EXHIBIT 10.36
MEDICAL SERVICES CONTRACT
FLORIDA HEALTHY KIDS CORPORATION
AND
AMERIGROUP FLORIDA, INC.
FOR
BROWARD, MIAMI-DADE, HILLSBOROUGH, ORANGE, PALM BEACH AND
PINELLAS
OCTOBER 1, 2003 - SEPTEMBER 30, 2005
AMERIGROUP Effective Date: 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 AMERIGROUP
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
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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
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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 AMERIGROUP Florida, Inc.,
hereinafter referred to as "AMERIGROUP".
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 AMERIGROUP, 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
AMERIGROUP to enter such a contractual arrangement on a prepaid per capita basis
whereby AMERIGROUP 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 AMERIGROUP 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, AMERIGROUP'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, AMERIGROUP 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, AMERIGROUP agrees that the Request for Proposals released by
FHKC in March 2003 and AMERIGROUP'S response to that RFP are incorporated by
reference and in any conflict between the RFP or AMERIGROUP'S response to the
RFP and this contract, the contract condition shall control; and
WHEREAS, FHKC is desirous of using AMERIGROUP'S provider network to
deliver comprehensive health care services to all eligible FHKC participants in
Broward, Miami-Dade, Hillsborough, Orange, Palm Beach and Pinellas counties;
NOW, THEREFORE, in consideration of the premises and the mutual
covenants and promises contained herein, the parties agree as follows:
SECTION 1 GENERAL PROVISIONS
1-1 Definitions
As used in this agreement, the term:
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A. "COMPREHENSIVE HEALTH CARE SERVICES" means those
services, medical equipment, and supplies to be
provided by AMERIGROUP 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. "AMERIGROUP PROVIDERS" shall mean those providers set
forth in AMERIGROUP'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, AMERIGROUP 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.
2) Any person or FHKC participant who:
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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 AMERIGROUP information to sufficiently identify
participants in the Comprehensive Health Care Services plan authorized by this
agreement. Additionally, FHKC shall provide AMERIGROUP 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. AMERIGROUP 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 AMERIGROUP 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,
AMERIGROUP reserves the right to deny FHKC's request.
2-2 Payments
FHKC will promptly forward the authorized premiums in accordance with Exhibit A
attached hereto and incorporated herein as part of this Agreement on or before
the 1st day of each month
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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, AMERIGROUP 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 AMERIGROUP, FHKC shall have the right
to negotiate specialty service fee arrangements with
non-AMERIGROUP affiliated providers and make such rates
available to AMERIGROUP. In such cases if there is a material
impact on the premium, the premium in Exhibit A will be
adjusted by AMERIGROUP 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,
AMERIGROUP agrees to reduce the premium in Exhibit A in an
amount consistent with sound actuarial practices.
2-4 Program Updates
FHKC shall provide AMERIGROUP with updates on program highlights such as
participant demographics, profiles, newsletters, legislative or regulatory
inquiries and program directives.
2-5 Change in Benefit Schedule
AMERIGROUP 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 AMERIGROUP in writing of the
required change and AMERIGROUP shall have thirty days (30) to agree to the
amended benefit schedule. If AMERIGROUP elects not to implement a change in the
benefit schedule, FHKC may terminate this Agreement by providing AMERIGROUP 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, AMERIGROUP 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 AMERIGROUP shall be allowed to participate in any scheduled
marketing efforts to include, but not be limited to, any scheduled open house
type activities. However, AMERIGROUP is prohibited from any direct marketing to
applicants or the use of FHKC's logo, name or corporate
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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 AMERIGROUP 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 AMERIGROUP 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.
AMERIGROUP also agrees to coordinate benefits with any insurer under contract
with FHKC to provide comprehensive dental benefits to FHKC participants.
If AMERIGROUP identifies a participant covered through another health benefits
program, AMERIGROUP 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 AMERIGROUP 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, AMERIGROUP shall be entitled to reimbursement from the
participant, at the prevailing rate, for the reasonable value of the services or
benefits provided. AMERIGROUP shall not be entitled to reimbursement in excess
of the participant's monetary recovery for medical expenses provided, from the
third party.
SECTION 3 AMERIGROUP RESPONSIBILITIES
3-1 Benefits
AMERIGROUP agrees to make its provider network available to FHKC participants in
Broward, Miami-Dade, Hillsborough, Orange, Palm Beach and Pinellas counties 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
AMERIGROUP agrees to meet or exceed the appointment and geographic
access standards for pediatric care existing in the community and as
specifically provided for in Exhibit E attached hereto and incorporated
herein as a part of this Agreement.
In the event AMERIGROUP'S provider network is unable to provide those
medically necessary benefits specified in Exhibit C, for any reason,
except force majeure,
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AMERIGROUP shall be responsible for those contract benefits obtained
from providers other than AMERIGROUP for eligible FHKC participants. In
the event AMERIGROUP fails to meet those access standards set forth in
Exhibit E, FHKC shall notify AMERIGROUP 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 AMERIGROUP.
3-2-2 Integrity of Professional Advice to Enrollees
AMERIGROUP 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.
AMERIGROUP 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
AMERIGROUP ensures that it has appropriate measures in place to ensure against
fraud and abuse. AMERIGROUP 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.
AMERIGROUP agrees to FHKC access to monitor any fraud and abuse prevention
activities conducted by AMERIGROUP under this Agreement.
3-4 Marketing Materials
AMERIGROUP 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.
AMERIGROUP 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
AMERIGROUP 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, AMERIGROUP reserves the right to review and
concur in any such marketing materials prior to their dissemination.
3-6 Eligibility
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AMERIGROUP agrees to accept those participants that FHKC has determined meet the
program's eligibility requirements. AMERIGROUP 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. AMERIGROUP 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
AMERIGROUP 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, AMERIGROUP shall not
be required to provide such extended benefits beyond 12 calendar months from the
date the Agreement is terminated.
If AMERIGROUP 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 AMERIGROUP 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 AMERIGROUP, due to an illness or injury at any gainful job
for which the participant is suited by education, training, experience or
ability. Pregnancy, childbirth or hospitalization in and of themselves do not
constitute "total disability". In the case of maternity coverage, when
participant is eligible for
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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
AMERIGROUP 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
AMERIGROUP 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, AMERIGROUP agrees to offer individual coverage to all participants
without regard to health condition or status.
3-13 Grievances and Complaints
AMERIGROUP agrees to provide all FHKC participants a Grievance Process. The
grievance and complaint procedures shall be governed by any 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 such
exceptions, an additional extension shall be authorized upon
establishing good cause.
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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. AMERIGROUP shall also inform
FHKC of any grievances that are referred to the Statewide
Subscriber Assistance Panel prior to their presentation at the
panel.
J. AMERIGROUP 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
AMERIGROUP will pay any claims from its offices located at 0000 Xxxxxxxxxxx
Xxxx, Xxxxxxxx Xxxxx, XX 00000 (or any other designated claims office located in
its service area). AMERIGROUP 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. AMERIGROUP shall immediately notify FHKC in writing of:
1. Any judgment, decree, or order rendered by any court
of any jurisdiction or Florida Administrative Agency
enjoining AMERIGROUP from the sale or provision of
service under Chapter 641, Part II, Florida Statutes.
2. Any petition by AMERIGROUP 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 AMERIGROUP.
5. Any administrative action taken by the Department of
Financial Services or Agency for Health Care
Administration in regard to AMERIGROUP.
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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
AMERIGROUP 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 AMERIGROUP 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 AMERIGROUP, 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,
E. The minimum medical loss ratio on the proposed
premium rate shall be 85 percent.
II. Rate Adjustment Denials
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In the event that AMERIGROUP'S rate adjustment is denied by
the Board of Directors of the FHKC, AMERIGROUP 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 AMERIGROUP 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. AMERIGROUP 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 AMERIGROUP'S notification of
intention to seek a review of the denied rate.
C. FHKC shall select an actuary from the list provided
by AMERIGROUP no later than fourteen (14) calendar
days following receipt of the information from
AMERIGROUP.
D. The actuary's findings must be in writing and
communicated to both FHKC and AMERIGROUP 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 AMERIGROUP.
G. The decision of the independent actuary will be
binding on FHKC and AMERIGROUP.
3-18 Conditions of Services
Services shall be provided by AMERIGROUP 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 AMERIGROUP only when AMERIGROUP performs, prescribes,
arranges or authorizes the services. Services are available
only from and under the direction of AMERIGROUP and neither
AMERIGROUP nor AMERIGROUP 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 AMERIGROUP and confirmed in
writing except as provided for in Section 3-2.
C. Hospitalization. AMERIGROUP 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
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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. AMERIGROUP shall provide
and pay for emergency services both inside and outside the
service area.
3-19 Medical Records Requirements
AMERIGROUP 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
AMERIGROUP 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 by the
Contract. Additional reviews may also be conducted after
completion of the baseline review at the discretion of FHKC.
AMERIGROUP agrees to cooperate in all evaluation efforts
conducted or authorized by FHKC.
3-19-2 Privacy of Medical Records
AMERIGROUP will ensure that all individual medical records
will be maintained with confidentiality in accordance with
state and federal guidelines. AMERIGROUP agrees to abide by
all applicable state and federal laws governing the
confidentiality of minors and the privacy of individually
identifiable health information. AMERIGROUP'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
AMERIGROUP will ensure that each participant may request and
receive a copy of records and information pertaining to that
enrollee in a timely manner. Additionally, the participant may
request that such records be corrected or supplemented.
3-20 Quality Enhancement (Assurance)
AMERIGROUP shall have a quality enhancement program. If AMERIGROUP has an
existing program, it must satisfy the FHKC's quality enhancement standards.
Approval will be based on AMERIGROUP adherence to the minimum standards listed
below.
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 16 of 45
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.
(b) The ability and responsibility to evaluate the
appropriateness of care rendered by professionals.
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 17 of 45
(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
AMERIGROUP 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 AMERIGROUP 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
3-22- Accessibility of Records
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 18 of 45
AMERIGROUP 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
AMERIGROUP'S offices at all reasonable times. After the
contract period and for five years following, the records
shall be available at AMERIGROUP'S chosen location subject to
the approval of FHKC. If the records need to be sent to FHKC,
AMERIGROUP shall bear the expense of delivery. Prior approval
of the disposition of AMERIGROUP 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 AMERIGROUP refuses to allow such public access.
3-22-2 Financial Audit
Upon reasonable notice by FHKC, AMERIGROUP 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, AMERIGROUP agrees to provide an audited
financial statement to FHKC on an annual basis upon the
request of FHKC.
3-22-3 Post-Contract Audit
AMERIGROUP agrees to cooperate with the post-contract audit
requirements of appropriate regulatory authorities and in the
interim will forward promptly AMERIGROUP'S annually audited
financial statements to the FHKC. In addition, AMERIGROUP
agrees to the following:
AMERIGROUP 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 AMERIGROUP 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
AMERIGROUP'S duties and obligations are to be carried out by
an individual or entity subcontracting with AMERIGROUP and
that subcontractor is, to a significant extent, owns or is
owned by or has control of or is controlled by AMERIGROUP,
each subcontractor shall itself be subject to the access
requirement and AMERIGROUP hereby agrees to require such
subcontractors to meet the access requirement.
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 19 of 45
AMERIGROUP 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. AMERIGROUP 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
AMERIGROUP 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.
AMERIGROUP also agrees to cooperate in any evaluative efforts
conducted by FHKC or an authorized subcontractor of FHKC.
3-23 Indemnification
AMERIGROUP agrees to indemnify and hold harmless FHKC from any losses resulting
from negligent, dishonest, fraudulent or criminal acts of AMERIGROUP, its
officers, its directors, or its employees, whether acting alone or in collusion
with others.
AMERIGROUP 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 AMERIGROUP.
AMERIGROUP 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 AMERIGROUP.
AMERIGROUP 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 AMERIGROUP, its officers, employees, or
subcontractors to observe Florida law, including but not
limited to labor laws and minimum wage laws, regardless of
whether the FHKC knew or should have known of such failure.
With respect to the rights of indemnification given herein, FHKC agrees to
provide to AMERIGROUP, 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
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 20 of 45
3-24 Confidentiality of Information
AMERIGROUP 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. AMERIGROUP 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 AMERIGROUP 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 AMERIGROUP'S refusal to comply with this provision shall constitute
a breach of contract.
3-25 Insurance
AMERIGROUP 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 AMERIGROUP 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
AMERIGROUP 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
AMERIGROUP certifying that no state or federal funds have been or will be used
in lobbying activities, and the disclosure forms shall be used by AMERIGROUP 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
AMERIGROUP 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. AMERIGROUP also agrees to attest to the accuracy, completeness and
truthfulness of claims and payment data that are submitted to FHKC under penalty
of perjury. Access to participant claims data by FHKC, the State of Florida, the
federal Centers for 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.
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 21 of 45
3-28 Participant Liability
AMERIGROUP hereby agrees that no FHKC participant shall be liable to AMERIGROUP
or any AMERIGROUP network providers for any services covered by FHKC under this
Agreement. Neither AMERIGROUP nor any representative of AMERIGROUP shall collect
or attempt to collect from an FHKC participant any money for services covered by
the program and neither AMERIGROUP nor representatives of AMERIGROUP may
maintain any action at law against a FHKC participant to collect money owed to
AMERIGROUP by FHKC. FHKC participants shall not be liable to AMERIGROUP 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
AMERIGROUP 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
AMERIGROUP 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 AMERIGROUP'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
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.
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 22 of 45
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. AMERIGROUP is
responsible for issuing a certificate of creditable coverage
to those FHKC participants who disenroll from the Program.
Additionally, AMERIGROUP 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)
AMERIGROUP 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)
AMERIGROUP 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 AMERIGROUP to the FHKC shall be solely that of an
independent contractor. As an independent contractor, AMERIGROUP agrees to
comply with the following provisions:
a. Title VI of the Civil Rights Act of 1964, as amended,
42 U.S.C. 2000d et seq., which prohibits
discrimination on the basis of race, color, or
national origin.
b. Section 504 of the Rehabilitation Act of 1973, as
amended, 29 U.S.C. 794, which prohibits
discrimination on the basis of handicap.
c. Title IX of the Education Amendments of 1972, as
amended 29 U.S.C. 601 et seq., which prohibits
discrimination on the basis of sex.
d. The Age Discrimination Act of 1975, as amended, 42
U.S.C. 6101 et seq., which prohibits discrimination
on the basis of age.
e. Section 654 of the Omnibus Budget Reconciliation Act
of
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 23 of 45
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 AMERIGROUP 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 AMERIGROUP except with the prior written approval of FHKC.
4-7 Notice
Notice required or permitted under this Agreement shall be directed as follows:
For AMERIGROUP:
XX. XXXXX XXXXXX
MANAGER, REGULATORY COMPLIANCE
0000 XXXXXXXXXXX XXXX
XXXXXXXX XXXXX, XX 00000
For FHKC:
EXECUTIVE DIRECTOR
FLORIDA HEALTHY KIDS CORPORATION
XXXX XXXXXX XXX 000
XXXXXXXXXXX, XX 00000
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 24 of 45
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
AMERIGROUP 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 AMERIGROUP 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.
4-13 Termination
A. Termination for Cause
FHKC shall have the absolute right to terminate for cause, this
Agreement, and all obligations contained hereunder. Cause shall be
defined as any material breach of AMERIGROUP'S responsibilities as set
forth herein, which can not be cured by AMERIGROUP within 30 days from
the date of written notice from FHKC but, if the default condition
cannot be cured within the 30 days, AMERIGROUP may, if it has commenced
reasonable efforts to correct the condition within that 30 day period,
have
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 25 of 45
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.
AMERIGROUP 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 AMERIGROUP 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 AMERIGROUP. AMERIGROUP 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.
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
AMERIGROUP 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.
IN WITNESS WHEREOF the parties hereto have executed this Agreement on
the 15 day of July, 2003.
AMERIGROUP FLORIDA, INC.
BY:
/s/ [ILLEGIBLE] /s/ Xxxxxx Xxxxxxx
------------------------------ ----------------------------------------
Witness Name:
Title
FLORIDA HEALTHY KIDS CORPORATION
BY:
/s/ [ILLEGIBLE] /s/ Xxxx X. Xxxx
------------------------------ ----------------------------------------
Witness Xxxx X. Xxxx
Executive Director
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 26 of 45
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:
Broward County: $83.47 per member per month
Miami-Dade County: $83.47 per member per month
Hillsborough County: $69.15 per member per month
Orange County: $70.64 per member per month
Palm Beach County: $83.47 per member per month
Pinellas County: $69.15 per member per month
II. Additional Requirements for Premium Rates
The rate listed in Paragraph I 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.
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 27 of 45
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 AMERIGROUP with eligible participants who have
selected AMERIGROUP or who have been assigned by FHKC to AMERIGROUP
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, AMERIGROUP 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, AMERIGROUP 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 AMERIGROUP and AMERIGROUP 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. AMERIGROUP 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.
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 28 of 45
EXHIBIT C
ENROLLEE BENEFIT SCHEDULE
I. Minimum Benefits; Statutory Requirements
AMERIGROUP agrees to provide, at a minimum, those benefits that are
prescribed by state law under Section 409.815(2)(a-p) and 409.815
(r-t). AMERIGROUP 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 AMERIGROUP. NONE
All covered services provided for The length of the patient stay shall be determined based on
the medical care and treatment the medical condition of the enrollee in relation to
of an enrollee who is admitted the necessary and appropriate level of care.
as an inpatient to a hospital
licensed under part I of
Chapter 395. Room and board may be limited to semi-private accommodations,
Covered services include: unless a private room is considered medically necessary
physician's services; or semi-private accommodations are not available.
room and board; general Private duty nursing limited to circumstances where
nursing care; patient meals; such care is medically necessary.
use of operating room and Admissions for rehabilitation and physical therapy are limited
related facilities; use of to 15 days per contract year.
intensive care unit and Shall Not Include Experimental or Investigational Procedures as
services; radiological, defined as a drug, biological product, device, medical treatment
laboratory and other or procedure that meets any one of the following criteria,
diagnostic tests; drugs; as determined by AMERIGROUP.
medications; biologicals; 1. Reliable Evidence shows the drug, biological product, device,
anesthesia and oxygen medical treatment, or procedure when applied to the
services; special duty circumstances of a particular patient is the subject of
nursing; radiation and ongoing phase I, II or III clinical trials or
chemotherapy; respiratory 2. Reliable Evidence shows the drug, biological product,
therapy; administration of device, medical treatment or procedure when applied to
whole blood plasma; physical, the circumstances of a particular patient is under
speech and occupational therapy; study with a written protocol to determine maximum
medically necessary services tolerated dose, toxicity, safety, efficacy, or efficacy
of other health professionals. 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.
-------------------------------------------------------------------------------------------------------------------
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 29 of 45
-----------------------------------------------------------------------------------------------------------------
BENEFIT LIMITATIONS CO-PAYMENTS
-----------------------------------------------------------------------------------------------------------------
B. Emergency Services Must use a AMERIGROUP designated $ 10 per visit waived if
Covered Services include visits facility or provider for emergency care admitted or authorized
to an emergency room or other unless the time to reach such facilities by primary care physician
licensed facility if needed or providers would mean the risk of
immediately due to an injury permanent damage to patient's health.
or illness and delay
means risk of permanent AMERIGROUP must also comply with the
damage to the enrollee's provisions of s. 641.513, Florida
health. Statutes.
-----------------------------------------------------------------------------------------------------------------
C. Maternity Services and Infant is covered for up to three (3) NONE
Newborn Care days following birth or until the infant
Covered services include is transferred to another medical
maternity and newborn care; facility, whichever occurs first.
prenatal and postnatal care;
initial inpatient care of Coverage may be limited to the fee for
adolescent participants, vaginal deliveries.
including nursery charges and
initial pediatric or neonatal
examination.
-----------------------------------------------------------------------------------------------------------------
D. Organ Transplantation Coverage is available for transplants NONE
Services and medically related services if deemed
Covered services include necessary and appropriate within the
pretransplant, transplant and guidelines set by the Organ Transplant
postdischarge services and Advisory Council or the Bone Marrow
treatment of complications Transplant Advisory Council.
after transplantation.
-----------------------------------------------------------------------------------------------------------------
E. Outpatient Services Services must be provided directly by No co-payment for well
Preventive, diagnostic, AMERIGROUP or through pre-approved child care, preventive
therapeutic, palliative care, referrals. care or for routine vision
and other services provided to and hearing screenings.
an enrollee in the outpatient Routine hearing and screening must be
portion of a health facility provided by primary care physician.
licensed under chapter 395.
Family planning limited to one annual
visit and one supply visit each ninety $5 per office visit
days.
Covered services include
Well-child care, including Chiropractic services shall be provided
those services recommended in the same manner as in the Florida
in the Guidelines for Medicaid program.
Health Supervision of
Children and Youth as Podiatric services are limited to one visit
developed by Academy of per day totaling two visits per month for
Pediatrics; immunizations specific foot disorders. Dental services
and injections as must be provided to an oral surgeon for
recommended by the medically necessary reconstructive dental
Advisory Committee on surgery due to injury.
Immunization Practices;
health education Immunizations are to be provided by the
counseling and clinical primary care physician.
services; family planning
services, vision Treatment for temporomandibular joint
screening; hearing (TMJ) disease is specifically excluded.
screening; clinical
radiological, laboratory Shall Not Include Experimental or
and other outpatient Investigational Procedures as defined as a
diagnostic tests; drug, biological product, device, medical
ambulatory surgical treatment or procedure that meets any one of
procedures; splints and the following criteria, as determined by
casts; consultation with AMERIGROUP:
and treatment by referral 1. Reliable Evidence shows the drug,
physicians; radiation and biological product, device, medical
chemotherapy; treatment, or procedure when applied to the
circumstances of a particular patient is
the subject of
-----------------------------------------------------------------------------------------------------------------
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 30 of 45
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BENEFIT LIMITATIONS CO-PAYMENTS
-----------------------------------------------------------------------------------------------------
chiropractic services; ongoing phase I, II or III clinical trials or
podiatric services. 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 Services All services must be provided directly
Covered services include by AMERIGROUP or upon approved
inpatient and outpatient care referral.
for psychological or
psychiatric evaluation, Inpatient services are limited to not INPATIENT:
diagnosis and treatment by a more than thirty inpatient days per NONE
licensed mental health contract year for psychiatric
professional. admissions, or residential services in
lieu of inpatient psychiatric
admissions; however, a minimum of ten
of the thirty days shall be available
only for inpatient psychiatric
services when authorized by AMERIGROUP
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:
Includes coverage for AMERIGROUP or upon approved referral. NONE
inpatient and outpatient
care for drug and alcohol Inpatient services are limited to not more
abuse including counseling than seven inpatient days per contract
and placement assistance. year for medical detoxification only and
Outpatient services include thirty days residential services.
evaluation, diagnosis and
treatment by a licensed Outpatient visits are limited to a maximum
practitioner. of forty visits per contract year. OUTPATIENT:$5
per visit
-----------------------------------------------------------------------------------------------------
G. Therapy Services All treatments must be performed directly $5 per visit
Covered services include physical, or as authorized by AMERIGROUP.
occupational, respiratory and
speech therapies for Limited to up to twenty-four treatment
short-term rehabilitation sessions within a sixty day period per
where significant improvement episode or injury, with the sixty day
in the enrollee's condition period beginning with the first
will result. treatment.
-----------------------------------------------------------------------------------------------------
H. Home Health Services Coverage is limited to skilled nursing $5 per visit
Includes prescribed home services only. Meals, housekeeping and
visits by both registered and personal comfort items are excluded.
licensed practical nurses to Services must be provided directly by
provide skilled nursing AMERIGROUP.
services on a part-time
intermittent basis. Private duty nursing is limited to
circumstances where such care is
medically appropriate.
-----------------------------------------------------------------------------------------------------
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 31 of 45
-----------------------------------------------------------------------------------------------------------
BENEFIT LIMITATIONS CO-PAYMENTS
-----------------------------------------------------------------------------------------------------------
I. Hospice Services Once a family elects to receive hospice $5 per visit
Covered services include reasonable care for an enrollee, other services
and necessary services for palliation that treat the terminal condition will
or management of not be covered. an not be covered.
enrollee's terminal illness.
Services required for conditions totally
unrelated to the terminal condition are
covered to the extent that the services
are covered under this contract.
-----------------------------------------------------------------------------------------------------------
J.Nursing Facility Services All admissions must be authorized by NONE
AMERIGROUP and provided by a AMERIGROUP
Covered services include affiliated facility.
regular nursing services, Participant must require and receive skilled
rehabilitation services, services on a daily basis as ordered by
drugs and biologicals, AMERIGROUP physician.
medical supplies, and the
use of appliances and
equipment furnished by the The length of the enrollee's stay shall be
facility. determined by the medical condition of the
enrollee in relation to the necessary and
appropriate level of care, but is no more
than 100 days per contract year.
Room and board is limited to
semi-private accommodations unless a
private room is considered medically
necessary or semi-private accommodations
are not available.
Specialized treatment centers and independent
kidney disease treatment centers are excluded.
Private duty nurses, television, and custodial
care are excluded.
Admissions for rehabilitation and
physical therapy are limited to fifteen
days per contract year.
-----------------------------------------------------------------------------------------------------------
K. Durable Medical Equipment and devices must be provided NONE
Equipment and Prosthetic by authorized AMERIGROUP supplier.
Devices
Equipment and devices that Covered prosthetic devices include
are medically indicated to artificial eyes and limbs, braces, and
assist in the treatment of a other artificial aids.
medical condition and
specifically prescribed as Low vision and telescopic lenses are not
medically necessary by included.
enrollee's AMERIGROUP
physician. Hearing aids are covered only when
medically indicated to assist in the
treatment of a medical condition.
-----------------------------------------------------------------------------------------------------------
L. Refractions Enrollee must have failed vision $5 per visit
Examination by a screening by primary care physician.
AMERIGROUP optometrist
to determine the need Corrective lenses and frames are limited
for and to prescribe to one pair every two years unless head
corrective lenses as size or prescription changes. $ 10 for corrective
medically indicated. lenses
Coverage is limited to Medicaid frames
with plastic or SYL non-tinted lenses.
-----------------------------------------------------------------------------------------------------------
M. Pharmacy Prescribed drugs covered under this $5 per prescription
Prescribed drugs for the Agreement shall include all prescribed for up to a 31-day
treatment of illness or injury drugs covered under the Florida Medicaid supply
or injury. program. AMERIGROUP may implement a pharmacy
benefit management program if FHKC so
authorizes.
Brand name products are covered if a
generic substitution is not available or
where the prescribing physician indicates
that a brand name is medically necessary.
All medications must be dispensed through
AMERIGROUP or a AMERIGROUP designated
pharmacy.
All prescriptions must be written by the
participant's
-----------------------------------------------------------------------------------------------------------
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 32 of 45
----------------------------------------------------------------------------------------------------------------
BENEFIT LIMITATIONS CO-PAYMENTS
----------------------------------------------------------------------------------------------------------------
primary care physician, AMERIGROUP 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
AMERIGROUP 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 AMERIGROUP 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 AMERIGROUP 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. AMERIGROUP 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.
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 33 of 45
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
AMERIGROUP provides services or benefits to a participant who
is entitled to worker's compensation benefits, AMERIGROUP
shall complete and submit to the appropriate carrier, such
forms, assignments, consents and releases as are necessary to
enable AMERIGROUP to obtain payment, or reimbursement, under
the worker's compensation law.
B. THIRD PARTY CLAIMS
In the event AMERIGROUP 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,
AMERIGROUP shall be entitled to reimbursement from the
participant, at the prevailing rate, for the reasonable value
of the services or benefits provided. AMERIGROUP 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
AMERIGROUP 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 AMERIGROUP, or to the automobile insurance carrier, such
forms, assignments, consents and releases as are necessary to
enable AMERIGROUP to obtain payment or reimbursement from such
automobile insurance carrier.
D. COORDINATION OF BENEFITS AMONG HEALTH AMERIGROUPS
AMERIGROUP 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:
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 34 of 45
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;
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 35 of 45
(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 AMERIGROUP all information deemed
necessary by it to implement this provision.
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 36 of 45
EXHIBIT E
ACCESS AND CREDENTIALING STANDARDS
AMERIGROUP 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
AMERIGROUP'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 Broward, Miami-Dade, Hillsborough,
Orange, Palm Beach and Pinellas Counties.
Primary care physicians must provide covered
immunizations to enrollees.
AMERIGROUP 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 AMERIGROUP 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, AMERIGROUP 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 to be available
within sixty (60) minutes driving time from the
participant's residence to provider. Driving time
standards may be waived with sufficient
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 37 of 45
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 AMERIGROUP 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 AMERIGROUP, or its providers, has failed to
meet the access standards herein set forth, FHKC shall provide AMERIGROUP 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
AMERIGROUP to investigate and respond. Failure of AMERIGROUP 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 AMERIGROUP provider network as specified in Section 3-2-1 of
this Agreement. AMERIGROUP shall be financially responsible for all services
under this provision.
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 38 of 45
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 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.
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 39 of 45
EXHIBIT G
REPORTING REQUIREMENTS
AMERIGROUP 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 AMERIGROUP'S subcontractors. AMERIGROUP 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. AMERIGROUP
shall also provide quarterly tapes that reflect claims run-off
once the Agreement between AMERIGROUP 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
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 40 of 45
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
--------------------------------------------------------------------------------
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 41 of 45
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 AMERIGROUP whose contract\subcontract equals or exceeds
$25,000 in federal monies must sign this certification prior to execution of
each contract\subcontract. Additionally, AMERIGROUPs who audit federal programs
must also sign, regardless of the contract amount. The Florida Healthy Kids
Corporation cannot contract with these types of AMERIGROUPs 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. AMERIGROUP shall provide immediate written notice to the
contract manager at any time AMERIGROUP 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. AMERIGROUP 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. AMERIGROUP 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 AMERIGROUP 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 AMERIGROUP 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 AMERIGROUP is unable to certify to any of the statements
in this certification, such prospective AMERIGROUP shall attach an explanation
to this certification.
Signature /s/ Xxxxxx Xxxxxxx Date 7-15-03
-------------------------
Name and Title of Authorized Signee
XXXXXX XXXXXXX
PRESIDENT: CEO
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 42 of 45
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.
/s/ XXXXXX XXXXXXX 7-15-03
------------------ -------
Signature Date
XXXXXX XXXXXXX
-----------------------------
Name of Authorized Individual
--------------------------------------
Name and Address of Organization
AMERIGROUP FLORIDA, INC.
0000 X. XXXXXXX XX.
XXXXX, XX. 00000
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 43 of 45
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 AMERIGROUP 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 AMERIGROUP from or on behalf of
the FHKC.
2. Limits on Use and Disclosure of Protected Health Information (PHI)
AMERIGROUP shall not use or disclose Protected Health Information other
than as permitted by this Contract or by federal and state law.
AMERIGROUP 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. AMERIGROUP
will not divulge, disclose, or communicate in any manner any Protected
Health Information to any third party without prior written consent
from the FHKC. AMERIGROUP 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 AMERIGROUP 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. AMERIGROUP is permitted to use and disclose
Protected Health Information received from FHKC for the proper
management and administration of AMERIGROUP or to carry out the legal
responsibilities of AMERIGROUP, in accordance with 45 C.F.R.
164.504(e)(4). Such disclosure is only permissible where required by
law, or where AMERIGROUP 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 AMERIGROUP 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. AMERIGROUP 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 AMERIGROUP on behalf of, the FHKC. Such subcontract
shall contain the same terms, conditions, and restrictions that apply
to AMERIGROUP with respect to Protected Health Information.
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 44 of 45
5. Access to Information. AMERIGROUP 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. AMERIGROUP 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. AMERIGROUP 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. AMERIGROUP 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
AMERIGROUP 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, AMERIGROUP shall
return all Protected Health Information that AMERIGROUP still maintains
in any form, including any copies or hybrid or merged databases made by
AMERIGROUP; or with prior written approval of the FHKC, the Protected
Health Information may be destroyed by AMERIGROUP after its use. If the
Protected Health Information is destroyed pursuant to the FHKC's prior
written approval, AMERIGROUP 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, AMERIGROUP
agrees to protect the Protected Health Information and treat it as
strictly confidential.
CERTIFICATION
AMERIGROUP and the Florida Healthy Kids Corporation have caused this
Certification to be signed and delivered by their duly authorized
representatives, as of the date set forth below.
AMERIGROUP Name:
/s/ XXXXXX XXXXXXX 7-15-03
------------------ ---------
Signature Date
XXXXXX XXXXXXX
-----------------------------------
Name and Title of Authorized Signee
President & CEO
AMERIGROUP Effective Date: October 1, 2003 - September 30, 2005
Page 45 of 45
