EXHIBIT 10.5
MEDICAL SERVICES CONTRACT
FLORIDA HEALTHY KIDS CORPORATION
AND
HEALTHEASE
FOR
CITRUS, XXXXX, ESCAMBIA, HIGHLANDS, XXXXXX, XXXXXX AND
WAKULLA COUNTIES
AND
WELLCARE HMO/STAYWELL HEALTH PLAN
FOR
BROWARD, MIAMI-DADE, HERNANDO, HILLSBOROUGH, XXX, ORANGE,
OSCEOLA, PALM BEACH, PINELLAS, SEMINOLE COUNTIES
OCTOBER 1, 2003 - SEPTEMBER 30, 2005
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
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FLORIDA HEALTHY KIDS CORPORATION
CONTRACT FOR MEDICAL SERVICES
TABLE OF CONTENTS
SECTION 1 GENERAL PROVISIONS
1-1 Definitions
SECTION 2 FLORIDA HEALTHY KIDS CORPORATION RESPONSIBILITIES
2-1 Participant Identification
2-2 Payments
2-3 Reduced Fee Arrangements
2-3-1 Specialty Fee Arrangements
2-3-2 Children's Medical Services
2-4 Quarterly Program Updates
2-5 Change in Benefit Schedule
2-6 Marketing
2-7 Forms and Reports
2-8 Coordination of Benefits
2-9 Entitlement to Reimbursement
SECTION 3 HEALTH PLAN RESPONSIBILITIES
3-1 Benefits
3-2 Access to Care
3-2-1 Access and Appointment Standards
3-2-2 Integrity of Professional Advice to Enrollees
3-3 Fraud and Abuse
3-4 Marketing Materials
3-5 Use of Name
3-6 Eligibility
3-7 Effective Date of Coverage
3-8 Termination of Participation
3-9 Continuation of Coverage Upon Termination of this Agreement
3-10 Individual Contracts
3-11 Refusal of Coverage
3-12 Extended Coverage
3-13 Grievances and Complaints
3-14 Claims Payment
3-15 Notification
3-16 Rates
3-16 Rate Modification
3-16-1 Annual Adjustment
3-16-2 Denial of Rate Request
3-18 Conditions of Services
3-19 Medical Records Requirements
3-19-1 Medical Quality Review and Audit
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3-19-2 Privacy of Medical Records
3-19-3 Requests by Participants for Medical Records
3-20 Quality Enhancement
3-20-1 Authority
3-20-2 Staff
3-20-3 Peer Review
3-20-4 Referrals
3-21 Availability of Records
3-22 Audits
3-22-1 Accessibility of Records
3-22-2 Financial Audit
3-22-3 Post-Contract Audit
3-22-4 Accessibility for Monitoring
3-23 Indemnification
3-24 Confidentiality of Information
3-25 Insurance
3-26 Lobbying Disclosure
3-27 Reporting Requirements
3-28 Participant Liability
3-29 Protection of Proprietary Information
3-30 Regulatory Filings
SECTION 4 TERMS AND CONDITIONS
4-1 Effective Date
4-2 Multi-year Agreement
4-3 Entire Understanding
4-4 Relation to Other Laws
4-4-1 Health Insurance Portability and Accountability Act
4-4-2 Mental Health Parity Act
4-4-3 Newborns and Mothers Health Protection Act of 1996
4-5 Independent Contractor
4-6 Assignment
4-7 Notice
4-8 Amendments
4-9 Governing Law
4-10 Contract Variation
4-11 Attorney's Fees
4-12 Representatives
4-13 Termination
4-14 Contingency
4-15 Gender and Case
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
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SECTION 5 EXHIBITS
Exhibit A: Premium Payment and Rates
Exhibit B: Enrollment Dates
Exhibit C: Benefits
Exhibit D: Coordination of Benefits
Exhibit E: Access Standards
Exhibit F: Eligibility
Exhibit G: Reporting Requirements
Exhibit H: Certification Regarding Debarment, Suspension and
Involuntary Cancellation
Exhibit I: Certification Regarding Lobbying Certification For
Contracts, Grants, Loans And Cooperative Agreements
Exhibit J: Certification Regarding Health Insurance Portability and
Accountability Access Act of 1996 Compliance
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
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AGREEMENT TO PROVIDE
COMPREHENSIVE HEALTH CARE SERVICES
This agreement is made by and between the Florida Healthy Kids
Corporation, hereinafter referred to as "FHKC" and HEALTHEASE OF FLORIDA, INC.
and WELL CARE HMO, INC. hereinafter collectively referred to as "HEALTH PLAN".
WHEREAS, FHKC has been specifically empowered in section 624.91
(4)(b)(12), Florida Statutes, to enter into contracts with Health Maintenance
Organization (HMO's), INSURERS, or any provider of health care services
hereinafter referred to as HEALTH PLAN, meeting standards established by FHKC,
for the provision of comprehensive health insurance coverage to participants;
and
WHEREAS, Sections 641.2017 (1) and (2), Florida Statutes, allows HEALTH
PLAN to enter such a contractual arrangement on a prepaid per capita basis
whereby HEALTH PLAN assumes the risk that costs exceed the amount paid on a
prepaid per capita basis; and
WHEREAS, FHKC desires to increase access to health care services and
improve children's health; and
WHEREAS, FHKC did issue an Request for Proposals in the FHKC Health
Insurance Program inviting HEALTH PLAN as well as other entities, to submit a
proposal for the provision of those comprehensive health care services set forth
in the Request for Proposals; and
WHEREAS, HEALTH PLAN'S proposal in response to the Request for
Proposals was selected through a competitive bid process as one of the most
responsive bids; and
WHEREAS, HEALTH PLAN has assured FHKC of full compliance with the
standards established in this Agreement and agrees to promptly respond to any
required revisions or changes in the FHKC operating procedures or benefits which
may be required by law or implementing regulations; and
WHEREAS, HEALTH PLAN agrees that the Request for Proposals released by
FHKC in March 2003 and HEALTH PLAN'S response to that RFP are incorporated by
reference and in any conflict between the RFP or HEALTH PLAN'S response to the
RFP and this contract, the contract condition shall control; and
WHEREAS, FHKC is desirous of using HEALTH PLAN'S provider network to
deliver comprehensive health care services to all eligible FHKC participants in
Citrus, Xxxxx, Escambia, Highlands, Xxxxxx, Xxxxxx and Wakulla Counties as to
HealthEase, and Broward, Miami-Dade, Hernando, Hillsborough, Xxx, Orange,
Osceola, Palm Beach, Pinellas, Seminole as to Well Care.
NOW, THEREFORE, in consideration of the premises and the mutual
covenants and promises contained herein, the parties agree as follows:
SECTION 1 GENERAL PROVISIONS
1-1 Definitions
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As used in this agreement, the term:
A. "COMPREHENSIVE HEALTH CARE SERVICES" means those
services, medical equipment, and supplies to be
provided by HEALTH PLAN in accordance with standards
set by FHKC and further described in Exhibit C.
B. "THE PROGRAM" shall mean the project established by
FHKC pursuant to Section 624.91, Florida Statutes and
specified herein.
C. "PARTICIPANT" or "ENROLLEE" means those individuals
meeting FHKC standards of eligibility and who have
been enrolled in the program.
D. "HEALTH PLAN PROVIDERS" shall mean those providers
set forth in HEALTH PLAN'S Response to the Request
for Proposals and the participant's handbook as from
time to time amended.
E. "CO-PAYMENT" or "COST SHARING" is the payment
required of the participant at the time of obtaining
service. In the event the participant fails to pay
the required co-payment, HEALTH PLAN may decline to
provide non-emergency or non-urgently needed care
unless the participant meets the conditions for
waiver of co-payments described in Exhibit C.
F. "FRAUD" shall mean:
1) Any FHKC participant or person who
knowingly:
a) Fails, by any false statement,
misrepresentation, impersonation,
or other fraudulent means, to a
disclose a material fact used in
making a determination as to such
person's qualification to receive
comprehensive health care services
coverage under the FHKC program;
b) Fails to disclose a change in
circumstances in order to obtain or
continue to receive comprehensive
health care services coverage under
the FHKC program to which he or she
is not entitled or in an amount
larger than that which he or she is
entitled;
c) Aids and abets another person in
the commission of any such act.
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2) Any person or FHKC participant who:
a) Uses, transfers, acquires,
traffics, alters, forges, or
possess, or
b) Attempts to use, transfer, acquire,
traffic, alter, forge or possess,
or
c) Aids and abets another person in
the use, transfer, acquisition,
traffic, alteration, forgery or
possession of an FHKC
identification card.
G. "STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP)"
OR "TITLE XXI" shall mean the program created by the
federal Balanced Budget Act of 1997 as Title XXI of
the Social Security Act.
SECTION 2 FLORIDA HEALTHY KIDS CORPORATION RESPONSIBILITIES
2-1 Participant Identification
FHKC shall promptly furnish to HEALTH PLAN information to sufficiently identify
participants in the Comprehensive Health Care Services plan authorized by this
agreement. Additionally, FHKC shall provide HEALTH PLAN a compatible computer
tape, or other computer-ready media, with the names of participants along with
monthly additions or deletions throughout the term of this Agreement in
accordance with the following:
A. With respect to participants who enroll during open
enrollment, such listing shall be furnished not less than
seven (7) working days prior to the effective date of
coverage.
B. With respect to additions and deletions occurring after open
enrollment, such listing shall be furnished not less than
seven (7) working days prior to effective date of coverage.
C. With respect to both A and B above, furnish a supplemental
list of eligible participants by the third day after the
effective date of coverage. HEALTH PLAN shall adjust
enrollment retroactively to the 1st day of that month in
accordance with the supplemental list and as listed in Exhibit
B.
D. FHKC may request HEALTH PLAN to accept additional participants
after the supplemental listing for enrollment retroactive to
the 1st of that coverage month. Such additions will be limited
to those participants who made timely payments but were not
included on the previous enrollment reports. If such additions
exceed more than one percent on that month's enrollment,
HEALTH PLAN reserves the right to deny FHKC's request.
2-2 Payments
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
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FHKC will promptly forward the authorized premiums in accordance with Exhibit A
attached hereto and incorporated herein as part of this Agreement on or before
the 1st day of each month this Agreement is in force commencing with the 1st day
of October 2003. Premiums are past due on the 15th day of each month.
In the case of non-payment of premiums by the 15th day of the month for that
month of coverage, HEALTH PLAN shall have the right to terminate coverage under
this Agreement, provided FHKC is given written notice prior to such termination.
Termination of coverage shall be retroactive to the last day for which premium
payment has been made.
2-3 Reduced Fee Arrangements
2-3-1 Specialty Service Fee Arrangements
Upon prior approval of HEALTH PLAN, FHKC shall have the right
to negotiate specialty service fee arrangements with
non-HEALTH PLAN affiliated providers and make such rates
available to HEALTH PLAN. In such cases if there is a material
impact on the premium, the premium in Exhibit A will be
adjusted by HEALTH PLAN in a manner consistent with sound
actuarial practices.
2-3-2 Children's Medical Services Network
If there is a material impact on the premium in Exhibit A due
to the implementation of the Children's Medical Services
Network as created in Chapter 391, Florida Statutes, HEALTH
PLAN agrees to reduce the premium in Exhibit A in an amount
consistent with sound actuarial practices.
2-4 Program Updates
FHKC shall provide HEALTH PLAN with updates on program highlights such as
participant demographics, profiles, newsletters, legislative or regulatory
inquiries and program directives.
2-5 Change in Benefit Schedule
HEALTH PLAN understands that changes in federal and state law may require
amendments to the participant benefit schedule as set forth in Exhibit C. Should
such changes be necessary, FHKC shall notify HEALTH PLAN in writing of the
required change and HEALTH PLAN shall have thirty days (30) to agree to the
amended benefit schedule. If HEALTH PLAN elects not to implement a change in the
benefit schedule, FHKC may terminate this Agreement by providing HEALTH PLAN
with a written notice of termination and include a termination date of not less
than ninety (90) days from date of the written notification.
If a change in the benefit schedule is required, HEALTH PLAN must provide an
actuarial memorandum indicating the actuarial value of the benefit change.
2-6 Marketing
FHKC will market the program primarily through the county school districts. FHKC
agrees that HEALTH PLAN shall be allowed to participate in any scheduled
marketing efforts to include, but
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not be limited to, any scheduled open house type activities. However, HEALTH
PLAN is prohibited from any direct marketing to applicants or the use of FHKC's
logo, name or corporate identity unless such activity has received prior written
authorization from FHKC. Written authorization must be received for every
individual activity.
FHKC will have the right of approval or disapproval of all descriptive plan
literature and forms.
2-7 Forms and Reports
FHKC agrees that HEALTH PLAN shall participate in the development of any FHKC
eligibility report formats that may be required from time to time.
2-8 Coordination of Benefits
FHKC agrees that HEALTH PLAN shall be able to coordinate health benefits with
other insurers as provided for in Florida Statutes and the procedures contained
in Exhibit D attached hereto and incorporated herein as part of this Agreement.
HEALTH PLAN also agrees to coordinate benefits with any insurer under contract
with FHKC to provide comprehensive dental benefits to FHKC participants.
If HEALTH PLAN identifies a participant covered through another health benefits
program, HEALTH PLAN shall notify FHKC. FHKC shall make the decision as to
whether the participant may continue coverage through FHKC in accordance with
the eligibility standards adopted by FHKC and in accordance with any applicable
state laws.
2-9 Entitlement to Reimbursement
In the event HEALTH PLAN provides medical services or benefits to participants
who suffer injury, disease or illness by virtue of the negligent act or omission
of a third party, HEALTH PLAN shall be entitled to reimbursement from the
participant, at the prevailing rate, for the reasonable value of the services or
benefits provided. HEALTH PLAN shall not be entitled to reimbursement in excess
of the participant's monetary recovery for medical expenses provided, from the
third party.
SECTION 3 HEALTH PLAN RESPONSIBILITIES
3-1 Benefits
HEALTH PLAN agrees to make its provider network available to FHKC participants
in the counties covered by this contract and to provide the comprehensive health
care services as set forth in Exhibit C attached hereto and by reference made a
part hereof.
3-2 Access to Care
3-2-1 Access and Appointment Standards
HEALTH PLAN agrees to meet or exceed the appointment and geographic
access standards for pediatric care existing in the community and as
specifically provided for in Exhibit E attached hereto and incorporated
herein as a part of this Agreement.
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In the event HEALTH PLAN'S provider network is unable to provide those
medically necessary benefits specified in Exhibit C, for any reason,
except force majeure, HEALTH PLAN shall be responsible for those
contract benefits obtained from providers other than HEALTH PLAN for
eligible FHKC participants. In the event HEALTH PLAN fails to meet
those access standards set forth in Exhibit E, FHKC shall notify HEALTH
PLAN of its noncompliance with the standards in Exhibit E. If the
non-compliance is not corrected within ninety (90) days, FHKC may,
after following procedures set forth in Exhibit E, direct its
participants to obtain such contract benefit from other providers and
may contract for such services. All financial responsibility related to
services received under these specific circumstances shall be assumed
by HEALTH PLAN.
3-2-2 Integrity of Professional Advice to Enrollees
HEALTH PLAN ensures no interference with the advice of health care
professionals to enrollees and that information about treatments will
be provided to enrollees and their families in the appropriate manner.
HEALTH PLAN agrees to comply with any federal regulations related to
physician incentive plans and any disclosure requirements related to
such incentive plans.
3-3 Fraud and Abuse
HEALTH PLAN ensures that it has appropriate measures in place to ensure against
fraud and abuse. HEALTH PLAN shall report to FHKC any information on violations
by subcontractors or participants that pertain to enrollment or the payment and
provision of health care services under this Agreement.
HEALTH PLAN agrees to FHKC access to monitor any fraud and abuse prevention
activities conducted by HEALTH PLAN under this Agreement.
3-4 Marketing Materials
HEALTH PLAN agrees that it shall not utilize the marketing materials, logos,
trade names, service marks or other materials belonging to FHKC without FHKC's
consent that shall not be unreasonably withheld.
HEALTH PLAN will be responsible for all preparation, cost and distribution of
member handbooks, plan documents, materials, and orientation, for FHKC
participants. Materials will be appropriate to the population served and unique
to the program. All materials and documents that are distributed to FHKC
participants must be reviewed and approved by FHKC prior to distribution.
3-5 Use of Name
HEALTH PLAN consents to the use of its name in any marketing and advertising or
media presentations describing FHKC, which are developed and disseminated by
FHKC to participants, employees, employers, the general public or the County
School System, provided however, HEALTH PLAN reserves the right to review and
concur in any such marketing materials prior to their dissemination.
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3-6 Eligibility
HEALTH PLAN agrees to accept those participants that FHKC has determined meet
the program's eligibility requirements. HEALTH PLAN reserves the right to
request that FHKC review the eligibility of a particular enrollee. FHKC shall
ensure all records and findings concerning a particular eligibility
determination will be made available with reasonable promptness to the extent
permitted under section 624.91, Florida Statutes and 409.821, Florida Statutes,
regarding confidentiality of information held by FHKC. HEALTH PLAN agrees that
the FHKC is the sole determiner of whether or not a child is eligible for the
FHKC program.
3-7 Effective Date of Coverage
Coverage for every participant shall become effective at 12:01 a.m. EST/EDT, on
the first day of the participant's first coverage month, as determined by FHKC.
3-8 Termination of Participation
A participant's coverage under this program shall terminate on the last day of
the month in which the participant:
A. ceases to be eligible to participate in the program;
B. establishes residence outside the service area; or
C. is determined to have acted fraudulently pursuant to Section
1-1 (F).
Termination of coverage and the effective date of that termination shall be
determined solely by FHKC.
3-9 Continuation of Coverage Upon Termination of this Agreement
HEALTH PLAN agrees that, upon termination of this Agreement for any reason,
unless instructed otherwise by FHKC, it will continue to provide inpatient
services to FHKC participants who are then inpatients until such time as such
participants have been appropriately discharged. However, HEALTH PLAN shall not
be required to provide such extended benefits beyond 12 calendar months from the
date the Agreement is terminated.
If HEALTH PLAN terminates this Agreement at its sole option and through no fault
of the FHKC and if on the date of termination a participant is totally disabled
and such disability commenced while coverage was in effect, that participant
shall continue to receive all benefits otherwise available under this Agreement
for the condition under treatment which caused such total disability until the
earlier of (1) the expiration of the contract benefit period for such benefits;
(2) determination by the Medical Director of HEALTH PLAN that treatment is no
longer medically necessary; (3) twelve (12) months from the date of termination
of coverage; (4) a succeeding carrier elects to provide replacement coverage
without limitation as to the disability condition; provided however, that
benefits will be provided only so long as the participant is continuously
totally disabled and only for the illness or injury which caused the total
disability.
For the purpose of this section, a participant who is "totally disabled" shall
mean a participant who is physically unable to work, as determined by the
Medical Director of HEALTH PLAN, due to an illness or injury at any gainful job
for which the participant is suited by education,
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training, experience or ability. Pregnancy, childbirth or hospitalization in and
of themselves do not constitute "total disability". In the case of maternity
coverage, when participant is eligible for such coverage, when not covered by a
succeeding carrier, a reasonable period of extension of benefits shall be
granted. The extension of benefits shall be only for the period of pregnancy,
and shall not be based on total disability.
3-10 Participant Certificates and Handbooks
HEALTH PLAN will issue participant certificates, identification cards, provider
network listings and handbooks to all FHKC designated participants within five
business days of receipt of an eligibility tape. Except as specifically provided
in Sections 3-9 and 3-12 hereof, all participant rights and benefits shall
terminate upon termination of this Agreement or upon termination of
participation in the program. All participant handbooks and member materials
must be approved by FHKC prior to distribution.
3-11 Refusal of Coverage
HEALTH PLAN shall not refuse to provide coverage to any participant on the basis
of past or present health status.
3-12 Extended Coverage
With regards to those participants who have been terminated pursuant to Section
3-8 A, HEALTH PLAN agrees to offer individual coverage to all participants
without regard to health condition or status.
3-13 Grievances and Complaints
HEALTH PLAN agrees to provide all FHKC participants a Grievance Process. The
grievance and complaint procedures shall be governed by my applicable federal
and state laws and regulations issued for SCHIP, and the following additional
rules and guidelines also apply:
A. There must be sufficient support staff (clerical and
professional) available to process grievances.
B. Staff must be educated concerning the importance of the
procedure and the rights of the enrollee.
C. Someone with problem solving authority must be part of the
grievance procedure.
D. In order to initiate the grievance process, such grievance
must be filed in writing.
E. The parties will provide assistance to grievant during the
grievance process to the extent FHKC deems necessary.
F. Grievances shall be resolved within sixty days from initial
filing by the participant, unless information must be
collected from providers located outside the authorized
service area or from non-contract providers. In
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such exceptions, an additional extension shall be authorized
upon establishing good cause.
G. A record of informal complaints received that are not
grievances shall be maintained and shall Include the date,
name, nature of the complaint and the disposition.
H. The grievance procedures must conform to the federal
regulations governing the State Children's Health Insurance
Program (SCHIP).
I. A quarterly report of all grievances involving FHKC
participants must be submitted to FHKC. The report should list
the number of grievances received during the quarter and the
disposition of those grievances. HEALTH PLAN shall also inform
FHKC of any grievances that are referred to the Statewide
Subscriber Assistance Panel prior to their presentation at the
panel.
J. HEALTH PLAN shall provide FHKC with their current grievance
process for FHKC participants upon request of FHKC. Any
subsequent changes to the process must be reviewed and
approved by FHKC prior to implementation.
3-14 Claims Payment
HEALTH PLAN will pay any claims from its offices located at 0000 Xxxx Xxxxx
Xxxxxxx, Xxxxx 000. Tampa, Florida 33614 (or any other designated claims office
located in its service area). HEALTH PLAN will pay clean claims filed within
thirty (30) working days or request additional information of the claimant
necessary to process the claim.
3-15 Notification
A. HEALTH PLAN shall immediately notify FHKC in writing of:
1. Any judgment, decree, or order rendered by any court
of any jurisdiction on Florida Administrative Agency
enjoining HEALTH PLAN from the sale or provision of
service under Chapter 641, Part II, Florida Statutes.
2. Any petition by HEALTH PLAN in bankruptcy or for
approval of a plan of reorganization or arrangement
under the Bankruptcy Act or Chapter 631, Part I,
Florida Statutes, or an admission seeking the relief
provided therein.
3. Any petition or order of rehabilitation or
liquidation as provided in Chapters 631 or 641,
Florida Statutes.
4. Any order revoking the Certificate Of Authority
granted to HEALTH PLAN
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5. Any administrative action taken by the Department of
Financial Services or Agency for Health Care
Administration in regard to HEALTH PLAN.
6. Any medical malpractice action filed in a court of
law in which a FHKC participant is a party (or in
whose behalf a participant's allegations are to be
litigated).
7. The filing of an application for change of ownership
with the Florida Department of Financial Services.
8. Any change in subcontractors who are providing
services to FHKC participants.
B. Monthly Notification Requirements
HEALTH PLAN shall inform FHKC monthly of any changes to the
provider network that differ from the network presented in the
original bid proposal, including discontinuation of any
primary care providers or physician practice associations or
groups with Healthy Kids enrollees on their panels. FHKC may
require HEALTH PLAN to provide FHKC with evidence that its
provider network continues to meet the access standards
described in Exhibit E.
3-16 Rates
The rate charged for provision of Comprehensive Health Care Services shall be as
stated in Exhibit A.
3-17 Rate Modification
I. Annual Adjustment
Upon request by HEALTH PLAN, the Board of Directors of the
FHKC may approve an adjustment to the premium effective only
on October 1, however each adjustment must meet the following
minimum conditions:
A. Any request to adjust the premium must be received by
the preceding April 1;
B. The request for an adjustment must be accompanied by
a supporting actuarial memorandum;
C. The proposed premium shall not be excessive or
inadequate in accordance with the standards
established by the Department of Financial Services
for such determination;
D. The proposed premium rate shall not include an
administrative component which exceeds 15 percent;
and,
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E. The minimum medical loss ratio on the proposed
premium rate shall be 85 percent.
II. Rate Adjustment Denials
In the event that HEALTH PLAN'S rate adjustment is denied by
the Board of Directors of the FHKC, HEALTH PLAN may request
that an independent actuary be retained to determine whether
or not the proposed rate is excessive or inadequate.
A. Any request for a review of a denied rate must be
submitted by HEALTH PLAN to the FHKC in writing
within fourteen (14) calendar days of the date of the
board meeting in which the Board of Directors' denied
the rate request.
B. HEALTH PLAN must provide FHKC with a list of three
qualified Independent actuaries and also provide the
curriculum vitae for each proposed actuary within
thirty (30) days from HEALTH PLAN'S notification of
intention to seek a review of the denied rate.
C. FHKC shall select an actuary from the list provided
by HEALTH PLAN no later than fourteen (14) calendar
days following receipt of the information from HEALTH
PLAN.
D. The actuary's findings must be in writing and
communicated to both FHKC and HEALTH PLAN within
thirty (30) days after execution of the Letter of the
Engagement by all parties.
E. The effective date of the actuary's determination
shall be October 1st or the first of the month
following the receipt of the actuary's findings,
whichever occurs later.
F. The cost for such review will be shared equally
between FHKC and HEALTH PLAN.
G. The decision of the independent actuary will be
binding on FHKC and HEALTH PLAN.
3-18 Conditions of Services
Services shall be provided by HEALTH PLAN under the following
conditions:
A. Appointment. Participants shall first contact their assigned
primary care physician for an appointment in order to receive
non-emergency health services.
B. Provision of Services. Services shall be provided and paid for
by HEALTH PLAN only when HEALTH PLAN performs, prescribes,
arranges or authorizes the services. Services are available
only from and under the direction of HEALTH PLAN and neither
HEALTH PLAN nor HEALTH PLAN Physicians shall have any
liability or obligation whatsoever on account of any service
or benefit sought or received by any member from any other
physician or other person, institution or organization, unless
prior special arrangements are made by HEALTH PLAN and
confirmed in writing except as provided for in Section 3-2.
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C. Hospitalization. HEALTH PLAN does not guarantee the admission
of a participant to any specific hospital or other facility or
the availability of any accommodations or services therein.
Inpatient Hospital Service is subject to all rules and
regulations of the hospital or other medical facility to which
the member is admitted.
D. Emergency Services. Exceptions to Section 3-17 A, B and C are
services which are needed immediately for treatment of an
injury or sudden illness where delay means risk of permanent
damage to the participant's health. HEALTH PLAN shall provide
and pay for emergency services both inside and outside the
service area.
3-19 Medical Records Requirements
HEALTH PLAN shall require providers to maintain medical records for each
participant under this Agreement in accordance with applicable state and federal
law.
3-19-1 Medical Quality Review and Audit
FHKC shall conduct an independent medical quality review of
HEALTH PLAN during the contract term. The independent
auditor's report will include a written review and evaluation
of care provided to FHKC participants in the counties covered
under this Contract. Additional reviews may also be conducted
after completion of the baseline review at the discretion of
FHKC. HEALTH PLAN agrees to cooperate in all evaluation
efforts conducted or authorized by FHKC.
3-19-2 Privacy of Medical Records
HEALTH PLAN will ensure that all individual medical records
will be maintained with confidentiality in accordance with
state and federal guidelines. HEALTH PLAN agrees to abide by
all applicable state and federal laws governing the
confidentiality of minors and the privacy of individually
identifiable health information. HEALTH PLAN'S policies and
procedures for handling medical records and protected health
information (PHI) shall be compliant with the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) and shall
include provisions for when an enrollee's PHI may be disclosed
without consent or authorization.
3-19-3 Requests by Participants for Medical Records
HEALTH PLAN will ensure that each participant may request and
receive a copy of records and information pertaining to that
enrollee in a timely manner. Additionally, the participant may
request that such records be corrected on supplemented.
3-20 Quality Enhancement (Assurance)
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 16 of 50
HEALTH PLAN shall have a quality enhancement program. If HEALTH PLAN has an
existing program, it must satisfy the FHKC's quality enhancement standards.
Approval will be based on HEALTH PLAN'S adherence to the minimum standards
listed below.
3-20-1 Quality Enhancement Authority. The Plan shall have a quality
enhancement review authority that shall:
(a) Direct and review all quality enhancement activities.
(b) Assure that quality enhancement activities take place
in all areas of the plan.
(c) Review and suggest new or improved quality
enhancement activities.
(d) Direct task forces/committees in the review of
focused concern.
(e) Designate evaluation and study design procedures.
(f) Publicize findings to appropriate staff and
departments within the plan.
(g) Report findings and recommendations to the
appropriate executive authority.
(h) Direct and analyze periodic reviews of enrollees'
service utilization patterns.
3-20-2 Quality Enhancement Staff. The plan shall provide for quality
enhancement staff which has the responsibility for:
(a) Working with personnel in each clinical and
administrative department to identify problems
related to quality of care for all covered
professional services.
(b) Prioritizing problem areas for resolution and
designing strategies for change.
(c) Implementing improvement activities and measuring
success.
(d) Providing outcome of any Quality Enhancement
activities involving children 5-19 years of age to
the FHKC.
3-20-3 Peer Review Authority. The plan's quality enhancement program
shall have a peer review component and a peer review
authority.
Scope of Activities
(a) The review of the practice methods and patterns of
individual physicians and other health care
professionals.
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 17 of 50
(b) The ability and responsibility to evaluate the
appropriateness of care rendered by professionals.
(c) The authority to implement corrective action when
deemed necessary.
(d) The responsibility to develop policy recommendations
to maintain or enhance the quality of care provided
to plan participants.
(e) A review process which includes the appropriateness
of diagnosis and subsequent treatment, maintenance of
medical record requirements, adherence to standards
generally accepted by professional group peers, and
the process and outcome of care.
(f) The maintenance of written minutes of the meetings
and provision of reports to FHKC of any activities
related to FHKC participants.
(g) Peer review must include examination of morbidity and
mortality.
3-20-4 Referrals To Peer Review Authority
(a) All written and/or oral allegations of inappropriate
or aberrant service must be referred to the Peer
Review Authority.
(b) Recipients and staff must be advised of the role of
the Peer Review Authority and the process to advise
the authority of situations or problems.
(c) All grievances related to medical treatment must be
presented to the Authority for examination and, when
a FHKC participant is involved, the outcome of the
grievance resolution reported to FHKC.
3-21 Availability of Records
HEALTH PLAN shall make all records available at its own expense for review,
audit, or evaluation by authorized federal, state and FHKC personnel. The
location will be determined by HEALTH PLAN subject to approval of FHKC Access
will be during normal business hours and will be either through on-site review
of records or through the mail.
Copies of all records, will be sent to FHKC by certified mail within seven
working days of request. It is FHKC's responsibility to obtain sufficient
authority, as provided for by applicable statute or requirement, to provide for
the release of any patient specific information or records requested by the
FHKC, State or Federal agencies.
3-22 Audits
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Page 18 of 50
3-22- Accessibility of Records
HEALTH PLAN shall maintain books, records, documents, and
other evidence pertaining to the administrative costs and
expenses of the Agreement relating to the individual
participants for the purposes of audit requirements. These
records, books, documents, etc., shall be available for review
by authorized federal, state and FHKC personnel during the
Agreement period and five (5) years thereafter, except if an
audit is in progress or audit findings are yet unresolved in
which case records shall be kept until all tasks are
completed. During the contract period these records shall be
available at HEALTH PLAN'S offices at ail reasonable times.
After the contract period and for five years following, the
records shall be available at HEALTH PLAN'S chosen location
subject to the approval of FHKC. If the records need to be
sent to FHKC, HEALTH PLAN shall bear the expense of delivery.
Prior approval of the disposition of HEALTH PLAN and
subcontractor records must be requested and approved if the
contract or subcontract is continuous.
This agreement is subject to unilateral cancellation by FHKC
if HEALTH PLAN refuses to allow such public access.
3-22-2 Financial Audit
Upon reasonable notice by FHKC, HEALTH PLAN shall permit an
independent audit by FHKC of its financial condition or
performance standard in accordance with the provisions of this
agreement and the Florida Insurance Code and regulations
adopted thereunder.
Additionally, HEALTH PLAN agrees to provide an audited
financial statement to FHKC on an annual basis upon the
request of FHKC.
3-22-3 Post-Contract Audit
HEALTH PLAN agrees to cooperate with the post-contract audit
requirements of appropriate regulatory authorities and in the
interim will forward promptly HEALTH PLAN'S annually audited
financial statements to the FHKC. In addition, HEALTH PLAN
agrees to the following:
HEALTH PLAN agrees to retain and make available upon request,
all books, documents and records necessary to verify the
nature and extent of the costs of the services provided under
this Agreement, and that such records will be retained and
held available by HEALTH PLAN for such inspection until the
expiration of four (4) years after the services are furnished
under this Agreement. If, pursuant to this Agreement and if
HEALTH PLAN'S duties and obligations are to be carried out by
an individual or entity subcontracting with HEALTH PLAN and
that subcontractor is, to a significant extent, owns or is
owned by or has control of or is controlled by HEALTH PLAN,
each subcontractor shall
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 19 of 50
itself be subject to the access requirement and HEALTH PLAN
hereby agrees to require such subcontractors to meet the
access requirement.
HEALTH PLAN understands that any request for access must be in
writing and contain reasonable identification of the
documents, along with a statement as to the reason that the
appropriateness of the costs or value of the services in
question cannot be adequately or efficiently determined
without access to its books or records. HEALTH PLAN agrees
that it will notify FHKC in writing within ten (10) days upon
receipt of a request for access.
3-22-4 Accessibility for Monitoring
HEALTH PLAN shall make available to all authorized federal,
state and FHKC personnel, records, books, documents, and other
evidence pertaining to the Agreement as well as appropriate
personnel for the purpose of monitoring under this Agreement.
The monitoring shall occur periodically during the contract
period.
HEALTH PLAN also agrees to cooperate in any evaluative efforts
conducted by FHKC or an authorized subcontractor of FHKC.
3-23 Indemnification
The applicable HEALTH PLAN agrees to indemnify and hold harmless FHKC from any
losses resulting from negligent, dishonest, fraudulent or criminal acts of the
applicable HEALTH PLAN its officers, its directors, or its employees, whether
acting alone or in collusion with others.
The applicable HEALTH PLAN shall indemnify, defend, and hold FHKC and its
officers, employees and agents harmless from all claims, suits, judgments or
damages, including court costs and attorney fees, arising out of any negligent
or intentional torts by the applicable HEALTH PLAN.
The applicable HEALTH PLAN shall hold all enrolled participants harmless from
all claims for payment of covered services, except co-payments, including court
costs and attorney fees arising out of or in the course of this Agreement
pertaining to covered services. In no case will FHKC or program participants be
liable for any debts of HEALTH PLAN.
The applicable HEALTH PLAN agrees to indemnify, defend, and save harmless FHKC,
its officers, agents, and employees from:
A. Any claims or losses attributable to a service rendered by any
subcontractor, person, or firm performing or supplying
services, materials, or supplies in connection with the
performance of the contract regardless of whether FHKC knew or
should have known of such improper service, performance,
materials or supplies.
B. Any failure of HEALTH PLAN, its officers, employees, or
subcontractors to observe Florida law, including but not
limited to labor laws and minimum wage laws, regardless of
whether the FHKC knew or should have known of such failure.
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 20 of 50
With respect to the rights of indemnification given herein, FHKC agrees to
provide to HEALTH PLAN, if known to FHKC, timely written notice of any loss or
claim and the opportunity to mitigate, defend and settle such loss or claim as a
condition to indemnification
3-24 Confidentiality of Information
HEALTH PLAN shall treat all information, and in particular information relating
to participants which is obtained by or through its performance under the
Agreement, as confidential information to the extent confidential treatment is
provided under state and federal laws. HEALTH PLAN shall not use any information
so obtained in any manner except as necessary for the proper discharge of its
obligations and securement of its rights under the Agreement.
All information as to personal facts and circumstances concerning participants
obtained by HEALTH PLAN shall be treated as privileged communications, shall be
held confidential, and shall not be divulged without the written consent of FHKC
or the participant, provided that nothing stated herein shall prohibit the
disclosure of information in summary, statistical, or other form which does not
identify particular individuals. The use or disclosure of information concerning
participants will be limited to purposes directly connected with the
administration of the Agreement. It is expressly understood that substantial
evidence of HEALTH PLAN'S refusal to comply with this provision shall constitute
a breach of contract.
3-25 Insurance
HEALTH PLAN shall not commit any work in connection with the Agreement until it
has obtained all types and levels of insurance required and approved by
appropriate state regulatory agencies. The insurance includes but is not limited
to worker's compensation, liability, fire insurance, and property insurance.
Upon request, FHKC shall be provided proof of coverage of insurance by a
certificate of insurance accompanying the contract documents.
FHKC shall be exempt from and in no way liable for any sums of money that may
represent a deductible in any insurance policy. The payment of such a deductible
shall be the sole responsibility of HEALTH PLAN and/or subcontractor holding
such insurance. The same holds true of any premiums paid on any insurance policy
pursuant to this Agreement. Failure to provide proof of coverage may result in
the Agreement being terminated.
3-26 Lobbying Disclosure
HEALTH PLAN shall comply with applicable state and federal requirements for the
disclosure of information regarding lobbying activities of the firm,
subcontractors or any authorized agent. Certification forms shall be filed by
HEALTH PLAN certifying that no state or federal funds have been or will be used
in lobbying activities, and the disclosure forms shall be used by HEALTH PLAN to
disclose lobbying activities in connection with the Program that have been or
will be paid for with non-federal funds.
3-27 Reporting Requirements
HEALTH PLAN agrees to provide on a timely basis the quarterly statistical
reports detailed in Exhibit G to FHKC that FHKC must have to satisfy reporting
requirements. HEALTH PLAN also agrees to attest to the accuracy, completeness
and truthfulness of claims and payment data that are submitted to FHKC under
penalty of perjury. Access to participant claims data by FHKC,
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 21 of 50
the State of Florida, the federal Centers for Medicare and Medicaid Services,
the Department of Health and Human Services Inspector General will be allowed to
the extent allowed under any state privacy protections.
3-28 Participant Liability
HEALTH PLAN hereby agrees that no FHKC participant shall be liable to HEALTH
PLAN or any HEALTH PLAN'S network providers for any services covered by FHKC
under this Agreement. Neither HEALTH PLAN nor any representative of HEALTH PLAN
shall collect or attempt to collect from an FHKC participant any money for
services covered by the program and neither HEALTH PLAN nor representatives of
HEALTH PLAN may maintain any action at law against a FHKC participant to collect
money owed to HEALTH PLAN by FHKC. FHKC participants shall not be liable to
HEALTH PLAN for any services covered by the participant's contract with FHKC.
This provision shall not prohibit collection of co-payments made in accordance
with the terms of this Agreement. Nor shall this provision prohibit collection
for services not covered by the contract between FHKC and the participants.
3-29 Protection of Proprietary Information
HEALTH PLAN and FHKC mutually agree to maintain the integrity of all proprietary
information, including but not limited to membership lists, including names,
addresses and telephone numbers. Neither party will disclose or allow to
disclose proprietary information, by any means, to any person without the prior
written approval of the other party. All proprietary information will be so
designated.
This requirement does not extend to routine reports and membership disclosure
necessary for efficient management of the program.
3-30 Regulatory Filings
HEALTH PLAN will forward all regulatory filings, (i.e., documents, forms and
rates) relating to this Agreement to FHKC for their review and approval. Once
such regulatory filings are approved, FHKC will submit them to the Department of
Financial Services on HEALTH PLAN'S behalf.
SECTION 4 TERMS AND CONDITIONS
4-1 Effective Date
This Agreement shall be effective on the first (1st) day of October 2003 and
shall remain in effect through September 30, 2005.
4-2 Multiple Year Agreement
Parties hereto agree this is a "Multiple Year Agreement" meaning this Agreement
which is effective as of October 1, 2003 shall extend through September 30, 2005
and shall thereafter be automatically renewed for no more than (2) successive
one year periods. Either party may elect not to renew this Agreement and in that
event shall give written notice to said effect to the other party at least six
(6) months prior to the expiration of the then current term.
4-3 Entire Understanding
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Page 22 of 50
This Agreement embodies the entire understanding of the parties in relationship
to the subject matter hereof. No other agreement, understanding or
representation, verbal or otherwise, relative to the subject matter hereof
exists between the parties at the time of execution of this Agreement.
4-4 Relation to Other Laws
4-4-1 Health Insurance Portability and Accountability Act (HIPAA)
Coverage offered under this Agreement is considered creditable
coverage for the purposes of part 7 of subtitle B of title II
of ERISA, title XXVII of the Public Health Services Act and
subtitle K of the Internal Revenue Code of 1986. HEALTH PLAN
is responsible for issuing a certificate of creditable
coverage to those FHKC participants who disenroll from the
Program.
Additionally, HEALTH PLAN agrees to comply with all other
applicable provisions of the HIPAA, and will certify
compliance under Exhibit J.
4-4-2 Mental Health Parity Act(MHPA)
HEALTH PLAN agrees to comply with the requirements of the
Mental Health Parity Act of 1996 regarding parity in the
application of annual and lifetime dollar limits to mental
health benefits in accordance with 45 CFR 146.136.
4-4-3 Newborns and Mothers Health Protection Act of 1996 (NMHPA)
HEALTH PLAN agrees to comply with the requirements of the
NMHPA of 1996 regarding requirements for minimum hospital
stays for mothers and newborns in accordance with 45 CFR
146.130 and 148.170.
4-5 Independent Contractor
The relationship of HEALTH PLAN to the FHKC shall be solely that of an
independent contractor. As an independent contractor, HEALTH PLAN agrees to
comply with the following provisions:
a. Title VI of the Civil Rights Act of 1964, as amended,
42 U.S.C. 2000d et seq., which prohibits
discrimination on the basis of race, color, or
national origin.
b. Section 504 of the Rehabilitation Act of 1973, as
amended, 29 U.S.C. 794, which prohibits
discrimination on the basis of handicap.
c. Title IX of the Education Amendments of 1972, as
amended 29 U.S.C. 601 et seq., which prohibits
discrimination on the basis of sex.
d. The Age Discrimination Act of 1975, as amended, 42
U.S.C.
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 23 of 50
6101 et seq., which prohibits discrimination on the
basis of age.
e. Section 654 of the Omnibus Budget Reconciliation Act
of 1981, as amended, 42 U.S.C. 9848, which prohibits
discrimination on the basis of race, creed, color,
national origin, sex, handicap, political affiliation
or beliefs.
f. The American with Disabilities Act of 1990, P.L.
101-336, which prohibits discrimination on the basis
of disability and requires reasonable accommodation
for persons with disabilities.
g. Section 274A (e) of the Immigration and
Nationalization Act, FHKC shall consider the
employment by any contractor of unauthorized aliens a
violation of this Act. Such violation shall be cause
for unilateral cancellation of this Agreement.
h. OMB Circular A-110 (Appendix A-4) which identifies
procurement procedures which conform to applicable
federal law and regulations with regard to debarment,
suspension, ineligibility, and involuntary exclusion
of contracts and subcontracts and as contained in
Exhibit I of this Agreement. Covered transactions
include procurement contracts for services equal to
or in excess of $100,000 and all non-procurement
transactions.
i. The federal regulations implementing the State
Children's Health Insurance Program (SCHIP) as found
in 42 CFR Parts 431, 433, 435, 436 and 457 and any
subsequent revisions to the regulation.
4-6 Assignment
This Agreement may not be assigned by HEALTH PLAN without the express prior
written consent of FHKC. Any purported assignment shall be deemed null and void.
This Agreement and the monies that may become due hereunder are not assignable
by HEALTH PLAN except with the prior written approval of FHKC.
4-7 Notice
Notice required or permitted under this Agreement shall be directed as follows:
For HEALTHEASE:
PRESIDENT OR CHIEF EXECUTIVE OFFICER
0000 XXXX XXXXX XXXXXXX
XXXXX 000
XXXXX, XXXXXXX 00000
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 24 of 50
For WELL CARE HMO:
PRESIDENT OR CHIEF EXECUTIVE OFFICER
0000 XXXX XXXXX XXXXXXX
XXXXX 000
XXXXX, XXXXXXX 00000
For FHKC:
EXECUTIVE DIRECTOR
FLORIDA HEALTHY KIDS CORPORATION
POST OFFICE BOX 980
TALLAHASSEE, FL 32302
or to such other place or person as written notice thereof may
be given to the other party.
4-8 Amendment
Not withstanding anything to the contrary contained herein, this Agreement may
be amended by mutual written consent of the parties at any time.
4-9 Governing Law
This Agreement shall be construed and governed in accordance with the laws of
the State of Florida. In the event any action is brought to enforce the
provisions of this Agreement, venue shall be in Xxxx County, Florida.
4-10 Contract Variation
If any provision of the Agreement (including items incorporated by reference) is
declared or found to be illegal, unenforceable, or void, then both FHKC and
HEALTH PLAN shall be relieved of all obligations arising under such provisions.
If the remainder of the Agreement is capable of performance, it shall not be
affected by such declaration or finding and shall be fully performed. In
addition, if the laws or regulations governing this Agreement should be amended
or judicially interpreted as to render the fulfillment of the Agreement
impossible or economically infeasible, both FHKC and HEALTH PLAN will be
discharged from further obligations created under the terms of the Agreement.
4-11 Attorneys Fees
In the event that either party deems it necessary to take legal action to
enforce any provision of this Agreement the court or hearing officer, in his
discretion, may award costs and attorneys' fees to the prevailing party. Legal
actions are defined to include administrative proceedings.
4-12 Representatives
Each party shall designate a representative to serve as the day to day
management of FHKC Health Insurance Plan, helping to resolve services questions,
assuring proper arbitration in the event of a dispute, as well as responding to
general administrative and procedural problems. These individuals will be the
principal points of contact for all inquiries unless the designated
representatives specifically refer the inquiry to another party within their
respective organizations.
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 25 of 50
4-13 Termination
A. Termination for Cause
FHKC shall have the absolute right to terminate for cause, this
Agreement as to the applicable HEALTH PLAN, and all obligations
contained hereunder. Cause shall be defined as any material breach of
the applicable HEALTH PLAN'S responsibilities as set forth herein,
which can not be cured by the applicable HEALTH PLAN within 30 days
from the date of written notice from FHKC but, if the default condition
cannot be cured within the 30 days, the applicable HEALTH PLAN may, if
it has commenced reasonable efforts to correct the condition within
that 30 day period, have up to 90 days to complete the required cure.
Nothing in this Agreement shall extend this 90 day period except the
mutual consent of the parties hereto.
HEALTH PLAN shall have the absolute right to terminate for cause this
Agreement, and all obligations contained hereunder. Cause shall be
defined as any material breach of FHKC's responsibilities as set forth
herein, which can not be cured by FHKC within 30 days from the date of
written notice from HEALTH PLAN but, if the default condition cannot be
cured within the 30 days, FHKC may, if it has commenced reasonable
efforts to correct the condition within that 30 day period, have up to
90 days to complete the required cure. Nothing in this Agreement shall
extend this 90 day period except the mutual consent of the parties
hereto.
B. Change of Controlling Interest
FHKC shall have the absolute right to elect to continue or terminate
this Agreement, at its sole discretion, in the event of a change in the
ownership or controlling interest of HEALTH PLAN. HEALTH PLAN shall
provide notice of regulatory agency approval prior to any transfer or
change in control, and FHKC shall have ten (10) days thereafter to
elect continuation or termination of this Agreement. Upon such an
accepted change of controlling interest, in which the ownership of
either Well Care or HealthEase is no longer joint, FHKC shall, at the
request of HEALTH PLAN, provide each a separate contract for the
remainder of the contract term with the applicable counties as are
described herein.
C. Lack of Funding
FHKC shall have the absolute right to terminate this Agreement should
state, federal or other funds for the Program be reduced or terminated
such that the Program cannot be sustained at the sole discretion of the
FHKC. Should FHKC elect to terminate this Agreement, FHKC shall provide
HEALTH PLAN a written notice of termination and include a termination
date of not less than thirty (30) days from the date of the notice.
4-14 Contingency
This Agreement and all obligations created hereunder, are subject to
continuation and approval of funding of the FHKC by the appropriate
state and federal or local agencies.
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Page 26 of 50
4-15 Gender and Case.
Wherever in this Agreement, the singular number is used, the same shall
include the plural, and the masculine gender shall include the feminine
and neuter genders, and vice versa, as the context shall require. All
references in this Agreement to HEALTH PLAN shall be interpreted to
refer to either WellCare or HealthEase as applicable, sometimes
referred to as the "applicable HEALTH PLAN."
IN WITNESS WHEREOF the parties hereto have executed this Agreement on
the 5th day of Sept., 2003.
APPROVED AUG 21 2003 WELLCARE LEGAL SERVICES
HEALTHEASE OF FLORIDA, INC.
[ILLEGIBLE] By: /s/ Xxxx X. Xxxxx
------------------------------------ -------------------------------------
Witness Xxxxxxxx Xxxxxxx Name:
Senior Vice President & Title
General Counsel
WELL CARE HMO, INC.
[ILLEGIBLE] By: /s/ Xxxx X. Xxxxx
------------------------------------ -------------------------------------
Witness Xxxxxxxx Xxxxxxx Name:
Senior Vice President & Title
General Counsel
FLORIDA HEALTHY KIDS CORPORATION
[ILLEGIBLE] By: /s/ Xxxx X. Xxxx
------------------------------------ -------------------------------------
Witness Xxxx X. Xxxx
Executive Director
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 27 of 50
EXHIBIT A
HEALTH SERVICES AGREEMENT
I. Premium Rate
The Comprehensive Health Care Services premium for
participants in the Florida Healthy Kids Health Insurance
Program for the coverage period October 1, 2003 through
September 30, 2004 shall be as follows for each county:
As to HealthEase:
Citrus County: $83.59 per member per month
Xxxxx County: $98.53 per member per month
Escambia County: $87.51 per member per month
Highlands County: $96.54 per member per month
Xxxxxx County: $86.68 per member per month
Xxxxxx County: $79.61 per member per month
Wakulla County: $83.59 per member per month
As to Well Care:
Broward County: $83.47 per member per month
Miami-Dade County: $83.47 per member per month
Hernando County: $108.49 per member per month
Hillsborough County: $69.15 per member per month
Xxx County: $83.47 per member per month
Orange County: $69.15 per member per month
Osceola County: $69.15 per member per month
Palm Beach County: $83.47 per member per month
Pinellas County: $69.15 per member per month
Seminole County: $69.15 per member per month
II. Additional Requirements for Premium Rates
The rate listed in Paragraph of this Exhibit also
incorporates the following requirements:
A. Minimum Medical Loss Ratio
The minimum medical loss ratio
shall be 85 percent.
B. Maximum Administrative Component
The maximum administrative cost for
the premium listed in Paragraph I
of this Exhibit shall not exceed 15
percent.
III. Experience Adjustment
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Page 28 of 50
In the event that the actual experience is less than 85
percent, in the aggregate for both Well Care and HealthEase,
HEALTH PLAN shall pay to FHKC one-half of the difference.
HEALTH PLAN shall annually provide FHKC with an aggregate
experience report no later than March 1st for the prior
calendar year. If any payments are due under this provision,
HEALTH PLAN shall forward such payment with its written
notification. HEALTH PLAN may be subject to audit or
verification by FHKC or its designated agents.
FHKC is not under any further obligation if the actual loss
ratio exceeds 85%.
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 29 of 50
EXHIBIT B
ENROLLMENT PROCEDURES
1 All FHKC eligible participants will be provided with necessary
enrollment materials and forms from FHKC or its assignee.
2. FHKC will provide HEALTH PLAN with eligible participants who have
selected HEALTH PLAN or who have beet assigned by FHKC to HEALTH PLAN
according to the provisions of Section 2-1 via an enrollment tape,
using a tape layout to be specified by FHKC.
3. Upon receipt of such enrollment tape, HEALTH PLAN acting as an agent
for FHKC shall provide each participant with an enrollment package
within five business days of receipt of an enrollment tape that
includes at a minimum the following items:
A. A membership card displaying participant's name, participation
number and effective date of coverage.
B. A Participant's handbook that complies with any federal
requirements and has been approved by the FHKC, including at
a minimum, a description of how to access services, a listing
of any copayment requirements, the grievance process and the
covered benefits.
C. Current listing of all primary care physicians, specialists
and hospital providers.
4. All additions or deletions will be submitted in accordance with
referenced sections of this Agreement and Exhibit B.
5. Upon receipt of monthly tape from FHKC, HEALTH PLAN will process all
new enrollments and provide new participants with an enrollment package
within five business days of receipt of the enrollment tape.
6. Deletions will be processed by HEALTH PLAN and HEALTH PLAN will notify
each cancelled participant in writing by regular mail of the effective
date of deletion.
7. In accordance with state law, a waiting period of sixty days will be
imposed on those participants who voluntarily cancel their coverage by
non-payment of the required monthly premium. Cancelled participants
must request reinstatement from FHKC and wait at least sixty days from
the date of that request before coverage can be reinstated.
8. FHKC is the sole determiner of eligibility and effective dates of
coverage.
9. HEALTH PLAN must also comply with the guidance issued by the Office of
Civil Rights of the United States Department of Health and Human
Services ("Policy Guidance on the Title VI Prohibition against National
Origin Discrimination as it Effects Persons with Limited English
Proficiency") regarding the availability of information and assistance
for persons with limited English proficiency.
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 30 of 50
EXHIBIT C
ENROLLEE BENEFIT SCHEDULE
I. Minimum Benefits; Statutory Requirements
HEALTH PLAN agrees to provide, at a minimum, those benefits that are
prescribed by state law under Section 409.815(2)(a-b) and 409.815
(r-t). HEALTH PLAN shall pay an enrollees' covered expenses up to a
lifetime maximum of $1 million per covered enrollee.
The following health care benefits are included under this
Agreement:
BENEFIT LIMITATIONS CO-PAYMENTS
---------------------------------------------------------------------------------------------
A. Inpatient Services All admissions must be authorized by NONE
All covered services provided HEALTH PLAN. The length of the patient
for the medical care and stay shall be determined based on the
treatment of an enrollee who medical condition of the enrollee in
is admitted as an inpatient to relation to the necessary and appropriate
a hospital licensed under part level of care.
I of Chapter 395.
Room and board may be limited to
Covered services include: semi-private accommodations, unless a
physician's services; private room is considered medically
room and board; general necessary or semi-private accommodations
nursing care; patient meals; are not available.
use of operating room and
related facilities; use of Private duty nursing limited to
intensive care unit and circumstances where such care is
services; radiological, medically necessary.
laboratory and other
diagnostic tests; drugs; Admissions for rehabilitation and
medications; biologicals; physical therapy are limited to 15 days
anesthesia and oxygen per contract year.
services; special duty
nursing; radiation and Shall Not Include Experimental or
chemotherapy; respiratory Investigational Procedures as defined as
therapy; administration of a drug, biological product, device,
whole blood plasma; physical, medical treatment or procedure that meets
speech and occupational any one of the following criteria, as
therapy; medically necessary determined by HEALTH PLAN.
services of other health
professionals. 1. Reliable Evidence shows the drug,
biological product, device, medical
treatment, or procedure when applied to
the circumstances of a particular patient
is the subject of ongoing phase I, II or
III clinical trials or
2. Reliable Evidence shows the drug,
biological product, device, medical
treatment or procedure when applied to
the circumstances of a particular patient
is under study with a written protocol to
determine maximum tolerated dose,
toxicity, safety, efficacy, or efficacy
in comparison to conventional
alternatives, or
3. Reliable Evidence shows the drug,
biological product, device, medical
treatment, or procedure is being
delivered or should be delivered subject
to the approval and supervision of an
Institutional Review Board (IRB) as
required and defined by federal
regulations, particularly those of the
U.S. Food and Drug Administration or the
Department of Health and Human Services.
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Page 31 of 50
BENEFIT LIMITATIONS CO-PAYMENTS
---------------------------------------------------------------------------------------------------
B. Emergency Services Must use a HEALTH PLAN designated $10 per visit
facility or provider for emergency care waived if admitted
Covered Services include unless the time to reach such facilities or authorized by
visits to an emergency room or or providers would mean the risk of primary care
other licensed facility if permanent damage to patient's health. physician
needed immediately due to an
injury or illness and delay
means risk of permanent damage HEALTH PLAN must also comply with the
to the enrollee's health. provisions of s. 641.513, Florida
Statutes.
Infant is covered for up to three (3) days NONE
C. Maternity Services and following birth or until the infant is
Newborn Care transferred to another medical facility,
whichever occur first.
Covered services include
maternity and newborn care; Coverage may by limited to the fee for
prenatal and postnatal care; vaginal deliveries.
initial inpatient care of
adolescent participants,
including nursery charges and
initial pediatric or neonatal
examination.
Coverage is available for transplants and NONE
D. Organ Transplantation medically related services if deemed
Services necessary and appropriate within the
guidelines set by the Organ Transplant
Covered services include Advisory Council or the Bone Marrow
pretransplant, transplant and Transplant Advisory Council.
postdischarge services and
treatment of complications
after transplantation.
Services must be provided directly by No co-payment for
E. Outpatient Services HEALTH PLAN or through pre-approved office visits to the
referrals. primary care
Preventive, diagnostic, physician or for
therapeutic, palliative care, Xxxxxxx hearing and screening must be routine vision and
and other services provided to provided by primary care physician. hearing screenings.
an enrollee in the outpatient
portion of a health facility Family planning limited to one annual $5 per office visit
licensed under chapter 395. visit and one supply visit each ninety
days.
Covered services include Well- Chiropractic services shall be provided in
child care, including those the same manner as in the Florida
services recommended in the Medicaid program.
Guidelines for Health
Supervision of Children and Podiatric services are limited to one
Youth as developed by Academy visit per day totaling two visits per
of Pediatrics; immunizations month for specific foot disorders. Dental
and injections as recommended services must be provided to an oral
by the Advisory Committee on surgeon for medically necessary
Immunization Practices; health reconstructive dental surgery due to
education counseling and injury.
clinical services; family
planning services, vision Immunizations are to be provided by the
screening; hearing screening; primary care physician.
clinical radiological,
laboratory and other
outpatient diagnostic tests; Treatment for temporomandibular joint
ambulatory surgical (TMJ) disease is specifically excluded.
procedures; splints and casts;
consultation with and Shall Not Include Experimental or
treatment by referral Investigational Procedures as defined as a
physicians; radiation and drug, biological product, device, medical
chemotherapy; treatment or procedure that meets any one
of the following criteria, is determined
by HEALTH PLAN:
1. Reliable Evidence shows the drug,
biological product, device, medical
treatment, or procedure when applied to
the circumstances of a particular patient
is the subject of
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Page 32 of 50
BENEFIT LIMITATIONS CO-PAYMENTS
---------------------------------------------------------------------------------------------------
chiropractic services; podiatric ongoing phase I, II or III clinical trials
services. or
2. Reliable Evidence shows the drug,
biological product, device, medical
treatment or procedure when applied to the
circumstances of a particular patient is
under study with a written protocol to
determine maximum tolerated dose,
toxicity, safety, efficacy, or efficacy in
comparison to conventional alternatives,
or
3. Reliable Evidence shows the drug,
biological product, device, medical
treatment, or procedure is being delivered
or should be delivered subject to the
approval and supervision of an
Institutional Review Board (IRB) as
required and defined by federal
regulations, particularly those of the
U.S. Food and Drug Administration or the
Department of Health and Human Services
E. Behavioral Health All services must be provided directly by
HEALTH PLAN or upon approved referral.
Services Covered services
include inpatient and
outpatient care for Inpatient services are limited to not more INPATIENT:
psychological or psychiatric than thirty inpatient days per contract NONE
evaluation, diagnosis and year for psychiatric admissions, or
treatment by a licensed residential services in lieu of inpatient
mental health professional. psychiatric admissions; however, a
minimum of ten of the thirty days shall be
available only for inpatient psychiatric
services when authorized by HEALTH PLAN
physician.
Outpatient services are limited to a
maximum of forty outpatient visits per
contract year. OUTPATIENT: $5
per visit
F. Substance Abuse Services All services must be provided directly by INPATIENT:
HEALTH PLAN or upon approved referral. NONE
Includes coverage for
inpatient and outpatient care
for drug and alcohol abuse Inpatient services are limited to not more
including counseling and than seven inpatient days per contract
placement assistance. year for medical detoxification only and
thirty days residential services.
Outpatient services include
evaluation, diagnosis and Outpatient visits are limited to a maximum OUTPATIENT: $5
treatment by a licensed of forty visits per contract year. per visit
practitioner.
G. Therapy Services All treatments must be performed directly $5 per visit
or as authorized by HEALTH PLAN.
Covered services include physical,
occupational, respiratory and Limited to up to twenty-four treatment
speech therapies for sessions within a sixty day period per
short-term rehabilitation episode or injury, with the sixty day
where significant improvement period beginning with the first treatment.
in the enrollee's condition
will result.
H. Home Health Services Coverage is limited to skilled nursing $5 per visit
services only. Meals, housekeeping and
Includes prescribed home personal comfort items are excluded.
visits by both registered and
licensed practical nurses to Services must be provided directly by
provide skilled nursing HEALTH PLAN. Private duty nursing is
services on a part-time limited to circumstances where such care
intermittent basis. is medically appropriate.
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Page 33 of 50
BENEFIT LIMITATIONS CO-PAYMENTS
--------------------------- --------------------------------------------------- -------------------
I. Hospice Services Once a family elects to receive hospice care for an $5 per visit
enrollee, other services that treat the terminal
Covered services include condition will not be covered.
reasonable and necessary
services for palliation or Services required for conditions totally unrelated
management of an enrollee's to the terminal condition are covered to the extent
terminal illness. that the services are covered under this contract.
J. Nursing Facility Services All admissions must be authorized by HEALTH NONE
PLAN and provided by a HEALTH PLAN affiliated
Covered services include facility.
regular nursing services,
rehabilitation services, Participant must require and receive skilled
drugs and biologicals, services on a daily basis as ordered by HEALTH
medical supplies, and the PLAN physician. The length of the enrollee's stay
use of appliances and shall be determined by the medical condition of
equipment furnished by the the enrollee in relation to the necessary and
facility. appropriate level of care, but is no more than 100
days per contract year.
Room and board is limited to semi-private
accommodations unless a private room is considered
medically necessary or semi-private accommodations
are not available.
Specialized treatment centers and independent
kidney disease treatment centers are excluded.
Private duty nurses, television, and custodial care
are excluded.
Admissions for rehabilitation and physical therapy
are limited to fifteen days per contract year.
K. Durable Medical Equipment and devices must be provided by NONE
Equipment and Prosthetic authorized HEALTH PLAN supplier.
Devices
Covered prosthetic devices include artificial eyes
Equipment and devices that and limbs, braces, and other artificial aids.
are medically indicated to
assist in the treatment of Low vision and telescopic lenses are not included.
a medical condition and
specifically prescribed as Hearing aids are covered only when medically
medically necessary by indicated to assist in the treatment of a medical
enrollee's HEALTH PLAN condition.
physician.
L. Refractions Enrollee must have failed vision screening by $5 per visit
primary care physician.
Examination by a HEALTH $10 for corrective
PLAN optometrist to Corrective lenses and frames are limited to one lenses
determine the need for and pair every two years unless head size or
to prescribe corrective prescription changes.
lenses as medically
indicated. Coverage is limited to Medicaid frames with plastic
or SYL non-tinted lenses.
M. Pharmacy Prescribed drugs covered under this Agreement shall $5 per prescription
include all prescribed drugs covered under the for up to a 31-day
Prescribed drugs for the Florida Medicaid program. HEALTH PLAN may implement supply
treatment of illness or a pharmacy benefit management program if FHKC so
injury or injury. authorizes.
Brand name products are covered if a generic
substitution is not available or where the
prescribing physician indicates that a brand name
is medically necessary.
All medications must be dispensed through HEALTH
PLAN or a HEALTH PLAN designated pharmacy. All
prescriptions must be written by the participant's
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 34 of 50
BENEFIT LIMITATIONS CO-PAYMENTS
--------------------------- --------------------------------------------------- ----------------
primary care physician, HEALTH PLAN approved
specialist or consultant physician.
N. Transportation Services Must be in response to an emergency situation. $10 per service
Emergency transportation
as determined to be
medically necessary in
response to an emergency
situation.
II. Cost Sharing Provisions
HEALTH PLAN agrees to comply with all cost sharing restrictions imposed on FHKC
participants by federal or state laws and regulations, including the following
specific provisions:
A. Special Populations
Enrollees identified by FHKC to HEALTH PLAN as Native Americans or
Alaskan Natives are prohibited from paying any cost sharing amounts.
B. Cost Sharing Limited to No More than Five Percent of Family's Income
FHKC may identify to HEALTH PLAN other enrollees who have met
federal requirements regarding maximum out of pocket expenditures.
Enrollees identified by FHKC as having met this threshold are not
required to pay any further cost sharing for covered services for a
time specified by FHKC.
C. HEALTH PLAN is responsible for informing its providers of these
provisions and ensuring that enrollees under this section incur no
further out of pocket costs for covered services and are not denied
access to services. FHKC will provide these enrollees with a letter
indicating that they may not incur any cost sharing obligations.
III. Other Benefit Provision
All requirements for prior authorizations must conform with federal
and state regulations and must be completed within fourteen (14)
days of request by the enrollee. Extensions to this process may be
granted in accordance with federal and/or state regulations.
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 35 of 50
EXHIBIT D
WORKER'S COMPENSATION, THIRD PARTY CLAIM
PERSONAL INJURY PROTECTION BENEFITS, AND
COORDINATION OF BENEFITS
A. WORKER'S COMPENSATION
Worker's compensation benefits are primary to all benefits that may
be provided pursuant to this Agreement. In the event HEALTH PLAN
provides services or benefits to a participant who is entitled to
worker's compensation benefits, HEALTH PLAN shall complete and
submit to the appropriate carrier, such forms, assignments, consents
and releases as are necessary to enable HEALTH PLAN to obtain
payment, or reimbursement, under the worker's compensation law.
B. THIRD PARTY CLAIMS
In the event HEALTH PLAN provides medical services or benefits to
participants who suffer injury, disease or illness by virtue of the
negligent act or omission of a third party, HEALTH PLAN shall be
entitled to reimbursement from the participant, at the prevailing
rate, for the reasonable value of the services or benefits provided.
HEALTH PLAN shall not be entitled to reimbursement in excess of the
participant's monetary recovery for medical expenses provided, from
the third party.
C. NO-FAULT, PERSONAL INJURY PROTECTION AND MEDICAL PAYMENTS COVERAGE
As noted in the Florida Statutes (F.S. 641.31(8)), automobile
no-fault, personal injury protection, and medical payments
insurance, maintained by or for the benefit of the participant,
shall be primary to all services or benefits that may be provided
pursuant to this Agreement. In the event HEALTH PLAN provides
services or benefits to a participant who is entitled to the
aforesaid automobile insurance benefits, the parent/guardian or
participant shall complete and submit to HEALTH PLAN, or to the
automobile insurance carrier, such forms, assignments, consents and
releases as are necessary to enable HEALTH PLAN to obtain payment or
reimbursement from such automobile insurance carrier.
D. COORDINATION OF BENEFITS AMONG HEALTH HEALTH PLAN
HEALTH PLAN shall coordinate benefits in accordance with NAIC
principles as may be amended from time to time. If any benefits to
which a participant is entitled under this Agreement are also
covered under any other group health benefit plan or insurance
policy, the benefits hereunder shall be reduced to the extent that
benefits are available to participant under such other plan or
policy whether or not a claim is made for the same, subject to the
following:
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 36 of 50
EXHIBIT D
(CONTINUED)
1. The rules establishing the order of benefit determination between
this Agreement and other plan covering the participant on whose
behalf a claim is made are as follows:
(a) The benefits of a policy or plan that covers the person as an
employee, member, or subscriber, other than as a dependent are
determined before those of the policy or plan that covers the
person as a dependent.
(b) Except as stated in paragraph C, when two or more policies or
plans cover the same child as a dependent of different
parents:
(l)The benefits of the policy or plan of the parent whose
birthday, excluding year of birth, falls earlier in a year are
determined before those of the policy of the parent whose
birthday, excluding year of birth, falls later in that year;
but
(2)If both parents have the same birthday, the benefits of the
policy or plan that covered the parent for a longer period of
time are determined before those of the policy or plan which
covered the parent for shorter period of time. However, if a
policy or plan subject to the rule based on the birthday of
the parents as stated above coordinates with an out-of-state
policy or plan which contains provisions under the benefits of
a policy or a person as a dependent of a male are determined
before those of a policy or plan which covers the person as a
dependent of a female and if, as a result, the policies or
plans do not agree in the order of benefits, the provisions or
the other policy or plan shall determine the order of
benefits.
(c) If two or more policies or plans cover a dependent child of
divorced or separated parents, benefits for the child are
determined in this order:
(l)First, the policy or plan of the parent with custody of the
child;
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 37 of 50
(2)Second, the policy or plan of the spouse of the parent with
custody of the child, and (3)Third, the policy or plan of the
parent not having custody of the child. However, if the
specific terms of a court decree state that one of the parents
is responsible for the health care expenses of the child and
of the entity obliged to pay or provide the benefits of the
policy or plan or that parent has actual knowledge of those
terms, the benefits of that policy are determined first. This
does not apply with respect to any claim determination period
or plan or policy year during which any benefits are actually
paid or provided before the entity has that knowledge.
(d) The benefits of a policy or plan which covers a person as an
employee which is neither laid off nor retired, or as that
employee's dependent, are determined before those of a policy
or plan which covers that person as a laid off or retired
employee or as that employee's dependent. If the other policy
or plan is not subject to this rule, and if, as result, the
policies or plans do not agree on the order of benefits, this
paragraph shall not apply.
(e) If none of the rules in paragraph a, paragraph b, paragraph c,
or paragraph d, determine the order of benefits of the policy
or plan which covered an employee, member or subscriber for a
longer period of time are determined before those of the
policy or plan which covered that person for the shorter
period of time.
2. None of the above rules as to coordination of benefits shall limit
the participant's right to receive direct health services hereunder.
3. Any participant claiming benefits under the Agreement shall furnish
to HEALTH PLAN all information deemed necessary by it to implement
this provision.
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 38 of 50
EXHIBIT E
ACCESS AND CREDENTIALING STANDARDS
HEALTH PLAN shall maintain a medical staff, under contract, sufficient to permit
reasonably prompt medical service to all participants in accordance with the
following:
1. Physician and Facility Standards
A. Physician and Medical Provider Standards
HEALTH PLAN'S network shall include only board certified pediatricians and
family practice physicians or physician extenders working under the direct
supervision of a board certified practitioner to serve as primary care
physicians in its provider network for Xxxxx, Citrus, Escambia, Highlands,
Xxxxxx, Xxxxxx and Wakulla counties, as to HealthEase, and Broward,
Miami-Dade, Hernando, Hillsborough, Xxx, Orange, Osceola, Palm Beach,
Pinellas, Seminole, as to Well Care.
Primary care physicians must provide covered immunizations to enrollees.
HEALTH PLAN may request that an individual provider be granted an
exception to this policy by making such a request in writing to the
Corporation and providing the provider's curriculum vitae and a reason why
the provider should be granted an exception to the accepted standard. Such
requests will be reviewed by the Corporation on a case by case basis and a
written response will be made to HEALTH PLAN on the outcome of the
request.
B. Facility Standards
Facilities used for participants shall meet applicable accreditation and
licensure requirements and meet facility regulations specified by the
Agency for Health Care Administration.
2. Geographical Access:
A. Primary Care Providers
Geographical access to board certified family practice physicians,
pediatric physicians, primary care dental providers or ARNP's, experienced
in child health care, of approximately twenty (20) minutes driving time
from residence to provider, except that this driving time limitation shall
be reasonably extended in those areas where such limitation with respect
to rural residence is unreasonable. In such instance, HEALTH PLAN shall
provide access for urgent care through contracts with nearest providers.
B. Specialty Physician Services
Specialty physician services, ancillary services and specialty hospital
services are
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 39 of 50
to be available within sixty (60) minutes driving time from the
participant's residence to provider. Driving time standards may be waived
with sufficient justification if specialty care services are not
obtainable due to a limitation of providers, such as in rural areas.
3. Timely Treatment:
Timely treatment by providers, such that the participant shall be seen by
a provider in accordance with the following:
A. Emergency care shall be provided immediately;
B. Urgently needed care shall be provided within twenty-four (24) hours;
C. Routine care of patients who do not require emergency or urgently
needed care shall be provided within seven (7) calendar days;
D. Follow-up care shall be provided as medically appropriate.
For the purposes of this section, the following definitions shall apply:
Emergency care is that required for the treatment of an injury or acute
illness that, if not treated immediately, could reasonably result in
serious or permanent damage to the patient's health.
Urgently needed care is that required within a twenty-four (24) hour
period to prevent a condition from requiring emergency care.
Routine care is that level of care that can be delayed without anticipated
deterioration in the patient's medical condition for a period of seven (7)
calendar days.
By utilization of the foregoing standards, FHKC does not intend to create
standards of care or access different from those that are deemed acceptable
within HEALTH PLAN service area. Rather FHKC intends that the provider timely
and appropriately respond to patient care needs, as they are presented, in
accordance with standards of care existing within the service area. In applying
the foregoing standards, the provider shall give due regard to the level of
discomfort and anxiety of the patient and/or parent.
In the event FHKC determines that HEALTH PLAN, or its providers, has failed to
meet the access standards herein set forth, FHKC shall provide HEALTH PLAN with
written notice of non-compliance. Such notice can be provided via facsimile or
other means, specifying the failure in such detail as will reasonably allow
HEALTH PLAN to investigate and respond. Failure of HEALTH PLAN to obtain
reasonable compliance or acceptable community care under the following
conditions shall constitute a breach of this agreement:
A. immediately upon receipt of notice for emergency or urgent problem; or
B. within ten (10) days of receipt of notice for routine visit access.
Such breach shall entitle FHKC to such legal and equitable relief as may be
appropriate. In particular, FHKC may direct its participants to obtain such
services outside HEALTH PLAN
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 40 of 50
provider network as specified in Section 3-2-1 of this Agreement. HEALTH PLAN
shall be financially responsible for all services under this provision.
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 41 of 50
EXHIBIT F
ELIGIBILITY STANDARDS
PARTICIPANT ELIGIBILITY CRITERIA
The following eligibility criteria for participation in the Healthy Kids Program
must be met:
1. The participants must be children who are age 5 through 18. Participants
who applied for coverage prior to July 1, 1998 are eligible for coverage
through their 19th birthday.
For Escambia, Xxxxx and Highlands counties, some children may have age
eligibility from age 1 to 5 based on date of application to the program.
For Broward, Miami-Dade, Palm Beach and Pinellas some children may have
age eligibility from age 3 to 5 based on date of application to the
program.
2. Participants must meet the eligibility criteria established under Section
624.91, Florida Statutes, and as implemented by FHKC Board of Directors.
3. Eligible participants may enroll during time periods established by FHKC
Board of Directors and in accordance with Section 624.91, Florida
Statutes.
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 42 of 50
EXHIBIT G
REPORTING REQUIREMENTS
HEALTH PLAN shall provide the following reports and data tapes to FHKC according
to the time schedules detailed below. This information shall include all
services provided by HEALTH PLAN'S subcontractors. HEALTH PLAN is responsible
for ensuring that all subcontractors comply with these reporting requirements.
I. Data Tape
A quarterly data tape shall be prepared that will contain the following
data fields. The tape shall reflect claims and encounters entered during
the quarter and shall be delivered to FHKC according to the time table
listed below. HEALTH PLAN shall also provide quarterly tapes that reflect
claims run-off once the Agreement between HEALTH PLAN and FHKC terminates.
REQUIRED DATA FIELDS TO BE CAPTURED
- Provider's name, address and tax I.D. number (and payee's group
number if applicable)
- Patient's name address, social security number, I.D. number, birth
date, and sex
- Third party payor information, including amount(s) paid by other
payor(s).
- Primary and secondary diagnosis code(s) and treatment(s) related to
diagnosis
- Date(s) of service
- Procedure code(s)
- Unit(s) of service
- Total charge(s)
- Total payment(s)
Additional required hospital fields include the following:
- Date and type of admission (emergency, outpatient, inpatient,
newborn, etc.)
- For inpatient care: covered days and date of discharge
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 43 of 50
EXHIBIT G
(CONTINUED)
Specific pharmacy fields include:
- Pharmacy name and tax I.D. number
- Other payor information
- Rx number and date filled
- National drug code, manufacturer number, item number, package size,
quantity, days supply
- Prescriber's Florida Department of Professional Regulations number
REQUIRED TAPE FORMAT SPECIFICATIONS
The tape format is as follows or an alternative format as mutually agreed
upon by both parties:
- 1600 BPI
- EBCDIC
- 9 Track
- no labels
- each file not to exceed 100 megs in size
- fixed record length
TIME TABLE FOR DELIVERY OF TAPE
For encounters and claims processed during: Claims tape due to FHKC by:
------------------------------------------- ----------------------------
January 1 - March 31 April 15
April 1 - June 30 July 15
July 1 - September 30 October 15
October 1 - December 31 January 15
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 44 of 50
EXHIBIT H
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY,
AND VOLUNTARY EXCLUSION
CONTRACTS AND SUBCONTRACTS
THIS CERTIFICATION IS REQUIRED BY THE REGULATIONS IMPLEMENTING EXECUTIVE ORDER
12549, DEBARMENT AND SUSPENSION, SIGNED FEBRUARY 18, 1986. THE GUIDELINES WERE
PUBLISHED IN THE MAY 29, 1987, FEDERAL REGISTER (52 FED. REG., PAGES
20360-20369).
INSTRUCTIONS
A. Each HEALTH PLAN whose contract\subcontract equals or exceeds $25,000 in
federal monies must sign this certification prior to execution of each
contract\subcontract. Additionally, HEALTH PLAN'S who audit federal programs
must also sign, regardless of the contract amount. The Florida Healthy Kids
Corporation cannot contract with these types of HEALTH PLAN is if they are
debarred or suspended by the federal government.
B. This certification is a material representation of fact upon which
reliance is placed when this contract\subcontract is entered into. If it is
later determined that the signer knowingly rendered an erroneous certification,
the Federal Government may pursue available remedies, including suspension
and/or debarment.
C. HEALTH PLAN shall provide immediate written notice to the contract manager
at any time HEALTH PLAN learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
D. The terms "debarred," "suspended," "ineligible," "person," "principal,"
and "voluntarily excluded," as used in this certification, have the meanings set
out in the Definitions and Coverage sections of rules implementing Executive
Order 12549. You may contact the contract manager for assistance in obtaining a
copy of those regulations.
E. HEALTH PLAN agrees by submitting this certification that, it shall not
knowingly enter into any subcontract with a person who is debarred, suspended,
declared ineligible, or voluntarily excluded from participation in this
contract/subcontract unless authorized by the Federal Government.
F. HEALTH PLAN further agrees by submitting this certification that it will
require each subcontractor of this contract/subcontract whose payment will equal
or exceed $25,000 in federal monies, to submit a signed copy of this
certification.
G. The Florida Healthy Kids Corporation may rely upon a certification of a
HEALTH PLAN that it is not debarred, suspended, ineligible, or voluntarily
excluded from contracting\subcontracting unless it knows that the certification
is erroneous.
H. This signed certification must be kept in the contract manager's file.
Subcontractor's certifications must be kept at the contractor's business
location.
CERTIFICATION
The prospective HEALTH PLAN certifies, by signing this certification, that
neither he nor his principals is presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from participation in
this contract/subcontract by any federal agency.
Where the prospective HEALTH PLAN is unable to certify to any of the statements
in this certification, such prospective HEALTH PLAN shall attach an explanation
to this certification.
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 45 of 50
Name and Address of Organization
HEALTHEASE OF FLORIDA, INC. 0000 XXXX XXXXX XXXXXXX, XXXXX 000, XXXXX, XXXXXXX
00000
BY:/s/ Xxxx X. Xxxxx 9/8/03
--------------------------- ------
Signature Date
Xxxx X. Xxxxx
-----------------------------
Name of Authorized Individual
Name and Address of Organization
WELL CARE HMO, INC. 0000 XXXX XXXXX XXXXXXX, XXXXX 000, XXXXX, XXXXXXX 00000
BY:/s/ Xxxx X. Xxxxx 9/8/03
--------------------------- ------
Signature Date
Xxxx X. Xxxxx
-----------------------------
Name of Authorized Individual
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 46 of 50
EXHIBIT I
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE
AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No federal appropriated funds have been paid or will be paid, by or on
behalf of the undersigned, to any person for influencing or attempting to
influence an officer or employee of any agency, a member of congress, an
officer or employee of congress, or an employee of a member of congress in
connection with the awarding of any federal contract, the making of any
federal grant, the making of any federal loan, the entering into of any
cooperative agreement, and the extension, continuation, renewal,
amendment, or modification of any federal contract, grant, loan, or
cooperative agreement.
(2) If any funds other than federal appropriated funds have been paid or will
be paid to any person for influencing or attempting to influence an
officer or employee of any agency, a member of congress, an officer or
employee of congress, or an employee of a member of congress in connection
with this federal contract, grant, loan, or cooperative agreement, the
undersigned shall complete and submit Standard Form-LLL, "Disclosure Form
to Report Lobbying," in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be
included in the award documents for all subawards at all tiers (including
subcontracts, subgrants, and contracts under grants, loans, and
cooperative agreements) and that all subrecipients shall certify and
disclose accordingly.
This certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction
imposed by section 1352, Title 31, U.S. Code. Any person who fails to file the
required certification shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.
Name and Address of Organization
HEALTHEASE OF FLORIDA, INC. 0000 XXXX XXXXX XXXXXXX, XXXXX 000, XXXXX, XXXXXXX
00000
BY:/s/ Xxxx X. Xxxxx 9/8/03
--------------------------- ------
Signature Date
Xxxx X. Xxxxx
-----------------------------
Name of Authorized Individual
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 47 of 50
Name and Address of Organization
WELL CARE HMO, INC. 0000 XXXX XXXXX XXXXXXX, XXXXX 000, XXXXX, XXXXXXX 00000
BY:/s/ Xxxx X. Xxxxx 9/8/03
--------------------------- ------
Signature Date
Xxxx X. Xxxxx
-----------------------------
Name of Authorized Individual
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 48 of 50
EXHIBIT J
CERTIFICATION
REGARDING HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996
COMPLIANCE
This certification is required for compliance with the requirements of the
Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The undersigned HEALTH PLAN certifies and agrees as to abide by the following:
1. Protected Health Information. For purposes of this Certification,
Protected Health Information shall have the same meaning as the term
"protected health information" in 45 C.F.R. Section 164.501, limited
to the information created or received by HEALTH PLAN from or on
behalf of the FHKC.
2. Limits on Use and Disclosure of Protected Health Information (PHI)
HEALTH PLAN shall not use or disclose Protected Health Information
other than as permitted by this Contract or by federal and state
law. HEALTH PLAN will use appropriate safeguards to prevent the use
or disclosure of Protected Health Information for any purpose not in
conformity with this Contract and federal and state law. HEALTH PLAN
will not divulge, disclose, or communicate in any manner any
Protected Health Information to any third party without prior
written consent from the FHKC. HEALTH PLAN will report to the FHKC,
within two (2) business days of discovery, any use or disclosure of
Protected Health Information not provided for in this Contract of
which HEALTH PLAN is aware. A violation of this paragraph shall be a
material violation of this Contract.
3. Use and Disclosure of Information for Management, Administration,
and Legal Responsibilities. HEALTH PLAN is permitted to use and
disclose Protected Health Information received from FHKC for the
proper management and administration of HEALTH PLAN or to carry out
the legal responsibilities of HEALTHEASE, in accordance with 45
C.F.R. 164.504(e)(4). Such disclosure is only permissible where
required by law, or where HEALTH PLAN obtains reasonable assurances
from the person to whom the Protected Health Information is
disclosed that: (1) the Protected Health Information will be held
confidentially, (2) the Protected Health Information will be used or
further disclosed only as required by law or for the purposes for
which it was disclosed to the person, and (3) the person notifies
HEALTH PLAN of any instance of which it is aware in which the
confidentiality of the Protected Health Information has been
breached.
4. Disclosure to Subcontractors or Agents. HEALTH PLAN agrees to enter
into a subcontract with any person, including a subcontractor or
agent, to whom it provides Protected Health Information received
from, or created or received by HEALTH PLAN on behalf of, the FHKC.
Such subcontract shall contain the same terms, conditions, and
restrictions that apply to HEALTH PLAN with respect to Protected
Health Information.
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 49 of 50
5. Access to Information. HEALTH PLAN shall make Protected Health
Information available in accordance with federal and state law,
including providing a right of access to persons who are the
subjects of the Protected Health Information.
6. Amendment and Incorporation of Amendments. HEALTH PLAN shall make
Protected Health Information available for amendment and to
incorporate any amendments to the Protected Health Information in
accordance with 45 C.F.R. Section 164.526.
7. Accounting for Disclosures. HEALTH PLAN shall make Protected Health
Information available as required to provide an accounting of
disclosures in accordance with 45 C.F.R. Section 164.528.
8. Access to Books and Records. HEALTH PLAN shall make its internal
practices, books, and records relating to the use and disclosure of
Protected Health Information received from, or created or received
by HEALTH PLAN on behalf of, the FHKC to the Secretary of the
Department of Health and Human Services or the Secretary's designee
for purposes of determining compliance with the Department of Health
and Human Services Privacy Regulations.
9. Termination. At the termination of this contract, HEALTH PLAN shall
return all Protected Health Information that HEALTH PLAN still
maintains in any form, including any copies or hybrid or merged
databases made by HEALTH PLAN; or with prior written approval of the
FHKC, the Protected Health Information may be destroyed by HEALTH
PLAN after its use. If the Protected Health Information is destroyed
pursuant to the FHKC's prior written approval, HEALTH PLAN must
provide a written confirmation of such destruction to the FHKC. If
return or destruction of the Protected Health Information is
determined not feasible by the FHKC, HEALTH PLAN agrees to protect
the Protected Health Information and treat it as strictly
confidential.
CERTIFICATION
HEALTH PLAN and the Florida Healthy Kids Corporation have caused
this Certification to be signed and delivered by their duty
authorized representatives, as of the date set forth below.
HEALTHEASE:
/s/ Xxxx X. Xxxxx 9/8/03
------------------- ------
Signature Date
Xxxx X. Xxxxx, President & CEO
-----------------------------------
Name and Title of Authorized Signee
WELL CARE HMO:
/s/ Xxxx X. Xxxxx 9/8/03
----------------------------------- ------
Signature Date
Xxxx X. Xxxxx, President & CEO
-----------------------------------
Name and Title of Authorized Signee
HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005
Page 50 of 50
