Member Medical Check-Ups
|
90%
of new members will receive a reminder/insert in the new member
packets to remind members to schedule a new patient
check-up.
|
within
90 days of Enrollment
|
100%
of new members with working phone numbers and with default or no
PCP will
have a new PCP assignment within 60 days of
enrollment.
|
Subject:
Attachment B-4 – Performance Improvement Goals Version 1.8
HMO
Performance Improvement Goal
Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
2008)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: STAR
HMO
Service Delivery Area: Lubbock SDA
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1:
|
|
Improve
Access to Primary Care
|
90%
of new members will receive a reminder/insert in the within 75 days
of receipt of application.
|
Services
for Members
|
The
percentage of Family Practitioners with open panels will increase
by 1.4
percentage points over baseline.
|
Goal
2: Improve Access to Behavioral Health Services for
Members
|
Increase
Behavioral Health Urgent Care Appointment Availability by 5 percentage
points over the baseline.
Increase
Behavioral Health Routine Care Appointment Availability by 5 percentage
points over the baseline.
|
Goal
3:
|
|
Increase
Utilization of New Member Medical Check-Ups
|
90%
of new members will receive a reminder/insert in the new member
packets to remind members to schedule a new patient
check-up.
|
within
90 days of Enrollment
|
100%
of new members with working phone numbers and with default or no
PCP will
have a new PCP assignment within 60 days of
enrollment.
|
Subject:
Attachment B-4 – Performance Improvement Goals Version 1.8
HMO
Performance Improvement Goal
Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
2008)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: STAR
HMO
Service Delivery Area: Nueces SDA
|
|
Goal
1:
|
|
Improve
Access to Primary Care
|
90%
of new members will receive a reminder/insert in the within 75 days
of receipt of application.
|
Services
for Members
|
The
percentage of Family Practitioners with open panels will increase
by 10
percentage points over baseline.
|
Goal
2: Improve Access to Behavioral Health Services for
Members
|
Increase
Behavioral Health Urgent Care Appointment Availability by 5 percentage
points over the baseline.
Increase
Behavioral Health Routine Care Appointment Availability by 5 percentage
points over the baseline.
|
Goal
3:
|
|
Increase
Utilization of New Member Medical Check-Ups
|
90%
of new members will receive a reminder/insert in the new member
packets to remind members to schedule a new patient
check-up.
|
within
90 days of Enrollment
|
100%
of new members with working phone numbers and with default or no
PCP will
have a new PCP assignment within 60 days of
enrollment.
|
Subject:
Attachment B-4 – Performance Improvement Goals Version 1.8
HMO
Performance Improvement Goal
Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
2008)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: STAR
HMO
Service Delivery Area: Xxxxxx
|
|
||||
X.
Overarching Goal
|
|||||
Goal
1:
|
|
|
|||
Improve
Access to Primary Care
|
90%
of initial credentialing of PCPs will be finalized within 75 days
of receipt of application.
|
||||
Services
for Members
|
|
The
percentage of Family Practitioners with open panels will increase
by 10
percentage points over baseline.
|
|||
Goal
2: Improve Access to Behavioral Health Services for
Members
|
|
Increase
Behavioral Health Urgent Care Appointment Availability by 5 percentage
points over the baseline.
Increase
Behavioral Health Routine Care Appointment Availability by 5 percentage
points over the baseline.
|
|||
Goal
3:
|
|
|
|||
Increase
Utilization of New Member Medical Check-Ups
|
90%
of new members will receive a reminder/insert in the new member
packets to remind members to schedule a new patient
check-up.
|
||||
within
90 days of Enrollment
|
|
100%
of new members with working phone numbers and with default or no
PCP will
have a new PCP assignment within 60 days of
enrollment.
|
Subject:
Attachment B-4 – Performance Improvement Goals Version 1.8
HMO
Performance Improvement Goal
Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
2008)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: STAR+PLUS
HMO
Service Delivery Area: Bexar SDA
|
|
||||
B.
Overarching Goal
|
C.
Sub Goals:
|
||||
Goal
1:
|
|
|
|||
Improve
Access to Primary Care
|
90%
of initial credentialing of PCPs will be finalized within 75 days
of receipt of application.
|
||||
Services
for Members
|
|
The
percentage of Family Practitioners with open panels will increase
by 10
percentage points over baseline.
|
|||
Goal
2: Improve Access to Behavioral Health Services for
Members
|
|
Increase
Behavioral Health Urgent Care Appointment Availability by 5 percentage
points over the baseline.
Increase
Behavioral Health Routine Care Appointment Availability by 5 percentage
points over the baseline.
|
|||
Goal
3:
|
|
|
|||
Improve
Member Understanding of Service Coordination
|
|
100%
of new members with a Face to Face assessment occurring
between 9-1-07 and 7-31-08 will receive a newly developed Service
Coordination information/pamphlet.
100%
of all members NOT receiving Service Coordination are
mailed an informational pamphlet about service coordination availability
each quarter.
|
Subject:
Attachment B-4 – Performance Improvement Goals Version 1.8
HMO
Performance Improvement Goal
Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
2008)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: STAR+PLUS
HMO
Service Delivery Area: Nueces
|
|||||
Goal
1:
|
|
|
|||
Improve
Access to Primary Care
|
90%
of initial credentialing of PCPs will be finalized within 75
days of receipt of application.
|
||||
Services
for Members
|
|
The
percentage of Family Practitioners with open panels will increase
by 10
percentage points over baseline.
|
|||
Goal
2: Improve Access to Behavioral Health Services for
Members
|
|
Increase
Behavioral Health Urgent Care Appointment Availability by 5 percentage
points over the baseline.
Increase
Behavioral Health Routine Care Appointment Availability by 5 percentage
points over the baseline.
|
|||
Goal
3:
|
|
|
|||
Improve
Member Understanding of Service Coordination
|
|
100%
of new members with a Face to Face assessment occurring between
9-1-07 and 7-31-08 will receive a newly developed Service Coordination
information/pamphlet.
100%
of all members NOT receiving Service Coordination are
mailed an informational pamphlet about service coordination availability
each quarter.
|
Subject:
Attachment B-4.1 – FY2008 Performance Improvement
Goals
DOCUMENT
HISTORY LOG
|
||||
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
|
Baseline
|
1.0
|
Initial
version of Attachment B-4, Performance Improvement Goals.
|
||
Revision
|
1.1
|
June
30, 2006
|
Revised
Attachment B-4, Performance Improvement Goals Template, by adding
Attachment B-4.1, FY2008 Performance Improvement Goals Template.
This is
the initial version of Attachment B-4.1, FY2008 Performance Improvement
Goals.
|
|
Revision
|
1.2
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
Goals.
|
|
Revision
|
1.3
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
Goals.
|
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
Goals, but did change format.
|
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
Goals.
|
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
Goals.
|
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
Goals.
|
|
Cancellation
|
1.8
|
September
1, 2007
|
Attachment
B-4.1 is cancelled as duplicative. Attachment B-4 will be
updated with FY2008 Performance Improvement Goals by Program and
by
Service Area.
|
|
1
Status should be represented as “Baseline” for initial issuances,
“Revision” for changes to the Baseline version, and “Cancellation” for
withdrawn versions
2
Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3 Brief
description of the changes to the document made in the
revision.
|
Texas
Health and Human Services Commission
HMO
Performance Improvement Goal Template
for
State Fiscal Year 2008
(September
1, 2007 – August 31, 2008)
A. Health
Plan Information
Plan
Name:
HMO
Program:
HMO
Service Delivery Area:
|
||
B. Overarching
Goal
|
||
Goal
1-5:
Three
to five Goals for all applicable HMO Programs to be determined
and
negotiated prior to FY2008.
|
To
be determined for FY2008.
|
|
Goal
6:
(STAR+PLUS
HMOs)
Increase the use of the Consumer Directed Services (CDS)
Program
|
Increase
the percentage of enrollees receiving Personal Assistance Services
(PAS)
through the Consumer Directed Services (CDS) Program by 15% as
compared to
the baseline rate of ____
|
A. Health
Plan Information
Plan
Name:
HMO
Program:
HMO
Service Delivery Area:
|
||
B. Overarching
Goal
|
||
Goal
1-5:
Three
to five Goals for all applicable HMO Programs to be determined and
negotiated prior to FY2008.
|
To
be determined for FY2008.
|
|
Goal
6:
(STAR+PLUS
HMOs)
Increase the use of the Consumer Directed Services (CDS)
Program
|
Increase
the percentage of enrollees receiving Personal Assistance Services
(PAS)
through the Consumer Directed Services (CDS) Program by 15% as compared
to
the baseline rate of ____
|
Specific
percentages for Sub-Goals will be negotiated by HHSC and the HMO before the
beginning of FY2008.
Responsible
Office: HHSC Office of General Counsel (OGC)
Subject:
Attachment B-5 –Deliverables/Liquidated Damages
Matrix
DOCUMENT
HISTORY LOG
DOCUMENT
HISTORY LOG
|
||||
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
|
Baseline
|
n/a
|
Initial
version of Attachment B-5, Deiverables/Liquidated Damage
Matrix.
|
||
Revision
|
1.1
|
June
30, 2006
|
Contract
amendment did not revise Attachment B-5, Deliverables/Liquidated
Damage
Matrix.
|
|
Revision
|
1.2
|
September
1, 2006
|
Amended
Attachment B-5, Deliverables/Liquidated Damages Matrix, to add
a
footnote
clarifying the deliverable due dates. Also amended the provisions
regarding Claims
Processing Requirements and the Reporting Requirements for the
Claims
Summary
Report.
|
|
Revision
|
1.3
|
September
1, 2006
|
Amended
Attachment B-5, Deliverables/Liquidated Damages Matrix, performance
standard
for Provider Directories for the CHIP Perinatal
Program.
|
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-5, Deliverables/Liquidated
Damage
Matrix.
|
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-5,
Deliverables/Liquidated
Damage
Matrix.
|
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-5,
Deliverables/Liquidated
Damage
Matrix.
|
|
Revision
|
1.7
|
July
1, 2007
|
Amended
Attachment B-5, Deliverables/Liquidated Damages Matrix, to
add
clarifications
to the provisions addressing Claims Processing Requirements and
the
Reporting
Requirements for the Claims Summary Report.
|
|
Cancellation
|
1.8
|
September
1, 2007
|
Contract
amendment did not revise Attachment B-5, Deliverables/Liquidated
Damage
Matrix.
|
|
1
Status should be represented as “Baseline” for initial issuances,
“Revision” for changes to the Baseline version, and “Cancellation” for
withdrawn versions
2
Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3 Brief
description of the changes to the document made in the
revision.
|
Deliverables/Liquidated
Damages Matrix
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
Contract
Attachment
B-1,
RFP
§7.3 --
Transition
Phase
Schedule
Contract
Attachment
B-1,
RFP
§7.3.1 --
Transition
Phase
Tasks
Contract
Attachment
B-1,
RFP
§8.1 --
General
Scope
|
The
HMO must be operational no
later
than the agreed upon
Operations
Start Date. HHSC, or
its
agent, will determine when the
HMO
is considered to be
operational
based on the
requirements
in Section 7 and 8 of
Attachment
B-1.
|
Operations
Start
Date
|
Each
calendar day of
non-compliance,
per
HMO
Program, per
Service
Area (SA).
|
HHSC
may assess up to $10,000 per
calendar
day for each day beyond the
Operations
Start date that the HMO is
not
operational until the day that the
HMO
is operational, including all
systems.
|
Contract
Attachment
B-1
RFP
§7.3.1.5 --
Systems
Readiness
Review
|
The
HMO must submit to HHSC or
to
the designated Readiness
Review
Contractor the following
plans
for review, by December 14,
2005
for STAR and CHIP, and by
July
31, 2006 for STAR+PLUS:
•
Joint
Interface
Plan;
•
Disaster
Recovery
Plan;
|
Transition Period |
Each
calendar day of
non-compliance,
per
report,
per HMO
Program,
and per SA.
|
HHSC
may assess up to $1,000 per
calendar
day for each day a
deliverable
is late, inaccurate or
incomplete.
|
1
Derived from the Contract or HHSC’s Uniform Managed Care Manual.
2Standard
specified in the Contract. Note: Where the due date states 30 days, the
HMO is
to provide the deliverable by the last day of the month following
the end of the reporting period. Where the due date states 45 days, the
HMO is
to provide the deliverable by the 15th day of the second month
following the end of the reporting period.
3
Period during which HHSC will evaluate service for purposes of tailored
remedies.
4
Measure against which HHSC will apply remedies
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
|
•
Business
Continuity Plan;
•
Risk
Management
Plan;
and
•
Systems
Quality
Assurance
Plan.
|
|
|
|
Contract
Attachment
B-1
RFP
§7.3.1.7 –
Operations
Readiness
|
Contract
Attachment
B-1 RFP
§7.3.1.7 –
Operations
Readiness
Final
versions of the Provider Directory
must be submitted to the
Administrative
Services Contractor no
later than 95 days prior to the Operational
Start Date for the CHIP, STAR,
and STAR+PLUS HMOs, and
no later than 30 days prior to
the
Operational Start Date for the CHIP
Perinatal HMOs.
|
Transition Period |
Each
calendar day of
non-compliance,
per
directory,
per HMO
Program
and per SA.
|
HHSC
may assess up to $1,000 per
calendar
day for each day the
directory
is late, inaccurate or
incomplete.
|
Contract
Attachment
B-1
RFP
§§ 6, 7, 8
and
9
Uniform
Managed
Care
Manual
|
All
reports and deliverables as
specified
in Sections 6, 7, 8 and 9
of
Attachment B-1 must be
submitted
according to the
timeframes
and requirements stated
in
the Contract (including all
attachments)
and HHSC’s Uniform
Managed
Care Manual. (Specific
Reports
or deliverables listed
separately
in this matrix are subject
to
the specified liquidated
damages.)
|
Transition
Period,
Quarterly
during
Operations
Period
|
Each
calendar day of
non-compliance,
per
HMO
Program, per SA.
|
HHSC
may assess up to $250 per
calendar
day if the report/deliverable
is
late, inaccurate, or incomplete.
|
Contract | The HMO may not engage in | Transition, | Per incident of non- | HHSC may assess up to $1,000 per. |
1
Derived from the Contract or HHSC’s Uniform Managed Care Manual.
2Standard
specified in the Contract. Note: Where the due date states 30 days, the
HMO is
to provide the deliverable by the last day of the month following
the end of the reporting period. Where the due date states 45 days, the
HMO is
to provide the deliverable by the 15th day of the second month
following the end of the reporting period.
3
Period during which HHSC will evaluate service for purposes of tailored
remedies.
4
Measure against which HHSC will apply remedies
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
Attachment
B-1
RFP
§8.1.6 --
Marketing
&
Prohibited
Practices
Uniform
Managed
Care
Manual
|
prohibited
marketing practices.
|
Measured
Quarterly
during
the
Operations
Period
|
compliance.
|
incident
of non-compliance.
|
Contract
Attachment
B-1
RFP
§8.1.17.2 --
Financial
Reporting
Requirements
Uniform
Managed
Care
Manual
–
Chapter
5
|
Financial
Statistical Reports (FSR):
For
each SA, the HMO must file
quarterly
and annual FSRs.
Quarterly
reports are due no later
than
30 days after the conclusion of
each
State Fiscal Quarter (SFQ).
The
first annual report is due no
later
than 120 days after the end of
each
Contract Year and the second
annual
report is due no later than
365
days after the end of each
Contract
Year.
|
Quarterly
during
the
Operations
Period
|
Per
calendar day of
non-compliance,
per
HMO
Program, per SA.
|
HHSC
may assess up to $1,000 per
calendar
day a quarterly or annual
report
is late, inaccurate or
incomplete.
|
Contract
Attachment
B-1
RFP
§8.1.17.2 --
Financial
Reporting
Requirements:
|
Medicaid
Disproportionate Share
Hospital
(DSH) Reports: The
Medicaid
HMO must submit, on an
annual
basis, preliminary and final
DSH
Reports. The Preliminary
report
is due no later than June
1st
after
each reporting year, and the
|
Measured
during
4th
Quarter
of
the
Operations
Period
(6/1–8/31)
|
Per
calendar day of
non-compliance,
per
HMO
Program, per SA.
|
HHSC
may assess up to $1,000 per
calendar
day, per program, per
service
area, for each day the report
is
late, incorrect, inaccurate or
incomplete.
|
1
Derived from the Contract or HHSC’s Uniform Managed Care Manual.
2Standard
specified in the Contract. Note: Where the due date states 30 days,
the HMO is
to provide the deliverable by the last day of the month following
the end of the reporting period. Where the due date states 45 days,
the HMO is
to provide the deliverable by the 15th day of the second month
following the end of the reporting period.
3
Period during which HHSC will evaluate service for purposes of tailored
remedies.
4
Measure against which HHSC will apply
remedies
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
Uniform
Managed
Care
Manual
–
Chapter
5
|
final
report is due no later than July
15th
after
each reporting
year. This
standard
does not apply to CHIP
HMOs.
|
|
|
|
Attachment
B-1
RFP
§8.1.18 –
Management
Information
System
(MIS)
Requirements
|
The
HMO’s MIS must be able to
resume
operations within 72 hours
of
employing its Disaster Recovery
Plan.
|
Quarterly
during
the
Operations
Period
|
Per
calendar day of
non-compliance,
per
HMO
Program, per SA.
|
HHSC
may assess up to $5,000 per
calendar
day of non-compliance
|
Contract
Attachment
B-1
RFP
§8.1.18.3 –
Management
Information
System
(MIS)
Requirements:
Functions
|
The
HMO’s MIS system must meet
all
requirements in Section 8.1.18.3
of
Attachment B-1.
|
Quarterly
during
the
Operations
Period
|
Per
calendar day of
non-compliance,
per
HMO
Program, per SA.
|
calendar
day of non-compliance.
|
Contract
Attachment
B-1
RFP
§8.1.18.5 --
Claims
Processing
Requirements
|
The
HMO must adjudicate all
provider
Clean Claims within 30
days
of receipt by the HMO. The
HMO
must pay providers interest at
an
18% per annum, calculated daily
for
the full period in which the Clean
|
Measured
Quarterly
during
the
Operations
Period
|
Per incident of noncompliance. |
HHSC
may assess up to $1,000 per
claim
if the HMO fails to timely pay
interest.
|
1
Derived from the Contract or HHSC’s Uniform Managed Care Manual.
2Standard
specified in the Contract. Note: Where the due date states 30 days,
the HMO is
to provide the deliverable by the last day of the month following
the end of the reporting period. Where the due date states 45 days,
the HMO is
to provide the deliverable by the 15th day of the second month
following the end of the reporting period.
3
Period during which HHSC will evaluate service for purposes of tailored
remedies.
4
Measure against which HHSC will apply
remedies
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
Uniform
Managed
Care
Manual
Chapter
2
|
beyond
the 30-day claims
processing
deadline. Interest owed
the
provider must be paid on the
same
date that the claim is
adjudicated.
|
|
|
|
Contract
Attachment
B-1
RFP
§8.1.18.5 --
Claims
Processing
Requirements
Uniform
Managed
Care
Manual
–
Chapter
2
|
The
HMO must comply with the
claims
processing requirements and
standards
as described in Section
8.1.18.5
of Attachment B-1 and in
Chapter
2 of the Uniform Managed
Care
Manual.
|
Measured
Quarterly
during
the
Operations
Period
|
period,
per HMO
Program,
per Service
Area,
per claim type.
|
HHSC
may assess liquidated
damages
of up to $5,000 for the first
quarter
that an HMO’s Claims
Performance
percentages by claim
type,
by Program, and by service
area,
fall below the performance
standards.
HHSC may assess up to
$25,000
per quarter for each
additional
quarter that the Claims
Performance
percentages by claim
type,
by Program, and by service
area,
fall below the performance
standards.
|
Attachment
B-1
RFP
§8.1.20.2--
Reporting
Requirements
Uniform
Managed
Care
|
Claims
Summary Report:
The
HMO must submit quarterly,
Claims
Summary Reports to HHSC
by
HMO Program, by Service Area,
and
by claim type, by the 30th
day
following
the reporting period unless
otherwise
specified.
|
Measured
Quarterly
during
the
Operations
Period
|
Per
calendar day of
non-compliance,
per
HMO
Program, per
Service
Area, per claim
type.
|
calendar
day the report is late,
inaccurate,
or incomplete.
|
1
Derived from the Contract or HHSC’s Uniform Managed Care Manual.
2Standard
specified in the Contract. Note: Where the due date states 30 days,
the HMO is
to provide the deliverable by the last day of the month following
the end of the reporting period. Where the due date states 45 days,
the HMO is
to provide the deliverable by the 15th day of the second month
following the end of the reporting period.
3
Period during which HHSC will evaluate service for purposes of tailored
remedies.
4
Measure against which HHSC will apply remedies
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
Manual
Chapters
2 and
5
|
|
|
|
|
Attachment
B-1
RFP
§8.1.5.9--
Member
Complaint
and
Appeal
Process
Contract
Attachment
B-1
RFP
§8.2.7.1 --
Member
Complaint
Process
Contract
Attachment
B-1
RFP
§8.4.3 –
CHIP
Member
Complaint
and
Appeal
Process
|
The
HMO must resolve at least
98%
of Member Complaints within
30
calendar days from the date the
Complaint
is received by the HMO.
|
Measured
Quarterly
during
the
Operations
Period
|
per
HMO Program, per
SA.
|
reporting
period if the HMO fails to
meet
the performance standard.
|
Attachment
B-1
RFP
§8.3.3 –
STAR+PLUS
Assessment
Instruments
Uniform
|
The
MDS-HC instrument must be
completed
and electronically
submitted
to HHSC in the specified
format
within 30 days of enrollment
for
every Member receiving
Community-based
Long-term Care
Services,
and then each year by the
|
Operations,
Turnover
|
Per
calendar day of
non-compliance,
per
Service
Area.
|
calendar
day per Service Area, for
each
day a report is late, inaccurate
or
incomplete.
|
1
Derived from the Contract or HHSC’s Uniform Managed Care Manual.
2Standard
specified in the Contract. Note: Where the due date states
30 days, the HMO is
to provide the deliverable by the last day of the month following
the end of the reporting period. Where the due date states
45 days, the HMO is
to provide the deliverable by the 15th day of the second month
following the end of the reporting period.
3
Period during which HHSC will evaluate service for purposes
of tailored
remedies.
4
Measure against which HHSC will apply remedies
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
Managed
Care
Manual
|
enrollment.
|
|
|
|
Contract
Attachment
B-1
RFP
§8.1.5.9—
Member
Complaint
and
Appeal
Process
Contract
Attachment
B-1
RFP
§8.2.7.2 --
Medicaid
Standard
Member
Appeal
Process
Contract
Attachment
B-1
RFP
§ 8.4.3
CHIP
Member
Complaint
and
Appeal
Process
|
The
HMO must resolve at least
98%
of Member Appeals within 30
calendar
days from the date the
Appeal
is filed with the HMO.
|
Measured
Quarterly
during
the
Operations
Period
|
Per
reporting period,
per
HMO Program, per
SA.
|
reporting
period if the HMO fails to
meet
the performance standard.
|
Contract
Attachment
B-1
RFP
§9.2 --
Transfer
of Data
|
regarding
the provision of Covered
Services
to Members to HHSC or a
new
HMO, at the sole discretion of
HHSC
and as directed by HHSC.
All
transferred data must comply
with
the Contract requirements,
|
Measured
at Time
of
Transfer of Data
and
ongoing after
the
Transfer of
Data
until
satisfactorily
completed
|
Per
incident of noncompliance
(failure
to
provide
data and/or
failure
to provide data
in
required format), per
HMO
Program, per SA.
|
HHSC
may assess up to $10,000 per
calendar
day the data is late,
inaccurate
or incomplete.
|
1
Derived from the Contract or HHSC’s Uniform Managed Care Manual.
2Standard
specified in the Contract. Note: Where the due date
states 30 days, the HMO is
to provide the deliverable by the last day of the month
following
the end of the reporting period. Where the due date
states 45 days, the HMO is
to provide the deliverable by the 15th day of the second
month
following the end of the reporting period.
3
Period during which HHSC will evaluate service for
purposes of tailored
remedies.
4
Measure against which HHSC will apply
remedies
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
|
including
HIPAA.
|
|
|
|
Contract
Attachment
B-1
RFP
§9.3 --
Turnover
Services
|
Six
months prior to the end of the
contract
period or any extension
thereof,
the HMO must propose a
Turnover
Plan covering the possible
turnover
of the records and
information
maintained to either the
State
(HHSC) or a successor HMO.
|
Measured
at Six
Months
prior to the
end
of the contract
period
or any
extension
thereof
and
ongoing until
satisfactorily
completed
|
Each
calendar day of
non-compliance,
per
HMO
Program, per SA.
|
HHSC
may assess up to $1,000 per
calendar
day the Plan is late,
inaccurate,
or incomplete.
|
Contract
Attachment
B-1
RFP
§9.4 --
Post-Turnover
Services
|
The
HMO must provide the State
(HHSC)
with a Turnover Results
report
documenting the completion
and
results of each step of the
Turnover
Plan 30 days after the
Turnover
of Operations.
|
Measured
30 days
after
the Turnover
of
Operations
|
Each
calendar day of
non-compliance,
per
HMO
program, per SA.
|
HHSC
may assess up to $250 per
calendar
day the report is late,
inaccurate
or incomplete.
|
Attachment
A
HHSC
Uniform
Managed
Care
Contract
Terms
and
Conditions,
Section
4.08
Subcontractors
|
The
HMO must notify HHSC in
writing
immediately upon making a
decision
to terminate a subcontract
with
a Material Subcontractor or
upon
receiving notification from the
Material
Subcontractor of its intent
to
terminate such subcontract.
|
Transition,
Measured
Quarterly
during
the
Operations
Period
|
Each
calendar day of
non-compliance,
per
HMO
Program, per SA.
|
HHSC
may assess up to $5,000 per
calendar
day of non-compliance.
|
1
Derived from the Contract or HHSC’s Uniform Managed Care Manual.
2Standard
specified in the Contract. Note: Where the due date
states 30 days, the HMO is
to provide the deliverable by the last day of the month
following
the end of the reporting period. Where the due date
states 45 days, the HMO is
to provide the deliverable by the 15th day of the second
month
following the end of the reporting period.
3
Period during which HHSC will evaluate service for
purposes of tailored
remedies.
4
Measure against which HHSC will apply
remedies
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Subject:
Attachment B-7 – STAR+PLUS Attendant Care Enhanced Payments
Methodology
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
January
1, 2007
|
Initial
version of Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments
Methodology, was incorporated into Version 1.5 of the
Contract.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-7, STAR+PLUS Attendant Care
Enhanced
Payments Methodology.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-7, STAR+PLUS Attendant Care
Enhanced
Payments Methodology.
|
Revision
|
1.8
|
September
1, 2007
|
Contract
amendment did not revise Attachment B-7, STAR+PLUS Attendant Care
Enhanced
Payments Methodology.
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn versions
2Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3
Brief
description of the changes to the document made in the
revision.
|
ATTACHMENT
B-7: STAR+PLUS ATTENDANT CARE ENHANCED PAYMENTS
METHODOLOGY
HMO:
Superior Health Plan
SERVICE
AREA(S): Bexar & Nueces
I.
Provider Contracting
|
(a)
Description of criteria the HMO will use to allow participation
in the
STAR+PLUS Attendant Care Enhanced Payments. Will the HMO have a
enrollment period that corresponds to the DADS enrollment period
to allow
new providers to participate in the HMO's Attendant Care Enhanced
Payments, or will the HMO have it's own enrollment period that
is separate
and not tied to the DADS enrollment? (b) Description of any limitations
or
restrictions.
|
Superior
HealthPlan will only allow those providers that are currently
participating in the DADS Attendant Compensation Rate Enhancements
to
participate in the STAR+PLUS Attendant Care Enhanced Payments.
SHP will
have an enrollment period corresponding to the DADS enrollment
period to
allow new providers to participate in the SHP Attendant Care Enhanced
Payments.
|
II.
Payment for STAR+PLUS Attendant Care Enhanced
Payments
|
Description
of methodology the HMO will use to pay for the Attendant Care Enhanced
Payments. Provide sufficient detail to fully explain the
planned methodology.
|
Superior
will not use the DADS rates. SHP will establish an additional amount
to be
added on to the unit rate by type of service.
|
|
III.
Timing of the Attendant Care Enhanced Payments
|
Description
of when the payments will be made to the Providers and the frequency
of
payments. Also include timeframes for Providers complaints and
appeals regarding enhanced payments.
|
The
enhanced rate payment amount will be paid at the time of claims
payment so
the frequency will depend on the frequency with which providers
file their
claims. Provider complaints and appeals will be handled through
the normal
complaint and appeal process and finalized within 30 days from
receipt.
|
Additional
information related to the Attendant Care Enhanced Payments can be found
in
Attachment B-1, Section 8.3.7.3 of the Contract.
IV.
Assurances from Participating Providers
|
Description
of how the HMO will ensure that the participating Providers are
using the
enhancement funds to compensate direct care workers as intended
by the
2000-01 General Appropriations Act (Rider 27, House Xxxx 1, 76th Legislature,
Regular
Session, 1999) and by T.A.C. Title 1, Part 15, Chapter
355.
|
Participating
Providers will be required by contract to complete and submit an
affidavit
annually stating they applied the enhancement funds to the compensation
for direct care staff. Compensation may include increased hourly
rates,
bonuses, paid holidays or additional benefits such as employer
paid
insurance.
|
|
V.
Monitoring of Attendant Care Enhanced Payments
|
Explanation
of the Monitoring Process that the HMO will use to monitor whether
the
Attendant Care Enhanced Payments are used for the purposes intended
by the
Texas Legislature.
|
Each
Provider’s compliance with the attendant compensation spending requirement
for the reporting period will be monitored on an annual basis via
the
submission of the affidavit stating they applied the enhancement
funds to
the compensation for direct care staff. Compensation may include
increased
hourly rates, bonuses, paid holidays or additional benefits such
as
employer paid insurance. In addition, providers may be audited
on as
as-needed basis to ensure financial records support the pass through
of
the enhanced funds. Enhanced payments could potentially be recouped
for
those Providers who fail to pass the funds to their direct care
staff.
|
By
signing the Contract and/or Contract Amendment, HMO certifies that the approved
STAR+PLUS Attendant Care Enhanced Payments Methodology described herein is
the
methodology the HMO will use to make the legislatively mandated payments
to its
Long Term Services and Support (LTSS) Providers participating in the Attendant
Care Enhanced Payments.
Additional
informationrelated to the Attendant
Care Enhanced Payments can be found in Attachment B-1, Section 8.3.7.3 of
the
Contract.