EXHIBIT 10.10
PURCHASE OF SERVICE CONTRACT
BETWEEN
THE CONNECTICUT DEPARTMENT OF SOCIAL SERVICES
AND
MCO
PART I: STANDARD CONNECTICUT CONTRACT TERMS
PART II: GENERAL CONTRACT TERMS FOR MCOS
1. DEFINITIONS
2. DELEGATIONS OF AUTHORITY
3. FUNCTIONS AND DUTIES OF THE MCO
3.01 Provision of Services
3.02 Non-Discrimination
3.03 Gag Rules
3.04 Coordination and Continuation of Care
3.05 Emergency Services
3.06 Geographic Coverage
3.07 Choice of Health Professional
3.08 Provider Network
3.09 Network Adequacy and Maximum Enrollment Levels
3.10 Provider Contracts
3.11 Provider Credentialing and Enrollment
3.12 Specialist Providers and the Referral Process
3.13 PCP Selection, Scheduling and Capacity
3.14 Family Planning Access and Confidentiality
3.15 Pharmacy Access
3.16 Mental Health and Substance Abuse Access
3.17 Children's Issues and EPSDT Compliance
3.18 Special Services for Children /Reinsurance
3.19 Prenatal Care
3.20 Dental Care
3.21 Other Access Features
3.22 Pre-Existing Conditions
3.23 Newborn Enrollment
3.24 Acute Care Hospitalization, Nursing Home or Subacute Stay at Time of
Enrollment or Disenrollment
3.25 Open Enrollment
3.26 Special Disenrollment
3.27 Linguistic Access
3.28 Services to Members
3.29 Information to Potential Members
3.30 Marketing Requirements
3.31 Health Education
3.32 Internal and External Quality Assurance
3.33 Inspection of Facilities
3.34 Examination of Records
3.35 Medical Records
3.36 Audit Liabilities
3.37 Clinical Data Reporting
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3.38 Utilization Management
3.39 Financial Records
3.40 Insurance
3.41 Third Party Coverage
3.42 Coordination of Benefits and Delivery of Services
3.43 Passive Billing
3.44 Subcontracting for Services
3.45 Timely Payment of Claims
3.46 Copayment Limits and Member Charges for Noncovered Services
3.47 Insolvency Protection
3.48 Acceptance of DSS Rulings
3.49 Policy Transmittals
3.50 Fraud and Abuse
3.51 Children with Special Health Care Needs
4. FUNCTIONS AND DUTIES OF THE DEPARTMENT
4.01 Eligibility Determinations
4.02 Populations Eligible to Enroll
4.03 Enrollment/Disenrollment
4.04 Default Enrollment
4.05 Lock-In
4.06 Capitation Payments to MCO
4.07 Retroactive Adjustments
4.08 Information
4.09 Ongoing MCO monitoring
4.10 Utilization Review and Control
5. DECLARATIONS AND MISCELLANEOUS PROVISIONS
5.01 Competition Not Restricted
5.02 Nonsegregated Facilities
5.03 Offer of Gratuities
5.04 Employment/Affirmative Action Clause
5.05 Confidentiality
5.06 Independent Capacity
5.07 Liaison
5.08 Freedom of Information
5.09 Waivers
5.10 Force Majeure
5.11 Financial Responsibilities of the MCO
5.12 Capitalization and Reserves
5.13 Provider Compensation
5.14 Members Held Harmless
5.15 Compliance with Applicable Laws, Rules and Policies
5.16 Federal Requirements and Assurances
5.17 Civil Rights
5.18 Statutory Requirements
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5.19 Disclosure of Interlocking Relationships
5.20 DEPARTMENT's Data Files
5.21 Changes Due to a Section 1115 or 1915(b) Freedom of Choice
5.22 Hold Harmless
5.23 Executive Order Number 16
6. MCO RESPONSIBILITIES CONCERNING NOTICES OF ACTION, GRIEVANCES AND
ADMINISTRATIVE HEARINGS
6.01 Notices of Action
6.02 Grievances and Administrative Hearing Process
6.03 Expedited Review and Administrative Hearings
6.04 Provider Appeal Process
7. CORRECTIVE ACTION AND CONTRACT TERMINATION
7.01 Performance Review
7.02 Settlement of Disputes
7.03 Administrative Errors
7.04 Suspension of New Enrollment
7.05 Sanctions
7.06 Payment Withhold, Class C Sanctions or Termination for Clause
7.07 Emergency Services Denials
7.08 Termination for Default
7.09 Termination for Mutual Convenience
7.10 Termination for the MCO Bankruptcy
7.11 Termination for Unavailability of Funds
7.12 Termination for Collusion in Price Determination
7.13 Termination Obligations of Contracting Parties
7.14 Waiver of Default
8. OTHER PROVISIONS
8.01 Severability
8.02 Effective Date
8.03 Order of Precedence
8.04 Correction of Deficiencies
8.05 This is not a Public Works Contract
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9. APPENDICES
A. Covered Benefits HUSKY A Covered Benefits
B. Provider Credentialing and Enrollment Requirements
C. EPSDT Periodicity Schedule
D. DSS Marketing Guidelines
E. Quality Assurance Program for Managed Care
F. Unaudited Quarterly Financial Reports
G. Medicaid Managed Care Eligibility Categories
H. Managed Care Policy Transmittals
I. Capitation Payment Amounts
J. Physician Incentive Payments
K. Recategorization Chart
L. Non-Hyde Amendment Abortions
10. SIGNATURES
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PART I: STANDARD CONNECTICUT CONTRACT TERMS
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PART II: GENERAL CONTRACT TERMS FOR MCOs
1. DEFINITIONS
As used throughout this contract, the following terms shall have the meanings
set forth below.
ABUSE: Provider and/or MCO practices that are inconsistent with sound fiscal,
business or medical practices and that result in an unnecessary cost to the
HUSKY A program, or the reimbursement for services that are not medically
necessary or that fail to meet professionally recognized standards for health
care, or a pattern of failing to provide medically necessary services required
by this contract. Member practices that result in unnecessary cost to the HUSKY
A program also constitute abuse.
AGENT: An entity with the authority to action behalf of the DEPARTMENT.
BENOVA: The organization contracted by the DEPARTMENT to perform certain
administrative and operational functions for the HUSKY A and B programs.
Contracted functions include HUSKY application processing, HUSKY B eligibility
determinations, passive billing and enrollment brokering.
CAPITATION RATE: The amount paid per Member by the DEPARTMENT to each Managed
Care Organization (MCO) on a monthly basis.
CAPITATION PAYMENT: The individualized monthly payment made by the DEPARTMENT to
the MCO on behalf of Members.
CHILDREN'S HEALTH COUNCIL: The Children's Health Council was established by the
Connecticut General Assembly in 1995 in order to (1) monitor and evaluate
compliance of the HUSKY A program with the requirements of the Early and
Periodic Screening, Diagnosis and Treatment Program (EPSDT); (2) develop a
coordinated health care delivery system in each region of the State and (3)
implement outreach efforts in each region of the State to ensure uniform
statewide health care access for children. The Children's Health Council is
operated by the Hartford Foundation for Public Giving, Inc. in accordance with a
contract between the DEPARTMENT and the foundation. To carry out its
responsibilities, the Children's Health Council has contracted with MAXIMUS,
Inc. to operate the Connecticut Children's Health Project.
CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN): Children up to age nineteen
(19) who have, or are at elevated risk for chronic physical, developmental,
behavioral or emotional conditions, whether biologic or acquired. They require
health and related services (not educational or recreational) of a type and
amount not usually required by children of the same age. CSHCN also includes
children who are blind or disabled
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(eligible for SSI under Title XVI; in xxxxxx or other out-of-home placement; are
receiving xxxxxx care or adoption assistance; or are receiving services funded
through Section 501(a)(1)(d) of Title V.
CLEAN CLAIM: A xxxx for service(s) or good (s), a line item of services or all
services and/or goods for a recipient contained on one xxxx which can be
processed without obtaining additional information from the provider of
service(s) or a third party. A clean claim does not include a claim from a
provider who is under investigation for fraud or abuse or a claim under review
for medical necessity.
COMMISSIONER: The Commissioner of the Department of Social Services, as defined
in Section 17b-3 of the Connecticut General Statutes.
COMPLAINT: A written or oral communication from a Member expressing
dissatisfaction with some aspect of the MCO's services.
CONNECTICUT CHILDREN'S HEALTH PROJECT: The program established by the Children's
Health Council to carry out its responsibilities, especially its responsibility
to monitor and evaluate compliance of the HUSKY A program with the requirements
of the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT).
CONSULTANT: A corporation, company, organization or person or their affiliates
retained by the DEPARTMENT to provide assistance in this project or any other
project, not the MCO or subcontractor.
CONTINUOUS ELIGIBILITY (CE): For purposes of the HUSKY A program, the twelve
(12) month period of time during which a child under nineteen (19) years of age
who qualifies for medical assistance under a categorically needy coverage group
remains eligible for Medicaid despite a change in certain circumstances that
would otherwise cause the child to lose Medicaid eligibility. Changes in
household composition or income will not cause a loss of eligibility during the
continuously eligible twelve (12) month period.
CONTRACT ADMINISTRATOR: The DEPARTMENT employee responsible for fulfilling the
administrative responsibilities associated with this managed care project.
CONTRACT SERVICES: Those services which the MCO is required to provide to
Members under this contract.
DATE OF APPLICATION: The date on which a completed application for the HUSKY A
program is received by the DEPARTMENT or its agent, containing the applicant's
signature.
DAY: Except where the term business day is expressly used, all references in
this contract will be construed as calendar days.
DEPARTMENT: The Department of Social Services, State of Connecticut.
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EMERGENCY OR EMERGENCY MEDICAL CONDITION: A medical condition manifesting itself
by acute symptoms of sufficient severity (including severe pain) such that a
prudent layperson, who possesses an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical attention to result in
placing the health of the individual (or with respect to a pregnant woman, the
health of the woman or her unborn child) in serious jeopardy, serious impairment
to body functions or serious dysfunction of any body organ or part.
EMERGENCY SERVICES: Inpatient and outpatient services including, but not limited
to, behavioral health and detoxification needed to evaluate or stabilize an
emergency medical condition that is found to exist using the prudent layperson
standard.
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) CASE MANAGEMENT
SERVICES: Services such as making and facilitating referrals and development and
coordination of a plan of services that will assist Members under twenty-one
(21) years of age in gaining access to needed medical, social, educational, and
other services.
EPSDT DIAGNOSTIC AND TREATMENT SERVICES: All health care, diagnostic services,
and treatment necessary to correct or ameliorate defects and physical and mental
illnesses and conditions discovered by an interperiodic or periodic EPSDT
screening examination.
EPSDT SCREENING SERVICES: Comprehensive, periodic health examinations for
Members under the age of twenty-one (21) provided in accordance with the
requirements of the federal Medicaid statute at 42 U.S.C. Section 1396d(r)(l).
EPSDT SERVICES: Comprehensive child health care services to Members under
twenty-one (21) years of age, including all medically necessary prevention,
screening, diagnosis and treatment services listed in Section 1905 (r) of the
Social Security Act.
EXTERNAL QUALITY REVIEW ORGANIZATION (EQRO): An entity responsible for
conducting reviews of the quality outcomes, timeliness of the delivery of care
and access to items and services for which the MCO is responsible under this
contract.
FORMULARY: A list of selected pharmaceuticals determined to be the most useful
and cost effective for patient care, developed by a pharmacy and therapeutics
committee at the MCO.
FQHC-SPONSORED MCO: An MCO that is more than fifty (50) percent owned by
Connecticut Federally Qualified Health Centers, certified by the Department of
Social Services to enroll Medicaid Members.
FRAUD: Intentional deception or misrepresentation, or reckless disregard or
willful blindness, by a person or entity with the Knowledge that the deception,
misrepresentation,
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disregard or blindness could result in some unauthorized benefit to himself or
some other person, including any act that constitutes fraud under applicable
federal or state law.
GRIEVANCE: A written request to the MCO from a Member for a formal review of an
MCO decision related to the denial, termination, suspension or reduction of a
good or service. The DEPARTMENT automatically treats such a request as a request
for an administrative hearing.
GUARANTEED ELIGIBILITY: Six (6) consecutive month period during which a person
remains eligible for HUSKY A services despite a change in certain circumstances
that would otherwise make the person ineligible for Medicaid. The DEPARTMENT
will assign a six (6) month period of guaranteed eligibility to eligible
individuals upon their first enrollment.
HCFA OR CMS: The Health Care Financing Administration (HCFA) also known as
Center for Medicare and Medicaid Services (CMS), a division within the United
States Department of Health and Human Services.
HEALTH EMPLOYER DATA INFORMATION SET (HEDIS): A standardized performance
measurement tool that enables users to evaluate the quality of different MCOs
based on the following categories: effectiveness of care; MCO stability; use of
services; cost of care; informed health care choices; and MCO descriptive
information.
HHS: The United States Department of Health and Human Services.
HUSKY, PART A OR HUSKY A: For purposes of this contract, HUSKY A includes all
those coverage groups previously covered in Connecticut Access, subject to
expansion of eligibility groups pursuant to Section 17b-266 of the Connecticut
General Statutes.
IN-NETWORK PROVIDERS: Providers who have contracted with the MCO to provide
services to Members.
LOCK-IN: Limitations on Member change of managed care plans for a period of
time, not to exceed twelve (12) months.
MANAGED CARE ORGANIZATION (MCO): The organization signing this agreement with
the Department of Social Services.
MARKETING: A communication from an MCO to a Member or potential Member that can
be reasonably interpreted as intended to influence the Member to enroll or
reenroll in that particular MCO or either to enroll in, or disenroll from,
another MCO.
MEDICAID: The Connecticut Medical Assistance Program operated by the Connecticut
Department of Social Services under Title XIX of the Federal Social Security
Act, and related State and Federal rules and regulations.
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MEDICAID PROGRAM PROVIDER MANUALS: Service-specific documents created by
Connecticut Medicaid to describe policies and procedures applicable to the
Medicaid program generally and that service specifically.
MEDICAL APPROPRIATENESS OR MEDICALLY APPROPRIATE: Health care that is provided
in a timely manner and meets professionally recognized standards of acceptable
medical care; is delivered in the appropriate medical setting; and is the least
costly of multiple, equally-effective alternative treatments or diagnostic
modalities.
MEDICALLY NECESSARY/MEDICAL NECESSITY: Health care provided to correct or
diminish the adverse effects of a medical condition or mental illness; to assist
an individual in attaining or maintaining an optimal level of health, to
diagnose a condition or prevent a medical condition from occurring.
MEMBER: For the purposes of HUSKY A, a Medicaid client who has been certified by
the State as eligible to enroll under this contract, and whose name appears on
the MCO enrollment information which the DEPARTMENT will transmit to the MCO
every month in accordance with an established notification schedule.
NATIONAL COMMITTEE ON QUALITY ASSURANCE(NCQA): NCQA is a not-for-profit
organization that develops and defines quality and performance measures for
managed care, thereby providing an external standard of accountability.
OUT-OF-NETWORK PROVIDER: A provider that has not contracted with the MCO.
PASSIVE BILLING: Automatic capitation payments generated by the DEPARTMENT or
its agent based on enrollment.
PEER REVIEW ORGANIZATION (PRO): A professional medical organization which
conducts peer review of medical care certified by HCFA or CMS.
POST-STABILIZATION SERVICES: Services provided subsequent to an emergency that a
treating physician views as medically necessary after an emergency medical
condition has been stabilized during an emergency room visit.
PRIMARY CARE PROVIDER (PCP): A licensed health care professional responsible for
performing or directly supervising the primary care services of Members.
PRIOR AUTHORIZATION: The process of obtaining prior approval as to the medical
necessity or appropriateness of a service or plan of treatment.
RISK: The possibility of monetary loss or gain by the MCO resulting from service
costs exceeding or being less than payments made to it by the DEPARTMENT.
ROUTINE CASES: A symptomatic situation (such as a chronic back condition) for
which the Member is seeking care, but for which treatment is neither of an
emergency nor an urgent nature.
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SUBCONTRACT: Any written agreement between the MCO and another party to fulfill
any requirements of this contract.
SUBCONTRACTOR: The party contracting with the MCO to manage or arrange for one
or more of the Medicaid services provided by the MCO pursuant to this contract.
THIRD-PARTY: Any individual, entity or program which is or may be liable to pay
all or part of the expenditures for Medicaid furnished under a State plan.
TITLE XIX: Xxx xxxxxxxxxx xx 00 Xxxxxx Xxxxxx Code Section 1396 et seq.,
including any amendments thereto. (see Medicaid)
URGENT CASES: Illnesses or injuries of a less serious nature than those
constituting emergencies but for which treatment is required to prevent a
serious deterioration in the Member's health and for which treatment cannot be
delayed without imposing undue risk on the Members' well-being until the Member
is able to secure services from his/her regular physician(s).
VENDOR: Any party with which the MCO has subcontracted to provide administrative
services.
WELL-CARE VISITS: Routine physical examinations, immunizations and other
preventive services that are not prompted by the presence of any adverse medical
symptoms.
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2. DELEGATIONS OF AUTHORITY
The State of Connecticut Department of Social Services is the single state
agency responsible for administering the Medicaid program. No delegation by
either party in administering this contract shall relieve either party of
responsibility for carrying out the terms of this contract.
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3. FUNCTIONS AND DUTIES OF THE MCO
The MCO agrees to the following duties:
3.01 PROVISION OF SERVICES
a. The MCO shall provide to individuals enrolled under this contract,
directly or through arrangements with others, all of the covered services
described in Appendix A of this contract.
b. The MCO shall ensure that utilization management/review and coverage
decisions concerning acute or chronic care services to each Member are
made on an individualized basis in accordance with the contractual
definitions for Medical Appropriateness or Medically Appropriate and
Medically Necessary or Medical Necessity at Part II Section 1, General
Contract Terms for MCOs. The MCO shall also ensure that its contracts with
network providers requires that the decisions of network providers
affecting the delivery of acute or chronic care services to Members are
made in accordance with the contractual definitions for Medical
Appropriateness or Medically Appropriate and Medically Necessary and
Medical Necessity.
c. The MCO shall provide twenty-four (24) hour accessibility to qualified
medical personnel for Members in need of urgent or emergency care. The MCO
may provide such access to medical personnel through either: 1) a hotline
staffed by physicians, physicians on-call or registered nurses; or 2) a
PCP on-call system. Whether the MCO utilizes a hotline or PCPs on-call,
Members shall gain access to medical personnel within thirty (30) minutes
of their call. The MCO Member handbook and MCO taped telephone message
shall instruct Members to go directly to an emergency room if the Member
needs emergency care. If the Member needs urgent care and has not gained
access to medical personnel within thirty (30) minutes, the Member shall
be instructed to go to the emergency room. The DEPARTMENT will randomly
monitor the availability of such access.
d. Changes to Medicaid covered services mandated by Federal or State law, or
adopted by amendment to the State Plan for Medicaid, subsequent to the
signing of this contract will not affect the contract services for the
term of this contract, unless (1) agreed to by mutual consent of the
DEPARTMENT and the MCO, or (2) unless the change is necessary to continue
federal financial participation, or due to action of a state or federal
court of law. If Medicaid coverage were expanded to include new services,
such services would be paid for via the traditional Medicaid
fee-for-service system unless covered by mutual consent between the
DEPARTMENT and the MCO (in which case an appropriate adjustment to the
capitation rates would be made). If Medicaid covered services are changed
to exclude services the DEPARTMENT may determine that such
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services will no longer be covered under HUSKY A and the DEPARTMENT will
propose a contract amendment to reduce the capitation rate accordingly.
In the event that the DEPARTMENT and the MCO can not concur on a contract
amendment concerning the change to Medicaid covered services, the
DEPARTMENT and the MCO shall negotiate a termination agreement to
facilitate the transition of the MCO's Members to another MCO within a
period of no less than ninety (90) days.
3.02 NON-DISCRIMINATION
a. The MCO shall comply with all Federal and State laws relating to
non-discrimination and equal employment opportunity, including but not
necessarily limited to the Americans with Disabilities Act of 1990, 42
U.S.C. Section 12101 et seq.; 47 U.S.C. Section 225; 47 U.S.C. Section
611; Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C.
Section 2000e; Title VI of the Civil Rights Act, 42 U.S.C. 2000d et seq.;
the Civil Rights Act of 1991; Section 504 of the Rehabilitation Act, 29
U.S.C. Section 794 et seq.; the Age Discrimination in Employment Act of
1967, 29 U.S.C. Sections 621-634; regulations issued pursuant to those
Acts; and the provisions of Executive Order 11246 dated September 26, 1965
entitled "Equal Employment Opportunity" as amended by Federal Executive
Order 11375, as supplemented in the United States Department of Labor
Regulations (41 C.F.R. Part 60-1 et seq., Obligations of Contractors and
Subcontractors). The MCO shall also comply with Sections 4a-60, 4a-61,
17b-520, 31-51d, 46a-64, 46a-71, 46a-75 and 46a-81 of the Connecticut
General Statutes.
The MCO shall also comply with the HCFA Civil Rights Compliance Policy,
which mandates that all Members have equal access to the best health care,
regardless of race, color, national origin, age, sex, or disability.
The HCFA Civil Rights Compliance Policy further mandates that the MCO
shall ensure that its subcontractors and providers render services to
Members in a non-discriminatory manner. The MCO shall also ensure that
Members are not excluded from participation in or denied the benefits of
the HUSKY programs because of prohibited discrimination.
The MCO acknowledges that in order to achieve the civil rights goals set
forth in the HCFA Civil Rights Compliance Policy, HCFA has committed
itself to incorporating civil rights concerns into the culture of its
agency and its programs and has asked all of its partners, including the
DEPARTMENT and the MCO, to do the same. The MCO further acknowledges that
HCFA will be including the following civil rights concerns into its
regular program review and audit activities: collecting data on access to
and participation of minority and disabled Members; furnishing information
to Members, subcontractors, and providers
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about civil rights compliance; reviewing HCFA publications, program
regulations, and instructions to assure support for civil rights; and
initiating orientation and training programs on civil rights. The MCO
shall provide to the DEPARTMENT or to HCFA, upon request, any available
data or information regarding these civil rights concerns.
Within the resources available through the capitation rate, the MCO shall
allocate financial resources to ensure equal access and prevent
discrimination on the basis of race, color, national origin, age, sex, or
disability.
b. Unless otherwise specified by the contract, the MCO shall provide covered
services to HUSKY A Members under this contract in the same manner as
those services are provided to other Members of the MCO, although delivery
sites, covered services and provider payment levels may vary. The MCO
shall ensure that the locations of facilities and practitioners providing
health care services to Members are sufficient in terms of geographic
convenience to low-income areas, handicapped accessibility and proximity
to public transportation routes, where available. The MCO and its
providers shall not discriminate among Members of HUSKY A and other
Members of the MCO.
3.03 GAG RULES
The MCO shall not prohibit or otherwise restrict a health care provider acting
within his or her lawful scope of practice from advising a Member, who is a
patient of the provider, about the health status of the Member or medical care
treatment for the Member's condition or disease, regardless of whether benefits
for such care or treatment are provided under this contract. This prohibition is
subject to the limitations described in 42 U.S.C. Section 1396u-2(b)(3)(B) and
(C).
3.04 COORDINATION AND CONTINUATION OF CARE
a. The MCO shall have systems in place to provide well-managed patient care
which satisfies the DEPARTMENT that appropriate patient care is being
provided, including at a minimum:
1. Management and integration of health care through a PCP, gatekeeper
or other means.
2. Systems to assure referrals for medically necessary, specialty,
secondary and tertiary care.
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3. Systems to assure provision of care in emergency situations,
including an education process to help assure that Members know
where and how to obtain medically necessary are in emergency
situations.
4. A system by which Members may obtain a covered service or services
that the MCO does not provide or for which the MCO does not arrange
because it would violate a religious or moral teaching of the
religious institution or organization by which the MCO is owned,
controlled, sponsored or affiliated.
5. Coordination and provision of EPSDT screening services in accordance
with the schedules for immunizations and periodicity of well-child
services as established by the DEPARTMENT and federal regulations.
6. Provide or arrange for the provision of EPSDT case management
services for Members under twenty-one (21) years of age when the
Member has a physical or mental health condition that makes the
coordination of medical, social, and educational services medically
necessary. As necessary, case management services shall include but
not be limited to:
a. Assessment of the need for case management and development of
a plan for services;
b. Periodic reassessment of the need for case management and
review of the plan for services;
c. Making referrals for related medical, social, and educational
services;
d. Facilitating referrals by providing assistance in scheduling
appointments for health and health-related services, and
arranging transportation and interpreter services;
e. Coordinating and integrating the plan of services through
direct or collateral contacts with the family and those
agencies and providers providing services to the child;
f. Monitoring the quality and quantity of services being
provided;
g. Providing health education as needed; and
h. Advocacy necessary to minimize conflict between service
providers and to mobilize resources to obtain needed services.
7. Provide necessary coordination and case management services for
children with special health care needs.
8. If notified, PCPs will participate in the review and authorization
of Individual Education Plans for Members receiving School Based
Child Health services and Individual Family Service Plans for
Members receiving services from the Birth to Three program.
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3.05 EMERGENCY SERVICES
a. The MCO shall provide all emergency services twenty-four (24) hours each
day, seven (7) days a week or arrange for the provision of said services
twenty-four (24) hours each day, seven (7) days a week through its
provider network.
b. Emergency services must be provided without regard to prior authorization
or the emergency care provider's contractual relationship with the MCO.
c. The MCO may not limit the number of emergency visits.
d. The MCO must cover all services necessary to determine whether or not an
emergency condition exists, even if it is later determined that the
condition was not an emergency.
e. The MCO may not retroactively deny a claim for an emergency screening
examination because the condition, which appeared to be an emergency
medical condition under the prudent layperson standard, turned out to be
non-emergent in nature.
f. If the screening examination leads to a clinical determination by the
examining physician that an actual emergency does not exist, then the
nature and extent of payment liability will be based on whether the Member
had acute symptoms under the prudent layperson standard at the time of
presentation.
g. The determination of whether the prudent layperson standard is met must be
made on a case-by-case basis. The only exception to this general rule is
that the MCO may approve coverage on the basis of an ICD-9 code.
h. Once the individual's condition is stabilized, the MCO may require prior
authorization for a hospital admission or follow-up care.
i. The MCO must cover post-stabilization services attendant to the primary
presenting diagnosis that were either approved by the MCO or were
delivered by the emergency service provider when the MCO failed to
respond to a request for pre-approval of such services within one hour of
the request to approve post-stabilization care, or could not be contacted
for pre-approval.
j. If there is a disagreement between a hospital and an MCO concerning
whether the Member is stable enough for discharge or transfer from the
emergency room, the judgment of the attending physician(s) actually
caring for the Member at the treating facility prevails and is binding on
the MCO. This subsection shall not apply to a disagreement concerning
discharge or transfer following an inpatient admission. The MCO may
establish arrangements with hospitals whereby the MCO may send one of its
own physicians or may contract with appropriate
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physicians with appropriate emergency room privileges to assume the
attending physician's responsibilities to stabilize, treat, and transfer
the Member.
k. When a Member's PCP or another plan representative instructs the Member to
seek emergency care in-network or out-of-network, the MCO is responsible
for payment for the screening examination and for other medically
necessary emergency services, without regard to whether the patient meets
the prudent layperson standard described above.
l. If a Member believes that a claim for emergency services has been
inappropriately denied by the MCO, the Member may seek recourse through
the MCO's grievance and the DEPARTMENT's administrative hearing process.
m. When the MCO reimburses emergency services provided by an in-network
provider, the rate of reimbursement will be subject to the contractual
relationship that has been negotiated with said provider. When the MCO
reimburses emergency services provided by an out-of-network provider
within Connecticut, the rate of reimbursement will be no less than the
fees established by the DEPARTMENT for the Medicaid fee-for-service
program. When the MCO reimburses emergency services provided by an
out-of-network provider outside of Connecticut, the MCO may negotiate a
rate of reimbursement with said provider.
n. The MCO may not make payment for emergency services contingent on the
Member providing the MCO with notification either before or after
receiving emergency services. The MCO may, however, enter into contracts
with providers or facilities that require, as a condition of payment, the
provider or facility to provide notification to the MCO after Members are
present at the emergency room, assuming adequate provision is given for
such notification.
3.06 GEOGRAPHIC COVERAGE
a. The MCO shall serve Members statewide. The MCO shall ensure that its
provider network includes access for each Member to PCPs,
Obstetric/Gynecological Providers and mental health providers at a
distance of no more than fifteen (15) miles for PCPs and
Obstetric/Gynecological Providers and no more than twenty (20) miles for
general dentists and mental health providers as measured by the Public
Utility Commission. The MCO shall ensure that its provider network has
the capacity to deliver or arrange for all the goods and services
reimbursable under the Medicaid fee-for-service program.
b. On a monthly basis, the MCO will provide the DEPARTMENT or its agent with
a list of all contracted network providers. The list shall be in a format
and contain such information as the DEPARTMENT may specify.
27
PERFORMANCE MEASURE: Geographic Access. The DEPARTMENT will randomly monitor
geographic access by reviewing the mileage to the nearest town containing a PCP
for every town in which the MCO has Members.
SANCTION: In any sampling, if more than two (2) percent of Members reside in
towns beyond fifteen (15) miles of a town containing a PCP the DEPARTMENT may
impose a strike towards a Class A sanction pursuant to Section 7.05.
3.07 CHOICE OF HEALTH PROFESSIONAL
The MCO must inform each Member about the full panel of participating providers
in its network. To the extent possible and appropriate, the MCO must offer each
Member covered under this contract the opportunity to choose among participating
providers.
3.08 PROVIDER NETWORK
a. The MCO shall maintain a provider network capable of delivering or
arranging for the delivery of all covered health goods and services to all
Members. In addition, the MCO's provider network shall have the capacity
to deliver or arrange for the delivery of all the goods and services
reimbursable under this contract regardless of whether all of the goods
and services are provided through direct provider contracts. The MCO shall
submit a file of their most current provider network listing to the
DEPARTMENT or its agent. The file shall be submitted, at a minimum, once a
month in the format specified by the DEPARTMENT.
b. The MCO shall notify the DEPARTMENT or its agent, in a timely manner, of
any changes made in the MCO's provider network. The monthly file submitted
to the DEPARTMENT or its agent shall not contain any providers who are no
longer in the MCO's network. The DEPARTMENT will randomly audit the
provider network file for accuracy and completeness and take corrective
action, if the provider network file fails to meet these requirements.
c. The MCO shall not discriminate against providers with respect to
participation, reimbursement, or indemnification for any provider who is
acting within the scope of that provider's license or certification under
applicable State law, solely on the basis of the provider's license or
certification. This shall not be construed to prohibit the MCO from
including providers only to the extent necessary to meet the needs of the
MCO's Members or from establishing measures designed to maintain the
quality of services and control costs, consistent with its
responsibilities. This shall not preclude the MCO from using different
reimbursement amounts for different specialties or for different
practitioners in the same specialty.
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3.09 NETWORK ADEQUACY AND MAXIMUM ENROLLMENT LEVELS
a. On a quarterly basis, except as otherwise specified by the DEPARTMENT, the
DEPARTMENT shall evaluate the adequacy of the MCO's provider network. Such
evaluations shall use ratios of Members to specific types of providers
based on Medicaid fee-for-service experience in order to ensure that
access in the MCO is at least equal to access experienced in the Medicaid
fee-for-service program for a similar population. For each county the
maximum ratio of Members to each provider type shall be:
1. adult PCPs, including general practice specialists counted at 60.8%,
internal medicine specialists counted at 88.9%, family practice
specialists counted at 66.9%, nurse practitioners of the appropriate
specialties, and physician assistants, 387 Members per provider;
2. children's PCPs, including pediatric specialists counted at 100%,
general practice specialists counted at 39.2%, internal medicine
specialists counted at 11.1%, family practice specialists counted at
33.1%, nurse practitioners of the appropriate specialties, and
physician assistants, 301 Members per provider; obstetrics and
gynecology providers, including obstetrics and gynecology
specialists, nurse midwives, and nurse practitioners of the
appropriate specialty, 835 Members per provider;
3. dental providers, including general and pediatric dentists counted
at 100%, and dental hygienists counted at 50%, 486 Members per
provider; and
4. behavioral health providers, including psychiatrists, psychologists,
social workers, and psychiatric nurse practitioners, 459 Members per
provider.
b. In the event that the number of Members in a given county equals or
exceeds ninety percent (90%) of the capacity determined in accordance with
section a noted above, the DEPARTMENT shall evaluate the adequacy of the
MCO's network on a monthly basis.
c. Maximum Enrollment Levels: Based on the adequacy of the MCO's provider
network the DEPARTMENT may establish a maximum HUSKY A enrollment level
for Members in the MCO on a county-specific basis. The DEPARTMENT shall
provide the MCO with written notification no less than thirty (30) days
prior to the effective date of the maximum enrollment level.
d. Subsequent to the establishment of this limit, if the MCO wishes to change
its maximum enrollment level in a specific county, the MCO must notify the
DEPARTMENT thirty (30) days prior to the desired effective date of the
change. If the change is an increase, the MCO must demonstrate an
increase in their
29
provider network which would allow the MCO to serve additional Members. To
do so the MCO must provide the DEPARTMENT with the signature pages from
the executed provider contracts and/or signed letters of intent. The
DEPARTMENT will not accept any other proof or documentation as evidence of
a provider's participation in the MCO's provider network. The DEPARTMENT
shall review the existence of additional capacity for confirmation no
later than thirty (30) days following notice by the MCO. An increase will
be effective the first of the month after the DEPARTMENT confirms
additional capacity exists.
e. In the event the DEPARTMENT deems that the MCO's provider network is not
capable of accepting additional enrollments, the DEPARTMENT may exercise
its rights under Section 7 of this contact, including but not limited to
the rights under Section 7.04, Suspension of New Enrollments.
SANCTION: In the event of a suspension of enrollment due to any network
deficiencies, the MCO shall submit a corrective action plan to the DEPARTMENT.
If, subsequent to the DEPARTMENT'S approval of the corrective action plan, the
network deficiency is not remedied within the time specified in the corrective
action plan, or if the MCO does not develop a corrective action plan
satisfactory to the DEPARTMENT, the DEPARTMENT may impose a strike towards a
Class A sanction for each month said suspension is in effect, in accordance with
Section 7.05.
3.10 PROVIDER CONTRACTS
All contracts between the MCO and its in-network providers shall, at a minimum,
include each of the following provisions:
a. MCO network providers serving the Medicaid population must meet the
minimum requirements for participation in the Medicaid program as set
forth in the Regulations of Connecticut State Agencies, Section
17b-262-522 to Section 17b-262-533, as applicable;
b. MCO Members shall be held harmless for the costs of all Medicaid-covered
goods and services provided;
c. Providers must provide evidence of and maintain adequate malpractice
insurance. For physicians, the minimum malpractice coverage requirements
are $1 million per individual episode and $3 million in the aggregate;
d. Specific terms regarding provider reimbursement as specified in Timely
Payment of Claims, Section 3.45 of this contract;
e. Specific terms concerning each party's rights to terminate the contract;
30
f. That any risk shifted to individual providers does not jeopardize access
to care or appropriate service delivery;
g. The exclusion of any provider that has been suspended from the Medicare or
Medicaid program in any state;
h. For PCPs, the provision of "on-call" coverage through arrangements with
other PCPs; and
i. That the MCOs and subcontractors require in-network behavioral health
providers to participate in the DEPARTMENT's efforts to study access,
quality and outcome. Upon renewal of its subcontracts and other provider
contracts, the MCO shall include a provision that failure to participate
shall constitute cause for termination of the in-network provider's
contract, except that MCOs which have demonstrated to the DEPARTMENT's
satisfaction that they have ensured provider participation in such efforts
through means other than the provider contracts need not include this
provision. In any event, the DEPARTMENT shall reimburse providers for
costs above and beyond nominal costs incurred by such participation.
3.11 PROVIDER CREDENTIALING AND ENROLLMENT
a. The MCO shall establish minimum credentialing criteria and shall formally
re-credential all professional participating providers in their network
at least once every two (2) years or such other time period as established
by the NCQA. The MCO shall create and maintain a credentialing file for
each participating provider that contains evidence that all credentialing
requirements have been met. The file shall include copies of all
documentation to support that credentialing criteria have been met,
including licenses, Drug Enforcement Agency (DEA) certificates and
provider statements regarding lack of impairment. Credentialing files
shall be subject to inspection by the DEPARTMENT or its agent.
b. MCO's credentialing and recredentialing criteria for professional
providers shall include at a minimum:
1. Appropriate license or certification as required by Connecticut law;
2. Verification that providers have not been suspended or terminated
from participation in Medicare or the Medicaid program in any state;
3. Verification that providers of covered services meet minimum
requirements for Medicaid participation;
4. Evidence of malpractice or liability insurance, as appropriate;
5. Board certification or eligibility, as appropriate;
6. A current statement from the provider addressing:
a. lack of impairment due to chemical dependency/drug abuse;
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b. physical and mental health status;
c. history of past or pending professional disciplinary actions,
sanctions, or license limitations;
d. revocation and suspension of hospital privileges;
e. a history of malpractice claims; and
7. Evidence of compliance with Clinical Laboratory Improvement
Amendments of 1988 (CLIA), Public Law 100-578, 42 USC Section
1395aa et seq. And 42 C.F.R. Part 493
c. The MCO may require more stringent credentialing criteria. Any other
criteria shall be in addition to the minimum criteria set forth above.
d. Additional MCO credentialing/recredentialing criteria for PCPs shall
include, but not be limited to:
1. Adherence to the principles of Ethics of the American Medical
Association, the American Osteopathic Association or other
appropriate professional organization;
2. Ability to perform or directly supervise the ambulatory primary care
services of Members;
3. Membership on the medical staff with admitting privileges to at
least one accredited general hospital an acceptable arrangement
with a PCP with admitting privileges;
4. Continuing medical education credits;
5. A valid DEA certification; and
6. Assurances that any Advanced Practice Registered Nurses (APRN),
Nurse Midwives or Physician Assistants are performing within the
scope of their licensure.
e. For purposes of credentialing and recredentialing, the MCO shall perform a
check on all PCPs and other participating providers by contacting the
National Practitioner Data Bank (NPDB). The DEPARTMENT will notify the MCO
immediately if a provider under contract with the MCO is subsequently
terminated or suspended from participation in the Medicare or Medicaid
programs. Upon such notification from the DEPARTMENT or any other
appropriate source, the MCO shall immediately act to terminate the
provider from participation in its network.
f. The MCO may delegate credentialing functions to a subcontractor. The MCO
is ultimately responsible and accountable to the DEPARTMENT for compliance
with the credentialing requirements. The MCO shall demonstrate and
document to the DEPARTMENT the MCO's significant oversight of its
subcontractors performing any and all provider credentialing, including
facility or delegated credentialing. The MCO and any such entity shall be
required to cooperate in the performance of financial, quality or other
audits conducted by the
32
DEPARTMENT or its agent(s). Any subcontracted entity shall maintain a
credentialing file for each in-network provider as set forth above.
g. The MCO must adhere to the additional credentialing requirements set
forth in Appendix B.
SANCTION: The DEPARTMENT may impose a Class B sanction pursuant to Section 7.05
if, upon completion of a performance review, it is established that a provider
in the MCO's network fails to meet the minimum credentialing criteria for
participation set forth in (a) and (b) above, and PCPs must also meet the
criteria set forth in (d).
3.12 SPECIALIST PROVIDERS AND THE REFERRAL PROCESS
The MCO shall contract with a sufficient number and mix of specialists so that
the Member population's anticipated specialty care needs can be substantially
met within the MCO's network of providers. The MCO will also be required to have
a system to refer Members to out-of-network specialists if appropriate
participating specialists are not available. The MCO shall make specialist
referrals available to its Members when it is medically necessary and medically
appropriate and shall assume all financial responsibility for any such referrals
whether they be in-network or out-of-network. The MCO must have policies and
written procedures for the coordination of care and the arrangement, tracking
and documentation of all referrals to specialty providers.
3.13 PCP SELECTION, SCHEDULING AND CAPACITY
a. The MCO shall provide Members with the opportunity to select a PCP within
thirty (30) days of enrollment. The MCO shall assign a Member to a PCP
when a Member fails to choose a PCP within thirty (30) days after being
notified to do so. The assignment must be appropriate to the Member's age,
gender and residence.
b. The MCO shall ensure that the PCPs in its network adhere to the following
PCP scheduling practices:
1. Emergency cases shall be seen immediately or referred to an
emergency facility;
2. Urgent cases shall be seen within forty-eight (48) hours of PCP
notification;
3. Routine cases shall be seen within ten (10) days of PCP
notification;
4. Well-care visits shall be scheduled within six (6) weeks of PCP
notification;
5. EPSDT/HealthTrack comprehensive health screens and immunizations
shall be scheduled in accordance with the DEPARTMENT's HealthTrack
periodicity and immunization schedules;
33
6. New Members shall receive an initial PCP appointment in a timely
manner; (for those Members who do not access goods and services
within the first six (6) months of enrollment, the MCO shall
identify and remedy any access problems); and
7. Waiting times at PCPs are kept to a minimum.
c. The MCO shall report quarterly on each PCP's panel size, group practice
and hospital affiliations in a format specified by the DEPARTMENT. The
DEPARTMENT will aggregate reports received from all MCOs for both HUSKY A
and HUSKY B. In the event that the DEPARTMENT finds a PCP with more than
1,200 HUSKY (combined HUSKY A and HUSKY B) panel Members, the DEPARTMENT
will notify the MCO if the PCP is part of the MCO's network. The
DEPARTMENT expects that the MCO will take appropriate action to ensure
that patient access to the PCP is assured.
d. The MCO shall maintain a record of each Member's PCP assignments for a
period of two (2) years.
e. The MCO shall track each Member's use of primary medical care services. In
the event that a Member does not regularly receive primary medical care
services from the PCP or the PCP's group other than visits to school based
health clinics, the MCO shall contact the Member and offer to assist the
Member in selecting a PCP.
f. If the Member has not received any primary care services, the MCO shall
contact the Member and offer to assist the Member in scheduling a
well-care visit if the Member's last well-care visit was not within the
appropriate guidelines for his or her age and gender.
PERFORMANCE MEASURE: PCP Appointment Availability. The DEPARTMENT or its agent
will routinely monitor appointment availability as measured by b(1) through
b(6) by using test cases to arrange appointments of various kinds with selected
PCPs. If less than ninety (90) percent of the sample make appointments available
within the required time, the DEPARTMENT shall require that the MCO submit a
corrective action plan, which will outline the steps that the MCO will take to
rectify the problem, within thirty (30) days.
3.14 FAMILY PLANNING ACCESS AND CONFIDENTIALITY
a. The MCO shall notify and give each Member, including adolescents, the
opportunity to use his or her own PCP or utilize any family planning
service provider for family planning services without requiring a referral
or authorization. The MCO shall make a reasonable effort to subcontract
with all local family planning clinics and providers, including those
funded by Title X of the Public
34
Health Services Act, and shall reimburse providers for all family planning
services regardless of whether that provider is a participating provider.
The MCO shall reimburse out-of-network providers of family planning
services at least the Medicaid fee-for-service rate for the service. The
MCO may require family planning providers to submit claims or reports in
specified formats before reimbursing services.
b. The MCO shall keep family planning information and records for each
individual patient confidential, even if the patient is a minor.
c. Family planning services which must be covered include:
1. reproductive health exams;
2. patient counseling;
3. patient education;
4. lab tests to detect the presence of conditions affecting
reproductive health;
5. sterilizations;
6. screening, testing, and treatment of and pre and post- test
counseling for sexually transmitted diseases and HIV; and
7. abortions, if the pregnancy is the result of an act of rape or
incest or in the case where a woman suffers from a physical
disorder, physical injury, or physical illness, including a
life-endangering physical condition caused by or arising from the
pregnancy itself, that would, as certified by a physician, place the
woman in danger of death unless an abortion is performed.
d. Pursuant to federal law ("the Hyde Amendment") and 42 C.F.R. Part 441,
Subpart E, the DEPARTMENT may only seek federal funding for those
abortions described in (c)(7) above. The MCO shall cover all abortions
that fall within these circumstances. The MCO shall submit a Form W-384
for any such abortions and comply with the DEPARTMENT's Medical Services
Policy concerning abortions.
e. The MCO shall also cover all other medically necessary abortions not
covered under federal law and described in (c)(7) above. The determination
as to whether an abortion is medically necessary shall be made by the
Member's PCP or another physician, in consultation with the member. The
MCO shall not require prior authorization for any such medically necessary
abortion. The DEPARTMENT will not seek any federal funding for any
abortions covered under this subsection. The DEPARTMENT and the MCO shall
enter into a separate contract for abortions that do not qualify for
federal matching funds, as described in section (d) above.
f. The MCO shall submit a report on a quarterly report due 15 days after the
end of the quarter for all abortions performed pursuant to section (e)
above. The report format is attached hereto as Appendix L.
35
SANCTION: If the MCO fails to provide the reports required in subsection (f),
the DEPARTMENT may impose a Class B sanction, pursuant to Section 7.05.
3.15 PHARMACY ACCESS
For purposes of this section, "prescription" shall include authorization for
legend and over the counter drugs covered by Medicaid policy.
a. Pharmacies must be available and accessible on a statewide basis. The
MCO shall:
1. Maintain a comprehensive provider network of pharmacies that will
within available resources assure twenty four (24) hour access to
pharmaceutical goods and services;
2. Have established protocols to respond to urgent requests for
medications;
3. Monitor and take steps to correct excessive utilization of regulated
substances; and
4. Require pharmacists to utilize the Automated Eligibility
Verification System (AEVS) to determine client eligibility and MCO
affiliation when there is a discrepancy between the information in
the MCO's eligibility system and information given to the
pharmacists by the Member, the Member's physician or other third
party.
b. The MCO shall require that its provider network of pharmacies offer
medically necessary goods and services to the MCO's Members. The MCO may
have a drug management program that includes a prescription drug
formulary. The MCO drug formulary must include only Food and Drug
Administration approved drug products and must be broad enough in scope to
meet the needs of all Members. The MCO drug formulary shall consist of a
reasonable selection of drugs which do not require prior approval for each
specific therapeutic drug class.
c. The MCO shall submit a copy of its formulary to the DEPARTMENT no later
than thirty (30) days after the effective date of this contract. The MCO
shall submit any subsequent deletions to the formulary to the DEPARTMENT
thirty (30) days prior to making the change. The MCO shall also submit
subsequent additions to the formulary immediately without seeking prior
approval by the DEPARTMENT. The DEPARTMENT reserves the right to identify
deficiencies in the content or operation of the formulary. In this
instance, the MCO shall have thirty (30) days to address in writing the
identified deficiencies to the DEPARTMENT's satisfaction. The MCO may
request to meet with the DEPARTMENT prior to submission of the written
response.
36
d. The MCO shall ensure that Members using maintenance drugs (drugs usually
prescribed to treat long-term or chronic conditions including, but not
limited to, diabetes, arthritis and high blood pressure) are informed in
advance, but no less than thirty (30) days in advance of any changes to
the prescription drug formulary related to such maintenance drugs if the
Member using the drug will not be able to continue using the drug without
a new authorization. If a Member requests a grievance and administrative
hearing concerning a denial or termination that results from or relates to
the removal of the maintenance drug from the formulary, the MCO shall
continue to authorize the drug for that Member pending a hearing decision.
e. The MCO shall require that its provider network of pharmacies adheres to
the provisions of Connecticut General Statutes Section 20-619 (b) and (c)
related to generic substitutions for Medicaid recipients.
f. If the MCO maintains a drug formulary, the MCO shall have a prior
authorization process to permit access, at a minimum, to all medically
necessary and appropriate drugs covered for the Medicaid fee-for-service
population. Medicaid pharmacy policy is set forth at Sections 174 through
174H.IV.A.4 of the Regulations of Connecticut State Agencies. The MCO
shall develop a timely and efficient authorization process to obtain
information from providers on medical necessity for a non-formulary drug,
a formulary drug requiring prior authorization or a brand name drug where
a generic substitution is available. The MCO shall make an individualized
determination concerning medical necessity in each instance when a
Member's prescribing provider requests a non-formulary drug, formulary
drug requiring prior authorization or a brand name drug in accordance with
the provisions of (e) above. If no request for prior authorization has
been received by the MCO or the Pharmacy Benefits Manager (PBM) prior to
the submission of a prescription to a pharmacy, the pharmacist may contact
the prescribing physician and inform him or her of the prior authorization
requirement.
g. Except as provided in subsection (j) below, in the event that a provider
requests authorization for, or prescribes a non-formulary drug, a
formulary drug requiring prior authorization or a brand name drug where a
generic substitution is available prior to prescribing a prescription for
that drug, but elects during the prior authorization process or in
discussions with the pharmacist to prescribe a formulary, generic or
alternate formulary drug that the provider agrees will be equally
effective for the Member, the MCO is not required to issue a notice of
37
action and is not required to provide a temporary supply of the drug for
which the provider initially sought authorization.
h. In the event that a provider requests authorization, or prescribes a
non-formulary drug, a formulary drug requiring prior authorization or a
brand name drug where a generic substitution is available, and the
provider and the MCO cannot reach an agreement that another drug is
equally effective, the MCO shall issue a notice of action.
The MCO or its PBM shall without delay authorize a thirty (30) day
temporary supply of the drug if the provider certifies to the MCO or its
PBM that the drug is necessary to address an urgent or emergent condition.
The MCO is also required to authorize a thirty (30) day temporary supply
of the drug on the day of submission of the prescription to the pharmacy
if the MCO has been unable to contact the provider to discuss an effective
formulary drug during normal business hours. The certification shall be in
a manner to be specified by the MCO, subject to the DEPARTMENT's approval.
If the original prescription was for a period less then thirty (30) days,
the override will be for the period prescribed. If the Member, upon
receipt of the notice of action, requests a grievance and administrative
hearing within ten (10) days, the MCO shall continue to authorize the drug
for the Member pending a hearing decision or other resolution of the
dispute concerning the prescription. If the Member does not request a
grievance and administrative hearing, the MCO is not required to authorize
any further refills.
i. The MCO shall, on a quarterly basis, in a format specified and approved by
the DEPARTMENT, submit a report detailing its prior authorization process
to the DEPARTMENT or its agent to be developed jointly between the
DEPARTMENT and the MCOs.
j. If the DEPARTMENT or its agent determines that there is a pattern of
denials for requested authorization for particular drugs, or any other
pattern suggesting that the MCO's authorization process is one that does
not appropriately consider each Member's individualized medical needs, the
DEPARTMENT may require notices of action in circumstances other than those
described above and/or may require the addition of a particular drug or
drugs to the MCO's formulary as drugs that do not require prior
authorizations.
3.16 MENTAL HEALTH AND SUBSTANCE ABUSE ACCESS
a. The MCO shall provide to its Members all behavioral health care services
(mental health and substance abuse) covered by Medicaid that are medically
necessary and medically appropriate. These services may be provided by the
MCO through contracts with providers of services or through subcontracted
relationships with
38
specialized behavioral health management entities. A Member will not need
a PCP referral to obtain services; self-referral will be sufficient to
obtain an initial service visit. The MCO may require prior authorization
for an ongoing course of treatment. Members with mental health and
substance abuse disorders shall not be denied coverage by the MCO for the
initial visit, simply because they did not abide by MCO's rules (either by
going to an out-of-network provider or going to an in-network provider
without an appropriate referral).
b. Notwithstanding any contractual arrangement with a specialized management
agency, the MCO is wholly responsible to ensure that medically necessary
and medically appropriate services are provided to its Medicaid Members.
c. The MCO shall contract with a consultant or employ a doctoral level mental
health professional with appropriate qualifications, credentials and
decision making authority who will have specific responsibilities for
exercising oversight of the delivery of behavioral health services by the
MCO or its subcontractors. Such person shall be responsible for promoting
efforts to better integrate and coordinate the provision of behavioral
health care with other services. The individual shall be available by
phone for consultation on an as needed basis, dedicated to the Connecticut
Members, as well as have an extensive understanding of the State of
Connecticut's Medicaid rules and regulations.
d. In reference to services for children with psychiatric/mental health and
substance abuse needs, the MCO and any subcontracted entity is required to
contract with and refer Members to qualified Medicaid providers who meet
benchmark requirements or demonstrate that equal or superior services are
being made available through other providers. The benchmark providers are
child guidance clinics, community mental health centers and clinics,
family service agencies and other qualified substance abuse providers (who
provide services in compliance with state law) with a specialization in
serving children. Continuation of benchmark status is contingent upon
participation in the DSS Study of Behavioral Health Outcomes. Any
benchmark providers who refuse to participate in the study will lose this
status.
e. The MCO and any subcontractor entity will cooperate in the identification
and improvement of processes working toward the development and
standardization of administrative procedures. The MCO and any
subcontracted entity shall take steps to promote successful provider
-Member relationships and will monitor the effectiveness of these
relationships.
f. The MCO is responsible for monitoring the performance of its network
providers and for monitoring and ensuring contract compliance. The MCO
shall also be responsible for ensuring that its subcontractors comply with
Medicaid policy and this contract. Such monitoring will ensure that
providers and subcontractors observe all contractual and policy
requirements as well as measuring performance relating to such areas as
access to care and ensuring quality of care. The MCO
39
and any subcontracted entity are required to cooperate in the performance
of financial, quality or other audits conducted by the DEPARTMENT or its
agent(s).
g. The MCO and its behavioral health subcontractor are required to
participate in the DSS Study on Behavioral Health Outcomes for children
receiving outpatient treatment services.
SANCTION: Failure of the MCO and or its subcontractor(s) to participate in the
DEPARTMENT Study may constitute grounds for the imposition of a Class B sanction
pursuant to Section 7.05.
3.17 CHILDREN'S ISSUES AND EPSDT COMPLIANCE
In order to meet the requirements of the EPSDT program as set forth in Sections
1902(a)(43) and 1905(r) of the Social Security Act, the MCO shall:
a. Provide EPSDT screening services in accordance with the periodicity
schedule attached to this contract as Appendix C. Any changes in the
periodicity schedule subsequent to the effective date of this contract
shall be provided to the MCO sixty (60) days before the effective date of
the change. The MCO shall not require prior authorization of EPSDT
screening services;
b. Provide interperiodic screening examinations when medically necessary, or
in accordance with the provisions of Section 3.18 (5)(a), to determine the
existence of a physical or mental illness or condition, or to assist
Members in meeting the medical requirements for certification or
recertification in WIC. Such interperiodic screens shall include screens
for anemia as recommended by the Centers for Disease Control (CDC). The
MCO shall not require prior authorization of interperiodic screening
examinations;
c. Provide EPSDT screening services that at a minimum, include:
1. A comprehensive health and developmental history (including
assessment of both physical and mental health development and
assessment of nutritional status);
2. A comprehensive unclothed or partially draped physical exam;
3. Appropriate immunizations as currently recommended by the
Connecticut Department of Public Health
4. Laboratory tests, as set forth in the periodicity schedule at
Appendix C
5. Vision and hearing screenings as set forth in the periodicity
schedule at Appendix C;
6. Dental assessments as set forth in the periodicity schedule at
Appendix C and
7. Health education, including anticipatory guidance.
40
d. Provide all medically necessary health care, diagnostic services, and
treatment for Members under twenty-one (21) covered under the federal
Medicaid program and described in Section 1905(a) of the Social Security
Act regardless of whether the health care, diagnostic services, and
treatment are specified in the list of covered services at Appendix A of
this contract and regardless of any limitations on the amount, duration,
or scope of the services that would otherwise be applied.
e. Take all necessary steps to ensure that its Members under the age of
twenty-one (21) receive EPSDT screening services and any necessary
diagnostic and treatment services, including, but not limited to:
1. Providing assistance in arranging and scheduling appointments;
2. Providing and arranging transportation;
3. Following up on missed appointments; and
4. Providing interpreters to Members with limited English proficiency
and Members who are hearing and visually impaired.
f. No later than sixty (60) days after enrollment in the plan and annually
thereafter, use a combination of oral and written methods including
methods for communicating with Members with limited English proficiency,
Members who cannot read, and Members who are visually or hearing impaired,
to:
1. Inform its Members about the availability of EPSDT screening,
diagnostic and treatment services;
2. Inform its Members about the importance and benefits of EPSDT
screening services;
3. Inform its Members about how to obtain EPSDT screening services; and
4. Inform its Members that assistance with scheduling appointments and
transportation is available, and inform them how to obtain this
assistance.
g. Coordinate and enhance the services provided to Members under twenty-one
(21) through the development and execution of memorandums of understanding
(MOUs) with the following programs:
1. Healthy Families Connecticut;
2. Connecticut Community Health Initiative (CCHI);
3. The Special Supplemental Food Program for Women, Infants, and
Children (WIC);
4. Birth-to-Three;
5. Head Start;
6. InfoLine's Maternal and Child Health Project; and
7. Other programs operated by the Departments of Children and Families,
Education, Public Health, Mental Health and Addiction Services and
Mental Retardation as designated by the DEPARTMENT.
41
h. Include in the MOUs developed and executed under subsection (g) of this
section provisions that specify how the MCO will work with the program,
including, but not limited to:
1. A description of the services provided by the program;
2. Designation of a liaison at the MCO to work with the program on
ensuring the provision of medically necessary and appropriate
covered services by the MCO and the coordination of services
provided by the MCO and the program;
3. Protocols for referrals to the program by the MCO;
4. Protocols for communication of information concerning individuals
who are Members of the MCO who are receiving services from the
program;
5. Protocols for the resolution of any issues that arise concerning the
delivery of services to HUSKY Members who are receiving services
from the program; and
6. Any other mutually agreed upon provisions.
i. The MCOs shall require PCPs to obtain all available vaccines free of
charge from the Department of Public Health under the Vaccines for
Children program.
j. Contract with the Connecticut Immunization Registry and Tracking System to
track childhood immunizations of its Members and report the immunizations
to the DEPARTMENT.
k. In order to carry out the responsibilities set forth in this section, the
MCO shall work with the Children's Health Council and the Connecticut
Children's Health Project. The MCO shall meet with representatives of the
Connecticut Children's Health Project on a regular basis to review the
reports provided by the Connecticut Children's Health Project that detail
the Members of the MCO who are due for EPSDT screening services, those who
are overdue for EPSDT screening services, and those who have missed EPSDT
screening services. The MCO shall work with the Connecticut Children's
Health Project to develop a plan for ensuring that Members under
twenty-one (21) years of age who are overdue or late for screening
examinations receive their EPSDT screening services and that other Members
continue to receive their examinations on a regular basis.
l. The MCO shall attain an annual EPSDT participation ratio and an annual
EPSDT screening ratio of at least eighty (80) percent as measured from
April 1, 2001 to March 31, 2002. The DEPARTMENT shall determine the MCO's
participation and screening ratio from the encounter data as reported to
and analyzed by The Children's Health Project subject to validation by the
DEPARTMENT or its agent(s) in accordance with the methodology established
by HCFA or CMS for the HCFA-416 report.
SANCTION: Failure to achieve a participation and/or screening ratio of eighty
(80) percent may subject the MCO to a Class B sanction in accordance with the
provisions of Section,
42
7.05. However, no sanction shall apply if the MCO's participation and screening
ratios, although less than eighty (80) percent, are greater than the
participation and screening ratios for the MCO and, if applicable, its
predecessor, for the equivalent period one year earlier (April 1, 2000 to March
31, 2001) plus one half the difference between the ratios for the earlier period
and eighty (80) percent.
3.18 SPECIAL SERVICES FOR CHILDREN/REINSURANCE
1. DISCHARGE PLANNING PROCESS AND IMPATIENT PSYCHIATRIC HOSPITAL REINSURANCE
FOR CHILDREN
a. The discharge planning process for children and adolescents with
significant mental health and substance abuse disorders is of particular
concern to the DEPARTMENT and DCF due to the potential unavailability of
appropriate subacute or step-down placements (e.g., residential treatment
with a clinical component, group home, specialized xxxxxx care). In order
to protect these particularly vulnerable minors, MCOs are required to seek
or develop alternatives to hospital-based care. MCOs are required to
negotiate "step-down" rates with qualified institutional providers, as
defined by the DEPARTMENT, to address the financial issues that arise in
the discharge planning circumstances described in this section.
b. The following provisions of this Section shall apply to all new admissions
of children and adolescents eighteen (18) years of age and younger in
qualified institutions.
1. REINSURANCE FOR ADMINISTRATIVELY NECESSARY DAYS
On a limited basis, the MCO may authorize the admission of a child
to a qualified institution for a one-day evaluation. If at the end
of a twenty-four (24) hour period the MCO determines that there is
no medical necessity for the continued admission but there is no
immediate discharge option available, the remainder of the stay will
qualify for 100% reinsurance by the DEPARTMENT. For the evaluation
day, the MCO will pay the institution the rate for an acute care
day. Beginning on day two (2) of the stay, the MCO will pay the
institution a negotiated rate and xxxx the DEPARTMENT in the month
following service delivery according to the process described below.
Reinsurance for non-medically necessary days attendant to an
evaluation stay may be claimed once per child per calendar year.
2. REINSURANCE FOR MEDICALLY NECESSARY DAYS
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Other than in the cases described above, where the length of stay in
either a step down program or a hospital setting pursuant to a medically
necessary admission extends beyond fifteen (15) days, the DEPARTMENT will
provide reinsurance for the MCOs. Reinsurance shall be provided for
medically necessary days of care provided at either an acute or a subacute
level of care. Care provided to children admitted to subacute care
pursuant to an observation bed stay shall be subject to the provisions of
this section. For the purpose of this section, a medically necessary
admission to inpatient psychiatric care for children will be defined to
include those admissions which are court ordered, provided that there is
consultation with the plan prior to the order regarding the appropriate
level and setting for the care.
The MCO may make decisions on the medical necessity of the admission and
may evaluate the level of acuity of the child or adolescent at any time
during the course of the stay. MCOs may redetermine the need for an acute
level of care at any time based on changes in the patient's condition.
However, within the first fifteen (15) days, the MCO shall provide all
necessary acute or subacute care as part of the discharge process.
3. THE SCHEDULE FOR REINSURANCE IS AS FOLLOWS:
# of days State's Share MCO's Share
0-15 0% 100%
16-45 75% 25%
46-60 90% 10%
60+ 100% 0%
If a psychiatric inpatient stay is interrupted due to an acute medical
condition requiring an admission to a general hospital, the reinsurance
day count will be suspended upon discharge from the psychiatric facility
and will resume when the Member is readmitted to the psychiatric inpatient
facility, if the readmission to the psychiatric inpatient facility is on
the same day as the discharge from the general hospital.
If there is a gap of one day or more between the discharge from the
general hospital and readmission to the psychiatric facility, the
admission to the psychiatric inpatient facility will be treated as a new
admission and the new inpatient day count will be reset.
4. The MCO or its subcontractor shall incur the costs for the reinsurance and
may xxxx the DEPARTMENT during the month following service delivery.
Reinsurance claims shall be submitted to the DEPARTMENT's Division of
Fiscal Analysis and shall be reimbursed as a percentage of the facility
specific per diem according to the state share described above. Claims
44
may be submitted by the MCO or its behavioral health subcontractor
with prior approval by the DEPARTMENT. The DEPARTMENT reserves the
right to review the level of payments made under the reinsurance
program retrospectively.
The DEPARTMENT will designate a contact person for reinsurance
claims.
3. RESPONSIBILITIES OF THE DEPARTMENT OF CHILDREN AND FAMILIES
a. DCF shall approve any placement, which is deemed by the MCO to be not
medically necessary. If the DEPARTMENT determines that reinsurance claims
were paid for services that were administratively necessary and not
medically necessary, the DEPARTMENT will pursue reimbursement from DCF.
b. In cases where the hospital identifies a discharge planning difficulty for
youth under the direct auspices of DCF who are utilizing inpatient,
hospital-based mental health or substance abuse services, the following
discharge planning process will apply:
1. As soon as the hospital identifies a discharge planning difficulty,
the MCO must contact DCF for assistance and notify the DEPARTMENT.
The MCO in conjunction with the hospital and DCF, must attempt to
resolve the discharge planning immediately. Service providers, the
MCO, DCF and the Member and family must develop an individualized
service plan that resolves the discharge issue while effectuating
appropriate ongoing treatment. The MCO shall consult with DCF
regarding the appropriate state licensed treatment setting. MCOs
have the authority to transition the patient to any qualified
provider of this level of care. Nothing in this section shall be
construed to imply a time limit on the overall behavioral health or
health care benefit in Medicaid managed care.
2. The DEPARTMENT will designate a contact person for clinical issues
regarding discharge planning. The MCO shall provide bi-weekly child-
specific reports on the progress of discharge planning to the
DEPARTMENT's designated contact person.
4. THE FOLLOWING PROVISIONS WILL APPLY TO ADMISSIONS AT STATE FACILITIES.
a. The discharge planning and reinsurance provisions described in this
section shall apply to all new medically necessary and administratively
necessary admissions at state operated facilities effective October 1,
1998. When a child is admitted to a DCF facility, the MCO must reimburse
the DCF facility at the rate as calculated by the Office of the
Comptroller, provided that such admissions shall be governed
45
by a memorandum of understanding between the MCOs and DCF outlining the
terms and conditions for admissions and stays at the facility.
b. This discharge planning process and reinsurance program is not intended to
force MCOs to continue funding the most restrictive levels of care in
perpetuity; rather it is meant to insure the safety of children and
adolescents and encourage the development of appropriate alternatives to
hospital-based services.
5. SPECIALIZED OUTPATIENT SERVICES FOR CHILDREN UNDER DCF CARE
a. The MCO shall pay for a comprehensive multi-disciplinary examination for
initial placement only, for each child entering DCF care, within thirty
(30) days of placement into out-of-home care. The multi-disciplinary
examination shall be authorized by either the child's PCP or the MCO and
shall consist of a thorough assessment of the child's functional, medical,
developmental, educational, and mental health status. Within each area of
the assessment, the evaluation shall identify any additional specialized
diagnostic and therapeutic needs. Physicians and other medical and mental
health providers specializing in the assessment areas shall conduct the
multi-disciplinary examination. Each multi-disciplinary examination shall
occur at a single location. All components of the examination shall be
performed on the same day, excluding additionally needed examinations,
unless otherwise indicated. The provider shall report the findings and
conclusions of the examination in a form acceptable to DCF. The report
must be received by DCF within fifteen (15) days of the examination. The
provider shall also provide for updates to DCF on any additional
examinations.
b. The providers of the MCO shall provide for training of xxxxxx parents on
the use of special equipment or medications as needed.
c. The MCO shall require regular collaboration between providers and DCF
Regional Offices and Central Office medical, mental health and social work
staff and consultants. The MCO shall a assign staff to act as liaisons to
identify, address and resolve health care delivery issues, barriers to
comprehensive care and other problem areas. DCF shall specify the contact
persons by name, title and phone number who will be available for
quarterly meetings between DCF and the MCO and shall facilitate the
initiation of these meetings with the MCO.
d. The MCO shall include a panel of mental health providers who shall be
qualified to perform psychological, psychiatric and developmental
evaluations and perform assessment and treatment of sexual abuse and
juvenile sexual offenders. DCF shall be available for consultation in the
identification of such providers.
e. In addition to standard prescription coverage, the MCO shall cover
prescriptions in compliance with DCF policy for "Placement Medications"
which are additional prescriptions which may be needed when children are
placed or change
46
placements. The MCO shall cover "Home Visit Medications". Home Visit
Medications are additional prescriptions, which may be needed when
children placed in out-of-home settings leave the placement for a home
visit. Home Visit Medications should include only those doses which will
be needed during the home visit, plus one extra dose.
f. The MCO shall deliver a notice of action to an identified person at the
DCF Central Office when a service is to be reduced, denied or terminated.
DCF will, in turn, distribute the notice of action to its appropriate
regional and local personnel.
3.19 PRENATAL CARE
a. In order to promote healthy birth outcomes, the MCO or its contracted
providers shall:
1. Identify enrolled pregnant women as early as possible in the
pregnancy;
2. Conduct prenatal risk assessments in order to identify high risk
pregnant women, arrange for specialized prenatal care and support
services tailored to risk status, and begin care coordination that
will continue throughout the pregnancy and early weeks of
postpartum;
3. Refer enrolled pregnant women to the WIC program;
4. Offer case management services for assistance with obtaining
prenatal care appointments, transportation, WIC, and other support
services as necessary;
5. Offer prenatal health education materials and/or programs aimed at
promoting healthy birth outcomes;
6. Offer HIV testing and counseling and all appropriate prophylaxis and
treatment to all enrolled pregnant women;
7. Refer any pregnant Member who is actively abusing drugs or alcohol
to a behavioral health subcontractor or provider of behavioral
health/substance abuse services and treatment; and
8. Educate new mothers about the importance of the postpartum visit and
well-baby care.
PERFORMANCE MEASURE: Early access to prenatal care: Percentage of enrolled women
who had a live birth, who were continuously enrolled in the MCO for 280 days
prior to delivery who had a prenatal visit in the MCO on or between 176 to 280
days prior to delivery.
PERFORMANCE MEASURE: Adequacy of prenatal care: Percentage of women with live
births who were continuously enrolled during pregnancy who had more than eighty
(80) percent of the prenatal visits recommended by the American College of
Obstetrics and Gynecology, adjusted for gestational age at enrollment and
delivery.
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3.20 DENTAL CARE
a. The MCO shall contract with a sufficient number of dentists throughout the
state to assure access to oral health care. The MCO shall:
1. Maintain an adequate dental provider network throughout the state's
eight (8) counties including access to orthodontic services;
2. For the purpose of enrollment capacity a dental hygienist meeting
the criteria of Section 20-1261 of the Connecticut General Statutes,
as amended by PA 01-2, June, 2000 Special Session, with two (2)
years of experience, working in an institution (other than
hospital), a community health center, a group home, a preschool
operated by a local board of education or head start program, or a
school setting shall be counted as fifty (50) percent of a general
dentist. If the MCO's provider network includes dental hygienists
acting independently within their scope of practice to provide
preventive services to Members, the MCO shall require that dental
hygienists make appropriate referrals to in-network dentists for
appropriate restorative and diagnostic services;
3. Implement a plan that includes a systematic approach for enhancing
access to dental care through monitoring appointment availability,
provision of training to providers around issues of cultural
diversity and any other specialized programs;
4. To ensure that access standards are met with respect to dental
screens and appointment availability. The MCO shall ensure that the
scheduling of a routine dental visit is six (6) weeks;
5. Certify that all dentists in the MCO's network shall take Members
and that MCO's HUSKY Members shall be assured the same access to
providers as non-HUSKY Members. Nothing in this section shall
preclude the implementation of limits on panel size by providers;
6. Implement procedures to provide all Members with the opportunity to
choose a general dentist;
7. Implement specific outreach strategies to educate Members about the
importance of regular dental care, with a focus on accessing age
appropriate preventive care such as screenings and cleanings at
least twice a year;
8. Provide for sufficient access to dental services for different age
groups; and
48
9. Devise mechanisms to avoid unnecessary PCP visits related to dental
problems.
PERFORMANCE MEASURE: The MCO shall ensure that no less than eighty (80) percent
of continuously enrolled Members two (2) to twenty (20) years of age shall
receive one screening and dental cleaning per twelve (12) month period. On a
quarterly basis, the DEPARTMENT shall, through the encounter data submitted by
the MCO, review the MCO's performance under children's dental access.
PERFORMANCE MEASURE: The MCO shall ensure that no less than eighty (80) percent
of continuously enrolled Members twenty-one (21) years of age and over shall
receive one screening and dental cleaning per twelve (12) month period. On a
quarterly basis, the DEPARTMENT shall, through the encounter data submitted by
the MCO, review the MCO's performance under adult dental access.
3.21 OTHER ACCESS FEATURES
a. The MCO shall have systems in place to ensure access to medically
necessary and medically appropriate well-care by its Members. The MCO
shall develop procedures to identify access problems and shall take
corrective action as problems are identified. These systems and
initiatives shall include, but not be limited to:
1. Monitoring new Members to ensure that a well-care appointment is
scheduled within six (6) months of enrollment for those whose last
well-care visit does not fall within the recommended age and gender
appropriate schedules;
2. Monitoring and ensuring that Members receive well-care visits based
on age and gender appropriate schedules;
3. Contacting and counseling Members who miss scheduled appointments;
4. Coverage and provision of services to newborns from the time of
birth;
5. Assisting Members in accessing and locating linguistically and
culturally appropriate services, including but not limited to,
appropriate accommodation for Members with hearing disabilities;
6. Assisting disabled Members in accessing and locating services and
providers that can appropriately accommodate their needs, for
example wheelchair access to provider's office;
7. Development of special initiatives, case management, care
coordination, and outreach to Members with special or multiple
medical needs, for example persons with AIDS or HIV infected
individuals;
8. Development of goals and action plans for incremental increases in
utilization of services such as postpartum care, adolescent health,
dental
49
care and other health care measures agreed upon between the MCO and
the DEPARTMENT; and
9. Encouraging providers to offer extended business hours and weekend
(Saturday) openings.
b. The MCO's access systems will be assessed as part of the annual
performance review of the MCO.
3.22 PRE-EXISTING CONDITIONS
a. The MCO shall assume responsibility for all covered services as outlined
in Appendix A for of each Member as of the effective date of coverage
under the contract regardless of the new Member's health status.
b. As outlined in Appendix K, for new Members who have transferred enrollment
from another HUSKY MCO, coverage of services other than acute care
hospitalization, nursing home care or care in a subacute facility shall be
the responsibility of the MCO as of the beginning of the month during
which enrollment becomes effective. Responsibility for acute
hospitalization, nursing home or subacute care services at the time of
enrollment or disenrollment is described in Section 3.24.
3.23 NEWBORN ENROLLMENT
Within six (6) months of a child's date of birth, the MCO must notify the
DEPARTMENT of newborn for which they have not received enrollment notification
from the DEPARTMENT. The MCO shall use the notification form made available by
the DEPARTMENT for this purpose. Should the MCO fail to report the child's
birth, the MCO shall reimburse the DEPARTMENT for any fee-for-service claims
paid for covered services that occurred for the newborn Members prior to
processing the newborn's enrollment into the MCO.
3.24 ACUTE CARE HOSPITALIZATION, NURSING HOME OR SUBACUTE STAY AT TIME OF
ENROLLMENT OR DISENROLLMENT
For acute care requiring inpatient stay at a hospital, nursing home or subacute
facility, financial responsibility for covered services shall be determined as
follows:
50
a. INPATIENT AT TIME OF ENROLLMENT
Initial enrollment in HUSKY A should not commence during a recipient's
inpatient stay at a hospital, nursing home or subacute facility unless the
recipient is a newborn, born to a Member.
The MCO shall notify the DEPARTMENT within sixty (60) days of the MCO's
discovery of or from the date that the MCO receives information from which
a determination can be made that initial enrollment will take effect
during the course of a hospitalization. For those individuals who are
inpatient in an MCO participating facility, the time period in which an
MCO must notify the DEPARTMENT is limited to six (6) months from the
enrollment effective date or sixty (60) days of discovery, whichever
comes first. Upon timely notification to the DEPARTMENT by the MCO, the
DEPARTMENT shall change the effective date to the first of the month after
discharge. If the MCO fails to notify the DEPARTMENT of the inpatient
status within the above specified time periods, the DEPARTMENT shall be
relieved of its responsibility to change the enrollment effective date and
the individual's initial enrollment effective date into the MCO shall be
retained.
b. HOSPITALIZATION AT TIME OF DISENROLLMENT
Inpatient costs for Members who are hospitalized at a hospital at the time
of disenrollment from the MCO shall remain the financial responsibility of
the MCO until discharge. Individuals who are disenrolled due to
recategorization of their Medicaid coverage to a non-managed care category
shall revert to fee-for-service upon recategorization.
Members who are inpatient in a subacute facility or a nursing home will
remain the responsibility of the MCO until they are discharged from the
MCO. If the MCO reports to DSS or its agent, any patient in a subacute
facility or a nursing home other than for the purpose of behavioral health
prior to the ninety (90) days from the date of admission, the DEPARTMENT
will disenroll the Member at the end of the month, that the Member has
been inpatient for ninety (90) days. If the MCO reports to the DEPARTMENT
beyond ninety (90) days, the change will be effective the month end of the
month reported to DSS or its agent.
3.25 OPEN ENROLLMENT
a. The MCO shall conduct continuous open enrollment during which the MCO
shall accept clients eligible for coverage under this contract in the
order in which they are enrolled without regard to the health status of
the client or any other factor(s).
b. The MCO shall accept membership of newborns born to a Member upon the
child's date of birth with the exception of newborns that are placed for
private
51
adoption or when the mother has indicated in writing that she does not
wish Medicaid coverage for the child. The enrollment effective date for
newborns shall be the first of the month in which the child was born.
c. The MCO shall not discriminate in enrollment activities on the basis of
health status or the client's need for health care services or on any
other basis, and shall not attempt to discourage or delay enrollment with
the MCO or encourage disenrollment from the MCO of eligible Medicaid
clients.
d. If the MCO discovers that a Member's new or continued enrollment was in
error, the MCO shall notify the DEPARTMENT or its agent within sixty (60)
days of the discovery or sixty (60) days from the date that the MCO had
the data to determine that the enrollment was in error, whichever comes
first. Other than the case of a newborn retroactively enrolled, failure to
notify the DEPARTMENT or its agent within the parameters defined in this
section and within established procedures will result in the retention of
the Member by the MCO for the erroneous period of enrollment.
3.26 SPECIAL DISENROLLMENT
a. The MCO may request in writing and the DEPARTMENT may approve
disenrollment for specific persons when there is good cause. The request
shall cite the specific event(s), date(s) and other pertinent information
substantiating the MCO's request. Additionally, the MCO shall submit any
other information concerning the MCO's request that the DEPARTMENT may
require in order to make a determination in the case.
b. Good cause is defined as a case in which a Member:
1. Exhibits disruptive or inappropriate behavior that is not related to
a medical condition to the extent that the Member's continued
enrollment seriously impairs the MCO's ability to furnish services
to either the particular Member or others; or
2. Permits others to use or loans his or her membership card to others
to obtain care or services.
c. Extensive or expensive health care needs shall not constitute good cause.
d. The DEPARTMENT will notify the MCO if a Member is disenrolled for cause
from another plan pursuant to this section prior to enrollment.
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3.27 LINGUISTIC ACCESS
a. The MCO shall take appropriate measures to ensure adequate access to
services by Members with limited English proficiency. These measures shall
include, but not be limited to the promulgation and implementation of
policies on linguistic accessibility for MCO staff, network providers and
subcontractors; the identification of a single individual at the MCO for
ensuring compliance with linguistic accessibility policies; identification
of persons with limited English proficiency as soon as possible following
enrollment; provisions for translation services; and the provision of a
Member handbook, notices of action and grievance/administrative hearing
information in languages other than English.
b. Member educational materials must also be available in languages other
than English and Spanish when more than five (5) percent of the MCO's
Members in any county served by the MCO speaks the alternative language,
provided, however, this requirement shall not apply if the alternative
language has no written form. The MCO may rely upon initial enrollment and
monthly enrollment data from the DEPARTMENT's Eligibility Management
System (EMS) to determine the percentage of Members who speak alternative
languages. All Member educational materials must be made available in
alternate formats to the visually impaired.
c. The MCO shall also take appropriate measures to ensure access to services
by persons with visual and hearing disabilities. Information concerning
Members with visual impairments and hearing disabilities will be made
available through the daily and monthly EMS enrollment data.
SANCTION: For each documented instance of failure to provide appropriate
linguistic accessibility to Members, the DEPARTMENT may impose a strike towards
a Class A sanction pursuant to Section 7.05.
3.28 SERVICES TO MEMBERS
a. The MCO shall have in place an ongoing process of Member education which
includes, but is not limited to: development of a Member handbook;
provider directory; newsletter; and other Member educational materials.
All written materials and correspondence to Members shall be culturally
sensitive and written at no higher than a seventh grade reading level. All
Member educational materials must be in both English and Spanish.
53
b. The MCO shall mail the Member handbook and provider directory to Members
within one week of enrollment notification. The Member handbook shall
address and explain, at a minimum, the following:
1. Covered services;
2. Restrictions on services (including limitations and services not
covered):
3. Prior authorization process;
4. Definition of and distinction between emergency care and urgent care;
5. Policies on the use of emergency and urgent care services including
a phone number which can be used for assistance in obtaining urgent
care;
6. How to access care twenty-four (24) hours a day;
7. Assistance with appointment scheduling;
8. Member rights and responsibilities;
9. Member services, including hours of operation;
10. Enrollment/disenrollment/plan changes;
11. Procedures for selecting and changing PCPs;
12. Availability of provider network directory and updates;
13. That a Member is not liable for copayments;
14. Limited liability for services from out-of-network providers;
15. Access and availability standards;
16. Special access and other MCO features of the health plan's program;
17. Family planning services;
18. Case management services targeted to Members as medically necessary
and appropriate;
19. The MCO's grievance and the DEPARTMENT's administrative hearing
process;
20. Procedures to request non-emergency transportation and
transportation options;
21. EPSDT services for children;
22. Coordination of benefits and third party liability; and
23. Description of drug formulary, prior approval and override process,
if applicable.
c. All Member educational materials must be prior approved by the DEPARTMENT.
Educational materials include, but are not limited to: Member handbook;
Membership card; introductory and other text language from the provider
directory; and all communications to Members that include HUSKY A program
information. The MCO must wait until receiving DEPARTMENT written approval
or thirty (30) days from the date of submittal before disseminating
educational materials to Members. The DEPARTMENT reserves the right to
request revisions or changes in the material at any time.
d. The MCO must provide periodic updates to the handbook or inform Members,
as needed, of changes to the Member information discussed above. The MCO
shall update its Member handbook to incorporate all provisions and
requirements of this contract within six (6) weeks of the start date. The
MCO shall distribute the
54
Member handbook within six (6) weeks of receiving the DEPARTMENT's written
approval.
e. The MCO shall maintain an adequately staffed Member services office to
receive telephone calls and to meet personally with Members in order to
answer Members' questions, respond to Members' complaints and resolve
problems informally.
f. The MCO shall identify to the DEPARTMENT the individual who is responsible
for the performance of the Member Services Department.
g. The MCO's Member Services Department shall include bilingual staff
(Spanish and English) and translation services for non-English speaking
Members. The MCO shall also make available translation services at
provider sites either directly or through a contractual obligation with
the service provider.
h. The MCO shall require members of the Member Services Department to
identify themselves to Members when responding to Members' questions or
complaints. At a minimum, ninety (90) percent of all incoming calls shall
be answered by a staff Member within the first minute and the call
abandonment rate shall not exceed five (5) percent. The MCO shall submit
call response and abandonment reports for the preceding six (6) month
period to the DEPARTMENT upon request.
i. When Members contact the Member Services Department to ask questions
about, or complain about, the MCO's failure to respond promptly to a
request for goods or services, or the denial, reduction, suspension or
termination of goods or services, the MCO shall: attempt to resolve such
concerns informally, and inform Members of the grievance and
administrative hearing processes and, upon request, mail to them, within
one business day, forms and instructions for filing a grievance.
j. The MCO shall maintain a log of complaints resolved informally which shall
be made available to the DEPARTMENT upon request and which shall include a
short dated summary of the problem, the response and the resolution.
k. At the time of enrollment and at least annually thereafter, the MCO shall
inform its Members of the procedural steps for filing a grievance and
requesting an administrative hearing.
l. The MCO shall monitor and track PCP transfer requests and follow up on
complaints made by Members as necessary
m. The MCO will participate in two (2) Member surveys. The first such survey
will be an analysis of Members with special needs as defined by the
DEPARTMENT after consultation with the Children's Health Council, EQRO,
and the MCO, to be
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conducted at the DEPARTMENT's expense. The survey will be developed and
the sample will be chosen by the Children's Health Council, with input
from the MCOs and the DEPARTMENT. The other survey will be a NCQA Consumer
Assessment of Health Plans Survey (CAHPS) of combined HUSKY A and B
Members using an independent vendor, and paid for by the MCO.
n. The MCO may provide outreach to its current Members at the time of the
Member's renewal of eligibility. The outreach may involve special mailings
or phone calls as reminders that the Member must complete the HUSKY
renewal forms to ensure continued coverage.
SANCTION: If either the incoming call response or call abandonment standards set
forth in paragraph h are not met for ninety (90) percent of the days during the
six (6) month review period, the DEPARTMENT may impose a strike towards a Class
A sanction pursuant to Section 7.05.
3.29 INFORMATION TO POTENTIAL MEMBERS
The MCO shall, upon request, make the following information available to
potential Members:
a. the identity, locations, qualifications and availability of the
MCO's network providers;
b. rights and responsibilities of Members;
c. grievance procedures; and
d. all covered items and services that are available either directly or
indirectly or through referral and prior authorization.
3.30 MARKETING REQUIREMENTS
DSS marketing restrictions apply to providers of care as well as to the MCOs.
The MCO shall notify all its participating providers of the DEPARTMENT's
marketing restrictions. The detailed marketing guidelines are set forth in
Appendix D.
a. PROHIBITED MARKETING ACTIVITIES
The following activities are prohibited, in all forms of communication,
regardless of whether they are performed by the MCO directly, by its
contracted providers, or its subcontractors:
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1. Asserting or implying that a Member will lose or not qualify for
HUSKY benefits unless he/she enrolls in the MCO, or creating other
threatening scenarios that do not accurately depict the consequences
of choosing a different MCO;
2. Discriminating (in marketing or in the course of the enrollment
process) against any eligible individual on the basis of health
status or need for future health care services.
3. Making inaccurate, misleading or exaggerated statements (e.g. about
the nature of the eligibility or enrollment process, the positive
attributes of the MCO, or about the disadvantages of competing
MCOs);
4. Telephonic, door-to-door marketing or other cold call marketing or
enrollment activities to prospective Members;
5. Failing to submit for approval marketing materials or marketing
approaches when such approval is required by DSS (see Appendix D).
MCOs and their providers must wait until receiving DSS written
approval or thirty (30) days from the date of submittal before
disseminating any such information to potential Members. DSS
reserves the right to request revisions or changes in material at
any time; and
6. Conducting any form of individual or group solicitation activity
other than those expressly permitted under Appendix D, the DSS
Marketing Guidelines, unless prior approval is obtained from DSS.
b. Any type of marketing activity which has not been clearly specified as
permissible under these guidelines should be assumed to be prohibited. The
MCO shall contact the DEPARTMENT for guidance and approval for any
activity not clearly permissible under these guidelines.
SANCTION: If the MCO or its providers fails to submit marketing materials for
prior approval, the DEPARTMENT may impose a Class B sanction pursuant to Section
7.05.
SANCTION: If the MCO or its providers engages in inappropriate marketing
activities at provider sites, the DEPARTMENT may impose a Class B or Class C
sanction pursuant to Section 7.05 as it deems appropriate.
SANCTION: If the MCO or its providers engages in cold call or door-to-door
marketing, the DEPARTMENT may impose Class C sanctions pursuant to Section 7.05.
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3.31 HEALTH EDUCATION
The MCO must routinely, but no less frequently than annually, remind and
encourage the Members to utilize benefits including physical examinations which
are available and designed to prevent illness. The MCO must also offer periodic
screening programs which in the opinion of the medical staff would effectively
identify conditions indicative of a health problem. The MCO shall keep a record
of all activities it has conducted to satisfy this requirement.
3.32 INTERNAL AND EXTERNAL QUALITY ASSURANCE
a. The MCO is required to provide a quality level of care for all services
that it provides and for which it contracts. These services are expected
to be medically necessary and may be provided by participating providers.
A Quality Assessment and Performance Improvement program shall be
implemented by the MCO to assure the quality of care. The EQRO shall
monitor the MCO's compliance with all requirements in this section.
b. The MCO shall comply with federal regulations and DEPARTMENT policies and
requirements concerning Quality Assessment and Performance Improvement and
utilization review set forth below. The MCO will develop and implement an
internal Quality Assessment and Performance Improvement program consistent
with the Quality Assessment and Performance program guidelines as provided
in Appendix E.
c. The MCO shall comply with all applicable federal regulations concerning
Quality Assessment and Performance Improvement.
d. The MCO shall operate a Quality Assessment and Performance Improvement
system which:
1. Is consistent with applicable federal regulations;
2. Provides for review by appropriate health professionals of the
process followed in providing health services;
3. Provides for systematic data collection of performance and
participant results;
4. Provides for interpretation of these data to the practitioners;
5. Provides for making needed changes;
6. Provides for the performance of at least one performance improvement
project of the MCO's own choosing;
7. Provides for participation in at least one performance improvement
project conducted by the EQRO; and
8. Has in effect mechanisms to detect both under utilization and over
utilization of services.
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e. The MCO shall provide descriptive information on the operation,
performance and success of its Quality Assessment and Performance
Improvement program to the DEPARTMENT or its agent upon request.
f. The MCO shall maintain and operate a Quality Assessment and Performance
Improvement program which includes at least the following elements:
1. A Quality Assessment and Performance Improvement plan.
2. A full-time Quality Assessment and Performance Improvement Director,
who is responsible for the operation and success of the Quality
Assessment and Performance Improvement Program. This person shall
have adequate experience to ensure successful Quality Assessment and
Performance Improvement, and shall be accountable for the Quality
Assessment and Performance Improvement systems of all the MCO's
providers, as well as the MCO's subcontractors.
3. The Quality Assessment and Performance Improvement Director shall
spend an adequate percentage of time on Quality Assessment and
Performance Improvement activities to ensure that a successful
Quality Assessment and Performance Improvement Program will exist.
Under the Quality Assessment and Performance Improvement program,
there shall be access on an as-needed basis to the full compliment
of health professions (e.g., pharmacy, physical therapy, nursing,
etc.) and administrative staff. Oversight of the program shall be
provided by a Quality Assessment and Performance Improvement
committee that includes representatives from:
a. a variety of medical disciplines (e.g., medicine,
surgery, mental health, etc.);
b. administrative staff; and
c. Board of Directors of the MCO.
4. Make available case management training for PCPs designed by the
DEPARTMENT or its agent.
g. The Quality Assessment and Performance Improvement committee shall be
organized operationally within the MCO such that it can be responsible for
all aspects of the Quality Assessment and Performance Improvement program.
h. Quality Assessment and Performance Improvement activities shall be
sufficiently separate from Utilization Review activities, so that Quality
Assessment and Performance Improvement activities can be distinctly
identified as such.
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i. The Quality Assessment and Performance Improvement activities of the MCO's
in-network providers and subcontractors, if separate from the MCO's
Quality Assessment and Performance Improvement activities, shall be
integrated into the overall MCO Quality Assessment and Performance
Improvement program, and the MCO shall provide feedback to the in-network
providers/subcontractors regarding the operation of any such independent
Quality Assessment and Performance Improvement effort. The MCO shall
remain, however, fully accountable for all Quality Assessment and
Performance Improvement relative to its in-network providers and
subcontractors.
j. The Quality Assessment and Performance Improvement committee shall meet
at least quarterly and produce written documentation of committee
activities to be shared with the DEPARTMENT.
k. The results of the Quality Assessment and Performance Improvement
activities shall be reported in writing at each meeting of the Board of
Directors.
l. The MCO shall have a written procedure for following up on the results of
Quality Assessment and Performance Improvement activities to determine
success of implementation. Follow-up shall be documented in writing.
m. Where the DEPARTMENT determines that a Quality Assessment and Performance
Improvement plan does not meet the above requirements, the DEPARTMENT may
provide the MCO with a model plan. The MCO agrees to modify its Quality
Assessment and Performance Improvement plan based on negotiations with the
DEPARTMENT.
n. The MCO shall monitor access to and quality of health care goods and
services for its Member population, and, at a minimum, use this mechanism
to capture and report all of the DEPARTMENT's required utilization data.
The MCO shall be subject to an annual medical audit by the DEPARTMENT's
Quality Assessment and Performance Improvement contractor and shall
provide access to the data and records requested for this purpose.
o. To the extent permitted under state and federal law, the MCO certifies
that all data and records requested shall, upon reasonable notice, be made
available to the DEPARTMENT or its agent.
p. The MCO will be an active participant in at least one of the EQRO's
quality improvement focus studies each year.
q. The MCO must comply with external quality review that will be implemented
by an organization contracted by the DEPARTMENT. This may include
participating in the design of the external review, collecting data
including, but not limited to, encounter and medical data, and/or making
data available to the review organization.
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r. The MCO must conduct at least one performance improvement project that:
1. Focuses on one of the following areas:
a. Prevention and care of acute and chronic conditions;
b. High volume services;
c. Continuity and coordination of care;
d. Appeals, grievances and complaints;
e. Access to and availability of services; or
f. Other projects subject to DEPARTMENT approval.
2. Includes the measurement of performance and quality indicators that
are:
a. Objective;
b. Clearly and unambiguously defined;
c. Based on current clinical knowledge or health services
research;
d. Valid and reliable;
e. Systematically collected; and
f. Capable of measuring outcomes such as changes in health status
or Member satisfaction or valid proxies of those outcomes.
3. Implements system interventions to achieve quality improvement;
4. Evaluates the effectiveness of the interventions;
5. Plans and initiates activities for increasing or sustaining
improvement; and
6. Represents the entire population to which the quality indicator is
relevant.
s. With the approval of the DEPARTMENT, the MCO may conduct performance
improvement projects for the combined HUSKY A and HUSKY B populations.
3.33 INSPECTION OF FACILITIES
a. The MCO shall provide the State of Connecticut and any other legally
authorized governmental entity, or their authorized representatives, the
right to enter at all reasonable times the MCO's premises or other places,
including the premises of any subcontractor, where work under this
contract is performed to inspect, monitor or otherwise evaluate work
performed pursuant to this contract. The MCO shall provide reasonable
facilities and assistance for the safety and convenience of the persons
performing those duties. The DEPARTMENT and its authorized agents will
request access in advance in writing except in case of suspected fraud and
abuse.
b. In the event right of access is requested under this section, the MCO or
subcontractor shall upon request provide and make available staff to
assist in the audit or inspection effort, and provide adequate space on
the premises to reasonably accommodate the State or Federal
representatives conducting the audit or inspection effort.
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c. The MCO shall be given ten (10) business days to respond to any findings
of an audit before the DEPARTMENT shall finalize its findings. All
information so obtained will be accorded confidential treatment as
provided under applicable law.
3.34 EXAMINATION OF RECORDS
a. The MCO shall develop and keep such records as are required by law or
other authority or as the DEPARTMENT determines are necessary or useful
for assuring quality performance of this contract. The DEPARTMENT shall
have an unqualified right of access to such records in accordance with
Part II Section 3.33.
b. Upon non-renewal or termination of this contract, the MCO shall turn over
or provide copies to the DEPARTMENT or to a designee of the DEPARTMENT all
documents, files and records relating to persons receiving services and to
the administration of this contract that the DEPARTMENT may request, in
accordance with Part II, Section 3.33.
c. The MCO shall provide the DEPARTMENT and its authorized agents with
reasonable access to records the MCO maintains for the purposes of this
contract. The DEPARTMENT and its authorized agents will request access in
writing except in cases of suspected fraud and abuse. The MCO must make
all requested medical records available within thirty (30) days of the
DEPARTMENT's request. Any contract with a subcontractor must include a
provision specifically authorizing access in accordance with the terms set
forth in Part II, Section 3.33.
d. The MCO shall maintain the confidentiality of patients' records in
conformance with this contract and state and federal statutes and
regulations, including but not limited to the Health Insurance Portability
and Accountability Act (HIPPA), 42 U.S.C. Section 1320 d-2 et seq.
e. The MCO, for purposes of audit or investigation, shall provide the State
of Connecticut, the Secretary of HHS and his/her designated agent, and any
other legally authorized governmental entity or their authorized agents
access to all the MCO's materials and information pertinent to the
services provided under this contract, at any time, until the expiration
of three (3) years from the completion date of this contract as extended.
f. The State and its authorized agents may record any information and make
copies of any materials necessary for the audit.
g. The MCO and its subcontractors shall retain financial records, supporting
documents, statistical records and all other records supporting the
services provided under this contract for a period of five (5) years from
the completion date of this contract. The MCO shall make the records
available at all reasonable
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times at the MCO's general offices. The DEPARTMENT and its authorized
agents will request access in writing except in cases of suspected fraud
and abuse. If any litigation, claim or audit is started before the
expiration of the six (6) year period, the records must be retained until
all litigation, claims or audit findings involving the records have been
resolved. The MCO must make all requested records available within thirty
(30) days of the DEPARTMENT's request.
3.35 MEDICAL RECORDS
a. In compliance with all state and federal law governing the privacy of
individually identifiable health care information including the Health
Insurance Portability and Accountability Act (HIPPA), 42 USC Sections
1320d-2 et seq., the MCO shall establish a confidential, centralized
record, for each Member, which includes information of all medical goods
and services received. The MCO may delegate maintenance of the centralized
medical record to the Member's PCP, provided however, that the record
shall be made available upon request and reasonable notice, to the
DEPARTMENT or its agent(s) at a centralized location. The medical record
shall meet the DEPARTMENT's medical record requirements as defined by the
DEPARTMENT in its regulations, and shall comply with the requirements of
NCQA or other national accrediting body with a recognized expertise in
managed care.
b. The MCO shall also simultaneously maintain, with the medical record, a
record of all contacts with each Member that the MCO will maintain in a
computerized database and make available to the DEPARTMENT, at its
request. Claims and encounter records will be provided to the DEPARTMENT
in an electronic medium as specified by the DEPARTMENT, and its agent(s).
The medical record shall demonstrate coordination of Member care; for
example, relevant medical information from referral sources and
out-of-network family planning providers shall be reviewed and entered
into Members' medical records. For those MCOs that are governed under
Connecticut General Statutes Chapter 705 Section 38a-975 et seq., known as
the "Connecticut Insurance Information and Privacy Act", such MCO shall be
required to observe the provisions of such Act with respect to disclosure
of personal and privileged information as such terms are defined under the
Act.
c. The MCO shall not turn over or provide documents, files and records
pertaining to a Member to another health plan unless the Member has
changed enrollment to the other plan and the MCO has bee so notified by
the DEPARTMENT or its agent.
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3.36 AUDIT LIABILITIES
In addition to and not in any way in limitation of the MCO's obligations
pursuant to this contract, it is understood and agreed by the MCO that the MCO
shall be held liable for any finally determined State or Federal audit
exceptions and shall return to the DEPARTMENT all payments made under the
contract to which exception has been taken or which have been disallowed because
of such an exception.
3.37 CLINICAL DATA REPORTING
a. Utilization Reporting: The MCO shall submit reports to the DEPARTMENT in
the areas listed below. The purpose of the reports is to assist the
DEPARTMENT in its efforts to assess utilization and evaluate the
performance of the HUSKY A program and of the MCO.
Utilization reports shall cover the following areas:
1. Inpatient Care;
2. Preventive Care;
3. Dental Care;
4. Behavioral Health Care;
5. Other Services;
6. Maternal and Child Health;
7. EPSDT, known as HealthTrack; and
8. Immunization Information.
b. The DEPARTMENT shall consult with the MCO, through a workgroup comprised
of DEPARTMENT and MCO representatives that meets on a periodic basis, or a
similar process, on the necessary data, methods of collecting the data and
the format and media for new reports or changes to existing reports.
c. The DEPARTMENT shall provide the MCO with final specifications for
submitting all reports no less than ninety (90) days before the reports
are due. The MCO shall submit reports on a schedule to be determined by
the DEPARTMENT, but not more frequently than quarterly. Before the
beginning of each calendar year, the DEPARTMENT shall provide the MCO with
a schedule of utilization reports which shall be due that calendar year.
Due dates for the reports shall be at the discretion of the DEPARTMENT,
but not earlier than ninety (90) days after the end of the period that
they cover.
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d. For each report the DEPARTMENT shall consider using any HEDIS standards
promulgated by the NCQA which covers the same or similar subject matter.
The DEPARTMENT reserves the right to modify HEDIS standards, or not use
them at all, if in the DEPARTMENT's judgment, the objectives of the HUSKY
A program can be better served by using other methods.
e. EPSDT (HealthTrack): The MCO shall submit to the DEPARTMENT reports on
compliance with screening requirements of the EPSDT program sufficient to
enable the DEPARTMENT to comply with its reporting obligations under
federal and state requirements and to assess and evaluate the performance
of the MCO in the screening requirements of the EPSDT program. These
obligations include, but are not limited to, submitting reports to federal
and state agencies.
f. Maternal and Prenatal Care:
The MCO shall report aggregate summary data on outcomes of maternal and
prenatal care to the DEPARTMENT no less frequently than quarterly. Such
data will include:
1. Number of deliveries during the quarter to women enrolled in the MCO
at the time of delivery;
2. Number of live births;
3. Number of fetal deaths;
4. Number of very low birthweight babies, defined as weighing less than
one thousand five hundred grams;
5. Number of moderately low birthweight babies, defined as weighing
less than two thousand five hundred grams;
6. Number of deliveries by cesarean section;
7. Number of women who delivered and had no prenatal care;
8. Number of women with inadequate prenatal care;
9. Number of women with deliveries who have received a postpartum
visit; and
10. For the purpose of adjusting comparisons amongst plans, aggregate
measures of weeks of pregnancy at the time of enrollment in the
plan.
The report will be due within six (6) months after the last day of the
quarter in which the deliveries occurred. The DEPARTMENT will specify the
methodology for preparing the report, no less than ninety (90) days prior
to the end of the quarter which is the subject of the report and after
consultation with the MCO. If the change requires the collection of
additional data elements not currently being captured, the DEPARTMENT will
notify the MCO no less than ninety (90) days prior to the beginning of the
first quarter affected by the change.
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g. Encounter Data:
1. The MCO shall provide the DEPARTMENT with an electronic record of
every encounter between a network provider and a Member within
fifteen (15) days of the close of the month in which the specific
encounter occurred, was paid for, or was processed whichever is
later but no later than 180 days from the encounter. Such encounters
shall be coded and formatted in accordance with the specifications
outlined in the State's Encounter Submission and Reporting Guide.
The DEPARTMENT or its agent shall analyze each month's encounter
submission file. The DEPARTMENT or its agent will reject those
records that contain invalid or missing data and result in a
critical edit failures as outlined in the Encounter Submission and
Reporting Guide.
PERFORMANCE MEASURE: The overall volume of rejected encounters shall not
exceed five (5) percent in any given month.
2. The DEPARTMENT or its agent shall also analyze the MCO's encounter
submissions for completeness. On a quarterly basis, no less than six
(6) months from the date of service on the encounter, the DEPARTMENT
or its agent will compare encounter data utilization levels to the
utilization levels in the reports specified in Sections 3.37a-f.
PERFORMANCE MEASURE: Encounter data shall not be over or under the
reported utilization by ten (10) percent or more.
3. The DEPARTMENT or its EQRO, will choose a random sample of no more
than one hundred (100) encounters for each year. The MCO will make
the medical records of each encounter so chosen available to the
DEPARTMENT or EQRO at a central location upon reasonable notice. The
EQRO shall review the medical records and report back to the
DEPARTMENT on the extent to which the information in each field of
the encounter record corresponds to the information contained in the
medical record. Prior to making its report to the DEPARTMENT, the
EQRO shall afford the MCO a reasonable opportunity to suggest
corrections to or comment upon the EQRO's findings.
PERFORMANCE MEASURE: The MCO shall re-submit corrected returned data
within thirty (30) days of its return to the MCO.
SANCTION: Failure to comply with the above reporting requirements in a complete
and timely manner may result in a strike towards a Class A sanction pursuant to
Section 7.05.
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3.38 UTILIZATION MANAGEMENT
a. The MCO and any subcontractor is required to be licensed by the
Connecticut Department of Insurance as a utilization review company. The
MCO may subcontract with a licensed utilization review company to perform
some or all of the MCO's utilization management functions.
b. If the MCO subcontracts for any portion of the utilization management
function, the MCO shall provide a copy of any such subcontract to the
DEPARTMENT and any such subcontracts will be subject to the provisions of
Section 5.08 of this contract. The DEPARTMENT will review and approve the
subcontract, subject to the provisions of Section 3.44, to ensure the
appropriateness of the subcontractor's policies and procedures. The MCO is
required to conduct regular and comprehensive monitoring of the
utilization management subcontractor.
The MCO and its subcontractors shall comply with the utilization review
provisions of Connecticut General Statutes Section 38a-226c(a)(1).
3.39 FINANCIAL RECORDS
a. Accounting: The MCO shall maintain for the purpose of this contract, an
accounting system of procedures and practices that conforms to Generally
Accepted Accounting Principles.
b. The MCO shall permit audits or reviews by the DEPARTMENT or its agent(s),
of the MCO's financial records related to the performance of this
contract. In addition, the MCO will be required to provide Claims Aging
Inventory Reports, Claims Turn Around Time Reports, cost, and other
reports as outlined in sections c and d below or as otherwise directed by
the DEPARTMENT.
c. Reports specific to the MCO's Medicaid line of business shall be provided
in formats developed by the DEPARTMENT. All reports described in Sections
3.39 c (1) and 3.39 c (2) shall contain separate sections for HUSKY A and
HUSKY B. It is anticipated that the requirements in this area will be
modified to enable the DEPARTMENT to respond to inquiries that the
DEPARTMENT receives regarding the financial status of the HUSKY program,
to determine the relationship of capitation payments to actual
appropriations for the program, and to allow for proper oversight of
fiscal issues related to the managed care programs. The MCO will cooperate
with the DEPARTMENT or its agent(s) to meet these objectives. The
following is a list of required reports:
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1. Audited financial reports with an income statement by MCO HUSKY line
of business. If the MCO is licensed as a health care center or
insurance company, both the annual audited financial reports for the
MCO and the audited financial reports per MCO HUSKY line of business
shall be conducted and reported in accordance with C.G.S. Section
38a - 54. If the MCO is not licensed as a health care center or
insurance company, the annual audited financial reports for the MCO
and the audited financial reports per MCO line of business shall be
completed in accordance with generally accepted auditing principles.
The MCO may elect to combine HUSKY A and HUSKY B in the audited
financial statement. If this election is made, the MCO shall also
submit the following: a separate unaudited income statement for
HUSKY A and HUSKY B, which will be compared to the audited financial
statement.
2. Unaudited financial reports, HUSKY line of business (formats shown
in Appendix F). The reports shall be submitted quarterly, forty-five
(45) days subsequent to the end of each quarter. Every line of the
requested report must contain a dollar figure or an indication that
said line is not applicable.
3. Annual and Quarterly Statements. If the MCO is licensed as a health
care center or insurance company, the MCO is required to submit
Annual and Quarterly Statements to the Department of Insurance in
accordance with C.G.S. Section 38a-53. One copy of each statement
shall be submitted to the DEPARTMENT in accordance with the
following due dates: Annual Statements are due on March 1st and
Quarterly Statements are due forty-five (45) days subsequent to the
end of each quarter.
4. Claims Aging Inventory Report (format shown in Appendix F, or any
other format approved by the DEPARTMENT). The Claims Aging Inventory
Report will include all HUSKY claims outstanding as of the end of
each quarter by type of claim, claim status and aging categories. If
a subcontractor is used to provide services and adjudicate claims or
a vendor is used to adjudicate claims, the MCO is responsible for
providing a Claims Aging Inventory Report in the required format for
each current or prior subcontractor who has claims outstanding. The
Claims Aging Inventory Reports will be submitted to the DEPARTMENT
forty-five (45) days subsequent to the end of each quarter.
5. Claims Turn Around Time Report (format shown in Appendix F, or any
other format approved by the DEPARTMENT). For those claims processed
in forty-six (46) days or more, the report shall indicate if
interest was paid in accordance with Section 3.45 of this contract.
If a subcontractor is used to provide services and adjudicate claims
or a vendor is used to adjudicate claims, the MCO is responsible for
providing a
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Claims Turn Around Time Report in the required format for each
current or prior subcontractor who has claims outstanding. The
Claims Turn Around Time Report will be submitted to the DEPARTMENT
forty-five (45) days subsequent to the end of each quarter.
d. The MCO shall maintain accounting records in a manner which will enable
the DEPARTMENT to easily audit and examine any books, documents, papers
and records maintained in support of the contract. All such documents
shall be made available to the DEPARTMENT at its request, and shall be
clearly identifiable as pertaining to the contract.
e. The MCO shall make available on request all financial reports required by
the terms of any current contract with any other state agency(s) provided
the said agency agrees that such information may be shared with the
DEPARTMENT.
3.40 INSURANCE
a. The MCO, its successors and assignees shall procure and maintain such
insurance as is required by currently applicable federal and state law and
regulation. Such insurance should include, but not be limited to, the
following:
1. liability insurance (general, errors and omissions, and directors
and officers coverage);
2. fidelity bonding or coverage of persons entrusted with handling of
funds;
3. workers compensation; and
4. unemployment insurance.
b. The MCO shall name the State of Connecticut as an additional insured party
under any insurance, except for professional liability, workers
compensation, unemployment insurance, and fidelity bonding maintained for
the purposes of this contract. However, the MCO shall name the State of
Connecticut as either a loss payee or additional insured for fidelity
bonding coverage.
3.41 THIRD PARTY COVERAGE
The DEPARTMENT is the payer of last resort when third party resources are
available to cover the costs of medical services provided to Medicaid
recipients. Pursuant to this requirement, the MCO is required to comply with
federal and state statutes and regulations regarding third party liability. The
MCO shall be responsible for making every reasonable effort to determine the
lega1 liability of third parties to pay for services rendered to Members under
this contract. The MCO shall be responsible for identifying appropriate third
party resources, and if questions arise they shall consult with the
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DEPARTMENT. The MCO shall pursue, collect, and retain any monies from third
party payers for services to the MCO's Members under this contract, subject to
the following terms and conditions:
a. The DEPARTMENT hereby assigns to the MCO all rights to third party
recoveries from Medicare, health insurance, casualty insurance, workers'
compensation, tortfeasors, or any other third parties who may be
responsible for payment of medical costs for the MCO's Members.
1. The MCO will have primary responsibility for cost avoidance through
the coordination of benefits relative to federal and private health
insurance resources including, but not limited to Medicare,
individual health insurance, employment-related group health
insurance and self administered or self funded health benefit plan,
including ERISA (Employee Retirement and Income Security Act) plans.
The MCO shall avoid initial payments of claims, as permitted by
federal law, where federal or private health insurance resources are
available. When cost avoidance is not possible, the MCO may utilize
post payment recovery. If a third party insurer requires the Member
to pay any copayment, coinsurance or deductible, the MCO is
responsible for making any such payments.
2. The MCO may assign the right of recovery to their subcontractors
and/or network providers. Notwithstanding any such assignment of the
right of recovery, the MCO remains responsible for the effective and
diligent performance of third party recovery.
3. In pursing third party recovery, the MCO, network providers, and
subcontractors shall seek recovery of the cost of services actually
rendered to the Member, notwithstanding the fact that the MCO may
pay the subcontractor on a capitated basis.
4. The MCO or its assignee must initiate third party recoveries within
sixty (60) days of the date of service or within sixty (60) days
after the end of the month in which the MCO learns of the existence
of the liable third party. The MCO or its assignees must maintain
dated documentation of all claims to third parties. The MCO must
document initiation of recovery by formal communication in written
or electronic form to the liable third party, specifically
requesting reimbursement up to the legal limit of liability for any
services provided to the MCO's Member covered under the State
Medicaid Plan.
5. The right to pursue, collect and retain recovery from claims not
initiated and documented within sixty (60) days as stated above,
will revert to the DEPARTMENT and the MCO or its assignees will lose
any right of recovery.
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6. When the MCO seeks recovery from a third party for care provided to
a Member following an accident, the MCO may recover only its cost of
care.
b. The MCO shall maintain records of recoveries of all third party
collections, including cost avoidance, and recovery actions. The
DEPARTMENT will specify a schedule and format for reporting such
collections. The amounts avoided or recovered by the MCO shall be
considered in establishing future capitated rates paid to the MCO.
c. The MCO shall fully cooperate with the DEPARTMENT in all third party
recovery efforts.
d. The DEPARTMENT shall supply the MCO with a monthly file of Members where
third party coverage has been identified. The information shall also be
available to the MCO and its assignees from the DEPARTMENT's Automated
Electronic Voice Response System.
e. The MCO shall notify the DEPARTMENT within thirty (30) days if the MCO or
its network provider or subcontractor discovers that a Member has become
eligible for coverage by a liable third party. The MCO shall notify the
DEPARTMENT within thirty (30) days if the MCO or its in-network provider
or subcontractor discovers that a Member has lost eligibility for coverage
by a liable third party.
3.42 COORDINATION OF BENEFITS AND DELIVERY OF SERVICES
a. The MCO shall ensure that the rules related to the coordination of
benefits in Section 3.41 do not present any barriers to Members' access to
the covered services under this contract.
b. The MCO shall educate its Members on how to access services when a Member
is covered by a third party insurer.
c. If a third party insurer requires the Member to pay any copayment,
coinsurance or deductible, the MCO is responsible for making these
payments on behalf of the Member, even if the services are provided
outside of the MCO's provider network.
d. If a Member's third party insurer pays for only some services covered
under this contract or for only part of a particular service, the MCO
shall be liable up to the amount covered by Medicaid for the full extent
of services covered under this contract, even if the services are provided
outside of the MCO's provider
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network. In no instance, shall Members be liable for copayments for said
services.
e. If a Member is covered by a third party insurer, the MCO is bound by any
prior authorization decisions made by the third party insurer.
3.43 PASSIVE BILLING
Capitation payments to the MCO shall be based on a passive billing system. The
MCO is not required to submit claims for the capitation payment for its HUSKY A
membership. Capitation payments will be based on MCO (membership data as
reflected in the enrollment files provided by the DEPARTMENT to the MCOs. On a
monthly basis BENOVA will provide the MCO with a detailed capitation remittance
file.
3.44 SUBCONTRACTING FOR SERVICES
a. Licensed health care facilities, group practices and licensed health care
professionals operating within the scope of their practice may contract
with the MCO directly or indirectly through a subcontractor who directly
contracts with the MCO. The MCO shall be held directly accountable and
liable for all of the contractual provisions under this contract
regardless of whether the MCO chooses to subcontract their
responsibilities to a third party. No subcontract shall operate to
terminate the legal responsibility of the MCO to assure that all
activities carried out by the subcontractor conform to the provisions of
the contract. Subcontracts shall not terminate the legal liability of the
MCO under this contract.
b. The MCO may subcontract for any function, excluding Member Services,
covered by this contract, subject to the requirements of this contract.
All subcontracts shall be in writing, shall include any general
requirements of this contract that are appropriate to the services being
provided, and shall assure that all delegated duties of the MCO under this
contract are performed. All subcontracts shall also provide for the right
of the DEPARTMENT or other governmental entity to enter the
subcontractor's premises to inspect, monitor or otherwise evaluate the
work being performed as a delegated duty of this contract, as specified in
Section 3.33, Inspection of Facilities. All subcontracts shall comply with
42 CFR Section 434.6 (b) and (c).
c. With the exception of subcontracts specifically excluded by the
DEPARTMENT, all subcontracts shall include verbatim the HUSKY A
definitions of Medical Appropriateness / Medically Appropriate and
Medically Necessary/Medical Necessity as set forth in Part II, General
Contract Terms for the MCOs. All subcontracts shall require the use of
these definitions by subcontractors in all requests for approval of
coverage of goods or services made on behalf of HUSKY
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A Members. All subcontracts shall also provide that decisions concerning
both acute and chronic care must be made according to these definitions.
d. Within fifteen (15) days of the effective date of this contract, the MCO
shall provide the DEPARTMENT with a report of those functions under this
contract that MCO shall be providing through a subcontract and copies of
the contracts between the MCO and the subcontractor. The report shall
identify the names of the subcontractors, their addresses and a summary of
the services they will be providing. If the MCO enters into any additional
subcontracts after the MCO's initial compliance with this section, the MCO
shall obtain the advance written approval of the DEPARTMENT. The MCO shall
provide the DEPARTMENT with a draft of the proposed subcontract thirty
(30) days in advance of the completion of the MCO's negotiation of such
subcontract. In addition, amendments to any subcontract, excluding those
of a technical nature, shall require the pre-review and approval of the
DEPARTMENT.
e. In accordance with JUNE SPECIAL SESSION, PUBLIC ACT NO.01-2, all
behavioral health and dental subcontracts which include the payment of
claims on behalf of HUSKY A Members for the provision of goods and
services to HUSKY A Members shall require a performance bond, letter of
credit, statement of financial reserves or payment withhold requirements.
The performance bond, letter of credit, statement of financial reserves or
payment withhold requirements shall be in a form mutually agreed upon by
the MCO and the subcontractor. The amount of the performance bond shall be
sufficient to ensure the completion of the subcontractor's claims
processing and provider payment obligations under the subcontract in the
event the contract between the MCO and the subcontractor is terminated.
The MCO shall submit reports to the DEPARTMENT upon the DEPARTMENT's
request related to any payments made from the performance bonds or any
payment withholds.
f. All subcontracts shall include provisions for a well-organized transition
in the event of termination of the subcontact for any reason. Such
provisions shall ensure that an adequate provider network will be
maintained at all times during any such transition period and that
continuity of care is maintained for all Members.
g. In the event that a subcontract is terminated, the MCO shall submit a
written transition plan to the DEPARTMENT sixty (60) days in advance of
the scheduled termination. The transition plan shall include provisions
concerning financial responsibility for the final settlement of provider
claims and data reporting, which at a minimum must include a claims aging
report prepared in accordance with Section 3.39 c (5) of this contract,
with steps to ensure the resolution of the outstanding amounts. This plan
shall be submitted prior to the DEPARTMENT's approval of the replacement
subcontractor.
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h. All subcontracts shall also include a provision that the MCO will withhold
a portion of the final payment to the subcontractor, as a surety bond to
ensure compliance under the terminated subcontract.
i. The MCO shall have no right to and shall not assign, transfer or delegate
this contract in its entirety, or any right or duty arising under this
contract without the prior written approval of the DEPARTMENT. The
DEPARTMENT in its discretion may grant such written approval of an
assignment, transfer or delegation provided, however, that this paragraph
shall not be construed to grant the MCO any right to such approval.
j. This section shall not be construed as restricting the MCO from entering
into contracts with participating providers to provide health care
services to Members.
3.45 TIMELY PAYMENT OF CLAIMS
If the MCO or any subcontractor or vendor who adjudicates claims fails to pay a
clean claim within forty-five (45) days of receipt, or as otherwise stipulated
by a provider contract, the MCO, vendor or subcontractor shall pay the provider
the amount of such clean claims plus interest at the rate of fifteen (15)
percent per annum or otherwise as stipulated by a provider contract. In
accordance with Section 3.39 (c)(5), Financial Records, the MCO shall provide to
the DEPARTMENT information related to interest paid beyond the forty-five (45)
day timely filing limit or otherwise stipulated by a provider contract.
3.46 CO-PAYMENT LIMITS AND MEMBER CHARGES FOR NONCOVERED SERVICES
No deductibles or co-payments are permitted for HUSKY A covered services.
A provider shall be permitted to charge an eligible Member for goods or services
which are not coverable only if the Member knowingly elects to receive the goods
or services and enters into an agreement in writing to pay for such goods or
services prior to receiving them. For purposes of this section noncovered
services are services not covered under the Medicaid state plan, services which
are provided in the absence of appropriate authorization, and services which are
provided out-of-network unless otherwise specified in the contract, policy or
regulation (e.g., family planning, mental health or emergency room services).
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3.47 INSOLVENCY PROTECTION
The MCO must maintain protection against insolvency as required by the
DEPARTMENT including demonstration of adequate initial capital and ongoing
reserve contributions. The MCO must provide financial data to the DEPARTMENT in
accordance with the DEPARTMENT's required formats and timing.
3.48 ACCEPTANCE OF DSS RULINGS
In cases where there is a dispute between the MCO and an out-of-network provider
about whether a service is medically necessary, is an emergency, or is an
appropriate diagnostic test to determine whether an emergency condition exists,
the DEPARTMENT will hear appeals, filed within one year following the date of
service and make final determinations. The DEPARTMENT will accept written
comments from all parties to the dispute prior to making the decision, and order
or not order payment, as appropriate. The MCO shall accept the DEPARTMENT's
determinations regarding appeals.
3.49 POLICY TRANSMITTALS
The MCO shall comply with the provisions and requirements in the DEPARTMENT's
Managed Care Policy Transmittals as set forth in Appendix H. In addition, the
MCO shall comply with any future Managed Care Policy Transmittals issued by the
DEPARTMENT. The MCO shall comply with the Medical Services Policy as set forth
in the DEPARTMENT's provider manuals and the Regulations of Connecticut State
Agencies.
3.50 FRAUD AND ABUSE
a. The MCO shall not knowingly take any action or fail to take action that
could result in an unauthorized benefit to the MCO, its employees, its
subcontractors, its vendors, or to a Member.
b. The MCO commits to preventing, detecting, investigating, and reporting
potential fraud and abuse occurrences, and shall assist the DEPARTMENT and
HHS in preventing and prosecuting fraud and abuse in the HUSKY program.
c. The MCO acknowledges that the HHS, Office of the Inspector General, has
the authority to impose civil monetary penalties on individuals and
entities that submit false and fraudulent claims to the HUSKY program.
d. The MCO shall immediately notify the DEPARTMENT when it detects a
situation of potential fraud or abuse, including, but not limited to, the
following:
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1. False statements, misrepresentation, concealment, failure to
disclose, and conversion of benefits;
2. Any giving or seeking of kickbacks, rebates, or similar
remuneration;
3. Charging or receiving reimbursement in excess of that provided by
the DEPARTMENT; and
4. False statements or misrepresentation made by a provider,
subcontractor, or Member in order to qualify for the HUSKY program.
e. Upon written notification of the DEPARTMENT, the MCO shall cease any
conduct that the DEPARTMENT or its agent deems to be abusive of the HUSKY
program, and to take any corrective actions requested by the DEPARTMENT or
its agent.
f. The MCO attests to the truthfulness, accuracy, and completeness of all
data submitted to the DEPARTMENT, based on the MCO's best knowledge,
information, and belief. This data certification requirement includes
encounter data and also applies to the MCO's subcontractors.
g. The MCO shall establish a fraud and abuse plan, including, but not
necessarily limited to, the following efforts:
1. Conducting regular reviews and audits of operations to guard against
fraud and abuse;
2. Assessing and strengthening internal controls to ensure claims are
submitted and payments are made properly;
3. Educating employees, providers, and subcontractors about fraud and
abuse and how to report it;
4. Effectively organizing resources to respond to complaints of fraud
and abuse;
5. Establishing procedures to process fraud and abuse complaints; and
6. Establishing procedures for reporting information to the DEPARTMENT.
h. The MCO shall examine publicly available data, including but not limited
to the HCFA Medicare/Medicaid Sanction Report and the HCFA website
(xxxx://xxx.xxxx.xxx.xxx) to determine whether any potential or current
employees, providers, or subcontractors have been suspended or excluded or
terminated from the Medicare or Medicaid programs and shall comply with,
and give effect to, any such suspension, exclusion, or termination in
accordance with the requirements of state and federal law.
i. The MCO must provide full and complete information on the identity of each
person or corporation with an ownership or controlling interest, five (5)
percent, in the managed care plan, or any subcontractor in which the MCO
has a five (5) percent or more ownership interest.
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j. The MCO must immediately provide full and complete information when it
becomes aware of any employee or subcontractor who has been convicted of a
civil or criminal offense related to that person's involvement under
Medicare, Medicaid, or any other federal or state assistance program prior
to entering into or renewing this contract.
SANCTION: The DEPARTMENT may impose a sanction, up to and including a Class C
sanction for the failure to comply with any provision of this section, or take
any other action set forth in Section 7 of this contract, including terminating
or refusing to renew this contract or any other Sanction or remedy allowed by
federal or state law.
3.51 CHILDREN WITH SPECIAL HEALTH CARE NEEDS
a. The DEPARTMENT will provide to the MCO information to identify Members who
meet the definition of children with special health care needs as set
forth in Section 1932(a)(2)(A)(i), (iii), (iv) and (v) of the Social
Security Act.
b. The MCO shall conduct an assessment of these and other children identified
by the MCO to identify medical needs and implement a plan of treatment
based on the assessment.
c. The MCO shall report to the DEPARTMENT, in a format specified by the
DEPARTMENT, on quality indicators such as utilization of specialty
services and case management to be developed jointly between the
DEPARTMENT and the MCOs.
4. FUNCTIONS AND DUTIES OF THE DEPARTMENT
4.01 ELIGIBILITY DETERMINATIONS
The DEPARTMENT will determine the initial and ongoing eligibility for medical
assistance of each individual enrolled under this contract in accordance with
the DEPARTMENT's continuous and guaranteed eligibility policies.
4.02 POPULATIONS ELIGIBLE TO ENROLL
Appendix G contains a list of the Medicaid groups currently eligible for managed
care enrollment. New eligibility groups may be added to the managed care
population. The DEPARTMENT will notify the MCO of any changes in the eligibility
categories to be included. Additional groups included by the DEPARTMENT may be
served at the MCO's option.
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4.03 ENROLLMENT/DISENROLLMENT
Enrollment, disenrollment and initial selection of PCP will be handled by the
DEPARTMENT through a contract with a central enrollment broker. Coverage
for new Members will be effective the first of the month and coverage for
disenrollments will terminate at the end of the month. Members remain
continuously enrolled throughout the term of this contract, except in situations
where clients change health plans, lose their Medicaid eligibility, receive
Medicare, or are recategorized into a Medicaid category not included in the
managed care initiative. Disenrollments due to loss of eligibility become
effective upon loss of eligibility and are effective on the last day of the
month. Disenrollments due to receipt of Medicare become effective the month
following the month in which DSS receives information of the existence of the
Medicare coverage. Adults receiving SSI become disenrolled from the MCO upon the
recategorizing of their Medicaid status from a family to an adult coverage group
or the month following the month in which the DEPARTMENT receives information of
the individual's receipt of SSI, whichever comes first. The DEPARTMENT will
notify the MCO of enrollments and disenrollments specific to the MCO via a daily
data file. The enrollments and disenrollments processed on any given day will be
made available to the MCO via the data file the following day (i.e. after the
daily overnight batching has been processed).
In addition to the daily data file, a full file of all the Members will be made
available on a monthly basis. Both the daily data file and the monthly full file
can be accessed by the MCO electronically via dial-up.
4.04 DEFAULT ENROLLMENT
The DEPARTMENT shall, on a rotating basis among all of the participating MCO's
and as the MCO's enrollment capacity allows, assign default Members to the MCO.
The default assignment methodology is structured to evenly distribute families
among all the participating MCOs. However, due to variability in MCO service
area and enrollment capacity, family size and loss of Medicaid eligibility, the
outcome of the default assignment may not result in an even net default
distribution among all the MCOs.
4.05 LOCK-IN
a. Upon availability of MIS Support, the DEPARTMENT will implement a lock-in
period of up to twelve (12) months for managed care Members. Members will
not be allowed to change plan enrollment during the lock-in period except
for cause. The lock-in period is subject to the following provisions and
exceptions:
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1. The first ninety (90) days of enrollment into a new MCO will be
designated as the free-look period during which time the Member may
change plans;
2. The last sixty (60) days of the lock-in period will be an open
enrollment period, during which time Members may change plans;
3. Plan changes made during the open enrollment period will go into
effect on the first day of the month following the end of the
lock-in period; and
4. Members who do not change plans during the open enrollment period
will continue the enrollment in the same MCO and be assigned to a
new twelve (12) month lock-in period.
The process being considered for implementation of lock-in for the
existing HUSKY A membership is as follows: lock-in will be imposed on
approximately twenty (20) percent of the membership each month over a
consecutive five (5) month period. Targeting for each month will be based
on the last digit of the client ID number for the head-of-household. For
example, families whose head-of-household has a client ID number that ends
in 0 or 1 will be phased-in during the first month, those with 2 and 3
will be done in the second month, etc.
b. The following shall constitute good cause for a Member to disenroll from
the plan during the lock-in period:
1. Unfavorable resolution of the MCO's internal complaint process and
continued dissatisfaction due to repeated incidents of any of the
following:
a. documented long waiting times for appointments:
1. more than forty-five (45) days for well-care visit;
2. more than two (2) business days for non-urgent, symptomatic office
visit; and
3. unavailability of same day office visit or same day referral to an
emergency provider for emergency care services
b. documented inaccessibility of health plan by phone or mail:
1. phone calls not answered promptly;
2. caller placed on hold for extended periods of time;
3. phone messages and letters not responded to promptly; and
4. repeated rude and demeaning treatment by MCO staff.
c. Prior to pursuing the MCO's internal complaint process and without filing
a grievance through the plan, dissatisfaction due to any of the following:
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1. Discriminatory treatment as documented in a complaint filed with
the State of Connecticut Commission on Human Rights and
Opportunities (CHRO) or the DEPARTMENT's Affirmative Action
Division;
2. PCP who has served the Member's specific documentable needs (i.e.
language or physical accessibility) left health plan and there is
no other suitable PCP within reasonable distance to the Member; or
3. Member has a pending lawsuit against the MCO (verification of
pending lawsuit must be provided).
d. Child placed under DCF guardianship whose placement is changed to a
location or facility not affiliated with the current health plan.
4.06 CAPITATION PAYMENTS TO MCO
a. In full consideration of contract services rendered by the MCO, the
DEPARTMENT agrees to pay the MCO monthly payments based on the capitation
rates specified in Appendix I, as amended.
b. Upon validation of client eligibility and MCO membership, the DEPARTMENT
will pay the capitation payments in the month following the month to which
the capitation payments apply or for retroactive enrollments, the month
following the enrollment processing month in accordance with Connecticut
General Statutes Section 4a-71 through 4a-72.
c. Payment to the MCO shall be based on the enrollment data transmitted from
the DEPARTMENT to BENOVA each month. The MCO will be responsible for
detecting the source of any inconsistency in capitation payments. The MCO
must notify the DEPARTMENT of any inconsistency between enrollment and
payment data. The DEPARTMENT agrees to provide to the MCO information
needed to determine the source of the inconsistency within sixty (60)
working days after receiving written notice of the request to furnish such
information. The DEPARTMENT will recoup overpayments or reimburse
underpayments. The adjusted payment (representing reinstated recipients)
for each month of coverage shall be included in the next monthly
capitation payment, based on updated MCO enrollment information for that
month of coverage.
d. Any retrospective adjustments to prior payments will be made in the form
of an addition to or subtraction from the current month's capitation
payment. Positive adjustments are particularly likely for newborns,
because the MCO may be aware of births before the DEPARTMENT.
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4.07 RETROACTIVE ADJUSTMENTS
a. When a Member loses Medicaid eligibility and managed care enrollment but
regains coverage within sixty (60) days, and the coverage is made
retroactive such that the entire coverage gap is eliminated, the
DEPARTMENT shall reinstate enrollment into the MCO retroactive to the time
of disenrollment. The MCO will remain responsible for the cost of in-
network covered services and the cost of emergency and family planning
services received by the Member during this sixty (60) day period.
b. In instances where enrollment is disputed between two (2) MCOs or the MCO
and Medicaid fee-for-service program, the DEPARTMENT will be the final
arbiter of Membership status and reserves the right to recover
inappropriate capitation payments. Capitation payments for retroactive
enrollment adjustments will be made to the MCO pursuant to rules outlined
in Section II, 4.06d, Capitation Payments to MCO.
4.08 INFORMATION
The DEPARTMENT will make known to each MCO complete and current information
which relates to pertinent statutes, regulations, policies, procedures, and
guidelines affecting the operation of this contract. This information shall be
available either through direct transmission to the MCO by reference to public
resource files accessible to the MCO personnel.
4.09 ONGOING MCO MONITORING
a. To ensure access and the quality of care, the DEPARTMENT or its EQRO, or
the Children's Health Council as assigned, shall undertake plans to
undertake monitoring activities, including but not limited to the
following:
1. Analyze the MCO's access enhancement programs, financial and
utilization data, and other reports to monitor the value the MCO is
providing in return for the State's capitation payments. Such
efforts shall include, but not be limited to, on-site reviews and
audits of the MCO and its subcontractors and network providers.
2. Conduct regular recipient surveys of Members to address issues such
as satisfaction with plan services to include administrative
services, satisfaction with treatment by the plan or its providers,
and reasons for disenrollment and access.
3. Review the MCO certifications on a regular basis.
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4. Analyze encounter data, actual medical records, correspondence,
telephone logs and other data to make inferences about the quality
of and access to specific services.
5. Sample and analyze encounter data, actual medical records,
correspondence, telephone logs and other data to make inferences
about the quality of and access to MCO services.
6. Test the availability of and access to MCO services by attempting to
make appointments.
7. At its discretion, commission or conduct additional objective
studies of the effectiveness of the MCO, as well as the availability
of, quality of and access to its services.
4.10 UTILIZATION REVIEW AND CONTROL
The DEPARTMENT shall waive, to the extent allowed by law, any current DEPARTMENT
requirements for prior authorization, second opinions, copayment, or other
Medicaid restrictions for the provision of contract services provided by the MCO
to Members.
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5. DECLARATIONS AND MISCELLANEOUS PROVISIONS
5.01 COMPETITION NOT RESTRICTED
In signing this contract, the MCO asserts that no attempt has been made or will
be made by the MCO to induce any other person or firm to submit or not to submit
an application for the purpose of restricting competition.
5.02 NONSEGREGATED FACILITIES
a. The MCO certifies that it does not and will not maintain or provide for
its employees any segregated facilities at any of its establishments; and
that it does not permit its employees to perform their services at any
location, under its control, where segregated facilities are maintained.
As Contractor, the MCO agrees that a breach of this certification is a
violation of Equal Opportunity in Federal employment. In addition,
Contractor must comply with the Federal Executive Order 11246 entitled
"Equal Employment Opportunity" as amended by Executive Order 11375 and as
supplemented in the United States Department of Labor Regulations (41 CFR
Part 30). As used in this certification, the term "segregated facilities"
includes any waiting rooms, restaurants and other eating areas, parking
lots, drinking fountain, recreation or entertainment areas,
transportation, and housing facilities provided for employees which are
segregated on the basis of race, color, religion, or national origin,
because of habit, local custom, national origin or otherwise.
b. The MCO further agrees, (except where it has obtained identical
certifications from proposed subcontractors for specific time periods)
that it will obtain identical certifications from proposed subcontractors
which are not exempt from the provisions for Equal Employment Opportunity;
that it will retain such certifications in its files; and that it will
forward a copy of this clause to such proposed subcontractors (except
where the proposed subcontractors have submitted identical certifications
for specific time periods).
5.03 OFFER OF GRATUITIES
The MCO, its agents and employees, certify that no elected or appointed official
or employee of the DEPARTMENT has or will benefit financially or materially from
this contract. The contract may be terminated by the DEPARTMENT if it is
determined that gratuities of any kind were either offered to or received by any
of the aforementioned officials or employees of the MCO, its agent or employee.
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5.04 EMPLOYMENT/AFFIRMATIVE ACTIOIN CLAUSE
The MCO agrees to supply employment/affirmative action information as required
for agency compliance with Title VI and VII of the Civil Rights Acts of 1964 and
Connecticut General Statutes, Section 46a-68 and Section 46a-71.
5.05 CONFIDENTIALITY
a. The MCO agrees that all material and information, and particularly
information relative to individual applicants or recipients of assistance
through the DEPARTMENT, provided to the Contractor by the State or
acquired by the Contractor in performance of the contract whether verbal,
written, recorded magnetic media, cards or otherwise shall be regarded as
confidential information and all necessary steps shall be taken by the
Contractor to safeguard the confidentiality of such material or
information in conformance with federal and state statutes and
regulations.
b. The MCO agrees not to release any information provided by the DEPARTMENT
or providers or any information generated by the MCO without the express
consent of the Contract Administrator, except as specified in this
contract and as permitted by applicable law.
5.06 INDEPENDENT CAPACITY
The MCO, its officers, employees, subcontractors, or any other agent of the
Contractor in performance of this contract will act in an independent capacity
and not as officers or employees of the State of Connecticut or of the
DEPARTMENT.
5.07 LIAISON
Both parties agree to have specifically named liaisons at all times. These
representatives of the parties will be the first contacts regarding any
questions and problems which arise during implementation and operation of the
contract.
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5.08 FREEDOM OF INFORMATION
a. Due regard will be given for the protection of proprietary information
contained in all applications and documents received; however, the MCO
should be aware that all materials associated with the contract are
subject to the terms of the Freedom of Information Act, the Privacy Act
and all rules, regulations and interpretations resulting therefrom. It
will not be sufficient for the MCO to merely state generally that the
material is proprietary in nature and not therefore subject to release to
third parties. Those particular pages of sections which the MCO believes
to be proprietary must be specifically identified as such. Convincing
explanation and rationale sufficient to justify each exemption from
release consistent with Section 1-210 of the Connecticut General Statutes
must accompany the documents. The rationale and explanation must be stated
in terms of the prospective harm to the MCO's competitive position that
would result if the identified material were to be released and the
reasons why the materials are legally exempt from release pursuant to the
above cited statue. Between the MCO and the DEPARTMENT the final
administrative authority to release or exempt any or all material so
identified rests with the DEPARTMENT.
b. The MCO understands the DEPARTMENT's need for access to eligibility and
paid claims information and is willing to provide such data relating to
the MCO to accommodate that need. The MCO is committed to providing the
DEPARTMENT access to all information necessary to analyze cost and
utilization trends; to evaluate the effectiveness of Provider Networks,
benefit design, and medical appropriateness; and to show how the HUSKY
population compares to the MCO's enrolled population as a whole. The MCO
and the DEPARTMENT each understand and agree that the systems, procedures
and methodologies and practices used by the MCO, its affiliates and agents
in connection with the underwriting, claims processing, claims payment and
utilization monitoring functions of the MCO, together with the
underwriting, Provider Network, claims processing, claims history and
utilization data and information related to the MCO and its agents, may
constitute information which is proprietary to the MCO and/or its
affiliates (collectively, the "Proprietary Information"). Accordingly, the
DEPARTMENT acknowledges that the MCO shall not be required to divulge
Proprietary Information if such disclosure would jeopardize or impair its
relationships with providers or suppliers or would materially adversely
affect the MCO's or any of its Affiliates' ability to service the needs
of its customers or the DEPARTMENT as provided under this Contract unless
the DEPARTMENT determines that such information is necessary in order to
monitor contract compliance or to fulfill Part II Sections 3.33 and 3.34
of Part II of this contract. The DEPARTMENT agrees not to disclose
publicly and to protect from public disclosure any proprietary or trade
secret information provided to the DEPARTMENT by the MCO and/or its
Affiliates' under this contract to the extent that such proprietary
information is exempted from public disclosure under Section 1-213 of the
Connecticut Freedom of Information Act.
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5.09 WAIVERS
Except as specifically provided in any section of this contract, no covenant,
condition, duty, obligation or undertaking contained in or made a part of the
contract shall be waived except by the written agreement of the parties, and
forbearance or indulgence in any form or manner by the DEPARTMENT or the MCO in
any regard whatsoever shall not constitute a waiver of the covenant, condition,
duty, obligation or undertaking to be kept, performed, or discharged by the
DEPARTMENT or the MCO; and not withstanding any such forbearance or indulgence,
until complete performance or satisfaction of all such covenants, conditions,
duties, obligations and undertakings, the DEPARTMENT or MCO shall have the right
to invoke any remedy available under the contract, or under law or equity.
5.10 FORCE MAJEURE
The MCO shall be excused from performance hereunder for any period that it is
prevented from providing, arranging for, or paying for services as a result of a
catastrophic occurrence or natural disaster including but not limited to an act
of war, and excluding labor disputes.
5.11 FINANCIAL RESPONSIBILITIES OF THE MCO
a. The MCO must maintain at all times financial reserves in accordance with
the Connecticut Health Centers Act under Section 38a-175 et seq. of the
Connecticut General Statutes and with the requirements outlined in the
DEPARTMENT's Request for Application.
b. The MCO's physician incentive plans must comply with the requirements of
1903(m)(2)(a)(x) of the Social Security Act.
c. The DEPARTMENT reserves the right to inspect any physician incentive
plans.
d. If the MCO is not a federally-qualified MCO or Competitive Medical Plan,
the MCO must complete a HCFA Section 1318 Financial Disclosure Report,
prior to the start of the contract.
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5.12 CAPITALIZATION AND RESERVES
a. The MCO shall comply with and maintain capitalization and reserves as
required by the appropriate regulatory authority.
b. If the MCO is licensed by the State of Connecticut, the MCO shall
establish and maintain capitalization and reserves as required by the
Connecticut Department of Insurance.
c. If the MCO is majority-owned by federally qualified health centers (FQHCs)
and not licensed by the State of Connecticut, the MCO will establish and
maintain sequestered capital of $500,000 plus two (2) percent of ongoing
annual capitation premiums.
1. These funds shall be placed in a restricted account for the duration
of the FQHC plan's existence, to be accessed only in the event such
funds are needed to meet unpaid claims liabilities.
2. This restricted account shall be established such that any
withdrawals or transfers of funds will require signatures of
authorized representatives of the FQHC plan and the DEPARTMENT.
3. The initial $500,000 must be deposited into the account by the
beginning of the MCO's first enrollment period.
4. The MCO must make quarterly deposits into this account so that the
account balance is equal to $500,000 plus two (2) percent of the
premiums received during the preceding twelve (12) months.
5.13 PROVIDER COMPENSATION
a. The MCO shall comply with HCFA's Physician Incentive Plan (PIP)
requirements in 42 CFR 434.70. The MCO may operate a PIP only if:
1. no specific payment can be made directly or indirectly under a PIP
to a physician or physician group as an inducement to reduce or
limit medically necessary services furnished to an individual
Member; and
2. the stop-loss protection, Member survey, and disclosure requirements
of 42 C.F.R. 417.479 are met.
b. The MCO shall disclose to the DEPARTMENT the following information on PIPs
in sufficient detail to determine whether the incentive plan complies with
the regulatory requirements of 42 CFR 417.479. The disclosure must
contain:
1. Whether services not furnished by the physician or physician group
are covered by the PIP. If only the services furnished by the
physician or physician group are covered by the incentive plan,
disclosure of other aspects of the plan need not be made.
2. The type of incentive arrangement (i.e. withhold, bonus,
capitation).
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3. If the incentive plan involves a withhold or bonus, the percent of
the withhold or bonus.
4. Proof that the physician or physician group has adequate stop-loss
protection, including the amount and type of stop-loss protection.
5. The panel size and, if patients are pooled, the method used.
6. In the case of those MCOs that are required by 42 C.F.R. 417.479
provision to conduct Member surveys, the survey results.
c. The MCO shall disclose this information to the DEPARTMENT (1) prior to
approval of its contract as required by federal regulation and (2) upon
the contract anniversary or renewal effective date. The MCO shall provide
the capitation data required (see (6) above) for the previous contract
year to the DEPARTMENT three (3) months after the end of the contract
year. The MCO will provide to the Member upon request information
regarding whether the MCO uses a physician incentive plan that affects the
use of referral services, the type of incentive arrangement, whether
stop-loss protection is provided, and the survey results of any Member
survey conducted. See Appendix J for the applicable regulations and
disclosure forms.
d. The DEPARTMENT may impose Class C sanctions pursuant to Section 7.05 for
failure to comply with 42 C.F.R. 417.479
5.14 MEMBERS HELD HARMLESS
a. The MCO shall not hold a Member liable for:
1. The debts of the MCO in the event of the MCO's insolvency;
2. The cost of Medicaid-covered services provided pursuant to this
contract to the Member if the MCO or provider fails to receive
payment; and/or
3. Payments to a provider which exceed the amount that would be owed if
the MCO directly provided the service.
5.15 COMPLIANCE WITH APPLICABLE LAWS, RULES AND POLICIES
The MCO in performing this contract shall comply with all applicable federal and
state laws, regulations and written policies, including those pertaining to
licensing.
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5.16 FEDERAL REQUIREMENTS AND ASSURANCES
GENERAL
a. The MCO must comply with 42 CFR 489, Subpart I and 42 CFR Sections 417-
436(d), relating to written policies and procedures respecting advance
directives. This requirement includes provisions to inform and distribute
written information to adult individuals concerning policies on advance
directives upon enrollment.
b. The MCO shall comply with those federal requirements and assurances for
recipients of federal grants provided in OMB Standard Form 424B (4-88)
which are applicable to the MCO. The MCO is responsible for determining
which requirements and assurances are applicable to the MCO. Copies of the
form are available from the DEPARTMENT.
c. The MCO shall provide for the compliance of any subcontractors with
applicable federal requirements and assurances.
LOBBYING
a. The MCO, as provided by 31 U.S.C. 1352 and 45 CFR 93.100 et seq., shall
not pay federally appropriated funds to any person for influencing or
attempting to influence an officer or employee of any agency, a member of
the U.S. Congress, an officer or employee of the U.S. Congress or an
employee of a member of the U.S. Congress in connection with the awarding
of any federal contract, the making of any cooperative agreement or the
extension, continuation, renewal, amendment or modification of any federal
contract, grant, loan or cooperative agreement.
b. The MCO shall submit to the DEPARTMENT a disclosure form as provided in 45
CFR 93.110 and Appendix B to 45 CFR Part 93, if any funds other than
federally 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 the U.S. Congress, an officer or employee of the U.S.
Congress or an employee of a member of the U.S. Congress in connection
with this contract.
BALANCED BUDGET ACT
The MCO shall comply with all applicable provisions of the Balanced Budget Act
of 1997, P.L. 105-33 (HR 2015), approved August 5, 1997.
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CLEAN AIR AND WATER ACTS
The MCO shall comply with all applicable standards, orders or regulations issued
pursuant to the Clean Air Act as amended, 42 U.S.C. 7401, et seq. and the
Federal Water Pollution Control Act as amended, 33 U.S.C. 1251 et seq.
ENERGY STANDARDS
The MCO shall comply with all applicable standards and policies relating to
energy efficiency which are contained in the state energy plan issued in
compliance with the federal Energy Policy and Conservation Act, 42 USC Sections
6231 - 6246. The MCO further covenants that no federally appropriated funds
have been paid or will be paid on behalf of the DEPARTMENT or the contractor to
any person for influencing or attempting to influence an officer or employee of
any federal 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, or the extension,
continuation, renewal, amendment, or modification of any federal contract,
grant, loan, or cooperative agreement. If any funds other than federally
appropriated funds have been paid or will be paid to any person for influencing
or attempting to influence an officer or employee of any federal agency, a
member of Congress, or an employee of a member of Congress in connection with
this contract, grant, loan, or cooperative agreement, the contractor shall
complete and submit Standard Form - LLL, "Disclosure Form to Report Lobbying,"
in accordance with its instructions.
MATERNITY ACCESS AND MENTAL HEALTH PARITY
The MCO shall comply with the maternity access and mental health parity
requirements of the Public Health Services Act, Title XXVII, Subpart 2, Part A,
Section 2704, as added September 26, 1996, 42 U.S.C. Section 300gg-4, 300gg-5,
insofar as such requirements apply to providers of group health insurance.
5.17 CIVIL RIGHTS
FEDERAL AUTHORITY
The MCO shall comply with the Civil Rights Act of 1964 (42 U.S.C. Section 2000d,
et seq.), the Age Discrimination Act of 1975 (42 U.S.C. 6101, et seq.), the
Americans with Disabilities Act of 1990 (42 U.S.C. Section 12101, et seq.) and
Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, et seq.
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DISCRIMINATION
Persons may not, on the grounds of race, color, national origin, creed, sex,
religion, political ideas, marital status, age or disability be excluded from
employment in, denied participation in, denied benefits or be otherwise
subjected to discrimination under any program or activity connected with the
implementation of this contract. The MCO shall use hiring processes that xxxxxx
the employment and advancement of qualified persons with disabilities.
MERIT QUALIFICATIONS
All hiring done in connection with this contract must be on the basis of merit
qualifications genuinely related to competent performance of the particular
occupational task. The MCO, in accordance with Federal Executive Order 11246,
dated September 24, 1965 entitled "Equal Employment Opportunity", as amended by
Federal Executive Order 11375 and as supplemented in the United States
Department of Labor Regulations, 41 CFR Part 60-1, et seq., must provide for
equal employment opportunities in its employment practices.
CONFIDENTIALITY
The MCO shall, in accordance with relevant laws, regulations and policies,
protect the confidentiality of any material and information concerning an
applicant for or recipient of services funded by the DEPARTMENT. Access to
patient information, records, and data shall be limited to the purposes outlined
in 42 CFR 434.6(a)(8). All requests for data or patient records for
participation in studies, whether conducted by the MCO or outside parties, are
subject to approval by the DEPARTMENT.
5.18 STATUTORY REQUIREMENTS
a. A State licensed MCO shall retain at all times during the period of this
contract a valid Certificate of Authority issued by the State Commissioner
of Insurance.
b. The MCO shall adhere to the provisions of the Clinical Laboratory
Improvement Amendments of 1988 (CLIA) Public Law 100-578, 42 USC Section
1395aa et seq.
5.19 DISCLOSURE OF INTERLOCKING RELATIONSHIPS
An MCO which is not also a Federally-qualified Health Plan or a Competitive
Medical Plan under the Public Health Service Act must report on request to the
State, to the Secretary and the Inspector General of DHHS, and the Comptroller
General, a description of transactions between the MCO and parties in interest
including related parties as defined by federal and state law. Transactions that
must be reported include: (a) any
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sale, exchange, or leasing of property; (b) any furnishing for consideration of
goods, services or facilities (but not salaries paid to employees); and (c) any
loans or extensions of credit.
5.20 DEPARTMENT'S DATA FILES
a. The DEPARTMENT's data files and data contained therein shall be and remain
the DEPARTMENT's property and shall be returned to the DEPARTMENT by the
MCO upon the termination of this contract at the DEPARTMENT's request,
except that any DEPARTMENT data files no longer required by the MCO to
render services under this contract shall be returned upon such
determination at the DEPARTMENT's request.
b. The DEPARTMENT's data shall not be utilized by the MCO for any purpose
other than that of rendering services to the DEPARTMENT under this
contract, nor shall the DEPARTMENT's data or any part thereof be
disclosed, sold, assigned, leased or otherwise disposed of to third
parties by the MCO unless there has been prior written DEPARTMENT
approval. The MCO may disclose material and information to subcontractors
and vendors, as necessary to fulfill the obligations of this contract.
c. The DEPARTMENT shall have the right of access and use of any data files
retained or created by the MCO for systems operation under this contract
subject to the access procedures defined in Part II Section 3.34.
d. The MCO shall establish and maintain at all times reasonable safeguards
against the destruction, loss or alteration of the DEPARTMENT's data and
any other data in the possession of the MCO necessary to the performance
of operations under this contract.
5.21 CHANGES DUE TO A SECTION 1115 OR 1915(b) FREEDOM OF CHOICE WAIVER
The conditions of enrollment described in the contract, including but not
limited to enrollment and the right to disenrollment, an subject to change as
provided in any waiver under Section 1115 or 1915(b) of the Social Security Act
(as amended) obtained by the DEPARTMENT.
5.22 HOLD HARMLESS
The MCO agrees to indemnify, defend and hold harmless the State of Connecticut
as well as all Departments, officers, agents and employees of the State from all
claims, losses or suits accruing or resulting to any contractors,
subcontractors, laborers and any person,
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firm or corporation who may be injured or damaged through the fault of the MCO
in the performance of the contract.
The MCO, at its own expense, shall defend any claims or suits which are brought
against the DEPARTMENT or the State for the infringement of any patents,
copyrights, or other proprietary rights arising from the MCO's or the State's
use of any material or information prepared or developed by the MCO in
conjunction with the performance of this contract; provided any such use by the
State is expressly contemplated by this contract and approved by the MCO. The
State, its Departments, officers, employees, contractors, and agents shall
cooperate fully in the MCO's defense of any such claim or suit as directed by
the MCO. The MCO shall, in any such suit, satisfy any damages for infringement
assessed against the State or the DEPARTMENT, be it resolved by settlement
negotiated by the MCO, final judgment of a court with jurisdiction after
exhaustion of available appeals, consent decree, or any other manner approved by
the MCO.
5.23 EXECUTIVE ORDER NUMBER 16
This contract is subject to Executive Order No. 16 of Governor Xxxx X. Xxxxxxx
promulgated August 4, 1999 and, as such, this Agreement may be cancelled,
terminated or suspended by the State for violation of or noncompliance with said
Executive Order No. 16. The parties to this contract, as part of the
consideration hereof, agree that:
a. The MCO shall prohibit employees from bringing into the state work site,
except as may be required as a condition of employment, any weapon or
dangerous instrument as defined in b.
b. Weapon means any firearm, including a BB gun, whether loaded unloaded, any
knife (excluding a small pen or pocket knife), including a switchblade or
other knife having an automatic spring release device, a stiletto, any
police baton or nightstick or any martial arts weapon or electronic
defense weapon dangerous instrument means any instrument, article or
substance that, under the circumstances, is capable of causing death or
serious physical injury.
c. The MCO shall prohibit employees from attempting to use or threaten to use
any such weapon or dangerous instrument in the state work site and
employees shall be prohibited from causing or threatening to cause
physical injury or death to any individual in the state work site.
d. The MCO shall adopt the above prohibitions as work rules, violations of which
shall subject the employee to disciplinary action up to and including
discharge. The MCO shall insure that all employees are aware of such work
rules.
e. The MCO agrees that any subcontract it enters into in furtherance of the work
to be performed hereunder shall contain the provisions (a) through (d).
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6. MCO RESPONSIBILITIES CONCERNING NOTICES OF ACTION, GRIEVANCES AND
ADMINISTRATIVE HEARINGS
6.01 NOTICES OF ACTION
a. The MCO or its subcontractor (as duly authorized by the MCO) shall mail a
notice of action to a Member when the MCO denies or partially denies
coverage of goods or services prescribed by the Member's treating PCP, or
other treating provider, functioning within his or her scope of practice
as defined under state law; or the MCO reduces, suspends, or terminates
ongoing goods or services being provided to a Member. The notice
requirements shall apply to all categories of covered services including
transportation to medically necessary appointments.
b. The MCO may request additional information from a provider if additional
information is needed for the MCO's consideration of a request for
approval of coverage of goods or services. If the provider does not
respond to the request for additional information within twenty (20)
business days and the MCO still does not have adequate information to
approve the request, a notice of action must be sent. The notice of action
shall state that the lack of sufficient information from the provider is
the reason for the denial.
c. The MCO shall issue a notice of action if the MCO approves a good or
service that is not the same type, amount, duration, frequency or
intensity as that requested by the provider, consistent with current DSS
policy.
d. The MCO shall identify if the Member reads only a language other than
English. In that case, the notice of action shall be in the Member's
native language, if possible.
e. Except as provided in (h) below the MCO shall mail an advance notice of
action to a Member at least ten (10) days before the date of any action
described in (a) above, consistent with current DSS policy.
f. All notices related to actions described in (a) above shall clearly state
or explain:
1. the action the MCO intends to take or has taken;
2. the reasons for the action;
3. the statute, regulation, the DEPARTMENT's Medical Services Policy
section, or when there is no appropriate regulation, policy or
statute, the HUSKY A contract provision that supports the action;
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4. the address and toll-free number of the MCO's Member Services
Department;
5. the Member's right to challenge the action by filing a grievance and
requesting an administrative hearing;
6. the procedure for filing a grievance and for requesting an
administrative hearing;
7. how the Member may obtain a grievance form and, if desired,
assistance in completing and submitting the grievance form;
8. that the Member will lose his or her right to challenge the action
if he or she does not complete and file a written grievance form
with the DEPARTMENT within sixty (60) days from the date the MCO
mailed the initial notice of action;
9. that the MCO must issue a decision regarding a grievance by the date
that the administrative hearing is scheduled, but no more than
thirty (30) days following the date the DEPARTMENT receives it;
10. that, if the Member files a grievance he or she is entitled to meet
with or speak by telephone with the MCO representative who will
decide the grievance, and is entitled to submit additional
documentation or written material for the MCO's consideration;
11. that the Member may proceed automatically to an administrative
hearing if he or she is dissatisfied with the MCO's grievance
decision concerning the denial of coverage of goods or services or a
reduction, suspension, or termination of ongoing goods or services,
or if the MCO fails to render a decision by the date the
administrative hearing is scheduled;
12. that at an administrative hearing, the Member may represent himself
or herself or use legal counsel, a relative, a friend, or other
spokesperson;
13. that if the Member obtains legal counsel who will represent the
Member during the grievance or administrative hearing process, the
Member must direct his or her legal counsel to send written
notification of the representation to the MCO and the DEPARTMENT;
14. that if the circumstances require advance notice, the Member's right
to continuation of ongoing goods and services, provided that:
a. the Member files a grievance/request for administrative
hearing form with the DEPARTMENT within ten (10) calendar days
of the date the notice of action is mailed to the Member; and
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b. the reduction, suspension, or termination of goods or services
was not ordered by the Member's treating physician or PCP,
functioning within his or her scope of practice as defined
under state law;
15. if the circumstances are an exception to the advance notice
requirement as set forth in (h) below, that the Member does not have
the automatic right to continuation of ongoing goods or services. In
these circumstances, however, the reduced, suspended, or terminated
goods and services must be reinstated if the Member files a written
grievance/request for administrative hearing form with the
DEPARTMENT within ten (10) days of the date the notice is mailed to
the Member. The right to continuation of ongoing goods or services
applies to the scope of services previously authorized. The right to
continuation of services does not apply to subsequent requests for
approval that result in denial of the additional request or
re-authorization of the request at a different level than requested.
The MCO shall treat such requests as a new service authorization
request and provide a denial notice; and
16. any other information specified by the DEPARTMENT.
g. In the case of a child who is under the care of the Department of Children
and Families (DCF), the MCO must send the notice of action to the
identified person at DCF's central office.
h. Notice of action need not be sent to the Member ten (10) days in advance
of the action, but may be sent no later than the date of action and will
be considered an exception to the advance notice requirement, if the
action is based on any of the following circumstances:
1. denial of goods or services;
2. the MCO has received a clear, written statement signed by the Member
that:
a. the Member no longer wishes to receive the goods or services;
or
b. the Member gives information which requires the reduction,
suspension, or termination of the goods or services, and the
Member indicates that he or she understands that this must be
the result of supplying that information; and
3. the Member has been admitted to an institution where he or she is
ineligible for the goods or services. In this instance, the Member
must be notified on the notice of admission that any goods or
services being reduced, suspended, or terminated will be reevaluated
for medical necessity upon discharge, and the Member will have the
right to appeal any post-discharge decisions
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i. The DEPARTMENT will provide a standardized notice of action form to
be used by the MCO and its subcontractors. The DEPARTMENT will also
provide a standardized grievance/administrative hearing request form to be
used by the MCO and its subcontractors. The MCO and its subcontractors
shall not alter the standard format of either form without prior, written
approval of the DEPARTMENT.
SANCTION: If the DEPARTMENT determines during any audit or random monitoring
visit to the MCO or one of its subcontractors that a notice of action fails to
meet any of the criteria set forth herein, the DEPARTMENT may impose a strike
towards a Class A sanction. If the deficiencies which give rise to a Class A
sanction continue for a period in excess of ninety (90) days, the DEPARTMENT may
impose a Class B sanction.
6.02 GRIEVANCE AND ADMINISTRATIVE HEARING PROCESS
a. The MCOs shall have a timely and organized grievance process. The
grievance process shall be available for resolution of disputes between
the MCO and its Members concerning the MCO's denial, reduction, suspension
or termination of goods or services or the MCO's failure to respond to a
request for goods and services.
b. The MCO shall develop written policies and procedures for its grievance
process. Those policies and procedures must be approved by the DEPARTMENT
in writing and must include the elements specified in this contract. The
MCO shall not be excused from providing the elements specified in this
contract pending the DEPARTMENT's written approval of the MCO's policies
and procedures.
c. The MCO shall maintain a record keeping system for grievances which shall
include a copy of the grievance, the response, the resolution and
supporting documentation.
d. The MCO must clearly specify in its Member handbook/packet the procedural
steps and timeframes for filing a grievance and administrative hearing
request, including the timeframe for maintaining benefits pending the
conclusion of the grievance and administrative hearing process. The Member
handbook/packet shall also list the addresses, office hours, and toll-free
telephone numbers for the Member Services office.
e. The MCO shall ensure that network providers and subcontractors are
familiar with the grievance process and shall provide information on the
process to providers and subcontractors. The MCO must ensure that
grievance/request for administrative hearing forms are available at each
primary care site. At a minimum, grievance assistance must include
providing grievance/request for administrative hearing forms on request,
assisting the Member in filling out the
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forms upon request, and sending the completed form to the DEPARTMENT upon
request.
f. The MCO shall develop and make available to Members and potential Members
appropriate foreign language versions of grievance materials, including
but not limited to, the standard information contained in notices of
action and grievance/request for administrative hearing forms. Such
materials shall be made available in Spanish, English, or any other
languages if more than five (5) percent of the MCO's Members in any county
of the State served by the MCO speak the alternative language. Such
foreign language materials must be approved, in writing, by the
DEPARTMENT.
g. A Member must file a written signed grievance in order to receive an
administrative hearing, before the DEPARTMENT, concerning the MCO's
denial, reduction, suspension, or termination of goods or services. The
process for pursuing a grievance and for requesting an administrative
hearing shall be unified. The MCO and the DEPARTMENT shall treat the
filing of a grievance as a simultaneous request for an administrative
hearing. The MCO shall attempt to resolve grievances at the earliest point
possible. If the MCO is not able to render a decision by the time the
administrative hearing is scheduled, the Member will automatically proceed
to the administrative hearing.
h. Grievances shall be filed by the Member, the Member's authorized
representative, or the Member's conservator on a form approved by the
DEPARTMENT. Grievances shall be mailed or faxed to a single address within
the DEPARTMENT. The grievance form must state both the mailing address and
fax number at the DEPARTMENT where the form must be sent. If the MCO or
its subcontractor receive a grievance form directly from a Member or the
Member's authorized representative or conservator, the MCO shall date
stamp and fax the grievance to the appropriate fax number at the
DEPARTMENT within two (2) business days.
i. The DEPARTMENT will schedule an administrative hearing and notify the
Member and MCO of the hearing date and location. If a Member is disabled,
the hearing may be scheduled for the Member's home, if requested by the
Member.
j. The DEPARTMENT will date stamp and forward the grievance by fax to the MCO
within two (2) business days of receipt. The fax to the MCO will include
the date the Member mailed the appeal to the DEPARTMENT. The postmark on
the envelope will be used to determine the date the appeal was mailed.
k. The MCO's review of the grievance must be carried out by an individual or
individuals having final decisionmaking authority. Any grievance stemming
from an action based on a determination of medical necessity must be
decided by one or more physicians who were not involved in making that
medical determination.
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l. The MCO may decide a grievance on the basis of the written documentation
available unless the Member requests an opportunity to meet with the
individual or individuals making that determination on behalf of the MCO
and/or requests the opportunity to submit additional documentation or
other written material.
m. If the Member wishes to meet with the decisionmaker, the meeting can be
held via the telephone or at a location accessible to the Member,
including the Member's home if requested by a disabled Member. Subject to
approval of the DEPARTMENT's Regional Offices, any of the DEPARTMENT's
office locations may be available for video conferencing. The MCO must
invite a representative of the DEPARTMENT to attend any such meeting.
n. The MCO must mail to the Member, by certified mail, a written grievance
decision, described below, with a copy to the DEPARTMENT, by the date of
the DEPARTMENT's administrative hearing but no later than thirty (30) days
from the date on which the grievance was received by the DEPARTMENT. If
the Member is dissatisfied with the MCO's decision regarding the denial,
reduction, suspension, or termination of goods or services, or if the MCO
does not render a decision by the time of the administrative hearing, the
Member may automatically proceed to the administrative hearing.
o. The MCO's written grievance decision must include the Member's name and
address; the provider's name and address; the MCO name and address; a
complete description of the information or documents reviewed by the MCO;
a complete statement of the MCO's findings and conclusions, including the
section number and text of any contractual provision or DEPARTMENTAL
policy provision that is relevant to the grievance decision; and a clear
statement of the MCO disposition of the grievance.
p. Along with its written grievance decision, the MCO must remind the Member,
on a form approved by the DEPARTMENT, that:
1. if the Member is dissatisfied with the MCO's denial, reduction,
suspension, or termination of goods or services, the DEPARTMENT has
already reserved a time to hold an administrative hearing concerning
that decision;
2. that the Member has the right to automatically proceed to the
administrative hearing, and that the MCO must continue to maintain
the disputed goods and services pending the administrative hearing
decision;
3. if the grievance pertains to the suspension, reduction, or
termination of goods or services which have been maintained during
the grievance process, and the MCO's grievance decision affirms the
suspension, reduction, or termination of goods or services, those
goods or services will be suspended, reduced, or terminated in
accordance with the MCO's
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grievance decision unless the Member proceeds to an administrative
hearing; and
4. if the Member fails to appear at the administrative hearing, the
Member's reserved hearing time will be cancelled and any disputed
goods or services that were maintained will be suspended, reduced,
or terminated in accordance with the MCO's grievance decision.
q. If the Member proceeds to an administrative hearing, the MCO must make its
entire file concerning the Member and the grievance, including any
materials considered in making its decision, available to the DEPARTMENT.
r. If the MCO fails to issue a grievance decision by the date that an
administrative hearing is scheduled, but no later than thirty (30) days
following the date the grievance was received by the DEPARTMENT, an
administrative hearing will be held as originally scheduled. At the
hearing, the MCO must prove good cause for having failed to issue a timely
decision regarding the grievance. Good cause for the MCO's failure to
issue a timely decision shall include, but not be limited to, documented
efforts to obtain additional medical records necessary for the MCO's
decision on the grievance and the Member's refusal to sign a release for
medical records necessary for the decision on the grievance.
The MCO's inability to prove good cause shall constitute a sufficient
basis for upholding the grievance, and the hearing officer, in his or her
discretion, may uphold the grievance solely on that basis.
If the MCO proves good cause for having failed to issue a timely grievance
decision, the hearing officer may order a continuance of the hearing
pending the issuance of the grievance decision by a certain date, or the
hearing officer may proceed with the hearing.
s. A representative of the MCO shall prepare the summary for the
administrative hearing, subject to approval by the DEPARTMENT prior to the
hearing, and shall present proof of all facts supporting its initial
action if the administrative hearing proceeds in the absence of a
grievance decision. The MCO shall submit a final, signed hearing summary
to the DEPARTMENT no later than five (5) business days prior to the
scheduled hearing date. The MCO's representative shall also present any
provisions of this contract or any DEPARTMENT policies which support its
decision.
t. If a representative of the MCO fails to attend a scheduled session of an
administrative hearing, the MCO's failure to attend shall constitute a
sufficient basis for upholding the grievance, and the hearing officer, in
his or her discretion, may close the hearing and uphold the grievance
solely on that basis.
100
u. If the DEPARTMENT is advised that the Member does not intend to proceed to
an administrative hearing, the DEPARTMENT will fax such notice to the MCO.
v. The MCO must designate one primary and one back-up contact person for its
grievance/administrative hearing process.
6.03 EXPEDITED REVIEW AND ADMINISTRATIVE HEARINGS
a. Subject to Section 6.02 above, the grievance process must allow for
expedited review. If the grievance contains a request for expedited
review, it will be forwarded by fax to the MCO within one business day of
receipt by the DEPARTMENT. The fax will include the date the Member mailed
the appeal. The postmark on the envelope will be used to determine the
date the appeal was mailed.
b. The MCO must determine, within one business day of receiving the grievance
which contains a request for an expedited review from the DEPARTMENT,
whether to expedite the review or whether to perform a review according
to the standard timeframes.
c. An expedited review must be performed when the standard timeframes for
determining a grievance could jeopardize the life or health of the Member
or the Member's ability to regain maximum function. The MCO must expedite
its review in all cases in which such a review is requested by the
Member's treating physician or PCP, functioning within his or her scope of
practice as defined under state law, or by the DEPARTMENT.
d. Unless the Member asks to meet with the decisionmaker or to submit
additional information, an expedited review must be completed and a
grievance decision must be issued within a timeframe appropriate to the
condition or situation of the Member, but no more than three (3) business
days from the MCO's receipt of the grievance from the DEPARTMENT.
e. If the Member asks to meet with the decisionmaker and/or submit additional
information, the decisionmaker must offer to meet with the Member within
three (3) business days of receiving the grievance from the DEPARTMENT,
and the MCO must issue its decision not later than five (5) business days
after receiving the grievance. The meeting with the Member can be held via
the telephone or at a location accessible to the Member, and subject to
approval of the DEPARTMENT's Regional Offices any of the DEPARTMENT's
office locations may be available for video conferencing.
f. The DEPARTMENT also provides expedited administrative hearings for HUSKY A
Members if a Member's physician shows that it would put the Member's life
at risk or pose serious risk of illness or injury to follow the regular
101
timeframes for administrative hearings. The DEPARTMENT will notify the MCO
of the granting of any Member's request for an expedited administrative
hearing. The MCO shall conduct its grievance review for any such hearing
on an expedited basis.
SANCTION: If the MCO fails to provide expedited grievance reviews in appropriate
circumstances, the DEPARTMENT may impose a Class B sanction pursuant to Section
7.05.
6.04 PROVIDER APPEAL PROCESS
a. The MCO shall have an internal appeal process through which a health care
provider may appeal the MCO decision on behalf of a Member.
b. The health care provider appeal process shall not include any appeal
rights to the DEPARTMENT or any rights to an administrative hearing.
102
7. CORRECTIVE ACTION AND CONTRACT TERMINATION
7.01 PERFORMANCE REVIEW
a. A designated representative of the MCO and a designated representative of
the DEPARTMENT shall meet on an annual basis, and as requested by either
party, to review the performance of the MCO under this contract. The
DEPARTMENT will keep written minutes of such meetings. In the event of any
disagreement regarding the performance of services by the MCO under this
contract, the designated representatives shall discuss the problem and
shall negotiate in good faith in an effort to resolve the disagreement.
b. In the event that no such resolution is achieved within a reasonable time,
the matter shall be referred to the Contract Administrator as provided
under Article 7.02, the Disputes clause of this contract. If the Contract
Administrator determines that the MCO has failed to perform as measured
against applicable contract provisions, the Contract Administrator may
impose sanctions or any other penalty, set forth in this Section including
the termination of this contract in whole or in part, as provided under
this Section.
7.02 SETTLEMENT OF DISPUTES
Any dispute arising under the contract which is not disposed of by agreement
shall be decided by the Contract Administrator whose decision shall be final and
conclusive subject to any rights the MCO may have in a court of law. The
foregoing shall not limit any right the MCO may have to present claims under
Connecticut General Statutes Section 4-141 et seq. or successor provisions
regarding the claims commissioner, including without limitation Connecticut
General Statutes Section 4-160 regarding authorization of actions. In connection
with any appeal to the Contract Administrator under this paragraph, the MCO
shall be afforded an opportunity to be heard and to offer evidence in support of
its appeal. Pending final decision of a dispute, the MCO shall proceed
diligently with the performance of the contract in accordance with the Contract
Administrator's decision.
7.03 ADMINISTRATIVE ERRORS
The MCO shall be liable for the actual amount of any costs in excess of $5,000
incurred by the DEPARTMENT as the result of any administrative error (e.g.
submission of erroneous capitation, encounter or reinsurance data) of the MCO or
its subcontractors. The DEPARTMENT may request a refund of, or recoup from
subsequent capitation payments, the actual amount of such costs.
103
7.04 SUSPENSION OF NEW ENROLLMENT
Whenever the DEPARTMENT determines that the MCO is out of compliance with this
contract, unless corrective action is taken to the satisfaction of the
DEPARTMENT, the DEPARTMENT may suspend enrollment of new Members under this
contract. The DEPARTMENT, when exercising this option, must notify the MCO in
writing of its intent to suspend new enrollment at least thirty (30) days prior
to the beginning of the suspension period. The suspension period may be for any
length of time specified by the DEPARTMENT, or may be indefinite. The suspension
period may extend up to the contract expiration date as provided under PART I.
(The DEPARTMENT may also notify existing Members of MCO non-compliance and
provide an opportunity to disenroll from the MCO and to re-enroll in another
MCO.)
7.05 SANCTIONS
It is agreed by the DEPARTMENT and the MCO that if by any means, including any
report, filing, examination, audit, survey, inspection or investigation, the MCO
is determined to be out of compliance with this contract, damage to the
DEPARTMENT may or could result. Consequently, the MCO agrees that the DEPARTMENT
may impose any of the following sanctions for noncompliance under this contract.
Unless otherwise provided in this contract, sanctions imposed under this section
shall be deducted from capitation payment or, at the discretion of the
DEPARTMENT, paid directly to the DEPARTMENT.
a. SANCTIONS FOR NONCOMPLIANCE
1. CLASS A SANCTIONS. THREE (3) STRIKES. SANCTIONS WARRANTED AFTER THREE
(3) OCCURRENCES
For noncompliance of the contract which does not rise to the level
warranting Class B sanctions as defined in subsection a(2) of this section
or Class C sanctions as defined in subsection (b) of this section,
including, but not limited to, those violations defined as Class A
sanctions in any provision of this contract, the following course of
action will be taken by the DEPARTMENT:
Each time the MCO fails to comply with the contract on an issue
warranting a Class A sanction, the MCO receives a strike. The MCO
will be notified each time a strike is imposed. After the third
strike for the same contract provision, a sanction may be imposed.
If no specific time frame is set forth in any such contractual
provision, the time frame is deemed to be the full length of the
contract.
104
The MCO will be notified in writing at least thirty (30) days in
advance of any sanction being imposed and will be given an
opportunity to meet with the DEPARTMENT to present its position as
to the DEPARTMENT's determination of a violation warranting a Class
A sanction. At the DEPARTMENT's discretion, a sanction will
thereafter be imposed. Said sanction will be no more than $2,500
after the first three (3) strikes. The next strike for noncompliance
of the same contractual provision will result in a sanction of no
more than $5,000 and any subsequent strike for noncompliance of the
same contractual provision will result in a Class A sanction of no
more than $10,000.
2. CLASS B SANCTIONS. SANCTIONS WARRANTED UPON SINGLE OCCURRENCE
For noncompliance with the contract which does not warrant the imposition
of Class C sanctions as defined in subsection (b) of this section,
including, but not limited to, those violations defined as Class B
sanctions in any provision of this contract, the following course of act
on will be taken by the DEPARTMENT:
The DEPARTMENT may impose a sanction at the DEPARTMENT's discretion
if, after at least thirty (30) days notice to the MCO and an
opportunity to meet with the DEPARTMENT to present the MCO's
position as to the DEPARTMENT's determination of a violation
warranting a Class B sanction, the DEPARTMENT determines that the
MCO has failed to meet a performance measure which merits the
imposition of a Class B sanction not to exceed $10,000.
b. CLASS C SANCTIONS. SANCTIONS RELATED TO NONCOMPLIANCE POTENTIALLY
RESULTING IN HARM TO AN INDIVIDUAL MEMBER
(i) The DEPARTMENT may impose a Class C sanction on the MCO for
noncompliance potentially resulting in harm to an individual
Member, including, but not limited to, the following:
1. failing to substantially authorize medically necessary items
and services that are required (under law or under this
contract) to be provided to an Member covered under this
contract;
2. imposing a premium or charge on Members except as specifically
permitted under provisions of the approved Medicaid State
Plan;
3. discriminating among Members on the basis of their health
status or requirements for health care services, including
expulsion or refusal to re-enroll an individual, except as
permitted by Title XIX, or engaging in any practice that would
reasonably be expected to have the effect of denying or
discouraging enrollment with the MCO by eligible individuals
whose medical condition or history indicates a need for
substantial future medical services;
105
4. misrepresenting or falsifying information that is furnished to the
Secretary, the DEPARTMENT; Member, potential Member, or a health
care provider;
5. failing to comply with the physician incentive requirements under
Section 1903(m)(2)(A)(x) of the Social Security Act; and
6. distributing directly or through any agent or independent contractor
marketing materials containing false or misleading information.
(ii) Class C sanctions for noncompliance with the contract under this subsection
include the following:
1. withholding the next month's capitation payment to the MCO in full or
in part;
2. assessment of liquidated damages:
a. for each determination that the MCO fails to substantially
provide medically necessary services or fails to comply with
the physician incentive plan requirements, not more than
$25,000;
b. for each determination that the MCO discriminates among
Members on the basis of their health status or requirements for
health care services or engages in any practice that has the
effect of denying or discouraging enrollment with the MCO by
eligible individuals based on their medical condition or
history that indicates a need for substantial future medical
services, or the MCO misrepresents or falsifies information
furnished to the Secretary, DEPARTMENT, Member, potential
Member or health care provider, not more than $100,000;
c. for each determination that the MCO has discriminated among
Members or engaged in any practice that has denied or
discouraged enrollment, $15,000 for each individual not
enrolled as a result of the practice up to a total of
$100,000; for a determination that the MCO has imposed
premiums or charges on Members in excess of the premiums or
charges permitted, double the excess amount. The excess amount
charged in such a circumstance must be deducted from the penalty
and returned to the Member concerned;
3. freeze on new enrollment and/or alter the current enrollment; or
4. appointment of temporary management upon a finding by the DEPARTMENT
that there is continued egregious behavior by the MCO or there is a
substantial risk to the health of the Members. After a finding
pursuant to this subsection, individuals enrolled with the MCO must
be permitted to terminate enrollment without cause and the MCO
shall be responsible for notification of such right to terminate
enrollment. Nothing
106
in this subsection shall preclude the DEPARTMENT from proceeding
under the termination provisions of the contract rather than
appointing temporary management. If however, the DEPARTMENT chooses
not to first terminate the contract and repeated violations occur,
the DEPARTMENT must than appoint temporary management on the MCO and
allow individuals to disenroll without cause.
(iii) Prior to imposition of any Class C sanction, the MCO will be notified
at least thirty (30) days in advance and provided, at a minimum, an
opportunity to meet with the DEPARTMENT to present its position as to
the DEPARTMENT's determination of a violation warranting a Class C
Sanction. For any contract violation under this subsection, at the
DEPARTMENT's discretion, the MCO may be permitted to submit a
corrective action plan within twenty (20) days of the notice to the
MCO of the violation. Immediate compliance (within thirty (30) days)
under any such corrective action plan may result in the imposition of
a lessor sanction on the MCO. If any sanction issued under this
subsection is equivalent to termination of the contract, the MCO shall
be offered a hearing to contest the imposition of such a sanction.
c. OTHER REMEDIES
1. Notwithstanding the provisions of this section, failure to provide
required services will place the MCO in default of this contract,
and the remedies in this section are not a substitute for other
remedies for default which the DEPARTMENT may impose as set forth in
this contract.
2. The imposition of any sanction under this section does not preclude
the DEPARTMENT from obtaining any other legal relief to which it may be
entitled pursuant to state or federal law.
7.06 PAYMENT WITHHOLD, CLASS C SANCTIONS OR TERMINATION FOR CAUSE
The DEPARTMENT may withhold capitation payments, impose sanctions including
Class C Sanctions set forth in Section 7.05 or terminate the contract for cause.
Cause shall include, but not be limited to: 1) use of funds and/or personnel for
purposes other than those described in the HUSKY A program and this contract and
2) if a civil action or suit in federal or state court involving allegations of
health fraud or violation of 18 U.S.C. Section 1961 et seq. is brought on
behalf of the DEPARTMENT.
107
7.07 EMERGENCY SERVICES DENIALS
If the MCO has a pattern of inappropriately denying payments for emergency
services as defined in Part II, Definitions, the MCO may be subject to
suspension of new enrollments, withholding of capitation payments, contract
termination, or refusal to contract in a future time period. This applies not
only to cases where the DEPARTMENT has ordered payment after appeal, but also to
cases where no appeal has been made (i.e., the DEPARTMENT is knowledgeable about
documented abuse from other sources.)
7.08 TERMINATION FOR DEFAULT
a. The DEPARTMENT may terminate performance of work under this contract in
whole, or in part, whenever the MCO materially defaults in performance of
this contract and fails to cure such default or make progress satisfactory
to the DEPARTMENT toward contract performance within a period of thirty
(30) days (or such longer period as the DEPARTMENT may allow). Such
termination shall be referred to herein as "Termination for Default."
b. If after notice of termination of the contract for default, it is
determined by the DEPARTMENT or a court that the MCO was not in default,
the notice of termination shall be deemed to have been rescinded and the
contract reinstated for the balance of the term.
c. If after notice of termination of the contract for default, it is
determined by the DEPARTMENT or a court that the MCO was not in default or
that the MCO's failure to perform or make progress in performance was due
to causes beyond control and without the error or negligence of the MCO,
or any subcontractor, the notice of termination shall be deemed to have
been issued as a termination for convenience pursuant to Section 7.09 and
the rights and obligations of the parties shall be governed accordingly.
d. In the event the DEPARTMENT terminates the contract in full or in part as
provided in this clause, the DEPARTMENT may procure, services similar to
those terminated, and the MCO shall be liable to the DEPARTMENT for any
excess costs for such similar services for any calendar month for which
the MCO has been paid to provide services to HUSKY A clients. In addition,
the MCO shall be liable to the DEPARTMENT for administrative costs
incurred by the DEPARTMENT in procuring such similar services. Provided,
however, that the MCO shall not be liable for any excess costs or
administrative costs if the failure to perform the contract arises out of
causes beyond the control and without error or negligence of the MCO or
any of its subcontractors.
108
e. In the event of a termination for default, the MCO shall be financially
responsible for Members in the current month at the applicable capitation
rate.
f. The rights and remedies of the DEPARTMENT provided in this clause shall
not be exclusive and are in addition to any other rights and remedies
provided by law or under this contract.
g. In addition to the termination rights under Part I Section 8, the MCO may
terminate this contract on ninety (90) days written notice in the event
that the DEPARTMENT fails to (a) pay capitation claims in accordance with
Part II Section 4.06 and Part II Section 3.01 of this contract (b) provide
eligibility or enrollment/disenrollment information and shall fail to cure
such default or make progress satisfactory to the MCO within a period of
sixty (60) days of such default.
7.09 TERMINATION FOR MUTUAL CONVENIENCE
The DEPARTMENT and the MCO may terminate this contract at any time if both
parties mutually agree in writing to termination. At least sixty (60) days shall
be allowed. The effective date must be the first day of a month. The MCO shall,
upon such mutual agreement being reached, be paid at the capitation rate for
enrolled recipients through the termination of the contract.
7.10 TERMINATION FOR FINANCIAL INSTABILITY OF THE MCO
In the event of financial instability of the MCO, the DEPARTMENT shall have the
right to terminate the contract upon the same terms and conditions as a
Termination for Default.
7.11 TERMINATION FOR UNAVAILABILITY OF FUNDS
a. The DEPARTMENT at its discretion may terminate at any time the whole or
any part of this contract or modify the terms of the contract if federal
or state funding for the contract or for the Medicaid program as a whole
is reduced or terminated for any reason. Modification of the contract
includes, but is not limited to, reduction of the rates or amounts of
consideration, reducing services covered by the MCO, or the alteration of
the manner of the performance in order to reduce expenditures under the
contract. Whenever possible, the MCO will be given thirty (30) days
notification of termination.
109
b. In the event of a reduction in the appropriation from the state or federal
budget for the Division of Health Care Financing of the Department of
Social Services or an across-the-board budget reduction affecting the
Department of Social Services, the DEPARTMENT may either re-negotiate this
contract or terminate with thirty (30) days written notice. Any reduction
in the capitation rates that is agreed upon by the parties or any
subsequent termination of this contract by the DEPARTMENT in accordance
with this provision shall only affect capitation payments or portions
thereof for covered services purchased on or after the effective date of
any such reduction or termination. Should the DEPARTMENT elect to
renegotiate the contract, the DEPARTMENT will provide the MCO with those
contract modifications, including capitation rate revisions, it would deem
acceptable.
c. The MCO shall have the right not to extend the contract if the new
contract terms are deemed to be insufficient notwithstanding any other
provision of this contract. The MCO shall have a minimum of sixty (60)
days to notify the DEPARTMENT regarding its desire to accept new terms. If
the new capitation rates and any other contract modifications are not
established at least sixty (60) days prior to the expiration of the
initial or extension agreement, the DEPARTMENT will reimburse the MCO at
the higher of the new or current capitation rates for that period during
which the new contract period had commenced and the MCO's sixty (60) day
determination and notification period had not been completed, and the MCO
will be held to the terms of the executed contract.
7.12 TERMINATION FOR COLLUSION IN PRICE DETERMINATION
In competitive bidding markets, the MCO has previously certified that the prices
presented in its proposal were arrived at independently, without consultation,
communication, or agreement with any other bidder for the purpose of restricting
competition; that, unless otherwise required by law, the prices quoted have not
been knowingly disclosed by the MCO, prior to bid opening, directly or
indirectly to any other bidder or to any competitor; and that no attempt has
been made by the MCO to induce any other person or firm to submit or not to
submit a proposal for the purpose of restricting competition.
In the event that such action is proven, the DEPARTMENT shall have the right to
terminate this contract upon the same terms and conditions as a Termination for
Default.
7.13 TERMINATION OBLIGATIONS OF CONTRACTING PARTIES
a. The MCO shall be provided the opportunity for a hearing prior to any
termination of this contract pursuant to any provision of this contract.
The DEPARTMENT may notify Members of the MCO and permit such Members to
disenroll immediately without cause during the hearing process.
110
b. Upon contract termination, the MCO shall allow the DEPARTMENT, its agents
and representatives full access to the MCO's facilities and records to
arrange the orderly transfer of the contracted activities. These records
include the information necessary for the reimbursement of any outstanding
Medicaid claims.
c. Where this contract is terminated due to cause or default by the MCO: 1)
The DEPARTMENT shall be responsible for notifying all Members of the date
of termination and process by which the Members will continue to receive
services and 2) the MCO shall notify all providers and be responsible for
all expenses related to notification to providers and members.
d. If this contract is terminated for any reason other than default by the
MCO,
1. The MCO shall ensure that an adequate provider network will be
maintained at all times during the transition period and that
continuity of care is maintained for all Members;
2. The MCO shall submit a written transition plan to the DEPARTMENT
sixty (60) days in advance of the scheduled termination;
3. The DEPARTMENT shall be responsible for notifying all Members of the
date of termination and progress by which the Members will continue
to receive services;
4. The DEPARTMENT shall be responsible for all expenses relating to
said notification to members;
5. The MCO shall notify all providers and be responsible for all
expenses related to such notification; and
6. The DEPARTMENT shall withhold a portion, not to exceed $100,000, of
the last month's capitation payment as a surety bond for a six (6)
month period to ensure compliance under the contract.
7.14 WAIVER OF DEFAULT
Waiver of any default shall not be deemed to be a waiver of any subsequent
default. Waiver of breach of any provision of the contract shall not be deemed
to be a waiver of any other or subsequent breach and shall not be construed to
be a modification of the terms of the contract unless stated to be such in
writing, signed by an authorized representative of the DEPARTMENT, and attached
to the original contract.
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8. OTHER PROVISIONS
8.01 SEVERABILITY
If any provision of this procurement or the resultant contract is declared or
found to be illegal, unenforceable, or void, then both parties shall be relieved
of all obligations under that provision. The remainder of this procurement or
the resultant contract shall be enforced to the fullest extent permitted by law.
8.02 EFFECTIVE DATE
This contract is subject to review for form and substance by the U.S. Department
of Health and Human Services Health Care Financing Administration, the
Connecticut Attorney General's Office and the DEPARTMENT, and will not become
effective until it is approved by all of those agencies.
8.03 ORDER OF PRECEDENCE
This contract shall be read together to achieve one harmonious whole. However,
should any irreconcilable conflict arise between Part I and Part II of this
contract, Part II shall prevail.
8.04 CORRECTION OF DEFICIENCIES
This contract does not release the MCO from its obligation to correct any and
all outstanding certification deficiencies. Failure to correct all outstanding
material deficiencies may cause the MCO to be determined in Default of this
contract.
8.05 THIS IS NOT A PUBLIC WORKS CONTRACT
The DEPARTMENT and the MCO as parties to this purchase of service Contract
mutually covenant, acknowledge and agree that this contract does not constitute
and shall not be construed to constitute a public works contract. The DEPARTMENT
and the MCO's mutual agreement that this contract is not a public works contract
shall have full force and effect on Part I Section 32 and other Sections of this
contract as applicable.
112
APPENDIX A
HUSKY A Covered Services
HUSKY A CONTRACT
APPENDICES
APPENDIX A HUSKY A COVERED SERVICES
APPENDIX B PROVIDER CREDENTIALING AND ENROLLMENT
APPENDIX C EPSDT PERIODICITY SCHEDULE
APPENDIX D DSS MARKETING GUIDELINES
APPENDIX E QUALITY ASSURANCE PROGRAM
APPENDIX F UNAUDITED QUARTERLY FINANCIAL REPORTS
APPENDIX G MEDICAID MANAGED CARE ELIGIBILITY CATEGORIES
APPENDIX H MANAGED CARE POLICY TRANSMITTALS
APPENDIX I CAPITATION PAYMENT AMOUNTS
APPENDIX J PHYSICIAN INCENTIVE PAYMENTS
APPENDIX K RECATEGORIZATION CHART
APPENDIX L ABORTION REPORTING
08/03/01 2
BENEFIT FEATURES HUSKY COVERAGE
--------------------------------------------------------------------------------
OUTPATIENT PHYSICIAN VISITS $5 copay *
--------------------------------------------------------------------------------
PREVENTIVE CARE No copay *
Periodic and well child visits, immunizations,
WIC evaluations as applicable, and
prenatal care covered in full with $5 copay on
other visits.
PERIODICITY SCHEDULE and reporting based on
the American Academy of Pediatrics (AAP) as
amended from time to time:
AGE CATEGORY # OF EXAMS
-------------- ------------------
Birth to Age 1 6 exams
Ages 1-5 6 exams
Ages 6-0 1 exam every 2 yrs.
Ages 11-19 1 exam every yr.
IMMUNIZATION SCHEDULE per the Advisory
Committee on Immunization Practices (ACIP), as
amended from time to time. As of January 1,
2001, the schedule is as follows:
AGE CATEGORY VACCINE TYPE
------------ --------------------------
Birth Hepatitis X-0xx xxxx
x-0 mos. Hepatitis B-2nd dose
2 mos. Diphtheria, Tetanus,
Pertussis (DTP)- 1st
Dose; Haemophilus Influenza
Type B (hib)-1st dose;
Polio (OVP)-1st dose
4 mos. Diphtheria, Tetanus,
Pertussis (DTP)-2nd
Dose; Haemophilus
Influenza Type B
(hib)-2nd dose; Polio
(OVP)-2nd dose
6 mos. Diphtheria, Tetanus,
Pertussis (DTP)-3rd
Dose; Haemophilus
- Prior authorization may be required by the MCO unless otherwise noted
by an asterisk (*).
- Copayment not required for preventive services.
08/03/01 3
Influenza Type B
(hib)-3rd dose
6-12 mos. Hepatitis B-3rd dose;
Polio (OVP)-3rd Dose
12-15 mos. Haemophilus Influenza
(hib)-3rd Dose; Measles,
Mumps, Rubella
(MMR)- 1st dose
12-18 mos. Chicken Pox (Var)-
single dose;
Diphtheria, Tetanus,
Pertussis (DTP)-4th
Dose
4-6 yrs. Diphtheria, Tetanus,
Pertussis (DTP)-5th
Dose; Measles,
Mumps, Rubella
(MMR)-2nd dose;
Polio (OVP)-4th
Dose.
11-12 yrs. Tetanus Diphtheria (Td)
Influenza -- Every year beginning at 6 months
for children who have serious long-term health
problems such as heart disease, lung disease,
kidney disease, metabolic disease, diabetes,
asthma, anemia, &/or are on long-term is
aspirin treatment.
Pneumococcal -- Vaccinate children 2 years and
older who are at risk of pneumococcal disease
or its complications.
- Prior authorization may be required by the MCO unless otherwise
noted by an asterisk (*).
- Copayment not required for preventive services.
08/03/01 4
--------------------------------------------------------------------------------
FAMILY PLANNING 100%
Family Planning services
include:
Reproductive health exams;
Patient counseling;
Patient education;
Lab tests to detect the
presence of conditions
affecting reproductive
health;
Screening, testing and
treatment;
Pre and post-test
counseling for sexually
transmitted disease and
HIV; abortions that are
necessary to save the
life of the mother or
if the pregnancy
resulted from rape or
incest;- and other
medically necessary
abortions as defined in
Section 3.14 of the
contract, until the MCO
and Department execute a
separate abortion
contract.
--------------------------------------------------------------------------------
Preventive Family Planning 100% *
Services
--------------------------------------------------------------------------------
Oral Contraceptives $5 copay (included in prescription drugs) *
--------------------------------------------------------------------------------
INPATIENT PHYSICIAN 100% *
--------------------------------------------------------------------------------
INPATIENT HOSPITAL 100%
--------------------------------------------------------------------------------
OUTPATIENT SURGICAL
FACILITY 100%
--------------------------------------------------------------------------------
AMBULANCE 100% if determined to be an emergency in
accordance with state law
--------------------------------------------------------------------------------
PRE-ADMISSION/CONTINUED Arranged through provider
STAY
--------------------------------------------------------------------------------
- Prior authorization may be required by the MCO unless otherwise noted
by an asterisk (*).
- Copayment not required for preventive services.
08/03/01 5
--------------------------------------------------------------------------------
PRESCRIPTION DRUG $3 copay on generics *
$5 copay on oral contraceptives
$6 copay on brand names-formularies
--------------------------------------------------------------------------------
MENTAL HEALTH 100% except for the following
Inpatient conditions; additional limitations apply:
Mental retardation;
Learning disorders;
Motor skills disorders;
Communication disorders;
Caffeine-related disorders;
Relational problems; and
other conditions that may be the focus
of clinical attention that are not
defined as mental disorders in the
American Psychiatric Associations
"Diagnostic Statistical Manual of
Mental Disorders."
These limitations are:
60 day maximum exchangeable with
alternate levels of care.
--------------------------------------------------------------------------------
Outpatient Limited to evaluation, crisis
intervention, and treatment for
conditions which, in the judgment of
a physician, are subject to significant
improvement. $5 copay except for the
following conditions:
Mental retardation;
Learning disorders;
Motor skills disorders;
Communication disorders;
Caffeine-related disorders;
Relational problems; and other
conditions that may be the focus
of clinical attention that are not
defined as mental disorders in the
American Psychiatric Associations
"Diagnostic & Statistical Manual of
Mental disorders."
--------------------------------------------------------------------------------
- Prior authorization may be required by the MCO unless otherwise
noted by an asterisk (*).
- Copayment not required for preventive services.
08/03/01 6
-----------------------------------------------------------------------------
For these above stated conditions, the
following limitations apply:
30 visits.
1-10 100%
11-20 $25 copay
21-30 Lesser of a $50 copay or 50%
Separate limit for substance abuse.
Supplemental coverage available under HUSKY
Plus for medically eligible children.
-----------------------------------------------------------------------------
SUBSTANCE ABUSE
Detoxification 100%
Inpatient 100% except for the following conditions
additional limitations apply
Mental retardation;
Learning disorders; Motor skills disorders;
Communication disorders;
Caffeine-related disorders;
Relational problems; and
other conditions that may be the focus of clinical
attention that are not defined as mental disorders
the American Psychiatric Associations
in Diagnostic & Statistical Manual of Mental
Disorders."
These limitations are:
Drug: 60 days
Alcohol: 45 days
-----------------------------------------------------------------------------
Outpatient Services include individual and group counseling
and family therapy. 100% except for the following
conditions additional limitations apply:
Mental retardation;
Motor skills disorders;
Communication disorders;
Caffeine-related disorders;
Relational problems; and other
-----------------------------------------------------------------------------
- Prior authorization may be required by the MCO unless otherwise noted
by an asterisk (*).
- Copayment not required for preventive services.
08/03/01 7
--------------------------------------------------------------------------------
conditions that may be the focus of
clinical attention that are not defined
as mental disorders in the American
Psychiatric Associations "Diagnostic
& Statistical Manual of Mental
Disorders."
These limitations are:
60 visit per calender year.
Supplemental coverage available
under HUSKY Plus for medically
eligible children.
--------------------------------------------------------------------------------
SHORT TERM REHABILITATION 100%
FOR CONDITIONS WHERE
SIGNIFICANT IMPROVEMENT IS
EXPECTED WITHIN SIXTY DAYS,
INCLUDING: PHYSICAL
THERAPY, SPEECH THERAPY,
OCCUPATIONAL THERAPY AND
SKILLED NURSING CARE
(EXCLUDES PRIVATE DUTY
NURSING)
--------------------------------------------------------------------------------
- Prior authorization may be required by the MCO unless otherwise noted
by an asterisk (*).
- Copayment not required for preventive services.
08/03/01 8
--------------------------------------------------------------------------------
HOME HEALTH CARE (INCLUDES 100%, excludes custodial care;
DISPOSABLE MEDICAL homemaker care or care that may be provided
SUPPLIES) FOR HOMEBOUND in a medical office, hospital or skilled
MEMBERS nursing facility and offered to member in such
setting.
--------------------------------------------------------------------------------
HOSPICE 100%, provided to members who are diagnosed as
having a terminal illness with a life expectancy of
six months or less. Covered care includes nursing
care, physical therapy, speech therapy and
occupational therapy; medical social services;
home health aides and homemakers; medical
supplies; drugs; appliances; DME; physician
services; short-term inpatient care, including
respite care and care for pain control and
acute and chronic symptom management; services
of volunteers and other benefits when ordered
by a physician. Limitations on short-term
therapies do not apply.
--------------------------------------------------------------------------------
LONG TERM REHABILITATION, Not covered under HUSKY B.
LONG TERM PHYSICAL Supplemental coverage available
THERAPY AND LONG TERM under HUSKY Plus for medically
SKILLED NURSING CARE eligible children.
--------------------------------------------------------------------------------
LAB AND X-RAY 100%
--------------------------------------------------------------------------------
PRE-ADMISSION TESTING 100%
--------------------------------------------------------------------------------
EMERGENCY CARE 100% if determined to be an emergency in *
accordance with state law. $25 copay if
determined a non-emergency. $25 copay waived
if the patient is admitted.
--------------------------------------------------------------------------------
DURABLE MEDICAL 100%
EQUIPMENT (DME) MEANS Does not include power wheelchairs
EQUIPMENT, FURNISHED BY A for members eligible for HUSKY
SUPPLIER OR HOME HEALTH Plus Physical; devices not medical in
AGENCY THAT: (1) CAN nature, such as, whirlpools, saunas,
WITHSTAND REPEATED USE; (2) elevators, vans, van lifts, hearing
IS PRIMARILY AND aids, home convenience items (e.g.,
--------------------------------------------------------------------------------
- Prior authorization may be required by the MCO unless otherwise
noted by an asterisk (*).
- Copayment not required for preventive services.
08/03/01 9
--------------------------------------------------------------------------------
CUSTOMARILY USED TO SERVE A air cleaners, filtration units and
MEDICAL PURPOSE; (3) IS related apparatus, exercise bicycles
GENERALLY NOT USEFUL TO AN and other types of exercise
INDIVIDUAL IN THE ABSENCE equipment), insulin injectors, non-
OF AN ILLNESS OR INJURY; rigid appliances and supplies, such as,
AND (4) IS APPROPRIATE FOR sheets, self-help devices,
USE IN THE HOME. experimental or investigational research
equipment, and items for personal comfort and
or usefulness to the members' household.
Supplemental coverage available under HUSKY
Plus for medically eligible children.
--------------------------------------------------------------------------------
PROSTHETICS -DEVICES 100%
WHETHER WORN ANATOMICALLY Does not include orthopedic shoes,
OR SURGICALLY IMPLANTED, foot orthotics, wigs or hairpieces.
WHICH REPLACE ALL OR PART Supplemental coverage available
OF A BODY ORGAN OR under HUSKY Plus for medically
STRUCTURE AND WHICH eligible children.
CORRECT, STRENGTHEN OR
PROVIDE NECESSARY SUPPORT
TO THE BODY, WILL BE
COVERED WHEN MEDICALLY
NECESSARY.
--------------------------------------------------------------------------------
EYE CARE *
Eye Exams $5 copay
--------------------------------------------------------------------------------
HEARING EXAM $5 copay *
--------------------------------------------------------------------------------
NURSE MIDWIVES $5 copay (except for preventive *
services)
--------------------------------------------------------------------------------
NURSE PRACTITIONERS $5 copay (except for preventive *
services)
--------------------------------------------------------------------------------
PODIATRISTS $5 copay *
--------------------------------------------------------------------------------
CHIROPRACTORS $5 copay *
--------------------------------------------------------------------------------
NATUROPATHS $5 copay *
--------------------------------------------------------------------------------
- Prior authorization may be required by the MCO unless otherwise
noted by an asterisk (*).
- Copayment not required for preventive services.
08/03/01 10
--------------------------------------------------------------------------------
DENTAL 100% *
Dental services include:
Exams, 1 every 6 months;
X-Rays;
Fillings;
Fluoride Treatments;
Oral Surgery
LIMITED BENEFITS
BENEFIT FEATURES HUSKY COVERAGE
---------------------------------------------------------------------------------------------------
EYE CARE
Eyeglass frames and lenses Once every 2 consecutive Continuous
or contact lenses Eligibility (CE) periods with an allowance of
$100 toward the purchase of these goods. The
optical hardware must be provided without
charge under the following
conditions:
(i) one pair of contact lenses every 2
consecutive CE periods when such lenses
are determined to be the primary and the
best method for aiding the member
vision and the lenses are not needed
solely for the correction of vision;
(ii) eyeglass frames and lenses
and contact lenses that are determined
to be medically necessary after eye
surgery, the initial pair only; and
(iii) contact lenses, as needed, for the
treatment of Keratonconus.
--------------------------------------------------------------------------------
DENTAL
Orthodontia $725 allowance per orthodontia case.
--------------------------------------------------------------------------------
Bridges or crowns; root $50 allowance per procedure, per
canals; full or partial member but no more than an
dentures; or extractions aggregate allowance for all such
procedures of $250 per CE period.
--------------------------------------------------------------------------------
- Prior authorization may be required by the MCO unless otherwise
noted by an asterisk (*).
- Copayment not required for preventive services.
08/03/01 11
--------------------------------------------------------------------------------
CONTRACEPTIVES
Intrauterine Device (IUD) $50 allowance per member *
and insertion of the IUD
--------------------------------------------------------------------------------
Internally implantable $50 allowance per member *
time-release devices & their
insertion
--------------------------------------------------------------------------------
Time-released contraceptive $15 allowance per member per *
injections injection
--------------------------------------------------------------------------------
NUTRITIONAL FORMULAS 100% limited to medically necessary amino *
acid modified preparations and low protein
modified food products for the treatment of
inherited metabolic diseases when ordered by a
participating physician
--------------------------------------------------------------------------------
Annual copayments cannot exceed $600/1250 (Income Band 1/Income Band 2),
including premiums, per CE period.
EXCLUSIONS AND LIMITATIONS
1. Services and/or procedures considered to be of an unproven,
experimental, or research nature or cosmetic, social, habilitarive,
vocational, recreational, or educational.
2. Services in excess of those deemed medically necessary to treat the
patient's condition.
3. Services for a condition that is not medical in nature.
4. Devices required by third parties, such as school or employment
physicals, physicals for summer camp, enrollment in health, athletic,
or similar clubs, premarital blood work or physicals, or physicals
required by insurance companies or court ordered alcohol or drug
abuse course.
5. Cosmetic and reconstructive surgery is excluded, except when surgery
is required for:
a) reconstructive surgery in connection with the treatment of
malignant tumors or other destructive pathology that causes
dysfunction;
b) reduction mammoplasty in females when Medically Necessary and
breast surgery in males only in cases of suspected malignancy.
Surgery must be necessary to achieve normal physical or bodily
function.
- Prior authorization may be required by the MCO unless otherwise
noted by an asterisk (*).
- Copayment not required for preventive services.
08/03/01 12
6. Routine foot care rendered:
a) in the examination, treatment or removal of all or part of
corns, callosities, hypertrophy or hyperplasia of the skin or
subcutaneous tissues of the foot;
b) in the cutting, trimming or other non-operative partial removal
of toenails, except when Medically Necessary in the treatment
of neuro-circulatory conditions.
7. Evaluation, treatment and procedures related to, and performance of,
sex-change operations.
8. Surgical treatment or hospitalization for the treatment of morbid
obesity except where prior authorized as Medically Necessary.
9. Care, treatment, procedures, services or supplies that are primarily
for dietary control including, but not limited to, any exercise or
weight reduction programs, whether formal or informal, and whether or
not recommended by an In-network Physician or an Out-of-Network
Physician.
10. Acupuncture biofeedback, or hypnosis.
11. Treatment at pain clinics unless determined to be Medically
Necessary.
12. Ambulatory blood pressure monitoring.
13. Any court order for testing, diagnosis, care or treatment deemed not
Medically Necessary.
- Prior authorization may be required by the MCO unless otherwise
noted by an asterisk (*).
- Copayment not required for preventive services.
APPENDIX B
PROVIDER CREDENTIALING AND ENROLLMENT
HUSKY PROVIDER CREDENTIALING AND ENROLLMENT
REQUIREMENTS
1. PROVIDER CREDENTIALING AND ENROLLMENT DISTINCTION
Provider Credentialing and provider enrollment are separate and distinct
processes in the HUSKY Programs. However, credentialing and enrollment are
linked in that these requirements affect direct service providers as well
as the manner in which MCOs submit provider network information to the
Department of Social Services.
2. CREDENTIALING DEFINITION
For the purpose of the HUSKY programs, the term Credentialing means the
requirements for provider participation specified in the contracts between
the Department of Social Services (DSS or the Department) and the MCO (Part
II, 3.11, Provider Credentialing and Enrollment). In this section of the
contract, the Department specifies the minimum criteria that the MCOs must
require for provider participation in a health plan. The MCOs must ensure
that their providers meet the Department's Credentialing requirements.
3. OTHER SOURCES CREDENTIALING
Credentialing is sometimes used to refer to a variety of requirements or
entities, which issue credentialing standards. Examples include: the MCO's
individual credentialing requirements; the managed care subcontractor's
credentialing requirements; an accreditation organization requirements,
such as the National Committee on Quality Assurance (NCQA); the licensure
process; a trade organization or association such as the Joint Commission
on Accreditation of Health Organizations (JCAHO).
4. DSS REQUIREMENTS AND OTHER CREDENTIALING SOURCES
DSS credentialing requirements represent the minimum criteria for provider
participation in a health plan. The Department will allow flexibility to
the MCOs to use more stringent criteria, particularly as it concerns
quality level of care for clients. While the MCOs may require additional,
more stringent criteria, the Department is concerned with the impact on
access to care. Therefore, DSS expects the MCOs to balance the need for
stringent credentialing standards with the need to assure accessibility and
continuity of care.
5. DELEGATED CREDENTIALING
The contract between the Department and the MCOs permits the plan to
delegate credentialing of individual providers to a facility. However, the
MCO is ultimately responsible and accountable to DSS for compliance with
the Department's credentialing requirements.
For the purpose of HUSKY, delegated credentialing means that the MCO
entrusts the Department's credentialing requirements to another entity.
MCOs delegate credentialing to a variety of entities depending on the
nature of the services and the type of provider.
In delegated credentialing, the MCO remains responsible to DSS to verify and
monitor compliance with the Department's credentialing requirements. The
Department views delegated credentialing as a form of subcontract, therefore,
similar oversight issues arise in the performance of the credentialing
requirements. The Department requires the plans to demonstrate and document to
DSS the plan's strong oversight of its delegated credentialing facilities. (Part
II, Section 3.41 in B 3.44 in A, Subcontracting for Services).
6. IMPLICATIONS OF DELEGATED CREDENTIALING
In some instances, the MCO credentials the individual provider directly or
delegates credentialing of the providers to the following entities:
- A subcontractor providing specific services (e.g., behavioral health
or dental care);
- A credentialing subcontractor; or
- A facility (e.g., a freestanding clinic or hospital)
The relationship between the MCO and the delegated entity as well as the
interplay with various credentialing requirements may take any number of
configurations. Currently, the Department reiterates that the MCO may
delegate credentialing of individual providers to a facility (e.g., a
school based health center, freestanding clinic or hospital). However, the
Department emphasizes that the MCO is ultimately responsible and
accountable to DSS for compliance with all of the Department's
credentialing requirements.
7. OVERSIGHT OF DELEGATED CREDENTIALING
The Department requires the MCO to demonstrate strong oversight of their
delegated credentialing facilities, as with any subcontact. Therefore, the
Department reiterates that these arrangements are subject to the
Department's review and approval. For the purpose of delegated
credentialing, the MCOs must provide assurances to DSS at a minimum of the
following:
- The MCO and the delegated entity should clearly identify in detail
each party's responsibility for credentialing of providers.
- The Department's credentialing requirements should be clearly
identified as well as each party's role in adhering to these
requirements.
- The credentialing files must be available to the plan in order to
perform its oversight of the credentialing requirements. The
Department must also have adequate access to credentialing files for
the purposes of administering the managed care contracts.
(DSS/MCO Contract, Part II, Section 3.41 in B 3.44 in A Subcontracting for
Services.)
2
8. PROVIDER ENROLLMENT CLARIFICATIONS
For the purpose of HUSKY, the Department refers to provider enrollment as
the process of capturing information on providers participating with MCOs
contracted by DSS to provide services to clients. This process results in a
profile of an MCO's provider network. The MCOs submit the provider network
information to DSS via the Department's agent on a continuous basis. The
Department utilizes the provider network information to facilitate the
administration of managed care contracts and the Medicaid program.
Provider enrollment information serves the following purposes:
a) to evaluate each MCO's service area and access to services
which are used to establish enrollment ceiling or cap
(currently summarized by plan submittals of provider tables);
b) to provide accurate information to clients for the purpose of
client enrollment in an MCO; and
c) to maintain each plan's provider network information consistent
with the provider directory.
Based on the previous discussion of credentialing, the Department
clarifies the relationship between credentialing or delegated credentialing
and provider enrollment as follows:
a) Enrollment for purposes of cap determination.
- The MCO must credential and enroll individual providers when
the providers are counted towards the member enrollment
ceiling.
- DSS credentialing requirements and provider enrollment
processes also apply to individual providers in a facility when
the individual provider is included in the count for cap
determination.
- The MCO may delegate credentialing of individual providers to a
facility (e.g., a clinic or hospital) and enroll the facility
as such. In this case, neither the facility nor the individual
providers are provided in the count for cap determination.
b) Enrollment for purposes of accurate information to clients
- The MCO must enroll and credential individual providers as well
as facilities in order to maintain accurate and updated
information on the providers participating with a health plan.
The provider network information is used by the Department's
enrollment broker during enrollment.
3
- The Department stresses the importance of maintaining provider
network information accurate and up-to-date. It is crucial that
clients should have access to provider network information
during the MCO selection process.
c) Enrollment for purposes of inclusion in the provider network
directory.
- The MCO must credential and enroll individual providers when
the providers are included and listed as individual providers
in the health plan's provider directory.
- DSS credentialing requirements and provider enrollment
processes also apply to individual providers in a facility when
the individual provider is included and listed in the provider
directory.
- If the MCO delegates credentialing of individual providers to a
facility and enrolls the facility, the facility is included and
listed in the provider directory. The facility's individual
providers are listed in the provider directory. The facility's
providers are not listed in the provider directory.
9. SPECIFIC ISSUES AND DSS CREDENTIALING REQUIREMENTS
a) Medicaid participation
The MCO or the delegated credentialing entity is responsible for the
determination and verification that the provider meets the minimum
requirements for Medicaid participation. The MCO or its subcontractors may
not delegate this provision to the Department nor require providers to
enroll or participate in fee-for-service Medicaid to fulfill the
requirement. While the Department encourages the MCO to contract with
traditional and existing Medicaid providers, Medicaid participation in
itself is not a requirement of the HUSKY contracts.
b) Allied Health Professional Licensed Clinics or Hospitals
The Department pays freestanding clinics participating in the Medicaid
program for a variety of services. In Connecticut, clinic services include
for example, medical services, well-child care, dental care, mental health
and substance abuse services, rehabilitation services and other services.
Clinic providers must meet federal and state requirements for participation
in the Medicaid program. In accordance with Title 42 of the Code of Federal
Regulations, Part 440.90 and Section 171 of the Medical Services Policy of
the Connecticut Medical Assistance Program clinic services are provided by
or under the direction or a physician, dentist or psychiatrist.
The physician direction requirement means that the free-standing clinic's
services may be provided by the clinic's allied health professionals
whether or not the physician is physically present at the time that the
services are provided. An allied health professional
4
is further defined as an individual, employed in a clinic, who is qualified
by special education and training, skills, and experience in providing care
and treatment. The clinic is staffed by physicians and allied health
professionals who are directly involved in the facility's programs. The
allied health professionals provide services under the direction of a
physician who is a licensed practitioner performing within the scope of
his/her practice.
Based on the Department's definition of clinic services, the services provided
by allied health professionals are included under the terms of the contracts
between the Department and the MCOs.
As with all services, clinic services must be properly credentialed according to
the Department's requirements, including licensure and certification standards.
Allied health professionals may have licensure or certification requirements,
such as Certified Addition Counselors or Licensed Social Workers. In accordance
with the Department's definition, other allied health professions may qualify by
virtue of their skills or experience and must function under the direction of a
physician. In this case the directing physician, as opposed to the allied health
professional, is subject to the credentialing requirements as well as provider
enrollment. The MCO may credential the physician directly or may delegate
credentialing.
The Department's provisions for credentialing, delegated and provider enrollment
would remain in effect for the directing physician (please refer to Section 8,
Provider Enrollment Clarifications).
c) NCQA Standards and DSS requirements
While NCQA standards do not address credentialing of allied health
professionals, services provided by allied health professionals may qualify for
reimbursement by virtue of their skills or experience, however, the allied
health professionals must function under the direction of a physician. In this
case, the directing physician is subject to the credentialing requirements.
MAY 2001
5
APPENDIX C
EPSDT PERIODICITY SCHEDULE
[LOGO] State of Connecticut
Department of Social Services
Health Care Financing Division
00 Xxxxxxxxx Xxxxxx
Xxxxxxxx, XX 00000-0000
Policy Transmittal 2001-07
PB 2001-18 March 20, 2001
Contact: Xxxxx Xxxxxxx
(000)000-0000
July 1, 2001
--------------
/s/ Xxxxxxx X. Xxxxxxxxxx Effective Date
----------------------------------------
Xxxxxxx X. Xxxxxxxxxx
Deputy Commissioner
TO: PHYSICIANS, CLINICS, HOSPITALS, MANAGED CARE PLANS, NURSE PRACTITIONERS,
HOME HEALTH AGENCIES, NURSE MIDWIVES, DENTISTS AND DENTAL HYGIENISTS
SUBJECT: NEW EPSDT (EARLY, AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT
SERVICES) PERIODICITY SCHEDULE AND IMMUNIZATION SCHEDULE
The Department of Social Services is revising the EPSDT Periodicity Schedule to
follow the recently issued American Academy of Pediatrics (AAP) guidelines. This
Policy Transmittal contains the EPSDT Periodicity Schedule that is to be
effective as of 7/1/2001 and a revised immunization schedule. Please replace the
enclosed pages in Chapter 8 of your Connecticut Medical Assistance Provider
Manual. Changes to the periodicity schedule include the following:
- A newborn hearing screening is now required by Connecticut law and
is recommended by the AAP. Therefore, this screening is being
changed from a subjective to objective screen on the periodicity
schedule.
- Infants at high risk for tuberculosis should receive a tuberculin
test at 12 months, 15 Months and 18 Months.
- Infants who have anemia at 1 year should be retested for it at 15
and 18 Months.
- A hematocrit/hemoglobin test has been added at age 2 in accordance
with AAP guidelines. The hematocrit/hemoglobin test should be
repeated for high-risk clients and WIC clients at age 3, 4, and 5.
- The 3-year-old vision screening has been changed from subjective to
objective. An asterisk has been added indicating that if the child
is uncooperative, he or she should be rescreened within six months.
1
- Objective hearing and vision screenings have been added to the
periodicity schedule for ages 6 and 8. Section 10-214 of the
Connecticut General Statutes requires local or regional boards of
education in Connecticut to provide these screenings in kindergarten
through sixth grade. Objective hearing and vision screenings should
be done by the Primary Care Provider (PCP) at age 6 and 8 if there
is reason to believe that the screenings were not done at school.
- A note has been added that the screenings given at age 7-8 and age
9-10 should be performed at two-year intervals.
The American Academy of Pediatrics recommends a prenatal visit to a pediatrician
for high-risk parents. Such a visit is medically necessary for the well-being of
a yet-to-be-born child and is a covered EPSDT service under Connecticut
Medicaid.
The new Recommended Childhood Immunization Schedule recommends administering
four doses of pneumococcal conjugate vaccine at age 2 months, 4 months, 6 months
and 12-15 months. The immunization schedule recommends administration of "DTaP"
not "DTP" at age 2 months, 4 months, 6 months, 15-18 months and 4-6 years.
Hepatitis A appears on the immunization schedule as recommended in some parts of
the United States, but is not a recommended vaccine in Connecticut.
A new Women, Infants and Children (WIC) Coordinators contact sheet is also
included.
POSTING INSTRUCTIONS: Holders of the Connecticut Medical Assistance Program
Provider Manual should replace the current EPSDT Periodicity Schedule,
Immunization Schedule and WIC Coordinators contact sheet with the attached
schedules and contact sheet for use effective 7/1/2001. Policy transmittals can
also be downloaded from EDS' Web site at xxx.xxxxxxxxxxxxxxxx.xxx.
DISTRIBUTION: This policy transmittal is being distributed to holders of the
Medical Services Policy Manual by EDS, and the Medicaid Mailing List by the
Department of Social Services. Managed Care Organizations are requested to send
this information to their network providers and subcontractors.
RESPONSIBLE UNIT: DSS,HUSKY, Xxxxx Xxxxxxx, Manager, Program Analysis
and-Enrollment at (000) 000-0000.
DATE ISSUED : March 20, 2001
2
HEALTHTRACK/EPSDT PERIODICITY "SCHEDULE OF PREVENTIVE HEALTH SERVICES
DEPARTMENT OF SOCIAL SERVICES [ILLEGIBLE] 7/1/01
INFANCY EARLY CHILDHOOD
------- ---------------
[ILLEGIBLE] [ILLEGIBLE] [ILLEGIBLE]
----------- ----------- -----------
[ILLEGIBLE]
History: Initial/Interval X X X X X X X X X X X X X X
Physical Examination (2) X X X X X X X X X X X X X X
Height/Weight X X X X X X X X X X X X X X
Head Circumference X X X X X X X X X X X
Blood Pressure X X X
Health Education(3) SEE ATTACHED RECOMMENDATIONS
Anticipatory Guidance
Developmental/ Beh.
Assessment(4) X X X X X X X X X X X X X X
Immunizations(5) SEE ATTACHED IMMUNIZATIONS SCHEDULE
Hereditary Metabolic X------------->
Screening(6)
Lead Screening(7) X------------> X
Hematocrit /Hemoglobin X------------> W-HR W-HR X W-HR W-HR W-HR
Cholesterol Screening HR HR HR HR
Xxxxxxxxxx Xxxx XX XX XX XX XX XX XX
Hearing Screening O S S S S S S S S S S S O* O
Vision Screening S S S S S S S S S S S O* O O
Initial Dental Referral X--->
(9)
Evaluate Dental Fluoride X X X X X X X X X
Access
KEY: X = To be performed; HR = To be performed for patients at risk; S =
Subjective, by history; O = By Objective Standardized Test (SNELLEN;
AUDIOMETRIC); < --- > = The range during which a service may be provided, * If
child uncooperative, re-screen within 6 months. W-HR = Required by WIC. Covered
for WIC clients or high risk clients.
FOOTNOTES: (1) For Newborns discharged less than 48 hours after delivery;(2)At
each visit, a complete physical examination is essential, with infant totally
unclothed, older child undressed and suitably draped; (3) Age
appropriate/patient specific health education and counselling should be part of
every visit; (4) By history and appropriate physical examination; if suspicious,
by specific objective development testing;(5)Childhood immunizations are based
on age and health history, and should be screened each visit. (6) Metabolic
Screening (e.g., thyroid, hemoglobinopathies, PK galactosemia) should be done
according to State law. Sickle Cell Screening if appropriate; (7) Further venous
blood level measurement is required for children showing elevated lead level
(greater than or equal to 10ug/deciliter of whole blood); Children aged 2-5
should be screened at annual exam if there is no record of a negative lead
screen. (9) Earlier referral should be made if problem indicated.
HEALTHTRACK/EPSDT PERIODICITY SCHEDULE OF PREVENTIVE HEALTH SERVICES
DEPARTMENT OF SOCIAL SERVICES [ILLEGIBLE] 7/1/01
MIDDLE CHILDHOOD ADOLESCENCE
---------------- -----------
[ILLEGIBLE] [ILLEGIBLE] [ILLEGIBLE]
----------- ----------- -----------
Screening Components:
History: Initial/Interval X X X X X X X X X X X X X X
Physical Examination (2) X X X X X X X X X X X X X X
Height/Weight X X X X X X X X X X X X X X
Blood Pressure X X X X X X X X X X X X X X
Health Education(3) SEE ATTACHED RECOMMENDATIONS
Anticipatory Guidance
Developmental/ Beh.
Assessment(4) X X X X X X X X X X X X X X
Immunizations(5) SEE ATTACHED IMMUNIZATION SCHEDULE
Hematocrit/Hemoglobin <-----------------------------(9)---------------------------->
Urinalysis <------------------------------------(10)------------------------>
Cholesterol Screening HR HR HR HR HR HR HR HR HR HR HR HR HR HR
Tuberculin Test HR HR HR HR HR HR HR HR HR HR HR HR HR HR
Pelvic Exam/PAP Smear <--------------------------------------(11-HR)
STD Screenings <--------------------------------------(12-HR)
Hearing Screening O(8) O(8) O S O S S O S S O S S S
Vision Screening O(8) O(8) O S O S S O S S O S S S
Evaluate Dental Fluoride Access X X X X
KEY: X = To be performed; HR = To be performed for patients at risk; S =
Subjective, by history; O = By Objective Standardized Test; <---> = The range
during at which a service may be provided; Appropriate provision of EPSDT
services is required through age 20, up to, but not including, the 21st
birthday. (b) Biannually, at 2 year intervals.
FOOTNOTES: (2) At each visit, a complete physical examination is essential with
infant totally undressed and older child undressed and suitably draped; (3) Age
appropriate and patient specific health education and counseling should be a
part of every visit; (4) By history and appropriate physical examination, if
suspicious, by specific objective developmental testing; (5) Childhood
immunizations are based on age and health history and should be screened each
visit. (8) State law requires screening at school. Screening should be done if
there is evidence it was not done at school. (9) Hemoglobin or Hematocrit to be
administered x1 during adolescence, annually for menstruating females that are
at risk for anemia; (10) Urinalysis to be administered x1 during adolescence,
annually for sexually active clients at risk for STD's (i.e. gonorrhea,
syphilis/serology, chlamydia, HIV, etc.); (11) All sexually active females
should have a pelvic examination and a routine pap smear annually. A pelvic
examination and routine pap smear should be offered as part of preventive health
maintenance between 18-21 years. (12) All sexually active patient should be
screened for sexually transmitted diseases(STD's)
RECOMMENDED CHILDHOOD IMMUNIZATION SCHEDULE
UNITED STATES, JANUARY - DECEMBER 2001
Vaccines(1) are listed under routinely recommended ages. Bars indicate range of
recommended ages for immunization. Any dose not given at the recommended age
should be given as a "catch-up" immunization at any subsequent visit when
indicated and feasible. [ILLEGIBLE] indicate vaccines to be given if previously
recommended doses were missed or given earlier than the
recommended minimum age.
Information in bold has been added by the American Academy of Family
Physicians (AAFP).
AGE 1 2 4 6 12 15 18 24 4-6 11-12 14-18
VACCINE BIRTH MO MOS MOS MOS MOS MOS MOS MOS YRS YRS YRS
------- ----- -- --- --- --- --- --- --- --- --- --- ---
HEPATITIS B(2) HEP B #1
HEP B #2 HEP B #3 HEP B
DIPTHERIA,
TETANUS, DTAP DTAP DTAP DTAP(2) DTAP TD
PERTUSSIS(2)
H. INFLUENZAE
TYPE B(4) HIB HIB HIB HIB
INACTIVATED
POLLO [ILLEGIBLE] IPV IPV IPV [ILLEGIBLE] IPV [ILLEGIBLE]
PNEUMOCOCCAL
CONJUGATE [ILLEGIBLE] PCV PCV PCV PCV
MEASLES, MUMPS, MMR MMR(7) MMR
RUBELLA(7)
VARICELLA [ILLEGIBLE] VAR VAR [ILLEGIBLE]
HEPATITIS A [ILLEGIBLE] HEP A -- IN SELECTED AREAS [ILLEGIBLE]
Approved by the Advisory Committee on Immunization Practices (ACIP), the
American Academy of Pediatrics (AAP),and the American
Academy of Family Physicians (AAFP).
1. This schedule indicates the recommended ages for routine administration of
currently licensed childhood vaccines, as of 11/1/00, for children through
18 years of age. Additional vaccines may be licensed and recommended
during the year. Licensed combination vaccines may be used whenever any
components of the combination are indicated and its other components are
not contraindicated. Provides should consult the manufacturer's package
inserts for detailed recommendations.
2. INFANTS BORN TO HBSAG-NEGATIVE MOTHERS should receive the 1st dose of
hepatitis B (HEP B) vaccine by age 2 months. The 2nd dose should be at
least one month after the 1st dose. The 3rd dose should be administered at
least 4 months after the 1st dose and at least 2 months after the 2nd
dose, but not before 6 months of age for infants.
INFANTS BORN TO HBSAG-POSITIVE MOTHERS should receive hepatitis B vaccine
and 0.5 mL hepatitis B immune globulin (HBIG) within 12 hours of birth at
separate sites. The 2nd dose is recommended at 1-2 months of age and the
3rd dose at 6 months of age.
INFANTS BORN TO MOTHERS WHOSE HBSAG STATUS IS UNKNOWN should receive
hepatitis B vaccine within 12 hours of birth. Maternal blood should be
drawn at the time of delivery to determine the mother's HBsAg status; if
the HBsAg test is positive, the infant should receive HBIG as soon as
possible (no later than 1 week of age).
ALL CHILDREN AND ADOLESCENTS who have not been immunized against hepatitis
B should begin the series during any visit. Special efforts should be
made to immunize children who were born in or whose parents were born in
areas of the world with moderate or high endemicity of hepatitis B virus
infection.
3. The 4th dose of DTaP (diphtheria and tetanus toxoids and acellular
pertussis vaccine) may be administered as early as 12 months of age,
provided 6 months have elapsed since the 3rd dose and the child is
unlikely to return at age 15-18 months. Td(tetanus and diphtheria toxoids)
is recommended at 11-12 years of age if at least 5 years have elapsed
since the last dose of DTP, DTaP or DT. Subsequent routine Td boosters are
recommended every 10 years.
4. Three Haemophilus influenzae type b(Hib) conjugate vaccines are licensed
for infant use. If PRP-OMP (PedvaxHIB(R) or ComVax(R) [Merck]) is
administered at 2 and 4 months of age, a dose at 6 months is not required.
Because clinical studies in infants have demonstrated that using some
combination products may induce a lower immune response to the Hib vaccine
component, DTaP/Hib combination products should not be used for primary
immunization in infants at 2, 4 or 6 months of age, unless FDA-approved
for these ages.
5. An all-IPV schedule is recommended for routine childhood polio vaccination
in the United State. All children should receive four doses of IPV at 2
months, 4 months, 6-18 months, and 4-6 years of age. Oral polio vaccine
(OPV) should be used only in selected circumstances. (See MMWR May 19,
2000/49(RR-5);1-22).
6. The heptavalent conjugate pneumococcal vaccine (PCV) is recommended for
all children 2-23 months of age. It also is recommended for certain
children 24-59 months of age. (See MMWR Oct. 6, 2000/49(RR-9);1-35). THE
FULL AAFP CLINICAL POLICY ON PNEUMOCOCCAL CONJUGATE VACCINE IS available
at xxx.xxxx.xxx/xxxxxx/xxxx/00.xxxx.
7. The 2nd dose of measles,mumps, and rubella (MMR)vaccine is recommended
routinely at 4-6 years of age but may be administered during any visit,
provided at least 4 weeks have elapsed since receipt of the 1st dose and
that both doses are administered beginning at or after 12 months of age.
Those who have not previously received the second dose should complete the
schedule by the 11-12 year old visit.
8. Varicella (Var) vaccine is recommended at any visit on or after the first
birthday for susceptible children, i.e. those who lack a reliable history
of chickenpox (as judged by a health care provider) and who have not been
immunized. Susceptible persons 13 years of age or older should receive 2
doses, given at least 4 weeks apart.
9. Hepatitis A (Hep A) is shaded to indicate its recommended use in selected
states and/or regions, and for certain high risk groups; consult your
local public health authority. (See MMWR Oct. 1, 1999/48(RR-12); 1-37).
For additional information about the vaccines listed above, please visit the
National Immunization Program Home Page at xxxx://xxx.xxx.xxx/xxx/ or call the
National Immunization Hotline at 000-000-0000 (English) or 000-000-0000
(Spanish).
FULL AAFP IMMUNIZATION POLICIES CAN BE FOUND AT THE AAFP WEBSITE
XXX.XXXX.XXX/XXXXXXXX.
APPENDIX D
DSS MARKETING GUIDELINES
A. DETAILED MARKETING GUIDELINES
1) GENERAL HUSKY MARKETING MATERIALS
Marketing materials are defined as all media, including brochures and
leaflets; newspaper, magazine, radio, television, billboard and yellow
pages advertisements; and presentation materials used by MCO
representatives.
The DEPARTMENT will not restrict the MCO's general communications to the
public. However, the MCO must obtain prior approval from the DEPARTMENT
prior to any written material or advertisement that is mailed to,
distributed to, or aimed at HUSKY recipients or individuals potentially
eligible for HUSKY, specifically, material that mentions Medicaid, Medical
Assistance, Title XIX, Title XXI State Children's Health Insurance Program
(SCHIP) or HUSKY. Examples of HUSKY-specific materials would be those which
are in any way targeted to HUSKY populations (such as billboards or bus
posters disproportionately located in low-income neighborhoods); those that
mention the MCO's HUSKY product name; or those that contain language or
information specifically designed to attract HUSKY enrollment.
2) GENERAL MCO MARKETING/ADVERTISING
All MCO-specific marketing activities for the HUSKY population, as defined
above, and all marketing materials /advertising put forth by HUSKY-only MCO
require DEPARTMENT prior approval.
In determining whether to approve a particular marketing activity, the
DEPARTMENT will apply a variety of criteria, including, but not limited to:
a) Accuracy: The content of the material must be accurate. Any
information that is deemed inaccurate will be disallowed.
b) Misleading references to the MCO's positive attributes: Misleading
information will be disallowed even if it is accurate. For example,
the MCO may seek to advertise that its health care services are free
to its Medicaid (HUSKY A) Members. In this situation, DEPARTMENT
would disallow the language since this could be construed by
Members as being a particular advantage of the plan (e.g. they might
believe they would have to pay for health services if they chose
another MCO or remained in fee-for-service).
c) Threatening Messages: MCOs shall not imply that the managed care
program or the failure to join a particular MCO would endanger the
Member's health status, personal dignity, or the opportunity to
succeed in various aspects of their lives. MCOs are strictly
prohibited from creating threatening implications about the State's
mandatory assignment process for HUSKY A Members or other aspects of
the HUSKY A or HUSKY B programs.
d) MCO's Legitimate Strengths: MCOs may differentiate themselves by
promoting their legitimate positive attributes.
1
3) MCO ADVERTISING AT PROVIDER CARE SITES
Promotional and health education materials at care delivery sites
(including patient waiting areas) are permitted, subject to prior
DEPARTMENT content approval. MCO member services staff may provide member
services (e.g. face-to-face member education) at provider care sites,
however, face-to-face meetings, for purposes of marketing, at care delivery
sites between individual Members and MCO staff are not permitted.
4) MCO ADVERTISING IN DEPARTMENT ELIGIBILITY OFFICES
MCOs may make their materials available at DEPARTMENT offices only through
the DEPARTMENT or its agent. This restriction applies to all eligibility
offices, including those based in hospitals. MCO marketing staff and
provider staff are not permitted to solicit Member enrollment by
positioning themselves at or near eligibility offices. Note that the only
face-to-face marketing activities allowed are those directly permitted
under items #5, #7, #11 and #12 of these guidelines. All other face-to-face
marketing activities are prohibited.
5) PROVIDER COMMUNICATIONS WITH HUSKY PATIENTS ABOUT MCO OPTIONS
DEPARTMENT marketing restrictions apply to the MCO's participating
providers as [ILLEGIBLE] as to the MCOs. MCOs must notify all of their
participating providers of the DEPARTMENT marketing restrictions and provide
them with a copy of this document.
Each provider entity is allowed to notify its patients of the HUSKY-certified
MCOs it participates in, and to explain that the patients must enroll in one of
these MCOs if they wish to preserve their existing relationship. This must be
done through written materials prior-approved by DEPARTMENT, and must be
distributed to HUSKY patients without regard to health status. Providers must
not indicate a preference between the MCOs in which they participate.
6) MEMBER-INITIATED TELEPHONE CONVERSATIONS WITH MCOS AND PROVIDERS
These conversations are permitted and do not require prior approval by the
DEPARTMENT, but information given to potential Members, during such
telephone conversation must be in accordance with the DEPARTMENT's marketing
guidelines. However, telephone conversations must be initiated by the
potential Member, not by the MCO staff (or provider staff). MCOs and
providers may return calls to Members and potential Members when Members
and potential Members leave a message requesting that this occur.
2
7) MEMBER-INITIATED ONE-ON-ONE MEETINGS WITH MCO STAFF PRIOR TO
ENROLLMENT
Such meetings, when requested by the Member, are permitted but may not occur
at a participating provider's care delivery site or at the Member's
residence. These meetings must occur at the MCO's offices or another
mutually-agreed upon public location. All verbal interaction with the
Member must be in compliance with the DEPARTMENT's marketing guidelines.
8) MAILINGS BY MCO IN RESPONSE TO MEMBER REQUESTS
MCO mailings are permitted in response to Member verbal or written requests
for information. The content of such mailings must be prior-approved by the
DEPARTMENT. MCOs may include gifts of nominal value (unit cost less than
$2, e.g. magnets, pens, bags, jar grippers, etc.) in these mailings.
9) UNSOLICITED MCO MAILINGS
MCOs are permitted to send unsolicited mailings. The content of such
mailings must be prior-approved by DEPARTMENT. In addition, the target
audiences must be prior-approved by DEPARTMENT, and the MCOs must explain
how they obtained the list of names, addresses and phone numbers.
10) TELEMARKETING
Telemarketing is not a permitted marketing activity
11) MCO GROUP MEETINGS HELD AT MCO
These meetings must be prior approved by the DEPARTMENT. The MCO may not
notify prospective Members until DEPARTMENT prior approval has been
obtained
12) MCO GROUP MEETINGS HELD IN PUBLIC FACILITIES, CHURCHES, HEALTH FAIRS,
OR OTHER COMMUNITY SITES
These are permitted activities as long as DEPARTMENT approved materials are
utilized in the presentations and the DEPARTMENT's marketing guidelines are
followed. The DEPARTMENT reserves the right to monitor such meetings on an
ad hoc basis. MCOs are required to notify the DEPARTMENT sufficiently in
advance to allow DEPARTMENT representatives to attend such meetings in
order to monitor MCO activities if desired. As soon as the MCO has
scheduled these activities, the DEPARTMENT should be notified.
3
13) MCO GROUP MEETINGS HELD IN PRIVATE CLUBS OR HOMES
These activities are prohibited. The only permitted group meetings are
those described under items #11 and #12.
14) INDIVIDUAL SOLICITATION, RESIDENCES
MCO (and provider) staff are not permitted to visit potential Members at
their places of residence for purposes of explaining MCO features and
promoting enrollment. This prohibition is absolute, and applies even in
situations where the potential Member desires and/or requests a home visit.
MCO staff can visit Member homes after enrollment becomes effective, as
part of their orientation/education efforts.
15) GIFTS, CASH INCENTIVES, OR REBATES TO POTENTIAL MEMBERS AND MEMBERS.
MCOs (and their providers) are prohibited from disseminating gift items,
except those of a nominal value (pens, key chains, magnets, etc.), to
potential Members. DEPARTMENT-approved written materials may also be
disseminated to prospective Members along with similar nominal value gifts.
MCOs may give items of nominal value (unit cost less than $2), with their
logo on it, to persons (potential Members and others) attending health
fairs, presentations at community forums organized through or other
sanctioned events, with DEPARTMENT approval. Such items would include
magnets, pens, bags, plastic band-aid dispensers, etc. Pre-approved nominal
value items may also be included with new Member information packets.
16) GIFTS TO MEMBERS FOR SPECIFIC HEALTH-RELATED EVENTS
Gifts to Members are allowed for medically "good" behavior (e.g. baby
T-shirt showing immunization schedule once a woman completes targeted
series of prenatal visits). All such gifts, including any written materials
included with them (or on them), must be prior-approved by the DEPARTMENT.
The criteria for providing such gifts must also be prior-approved by
DEPARTMENT. MCOs must not provide gifts in any situations other than those
that have been prior-approved by DEPARTMENT. Additional DEPARTMENT prior
approval is required for all additional uses of the gift items or for new
gifts.
4
The DEPARTMENT may approve magnets, phone labels, and other nominal items
that reinforce a MCO's care coordination programs (e.g. through advertising
the Member Services hotline and/or the PCP office phone number). All such
items must be prior-approved by the DEPARTMENT. The criteria for
disseminating this information must also be prior-approved, although the
DEPARTMENT is likely to be amenable to the MCOs' inclusion of this
information in "welcome" packets sent to new Members.
Health education videos are also allowed, but must be prior-approved by
DEPARTMENT.
17) PHONING BY MEMBERS FROM HEALTH CARE PROVIDER LOCATIONS
Providers may provide the use of a phone to potential HUSKY Members or
HUSKY Members subject to the following restrictions:
a) MCO or provider staff may not coach or instruct the caller;
b) Privacy must be given to the MEMBER during their phone conversation with the
HUSKY application and enrollment center.
18) NON-ALCOHOLIC BEVERAGES AND LIGHT REFRESHMENTS FOR POTENTIAL MEMBERS
AT MEETINGS
Non-alcoholic beverages and light refreshments are permitted at DEPARTMENT
approved group meetings.
5
C. USE OF HUSKY NAME; HUSKY LOGO AND MANDATORY LANGUAGE REQUIREMENTS
MCOs will be allowed use of the HUSKY logo and name for use in their
marketing materials, subject to the following:
1) must be used in conjunction with the following language unless
alternative language has been prior approved by the DEPARTMENT.
HUSKY GIVES FAMILIES THE FREEDOM OF CHOICE TO ENROLL IN ONE OF
SEVERAL PARTICIPATING HEALTH PLANS. TOLL-FREE INFORMATION:
1-877-CT-HUSKY;
2) the above mandatory language must be placed in the vicinity of the
HUSKY logo; and
6
------------------------------------------------------------------------------------------------
Permitted With
DEPARTMENT
Type of Marketing Activity Permitted Not Permitted Approval
------------------------------------------------------------------------------------------------
1. General HUSKY marketing X
materials
------------------------------------------------------------------------------------------------
2. General, MCO X
advertising/marketing
------------------------------------------------------------------------------------------------
3. MCO advertising in provider care X
sites
------------------------------------------------------------------------------------------------
4. MCO advertising in all X
DEPARTMENT
eligibility offices, including
hospital-based (Must be made available
only through the DEPARTMENT or its agent)
------------------------------------------------------------------------------------------------
5. Provider communications with X
Medicaid patients about MCO options
------------------------------------------------------------------------------------------------
6. Member-initiated telephone X
conversations with MCO and Provider staff
------------------------------------------------------------------------------------------------
7. Member-initiated one-on-one X
meetings with MCO staff prior to enrollment
------------------------------------------------------------------------------------------------
8. Mailings by MCO in response to X
Member requests
------------------------------------------------------------------------------------------------
9. Unsolicited MCO mailings to X
Members
------------------------------------------------------------------------------------------------
10. Telemarketing X
------------------------------------------------------------------------------------------------
11. MCO group meetings held at MCO X
------------------------------------------------------------------------------------------------
12. MCO group meetings held in public X
facilities such as churches, health fairs, WIC
program or other community sites
------------------------------------------------------------------------------------------------
13. MCO group meetings held in private X
clubs or homes
------------------------------------------------------------------------------------------------
7
------------------------------------------------------------------------------------------------
PERMITTED, WITH
DEPARTMENT
Type of Marketing Activity Permitted Not Permitted APPROVAL
------------------------------------------------------------------------------------------------
14. Individual solicitation at X
residences
------------------------------------------------------------------------------------------------
15. Items of nominal value along with X
written information about the MCO or
general health education information to
potential Members or included in new
Member information packets.
------------------------------------------------------------------------------------------------
16. Gifts to Members (e.g. baby X
T-shirt showing immunization schedule) based
on specific health events unrelated to
enrollment
------------------------------------------------------------------------------------------------
17. Phoning by Members from health X
care provider locations
------------------------------------------------------------------------------------------------
18. Non-alcoholic beverages and X
light refreshments (e.g. fruit,
cookies) for potential Members at
meetings (may not mention
refreshments in advertisements for
meetings)
------------------------------------------------------------------------------------------------
8
APPENDIX E
QUALITY ASSURANCE PROGRAM
STANDARDS FOR INTERNAL QUALITY ASSURANCE PROGRAMS FOR HEALTH PLANS
Standard I: Written QAP Description
The organization has a written description of its Quality Assurance Program
(QAP). This written description meets the following criteria:
A Goals and objectives - There is a written description of the QA
program with detailed goals and annually developed objectives that
outline the program structure and design and include a timetable for
implementation and accomplishment.
B. Scope -
1. The scope of the QAP is comprehensive, addressing both the quality
of clinical care and quality of non-clinical aspects of services,
such as and including: availability, accessibility, coordination, and
continuity of care.
2. The QAP methodology provides for review of the entire range of
care provided by the organization, by assuring that all demographic
groups, care settings (e.g. inpatient, ambulatory, [including care
provided in private practice offices] and home care), and types of
services (e.g. preventive, primary, specialty care and ancillary) are
included in the scope of the review. This review should be carried
out over multiple review periods and not on just a concurrent basis.
C. Specific activities - The written description specifies quality of
care studies and other activities to be undertaken over a prescribed
period of time, and methodologies and organizational arrangements to
be used to accomplish them. Individuals responsible for the studies
and other activities are clearly identified and are appropriate.
D. Continuous activity - The written description provides for continuous
performance of the activities, including tracking of issues over
time.
E Provider review - The QAP provides:
1. Review by physicians and other health professionals of the process
followed in the provision of health services;
2. Feedback to health professionals and HMO staff regarding
performance and patient results.
F. Focus on health outcomes - The QAP methodology addresses health
outcomes to the extent consistent with existing technology.
Standard II: Systematic Process of Quality Assessment and Improvement
The QAP objectively and systematically monitors and evaluates the quality
and appropriateness of care and service provided members, through quality
of care studies and related activities, and pursues opportunities for
improvement on an ongoing basis.
The QAP has written guidelines for its quality of care studies and related
activities which include:
A. Specification of clinical or health services delivery areas to be
monitored
1. Monitoring and evaluation of clinical care reflects the population
served by the MCO, in terms of age groups, disease categories, and
special risk status.
2. For the Medicaid population, the QAP monitors and evaluates at a
minimum, care and services in certain priority areas of concern
selected by the State. It is recommended that these be taken from
among those identified by the Health Care Financing Administration's
(HCFA's) Medicaid Bureau and jointly determined by the State and the
Managed Care Organization (MCO).
3. At its discretion and/or as DSS directs, the MCO's QAP also
monitors and evaluates other aspects of care and service.
B. Use of quality indicators
Quality indicators are measurable variables relating to a specified
clinical or health services delivery area, which are reviewed over a period
of time to monitor the process or outcomes of care delivered in that area.
1. The MCO identifies and uses quality indicators that are
measurable, objective, and based on current knowledge and clinical
experience.
2. For the priority area selected by DSS from the HCFA Medicaid
Bureau's list of priority clinical and health service delivery areas
of concern, the MCO monitors and evaluates quality of care through
studies, which include, but are not limited to, the quality
indicators also specified by the HCFA Medicaid Bureau.
3. Methods and frequency of data collection are appropriate and
sufficient to detect need for program change.
C. Use of clinical care standards/practice guidelines
2
1. The QAP studies and other activities monitor quality of care
against clinical care or health services delivery standards or
practice guidelines specified for each area identified.
2. The clinical standards/practice guidelines are based on reasonable
scientific evidence and are developed or reviewed by plan providers.
3. The clinical standards/practice guidelines focus on the process
and outcomes of health care delivery, as well as access to care.
4. A mechanism is in place for continuously updating the
standards/practice guidelines.
5. The clinical standards/practice guidelines shall be included in
provider manuals developed for use by MCO providers or otherwise
disseminated to the providers as they are adopted.
6. The clinical standards/practice guidelines address preventive
health services.
7. The clinical standards/practice guidelines are developed for the
full spectrum of populations enrolled in the plan.
8. The QAP shall use these clinical standards/practice guidelines to
evaluate the quality of care provided by the MCO's providers, whether
the providers are organized in groups, as individuals, as IPAs, or in
combinations thereof.
D. Analysis of clinical care and related services
1. Appropriate clinicians monitor and evaluate quality through review
of individual cases where there are questions about care and through
studies analyzing patterns of clinical care and related service. For
quality issues identified in the QAP's targeted clinical areas, the
analysis includes the identified quality indicators and uses clinical
care standards or practice guidelines.
2. Multidisciplinary teams are used, where indicated, to analyze and
address system issues.
3. For the D.1. and D.2. above, clinical and related services
requiring improvement are identified.
E. Implementation of remedial/corrective actions
The QAP includes written procedures for taking appropriate remedial action
whenever, as determined under the QAP, inappropriate or substandard
services are furnished, or services that should have been furnished were
not.
3
These written remedial corrective action procedures include:
1. Specification of the types of problems requiring
remedial/corrective action.
2. Specification of the person(s) or body responsible for making the
final determinations regarding quality problems.
3. Specific actions to be taken.
4. Provision of feedback to appropriate health professionals,
providers and staff.
5. The schedule and accountability for implementing corrective
actions.
6. The approach to modify the corrective action if improvements do
not occur.
7. Procedures for terminating the affiliation with the physician, or
other health professional or provider.
F. Assessment of effectiveness of corrective actions
1. As actions are taken to improve care, there is monitoring and
evaluation of corrective actions to assure that appropriate changes
have been made. In addition, changes in practice patterns are
tracked.
2. The MCO assures follow-up on identified issues to ensure that
actions for improvement have been effective.
G. Evaluation of continuity and effectiveness of the QAP
1. The MCO conducts a regular and periodic examination of the scope
and content of the QAP to ensure that it covers all types of services
in all settings, as specified in standard I.B.2.
2. At the end of each year, a written report on the QAP is prepared
that addresses: QA studies and other activities completed, trending
of clinical and services indicators and other performance data;
demonstrated improvements in quality; areas of deficiency and
recommendations for corrective action; and an evaluation of the
overall effectiveness of the QAP
3. There is evidence that QA activities have contributed to
significant improvements in the care and services delivered to
members.
Standard III: Accountability to the Governing Body
4
The QA committee is accountable to the governing body of the managed care
organization. The governing body should be the board of directors, or a
committee of senior management may be designated in instances in which the
board's participation with QA issues is not direct. There is evidence of a
formally designated structure, accountability at the highest levels of the
organization, and ongoing and/or continuous oversight of the QA program.
Responsibilities of the Governing Board for monitoring, evaluating, and
making improvements to care include:
A. Oversight of the QAP - There is documentation that the governing body
has approved the overall QAP and the annual QAP.
B. Oversight of entity - The Governing Body has formally designated an
accountable entity or entities within the organization to provide oversight
of QA, or has formally decided to provide such oversight as a committee of
the whole.
C. QAP progress reports - The Governing body routinely receives written
reports from the QAP describing actions taken, progress in meeting QA
objectives, and improvements made.
D. Annual QAP review - The Governing Body formally reviews on a periodic
basis (but no less frequently than annually) a written report on the QAP
that includes: studies undertaken, results, subsequent actions, and
aggregate data on utilization and quality of services rendered, to assess
the QAP's continuity, effectiveness and current acceptability.
E. Program modification - Upon receipt of regular written reports from the
QAP delineating actions taken and improvements made, the Governing Body
takes actions when appropriate and directs that the operational QAP be
modified on an ongoing basis to accommodate review findings and issues of
concern within the MCO. Minutes of the meetings of the Governing Board
demonstrate that the Board has directed and followed up on necessary
actions pertaining to QA.
Standard IV: Active QA Committee
The QAP delineates an identifiable structure responsible for performing QA
functions within the MCO. The committee or other structure has:
A. Regular meetings - The structure/committee meets on a regular basis with
specified frequency to oversee QAP activities. This frequency is sufficient
to demonstrate that the structure committee is following up on all findings
and required actions, but in no case are such meetings less frequent than
quarterly.
B. Established parameters for operating - The role, structure and function of
the structure committee are specified.
5
C. Documentation - There are contemporaneous records documenting the
structure's committee's activities, findings, recommendations and actions.
D. Accountability - The QAP committee is accountable to the Governing Body
and reports to it (or its designee) on a scheduled basis on activities,
findings, recommendations and actions.
E. Membership - There is active participation in the QA committee from
health plan providers, who are representative of the composition of the
health plan's providers.
Standard V: QAP Supervision
There is a designated senior executive who is responsible for program
implementation. The organization's Medical Director has substantial
involvement in QA activities.
Standard VI: Adequate Resources
The QAP has sufficient material resources, and staff with the necessary
education, experience, or training to effectively carry out its specified
activities.
Standard VII: Provider Participation in the QAP
A. Participating physicians and other providers are kept informed about the
written QA plan.
B. The MCO includes in all its provider contracts and employment
agreements, for both physicians and nonphysician providers, a requirement
securing cooperation with the QAP.
C. Contracts specify that hospitals, physicians, and other contractors will
allow the MCO access to the medical records of its members.
Standard VIII: Delegation of QAP Activities
The MCO remains accountable for all QAP functions, even if certain
functions are delegated to other entities. If the MCO delegates any QA
activities to contractors:
A. There is a written description of delegated activities; the delegate's
accountability for these activities; and the frequency of reporting to the
MCO.
B. The MCO has written procedures for monitoring the implementation of the
delegated functions and for verifying the actual quality of care being
provided.
6
C. There is evidence of continuous and ongoing evaluation of delegated
activities, including approval of quality improvement plans and regular
specified reports.
Standard IX: Members Rights and Responsibilities
The MCO demonstrates a commitment to treating members in a manner that
acknowledges their rights and responsibilities.
A. Written policy on members rights
The MCO has a written policy that recognizes the following rights of
members:
1. To be treated with respect, and recognition of their dignity and
need for privacy;
2. To be provided with information about the MCO, its services, the
practitioners providing care, and members' rights and
responsibilities;
3. To be able to choose primary care practitioners, within the limits
of the plan network, including the right to refuse care from specific
practitioners;
4. To participate in decision-making regarding their health care;
5. To voice grievances about the MCO or care provided;
6. To formulate advance directives; and
7. To have access to his/her medical records on accordance with
applicable Federal and State laws.
A. Written policy members responsibilities - The MCO has a written policy
that addresses members' responsibility for cooperating with those
providing health care services. This written policy addresses
members' responsibility for:
1. Providing, to the extent possible, information needed by
professional staff in caring for the member; and
2. Following instructions and guidelines given by those providing
health care services.
C. Communication of policies to providers - A copy of the organization's
policies on members' rights and responsibilities is provided to all
participating providers.
D. Communication of policies to members - Upon enrollment, members are
provided a written statement that includes information on the following:
7
1. Rights and responsibilities of members;
2. Benefits and services included and excluded as a condition of
membership, and how to obtain them, including a description of:
a. any special benefit provisions (example, co-payment, higher
deductibles, rejection of claim) that may apply to service obtained
outside the system; and
b. the procedures for obtaining out-of-area coverage;
3. Provisions for after-hours and emergency coverage;
4. The organization's policy on referrals for specialty care;
5. Charges to members, if applicable, including:
a. policy on payment of charges; and
b. copayment and fees for which the member is responsible.
6. Procedures for notifying those members affected by the termination or
changes in any benefit services, or service delivery office/site;
7. Procedures for appealing decisions adversely affecting the members'
coverage, benefits, or relationship with the organization;
8. Procedures for changing practitioners;
9. Procedures for disenrollment; and
10. Procedures for voicing complaints and/or grievances and for
recommending changes in policies and services.
E. Member grievance procedures - The organization has a system(s) linked to the
QAP, for resolving members' complaints and formal grievances. This system
includes:
1. Procedures for registering and responding to complaints and grievances in a
timely fashion (organizations should establish and monitor standards for
timeliness);
2. Documentation of the substance of the complaint or grievances, and actions
taken;
3. Procedures to ensure a resolution of the compliant or grievance;
8
4. Aggregation and analysis of complaint and grievance data and use of the data
for quality improvement; and
5. An appeal process for grievances.
F. Member suggestions - Opportunity is provided for members to offer suggestions
for changes in policies and procedures.
G. Steps to assure accessibility of services - The MCO takes steps to promote
accessibility of services offered to members. These steps include:
1. The points of access to primary care, specialty care and hospital
services are identified for members;
2. At a minimum, members are given information about:
a. How to obtain services during regularly hours of operation
b. How to obtain emergency and after-hours care; and
c. How to obtain the names qualifications, and titles of the
professionals providing and/or responsible for their care.
H. Written information for members
1. Member information is written in prose that is readable and easily
understood; and
2. Written information is available, as needed, in the languages of the major
population groups served. A "major" population group is one which represents at
least 10% of plan's membership.
L Confidentiality of patient information - The MCO acts to ensure that the
confidentiality of the specified patient information and records is protected.
1. The MCO has established in writing, and enforced, policies and
procedures on confidentiality of medical records.
2. The MCO ensures that patient care offices/sites have implemented
mechanisms that guard against the unauthorized or inadvertent disclosure
of confidential information to persons outside of the medical care
organization.
3. The MCO shall hold confidential all information obtained by its
personnel about members related to their examination, care and treatment
and shall not divulge it without the members's authorization, unless:
a. it is required by law;
9
b. it is necessary to coordinate the patient's care with physicians,
hospitals, or other health care entities, or to coordinate insurance or
other matters pertaining to payment; or
c. it is necessary in compelling circumstances to protect the health
or safety of an individual.
4. Any release of information in response to a court order is reported to
the patient in a timely manner; and
5. Member records may be disclosed, whether or not authorized by the
members, to qualified personnel for the purpose of conducting scientific
research, but these personnel may not identify, directly or indirectly,
any individual members in any report of the research or otherwise disclose
participant identity in any manner.
J. Treatment of minors - The MCO has written policies regarding the appropriate
treatment of minors.
K. Assessment of member satisfaction - The MCO conducts periodic surveys of
member satisfaction with its services.
1. The surveys include content on perceived problems in the quality,
accessibility, and availability of care.
2. The surveys assess at least a sample of:
a. All Medicaid members;
b. Medicaid member requests to change practitioners and/or facilities; and
c. Disenrollment by Medicaid members.
3. As a results of the surveys, the organization:
a. Identifies and investigates sources of dissatisfaction;.
b. Outlines action steps to follow-up on the findings; and
c. Informs practitioners and providers of assessment results.
3. The MCO reevaluates the effects of the above activities.
Standard X: Standards for Availability and Accessibility
The MCO has established standards for access (e.g. to routine, urgent and
emergency care; telephone appointment; advice; and member service lines).
10
Performance on these dimensions of access are assessed against the standards.
Standard XI: Medical Records Standards
A. Accessibility and availability of medical records - The MCO shall include
provisions in provider contracts for appropriate access to the medical records
of its members for purposes of quality reviews conducted by the Secretary of
HHS, DSS, or agents thereof.
B. Record keeping - Medical records nay be on paper or electronic. The plan
takes steps to promote maintenance of medical records in a legible, current,
detailed, organized and comprehensive manner that permits effective patient care
and quality review as follows:
1. Medical records standards- The MCO sets standards for medical records.
The records reflect all aspects of patient care, including ancillary
services. These standards shall at a minimum, include requirements for:
a. Patient identification information - Each page or electronic file
in the record contains the patient's name or patient ID number.
b. Personal/biographical data - Personal/biographical data includes:
age, sex, address; employer; home and work telephone numbers; and marital
status.
c. Entry date - All entries are dated.
d. Provider identification - All entries are identified as to
author.
e. Legibility - The record is legible to someone other than the
writer. A second reviewer should evaluate any record judged
illegible by one physician reviewer.
f. Allergies - Medication allergies and adverse reactions are
prominently noted on the record. Absence of allergies (no known
allergies-NKA) is noted in an easily recognizable location.
g. Past medical history - (for patients seen 3 or more times) Past
medical history is easily identified including serious accidents,
operations, illnesses. For children, past medical history relates to
prenatal care and birth.
h. Immunizations- For pediatric records (ages 12 and under) there is
a completed immunization record or a notation that immunizations are
up- to-date.
11
i Diagnostic information
j. Medication information
k. Identification of current problems - Significant illness, medical
conditions and health maintenance concerns are identified in the
medical record.
l. Smoking/ETOH/substance abuse - Notation concerning cigarettes and
alcohol use and substance abuse is present (for patients 12 years
and over and seen three or more times). Abbreviations and symbols
may be appropriate.
m. Consultations, referral and specialist reports - Notes from
consultations are in the record. Consultation, lab, and x-ray
reports filed in the chart have the ordering physicians initials or
other documentation signifying review. Consultation and
significantly abnormal lab and imaging study results have an
explicit notation in the record of follow-up plans.
n. Emergency care
o. Hospital discharge summaries - Discharge summaries are included
as part of the medical record for (1) all hospital admissions which
occur while the patient is enrolled in the MCO and (2) prior
admissions as necessary.
p. Advance directives - For medical records of adults, the medical
record documents whether or not the individual has executed an
advance directive. An advance directive is a written instruction
such as a living will or durable power of attorney for health care
relating to the provision of health care when the individual is
incapacitated.
2. Patient visit data - Documentation of individual encounters must
provide adequate evidence of, at a minimum;
a. History and physical examination - Appropriate subjective and
objective information is obtained for the presenting complaints.
b. Plan of treatment
d. Diagnostic tests
e. Therapies and other prescribed regimens; and
12
f. Follow-up - Encounter forms or notes have a notation, when
indicated, concerning follow-up care, call, or visit. Specific time
to return is noted in weeks, months, or PRN. Unresolved problems
from previous visits are addressed in subsequent visits.
f. Referrals and results thereof; and
g. All other aspects of patient care, including ancillary services.
3. Record review process-
a. The MCO has a system (record review process) to assess the
content of medical records for legibility, organization, completion
and conformance to its standards.
b. The record assessment system addresses documentation of the items
listed in B, above.
Standard XII: Utilization Review
A. Written program description- The MCO has a written utilization management
program description which includes, at a minimum, procedures to evaluate medical
necessity, criteria used, information sources and the process used to review and
approve the provision of medical services.
B. Scope - The program has mechanisms to detect underutilization as well as
overutilization.
C. Preauthorization and concurrent review - For MCO with preauthorization or
concurrent review programs:
1. Preauthorization and concurrent review decisions are supervised by
qualified medical professionals;
2. Efforts are made to obtain all necessary information, including
pertinent clinical information, and consult with the treating physician as
appropriate;
3. The reasons for decisions are clearly documented and available to the
member.
4. There are well-publicized and readily available appeals-mechanisms for
both providers and patients. Notification of a denial includes a
description of how file an appeal;
5. Decisions and appeals are made in a timely manner as required by the
exigencies of the situation;
13
6. There are mechanisms to evaluate the effects of the program using data
on member satisfaction, provider satisfaction or other appropriate; and
7. If the MCO delegates responsibilities for utilization management, it
has mechanisms to ensure that these standards are met by the delegate.
Standard XIII. Continuity of Care System
The MCO has put a basic system in place which promotes continuity of care and
case management.
Standard XIV: QAP Documentation
A. Scope - The MCO shall document that it is monitoring the quality of care
across all services and all treatment modalities, according to its written QAP.
B. Maintenance and availability of documentation - The IVICO must maintain and
make available to the State, and upon request to the Secretary of HHS, studies,
reports, appropriate, concerning the activities and corrective actions.
'Standard XV: Coordination of QA Activity with other Management Activity
The findings, conclusions, recommendations, actions taken, and results of
actions taken as a result of QA activity, are documented and reported to
appropriate individuals within the MCO and through established QA channels.
A. QA information is used in recredentialing, recontracting, and/or annual
performance evaluations.
B. QA activities are coordinated with other performance monitoring activities,
including utilization management, risk management, and resolution and monitoring
of member complaints and grievances.
C. There is a linkage between QA and other management functions of the MCO, such
as: network changes, benefit redesign, medical management systems, practice
feedback to providers, patient education and member services.
14
APPENDIX F
UNAUDITED QUARTERLY FINANCIAL REPORTS
APPENDIX F
UNAUDITED QUARTERLY FINANCIAL REPORTS
CURRENT ASSETS: CURRENT YEAR PREVIOUS YEAR
--------------- ------------ -------------
1. Cash and Cash Equivalents
2. Short-term Investments
3. Premiums Receivable
4. Investment Income Receivables
5. Health Care Receivables
6. Amounts Due from Affiliates
7. Aggregate Write-Ins for Current Assets
8. TOTAL CURRENT ASSETS (Items 1 to 7)
OTHER ASSETS:
9. Restricted Cash and Other Assets
10. Long-term investments
11. Amounts Due from Affiliates
12. Aggregate Write-Ins for Other Assets
13. TOTAL OTHER ASSETS (items 9 to 12)
PROPERTY AND EQUIPMENT:
14. Land, Building and Improvements
15. Furniture and Equipment
16. Leasehold Improvements
17. Aggregate Write-Ins for Other Equipment
18. TOTAL PROPERTY (items 7 to 14)
19. TOTAL ASSETS (items 8, 13 and 18)
DETAILS OF WRITE-INS AGGREGATED AT ITEM 7 FOR CURRENT ASSETS:
701
702
703
704
705
798 Summary of remaining write-ins tor item 7 from overflow page
799 TOTALS (items 701 thru 705 plus 798) Page 2, item 7
DETAILS OF WRITE-INS AGGREGATED AT ITEM 12 FOR OTHER ASSETS
1201
1202
1203
1204
1205
1298 Summary of remaining write-ins for item 12 from overflow page
1299 TOTALS (items 1201 thru 1205 plus 1298) (Page 2, item 12)
DETAILS OF WRITE-INS AGGREGATED AT ITEM 17 FOR OTHER EQUIPMENT
1701
1702
1703
1704
1705
1798 Summary of remaining write-ins for item 17 from overflow page
1799 TOTALS (items 1701 thru 1705 plus 1798) (Page 2, item 17)
MEMBER MONTHS CURRENT YEAR PREVIOUS YEAR
------------- ------------ -------------
REVENUES:
1. Premium
2. Fee-For-Service
3. Title XVIII - Medicare
4. Title XIX O Medicaid
5. Investment
6. Aggregate Write-Ins for Other Revenues
7. TOTAL REVENUES (items 1 to 6)
EXPENSES:
8. Medical and Hospital
9. Other Professional Services
10. Outside Referrals
11. Emergency Room & Out of Area
12. Occupancy, Depreciation & Amortization
13. [ILLEGIBLE]
14. Incentive Pool and Withhold Adjustments
15. Aggregate Write-Ins for Other Medical & Hospital Expenses
16. Subtotal (items 8 to 15)
17. Reinsurance Expenses Net of Recoveries
LESS:
18. Copayments
19. COB and [ILLEGIBLE]
20. Subtotal (items 18 and 19)
21. TOTAL MEDICAL AND HOSPITAL (items 16 and 17 less 20)
Administration
22. Compensation
23. Interest Expense
24. Occupancy, Depreciation and Amortization
25. Marketing
26. Aggregate Write-Ins for Other Administration Expenses
27. TOTAL ADMINISTRATION (items 22 to 26)
28. TOTAL EXPENSES (items 21 and 27)
29. Income (LOSS) (item 21 and 27
30. Cumulative Effect of [ILLEGIBLE] Change
31. Provision for Federal Income Taxes
32. NET INCOME (item 29, less items 30 and 31)
DETAILS OF WRITE-INS AGGREGATED AT ITEM 6 FOR OTHER REVENUES
601 Other Income
602
603
604
605
698
699 Summary of remaining write-ins for item 6 from overflow page
699 TOTALS (items 601 through 605 plus 698) (page 4, item 6)
QUARTERLY CLAIMS AGING [ILLEGIBLE] AS OF _______ (DOLLARS)
0-30 31-45 00-00 00-000 GREATER THAN
CLAIMS IN-PROCESS (1) DAYS DAYS [ILLEGIBLE] DAYS DAYS 120 DAYS [ILLEGIBLE]
---------------------------------------------------------------------------------------------------------------------
Institutional (UB92) 1,050 750 1,800
Non - Institutional (HCFA 1500) 1,000 2,000 3,000
------------------------------------------------------------------------------------------------------------------
Subtotal - Claims In Process 2,050 2,750 - - - - 4,800
==================================================================================================================
0-30 31-45 46-60 61-90 91-120 GREATER THAN TOTAL
UNPAID ADJUDICATED CLAIMS (2) DAYS DAYS DAYS DAYS DAYS 120 DAYS OUTSTANDING
---------------------------------------------------------------------------------------------------------------------
Institutional (UB92) 500 250 750
Non - Institutional (HCFA 1500) 1,000 2,000 3,000
------------------------------------------------------------------------------------------------------------------
Subtotal - Unpaid Adjudicated Claims 1,500 2,250 - - - - 3,750
==================================================================================================================
TICK XXXX LEGAND
(1) Claims in-process represents those claims which have been received by the
MCO, recorded in the system but have not been adjudicated. Since these
claims have not been adjudicated, and the final pay amount is unknown,
these amounts should be recorded at the billed amount.
(2) Claims which have been adjudicated and have a known pay amount, however, a
check has not been issued for these claims.
Note: The titles above have been identified as Medicaid, the MCO can elect to
report HUSKY A & B separately or together as long In addition, alt source
documentation used to complete this schedule should be available for
review at the DEPARTMENT's request.
CLAIMS TURN AROUND TIME REPORT FROM_ _THROUGH ____________ (NUMBER OF CLAIMS)
GREATER THAN
0-30 31-[ILLEGIBLE] 00-00 00-00 00-000 000 DAYS TOTAL [ILLEGIBLE]
------------------------------------------------------------------------
Paper Claims
Husky Institution - UB92
Husky Non-Institution - HCFA 1500
Subtotal Paper Claims
Electronic Claims
Husky Institution - UB92
Husky Non-Institution - HCFA 1500
Subtotal Electronic
-----------------------------------------------------------------------------------------------------------------------------
Total Claims Paid
=============================================================================================================================
Please file a claims incurred to paid triangle which would show the entire
population of claims paid by HUSKY A & B lines of business.
In addition, for those claims processed in excess of 45 days, include a
list of the claims, date of service, date received, date paid, the the
amount paid on the claim, the age of the claim when paid and amount of
interest paid.
Note: The titles above have been identified as Medicaid, the MCO can elect to
report HUSKY A & B separately or together.
CURRENT ASSETS: CURRENT YEAR PREVIOUS YEAR
--------------- ------------ -------------
1. Cash and Cash Equivalents
2. Short-term Investments
3. Premiums Receivable
4. Investment Income Receivables
5. Health Care Receivables
6. Amounts Due from Affiliates
7. Aggregate Write-Ins for Current Assets
8. TOTAL CURRENT ASSETS (items 1 to 7)
OTHER ASSETS:
9. Restricted Cash and Other Assets
10. Long-term Investments
11. Amounts Due from Affiliates
12. Aggregate Write-Ins for Other Assets
13. TOTAL OTHER ASSETS (items 9 to 12)
PROPERTY AND EQUIPMENT:
14. Land, Building and Improvements
15. Furniture and Equipment
16. Leasehold Improvements
17. Aggregate Write-Ins for Other Equipment
18. TOTAL PROPERTY (items 7 to 14)
19. TOTAL ASSETS (items 8, 13 and 18)
DETAILS OF WRITE-INS AGGREGATED AT ITEM 7 FOR CURRENT ASSETS
701
702
703
704
705
798 Summary of remaining write-ins for item 7 from overflow page
799 TOTALS (items 701 thru 705 plus 798) Page 2, item 7
DETAILS OF WRITE-INS AGGREGATED AT ITEM 12 FOR OTHER ASSETS
1201
1202
1203
1204
1205
1298 Summary of remaining write-ins for item 12 overflow page
1299 TOTALS (items 1201 thru 1205 plus 1298) (Page 2, item 12)
DETAILS OF WRITE-INS AGGREGATED AT ITEM 17 FOR OTHER EQUIPMENT
1701
1702
1703
1704
1705
1798 Summary of remaining write-ins for item 17 from overflow page
1799 TOTALS (items 1701 thru 1705 plus 1798) (Page 2, item 17)
CURRENT LIABILITIES: CURRENT YEAR PREVIOUS YEAR
-------------------- ------------ -------------
1. Accounts Payable (Schedule G)
2. Claims Payable (Reported and Unreported) (Schedule H)
3. Accrued Medical Incentive Pool (Schedule H)
4. Unearned Premiums.
6. Amounts Due to Affiliates (Schedule J)
7. Aggregate Write-Ins for Current Liabilities
8. TOTAL CURRENT LIABILITIES (items 1 to 7)
OTHER LIABILITIES:
9. Loans and Notes Payable (Schedule I)
10. Amounts Due to Affiliates (Schedule J)
11. Aggregate Write-Ins for Other Liabilities
12. TOTAL OTHER LIABILITIES (items 9 to 11)
13. TOTAL LIABILITIES (items 8 and 12)
NET WORTH:
14. Common Stock
15. Preferred Stock
16. Paid in Surplus
17. Contigency Capital
18. Surplus Notes (Schedule K)
19. Contingency Reserves
20. Retained Earnings/Fund Balance
21. Aggregate Write-Ins for Other Net Worth Items
22. TOTAL NET WORTH (Items 14 to 21)
23. TOTAL LIABILITIES AND NET WORTH (items 13 and 22)
DETAILS OF WRITE-INS AGGREGATED AT ITEM 7 FOR CURRENT LIABILITIES
701 Payroll & Related Liabilities
702 Accrued Audit & Actuarial Fees
703
704
705
798 Summary of remaining Write-ins for item 7 from overflow page
799 TOTALS (items 0701 thru 0705 plus 0798 Page 3, item 7)
DETAILS OF WRITE-INS AGGREGATE AT ITEM 11 FOR OTHER LIABILITIES
1101
1102
1103
1104
1105
1198 Summary of remaining write-ins for item 11 from overflow page
1199 TOTALS (items 1101 thru 1105 plus 1198 Page 3, Item 11)
DETAILS OF WRITE-INS AGGREGATED AT ITEM 21 FOR OTHER NET WORTH ITEMS
2101
2102
2103
2104
2105
2198 Summary of remaining write-Ins for item 21 from overflow page
2199 TOTALS items 2101 thru 2105 plus 2198 Page 3, item 21
MEMBER MONTHS CURRENT YEAR PREVIOUS YEAR
------------- ------------ -------------
REVENUES:
1. Premium
2. Fee-For-Service
3. Title XVIII - Medicare
4. Title XIX O Medicaid
5. Investment
6. Aggregate Write-Ins for Other Revenues
7. TOTAL REVENUES (items 1 to 6)
EXPENSES:
8. Medical and Hospital
9. Other Professional Services
10. Outside Referrals
11. Emergency Room & Out of Area
12. Occupancy, Depreciation & Amortization
13. [ILLEGIBLE]
14. Incentive Pool and Withhold Adjustments
15. Aggregate Write-Ins for Other Medical & Hospital Expenses
16. Subtotal (items 8 to 15)
17. Reinsurance Expenses Net of Recoveries
LESS:
18. Copayments
19. COB and [ILLEGIBLE]
20. Subtotal (items 18 and 19)
21. TOTAL MEDICAL AND HOSPITAL (items 16 and 17 less 20)
Administration
22. Copayments
23. Interest [ILLEGIBLE]
24. Occupancy, Depreciation and Amortization
25. Marketing
26. Aggregate Write-Ins for Other Administration Expenses
27. TOTAL ADMINISTRATION (items 22 to 26)
28. TOTAL EXPENSES (items 21 and 27)
29. Income (LOSS) (item 21 and 27
30. Cumulative Effect of [ILLEGIBLE] Change
31. Provision for Federal Income Taxes
32. NET INCOME (item 29, less items 30 and 31)
DETAILS OF WRITE-INS AGGREGATED AT ITEM 6 FOR OTHER REVENUES
601 Other Income
602
603
604
605
698
699 Summary of remaining write-ins for item 6 from overflow [ILLEGIBLE]
699 TOTALS (items 601 through 605 plus 698) (page 4, item 6)
MEMBER MONTHS CURRENT YEAR PREVIOUS YEAR
------------- ------------ -------------
DETAILS OF WRITE-INS AGGREGATED AT ITEM [ILLEGIBLE] FOR OTHER REVENUES
1501 Drugs
1502 Outpatient
1503
1504
1505
1598 Summary if remaining write-ins for item 15 from overflow page
DETAILS OF WRITE-INS AGGREGATED AT ITEM 26 FOR OTHER ADMINISTRATION EXPENSES
2601 MGMT Fee Income - SWWA
2602 MGMT Fee Expense XXXX
2603 Other Admin. Expense
2604 MGMT Fee Expense Corp.
2605 Accrued Audit & Actuarial Expense
2698 Summary of remaining, write-ins for item 26 from overflow page
[ILLEGIBLE] TOTALS (items 2601 thru 2505 plus 2598) (Page 4, item 26)
QUARTERLY CLAIMS AGING INVENTORY REPORT AS OF _______ (DOLLARS)
0-30 31-45 00-00 00-00 91 - 120 GREATER THAN TOTAL
CLAIMS IN-PROCESS (1) DAYS DAYS DAYS DAYS DAYS 120 DAYS OUTSTANDING
-------------------------------- ----- ----- ----- ----- -------- ------------ -----------
Institutional (UB92) 1,050 750 1,800
Non - Institutional (HCFA 1500) 1,000 2,000 3,000
----- ----- ---- ---- ----- ---------- -----
SUBTOTAL - CLAIMS IN PROCESS 2,050 2,750 - - - - 4,800
===== ===== ==== ==== ===== ========== =====
0-30 31-45 00-00 00-00 91 - 120 GREATER THAN TOTAL
UNPAID ADJUDICATED CLAIMS (2) DAYS DAYS DAYS DAYS DAYS 120 DAYS OUTSTANDING
-------------------------------- ----- ----- ----- ----- -------- ------------ -----------
Institutional (UB92) 500 250 750
Non - Institutional (HCFA 1500) 1,000 2,000 3,000
----- ----- ---- ---- ----- ---------- -----
SUBTOTAL - UNPAID ADJUDICATED CLAIMS 1,500 2,250 - - - - 3,750
===== ===== ==== ==== ===== ========== =====
TICK XXXX LEGEND
(1) Claims in-process represents those claims which have been received by the
MCO, recorded in the system but have not been adjudicated. Since these
claims have not been adjudicated, and the final pay amount is unknown,
these amounts should be recorded at the billed amount.
(2) Claims which have been adjudicated and have a known pay amount, however, a
check has not been issued for these claims.
NOTE: The titles above have been identified as Medicaid, the MCO can elect to
report HUSKY A & B separately or together as long in addition, all source
documentation used to complete this schedule should be available for
review at the DEPARTMENT's request.
QUARTERLY CLAIMS AGING INVENTORY REPORT AS OF _____________ (NUMBER OF CLAIMS)
0-30 31-45 00-00 00-00 91 - 120 GREATER THAN TOTAL
INSTITUTIONAL CLAIMS (UB92) DAYS DAYS DAYS DAYS DAYS 120 DAYS OUTSTANDING
--------------------------- ---- ----- ----- ----- ------ ------------ -----------
Estimated Claims received but not
in the system (1) 55 55
Claims in-process (2) 350 350
Unpaid Adjudicated Claims (3) 125 125 250
--- --- ----- ----- ------ ------------ --------
SUBTOTAL 000 000 - - - - 000
=== === ===== ===== ====== ============ ========
0-30 31-45 00-00 00-00 91 - 120 GREATER THAN TOTAL
NON - INSTITUTIONAL CLAIMS (HCFA 1500) DAYS DAYS DAYS DAYS DAYS 120 DAYS OUTSTANDING
-------------------------------------- ---- ----- ----- ----- ------ ------------ -----------
Estimated Claims received but not in
the system (1) 20 20 40
Claims in-process (2) 15 15 30
Unpaid Adjudicated Claims (3) 5 5 10
--- --- ----- ----- ------ ------------ --------
SUBTOTAL 40 40 - - - - 80
=== === ===== ===== ====== ============ ========
0-30 31-45 00-00 00-00 91 - 120 GREATER THAN TOTAL
TOTAL CLAIMS DAYS DAYS DAYS DAYS DAYS 120 DAYS OUTSTANDING
------------------------------------ ---- ----- ----- ----- ------ ------------ -----------
Estimated Claims received but not in
the system (1) 75 20 95
Claims in-process (2) 365 15 380
Unpaid Adjudicated Claims (3) 130 130 - - - - 260
--- --- ----- ----- ------ ------------ --------
TOTAL CLAIMS 000 000 - - - - 000
=== === ===== ===== ====== ============ ========
TICK XXXX LEGEND
(1) This category would include any claim that has been received and not input
in the system (I.e. claims in the mailroom).
(2) Claims in process represents those claims which have been received by the
MCO, recorded in the system but have not been adjudicated. Since these
claims have not been adjudicated, and the final pay amount is unknown,
these amounts should be recorded at the billed amount.
(3) Claims which have been adjudicated and have a known pay amount, however, a
check has not been issued for these claims.
NOTE: The titles above have been identified as Medicaid, the MCO can elect to
report HUSKY A & B separately or together.
[ILLEGIBLE]
GREATER THAN
0-30 31-40 00-00 00-00 91 - 120 120 DAYS TOTAL PAID
---- ----- ----- ----- -------- ------------ ----------
Paper Claims
Husky Institution - UB92
Husky Non-Institution - HCFA 1500
SUBTOTAL PAPER CLAIMS
Electronic Claims
Husky Institution - UB92
Husky Non-Institution - HCFA 1500
SUBTOTAL ELECTRONIC
---- ----- ----- ----- -------- ------------ ----------
TOTAL CLAIMS PAID
==== ===== ===== ===== ======== ============ ==========
PLEASE FILE A CLAIMS INCURRED TO PAID TRIANGLE WHICH WOULD SHOW THE ENTIRE
POPULATION OF CLAIMS PAID BY HUSKY A & B LINES OF BUSINESS.
IN ADDITION, FOR THOSE CLAIMS PROCESSED IN EXCESS OF 45 DAYS, INCLUDE A
LIST OF THE CLAIMS, DATE OF SERVICE, DATE RECEIVED, DATE PAID, THE AMOUNT
PAID ON THE CLAIM, THE AGE OF THE CLAIM WHEN PAID AND THE AMOUNT OF
INTEREST PAID.
NOTE: THE TITLES ABOVE HAVE BEEN IDENTIFIED AS MEDICAID, THE MCO CAN ELECT TO
REPORT HUSKY A & B SEPARATELY OR TOGETHER.
REVISED 7/6/01
APPENDIX G
MEDICAID MANAGED CARE ELIGIBILITY CATEGORIES
HUSKY A MEDICAID COVERAGE GROUPS
Eligibility
Code Description
----------- -----------
F01 Temporary Assistance to Needy Families (TANF)
F03 Transitional Work Extension
F04 Child Support Extension
F05 Work Supplementation
F07 Family Coverage (150 % FPL)
F08 Special Child Care Deduction
F09 Eligible for TANF except for Non-Medicaid Requirements
F10 Newborn Coverage
F11 Newborn Children
F12 CN Ribicoff Children
F13* Children < 1, under 1859 of the Federal Poverty Level (FPL)
F20* Children 1-6, under 185 % of the Federal Poverty Level (FPL)
F25 Children under 185 % of the Federal Poverty Level (FPL)
F26 Continuous and Guaranteed Eligibility
F95 Children under 18, 18-21, and caretaker Relatives
P01 Pregnant Women who meet TANF Financial Requirements
P02 Pregnant Women under 185 % of the Federal Poverty Level (FPL)
P95 Pregnant Women Coverage
MO1\M02 Pregnant Women Extension (Post-Partum)
D01\D02 DCF Children
* 1) The F13 and F20 coverage groups have been collapsed into the F25 coverage
group.
2) All newly granted children under 185 % of the FPL are being granted
eligibility under the F25 coverage group.
3) Already eligible children in the F13 and F20 coverage group will be
transferred to
APPENDIX H
MANAGED CARE POLICY TRANSMITTALS
APPENDIX H
MANAGED CARE POLICY TRANSMITTALS
[LOGO] STATE OF CONNECTICUT
DEPARTMENT OF SOCIAL SERVICES
TELEPHONE
XXXXXXX X. XXXXXXXXXX (000) 000-0000
DEPUTY COMMISSIONER
TDD/TTY
1-800-842-4524
HEALTH CARE FINANCING DIVISION FAX
(000) 000-0000
MANAGED CARE ORGANIZATIONS
PB-98-35
/s/ Xxxxxxx X. Xxxxxxxxxx MAY 1, 1998
------------------------- --------------
XXXXXXX X. XXXXXXXXXX EFFECTIVE DATE
DEPUTY COMMISSIONER
POLICY TRANSMITTAL: MS 98-02
SUBJECT: TRANSPORTATION
This policy transmittal is issued to Managed Care Organizations to establish
uniform policy regarding transportation of unescorted children to medically
necessary and medically appropriate appointments.
Effective May 1, 1998:
1) Children under 12 years of age shall be escorted to medically
necessary and medically appropriate appointments. Either the child's
parent, xxxxxx parent, caretaker, legal guardian, or the Department
of Children and Families (DCF), as appropriate, shall be responsible
for providing the escort.
2) For children between the ages of 12 to 15 years, a consent form
signed by a parent, caretaker, or guardian shall be required in
order for a child to be transported without an escort, unless access
to the service without parental consent is specified by state
statute (i.e. for family planning and mental health treatment).
3) For children 16 years of age and older, no consent form shall be
required.
NOTE: THE DEPARTMENT OF SOCIAL SERVICES AND THE DEPARTMENT OF CHILDREN AND
FAMILIES, WITHIN 30 DAYS OF ISSUANCE OF THIS TRANSMITTAL, INTEND TO WORK WITH
MANAGED CARE ORGANIZATIONS TO DEVELOP A STANDARDIZED CONSENT FORM.
DISTRIBUTION: This policy transmittal is being distributed by Electronic Data
Systems to holders of the Medical Services Policy Manual and to the Medicaid
Mailing List by the Department of Social Services. Managed Care Organizations
are requested to send this information to their network providers and
subcontractors.
RESPONSIBLE UNIT: Medical Administration Policy, Xxxxxx XxXxxxxx, Lead Planning
Analyst, (860) 424-5135.
00 XXXXXXXXX XXXXXX - XXXXXXXX, XXXXXXXXXXX 00000-0000
AN EQUAL OPPORTUNITY AFFIRMATIVE ACTION EMPLOYER
PRINTED ON RECYCLED OR RECOVERED PAPER
[CONNECTICUT DEPARTMENT
OF SOCIAL SERVICES LOGO] XXXX X. XXXXXXX [LOGO] XXXXXXX X. XXXXXXXXXX
GOVERNOR DEPUTY COMMISSIONER
(000) 000-0000 0-000-000-0000 TDD/TYY FAX (000) 000-0000
HEALTH CARE FINANCING DIVISION
PB-00-57
All Providers and MCO's
/s/ Xxxxxxx X. Xxxxxxxxxx JULY 1, 2000
------------------------- ---------------
XXXXXXX X. XXXXXXXXXX EFFECTIVE DATE:
DEPUTY COMMISSIONER
Policy Transmittal: MS 00-08 CONTACT: XXXXXX XXXXXX AT: 000 000-0000
Subject: Clarification Regarding Notices of Action and Partial Denials
This Policy Transmittal further clarifies requirements in Sections 6.1 and 6.2
of the HUSKY A contract in effect as of February 1, 1999 (the "HUSKY A
Contract"). This Policy Transmittal is based upon the guidance set forth in
Xxxxx Xxxxxxxx'x April 18, 2000 letter to the managed care organizations
("MCOs") and replaces and supersedes the guidance in that letter.
Partial Denials
Section 6.1 of the HUSKY A contract requires the MCO or its subcontractor
to send a notice of action whenever the MCO denies coverage of goods or
services, or reduces, suspends or terminates ongoing goods or services. A notice
of action is required whenever the MCO denies a request for goods or services -
whether the request is submitted in oral, written or electronic form, so long as
it is in a form in which the MCO accepts prior authorization requests. This
contractual requirement reflects federal Medicaid regulations and constitutional
due process obligations that require the issuance of notice in these
circumstances. A number of questions have arisen concerning what constitutes a
"denial" for purposes of the notice of action requirements. The Department
recognizes that the MCO may not be prepared to approve a request for prior
authorization as submitted because the patient and the requesting provider may
not have demonstrated that all of the requested services are medically
necessary. The MCO may not be prepared to approve the request as submitted,
notwithstanding that it may acknowledge that it has been demonstrated by the
information submitted that the patient needs some, but perhaps not all, of the
services requested by the provider.
For example, if a provider requests 30 outpatient mental health sessions
for a member, but it has not been demonstrated to the satisfaction of the MCO
that the member
JOBS FIRST INITIATIVE
Call us at 0-000-000-0000 if you have an employment position to fill.
00 Xxxxxxxxx Xxxxxx, Xxxxxxxx, Xxxxxxxxxxx 00000-0000
An Equal Opportunity/Affirmative Action Employer.
Printed on Recycled or Recovered Paper.
will require 30 sessions, the MCO may respond to such a request for services in
one of the following ways:
1) If the MCO determines that the goods or services requested are not
medically necessary, the MCO may issue a denial notice to the member. The 10 day
advance notice requirement does not apply in these circumstances. The notice may
be sent at the time of the MCO's decision. Continuation of care requirements do
not apply in these circumstances. In the example described above, the MCO is
required to send a notice of action to the member denying the 30 sessions. This
option may not be used if the MCO believes that some goods or services are
medically necessary. In such situations, options 2 and 3 described below are
appropriate. This option may be appropriately used when the prior authorization
request relates to a discrete or single good or service that permits a "yes" or
"no" authorization decision or when the MCO determines that none of the
requested services are medically necessary.
2) If the MCO determines that the requested goods or services are
medically necessary to some extent, but not for the type of services or the
scope, duration and intensity requested, the MCO may alternatively issue a
denial notice, that is, the MCO may partially approve and partially deny the
request for services. If the MCO does not approve the request as submitted, the
MCO must send a denial notice to the member at the time of the partial denial.
In the example above, the MCO could determine that the provider demonstrated
that the member needs 15 sessions, but not all 30 sessions requested. The MCO
could send a notice granting a request for 15 sessions and denying a request for
15 sessions. The member could receive the 15 undisputed sessions and could
request a grievance/fair hearing or the remaining 15 sessions. If the member
requests a hearing on the disputed 15 sessions, continuation of care
requirements would not apply.
3) If the MCO determines that the goods or services are necessary, but
lacks sufficient information to make a final determination as to the full scope
of the request, the MCO alternatively may approve the authorization request as
submitted with notice to the provider that the MCO will review the medical
necessity for the full request at periodic intervals. In the example above, the
MCO may approve the requested 30 sessions. The notice or communication to the
provider, however, could note that approval is contingent upon demonstration of
the continuing need for the services. The MCO may inform the provider that
provision of the services is contingent upon such a demonstration at "check-in"
points - visits 10 and 20 - for example. If, prior to the 30th session, the MCO
determines that the remaining sessions are not necessary and elects to
discontinue coverage of the remaining previously approved sessions, this will
constitute a termination of services. The MCO would be required to send a 10 day
advance notice of termination and continue benefits pending a hearing decision,
up to the 30 sessions that were previously approved, if the patient requests a
hearing within the 10 day period.
The MCOs may use the existing notice of action forms to issue notices of
partial denial. The Department is in the process of revising the model form
currently in use and will distribute the forms to the MCOs.
2
The Department will monitor the use of these three notice options. The
Department believes that these options afford the MCOs sufficient flexibility to
respond to a request for goods or services while still allowing the MCO to
manage the care provided. The failure to issue notices of action as required by
the HUSKY A contract and in accordance with the partial denial requirements
above, may result in the imposition of Class B or Class C Sanctions.
The HUSKY A organizations are bound by the formal and complex due
process requirements of federal Medicaid regulations. The Department recognizes
that these notice requirements may differ significantly from notice requirements
in the private sector. Nonetheless, the Department believes that the MCOs can
and must review the medical necessity of services and manage the care provided
to their Medicaid members, while at the same time, affording notice and hearing
rights that comply with federal and state law and the terms of the HUSKY A
contract.
Reasons for Denials
The notice of action must cite to the legal authority for the MCO's
decision. If an adverse action is based upon a medical necessity determination,
the notice should cite to the medical necessity definition from the Department's
regulations. For example, a denial of physician's services on the basis of lack
of medical necessity shall cite to Regulations, Conn. Stat. Ag. Section
17b-262-338(31). The MCO should not cite internal MCO policy as a basis for a
denial, termination, suspension or reduction of services. If a good or service
is denied because it is not a covered benefit, the notice should cite to the
particular exclusion from the Department's Medical Services Policy manual, as
listed in Appendix A of the HUSKY A contract.
If a MCO or one of its subcontractors fails to cite to the appropriate
legal basis for an authorization decision, the Department may impose Class B or
C sanctions on the MCO.
Utilization Review and Medical Necessity
Utilization review decisions must be based upon an individual
assessment of the member and the member's medical condition. Arbitrary time
periods or arbitrary limitations on number of service visits are inconsistent
with an individualized determination of medical necessity. The MCO coverage and
utilization decisions must be consistent with the scope of covered services as
set forth in Appendix A of the HUSKY A contract. Medical necessity
determinations by the MCO must be made in accordance with the definition in the
HUSKY A contract. MCOs must employ the definition of "medical necessity" set
forth in Section EE of the definitions section of the HUSKY A contract.
Children's medical necessity decisions will be governed by the EPSDT coverage
rules (42 U.S.C. Section 1396d(r) and 42 U.S.C. Section 1396a(a)(43), as
described
3
in Section 3.17 of the HUSKY A Contract. MCOs are also responsible for ensuring
subcontractor compliance with these requirements.
Coverage for Chronic Conditions
There is no distinction in the HUSKY A contract between acute and
long-term services. MCOs may not deny services on the basis that the goods or
services requested are for a chronic condition, rather than a service that is
short-term or acute in nature. In addition, MCOs may not adopt practices that
have the effect of denying or limiting access to medically necessary services
for chronic or long term conditions. These principles apply with equal force to
MCO subcontractors and MCOs are responsible for ensuring subcontractor
compliance.
If a MCO or one of its subcontractors fails to issue a proper notice of
action or fails to use the medical necessity criteria a set forth in the HUSKY A
contract, the Department may impose Class B or Class C Sanctions on the MCO. If
a MCO or one of its subcontractors uses arbitrary limits in the utilization
review process, this may also result in the imposition of Class B or C
sanctions.
Distribution: This policy transmittal is being distributed by Electronic
Data Systems to holders of the Medical Services Policy Manual and to the
Medicaid Mailing List, by the Department of Social Services. HUSKY A managed
care organizations are requested to send this information to their network
providers and subcontractors.
Responsible Unit Medicaid Managed Care, Xxxxxx Xxxxxx, Manager/Compliance,
at (000) 000-0000.
DATE ISSUED: JUNE 29, 2000
4
[CONNECTICUT DEPARTMENT OF SOCIAL SERVICES LOGO]
(000) 000-0000 0-000-000-0000 TDD/TTY FAX (000) 000-0000
HEALTH CARE FINANCING DIVISION
July 1997
All Providers
/s/ Xxxxxxx Xxxxxxxxxx ONGOING
---------------------- --------------
XXXXXXX XXXXXXXXXX EFFECTIVE DATE
DEPUTY COMMISSIONER
POLICY TRANSMITTAL: MS 97-05 PB-97-44
SUBJECT: Coordination and Continuation of Goods and Services
This Policy Transmittal clarifies the requirement for providing coordination and
continuation of care relative to the covered goods and services referred to in
Section 3.1 of the Health Plan Purchase of Service Contract. Those health plans
licensed by the State of Connecticut Insurance Department under Chapter 698,
698a or 670 of the Connecticut General Statutes are also bound by Public Act 97-
99, An Act Concerning Managed Care, as the provisions of the Act, upon the date
they are effective, may apply to the requirements of coordination and
continuation of goods and services addressed in this transmittal.
Specifically addressed in this transmittal is the coordination and continuity of
goods and services provided to: (1) a Medical Assistance Program client who is
in the process of transitioning into a health plan; or (2) a client who is an
established member of a health plan.
The Department of Social Services defines goods and services as medical care or
items which are furnished to a client to meet a medical necessity in accordance
with applicable statutes, regulations, or policy governing the Medical
Assistance Program.
(a) COORDINATION AND CONTINUATION OF GOODS AND SERVICES FOR HEALTH PLAN
MEMBERS
Section 3.2 of the Health Plan Purchase of Service Contract requires that
a Connecticut Access Health Plan shall have a system in place to provide
well-managed patient care. Section 3.2 focuses on the coordination and
continuation of care provided by a health plan for its members. For the
purposes of this transmittal, coordination and continuation of goods and
services includes:
- a health plan member who is receiving ongoing goods and services
from a fee-for-service system (FFS) provider at the time of
transitioning into the health plan;
- a health plan member who is receiving ongoing goods and services
under one health plan at the time of transitioning into another
health plan; and
1
JOBS FIRST INITIATIVE
Call us at 0-000-000-0000 if you have an employment position to fill.
00 Xxxxxxxxx Xxxxxx, Xxxxxxxx, Xxxxxxxxxxx 00000-0000
An Equal Opportunity/Affirmative Action Employer.
Printed on Recycled or Recovered Paper.
available in the health plan's provider network, the health
plan shall continue to provide the care through the member's
FFS or outgoing health plan provider until such time an
appropriate specialist is available in the plan's provider
network.
In other words, until the health plan can make arrangements to
effect the smooth transition of the care to an appropriate
network provider, care shall continue to be provided by the
out-of-network provider beyond the member's effective date of
enrollment into the new health plan.
(2) Maintaining Continuity of Care for Established (Non-Transitioning)
Health Plan Members Currently Receiving Ongoing Goods and Services
Health plans shall not reduce, suspend, or eliminate the ongoing
goods and services an established member (non-transitioning) is
currently receiving from the member's health plan until the plan has
completed a review of medical necessity and met the requirements of
Section (d) below.
(d) REQUIREMENTS FOR THE NOTICE OF ACTION AND NOTIFICATION OF THE GRIEVANCE
PROCESS TO TRANSITIONING AND ESTABLISHED HEALTH PLAN MEMBERS
In order for the health plans to be in compliance with Section 6.1 of the
Health Plan Purchase of Service Contract concerning grievance procedures
and Section (c) above, the following requirements shall be met by the
health plans with regard to the right of transitioning and established
health plan members to appeal an adverse decision by the health plan
concerning the goods and services they are receiving.
(1) Notice of Action
The health plan, or its subcontractor (as duly authorized by the
health plan), shall mail an initial notice of action to the member
regarding the results of the initial review of medical necessity,
provided for in Section (c)(1) and (c)(2) above, at least 10
calendar days before the date of any action to reduce, suspend, or
terminate the goods and services. The health plan shall allow an
additional 2 days for mail delivery time beyond the 10 days to allow
for receipt of the notice by the member. The health plan shall
identify if the member is Spanish speaking only. In this case, the
notice of action shall be in Spanish.
The initial notice of action shall clearly explain the member's
right to:
(A) file a grievance with the health plan using the grievance
process established by the health plan in accordance with
Section 6.1 of the Health Plan Purchase of Service Contract;
(B) request a fair hearing in writing to the Department as
provided for under Section 6.2 of the contract, and that the
request must be made within 60 days from the date the health
plan initial Notice of Action is mailed to the member;
(C) continuation of ongoing goods and services if the appeal to
the plan or the Department is made on or before 10 calendar
days from the date the notice is received by the member. (See
subsection (c)(2) and (d)(5) below).
3
Division renders a decision in the matter. (See (d)(5) below
concerning documentation and tracking of the ten day
requirement.)
(3) In accordance with Section 6.1 of the Health Plan Purchase of
Service Contract, the grievance process within the health plan shall
be concluded within 30 days of receipt.
(4) Decisions by the Department's Administrative Hearing and Appeals
Division concerning fair hearings shall be made within 90 days of
receipt of a fair hearings request. It is the responsibility of the
health plan to assign a staff person to attend the fair hearing to
present their views. Failure on the part of the health plan to
attend the hearing would cause the hearing to be decided in favor of
the member.
(5) Documentation Requirements
(A) It shall be the responsibility of the health plan to document
in its grievance recordkeeping system required by Section 6.1
of the Health Plan Purchase of Service Contract: (i) the date
the initial notice of action is mailed to the member; (ii) the
date the member files a grievance resulting from the notice of
action; and (iii) the date the Department receives the
member's request for a fair hearing resulting from the notice
of action.
(B) It shall be the responsibility of the health plan to track the
time period for determination of continuation of services.
(C) In case of a dispute involving a request for continuation of
services or a fair hearing request, the health plan shall have
a system in place to verify the actual date the initial Notice
of Action is mailed to the member.
(e) MAINTAINING CONTINUITY OF CARE FOR A TRANSITIONING HEALTH PLAN MEMBER
RECEIVING GOODS NOT SUBJECT TO SECTION (c) ABOVE
(1) The following goods, which are not deemed ongoing goods as defined
in section (c) above, are included in this section: durable medical
equipment; prosthetic or orthotic devices; hearing aids; dentures;
orthodontics; and eyeglasses. The goods covered in this section may
involve the purchase, repair, or modification of such goods.
(2) Goods requiring prior authorization under the FFS system or the
outgoing health plan
(A) The new health plan shall be responsible for payment of goods
covered in this section for a member who is transitioning into
the health plan from either the FFS system or another health
plan and who has a written authorization for such goods
subject to paragraph (C) of this section.
(B) The new health plan shall not deny, reduce, terminate, or
suspend such goods. The goods shall be provided by the new
health plan according to the terms of the authorization, i.e.,
the amount or duration of goods.
(C) Payment shall be the responsibility of the new health plan
when the goods were approved under the terms of a written
prior authorization either given by the Department to a
fee-for-service provider (see subsection (4) below) or by the
outgoing health plan to one of its providers, and:
5
only.
Therefore, when a client joins a health plan, the prior
authorization by the Department for goods and services provided
after the effective date of enrollment into a health plan is no
longer valid, except when such goods meet the requirements of
Section (d)(2) above. The Department also extends this rationale to
the goods authorized by an outgoing health plan.
(f) MAINTAINING CONTINUITY OF CARE FOR TRANSITIONING HEALTH PLAN MEMBERS WHO
ARE HOSPITALIZED
The following continuity of care requirements shall be followed for health
plan members who are hospitalized.
(1) The admitting health plan shall be responsible for payment of a
hospital stay for a member who transitions into another health plan
or returns to the FFS system while hospitalized. Payment shall be
the responsibility of the admitting health plan when the effective
date of disenrollment from the admitting health plan occurs during
the period of hospitalization. The admitting health plan shall be
responsible for covering the hospital stay until the member is
discharged. This applies to fully capitated health plans only. The
hospital stay refers to the financial arrangement made between the
admitting health plan and the hospital to cover certain inpatient
services.
The services related to the Inpatient stay but performed and billed
separately from the hospital's charges, as for example, the services
of the attending physician or a specialist, would be the
responsibility of the new health plan or FFS system, whichever
applies, beginning with the effective date of enrollment of the
member into the new health plan It is important for the outgoing
health plan and the member's new health plan to coordinate the
inpatient related services received by the hospitalized member.
It is equally necessary, in situations involving the discharge of a
member who is transitioned into a new health plan while
hospitalized, for the discharge planning to be coordinated with the
member's new health plan This means that the admitting health plan
and the hospital should Involve the member's new health plan in the
planning process, especially in situations involving planned
transfers to another inpatient facility, e.g., transfer to a
psychiatric hospital, or transfer to a stepdown ambulatory program,
such as a partial hospital program. Health plans should refer to
Appendix K of the Request For Application (RFA) for current
requirements concerning the discharge planning process for children
who are hospitalized with significant mental health or substance
abuse needs.
(2) A health plan member who was admitted to an inpatient facility under
the FFS system, and whose effective date of enrollment in a health
plan for the first time occurs during the period of hospitalization,
is exempted from such enrollment until the 1st of the month
following discharge from inpatient care.
Distribution: This policy transmittal is being distributed by Electronic Data
Systems to holders of the Medical Services Policy Manual and to the Medicaid
Mailing List by the Department of Social Services. Health Plans are requested to
send this information to their network providers and subcontractors.
Responsible Unit: Medical Administration Policy Xxx XxxXxxxxx, Medicaid Policy
Consultant, (000) 000-0000, or Xxxxxx Xxxxxx, Lead Planning Analyst,
000-000-0000
ISSUED: JULY 9, 1997
7
[LOGO] [ILLEGIBLE]
DEPARTMENT OF SOCIAL SERVICES
TELEPHONE
XXXXXXX X. XXXXXXXXXX (000) 000-0000
DEPUTY COMMISSIONER
TDD/TTY
1-800-842-4524
HEALTH CARE FINANCING DIVISION FAX
(000) 000-0000
February 1998
All Providers
/s/ Xxxxxxx X. Xxxxxxxxxx Immediately
------------------------- -----------
Xxxxxxx X. Xxxxxxxxxx Effective Date
Deputy Commissioner
Policy Transmittal: MS 98-01 PB 98-29
Subject: Clarification Regarding Notices of Action and Coordination and
Continuation of Goods and Services
This Policy Transmittal further clarifies the requirements of Section 6.1 and
6.2 of the Health Plan Purchase of Service Contract regarding requirements for
the notice of action and notification of the grievance process to transitioning
and established health plan members previously addressed in Policy Transmittal
MS 97-05(d) and addresses questions regarding payment for goods not subject to
Section (c) of Policy Transmittal MS 97-05.
(a) Notice of Action
(1) The health plan, or its subcontractor (as duly authorized by the
health plan) shall mail an initial notice of action to the member
regarding the results of the initial review of medical necessity,
provided for in Section (c)(1) and (c)(2) of Policy Transmittal MS
97-05, at least 10 calendar days before the date of any action to
reduce, suspend, or terminate the goods or services. The health plan
shall identify if the member is Spanish speaking only. In this case,
the notice of action shall be in Spanish.
The health plan is not required to allow an additional 2 days for
mail delivery beyond the 10 days specified above.
(2) In addition to providing a notice of action to the member when
ongoing goods or services are reduced, suspended, or terminated, the
health plan must also provide a notice of action promptly whenever
the plan denies coverage of goods or services prescribed by the
treating physician or primary care provider.
00 XXXXXXXXX XXXXXX-XXXXXXXX, XXXXXXXXXXX 00000-0000
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
PRINTED ON RECYCLED OR RECOVERED PAPER
(3) All notices of action shall clearly state or explain:
(A) what action the health plan intends to take;
(B) the reasons for the intended action;
(C) a citation to the statute, regulation, policy section, or
managed care contract provision which supports the intended
action;
(D) the member's right to file a grievance with the health plan
using the grievance process established by the health plan in
accordance with Section 6.1 of the Health Plan Purchase of
Service Contract;
(E) (i) the member's right to request, in writing, a fair
hearing from the Department;
(ii) that a written request for a fair hearing must be made
to the Department within 60 days from the date the
health plan mailed the initial notice of action to the
member;
(iii) that, at a fair hearing, the member may represent
himself or herself or use legal counsel, a relative, a
friend, or other spokesperson;
(iv) that filing a grievance with the health plan does not
preclude the member from requesting a fair hearing from
the Department;
(v) that filing a grievance with the health plan does not
automatically preserve the member's right to request a
fair hearing; and
(F) the member's right to continuation of ongoing goods or
services:
(i) provided the reduction, suspension, or termination of
goods or services was not ordered by the member's
treating physician or primary care provider, functioning
within his or her respective scope of practice, as
defined under state law, and
(ii) provided the member files a formal grievance with the
health plan or files a written request for a fair
hearing with the Department within 10 calendar days of
the date the notice is mailed to the member.
(4) In the case of a child under the care of the Department of Children
and Families (DCF) the health plan is required to send the notice of
action to the child's DCF social worker and a copy to the child's
xxxxxx parent.
(b) Exception From Advance Notice
(1) Notice of action may be mailed to a member no later than the date of
action if a reduction, suspension, or termination of goods or
services is prescribed by
the member's treating physician or primary care provider,
functioning within his or her scope of practice, as defined under
state law.
(2) In the foregoing situation, although notice of action is required,
goods or services may be reduced, suspended, or terminated, in
accordance with the order of the treating physician or primary care
provider, functioning within his or her respective scope of
practice, as defined under state law, as of the date of action.
(c) Payment for Goods Received by Members not Subject to Policy Transmittal MS
97-05(c)
(1) For goods which are not deemed ongoing goods as defined in Policy
Transmittal MS 97-05(e), the health plan which authorizes the goods
shall pay for the goods, even if the member has transitioned into
another health plan or fee-for-service Medicaid by the time the
goods are delivered.
(2) In situations where prior authorization has been given by the
Department to a fee-for-service provider prior to a member
transitioning into a health plan, and the goods are delivered after
the member has transitioned into a health plan, the new health plan
shall pay the provider whom the Department authorized to supply the
goods.
(d) Delegation of Responsibility to Issue Notice of Action
The Connecticut Access managed care contracts permit health plans to
delegate to subcontractors the responsibility for providing notices of
action to members. Please note, however, that it remains the health plan's
responsibility to ensure that all notice requirements are met.
(e) Standardized Notice of Action
Following issuance of this policy transmittal, it is the Department's
intent to work with health plans to develop a standardized notice of
action. However, plans are not relieved of their obligation to comply with
each of the terms of this policy transmittal in the interim while this
standard notice is being developed.
DISTRIBUTION: This policy transmittal is being distributed by Electronic Data
Systems to holders of the Medical Services Policy Manual and to the Medicaid
Mailing List, by the Department of Social Services. Health Plans are requested
to sent this information to their network providers and subcontractors.
RESPONSIBLE UNIT: Medical Administration policy, J. Xxxxxxxx Xxxxxxxxxxx, Ph.D.,
Supervisor, (000) 000-0000.
APPENDIX I
CAPITATION PAYMENT AMOUNTS
SUMMARY DESCRIPTION OF BENEFITS
A. COVERED SERVICES INCLUDED IN THE CAPITATION PAYMENT
1. Hospital Inpatient Care (acute care hospitals) - Medically necessary and
medically appropriate hospital inpatient acute care, procedures, and
services, as authorized by the responsible physician(s) or dentist, and
covered under Department of Social Services (DSS) policies and
regulations.
a. Administratively Necessary Days (ANDs) are covered when a nursing
home placement delay is due to unavailability of beds. However, a
patient is required to accept the first available, medically
appropriate bed.
b. Organ transplants are covered if they are of demonstrated
therapeutic value, medically necessary and medically appropriate,
and likely to result in the prolongation and the improvement in the
quality of life of the applicant. The DSS Transplant Advisory
Committee has developed, and continues to develop, medical criteria
relating to particular organ transplant procedures. These criteria
are available for use by health plans. The criteria are guidelines.
However, a final decision to deny a transplant request is not to be
rendered without considering the medical opinion of a qualified
organ transplantation expert(s) in the community.
c. Mental health and substance abuse services in a general hospital
psychiatric unit are covered--regardless of the age of the
individual.
2. Psychiatric (mental health/substance abuse) Facility Inpatient Care
a. Medically necessary psychiatric hospital care, procedures, and
services as covered under DSS policy and regulation.
b. Some psychiatric hospitals may qualify as an Institution for Mental
Diseases (IMD). An IMD is defined as a facility of more than sixteen
(16) beds that is primarily engaged in providing diagnosis,
treatment, or care of persons with mental diseases. Medically IMD
necessary care is only covered for individuals under age 21 and 65
years of age or older. IMD services for individuals aged 21 through
64 are noncovered services (see Section C.1 of this summary
overview).
3. Freestanding Alcohol Treatment Center Inpatient Care
a. Services must be provided by a program holding a current and active
license to operate a Private Freestanding Facility for the Care and
Treatment of Substance Abusive or Dependent Persons.
b. Services under the Medicaid program shall be for alcohol
detoxification and shall be limited to: a) the acute and evaluation
phase of the treatment program and b) a ten (10) day period for each
occurrence. Acute treatment and evaluation provides medical
management of detoxification and assessment of the individual's
total situation in an inpatient milieu for
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the purpose of formulating and implementing a plan of care in
addition to detoxification.
c. Services must predominately focus on the medical and/or
psychological management of alcohol abuse and other medical or
psychological conditions which impact upon or are related to alcohol
abuse. Treatment and care shall be provided under the direction of a
physician within the scope of accepted medical practice.
4. Chronic Disease Hospital Inpatient Care - Such medically necessary care,
procedures, and services as covered under DSS policy and regulation.
5. Nursing Facility (Skilled Nursing and Intermediate Care) Inpatient Care -
Such medically necessary care is covered while the patient remains in a
managed care coverage group. For coverage in nursing homes which are
characterized as, institutions for mental disease' see Section CA of this
summary overview.
6. Intermediate Care Facility (Mentally Retarded) Inpatient Care - Such
medically necessary care is covered while the patient remains in a managed
care coverage group.
7. Christian Science Sanitoria Service - Such medically necessary care is
covered while the patient remains in a managed care coverage group.
8. Hospital Outpatient Care (General Hospital, Psychiatric Hospital, and
Chronic Disease Hospital) - Preventive, diagnostic, therapeutic,
rehabilitative, or palliative medical services provided to an outpatient
by or under the direction of a physician or dentist in a licensed
hospital facility.
9. Physician Services - Primary and Specialty services provided by a licensed
physician or doctor of osteopathy and performed within the scope of
practice of medicine or osteopathy as defined by State law.
10. Psychologist Services - Clinical, diagnostic, and remedial services
personally performed by a psychologist. Services include: a) counseling
and psychotherapy to individuals who are experiencing problems of a mental
or behavioral nature and b) measuring and testing of personality,
aptitudes, emotions, and attitudes.
11. Nurse-Midwifery Services - Services provided by a licensed, certified
nurse--midwife which are related to the care, and to the management of the
care, of essentially normal mothers and newborns (only throughout the
maternity cycle) and well woman gynecological care, including family
planning services.
12. Nurse Practitioner Services - Services which are provided by a licensed
Advanced Practice Registered Nurse (APRN) and which are within his or her
scope of practice as defined by State law.
13. Chiropractor Services - Manual manipulation of the spine performed by a
licensed chiropractor within the scope of chiropractic practice.
Noncovered services:
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a. Prescription or administration of any medicine or drug or the
performance of any surgery;
b. X-rays furnished by a chiropractor.
c. Manipulation of other parts of the body (e.g., shoulder, arm, knee,
etc.) even when for subluxation of the spine; and
d. Lab work ordered by a chiropractor.
14. Naturopathic Services - Services provided by a licensed naturopath which
conform to accepted methods of diagnosis and treatment and which are
within the scope of naturopathic practice.
15. Podiatrist Services - Services provided by a licensed podiatrist which
conform to accepted methods of diagnosis and treatment and which are
within the scope of podiatric practice.
a. Limitations of Coverage
i. Orthotic and/or corrective arch supports for recipients under
five years of age; and
ii. Orthotic and/or corrective arch supports only once every two
(2) years.
b. Noncovered Services
i. Services of assistants at surgery;
ii. Simplified tests requiring minimal time or equipment and
employing materials nominal in cost such as Clinitest,
testape, Hematest, Bumintest, Dextrostix, nonphotolitric
hemogloblin, etc.;
iii. Simple foot hygiene; and
iv. Repairs to devices judged to be necessitated by willful or
malicious abuse on the part of the patient.
16. Laboratory Services - Laboratory services: a) ordered by a duly licensed
physician or other licensed practitioner of the healing arts; and b)
performed in a laboratory which is certified according to the applicable
provisions of the Clinical Laboratory Improvement Amendments of 1988
(CLIA) and meets all applicable licensing, accreditation and certification
requirements for the specific services and procedures it provides.
17. Outpatient Medical Rehabilitation Services - Medically necessary and
medically appropriate outpatient rehabilitation services provided by a
licensed or certified practitioner. Such services include: physical
therapy, occupational therapy, speech therapy, audiology, inhalation
therapy, social services, psychological services, traumatic brain injury
(T.B.I.) day treatment, neuropsychological evaluation,
electonystagmography, and early childhood intervention services.
a. Limitations include:
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i. Sheltered workshop services for individuals who are primarily
developmentally disabled are covered only if their need for
this type of program stems from an etiology readily
identifiable as medical or psychological in origin;
ii. T.B.I. treatment programs are limited to individuals who have
sustained injury from interaction of any external forces
resulting in the central nervous system (brain) dysfunctions.
Developmental impairment primarily contributing to brain
dysfunction is not included. The impairment must be readily
identifiable as having been sustained through injury;
iii. The T.B.I. program is primarily a medical rehabilitation
program, however, vocational, social, and educational services
may be covered only when these services are: a) related to the
individual's injury, b) are reasonable and necessary for the
diagnosis or treatment of the injury, and c) are a part of the
recipient's written individual plan of care; and
iv. Programs relating to the learning of basic living skills, or
other activities of daily living, are limited to individuals
who have lost or had impaired functions of daily living and
require retraining to maximize restoration of these skills.
b. Noncovered Services include:
i. Services which are related solely to specific employment
opportunities, work skills, work settings, and/or academic
skills and are not reasonable or necessary for the diagnosis
or treatment of an illness or injury;
ii. Speech services involving nondiagnostic, nontherapeutic,
routine, repetitive, and reinforced procedures or services for
the patient's general good and welfare; and
iii. Services ordinarily covered are not covered if an individual's
expected restoration potential would be insignificant in
relation to the extent and duration of rehabilitation services
required to achieve such potential.
18. Vision Care - Services performed by a licensed ophthalmologist,
optometrist, or optician which conform to accepted methods of diagnosis
and treatment.
Limitations of Coverage
i. Contact lenses are covered when such lenses provide better
management of a visual or ocular condition than can be
achieved with spectacle lenses, including, but not limited to
the diagnosis of Unilateral Aphakia, Keratoconus, Coeal
Transplant, and High Anisometropia;
ii. Prescription sunglasses are covered when light sensitivity
which will hinder driving or seriously handicap the outdoor
activity of a patient is evident;
iii. Trifocals are covered when the patient has a special need due
to job training program or extenuating circumstances;
iv. Extended wear contact lenses are covered for aphakia and for
members whose coordination or physical condition make daily
usage of contact lenses impossible;
v. Oversize lens are covered only when needed for physiological
reasons, and not for cosmetic reasons; and
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vi. A spare pair of eyeglasses is not covered.
19. Dental Care - Services performed by a licensed dentist or dental hygienist
which conform to accepted methods of diagnosis and treatment.
The categories of covered services are as follows:
a. Diagnostic Services
i. Home visits;
ii. Radiographs: a) intraoral, complete series; b) bitewing films;
and c) periapical films; and
iii. Oral examinations: a) initial oral exam; b) periodic oral
exam; and c) emergency oral exam.
b. Preventive Services
i. Prophylaxis;
ii. Fluoride treatment for children under 21;
iii. Space maintainers;
iv. Night guards; and
v. Pit and fissure sealants for children ages 5 through 16. Prior
authorization is required for children under 5 and persons
over 16.
c. Restorative Services - limited to the restoration of carious
permanent, and primary teeth.
i. Fillings; and
ii. Crowns.
d. Endodontics
i. Root canal therapy and/or abicoectomy; and
ii. Apexification.
e. Prosthodontics - removable, complete, and partial prostheses;
f. Dental Surgery;
g. Edodontia (extractions);
h. Orthodontics under the Early Periodic Screening, Diagnosis and
Treatment (EPSDT) program;
i. Alveolectomy (alveoplasty);
j. Patient Management - in connection with dental services to
individuals with cognitive disabilities;
k. General Surgical Anesthesia;
l. Prosthodontics with use on a regular basis;
m. Removable, complete and partial denture prostheses only; and
n. Replacement of existing dentures, only once in any five (5) years.
8
o. Relining or rebasing existing dentures - Two (2) year period.
p. Denture labeling, for patients in long-term care facilities only.
The categories of noncovered services are as follows:
a. Fixed Bridges
b. Periodontia
c. Implants
d. Transplants
e. Cosmetic Dentistry
f. Vestibuloplasty
g. Unilateral Removable Appliances
h. Partial dentures where there are at least eight (8) posterior teeth
in occlusion and no missing anterior teeth.
i. Restorative procedures to deciduous teeth nearing exfoliation.
20. Durable Medical Equipment - equipment which: a) can stand repeated use; b)
is primarily and customarily used to serve a medical purpose; c) is
generally not useful to a person in the absence of an illness or injury;
and d) excludes items that are disposable.
Equipment covered includes: wheelchairs and accessories, walking aids,
bathroom equipment (e.g., commode and safety equipment), hospital
beds and accessories, inhalation therapy equipment (e.g., IPPR
machines, suction machines, nebulizers, and related equipment),
enteral/parenteral therapy equipment, and the repair and replacement
of durable medical equipment (DME) and related equipment.
21. Orthotic and Prosthetic Devices - Mechanical appliances and devices for
the purpose of providing artificial replacement of missing parts, and/or
prevention or correction of disorders in involving physical deformities
and impairments.
a. Devices covered include: braces, corsets, collars, arch supports,
footplates, orthopedic shoes, orthopedic prostheses, hearing aids
(including batteries, earmolds, and cords).
b. Limitations: i) orthotic and/or corrective arch supports are not
provided for recipients under five years of age; ii) Metatarsus
Adductus Shoes are limited to a congenital metatarsus adductus
condition and are limited to children through age four as medically
necessary.
22. Oxygen Therapy - oxygen, equipment, supplies, and services related to the
delivery of oxygen.
9
23. Respiratory Therapy - services include: intermittent positive pressure
breathing, ultrasonography, aerosol, sputum induction, percussion and
postural drainage, arterial puncture, and withdrawal of blood for
diagnosis.
24. Dialysis - hemodialysis and peritoneal dialysis services are covered,
including the treatment of end stage renal disease.
25. School-Based Clinics - services provided at a facility: a) located on the
grounds of a public school; b) serving enrolled recipients on a scheduled
basis or for an emergency situation; and c) licensed as an outpatient
medical facility to provide comprehensive care.
a. Covered services include: health assessments; family planning
services; diagnosis and/or treatment of illness or injuries;
laboratory testing (performed by the School-Based Health Clinic);
follow-up visits; EPSDT services; one-on-one health education,
medical social work services, and nutritional counseling; and mental
health and substance abuse services including diagnostic
assessments, individual, group, and family therapy or counseling.
b. Noncovered services include: mandated school health screenings,
simple intervention of a health problem such as nonmedical personnel
could render, visits where the presenting health problem does not
require a health or mental health assessment/evaluation, visits for
the sole purpose of administering or monitoring medications,
services which are not part of the written individual plan of care,
and visits for mental health or substance abuse determined by the
clinic to be beyond the scope of the clinic.
26. Family Planning and Abortion - medically approved diagnostic procedures,
treatment, counseling, drugs, supplies, or devices which are prescribed or
furnished by a provider to individuals of child bearing age for the
purpose of enabling such individuals to freely determine the number and
spacing of their children.
Noncovered services include: a) sterilizations for patients who are under
age twenty-one (21), mentally incompetent, or institutionalized; and b)
hysterectomies performed solely for the purpose of rendering an individual
permanently incapable of reproducing.
27. Ambulatory Surgery - Services include preoperative examinations, operating
and recovery room services, and all required drugs and medicine.
28. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services
(Health Track Services)- Comprehensive child health care services to
recipients under twenty-one (21) years of age, including all medically
necessary prevention, screening, diagnosis, and treatment services listed
in Section 1905(r) of the Social Security Act.
EPSDT Covered Services are described below:
a. Initial and Periodic Comprehensive Health Screenings - includes the
following services provided at the intervals recommended in the
Periodicity Schedule consistent with the standards of the American
Academy of Pediatrics and Center for Disease Control:
i. a comprehensive health and developmental history, including
assessment of both physical and mental health development and
nutritional assessments;
ii. a comprehensive unclothed physical examination;
10
iii. appropriate immunizations according to age and health history,
unless medically contraindicated at the time;
iv. appropriate laboratory tests (including blood lead level
assessments appropriate for age and risk factors);
v. health education (including anticipatory guidance and risk
assessment);
vi. diagnosis and treatment of problems found during the
screening;
vii. vision screenings - an objective vision screening is indicated
beginning at three years of age as indicated in accordance
with the Periodicity Schedule;
viii. hearing screenings - an objective hearing screening is
indicated beginning at four years of age according to the
Periodicity Schedule; and
ix. dental screenings are recommended in the Periodicity Schedule,
for example, an initial direct referral to a dentist beginning
at age two.
b. Dental Services - includes those dental services provided by or
under the direction of a dentist, in addition to the dental
screening, that are recommended in the Periodicity Schedule. Dental
services also include relief of pain and infections, restoration of
teeth, and maintenance of dental health.
c. Administration and Medical Interpretation of Developmental Tests -
objective standardized tests, recognized by the Connecticut
Birth-To-Three Council, for further diagnosis and treatment of
problems found during a periodic comprehensive health screen or
interperiodic encounter. Such tests include, but are not limited to,
the Battelle, the Xxxxxx, and the Bayley.
d. Case Management Services - The following services are determined to
be necessary when a child evidences a need for such services as a
result of a periodic comprehensive health screening or interperiodic
encounter:
i. Initial case management assessment and periodic reassessment,
including development of the plan of services and revision as
necessary.
ii. Ongoing case management, including, at a minimum:
A) assistance in implementing the plan of services, which
includes: facilitating referrals, providing assistance
in scheduling needed health or health-related services,
and helping to identify and link with the child's health
and social service providers. Particularly, the case
management provider shall identify the child's health
home or, if necessary, participate in linking the child
with a quality health home, and encourage continuity of
care;
B) monitoring the delivery of and facilitating access to a
periodic comprehensive health screening at the intervals
recommended in the Periodicity Schedule, and other
screening, diagnosis, and treatment services. Such
activities also include follow-up on missed
appointments, and, if necessary, assistance with
arranging medical transportation, child care, and
interpreter services;
C) coordinating and integrating the plan of services, as
necessary, through direct or collateral contacts with
the family and members of their team of direct service
providers, as appropriate;
11
D) monitoring the quality and quantity of needed services
that are being provided, and evaluating outcomes and
assessing future needs which might support changes in
the plan of services, including completing a quarterly
progress note;
E) providing health education, as needed, and in
coordinating with a direct service provider interpreting
and reinforcing the service provider's recommendations
for the health of the child; and
F) providing client advocacy to ensure the smooth flow of
information between the child, the child's
representative, providers, and agencies, to minimize
conflict between service providers, and to mobilize
resources to obtain needed services.
e. Interperiodic Encounters
i. An encounter or visit to determine if there is a problem, or
to treat a problem that was not evident at the time of the
regularly scheduled periodic comprehensive screening but needs
to be addressed before the next periodic comprehensive
screening;
ii. Any screening, in addition to the screenings recommended in
the Periodicity Schedule, to determine the existence of
suspected physical, mental, or developmental conditions;
iii. An encounter or follow-up visit in the case of a child whose
physical, mental, or developmental illness or condition has
already been diagnosed prior to the child being Medicaid
eligible (e.g., a pre-existing condition), but needs to be
addressed before the next scheduled screening interval
recommended in the Periodicity Schedule, if there are
indications that the illness or condition may have become more
severe or changed sufficiently so that further examination is
medically necessary; and
iv. An encounter necessary to provide immunizations, vision,
and/or hearing screenings (e.g., which had been deemed
medically contraindicated at the time of the periodic
comprehensive health screening).
f. Personal Care Services - services for a child who has a diagnosed
disability and is judged to be able to benefit from one (1) or more
personal care service activities as the result of a periodic
comprehensive health screen or interperiodic encounter performed by
a primary care provider.
i. Covered personal care services include all tasks to assist a
child with major life activities of self-care and instrumental
activities as identified in the personal care services plan of
care:
A) covered major life activities include, but are not
limited to, dressing, bathing, eating, and personal
health care maintenance; and
B) covered instrumental activities include, but are not
limited to, cooking, cleaning, travel, and shopping.
ii. The following services are not covered:
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A) personal care services provided to an individual who
does not reside at home;
B) personal care services provided by a family member;
C) home health services which duplicate personal care
services (e.g., home health aide services are not
covered when personal care services are appropriate);
D) transportation of the personal attendant to and from the
child's home to provide services;
E) acute health care services which are covered under other
DSS regulations;
F) personal care services when the child is eligible for or
receiving comparable services from another agency or
program; and
G) personal care services for the care or assistance that
would routinely be given to a child in the absence of a
disability.
g. EPSDT Special Services - other medically necessary and medically
appropriate health care, diagnostic services, treatment, or other
measures necessary to correct or ameliorate disabilities and
physical and mental illnesses and conditions discovered as a result
of a periodic comprehensive health screening or interperiodic
encounter, whether or not the good or service is included in the
Connecticut Medicaid Program State Plan as a good or service
available to all other Medicaid recipients. Such services include,
but are not limited to, medically necessary and medically
appropriate over-the-counter drugs and personal care services.
h. All medically necessary diagnosis and treatment services available
to all Medicaid recipients under the Connecticut Medical Assistance
Program.
29. Diagnostic Services - Medical procedures (e.g., radiology, cardiology,
EEG, and ultrasound procedures) or supplies recommended by a physician or
other licensed practitioner of the healing arts, within the scope of
his/her practice under State law, to enable the identification of the
existence, nature, or extent of illness, injury, or other health
deviation.
30. Home Health Care - Medically necessary home health services ordered by the
licensed practitioner and provided by a licensed home health agency on a
part-time or intermittent basis to members who reside at home, as defined
by Departmental policy, for the purpose of enabling the patient to remain
at home or to provide a less costly alternative to institutional care.
31. Mental Health/Substance Abuse Services - Medically necessary outpatient
Mental Health and Substance Abuse services provided by a licensed
psychiatrist (or under the supervision of a licensed psychiatrist) or
other licensed or certified mental health practitioner. Such services must
be provided within the scope of the practitioner's license/certification.
a. Covered services include:
i. Initial evaluation (diagnostic);
ii. Mental health and substance abuse treatment services:
13
A) Individual psychotherapy;
B) Group psychotherapy;
C) Family therapy;
D) Specialized treatment, such as methadone maintenance and
outpatient detoxification; and
E) Partial hospitalization.
iii. Physical/neurological exams in connection with evaluation of
mental illness;
iv. Parent interview/group - Children's Mental Health Services;
v. Psychological testing - performed by licensed psychologists
only; and
vi. Neuropsychological evaluation performed by a qualified
neuropsychologist.
b. Noncovered services: Hypnosis or electroshock therapy, unless
personally performed by a licensed practicing physician (M.D.).
32. Medical Transportation Services
a. Emergency and Nonemergency Ambulance Service is covered when: Q the
patient's condition requires medical attention during transit; or
ii) the patient's diagnosis indicates that the patient's condition
might deteriorate in transit to the point where medical attention
would be needed; or iii) the patient's condition requires hand
and/or feet restraints; or iv) the ambulance is responding to an
emergency; or v) no alternative less expensive means of
transportation is available. Ambulance trips to an emergency room,
regardless of the outcome, nor ambulance trips in response to a 911
call, cannot be subject to prior authorization.
b. Air Transportation - when a medical condition or time constraint
dictates its use.
c. Critical Care Helicopter - when a medical condition or time
constraint dictates its use.
d. Other Nonambulance Transportation [Livery, Invalid Coach, Commercial
Carrier, Taxi, Private Transportation, Service bus ('Dial-a-Ride"
type service), etc.] - when needed to obtain necessary medical
services covered by Medicaid, and when it is not available from
volunteer organizations, other agencies, personal resources, etc. To
administer this benefit, DSS currently employs the following
limitations on services:
i. requirement of prior authorization;
ii. requirement of the use of the nearest appropriate provider of
medical services when a determination has been made that
traveling further distances provides no medical benefit to the
patient; and
iii. requirement of the use of the least expensive appropriate
method of transportation, depending on the availability of the
service and the physical and medical circumstances of the
patient.
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e. Transportation for relatives or xxxxxx parents of a Medicaid
recipient - only under the following circumstances:
i. the person needs to be present at and during the medical service being
provided to the patient (for example, in parent/child situations); and
ii. the person needs to be trained by hospital staff to provide unpaid health
care in the home to the patient, and without this health care being provided
the patient would not be able to return home.
vii. Children under twelve (12) years of age shall be escorted to medical
appointments. Either the child's parent, xxxxxx parent, caretaker, legal
guardian or the Department of Children and Families (DCF), as
appropriate, shall be responsible for providing the escort.
viii. For children between the ages of twelve (12) to fifteen (15) years, a
consent form signed by a parent, caretaker or guardian shall be required
in order for a child to be transported without parental consent as
specified by state statute (i.e., for family planning and mental health
treatment).
ix. For children sixteen (16) years or older, no consent form shall be
required.
f. Out-of-State Transportation Services - when out-of-state- medical
services are needed because of the following:
i. a medical emergency;
ii. the patient's health would be endangered ff. required to
travel to Connecticut; and
iii. needed medical services are not available in Connecticut.
33. Medical Surgical Supplies - those items which are prescribed by a
physician to meet the needs or requirements of a specific medical and/or
surgical treatment. They are generally disposable and not reusable.
a. Covered services include: gauze pads, surgical dressing material,
splints, tracheotomy tube, diabetic supplies, elastic hosiery,
sterile gloves, incontinence supplies, thermometers, blood pressure
kit (aneroid type including stethoscope, but limited to use in the
home for patient's diagnosed to have complicated cardiac conditions
and labile hypertension), enteral/parenteral feeding therapy
supplies including solutions and manufacturing materials,
b. Items considered first aid supplies such as, bandages, solutions,
vaseline, etc., are not covered services.
34. Pharmacy Services
a. Covered services
i. Drugs prescribed by a licensed authorized practitioner. The MCO may use
a prescription drug formulary which is described in Section 3.15, Pharmacy
Access of the contract.
15
ii. Over-The-Counter (OTC) Drugs on the State of Connecticut's OTC Formulary,
including liquid generic antacids, birth control products, calcium
preparations, diabetic- related products, electrolyte replacement
products, heratinics, nutritional supplements and vitamins (prenatal,
pediatric, high potency).
iii. b. Noncovered Services
i. Drugs included in the Food and Drug Administration's Drug Efficacy Study
Implementation Program;
ii. Alcoholic liquors;
iii. Items used for personal care and hygiene or cosmetic purposes;
iv. Drugs solely used to promote fertility;
x. Drugs not directly related to the patient's diagnosis, when diagnosis is
required by the DEPARTMENT to be written on the prescription;
xi. Any vaccines and/or biologicals which can be obtained free of charge from
the CT. State Department of Health Services. The DEPARTMENT will notify
pharmacists of such vaccines or biologicals;
xii. Any drugs used in the treatment of obesity unless caused by a medical
condition;
xiii. Controlled substances dispensed to HUSKY members which are in excess of
the product manufacturer's recommendation for safe and effective use for
which there is no documentation of medical justification in the pharmacy's
file; and,
xiv. drugs used to promote smoking cessation.
35. Emergency Services - such inpatient and outpatient services in and out of
the health plan's service area are covered services.
36. Dental Hygienist Services - Services which are provided by a licensed
dental hygienist and which are within his or her scope of practice as
defined by State Law.
B. COVERED SERVICES NOT INCLUDED IN THE CAPITATION PAYMENT
1. School-Based Child Health Services - Medically necessary special education
related diagnostic and treatment services provided to children by or on
behalf of school districts pursuant to the Individuals with Disabilities
Education Act (IDEA) and Connecticut General Statutes (CGS). Diagnostic
services must be ordered by a Planning and Placement Team and treatment
services must be prescribed in a child's Individualized Education Program
(IEP)--and verified by a physician's signature.
2. Connecticut Birth to Three Program Services - The Connecticut Birth to
Three Program, pursuant to the Individuals with Disabilities Education Act
(IDEA) and Connecticut General Statutes (CGS), provides a range of early
intervention services for eligible children from birth to three years of age
with
16
developmental delays and disabilities. Eligibility of children is
determined by Department of Mental Retardation (DMR) staff or entities
with which DMR contracts. Services are authorized in an Individualized
Family Service Plan (IFSP) and verified by a physician's signature.
3. Inpatient Department of Children and Families (DCF). Operated Psychiatric
Facilities - The discharge planning and reinsurance provisions described
in Section 3.18 (Special Services for children) shall apply to all new
medically necessary and administratively necessary admissions at DCF
operated facilities effective October 1, 1998. When a child is admitted to
a DCF facility, the child will remain enrolled in the MCO and the MCO must
reimburse the DCF facility at the rate as calculated by the Office of the
Comptroller, provided that such admissions shall be governed by a
memorandum of understanding between the MCOs and DCF outlining the terms
and conditions for admission and stays at the facility.
C. NONCOVERED SERVICES
1. Institutions for Mental Disease (IMD) - The federal definition of an IMD
is a hospital, nursing facility, freestanding alcohol treatment center, or
other institution of more than sixteen (16) beds that is primarily engaged
in providing diagnosis, treatment, or care of persons with mental
diseases.
a. IMD Exclusion - Medicaid does not cover IMD services (i.e., these
services are excluded). States, rather than the Federal Government,
have principle responsibility for funding inpatient psychiatric
services; therefore, State funding of IMI)s is not through the
Medicaid program.
b. Exceptions - certain individuals are not part of the IMD exclusion
(i.e., they are covered by Medicaid for services in IMDs):
i. inpatient psychiatric services for individuals under age 21;
ii. individuals 65 years of age or older who are in hospitals or
nursing facilities that are IMDs.
2. Services and/or procedures considered to be of an unproven, experimental,
or research nature or cosmetic, social, habilitative, vocational,
recreational, or educational.
3. Services in excess of those deemed medically necessary to treat the
patient's condition.
4. Services not directly related to the patient's diagnosis, symptoms, or
medical history.
5. Any services or items furnished for which the provider does not usually
charge.
6. Medical services or procedures in the treatment of obesity, including
gastric stapling. When obesity is caused by an illness (hypothyroidism,
Xxxxxxx'x disease, hypothalamic lesions) or aggravates an illness (cardiac
and respiratory diseases, diabetes, hypertension) services in connection
with the treatment of obesity could be covered services.
17
7. Services related to transsexual surgery or for a procedure which is
performed as part of the process of preparing an individual for
transsexual surgery, such as hormone therapy and electrolysis.
8. Services for a condition that is not medical in nature.
9. Routine physical examinations requested by third parties, such as
employers or insurance companies.
10. Drugs that the Food and Drug Administration (FDA) has proposed to withdraw
from the market in a notice of opportunity for hearing.
11. Tattooing or tattoo removal.
12. Punch graft hair transplants.
13. Tuboplasty and sterilization reversal.
14. Implantation of nuclear-powered pacemaker.
15. Nuclear powered pacemakers.
16. Inpatient charges related to autopsy.
17. All services or procedures of a plastic or cosmetic nature performed for
reconstructive purposes, including but not limited to lipectomy, hair
transplant, rhinoplasty, dermabrasion, and chernabrasion.
18. Drugs solely used to promote fertility.
19. Drugs used to promote smoking cessation.
20. Services which are not within the scope of a practitioner's practice under
state law.
18
APPENDIX J
PHYSICIAN INCENTIVE PAYMENTS
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Physician Incentive Plan Disclosure Guidance
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PHYSICIAN INCENTIVE PLAN (PIP)
REGULATION GUIDANCE
OVERVIEW AND GENERAL INFORMATION
- Overview of Physician Incentive Regulation, revised 10/2000
- August 5, 1999 Memo: Survey Update
- Guidance on Disclosure of Physician Incentive Plan Information to
Beneficiaries revised 10/2000
- Compilation of PIP Questions and Answers revised 10/2000
- Glossary of Terms revised 10/2000
COMPLIANCE FORMS AND INSTRUCTIONS
- December 22, 2000 memo: Physician Incentive Plan Regulation
Requirements for 2001
- Managed Care Organization (MCO) Disclosure Compliance Package (1)
for Medicare+Choice Applicants, revised 10/2000; and (2) Data
Summary Form, Worksheet and Instructions for providers who contract
with Managed Care Organizations, revised 10/2000
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OVERVIEW OF THE PHYSICIAN INCENTIVE PLAN REGULATION
FOR MEDICARE MANAGED CARE ORGANIZATIONS
LEGAL BACKGROUND
Legislative action to regulate physician incentive plans (PIP) was first enacted
in the Omnibus Budget Reconciliation Acts (OBRA) of 1986 and 1987. In 1990,
these laws were superseded by a new OBRA. Statutory authority for this
regulation can be found in sections 1876(I)(8) of the Social Security Act (the
Act). These portions of the statute are elaborated by regulation in 42 CFR Parts
417.
Legislation at Section 1852 of the Act created a new Medicare + Choice Program.
Medicare regulations, Part 422, of June 26, 1998, with the final rule in July
2000, include requirements for PIP disclosure at sections 42 CFR 422.208/210.
1. DISCLOSURE REQUIREMENTS
Disclosure to the Health Care Financing Administration
A PIP is defined as "any compensation to pay a physician or physician
group that may directly or indirectly have the effect of reducing or
limiting services furnished to any plan enrollee.@ The compensation
arrangements negotiated between subcontractors of an MCO (e.g.,
physician-hospital organizations, IPAs) and a physician or group are of
particular importance, given that the compensation arrangements with which
a physician is most familiar will have the greatest potential to affect
the physician=s referral behavior. For this reason, all subcontracting
tiers of the MCO=s arrangements are subject to the regulation and must be
disclosed to HCFA. Documents are available on HCFA's web site for an MCO's
use in obtaining data from subcontracting providers.
Note that PIP rules differentiate between physician groups and
intermediate entities.@ Examples of intermediate entities include
individual practice associations (IPAs) that contract with one or more
physician groups, as well as physician-hospital organizations. IPAs that
contract only with individual physicians and not with physician groups are
considered physician groups under this rule.
In order to determine compliance with the law, the information requested
includes the following for each medical group and physician providing
health services to the MCO=s Medicare enrollees:
whether any risk is transferred to the provider
whether risk is transferred to the provide for referral services
what method is used to transfer risk
what percent of the total potential payment to the provider is at risk for
referrals
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what is the number of patients included in the same risk arrangement
if the number of patients is 25,000 or fewer, what is the type and amount
of stop-loss insurance
At the time of application, each organization must report physician
incentive arrangements using the HCFA PIP Disclosure Form (OMB No.
0938-0700). The disclosure form and instructions are available at HCFA=s
web site. The hard copy disclosure form is required to be in the
application.
After approval of a Medicare contract, electronic disclosure is required
for organizations with a Medicare managed care contract as of January 1 of
any year. Organizations should refer to HCFA=s web site for the most
recent information on disclosure requirements, including annual disclosure
dates, method of electronic disclosure, instructions for aggregating and
entering disclosure data and a PIP Questions & Answers document. The
Questions and Answers is an extensive document that provides operational
guidance on preparing PIP disclosures. There are also forms that the MCO
may use to obtain information about incentive arrangements from their
medical contractors.
HCFA's web site is: XXX.xxxx.xxx/xxxxxxxx/xxxxxxxx/xxx-xxxx.xxxx
Disclosure to Beneficiaries
At Medicare beneficiaries= request, MCOs must provide information
indicating whether the MCO or any of its contractors or subcontractors use
a PIP that may affect the use of referral services, the type of incentive
arrangement(s) used, and whether stop-loss protection is provided. If the
MCO is required to conduct a survey, it must also provide beneficiary
requestors with a summary of survey results. (See Guidance on Disclosure
of Physician Incentive Regulation Information to Beneficiaries on HCFA's
web site.)
2. SUBSTANTIAL FINANCIAL RISK (SFR):
Determination of SFR:
The amount of referral risk can be determined by using the following formula:
Amount at risk for referral services
I Referral Risk = Maximum potential payments
The amount at risk for referral services is the difference between the maximum
potential referral payments and the minimum potential referral payments. Bonuses
unrelated to utilization (e.g., quality bonuses such as those related to member
satisfaction or open physician panels) should not be counted towards referral
payments. Maximum potential payments is defined as the maximum anticipated total
payments that the physician/group could receive. If there is no specific dollar
or percentage amount noted in the incentive arrangement, then the PIP should be
considered as potentially putting 100% of the potential payments at risk for
referral services.
The SFR threshold is set at 25% of "potential payments" for covered services,
regardless of the frequency of assessment (i.e. collection) or distribution of
payments. SFR is present when the 25% threshold is exceeded. However, if the
pool of patients that are included in the risk arrangement exceeds 25,000, the
arrangement is not considered to be at SFR because the risk is spread over so
many lives. See pooling rules below.
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The following incentive arrangements should be considered as SFR:
(a) Withholds greater than 25 percent of potential payments.
(b) Withholds less than 25 percent of potential payments if the
physician or physician group is potentially liable for amounts
exceeding 25 percent of potential payments.
(c) Bonuses that are greater than 33 percent of potential payments
minus the bonus.
(d) Withholds plus bonuses if the withholds plus bonuses equal more
than 25 percent of potential payments. The threshold bonus
percentage for a particular withhold percentage may be calculated
using the formula -- Withhold %=0.75 (Bonus %)+25%.
(e) Capitation, arrangements, if the difference between the maximum
potential payments and the minimum potential payments is more than
25 percent of the maximum potential payments; or the maximum and
minimum potential payments are not clearly explained in the
physician's or physician group's contract.
(f) Any other incentive arrangements that have the potential to hold
a physician or physician group liable for more than 25 percent of
potential payments.
Requirements if SFR is determined:
A. Stop Loss Protection
Stop-loss protection must be in place to protect physicians and/or physician
groups to whom substantial financial risk has been transferred. Either aggregate
or per patient stop-loss may be acquired. Aggregate insurance is excess loss
coverage that accumulates based on total costs of the entire population for
which they are at risk and which provides reimbursement after the expected total
cost exceeds a pre-determined level. Individual insurance is where a specific
provider excess loss accumulates based on per member per year claims.
The rule specifies that if aggregate stop loss is provided, it must cover 90% of
the cost of referral services that exceed 25% of potential payments. Physicians
and groups can be liable for only 10%. If per patient stop-loss is acquired, it
must be determined based on the physician or physician group=s patient panel
size and cover 90% of the referral costs which exceed the following per patient
limits:
Combined
Institutional &
Professional Institutional Professional
Panel Size Deductible Deductible Deductible
---------- ---------- ---------- ----------
1-1000 $ 6,000* $ 10,000* $ 3,000*
1,001 - 5000 $ 30,000 $ 40,000 $10,000
5,001 - 8,000 $ 40,000 $ 60,000 $15,000
8,001 - 10,000 $ 75,000 $100,000 $20,000
10,001 - 25,000 $150,000 $200,000 $25,000
> 25,000 none none none
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* The asterisks in this table indicate that, in these situations, stop-loss
insurance would be impractical. Not only would the premiums be Prohibitively
expensive, but the protections for patients would likely not be adequate for
panels of fewer than 500 patients. MCOs and physician groups clearly should not
be putting physicians at financial risk for panel sizes this small. It is our
understanding that doing so is not common. For completeness, however, we do show
what the limits would be in these circumstances.
The institutional and professional stop loss limits above represent the
actuarial equivalents of the combined institutional and professional deductible.
The physician group or MCO may choose to purchase whatever type is best suited
to cover the referral risk in the incentive arrangement.
B. Pooling Criteria
To determine the Patient Panel Size in the above chart, you may pool according
to the specific criteria below. Any entity that meets all five criteria required
for the pooling of risk is allowed to pool that risk in order to determine the
amount of stop loss required by the regulation:
(i) Pooling of patients is otherwise consistent with the relevant
contracts governing the compensation arrangements for the physician
or group;
(ii) The physician or group is at risk or referral services with
respect to each of the categories of patients being pooled;
(iii) The terms of the compensation arrangements permit the
physician or group to spread the risk across the categories of
patients being pooled (i.e., payments must be held in a common risk
pool);
(iv) The distribution of payments to physicians from the risk pool
is not calculated separately by patient category (either by MCO or
by Medicaid, Medicare, or commercial); and
(v) The terms of the risk borne by the physician or group are
comparable for all categories of patients being pooled.
C. Surveys
When substantial financial risk exists for providers or provider groups under
contract with an M+C organization, the organization must conduct periodic
surveys of current and former enrollees.
HCFA=s national administration of the Consumer Assessments of Health Plans Study
(CAHPS) is well established for enrollees and disenrollees. Therefore, HCFA has
determined that Medicare MCOs who are or will be included in CAHPS no longer
need to conduct independent surveys for meeting PIP requirements. HCFA will
consider such MCOs with medical groups or physicians at substantial financial
risk to be in compliance with the survey mandate. Organizations now meet the
survey disclosure requirement of the regulations by giving Medicare enrollees a
copy of the CAHPS enrollment survey results available on the Internet. Further,
these MCOs no longer need to submit survey summaries to HCFA.
3. ENFORCEMENT
As described in 42 CFR section 417.500 and 422.208(i), HCFA may apply
intermediate sanctions or the Office of Inspector General may apply civil money
penalties if HCFA determines that a Medicare plan fails to comply with the
requirements of this rule.
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GUIDANCE ON SURVEYS REQUIRED BY THE PHYSICIAN INCENTIVE REGULATION
The Physician Incentive Regulation requires that MCOs conduct a customer
satisfaction survey of both enrollees and disenrollees (1) if any physicians or
physician groups in the MCO's network are placed at substantial financial risk
for referral services, as defined by the regulation. If a survey is required, it
must be conducted within one year of the MCO's compliance date for disclosure.
That date is the date on or after 1/1/97 on which the MCO contract either renews
or is made effective as a new contract. As long as physicians or physician
groups are placed at substantial financial risk for referral services, surveys
must be conducted annually thereafter.
(1) - There are two separate populations which will require both different
survey instruments and separate sampling strategies.
The survey must include either all current Medicare/Medicaid enrollees in the
MCO and those who have disenrolled in the past twelve months, or a sample of
these same enrollees/disenrollees. It must be designed in accordance with
commonly accepted principles of survey design, implementation, and analysis. The
survey must address enrollees/disenrollees satisfaction with the quality of
services provided and their degree of access to the services. This document is
intended to provide you with some guidance regarding the selection and
administration of surveys that will satisfy the requirement.
BACKGROUND -- CUSTOMER SATISFACTION SURVEYS -- THEIR CURRENT STATE
There are numerous consumer satisfaction instruments currently in use by MCOs,
states, business coalitions, and other organizations. Industry, the government,
and consumer groups are in agreement that it would be highly desirable to
consolidate support behind one instrument that everyone could use to survey
their customers, so that the results obtained could be compared and the need for
MCOs and other entities to field separate surveys in response to different
demands could be eliminated. However, while much progress has been made towards
the achievement of that goal, it will probably not be realized for at least
another year or two Therefore, until such agreement is reached, it will be
necessary for you to choose your own survey(s). This letter is intended to
assist you in the selection process.
SELECTING A SURVEY - GETTING STARTED
When considering the selection of an instrument, it is also important to
evaluate the resources you have to actually conduct a survey. If you do not have
sufficient skilled personnel, computer capacity, and other resources needed to
conduct a mail, telephone, or in person survey and analyze and report the
results, you will have to hire an outside contractor to perform these tasks.
Consultation with some of the contact persons listed on the attached reference
guide and learning about their experiences may assist you in making a decision
about the most appropriate method of implementation.
THE "CAHPS" SURVEYS. In addition to perusing the reference guide, it is
important for you to be aware of a major national initiative already well
underway to develop a set of standardized consumer satisfaction instruments,
user manuals, and recommended report formats. This effort is sponsored by the
Agency for Health Care Policy and Research (AHCPR) through their Consumer
Assessments of Health Plans Study (CAHPS) process. CAHPS is a five year project,
funding three grantees, RAND, Research Triangle Institute and Harvard, in a
cooperative arrangement designed to produce a set of
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Guidance on Surveys Required by the Physician Incentive Plan Regulation
consumer satisfaction instruments that will be capable of yielding
comparable data for the commercial, Medicare, Medicaid, chronically
ill/disabled, and child populations. The surveys, accompanying manuals,
and report formats will be available to the public in early spring of
1997.
The CAHPS instrument will satisfy the requirement for a customer
satisfaction survey of enrollees. Unfortunately, a planned CAHPS
disenrollment module will not be available until 1999. Until then, each
MCO is responsible for developing its own disenrollee survey. While this
survey does not require HCFA approval, routine HCFA monitoring will
include validating the questions and sampling methodology before the
findings can be marketed to enrollees.
As of the 1997 contract year, all MEDICARE contracting MCOs whose
contracts were in effect on or before 1/1/96 will be required to
participate in an independent administration of the Medicare version of
the CAHPS survey sponsored by HCFA. HCFA will not make the same
requirement of Medicaid MCOs with respect to the use of the Medicaid
version of CAHPS, but individual States have the authority to do so. You
may obtain a set of the draft instruments (which are currently being field
tested) from AHCPR by calling 0-000-000-0000. Request document number
96R114.
SURVEYING ENROLLEES AND DISENROLLEES
As mentioned earlier, the regulation requires that both enrollees and
disenrollees be surveyed. Because they are two separate populations,
different instruments and sampling strategies must be employed. Just as
there is no current national standard for enrollee satisfaction surveys,
neither is there one for disenrollees, although individual MCOs have
frequently surveyed their disenrollees. It is important to recognize that
different questions are asked of the two groups, and that therefore, the
same survey cannot be used for both populations. Most surveys of enrollees
ask for ratings or reports of their recent experiences in the MCO, while
surveys of disenrollees focus on what circumstances contributed to their
decision to leave the MCO.
In addition, the sampling strategies for the two populations differ.
Enrollees are those who are still getting their care from the MCO and are
often defined as those who have been continuously enrolled in a MCO for
six months or longer. By contrast, disenrollees are those who have left
the MCO and are defined by both the length of time that has elapsed since
they left and the length of time they were enrolled in the MCO. Different
reasons for disenrollment are associated with these factors: how soon
disenrollees are surveyed after they have left a MCO (e.g., several weeks,
several months, or a year or more) will affect the quality of their recall
and influence their answers; those who spent only a brief period of time
in the MCO before leaving ("rapid" disenrollers) often have different
reasons for leaving than do those who were enrolled for a year or more
before leaving. The Physician Incentive Regulation specifies that
disenrollees must be surveyed within one year of leaving the MCO.
Beneficiaries who were disenrolled due to loss of Medicaid eligibility or
relocation out of the MCO's service area do not need to be surveyed.
DISSEMINATION OF SATISFACTION RESULTS TO CONSUMERS
The regulation says that MCOs that are required to conduct a survey must
provide a summary of the survey results to any beneficiary who requests
the information. Distribution of satisfaction information to consumers is
a relatively recent development, and both experience and research on how
best to present such information is limited. Employers and other
purchasers, who have been in the forefront of such information efforts and
have the most experience, only began in the last three to five years.
Frequently, satisfaction information has been presented in a "report card"
format and disseminated through the workplace, sent by direct mail to the
consumer, or displayed in newspapers (Minnesota presented their results in
the Minneapolis-Star Tribune) or magazines (Health Pages). The state of
Massachusetts has conducted cutting-edge research to determine how best to
present the results of comparative performance measures, including
satisfaction surveys, to their Medicaid population, and is in the midst of
an initiative to provide that information in a consumer friendly format.
Again, one of the best ways to determine how to successfully present the
results of these
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Guidance on Surveys Required by the Physician Incentive Plan Regulation
surveys is to consult with state, private employer, or MCO counterparts
who have already attempted to distribute the results of satisfaction
surveys to their customers.
MCOs will be expected to compile, analyze and summarize survey data within
a reasonable period of time after conducting the survey. Generally, this
would mean summary survey results should be available to beneficiaries and
provided to regulators within four months of conducting the survey.
FUTURE STRATEGIES -- A FINAL NOTE
At present, most consumer satisfaction surveys require a random sample of
enrollees within a MCO, so that at best, MCO to MCO comparisons can be
made. MCO participation in the administration of customer satisfaction
surveys at the MCO level appears to meet the letter of the regulation's
requirement for MCOs to perform satisfaction surveys when physicians or
physician groups are placed at substantial financial risk for referrals.
However, in order to determine whether access and quality of care are
truly affected by differing risk arrangements, it is necessary to obtain a
statistically valid sample of beneficiaries in those physician groups
whose incentive arrangements put them at substantial financial risk and
compare them to beneficiaries served by groups that are not at substantial
financial risk. Because the current sampling strategy for most consumer
satisfaction surveys is at the MCO level, they cannot provide this needed
level of specificity. Thus, HCFA is considering both methods to accurately
identify those physician groups at substantial financial risk and the
development of sampling strategies that will permit the needed data to be
collected so that the relevant comparisons can be made. HCFA is
considering whether MCOs should be required, in future years, to sample at
the physician group level in order to properly deal with the concerns this
regulation addresses. For now, MCOs are required to sample at the market
level, rather than sample from a nationwide or regional base of
enrollees/disenrollees.
In conjunction with the CAHPS survey effort, HCFA will assess each
Medicare MCO's contract service area to determine whether sampling,
collecting, and reporting of data should be conducted on the basis of the
MCO's contract service area, or by Metropolitan Statistical Area (MSA).
The MSA approach will apply in cases where an MCO's service area includes
more than one "market area" (i.e., covers more than one major community or
city) or covers multiple states. HCFA expects to notify Medicare MCOs as
to whether the MSA approach is warranted by the end of 1997. Medicare MCOs
should conduct the disenrollee survey needed for the physician incentive
regulation according to the same method (contract service area or MSA)
determined necessary for the purposes of the CAHPS survey. Medicaid MCOs
are encouraged to contact their State Medicaid Agency contacts if they are
unsure as to whether the MSA approach is needed for their conduct of the
physician incentive enrollee and disenrollee surveys.
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GUIDANCE ON DISCLOSURE OF PHYSICIAN INCENTIVE PLAN INFORMATION TO MEDICARE
BENEFICIARIES
Managed Care Organizations (MCOs) are required to provide information on the
incentive arrangements affecting the MCO's physicians to any person receiving
Medicare (i.e., a "beneficiary") who requests the information. Therefore, MCOs
must make the following pieces of information available, upon request, to
current, previous, and prospective enrollees:
1. Whether the MCO's contracts or subcontracts include physician
incentive plans that affect the use of referral services.
2. Information on the type of incentive arrangements used.
3. Whether stop-loss protection is provide for physicians or physician
groups.
4. If the MCO is required by the regulation to conduct a customer
satisfaction survey, a summary of the survey results.
HCFA's Regional Offices (ROs) will review Medicare MCO materials related to this
regulation as part of their usual responsibilities for pre-approving beneficiary
materials. The ROs have received initial guidance regarding the review of
materials related to this regulation and will continue to receive technical
assistance in this area from core Central Office staff assigned to the
implementation of this regulation. These efforts are being undertaken so as to
balance MCOs' desire for flexibility in the crafting of beneficiary information,
while still assuring that materials are compliant with the regulation and
consistent nationwide.
HCFA's national administration of the Consumer Assessments of Health Plans Study
(CAHPS) is well established and includes both enrollees and disenrollees.
Therefore, HCFA has determined that the Medicare MCOs who will be included in
CAHPS no longer need to conduct independent surveys for meeting PIP
requirements. HCFA will consider all such Medicare MCOs with medical groups or
physicians at substantial financial risk to be in compliance with the survey
mandate in 42 CFR 422.208/210.
Medicare MCOs can now meet the survey disclosure requirement of the regulations
by giving Medicare enrollees a copy of the CAHPS enrollment survey results
available on the Internet.
The remainder of this document offers guidance on how your MCO may best provide
information required by this regulation to beneficiaries who request it.
***************************************
SUGGESTED LANGUAGE FOR THE ANNUAL NOTICE AND FOR PRE-ENROLLMENT MATERIALS SUCH
AS THE MEMBER HANDBOOK: If you are considering enrolling in our plan, you are
entitled to ask if the plan has special financial arrangements with our
physicians that can affect the use of referrals and other services that you
might need. To get this information, call our Member Services Department at
(telephone number) and request information about our physician payment
arrangements. [Note to MCOs: MCOs may note in any materials that the information
required to be available for beneficiaries and provided to regulators may not
yet be collected by the MCO due to the fact that Federal guidance as to how
MCOs' should comply with the regulation was only recently received.]
SUGGESTED LANGUAGE FOR THE EVIDENCE OF COVERAGE: You are entitled to ask if we
have special financial arrangements with our physicians that can affect the use
of referrals and other services that
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Physician Incentive Plan Regulation Disclosure Requirements
you might need. To get this information, call our Member Services Department at
(telephone number) and request information about our physician payment
arrangements.
SUGGESTED RESPONSE TO REQUEST FROM BENEFICIARY: HCFA requires us to give our
members important information about the contractual relationships we have with
our physicians. These contractual relationships include the way we pay
physicians and could affect your use of referrals and other services that you
might need. To understand these arrangements, we need to define several words.
[Note to MCOs: You do not need to include any terms that are not used in the
incentive plans of your physicians.]
1. DISCOUNTED FEE FOR SERVICE Physicians are paid a pre-determined
amount for each service they provide. Both the physicians and the
HMO agree on this amount each year. This amount may be different
than the amount the physician usually receives from other payers.
2. CAPITATION. Physicians are paid a fixed amount of money each
month to provide specific services to the members they see. This
capitation payment may be divided into separate amounts for the
services they provide directly to their patients, services provided
by referral physicians, and for hospital and other types of
services.
3. BONUS. At the beginning of each year, both physicians and the HMO
agree on a goal for the amount of services or cost of services
patients will use. At the end of the year, the HMO pays physicians
an extra amount of money if patient care cost less money or patients
used fewer services than the budgeted goal agreed to at the
beginning of the year.
4. WITHHOLD. At the beginning of each year, both physicians and the HMO
agree on a goal for the amount of services or the cost of services
their patients will use. However, the HMO keeps a portion of this
payment. At the end of the year, if physicians overspend or exceed
this budgeted goal, the HMO keeps the amount of money it withheld.
If physicians underspend or use fewer services than budgeted, the
HMO gives the withheld amount of money back to the physicians.
5. STOP-LOSS INSURANCE. Special insurance for physicians that protects
them from very large financial losses. HCFA requires physicians to
have this insurance if more than 25 percent of their pay could be
lost if they refer patients for more than the HMO budgeted goal.
[Note to MCOs: MCO should note here or elsewhere in the notice
whether or not stop-loss protection is provided to your physicians
and physician groups if required by the regulation.]
We have several different types of contractual an arrangements with our
physicians. Your physician is paid according to one or more of the following
types of arrangements. [Note to MCOs: The following are some examples of
arrangements frequently used in the contracts or subcontracts of MCOs. You
should provide general descriptions on a representative sample of arrangements
used in your contracts and subcontracts. This set of descriptions can then be
used for all beneficiaries requesting physician incentive plan information. You
are not expected to provide specific information on the incentives faced by a
given beneficiary's physician.]
- ARRANGEMENT A. We pay our physicians a salary. At the end of the
year, physicians can get a bonus if their patients used fewer
referral services than the budgeted goal.
- ARRANGEMENT B. We pay our physicians a capitation for primary care.
We withhold separate amounts for referral and for hospital services.
At the end of the year, physicians can get these amounts paid to
them if their patients used fewer referral services and spent fewer
days in the hospital than the budgeted goals.
- ARRANGEMENT C. We pay our physicians discounted fee-for service. We
withhold a separate amount for referral services. At the end of the
year, physicians can get this amount paid to them if their patients
used fewer referral services than the budgeted goal. We also pay
physicians a bonus if their patients spent fewer days in the
hospital than the budgeted goal.
[IF AN ARRANGEMENT WITH A PHYSICIAN GROUP OR PHYSICIAN IS AT SUBSTANTIAL RISK,
INCLUDE A STATEMENT ABOUT SURVEYS]
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Physician Incentive Plan Regulation Disclosure Requirements
The Health Care Financing Administration conducts an annual study of Medicare
members called the Consumer Assessments of Health Plans Study (CAHPS) of both
enrollees and disenrollees of (Your MCO's name). You can request information
about the results of this survey by contacting our Member Services Department
at (telephone number). We will send you the results of the survey as soon as we
receive it from HCFA.
[LOGO] Return to Physician Incentive Plan Information Page
[LOGO] Return to Medicare Managed Care Homepage
Last Updated December 15, 0000
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HEALTH & HUMAN
SERVICES LOGO]
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MEDICARE MEDICAID CHIP CUSTOMER SERVICE FAQs SEARCH
HEALTH CARE FINANCING ADMINISTRATION
PHYSICIAN INCENTIVE PLAN REGULATION
FOR MEDICARE MANAGED CARE ORGANIZATIONS
QUESTIONS AND ANSWERS
COMPILATION OF 1996, 1997 AND 1998
UPDATED OCTOBER 2000
Table of Contents
You may link directly to any of the following question topics or scroll
down through the complete listing.
- Substantial Financial Risk
- Stop Loss Protection
- Disclosure
- Survey
- Miscellaneous
****************************************
PHYSICIAN INCENTIVE PLAN REQUIREMENTS FOR MEDICARE
COMPILATION OF 1996 AND 1997 QUESTIONS AND ANSWERS, UPDATED AUGUST 2000
The PIP requirements apply to the M+C Organizations, Section 1876 Cost and
Closed Cost Healthplans, Social HMOs, Medicare Choices, Evercare and other
demonstrations where the PIP requirement is not waived.
SUBSTANTIAL FINANCIAL RISK
DEFINITION:
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Substantial financial risk is set at greater than 25% of potential payments for
covered services. The term "potential payments" means the maximum anticipated
total payments that the physician or physician group could receive if the use or
cost of referral services were low enough. If the cost of referrals exceeds the
25% level, the financial arrangement is considered to put the physician or group
at substantial financial risk.
For example, a doctor contracts with an MCO and that MCO holds back a certain
amount of the doctor's pay (e.g., $6 per member per month). The MCO will give
the doctor the $6 per member per month only if the cost of referral services
falls below a targeted level. Those six dollars are considered to be "at risk"
for referral services. The amount is equal to the difference between the maximum
potential referral payment and the minimum potential referral payment (but does
not include any bonus payment unrelated to referral services). The six dollars
is put into the numerator of the risk equation.
The denominator of the risk equation is equal to the maximum potential payment
that the doctor could receive which is the sum of the MCO payment for directly
provided services, referral services and administration. Therefore, if the same
doctor receives $24 per member per month for the primary care services he
provides, and is subject to the $6 withhold, the risk equation is as follows:
Risk level: 6/24 = 25% Not at substantial financial risk.
If risk is substantial (>25%), in addition to stop-loss insurance the MCO must
conduct a survey of patient satisfaction that includes information from current
enrollees and recent disenrollees.
Note: If a physician group's patient panel is more than 25,000 patients, then
that physician group and the group's physicians are not considered to be at
substantial financial risk. The group's arrangements do not trigger the need for
a beneficiary survey, and the group and the group's physicians are not required
by the regulation to have stop-loss protection. For the purpose of making this
determination, the patients of the group can be pooled across MCOs and across
Medicare, Medicaid, and commercial enrollees if specific criteria are met. See
Stop-loss Protection (SLP) Questions 6-17 below for additional clarification on
pooling issues.
QUESTIONS AND ANSWERS:
SFR QUESTION 1: For purposes of calculating substantial financial risk, are
ancillary services considered referral services?
ANSWER: If the physician group performs the ancillary services, then
the services are not referral services. If the physician group
refers patients to other providers (including independent
contractors to the group) to perform the ancillary services, then
the services are referral services.
SFR QUESTION 2: How does the regulation affect provider groups that are licensed
in a state and are allowed to accept full risk?
ANSWER. The regulation does not prohibit groups from accepting full
risk for all health services. It requires appropriate parties to
ensure that adequate stop-loss is in place and that beneficiary
surveys be conducted when the 25 percent threshold is exceeded.
SFR QUESTION 3: If a physician is paid straight capitation (i.e., the
compensation arrangement calls for no withholds or bonuses), and that capitation
covers services that the physician does not provide, would the physician be at
substantial financial risk?
ANSWER: Yes, this compensation arrangement would require a finding
of substantial financial risk, because the risk is not limited. If a
capitation arrangement places no limit on the referral risk, it
essentially requires a finding of 100% risk (with potentially
greater risk).
SFR QUESTION 4: Does the determination of risk apply only to Medicare covered
benefits, or if the MCO provides additional benefits at its own expense, should
these be included in the determination?
ANSWER. All payments related to referral services furnished to
enrolled Medicare beneficiaries are to be included in the risk
determination, even if those services are not Medicare covered
services.
SFR QUESTION 5: Will HCFA include quality bonuses in the denominator of the
equation for substantial financial risk?
ANSWER. No. The regulation does not include quality bonuses as a
factor in the substantial financial risk
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calculation. A bonus based upon quality and/or access should not be
counted in either the numerator (amount at risk) or the denominator
(maximum potential payments).
SFR QUESTION 6: Would a physician be at substantial financial risk if his/her
MCO's annual payment to him/her for services and administration total $100,000
and the organization withholds 25 percent (or $25,000) to cover deficits in the
referral or inpatient hospital pool? Assume the MCO does not hold the physician
liable for referral costs that exceed the withhold.
ANSWER: No. The physician is not at substantial financial risk
because s/he is not at risk for more than 25 percent of payments.
SFR QUESTION 7: Please clarify how substantial financial risk is determined when
various risk arrangements are used. a. Say an MCO pays its doctors $100 per
member per month and puts $24 at risk through a withhold, then the same doctors
are part of a physician-hospital risk pool where they can get $50 if utilization
goals are met. Is the risk seen as 24/100, 50/50, 74/150, or something else?
b. Assume that an MCO pays its physicians based on a fee schedule with
risk-sharing arrangements that do not trigger SFR. Also assume that the MCO
subcontracts with a disease management company to manage cases of patients with
a certain disease. The disease management company pays the physicians in a
variety of different ways, some of which put the physicians at risk for referral
services. For purposes of SFR analysis, should each source of payment (MCO and
disease management company) be analyzed separately?
ANSWERS:
a. The risk is 74/150 and therefore the doctors are at substantial
financial risk. The ratio is arrived at by adding the amount at risk
for referral services (the sum of the withhold and hospital pool
bonuses [24 + 50]) then dividing by the sum of the maximum potential
payment [100 + 50].
b. No. The payments from both the MCO and the disease management
company must be analyzed together to arrive at a single analysis of
SFR for these patients of the MCO.
SFR QUESTION 8: If a contractor capitates a physician group comprised of
physicians (e.g., psychiatrists) and non-physicians (e.g., other mental health
providers), would the calculation to determine substantial financial risk
assumed by the group change if the group is comprised exclusively of physicians?
ANSWER: No. As long as physicians are part of the group and the
contracted services include physician services, the calculation of
the amount of risk transferred to the physicians remains the same.
However, non-physician services can be calculated as part of the
costs analyzed in the substantial financial risk equation.
SFR QUESTION 9: Would a physician be at substantial financial risk in the
following example? An MCO's annual payments to this physician total $100,000 and
the MCO imposes a 20 percent withhold ($20,000) for referrals. In addition, the
MCO holds the physician liable for up to $5,000 of any referral costs not
covered by the withhold. The physician's referrals total $35,000, exceeding the
withhold by $15,000; however, the MCO does not hold its physicians liable for
amounts over 25 percent of payments (or $25,000).
ANSWER: No, the physician is not at substantial financial risk
because the risk is limited to $25,000, which is the maximum
liability imposed by the MCO based on written contractual
provisions.
SFR QUESTION 10: Is a physician at substantial financial risk if his/her
payments from the MCO total $75,000, s/he does not exceed utilization targets
for referral and inpatient hospital services, but s/he is eligible for a $25,000
bonus (33 percent of $75,000).
ANSWER: No, because this physician's bonus did not exceed the limit
of 33 percent of potential payments, not counting the bonus itself
(in other words, 25 percent of the potential payments if you
included the bonus as part of the potential payments).
SFR QUESTION 11: What if an MCO has the following arrangement: A physician is
not permitted to keep any savings from the referral account. Then if referrals
cost less than $100,000, the physician must return the remainder of the referral
account to the MCO. If referral costs are more than $100,000, s/he may be liable
for up to 25 percent of the capitation for his/her own services. The contract
clearly states the following:
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If referrals exceed $125,000, the physician will receive no less
than $75,000. If referrals are less than $100,000, the physician
will receive no more than $100,000.
Question: Is this physician at substantial financial risk?
ANSWER: No. The difference between the maximum potential payments
($100,000) and the minimum potential payments ($75,000) is no more
than 25 percent of the maximum potential payments (the difference is
$25,000). Therefore the physician is not at substantial financial
risk.
SFR QUESTION 12: Must a plan that places its physicians at SFR disclose to HCFA
the exact percentage for which the physicians are at risk? Is it sufficient for
the MCO to simply check the box that acknowledges that SFR has been triggered,
but not specify the exact percentage over the threshold?
ANSWER: MCOs and their subcontracting providers are expected to
disclose a reasonable estimate of the percentage for which the
physician, physician group, or intermediate entity in question is at
risk for referrals. If a reasonable percentage estimate cannot be
determined, the disclosure should specify "100%."
SFR QUESTION 13: What if the MCO has a performance history of three or five
years and can show that its physicians have not lost more than 25% of the
capitated amount?
ANSWER: Regarding the use of past history as a means of predicting
future behavior, such experience is no guarantee of future referral
behavior or the future health care needs and costs of the current
enrollees served. If historical performance shows that physicians
have never lost more than 25% of the capitated amount, the MCO can
modify its physician contracts to contractually limit risk to that
historical amount (25%) and hence avoid a determination of SFR and
the need for stop-loss insurance and surveys.
SFR QUESTION 14: Consider the following scenario: An MCO enters into a capitated
contract with a physician group for all professional services. Under the
contract the physician group has the option to provide the professional services
or subcontract with qualified specialists for such services. The physician
group's patient panel is less than 25,000. Does the MCO contract place the
physician group at substantial financial risk?
ANSWER: Yes. The option to subcontract for specialist services means
that the physician group is potentially at risk for services not
directly provided by the group.
SFR QUESTION 15: If the physician group in SFR Question 16 decides to
subcontract for certain services, are the physician specialist subcontractors
subject to regulation under the PIP rule?
ANSWER: Yes.
SFR QUESTION 16: What should be considered a referral service when determining
substantial financial risk for referrals? Should such things as pharmaceuticals
and DME be considered referral services?
ANSWER: Any service that a physician does not provide him or
herself, or that is not provided by another member of the
physician's group, should be considered a referral service. Whether
or not such referrals contribute to the financial risk borne by the
physician will depend on whether his or her compensation
arrangements are such that referrals for those services or supplies
could impact upon the physician's income.
SFR QUESTION 17: When calculating SFR, should MCOs use the theoretical potential
payment, or the probable potential payment?
ANSWER: The theoretical payment should be used, based on the terms
of the physician's contract.
STOP LOSS PROTECTION
DEFINITION:
Organizations whose contracts or subcontracts place physicians or physician
groups at substantial financial risk must ensure that those providers have
either aggregate or per-patient stop-loss protection as appropriate for their
patient panel
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The aggregate stop-loss protection requires coverage of at least 90% of the
costs of referral services that exceed 25% of potential payments. The
per-patient stop-loss protection requires coverage of 90% of the costs of
referral services that exceed specified per-patient limits.
QUESTIONS AND ANSWERS:
SLP QUESTION 1: What does stop-loss protection mean?
ANSWER: Stop-loss is a type of insurance coverage designed to limit
the amount of financial loss experienced by a health care provider.
An MCO or physician group normally buys this insurance so that, if
the liabilities of the MCO or group exceed what is expected based on
prior experience, the insurer will "stop" further losses by paying
the liabilities which exceed either a total dollar (aggregate)
amount, or a per patient amount.
SLP QUESTION 2: Is the MCO required to provide stop-loss protection to
physicians or physicians groups at substantial financial risk?
ANSWER:
The MCO does not itself need to provide the stop-loss protection.
However, the MCO must assure that stop-loss is in effect and
disclose the stop-loss type and amounts for any contractor or
subcontractor that exceeds the 25% risk threshold and is required to
have stop-loss protection.
SLP QUESTION 3: Does stop-loss protection apply only to referral services?
ANSWER: Generally, stop-loss protection applies to the costs of all
services furnished by a physician or physician group. For the
purposes of this regulation, however, stop-loss coverage must cover
at least 90% of the costs of referral services above the substantial
financial risk threshold. The physician or physician group is liable
for no more than 10% of the remaining referral costs above the
threshold.
SLP QUESTION 4: If a MCO or physician group chooses to obtain per-patient
stop-loss protection for the purposes of this regulation, what are the
appropriate per-patient stop-loss deductibles, or attachment points, that are
required?
ANSWER: HCFA allows the provision of either a combined deductible
that includes inpatient and professional services or separate limits
for professional and institutional services. Based on actuarial
analyses and consultation with experts knowledgeable about t
stop-loss insurance practices, these limits are indicated in the
following table:
Combined Institutional
& Professional Institutional Professional
Panel Size Deductible Deductible Deductible
---------- ---------- ---------- ----------
1-1000 $ 6,000* $ 10,000* $ 3,000*
1,001 - 5000 $ 30,000 $ 40,000 $10,000
5,001 - 8,000 $ 40,000 $ 60,000 $15,000
8,001 - 10,000 $ 75,000 $100,000 $20,000
10,001 - 25,000 $ 150,000 $200,000 $25,000
> 25,000 none none none
* NOTE REGARDING SMALL PATIENT PANELS: THE ASTERISKS IN THIS TABLE INDICATE
THAT, IN THESE SITUATIONS, STOP-LOSS INSURANCE WOULD BE IMPRACTICAL. NOT ONLY
WOULD THE PREMIUMS BE PROHIBITIVELY EXPENSIVE, BUT THE PROTECTION FOR PATIENTS
WOULD LIKELY NOT BE ADEQUATE FOR PANELS OF FEWER THAN 500 PATIENTS. MCOS AND
PHYSICIAN GROUPS CLEARLY SHOULD NOT BE PUTTING PHYSICIANS AT FINANCIAL RISK FOR
PANEL SIZES THIS SMALL. IT IS OUR UNDERSTANDING THAT DOING SO IS NOT COMMON. FOR
COMPLETENESS, HOWEVER, WE DO SHOW WHAT THE LIMITS WOULD BE IN THESE
CIRCUMSTANCES.
SLP QUESTION 5: Does aggregate stop loss take panel size into account?
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ANSWER: Yes. To the extent that aggregate stop-loss limits require
coverage of 90% of the costs of referral services that exceed 25% of
potential payments, those limits reflect payments based on panel
size.
SLP QUESTION 6: Under what circumstances is pooling permissible for purposes of
determining the appropriate stop loss limit?
ANSWER: The Medicare, Medicaid and commercial enrollees of one or
more MCOs served by a physician group may be pooled as long as
certain criteria are met. The pooling of patients calculation may be
applicable as following examples show. The calculation may show that
the physician group serves more than 25,000 patients and, therefore,
stop-loss protection is not needed. Or the calculation may show that
the physician group serves 25,000 or fewer patients, in which case
stop-loss is required if the incentive arrangements put the group at
substantial financial risk. If per patient (as opposed to aggregate)
protection is obtained, it must be for the single combined or
separate professional and institutional limits shown above. The
group's pooled patient panel size would determine the required level
of stop-loss.
Pooling of patients is allowed only if all of the following five
criteria are met:
- Pooling is otherwise consistent with the relevant contracts
governing the compensation arrangements for the physician or
physician group.
- The physician or physician group is at risk for referral services
with respect to each of the categories of patients being pooled.
- The terms of the compensation arrangements permit the physician or
physician group to spread the risk across the categories of patients
being pooled.
- The distribution of payments to the physicians from the risk pool is
not calculated separately by patient category.
- The terms of the risk borne by the physician or physician group are
comparable for all categories of patients being pooled.
SLP QUESTION 7: If the capitation rate or fee-for-service schedule is different
among three lines of business due to the expected differences in health care
needs and resultant costs for the Medicare, Medicaid and commercial populations,
does this mean these patients cannot be pooled?
ANSWER: Specific criteria must be met in order to pool patients
across product lines and/or across MCOs. See SLP Question 6 above.
SLP QUESTION 8: Stop Loss Requirements By Contracting Level -- HCFA has said
that arrangements between HMOs and PHOs are not subject to the stop-loss
arrangements because the PHO is not a physician group. Is the answer still the
same if we look at a contract between an HMO and an IPA where the IPA is not a
"physician group" because some (but not all) of its contracts are with physician
groups and not individual physicians? Our principle interest is the stop-loss
arrangement requirements.
ANSWER: In this case, the IPA, like the PHO, is defined as an
Intermediate Entity. The Intermediate Entity itself is not subject
to stop-loss, however those physicians who are individually
contracted with the IPA would need to be protected by stop-loss, if
they are put at SFR by incentive arrangements. Stop-loss coverage is
required for physician groups at SFR, physicians at SFR, and for
physicians in groups that are at SFR.
SLP QUESTION 9: Pooling by Entities Other than Physician Groups -- Can a managed
care organization pool the patient lives served by some or all of its
subcontracted physicians for the purposes of determining the level of stop loss
protection necessary? If so, can an IPA, PHO, or other "intermediate entity"
under the regulation pool the patient lives served by their physicians?
ANSWER: Any entity that meets all five criteria required for the
pooling of risk is allowed to pool that risk in order to determine
the amount of stop-loss required by the regulation. We would point
out, however, that unrelated entities or physicians being pooled are
typically covered by the same reinsurance arrangement.
SLP QUESTION 10: Consider the following example: Otherwise unaffiliated primary
care physicians are organized into pools of doctors or "PODs" and risk pool
withholds and bonuses are distributed based on the overall performance of the
POD. PCPs will be paid on a fee-for-service basis with a withhold of 20 percent.
PCPs would have no further downside financial risk beyond the 20 percent
withhold. A budget is established for each POD based on all expected medical
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expenses. If the POD's expenses are less than budgeted expenses, the withholds
are returned and any additional surpluses are distributed to the PCPs in that
POD based on a formula. The formula for distributions of withholds and bonuses
to PCPs in the POD would be based on the same methodology for all PCPs within
their respective PODs. In this example, would HCFA agree that any individual POD
meets the criteria for pooling and, therefore, the level of stop loss protection
that must be provided may be determined based on the size of the POD's patient
panel?
ANSWER: As long as all five conditions in the regulation related to
pooling are met (see SLP Question 6 above), then the patients in the
POD meeting those pooling conditions can be pooled. Thus, a POD
could be considered for pooling purposes, even if that POD is not a
legal entity unto itself.
SLP QUESTION 11: Consider this scenario: A PHO contracts with many physician
groups. The groups get a percent of premium revenue from the PHO. Each group
shares risk separately. However, the PHO purchases stop loss for all of the
groups. The stop-loss reinsurance payments (recoveries) are credited to the
group where the patient is assigned. Can the PHO pool patients covered under all
the groups in determining the amount of stop loss to purchase?
ANSWER: No. The stop loss amounts need to be based on each group's
patient panel size because the groups are managing the risk within
each group, rather than sharing it across all the groups. In this
example, the referral risk is not commonly pooled across the groups,
even though it is reinsured across all groups. Each group will
retain the revenue from the percent of premium it received dependent
upon the experience and reinsurance recoveries attributable to that
particular group.
SLP QUESTION 12: What if separate risk pools are combined at the end of the year
for distribution purposes? If the surplus in one offsets the deficit in another,
could we say that the risk is commonly pooled?
ANSWER: If the surplus in one pool, or part of the pool, offsets the
deficit in another pool, or part of the same pool, then the risk
would not be considered truly pooled according to the regulation.
Basically, the lives can be pooled if the physician is not going to
get separate checks based on different patient categories, or if
there is not a separate accounting by patient category showing how
the experience of the different patients contributed to the outcome
of the single check.
SLP QUESTION 13: What is meant by the pooling condition that incentive
arrangements be "comparable for all categories of patients being pooled"? For
example, can patients be pooled by the group when the extent of risk borne by
the group is greater with one MCO than with another? Say the same physician
group contracts with two MCOs where both arrangements are fee-for-service with a
withhold. Based on SFR calculations, 28% of the total maximum payment from MCO A
is at risk for referrals, while 33% of the same group's maximum payment from MCO
B is at risk for referrals. Can the group pool the patients of MCOs A and B for
the purpose of determining the appropriate amount of stop-loss to acquire?
ANSWER: Yes, the extent of risk in these two MCO contracts with the
physician group would be considered comparable. However, HCFA
prefers not to set a hard and fast definition of what is comparable
given the rapid and complex development of payment arrangements
under managed care. MCOs are expected to use their best judgment in
determining whether arrangements are to be considered comparable.
SLP QUESTION 14: If a physician is at SFR, is stop loss protection needed to
cover all the physician's patients (including commercial enrollees), or only for
Medicare beneficiaries.
ANSWER: Stop-loss must cover 90% of the risk the physician
experiences for referral costs for Medicare patients that exceed the
risk threshold. Commercial and Medicaid patients may be "pooled"
with Medicare patients in order to determine the amount of stop-loss
required for the latter patients without necessitating that the
commercial patients be covered by the same level of stop-loss
coverage. This is because the referral risk attributable to the
Medicare patients is lessened by the fact that the physicians are
also serving Medicaid and commercial patients under similar risk
arrangements.
SLP QUESTION 15: If separate policies are in place for institutional and
professional stop loss coverage by the same group, do the "combined" or
"individual" stop-loss limits apply?
ANSWER: If a group has separate policies for institutional and
professional, then the stop loss needs to be in compliance with
those separate limits for each part of the policy. (E.g., if patient
panel is 1500, the group would need a $40,000 institutional
deductible and a $10,000 professional services deductible.)
SLP QUESTION 16: Can a group that contracts with both an MCO with a Medicare
contract and another MCO without a Medicare contract pool patients from both
MCOs in order to meet stop-loss requirements?
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ANSWER: Yes, as long as the five pooling conditions cited in the
regulation are met. See SLP Question 6 above.
SLP QUESTION 17: For subcontractors with PIPs where substantial financial risk
exists and stop-loss coverage is required, what responsibility does the MCO have
for validating that stop-loss coverage is in place, outside of completion of the
summary charts based on information provided by the subcontractor?
ANSWER: Since the MCO contracting with HCFA may face intermediate
sanctions and civil money penalties for non-compliance by any
contracting provider within its network, the MCO would be wise to
validate information submitted to it by a subcontractor regarding
which the MCO has any question. As part of monitoring related to
this regulation, HCFA expects to sample for validity information
submitted by MCOs and their subcontractors.
SLP QUESTION 18: When is an IPA required to have stop-loss coverage for itself?
Answer: The regulation specifies that the MCO must provide proof
that the physician or physician group has adequate stop-loss, if the
group and/or the physicians are at SFR. The regulation further
specifies that an IPA is a physician group only if it is composed of
individual physicians. If an IPA contracts with one or more
physician groups then it is an intermediate entity. The IPA is
exempt from a stop-loss requirement if it contracts with at least
one physician group. As a practical matter, most IPAs purchase
stop-loss for themselves as an organization as well as for their
physicians. The regulation only requires that the physician groups
and the individual physicians are covered by stop-loss if at SFR.
SLP QUESTION 19: Does stop-loss that is purchased for a physician group also
cover the individual physicians if they are also at SFR.
ANSWER: Not necessarily. The regulation specifies that both the
physician group and individual physicians in that group must be
covered by stop-loss, if they are both at SFR. However, it is
possible that the policy that the group purchases covers only the
group's financial risk.
SLP QUESTION 20: What if a multi-specialty group is not placed at SFR, but the
primary care physicians within that group are at SFR.
ANSWER: In that case only the primary care physicians would need to
be covered by stop-loss.
SLP QUESTION 21: If a physician group contracts with one or more other physician
groups, does the stop-loss requirement of the primary physician group apply to
the subcontracting groups?
ANSWER: No, stop-loss requirements of one group cannot be extended
to a subcontracting level. For example:
- A physician group has greater than 25,000 patients that meet pooling
criteria and therefore has no stop-loss requirement.
- This group contracts with another physician group, which has 25,000
or fewer patients and bears risk for referrals above 25%.
In this case, the first group is exempt from stop-loss requirements;
however, the second group must comply with stop-loss requirements
and the MCO must comply with survey requirements.
DISCLOSURE '
DISCLOSURE QUESTION 1: If no provider is placed at risk or at risk for
referrals, or if an MCO agrees to provide stop-loss and to conduct surveys, must
the MCO still disclose the information to HCFA as required by the regulation?
ANSWER: Yes, pursuant to the regulation, MCOs must still disclose
the information. This information serves many purposes. It will be
used to monitor compliance, evaluate the impact of the regulation
and to ensure the delivery of high quality health care. In enacting
this legislation Congress clearly intended MCOs to disclose at least
some information about the nature of the MCO's physician incentive
compensation arrangements and the extent to which physicians are
being placed at substantial risk by the arrangements.
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DISCLOSURE QUESTION 2: It seems that the information disclosed pursuant to the
regulation is proprietary and should be protected under the Freedom of
Information Act (FOIA). What information is proprietary?
ANSWER: For information submitted to HCFA, a precise determination
of what is proprietary information cannot be made until we have
reviewed specific FOIA requests. At that time, the FOIA office will
request that the plan involved specify what it feels is proprietary
and the office will then determine what is proprietary. An MCO may,
if it so desires, designate the information as proprietary at the
time of submission. Requests will be evaluated on a case-by-case
basis, balancing the needs of the party to protect proprietary
information against the public interest in disclosing information
that will serve the goals of the regulation.
DISCLOSURE QUESTION 3: Will disclosure to beneficiaries of financial incentives
information be required at the time of their enrollment? Also, will MCOs be
allowed broad discretion to decide how the information is presented?
ANSWER: MCOs will be required to publish in the evidence of coverage
(EOC) notices, or such other notice as approved by the applicable
HCFA Regional Office, that beneficiaries can request summary
information on the MCO's physician incentive plans. These EOC
notices are available upon enrollment. The nature of the disclosure
to beneficiaries will be general, as opposed to providing
physician-specific financial incentives information. Materials must
convey information about the types of incentives used in contracts
affecting physicians in the MCO's network. MCOs will not be required
to disclose the details of the particular incentive arrangement for
a specific physician. MCOs will be allowed some discretion in
crafting language to convey the required information to
beneficiaries. A separate document of recommended language for
beneficiary materials is available from HCFA.
DISCLOSURE QUESTION 4: For purposes of the disclosure requirement (42CFR
422.210(b), 42 CFR 417.479(h)(3)) who does the term "beneficiaries" include?
ANSWER: The term refers to persons receiving Medicare benefits. It
includes potential enrollees, current enrollees, and disenrollees of
MCOs contracting with the Medicare.
DISCLOSURE QUESTION 5: What about Pools of Doctors (PODs) (i.e., groups of
independent physicians who are aggregated into a single risk pool by an MCO or
PHO) that aren't actually private corporations like a physician group or an IPA?
Example 1: Would they need to report if the POD includes PCPs only sharing risk
for their own services? Example 2: What about if the POD includes PCPs and
specialists sharing risk for their services as a POD?
Example 3: Finally, would PODs need to report if comprised of PCPs, specialists,
hospital and ancillary services?
ANSWER: In all three instances, some reporting would need to occur,
but the extent of the disclosure would vary. In the first two
examples, the MCO would simply report that the POD was not at risk
for services it did not provide. In the third example, disclosure
would need to detail the types of risk arrangements used (e.g.,
capitation, withhold, bonus), the percent of total potential income
at risk for referrals, and if that percentage exceeded 25%,
information about stop-loss protection.
DISCLOSURE QUESTION 6: If a subcontractor refuses to provide data on individual
physician incentive arrangements, what action is the MCO expected to take? What
action will HCFA or the State take?
ANSWER: The MCO should try with due diligence to collect the
required data from subcontractors. Some MCOs may need to enforce the
terms of their contracts which require subcontractor compliance with
all Federal and State laws. MCOs not in compliance with this
regulation may face intermediate sanctions (e.g., freezing of
enrollment, suspension of marketing) and civil monetary penalties.
It is HCFA's expectation that providers will recognize the steps
that have been taken to address proprietary concerns and will submit
the required information to the MCOs with whom they contract.
DISCLOSURE QUESTION 7: One can expect that the patient panel size of any given
provider group will likely change over the course of a contract. Should
providers or the MCO report such changes to HCFA and should stop-loss protection
be altered to reflect such changes? What about multi-year contracts?
ANSWER: We expect PIP disclosure to be accurate on a "snap-shot"
basis, i.e., it should accurately reflect physician incentive
arrangements as of January 1 of each disclosure year. An average
panel size should be projected for the year starting January 1. If
there are phased-in incentive arrangements or other changes during
the year, stop-loss protections should be adjusted so that the MCO
remains in compliance with PIP rules at all times, even though HCFA
does not request interim disclosures. Regarding multi-year
contracts,
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we would expect the annual disclosures for ensuing years to reflect
significant changes, if any, in the arrangements.
DISCLOSURE QUESTION 8: How will Medicare beneficiaries learn that they can
request information from the MCO regarding PIPs, etc.? Also, who should accept
beneficiary complaints regarding this disclosure?
ANSWER: It is the responsibility of MCOs to notify current and
prospective enrollees of their right to certain information related
to physician compensation arrangements. The MCO's Evidence of
Coverage, Annual Notice to Medicare members, marketing materials,
and/or other formal means of communication should be used to
communicate that the following pieces of information are available
to beneficiaries upon request: (1) if the MCO has a PIP that covers
referral services; (2) the type of incentive arrangement; (3)
whether stop-loss protection is provided; and (4) a summary of
survey results, if conduct of a survey is required of the MCO.
Should a beneficiary have a complaint regarding disclosure, the
beneficiary should first attempt to resolve the problem through
contact with the MCO's membership services department. If that is
unsuccessful, the beneficiary can pursue the complaint through the
MCO's internal grievance process. Additionally, the beneficiary can
contact the HCFA Medicare Regional Office.
DISCLOSURE QUESTION 9: If a beneficiary wants to know the incentive arrangement
of an individual physician, is the MCO required to disclose it?
ANSWER: The MCO is only required to provide a summary statement or
letter outlining all of the incentive arrangements in place
throughout the MCO. However, there is nothing in federal statute or
regulation to prevent a MCO or individual physician from providing
physician-specific information to a beneficiary who requests it.
DISCLOSURE QUESTION 10: The HCFA guidance package on the regulation, dated
December 27, 1996, says that marketing material must be reviewed by ROs. If an
MCO uses the exact language in HCFA's guidance paper on beneficiary disclosure,
must it still be reviewed by the RO?
ANSWER: Yes. The RO is still responsible or ensuring that the MCO is
providing accurate information to its enrollees. Use of the HCFA
model language cannot address the MCO-specific incentive information
which each RO must review, but it will expedite the RO's review of
how that information is phrased for optimal beneficiary
understanding.
DISCLOSURE QUESTION 11: Will disclosure need to be repeated annually, even if
there is no change?
ANSWER: Yes, annual disclosure is required. However, if arrangements
with providers are substantially the same as the previous disclosure
year, new Worksheets need not be completed so long as the previous
documents will be available to regulators and the MCO has assurances
from its providers that the arrangements are substantially the same.
DISCLOSURE QUESTION 12: Is PIP disclosure required for applicants for
Medicare+Choice contracts?
ANSWER: Yes, compliance with PIP is required before HCFA contracts
with an MCO. The M+C application should include completed PIP
disclosure forms in hard copy in the documents part. This is the
only time that hard copy is acceptable. All contractors who have had
a HCFA Medicare contract as of January 1 of any year must disclose
electronically and will receive instructions from HCFA. MCOs who
contract after January 1 will not disclose until the following year,
but must be in compliance with PIP at all times. PIP forms,
instructions, worksheets and any updates are in HCFA's web site at:
xxx.xxxx.xxx/xxxxxxxx/xxxxxxxx/xxx-xxxx.xxx.
DISCLOSURE QUESTION 13: When an MCO makes its disclosure electronically, should
it send a hard copy of a signature page to HCFA?
ANSWER: No, a signature page is not required.
SURVEY
SURVEY QUESTION 1: Will HCFA facilitate the survey requirement by using such
items as a standard survey questionnaire,
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detailed instructions on survey design and/or a comparative report card?
ANSWER. Yes, HCFA issued a memo in August 1999 that stated the
following:
HCFA's national administration of the Consumer Assessments of Health
Plans Study (CAHPS) is well established and will include both
enrollees and disenrollees, starting in 2000. Therefore, HCFA has
determined that these Medicare Managed Care Organizations (MCOs) no
longer need to conduct independent surveys for meeting PIP
requirements. HCFA will consider all such Medicare MCOs with
physician groups or physicians at substantial financial risk to be
in compliance with the survey mandate in 42 CFR 422.208(h) and 42
CFR 417.179(g)(1).
Organizations can now meet the survey disclosure requirement of the
regulations by giving Medicare enrollees a copy of the CAHPS
enrollment and disenrollment survey results when they are available
on the Internet. Further, these MCOs will no longer need to submit
survey summaries to HCFA.
MISCELLANEOUS
MISC. QUESTION 1: Why was Congress concerned about physician incentive plans?
ANSWER: Congress was concerned about under-use of referral for
medically necessary services due to physician incentive arrangements
to control costs. The regulations implement the Federal law and
provide protection to Medicare beneficiaries so that they have
access to necessary and appropriate care.
MISC. QUESTION 2: How is a withhold different from capitation?
ANSWER: Capitation means a set dollar payment per patient per unit
of time (usually per month) that is paid to a physician or physician
group to cover a specified set of services and administrative costs
without regard to the actual number of services provided. The
services covered may include the physician's own services, referral
services, or all medical services. A withhold is the percentage of
payments or set dollar amounts that is held back from a physician or
physician group's capitation or fee-for-service payments. This
amount may or may not be returned to the physician/group, depending
on specific predetermined factors.
MISC. QUESTION 3: Do the PIP regulations apply to ancillary providers who
contract with both physicians and non-physicians? (e.g., mental health plans) If
yes, would the PIP regulations apply to all providers employed by the ancillary
provider, or just physicians?
ANSWER: The PIP regulation applies only to physicians. If an
ancillary provider employs 100 health professionals, for instance,
but only 20 of them are physicians, then the PIP regulation applies
only to those 20 physicians.
MISC. QUESTION 4: Are dentists or groups of dentists considered physicians for
purposes of the PIP regulation? What is the definition of "physician" for
purposes of the physician incentive regulation?
ANSWER: Dentists may be considered physicians for purposes of the
PIP regulation. The term "physician" is defined for purposes of
Title XVIII (Medicare) at 1861(r). "Physicians" include doctors of
medicine, doctors of osteopathy, doctors of dental surgery or dental
medicine, doctors of podiatric medicine, doctors of optometry and
chiropractors. For purposes of the Social Security Act, the
definition of "physician" is limited to instances when "limited
practice" providers actually provide services covered under the Act
based on State authority to perform such services. For instance,
under the Act, chiropractors are defined as "physicians" only in so
far as they provide manual manipulation of the spine to correct a
subluxation demonstrated by X-ray. For purposes of the PIP
regulation, "physician" is similarly defined. In so far as "limited
practice" providers such as dentists are providing services covered
under an MCO's ACR (Medicare risk plans), or under an MCO's cost
report (Medicare cost plans), the "limited practice" provider is a
"physician" for purposes of the PIP regulation.
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PHYSICIAN INCENTIVE PLAN
GLOSSARY OF TERMS
Bonus means a payment a physician or entity receives beyond any salary,
fee-for-service payments, capitation or returned withhold. Bonuses and other
compensation that are not based on referral or utilization levels (such as
bonuses based solely on quality of care, patient satisfaction or physician
participation on a committee) are not considered in the calculation of
substantial financial risk.
Capitation means a set dollar payment per patient per unit of time (usually per
month) that is paid to cover a specified set of services and administrative
costs without regard to the actual number of services provided. The services
covered may include a physician's own services, referral services or all medical
services. The set dollar payment may be a percent of the premium that the
managed care organization collects for a beneficiary; the capitation received
from HCFA would be considered a premium for this purpose.
Panel size means the number of patients served by a physician or physician
group.
Physician group means a partnership, association, corporation, individual
practice association (IPA), or other group that distributes income from the
practice among members. An IPA is considered to be a physician group only if it
is composed of individual physicians and has no subcontracts with other
physician groups.
Intermediate entities are entities that contract with one or more physician
groups or other affiliations of physician groups and physicians. An IPA is
considered to be an intermediate entity if it contracts with one or more
physician groups in addition to contracting with individual physicians.
Physician incentive plan means any compensation arrangement at any contracting
level between an MCO and a physician or physician group that may directly or
indirectly have the effect of reducing or limiting services furnished to
Medicare or Medicaid enrollees in the MCO. MCOs must disclose physician
incentive plans between the MCO itself and individual physicians and groups and,
also, between groups or intermediate entities (e.g., certain IPAs,
Physician-Hospital Organizations) and individual physicians and groups.
Potential payments means the maximum payments possible to physicians or
physician groups including payments for services they furnish directly and
additional payments based on use and costs of referral services, such as
withholds, bonuses capitation, or any other compensation to the physician or
physician group. Payments based on committee participation, patient satisfaction
or other quality of care factors should not be included in the potential payment
calculations.
Referral services means any specialty, inpatient, outpatient or laboratory
services that are ordered or arranged, but not furnished directly.
Certain situations may exist that should be considered referral services for
purposes of determining if a physician/group is at substantial financial risk.
For example, an MCO may require a physician group/physician to authorize
"retroactive" referrals for emergency care received outside the MCO's network.
If the physician group/physician's payment from the MCO can be affected by the
utilization of emergency care, such as a bonus if emergence referrals are low,
then these emergency services are considered referral services and need to be
included in the calculation of substantial financial risk.
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Physician Incentive Plan Regulation Disclosure Requirements Page 2 of 2
Also, if a physician group contracts with an individual physician or another
group to provide services that the initial group cannot provide itself, any
services referred to the contracted physician group/physician should be
considered referral services.
Substantial financial risk means an incentive arrangement that places the
physician or physician group at risk for amounts beyond the risk threshold, if
the risk is based on the use or costs of referral services. The risk threshold
is 25%.
However, if the patient panel is greater than 25,000 patients, then the
physician group is not considered to be at substantial financial risk because
the risk is spread over the large number of patients. Stop loss and beneficiary
surveys would not be required.
Withhold means a percentage of payment or set dollar amounts that are deducted
from the payment to the physician group/physician that may or may not be
returned depending on specific predetermined factors.
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MEDICARE MEDICAID CHIP CUSTOMER SERVICE FAQs SEARCH
DATE: August 5, 1999
NOTE TO: Medicare Contracting Managed Care Organizations Who are Subject to
Physician Incentive Plan Disclosure Requirements
FROM: Director, Health Plan Purchasing & Administration, CHPP
Health Care Financing Administration
SUBJECT: Physician Incentive Plan Survey Requirements
We are pleased to inform you of a new determination regarding your survey
requirements under the Physician Incentive Plan (PIP) regulation.
FOR '1876 COST AND CLOSED COST HEALTHPLAN, M+C ORGANIZATIONS, SOCIAL HMOS AND
MEDICARE CHOICES*: HCFA=s national administration of the Consumer Assessments of
Health Plans Study (CAHPS) is well established and will include both enrollees
and disenrollees, starting in 1999. Therefore, HCFA has determined that these
Medicare Managed Care Organizations (MCOs) no longer need to conduct independent
surveys for meeting PIP requirements. HCFA will consider all such Medicare MCOs
with medical groups or physicians at substantial financial risk to be in
compliance with the survey mandate in 42 CFR 422.208/210.
Organizations can now meet the survey disclosure requirement of the regulations
by giving Medicare enrollees a copy of the CAHPS enrollment survey results
available on the Internet. HCFA anticipates that the disenrollment survey
results will be available Spring 2000. Further, these MCOs will no longer need
to submit survey summaries to HCFA.
FOR EVERCARE, PACE OR OTHER DEMONSTRATIONS*: These MCOs are required to disclose
under PIP but are not included in CAHPS. Therefore, they must conduct customer
satisfaction surveys of both enrollees and disenrollees if any physician or
physician group in an MCO=s network is placed at substantial risk for referral
services, as defined by regulation. MCOs who had a contract with HCFA on or
before January 1, 1999 will be required to submit a summary of each survey to
HCFA by March 31, 2000 and provide beneficiaries a summary upon their request.
We will provide further guidance at a later date.
If you have questions about the PIP survey requirements, you may call Xxxxxx
Xxxxxx at 000-000-0000, Xxxx Xxxxxx at 000-000-0000, or Xxxxx Xxxxxxxxxx at
000-000-0000.
/s/
Xxxx X. Xxxxxx
------------------
* For CAHPS requirements, see HCFA Operational Policy Letter 99.078,
Reporting Requirements for Medicare Managed Care Organizations in 1999:
HEDIS, HOS, CAHPS.
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MEDICARE MANAGED CARE ORGANIZATIONS Page 1 of 5
MEDICARE + CHOICE APPLICANT
PHYSICIAN INCENTIVE PLAN DISCLOSURE INSTRUCTIONS
GENERAL INSTRUCTIONS FOR SUBMISSION: Hard copy Physician Incentive Plan (PIP)
Disclosure is required only for new applicants for Medicare+Choice Contracts,
except for Private Fee For Service Plans or non-network Medicare Savings Account
Plans. Organizations that already hold a Medicare contract with HCFA must
disclose electronically PIP guidance, an extensive QS & AS, and all forms are
available at HCFA's web site:
xxx.xxxx.xxx/xxxxxxxx/xxxxxxxx/xxx-xxxx.xxx
A hard copy disclosure must be included in the completed application, as
directed within the application form. The disclosure should represent physician
incentive arrangements for providers within the Managed Care Organization's
(MCO) network at the time the application is submitted. A Medicare PIP
disclosure includes:
The disclosure COVER SHEET - This sheet should be the first page of
the PIP submission.
PIP DISCLOSURE FORM - This form may be duplicated as necessary to
capture all of the arrangements in effect amongst the applicant's
provider contractors and subcontractors down to the level of
physicians.
USING THE HCFA PIP PROVIDER WORKSHEET: The PIP Worksheet may be used as a guide
in determining if there is substantial financial risk in any provider
arrangement and to assist the MCO in entering data on the disclosure form. MCOs
may modify the Worksheet for their internal use as long as the necessary
information is captured that will document the data upon audit by regulators.
Generally, a separate Worksheet should be used or each type of contractual
relationship. Reproduce as many of these forms as needed. Do not submit the
Worksheets, but retain them and any other supporting information for review by
regulators.
The MCOs should analyze the data from different providers to determine whether
information from the same type of contracting entity can be aggregated for
disclosure to regulators.
MCOs need to determine if they have received all information from their
contractors down to the level of physicians, even if the providers bear no risk
or there is no substantial financial risk.
- An intermediate entity should report its direct contracts with
physicians as well as arrangements with its physician groups and
the physician groups' physicians. Even if there is no substantial
financial risk in any contractual arrangement, the lower levels must
be disclosed.
- A physician group should report arrangements with its physicians,
even if there is no substantial financial risk between the MCO and
the physician group.
Enter the information from the Worksheet on the appropriate lines on the
Disclosure Form after indicating the specific contractual relationship being
disclosed.
USING THE PIP DISCLOSURE FORM FOR M+C APPLICANTS: At the top of the Disclosure
Form, print the name of the MCO, give the Medicare contract number, and the
reporting year.
Nine contractual relationships are listed. Disclose one type of relationship on
each Form you complete. Submit as many Forms as you need to represent all of the
arrangements that serve the MCO's Medicare enrollees.
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(1) MCO to physician group
(2) MCO to intermediate entity
(3) MCO to individual physician
(4) Intermediate entity to physician group
(5) Intermediate entity to physician
(6) Physician group to physician group
(7) Physician group to physician
(8) Physician to physician
(9) Intermediate entity to intermediate entity
Each submission from an MCO must include contractual relationships (1), (2) or
(3), but MCOs may have multiple arrangements and need all three. Then the MCO
must disclose the subcontracting arrangements to the level of the physician. All
disclosures relating to one hierarchy of contracts should be stapled together.
The hierarchies are:
SELECTION OF: (1) MCO TO PHYSICIAN GROUP REQUIRES A DISCLOSURE OF:
(7) Physician group to physician OR (6) Physician group to
physician group
If (6) is selected, you MUST have (7) to disclose incentives
to physicians
There can be selection of: (8) Physician to physician [this is
not required]
SELECTION OF: (2) MCO TO INTERMEDIATE ENTITY REQUIRES DISCLOSURE OF:
(4) Intermediate entity to physician group OR
(5) Intermediate entity to physician OR
(9) Intermediate entity to intermediate entity
The intermediate entity can have multiple contracting
arrangements.
If (4) is selected, you MUST have (7) to disclose incentives
to physicians
If (9) is selected, you MUST have (4) or (5) to disclose
incentives to subcontractors
There can be selection of: (8) Physician to physician [this is
not required]
SELECTION OF: (3) MCO TO INDIVIDUAL PHYSICIAN DOES NOT REQUIRE ANY SUBCONTRACT.
There can be selection of: (8) Physician to physician [this is
not required]
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Single or aggregate disclosure: The Disclosure Form may reflect a single
incentive arrangement if that is a unique arrangement. However, MCOs should
aggregate information on one Form for contractual arrangements that are
substantially the same and the stop-loss requirements are the same.
For example, if an MCO contracts with 100 physician groups under a
very similar capitation payment that does not pass referral risk to
the groups, the MCO should check category one on the Disclosure Form
and disclose all 100 on one Form. If 55 physician groups do not pass
risk to their doctors and these 55 groups have a total of 450
physicians under this no risk compensation, then the MCO should
check category 7 on a new Disclosure Form and disclose all 450 on
the Form. Similarly, the MCO should disclose the physician
group-physician incentive arrangements for the other 45 groups,
aggregating those physicians who are placed at substantially the
same risk and who have the same stop loss requirements, if the risk
exceeds the SFR cutoff. Staple together all the forms that relate to
the 100 physician groups.
Entering the information: After checking the relationship you are disclosing,
follow the directions below.
1. ON LINE 1.A., give the name or identifier of a single provider (e.g., the
intermediate entity, physician group, or individual physician) or the
providers who are aggregated for the disclosure. The provider named or
identified is the party who receives payment under the provider contract
to which the Disclosure Form applies. The purpose here is to allow the
user to be able to identify the provider(s) after entering the data.
ON LINE 1.B., give the number of aggregated providers whose arrangements
are being disclosed. (See the discussion above.) Do not send lists of
provider names. For example, if #1 is selected, then give the number of
physician groups.
LINE 1.C. asks for disclosure of Federally Qualified Health Centers and
Rural Health Clinics (FQHC/RHCs). Please distinguish FQHC/RHCs by using a
separate Disclosure Form to report each FQHC/RHC, however you may
aggregate those with substantially the same incentive arrangements. If the
MCO is owned or controlled by a consortium of FQHC/RHCs or has FQHC/RHCs
in its network, be sure to indicate this on the cover sheet.
LINE 1.D. applies only to physicians of physician groups (selection of #7
contracting type) and asks for a breakout of the number of physicians who
are members of the group and those who independently contract with the
group. Members are typically owners, partners, or employees of the
physician group.
If either arrangement with providers that are intermediate entities (IE)
is selected on the Disclosure Form (either #2 or #9), complete items 1.A -
1.C only since stop loss requirements do not apply to intermediate
entities (IE). However, fully complete disclosures for IE's relationships
with provider groups and their physicians (#4 and #7) and IE with
individual physicians (#5) because stop loss requirements apply to these
levels.
2. QUESTION 2 identifies whether the incentive arrangement transfers any
risk. A capitation payment is considered a transfer of risk for his
question, even if the capitation is for services provided only by the
contracting physician or physician group. [This information is found in
the Worksheet.]
Check "yes" or "no" as applicable. If "no" is checked, then this
disclosure is complete. If "yes" is checked, identify the type of risk
transfer then go to Question 3.
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Risk transfer choices are: "capitation, bonus, withhold, percent of
premium or other." Check the appropriate choice or choices; more than one
choice should be checked if the arrangement has features of each type of
risk-sharing.
A choice of "Other" is provided if a combination of the four types of risk
arrangement does not define the arrangement. For the purpose of this
Disclosure Form, the obligation for the provider to fund deficits is
considered as a "withhold." A bonus for low utilization of referral
services is considered to be risk transference.
3. QUESTION 3 identifies whether risk is transferred for referrals. [This
information is in the Worksheet.] Check "yes" or "no" as applicable. A
bonus for low utilization of hospital, specialist or other services is
considered to be a risk for referral services. If "no" is checked, then
this disclosure is complete. If "yes" is checked, go to Question 4 to
identify the type of risk transfer.
4. QUESTION 4 identifies the type of risk-sharing arrangement. [This
information is found in the Worksheet.] See #2 above for instructions on
identifying risk arrangements.
The risk-sharing arrangement may be described briefly on the Disclosure
Form, particularly if 'other' is selected. [This information should be
available in the Worksheet from the contractors.]
5. The percentage of risk ATTRIBUTABLE TO REFERRALS ONLY should be stated in
QUESTION 5. This percentage corresponds to the "% Of Total Compensation At
Risk For Referrals" from the Worksheet. If the percentage is equal to or
below 25 %, the arrangement is not considered to be at substantial
financial risk and this disclosure is complete. Percent of premium is
treated as capitation for this calculation. If above 25 percent, proceed
to Question 6.
6. Information for QUESTION 6, about the number of patients, is found in the
Worksheet. Specific criteria must be met before pooling is allowed, as
stated in regulations. Any entity that meets all five criteria (below)
required for the pooling of risk will be allowed to pool that risk in
order to determine the amount of stop-loss required by the regulation. If
the number of patients is 25,000 or fewer, then go to Question 7. If
greater than 25,000, the disclosure is complete.
(1) Pooling of patients is otherwise consistent with the relevant
contracts governing the compensation arrangements for the physician or
group (i.e., no contracts can require risk be segmented by MCO or patient
category);
(2) The physician or group is at risk for referral services with respect
to each of the categories of patients being pooled;
(3) The terms of the compensation arrangements permit the physician or
group to spread the risk across the categories of patients being pooled
(i.e., payments must be held in a common risk pool);
(4) The distribution of payments to physicians from the risk pool is not
calculated separately by patient category (either by MCO or by Medicaid,
Medicare, or commercial); and
(5) The terms of the risk borne by the physician or group are comparable
for all categories of patients being pooled.
Note that pooling and stop-loss requirements applicable to a group cannot
be extended to a subcontracting level. For example:
- A physician group has greater than 25,000 patients that meet
pooling criteria.
xxxx://xxx.xxxx.xxx/xxxxxxxx/xxxxxxxx/00xxxxx0.xxx
MEDICARE MANAGED CARE ORGANIZATIONS Page 5 of 5
- This group contracts with another physician group, which has
25,000 or fewer patients and bears risk for referrals above
25%.
The first group is exempt from stop-loss
requirements; the second group must comply with
stop-loss requirements and the MCO must comply
with survey requirements.
1. For QUESTION 7, note the type and the levels or thresholds of
the stop-loss insurance if stop-loss coverage for the
physician group or physician is required.
Check the type of stop-loss, aggregate, individual per
patient, or other coverage. * If individual, give the
threshold (deductible) as a dollar amount. If aggregate
or other briefly describe the stop-loss coverage. If
there are arrangements that merit explanation, describe
the coverage (if needed, attach a sheet for additional
space).
A description should include whether the coverage is:
(1) Combined (professional and institutional);
(2) Broken down into institutional, professional and
other components;
(3) The deductible, co-insurance percentage, maximum
liability/pay-out by the policy;
(4) Whether the stop-loss coverage applies to all costs
or only the cost of referral services; and
(5) Any other key features of the coverage.
This information is found in the Worksheet.
If providers can be aggregated because of the similarity
of risk arrangements, the MCO should sort the providers
by stop loss requirements and then use a separate
Disclosure Form for each requirement. For example: 100
groups exceed the 25% risk threshold; 50 have a patient
pool exceeding 25,000 (under a very similar risk
arrangement); 25 have a patient pool of between 1,001
and 5,000 (under a very similar risk arrangement); and
another 25 of these groups have a patient pool of
between 8,001 and 10,000. The MCO should use three
Disclosure Forms to represent the groups that aggregate
into three stop loss requirements.
xxxx://xxx.xxxx.xxx/xxxxxxxx/xxxxxxxx/00xxxxx0.xxx
COVER SHEET
MANAGED CARE ORGANIZATION (MCO) DISCLOSURE COMPLIANCE PACKAGE
UNDER THE PHYSICIAN INCENTIVE REGULATION
SUBMITTED TO HEALTH CARE FINANCING ADMINISTRATION (HCFA)
FOR THE MEDICARE + CHOICE APPLICANT
NAME OF MCO _________________________________________________________________
MEDICARE CONTRACT #H ____________ PIP applies to Medicare+Choice applicants
(except for PFFS and non-network MSA)
MCO IS OWNED/CONTROLLED BY A FEDERALLY QUALIFIED HEALTH CENTER OR RURAL HEALTH
CLINIC (FQHC/RHC) OR CONSORTIUM OF FQHC/RHCS OR INCLUDES FQHC/RHCS IN ITS
NETWORK:
YES___________; NO _______
PRINTED NAME OF MCO CONTACT PERSON __________________________________________
PHONE # ______________________
THIS REPRESENTS OUR ORGANIZATION'S DISCLOSURE COMPLIANCE PACKAGE SUBMITTED TO
HCFA OR SMA. I CERTIFY THAT THE INFORMATION MADE IN THIS DISCLOSURE IS TRUE,
COMPLETE AND CURRENT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF AND IS
MADE IN GOOD FAITH.
PRINTED NAME OF CEO _________________________________________________________
SIGNATURE OF CEO __________________________________ DATE: ___________________
NOTE: PLEASE INCLUDE THIS COVER SHEET AS THE FIRST PAGE OF THE MCO DISCLOSURE
COMPLIANCE PACKAGE.
HCFA PIP Disclosure Form for M+C Applicants -revised 10/2000 Page 1
OMB No. 0938-0700
PHYSICIAN INCENTIVE PLAN DISCLOSURE FORM FOR M+C APPLICANTS
Managed Care Organization (MCO) Name: ______________________________________
Medicare Contract Number: H_________ Reporting year: __________
Note: Disclosure is required even if risk or substantial risk is not being
transferred or panel exceeds 25,000.
CHECK ONE - Use this Disclosure Form to disclose the incentive arrangement
between the first party (in the list below) that contracts with a second party
(underlined on list below) for services to the MCO's Medicare (or Medicaid)
enrollees. BE SURE TO DISCLOSE SUBCONTRACTING ARRANGEMENTS DOWN TO PHYSICIAN
LEVELS.
- Repeat forms as many times as needed to capture the various levels of
contractual relationships.(1)
- For simplicity, "provider" is used here to refer to the second party. See
instructions for completing this Form under "Single or aggregate disclosure" for
aggregating either the first or SECOND PARTY.(2)
- The HCFA Provider Data Worksheet can be the basis for this summary form. ALL
FORMS and instructions are available at:
xxx.xxxx.xxx/xxxxxxxx/xxxxxxxx/xxx-xxxx.xxx
(1) ____ MCO to physician group (2) ____ MCO to intermediate entity
(3) ____ MCO to individual physician (4) ____ Intermediate entity to physician
group
(5) ____ Intermediate entity to (6) ____ Physician group to physician
physician group
(7) ____ Physician group to physician (8) ____ Physician to physician
(9) ____ Intermediate entity to intermediate entity
1. PROVIDER(S) NAMED OR COUNTED SHOULD BE THE UNDERLINED PROVIDER IN THE LINE
CHECKED ABOVE.
A. Name or Identifier of Provider:_____________________________
Use the actual name or any identifier for the entity or aggregated
entities disclosed on this chart.
B. Number of Providers in the category selected:_____________
Give # of providers who are aggregated on this form; e.g., if this
form is for physician groups, category #1, then give the # of
physician groups; groups can be aggregated if risk arrangements are
substantially the same and stop loss requirements are the same.
1.C. Is provider an FQHC/RHC? Yes______; No______
If providers are aggregated, see instructions for disclosing FQHCs.
1.D. If #7 above is selected, give number of physicians who are:
Members (e.g. owners, employees) of the group #_____; Contracted
with the group # _______ These numbers must equal the number of
physicians given in I.B.
NOTE: If either #2 or #9 is checked above, this form is complete since stop loss
requirements do not apply to intermediate entities (IE). However, be sure to
complete disclosures for the IE's relationships with provider groups and their
physicians (#4 and #7) and with individual physicians (#5) because stop loss
requirements apply to these levels.
2. Is risk transferred to the provider? Yes_____; No_____
Note: A bonus for low utilization of referral services is considered to be
risk transference.
If YES, check all the risk transfer methods with the provider and go to
question 3.
Capitation______; Bonus______; Withhold ______; Percent of Premium______;
Other_______
Note: Consider the obligation for the provider to fund deficits as a
"withhold". Describe briefly:
HCFA PIP Disclosure Form for M+C Applicants -revised 10/2000 Page 2
PIP disclosure: MCO Name_______________________________
3. Is risk transferred for referrals? Yes _______; No ______
Note: A bonus for low utilization of hospital, specialist or other
services is considered to be at risk for referral services.
If NO, this chart is finished. If YES, proceed to next question.
4. Check all the referral risk transfer methods with the provider and go to
question 5.
Capitation_____; Bonus______; Withhold _____; Percent of Premium____;
Other______
Note: Consider the obligation for the provider to fund deficits as a
"withhold". If needed, describe briefly:
5. What percent of the total potential payment is at risk for referrals:
_________%
If above 25% proceed to question 6; if 25% or below you have completed
this disclosure.
6. Number of MCO patients served by the provider or the number of pooled
patients, if patients can be pooled (see criteria for pooling in the
instructions). Check one category:
A __ 1-1,000; B __ 1,001-5,000; C __ 5,001-8,000; D __ 8,001-10,000;
E __ 10,001-25,000; F __ 25,000+
If number is 25,000 or below, answer #7. If the number exceeds 25,000, you
have completed this disclosure.
7. State the type and amount of stop loss insuring the physician group and/or
physician:
Aggregate Insurance is excess loss coverage that accumulates based on
total costs of the entire population for which they are at risk and which
reimburses after the expected total cost exceeds a pre-determined level.
Individual insurance is where a specific provider excess loss accumulates
based on per member per year claims.
Type: Aggregate______; Individual ____; Other______[describe below if
aggregate or other]
If individual [based on costs per patient], enter threshold/deductible
amount: [enter only one amount] Threshold: Professional $___________;
Institutional $________; Combined $_____________
Describe if needed:
PUBLIC REPORTING BURDEN (FOR MANAGED CARE ORGANIZATIONS) "According to the
Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938-0700.
The time required to complete this information collection is estimated to
average 100 hours per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and
review the information collection. If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form,
please write to: HCFA, 0000 Xxxxxxxx Xxxxxxxxx, X0-00-00, Xxxxxxxxx,
Xxxxxxxx 00000-0000 and to the Office of the Information and Regulatory
Affairs, Office of Management and Budget, Washington, D.C. 20503."
-------------------------
(1)For example, if #1 for the MCO to physician group is checked on
one form, then use a separate form and check #7 to disclose the
physician group's arrangement with its physicians.
(2)You must correctly represent the hierarchy of contracting and
subcontracting relationships. For example, if you select # 1, you
should aggregate all physician groups you contract with that have
substantially the same incentive arrangements and stop-loss
requirements. Then, on a separate form, you should select #7 to
enter the physician group-physician arrangements only for the
physicians associated with those provider groups. These related
disclosures should be stapled together.
10/2000HCFA PIP Disclosure Form -revised 10/2000 Page 3
THE ENTITY COMPLETING THE WORKSHEET SHOULD RETAIN IT AND HAVE IT AVAILABLE FOR
REGULATORS IN THE EVENT OF AN AUDIT.
[ILLEGIBLE]
NOTE: EACH WORKSHEET SHOULD REFLECT A SINGLE INCENTIVE ARRANGEMENT OR AN
AGGREGATE OF MULTIPLE ARRANGEMENTS THAT ARE THE SAME OR SIMILAR.
THE WORKSHEET SHOULD BE COMPLETED FOR THE CONTRACTUAL ARRANGEMENTS THAT
WILL BE IN EFFECT ON JANUARY 1 OF THE DISCLOSURE YEAR. ANNUAL DISCLOSURE
IS REQUIRED EVEN IF RISK IS NOT TRANSFERRED TO PROVIDERS OR PATIENT POOL
EXCEEDS 25,000.
General Information
Disclosure year:_________
______________________________________________________________________________
(Print name of entity completing this Worksheet - the first entity in the line
checked below)
This Worksheet is being completed to describe the incentive arrangement between
(check one below):
(1) NA Managed Care Organization (MCO) to physician group*
(2) NA MCO to intermediate entity*
(3) NA MCO to individual physician
(4) ___ Intermediate entity to physician group*
(5) ___ Intermediate entity to physician
(6) ___ Physician group to physician group*
(7) ___ Physician group to physician
(8) ___ Physician to physician
(9) ___ Intermediate entity to intermediate entity*
["NOTE: DISCLOSURE IS REQUIRED DOWN TO THE LEVEL OF ARRANGEMENTS WITH
PHYSICIANS. USE SEPARATE WORKSHEETS FOR EACH LEVEL.]
Specify parties to contract:____________________________________________________
(the first entity in the line checked above)
and_____________________________________________________________________________
(the entity underlined in the line checked above)
[NOTE: IF WORKSHEET COVERS MULTIPLE CONTRACTS, NAME PARTIES ON A SEPARATE
ATTACHMENT.]
For the purposes of the regulation, the following definitions should be used:
INTERMEDIATE ENTITY -- a physician-hospital organization ("PHO"), integrated
delivery system, or individual practice association ["IPA"] that subcontracts
with physician groups or with another IPA.
PHYSICIAN CROUP -- a partnership, association, corporation, or other group that
distributes income from the practice among members, or an IPA that contracts
with individual physicians.
NOTE: IF #9 IS CHECKED ABOVE, STOP LOSS REQUIREMENTS DO NOT APPLY TO
INTERMEDIATE ENTITIES (IE). THEREFORE, SUCH ENTITIES MAY SKIP TO THE END OF THE
WORKSHEET AND COMPLETE THE SIGNATURE AND DATE INFORMATION. HOWEVER, BE SURE TO
COMPLETE DISCLOSURES FOR IE's RELATIONSHIPS WITH PROVIDER GROUPS AND THEIR
PHYSICIANS (#4 AND #7) AND WITH INDIVIDUAL PHYSICIANS (#5) BECAUSE STOP LOSS
REQUIREMENTS APPLY TO THESE LEVELS.
HCFA PIP Provider Worksheet - 10/2000 Page 1
[ILLEGIBLE] Physician Incentive Plan Information [ILLEGIBLE]
MEDICARE MEDICAID
2) Does the payment arrangement transfer risk?
YES______ _______
NO_______ _______
If risk is transferred, what method is used:
capitation___; bonus_____; withhold____; percent of premium___; other_____
Fee-for-service arrangements without withholds or bonuses do not transfer
risk.
3) Does the physician incentive plan (e.g., capitation, % of premium,
withholds, or bonuses) cover services not furnished by the physician or
physician group? If YES, proceed to next question.
YES______ _______
NO_______ _______
(Note: Bonuses or withhold arrangements based on utilization or cost factors
are included in these compensation arrangements. Incentives based: solely on
quality or access factors are not included.)
IF RESPONSE TO 2 OR 3 IS NO, GO TO LAST PAGE AND ENTER INFORMATION ABOUT PERSON
COMPLETING WORKSHEET.
4) If risk is transferred for referrals, what method is used:
capitation___; bonus_____; withhold____; percent of premium___; other_____
Fee-for-service arrangements without withholds or bonuses do not transfer
risk.
Percent of premium is similar to capitation. If the payment based on % of
premium covers referral services without any limit on the costs for referral
services, then the entire payment or 100% is at risk for referrals. In the
workboxes below, consider % of premium as capitation.
5) If you answered Question 4, please fill in the percentage(s) where
indicated and applicable. Note: If the contract does not limit the amount of
risk for referral services to a set percentage, insert '100' as the
percentage. Maximum compensation is defined as the maximum dollar amount
that a physician or physician group might receive for either direct or
referral services, or their administration. It does not include bonuses that
are not related to referral levels.
MAXIMUM COMPENSATION MEANS MAXIMUM POSSIBLE THEORETICAL COMPENSATION WITHOUT
REGARD TO HISTORICAL EXPERIENCE.
MEDICARE ARRANGEMENTS: Maximum compensation = maximum $ amount
that might be received.
line 1___Withhold ___% Withhold [where percent of withhold =
maximum possible withhold $$
maximum compensation $$]
line 2___Bonus *____% Bonus [where percent of bonus =
maximum possible bonus $$
maximum compensation $$]
* Note: Do not include bonuses based on quality or access in either the
calculation of maximum possible bonus or the maximum compensation.
line 3___Capitation __% Capitation [when percent of capitation
= maximum capitation $ entity is
potentially liable for referral services
maximum compensation $$ ]
__% Of Total Compensation At Risk For Referrals (add
lines 1,2 & 3)
THIS % IS TRANSFERRED TO QUESTION 5 ON THE PIP DISCLOSURE FORM; IF 25% OR
LOSS. SKIP TO LAST PAGE AND COMPLETE INFORMATION ABOUT PERSON COMPLETING
FORM.
IF % OF TOTAL COMPENSATION AT RISK FOR REFERRALS EXCEEDS 25%, THIS IS
SUBSTANTIAL FINANCIAL RISK AND YOU MOST PROCEED TO QUESTION 6.
HCFA PIP Provider Worksheet - 10/2000 Page 2
Physician Group Member Panel Size: Estimated members for contract year being
disclosed.
(6) State the total members served under the incentive arrangement(s) to which
this Worksheet applies by patient type (e.g. Medicare, Medicaid, and
commercial. Note: A physician group can pool to arrive at the total number
of MCO members to which this Worksheet applies if the criteria described
below are met. If pooling is used, attach an explanation of how it was
done to the Worksheet.
Total Commercial members ___________________
Total Medicare members ___________________
Total Medicaid members ___________________
TOTAL
IF THE TOTAL MEMBER PANEL SIZE FOR COMMERCIAL, MEDICARE AND/OR MEDICAID EXCEEDS
25.000. GO TO LAST PAGE AND ENTER INFORMATION ABOUT PERSON COMPLETING WORKSHEET.
Pooling Criteria:
(1) Pooling of patients is otherwise consistent with the relevant contracts
governing the compensation arrangements for the physician or group (i.e., no
contracts can require that risk be segmented by MCO or patient category);
(2) The physician or group is at risk for referral services with respect to each
of the categories of patients being pooled;
(3) The terms of the compensation arrangements permit the physician or group to
spread the risk across the categories of patients being pooled (i.e.,
payments must be held in a common risk pool);
(4) The distribution of payments to physicians from the risk pool is not
calculated separately by patient category (either by MCO or by Medicaid,
Medicare, or commercial); and
(5) The terms of the risk borne by the physician or group are comparable for all
categories of patients being pooled. Note that pooling and stop-loss
requirements applicable to a group cannot be extended to a subcontracting
level. For example:
--A physician group has greater than 25,000 patents that meet pooling
criteria.
-- This group contracts with another physician group, which has 25,000 or
fewer patients and bears risk for referrals above 25%.
The first group is exempt from stop-loss requirements; the second group
must comply with stop-loss requirements and the MCO must comply with
survey requirements.
STOP-LOSS INFORMATION: FILL TO IF % OF TOTAL COMPENSATION AT RISK FOR
REFERRAL IS > 25%
If incentive arrangements place either a physician or physician group at
substantial financial risk, there must be aggregate or per patient stop-loss
protection.
Aggregate stop-loss protection must cover 90% of the costs of referral services
that exceed 25% of potential payments.
Individual per patient coverage may be either combined coverage or separate
coverage for institutional and professional services. Per patient stop-loss
protection must cover at least 90% of the referral costs that: exceed the
following threshold, or attachment point, amounts in the chart below:
Combined Institutionals Institutionals Professional
Panel Size Professional Deductible Deductible Deductible
---------------- ----------------------- ------------- ------------
1-1000 $ 6,000 $ 10,000 $ 3.000
1,001-5000 $ 30.000 $ 40.000 $ 10.000
5,001 - 8.000 $ 40.000 $ 60.000 $ 15,000
8,001 - 10.000 $ 75,000 $100,000 $ 20,000
10,001 - 25.000 $150.000 $200.000 $ 22,500
> 25,000 NONE NONE NONE
HCFA PIP Provider Worksheet - 10/2000 Page 3
Name of carrier/entity(s) through which stop-loss is provided: Is this
carrier/entity:
________________________________________________ ____ stop-loss carrier
________________________________________________ ____ MCO
___ intermediate entity
____ physician
____ stop-loss carrier
____ MCO
____ intermediate entity
____ physician
7.) NOTE: This data is needed for ques. 7 of the PIP Disclosure Form if the
group or physician is at substantial financial risk and the patient pool
is 25,000 or less.
Describe stop-loss coverage that covers the incentive arrangement(s) that is
being reported on this Worksheet, for:
(A) PROFESSIONAL SERVICES: MEDICARE MEDICAID
Deductible ______________ _______________
Co-insurance percent ______________ _______________
Maximum liability ______________ _______________
DOES THIS COVER (CHECK ONE BELOW):
Individual Physicians YES ______________ _______________
NO ______________ _______________
Physician Group(s) YES ______________ _______________
NO ______________ _______________
Is this slop-loss coverage:
Individual per patient YES ______________ _______________
NO ______________ _______________
Aggregate YES ______________ _______________
NO ______________ _______________
For professional services, describe the services or nature of costs covered
under the stop-loss, including any exclusions, variations in coverage amounts,
and whether the stop-loss coverage applies to all costs or only referral costs.
(If additional space is required for this response, attach additional pages.)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
(B) HOSPITAL/INSTITUTIONAL SERVICES: MEDICARE MEDICAID
Deductible ______________ _______________
Co-insurance percent ______________ _______________
Maximum liability ______________ _______________
DOES THIS COVER (CHECK ONE BELOW):
Individual Physicians YES ______________ _______________
NO ______________ _______________
Physician Group(s) YES ______________ _______________
NO ______________ _______________
Is this stop-loss coverage:
Per patient YES ______________ _______________
NO ______________ _______________
Aggregate YES ______________ _______________
NO ______________ _______________
HCFA PIP Provider Worksheet - 10/2000 Page 4
For hospital/institutional services, describe the services or nature of costs
covered under the stop-loss, including any exclusions, variations in coverage
amounts, and whether the stop-loss coverage applies to all costs or only
referral costs. (If additional space is required for this response, attach
additional pages.)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
(C) COMBINED (PROFESSIONAL AND INSTITUTIONAL):
MEDICARE MEDICAID
Deductible ______________ _______________
Co-insurance percent ______________ _______________
Maximum liability ______________ _______________
DOES THIS COVER (CHECK ONE BELOW):
Individual Physicians YES ______________ _______________
NO ______________ _______________
Physician Group(s) YES ______________ _______________
NO ______________ _______________
Is this stop-loss coverage:
Per patient YES ______________ _______________
NO ______________ _______________
Aggregate YES ______________ _______________
NO ______________ _______________
For combined forms of stop-loss, describe the services or nature of costs
covered under the stop-loss, to all costs or only referral costs. (If additional
space is required for this response, attach additional pages.)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
DATE AND SIGNATURE INFORMATION
Printed name and title of person who completed the Worksheet:
Name of organization/employer of person listed above:___________________________
Telephone:_____________________________
I certify that the information made in this disclosure is true, complete and
current to the best of my knowledge and belief and is made in good faith.
________________________________________________________________________________
Signature Date
THE ENTITY COMPLETING THE WORKSHEET SHOULD RETAIN IT AND HAVE IT AVAILABLE FOR
REGULATORS IN THE EVENT OF AN AUDIT.
HCFA PIP Provider Worksheet - 10/2000 Page 5
[ILLEGIBLE]
HCFA BENEFICIARIES PLANS & PROVIDERS STATES RESEARCHERS STUDENTS
-----------------------------------------------------------------------------------
MEDICARE MEDICAID CHIP CUSTOMER SERVICE FAQS SEARCH
DEPARTMENT OF HEALTH & HUMAN SERVICES
HEALTH CARE FINANCING ADMINISTRATION
Center for Health Plans and Providers
Medicare Managed Care Group
0000 Xxxxxxxx Xxxxxxxxx, X0-00-00
Xxxxxxxxx, XX 00000-0000
Fax (000) 000-0000
NOTE TO: Medicare Contracting Managed Care Organizations Who are Subject to
Physician Incentive Plan Disclosure Requirements
DATE: December 22, 2000
FROM: Acting Director, Medicare Managed Care Group, CHPP
SUBJECT: Physician Incentive Plan Regulation Requirements for 2001
Survey Requirements for 2000
We are pleased to provide information on preparing your annual Physician
Incentive Plan (PIP)(1) disclosure for 2001. Most of the Medicare Managed Care
Organizations (MCOs) will be disclosing for the fifth year, so it is important
to note the changes in the 2001 disclosure.
The PIP database for 2000 includes disclosures from 299 MCOs who reported 8,092
arrangements. Using this information, we notified the MCOs who did not disclose,
whose disclosures were incomplete and those where the stop-loss did not meet
regulatory requirements. We appreciate the responses from the MCOs and trust
that compliance will be at a high level in the new disclosure year.
2001 DISCLOSURE REQUIREMENTS: Annual PIP disclosure is mandated for MCOs that
have Medicare contracts with the Health Care Financing Administration (HCFA) on
January 1, 2001. Most Medicare+Choice (M+C) organizations, demonstrations and
all Section 1876 Cost organizations are required to comply with the PIP
regulations. M+C organizations that are Private Fee For Service or Medical
Savings Account Plans and Section 1833 Health Care Prepayment Plans are not
subject to PIP.
Disclosure is required even if there are no incentive arrangements, the
arrangements carry low levels of risk, or the arrangements are the same as
previously reported to HCFA.
There are newly revised summary data forms for providers, worksheets and
instructions designed
xxxx://xxx.xxxx.xxx/xxxxxxxx/xxxxxxxx/00xxxxxx.xxx
Physician Incentive Plan Regulation Requirements for 2001 Survey Page 2 of 4
Requirements for 2000
specifically to assist your contractors in giving you information about the
incentive arrangements with subcontractors. These new forms and worksheets
are available at HCFA's web site, xxx.xxxx.xxx/xxxxxxxx/xxxxxxxx/xxx-xxxx.xxx.
You may elect to use them as you prepare your data for electronic disclosure to
HCFA. Be sure to maintain the documentation from your contractors so that it
will be available to regulators for verification of your data.
If arrangements with providers have not changed from the previous disclosure
year, you may request assurances from the providers that the arrangements are
substantially the same and enter the same information as last year. Again,
maintain the earlier documents and the assurances so they will be available to
regulators for verification.
MCOs must disclose the PIP arrangements that are effective January 1,2001. The
final date for submitting the completed disclosure to HCFA's contractor is APRIL
30, 2001. Medicare contractors who do not comply by this date are subject to
sanctions.
DISCLOSURE METHOD: The electronic submission is the same as last year, which
required the downloading of software and uploading of data via the Health Plan
Management System (HPMS). You will again access the HPMS through the Medicare
Data Communications Network (MDCN). Instructions for MDCN connectivity were
released in Operational Policy Letters 99.92 and 99.101. The PIP Data Entry
software will be available on the HPMS beginning January 16,2001. This site will
also include detailed instructions for entering PIP data on each screen and
submitting your disclosure electronically.
ENTERING DATA: Before you start entering data you should review the information
you receive from or about contracting and subcontracting providers who render
services to your Medicare enrollees to ensure that the information is complete
and accurate. We also suggest that you read the instructions for data entry to
become familiar with each data entry screen before you begin entering data.
An advantage of the electronic data entry is that it allows you to enter a
specific hierarchy of providers. For example, you should aggregate all medical
groups you contract with that have substantially the same incentive arrangements
and stop-loss requirements. Then you must enter the medical group-physician
arrangements only for the physicians associated with those provider groups, but
you should aggregate the physicians who have substantially the same arrangements
with the groups. The software will guide you to enter the various hierarchies of
contractual relationships within physician groups or intermediate entities.
Aggregation can save you much time in entering disclosure information. The large
number of disclosed arrangements for 1999 and 2000 included many arrangements
that could have been aggregated. We found many multiple entries by MCOs of their
direct contracts with physicians where they entered each physician separately
rather than using one entry that indicated the number of physicians who had
substantially the same arrangement.
The software is designed to inform you if an entry is incomplete and allows you
to add the additional information and edit your entries. Therefore, we urge you
to start your data entry early in 2001 so that you will have time to correct or
add data before the deadline for submission.
CHANGES IN DATA ENTRY FOR 2001: When you download and install the PIP software,
a screen will inform you of the changes. These changes are the result of
industry feedback as well as HCFA's experience with two years of electronic
disclosure. Two modifications are described below.
There is a change in the data entry related to aggregation - we now ask for the
name or 'identifier' of a provider or an aggregate of providers. This change
will allow you to name an aggregation of providers so that they can be
identified more easily. For example, if you have aggregated 12 physician groups
because they have substantially the same incentive arrangements and stop-loss
requirements, you may identify them as 'Group Red' (you can choose any
alpha/numeric identifier).
xxxx://xxx.xxxx.xxx/xxxxxxxx/xxxxxxxx/00xxxxxx.xxx
Physician Incentive Plan Regulation Requirements for 2001 Page 3 of 4
[ILLEGIBLE]
You then enter "12" for the number of groups you are disclosing for that
arrangement. The advantage to this change is that if we need to contact you
about 'Group Red', you will know the group of providers to which we are
referring.
Another change is in the disclosing of stop-loss insurance amounts. You can now
enter only one amount for the individual stop-loss threshold. If the insurance
includes both professional and institutional, please select the threshold that
most closely applies to the type of risk being disclosed.
SURVEY REQUIREMENTS: The PIP Regulation requires that MCOs conduct customer
satisfaction surveys of both enrollees and disenrollees if any physician or
physician group in an MCO's network is placed at substantial risk for referral
services, as defined by regulation. Please follow the guidance below for
specific survey requirements that are dependent on an MCO's inclusion in HCFA's
national survey effort.
For [ILLEGIBLE] 876 Cost and Closed Cost Healthplans, M+C Organizations, Social
HMOs and Medicare Choices: HCFA's national administration of the Consumer
Assessments of Health Plans Study (CAHPS) is well established for enrollees and
how includes disenrollees. Therefore, HCFA has determined that these Medicare
MCOs no longer need to conduct independent surveys in order to satisfy PEP
requirements. HCFA will consider all MCOs participating in the nationally
administered CAHPS survey to be in compliance with the survey mandate in 42 CFR
422.208/210(2)
Organizations can now meet the survey disclosure requirement of the regulations
by giving Medicare enrollees a copy of the CAHPS enrollment survey results,
which are available on the Internet. Further, these MCOs will no longer need to
submit survey summaries to HCFA.
QUESTIONS: If you have questions about the PIP disclosure requirements, you may
call Xxxxxx Xxxxxx at 000-000-0000, Xxxx Xxxxxx at 000-000-0000 or Xxxxx
Xxxxxxxxxx at 000-000-0000. Questions about technical aspects of the disclosure
should be directed to Fu Associates at 000-000-0000. Questions about the MDCN
should be directed to Xxx Xxxxxxxxxx at 000-000-0000.
Thank you for your continued cooperation in complying with the PIP requirements.
Sincerely,
/s/
Xxxx X. Xxxxxx
Acting Director
Medicare Managed Care Group
----------
(1) See regulations at 42 CFR 417.479 dated March 27,1996 and December
31, 1996. Also see 42 CFR
xxxx://xxx.xxxx.xxx/xxxxxxxx/xxxxxxxx/00xxxxxx.xxx
Physician Incentive Plan Regulation Requirements for 2001 Survey Page 4 of 4
Requirements for 2000
422.208/210 final rule dated June 29, 2000.
[2] For CAHPS requirements, see HCFA Operational Policy Letter 99.110,
Reporting Requirements for Medicare Managed Care Organizations in 2000:
HEDIS, HOS, and CAHPS, dated December 22, 1999. Also see any subsequent
reporting requirements in Operational Policy Letters for 2001.
[LOGO] Return to Physician Incentive Plan Homepage
[LOGO] Return to Medicare Managed Care Homepage
Last Updated December 28, 0000
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& HUMAN SERVICES LOGO]
xxxx://xxx.xxxx.xxx/xxxxxxxx/xxxxxxxx/00xxxxxx.xxx
Physician Incentive Plan Regulation Disclosure Requirements Page 1 of 2
HCFA BENEFICIARIES PLANS & PROVIDERS STATES RESEARCHERS STUDENTS
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MEDICARE MEDICAID CHIP CUSTOMER SERVICE FAQs SEARCH
MANAGED CARE ORGANIZATION (MCO)
PHYSICIAN INCENTIVE PLAN DISCLOSURE COMPLIANCE PACKAGE
THE FOLLOWING DOCUMENTS WILL ASSIST IN COMPLETING THE DISCLOSURE REQUIREMENTS:
PIP DISCLOSURE FOR THE MEDICARE+CHOICE APPLICANT
NOTE: THESE DOCUMENTS ARE REVISED AS OF OCTOBER 2000
- Physician Incentive Plan Disclosure Form for Medicare+Choice
Applicants Instructions - for completing the disclosure form -
downloadable only - Word (34,000 bytes) or PDF - revised 10/2000
- Disclosure Form for M+C Applicants : this form is required in the
application for a M+C contract - downloadable only - Word (17,000
bytes) or PDF - revised 10/2000
REPORTING PACKAGE FOR PROVIDERS OF MANAGED CARE ORGANIZATIONS
WHO CONTRACT WITH HCFA
NOTE: THESE DOCUMENTS ARE REVISED AS OF OCTOBER 2000
- HCFA PIP Summary Data Form for Providers: this form is for a
provider to transmit incentive information to Managed Care
Organizations, downloadable only - Word (17,000 bytes) or PDF -
revised 10/2000
- Instructions for Providers for the HCFA PIP Summary Data Form: this
document gives instructions for completing the Summary Data Form -
downloadable only - Word (34,000 bytes) or PDF - revised 10/2000
provinstructions.doc - Word - 53,000 bytes, revised 10/2000
- Physician Incentive Plan Worksheet for Providers: this form assists
the provider in detailing data and calculating amount of risk that
is needed on the Summary Data Form; it is designed to crosswalk
with the Form - downloadable only - Word (32,000 bytes) or PDF -
revised 10/2000
- Instructions for the PIP Worksheet for Providers: this gives
instructions for completing the worksheet - downloadable only - Word
(15,000 bytes) or PDF - revised 10/2000
[LOGO] Return to Physician Incentive Plan Information Page
[LOGO] Return to Medicare Managed Care Homepage
Last Updated December 18, 0000
XXXX XXXXXXXXXXXXX XXXXX & XXXXXXXXX XXXXXX RESEARCHERS STUDENTS
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[HCFA LOGO] [DEPARTMENT OF HEALTH
& HUMAN SERVICES LOGO]
xxxx://xxx.xxxx.xxx/xxxxxxxx/xxxxxxxx/xxxxxxxx.xxx
APPENDIX - K
RECATEGORIZATION CHART
HUSKY A & B
Inpatient /Eligibility Recategorization Changes
Description Admitting MCO New/Continued MCO Responsible Entity Reinsurance
----------- ------------- ----------------- ------------------ -----------
HUSKY A, different MCO A1 A2 A1 Yes
HUSKY A to FFS A1 FFS FFS N.A.
HUSKY A to HUSKY B, same MCO A1 B1 A1 No
HUSKY A to HUSKY B, different MCO A1 B2 A1 No
HUSKY B, different MCO B1 B2 B1 N.A.
HUSKY A to disenrolled due to loss of
eligibility A1 (infinity) A1 NO
(out of Program)
HUSKY B to disenrolled due to loss of
eligibility
(Out of Program) B1 (infinity) B1 N.A.
HUSKY B to A (same MCO, different coverage) B1 A1 A1 Yes
HUSKY B to A (different MCO, different coverage) B1 A2 A2 Yes
A1 = HUSKY A, MCO #1
A2 = HUSKY A, MCO #2
B1 = HUSKY B, MCO #1
B2 = HUSKY B, MCO #2
(infinity) = Disenrolled due to loss of elig.
APPENDIX J
RECATEGORIZATION CHART
APPENDIX L
ABORTION REPORTING
HYDE AMENDMENT CRITERIA
This report shall include all abortions, which do not meet the HYDE Amendment
criteria, which are paid by the MCO during the quarter (e.g. July 1 - September
30). These reports shall be submitted bye the 15th of the month following the
end of the quarter (e.g. October 15). The reports shall be submitted in hard
copy, signed by the COO or designee, as well as electronically to XXX XXXXXX,
Division of Fiscal Analysis.
PROCEDURE_CODE is one of the following:
69.01 69.51 69.93 74.91 75.0 0940Y 3131Y 59100 59105 59106 59800 59801
29810 59811 59840 59841 59850 59851 59852 59855 59856 59857 59866
AND
PRIMARY DIAGNOSIS in not one of the following:
'632 634* 636* 637* 638*
OR
PROCEDURE_CODE is one of the following:
00940 03140 03150 59200 59812 59820 59821 59830 S0190 S0191
S0199 69.02 69.52 69.59 72.7 72.71 '72.79 96.49
AND
PRIMARY DIAGNOSIS is between 635 And 635.99.
[LOGO] STATE OF CONNECTICUT
DEPARTMENT OF SOCIAL SERVICES
CONTRACT AMENDMENT
AMENDMENT NUMBER: 2
CONTRACT #: 093-MED-FCHP-1
CONTRACT PERIOD: 08/11/2001 - 6/30/2003
CONTRACTOR NAME: FIRST CHOICE HEALTH PLAN OF CT
CONTRACTOR ADDRESS: 00 XXXXXX XXXX, XXXXX XXXXX, XX 00000-0000
Contract number 093-MED-FCHP-1 by and between the Department of Social Services
(the "Department") and Firstchoice Health Plan of CT (the "Contractor") for the
provision of services under the HUSKY A program as amended by Amendment 1 is
hereby further amended as follows:
1. PARAGRAPH 1 OF PART I AS AMENDED BY AMENDMENTS 1 IS FURTHER AMENDED TO
EXTEND THE CONTRACT END DATE FOR A PERIOD OF NINE (9) MONTHS THROUGH JUNE
30, 2003.
2. APPENDIX I WHICH SETS FORTH THE CAPITATION RATES TO BE PAID BY THE
DEPARTMENT IN FULL CONSIDERATION OF THE CONTRACT SERVICES RENDERED BY THE
MCO IS REPLACED WITH APPENDIX I - AMENDED ATTACHED HERETO AND INCORPORATED
HEREIN.
3. THE EFFECTIVE DATE OF APPENDIX I - AMENDED IS JULY 1, 2002. THE DEPARTMENT
SHALL MAKE ANY NECESSARY ADJUSTMENTS TO CAPITATION PAYMENTS MADE TO THE
CONTRACTOR SINCE JULY 1, 2002 TO REFLECT THE AMENDED CAPITATION RATES.
This document constitutes an amendment to the above numbered contract. All
provisions of that contract, except those explicitly changed or described above
by this amendment, shall remain in full force and effect.
ACCEPTANCES AND APPROVALS
CONTRACTOR DEPARTMENT
FIRSTCHOICE HEALTH PLAN OF CT DEPARTMENT OF SOCIAL SERVICES
/s/ Xxxx X. Xxxxx 9/30/02
------------------------------ ------- ------------------------------ ----
Signature (Authorized Official) Date Signature (Authorized Official) Date
Xxxx X. Xxxxx CEO/President XXXXXXX X. XXXXXXXXXX DEPUTY COMMISSIONER
------------------------------- ----------------- ------------------------------- -------------------
Typed Name (Authorized Official) Title Typed Name (Authorized Official) Title
OFFICE OF THE ATTORNEY GENERAL
--------------------------------------------------------------------------------
Attorney General (as to form) Date
( ) THIS CONTRACT DOES NOT REQUIRE THE SIGNATURE OF THE ATTORNEY GENERAL
PURSUANT TO AN AGREEMENT BETWEEN THE DEPARTMENT AND THE OFFICE OF THE ATTORNEY
GENERAL DATED:______________________
CONNECTICUT DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION OF SIGNATURE DOCUMENT
I, Xxxx X. Xxxxx, Chief Executive Officer/ President of First Choice Health
Plans of Connecticut, Inc., a corporation organized under the laws of the State
of Connecticut, hereby certify that the following is a full and true copy of a
resolution adopted at a meeting of the Board of Director of said company, duly
held on the 30th day of September, 2002:
"RESOLVED that the Chief Executive Officer/President is hereby authorized
to make, execute and approve on behalf of this company, any and all
contracts and amendments and to execute and approve on behalf of this
company, other instruments, a part of or incident to such contracts and
amendments effective until otherwise ordered by the Board of Directors".
and I do further certify that the above resolution has not been in anyway
altered, amended or repealed, and is now in full force and effect. IN WITNESS
WHEREOF, I have hereunto set my hand and affixed the corporate seal of said
company this 30th day of September, 2002.
/s/ Xxxx X.Xxxxx
----------------------------
Signature
Chief Executive Officer/President
-----------------------------------
Title
[LOGO] STATE OF CONNECTICUT
DEPARTMENT OF SOCIAL SERVICES
CONTRACT AMENDMENT
AMENDMENT NUMBER: 3
CONTRACT #: 093-MED-FCHP-1 [[ILLEGIBLE] OF SOCIAL
SERVICES CONTRACTS/[ILLEGIBLE]
CONTRACT PERIOD: 08/11/2001-7/31/2003 JUN 30 [ILLEGIBLE]]
CONTRACTOR NAME: FIRST CHOICE HEALTH PLAN OF CT
CONTRACTOR ADDRESS: 00 XXXXXX XXXX, XXXXX XXXXX, XX 00000-0000
Contract number 093-MED-FCHP-1 by and between the Department of Social Services
(the "Department") and Firstchoice Health Plan of CT (the "Contractor") for
the provision of services under the HUSKY A program as amended by Amendments 1
and 2 is hereby further amended as follows:
1. PARAGRAPH 1 OF PART I AS AMENDED BY AMENDMENTS 1 AND 2 IS FURTHER AMENDED
TO EXTEND THE CONTRACT END DATE FOR A PERIOD OF ONE (1) MONTH THROUGH JULY
31, 2003.
2. PART I AS AMENDED BY AMENDMENTS 1 AND 2 IS FURTHER AMENDED TO ADD A NEW
SECTION 37 FOR COMPLIANCE PROVISIONS RELATED TO THE HEALTH INSURANCE
PORTABILITY AND PRIVACY ACT OF 1996 ("HIPAA") AS SET FORTH ON PAGES 3
THROUGH 8 OF THIS AMENDMENT.
3. APPENDIX I AS AMENDED BY AMENDMENT 2 IS HEREBY FURTHER AMENDED TO EXTEND
THE EFFECTIVE DATE OF THE CAPITATION RATES FOR A PERIOD OF ONE (1) MONTH
FROM 6/30/03 TO 7/31/03. IF, THROUGH THE PASSAGE OF A BUDGET FOR STATE
FISCAL YEAR ("SFY") 2004 THE CAPITATION RATES ARE TO BE REVISED EFFECTIVE
JULY 1, 2003, THE DEPARTMENT SHALL, IN THE NEXT AMENDMENT TO THIS
CONTRACT, AMEND THE CAPITATION RATES TO REFLECT SUCH REVISIONS AND SHALL
MAKE ANY NECESSARY ADJUSTMENTS TO CAPITATION PAYMENTS MADE TO THE
CONTRACTOR SINCE JULY 1, 2003 TO REFLECT THE REVISED CAPITATION RATES.
HIPAA ACKNOWLEDGMENT
THE CONTRACTOR HEREIN IS A BUSINESS ASSOCIATE UNDER HIPAA:
CONTRACTOR DEPARTMENT
FIRSTCHOICE HEALTH PLAN OF CT DEPARTMENT OF SOCIAL SERVICES
/s/ Xxxx X. Xxxxx 6/26/03 /s/ Xxxxxxx X. Xxxxxxxxxx 6/30/03
------------------------------ ------- --------------------------------- -------
Signature (Authorized Official) Date Signature (Authorized Official) Date
Xxxx X. Xxxxx Cheif Executive Officer XXXXXXX X. XXXXXXXXXX DEPUTY COMMISSIONER
-------------------------------- -------------------------- ------------------------------- --------------------
Typed Name (Authorized Official) Title Typed Name (Authorized Official) Title
[APPROVED
JUN 25 2003
WELLCARE
LEGAL SERVICES]
ACCEPTANCES AND APPROVALS
This document constitutes an amendment to the above numbered contract. All
provisions of that contract, except those explicitly changed or described above
by this amendment, shall remain in full force and effect.
CONTRACTOR DEPARTMENT
FIRSTCHOICE HEALTH PLAN OF CT DEPARTMENT OF SOCIAL SERVICES
/s/ Xxxx X. Xxxxx 6/26/03 /s/ Xxxxxxx X. Xxxxxxxxxx 6/30/03
--------------------------------- --------- ------------------------------ -------
Signature (Authorized Official) Date Signature (Authorized Official) Date
/s/ Xxxx X. Xxxxx Chief Executive officer XXXXXXX X. XXXXXXXXXX DEPUTY COMMISSIONER
-------------------------------- ----------------------- ------------------------------- ---------------------
Typed Name (Authorized Official) Title Typed Name (Authorized Official) Title
[APPROVED
JUN 25 2003
WELLCARE
LEGAL SERVICES]
OFFICE OF THE ATTORNEY GENERAL
________________________________________________________________________________
Attorney General (as to form) Date
( ) THIS CONTRACT DOES NOT REQUIRE THE SIGNATURE OF THE ATTORNEY GENERAL
PURSUANT TO AN AGREEMENT BETWEEN THE DEPARTMENT AND THE OFFICE OF THE ATTORNEY
GENERAL DATED:_____________________
HIPAA Section for Purchase of Services Contracts. Part. 3/26/03
(insert Section # here for Part I) HIPAA PROVISIONS
(a.) IF THE CONTRACTOR IS A BUSINESS ASSOCIATE UNDER HIPAA, THE CONTRACTOR MUST
COMPLY WITH ALL TERMS AND CONDITIONS OF THIS SECTION OF THE CONTRACT. IF THE
CONTRACTOR IS NOT A BUSINESS ASSOCIATE UNDER HIPAA, THIS SECTION OF THE CONTRACT
DOES NOT APPLY TO THE CONTRACTOR FOR THIS CONTRACT.
(b.) The Contractor is required to safeguard the use, publication and disclosure
of information on all applicants for, and all clients who receive, services
under the contract in accordance "with all applicable federal and state law
regarding confidentiality, which includes but is not limited to the requirements
of the Health Insurance Portability and Privacy Act of 1996 ("HIPAA"), more
specifically with the Privacy Rule at 45 C.F.R. Part 160 and Part 164, subparts
A and E; and
(c.) The State of Connecticut Department named on page 1 of this Contract
(hereinafter "DEPARTMENT") is a "covered entity" as that term is defined in 45
C.F.R. Section 160.103; and
(d.) The Contractor, on behalf of the Department, performs functions that
involve the use or disclosure of "individually identifiable health information,"
as that term is defined in 45 C.F.R. Section 160.103 ; and
(e.) The Contractor is a "business associate" of the Department, as that term is
defined in 45 C.F.R. Section 160.103; and
(f.) The Contractor and the Department agree to the following in order to secure
compliance with the Health Insurance Portability and Privacy Act of 1996
("HIPAA"), more specifically with the Privacy Rule at 45 C.F.R. Part 160 and
Part 164, subparts A and E:
I. DEFINITIONS
A. BUSINESS ASSOCIATE. "Business Associate" shall mean the Contractor.
B. COVERED ENTITY. "Covered Entity" shall mean the Department of the State
of Connecticut named on page 1 of this Contract.
C. DESIGNATED RECORD SET. "Designated Record Set" shall have the same
meaning as the term "designated record set" in 45 C.F.R. Section 164.501.
D. INDIVIDUAL. "Individual" shall have the same meaning as the term
"individual"' in 45 C.F.R. 164.501 and shall include a person who
qualifies as a personal representative as defined in 45 C.F.R. Section
164.502(g).
E. PRIVACY RULE. "Privacy Rule" shall mean the Standards for Privacy of
Individually Identifiable Health Information at 45 C.F.R. part 160 and
parts 164, subparts A and E.
F. PROTECTED HEALTH INFORMATION. "Protected Health Information" or "PHI"
shall have the same meaning as the term "protected health information" in
45 C.F.R. Section 164.501, limited to information created or received by
the Business Associate from or on behalf of the Covered Entity.
G. REQUIRED BY LAW. "Required by Law" shall have the same meaning as the
term "required by law" in 45 C.F.R. Section 164.501.
H. SECRETARY. "Secretary" shall mean the Secretary of the Department of
Health and Human Services or his designee.
I. MORE STRINGENT. "More stringent" shall have the same meaning as the
term "more stringent" in 45 C.F.R. Section 160.103.
J. SECTION OF CONTRACT. "(T)his Section of the Contract" refers to the
HIPAA Provisions stated herein, in their entirety.
II. OBLIGATIONS AND ACTIVITIES OF BUSINESS ASSOCIATE
A. Business Associate agrees not to use or disclose PHI other than as
permitted or required by this Section of the Contract or as Required by
Law
B. Business Associate agrees to use appropriate safeguards to prevent use
or disclosure of PHI other than as provided for in this Section of the
Contract.
C. Business Associate agrees to mitigate, to the extent practicable, any
harmful effect that is known to the Business Associate of a use or
disclosure of PHI by Business Associate in violation of this Section of
the Contract.
D. Business Associate agrees to report to Covered Entity any use or
disclosure of PHI not provided for by this Section of the Contract of
which it becomes aware.
E. Business Associate agrees to insure that any agent, including a
subcontractor, to whom it provides PHI received from, or created or
received by Business Associate, on behalf of the Covered Entity, agrees to
the same restrictions and conditions that apply through this Section of
the Contract to Business Associate with respect to such information.
F. Business Associate agrees to provide access, at the request of the
Covered Entity, and in the time and manner a agreed to by the parties, to
PHI in a
2
Designated Record Set, to Covered Entity or, as directed by Covered
Entity, to an Individual in order to meet the requirements under 45 C.F.R.
Section 164.524.
G. Business Associate agrees to make any amendments to PHI in a Designated
Record Set that the Covered Entity directs or agrees to pursuant to 45
C.F.R. Section 164.526 at the request of the Covered Entity, and in the
time and manner agreed to by the parties.
H. Business Associate agrees to make internal practices, books, and
records, including policies and procedures and PHI, relating to the use
and disclosure of PHI received from, or created or received by, Business
Associate on behalf of Covered Entity, available to Covered Entity or to
the Secretary in a time and manner agreed to by the parties or designated
by the Secretary, for purposes of the Secretary determining Covered
Entity's compliance with the Privacy Rule.
I. Business Associate agrees to document such disclosures of PHI and
information related to such disclosures as would be required for Covered
Entity to respond to a request by an Individual for an accounting of
disclosures of PHI in accordance with 45 C.F.R. Section 164.528.
J. Business Associate agrees to provide to Covered Entity, in a time and
manner agreed to by the parties, information collected in accordance with
paragraph I of this Section of the Contract, to permit Covered Entity to
respond to a request by an Individual for an accounting of disclosures of
PHI in accordance with 45 C.F.R. Section 164.528.
K. Business Associate agrees to comply with any state law that is more
stringent than the Privacy Rule.
III. PERMITTED USES AND DISCLOSURES BY BUSINESS ASSOCIATE
A. GENERAL USE AND DISCLOSURE PROVISIONS: Except as otherwise limited in
this Addendum, Business Associate may use or disclose PHI to perform
functions, activities, or services for, or on behalf of, Covered Entity as
specified in this Contract, provided that such use or disclosure would not
violate the Privacy Rule if done by Covered Entity or the minimum
necessary policies and procedures of the Covered Entity.
B. SPECIFIC USE AND DISCLOSURE PROVISIONS:
1. Except as otherwise limited in this Section of the Contract,
Business Associate may use PHI for the proper management and
administration of Business Associate or to carry out the legal
responsibilities of Business Associate.
3
2. Except as otherwise limited in this Section of the Contract,
Business Associate may disclose PHI for the proper management and
administration of Business Associate, provided that disclosures are
Required by Law, or Business Associate obtains reasonable assurances
from the person to whom the information is disclosed that it will
remain confidential and used or further disclosed only as Required by
Law or for the purpose for which it was disclosed to the person, and
the person notifies Business Associate of any instances of which it is
aware in which the confidentiality of the information has been
breached.
3. Except as otherwise limited in this Section of the Contract,
Business Associate may use PHI to provide Data Aggregation services to
Covered Entity as permitted by 45 C.F.R. Section 154.514(e)(2)(i)(B).
IV. OBLIGATIONS OF COVERED ENTITY
A. Covered Entity shall notify Business Associate of any limitations in
its notice of privacy practices of Covered Entity, in accordance with 45
C.F.R. 164.520, or to the extent that such limitation may affect Business
Associate's use or disclosure of PHI.
B. Covered Entity shall notify Business Associate of any changes in, or
revocation of, permission by Individual to use or disclose PHI, to the
extent that such changes may affect Business Associate's use or disclosure
of PHI.
C. Covered Entity shall notify Business Associate of any restriction to
the use or disclosure of PHI that Covered Entity has agreed to in
accordance with 45 C.F.R. Section 164.522, to the extent that such
restriction may affect Business Associate's use or disclosure of PHI.
V. PERMISSIBLE REQUESTS BY COVERED ENTITY
Covered Entity shall not request Business Associate to use or disclose PHI
in any manner that would not be permissible under the Privacy Rule if done
by the Covered Entity, except that Business Associate may use and disclose
PHI for data aggregation, and management and administrative activities of
Business Associate, as permitted under this Addendum.
VI. TERM AND TERMINATION
A. TERM. The Term of this Section of the Contract shall be effective as of
the date the Contract is effective and shall terminate when all of the PHI
provided by Covered Entity to Business Associate, or created or received
by Business Associate on behalf of Covered Entity, is destroyed or
returned to Covered Entity, or, if it is infeasible to return or destroy
PHI, protections are extended to such information, in accordance with the
termination provisions in this Section.
4
B. TERMINATION FOR CAUSE. Upon Covered Entity's knowledge of a material
breach by Business Associate, Covered Entity shall either:
1. Provide an opportunity for Business Associate to cure the breach or
end the violation and terminate the Contract if Business Associate does
not cure the breach or end the violation within the time specified by
the Covered Entity; or
2. Immediately terminate the Contract if Business Associate has
breached a material term of his Section of the Contract and cure is not
possible; or
3. If neither termination nor cure is feasible, Covered Entity shall
report the violation to the Secretary.
C. EFFECT OF TERMINATION.
1. Except as provided in paragraph (2) of this subsection C, upon
termination of this Contract, for any reason, Business Associate shall
return or destroy all PHI received from Covered Entity, or created or
received by Business Associate on behalf of Covered Entity. This
provision shall apply to PHI that is in the possession of
subcontractors or agents of Business Associate. Business Associate
shall retain no copies of the PHI.
2. In the event that Business Associate determines that returning or
destroying the PHI is infeasible, Business Associate shall provide to
Covered Entity notification of the conditions that make return or
destruction infeasible. Upon documentation by Business Associate that
return of destruction of PHI is infeasible, Business Associate shall
extend the protections of this Section of the Contract to such PHI and
limit further uses and disclosures of PHI to those purposes that make
return or destruction infeasible, for as long as Business Associate
maintains such PHI. Infeasibility of the return or destruction of PHI
includes, but is not limited to, requirements under state or federal
law that the Business Associate maintains or preserves the PHI or
copies thereof.
VII. MISCELLANEOUS PROVISIONS
A. REGULATORY REFERENCES. A reference in this Section of the Contract to a
section in the Privacy Rule means the section as in effect or as amended.
B. AMENDMENT. The Parties agree to take such action as in necessary to
amend this Section of the Contract from time to time as is necessary for
Covered
5
Entity to comply with requirements of the Privacy Rule and the Health
Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191.
C. SURVIVAL. The respective rights and obligations of Business Associate
under Section VI, Subsection C of this Section of the Contract shall
survive the termination of this Contract.
D. EFFECT ON CONTRACT Except as specifically required to implement the
purposes of this Section of the Contract, all other terms of the contract
shall remain in force and effect.
E. CONSTRUCTION. This Section of the Contract shall be construed as
broadly as necessary to implement and comply with the Privacy Standard.
Any ambiguity in this Section of the Contract shall be resolved in favor
of a meaning that complies, and is consistent with, the Privacy Standard.
F. DISCLAIMER. Covered Entity makes no warranty or representation that
compliance with this Section of the Contract will be adequate or
satisfactory for Business Associate's own purposes. Covered Entity shall
not be liable to Business Associate for any claim, loss or damage related
to or arising from the unauthorized use or disclosure of PHI by Business
Associate or any of its officers, directors, employees, contractors or
agents, or any third party to whom Business Associate has disclosed PHI
pursuant to paragraph II D of this Addendum. Business Associate is solely
responsible for all decisions made, and actions taken, by Business
Associate regarding the safeguarding, use and disclosure of PHI within its
possession, custody or control.
G. INDEMNIFICATION. The Business Associate shall indemnify and hold the
Covered Entity harmless from and against all claims, liabilities,
judgments, fines, assessments, penalties, awards, or other expenses, of
any kind or nature whatsoever, including, without limitation, attorney's
fees, expert witness fees, and costs of investigation, litigation or
dispute resolution, relating to or arising out of any violation by the
Business Associate and its agents, including subcontractors, of any
obligation of Business Associate and its agents, including subcontractors,
under this Section of the Contract.
6
THIS MUST BE INSERTED INTO EACH PURCHASE OF SERVICES CONTRACT ON THE SIGNATURE
PAGE:
THE CONTRACTOR HEREIN IS / IS NOT A BUSINESS ASSOCIATE UNDER HIPAA*:
--------------------------------------------------------------------------------
(circle one**)
/S/ Xxxx X. Xxxxx
--------------------------------------- ---------------------------------
AUTHORIZED SIGNATORY FOR THE CONTRACTOR AUTHORIZED SIGNATORY FOR
(AGENCY ABBREVIATION)
XXXX X. XXXXX, CHIEF EXECUTIVE OFFICER
------------------------------------- ---------------------------------
(TYPED NAME AND TITLE) (TYPED NAME AND TITLE)
6/26/03
------------------------------------- ---------------------------------
DATE DATE
[APPROVED
JUN 25 2003
WELLCARE
LEGAL SERVICES]
* Per/ Part I, Section (whatever section of Part I this ends up to be ...) of
this contract
** Department must make this determination before Contract is signed.
7
[LOGO] STATE OF CONNECTICUT
DEPARTMENT OF SOCIAL SERVICES
CONTRACT AMENDMENT
AMENDMENT NUMBER: 4
CONTRACT #: 093-MED-FCHP-1
CONTRACT PERIOD: 08/11/2001 - 8/12/2003
CONTRACTOR NAME: FIRST CHOICE HEALTH PLAN OF CT
CONTRACTOR ADDRESS: 00 XXXXXX XXXX, XXXXX XXXXX, XX 00000-0000
Contract number 093-MED-FCHP-1 by and between the Department of Social Services
(the "Department") and Firstchoice Health Plan of CT. the "Contractor") for the
provision of services under the HUSKY A program as amended by Amendments 1, 2
and 3 is hereby further amended as follows:
1. PARAGRAPH 1 OF PART I AS AMENDED BY AMENDMENTS 1, 2 AND 3 IS FURTHER AMENDED
TO EXTEND THE CONTRACT END DATE FOR A PERIOD OF TWELVE (12) DAYS THROUGH
AUGUST 12, 2003. THE PURPOSE OF THIS EXTENSION IS TO PERMIT TIME FOR THE
CENTERS FOR MEDICAID AND MEDICARE SERVICES TO REVIEW THE CONTRACT TERMS TO
BECOME EFFECTIVE AUGUST 13, 2003.
2. APPENDIX I AS AMENDED BY AMENDMENT 2 IS HEREBY FURTHER AMENDED TO EXTEND THE
EFFECTIVE DATE OF THE CAPITATION RATES FOR A PERIOD OF TWELVE (12) DAYS FROM
7/31/03 TO 8/12/03. IF, THROUGH THE PASSAGE OF A BUDGET FOR STATE FISCAL YEAR
("SFY") 2004 THe CAPITATION RATES ARE TO BE REVISED EFFECTIVE JULY 1, 2003,
THE DEPARTMENT SHALL, IN THE NEXT AMENDMENT TO THIS CONTRACT, AMEND THE
CAPITATION RATES TO REFLECT SUCH REVISIONS AND SHALL MAKE ANY NECESSARY
ADJUSTMENTS TO CAPITATION PAYMENTS MADE TO THE CONTRACTOR SINCE JULY 1, 2003
TO REFLECT THE REVISED CAPITATION RATES.
ACCEPTANCES AND APPROVALS
This document constitutes an amendment to the above numbered contract. All
provisions of that contract, except those explicitly changed or described above
by this amendment, shall remain in full force and effect.
FIRSTCHOICE HEALTH PLAN OF CT DEPARTMENT OF SOCIAL SERVICES
/s/ Xxxx X. Xxxxx 7/24/03
-------------------------------- ------- ----------------------------- ----
Signature (Authorized Official) Date Signature (Authorized Official) Date
CHIEF EXECUTIVE DEPUTY
XXXX X. XXXXX OFFICER XXXXXXX X. XXXXXXXXXX COMMISSIONER
----------------------- --------------- ---------------------- ------------
Typed Name Title Typed Name Title
(Authorized Official) (Authorized Official)
--------------------------------------------------------------------------------
Attorney General (as to form) Date
( ) THIS CONTRACT DOES NOT REQUIRE THE SIGNATURE OF THE ATTORNEY GENERAL
PURSUANT TO AN AGREEMENT BETWEEN THE DEPARTMENT AND THE OFFICE OF THE ATTORNEY
GENERAL DATED:__________________
APPENDIX - Amended
PLAN NAME:
FIRSTCHOICE
CAPITATION RATES
07/01/02-08/12/03
FAIRFIELD HARTFORD LITCHFIELD MIDDLESEX NEW HAVEN NEW LONDON TOLLAND XXXXXXX
--------- -------- ---------- --------- --------- ---------- ------- -------
UNDER ONE $536.44 $606.89 $605.12 $717.18 $602.97 $600.00 $724.78 $581.51
AGES 1 TO 14 $102.32 $110.46 $110.15 $130.10 $109.79 $109.23 $131.46 $107.71
MALE -AGES 15 TO 39 $127.22 $138.42 $138.03 $162.52 $137.60 $136.94 $164.18 $135.18
FEMALE - AGES 15 TO 39 $207.77 $231.48 $230.81 $273.76 $230.00 $228.84 $276.70 $223.07
MALE - AGES 40 AND OVER $227.33 $254.24 $253.48 $301.18 $252.59 $251.31 $304.41 $244.68
FEMALE - AGES 40 AND OVER $218.52 $244.15 $243.42 $289.20 $242.55 $241.32 $292.32 $235.04
PAGE 1 of 1
Effective 7/1/02
[LOGO] STATE OF CONNECTICUT
DEPARTMENT OF SOCIAL SERVICES
CONTRACT AMENDMENT
AMENDMENT NUMBER: 5
CONTRACT #: 093-MED-FCHP-1
CONTRACT PERIOD: 08/11/2001-9/30/2003
CONTRACTOR NAME: FIRST CHOICE HEALTH PLAN OF CT
CONTRACTOR ADDRESS: 00 XXXXXX XXXX, XXXXX XXXXX, XX 00000-0000
Contract number 093-MED-FCHP-1 by and between the Department of Social Services
(the "Department") and Firstchoice Health Plan of CT (the "Contractor") for the
provision of services under the HUSKY A program as amended by Amendments 1, 2, 3
and 4 is hereby further amended as follows:
1. PARAGRAPH 1 OF PART I AS AMENDED BY AMENDMENTS 1, 2, 3 AND 4 IS FURTHER
AMENDED TO EXTEND THE CONTRACT END DATE FROM AUGUST 12, 2003 TO SEPTEMBER
30, 2003.
2. PART II "GENERAL CONTRACT TERMS FOR MCOs" IS DELETED IN ITS ENTIRETY AND
REPLACED WITH PART II "GENERAL CONTRACT TERMS FOR MCOs" DATED AUGUST 13,
2003 PAGES 1 THROUGH 115 ATTACHED HERETO AND INCORPORATED HEREIN BY
REFERENCE.
3. THE CONTRACTOR AND THE DEPARTMENT FURTHER AGREE THAT THE PARTIES'
OBLIGATION TO COMPLY WITH PART II "GENERAL CONTRACT TERMS FOR MCOs" DATED
AUGUST 13, 2003 PAGES 1 THROUGH 115 ATTACHED HERETO AND INCORPORATED
HEREIN BY REFERENCE SHALL TERMINATE ON THE DATE THAT THIS AMENDMENT
EXPIRES UNLESS THE PARTIES AGREE IN A SUBSEQUENT AMENDMENT TO EXTEND THE
EFFECTIVE DATE OF THE CONTRACT.
4. THE CONTRACTOR AND THE DEPARTMENT FURTHER AGREE THAT THEY SHALL NEGOTIATE
A REIMBURSEMENT PROCESS IN THE EVENT OF A COURT DECISION REQUIRING FUTURE
RE-ENROLLMENT OF AND HUSKY ADULT WITH INCOME ABOVE ONE HUNDRED PERCENT
(100%) OF THE FEDERAL POVERTY LIMIT WHO CURRENTLY QUALIFIES FOR HUSKY
SOLELY ON THE BASIS OF THE INJUNCTION PENDING APPEAL IN RABIN v. DSS.
5. APPENDIX A IS DELETED IN ITS ENTIRETY AND REPLACED WITH APPENDIX A DATED
AUGUST 13, 2003 ATTACHED HERETO AND INCORPORATED HEREIN BY REFERENCE.
6. APPENDIX G IS DELETED IN ITS ENTIRETY AND REPLACED WITH APPENDIX G DATED
AUGUST 13, 2003 ATTACHED HERETO AND INCORPORATED HEREIN BY REFERENCE.
7. APPENDIX I IS HEREBY FURTHER AMENDED TO EXTEND THE EFFECTIVE DATE OF THE
CAPITATION RATES FROM 8/12/03 TO SEPTEMBER 30, 2003. IF, THROUGH THE
PASSAGE OF A BUDGET FOR STATE FISCAL YEAR ("SFY") 2004 THE CAPITATION
RATES ARE TO BE REVISED EFFECTIVE JULY 1, 2003, THE DEPARTMENT, IN THE
NEXT AMENDMENT TO THIS CONTRACT WHICH MAY BE ENTERED INTO PRIOR TO THE
EXPIRATION OF THIS AMENDMENT, SHALL AMEND THE CAPITATION RATES TO REFLECT
SUCH REVISIONS AND SHALL MAKE ANY NECESSARY ADJUSTMENTS TO CAPITATION
PAYMENTS MADE TO THE CONTRACTOR SINCE JULY 1, 2003 TO REFLECT THE REVISED
CAPITATION RATES.
8. A NEW APPENDIX L (TEMPLATES FOR PHARMACY REPORTS) DATED AUGUST 13, 2003
ATTACHED HERETO AND INCORPORATED HEREIN BY REFERENCE.
ACCEPTANCES AND APPROVALS
This document constitutes an amendment to the above numbered contract. All
provisions of that contract, except those explicitly changed or described above
by this amendment, shall remain in full force and effect.
CONTRACTOR DEPARTMENT
FIRSTCHOICE HEALTH PLAN OF CT DEPARTMENT OF SOCIAL SERVICES
/s/: Xxxx X. Xxxxx 8/11/03 /S/: Xxxxxxx X. Xxxxxxxxxx 8/12/03
----------------------- ------- ----------------------------- -------
Signature Date Signature (Authorized Official) Date
(Authorized Official)
CHIEF EXECUTIVE DEPUTY
XXXX X.XXXXX OFFICER XXXXXXX X.XXXXXXXXXX COMMISSIONER
---------------------- --------------- ---------------------- ------------
Typed Name Title Typed Name Title
(Authorized Official) (Authorized Official)
[APPROVED
AUG 11 2003
WELLCARE
LEGAL SERVICES]
OFFICE OF THE ATTORNEY GENERAL
--------------------------------------------------------------------------------
Attorney General (as to form) Date
( ) THIS CONTRACT DOES NOT REQUIRE THE SIGNATURE OF THE ATTORNEY GENERAL
PURSUANT TO AN AGREEMENT BETWEEN THE DEPARTMENT AND THE OFFICE OF THE ATTORNEY
GENERAL DATED:_____________________
ASSISTANT SECRETARY'S CERTIFICATE
I, Xxxxx Xxxxx , the duly elected Assistant Secretary of FirstChoice
HealthPlans of Connecticut, Inc., a corporation organized under the laws of the
State of Connecticut (the "Corporation"), do hereby certify that the following
is a full and true copy of a resolution adopted at a meeting of the Board of
Directors of said Corporation, duly held on the 23rd day of May, 2003:
"RESOLVED, that the officers of the Corporation be, and they hereby
are, authorized to sign and execute in the name of the Corporation
all applications contracts, leases and other deeds and documents or
instruments in writing of whatsoever nature that may be required in
the ordinary course of the business of the Corporation and that may
be necessary to secure for operation of the corporate affairs,
governmental permits and licenses for, and incidental to, the lawful
operations of the business of the Corporation, and to do such acts
and things as such officers deem necessary or advisable to fulfill
such legal requirements as are applicable to the Corporation and its
business."
"RESOLVED, that the officers of the Corporation and each of them
acting singly are hereby authorized, empowered and directed to
execute and deliver, in the name and on behalf of the Corporation,
such further agreements, instruments, documents, certificates and
filings, with such changes in the terms and provisions thereof as
the officer executing the same may determine necessary or
appropriate, and to do and perform such other acts and deeds as they
or any of them determine necessary or appropriate, in order to
effectuate the purposes and intent of the foregoing resolutions."
and I do further certify that the above resolution has not been in any way
altered, amended or repealed, and is now in full force and effect.
IN WITNESS WHEREOF, I have hereunto executed the Assistant Secretary's
Certificate this 11th day of August 2003.
FirstChoice HealthPlans of Connecticut, Inc.
/s/: Xxxxx Xxxxx
--------------------------
By: Xxxxx Xxxxx, Assistant Secretary
August 13, 2003
PART I: STANDARD CONNECTICUT CONTRACT TERMS
PART II: GENERAL CONTRACT TERMS FOR MCOS
1. DEFINITIONS
2. DELEGATIONS OF AUTHORITY
3. FUNCTIONS AND DUTIES OF THE MCO
3.01 Provision of Services
3.02 Non-Discrimination
3.03 Member Rights
3.04 Gag Rules
3.05 Coordination and Continuation of Care
3.06 Emergency Services
3.07 Geographic Coverage
3.08 Choice of Health Professional
3.09 Provider Network
3.10 Network Adequacy and Maximum Enrollment Levels
3.11 Provider Contracts
3.12 Provider Credentialing and Enrollment
3.13 Second Opinions, Specialist Providers and the Referral Process
3.14 PCP Selection, Scheduling and Capacity
3.15 Women's Health, Family Planning Access and Confidentiality
3.16 Pharmacy Access
3.17 Mental Health and Substance Abuse Access
3.18 Children's Issues and EPSDT Compliance
3.19 Special Services for Children/Reinsurance
3.20 Prenatal Care
3.21 Dental Care
3.22 Other Access Features
3.23 Pre-Existing Conditions
3.24 Newborn Enrollment
3.25 Acute Care Hospitalization, Nursing Home or Subacute Stay at Time of
Enrollment or Disenrollment
3.26 Open Enrollment
3.27 Special Disenrollment
3.28 Linguistic Access
3.29 Services to Members
3.30 Information to Potential Members
3.31 Marketing Requirements
3.32 Health Education
3.33 Internal and External Quality Assurance
3.34 Inspection of Facilities
3.35 Examination of Records
3.36 Medical Records
3.37 Audit Liabilities
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3.38 Clinical Data Reporting
3.39 Utilization Management
3.40 Financial Records
3.41 Insurance
3.42 Third Party Coverage
3.43 Coordination of Benefits and Delivery of Services
3.44 Passive Billing
3.45 Subcontracting for Services
3.46 Timely Payment of Claims
3.47 Copayment Limits and Member Charges for Noncovered Services
3.48 Insolvency Protection
3.49 Acceptance of DSS Rulings
3.50 Policy Transmittals
3.51 Fraud and Abuse
3.52 Persons with Special Health Care Needs
4. FUNCTIONS AND DUTIES OF THE DEPARTMENT
4.01 Eligibility Determinations
4.02 Populations Eligible to Enroll
4.03 Enrollment/Disenrollment
4.04 Default Enrollment
4.05 Lock-In
4.06 Capitation Payments to MCO
4.07 Retroactive Adjustments
4.08 Information
4.09 Ongoing MCO Monitoring
4.10 Utilization Review and Control
5. DECLARATIONS AND MISCELLANEOUS PROVISIONS
5.01 Competition Not Restricted
5.02 Nonsegregated Facilities
5.03 Offer of Gratuities
5.04 Employment/Affirmative Action Clause
5.05 Confidentiality
5.06 Independent Capacity
5.07 Liaison
5.08 Freedom of Information
5.09 Waivers
5.10 Force Majeure
5.11 Financial Responsibilities of the MCO
5.12 Capitalization and Reserves
5.13 Provider Compensation
5.14 Members Held Harmless
5.15 Compliance with Applicable Laws, Rules and Policies
5.16 Advance Directives
5.17 Federal Requirements and Assurances
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August 13 2003
5.18 Civil Rights
5.19 Statutory Requirements
5.20 Disclosure of Interlocking Relationships
5.21 DEPARTMENT'S Data Files
5.22 Changes Due to a Section 1115 or 1915(b) Freedom of Choice
5.23 Hold Harmless
5.24 Executive Order Number 16
6. GRIEVANCE SYSTEM AND PROVIDER DENIALS
6.01 Grievances
6.02 Notices of Action and Continuation of Services
6.03 Appeals and Administrative Hearing Processes
6.04 Expedited Appeals and Administrative Hearings
6.05 Provider Appeal Process
7. CORRECTIVE ACTION AND CONTRACT TERMINATION
7.01 Performance Review
7.02 Settlement of Disputes
7.03 Administrative Errors
7.04 Suspension of New Enrollment
7.05 Monetary Sanctions
7.06 Temporary Management
7.07 Payment Withhold, Class C Sanctions or Termination for Clause
7.08 Emergency Services Denials
7.09 Termination for Default
7.10 Termination for Mutual Convenience
7.11 Termination for the MCO Bankruptcy
7.12 Termination for Unavailability of Funds
7.13 Termination for Collusion in Price Determination
7.14 Termination Obligations of Contracting Parties
7.15 Waiver of Default
8. OTHER PROVISIONS
8.01 Severability
8.02 Effective Date
8.03 Order of Precedence
8.04 Correction of Deficiencies
8.05 This is not a Public Works Contract
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August 13 2003
9. APPENDICES
A. Covered Benefits HUSKY A Covered Benefits
B. Provider Credentialing and Enrollment Requirements
C. EPSDT Periodicity Schedule
D. DSS Marketing Guidelines
E. Quality Assurance Program for Managed Care
F. Unaudited Quarterly Financial Reports
G. Medicaid Managed Care Eligibility Categories
H. Managed Care Policy Transmittals
I. Capitation Payment Amounts
J. Physician Incentive Payments
K. Recategorization Chart
L. Quarterly Pharmacy Report
M. Non-Hyde Amendment Abortions
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August 13 2003
PART I: STANDARD CONNECTICUT CONTRACT TERMS
Part II
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August 13, 2003
PART II: GENERAL CONTRACT TERMS FOR MCOs
1. DEFINITIONS
As used throughout this contract, the following terms shall have the meanings
set forth below.
ABUSE: Provider and/or MCO practices that are inconsistent with sound fiscal,
business or medical practices and that result in an unnecessary cost to the
HUSKY A program, or the reimbursement for services that are not medically
necessary or that fail to meet professionally recognized standards for health
care, or a pattern of failing to provide medically necessary services required
by this contract. Member practices that result in unnecessary cost to the HUSKY
A program also constitute abuse.
ACS OR ACS STATE HEALTHCARE: The organization contracted by the DEPARTMENT to
perform certain administrative and operational functions for the HUSKY A and B
programs. Contracted functions include HUSKY application processing, HUSKY B
eligibility determinations, passive billing and enrollment brokering.
ACTION: The denial or limited authorization of a requested service, including
the type or level of service; the reduction, suspension, or termination of a
previously authorized service; the denial, in whole or in part, of payment for a
service; the failure to provide services in a timely manner, as defined by the
DEPARTMENT; the failure of an MCO to act within the timeframes for authorization
decisions set forth in this Contract.
ADVANCE DIRECTIVE: A written instruction, such as a living will or durable power
of attorney for health care, recognized under Connecticut law, relating to the
provision of health care when the individual is incapacitated.
AGENT: An entity with the authority to act on behalf of the DEPARTMENT.
APPEAL: A request to the MCO from a Member for a formal review of an MCO action.
CAPITATION RATE: The amount paid per Member by the DEPARTMENT to each Managed
Care Organization (MCO) on a monthly basis.
CAPITATION PAYMENT: The individualized monthly payment made by the DEPARTMENT
to the MCO on behalf of Members.
CMS: Centers for Medicare & Medicaid Services (CMS), a division within the
United States Department of Health and Human Services. This division was
formerly known as HCFA, the Health Care Financing Administration.
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August 13 2003
CLEAN CLAIM: A xxxx for service(s) or good(s), a line item of services or all
services and/or goods for a recipient contained on one xxxx which can be proces-
sed without obtaining additional information from the provider of service(s)or a
third party. A clean claim does not include a claim from a provider who is under
investigation for fraud or abuse or a claim under review for medical necessity.
COLD CALL MARKETING: Any unsolicited personal contact by the MCO with a
potential Member for the purpose of marketing.
COMMISSIONER: The Commissioner of the Department of Social Services, as defined
in Section 17b-3 of the Connecticut General Statutes.
CONSULTANT: A corporation, company, organization or person or their affiliates
retained by the DEPARTMENT to provide assistance in this project or any other
project, not the MCO or subcontractor.
CONTRACT ADMINISTRATOR: The DEPARTMENT employee responsible for fulfilling the
administrative responsibilities associated with this managed care project.
CONTRACT SERVICES: Those services which the MCO is required to provide to
Members under this contract.
DATE OF APPLICATION: The date on which a completed application for the HUSKY A
program is received by the DEPARTMENT or its agent, containing the applicant's
signature.
DAY: Except where the term business days is expressly used, all references in
this contract will be construed as calendar days.
DEPARTMENT OR DSS: The Department of Social Services, State of Connecticut.
EMERGENCY OR EMERGENCY MEDICAL CONDITION: A medical condition manifesting itself
by acute symptoms of sufficient severity (including severe pain) such that a
prudent layperson, who possesses an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical attention to result in
placing the health of the individual (or with respect to a pregnant woman, the
health of the woman or her unborn child) in serious jeopardy, serious impairment
to body functions or serious dysfunction of any body organ or part.
EMERGENCY SERVICES: Covered inpatient and outpatient services that are: 1)
furnished by a provider that is qualified to furnish Medicaid services; and 2)
needed to evaluate or stabilize an emergency medical condition. Such services
shall include, but not be limited
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August 13 2003
to, behavioral health and detoxification needed to evaluate or stabilize an
emergency medical condition that is found to exist using the prudent layperson
standard.
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) CASE MANAGEMENT
SERVICES: Services such as making and facilitating referrals and development
and coordination of a plan of services that will assist Members under twenty-one
(21) years of age in gaining access to needed medical, social, educational, and
other services.
EPSDT DIAGNOSTIC AND TREATMENT SERVICES: All health care, diagnostic services,
and treatment necessary to correct or ameliorate defects and physical and mental
illnesses and conditions discovered by an interperiodic or periodic EPSDT
screening examination.
EPSDT SCREENING SERVICES: Comprehensive, periodic health examinations for
Members under the age of twenty-one (21) provided in accordance with the
requirements of the federal Medicaid statute at 42 U.S.C. Section 1396d(r)(l).
EPSDT SERVICES: Comprehensive child health care services to Members under
twenty-one (21) years of age, including all medically necessary prevention,
screening, diagnosis and treatment services listed in Section 1905(r) of the
Social Security Act.
EXTERNAL QUALITY REVIEW ORGANIZATION (EQRO): An entity responsible for
conducting reviews of the quality outcomes, timeliness of the delivery of care
and access to items and services for which the MCO is responsible under this
contract.
FORMULARY: A list of selected pharmaceuticals determined to be the most useful
and cost effective for patient care, developed by a pharmacy and therapeutics
committee at the MCO.
FQHC-SPONSORED MCO: An MCO that is more than fifty (50) percent owned by
Connecticut Federally Qualified Health Centers, certified by the Department of
Social Services to enroll Medicaid Members.
FRAUD: Intentional deception or misrepresentation, or reckless disregard or
willful blindness, by a person or entity with the knowledge that the deception,
misrepresentation, disregard or blindness could result in some unauthorized
benefit to himself or some other person, including any act that constitutes
fraud under applicable federal or state law.
GRIEVANCE: An expression of dissatisfaction about the MCO on any matter other
than an "action" as defined herein. Possible subjects for grievances include,
but are not limited to, the quality of care or services provided by the MCO and
aspects of interpersonal relationships such as rudeness of a provider or an MCO
employee, or failure to respect a Member's rights.
HEALTH EMPLOYER DATA INFORMATION SET (HEDIS): A standardized performance
measurement tool that enables users to evaluate the quality of different MCOs
based on
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August 13 2003
the following categories: effectiveness of care; MCO stability; use of services;
cost of care; informed health care choices; and MCO descriptive information.
HHS: The United States Department of Health and Human Services.
HUSKY, PART A OR HUSKY A: For purposes of this contract, HUSKY A includes all
those coverage groups previously covered in Connecticut Access, subject to
expansion of eligibility groups pursuant to Section 17b-266 of the Connecticut
General Statutes.
IN-NETWORK PROVIDERS OR NETWORK PROVIDERS: Providers who have contracted with
the MCO to provide services to Members.
LOCK-IN: Limitations on Member changes of managed care plans for a period of
time, not to exceed twelve (12) months.
MANAGED CARE ORGANIZATION (MCO): The organization signing this agreement with
the Department of Social Services.
MARKETING: Any communication from an MCO to a Medicaid recipient who is not
enrolled in that entity, that can be reasonably interpreted as intended to
influence the recipient to enroll or reenroll in that particular MCO or either
to not enroll in, or disenroll from, another MCO.
MARKETING MATERIALS: Any materials produced in any medium, by or on behalf
of an MCO that can reasonably be interpreted as intended to market to potential
Members.
MEDICAID: The Connecticut Medical Assistance Program operated by the Connecticut
Department of Social Services under Title XIX of the Federal Social Security
Act, and related State and Federal rules and regulations.
MEDICAID PROGRAM PROVIDER MANUALS: Service-specific documents created by
Connecticut Medicaid to describe policies and procedures applicable to the
Medicaid program generally and that service specifically.
MEDICAL APPROPRIATENESS OR MEDICALLY APPROPRIATE: Health care that is provided
in a timely manner and meets professionally recognized standards of acceptable
medical care; is delivered in the appropriate medical setting; and is the least
costly of multiple, equally-effective alternative treatments or diagnostic
modalities.
MEDICALLY NECESSARY/MEDICAL NECESSITY: Health care provided to correct or
diminish the adverse effects of a medical condition or mental illness; to assist
an individual in attaining or maintaining an optimal level of health, to
diagnose a condition or prevent a medical condition from occurring.
MEMBER: For the purposes of HUSKY A, a Medicaid client who has been certified by
the State as eligible to enroll under this contract, and whose name appears on
the MCO
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August 13 2003
enrollment information which the DEPARTMENT will transmit to the MCO every month
in accordance with an established notification schedule.
NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA): NCQA is a not-for-profit
organization that develops and defines quality and performance measures for
managed care, thereby providing an external standard of accountability.
OUT-OF-NETWORK PROVIDER: A provider that has not contracted with the MCO.
PASSIVE BILLING: Automatic capitation payments generated by the DEPARTMENT or
its agent based on enrollment.
PEER REVIEW ORGANIZATION (PRO): A professional medical organization which
conducts peer review of medical care certified by HCFA or CMS.
PHARMACY BENEFITS MANAGER (PBM): An entity which, through an arrangement with
the MCO, is responsible for managing or arranging for one or more of the
Medicaid pharmacy services provided by the MCO pursuant to this contract.
PHARMACY LOCK-IN: An optional MCO program, subject to approval by the
DEPARTMENT, to restrict certain Members to a specific pharmacy in order to
monitor services and reduce unnecessary or inappropriate utilization.
POST-STABILIZATION SERVICES: Covered services related to an emergency medical
condition that are provided after a Member is stabilized in order to maintain
the stabilized condition, or under the circumstances described in 42 CFR
422.114(3), to improve or resolve the Member's condition.
POTENTIAL MEMBER: A Medicaid recipient who is subject to enrollment in a managed
care organization but is not yet a Member of a specific MCO.
PRIMARY CARE PROVIDER (PCP): A licensed health care professional responsible for
performing or directly supervising the primary care services of Members.
PRIOR AUTHORIZATION: The process of obtaining prior approval as to the medical
necessity or appropriateness of a service or plan of treatment.
RISK: The possibility of monetary loss or gain by the MCO resulting from service
costs exceeding or being less than payments made to it by the DEPARTMENT.
ROUTINE CASES: A symptomatic situation (such as a chronic back condition) for
which the Member is seeking care, but for which treatment is neither of an
emergency nor an urgent nature.
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August 13 2003
SUBCONTRACT: Any written agreement between the MCO and another party to fulfill
any requirements of this contract, except a written agreement between the MCO
and a vendor.
SUBCONTRACTOR: The party contracting with the MCO to manage or arrange for one
or more of the Medicaid services provided by the MCO pursuant to this contract,
but excluding services provided by a vendor.
THIRD-PARTY: Any individual, entity or program which is or may be liable to pay
all or part of the expenditures for Medicaid furnished under a State plan.
TITLE XIX: Xxx xxxxxxxxxx xx 00 Xxxxxx Xxxxxx Code Section 1396 et seq.,
including any amendments thereto. (see Medicaid)
URGENT CASES: Illnesses or injuries of a less serious nature than those
constituting emergencies but for which treatment is required to prevent a
serious deterioration in the Member's health and for which treatment cannot be
delayed without imposing undue risk on the Members' well-being until the Member
is able to secure services from his/her regular physician(s).
VENDOR: Any party with which the MCO has subcontracted to provide
administrative services.
WELL-CARE VISITS: Routine physical examinations, immunizations and other
preventive services that are not prompted by the presence of any adverse medical
symptoms.
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August 13 2003
2. DELEGATIONS OF AUTHORITY
The State of Connecticut Department of Social Services is the single state
agency responsible for administering the Medicaid program. No delegation by
either party in administering this contract shall relieve either party of
responsibility for carrying out the terms of this contract.
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August 13 2003
3. FUNCTIONS AND DUTIES OF THE MCO
The MCO agrees to the following duties:
3.01 PROVISION OF SERVICES
a. The MCO shall provide to individuals enrolled under this contract,
directly or through arrangements with others, all of the covered services
described in Appendix A of this contract.
b. The MCO shall ensure that the services provided to Members are sufficient
in amount, duration and scope to reasonably be expected to achieve the
purpose for which the service is provided. The services provided under
this contract shall be in an amount, duration and scope that is no less
than the amount, duration and scope of services for fee-for-service Medi-
caid clients. The MCO shall not arbitrarily deny or reduce the amount
duration or scope of a required service solely because of the Member's
diagnosis, type of illness or medical condition.
c. The MCO shall ensure that utilization management/review and coverage
decisions concerning acute or chronic care services to each Member are
made on an individualized basis in accordance with the contractual
definitions for Medical Appropriateness or Medically Appropriate and
Medically Necessary or Medical Necessity at Part II Section 1, General
Contract Terms for MCOs. The MCO shall also ensure that its contracts with
network providers require that the decisions of network providers
affecting the delivery of acute or chronic care services to Members are
made in accordance with the contractual definitions for Medical
Appropriateness or Medically Appropriate and Medically Necessary and
Medical Necessity.
d. The MCO shall provide twenty-four (24) hour, seven (7) day a week
accessibility to qualified medical personnel for Members in need of urgent
or emergency care. The MCO may provide such access to medical personnel
through either: 1) a hotline staffed by physicians, physicians on-call or
registered nurses; or 2) a PCP on-call system. Whether the MCO utilizes a
hotline or PCPs on-call, Members shall gain access to medical personnel
within thirty (30) minutes of their call. The MCO Member handbook and MCO
taped telephone message shall instruct Members to go directly to an
emergency room if the Member needs emergency care. If the Member needs
urgent care and has not gained access to medical personnel within thirty
(30) minutes, the Member shall be instructed to go to the emergency room.
The DEPARTMENT will randomly monitor the availability of such access.
e. Changes to Medicaid covered services mandated by Federal or State law, or
adopted by amendment to the State Plan for Medicaid, subsequent to the
signing of this contract will not affect the contract services for the
term of this contract, unless (1) agreed to by mutual consent of the
DEPARTMENT and the MCO, or
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August 13 2003
(2) unless the change is necessary to continue federal financial
participation, or due to action of a state or federal court of law. If
Medicaid coverage were expanded to include new services, such services
would be paid for via the traditional Medicaid fee-for-service system
unless covered by mutual consent between the DEPARTMENT and the MCO (in
which case an appropriate adjustment to the capitation rates would be
made). If Medicaid covered services are changed to exclude services, the
DEPARTMENT may determine that such services will no longer be covered
under HUSKY A and the DEPARTMENT will propose a contract amendment to
reduce the capitation rate accordingly.
In the event that the DEPARTMENT and the MCO are unable to agree on a
contract amendment concerning the change to Medicaid covered services, the
DEPARTMENT and the MCO shall negotiate a termination agreement to
facilitate the transition of the MCO's Members to another MCO within a
period of no less than ninety (90) days.
f. Any change regarding the provision of covered services that will become
effective during the term of this Contract shall be implemented by the MCO
within sixty (60) days of receiving notice of the change from the
DEPARTMENT, unless earlier compliance is required by law.
3.02 NON-DISCRIMINATION
a. The MCO shall comply with all Federal and State laws relating to
non-discrimination and equal employment opportunity, including but not
necessarily limited to the Americans with Disabilities Act of 1990, 42
U.S.C. Section 12101 et seq.; 47 U.S.C. Section 225; 47 U.S.C. Section
611; Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C.
Section 2000e; Title IX of the Education Amendments of 1972; Title VI of
the Civil Rights Act, 42 U.S.C. 2000d et seq.; the Civil Rights Act of
1991; Section 504 of the Rehabilitation Act, 29 U.S.C. Section 794 et
seq.; the Age Discrimination in Employment Act of 1975, 29 U.S.C. Sections
621-634; regulations issued pursuant to those Acts; and the provisions of
Executive Order 11246 dated September 26, 1965 entitled "Equal Employment
Opportunity" as amended by Federal Executive Order 11375, as supplemented
in the United States Department of Labor Regulations (41 CFR Part 60-1 et
seq., Obligations of Contractors and Subcontractors). The MCO shall also
comply with Sections 4a-60, 4a-61, 31-51d, 46a-64, 46a-71, 46a-75 and
46a-81 of the Connecticut General Statutes.
The MCO shall also comply with the HCFA Civil Rights Compliance Policy,
which mandates that all Members have equal access to the best health care,
regardless of race, color, national origin, age, sex, or disability.
The HCFA Civil Rights Compliance Policy further mandates that the MCO
shall ensure that its subcontractors and providers render services to
Members in a non-discriminatory manner. The MCO shall also ensure that
Members are not
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excluded from participation in or denied the benefits of the HUSKY
programs because of prohibited discrimination.
The MCO acknowledges that in order to achieve the civil rights goals set
forth in the HCFA Civil Rights Compliance Policy, CMS has committed itself
to incorporating civil rights concerns into the culture of its agency and
its programs and has asked all of its partners, including the DEPARTMENT
and the MCO, to do the same. The MCO further acknowledges that CMS will be
including the following civil rights concerns into its regular program
review and audit activities: collecting data on access to and
participation of minority and disabled Members; furnishing information to
Members, subcontractors, and providers about civil rights compliance;
reviewing HCFA publications, program regulations, and instructions to
assure support for civil rights; and initiating orientation and training
programs on civil rights. The MCO shall provide to the DEPARTMENT or to
CMS, upon request, any available data or information regarding these civil
rights concerns.
Within the resources available through the capitation rate, the MCO shall
allocate financial resources to ensure equal access and prevent
discrimination on the basis of race, color, national origin, age, sex, or
disability.
b. Unless otherwise specified by the contract, the MCO shall provide covered
services to HUSKY A Members under this contract in the same manner as
those services are provided to other Members of the MCO, although delivery
sites, covered services and provider payment levels may vary. The MCO
shall ensure that the locations of facilities and practitioners providing
health care services to Members are sufficient in terms of geographic
convenience to low-income areas, handicapped accessibility and proximity
to public transportation routes, where available. The MCO and its
providers shall not discriminate among Members of HUSKY A and other
Members of the MCO. The MCO shall ensure that its network providers offer
hours of operation that are no less than those offered to the MCO's
commercial members or comparable to Medicaid fee-for-service, if the
provider serves only Medicaid Members.
c. Nothing in this section shall preclude the implementation of a pharmacy
lock-in program by the MCO, if such program is approved by the DEPARTMENT.
3.03 MEMBER RIGHTS
The MCO shall have written policies regarding member rights. The MCO must comply
with all applicable state and federal laws pertaining to member rights and
privacy. The MCO shall further ensure that the MCO's employees, subcontractors
and network providers consider and respect those rights when providing services
to Members.
Member rights include, but are not limited to, the following:
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1. the right to be treated with respect and due consideration for the
Member's dignity and privacy;
2. the right to receive information on treatment options and
alternatives in a manner appropriate to the Member's condition and
ability to understand;
3. the right to participate in treatment decisions, including the right
to refuse treatment;
4. the right to be free from any form of restraint or seclusion as a
means of coercion, discipline, retaliation or convenience;
5. the right to receive a copy of his or her medical records,
including, if the HIPAA privacy rule applies, the right to request
that the records be amended or corrected as allowed in 45 CFR part
164; and
6. freedom to exercise the rights describe herein without any adverse
affect on the Member's treatment by the DEPARTMENT, the MCO or the
MCO's subcontractors or network providers.
3.04 GAG RULES
Subject to the limitations described in 42 U.S.C. Section 1396u-2(b)(3)(B) and
(C), the MCO shall not prohibit or otherwise restrict a health care provider
acting within his or her lawful scope of practice from advising or advocating on
behalf of a Member, who is a patient of the provider, for the following:
1. the Member's health status, medical care, or treatment options,
including any alternative treatment that may be self-administered;
2. any information the Member needs in order to decide among relevant
treatment options;
3. the risks, benefits and consequences of treatment of nontreatment;
4. the Member's right to participate in decisions regarding his or her
health care, including, the right to refuse treatment, and to
express preferences about future treatment decisions
This prohibition applies regardless of whether benefits for such care or
treatment are provided under this contract.
3.05 COORDINATION AND CONTINUATION OF CARE
a. The MCO shall have systems in place to provide well-managed patient care
which satisfies the DEPARTMENT that appropriate patient care is being
provided, including at a minimum:
1. Management and integration of health care through a PCP, gatekeeper
or other means.
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2. Systems to assure referrals for medically necessary specialty,
secondary and tertiary care.
3. Systems to assure provision of care in emergency situations,
including an education process to help assure that Members know
where and how to obtain medically necessary care in emergency
situations.
4. A system by which Members may obtain a covered service or services
that the MCO does not provide or for which the MCO does not arrange
because it would violate a religious or moral teaching of the
religious institution or organization by which the MCO is owned,
controlled, sponsored or affiliated.
5. Coordination and provision of EPSDT screening services in accordance
with the schedules for immunizations and periodicity of well-child
services as established by the DEPARTMENT and federal regulations.
6. Provide or arrange for the provision of EPSDT case management
services for Members under twenty-one (21) years of age when the
Member has a physical or mental health condition that makes the
coordination of medical, social, and educational services medically
necessary. As necessary, case management services shall include but
not be limited to:
a. Assessment of the need for case management and development of
a plan for services;
b. Periodic reassessment of the need for case management and
review of the plan for services;
c. Making referrals for related medical, social, and educational
services;
d. Facilitating referrals by providing assistance in scheduling
appointments for health and health-related services, and
arranging transportation and interpreter services;
e. Coordinating and integrating the plan of services through
direct or collateral contacts with the family and those
agencies and providers providing services to the child;
f. Monitoring the quality and quantity of services being
provided;
g. Providing health education as needed; and
h. Advocacy necessary to minimize conflict between service
providers and to mobilize resources to obtain needed services.
7. Provide necessary coordination and case management services for
children with special health care needs.
8. If notified, PCPs will participate in the review and authorization
of Individual Education Plans for Members receiving School Based
Child
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August 13 2003
Health services and Individual Family Service Plans for Members
receiving services from the Birth to Three program.
3.06 EMERGENCY SERVICES
a. The MCO shall provide all emergency services twenty-four (24) hours each
day, seven (7) days a week or arrange for the provision of said services
twenty-four (24) hours each day, seven (7) days a week through its
provider network.
b. The MCO shall cover and pay for emergency services without regard to prior
authorization and regardless of whether the provider that furnishes the
services has a contract with the MCO.
c. The MCO shall not limit the number of emergency visits.
d. The MCO shall cover all services necessary to determine whether or not an
emergency condition exists, even if it is later determined that the
condition was not an emergency medical condition.
e. The MCO shall not retroactively deny a claim for an emergency screening
examination because the condition, which appeared to be an emergency
medical condition under the prudent layperson standard, turned out to be
non-emergent in nature.
f. If the screening examination leads to a clinical determination by the
examining physician that an actual emergency does not exist, then the
nature and extent of payment liability will be based on whether the Member
had acute symptoms under the prudent layperson standard at the time of
presentation.
g. The MCO shall not base its determinations on what constitutes an emergency
medical condition on a list of diagnoses or symptoms. The determination of
whether the prudent layperson standard is met shall be made on a
case-by-case basis. However, the MCO may determine that the emergency
medical condition definition is met, based on a list such as ICD-9 codes.
h. Once the individual's condition is stabilized, the MCO may require prior
authorization for a hospital admission or follow-up care.
i. The MCO shall cover post-stabilization services obtained either within or
outside the MCO's provider network, under the following circumstances;
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1. the services were pre-approved by the MCO;
2. the services were not pre-approved by the MCO, but administered to
maintain the Member's stabilized condition within one hour of a
request to the MCO for pre-approval of further post-stabilization
care services.
j. The MCO shall cover post stabilization services that were obtained either
within or outside the MCO's provider network and not pre-approved, but
administered to maintain, improve or resolve the Member's stabilized
condition in the following circumstances:
1. The MCO does not respond to a request for pre-approval of such
services within one hour;
2. The MCO cannot be contacted; or
3. The MCO and the treating physician cannot reach an agreement
concerning the Member's care and an MCO physician is not available
for consultation. In this circumstance, the MCO must give the
treating physician the opportunity to consult with an MCO physician
and the treating physician may continue with care of the patient
until an MCO physician is reached or one of the following criteria
are met:
i. An MCO physician with privileges at the treating hospital
assumes responsibility for the Member's care;
ii. an MCO physician assumes responsibility for the member's care
through transfer;
iii. The MCO and the treating physician reach an agreement
concerning the Member's care.
k. If there is a disagreement between a hospital or other treating facility
and an MCO concerning whether the Member is stable enough for discharge or
transfer from the emergency room, the judgment of the attending
physician(s) or the provider actually treating the Member prevails and is
binding on the MCO. This subsection shall not apply to a disagreement
concerning discharge or transfer following an inpatient admission. The MCO
may establish arrangements with hospitals whereby the MCO may send one of
its own physicians or may contract with appropriate physicians with
appropriate emergency room privileges to assume the attending physician's
responsibilities to stabilize, treat, and transfer the Member.
l. When a Member's PCP or another MCO representative instructs the Member to
seek emergency care in-network or out-of-network, the MCO is responsible
for payment for the screening examination and for other medically
necessary emergency services, without regard to whether the Member's
condition meets the emergency medical condition definition.
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August 13 2003
m. If a Member believes that a claim for emergency services has been
inappropriately denied by the MCO, the Member may seek recourse through
the MCO's appeal and the DEPARTMENT's administrative hearing processes.
n. When the MCO reimburses emergency services provided by an in-network
provider, the rate of reimbursement will be subject to the contractual
relationship that has been negotiated with said provider. When the MCO
reimburses emergency services provided by an out-of-network provider
within Connecticut, the rate of reimbursement will be no less than the
fees established by the DEPARTMENT for the Medicaid fee-for-service
program. When the MCO reimburses emergency services provided by an
out-of-network provider outside of Connecticut, the MCO may negotiate a
rate of reimbursement with said provider.
o. The MCO may not make payment for emergency services contingent upon the
Member providing the MCO with notification either before or after
receiving emergency services. The MCO may, however, enter into contracts
with providers or facilities that require, as a condition of payment, the
provider or facility to provide notification to the MCO after Members are
present at the emergency room, assuming adequate provision is given for
such notification.
3.07 GEOGRAPHIC COVERAGE
a. The MCO shall serve Members statewide. The MCO shall ensure that its
provider network includes access for each Member to PCPs,
Obstetric/Gynecological Providers and mental health providers at a
distance of no more than fifteen (15) miles for PCPs and
Obstetric/Gynecological Providers and no more than twenty (20) miles for
general dentists and mental health providers as measured by the Public
Utility Commission. The MCO shall ensure that its provider network has the
capacity to deliver or arrange for all the goods and services reimbursable
under the Medicaid fee-for-service program.
b. On a monthly basis, the MCO shall provide the DEPARTMENT or its agent with
a list of all contracted network providers. The list shall be in a format
and contain such information as the DEPARTMENT may specify.
PERFORMANCE MEASURE: Geographic Access. The DEPARTMENT will randomly monitor
geographic access by reviewing the mileage to the nearest town containing a PCP
for every town in which the MCO has Members.
SANCTION: In any sampling, if more than two (2) percent of Members reside in
towns beyond fifteen (15) miles of a town containing a PCP the DEPARTMENT may
impose a strike towards a Class A sanction pursuant to Section 7.05.
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August 13 2003
3.08 CHOICE OF HEALTH PROFESSIONAL
The MCO must inform each Member about the full panel of participating providers
in its network. To the extent possible and appropriate, the MCO must offer each
Member covered under this contract the opportunity to choose among
participating providers.
3.09 PROVIDER NETWORK
a. The MCO shall maintain a provider network capable of delivering or
arranging for the delivery of all covered health goods and services to all
Members. In addition, the MCO's provider network shall have the capacity
to deliver or arrange for the delivery of all the goods and services
reimbursable under this contract regardless of whether all of the goods
and services are provided through direct provider contracts. The MCO shall
submit a file of their most current provider network listing to the
DEPARTMENT or its agent. The file shall be submitted, at a minimum, once a
month in the format specified by the DEPARTMENT.
b. In establishing and maintaining its provider network, the MCO shall
consider the following:
1. anticipated enrollment;
2. expected utilization of services, taking into consideration the
characteristics and health care needs of the specific Medicaid
populations in the MCO;
3. the number and types (in terms of training, experience, and
specialization) of providers required to furnish the contracted
Medicaid services;
4. the numbers of network providers who are not accepting new Medicaid
patients;
5. the geographic location of providers and Medicaid Members,
considering distance, travel time, the means of transportation
ordinarily used by Medicaid members, and whether the location
provider physical access for Members with disabilities.
c. The MCO shall notify the DEPARTMENT or its agent, in a timely manner, of
any changes made in the MCO's provider network. The monthly file submitted
to the DEPARTMENT or its agent shall not contain any providers who are no
longer in the MCO's network. The DEPARTMENT will randomly audit the
provider network file for accuracy and completeness and take corrective
action, if the provider network file fails to meet these requirements.
d. If the MCO declines to include a provider or group of provider in its
network, the MCO shall give the affected provider(s) written notice of the
reason for its decision.
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August 13 2003
e. The MCO shall not discriminate against providers with respect to
participation, reimbursement, or indemnification for any provider who is
acting within the scope of that provider's license or certification under
applicable State law, solely on the basis of the provider's license or
certification. This shall not be construed to prohibit the MCO from
including providers only to the extent necessary to meet the needs of the
MCO's Members or from establishing measures designed to maintain the
quality of services and control costs, consistent with its
responsibilities. This shall not preclude the MCO from using different
reimbursement amounts for different specialties or for different
practitioners in the same specialty.
f. The MCO's provider selection policies and procedures shall not
discriminate against particular providers that serve high-risk populations
or specialize in conditions that require costly treatment.
g. The MCO shall not employ or contract with any provider excluded from
participation in a Federal health care program under either Section 1128
or 1128A of the Social Security Act.
3.10 NETWORK ADEQUACY AND MAXIMUM ENROLLMENT LEVELS
a. On a quarterly basis, except as otherwise specified by the DEPARTMENT, the
DEPARTMENT shall evaluate the adequacy of the MCO's provider network. Such
evaluations shall use ratios of Members to specific types of providers
based on Medicaid fee-for-service experience in order to ensure that
access in the MCO is at least equal to access experienced in the Medicaid
fee-for-service program for a similar population. For each county the
maximum ratio of Members to each provider type shall be:
1. adult PCPs, including general practice specialists counted at 60.8%,
internal medicine specialists counted at 88.9%, family practice
specialists counted at 66.9%, nurse practitioners of the appropriate
specialties, and physician assistants, 387 Members per provider;
2. children's PCPs, including pediatric specialists counted at 100%,
general practice specialists counted at 39.2%, internal medicine
specialists counted at 11.1%, family practice specialists counted at
33.1%, nurse practitioners of the appropriate specialties, and
physician assistants, 301 Members per provider; obstetrics and
gynecology providers, including obstetrics and gynecology
specialists, nurse midwives, and nurse practitioners of the
appropriate specialty, 835 Members per provider;
3. dental providers, including general and pediatric dentists counted
at 100%, and dental hygienists counted at 50%, 486 Members per
provider; and
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August 13 2003
4. behavioral health providers, including psychiatrists, psychologists,
social workers, and psychiatric nurse practitioners, 459 Members per
provider.
b. In the event that the number of Members in a given county equals or
exceeds ninety percent (90%) of the capacity determined in accordance with
section a noted above, the DEPARTMENT shall evaluate the adequacy of the
MCO's network on a monthly basis.
c. Maximum Enrollment Levels: Based on the adequacy of the MCO's provider
network the DEPARTMENT may establish a maximum HUSKY A enrollment level
for Members in the MCO on a county-specific basis. The DEPARTMENT shall
provide the MCO with written notification no less than thirty (30) days
prior to the effective date of the maximum enrollment level.
d. Subsequent to the establishment of this limit, if the MCO wishes to change
its maximum enrollment level in a specific county, the MCO must notify the
DEPARTMENT thirty (30) days prior to the desired effective date of the
change. If the change is an increase, the MCO must demonstrate an increase
in their provider network which would allow the MCO to serve additional
Members. To do so the MCO must provide the DEPARTMENT with the signature
pages from the executed provider contracts and/or signed letters of
intent. The DEPARTMENT will not accept any other proof or documentation as
evidence of a provider's participation in the MCO's provider network. The
DEPARTMENT shall review the existence of additional capacity for
confirmation no later than thirty (30) days following notice by the MCO.
An increase will be effective the first of the month after the DEPARTMENT
confirms additional capacity exists.
e. In the event the DEPARTMENT deems that the MCO's provider network is not
capable of accepting additional enrollments, the DEPARTMENT may exercise
its rights under Section 7 of this contract, including but not limited to
the rights under Section 7.04, Suspension of New Enrollments.
SANCTION: In the event of a suspension of enrollment due to any network
deficiencies, the MCO shall submit a corrective action plan to the DEPARTMENT.
If, subsequent to the DEPARTMENT's approval of the corrective action plan, the
network deficiency is not remedied within the time specified in the corrective
action plan, or if the MCO does not develop a corrective action plan
satisfactory to the DEPARTMENT, the DEPARTMENT may impose a strike towards a
Class A sanction for each month said suspension is in effect, in accordance with
Section 7.05.
3.11 PROVIDER CONTRACTS
All contracts between the MCO and its in-network providers shall, at a minimum,
include each of the following provisions:
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August 13 2003
a. MCO network providers serving the Medicaid population must meet the
minimum requirements for participation in the Medicaid program as set
forth in the Regulations of Connecticut State Agencies, Section
17b-262-522 to Section 17b-262-533, as applicable;
b. MCO Members shall be held harmless for the costs of all Medicaid-covered
goods and services provided;
c. Providers must provide evidence of and maintain adequate malpractice
insurance. For physicians, the minimum malpractice coverage requirements
are $1 million per individual episode and $3 million in the aggregate;
d. Specific terms regarding provider reimbursement as specified in Timely
Payment of Claims, Section 3.46 of this contract;
e. Specific terms concerning each party's rights to terminate the contract;
f. That any risk shifted to individual providers does not jeopardize access
to care or appropriate service delivery;
g. The exclusion of any provider that has been suspended from the Medicare or
Medicaid program in any state;
h. For PCPs, the provision of "on-call" coverage through arrangements with
other PCPs; and
i. That the MCOs and subcontractors require in-network behavioral health
providers to participate in the DEPARTMENT's efforts to study access,
quality and outcome. Upon renewal of its subcontracts and other provider
contracts, the MCO shall include a provision that failure to participate
shall constitute cause for termination of the in-network provider's
contract, except that MCOs which have demonstrated to the DEPARTMENT's
satisfaction that they have ensured provider participation in such efforts
through means other than the provider contracts need not include this
provision. In any event, the DEPARTMENT shall reimburse providers for
costs above and beyond nominal costs incurred by such participation.
The MCO shall not adjust or change its reimbursements to federally qualified
health centers from the rate in effect at the time the DEPARTMENT implemented
the wraparound payment procedure.
3.12 PROVIDER CREDENTIALING AND ENROLLMENT
a. The MCO shall have written policies and procedures for the selection and
retention of providers. The MCO shall establish minimum credentialing
criteria
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August 13 2003
and shall formally re-credential all professional participating providers
in their network at least once every two (2) years or such other time
period as established by the NCQA. The MCO shall create and maintain a
credentialing file for each participating provider that contains evidence
that all credentialing requirements have been met. The file shall include
copies of all documentation to support that credentialing criteria have
been met, including licenses, Drug Enforcement Agency (DEA) certificates
and provider statements regarding lack of impairment. Credentialing files
shall be subject to inspection by the DEPARTMENT or its agent.
b. MCO's credentialing and recredentialing criteria for professional
providers shall include at a minimum:
1. Appropriate license or certification as required by Connecticut law;
2. Verification that providers have not been suspended or terminated
from participation in Medicare or the Medicaid program in any state;
3. Verification that providers of covered services meet minimum
requirements for Medicaid participation;
4. Evidence of malpractice or liability insurance, as appropriate;
5. Board certification or eligibility, as appropriate;
6. A current statement from the provider addressing:
a. lack of impairment due to chemical dependency/drug abuse;
b. physical and mental health status;
c. history of past or pending professional disciplinary actions,
sanctions, or license limitations;
d. revocation and suspension of hospital privileges;
e. a history of malpractice claims; and
7. Evidence of compliance with Clinical Laboratory Improvement
Amendments of 1988 (CLIA), Public Law 100-578, 42 USC Section 1395aa
et seq. and 42 CFR Part 493 (as amended, 68 Fed. Reg. 3639-3714
(2003)).
c. The MCO may require more stringent credentialing criteria. Any other
criteria shall be in addition to the minimum criteria set forth above.
d. Additional MCO credentialing/recredentialing criteria for PCPs shall
include, but not be limited to:
1. Adherence to the principles of Ethics of the American Medical
Association, the American Osteopathic Association or other
appropriate professional organization;
2. Ability to perform or directly supervise the ambulatory primary care
services of Members;
3. Membership on the medical staff with admitting privileges to at
least one accredited general hospital or an acceptable arrangement
with a PCP with admitting privileges;
4. Continuing medical education credits;
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August 13 2003
5. A valid DEA certification; and
6. Assurances that any Advanced Practice Registered Nurses (APRN),
Nurse Midwives or Physician Assistants are performing within the
scope of their licensure.
e. For purposes of credentialing and recredentialing, the MCO shall perform a
check on all PCPs and other participating providers by contacting the
National Practitioner Data Bank (NPDB). The DEPARTMENT will notify the MCO
immediately if a provider under contract with the MCO is subsequently
terminated or suspended from participation in the Medicare or Medicaid
programs. Upon such notification from the DEPARTMENT or any other
appropriate source, the MCO shall immediately act to terminate the
provider from participation in its network.
f. The MCO may delegate credentialing functions to a subcontractor. The MCO
is ultimately responsible and accountable to the DEPARTMENT for compliance
with the credentialing requirements. The MCO shall demonstrate and
document to the DEPARTMENT the MCO's significant oversight of its
subcontractors performing any and all provider credentialing, including
facility or delegated credentialing. The MCO and any such entity shall be
required to cooperate in the performance of financial, quality or other
audits conducted by the DEPARTMENT or its agent(s). Any subcontracted
entity shall maintain a credentialing file for each in-network provider as
set forth above.
g. The MCO must adhere to the additional credentialing requirements set forth
in Appendix B.
SANCTION: The DEPARTMENT may impose a Class B sanction pursuant to Section 7.05
if, upon completion of a performance review, it is established that a provider
in the MCO's network fails to meet the minimum credentialing criteria for
participation set forth in (a) and (b) above or a PCP in the MCO's network
fails to meet the criteria set forth in (d).
3.13 SECOND OPINIONS, SPECIALIST PROVIDERS AND THE REFERRAL PROCESS
a. The MCO shall provide for a second opinion from a qualified health care
professional within its provider network, or arrange for the ability of
the Member to obtain one outside the network, at no cost to the Member.
b. The MCO shall contract with a sufficient number and mix of specialists so
that the Member population's anticipated specialty care needs can be
substantially met within the MCO's network of providers. The MCO will also
be required to have a system to refer Members to out-of-network
specialists if appropriate participating specialists are not available.
The MCO shall make specialist referrals available to
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August 13 2003
its Members when it is medically necessary and medically appropriate and
shall assume all financial responsibility for any such referrals whether
they be in-network or out-of-network. The MCO shall ensure that the Member
does not incur any costs for such referrals whether the referral is to an
in-network or out-of network provider. The MCO must have policies and
written procedures for the coordination of care and the arrangement,
tracking and documentation of all referrals to specialty providers.
3.14 PCP SELECTION, SCHEDULING AND CAPACITY
a. The MCO shall implement procedures to ensure that each Member has an
ongoing source of primary care appropriate to his or her needs and a
person formally designated as primarily responsible for coordinating the
health care services furnished to the Member.
b. The MCO shall provide Members with the opportunity to select a PCP within
thirty (30) days of enrollment. The MCO shall assign a Member to a PCP
when a Member fails to choose a PCP within thirty (30) days after being
notified to do so. The assignment must be appropriate to the Member's age,
gender and residence.
c. The MCO shall ensure that the PCPs in its network adhere to the following
PCP scheduling practices:
1. Emergency cases shall be seen immediately or referred to an
emergency facility;
2. Urgent cases shall be seen within forty-eight (48) hours of PCP
notification;
3. Routine cases shall be seen within ten (10) days of PCP
notification;
4. Well-care visits shall be scheduled within six (6) weeks of PCP
notification;
5. EPSDT/HealthTrack comprehensive health screens and immunizations
shall be scheduled in accordance with the DEPARTMENT's HealthTrack
periodicity and immunization schedules;
6. New Members shall receive an initial PCP appointment in a timely
manner; (for those Members who do not access goods and services
within the first six (6) months of enrollment, the MCO shall
identify and remedy any access problems); and
7. Waiting times at PCPs are kept to a minimum.
d. The MCO shall report quarterly on each PCP's panel size, group practice
and hospital affiliations in a format specified by the DEPARTMENT. The
DEPARTMENT will aggregate reports received from all MCOs for both HUSKY A
and HUSKY B. In the event that the DEPARTMENT finds a PCP with more than
1,200 HUSKY (combined HUSKY A and HUSKY B) panel Members, the DEPARTMENT
will notify the MCO if the PCP is part of the MCO's network.
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August 13 2003
The DEPARTMENT expects that the MCO will take appropriate action to ensure
that patient access to the PCP is assured.
e. The MCO shall maintain a record of each Member's PCP assignments for a
period of two (2) years.
f. The MCO shall track each Member's use of primary medical care services. In
the event that a Member does not regularly receive primary medical care
services from the PCP or the PCP's group other than visits to school based
health clinics, the MCO shall contact the Member and offer to assist the
Member in selecting a PCP.
g. If the Member has not received any primary care services, the MCO shall
contact the Member and offer to assist the Member in scheduling a
well-care visit if the Member's last well-care visit was not within the
appropriate guidelines for his or her age and gender.
PERFORMANCE MEASURE: PCP Appointment Availability. The DEPARTMENT or its agent
will routinely monitor appointment availability as measured by (b)(1) through
(b)(6) by using test cases to arrange appointments of various kinds with
selected PCPs. If less than ninety (90) percent of the sample make appointments
available within the required time, the DEPARTMENT shall require that the MCO
submit a corrective action plan, which will outline the steps that the MCO will
take to rectify the problem, within thirty (30) days.
3.15 WOMEN'S HEALTH, FAMILY PLANNING ACCESS AND CONFIDENTIALITY
a. The MCO shall provide female Members with direct access to a women's
health specialist in network for covered care necessary to provide women's
routine and preventive health care services. This access shall be in
addition to the Member's PCP if that provider is not a women's health
specialist.
b. The MCO shall notify and give each Member, including adolescents, the
opportunity to use his or her own PCP or utilize any family planning
service provider for family planning services without requiring a referral
or authorization. The MCO shall make a reasonable effort to subcontract
with all local family planning clinics and providers, including those
funded by Title X of the Public Health Services Act, and shall reimburse
providers for all family planning services regardless of whether that
provider is a participating provider. The MCO shall reimburse
out-of-network providers of family planning services at least the Medicaid
fee-for-service rate for the service. The MCO may require family planning
providers to submit claims or reports in specified formats before
reimbursing services.
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c. The MCO shall keep family planning information and records for each
individual patient confidential, even if the patient is a minor.
d. Family planning services which must be covered include:
1. reproductive health exams;
2. patient counseling;
3. patient education;
4. lab tests to detect the presence of conditions affecting
reproductive health;
5. sterilizations;
6. screening, testing, and treatment of and pre and post- test
counseling for sexually transmitted diseases and HIV; and
7. abortions, if the pregnancy is the result of an act of rape or
incest or in the case where a woman suffers from a physical
disorder, physical injury, or physical illness, including a
life-endangering physical condition caused by or arising from the
pregnancy itself, that would, as certified by a physician, place the
woman in danger of death unless an abortion is performed.
e. Pursuant to federal law ("the Hyde Amendment," as reflected in the federal
appropriations for Title XIX) and 42 CFR Part 441, Subpart E, the
DEPARTMENT may only seek federal funding for those abortions described in
(d)(7) above. The MCO shall cover all abortions that fall within these
circumstances. The MCO shall submit a Form W-484 for any such abortions
and comply with the DEPARTMENT's Medical Services Policy concerning
abortions.
f. The MCO shall also cover all other medically necessary abortions not
covered under federal law and described in (d)(7) above. The determination
as to whether an abortion is medically necessary shall be made by the
Member's PCP or another physician, in consultation with the Member. The
MCO shall not require prior authorization for any such medically necessary
abortion. The DEPARTMENT will not seek federal funding for any abortion
covered under this contract. The DEPARTMENT shall only seek federal
funding for abortions covered pursuant to federal law. The DEPARTMENT and
the MCO shall enter into a separate contract for all medically necessary
abortions that do not qualify for federal matching funds, as described in
subsection (d) and (e) above.
g. The MCO shall submit a report on a quarterly basis due fifteen (15) days
after the end of the quarter for all abortions performed pursuant to
subsection (f) above. The report format is set forth in Appendix M.
SANCTION: If the MCO fails to comply with the provisions in subsection (e), and
fails to accurately maintain and submit accurate records of those abortions
which meet the federal definition for funding, the DEPARTMENT may impose a Class
A sanction, pursuant to Section 7.05.
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3.16 PHARMACY ACCESS
For purposes of this section, "prescription" shall include authorization for
legend and over-the-counter drugs covered by Medicaid policy.
a. Pharmacies must be available and accessible on a statewide basis. The MCO
shall:
1. Maintain a comprehensive provider network of pharmacies that will
within available resources assure twenty four (24) hour access to
pharmaceutical goods and services;
2. The MCO may establish a pharmacy lock-in program for Members
suspected of abuse or excessive utilization. Any MCO pharmacy
lock-in program will be subject to DEPARTMENT approval;
3. Have established protocols to respond to urgent requests for
medications;
4. Monitor and take steps to correct excessive utilization of regulated
substances, including but not limited to, restricting pharmacy
access pursuant to a pharmacy lock-in program approved by the
DEPARTMENT; and
5. Require pharmacists to utilize the Automated Eligibility
Verification System (AEVS) to determine client eligibility and MCO
affiliation when there is a discrepancy between the information in
the MCO's eligibility system and information given to the
pharmacists by the Member, the Member's physician or other third
party.
b. The MCO shall require that its provider network of pharmacies offer
medically necessary goods and services to the MCO's Members. The MCO may
have a drug management program that includes a prescription drug
formulary. The MCO drug formulary must include only Food and Drug
Administration approved drug products and must be broad enough in scope to
meet the needs of all Members. The MCO drug formulary shall consist of a
reasonable selection of drugs which do not require prior approval for each
specific therapeutic drug class.
c. The MCO shall submit any deletions to its formulary and any new prior
authorization requirements for formulary drugs to the DEPARTMENT at least
thirty (30) days prior to making any such change. The MCO shall also
submit all physician, pharmacist and Member letters, notices, e-mail
alerts or other electronic or written communications related to the
proposed formulary change to the DEPARTMENT thirty (30) days prior to
issuing or sending any such communication. The MCO shall not implement any
formulary deletion or additional prior authorization requirements without
the prior written approval of the DEPARTMENT. The MCO shall not send or
issue any communication
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August 13 2003
related to a formulary change without the prior written approval of the
DEPARTMENT. If, however, the DEPARTMENT does not respond to proposed
formulary changes or communications submitted for approval within thirty
(30) days of receipt from the MCO, the MCO may proceed with the change or
issue the communication, as applicable.
The MCO shall also submit subsequent additions to the formulary at the
time the addition is made without seeking prior approval by the DEPARTMENT
and regardless of whether the drug(s) to be added requires prior
authorization. If the MCO's formulary includes a legend drug that requires
prior authorization and the FDA approves the drug for over-the-counter
use, the MCO is not required to seek the DEPARTMENT's approval to
substitute the over-the-counter version with a prior authorization
requirement.
The MCO shall notify prescribing providers thirty (30) days in advance of
any changes to the MCO's formulary.
The DEPARTMENT reserves the right to identify clinical deficiencies in the
content of or operational deficiencies of the MCO's formulary. In this
instance, the MCO shall have thirty (30) days to address in writing the
identified deficiencies to the DEPARTMENT's satisfaction. The MCO may
request to meet with the DEPARTMENT prior to submission of the written
response. If the DEPARTMENT is not satisfied with the MCO's response, the
DEPARTMENT may require the MCO to add specific drugs to its formulary or
to or eliminate prior authorization requirements for specific drugs. If
the MCO disputes the DEPARTMENT's determination, the MCO may exercise its
rights pursuant to section 7.02 of this Contract.
d. The MCO shall ensure that Members using maintenance drugs (drugs usually
prescribed to treat long term or chronic conditions including, but not
limited to diabetes, arthritis and high blood pressure) are informed in
advance, but no less than thirty (30) days in advance of any changes to
the prescription drug formulary related to such maintenance drugs if the
Member using the drug will not be able to continue using the drug without
a new authorization. When the MCO deletes a drug from its formulary or
imposes prior authorization requirements on additional drug(s), the MCO
shall identify to the DEPARTMENT which of the affected drugs the MCO
intends to treat as maintenance drugs. The DEPARTMENT may require the MCO
to treat additional drugs as maintenance drugs for purposes of this
subsection and subsection (e). If the MCO treats all drugs affected by a
formulary change as maintenance drugs for purposes of this subsection and
for purposes of subsection e below, the MCO is not required to designate
specific drugs as maintenance drugs. In such circumstances, the MCO shall
notify the DEPARTMENT that all drugs affected by the formulary change will
be treated in the same manner.
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e. If a prescribing provider seeks authorization to continue a maintenance
drug that is being removed from the MCO's formulary or subjected to new
prior authorization requirements at any time prior to the effective date
of the change, the MCO shall conduct a medical necessity review. The MCO
shall conduct the review, and, if the MCO does not approve the request,
the MCO shall issue a notice of action in accordance with the provisions
of subsection (i) below. If the MCO denies the prior authorization request
for the maintenance drug, the MCO shall issue a notice of action at least
ten days in advance of the effective date of the action. The MCO shall
automatically continue authorization for the maintenance drug for at least
the medical necessity review period plus, if the MCO does not approve the
authorization, for the ten (10) day advance notic period, or the effective
date of the action, whichever is later. If a Member requests an appeal and
administrative hearing concerning a denial or termination that results
from or relates to the imposition of new prior authorization requirements
for or removal of the maintenance drug from the formulary, the MCO shall
continue to authorize the drug for that Member pending a hearing decision.
If the prescriber does not initiate the prior authorization process prior
to the expiration of the existing authorization period, the Member shall
receive a temporary supply of the maintenance drug if the conditions
described in subsection (i) are met. If the MCO grandfathers some or all
Members affected by the formulary changes for a period of more than ninety
(90) days, the MCO shall either: 1) send a second advance notice letter at
least thirty (30) days prior to the end of the extended authorization
period or 2) ensure that if the Member's prescriber requests authorization
prior to the end of the existing authorization period, that if the request
is denied and the Member appeals, that the authorization will continue
pending appeal.
f. The MCO shall require that its provider network of pharmacies adheres to
the provisions of Connecticut General Statutes Section 20-619 (b) and (c)
related to generic substitutions for Medicaid recipients.
g. If the MCO maintains a drug formulary, the MCO shall have a prior
authorization process to permit access, at a minimum, to all medically
necessary and appropriate drugs covered for the Medicaid fee-for-service
population. The MCO shall develop a timely and efficient authorization
process to obtain information from providers on medical necessity for a
non-formulary drug, a formulary drug requiring prior authorization or a
brand name drug where a generic substitution is available. The MCO shall
make an individualized determination concerning medical necessity and
appropriateness in each instance when a Member's prescribing provider
requests a non-formulary drug, formulary drug requiring prior
authorization or a brand name drug in accordance with the provisions of
(f) above. If no request for prior authorization has been received by the
MCO or the Pharmacy Benefits Manager (PBM) prior to the submission of a
prescription to a pharmacy, the pharmacist may contact the prescribing
physician and inform him or her of the prior authorization requirement.
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August 13 2003
h. Except as provided in subsection (n) below, in the event that a provider
requests authorization for, or prescribes a non-formulary drug, a
formulary drug requiring prior authorization or a brand name drug where a
generic substitution is available but elects during the prior
authorization process or in discussions with the pharmacist to prescribe a
formulary, generic or alternate formulary drug that the provider agrees
will be equally effective for the Member, the MCO is not required to issue
a notice of action and is not required to provide a temporary supply of
the drug for which the provider initially sought authorization.
i. In the event that a provider requests authorization, or prescribes a
non-formulary drug, a formulary drug requiring prior authorization or a
brand name drug where a generic substitution is available the MCO must
approve or deny the request as expeditiously as the Member's health
condition requires, but no later than 14 calendar days following the MCO's
receipt of the request.
An additional 14 calendar days will be allowed if: 1) the Member or the
requesting provider asks for the extension or 2) the MCO or its PBM
documents that the extension is in the Member's interest because
additional information is needed for the MCO to authorize the service and
the failure to extend the authorization timeframe will result in denial of
the service. The DEPARTMENT may request and review such documentation from
the MCO.
j. In the event that a provider certifies to the MCO or its PBM that the drug
is necessary to address an urgent or emergent condition or that the
standard authorization period could seriously jeopardize the Member's life
or health or ability to attain, maintain or regain maximum function, the
MCO or its PBM must make an expedited authorization decision and provide
notice as expeditiously as the member's health condition requires and no
later than 3 working days after receipt of the request for service. The
MCO or its PBM may extend the 3 working days time period by up to 14
additional calendar days if: 1) the Member or the provider requests the
extension or 2) if the MCO or its PBM documents that the extension is in
the Member's interest because additional information is needed for the MCO
to authorize the service and the failure to extend the authorization
timeframe will result in denial of the service. The DEPARTMENT may request
such documentation from the MCO.
k. The MCO or its PBM shall without delay authorize up to a thirty (30) day
temporary supply of the drug if the provider certifies to the MCO or its
PBM that the drug is necessary to address an urgent or emergent condition.
The MCO is also required to authorize a thirty (30) day temporary supply
of the drug on the day of submission of the prescription to the pharmacy
if the MCO has been unable to contact the provider to discuss an effective
formulary drug during normal business hours. The certification shall be in
a manner to be specified by the MCO, subject to the DEPARTMENT's approval.
If the original prescription
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August 13 2003
was for a period less then thirty (30) days, the temporary supply will be
for the period prescribed.
l. If the Member, upon receipt of a termination, suspension or reduction
notice of action, timely requests an appeal and administrative hearing the
MCO shall continue to authorize the drug for the Member pending a hearing
decision or other resolution of the dispute concerning the prescription.
As used within this section, "timely" means filing on or before the later
of the following: (1) within ten (10) days of the MCO mailing of the
notice of action; or (2) the intended effective date of the MCO's proposed
action. If the Member does not request an appeal and administrative
hearing, the MCO is no required to authorize any further refills.
m. The MCO shall, on a quarterly basis, submit the report at Appendix L.
n. If the DEPARTMENT or its agent determines that there is a pattern of
denials for requested authorization for particular drugs, or any other
pattern suggesting that the MCO's authorization process is one that does
not appropriately consider each Member's individualized medical needs, the
DEPARTMENT may require notices of action in circumstances other than those
described above and/or may require the addition of a particular drug or
drugs to the MCO's formulary as drugs that do not require prior
authorizations.
3.17 MENTAL HEALTH AND SUBSTANCE ABUSE ACCESS
a. The MCO shall provide to its Members all behavioral health care services
(mental health and substance abuse) covered by Medicaid that are medically
necessary and medically appropriate. These services may be provided by the
MCO through contracts with providers of services or through subcontracted
relationships with specialized behavioral health management entities. A
Member will not need a PCP referral to obtain services; self-referral will
be sufficient to obtain an initial service visit. The MCO may require
prior authorization for an ongoing course of treatment. Members with
mental health and substance abuse disorders shall not be denied coverage
by the MCO for the initial visit, simply because they did not abide by the
MCO's rules (either by going to an out-of-network provider or going to an
in-network provider without an appropriate referral).
b. Notwithstanding any contractual arrangement with a specialized management
agency, the MCO is wholly responsible to ensure that medically necessary
and medically appropriate services are provided to its Medicaid Members.
c. The MCO shall contract with a consultant or employ a doctoral level mental
health professional with appropriate qualifications, credentials and
decision making authority who will have specific responsibilities for
exercising oversight of the delivery of behavioral health services by the
MCO or its subcontractors. Such person shall be responsible for promoting
efforts to better integrate and
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August 13 2003
coordinate the provision of behavioral health care with other services.
The individual shall be available by phone for consultation on an as
needed basis, dedicated to the Connecticut Members, as well as have an
extensive understanding of the State of Connecticut's Medicaid rules and
regulations.
d. In reference to services for children with psychiatric/mental health and
substance abuse needs, the MCO and any subcontracted entity is required to
contract with and refer Members to qualified Medicaid providers who meet
benchmark requirements or demonstrate that equal or superior services are
being made available through other providers. The benchmark providers are
child guidance clinics, community mental health centers and clinics,
family service agencies and other qualified substance abuse providers (who
provide services in compliance with state law) with a specialization in
serving children. Continuation of benchmark status is contingent upon
participation in the DSS Study of Behavioral Health Outcomes. Any
benchmark poviders who refuse to participate in the study will lose this
status.
e. The MCO and any subcontractor entity will cooperate in the identification
and improvement of processes working toward the development and
standardization of administrative procedures. The MCO and any
subcontracted entity shall take steps to promote successful
provider-Member relationships and will monitor the effectiveness of these
relationships.
f. The MCO is responsible for monitoring the performance of its network
providers and for monitoring and ensuring contract compliance. The MCO
shall also be responsible for ensuring that its subcontractors comply with
Medicaid policy and this contract. Such monitoring will ensure that
providers and subcontractors observe all contractual and policy
requirements as well as measuring performance relating to such areas as
access to care and ensuring quality of care. The MCO and any subcontracted
entity are required to cooperate in the performance of financial, quality
or other audits conducted by the DEPARTMENT or its agent(s).
g. The MCO and its behavioral health subcontractor are required to
participate in the DSS Study on Behavioral. Health Outcomes for children
receiving outpatient treatment services.
SANCTION: Failure of the MCO and or its subcontractor(s) to participate in the
DEPARTMENT Study may constitute grounds for the imposition of a Class B sanction
pursuant to Section 7.05.
3.18 CHILDREN'S ISSUES AND EPSDT COMPLIANCE
In order to meet the requirements of the EPSDT program as set forth in Sections
1902(a)(43) and 1905(r) of the Social Security Act, the MCO shall:
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a. Provide EPSDT screening services in accordance with the periodicity
schedule attached to this contract as Appendix C. Any changes in the
periodicity schedule subsequent to the effective date of this contract
shall be provided to the MCO sixty (60) days before the effective date of
the change. The MCO shall not require prior authorization of EPSDT
screening services;
b. Provide interperiodic screening examinations when medically necessary, or
in accordance with the provisions of Section 3.19(5)(a), to determine the
existence of a physical or mental illness or condition, or to assist
Members in meeting the medical requirements for certification or
recertification in WIC. Such interperiodic screens shall include screens
for anemia as recommended by the Centers for Disease Control (CDC). The
MCO shall not require prior authorization of interperiodic screening
examinations;
c. Provide EPSDT screening services that at a minimum, include:
1. A comprehensive health and developmental history (including
assessment of both physical and mental health development and
assessment of nutritional status);
2. A comprehensive unclothed or partially draped physical exam;
3. Appropriate immunizations as currently recommended by the
Connecticut Department of Public Health;
4. Laboratory tests, as set forth in the periodicity schedule at
Appendix C
5. Vision and hearing screenings as set forth in the periodicity
schedule at Appendix C;
6. Dental assessments as set forth in the periodicity schedule at
Appendix C and
7. Health education, including anticipatory guidance.
d. Provide all medically necessary health care, diagnostic services, and
treatment for Members under twenty-one (21) covered under the federal
Medicaid program and described in Section 1905(a) of the Social Security
Act regardless of whether the health care, diagnostic services, and
treatment are specified in the list of covered services at Appendix A of
this contract and regardless of any limitations on the amount, duration,
or scope of the services that would otherwise be applied.
e. Take all necessary steps to ensure that its Members under the age of
twenty-one (21) receive EPSDT screening services and any necessary
diagnostic and treatment services, including, but not limited to:
1. Providing assistance in arranging and scheduling appointments;
2. Providing and arranging transportation;
3. Following up on missed appointments; and
4. Providing interpreters to Members with limited English proficiency
and Members who are hearing and visually impaired.
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August 13 2003
f. No later than sixty (60) days after enrollment in the plan and annually
thereafter, use a combination of oral and written methods including
methods for communicating with Members with limited English proficiency,
Members who cannot read, and Members who are visually or hearing impaired,
to:
1. Inform its Members about the availability of EPSDT screening,
diagnostic and treatment services;
2. Inform its Members about the importance and benefits of EPSDT
screening services;
3. Inform its Members about how to obtain EPSDT screening services; and
4. Inform its Members that assistance with scheduling appointments and
transportation is available, and inform them how to obtain this
assistance.
g. Coordinate and enhance the services provided to Members under twenty-one
(21) through the development and execution of memorandums of understanding
(MOUs) with the following programs:
1. Healthy Families Connecticut;
2. Healthy Start;
3. The Special Supplemental Food Program for Women, Infants, and
Children (WIC);
4. Birth-to-Three;
5. Head Start;
6. InfoLine's Maternal and Child Health Project; and
7. Other programs operated by the Departments of Children and Families,
Education, Public Health, Mental Health and Addiction Services and
Mental Retardation as designated by the DEPARTMENT.
h. Include in the MOUs developed and executed under subsection (g) of this
section provisions that specify how the MCO will work with the program,
including, but not limited to:
1. A description of the services provided by the program;
2. Designation of a liaison at the MCO to work with the program on
ensuring the provision of medically necessary and appropriate
covered services by the MCO and the coordination of services
provided by the MCO and the program;
3. Protocols for referrals to the program by the MCO;
4. Protocols for communication of information concerning individuals
who are Members of the MCO who are receiving services from the
program;
5. Protocols for the resolution of any issues that arise concerning the
delivery of services to HUSKY Members who are receiving services
from the program;
6. Compliance with HIPAA privacy rules if the agreement includes
exchange of members' protected health inforamation; and
7. Any other mutually agreed upon provisions.
i. The MCOs shall require PCPs to obtain all available vaccines free of
charge from the Department of Public Health under the Vaccines for
Children program.
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August 13 2003
j. Contract with the Connecticut Immunization Registry and Tracking System to
track childhood immunizations of its Members and report the immunizations
to the DEPARTMENT.
k. In order to carry out the responsibilities set forth in this section, the
MCO shall identify children who are overdue for EPSDT screening services,
and those who have missed EPSDT screening services. The MCO shall work to
develop a plan for ensuring that Members under twenty-one (21) years of
age who are overdue or late for screening examinations receive their EPSDT
screening services and that other Members continue to receive their
examinations on a regular basis.
l. The MCO shall attain an annual EPSDT participation ratio and an annual
EPSDT screening ratio of at least eighty (80) percent for the period from
October 1, 2002 through September 30, 2003. The DEPARTMENT shall determine
the MCO's participation and screening ratio from the encounter data as
reported to the DEPARTMENT or its agent(s) in accordance with the
methodology established by HCFA or CMS for the HCFA-416 report.
SANCTION: Failure to achieve a participation and/or screening ratio of eighty
(80) percent may subject the MCO to a Class B sanction in accordance with the
provisions of Section 7.05. However, no sanction shall apply if the MCO's
participation and screening ratios, although less than eighty (80) percent, are
greater than the participation and screening ratios for the MCO for the
equivalent period one year earlier plus one half the difference between the
ratios for the earlier period and eighty (80) percent.
3.19 SPECIAL SERVICES FOR CHILDREN/REINSURANCE
1. DISCHARGE PLANNING PROCESS AND INPATIENT PSYCHIATRIC HOSPITAL REINSURANCE
FOR CHILDREN
a. The discharge planning process for children and adolescents with
significant mental health and substance abuse disorders is of particular
concern to the DEPARTMENT and DCF due to the potential unavailability of
appropriate subacute or step-down placements (e.g., residential treatment
with a clinical component, group home, specialized xxxxxx care). In order
to protect these particularly vulnerable minors, MCOs are required to seek
or develop alternatives to hospital-based care. MCOs are required to
negotiate "step-down" rates with qualified institutional providers, as
defined by the DEPARTMENT, to address the financial issues that arise in
the discharge planning circumstances described in this section.
b. The following provisions of this Section shall apply to all new admissions
of children and adolescents eighteen (18) years of age and younger in
qualified institutions.
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August 13 2003
1. REINSURANCE FOR ADMINISTRATIVELY NECESSARY DAYS
On a limited basis, the MCO may authorize the admission of a child
to a qualified institution for a one-day evaluation. If at the end
of a twenty-four (24) hour period the MCO determines that there is
no medical necessity for the continued admission but there is no
immediate discharge option available, the remainder of the stay will
qualify for 100% reinsurance by the DEPARTMENT. For the evaluation
day, the MCO will pay the institution the rate for an acute care
day. Beginning on day two (2) of the stay, the MCO will pay the
institution a negotiated rate and xxxx the DEPARTMENT in the month
following service delivery according to the process described below.
Reinsurance for non-medically necessary days attendant to an
evaluation stay may be claimed once per child per calendar year.
2. REINSURANCE FOR MEDICALLY NECESSARY DAYS
Other than in the cases described above, where the length of stay in
either a step down program or a hospital setting pursuant to a
medically necessary admission extends beyond fifteen (15) days, the
DEPARTMENT will provide reinsurance for the MCOs. Reinsurance shall
be provided for medically necessary days of care provided at either
an acute or a subacute level of care. Care provided to children
admitted to subacute care pursuant to an observation bed stay shall
be subject to the provisions of this section. For the purpose of
this section, a medically necessary admission to inpatient
psychiatric care for children will be defined to include those
admissions which are court ordered, provided that there is
consultation with the plan prior to the order regarding the
appropriate level and setting for the care.
The MCO may make decisions on the medical necessity of the admission
and may evaluate the level of acuity of the child or adolescent at
any time during the course of the stay. MCOs may redetermine the
need for an acute level of care at any time based on changes in the
patient's condition. However, within the first fifteen (15) days,
the MCO shall provide all necessary acute or subacute care as part
of the discharge process.
3. THE SCHEDULE FOR REINSURANCE IS AS FOLLOWS:
# of days State's Share MCO's Share
0-15 0% 100%
16-45 75% 25%
46-60 90% 10%
60 + 100% 0%
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If a psychiatric inpatient stay is interrupted due to an acute
medical condition requiring an admission to a general hospital, the
reinsurance day count will be suspended upon discharge from the
psychiatric facility and will resume when the Member is readmitted
to the psychiatric inpatient facility, if the readmission to the
psychiatric inpatient facility is on the same day as the discharge
from the general hospital.
If there is a gap of one day or more between the discharge from the
general hospital and readmission to the psychiatric facility, the
admission to the psychiatric inpatient facility will be treated as a
new admission and the new inpatient day count will be reset.
4. The MCO or its subcontractor shall incur the costs for the
reinsurance and may xxxx the DEPARTMENT within ninety (90) days from
the date the provider submits the claim to the MCO or its
subcontractor. All initial reinsurance claims must be billed to the
DEPARTMENT within twelve (12) months following service delivery.
Reinsurance claims shall be submitted to the DEPARTMENT's Division
of Fiscal Analysis and shall be reimbursed as a percentage of the
facility specific per diem according to the state share described
above. Claims may be submitted by the MCO or its behavioral health
subcontractor with prior approval by the DEPARTMENT. The MCO or its
subcontractor may retrospectively review claims submitted to the
DEPARTMENT and submit corrections or readjustments to the DEPARTMENT
within the DEPARTMENT'S timely filing limit. The DEPARTMENT also
reserves the right to review the level of payments made under the
reinsurance program retrospectively.
The DEPARTMENT will designate a contact person for reinsurance
claims.
3. RESPONSIBILITIES OF THE DEPARTMENT OF CHILDREN AND FAMILIES
a. DCF shall approve any placement, which is deemed by the MCO to be not
medically necessary. If the DEPARTMENT determines that reinsurance claims
were paid for services that were administratively necessary and not
medically necessary, the DEPARTMENT will pursue reimbursement from DCF.
b. In cases where the hospital identifies a discharge planning difficulty for
youth under the direct auspices of DCF who are utilizing inpatient,
hospital-based mental health or substance abuse services, the following
discharge planning process will apply:
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1. As soon as the hospital identifies a discharge planning difficulty,
the MCO must contact DCF for assistance and notify the DEPARTMENT.
The MCO in conjunction with the hospital and DCF, must attempt to
resolve the discharge planning immediately. Service providers, the
MCO, DCF and the Member and family must develop an individualized
service plan that resolves the discharge issue while effectuating
appropriate ongoing treatment. The MCO shall consult with DCF
regarding the appropriate state licensed treatment setting. MCOs
have the authority to transition the patient to any qualified
provider of this level of care. Nothing in this section shall be
construed to imply a time limit on the overall behavioral health or
health care benefit in Medicaid managed care.
2. The DEPARTMENT will designate a contact person for clinical issues
regarding discharge planning.
4. THE FOLLOWING PROVISIONS WILL APPLY TO ADMISSIONS AT STATE FACILITIES.
a. The discharge planning and reinsurance provisions described in this
section shall apply to all new medically necessary and administratively
necessary admissions at state operated facilities effective October 1,
1998. When a child is admitted to a DCF facility, the MCO must reimburse
the DCF facility at the rate as calculated by the Office of the
Comptroller, provided that such admissions shall be governed by a
memorandum of understanding between the MCOs and DCF outlining the terms
and conditions for admissions and stays at the facility.
b. This discharge planning process and reinsurance program is not intended to
force MCOs to continue funding the most restrictive levels of care in
perpetuity; rather it is meant to insure the safety of children and
adolescents and encourage the development of appropriate alternatives to
hospital-based services.
5. SPECIALIZED OUTPATIENT SERVICES FOR CHILDREN UNDER DCF CARE
a. The MCO shall pay for a comprehensive multi-disciplinary examination for
initial placement only, for each child entering DCF care, within thirty
(30) days of placement into out-of-home care. The multi-disciplinary
examination shall be authorized by either the child's PCP or the MCO and
shall consist of a thorough assessment of the child's functional, medical,
developmental, educational, and mental health status. Within each area of
the assessment, the evaluation shall identify any additional specialized
diagnostic and therapeutic needs. Physicians and other medical and mental
health providers specializing in the assessment areas shall conduct the
multi-disciplinary examination. Each multi-disciplinary examination shall
occur at a single location. All components of the examination shall be
performed on the same day, excluding additionally needed examinations,
unless otherwise indicated. The provider shall report the findings and
conclusions
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of the examination in a form acceptable to DCF. The report must be
received by DCF within fifteen (15) days of the examination. The provider
shall also provide for updates to DCF on any additional examinations.
b. The providers of the MCO shall provide for training of xxxxxx parents on
the use of special equipment or medications as needed.
c. The MCO shall require regular collaboration between providers and DCF
Regional Offices and Central Office medical, mental health and social work
staff and consultants. The MCO shall assign staff to act as liaisons to
identify, address and resolve health care delivery issues, barriers to
comprehensive care and other problem areas. DCF shall specify the contact
persons by name, title and phone number who will be available for
quarterly meetings between DCF and the MCO and shall facilitate the
initiation of these meetings with the MCO.
d. The MCO shall include a panel of mental health providers who shall be
qualified to perform psychological, psychiatric and developmental
evaluations and perform assessment and treatment of sexual abuse and
juvenile sexual offenders. DCF shall be available for consultation in the
identification of such providers.
e. In addition to standard prescription coverage, the MCO shall cover
prescriptions in compliance with DCF policy for "Placement Medications"
which are additional prescriptions which may be needed when children are
placed or change placements. The MCO shall cover "Home Visit Medications".
Home Visit Medications are additional prescriptions, which may be needed
when children placed in out-of-home settings leave the placement for a
home visit. Home Visit Medications should include only those doses which
will be needed during the home visit, plus one extra dose.
f. The MCO shall deliver a notice of action to an identified person at the
DCF Central Office when a service is to be reduced, denied or terminated.
DCF will, in turn, distribute the notice of action to its appropriate
regional and local personnel.
3.20 PRENATAL CARE
a. In order to promote healthy birth outcomes, the MCO or its contracted
providers shall:
1. Identify enrolled pregnant women as early as possible in the
pregnancy;
2. Conduct prenatal risk assessments in order to identify high risk
pregnant women, arrange for specialized prenatal care and support
services tailored to risk status, and begin care coordination that
will continue throughout the pregnancy and early weeks of
postpartum;
3. Refer enrolled pregnant women to the WIC program;
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4. Offer case management services for assistance with obtaining
prenatal care appointments, transportation, WIC, and other support
services as necessary;
5. Offer prenatal health education materials and/or programs aimed at
promoting healthy birth outcomes;
6. Offer HIV testing and counseling and all appropriate prophylaxis and
treatment to all enrolled pregnant women;
7. Refer any pregnant Member who is actively abusing drugs or alcohol
to a behavioral health subcontractor or provider of behavioral
health/substance abuse services and treatment; and
8. Educate new mothers about the importance of the postpartum visit and
well-baby care.
PERFORMANCE MEASURE: Early access to prenatal care: Percentage of enrolled women
who had a live birth, who were continuously enrolled in the MCO for 280 days
prior to delivery who had a prenatal visit on or between 176 to 280 days prior
to delivery.
PERFORMANCE MEASURE: Adequacy of prenatal care: Percentage of women with live
births who were continuously enrolled during pregnancy who had more than eighty
(80) percent of the prenatal visits recommended by the American College of
Obstetrics and Gynecology, adjusted for gestational age at enrollment and
delivery.
3.21 DENTAL CARE
a. The MCO shall contract with a sufficient number of dentists throughout the
state to assure access to oral health care. The MCO shall:
1. Maintain an adequate dental provider network throughout the state's
eight (8) counties including access to orthodontic services;
2. For the purpose of enrollment capacity a dental hygienist meeting
the criteria of Connecticut General Statutes Section 20-1261, with
two (2) years of experience, working in an institution (other than
hospital), a community health center, a group home, a preschool
operated by a local board of education or head start program, or a
school setting shall be counted as fifty (50) percent of a general
dentist. If the MCO's provider network includes dental hygienists
acting independently within their scope of practice to provide
preventive services to Members, the MCO shall require that dental
hygienists make appropriate referrals to in-network dentists for
appropriate restorative and diagnostic services;
3. Implement a plan that includes a systematic approach for enhancing
access to dental care through monitoring appointment availability,
provision of training to providers around issues of cultural
diversity and any other specialized programs;
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4. To ensure that access standards are met with respect to dental
screens and appointment availability. The MCO shall ensure that the
scheduling of a routine dental visit is six (6) weeks;
5. Certify that all dentists in the MCO's network shall take Members
and that MCO's HUSKY Members shall be assured the same access to
providers as non-HUSKY Members. Nothing in this section shall
preclude the implementation of limits on panel size by providers;
6. Implement procedures to provide all Members with the opportunity to
choose a general dentist;
7. Implement specific outreach strategies to educate Members about the
importance of regular dental care, with a focus on accessing age
appropriate preventive care such as screenings and cleanings at
least twice a year;
8. Provide for sufficient access to dental services for different age
groups; and
9. Devise mechanisms to avoid unnecessary PCP visits related to dental
problems.
PERFORMANCE MEASURE: The MCO shall ensure that no less than eighty (80) percent
of continuously enrolled Members two (2) to twenty (20) years of age shall
receive one screening and dental cleaning per twelve (12) month period. On a
quarterly basis, the DEPARTMENT shall, through the encounter data submitted by
the MCO, review the MCO's performance under children's dental access.
PERFORMANCE MEASURE: The MCO shall ensure that no less than eighty (80) percent
of continuously enrolled Members twenty-one (21) years of age and over shall
receive one screening and dental cleaning per twelve (12) month period. On a
quarterly basis, the DEPARTMENT shall, through the encounter data submitted by
the MCO, review the MCO's performance under adult dental access.
3.22 OTHER ACCESS FEATURES
a. The MCO shall have systems in place to ensure access to medically
necessary and medically appropriate well-care by its Members. The MCO
shall develop procedures to identify access problems and shall take
corrective action as problems are identified. These systems and
initiatives shall include, but not be limited to:
1. Monitoring new Members to ensure that a well-care appointment is
scheduled within six (6) months of enrollment for those whose last
well-
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August 13 2003
care visit does not fall within the recommended age and gender
appropriate schedules;
2. Monitoring and ensuring that Members receive well-care visits based
on age and gender appropriate schedules;
3. Contacting and counseling Members who miss scheduled appointments;
4. Coverage and provision of services to newborns from the time of
birth;
5. Assisting Members in accessing and locating linguistically and
culturally appropriate services, including but not limited to,
appropriate accommodation for Members with hearing disabilities;
6. Assisting disabled Members in accessing and locating services and
providers that can appropriately accommodate their needs, for
example wheelchair access to provider's office;
7. Development of special initiatives, case management, care
coordination, and outreach to Members with special or multiple
medical needs, for example persons with AIDS or HIV infected
individuals;
8. Development of goals and action plans for incremental increases in
utilization of services such as postpartum care, adolescent health,
dental care and other health care measures agreed upon between the
MCO and the DEPARTMENT;
9. Encouraging providers to offer extended business hours and weekend
(Saturday) openings.
10. Monitoring timely access to care as described in Section 3.13(b).
b. The MCO's access systems will be assessed as part of the annual
performance review of the MCO.
c. On or before November 1, 2003, the MCO shall submit to the DEPARTMENT an
action plan to improve the delivery of well-child care to adolescents.
This plan shall include measures to increase the volume of well-child
screenings provided to adolescent members and to improve the quality and
the completeness of those screenings according to the guidelines provided
by the American Academy of Pediatrics. Emphasis should be placed on
improving health risk assessment and anticipatory guidance during these
visits. Following the submission of this plan, the MCOs will meet with the
DEPARTMENT and representatives of other state agencies to develop a best
practice model for the delivery of adolescent health care.
3.23 PRE-EXISTING CONDITIONS
a. The MCO shall assume responsibility for all covered services as outlined
in Appendix A for of each Member as of the effective date of coverage
under the contract regardless of the new Member's health status.
b. As outlined in Appendix K, for new Members who have transferred enrollment
from another HUSKY MCO, coverage of services other than acute care
hospitalization, nursing home care or care in a subacute facility shall be
the
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August 13 2003
responsibility of the MCO as of the beginning of the month during which
enrollment becomes effective. Responsibility for acute hospitalization,
nursing home or subacute care services at the time of enrollment or
disenrollment is described in Section 3.25.
3.24 NEWBORN ENROLLMENT
Within six (6) months of a child's date of birth, the MCO must notify the
DEPARTMENT of newborns for which they have not received enrollment notification
from the DEPARTMENT. The MCO shall use the notification form made available by
the DEPARTMENT for this purpose. Should the MCO fail to report the child's
birth, the MCO shall reimburse the DEPARTMENT for any fee-for-service claims
paid for covered services that occurred for the newborn Members prior to
processing the newborn's enrollment into the MCO.
3.25 ACUTE CARE HOSPITALIZATION, NURSING HOME OR SUBACUTE STAY AT TIME OF
ENROLLMENT OR DISENROLLMENT
For acute care requiring inpatient stay at a hospital, nursing home or subacute
facility, financial responsibility for covered services shall be determined as
follows:
a. INPATIENT AT TIME OF ENROLLMENT
Initial enrollment in HUSKY A should not commence during a recipient's
inpatient stay at a hospital, nursing home or subacute facility unless the
recipient is a newborn, born to a Member.
The MCO shall notify the DEPARTMENT within sixty (60) days of the MCO's
discovery of or from the date that the MCO receives information from which
a determination can be made that initial enrollment will take effect
during the course of a hospitalization. For those individuals who are
inpatient in an MCO participating facility, the time period in which an
MCO must notify the DEPARTMENT is limited to six (6) months from the
enrollment effective date or sixty (60) days of discovery, whichever comes
first. Upon timely notification to the DEPARTMENT by the MCO, the
DEPARTMENT shall change the effective date to the first of the month after
discharge. If the MCO fails to notify the DEPARTMENT of the inpatient
status within the above specified time periods, the DEPARTMENT shall be
relieved of its responsibility to change the enrollment effective date and
the individual's initial enrollment effective date into the MCO shall be
retained.
b. HOSPITALIZATION AT TIME OF DISENROLLMENT
Hospital costs for Members who are inpatient at the time of disenrollment
from the MCO shall remain the financial responsibility of the MCO until
discharge from the hospital. For purposes of this subsection, hospital
costs shall include the
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August 13 2003
per diem hospital charge. Hospital charges shall not include charges
related to the inpatient stay, but performed and billed separately, such
as the services of the attending physician or a consulting specialist.
Upon discovery of the Member's disenrollment, the MCO shall notify the
individual's new MCO of the inpatient status and coordinate care and
discharge planning with the new MCO. The MCO shall assume financial
responsibility for all non-hospital costs as of the enrollment effective
date for new Members who change MCOs while inpatient. Individuals who are
disenrolled due to recategorization of their Medicaid coverage to a
non-managed care category shall revert to fee-for-service upon
recategorization.
c. DISENROLLMENT RESULTING FROM LONG-TERM HOSPITALIZATION
1. Members who are inpatient in a subacute facility or a nursing home
will remain the responsibility of the MCO until they are discharged
from the facility. If the MCO reports to DSS or its agent, any
patient in a subacute facility or a nursing home other than for the
purpose of behavioral health prior to the ninety (90) continuous
days from the date of admission, the DEPARTMENT will disenroll the
Member at the end of the month, that the Member has been inpatient
in the facility for ninety (90) continuous days. If the MCO reports
to the DEPARTMENT beyond ninety (90) days, the change will be
effective the end of the month during which the change was reported
to DSS or its agent. The facility's per diem (room and board) costs
for a Member who is inpatient in a subacute facility or a nursing
home will remain the responsibility of the MCO unti1 the Member is
discharged from the facility or disenrolled from managed care
whichever comes first. Upon discovery of the Member's disenrollment,
the MCO shall notify the individual's new MCO of the inpatient
status and coordinate care and discharge planning with the new MCO.
The MCO shall assume financial responsibility for all non-room and
board costs as of the enrollment effective date for any new Member
who changed MCOs while inpatient.
2. Members between the ages of eighteen (18) and twenty (20),
inclusive, who are inpatient in Cedarcrest or Connecticut Valley
Hospital will remain the responsibility of the MCO until they are
discharged from the hospital. If the MCO reports to DSS or its
agent, any Member between the ages of eighteen (18) and twenty (20),
inclusive, who is a patient in Cedarcrest or Connecticut Valley
Hospital prior to forty-five (45) continuous days from the date of
admission, the DEPARTMENT will disenroll the Member at the end of
the month that the Member has been inpatient for forty-five (45)
continuous days. If the MCO reports to the DEPARTMENT beyond
forty-five (45) days, the change will be effective the end of the
month during which the change was reported to the DEPARTMENT or its
agent.
3.26 OPEN ENROLLMENT
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a. The MCO shall conduct continuous open enrollment during which the MCO
shall accept clients eligible for coverage under this contract in the
order in which they are enrolled without regard to the need for health
services, health status of the client or any other factor(s).
b. The MCO shall accept membership of newborns born to a Member upon the
child's date of birth with the exception of newborns that are placed for
private adoption or when the mother has indicated in writing that she does
not wish Medicaid coverage for the child. The enrollment effective date
for newborns shall be the first of the month in which the child was born.
c. The MCO shall not discriminate against individuals eligible to enroll on
the basis of race, color, or national origin and will not use any policy
or practice that has the effect of discriminating on the any such basis.
The MCO shall not discriminate in enrollment activities on the basis of
health status or the client's need for health care services or on any
other basis, and shall not attempt to discourage or delay enrollment with
the MCO or encourage disenrollment from the MCO of eligible Medicaid
clients.
d. If the MCO discovers that a Member's new or continued enrollment was in
error, the MCO shall notify the DEPARTMENT or its agent within sixty (60)
days of the discovery or sixty (60) days from the date that the MCO had
the data to determine that the enrollment was in error, whichever comes
first. Other than the case of a newborn retroactively enrolled, failure to
notify the DEPARTMENT or its agent within the parameters defined in this
section and within established procedures will result in the retention of
the Member by the MCO for the erroneous period of enrollment.
3.27 SPECIAL DISENROLLMENT
a. The MCO may request in writing and the DEPARTMENT may approve
disenrollment of specific Members when there is good cause. The request
shall cite the specific event(s), date(s) and other pertinent information
substantiating the MCO's request. Additionally, the MCO shall submit any
other information concerning the MCO's request that the DEPARTMENT may
require in order to make a determination in the case.
b. Good cause is defined as a case in which a Member:
1. Exhibits uncooperative or disruptive behavior. If, however, such
behavior results from the Member's special needs, good cause may
only be found if the Member's continued enrollment seriously impairs
the MCO's ability to furnish services to either the particular
Member or others; or
2. Permits others to use or loans his or her membership card to others
to obtain care or services.
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c. The following shall not constitute good cause:
1. extensive or expensive health care needs;
2. a change in the member's health; status;
3. the member's diminished mental capacity; or
4. uncooperative or disruptive behavior related to a medical condition
except as described in x.x, above.
d. The effective date for an approved disenrollment shall be no later than
the first day of the second month following the month in which the MCO
files the disenrollment request. If the DEPARTMENT fails to make the
determination within this timeframe, the disenrollment shall be deemed
approved.
e. The DEPARTMENT will notify an MCO prior to enrollment if a Member was
previously disenrolled for cause from another MCO pursuant to this section
3.28 LINGUISTIC ACCESS
a. The MCO shall take appropriate measures to ensure adequate access to
services by Members with limited English proficiency. These measures shall
include, but not be limited to the promulgation and implementation of
policies on linguistic accessibility for MCO staff, network providers and
subcontractors; the identification of a single individual at the MCO for
ensuring compliance with linguistic accessibility policies; identification
of persons with limited English proficiency as soon as possible following
enrollment; provisions for translation services; and the provision of a
Member handbook, notices of action and grievance/administrative hearing
information in languages other than English. The MCO shall notify its
members that oral interpretation is available for any language.
b. Member educational materials must also be available in languages other
than English and Spanish when more than five (5) percent of the MCO's
Members in any county served by the MCO speaks the alternative language,
provided, however, this requirement shall not apply if the alternative
language has no written form. The MCO may rely upon initial enrollment and
monthly enrollment data from the DEPARTMENT's Eligibility Management
System (EMS) to determine the percentage of Members who speak alternative
languages. The MCO shall inform members that written materials are
available in these alternative languages.
c. The MCO shall also take appropriate measures to ensure access to services
by persons with visual and hearing disabilities. This shall include the
provision of information in alternative formats and in an appropriate
manner that takes into
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consideration the special needs of Members with disabilities. Information
concerning Members with visual impairments and hearing disabilities will
be made available through the daily and monthly EMS enrollment data.
SANCTION: For each documented instance of failure to provide appropriate
linguistic accessibility to Members, the DEPARTMENT may impose a strike towards
a Class A sanction pursuant to Section 7.05.
3.29 SERVICES TO MEMBERS
a. The MCO shall have in place an ongoing process of Member education which
includes, but is not limited to: development of a Member handbook;
provider directory; newsletter; and other Member educational materials.
The MCO's written materials for members must be in a language and format
that may be easily understood. All written materials and correspondence to
Members shall be culturally sensitive and written at no higher than a
seventh grade reading level. All Member educational materials must be in
both English and Spanish.
b. At the time of initial enrollment, the MCO shall provide a member handbook
to each Member. If a Member loses eligibility and re-enrolls in the MCO
less than ninety (90) days after losing eligibility, the MCO is not
required to send a new handbook. If the lapse in enrollment is more than
ninety (90) days, the MCO shall send a new handbook. The MCO shall mail
the Member handbook and provider directory to Members within one week of
enrollment notification. At least once a year, thereafter, the MCO shall
notify the Members of their right to request the following information.
The Member handbook shall address and explain, at a minimum, the
following:
1. The amount, duration and scope of covered services under the
contract in sufficient detail that the Member understands the
benefits to which they are entitled;
2. Restrictions on services (including limitations and services not
covered) and circumstances in which the Member could be held liable
for payment for services;
3. Prior authorization process;
4. Definition of and distinction between emergency care and urgent care
and the extent to which emergency coverage is available, including:
the fact that prior authorization is not necessary for emergency
care, the procedures for obtaining emergency services including the
use of 911; the locations of emergency settings which provide
emergency services and post-stabilization services; the fact that
the Member can obtain emergency care in any hospital or other
setting and the post stabilization rules;
5. Policies on the use of urgent care services including a phone number
which can be used for assistance in obtaining urgent care;
6. How to access care twenty-four (24) hours a day;
7. Assistance with appointment scheduling;
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8. Member rights and responsibilities, as described in Section 3.03;
9. Member services, including hours of operation;
10. Enrollment/disenrollment/plan changes;
11. Procedures for selecting and changing PCPs;
12. Policies on referrals for specialty care and other benefits not
furnished by the PCP;
13. Availability of provider network directory and updates;
14. An explanation of circumstances in which a Member is responsible for
making co-payments;
15. Restrictions on the Member's freedom of choice among providers;
16. Limited liability for services from out-of-network providers;
17. Access and availability standards;
18. Special access and other MCO features of the health plan's program;
19. Family planning services and the availability of family planning
from out-of network providers;
20. Case management services targeted to Members as medically necessary
and appropriate;
21. The MCO's appeal and the DEPARTMENT's administrative hearing
process, including the right to a hearing, the method for obtaining
a hearing, the right to representation; the right to file appeals
and hearing requests and the time frames for filing; the
availability of assistance with filing; the toll-free numbers for
filing appeals; the circumstances in which services will be
continued pending a hearing; the MCO's provider appeal process;
22. Procedures to request non-emergency transportation and
transportation options;
23. EPSDT services for children;
24. Coordination of benefits and third party liability;
25. Description of drug formulary, prior approval and temporary supply
process, if applicable
26. Advance directives; and
27. How to obtain any benefits that are available under the Connecticut
Medicaid Plan but are not covered under this contract.
Upon request, the MCO shall also provide Members with information on the
structure and operation of the MCO and physician incentive plans.
c. The MCO's provider directory shall include, at a minimum, the names,
location, telephone numbers and non-English languages spoken by current
contracted providers in the Member's service area, including
identification of providers that are not accepting new patients. The
provider directory shall include, at a minimum, information on PCPs,
specialists and hospitals. The MCO shall make a good faith effort to give
written notice of termination of a network provider within fifteen (15)
days after receipt or issuance of the termination notice to each Member
who designated the provider as his or her PCP and each member who was seen
on a regular basis by the terminated provider.
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d. All Member educational materials must be prior approved by the DEPARTMENT.
Educational materials include, but are not limited to: Member handbook;
Membership card; introductory and other text language from the provider
directory; and all communications to Members that include HUSKY A program
information. The MCO must wait until receiving DEPARTMENT written approval
or thirty (30) days from the date of submittal before disseminating
educational materials to Members. The DEPARTMENT reserves the right to
request revisions or changes in the material at any time.
e. The DEPARTMENT shall, to the extent feasible, notify the MCO more than
thirty (30) days in advance of any significant change to the HUSKY
program, for example a change in the scope of covered services resulting
from legislation. The MCO shall give each Member written notice of any
significant change, at least 30 days before the intended effective date of
the change.
The MCO must provide periodic updates to the handbook or inform Members,
as needed, of changes to the Member information discussed above. The MCO
shall update its Member handbook to incorporate all provisions and
requirements of this contract within six (6) weeks of the start date. The
MCO shall distribute the Member handbook within six (6) weeks of receiving
the DEPARTMENT's written approval.
f. The MCO shall maintain an adequately staffed Member services office to
receive telephone calls and to meet personally with Members in order to
answer Members' questions, respond to Members' complaints and resolve
problems informally.
g. The MCO shall identify to the DEPARTMENT the individual who is responsible
for the performance of the Member Services Department.
h. The MCO's Member Services Department shall include bilingual staff
(Spanish and English) and translation services for non-English speaking
Members. The MCO shall also make available translation services at
provider sites either directly or through a contractual obligation with
the service provider.
i. The MCO shall require members of the Member Services Department to
identify themselves to Members when responding to Members' questions or
complaints. At a minimum, ninety (90) percent of all incoming calls shall
be answered by a staff Member within the first minute and the call
abandonment rate shall not exceed five (5) percent. The MCO sha11 submit
call response and abandonment reports for the preceding six (6) month
period to the DEPARTMENT upon request.
j. When Members contact the Member Services Department to ask questions
about, or complain about, the MCO's failure to respond promptly to a
request for goods
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or services, or the denial, reduction, suspension or termination of goods
or services, the MCO shall: attempt to resolve such concerns informally,
and inform Members of the appeal and administrative hearing processes and,
upon request, mail to them, within one business day, forms and
instructions for filing a grievance.
k. The MCO shall maintain a grievance report in the format designated by the
DEPARTMENT pursuant to Section 6.01. These reports shall be made available
to the DEPARTMENT upon request
l. At the time of enrollment and at least anually thereafter, the MCO shall
inform its Members of the procedural steps for filing an appeal and
requesting an administrative hearing.
m. The MCO shall monitor and track PCP transfer requests and follow up on
complaints made by Members as necessary.
n. The MCO will participate in an NCQA Consumer Assessment of Health Plans
Survey (CAHPS) of combined HUSKY A and B Members using an independent
vendor, and paid for by the MCO.
o. The MCO may provide outreach to its current Members at the time of the
Member's renewal of eligibility. The outreach may involve special mailings
or phone calls as reminders that the Member must complete the HUSKY
renewal forms to ensure continued coverage.
SANCTION: If either the incoming call response or call abandonment standards set
forth in paragraph h are not met for ninety (90) percent of the days during the
six (6) month review period, the DEPARTMENT may impose a strike towards a Class
A sanction pursuant to Section 7.05.
3.30 INFORMATION TO POTENTIAL MEMBERS
Informational materials for potential members shall also be provided in a manner
and format that may be easily understood. The MCO shall make the following
information available to potential Members, upon request the locations,
qualifications, non-English languages spoken by and availability of the MCO's
network providers. The MCO shall provide a summary of this information to the
DEPARTMENT, in a format to be approved by the DEPARTMENT. The DEPARTMENT shall
provide the summary information to all potential Members.
The MCO shall also provide oral interpretation services in all non-English
languages to potential Members.
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3.31 MARKETING REQUIREMENTS
DSS marketing restrictions apply to subcontractors and providers of care as well
as to the MCOs. The MCO shall notify all its subcontractors and network
providers of the DEPARTMENT's marketing restrictions. The detailed marketing
guidelines are set forth in Appendix D.
a. PROHIBITED MARKETING ACTIVITIES
The following activities are prohibited, in all forms of communication,
regardless of whether they are performed by the MCO directly, by its
contracted providers, or its subcontractors:
1. Asserting or implying that a Member will lose or not qualify for
HUSKY benefits unless he/she enrolls in the MCO, or creating other
threatening scenarios that do not accurately depict the consequences
of choosing a different MCO;
2. Discriminating (in marketing or in the course of the enrollment
process) against any eligible individual on the basis of health
status or need for future health care services;
3. Making inaccurate, misleading or exaggerated statements (e.g. about
the nature of the eligibility or enrollment process, the positive
attributes of the MCO, or about the disadvantages of competing
MCOs);
4. Any unsolicited personal contact including telephonic, door-to-door
marketing or other cold call marketing or enrollment activities to
potential Members;
5. Failing to submit for approval marketing materials or marketing
approaches when such approval is required by DSS (see Appendix D).
MCOs, subcontractors and their providers must wait until receiving
DSS written approval before disseminating any such information to
potential Members. DSS reserves the right to request revisions or
changes in material at any time;
6. Making any statements or assertions that the MCO is endorsed by the
DEPARTMENT or CMS or any other governmental entity;
7. Seeking to influence enrollment in conjunction with the sale or
offering of private insurance; and
8. Conducting any form of individual or group solicitation activity
other than those expressly permitted under Appendix D, the DSS
Marketing Guidelines, unless prior approval is obtained from DSS.
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b. Any type of marketing activity which has not been clearly specified as
permissible under these guidelines should be assumed to be prohibited. The
MCO shall contact the DEPARTMENT for guidance and approval for any
activity not clearly permissible under these guidelines.
c. The MCO shall submit all marketing materials to the DEPARTMENT for
approval. The DEPARTMENT will provide comments on the marketing materials
to the MCO within thirty (30) days of receipt of the materials.
d. The MCO shall ensure that, before enrolling, members receive accurate
written information needed to make an informed decision on whether to
enroll.
e. The MCO shall distribute marketing materials on a statewide basis.
SANCTION: If the MCO or its providers fails to submit marketing materials for
prior approval, the DEPARTMENT may impose a Class B sanction pursuant to Section
7.05.
SANCTION: If the MCO or its providers engages in inappropriate marketing
activities at provider sites, the DEPARTMENT may impose a Class B or Class C
sanction pursuant to Section 7.05 as it deems appropriate.
SANCTION: If the MCO or its providers engages in cold call or door-to-door
marketing, the DEPARTMENT may impose Class C sanctions pursuant to Section 7.05.
3.32 HEALTH EDUCATION
The MCO must routinely, but no less frequently than annually, remind and
encourage Members to utilize benefits including physical examinations which are
available and designed to prevent illness. The MCO must also offer periodic
screening programs which in the opinion of the medical staff would effectively
identify conditions indicative of a health problem. The MCO shall keep a record
of all activities it has conducted to satisfy this requirement.
3.33 INTERNAL AND EXTERNAL QUALITY ASSURANCE
a. The MCO is required to provide a quality level of care for all services
that it provides and for which it contracts. These services are expected
to be medically necessary and may be provided by participating providers.
A Quality Assessment and Performance Improvement program shall be
implemented by the MCO to assure the quality of care. The EQRO shall
monitor the MCO's compliance with all requirements in this section.
b. The MCO shall comply with federal regulations and DEPARTMENT policies and
requirements concerning Quality Assessment and Performance Improvement and
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August 13 2003
utilization review set forth below. The MCO will develop and implement an
internal Quality Assessment and Performance Improvement program consistent
with the Quality Assessment and Performance program guidelines as provided
in Appendix E.
c. The MCO shall comply with all applicable federal regulations concerning
Quality Assessment and Performance Improvement.
d. The MCO shall operate a Quality Assessment and Performance Improvement
system which:
1. Is consistent with applicable federal regulations;
2. Provides for review by appropriate health professionals of the
process followed in providing health services;
3. Provides for systematic data collection of performance and
participant results;
4. Provides for interpretation of these data to the practitioners;
5. Provides for making needed changes;
6. Provides for the performance of at least one performance improvement
project of the MCO's own choosing;
7. Provides for participation in at least one performance improvement
project conducted by the EQRO; and
8. Has in effect mechanisms to detect both under utilization and over
utilization of services.
e. The MCO shall provide descriptive information on the operation,
performance and success of its Quality Assessment and Performance
Improvement program to the DEPARTMENT or its agent upon request.
f. The MCO shall maintain and operate a Quality Assessment and Performance
Improvement program which includes at least the following elements:
1. A Quality Assessment and Performance Improvement plan.
2. A full-time Quality Assessment and Performance Improvement Director,
who is responsible for the operation and success of the Quality
Assessment and Performance Improvement Program. This person shall
have adequate experience to ensure successful Quality Assessment and
Performance Improvement, and shall be accountable for the Quality
Assessment and Performance Improvement systems of all the MCO's
providers, as well as the MCC's subcontractors.
3. The Quality Assessment and Performance Improvement Director shall
spend an adequate percentage of time on Quality Assessment and
Performance Improvement activities to ensure that a successful
Quality Assessment and Performance Improvement Program will exist.
Under the
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Quality Assessment and Performance Improvement program, there shall
be access on an as-needed basis to the full compliment of health
professions (e.g., pharmacy, physical therapy, nursing, etc.) and
administrative staff. Oversight of the program shall be provided by
a Quality Assessment and Performance Improvement committee that
includes representatives from:
a. a variety of medical disciplines (e.g., medicine,
surgery, mental health, etc.);
b. administrative staff; and Board of Directors of the MCO.
4. Make available case management training for PCPs designed by the
DEPARTMENT or its agent.
g. The Quality Assessment and Performance Improvement committee shall be
organized operationally within the MCO such that it can be responsible for
all aspects of the Quality Assessment and Performance Improvement program.
h. Quality Assessment and Performance Improvement activities shall be
sufficiently separate from Utilization Review activities, so that Quality
Assessment and Performance Improvement activities can be distinctly
identified as such.
i. The Quality Assessment and Performance Improvement activities of the MCO's
network providers and subcontractors, if separate from the MCO's Quality
Assessment and Performance Improvement activities, shall be integrated
into the overall MCO Quality Assessment and Performance Improvement
program, and the MCO shall provide feedback to the in-network
providers/subcontractors regarding the operation of any such independent
Quality Assessment and Performance Improvement effort. The MCO shall
remain, however, fully accountable for all Quality Assessment and
Performance Improvement relative to its in-network providers and
subcontractors.
j. The Quality Assessment and Performance Improvement committee shall meet at
least quarterly and produce written documentation of committee activities
to be shared with the DEPARTMENT.
k. The results of the Quality Assessment and Performance Improvement
activities shall be reported in writing at each meeting of the Board of
Directors.
l. The MCO shall have a written procedure for following up on the results of
Quality Assessment and Performance Improvement activities to determine
success of implementation. Follow-up shall be documented in writing.
m. Where the DEPARTMENT determines that a Quality Assessment and Performance
Improvement plan does not meet the above requirements, the DEPARTMENT may
provide the MCO with a model plan. The MCO agrees to
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August 13 2003
modify its Quality Assessment and Performance Improvement plan based on
negotiations with the DEPARTMENT.
n. The MCO shall monitor access to and quality of health care goods and
services for its Member population, and, at a minimum, use this mechanism
to capture and report all of the DEPARTMENT's required utilization data.
The MCO shall be subject to an annual medical audit by the DEPARTMENT's
Quality Assessment and Performance Improvement contractor and shall
provide access to the data and records requested for this purpose.
o. To the extent permitted under state and federal law, the MCO certifies
that all data and records requested shall, upon reasonable notice, be made
available to the DEPARTMENT or its agent.
p. The MCO will be an active participant in at least one of the EQRO's
quality improvement focus studies each year
q. The MCO must comply with external quality review that will be implemented
by an organization contracted by the DEPARTMENT. This may include
participating in the design of the external review, collecting data
including, but not limited to, encounter and medical data, and/or making
data available to the review organization.
r. The MCO must conduct at least one performance improvement project that:
1. Focuses on one of the following areas:
a. Prevention and care of acute and chronic conditions;
b. High volume services;
c. Continuity and coordination of care;
d. Appeals, grievances and complaints;
e. Access to and availability of services; or
f. Other projects subject to DEPARTMENT approval.
2. Includes the measurement of performance and quality indicators that
are:
a. Objective;
b. Clearly and unambiguously defined;
c. Based on current clinica1 knowledge or health services
research;
d. Valid and reliable;
e. Systematically collected; and
f. Capable of measuring outcomes such as changes in health status
or Member satisfaction or valid proxies of those outcomes.
3. Implements system interventions to achieve quality improvement;
4. Evaluates the effectiveness of the interventions;
5. Plans and initiates activities for increasing or sustaining
improvement; and
6. Represents the entire population to which the quality indicator is
relevant.
s. The MCO shall maintain a health information system that collects,
analyzes,
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integrates and reports data. The system must provide information on areas
including but not limited to utilization, appeals and hearings.
t. With the approval of the DEPARTMENT, the MCO may conduct performance
improvement projects for the combined HUSKY A and HUSKY B populations.
3.34 INSPECTION OF FACILITIES
a. The MCO shall provide the State of Connecticut and any other legally
authorized governmental entity, or their authorized representatives, the
right to enter at all reasonable times the MCO's premises or other places,
including the premises of any subcontractor, where work under this
contract is performed to inspect, monitor or otherwise evaluate work
performed pursuant to this contract. The MCO shall provide reasonable
facilities and assistance for the safety and convenience of the persons
performing those duties. The DEPARTMENT and its authorized agents will
request access in advance in writing except in case of suspected fraud and
abuse.
b. In the event right of access is requested under this section, the MCO or
subcontractor shall upon request provide and make available staff to
assist in the audit or inspection effort, and provide adequate space on
the premises to reasonably accommodate the State or Federal
representatives conducting the audit or inspection effort.
c. The MCO shall be given ten (10) business days to respond to any findings
of an audit before the DEPARTMENT shall finalize its findings. All
information so obtained will be accorded confidential treatment as
provided under applicable law.
3.35 EXAMINATION OF RECORDS
a. The MCO shall develop and keep such records as are required by law or
other authority or as the DEPARTMENT determines are necessary or useful
for assuring quality performance of this contract. The DEPARTMENT shall
have an unqualified right of access to such records in accordance with
Part II Section 3.34.
b. Upon non-renewal or termination of this contract, the MCO shall turn over
or provide copies to the DEPARTMENT or to a designee of the DEPARTMENT all
documents, files and records relating to persons receiving services and to
the administration of this contract that the DEPARTMENT may request, in
accordance with Part II, Section 3.34.
c. The MCO shall provide the DEPARTMENT and its authorized agents with
reasonable access to records the MCO maintains for the purposes of this
contract.
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August 13 2003
The DEPARTMENT and its authorized agents will request access in writing
except in cases of suspected fraud and abuse. The MCO must make all
requested medical records available within thirty (30) days of the
DEPARTMENT's request. Any contract with a subcontractor must include a
provision specifically authorizing access in accordance with the terms set
forth in Part II, Section 3.34.
d. The MCO shall maintain the confidentiality of patients' records in
conformance with this contract and state and federa1 statutes and
regulations, including but not limited to the Health Insurance Portability
and Accountability Act (HIPAA), 42 U.S.C. Section 1320 d-2 et seq. and the
implementing privacy regulations at 45 CFR pts. 160 and 164.
e. The MCO, for purposes of audit or investigation, shall provide the State
of Connecticut, the Secretary of HHS and his/her designated agent, and any
other legally authorized governmental entity or their authorized agents
access to all the MCO's materials and information pertinent to the
services provided under this contract, at any time, until the expiration
of three (3) years from the completion date of this contract as extended.
f. The State and its authorized agents may record any information and make
copies of any materials necessary for the audit.
g. The MCO and its subcontractors shall retain financial records, supporting
documents, statistical records and all other records supporting the
services provided under this contract for a period of five (5) years from
the completion date of this contract. The MCO shall make the records
available at all reasonable times at the MCO's general offices. The
DEPARTMENT and its authorized agents will request access in writing except
in cases of suspected fraud and abuse. If any litigation, claim or audit
is started before the expiration of the five (5) year period, the records
must be retained until all litigation, claims or audit findings involving
the records have been resolved. The MCO must make all requested records
available within thirty (30) days of the DEPARTMENT's request.
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August 13, 2003
3.36 MEDICAL RECORDS
a. In compliance with all state and federal law governing the privacy of
individually identifiable health care information including the Health
Insurance Portability and Accountability Act (HIPAA), 42 USC Sections
1320d-2 et seq., and the implementing privacy regulations at 45 CFR pts
160 and 164, the MCO shall establish a confidential, centralized record,
for each Member, which includes information of all medical goods and
services received. The MCO may delegate maintenance of the centralized
medical record to the Member's PCP, provided however, that the record
shall be made available upon request and reasonable notice, to the
DEPARTMENT or its agent(s) at a centralized location. The medical record
shall meet the DEPARTMENT's medical record requirements as defined by the
DEPARTMENT in its regulations, and shall comply with the requirements of
NCQA or other national accrediting body with a recognized expertise in
managed care.
b. The MCO shall also simultaneously maintain, with the medical record, a
record of all contacts with each Member that the MCO will maintain in a
computerized database and make available to the DEPARTMENT, at its
request. Claims and encounter records will be provided to the DEPARTMENT
in an electronic medium as specified by the DEPARTMENT, and its agent(s).
The medical record shall demonstrate coordination of Member care; for
example, relevant medical information from referral sources and
out-of-network family planning providers shall be reviewed and entered
into Members' medical records. For those MCOs that are governed under
Connecticut General Statutes Chapter 705 Section 38a-975 et seq., known as
the "Connecticut Insurance Information and Privacy Act", such MCO shall be
required to observe the provisions of such Act with respect to disclosure
of personal and privileged information as such terms are defined under the
Act.
c. The MCO shall not turn over or provide documents, files and records
pertaining to a Member to another health plan unless the Member has
changed enrollment to the other plan and the MCO has been so notified by
the DEPARTMENT or its agent.
3.37 AUDIT LIABILITIES
In addition to and not in any way in limitation of the MCO's obligations
pursuant to this contract, it is understood and agreed by the MCO that the MCO
shall be held liable for any finally determined State or Federal audit
exceptions and shall return to the DEPARTMENT all payments made under the
contract to which exception has been taken or which have been disallowed because
of such an exception.
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August 13, 2003
3.38 CLINICAL DATA REPORTING
a. Utilization Reporting: The MCO shall submit reports to the DEPARTMENT in
the areas listed below. The purpose of the reports is to assist the
DEPARTMENT in its efforts to assess utilization and evaluate the
performance of the HUSKY A program and of the MCO.
Utilization reports shall cover the following areas:
1. Inpatient Care;
2. Preventive Care;
3. Dental Care;
4. Behavioral Health Care;
5. Other Services;
6. Maternal and Child Health;
7. EPSDT, known as HealthTrack; and
8. Immunization Information.
b. The DEPARTMENT shall consult with the MCO, through a workgroup comprised
of DEPARTMENT and MCO representatives that meets on a periodic basis, or a
similar process, on the necessary data, methods of collecting the data and
the format and media for new reports or changes to existing reports.
c. The DEPARTMENT shall provide the MCO with final specifications for
submitting all reports no less than ninety (90) days before the reports
are due. The MCO shall submit reports on a schedule to be determined by
the DEPARTMENT, but not more frequently than quarterly. Before the
beginning of each calendar year, the DEPARTMENT shall provide the MCO with
a schedule of utilization reports which shall be due that calendar year.
Due dates for the reports shall be at the discretion of the DEPARTMENT,
but not earlier than ninety (90) days after the end of the period that
they cover.
d. For each report the DEPARTMENT shall consider using any HEDIS standards
promulgated by the NCQA which cover the same or similar subject matter.
The DEPARTMENT reserves the right to modify HEDIS standards, or not use
them at all, if in the DEPARTMENT's judgment, the objectives of the HUSKY
A program can be better served by using other methods.
e. EPSDT (HealthTrack): The MCO shall submit to the DEPARTMENT reports on
compliance with screening requirements of the EPSDT program sufficient to
enable the DEPARTMENT to comply with its reporting obligations under
federal and state requirements and to assess and evaluate the performance
of the MCO in the screening requirements of the EPSDT program. These
obligations include, but are not limited to, submitting reports to federal
and state agencies.
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August 13, 2003
f. Maternal and Prenatal Care:
The MCO shall report aggregate summary data on outcomes of maternal and
prenatal care to the DEPARTMENT no less frequently than quarterly. Such
data will include:
1. Number of deliveries during the quarter to women enrolled in the MCO
at the time of delivery;
2. Number of live births;
3. Number of fetal deaths;
4. Number of very low birthweight babies, defined as weighing less than
one thousand five hundred grams;
5. Number of hospital inpatient/NICU days for very low birthweight
babies;
6. Number of moderately low birthweight babies, defined as weighing
less than two thousand five hundred grams;
7. Number of hospital/NICU days for moderately low birthweight babies;
8. Number of deliveries by cesarean section;
9. Number of women who delivered and had no prenatal care;
10. Number of women with inadequate prenatal care;
11. Number of women with deliveries who have received a postpartum
visit; and
12. For the purpose of adjusting comparisons amongst plans, aggregate
measures of weeks of pregnancy at the time of enrollment in the
plan.
The report will be due within six (6) months after the last day of the
quarter in which the deliveries occurred. The DEPARTMENT will specify the
methodology for preparing the report, no less than ninety (90) days prior
to the end of the quarter which is the subject of the report and after
consultation with the MCO. If the change requires the collection of
additional data elements not currently being captured, the DEPARTMENT will
notify the MCO no less than ninety (90) days prior to the beginning of the
first quarter affected by the change.
g. Encounter Data:
1. The MCO shall provide the DEPARTMENT with an electronic record of
every encounter between a network provider and a Member within
fifteen (15) days of the close of the month in which the specific
encounter occurred, was paid for, or was processed whichever is
later but no later than 180 days from the encounter. Such encounters
shall be coded and formatted in accordance with the specifications
outlined in the State's Encounter Submission and Reporting Guide.
The DEPARTMENT or its agent shall analyze each month's encounter
submission file. The DEPARTMENT or its agent wi11 reject those
records that contain invalid or missing data and result in a
critical edit failures as outlined in the Encounter Submission and
Reporting Guide.
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2. Encounter data and any other types of data submitted by the MCO that
the DEPARTMENT designates as data relied upon by the DEPARTMENT to
set rates must be certified by one of the following: the MCO's Chief
Executive Officer or Chief Financial Officer or an individual who
has delegated authority to sign for and who reports directly to
either the Chief Executive Officer or Chief Financial Officer. The
certification must attest, based on the best knowledge, information
and belief, as follows: 1) to the accuracy, completeness and
truthfulness of the data and 2) to the accuracy, completeness and
truthfulness of the reports required pursuant to this section. The
MCO shall submit the certification concurrently with the certified
data.
PERFORMANCE MEASURE: The overall volume of rejected encounters shall not
exceed five (5) percent in any given month.
3. The MCO shall resubmit rejected encounter records in accordance with
the following schedule:
a. 90% of rejected encounters shall be resubmitted within 30
days;
b. 95% of rejected encounters shall be resubmitted within 60
days;
c. no less than 98% of rejected encounters shall be resubmitted
within 90 days.
4. The DEPARTMENT or its agent shall also analyze the MCO's encounter
submissions for completeness. On a quarterly basis, no less than six
(6) months from the date of service on the encounter, the DEPARTMENT
or its agent will compare encounter data utilization levels to the
MCO self-reported utilization levels in the reports specified in
Sections 3.38(a)-(f).
PERFORMANCE MEASURE: Encounter data shall not be over or under the MCO
self-reported utilization levels for the same time period by ten (10)
percent or more.
5. The DEPARTMENT or its EQRO, may choose a random sample of no more
than one hundred (100) encounters for each year. The MCO will make
the medical records of each encounter so chosen available to the
DEPARTMENT or EQRO at a central location upon reasonable notice. The
EQRO shall review the medical records and report back to the
DEPARTMENT on the extent to which the information in each field of
the encounter record corresponds to the information contained in the
medical record. Prior to making its report to the DEPARTMENT, the
EQRO shall afford the MCO a reasonable opportunity to suggest
corrections to or comment upon the EQRO's findings.
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August 8, 2003
SANCTION: Failure to comply with the above reporting requirements in a complete
and timely manner may result in a strike towards a Class A sanction pursuant to
Section 7.05.
3.39 UTILIZATION MANAGEMENT
a. The MCO and all subcontractors are required to be licensed by the
Connecticut Department of Insurance as utilization review companies. The
MCO may subcontract with a licensed utilization review company to perform
some or all of the MCO's utilization management functions.
b. The MCO and its subcontractors shall develop and adhere to written
policies and procedures for processing requests for initial and continuing
authorizations of services. The MCO shall have mechanisms in place to
ensure consistent application of review criteria for authorization
decisions. Authorization decisions must be made by a health care
professional who has appropriate clinical expertise in treating the
Member's condition or disease.
c. The MCO must provide a written notice of action, as described in Section
6.02, of any decision to deny a service authorization request or to
authorize a service in an amount, duration, or scope that is less than
requested or any decision to terminate, suspend or reduce a previously
authorized Medicaid-covered service. The provider requesting authorization
shall also receive notice of authorization decisions, except the provider
notice need not be in writing.
d. The MCO shall make authorization decisions and issue a written notice of
action and notice to the provider as expeditiously as the Member's health
condition requires, but not to exceed fourteen (14) calendar days
following receipt of the request for service. This standard 14 day
authorization period may be extended one time only by an additional
fourteen (14) days if:
1. the Member or requesting provider asks for an extension; or
2. the MCO documents that the extension is in the Member's interest
because additional information is needed to authorize the service
and the failure to extend the timeframe will result in the denial of
the service. The DEPARTMENT may request such documentation from the
MCO.
e. The MCO shall expedite its authorization decision if a provider indicates,
or the MCO determines that following the timeframe in subsection (d) of
this section could seriously jeopardize the Member's life or health or
ability to attain, maintain or regain maximum function. In such
circumstances the MCO shall issue a decision no later than three working
days after receipt of the request for service. This three day period may
be extended for an additional fourteen days if either criteria in (d)(l)
or (d)(2). above, are met.
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August 8, 2003
f. If the MCO subcontracts for any portion of the utilization management
function, the MCO shall provide a copy of any such subcontract to the
DEPARTMENT and any such subcontracts will be subject to the provisions of
Section 5.08 of this contract. The DEPARTMENT will review and approve the
subcontract, subject to the provisions of Section 3.45, to ensure the
appropriateness of the subcontractor's policies and procedures. The MCO is
required to conduct regular and comprehensive monitoring of the
utilization management subcontractor.
g. The MCO shall not compensate any subcontractor or other entity performing
utilization management or utilization review functions so as to provide
any incentive for the individual to deny, limit or discontinue medically
necessary services to any Member.
3.40 FINANCIAL RECORDS
a. Accounting: The MCO shall maintain for the purpose of this contract, an
accounting system of procedures and practices that conforms to Generally
Accepted Accounting Principles.
b. The MCO shall permit audits or reviewe by the DEPARTMENT and HHS or their
agent(s) of the MCO's financial records related to the performance of this
contract and, for any subcontract that is a risk contract as defined in 42
CFR 438.2, any such subcontractors' financial records related to the
performance of this contract. In addition, the MCO will be required to
provide Claims Aging Inventory Reports, Claims Turn Around Time Reports,
cost, and other reports as outlined in subsections (c) and (d) below or as
otherwise directed by the DEPARTMENT.
c. Reports specific to the MCO's Medicaid line of business shall be provided
in formats developed by the DEPARTMENT. All reports described in Sections
3.40(c)(1) and 3.40(c)(2) shall contain separate sections for HUSKY A and
HUSKY B. It is anticipated that the requirements in this area will be
modified to enable the DEPARTMENT to respond to inquiries that the
DEPARTMENT receives regarding the financial status of the HUSKY program,
to determine the relationship of capitation payments to actual
appropriations for the program, and to allow for proper oversight of
fiscal issues related to the managed care programs. The MCO will cooperate
with the DEPARTMENT or its agent(s) to meet these objectives. The
following is a list of required reports:
1. Audited financial reports with an income statement by MCO HUSKY line
of business. If the MCO is licensed as a health care center or
insurance company, both the annual audited financial reports for the
MCO and the audited financial reports per MCO HUSKY line of business
shall be conducted and reported in accordance with C.G.S. Section
38a - 54. If the MCO is not licensed as a health care center or
insurance company, the annual audited financial reports for the MCO
and the audited financial reports per
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August 8, 2003
MCO line of business shall be completed in accordance with generally
accepted auditing principles.
The MCO may elect to combine HUSKY A and HUSKY B in the audited
financial statement. If this election is made, the MCO shall also
submit the following: a separate unaudited income statement for
HUSKY A and HUSKY B, which will be compared to the audited financial
statement.
2. Unaudited financial reports, HUSKY line of business (formats shown
in Appendix F). The reports shall be submitted quarterly, forty-five
(45) days subsequent to the end of each quarter. Every line of the
requested report must contain a dollar figure or an indication that
said line is not applicable.
3. Annual and Quarterly Statements. If the MCO is licensed as a health
care center or insurance company, the MCO is required to submit
Annual and Quarterly Statements to the Department of Insurance in
accordance with C.G.S. Section 38a-53. One copy of each statement
shall be submitted to the DEPARTMENT in accordance with the
Department of Insurance submittal schedule.
4. Claims Aging Inventory Report (format shown in Appendix F, or any
other format approved by the DEPARTMENT). The Claims Aging Inventory
Report will include x00 XXXXX claims outstanding as of the end of
each quarter by type of claim, claim status and aging categories. If
a subcontractor is used to provide services and adjudicate claims or
a vendor is used to adjudicate claims, the MCO is responsible for
providing a Claims Aging Inventory Report in the required format for
each current or prior subcontractor who has claims outstanding. The
Claims Aging Inventory Reports will be submitted to the DEPARTMENT
forty-five (45) days subsequent to the end of each quarter.
5. Denied Claims Report. The MCO shall also submit a Denied Claims
report, to include all HUSKY provider claims denied as of the end of
each quarter. The MCO and the DEPARTMENT shall establish a joint
workgroup to develop the criteria and format for the denied claims
report.
6 Claims Turn Around Time Report (format shown in Appendix F, or any
other format approved by the DEPARTMENT). For those claims processed
in forty-six (46) days or more, the report shall indicate if
interest was paid in accordance with Section 3.46 of this contract.
If a subcontractor is used to provide services and adjudicate claims
or a vendor is used to adjudicate claims, the MCO is responsible for
providing a Claims Turn Around Time Report in the required format
for each current or prior subcontractor who has claims outstanding.
The Claims Turn
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Around Time Report will be submitted to the DEPARTMENT forty-five
(45) days subsequent to the end of each quarter.
d. The MCO shall maintain accounting records in a manner which will enable
the DEPARTMENT to easily audit and examine any books, documents, papers
and records maintained in support of the contract. All such documents
shall be made available to the DEPARTMENT at its request, and shall be
clearly identifiable as pertaining to the contract.
e. The MCO shall make available on request all financial reports required by
the terms of any current contract with any other state agency(s) provided
the said agency agrees that such information may be shared with the
DEPARTMENT.
f. The MCO shall submit to the DEPARTMENT on a quarterly basis, capitation
income and disbursement reports from mental health and dental
subcontractors with whom they have a risk arrangement. The report shall be
in a format specified by the DEPARTMENT and shall include total payment
received for Medicaid members from the MCO and breakdown of payment by
categories as specified in Sec. 3.45 (j)(2).
3.41 INSURANCE
a. The MCO, its successors and assignees shall procure and maintain such
insurance as is required by currently applicable federal and state law and
regulation. Such insurance should include, but not be limited to, the
following:
1. liability insurance (general, errors and omissions, and directors
and officers coverage);
2. fidelity bonding or coverage of persons entrusted with handling of
funds;
3. workers compensation; and
4. unemployment insurance.
b. The MCO shall name the State of Connecticut as an additional insured party
under any insurance, except for professional liability, workers
compensation, unemployment insurance, and fidelity bonding maintained for
the purposes of this contract. However, the MCO shall name the State of
Connecticut as either a loss payee or additional insured for fidelity
bonding coverage.
3.42 THIRD PARTY COVERAGE
The DEPARTMENT is the payer of last reson when third party resources are
available to cover the costs of medical services provided to Medicaid
recipients. Pursuant to this requirement, the MCO is required to comply with
federal and state statutes and regulations regarding third party liability. The
MCO shall be responsible for making every reasonable effort to determine the
legal liability of third parties to pay for services rendered to Members under
this contract. The MCO shall be responsible for identifying
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appropriate third party resources, and if questions arise they shall consult
with the DEPARTMENT. The MCO shall pursue, collect, and retain any monies from
third party payers for services to the MCO's Members under this contract,
subject to the following terms and conditions:
a. The DEPARTMENT hereby assigns to the MCO all rights to third party
recoveries from Medicare, health insurance, casualty insurance, workers'
compensation, tortfeasors, or any other third parties who may be
responsible for payment of medical costs for the MCO's Members.
1. The MCO will have primary responsibility for cost avoidance through
the coordination of benefits relative to federal and private health
insurance resources including, but not limited to Medicare,
individual health insurance, employment-related group health
insurance and self administered or self funded health benefit plan,
including ERISA (Employee Retirement and Income Security Act) plans.
The MCO shall avoid initial payments of claims, as permitted by
federal law, where federal or private health insurance resources are
available. When cost avoidance is not possible, the MCO may utilize
post payment recovery. If a third party insurer requires the Member
to pay any copayment, coinsurance or deductible, the MCO is
responsible for making any such payments to the extent that the
third party insurer's co-payment exceeds the co-payment applicable
under this contract.
2. The MCO may assign the right of recovery to their subcontractors
and/or network providers. Notwithstanding any such assignment of the
right of recovery, the MCO remains responsible for the effective and
diligent performance of third party recovery.
3. In pursing third party recovery, the MCO, network providers, and
subcontractors shall seek recovery of the cost of services actually
rendered to the Member, notwithstanding the fact that the MCO may
pay the subcontractor on a capitated basis.
4. The MCO or its assignee must initiate third party recoveries within
sixty (60) days of the date of service or within sixty (60) days
after the end of the month in which the MCO 1earns of the existence
of the liable third party. The MCO or its assignees must maintain
dated documentation of all claims to third parties. The MCO must
document initiation of recovery by formal communication in written
or electronic form to the liable third party, specifically
requesting reimbursement up to the legal limit of liability for any
services provided to the MCO's Member covered under the State
Medicaid Plan.
5. The right to pursue, collect and retain recovery from claims not
initiated and documented within sixty (60) days as stated above,
will revert to the
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DEPARTMENT and the MCC or its assignees will lose any right of
recovery.
6. When the MCO seeks recovery from a third party for care provided to
a Member following an accident, the MCO may recover only its cost of
care.
b. The MCO shall maintain records of recoveries of all third party
collections, including cost avoidance, and recovery actions. The
DEPARTMENT will specify a schedule and format for reporting such
collections. The amounts avoided or recovered by the MCO shall be
considered in establishing future capitated rates paid to the MCO.
c. The MCO shall fully cooperate with the DEPARTMENT in all third party
recovery efforts.
d. The DEPARTMENT shall supply the MCO with a monthly file of Members where
third party coverage has been identified. The information shall also be
available to the MCO and its assignees from the DEPARTMENT'S Automated
Electronic Voice Response System.
e. The MCO shall notify the DEPARTMENT within thirty (30) days if the MCO or
its network provider or subcontractor discovers that a Member has become
eligible for coverage by a liable third party. The MCO shall notify the
DEPARTMENT within thirty (30) days if the MCO or its in-network provider
or subcontractor discovers that a Member has lost eligibility for coverage
by a liable third party.
3.43 COORDINATION OF BENEFITS AND DELIVERY OF SERVICES
a. The MCO shall ensure that the rules related to the coordination of
benefits in Section 3.41 do not present any barriers to Members' access to
the covered services under this contract.
b. The MCO shall educate its Members on how to access services when a Member
is covered by a third party insurer.
c. If a third party insurer requires the Member to pay any co-payment,
coinsurance or deductible, the MCO is responsible for paying the portion
of the third party insurer's co-payment that exceeds the co-payment
applicable under this contract, not to exceed the amount allowed per the
MCO's fee schedule, even if the services are provided outside of the MCO's
provider network.
d. If a Member's third party insurer pays for only some services covered
under this contract or for only part of a particular service, the MCO
shall be liable up to the allowed amount in accordance with the MCO's fee
schedule, for the full extent of
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services covered under this contract, even if the services are provided
outside of the MCO's provider network.
e. If a Member is covered by a third party insurer, the MCO is bound by any
prior authorization decisions made by the third party insurer.
3.44 PASSIVE BILLING
Capitation payments to the MCO shall be based on a passive billing system. The
MCO is not required to submit claims for the capitation payment for its HUSKY A
membership. Capitation payments will be based on MCO membership data as
reflected in the enrollment files provided by the DEPARTMENT to the MCOs. On a
monthly basis ACS will provide the MCO with a detailed capitation remittance
file.
3.45 SUBCONTRACTING FOR SERVICES
a. Licensed health care facilities, group practices and licensed health care
professionals operating within the scope of their practice may contract
with the MCO directly or indirectly through a subcontractor who directly
contracts with the MCO. The MCO shall be held directly accountable and
liable for all of the contractual provisions under this contract
regardless of whether the MCO chooses to subcontract their
responsibilities to a third party. No subcontract shall operate to
terminate the legal responsibility of the MCO to assure that all
activities carried out by the subcontractor conform to the provisions of
the contract. Subcontracts shall not terminate the legal liability of the
MCO under this contract.
b. The MCO may subcontract for any function, excluding Member Services,
covered by this contract, subject to the requirements of this contract.
Before delegating any of the requirements of this contract, the MCO shall
evaluate the prospective subcontractor's ability to perform the activities
to be delegated. All subcontracts shall be in writing, shall include any
general requirements of this contract that are appropriate to the services
being provided, and shall assure that all delegated duties of the MCO
under this contract are performed, including any reporting requirements.
The subcontract shall also provide for revocation or other sanctions if
the subcontractor's performance is inadequate. All subcontracts shall also
provide for the right of the DEPARTMENT or other governmental entity to
enter the subcontractor's premises to inspect, monitor or otherwise
evaluate the work being performed as a delegated duty of this contract, as
specified in Section 3.34, Inspection of Facilities. All subcontracts
shall comply with the requirements of 42 CFR 4386 that are appropriate to
the service or activity delegated under the subcontract.
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c. With the exception of subcontracts specifically excluded by the
DEPARTMENT, all subcontracts shall include verbatim the HUSKY A
definitions of Medical Appropriateness / Medically Appropriate and
Medically Necessary/Medical Necessity as set forth in Part II, General
Contract Terms for the MCOs. All subcontracts shall require the use of
these definitions by subcontractors in all requests for approval of
coverage of goods or services made on behalf of HUSKY A Members. All
subcontracts shall also provide that decisions concerning both acute
and chronic care must be made according to these definitions.
d. Within fifteen (15) days of the effective date of this contract, the
MCO shall provide the DEPARTMENT with a report of those functions under
this contract that the MCO shall be providing through a subcontract and
copies of the contracts between the MCO and the subcontractor. The
report shall identify the names of the subcontractors, their addresses
and a summary of the services they will be providing. If the MCO enters
into any additional subcontracts after the MCO's initial compliance
with this section, the MCO shall obtain the advance written approval of
the DEPARTMENT. The MCO shall provide the DEPARTMENT with a draft of
the proposed subcontract thirty (30) days in advance of the completion
of the MCO's negotiation of such subcontract. In addition, amendments
to any subcontract, excluding those of a technical nature, shall
require the pre-review and approval of the DEPARTMENT.
e. All behavioral health and dental subcontracts which include the payment
of claims on behalf of HUSKY A Members for the provision of goods and
services to HUSKY A Members shall require a performance bond, letter of
credit, statement of financial reserves or payment withhold
requirements. The performance bond, letter of credit, statement of
financial reserves or payment withhold requirements shall be in a form
mutually agreed upon by the MCO and the subcontractor. The amount of
the performance bond shall be sufficient to ensure the completion of
the subcontractor's claims processing and provider payment obligations
under the subcontract in the event the contract between the MCO and the
subcontractor is terminated. The MCO shall submit reports to the
DEPARTMENT upon the DEPARTMENT's request related to any payments made
from the performance bonds or any payment withholds.
f. All behavioral health and dental subcontracts which include the payment
of claims on behalf of HUSKY A Members for the provision of goods and
services to HUSKY A members shall require the submission of a
capitation income and disbursement report in a format specified by the
DEPARTMENT. The report shall be submitted quarterly and shall include
the amount of payment received for Medicaid members; amount paid
directly to providers of health services on behalf of Medicaid members;
administrative costs and profits.
g. All subcontracts shall include provisions for a well-organized
transition in the event of termination of the subcontract for any
reason. Such provisions shall
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ensure that an adequate provider network will be maintained at all times
during any such transition period and that continuity of care is
maintained for all Members.
h. Prior to the approval by the DEPARTMENT of any subcontract with a
behavioral health or dental subcontractor, the MCO shall submit a plan to
the DEPARTMENT for the resolution of any outstanding claims submitted by
providers to the MCO's previous behavioral health or dental subcontractor.
Such plan shall meet the requirements described in subsection (j) below.
i. The MCO shall monitor all subcontractors' performance on an ongoing basis
and subject the subcontractor to formal review once a year. All
subcontracts shall provide that if the MCO identifies deficiencies or
areas for improvement, the MCO and the subcontractor shall take corrective
action.
j. In the event that a subcontract is terminated, the MCO shall submit a
written transition plan to the DEPARTMENT sixty (60) days in advance of
the scheduled termination. The transition plan shall include provisions
concerning financial responsibility for the final settlement of provider
claims and data reporting, which at a minimum must include a claims aging
report prepared in accordance with Section 3.39 (c)(5) of this contract,
with steps to ensure the resolution of the outstanding amounts. This plan
shall be submitted prior to the DEPARTMENT's approval of the replacement
subcontractor.
k. All subcontracts shall also include a provision that the MCO will withhold
a portion of the final payment to the subcontractor, as a surety bond to
ensure compliance under the terminated subcontract.
1. The MCO shall have no right to and shall not assign, transfer or delegate
this contract in its entirety, or any right on duty arising under this
contract without the prior written approval of the DEPARTMENT. The
DEPARTMENT in its discretion may grant such written approval of an
assignment, transfer or delegation provided, however, that this paragraph
shall not be construed to grant the MCO any right to such approval.
m. This section shall not be construed as restricting the MCO from entering
into contracts with participating providers to provide health care
services to Members.
3.46 TIMELY PAYMENT OF CLAIMS
The MCO shall pay 90 (ninety) percent of all clean claims from providers in
group or individual practices or who practice in shared health facilities within
thirty (30) days from the date of receipt. The MCO shall pay ninety-nine (99)
percent of all clean claims from providers in group or individual practices or
who practice in shared health facilities
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within ninety (90) days from the date of receipt. These time limitations do not
apply if the MCO and its providers stipulate to an alternative schedule in their
provider contracts. If the MCO or any subcontractor or vendor who adjudicates
claims fails to pay a clean claim within forty-five (45) days of receipt, or as
otherwise stipulated by a provider contract, the MCO, vendor or subcontractor
shall pay the provider the amount of such clean claims plus interest at the rate
of fifteen (15) percent per annum or otherwise as stipulated by a provider
contract. In accordance with Section 3.40 (c)(5), Financial Records, the MCO
shall provide to the DEPARTMENT information related to interest paid beyond the
forty-five (45) day timely filing limit or otherwise stipulated by a provider
contract.
3.47 CO-PAYMENT LIMITS AND MEMBER CHARGES FOR NONCOVERED SERVICES
Members shall be responsible for a $1.00 co-payment for prescription drugs. The
co-payment shall apply to each prescription drug, covered over the counter
medication and refill. The following services and individuals shall be exempt
from the co-payment requirement:
1) Members under the age of 21;
2) Pregnant women, including the period of 60 days post-partum. This
post-partum period begins on the 1ast day of pregnancy and extends
through the end of the month in which the 60-day period following
termination of pregnancy ends;
3) Members who are inpatients in the following medical institutions:
acute care hospital, psychiatric hospital, chronic disease hospital
or nursing facility;
4) Prescription for family planning drugs or supplies;
5) Compounded prescriptions.
The MCO shall ensure that the dispensing pharmacist is responsible for
collecting the co-payment at the time of the service unless the pharmacist, in
filling certain prescriptions, does not normally have face-to face contact with
the Member. If the pharmacist does not have face-to-face contact with the Member
in dispensing a prescription, the provider has the right to xxxx the Member for
the $1.00 co-payment.
Pursuant to 42 U.S.C. Section 1396o(e), no provider may deny care or services to
an individual eligible for such care or services because of an inability to pay
a co-payment. The MCO shall ensure that its providers do not refuse to render
the service or fill a prescription if the Member is unable to pay the
co-payment. The MCO may permit its providers to ask for the unpaid co-payment at
a subsequent visit or to xxxx the Member for the outstanding co-payment. The
pharmacist shall accept the Member's declaration that he is unable to pay the
co-payment.
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Except for the prescription drug co-payment described above, no deductibles or
co-payments or similar cost-sharing charges are permitted for HUSKY A covered
services.
A provider shall be permitted to charge an eligible Member for goods or services
which are not coverable only if the Member knowingly elects to receive the goods
or services and enters into an agreement in writing to pay for such goods or
services prior to receiving them. For purposes of this section noncovered
services are services not covered under the Medicaid state plan, services which
are provided in the absence of appropriate authorization, and services which are
provided out-of-network unless otherwise specified in the contract, policy or
regulation (e.g., family planning, mental health or emergency room services).
3.48 INSOLVENCY PROTECTION
Unless the MCO is (or is controlled by) one or more federally qualified health
care centers and meets the solvency standards established by the DEPARTMENT for
those centers, the MCO shall meet the solvency standards established by the
State of Connecticut for private health maintenance organizations, or be
licensed or certified by the State as a risk bearing entity. The MCO must
maintain protection against insolvency as required by the DEPARTMENT including
demonstration of adequate initial capital and ongoing reserve contributions. The
MCC must provide financial data to the DEPARTMENT in accordance with the
DEPARTMENT's required formats and timing.
3.49 ACCEPTANCE OF DSS RULINGS
In cases where there is a dispute between the MCO and an out-of-network provider
about whether a service is medically necessary, is an emergency, or is an
appropriate diagnostic test to determine whether an emergency condition exists,
the DEPARTMENT will hear appeals, filed within one year following the date of
service and make final determinations. The DEPARTMENT will accept written
comments from all parties to the dispute prior to making the decision, and order
or not order payment, as appropriate. The MCO shall accept the DEPARTMENT's
determinations regarding appeals.
3.50 POLICY TRANSMITTALS
The MCO shall comply with the provisions and requirements in the DEPARTMENT's
Managed Care Policy Transmittals as set forth in Appendix H. In addition, the
MCO shall comply with any future Managed Care Policy Transmittals issued by the
DEPARTMENT. The MCO shall comply with the Medical Services Policy as set forth
in the DEPARTMENT's provider manuals and the Regulations of Connecticut State
Agencies.
3.51 FRAUD AND ABUSE
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a. The MCO shall not knowingly take any action or fail to take action that
could result in an unauthorized benefit to the MCO, its employees, its
subcontractors, its vendors, or to a Member.
b. The MCO commits to preventing, detecting, investigating, and reporting
potential fraud and abuse occurrences, and shall assist the DEPARTMENT and
HHS in preventing and prosecuting fraud and abuse in the HUSKY program.
c. The MCO acknowledges that the HHS, Office of the Inspector General, has
the authority to impose civil monetary penalties on individuals and
entities that submit false and fraudulent claims to the HUSKY program.
d. The MCO shall immediately notify the DEPARTMENT when it detects a
situation of potential fraud or abuse, including, but not limited to, the
following:
1. False statements, misrepresentation, concealment, failure to
disclose, and conversion of benefits;
2. Any giving or seeking of kickbacks, rebates, or similar
remuneration;
3. Charging or receiving reimbursement in excess of that provided by
the DEPARTMENT; and
4. False statements or misrepresentation made by a provider,
subcontractor, or Member in order to qualify for the HUSKY program.
e. Upon written notification of the DEPARTMENT, the MCO shall cease any
conduct that the DEPARTMENT or its agent deems to be abusive of the HUSKY
program, and to take any corrective actions requested by the DEPARTMENT or
its agent.
f. The MCO attests to the truthfulness, accuracy, and completeness of all
data submitted to the DEPARTMENT, based on the MCO's best knowledge,
information, and belief. This data certification requirement includes
encounter data and also applies to the MCO's subcontractors.
g. The MCO shall have administrative and management procedures and a
mandatory compliance plan to guard against fraud and abuse. The MCO's
compliance plan shall include but not necessarily be limited to, the
following efforts:
1. The designation of a compliance officer and a compliance committee,
responsible to senior management;
2. Written policies, procedures and standards that demonstrate
commitment to comply with all applicable Federal and State
standards;
3. Effective lines of communication between the compliance officer and
MCO employees;
4. Conducting regular reviews and audits of operations to guard against
fraud and abuse;
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5. Assessing and strengthening internal controls to ensure claims are
submitted and payments are made properly;
6. Effectively training and educating employees, providers, and
subcontractors about fraud and abuse and how to report it;
7. Effectively organizing resources to respond to complaints of fraud
and abuse;
8 Establishing procedures to process fraud and abuse complaints; and
9. Establishing procedures for prompt responses to potential offenses
and reporting information to the DEPARTMENT.
h. The MCO shall examine publicly available data, including but not limited
to the CMS Medicare/Medicaid Sanction Report and the CMS website
(xxxx://xxx.xxx.xxx.xxx) to determine whether any potential or current
employees, providers, or subcontractors have been suspended or excluded or
terminated from the Medicare or Medicaid programs and shall comply with,
and give effect to, any such suspension, exclusion, or termination in
accordance with the requirements of state and federal law.
i. The MCO must provide full and complete information on the identity of each
person or corporation with an ownership or controlling interest, five (5)
percent, in the managed care plan, or any subcontractor in which the MCO
has a five (5) percent or more ownership interest.
j. The MCO must immediately provide full and complete information when it
becomes aware of any employee or subcontractor who has been convicted of a
civil or criminal offense related to that person's involvement under
Medicare, Medicaid, or any other federal or state assistance program prior
to entering into or renewing this contract.
SANCTION: The DEPARTMENT may impose a sanction, up to and including a Class C
sanction for the failure to comply with any provision of this section, or take
any other action set forth in Section 7 of this contract, including terminating
or refusing to renew this contract or any other Sanction or remedy allowed by
federal or state law.
3.52 PERSONS WITH SPECIAL HEALTH CARE NEEDS
a. The DEPARTMENT will provide to the MCO information to identify Members who
are: 1) eligible for Supplemental Security Income; 2) over sixty-five (65)
years of age; 3) children who are receiving xxxxxx care or otherwise in an
out of home placement or receiving Title IV E xxxxxx care or adoption
services; and 4) children who are enrolled in Title V's Children with
Special Health Care Needs program.
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b. The MCO shall conduct an assessment of these individuals and other persons
with special health care needs and make a referral to the Member's PCP to
develop a treatment plan, as appropriate.
c. The MCO shall report to the DEPARTMENT, in a format specified by the
DEPARTMENT, on quality indicators such as utilization of specialty
services and case management to be developed jointly between the
DEPARTMENT and the MCOs.
4. FUNCTIONS AND DUTIES OF THE DEPARTMENT
4.01 ELIGIBILITY DETERMINATIONS
The DEPARTMENT will determine the initial and ongoing eligibility for medical
assistance of each individual enrolled under this contract in accordance with
the DEPARTMENT's continuous and guaranteed eligibility policies.
4.02 POPULATIONS ELIGIBLE TO ENROLL
Appendix G contains a list of the Medicaid groups currently eligible for managed
care enrollment. New eligibility groups may be added to the managed care
population. The DEPARTMENT will notify the MCO of any changes in the eligibility
categories to be included. Additional groups included by the DEPARTMENT may be
served at the MCO's option.
4.03 ENROLLMENT/DISENROLLMENT
Enrollment, disenrollment and initial selection of PCP will be handled by the
DEPARTMENT through a contract with a central enrollment broker. Coverage for new
Members will be effective the first of the month and coverage for disenrollments
will terminate at the end of the month. Members remain continuously enrolled
throughout the term of this contract, except in situations where clients change
health plans, lose their Medicaid eligibility, receive Medicare, or are
recategorized into a Medicaid category not included in the managed care
initiative. Disenrollments due to loss of eligibility become effective upon loss
of eligibility and are effective on the last day of the month. Disenrollments
due to receipt of Medicare become effective the month following the month in
which DSS receives information of the existence of the Medicare coverage. Adults
receiving SSI become disenrolled from the MCO upon the recategorizing of their
Medicaid status from a family to an adult coverage group or the month following
the month in which the DEPARTMENT receives information of the individual's
receipt of SSI, whichever comes first. The DEPARTMENT will notify the MCO of
enrollments and disenrollments specific to the MCO via a daily data file. The
enrollments and
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disenrollments processed on any given day will be made available to the MCO via
the data file the following day (i.e. after the daily overnight batching has
been processed).
In addition to the daily data file, a full file of all the Members will be made
available on a monthly basis. Both the daily data file and the monthly full file
can be accessed by the MCO electronically via dial-up.
4.04 DEFAULT ENROLLMENT
The DEPARTMENT shall, on a rotating basis among all of the participating MCO's
and as the MCO's enrollment capacity allows, assign default Members to the MCO.
The default assignment methodology is structured to evenly distribute families
among all the participating MCOs. However, due to variability in MCO service
area and enrollment capacity, family size and loss of Medicaid eligibility, the
outcome of the default assignment may not result in an even net default
distribution among all the MCOs.
4.05 LOCK-IN
a. Members may request disenrollment from the MCO after one (1) month. Upon
availability of MIS Support, the DEPARTMENT will implement a lock-in
period of up to twelve (12) months for managed care Members. The
DEPARTMENT's implementation of lock-in will comply with all provisions of
42 CFR 438.56. Members will not be allowed to change plan enrollment
during the lock-in period except for cause. The lock-in period is subject
to the following provisions and exceptions:
1. The first ninety (90) days of enrollment into a new MCO will be
designated as the free-look period during which time the Member may
change plans;
2. The last sixty (60) days of the lock-in period will be an open
enrollment period, during which time Members may change plans;
3. Plan changes made during the open enrollment period will go into
effect on the first day of the month following the end of the
lock-in period; and
4. Members who do not change plans during the open enrollment period
will continue the enrollment in the same MCO and be assigned to a
new twelve (12) month lock-in period.
The process being considered for implementation of lock-in for the
existing HUSKY A membership is as follows: lock-in will be imposed on
approximately twenty (20) percent of the membership each month over a
consecutive five (5)
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month period. Targeting for each month will be based on the last digit of
the client ID number for the head-of-household. For example, families
whose head-of-household has a client ID number that ends in 0 or 1 will be
phased-in during the first month, those with 2 and 3 will be done in the
second month, etc.
b. The following shall constitute good a use for a Member to disenroll from
the plan during the lock-in period:
1. Unfavorable resolution of the MCO's internal complaint process and
continued dissatisfaction due to repeated incidents of any of the
following:
a. documented long waiting times for appointments:
1. more than forty-five (45) days for well-care visit;
2. more than two (2) business days for non-urgent, symptomatic
office visit; and
3. unavailability of same day office visit or same day referral
to an emergency provider for emergency care services
b. documented inaccessibility of health plan by phone or mail:
1. phone calls not answered promptly;
2. caller placed on hold for extended periods of time;
3. phone messages and letters not responded to promptly; and
4. repeated rude and demeaning treatment by MCO staff.
c. Prior to pursuing the MCO's internal grievance process and without filing
an appeal through the plan, dissatisfaction due to any of the following:
1. Discriminatory treatment as documented in a complaint filed with the
State of Connecticut Commission on Human Rights and Opportunities
(CHRO) or the DEPARTMENT's Affirmative Action Division;
2. PCP who has served the Member's specific documentable needs (i.e.
language or physical accessibility) left health plan and there is no
other suitable PCP within reasonable distance to the Member; or
3. Member has a pending lawsuit against the MCO (verification of
pending lawsuit must be provided).
d Child placed under DCF guardianship whose placement is changed to a
location or facility not affiliated with the current health plan.
4.06 CAPITATION PAYMENTS TO MCO
a. In full consideration of contract services rendered by the MCO, the
DEPARTMENT agrees to pay the MCO monthly payments based on the
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capitation rates specified in Appendix I, as amended. The DEPARTMENT shall
provide the actuarial basis for future capitation rates upon CMS review
and approval.
b. Upon validation of client eligibility and MCO membership, the DEPARTMENT
will pay the capitation payments in the month following the month to which
the capitation payments apply or for retroactive enrollments, the month
following the enrollment processing month in accordance with Connecticut
General Statutes Section 4a-71 through 4a-72.
c. Payment to the MCO shall be based on the enrollment data transmitted from
the DEPARTMENT to ACS each month. The MCO will be responsible for
detecting the source of any inconsistency in capitation payments. The MCO
must notify the DEPARTMENT of any inconsistency between enrollment and
payment data. The DEPARTMENT agrees to provide to the MCO information
needed to determine the source of the inconsistency within sixty (60)
working days after receiving written notice of the request to furnish such
information. The DEPARTMENT will recoup overpayments or reimburse
underpayments. The adjusted payment (representing reinstated recipients)
for each month of coverage shall be included in the next monthly
capitation payment, based on updated MCO enrollment information for that
month of coverage.
d. Any retrospective adjustments to prior payments will be made in the form
of an addition to or subtraction from the current month's capitation
payment. Positive adjustments are particularly likely for newborns,
because the MCO may be aware of births before the DEPARTMENT.
4.07 RETROACTIVE ADJUSTMENTS
a. When a Member loses Medicaid eligibility and managed care enrollment but
regains coverage within sixty (60) days, and the coverage is made
retroactive such that the entire coverage gap is eliminated, the
DEPARTMENT shall reinstate enrollment into the MCO retroactive to the time
of disenrollment. The MCO will remain responsible for the cost of
in-network covered services and the cost of emergency and family planning
services received by the Member during this sixty (60) day period.
b. In instances where enrollment is disputed between two (2) MCOs or the MCO
and Medicaid fee-for-service program the DEPARTMENT will be the final
arbiter of Membership status and reserves the right to recover
inappropriate capitation payments. Capitation payments for retroactive
enrollment adjustments will be made to the MCO pursuant to rules outlined
in Section II, 4.06(d), Capitation Payments to MCO.
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4.08 INFORMATION
The DEPARTMENT will make known to each MCO complete and current information
which relates to pertinent statutes, regulations policies, procedures, and
guidelines affecting the operation of this contract. This information shall be
available either through direct transmission to the MCO by reference to public
resource files accessible to the MCO personnel.
4.09 ONGOING MCO MONITORING
a. To ensure access and the quality of care, the DEPARTMENT or its agent
shall undertake plans to conduct monitoring activities, including but not
limited to the following:
1. Analyze the MCO's access enhancement programs, financial and
utilization data, and other reports to monitor the value the MCO is
providing in return for the State's capitation payments. Such
efforts shall include, but not be limited to, on-site reviews and
audits of the MCO and its subcontractors and network providers.
2. Conduct regular recipient surveys of Members to address issues such
as satisfaction with plan services to include administrative
services, satisfaction with treatment by the plan or its providers,
and reasons for disenrollment and access.
3. Review the MCO certifications on a regular basis.
4. Analyze encounter data, actual medical records, correspondence,
telephone logs and other data to make inferences about the quality
of and access to specific services.
5. Sample and analyze encounter data, actual medical records,
correspondence, telephone logs and other data to make inferences
about the quality of and access to MCO services.
6. Test the availability of and access to MCO services by attempting to
make appointments.
7. At its discretion, commission or conduct additional objective
studies of the effectiveness of the MCO, as well as the availability
of, quality of and access to its services.
4.10 UTILIZATION REVIEW AND CONTROL
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The DEPARTMENT shall waive, to the extent allowed by law, any current DEPARTMENT
requirements for prior authorization, second opinions, co-payment, or other
Medicaid restrictions for the provision of contract services provided by the MCO
to Members.
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5. DECLARATIONS AND MISCELLANEOUS PROVISIONS
5.01 COMPETITION NOT RESTRICTED
In signing this contract, the MCO asserts that no attempt has been made or will
be made by the MCO to induce any other person or firm to submit or not to submit
an application for the purpose of restricting competition.
5.02 NONSEGREGATED FACILITIES
a. The MCO certifies that it does not and will not maintain or provide for
its employees any segregated facilities at any of its establishments; and
that it does not permit its employees to perform their services at any
location, under its control, where segregated facilities are maintained.
As Contractor, the MCO agrees that a breach of this certification is a
violation of Equal Opportunity in Federal employment. In addition,
Contractor must comply with the Federal Executive Order 11246 entitled
"Equal Employment Opportunity" as amended by Executive Order 11375 and as
supplemented in the United States Department of Labor Regulations (41 CFR
Part 30). As used in this certification, the term "segregated facilities"
includes any waiting rooms, restaurants and other eating areas, parking
lots, drinking fountain, recreation or entertainment areas,
transportation, and housing facilities provided for employees which are
segregated on the basis of race, color, religion, or national origin,
because of habit, local custom, national origin or otherwise.
b. The MCO further agrees, (except where it has obtained identical
certifications from proposed subcontractors for specific time periods)
that it will obtain identical certifications from proposed subcontractors
which are not exempt from the provisions for Equal Employment Opportunity;
that it will retain such certifications in its files; and that it will
forward a copy of this clause to such proposed subcontractors (except
where the proposed subcontractors have submitted identical certifications
for specific time periods).
5.03 OFFER OF GRATUITIES
The MCO, its agents and employees, certify that no elected or appointed official
or employee of the DEPARTMENT has or will benefit financially or materially from
this contract. The contract may be terminated by the DEPARTMENT if it is
determined that gratuities of any kind were either offered to or received by any
of the aforementioned officials or employees of the MCO, its agent or employee.
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5.04 EMPLOYMENT/AFFIRMATIVE ACTION CLAUSE
The MCO agrees to supply employment/affirmative action information as required
for agency compliance with Title VI and VII of the Civil Rights Acts of 1964 and
Connecticut General Statutes, Section 46a-68 and Section 46a-71.
5.05 CONFIDENTIALITY
a. The MCO agrees that all material and information, and particularly
information relative to individual applicants or recipients of assistance
through the DEPARTMENT, provided to the Contractor by the State or
acquired by the Contractor in performance of the contract whether verbal,
written, recorded magnetic media, cards or otherwise shall be regarded as
confidential information and all necessary steps shall be taken by the
Contractor to safeguard the confidentiality of such material or
information in conformance with federal and state statutes and
regulations.
b. The MCO agrees not to release any information provided by the DEPARTMENT
or providers or any information generated by the MCO without the express
consent of the Contract Administrator, except as specified in this
contract and as permitted by applicable law.
5.06 INDEPENDENT CAPACITY
The MCO, its officers, employees, subcontractors, or any other agent of the
Contractor in performance of this contract will act in an independent capacity
and not as officers or employees of the State of Connecticut or of the
DEPARTMENT.
5.07 LIAISON
Both parties agree to have specifically named liaisons at all times. These
representatives of the parties will be the first contacts regarding any
questions and problems which arise during implementation and operation of the
contract.
5.08 FREEDOM OF INFORMATION
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a. Due regard will be given for the protection of proprietary information
contained in all documents received by the DEPARTMENT; however, the MCO is
aware that all materials associated with the contract are subject to the
terms of the state Freedom of Information Act, Conn. Gen. Stat. Sections
1-200 et seq., and all rules, regulations and interpretations resulting
therefrom. When materials are submitted by the MCO or a subcontractor to
the DEPARTMENT and the MCO or subcontractor believes that the materials
are proprietary or confidential in some way and that they should not be
subject to disclosure pursuant to the Freedom of Information Act, it is
not sufficient to protect the materials from disclosure for the MCO to
state generally that the material is proprietary in nature and therefore,
not subject to release to third parties. If the MCO or the MCO's
subcontractor believes that any portions of the materials submitted to the
DEPARTMENT are proprietary or confidential or constitute commercial or
financial information, given in confidence, those portions or pages or
sections the MCO believes to be proprietary must be specifically
identified as such. Convincing explanation and rationale sufficient to
justify each claimed exemption from release consistent with Section 1-210
of the Connecticut General Statutes must accompany the documents when they
are submitted to the DEPARTMENT. The rationale and explanation must be
stated in terms of the prospective harm to the MCO's or subcontractor's
competitive position that would result if the identified material were to
be released and the reasons why the materials are legally exempt from
release pursuant to the above cited statue. The final administrative
authority to release or exempt any or all material so identified by the
MCO or the subcontractor rests with the DEPARTMENT. The DEPARTMENT is not
obligated to protect the confidentiality of materials or documents
submitted to it by the MCO or the subcontractor if said materials or
documents are not identified in accordance with the above-described
procedure.
b. The MCO understands the DEPARTMENT's need for access to eligibility and
paid claims information and is willing to provide such data relating to
the MCO to accommodate that need. The MCO is committed to providing the
DEPARTMENT access to all information necessary to analyze cost and
utilization trends; to evaluate the effectiveness of Provider Networks,
benefit design, and medical appropriateness; and to show how the HUSKY
population compares to the MCO's enrolled population as a whole. The MCO
and the DEPARTMENT each understand and agree that the systems, procedures
and methodologies and practices used by the MCO, its affiliates and agents
in connection with the underwriting, claims processing, claims payment and
utilization monitoring functions of the MCO, together with the
underwriting, Provider Network, claims processing, claims history and
utilization data and information related to the MCO and its agents, may
constitute information which is proprietary to the MCO and/or its
affiliates (collectively, the "Proprietary Information"). Accordingly, the
DEPARTMENT acknowledges that the MCO shall not be required to divulge
Proprietary Information if such disclosure would jeopardize or impair its
relationships with providers or suppliers or would materially adversely
affect the MCO's or any of its Affiliates' ability to service
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the needs of its customers or the DEPARTMENT as provided under this
Contract unless the DEPARTMENT determine that such information is
necessary in order to monitor contract compliance or to fulfill Part II
Sections 3.33 and 3.34 of Part II of this contract. The DEPARTMENT agrees
not to disclose publicly and to protect from public disclosure any
proprietary or trade secret information provided to the DEPARTMENT by the
MCO and/or its Affiliates' under this contract to the extent that such
information is exempted from public disclosure under the Connecticut
Freedom of Information Act.
5.09 WAIVERS
Except as specifically provided in any section of this contract, no covenant,
condition, duty, obligation or undertaking contained in or made a part of the
contract shall be waived except by the written agreement of the parties, and
forbearance or indulgence in any form or manner by the DEPARTMENT or the MCO in
any regard whatsoever shall not constitute a waiver of the covenant, condition,
duty, obligation or undertaking to be kept, performed, or discharged by the
DEPARTMENT or the MCO; and not withstanding any such forbearance or indulgence,
until complete performance or satisfaction of all such covenants, conditions,
duties, obligations and undertakings, the DEPARTMENT or MCO shall have the right
to invoke any remedy available under the contract, or under law or equity.
5.10 FORCE MAJEURE
The MCO shall be excused from performance hereunder for any period that it is
prevented from providing, arranging for, or paying for services as a result of a
catastrophic occurrence or natural disaster including but not limited to an act
of war, and excluding labor disputes.
5.11 FINANCIAL RESPONSIBILITIES OF THE MCO
a. The MCO must maintain at all times financial reserves in accordance with
the Connecticut Health Centers Act under Section 38a-175 et seq. of the
Connecticut General Statutes and with the requirements outlined in the
DEPARTMENT's Request for Application.
b. The MCO's physician incentive plans must comply with the requirements of
1903(m)(2)(a)(x) of the Social Security Act and 42 CFR 422.208 and 42 CFR
422.210.
c. The DEPARTMENT reserves the right to inspect any physician incentive
plans.
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d. If the MCO is not a federally-qualified MCO or Competitive Medical Plan,
the MCO must complete a HCFA Section 1318 Financial Disclosure Report,
prior to the start of the contract.
5.12 CAPITALIZATION AND RESERVES
a. The MCO shall comply with and maintain capitalization and reserves as
required by the appropriate regulatory authority.
b. If the MCO is licensed by the State of Connecticut, the MCO shall
establish and maintain capitalization and reserves as required by the
Connecticut Department of Insurance.
c. If the MCO is majority-owned by federally qualified health centers (FQHCs)
and not licensed by the State of Connecticut, the MCO will establish and
maintain sequestered capital of $500,000 plus two (2) percent of ongoing
annual capitation premiums.
1. These funds shall be placed in restricted account for the duration
of the FQHC plan's existence, to be accessed only in the event such
funds are needed to meet unpaid claims liabilities.
2. This restricted account shall be established such that any
withdrawals or transfers of funds will require signatures of
authorized representatives of the FQHC plan and the DEPARTMENT.
3. The initial $500,000 must be deposited into the account by the
beginning of the MCO's first enrollment period.
4. The MCO must make quarterly deposits into this account so that the
account balance is equal to $500,000 plus two (2) percent of the
premiums received during the preceding twelve (12) months.
5.13 PROVIDER COMPENSATION
a. The MCO shall comply with CMS's Physician Incentive Plan (PIP)
requirements in 42 CFR 422.208 and 42 CFR 422.210. The MCO may operate a
PIP only if:
1. no specific payment can be made directly or indirectly under a PIP
to a physician or physician group as an inducement to reduce or
limit medically necessary services furnished to an individual
Member; and
2. the stop-loss protection, Member survey, and disclosure requirements
of 42 CFR. 422.208 and 42 CFR 422.210 are met.
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b. The MCO shall disclose to the DEPARTMENT the following information on PIPs
in sufficient detail to determine whether the incentive plan complies with
the regulatory requirements of 42 CFR 422.208. The disclosure must
contain:
1. Whether services not furnished by the physician or physician group
are covered by the PIP. If only the services furnished by the
physician or physician group are covered by the incentive plan,
disclosure of other aspects of the plan need not be made.
2. The type of incentive arrangement (i.e. withhold, bonus,
capitation).
3. If the incentive plan involves a withhold or bonus, the percent of
the withhold or bonus.
4. Proof that the physician or physician group has adequate stop-loss
protection, including the amount and type of stop-loss protection.
5. The panel size and, if patients are pooled, the method used.
6. In the case of those MCOs that are required by 42 CFR. 422.208(h) to
conduct Member surveys, the survey results.
c. The MCO shall disclose this information to the DEPARTMENT (1) prior to
approval of its contract as required by federal regulation and (2) upon
the contract anniversary or renewal effective date. The MCO shall provide
the capitation data required (see (6) above) for the previous contract
year to the DEPARTMENT three (3) months after the end of the contract
year. The MCO will provide to the Member upon request information
regarding whether the MCO uses a physician incentive plan that affects the
use of referral services, the type of incentive arrangement, whether
stop-loss protection is provided, and the survey results of any Member
survey conducted. See Appendix J for the applicable regulations and
disclosure forms.
d. The DEPARTMENT may impose Class C sanctions pursuant to Section 7.05 for
failure to comply with 42 CFR 422.208 and 422.210
5.14 MEMBERS HELD HARMLESS
a. The MCO shall not hold a Member liable for:
1. The debts of the MCO in the event of the MCO's insolvency;
2. The cost of Medicaid-covered services provided pursuant to this
contract to the Member if the DEPARTMENT does not pay the MCO or the
DEPARTMENT or the MCO does not pay the health care provider that
furnishes the services under a contractual, referral, or other
arrangement; and/or
3. Payments for covered services furnished under a contract, referral,
or other arrangement, to the extent those payments are in excess of
the amount that the Member would owe if the MCO directly provided
the service.
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5.15 COMPLIANCE WITH APPLICABLE LAWS, RULES AND POLICIES
The MCO in performing this contract shall comply with all applicable federal and
state laws, regulations and written policies, including those pertaining to
licensing. In the provision of services under this Contract, the MCO and its
subcontractors shall comply with all applicable federal and state statutes and
regulations, and all amendments thereto, that are in effect when the agreement
is signed, or that come into effect during the term of the Contract. This
includes, but is not limited to Title XIX of the Social Security Act and Title
42 of the Code of Federal Regulations.
5.16 ADVANCE DIRECTIVES
a. The MCO shall comply with the provisions of 42 CFR 422.128 relating to
written policies and procedures for advance directives. The MCO shall:
1. Maintain written policies and procedures that meet the requirements
for advance directives in Subpart 1 of 42 CFR pt. 489;
2. Maintain policies and procedures for all adults receiving medical
care through the MCO;
3. Provide each adult Member with written information on advance
directives policies, including a description of Connecticut General
Statutes Sections 19a-570-19a-580d; and
4. Provide each adult Member with information on changes in Connecticut
law regarding advance directives as soon as possible, but no later
than ninety (90) days after the effective date of the change.
5.17 FEDERAL REQUIREMENTS AND ASSURANCES
GENERAL
a. The MCO shall comply with those federal requirements and assurances for
recipients of federal grants provided in OMB Standard Form 424B (4-88)
which are applicable to the MCO. The MCO is responsible for determining
which requirements and assurances are applicable to the MCO. Copies of the
form are available from the DEPARTMENT.
b. The MCO shall provide for the compliance of any subcontractors with
applicable federal requirements and assurances.
c. The MCO shall comply with all applicable provisions of 45 CFR 74.48 and
all applicable requirements at 45 CFR 74.48 Appendix A.
LOBBYING
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a. The MCO, as provided by 31 U.S.C. 1352 and 45 CFR 93.100 et seq., shall
not pay federally appropriated funds to any person for influencing or
attempting to influence an officer or employee of any agency, a member of
the U.S. Congress, an officer or employee of the U.S. Congress or an
employee of a member of the U.S. Congress in connection with the awarding
of any federal contract, the making of any cooperative agreement or the
extension, continuation, renewal, amendment or modification of any federal
contract, grant, loan or cooperative agreement.
b. The MCO shall submit to the DEPARTMENT a disclosure form as provided in 45
CFR 93.110 and Appendix B to 45 CFR Part 93, if any funds other than
federally 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 the U.S. Congress, an officer or employee of the U.S.
Congress or an employee of a member of the U.S. Congress in connection
with this contract.
BALANCED BUDGET ACT AND IMPLEMENTING REGULATIONS
The MCO shall comply with all applicable provisions of 42 U.S.C. Section
1396u-2, 42 U.S.C. Section 1396b(m) and 42 CFR Parts 431 and 438.
CLEAN AIR AND WATER ACTS
The MCO and all subcontractors with contracts in excess of $100,000 shall
comply with all applicable standards, orders or regulations issued pursuant to
the Clean Air Act as amended, 42 U.S.C. 7401, et seq. and section 508 of the
Clear Water Act (33 U.S.C. 1368), Executive Order 11738, and 40 CFR Part 15).
ENERGY STANDARDS
The MCO shall comply with all applicable standards and policies relating to
energy efficiency which are contained in the state energy plan issued in
compliance with the federal Energy Policy and Conservation Act, 42 USC Sections
6231 - 6246. The MCO further covenants that no federally appropriated funds have
been paid or will be paid on behalf of the DEPARTMENT or the contractor to any
person for influencing or attempting to influence an officer or employee of any
federal 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, or the extension, continuation,
renewal, amendment, or modification of any federal contract, grant, loan, or
cooperative agreement. If any funds other than federally appropriated funds have
been
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paid or will be paid to any person for influencing or attempting to influence an
officer or employee of any federal agency, a member of Congress, or an employee
of a member of Congress in connection with this contract, grant, loan, or
cooperative agreement, the contractor shall complete and submit Standard Form -
LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.
MATERNITY ACCESS AND MENTAL HEALTH PARITY
The MCO shall comply with the maternity access and mental health parity
requirements of the Public Health Services Act, Title XXVII, Subpart 2, Part A,
Section 2704, as added September 26, 1996, 42 U.S.C. Section 300gg-4, 300 gg-5,
insofar as such requirements apply to providers of group health insurance.
5.18 CIVIL RIGHTS
FEDERAL AUTHORITY
The MCO shall comply with the Civil Rights Act of 1964 (42 U.S.C. Section 2000d,
et seq.), the Age Discrimination Act of 1975 (42 U.S.C. 6 [ILLEGIBLE] 01, et
seq.), the Americans with Disabilities Act of 1990 (42 U.S.C. Section 12101, et
seq.) and Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794,
et seq.
DISCRIMINATION
Persons may not, on the grounds of race, color, national origin, creed, sex,
religion, political ideas, marital status, age or disability be excluded from
employment in, denied participation in, denied benefits or be otherwise
subjected to discrimination under any program or activity connected with the
implementation of this contract. The MCO shall use hiring processes that xxxxxx
the employment and advancement of qualified persons with disabilities.
MERIT QUALIFICATIONS
All hiring done in connection with this contract must be on the basis of merit
qualifications genuinely related to competent performance of the particular
occupational task. The MCO, in accordance with Federal Executive Order 11246,
dated September 24, 1965 entitled "Equal Employment Opportunity", as amended by
Federal Executive Order 11375 and as supplemented in the United States
Department of Labor Regulations, 41 CFR Part 60-1, et seq., must provide for
equal employment opportunities in its employment practices.
CONFIDENTIALITY
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The MCO shall, in accordance with relevant laws, regulations and policies,
protect the confidentiality of any material and information concerning an
applicant for or recipient of services funded by the DEPARTMENT. Access to
patient information, records, and data shall be limited to the purposes outlined
in 42 CFR 434.6(a)(8) and Conn. Gen. Stat. Section 17b-90. All requests for data
or patient records for participation in studies, whether conducted by the MCO or
outside parties, are subject to approval by the DEPARTMENT.
5.19 STATUTORY REQUIREMENTS
a. A State licensed MCO shall retain at all times during the period of this
contract a valid Certificate of Authority issued by the State Commissioner
of Insurance.
b. The MCO shall adhere to the provisions of the Clinical Laboratory
Improvement Amendments of 1988 (CLIA) Public Law 100-578,42 USC Section
1395aa et seq.
5.20 DISCLOSURE OF INTERLOCKING RELATIONSHIPS
An MCO which is not also a Federally-qualified Health Plan or a Competitive
Medical Plan under the Public Health Service Act must report on request to the
State, to the Secretary and the Inspector General of DHHS and the Comptroller
General, a description of transactions between the MCO and parties in interest
including related parties as defined by federal and state law. Transactions that
must be reported include: (a) any sale, exchange, or leasing of property; (b)
any furnishing for consideration of goods, services or facilities (but not
salaries paid to employees); and (c) any loans or extensions of credit.
5.21 DEPARTMENT'S DATA FILES
a. The DEPARTMENT's data files and data contained therein shall be and remain
the DEPARTMENT's property and shall be returned to the DEPARTMENT by the
MCO upon the termination of this contract at the DEPARTMENT's request,
except that any DEPARTMENT data files no longer required by the MCO to
render services under this contract shall be returned upon such
determination at the DEPARTMENT's request.
b. The DEPARTMENT's data shall not be utilized by the MCO for any purpose
other than that of rendering services to the DEPARTMENT under this
contract, nor shall the DEPARTMENT's data or any part thereof be
disclosed, sold, assigned, leased or otherwise disposed of to third
parties by the MCO unless there has been prior written DEPARTMENT
approval. The MCO may disclose
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material and information to subcontractors and vendors, as necessary to
fulfill the obligations of this contract.
c. The DEPARTMENT shall have the right of access and use of any data files
retained or created by the MCO for systems operation under this contract
subject to the access procedures defined in Part II Section 3.34.
d. The MCO shall establish and maintain at all times reasonable safeguards
against the destruction, loss or alteration of the DEPARTMENT's data and
any other data in the possession of the MCO necessary to the performance
of operations under this contract.
5.22 CHANGES DUE TO A SECTION 1115 OR 1915(b) FREEDOM OF CHOICE WAIVER
The conditions of enrollment described in the contract, including but not
limited to enrollment and the right to disenrollment, are subject to change as
provided in any waiver under Section 1115 or 1915(b) of the Social Security Act
(as amended) obtained by the DEPARTMENT.
5.23 HOLD HARMLESS
The MCO agrees to indemnify, defend and hold harmless the State of Connecticut
as well as all Departments, officers, agents and employees of the State from all
claims, losses or suits accruing or resulting to any contractors,
subcontractors, laborers and any person, firm or corporation who may be injured
or damaged through the fault of the MCO in the performance of the contract.
The MCO, at its own expense, shall defend any claims or suits which are brought
against the DEPARTMENT or the State for the infringement of any patents,
copyrights, or other proprietary rights arising from the MCO's or the State's
use of any material or information prepared or developed by the MCO in
conjunction with the performance of this contract; provided any such use by the
State is expressly contemplated by this contract and approved by the MCO. The
State, its Departments, officers, employees, contractors, and agents shall
cooperate fully in the MCO's defense of any such claim or suit as directed by
the MCO. The MCO shall, in any such suit, satisfy any damages for infringement
assessed against the State or the DEPARTMENT, be it resolved by settlement
negotiated by the MCO, final judgment of a court with jurisdiction after
exhaustion of available appeals, consent decree, or any other manner approved by
the MCO.
5.24 EXECUTIVE ORDER NUMBER 16
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This contract is subject to Executive Order No. 16 of Governor Xxxx X. Xxxxxxx
promulgated August 4, 1999 and, as such, this Agreement may be cancelled,
terminated or suspended by the State for violation of or noncompliance with said
Executive Order No. 16. The parties to this contract, as part of the
consideration hereof, agree that:
a. The MCO shall prohibit employees from bringing into the state work site,
except as may be required as a condition of employment, any weapon or
dangerous instrument as defined in subsection (b).
b. Weapon means any firearm, including a BB gun, whether loaded or unloaded,
any knife (excluding a small pen or pocket knife), including a switchblade
or other knife having an automatic spring release device, a stiletto, any
police baton or nightstick or any martial arts weapon or electronic
defense weapon. Dangerous instrument means any instrument, article or
substance that, under the circumstances, is capable of causing death or
serious physical injury.
c. The MCO shall prohibit employees from using, attempting to use or
threatening to use any such weapon or dangerous instrument in the state
work site and employees shall be prohibited from causing or threatening to
cause physical injury or death to any individual in the state work site.
d. The MCO shall adopt the above prohibitions as work rules, violations of
which shall subject the employee to disciplinary action up to and
including discharge. The MCO shall insure that all employees are aware of
such work rules.
e. The MCO agrees that any subcontract it enters into in furtherance of the
work to be performed hereunder shall contain the provisions (a) through
(d).
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6. GRIEVANCE SYSTEM AND PROVIDER APPEALS
The MCO shall establish and maintain a grievance system that meets all
statutory and regulatory requirements. The MCO's grievance system shall
include a grievance process, an appeal process and access to and
participation in the DEPARTMENT'S administrative hearings process.
6.01 GRIEVANCES
a. The MCO shall have a system in place to handle grievances. Grievances are
expressions of dissatisfaction about any matter, other than those matters
that qualify as an action. The subject matters of grievances may include,
but are not limited to, quality of care, rudeness by a provider or MCO
staff person or failure to respect a Member's rights.
b. The MCO shall maintain adequate records to document the filing of a
grievance, the actions taken, the MCO personnel involved and the
resolution. The Department will prescribe a reporting format for tracking
of grievances.
c. A Member, or a provider acting on a Member's behalf, may file a grievance
either orally or in writing. The MCO shall acknowledge the receipt of each
grievance and provide reasonable assistance with the process, including
but not limited to providing interpreter services and toll free numbers
with TTY/TTD and interpreter capability.
d. If the grievance involves a denial of expedited review of an appeal or
some other clinical issue, the grievance must be reviewed by a health care
professional with appropriate clinical expertise.
e. The MCO shall dispose of each grievance as expeditiously as the member's
health requires. If the Member filed the grievance orally, the MCO may
resolve the grievance orally, but shall maintain documentation of the
grievance and its resolution. If the Member filed a written grievance, the
resolution shall be in writing. If applicable, each grievance shall be
handled by an individual who was not involved in any previous level of
decisionmaking. Each grievance shall be disposed of in ninety (90) days or
less
6.02 NOTICES OF ACTION AND CONTINUATION OF BENEFITS
a. The MCO or its subcontractor (as duly authorized by the MCO) shall mail a
notice of action to a Member when the MCO takes action upon a request for
services from the Member's treating PCP, or other treating provider,
functioning within his or her scope of practice as defined under state
law. For purposes of this requirement, an "action" includes:
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1. The denial or limited authorization of a requested service,
including the type or level of service;
2. The reduction, suspension or termination of a previously
authorized service;
3. The denial, in whole or in part, of payment for a service;
4. The failure to act within the timeframes for utilization
review decisions, as described in Section 3.39
5. The failure to provide access to services in a timely manner
as required by 3.14(c)(1) through (c)(4) and 3.21(a)(4) or the
failure to provide access to consultations and specialist
referrals within three (3) months.
The notice of action requirements shall apply to all categories of
covered services including transportation to medically necessary
appointments.
The MCO is required to issue a notice for actions described in
(a)(3) above if the denial of payment for services already rendered
may or will result in the Member being held financially responsible.
Such circumstances include, but are not limited to, the provision of
emergency services that do not appear to meet the prudent layperson
standard, the provision of services outside of the United States
without prior authorization, and the provision of non-covered
services with the Member's written consent as described in 3.47. The
MCO is not required to issue a notice of action for the denial of
payment for covered services that have already been provided to the
Member if the denial is based on a procedural or technical issue,
including but not limited to a provider's failure to comply with
prior authorization rules for services that the Member has already
received, incorrect coding or late filing by a provider for services
that the Member has already received. In these circumstances,
coverage of the service is not at issue and the Member may not be
held financially liable for the services. Nothing herein shall
relieve the MCO from its responsibility to issue a notice of action
in all circumstances in which a provider requests prior
authorization for a service and the request is denied in whole or in
part, as required in a.(1) above. Nothing herein shall relieve the
MCO from its responsibility to hold a Member harmless for the cost
of Medicaid covered services and its responsibility to ensure that
the MCO's network providers hold a Member harmless for the cost of
Medicaid covered services.
The MCO is required to issue a notice of action for actions
described in a.(5) above, only if the Member notifies the MCO of his
or her inability to obtain timely access to services. In such
instances, the MCO shall provide the Member with immediate
assistance in accessing the services. If the Member has been unable
to access emergency services, the MCO shall issue a notice of action
immediately. For non-emergent services, if a
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Member contacts the MCO concerning the inability to access a
covered service within the timeframes referenced in (a)(5)
above, and three (3) business days later the Member has not
accessed or made arrangements for receiving the service that
are satisfactory to the Member, the MCO shall issue a notice
of action.
b. The MCO shall issue a notice of action if the MCO approves a good or
service that is not the same type, amount, duration, frequency or
intensity as that requested by the provider, consistent with current DSS
policy.
c. The MCO shall identify if the Member reads only a language other than
English. For Members who do not read English, the notice of action shall
be provided in accordance with Sections 3.28(a) and 3.29(h).
d. Except as provided in (h) below, the MCO shall mail an advance notice of
action for a termination, suspension or reduction of a previously
authorized service to a Member at least ten (10) days before the date of
any action described in (a) above, consistent with current DSS policy. The
MCO may shorten the period of advance notice to five (5) days before the
date of action if: 1) the MCO has facts indicating that the action should
be taken because of probable fraud by the Member; and 2) the facts have
been verified, if possible, through secondary sources.
e. All notices related to actions described in (a) above shall clearly state
or explain:
1. the action the MCO intends to take or has taken;
2. the reasons for the action;
3. the statute, regulation, the DEPARTMENT's Medical Services Policy
section, or when there is no appropriate regulation, policy or
statute, the HUSKY A contract provision that supports the action;
4. the address and toll-free number of the MCO's Member Services
Department;
5. the Member's right to challenge the action by filing an appeal and
requesting an administrative hearing;
6. the procedure for filing an appeal and for requesting an
administrative hearing;
7. how the Member may obtain an appeal form and, if desired, assistance
in completing and submitting the appeal form;
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8. that the Member will lose his or her right to an appeal and
administrative hearing if he or she does not complete and file a
written appeal form with the DEPARTMENT within sixty (60) days from
the date the MCO mailed the initial notice of action;
9. that the MCO must issue a decision regarding an appeal by the date
that the administrative hearing is scheduled, but no more than
thirty (30) days following the date the DEPARTMENT receives it;
10. that, if the Member files an appeal he or she is entitled to meet
with or speak by telephone with the MCO representative who will
decide the appeal, and is entitled to submit additional
documentation or written material for the MCO's consideration;
11. that the Member may proceed automatically to an administrative
hearing if he or she is dissatisfied with the MCO's appeal decision
concerning the denial of coverage of goods or services or a
reduction, suspension, or termination of ongoing goods or services,
or if the MCO fails to render an appeal decision by the date the
administrative hearing is scheduled;
12. that at an administrative hearing, the Member may represent himself
or herself or use legal counsel, a relative, a friend, or other
spokesperson;
13. that if the Member obtains legal counsel who will represent the
Member during the appeal or administrative hearing process, the
Member must direct his or her legal counsel to send written
notification of the representation to the MCO and the DEPARTMENT;
14. that if the circumstances require advance notice, the Member's right
to continuation of previously authorized goods and services,
provided that the Member files a grievance/request for
administrative hearing form with the DEPARTMENT on or before the
intended effective date of the MCO's action or within ten (10)
calendar days of the date the notice of action is mailed to the
Member, whichever is later;
15. the circumstances under which expedited resolution is available and
how to request expedited resolution; and
16. any other information specified by the DEPARTMENT.
f. In the case of a child who is under the care of the Department of Children
and Families (DCF), the MCO must send the notice of action to the child's
xxxxxx parents and the DCF contact person specified by the DEPARTMENT.
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g. The NOA shall be mailed within the following timeframes:
1) for termination, suspension, or reduction of previously authorized
Medicaid covered services, 10 days in advance of the effective date;
2) for standard authorization decisions to deny or limit services, as
expeditiously as the Member's health condition requires, not to
exceed fourteen (14) calendar days following receipt of the request
for services;
3) if the MCO extends the fourteen day time frame for denial or
limitation of a service as permitted in Section 3.39d (1)(i) and
(ii), as expeditiously as the Member's condition requires and no
later than the date the extension expires;
4) for service authorization decisions not reached within the
timeframes in 3.39 (which constitutes a denial and thus is an
adverse action), on the date the timeframe expires;
5) for expedited service authorization decisions as expeditiously as
the Member's health condition requires and no later than three (3)
business days after receipt of the request for services;
6) for denial of payment where the Member may be held liable, at the
time of any action affecting the claim
7) for failure to provide timely access to services as expeditiously as
the Member's health requires, but no later than three (3) business
days after the Member contacts the MCO.
h. The ten (10) day advance notice requirements do not apply to the
circumstances described in 42 CFR 431.213. Notice of action need not
be sent to the Member ten (10) days in advance of the action, but
may be sent no later than the date of action and will be considered
an exception to the advance notice requirement, if the action is
based on any of the following circumstances:
1) a denial of services;
2) the MCO has received a clear, written statement signed by the Member
that:
a. the Member no longer wishes to receive the goods or services;
or
b. the Member gives information which requires the reduction,
suspension, or termination of the goods or services, and the
Member indicates that he or she understands that this must be
the result of supplying that information; and
3) the Member has been admitted to an institution where he or she is
ineligible for the goods or services. In this instance, the Member
must be notified on the notice of admission that any goods or
services being reduced, suspended, or terminated will be reevaluated
for medical necessity upon discharge, and the Member will have the
right to appeal any post-discharge decisions.
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If the circumstances are an exception to the advance notice
requirement as set forth above the Member does not have the
automatic right to continuation of ongoing goods or services. In
these circumstances, however, and in any instance in which the MCO
fails to issue an advance notice when required, the reduced,
suspended, or terminated goods and services must be reinstated if
the Member files a written appeal form with the DEPARTMENT within
ten (10) days of the date the notice is mailed to the Member.
i. The MCO shall follow the requirements for continuation of services set
forth in 42 CFR 438.420. The right to continuation of ongoing goods or
services applies to the scope of services previously authorized. The right
to continuation of services does not apply to subsequent requests for
approval that result in denial of the additional request or
re-authorization of the request at a different level than requested. For
example, the right to continuation of services does not apply:
1. when a prescription (including refills) runs out and the
Member requests a new prescription for the same
medication; or
2. to a request for additional home health care services
following the expiration of the approved number of home
health visits
The MCO shall treat such requests as a new service authorization request
and provide a denial notice.
j. Notice of action is not required if the member's treating physician or
PCP, using his or her professional judgment, refuses to prescribe (or
prescribes an alternative to) a particular service sought by a member.
Notice of action is also not required if the Member's treating physician
or PCP, using his or her professional judgment, orders the reduction,
suspension, or termination of goods or services. Such decisions do not
constitute an action by the MCO. If, however, the Member disagrees with
the provider and contacts the MCO to request authorization for the service
the MCO shall conduct an expedited review of the request, according to the
timeframe in 3.39(e). If the MCO affirms the provider's action to deny,
terminate, reduce or suspend the service, the MCO shall issue a notice of
action. If the Member requests an appeal and hearing, the MCO shall
continue authorization for the services, to the extent services were
previously authorized, unless the MCO determines that continued provision
of the services could be harmful to the Member. The MCO shall also advise
the Member of his or her right to a second opinion from another provider.
Because only a licensed health care provider, and not the MCO, may
prescribe or provide medical services, the Member may not be able to
receive some or all of the requested goods or services while the appeal is
pending. If the MCO approves the Member's request for the
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good or service, the MCO shall inform the Member of the approval and shall
inform the Member of the right to a second opinion.
k. The DEPARTMENT will provide a standardized notice of action form to be
used by the MCO and its subcontractors. The DEPARTMENT will also provide a
standardized appeal form to be used by the MCO and its subcontractors. The
MCO and its subcontractors shall not alter the standard format of either
form without prior, written approval of the DEPARTMENT.
l. The DEPARTMENT will conduct random reviews of the MCO and its
subcontractors, as appropriate, to ensure that Members are sent accurate,
complete and timely notices of action.
SANCTION: If the DEPARTMENT determines during any audit or random monitoring
visit to the MCO or one of its subcontractors that a notice of action fails to
meet any of the criteria set forth herein, the DEPARTMENT may impose a strike
towards a Class A sanction. If the deficiencies which give rise to a Class A
sanction continue for a period in excess of ninety (90) days, the DEPARTMENT may
impose a Class B sanction.
6.03 APPEALS AND ADMINISTRATIVE HEARING PROCESSES
a. The MCOs shall have a timely and organized appeals process. The appeals
process shall be available for resolution of disputes between the MCO and
its Members concerning the MCO's actions as defined in 6.02.
b. The MCO shall develop written policies and procedures for its appeals
process. Those policies and procedures must be approved by the DEPARTMENT
in writing and must include the elements specified in this contract. The
MCO shall not be excused from providing the elements specified in this
contract pending the DEPARTMENT's written approval of the MCO's policies
and procedures.
c. The MCO shall maintain a record keeping system for appeals which shall
include a copy of the appeal, the response, the resolution and supporting
documentation.
d. The MCO must clearly specify in its Member handbook/packet the procedural
steps and timeframes for filing an appeal and administrative hearing
request, including the timeframe for maintaining benefits pending the
conclusion of the appeal and administrative hearing processes. The Member
handbook/packet shall also list the addresses, office hours, and toll-free
telephone numbers for the Member Services office.
e. The MCO shall ensure that network providers and subcontractors are
familiar with the appeal process and shall provide information on the
process to providers and subcontractors. The MCO shall provide information
on the appeal process to its providers and subcontractors at the time it
enters into contracts or subcontracts.
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The MCO must ensure that appeal forms are available at each primary care
site. At a minimum, appeals assistance must include providing forms on
request, assisting the Member in filling out the forms upon request, and
sending the completed form to the DEPARTMENT upon request.
f. The MCO shall develop and make available to Members and potential Members
appropriate foreign language versions of appeals materials, including but
not limited to, the standard information contained in notices of action
and appeals forms. Such materials shall be made available in Spanish,
English, or any other languages if more than five (5) percent of the MCO's
Members in any county of the State served by the MCO speak the alternative
language. Such foreign language materials must be approved, in writing, by
the DEPARTMENT.
g. A Member may request an appeal either orally or in writing. When
requesting an appeal orally, unless the member is seeking an expedited
appeal review, the Member must follow up an oral request with a written,
signed appeal form within five (5) days of the oral request. The MCO shall
advise any member who requests an appeal orally, that the Member must file
a written appeal form in order to receive an administrative hearing. In
all other respects, the process for pursuing an appeal and for requesting
an administrative hearing shall be unified. The MCO and the DEPARTMENT
shall treat the filing of a written appeal as a simultaneous request for
an administrative hearing. The MCO shall attempt to resolve appeals at the
earliest point possible. If the MCO is not able to render a decision by
the time the administrative hearing is scheduled, the Member will
automatically proceed to the administrative hearing.
h. Appeals may be filed by the Member, the Member's authorized
representative, or the Member's conservator on a form approved by the
DEPARTMENT. A provider, acting on behalf of the member and with the
Member's written consent, may file an appeal. A provider may not file an
administrative hearing request on behalf of a Member unless the authorized
representative requirements in DSS Uniform Policy Manual Section 1525.05
are met. The MCO shall request a copy of the written consent from the
Member. Appeals shall be mailed or faxed to a single address within the
DEPARTMENT. The appeal form must state both the mailing address and fax
number at the DEPARTMENT where the form must be sent. If the MCO or its
subcontractor receive an appeal directly from a Member or the Member's
authorized representative or conservator, the MCO shall date stamp and fax
the appeal to the appropriate fax number at the DEPARTMENT within two (2)
business days.
i. Upon receipt of a written appeal, the DEPARTMENT will schedule an
administrative hearing and notify the Member and MCO of the hearing date
and location. If a Member is disabled, the hearing may be scheduled for
the Member's home, if requested by the Member.
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j. The DEPARTMENT will date stamp and forward the appeal by fax to the MCO
within two (2) business days of receipt. The fax to the MCO will include
the date the Member mailed the appeal to the DEPARTMENT. The postmark on
the envelope will be used to determine the date the appeal was mailed.
k. The MCO's review of the appeal must be carried out by an individual or
individuals having final decisionmaking authority. Any appeal stemming
from an action based on a determination of medical necessity or involving
any other clinical issues must be decided by one or more physicians who
were not involved in making that medical determination.
l. The MCO may decide an appeal on the basis of the written documentation
available unless the Member requests an opportunity to meet with the
individual or individuals making that determination on behalf of the MCO
and/or requests the opportunity to submit additional documentation or
other written material. The Member shall have a right to review his or her
MCO record, including medical records and any other documents or records
considered during the appeal process. The Member's right to access medical
records shall be consistent with HIPAA privacy regulations and any
applicable state or federal law.
m. If the Member wishes to meet with the decisionmaker, the meeting can be
held via the telephone or at a location accessible to the Member,
including the Member's home if requested by a disabled Member. Subject to
approval of the DEPARTMENT's Regional Offices, any of the DEPARTMENT'S
office locations may be available for video conferencing. The MCO must
invite a representative of the DEPARTMENT to attend any such meeting.
n. The MCO must mail to the Member, by certified mail, a written appeal
decision, described below, with a copy to the DEPARTMENT, by the date of
the DEPARTMENT's administrative hearing as expeditiously as the Member's
health condition requires, but no later than thirty (30) days from the
date on which the appeal was received by the DEPARTMENT. If the Member is
dissatisfied with the MCO's decision regarding the denial, reduction,
suspension, or termination of goods or services, or if the MCO does not
render a decision by the time of the administrative hearing, the Member
may automatically proceed to the administrative hearing.
o. The MCO's written appeal decision must include the Member's name and
address; the provider's name and address; the MCO name and address; a
complete description of the information or documents reviewed by the MCO;
a complete statement of the MCO's findings and conclusions, including the
section number and text of any contractual provision or DEPARTMENTAL
policy provision that is relevant to the grievance decision; and a clear
statement of the MCO disposition of the appeal.
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p. Along with its written appeal decision, the MCO must remind the Member, on
a form approved by the DEPARTMENT that:
1. if the Member is dissatisfied with the MCO's appeal decision, the
DEPARTMENT has already reserved a time to hold an administrative
hearing concerning that decision;
2. that the Member has the right to automatically proceed to the
administrative hearing, and that the MCO must continue previously
authorized goods and services pending the administrative hearing
decision;
3. if the appeal pertains to the suspension, reduction, or termination
of goods or services which have been maintained during the appeals
process, and the MCO's appeals decision affirms the suspension,
reduction, or termination of goods or services, those goods or
services will be suspended, reduced, or terminated in accordance
with the MCO's appeals decision unless the Member proceeds to an
administrative hearing; and
4. if the Member fails to appear at the administrative hearing, the
Member's reserved hearing time will be cancelled and any disputed
goods or services that were maintained will be suspended, reduced,
or terminated in accordance with the MCO's appeals decision.
q. If the Member proceeds to an administrative hearing, the MCO must make its
entire file concerning the Member and the appeal, including any materials
considered in making its decision, available to the DEPARTMENT.
r. If the MCO fails to issue an appeal decision by the date that an
administrative hearing is scheduled, but no later than thirty (30) days
following the date the grievance was received by the DEPARTMENT, an
administrative hearing will be held as originally scheduled. At the
hearing, the MCO must prove good cause for having failed to issue a timely
decision regarding the appeal. Good cause for the MCO's failure to issue a
timely decision shall include, but not be limited to, documented efforts
to obtain additional medical records necessary for the MCO's decision on
the appeal and the Member's refusal to sign a release for medical records
necessary for the decision on the appeal.
The MCO's inability to prove good cause shall constitute a sufficient
basis for upholding the appeal, and the hearing officer, in his or her
discretion, may uphold the appeal solely on that basis.
If the MCO proves good cause for having failed to issue a timely appeal
decision, the hearing officer may order a continuance of the hearing
pending the issuance of the grievance decision by a certain date or the
hearing officer may proceed with the hearing.
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s. A representative of the MCO shall prepare the summary for the
administrative hearing, subject to approval by the DEPARTMENT prior to the
hearing, and shall present proof of all facts supporting its initial
action if the administrative hearing proceeds in the absence of an appeal
decision. The MCO shall submit a final, signed hearing summary to the
DEPARTMENT no later than five (5) business days prior to the scheduled
hearing date. The MCO's representative shall also present any provisions
of this contract or any DEPARTMENT policies which support its decision.
t. If the Member is represented by legal counsel at the hearing and has not
notified either the DEPARTMENT or the MCC of the representation, the MCO
may request a continuance of the hearing or may ask the hearing officer to
hold the hearing record open for additional evidence or submissions. The
decision as to whether a continuance will be granted or the record will be
held upon is within the hearing officer's discretion.
u. If a representative of the MCO fails to attend a scheduled session of an
administrative hearing, the MCO's failure to attend shall constitute a
sufficient basis for upholding the appeal, and the hearing officer, in his
or her discretion, may close the hearing and uphold the appeal solely on
that basis. This provision shall not apply unless the MCO receives notice
of the hearing at least seven (7) business days prior to the
administrative hearing.
v. If the DEPARTMENT is advised that the Member does not intend to proceed to
an administrative hearing, the DEPARTMENT will fax such notice to the MCO.
w. The MCO must designate one primary and one back-up contact person for its
grievance/administrative hearing process.
x. If the DEPARTMENT's hearing officer reverses the MCO's decision to deny,
limit or delay services that were not furnished while the appeal was
pending, the MCO shall authorize or provide the disputed services
promptly, and as expeditiously as the Member's health condition requires.
6.04 EXPEDITED REVIEW AND ADMINISTRATIVE HEARINGS
a. Subject to Section 6.02 above, the appeal process must allow for expedited
review. If the appeal contains a request for expedited review, it will be
forwarded by fax to the MCO within one business day of receipt by the
DEPARTMENT. The fax will include the date the Member mailed the appeal.
The postmark on the envelope will be used to determine the date the appeal
was mailed. If the MCO
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receives an oral request for expedited appeal, the MCO shall notify the
DSS liaison by fax or telephone within one business day of the oral
request.
b. The MCO must determine, within one business day of receiving the grievance
which contains a request for an expedited review from the DEPARTMENT, or
within one business day of receiving an oral request for an expedited
appeal, whether to expedite the appeal or whether to perform it according
to the standard timeframes. If the Member's provider indicates or the MCO
determines that the appeal meets the criteria for expedited review, the
MCO shall notify the DEPARTMENT immediately that the MCO will be
conducting the appeal on an expedited basis.
c. An expedited appeal must be performed when the standard timeframes for
determining a grievance could seriously jeopardize the life or health of
the Member or the Member's ability to attain, maintain or regain maximum
function. The MCO must expedite its review in all cases in which the
Member's provider indicates, in making the request for expedited review
on behalf of the Member or supporting the member's request, that taking
the time for a standard grievance review could seriously jeopardize the
Member's life or health or ability to attain, maintain, or regain maximum
function and if the DEPARTMENT requests the MCO to conduct an expedited
review because the DEPARTMENT believes a specific case meets the criteria
for expedited review.
d. If the MCO denies a request for expedited review, the MCO shall perform
the review within the standard timeframe and make reasonable efforts to
give the Member prompt oral notice of the denial and follow up within two
calendar days with a written notice.
e. Unless the Member asks to meet with the decisionmaker or to submit
additional information, an expedited review must be completed and an
appeal decision must be issued within a timeframe appropriate to the
condition or situation of the Member, but no more than three (3) business
days from the DEPARTMENT's receipt of the written appeal or three (3)
business days from an oral request received by the MCO.
f. The MCO may extend the timeframe for decisions in paragraph d by up to 14
days if: 1) the Member requests the extension or 2) MCO can demonstrate
that the extension is in the member's interest because additional
information is needed to decide the appeal and if the timeframe is not
extended, the appeal will be denied. The DEPARTMENT may request this
documentation from the MCO. If an extension is given and the member asks
to meet with the decisionmaker and/or submit additional information, the
decisionmaker must offer to meet with the Member within three (3) business
days of receiving the appeal. The meeting with the Member can be held via
the telephone or at a location accessible to the Member, and subject to
approval of the DEPARTMENT's Regional Offices, any of the DEPARTMENT's
office locations may be available for video conferencing.
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g. The MCO shall ensure that no punitive action is taken against a provider
who requests an expedited appeal or supports a Member's appeal.
h. The MCO shall issue a written appeal decision for expedited appeals. The
written notice of the resolution must meet the requirements of 6.03(o) and
(p). The MCO shall also make reasonable efforts to provide the Member oral
notice of an expedited appeal decision.
i. The DEPARTMENT also provides expedited administrative hearings for HUSKY A
Members, where required. The DEPARTMENT shall issue a hearing decision as
expeditiously as the Member's health condition requires, but no later than
three (3) working days after the DEPARTMENT receives from the MCO, the
case file and information for any appeal that meets the requirements for
an expedited hearing. A Member is entitled to an expedited hearing for the
denial of a service if the denial met the criteria for expedited appeal
but was not resolved within the expedited appeals timeframe or was
resolved within the expedited appeals timeframe, but the appeals decision
was wholly or partially adverse to the Member.
SANCTION: If the MCO fails to provide expedited appeals in appropriate
circumstances, the DEPARTMENT may impose a Class B sanction pursuant to Section
7.05.
6.05 PROVIDER APPEAL PROCESS
a. The MCO shall have an internal appeal process through which a health care
provider may appeal the MCO decision on behalf of a Member.
b. The health care provider appeal process shall not include any appeal
rights to the DEPARTMENT or any rights to an administrative hearing.
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7. CORRECTIVE ACTION AND CONTRACT TERMINATION
7.01 PERFORMANCE REVIEW
a. A designated representative of the MCO and a designated representative of
the DEPARTMENT shall meet on an annual basis, and as requested by either
party, to review the performance of the MCO under this contract. The
DEPARTMENT will keep written minutes of such meetings. In the event of any
disagreement regarding the performance of services by the MCO under this
contract, the designated representatives shall discuss the problem and
shall negotiate in good faith in an effort to resolve the disagreement.
b. In the event that no such resolution is achieved within a reasonable time,
the matter shall be referred to the Contract Administrator as provided
under Article 7.02, the Disputes clause of this contract. If the Contract
Administrator determines that the MCO has failed to perform as measured
against applicable contract provisions, the Contract Administrator may
impose sanctions or any other penalty, set forth in this Section including
the termination of this contract in whole or in part, as provided under
this Section.
7.02 SETTLEMENT OF DISPUTES
Any dispute arising under the contract which is not disposed of by agreement
shall be decided by the Contract Administrator whose decision shall be final and
conclusive subject to any rights the MCO may have in a court of law. The
foregoing shall not limit any right the MCO may have to present claims under
Connecticut General Statutes Section 4-141 et seq. or successor provisions
regarding the claims commissioner, including without limitation Connecticut
General Statutes Section 4-160 regarding authorization of actions. In connection
with any appeal to the Contract Administrator under this paragraph, the MCO
shall be afforded an opportunity to be heard and to offer evidence in support of
its appeal. Pending final decision of a dispute, the MCO shall proceed
diligently with the performance of the contract in accordance with the Contract
Administrator's decision.
7.03 ADMINISTRATIVE ERRORS
The MCO shall be liable for the actual amount of any costs in excess of $5,000
incurred by the DEPARTMENT as the result of any administrative error (e.g.
submission of erroneous capitation, encounter or reinsurance data) of the MCO or
its subcontractors. The DEPARTMENT may request a refund of, or recoup from
subsequent capitation payments, the actual amount of such costs.
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7.04 SUSPENSION OF NEW ENROLLMENT
Whenever the DEPARTMENT determines that the MCO is out of compliance with this
contract, unless corrective action is taken to the satisfaction of the
DEPARTMENT, the DEPARTMENT may suspend enrollment of new Members under this
contract. The DEPARTMENT, when exercising this option, must notify the MCO in
writing of its intent to suspend new enrollment at least thirty (30) days prior
to the beginning of the suspension period. The suspension period may be for any
length of time specified by the DEPARTMENT, or may be indefinite. The suspension
period may extend up to the contract expiration date as provided under PART I.
(The DEPARTMENT may also notify existing Members of MCO non-compliance and
provide an opportunity to disenroll from the MCO and to re-enroll in another
MCO.)
7.05 MONETARY SANCTIONS
It is agreed by the DEPARTMENT and the MCO that if by any means, including any
report, filing, examination, audit, survey, inspection or investigation, the MCO
is determined to be out of compliance with this contract, damage to the
DEPARTMENT may or could result. Consequently, the MCO agrees that the DEPARTMENT
may impose any of the following sanctions for noncompliance under this contract.
Unless otherwise provided in this contract, sanctions imposed under this
section shall be deducted from capitation payment or, at the discretion of the
DEPARTMENT, paid directly to the DEPARTMENT.
A. SANCTIONS FOR NONCOMPLIANCE
1. CLASS A SANCTIONS. THREE (3) STRIKES. SANCTIONS WARRANTED AFTER
THREE (3) OCCURRENCES
For noncompliance of the contract which does not rise to the level
warranting Class B sanctions as defined in subsection (a)(2) of this
section or Class C sanctions as defined in subsection (b) of this section,
including, but not limited to, those violations defined as Class A
sanctions in any provision of this contract, the following course of
action will be taken by the DEPARTMENT:
Each time the MCO fails to comply with the contract on an issue
warranting a Class A sanction, the MCO receives a strike. The MCO
will be notified each time a strike is imposed. After the third
strike for the same contract provision, a sanction may be imposed.
If no specific time frame is set forth in any such contractual
provision, the time frame is deemed to be the full length of the
contract.
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The MCO will be notified in writing at least thirty (30) days in
advance of any sanction being imposed and will be given an
opportunity to meet with the DEPARTMENT to present its position as
to the DEPARTMENT's determination of a violation warranting a Class
A sanction. At the DEPARTMENT's discretion, a sanction will
thereafter be imposed. Said sanction will be no more than $2,500
after the first three (3) strikes. The next strike for noncompliance
of the same contractual provision will result in a sanction of no
more than $5,000 and any subsequent strike for noncompliance of the
same contractual provision will result in a Class A sanction of no
more than $10,000.
2. CLASS B SANCTIONS. SANCTIONS WARRANTED UPON SINGLE OCCURRENCE
For noncompliance with the contract which does not warrant the imposition
of Class C sanctions as defined in subsection (b) of this section,
including, but not limited to, those violations defined as Class B
sanctions in any provision of this contract, the following course of
action will be taken by the DEPARTMENT:
The DEPARTMENT may impose a sanction at the DEPARTMENT's discretion
if, after at least thirty (30) days notice to the MCO and an
opportunity to meet with the DEPARTMENT to present the MCO's
position as to the DEPARTMENT's determination of a violation
warranting a Class B sanction, the DEPARTMENT determines that the
MCO has failed to meet a performance measure which merits the
imposition of a Class B sanction not to exceed $10,000.
b. CLASS C SANCTIONS. SANCTIONS RELATED TO NONCOMPLIANCE POTENTIALLY
RESULTING IN HARM TO AN INDIVIDUAL MEMBER
(i) The DEPARTMENT may impose a Class C sanction on the MCO for
noncompliance potentially resulting in harm to an individual Member,
including, but not limited to, the following:
1. failing to substantially authorize medically necessary items and
services that are required (under law or under this contract) to be
provided to an Member covered under this contract;
2. imposing a premium or charge on Members except as specifically
permitted under provisions of the approved Medicaid State Plan and
the provisions of this Contract;
3. discriminating among Members on the basis of their health status or
requirements for health care services, including expulsion or
refusal to re-enroll an individual, except as permitted by Title
XIX, or engaging in any practice that would reasonably be expected
to have the effect of denying or discouraging enrollment with the
MCO by eligible individuals whose medical condition or history
indicates a need for substantial future medical services;
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4. misrepresenting or falsifying information that is furnished to the
Secretary, the DEPARTMENT; Member, potential Member, or a health
care provider;
5. failing to comply with the physician incentive requirements under
Section 1903(m)(2)(A)(x) of the Social Security Act and 42 CFR
422.208 and 422.210;
6. distributing directly or through any agent or independent contractor
marketing materials that have not been approved by the DEPARTMENT or
containing false or misleading information; and
7. failing to comply with any other requirements of 42 U.S.C. 1396b(m)
or 42 U.S.C. 1396u-2.
(ii) Class C sanctions for noncompliance with the contract under this
subsection include the following:
1. withholding the next month's capitation payment to the MCO in full or
in part;
2. assessment of liquidated damages:
a. for each determination that the MCO fails to substantially
provide medically necessary services, makes misrepresentations
or false statements to Members, potential Members or health
care providers, engages in marketing violations or fails to
comply with the physician incentive plan requirements, not
more than $25,000;
b. for each determination that the MCO discriminates among
Members on the basis of their health status or requirements
for health care services or engages in any practice that has
the effect of denying or discouraging enrollment with the
MCO by eligible individuals based on their medical condition
or history that indicates a need for substantial future
medical services, or the MCO misrepresents or falsifies
information furnished to the Secretary or DEPARTMENT, not more
than $100,000;
c. for each determination that the MCO has discriminated among
Members or engaged in any practice that has denied or
discouraged enrollment, $15,000 for each individual not
enrolled as a result of the practice up to a total of
$100,000;
d. for a determination that the MCO has imposed premiums or
charges on Members in excess of the premiums or charges
permitted, double the excess amount but not more than
$25,000. The excess amount charged in such a circumstance must
be deducted from the penalty and returned to the Member
concerned;
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3. freeze on new enrollment and/or alter the current enrollment; or
4. appointment of temporary management as described in 7.06.
(iii) Prior to imposition of any Class C sanction, the MCO will be
notified at least thirty (30) days in advance and provided, at a
minimum, an opportunity to meet with the DEPARTMENT to present its
position as to the DEPARTMENT's determination of a violation
warranting a Class C Sanction. For any contract violation under this
subsection, at the DEPARTMENT's discretion, the MCO may be permitted
to submit a corrective action plan within twenty (20) days of the
notice to the MCO of the violation. Immediate compliance (within
thirty (30) days) under any such corrective action plan may result
in the imposition of a lessor sanction on the MCO. If any sanction
issued under this subsection is equivalent to termination of the
contract, the MCO shall be offered a hearing to contest the
imposition of such a sanction.
C. OTHER REMEDIES
1. Notwithstanding the provisions of this section, failure to provide
required services will place the MCO in default of this contract,
and the remedies in this section are not a substitute for other
remedies for default which the DEPARTMENT may impose as set forth in
this contract.
2. The imposition of any sanction under this section does not preclude
the DEPARTMENT from obtaining any other legal relief to which it may
be entitled pursuant to state or federal law.
D. CMS SANCTIONS
Pursuant to 42 CFR 438.730, the DEPARTMENT may recommend the imposition of
sanctions to CMS and CMS may sanction the MCO as described in that
section. In the alternative, CMS may independently initiate the sanction
process described in 42 CFR 438.730(a) through (d). The MCO shall comply
with all applicable sanction provisions set forth in 42 CFR 438.730. CMS
may deny payment to the DEPARTMENT for new Members under the circumstances
described in 42 CFR 438.730(e) and capitation payments to the MCO will be
denied so long as payment for those Members is denied by CMS.
7.06 TEMPORARY MANAGEMENT
The DEPARTMENT may impose temporary management upon a finding by the DEPARTMENT
that: 1) there is continued egregious behavior by the MCO; 2) there is a
substantial risk to the health of the Members or 3) temporary management is
necessary to ensure the health of the MCO's members while improvements are made
to remedy the violations or until there is an orderly termination or
reorganization of the MCO. For purposes of this section, "egregious behavior"
shall include but not be limited to any of
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the violations described in 7.05b(ii)(2) or any other MCO behavior that is
contrary to Sections 1903(m) and 1932 of the Social Security Act. After a
finding pursuant to this subsection, individuals enrolled with the MCO must be
permitted to terminate enrollment without cause and the MCO shall be responsible
for notification of such right to terminate enrollment. Nothing in this
subsection shall preclude the DEPARTMENT from proceeding under the termination
provisions of the contract rather than imposing temporary management. If
however, the DEPARTMENT chooses not to first terminate the contract and repeated
violations of substantive requirements in section 1903(m) or 1932 of the Social
Security Act occur, the DEPARTMENT must than impose temporary management and
allow individuals to disenroll without cause. The Department may impose
temporary management without a hearing.
7.07 PAYMENT WITHHOLD, CLASS C SANCTIONS OR TERMINATION FOR CAUSE
The DEPARTMENT may withhold capitation payments, impose sanctions including
Class C Sanctions set forth in Section 7.05 or terminate the contract for cause.
Cause shall include, but not be limited to: 1) use of funds and/or personnel for
purposes other than those described in the HUSKY A program and this contract and
2) if a civil action or suit in federal or state court involving allegations of
health fraud or violation of 18 U.S.C. Section 1961 et seq. is brought on
behalf of the DEPARTMENT.
7.08 EMERGENCY SERVICES DENIALS
If the MCO has a pattern of inappropriately denying payments for emergency
services as defined in Part II, Definitions, the MCO may be subject to
suspension of new enrollments, withholding of capitation payments, contract
termination, or refusal to contract in a future time period. This applies not
only to cases where the DEPARTMENT has ordered payment after appeal, but also to
cases where no appeal has been made (i.e., the DEPARTMENT is knowledgeable about
documented abuse from other sources.)
7.09 TERMINATION FOR DEFAULT
a. The DEPARTMENT may terminate performance of work under this contract in
whole, or in part, whenever the MCO materially defaults in performance of
this contract and fails to cure such default or make progress satisfactory
to the DEPARTMENT toward contract performance within a period of thirty
(30) days (or such longer period as the DEPARTMENT may allow). Such
termination shall be referred to herein as "Termination for Default."
b. If after notice of termination of the contract for default, it is
determined by the DEPARTMENT or a court that the MCO was not in default,
the notice of
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termination shall be deemed to have been rescinded and the contract
reinstated for the balance of the term.
c. If after notice of termination of the contract for default, it is
determined by the DEPARTMENT or a court that the MCO was not in default
or that the MCO's failure to perform or make progress in performance was
due to causes beyond control and without the error or negligence of the
MCO, or any subcontractor, the notice of termination shall be deemed to
have been issued as a termination for convenience pursuant to Section 7.09
and the rights and obligations of the parties shall be governed
accordingly.
d. In the event the DEPARTMENT terminates the contract in full or in part as
provided in this clause, the DEPARTMENT may procure, services similar to
those terminated, and the MCO shall be liable to the DEPARTMENT for any
excess costs for such similar services for any calendar month for which
the MCO has been paid to provide services to HUSKY A clients. In addition,
the MCO shall be liable to the DEPARTMENT for administrative costs
incurred by the DEPARTMENT in procuring such similar services. Provided,
however, that the MCO shall not be liable for any excess costs or
administrative costs if the failure to perform the contract arises out of
causes beyond the control and without error or negligence of the MCO or
any of its subcontractors.
e. In the event of a termination for default, the MCO shall be financially
responsible for Members in the current month at the applicable capitation
rate.
f. The rights and remedies of the DEPARTMENT provided in this clause shall
not be exclusive and are in addition to any other rights and remedies
provided by law or under this contract.
g. In addition to the termination rights under Part I Section 8, the MCO may
terminate this contract on ninety (90) days written notice in the event
that the DEPARTMENT fails to (a) pay capitation claims in accordance with
Part II Section 4.06 and Part II Section 3.01 of this contract (b) provide
eligibility or enrollment/disenrollment information and shall fail to cure
such default or make progress satisfactory to the MCO within a period of
sixty (60) days of such default.
7.10 TERMINATION FOR MUTUAL CONVENIENCE
The DEPARTMENT and the MCO may terminate this contract at any time if both
parties mutually agree in writing to termination. At least sixty (60) days shall
be allowed. The effective date must be the first day of a month. The MCO shall,
upon such mutual agreement being reached, be paid at the capitation rate for
enrolled recipients through the termination of the contract.
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7.11 TERMINATION FOR FINANCIAL INSTABILITY OF THE MCO
In the event of financial instability of the MCO, the DEPARTMENT shall have the
right to terminate the contract upon the same terms and conditions as a
Termination for Default.
7.12 TERMINATION FOR UNAVAILABILITY OF FUNDS
a. The DEPARTMENT at its discretion may terminate at any time the whole or
any part of this contract or modify the terms of the contract if federal
or state funding for the contract or for the Medicaid program as a whole
is reduced or terminated for any reason. Modification of the contract
includes, but is not limited to, reduction of the rates or amounts of
consideration, reducing services covered by the MCO, or the alteration of
the manner of the performance in order to reduce expenditures under the
contract. Whenever possible, the MCO will be given thirty (30) days
notification of termination.
b. In the event of a reduction in the appropriation from the state or federal
budget for the Division of Health Care Financing of the Department of
Social Services or an across-the-board budget reduction affecting the
Department of Social Services, the DEPARTMENT may either re-negotiate this
contract or terminate with thirty (30) days written notice. Any reduction
in the capitation rates that is agreed upon by the parties or any
subsequent termination of this contract by the DEPARTMENT in accordance
with this provision shall only affect capitation payments or portions
thereof for covered services purchased on or after the effective date of
any such reduction or termination. Should the DEPARTMENT elect to
renegotiate the contract, the DEPARTMENT will provide the MCO with those
contract modifications, including capitation rate revisions, it would deem
acceptable.
c. The MCO shall have the right not to extend the contract if the new
contract terms are deemed to be insufficient notwithstanding any other
provision of this contract. The MCO shall have a minimum of sixty (60)
days to notify the DEPARTMENT regarding its desire to accept new terms. If
the new capitation rates and any other contract modifications are not
established at least sixty (60) days prior to the expiration of the
initial or extension agreement, the DEPARTMENT will reimburse the MCO at
the higher of the new or current capitation rates for that period during
which the new contract period had commenced and the MCO's sixty (60) day
determination and notification period had not been completed, and the MCO
will be held to the terms of the executed contract.
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7.13 TERMINATION FOR COLLUSION IN PRICE DETERMINATION
In competitive bidding markets, the MCO has previously certified that the prices
presented in its proposal were arrived at independently, without consultation,
communication, or agreement with any other bidder for the purpose of
restricting competition; that, unless otherwise required by law, the prices
quoted have not been knowingly disclosed by the MCO, prior to bid opening,
directly or indirectly to any other bidder or to any competitor; and that no
attempt has been made by the MCO to induce any other person or firm to submit or
not to submit a proposal for the purpose of restricting competition.
In the event that such action is proven, the DEPARTMENT shall have the right to
terminate this contract upon the same terms and conditions as a Termination for
Default.
7.14 TERMINATION OBLIGATIONS OF CONTRACTING PARTIES
a. The MCO shall be provided the opportunity for a hearing prior to any
termination of this contract pursuant to any provision of this contract.
The DEPARTMENT shall give the MCO written notice of its intent to
terminate, the reason for the termination and the date and time of the
hearing. After the hearing, the DEPARTMENT shall give the MCO written
notice of its decision affirming or reversing the proposed termination. In
the event of a decision to affirm the termination, the DEPARTMENT's
written notice shall include the effective date of termination. The
DEPARTMENT may notify Members of the MCO and permit such Members to
disenroll immediately without cause during the hearing process.
b. Upon contract termination, the MCO shall allow the DEPARTMENT, its agents
and representatives full access to the MCO's facilities and records to
arrange the orderly transfer of the contracted activities. These records
include the information necessary for the reimbursement of any outstanding
Medicaid claims.
c. Where this contract is terminated due to cause or default by the MCO: 1)
The DEPARTMENT shall be responsible for notifying all Members of the date
of termination and process by which the Members will continue to receive
services and 2) the MCO shall notify all providers and be responsible for
all expenses related to notification to providers and members.
d. If this contract is terminated for any reason other than default by the
MCO,
1. The MCO shall ensure that an adequate provider network will be
maintained at all times during the transition period and that
continuity of care is maintained for all Members;
2. The MCO shall submit a written transition plan to the DEPARTMENT
sixty (60) days in advance of the scheduled termination;
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3. The DEPARTMENT shall be responsible for notifying all Members of the
date of termination and process by which the Members will continue
to receive services;
4. The DEPARTMENT shall be responsible for all expenses relating to
said notification to members;
5. The MCO shall notify all providers and be responsible for all
expenses related to such notification; and
6. The DEPARTMENT shall withhold a portion, not to exceed $100,000, of
the last month's capitation payment as a surety bond for a six (6)
month period to ensure compliance under the contract.
7.15 WAIVER OF DEFAULT
Waiver of any default shall not be deemed to be a waiver of any subsequent
default. Waiver of breach of any provision of the contract shall not be deemed
to be a waiver of any other or subsequent breach and shall not be construed to
be a modification of the terms of the contract unless stated to be such in
writing, signed by an authorized representative of the DEPARTMENT, and attached
to the original contract.
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8. OTHER PROVISIONS
8.01 SEVERABILITY
If any provision of this procurement or the resultant contract is declared or
found to be illegal, unenforceable, or void, then both parties shall be relieved
of all obligations under that provision. The remainder of this procurement or
the resultant contract shall be enforced to the fullest extent permitted by law.
8.02 EFFECTIVE DATE
This contract is subject to review for form an substance by the U.S. Department
of Health and Human Services Centers for Medicare and Medicaid Services and the
DEPARTMENT, and will not become effective until it is approved by those
agencies.
8.03 ORDER OF PRECEDENCE
This contract shall be read together to achieve one harmonious whole. However,
should any irreconcilable conflict arise between Part I and Part II of this
contract, Part II shall prevail.
8.04 CORRECTION OF DEFICIENCIES
This contract does not release the MCO from its obligation to correct any and
all outstanding certification deficiencies. Failure to correct all outstanding
material deficiencies may cause the MCO to be determined in Default of this
contract.
8.05 THIS IS NOT A PUBLIC WORKS CONTRACT
The DEPARTMENT and the MCO as parties to this purchase of service Contract
mutually covenant, acknowledge and agree that this contract does not constitute
and shall not be construed to constitute a public works contract. The DEPARTMENT
and the MCO's mutual agreement that this contract is not a public works contract
shall have full force and effect on Part I Section 32 and other Sections of this
contract as applicable.
9.0 APPENDICES
The following appendices that were attached to the Purchase of Service Contract
between the MCO and the DEPARTMENT effective August 11, 2001, have not changed
since that date and are hereby incorporated by reference as if fully set forth
herein: Appendix B Provider Credentialing and Enrollment; Appendix C, EPSDT
Periodicity Schedule,
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Appendix D, DSS Marketing Guidelines; Appendix E, Quality Assurance Program;
Appendix F, Unaudited Quarterly Financial Reports; Appendix H, Managed Care
Policy Transmittals; Appendix J, Physician Incentive Payments, Appendix K.
Recategorization Chart. The remaining appendices are attached hereto.
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HUSKY A
Covered Services
For purposes of this contract, the information contained in the Department's
Medical Services Policy Manuals and Departmental regulations has been summarized
to provide an overview for reference of the goods and services covered by the
Medicaid program (see attached list of Medical Assistance Program policies and
regulations). Any limitations or exclusions to these covered goods and services
are also overviewed.
Plans should be advised that, notwithstanding the following summary overview,
guidance issued by the Department in the form of policy transmittals,
regulations, provider bulletins, provider manuals, letters, and other written
correspondence is the final authority regarding covered goods and services. The
intent of the summary is to provide a quick working guide. These policies are
available at the Connecticut Medical Assistance Program website:
xxx.xxxxxxxxxxxxxxxx.xxx. Whenever any questions regarding Medicaid policy
occur, health plans should consult with the Department's Medical Administration
Policy Unit for clarification.
Health plans are required to cover identical goods and services that are covered
under the Medicaid program; health plans do not have the option of adding or
subtracting from the 'benefit package'. These goods and services are included in
plans' capitation rates. However, this does not preclude a decision to provide
an additional benefit (i.e., a noncovered service) for a given member. For
example, on a case-by-case basis, a health plan may decide to cover the cost of
installing a ramp or providing homemaker services or provide inpatient
behavioral health services in an Institution for the Treatment of Mental
Diseases (IMD) (all noncovered services) if so doing would enable a member to
remain at home rather than be placed in an institutionalized setting or to
receive services in a more cost-effective manner.
Under current Medicaid Fee-For-Service (FFS) reimbursement methodology, various
administrative procedures related to payment for covered goods and services are
in place. These procedures are not incumbent upon health plans under Medicaid
Managed Care (MMC). For example, currently Medicaid FFS has administrative
procedures related to physical therapy provided in the home. When physical
therapy exceeds two (2) sessions per any consecutive seven (7) day period,
prior authorization is required.
Whether or not a given health plan requires prior authorization prior to
physical therapy being provided in the home, or requires prior authorization
after x number of visits, or does not require prior authorization at all is not
prescribed. The management of the "benefit" is at the discretion of the health
plan. However, a health plan cannot decide to limit a covered good or service
(e.g., cut off all physical therapy home visits after x number of visits). The
number of medically necessary visits will vary by member, and the health plan
cannot set a limit for members unless the Medicaid "benefit" itself is
specifically limited in Medical Services Policy.
Additionally, medically necessary behavioral health services for children in
Medicaid Managed Care shall include:
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a) the coordination of and linkage to those social and medical services which
ensure the health and safety of the child; b) preventive health care services
that are designed to avoid the need for future medically necessary services; c)
services for chronic, long-term disorders which if left untreated, will effect
the physical or mental health of the child; and (d) the duration of treatment
provided by a managed health plan for these children shall be based on the
individual needs of the child.
The summary overview is divided into three (3) sections. Section A contains a
listing of covered goods and services included in the capitation rates. It also
lists the major limitations and exclusions to these covered goods and services.
Section B contains a listing of covered goods and services not included in the
capitation rates. Section C contains a listing of noncovered services.
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SUMMARY DESCRIPTION OF BENEFITS
A. COVERED SERVICES INCLUDED IN THE CAPITATION PAYMENT
1. Hospital Inpatient Care (acute care hospitals) - Medically necessary and
medically appropriate hospital inpatient acute care, procedures, and
services, as authorized by the responsible physician(s) or dentist, and
covered under Department of Social Services (DSS) policies and regulations.
a. Administratively Necessary Days (ANDs) are covered when a nursing home
placement delay is due to unavailability of beds. However, a patient is
required to accept the first available, medically appropriate bed.
b. Organ transplants are covered if they are of demonstrated therapeutic
value, medically necessary and medically appropriate, and likely to
result in the prolongation and the improvement in the quality of life of
the applicant. The DSS Transplant Advisory Committee has developed, and
continues to develop, medical criteria relating to particular organ
transplant procedures. These criteria are available for use by health
plans. The criteria are guidelines. However, a final decision to deny a
transplant request is not to be rendered without considering the medical
opinion of a qualified organ transplantation expert(s) in the community.
c. Mental health and substance abuse services in a general hospital
psychiatric unit are covered--regardless of the age of the individual.
2. Psychiatric (mental health/substance abuse) Facility Inpatient Care
a. Medically necessary psychiatric hospital care, procedures, and services
as covered under DSS policy and regulation.
b. Some psychiatric hospitals may qualify as an Institution for Mental
Diseases (IMD). An IMD is defined as a facility of more than sixteen
(16) beds that is primarily engaged in providing diagnosis, treatment,
or care of persons with mental diseases. Medically IMD necessary care is
only covered for individuals under age 21 and 65 years of age or older.
IMD services for individuals aged 21 through 64 are noncovered services
(see Section C.1 of this summary overview).
3. Freestanding Alcohol Treatment Center Inpatient Care
a. Services must be provided by a program holding a current and active
license to operate a Private Freestanding Facility for the Care and
Treatment of Substance Abusive or Dependent Persons.
b. Services under the Medicaid program shall be for alcohol detoxification
and shall be limited to: a) the acute and evaluation phase of the
treatment program and b) a ten (10) day period for each occurrence Acute
treatment and evaluation provides medical management of detoxification
and assessment of the individual's total situation in an inpatient
milieu for the purpose of formulating and implementing a plan of care in
addition to detoxification.
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c. Services must predominately focus on the medical and/or psychological
management of alcohol abuse and other medical or psychological
conditions which impact upon or are related to alcohol abuse. Treatment
and care shall be provided under the direction of a physician within the
scope of accepted medical practice.
4. Chronic Disease Hospital Inpatient Care - Such medically necessary care,
procedures, and services as covered under DSS policy and regulation.
5. Nursing Facility (Skilled Nursing and Intermediate Care) Inpatient Care -
Such medically necessary care is covered while the patient remains in a
managed care coverage group. For coverage in nursing Homes which are
characterized as, institutions for mental disease' see Section CA of this
summary overview.
6. Intermediate Care Facility (Mentally Retarded) Inpatient Care - Such
medically necessary care is covered while the patient remains in a managed
care coverage group.
7. Christian Science Sanitoria Service - Such medically necessary care is
covered while the patient remains in a managed care coverage group.
8. Hospital Outpatient Care (General Hospital, Psychiatric Hospital, and
Chronic Disease Hospital) - Preventive, diagnostic, therapeutic,
rehabilitative, or palliative medical services provided to an outpatient by
or under the direction of a physician or dentist in a licensed hospital
facility.
9. Physician Services - Primary and specialty services provided by a licensed
physician or doctor of osteopathy and performed within the scope of practice
of medicine or osteopathy as defined by State law.
10. Psychologist Services - Clinical, diagnostic, and remedial services
personally performed by a psychologist. Services include: a) counseling and
psychotherapy to individuals who are experiencing problems of a mental or
behavioral nature and b) measuring and testing of personality, aptitudes,
emotions, and attitudes.
Note: Effective 9/1/03, psychologist services provided by independently
enrolled psychologists are no longer covered for individuals who are 21
years of age or older.
11. Nurse-Midwifery Services - Services provided by a licensed, certified
nurse-midwife which are related to the care, and to the management of the
care, of essentially normal mothers and newborns (only throughout the
maternity cycle) and well woman gynecological care, including family
planning services.
12. Nurse Practitioner Services - Services which are provided by a licensed
Advanced Practice Registered Nurse (APRN) and which are within his or her
scope of practice as defined by State law.
13. Chiropractor Services - Manual manipulation of the spine performed by a
licensed chiropractor within the scope of chiropractic practice. Noncovered
services:
a. Prescription or administration of any medicine or drug or the
performance of any surgery;
b. X-rays furnished by a chiropractor.
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c. Manipulation of other parts of the body (e.g., shoulder, arm, knee,
etc.) even when for subluxation of the spine; and
d. Lab work ordered by a chiropractor.
Note: Effective 1/1/03, chiropractor services provided by independently enrolled
chiropractors are no longer covered for individuals who are 21 years of age or
older.
14. Naturopathic Services - Services provided by a licensed naturopath which
conform to accepted methods of diagnosis and treatment and which are within
the scope of naturopathic practice.
Note: Effective 1/1/03, naturopathic services provided by independently enrolled
naturopaths are no longer covered for individuals who are 21 years of age or
older.
15. Podiatrist Services - Services provided by a licensed podiatrist which
conform to accepted methods of diagnosis and treatment and which are within
the scope of podiatric practice.
Note: Effective 1/1/03, podiatrist services provided by independently enrolled
podiatrists are no longer covered for individuals who are 21 years of age or
older.
a. Limitations of Coverage
i. Orthotic and/or corrective arch supports for recipients under five
years of age; and
ii. Orthotic and/or corrective arch supports only once every two (2)
years.
b. Noncovered Services
i. Services of assistants at surgery;
ii. Simplified tests requiring minimal time or equipment and employing
materials nominal in cost such as Clinitest, testape, Hematest,
Bumintest, Dextrostix, nonphotolitric hemogloblin, etc.;
iii. Simple foot hygiene; and
iv. Repairs to devices judged to be necessitated by willful or
malicious abuse on the part of the patient.
16. Laboratory Services - Laboratory services: a) ordered by a duly licensed
physician or other licensed practitioner of the healing arts; and b)
performed in a laboratory which is certified according to the applicable
provisions of the Clinical Laboratory Improvement Amendments of 1988 (CLIA )
and meets all applicable licensing, accreditation and certification
requirements for the specific services and procedures it provides.
17. Outpatient Medical Rehabilitation Services - Medically necessary and
medically appropriate outpatient rehabilitation services provided by a
licensed or certified practitioner. Such services include: physical
therapy, occupational therapy, speech therapy, audiology, inhalation
therapy, social services, psychological services, traumatic brain injury
(T.B.I.) day treatment, neuropsychological evaluation, electonystagmography,
and early childhood intervention services.
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Note: Effective 1/1/03, services provided by independently enrolled physical
therapists, audiologists and speech pathologists are no longer covered for
individuals who are 21 years of age or older. Services provided by independently
enrolled psychologists will no longer be covered for individuals who are 21
years of age or older effective 9/1/03.
a. Limitations include:
i. Sheltered workshop services for individuals who are primarily
developmentally disabled are covered only if their need for
this type of program stems from an etiology readily
identifiable as medical or psychological in origin;
ii. T.B.I. treatment programs are limited to individuals who have
sustained injury from interaction of any external forces
resulting in the central nervous system (brain) dysfunctions.
Developmental impairment primarily contributing to brain
dysfunction is not included. The impairment must be readily
identifiable as having been sustained through injury;
iii. The T.B.I. program is primarily a medical rehabilitation
program, however, vocational, social, and educational services
may be covered only when these services are: a) related to the
individual's injury, b) are reasonable and necessary for the
diagnosis or treatment of the injury, and c) are a part of the
recipient's written individual plan of care; and
iv. Programs relating to the learning of basic living skills, or
other activities of daily living, are limited to individuals
who have lost or had impaired functions of daily living and
require retraining to maximize restoration of these skills.
b. Noncovered Services include:
i. Services which are related solely to specific employment
opportunities, work skills, work settings, and/or academic
skills and are not reasonable or necessary for the diagnosis
or treatment of an illness or injury;
ii. Speech services involving nondiagnostic, nontherapeutic,
routine, repetitive, and reinforced procedures or services for
the patient's general good and welfare; and
iii. Services ordinarily covered are not covered if an individual's
expected restoration potential would be insignificant in
relation to the extent and duration of rehabilitation services
required to achieve such potential.
18. Vision Care - Services performed by a licensed ophthalmologist,
optometrist, or optician which conform to accepted methods of diagnosis
and treatment.
Limitations of Coverage
i. Contact lenses are covered when such lenses provide better
management of a visual or ocular condition than can be
achieved with spectacle lenses, including, but not limited to
the diagnosis of Unilateral Aphakia, Keratoconus, Corneal
Transplant, and High Anisometropia;
ii. Prescription sunglasses are covered when light sensitivity
which will hinder driving or seriously handicap the outdoor
activity of a patient is evident;
6
August 13, 2003
iii. Trifocals are covered when the patient has a special need due
to job training program or extenuating circumstances;
iv. Extended wear contact lenses are covered for aphakia and for
members whose coordination or physical condition make daily
usage of contact lenses impossible;
v. Oversize lens are covered only when needed for physiological
reasons, and not for cosmetic reasons; and
vi. A spare pair of eyeglasses is not covered.
19. Dental Care - Services performed by a licensed dentist or dental hygienist
which conform to accepted methods of diagnosis and treatment.
The categories of covered services are as follows:
a. Diagnostic Services
i. Home visits;
ii. Radiographs: a) intraoral, complete series; b) bitewing films;
and c) periapical films; and
iii. Oral examinations: a) initial oral exam; b) periodic oral
exam; and c) emergency oral exam.
b. Preventive Services
i. Prophylaxis;
ii. Fluoride treatment for children under 21;
iii. Space maintainers;
iv. Night guards; and
v. Pit and fissure sealants for children ages 5 through 16. Prior
authorization is required for children under 5 and persons
over 16.
c. Restorative Services - limited to the restoration of carious
permanent, and primary teeth.
i. Fillings; and
ii. Crowns.
d. Endodontics
i. Root canal therapy and/or apicoectomy; and
ii. Apexification.
e. Prosthodontics - removable, complete, and partial prostheses;
f. Dental Surgery;
9. Edodontia (extractions);
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August 13, 2003
h. Orthodontics under the Early Periodic Screening, Diagnosis and
Treatment (EPSDT) program;
i. Alveolectomy (alveoplasty);
j. Patient Management - in connection with dental services to
individuals with cognitive disabilities;
k. General Surgical Anesthesia;
l. Prosthodontics with use on a regular basis;
m. Removable, complete and partial denture prostheses only; and
n. Replacement of existing dentures, only once in any five (5) years.
o. Relining or rebasing existing dentures - Two (2) year period.
p. Denture labeling, for patients in long-term care facilities only.
The categories of noncovered services are as follows:
a. Fixed Bridges
b. Periodontia
c. Implants
d. Transplants
e. Cosmetic Dentistry
f. Vestibuloplasty
g. Unilateral Removable Appliances
h. Partial dentures where there are at least eight (8) posterior teeth
in occlusion and no missing anterior teeth.
i. Restorative procedures to deciduous teeth nearing exfoliation.
20. Durable Medical Equipment - equipment which: a) can stand repeated use; b)
is primarily and customarily used to serve a medical purpose; c) is
generally not useful to a person in the absence of an illness or injury;
and d) excludes items that are disposable.
Equipment covered includes: wheelchairs and accessories, walking aids,
bathroom equipment (e.g., commode and safety equipment), hospital beds
and accessories, inhalation therapy equipment (e.g., IPPR machines,
suction machines, nebulizers, and related equipment), enteral/parenteral
therapy equipment, and the repair and replacement of durable medical
equipment (DME) and related equipment.
21. Orthotic and Prosthetic Devices - Mechanical appliances and devices for
the purpose of providing artificial replacement of missing parts, and/or
prevention or correction of disorders in involving physical deformities
and impairments.
8
August 13, 2003
a. Devices covered include: braces, corsets, collars, arch supports,
footplates, orthopedic shoes, orthopedic prostheses, hearing aids
(including batteries, earmolds, and cords).
b. Limitations: i) orthotic and/or corrective arch supports are not
provided for recipients under five years of age; ii) Metatarsus
Adductus Shoes are limited to a congenital metatarsus adductus
condition and are limited to children through age four as medically
necessary.
22. Oxygen Therapy - oxygen, equipment, supplies, and services related to the
delivery of oxygen.
23. Respiratory Therapy - services include: intermittent positive pressure
breathing, ultrasonography, aerosol, sputum induction, percussion and
postural drainage, arterial puncture, and withdrawal of blood for
diagnosis.
24. Dialysis - hemodialysis and peritoneal dialysis services are covered,
including the treatment of end stage renal disease.
25. School-Based Clinics - services provided at a facility: a) located on the
grounds of a public school; b) serving enrolled recipients on a scheduled
basis or for an emergency situation; and c) licensed as an outpatient
medical facility to provide comprehensive care.
a. Covered services include: health assessments; family planning
services; diagnosis and/or treatment of illness or injuries;
laboratory testing (performed by the School-Based Health Clinic);
follow-up visits; EPSDT services; one-on- one health education,
medical social work services, and nutritional counseling; and mental
health and substance abuse services including diagnostic
assessments, individual, group, and family therapy or counseling.
b. Noncovered services include: mandated school health screenings,
simple intervention of a health problem such as nonmedical personnel
could render, visits where the presenting health problem does not
require a health or mental health assessment/evaluation, visits for
the sole purpose of administering or monitoring medications,
services which are not part of the written individual plan of care,
and visits for mental health or substance abuse determined by the
clinic to be beyond the scope of the clinic.
26. Family Planning and Abortion - medically approved diagnostic procedures,
treatment, counseling, drugs, supplies, or devices which are prescribed or
furnished by a provider to individuals of child bearing age for the
purpose of enabling such individuals to freely determine the number and
spacing of their children.
Noncovered services include: a) sterilizations for patients who are under
age twenty-one (21), mentally incompetent, or institutionalized; and b)
hysterectomies performed solely for the purpose of rendering an individual
permanently incapable of reproducing.
27. Ambulatory Surgery - Services include preoperative examinations, operating
and recovery room services, and all required drugs and medicine.
9
August 13, 2003
28. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services
(HealthTrack Services)- Comprehensive child health care services to
recipients under twenty-one (21) years of age, including all medically
necessary prevention, screening, diagnosis, and treatment services listed
in Section 1905(r) of the Social Security Act.
EPSDT Covered Services are described below:
a. Initial and Periodic Comprehensive Health Screenings - includes the
following services provided at the intervals recommended in the
Periodicity Schedule consistent with the standards of the American
Academy of Pediatrics and Center for Disease Control:
i. a comprehensive health and developmental history, including
assessment of both physical and mental health development and
nutritional assessments;
ii. a comprehensive unclothed physical examination;
iii. appropriate immunizations according to age and health history,
unless medically contraindicated at the time;
iv. appropriate laboratory tests (including blood lead level
assessments appropriate for age and risk factors);
v. health education (including anticipatory guidance and risk
assessment);
vi. diagnosis and treatment of problems found during the
screening;
vii. vision screenings - an objective vision screening is indicated
beginning at three years of age as indicated in accordance
with the Periodicity Schedule;
viii. hearing screenings - an objective hearing screening is
indicated beginning at four years of age according to the
Periodicity Schedule; and
ix. dental screenings are recommended in the Periodicity Schedule,
for example, an initial direct referral to a dentist beginning
at age two.
b. Dental Services - includes those dental services provided by or
under the direction of a dentist, in addition to the dental
screening, that are recommended in the Periodicity Schedule. Dental
services also include relief of pain and infections, restoration of
teeth, and maintenance of dental health.
c. Administration and Medical Interpretation of Developmental Tests -
objective standardized tests, recognized by the Connecticut
Birth-To-Three Council, for further diagnosis and treatment of
problems found during a periodic comprehensive health screen or
interperiodic encounter. Such tests include, but are not limited to,
the Battelle, the Xxxxxx, and the Bayley.
d. Case Management Services - The following services are determined to
be necessary when a child evidences a need for such services as a
result of a periodic comprehensive health screening or interperiodic
encounter:
i. Initial case management assessment and periodic reassessment,
including development of the plan of services and revision as
necessary.
ii. Ongoing case management, including, at a minimum:
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August 13, 2003
A) assistance in implementing the plan of services, which
includes: facilitating referrals, providing assistance in
scheduling needed health or health-related services, and
helping to identify and link with the child's health and
social service providers. Particularly, the case management
provider shall identify the child's health home or, if
necessary, participate in linking the child with a quality
health home, and encourage continuity of care;
B) monitoring the delivery of and facilitating access to a
periodic comprehensive health screening at the intervals
recommended in the Periodicity Schedule, and other
screening, diagnosis, and treatment services. Such
activities also include follow-up on missed
appointments, and, if necessary, assistance with
arranging medical transportation, child care, and
interpreter services;
C) coordinating and integrating the plan of services, as
necessary, through direct or collateral contacts with
the family and members of their team of direct service
providers, as appropriate;
D) monitoring the quality and quantity of needed services
that are being provided, and evaluating outcomes and
assessing future needs which might support changes in
the plan of services, including completing a quarterly
progress note;
E) providing health education, as needed, and in
coordinating with a direct service provider,
interpreting and reinforcing the service provider's
recommendations for the health of the child; and
F) providing client advocacy to ensure the smooth flow of
information between the child, the child's
representative, providers, and agencies, to minimize
conflict between service providers, and to mobilize
resources to obtain needed services.
e. Interperiodic Encounters
i. An encounter or visit to determine if there is a problem, or
to treat a problem that was not evident at the time of the
regularly scheduled periodic comprehensive screening but needs
to be addressed before the next periodic comprehensive
screening;
ii. Any screening, in addition to the screenings recommended in
the Periodicity Schedule, to determine the existence of
suspected physical, mental, or developmental conditions;
iii. An encounter or follow-up visit in the case of a child whose
physical, mental, or developmental illness or condition has
already been diagnosed prior to the child being Medicaid
eligible (e.g., a pre-existing condition), but needs to be
addressed before the next scheduled screening interval
recommended in the Periodicity Schedule, if there are
indications that the illness or condition may have become more
severe or changed sufficiently so that further examination is
medically necessary; and
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August 13, 2003
iv. An encounter necessary to provide immunizations, vision,
and/or hearing screenings (e.g., which had been deemed
medically contraindicated at the time of the periodic
comprehensive health screening).
f. Personal Care Services - services for a child who has a diagnosed
disability and is judged to be able to benefit from one (1) or more
personal care service activities as the result of a periodic
comprehensive health screen or interperiodic encounter performed by
a primary care provider.
i. Covered personal care services include all tasks to assist a
child with major life activities of self-care and instrumental
activities as identified in the personal care services plan of
care:
A) covered major life activities include, but are not
limited to, dressing, bathing, eating, and personal
health care maintenance; and
B) covered instrumental activities include, but are not
limited to, cooking, cleaning, travel, and shopping.
ii. The following services are not covered:
A) personal care services provided to an individual who
does not reside at home;
B) personal care services provided by a family member;
C) home health services which duplicate personal care
services (e.g., home health aide services are not
covered when personal care services are appropriate);
D) transportation of the personal attendant to and from the
child's home to provide services;
E) acute health care services which are covered under other
DSS regulations;
F) personal care services when the child is eligible for or
receiving comparable services from another agency or
program; and
G) personal care services for the care or assistance that
would routinely be given to a child in the absence of a
disability.
g. EPSDT Special Services - other medically necessary and medically
appropriate health care, diagnostic services, treatment, or other
measures necessary to correct or ameliorate disabilities and
physical and mental illnesses and conditions discovered as a result
of a periodic comprehensive health screening or interperiodic
encounter, whether or not the good or service is included in the
Connecticut Medicaid Program State Plan as a good or service
available to all other Medicaid recipients. Such services include,
but are not limited to, medically necessary and medically
appropriate over-the-counter drugs and personal care services.
h. All medically necessary diagnosis and treatment services available
to all Medicaid recipients under the Connecticut Medical Assistance
Program.
12
August 13, 2003
29. Diagnostic Services - Medical procedures (e.g., radiology, cardiology,
EEG, and ultrasound procedures) or supplies recommended by a physician or
other licensed practitioner of the healing arts, within the scope of
his/her practice under State law, to enable the identification of the
existence, nature, or extent of illness, injury, or other health
deviation.
30. Home Health Care - Medically necessary home health services ordered by the
licensed practitioner and provided by a licensed home health agency on a
part-time or intermittent basis to members who reside at home, as defined
by Departmental policy, for the purpose of enabling the patient to remain
at home or to provide a less costly alternative to institutional care.
31. Mental Health/Substance Abuse Services-Medically necessary outpatient
Mental Health and Substance Abuse services provided by a licensed
psychiatrist (or under the supervision of a licensed psychiatrist) or
other licensed or certified mental health practitioner. Such services
must be provided within the scope of the practitioner's
license/certification.
a. Covered services include:
i. Initial evaluation (diagnostic);
ii. Mental health and substance abuse treatment services:
A) Individual psychotherapy;
B) Group psychotherapy;
C) Family therapy;
D) Specialized treatment, such as methadone maintenance and
outpatient detoxification; and
E) Partial hospitalization.
iii. Physical/neurological exams in connection with evaluation of
mental illness;
iv. Parent interview/group - Children's Mental Health Services;
v. Psychological testing - performed by licensed psychologists
only; and
vi. Neuropsychological evaluation performed by a qualified
neuropsychologist.
b. Noncovered services: Hypnosis or electroshock therapy, unless
personally performed by a licensed practicing physician (M.D.).
32. Medical Transportation Services
a. Emergency and Nonemergency Ambulance Service is covered when: Q the
patient's condition requires medical attention during transit; or
ii) the patient's diagnosis indicates that the patient's condition
might deteriorate in transit to the point where medical attention
would be needed; or iii) the patient's condition requires hand
and/or feet restraints; or iv) the ambulance is responding to an
emergency; or v) no alternative less expensive means of
transportation is
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August 13, 2003
available. Ambulance trips to an emergency room, regardless of the
outcome, nor ambulance trips in response to a 911 call, cannot be
subject to prior authorization.
b. Air Transportation - when a medical condition or time constraint
dictates its use.
c. Critical Care Helicopter - when a medical condition or time
constraint dictates its use.
d. Other Nonambulance Transportation [Livery, Invalid Coach, Commercial
Carrier, Taxi, Private Transportation, Service bus ("Dial-a-Ride"
type service), etc.] - when needed to obtain necessary medical
services covered by Medicaid, and when it is not available from
volunteer organizations, other agencies, personal resources, etc. To
administer this benefit, DSS currently employs the following
limitations on services:
i. requirement of prior authorization;
ii. requirement of the use of the nearest appropriate provider of
medical services when a determination has been made that
traveling further distances provides no medical benefit to the
patient; and
iii. requirement of the use of the least expensive appropriate
method of transportation, depending on the availability of the
service and the physical and medical circumstances of the
patient.
e. Transportation for relatives or xxxxxx parents of a Medicaid
recipient - only under the following circumstances:
i. the person needs to be present at and during the medical service being
provided to the patient (for example, in parent/child situations); and
ii. the person needs to be trained by hospital staff to provide unpaid health
care in the home to the patient, and without this health care being
provided the patient would not be able to return home.
vii. Children under twelve (12) years of age shall be escorted to medical
appointments. Either the child's parent xxxxxx parent, caretaker, legal
guardian or the Department of Children and Families (DCF), as appropriate,
shall be responsible for providing the escort.
viii. For children between the ages of twelve (12) to fifteen (15) years, a
consent form signed by a parent, caretaker or guardian shall be required
in order for a child to be transported without parental consent as
specified by state statute (i.e., for family planning and mental health
treatment).
ix. For children sixteen (16) years or older, no consent form shall be
required.
f. Out-of-State Transportation Services - when out-of-state- medical
services are needed because of the following:
i. a medical emergency;
ii. the patient's health would be endangered if required to travel
to Connecticut; and
iii. needed medical services are not available in Connecticut.
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August 13, 2003
33. Medical Surgical Supplies - those items which are prescribed by a
physician to meet the needs or requirements of a specific medical and/or
surgical treatment. They are generally disposable and not reusable.
a. Covered services include: gauze pads, surgical dressing material,
splints, tracheotomy tube, diabetic supplies, elastic hosiery,
sterile gloves, incontinence supplies, thermometers, blood pressure
kit (aneroid type including stethoscope, but limited to use in the
home for patient's diagnosed to have complicated cardiac conditions
and labile hypertension), enteral/parenteral feeding therapy
supplies including solutions and manufacturing materials,
b. Items considered first aid supplies such as, bandages, solutions,
vaseline, etc., are not covered services.
34) Pharmacy Services
a) Covered services
i) Drugs prescribed by a licensed authorized practitioner. The
MCO may use a prescription drug formulary which is described
in Section 3.15, Pharmacy Access of the contract.
ii) Over-The-Counter (OTC) Drugs on the State of Connecticut's OTC
Formulary, including liquid generic antacids, birth control
products, calcium preparations, diabetic-related products,
electrolyte replacement products, heratinics, nutritional
supplements and vitamins (prenatal, pediatric, high potency).
b) Noncovered Services
i) Drugs included in the Food and Drug Administration's Drug
Efficacy Study Implementation Program;
ii) Alcoholic liquors;
iii) Items used for personal care and hygiene or cosmetic purposes;
iv) Drugs solely used to promote fertility;
v) Drugs not directly related to the patient's diagnosis, when
diagnosis is required by the DEPARTMENT to be written on the
prescription;
vi) Any vaccines and/or biologicals which can be obtained free of
charge from the CT. State Department of Health Services. The
DEPARTMENT will notify pharmacists of such vaccines or
biologicals;
vii) Any drugs used in the treatment of obesity unless caused by a
medical condition;
viii) Controlled substances dispensed to HUSKY members which are in
excess of the product manufacturer's recommendation for safe
and effective use for which there is no documentation of
medical justification in the pharmacy's file; and,
ix) drugs used to promote smoking cessation.
15
August 13, 2003
35. Emergency Services - such inpatient and outpatient services in and out of
the health plan's service area are covered services.
36. Dental Hygienist Services - Services which are provided by a licensed
dental hygienist and which are within his or her scope of practice as
defined by State Law.
B. COVERED SERVICES NOT INCLUDED IN THE CAPITATION PAYMENT
1. School-Based Child Health Services - Medically necessary special education
related diagnostic and treatment services provided to children by or on
behalf of school districts pursuant to the Individuals with Disabilities
Education Act (IDEA) and Connecticut General Statutes (CGS). Diagnostic
services must be ordered by a Planning and Placement Team and treatment
services must be prescribed in a child's Individualized Education Program
(IEP)--and verified by a physician's signature.
2. Connecticut Birth to Three Program Services - The Connecticut Birth to
Three Program, pursuant to the Individuals with Disabilities Education Act
(IDEA) and Connecticut General Statutes (CGS), provides a range of early
intervention services for eligible children from birth to three years of
age with developmental delays and disabilities. Eligibility of children is
determined by Department of Mental Retardation (DMR) staff or entities
with which DMR contracts. Services are authorized in an Individualized
Family Service Plan (IFSP) and verified by a physician's signature.
3. Inpatient Department of Children and Families (DCF). Operated Psychiatric
Facilities - The discharge planning and reinsurance provisions described
in Section 3.18 (Special Services for Children) shall apply to all new
medically necessary and administratively necessary admissions at DCF
operated facilities effective October 1, 1998. When a child is admitted to
a DCF facility, the child will remain enrolled in the MCO and the MCO must
reimburse the DCF facility at the rate as calculated by the Office of the
Comptroller, provided that such admissions shall be governed by a
memorandum of understanding between the MCOs and DCF outlining the terms
and conditions for admission and stays at the facility.
C. NONCOVERED SERVICES
1. Institutions for Mental Disease (IMD) - The federal definition of an IMD
is a hospital, nursing facility, freestanding alcohol treatment center, or
other institution of more than sixteen (16) beds that is primarily engaged
in providing diagnosis, treatment, or care of persons with mental
diseases.
a. IMD Exclusion - Medicaid does not cover IMD services (i.e., these
services are excluded). States, rather than the Federal Government,
have principle responsibility for funding inpatient psychiatric
services; therefore, State funding of IMI)s is not through the
Medicaid program.
b. Exceptions - certain individuals are not part of the IMD exclusion
(i.e., they are covered by Medicaid for services in IMDs):
i. inpatient psychiatric services for individuals under age 21;
16
August 13, 2003
ii. individuals 65 years of age or older who are in hospitals or
nursing facilities that are IMDs.
2. Services and/or procedures considered to be of an unproven, experimental,
or research nature or cosmetic, social, habilitative, vocational,
recreational, or educational.
3. Services in excess of those deemed medically necessary to treat the
patient's condition.
4. Services not directly related to the patient's diagnosis, symptoms, or
medical history.
5. Any services or items furnished for which the provider does not usually
charge.
6. Medical services or procedures in the treatment of obesity, including
gastric stapling. When obesity is caused by an illness (hypothyroidism,
Xxxxxxx'x disease, hypothalamic lesions) or aggravates an illness
(cardiac and respiratory diseases, diabetes, hypertension) services in
connection with the treatment of obesity could be covered services.
7. Services related to transsexual surgery or for a procedure which is
performed as part of the process of preparing an individual for
transsexual surgery, such as hormone therapy and electrolysis.
8. Services for a condition that is not medical in nature.
9. Routine physical examinations requested by third parties, such as
employers or insurance companies.
10. Drugs that the Food and Drug Administration (FDA) has proposed to withdraw
from the market in a notice of opportunity for hearing.
11. Tattooing or tattoo removal.
12. Punch graft hair transplants.
13. Tuboplasty and sterilization reversal.
14. Implantation of nuclear-powered pacemaker.
15. Nuclear powered pacemakers.
16. Inpatient charges related to autopsy.
17. All services or procedures of a plastic or cosmetic nature performed for
reconstructive purposes, including but not limited to lipedtomy, hair
transplant, rhinoplasty, dermabrasion, and chernabrasion.
18. Drugs solely used to promote fertility.
19. Drugs used to promote smoking cessation.
20. Services which are not within the scope of a practitioner's practice under
state law.
21. Acupuncture provided outside of pain management therapy.
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August 13, 2003
MEDICAL ASSISTANCE PROGRAM POLICIES AND REGULATIONS BY
PROVIDER AREA
Provider Area Policy or Regulation Sections
------------- -----------------------------
Birth to Three Sections 17b-262-597 through 17b-262-605
of the Regulations of Connecticut State
Agencies
Case Management Services to Persons Proposed Regulations
Under 21
Chiropractic Services Sections 17b-262-535 through 17b-262-545
of the Regulations of Connecticut State
Agencies
Clinics Sections 171 through 171 B. XI of Medical
Services Policy and Sections 17-134d-7
through 17-134d-8, 17-134d-56 and 17-
134d-70 through 17-134d-78 of the
Regulations of Connecticut State Agencies
Mental Health Clinics Sections 171.1 through 171.11.iii.m. of
Medical Services Policy
Rehabilitation Clinics Sections 171.2 through 171.2l.lll.k. of
Medical Services Policy
Dental Clinics Sections 171.3 through 171.3l.lll.f. of
Medical Services Policy
Medical Clinics Sections 171.4 through 171.4l.lll.i. of
Medical Services Policy
Dental Services Sections 184 through 184l.lll.h. of Medical
Services Policy and Section 17-134d-35 of
the Regulations of Connecticut State
Agencies
Dialysis Sections 17b-262-651 through 17b-262-
660 of the Regulations of Connecticut State
Agencies
Early and Periodic Screening, Diagnostic Included in Regulations with Other
and Treatment Services (Health Track Providers
Services)
Family Planning, Abortions and Sections 173 through 173l. of Medical
Hysterectomies Services Policy
Freestanding Alcohol Treatment Centers Sections 160 through 160l. of Medical
Services Policy
Home Health Services Sections 185 through 185l.lll.b.4. of
18
August 13, 2003
Medical Services Policy and Sections 17-134d-37,
17-134d-48, 17-134d-60, 17-134d-62 and 17b-262-1
through 17b-262-9 of the Regulations of Connecticut
State Agencies
Hospital Inpatient Services Sections 150.1 through 150.1I.VI.d of
Medical Services Policy and Sections 19a-630,
17b-225, 17b-238 through 17b-247, 17b-262,
19-13D, 19a-490 through 19a-493, 19a-495 of the
Regulations of Connecticut State Agencies
Hospital Outpatient Services Sections 150.2 through l50.2J.V.n of
Medical Services Policy and Sections 4-67c (fees),
17-311 (payments), 17-312 (payments), 19a-490
(licensing), 19a-493 (licensing) of the Connecticut
General Statutes and Sections 19-13D, 17-134d-2
(Medical Care), 17-134d-40 (payments - clinic),
17-134d-63 (out-of-state hospitals), 17-134d-86
(emergency room) of the Regulations of Connecticut
State Agencies.
Inpatient Psychiatric Hospital Services Sections 17b-262-499 through 17b-262-510 of the
Regulations of Connecticut State Agencies
Intermediate Care Facility Sections 156 through 156l.l.b.6. of Medical
Services Policy and Section 17-134d-47 of
the Regulations of Connecticut State
Agencies.
Independent Radiology and Ultrasound Sections 17b-262-512 through 17b-262-520 of the
Centers Regulations of Connecticut State Aagencies.
Independent Therapy Services Sections 17b-262-630 through 17b-262-640 of the
Regulations of Connecticut State Agencies.
Laboratory Services Sections 17b-262-641 through 17b-262-650 of the
Regulations of Connecticut State Agencies.
Medical Equipment, Devices and Supplies See Below.
(MEDS)
Medical Surgical Supplies Sections 188 through 188J. of Medical
Services Policy
Durable Medical Equipment Sections 17b-262-672 through 17b-262-
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August 13, 2003
682 of Medical Services Policy
Orthotic and Prosthetic Devices Sactions 190 through 190l.iii.k. of Medical
Services Policy
Oxygen Therapy Section 196 of Medical Services Policy and
17-134d-83 through 17-134d-85 of the
Regulations of Connecticut State Agencies
Natureopathic Services Sections 17b-262-547 through 17b-262-
557 of the Regulations of Connecticut State
Agencies
Nurse-Midwifery Services Sections 17b-262-573 through 17b-262-
585 of the Regulations of Connecticut State
Agencies
Nurse Practitioner Services Sections 17b-262-607 through 17b-262-
618 of the Regulations of Connecticut State
Agencies
Pharmacy Sections 174 through 174H.IV.a.4. of
Medical Services Policy and Section 17-
134d-81 of the Regulations of Connecticut
State Agencies
Physician's Services Sections 17b-262-337 through 17b-262-
449 of the Regulations of Connecticut State
Agencies
Podiatric Services Sections 179 through 179l.ll.b. of Medical
Services Policy
Provider Participation Sections 17b-262-522 through 17b-262-
533 of the Regulations of Connecticut State
Agencies
Psychiatrists Sections 17b-262-452 through 17b-262-
463 of the Regulations of Connecticut State
Agencies
Psychologists Sections 17b-262-467 through 17b-262-
478 of the Regulations of Connecticut State
Agencies
School Based Child Health Services Sections 17b-262-213 through 17b-262-
224 of the Regulations of Connecticut State
Agencies
Skilled Nursing Facility Sections 154 through 154l.l.b.6. of Medical
Services Policy and Sections 17-134d-46, 17-134d-68
and 117-134d-79 of the Regulations of Connecticut
State Agencies
20
August 13, 2003
Targeted Case Management Services Sections 194 through 194J.b and 195
through 195J. of Medical Services Policy and Sections
17-134d-82 and 17-134d-139 through 17-134d-149 of the
Regulations of Connecticut State Agencies
Transportation Services Section 17b-134d--33 of the Regulations
of Connecticut State Agencies
Vision Care Services Sections 17b-262-559 through 17b-262-
571 of the Regulations of Connecticut State
Agencies, DSS Policy Transmittal MS 93-
18 and DSS Policy Bulletin 98-19.
21
August 13, 2003
Appendix G: Medicaid Managed Care Eligibility
Categories
Revised 8/13/03
August 13, 2003
HUSKY A MEDICAID COVERAGE
GROUPS
Eligibility
Code Description
----------- -----------
F01 Temporary Assistance to Needy Families (TANF)
F03 Transitional Work Extension
F04 Child Support Extension
F05 Work Supplementation
F07 Family Coverage (100% FPL)
F08 Special Child Care Deduction
F09 Eligible for TANF except for Non-Medicaid Requirements
F10 Newborn Coverage
F11 Newborn Children
F12 CN Ribicoff Children
F25 Children under 185 % of the Federal Poverty Level (FPL)
F95 Children under 18, 18-21, and Caretaker Relatives
P01 Pregnant Women who meet TANF Financial Requirements
P02 Pregnant Women under 185 % of the Federal Poverty Level (FPL)
P95 Pregnant Women Coverage
MO1\M02 Pregnant Women Extension (Post-Partum)
D01\D02 DCF Children
Revised 8/13/03
APPENDI[ILLEGIBLE]-Amended
PLAN NAME:
FIRSTCHOICE
CAPITATION RATES
07/01/02 - 09/30/03
FAIRFIELD HARTFORD LITCHFIELD MIDDLESEX NEW HAVEN NEW LONDON TOLLAND XXXXXXX
---------- -------- ---------- --------- --------- ---------- ------- -------
UNDER ONE $536.44 $606.89 $605.12 $717.18 $602.97 $600.00 $724.78 $581.51
AGES 1 TO 14 $102.32 $110.46 $110.15 $130.10 $109.79 $109.23 $131.46 $107.71
MALE - AGES 15 TO 39 $127.22 $138.42 $138.03 $162.52 $137.60 $136.94 $164.18 $135.18
FEMALE - AGES 15 TO 39 $207.77 $231.48 $230.81 $273.76 $230.00 $228.84 $276.70 $223.07
MALE - AGES 40 AND OVER $227.33 $254.24 $253.48 $301.18 $252.59 $251.31 $304.41 $244.68
FEMALE - AGES 40 AND OVER $218.52 $244.15 $243.42 $289.20 $242.55 $241.32 $292.32 $235.04
PAGE 1 OF 1
Effective 7/1/02
August 13, 0000 Xxxxxxxx X
XXXXXXXX XXXXXX # 0: PRESCRIPTION EQUEST PROCESS FOR LEGEND DRUGS
NAME OF MCO Quarter Ending
NUMBERS ARE FOR PRESENTATION PURPOSES ONLY.
NUMBER OF REQUESTS *
-----------------------------------------------------
TEMPORARY
SUPPLY
REQUESTS FOR AUTHORIZATION AND OUTCOME TOTAL ** GRANTED APPROVED DENIED OTHER
-------------------------------------- -------- ------- -------- ------ -----
1. URGENT CERTIFIED BY PRESCRIBER = = = - -
2. ROUTINE - = = -
3. TEMPORARY SUPPLY ISSUED PENDING REVIEW = = = - -
4. UNDUPLICATED TOTAL OF REQUESTS FOR PERIOD - - - - -
NUMBER OF REQUESTS
-----------------------------------------------------
TEMPORARY
SUPPLY
REQUESTS FOR AUTHORIZATION AND OUTCOME TOTAL ** GRANTED APPROVED DENIED OTHER
-------------------------------------- -------- ------- -------- ------ -----
5. SUBSEQUENT REFILL OF A DRUG PREVIOUSLY
ISSUED AS A TEMP. SUPPLY IN EITHER 1 OR 3
ABOVE (URGENT CERTIFIED BY PRESCRIBER/TEMP
SUPPLY PENDING REVIEW) - = = -
6. A TEMPORARY SUPPLY ISSUED IN 1 OR 3 ABOVE,
BUT PRESCRIPTION DOES NOT HAVE ANY REFILLS
(I.E. 10 DAY TREATMENT) =
7. TOTAL MEMBER MONTHS THIS QUARTER =
8. NUMBER PER MEMBER PER MONTH (4/7) #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!
August 13, 2003 Appendix L
9. TOTAL PRESCRIPTIONS FILLED BY THE MCO
THIS QUARTER
10. PERCENT OF AUTH. REQUESTS TO TOTAL
PRESCRIPTIONS FILLED BY THE MCO
(EXAMPLE 2+5/9) #DIV/0!
TICK XXXX LEGEND
* Drugs requiring authorization include non-formulary drugs, formulary
drugs that require authorization, and brand name drugs where a
generic substitute is available. It excludes those prescriptions
which may require prior authorization but on-line edits in the POS
system approve and adjudicate the claim without any intervention on
the part of the MCO and/or Pharmacy Benefits Manager. It also
excludes over the counter drugs.
** Include only requests for authorization completed during this
quarter.
*** The time elapsed between when the request was received by PBM or MCO
and when the decision was made.
1. Initial requests received from a provider for an urgent/emergent
medication need, where a temporary supply is issued.
2. Requests for authorization of non-formulary drugs, formulary drugs
that require authorization, and brand name drugs where a generic
substitute is available. All scenarios which do not meet the
criteria of category 1 or 3.
3. All prescriptions that result in the issuance of a temporary supply
except for temporary supplies issued upon provider certification of
urgency
4. The total of request certified as urgent by prescriber, requests
that are routine, and requests pending review. The total of 1, 2 and
3 above.
5. Requests received from provider after a temporary supply has already
been issued in either 1 or 3 above.
6. A temporary supply was provided to the member in either 1 or 3
above, however, a refill of the prescription has not been requested.
7. The total member months for reporting period.
August 13, 2003 Appendix L
TURN AROUND TIME TO APPROVE/DENY OR ISSUE A TEMPORARY AVERAGE TIME ELAPSED SINCE AUTHORIZATION
PERCENT OF TOTAL SUPPLY (carret) REQUEST RECEIVED BY MCO (HOURS) *** (double carret)
-------------------- -------------------------------------------------------- ---------------------------------------------------
TEMP SUPPLY
GRANTED <24 HOURS - 5 WEIGHTED
/APPROVED DENIED DAYS 6 - 10 DAYS 11 - 14 DAYS >14 DAYS APPROVALS DENIALS AVERAGE TOTAL
---------- ------- ------------- ----------- ------------ -------- --------- ------- -------------
#VALUE! #VALUE! = - - - = 0.00 #VALUE!
#VALUE! #VALUE! = = 5 11 = = #VALUE!
#VALUE! #VALUE! = - - - = 0.00 #VALUE!
#DIV/0! #DIV/0! = - 5 11 #VALUE! #VALUE! #VALUE!
TURN AROUND TIME TO APPROVE/DENY OR ISSUE A TEMPORARY AVERAGE TIME ELAPSED SINCE REQUEST
PERCENT OF TOTAL SUPPLY RECEIVED BY MCO (DAYS) (doule carret)
-------------------- -------------------------------------------------------- -------------------------------------------
<24 HOURS - 5 WEIGHTED
APPROVED DENIED DAYS 6 - 10 DAYS 11 - 14 DAYS >14 DAYS APPROVALS DENIALS AVERAGE TOTAL
---------- ------- ------------- ----------- ------------ -------- --------- ------- -------------
#VALUE! #VALUE! 1,292 9 6 32 2.59 1.19 #VALUE!
#VALUE! #VALUE!
PHARMACY REPORT # 2: TOP 30 LEGED DRUGS BY NUMBER OF REQUESTS DENIED
NAME OF MCO Quarter Ending
PERCENT OF AUTHORIZATION
REQUESTS (EXCLUDING NO
NUMBER OF AUTHORIZATION REVIEWS REFILLS) COMPLETED DURING TEMPORARY
COMPLETED THIS QUARTER* THE QUARTER SUPPLY ISSUED
---------------------------------- ------------------------- ---------------
NUMBER NUMBER PERCENT PERCENT TEMPORARY
BRAND NAME OF DRUG THERAPEUTIC CLASS SUBTOTAL APPROVED DENIED (7) APPROVED DENIED SUPPLY
------------------ ----------------- -------- -------- ---------- -------- ------- ------------------
(Sum of Rows 1 & 3
from Report #1)
1
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2
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3
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4
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5
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6
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7
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8
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9
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10
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11
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12
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13
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14
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15
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16
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17
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18
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19
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20
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21
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22
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23
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24
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25
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26
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27
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28
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29
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30
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SUB TOTAL: 0 0 0 #DIV/0! #DIV/0! 0
-----------------------------------------------------------------------------
ALL OTHER DRUGS REQUIRING PRIOR AUTHORIZATION (1)
-----------------------------------------------------------------------------
GRAND TOTAL DRUGS REQUIRING AUTHORIZATION (2)
-----------------------------------------------------------------------------
TOTAL AUTHORIZATION REVIEWS COMPLETED DURING THE QUARTER REASON FOR DENIAL PERCENT %
-----------------------------------------------------------------------------
REASON FOR DENIAL
------------------------------------------------------------------------------------------------------------------------------
EQUALLY
STEP THERAPY QUANTITY EFFECTIVE MEDICAL NOT A COVERED
CRITERIA NOT LIMITS INAPPROPRIATE ALTERNATIVE NECESSITY NOT BENEFIT (I.E LACK OF TOTAL DENIAL
MET (4) EXCEEDED (5) DIAGNOSIS ON FORMULARY ESTABLISHED (6) FERTILITY DRUGS) INFORMATION OTHER CODE
------------ ------------ ------------- ------------ --------------- ---------------- ----------- ----- ------------
1
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2
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3
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4
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5
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6
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7
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8
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9
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10
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11
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12
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13
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14
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15
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16
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17
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18
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19
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20
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21
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22
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23
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24
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25
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26
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27
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28
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29
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30
------------------------------------------------------------------------------------------------------------------------------------
0 0 0 0 0 0 0 0 0
------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------
TOTAL AUTHORIZATION REVIEWS COMPLETED DURING THE QUARTER REASON FOR DENIAL PERCENT %
-------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
------------------------------------------------------------------------------------------------------------------------------
TOTAL PRESCRIPTIONS FILLED (3)
(INCLUDING AUTHORIZED (18) AND TEMPORARY SUPPLIES (15) FROM ABOVE)
PERCENT OF AUTH. REQUESTS TO TOTAL PRESCRIPTIONS FILLED BY THE MCO
(EXAMPLE 22/10,00)
TICK XXXX LEGEND
* Drugs requiring authorization include non-formulary drugs, formulary drugs
that require authorization, and brand name drugs where a generic
substitute is available. It excludes those prescriptions which may require
prior authorization but on-line edits in the POS system approve and
adjudicate the claim without any intervention on the part of the MCO
and/or Pharmacy Benefits Manager. This report also excludes over the
counter drugs.
** Include only requests for authorization completed during this quarter.
(1) Any additional prescriptions requiring prior authorization count not
accounted for within the top 30 denied drugs.
(2) The sum of all drugs which require authorization. This amount should tie
into the total approved, denied and temp supply given on the Prescription
Request Process Report.
(3) The total HUSKY A prescriptions filled (units dispensed) for the reporting
period being displayed.
(4) A process of reviewing prescription requests (e.g. might include
determining if drug A & B were used prior to approving drug C).
(5) Evaluation of the quantity of drugs being utilized over a specific time
period.
(6) Examples of medical necessity not established may include but not be
limited to off-label utilization per FDA.
(7) Sort Records/Rows 3-32 (Drugs 1-30) by Column F 'Number of Authorization
Reviews Denied' from most to least.
[QUI TRANSTULIT SUSTINET LOGO] STATE OF CONNECTICUT
DEPARTMENT OF SOCIAL SERVICES
CONTRACT AMENDMENT
AMENDMENT NUMBER: 6
CONTRACT #: 093-MED-FCHP-1
CONTRACT PERIOD: 08/11/2001 - 10/31/2003
CONTRACTOR NAME: FIRST CHOICE HEALTH PLAN OF CT
CONTRACTOR ADDRESS: 00 XXXXXX XXXX, XXXXX XXXXX, XX 00000-0000
Contract number 093-MED-FCHP-1 by and between the Department of Social Services
(the "Department") and Firstchoice Health Plan of CT (the "Contractor") for the
provision of services under the HUSKY A program as amended by Amendments 1, 2,
3, 4 and 5 is hereby further amended as follows:
1. PARAGRAPH 1 OF PART I AS AMENDED BY AMENDMENTS 1, 2,3, 4 AND 5 IS FURTHER
AMENDED TO EXTEND THE CONTRACT END DATE FROM SEPTEMBER 30, 2003 TO OCTOBER
31, 2003.
2. THE CONTRACTOR AND THE DEPARTMENT FURTHER AGREE THAT THE PARTIES'
OBLIGATION TO COMPLY WITH PART II "GENERAL CONTRACT TERMS FOR MCOS" DATED
AUGUST 13, 2003 PAGES 1 THROUGH 115 OF AMENDMENT 5 SHALL TERMINATE ON THE
DATE THAT THIS AMENDMENT EXPIRES UNLESS THE PARTIES AGREE IN A SUBSEQUENT
AMENDMENT TO EXTEND THE EFFECTIVE DATE OF THE CONTRACT.
3. APPENDIX I IS HEREBY FURTHER AMENDED TO EXTEND THE EFFECTIVE DATE OF THE
CAPITATION RATES FROM 9/30/03 TO OCTOBER 31, 2003. IF, THROUGH THE PASSAGE
OF A BUDGET FOR STATE FISCAL YEAR ("SFY") 2004 THE CAPITATION RATES ARE TO
BE REVISED EFFECTIVE JULY 1, 2003, THE DEPARTMENT, IN THE NEXT AMENDMENT
TO THIS CONTRACT WHICH MAY BE ENTERED INTO PRIOR TO THE EXPIRATION OF THIS
AMENDMENT, SHALL AMEND THE CAPITATION RATES TO REFLECT SUCH REVISIONS AND
SHALL MAKE ANY NECESSARY ADJUSTMENTS TO CAPITATION PAYMENTS MADE TO THE
CONTRACTOR SINCE JULY 1, 2003 TO REFLECT THE REVISED CAPITATION RATES.
ACCEPTANCES AND APPROVALS
This document constitutes an amendment to the above numbered contract. All
provisions of that contract and prior amendments, except those explicitly
changed or described above by this amendment, shall remain in full force and
effect.
CONTRACTOR
FIRSTCHOICE HEALTH PLAN OF CT [APPROVED SEP 29 2003 WELLCARE LEGAL SERVICES]
/s/ Xxxx X. Xxxxx 9/29/03
------------------------------- ---------------
Signature (Authorized Official) Date
XXXX X. XXXXX PRESIDENT & CEO
------------------------------- ---------------
Typed Name (Authorized Official) Title
DEPARTMENT
DEPARTMENT OF SOCIAL SERVICES
_____________________________ ______________
Signature (Authorized Official) Date
XXXXXXX X. XXXXXXXXXX DEPUTY COMMISSIONER
------------------------------- -------------------
Typed Name (Authorized Official) Title
OFFICE OF THE ATTORNEY GENERAL
______________________________ ________________
Attorney General (as to form) Date
( ) THIS CONTRACT DOES NOT REQUIRE THE SIGNATURE OF THE ATTORNEY GENERAL
PURSUANT TO AN AGREEMENT BETWEEN THE DEPARTMENT AND THE OFFICE OF THE ATTORNEY
GENERAL DATED:_____________________
APPEND -Amended
PLAN NAME:
FIRSTCHOICE
CAPITATION RATES
07/01/02 - 10/31/03
FAIRFIELD HARTFORD LITCHFIELD MIDDLESEX NEW HAVEN NEW LONDON TOLLAND XXXXXXX
--------- -------- ---------- --------- --------- ---------- ------- -------
UNDER ONE $536.44 $606.89 $605.12 $717.18 $602.97 $600.00 $724.78 $581.51
AGES 1 TO 14 $102.32 $110.46 $110.15 $130.10 $109.79 $109.23 $131.46 $107.71
MALE-AGES 15 TO 39 $127.22 $138.42 $138.03 $162.52 $137.60 $136.94 $164.18 $135.18
FEMALE-AGES 15 TO 39 $207.77 $231.48 $230.81 $273.76 $230.00 $228.84 $276.70 $223.07
MALE - AGES 40 AND OVER $227.33 $254.24 $253.48 $301.18 $252.59 $251.31 $304.41 $244.68
FEMALE - AGES 40 AND OVER $218.52 $244.15 $243.42 $289.20 $242.55 $241.32 $292.32 $235.04
PAGE 1 OF 1
Effective 7/1/02
SECRETARY'S CERTIFICATE
I, Xxxxxxxx Xxxxxxx, the duly elected Secretary of FirstChoice HealthPlans
of Connecticut, Inc., a corporation organized under the laws of the State of
Connecticut (the "Corporation"), do hereby certify that the following is a full
and true copy of a resolution adopted at a meeting of the Board of Directors of
said Corporation, duly held on the 23rd day of May, 2003:
"RESOLVED, that the officers of the Corporation be, and they hereby
are, authorized to sign and execute in the name of the Corporation
all applications, contracts, leases and other deeds and documents or
instruments in writing of whatsoever nature that may be required in
the ordinary course of the business of the Corporation and that may
be necessary to secure for operation of the corporate affairs,
governmental permits and licenses for, and incidental to, the lawful
operations of the business of the Corporation, and to do such acts
and things as such officers deem necessary or advisable to fulfill
such legal requirements as are applicable to the Corporation and its
business."
"RESOLVED, that the officers of the Corporation and each of them
acting singly are hereby authorized, empowered and directed to
execute and deliver, in the name and on behalf of the Corporation
such further agreements, instruments, documents, certificates and
filings, with such changes in the terms and provisions thereof as
the officer executing the same may determine necessary or
appropriate, and to do and perform such other acts and deeds as they
or any of them determine necessary or appropriate, in order to
effectuate the purposes and intent of the foregoing resolutions."
and I do further certify that the above resolution has not been in any way
altered, amended or repealed, and is now in full force and effect.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed the corporate
seal of said Corporation this 29th day of September, 2003.
FirstChoice HealthPlans of Connecticut, Inc.
/s/ Xxxxxxxx Xxxxxxx
--------------------------------------------
By: Xxxxxxxx Xxxxxxx, Secretary
STATE OF CONNECTICUT
[QUI TRANSTULIT SUSTINET LOGO] DEPARTMENT OF SOCIAL SERVICES
CONTRACT AMENDMENT
AMENDMENT NUMBER: 7
CONTRACT #: 093-MED-FCHP-1
CONTRACT PERIOD: 08/11/2001 - 11/30/2003
CONTRACTOR NAME: FIRST CHOICE HEALTH PLAN OF CT
CONTRACTOR ADDRESS: 00 XXXXXX XXXX, XXXXX XXXXX, XX 00000-0000
Contract number 093-MED-FCHP-1 by and between the Department of Social Services
(the "Department") and Firstchoice Health Plan of CT (the "Contractor") for the
provision of services under the HUSKY A program as amended by Amendments 1, 2,
3, 4, 5 and 6 is hereby further amended as follows:
1. PARAGRAPH 1 OF PART I AS AMENDED BY AMENDMENTS 1, 2, 3, 4, 5 AND 6 IS
FURTHER AMENDED TO EXTEND THE CONTRACT END DATE FROM OCTOBER: 1, 2003 TO
NOVEMBER 30, 2003.
2. THE CONTRACTOR AND THE DEPARTMENT FURTHER AGREE THAT THE PARTIES'
OBLIGATION TO COMPLY WITH PART II "GENERAL CONTRACT TERMS FOR MCOS" DATED
AUGUST 13, 2003 PAGES 1 THROUGH 115 OF AMENDMENT 5 SHALL TERMINATE ON THE
DATE THAT THIS AMENDMENT EXPIRES UNLESS THE PARTIES AGREE IN A SUBSEQUENT
AMENDMENT TO EXTEND THE EFFECTIVE DATE OF THE CONTRACT.
3. SECTION 3.47 OF PART II "GENERAL CONTRACT TERMS FOR MCOS" DATED AUGUST 13,
2003 IS DELETED IN ITS ENTIRETY AND REPLACED WITH SECTION 3.47 (EFFECTIVE
11/01/03) AS SET FORTH ON PAGE 3 OF THIS AMENDMENT.
4. APPENDIX I IS HEREBY FURTHER AMENDED TO EXTEND THE EFFECTIVE DATE OF THE
CAPITATION RATES FROM 10/31/03 TO NOVEMBER 30, 2003. IF, THROUGH THE
PASSAGE OF A BUDGET FOR STATE FISCAL YEAR ("SFY") 2004 THE CAPITATION
RATES ARE TO BE REVISED EFFECTIVE JULY 1, 2003, THE DEPARTMENT, IN THE
NEXT AMENDMENT TO THIS CONTRACT WHICH MAY BE ENTERED INTO PRIOR TO THE
EXPIRATION OF THIS AMENDMENT, SHALL AMEND THE CAPITATION RATES TO REFLECT
SUCH REVISIONS AND SHALL MAKE ANY NECESSARY ADJUSTMENTS TO CAPITATION
PAYMENTS MADE TO THE CONTRACTOR SINCE JULY 1, 2003 TO REFLECT THE REVISED
CAPITATION RATES.
ACCEPTANCES AND APPROVALS
This document constitutes an amendment to the above numbered contract. All
provisions of that contract and prior amendments, except those explicitly
changed or described above by this amendment, shall remain in full force and
effect.
Page 1 of 3
CONTRACTOR
FIRSTCHOICE HEALTH PLAN OF CT
/s/ Xxxxxxxx Xxxxxxx 10/29/03
--------------------
Signature (Authorized Official) Date
Xxxxxxxx Xxxxxxx
Senior Vice President &
General Counsel _________________________
Typed Name (Authorized Official) Title
DEPARTMENT
DEPARTMENT OF SOCIAL SERVICES
/s/ Xxxxxxx X. Xxxxxxxxxx 10/31/03
-----------------------------
Signature (Authorized Official) Date
XXXXXXX X. XXXXXXXXXX DEPUTY COMMISSIONER
Typed Name (Authorized Official) Title
OFFICE OF THE ATTORNEY GENERAL
_____________________________ ________________________
Attorney General (as to form) Date
( ) THIS CONTRACT DOES NOT REQUIRE THE SIGNATURE OF THE ATTORNEY GENERAL
PURSUANT TO AN AGREEMENT BETWEEN THE DEPARTMENT AND THE OFFICE OF THE ATTORNEY
GENERAL DATED:_____________________
Page 2 of 3
\
3.47 CO-PAYMENT LIMITS AND MEMBER CHARGES FOR NONCOVERED SERVICES
(EFFECTIVE 11/01/03)
a. Pursuant to Section 72 of Public Act 3-03 of the June 30 Special Session
and Section 11 of Public Act 03-1 of the September 8 Special Session,
Members shall be responsible for a $1.50 co-payment for prescription drugs
and a $2.00 co-payment for outpatient services.
b. The MCO shall implement the $2.00 co-pay for outpatient services in
accordance with the provisions of Provider Bulletin PB 2003-89, September
2003.
c. The $1.50 co-payment for prescription drugs shall apply to each
prescription drug, covered over the counter medication and refill. The
following services and individuals shall be exempt from the $1.50
co-payment for prescription drugs requirement:
1) Members under the age of 21;
2) Pregnant women, including the period of 60 days post-partum.
This post-partum period begins on the last day of pregnancy
and extends through the end of the month in which the 60-day
period following termination of pregnancy ends;
3) Members who are inpatients in the following medical
institutions: acute care hospital, psychiatric hospital,
chronic disease hospital or nursing facility, as more fully
described in Provider Bulletin PB 2003-45, June 2003;
4) Prescription for family planning drugs or supplies;
5) Compounded prescriptions.
d. The MCO shall ensure that the dispensing pharmacist is responsible for
collecting the co-payment at the time of the service unless the
pharmacist, in filling certain prescriptions, does not normally have
face to face contact with the Member. If the pharmacist does not have
face-to-face contact with the Member in dispensing a prescription, the
provider has the right to xxxx the Member for the $1.50 co-payment.
e. Pursuant to 42 U.S.C. 13960(e), no provider may deny care or services to
an individual eligible for such care or services because of an inability
to pay a co-payment. The MCO shall ensure that its providers do not refuse
to render the service or fil1 a prescription if the Member is unable to
pay the co-payment. The MCO may permit its providers to ask for the unpaid
co-payment at a subsequent visit or to xxxx the Member for the outstanding
co-payment. The provider shall accept the Member's declaration that he is
unable to pay the co-payment.
f. Except for the prescription drug and outpatient services co-payments
described above, no deductibles or co-payments or similar cost-sharing
charges are permitted for HUSKY A covered services.
g. A provider shall be permitted to charge an eligible Member for goods or
services which are not coverable only if the Member knowingly elects to
receive the goods or services and enters into an agreement in writing to
pay for such goods or services prior to receiving them. For purposes of
this section noncovered services are services not covered under the
Medicaid state plan, services which are provided in the absence of
appropriate authorization, and services which are provided out-of-network
unless otherwise specified in the contract, policy or regulation (e.g.,
family planning, mental health or emergency room services).
Page 3 of 3
APPENDIX Amended
PLAN NAME:
FIRST CHOICE
CAPITATION RATES
07/01/02 - 11/30/03
FAIRFIELD HARTFORD LITCHFIELD MIDDLESEX NEW HAVEN NEW LONDON TOLLAND XXXXXXX
--------- -------- ---------- --------- --------- ---------- ------- -------
UNDER ONE $536.44 $606.89 $605.12 $717.18 $602.97 $600.00 $724.78 $581.51
AGE 1 TO 14 $102.32 $110.46 $110.15 $130.10 $109.79 $109.23 $131.46 $107.71
MALE - AGES 15 TO 39 $127.22 $138.42 $138.03 $162.52 $137.60 $136.94 $164.18 $135.18
FEMALE - AGE 15 TO 39 $207.77 $231.48 $230.81 $273.76 $230.00 $228.84 $276.70 $223.07
MALE - AGES 40 AND OVER $227.33 $254.24 $253.48 $301.18 $252.59 $251.31 $304.41 $244.68
FEMALE - AGES 40 AND OVER $218.52 $244.15 $243.42 $289.20 $242.55 $241.32 $292.32 $235.04
PAGE 1 OF 1
Effective 7/1/02
SECRETARY'S CERTIFICATE
I, Xxxxxxxx Xxxxxxx, the duly elected Secretary of FirstChoice HealthPlans
of Connecticut, Inc., a corporation organized under the laws of the State of
Connecticut (the "Corporation"), do hereby certify that the following is a full
and true copy of a resolution adopted at a meeting of the Board of Directors of
said Corporation, duly held on the 23rd day of May, 2003:
"RESOLVED, that the officers of the Corporation be, and they hereby
are, authorized to sign and execute in the name of the Corporation
all applications, contracts, leases and other deeds and documents or
instruments in writing of whatsoever nature that may be required in
the ordinary course of the business of the Corporation and that may
be necessary to secure for operation of the corporate affairs,
governmental permits and licenses for, and incidental to, the lawful
operations of the business of the Corporation, and to do such acts
and things as such officers deem necessary or advisable to fulfill
such legal requirements as are applicable to the Corporation and its
business."
"RESOLVED, that the officers of the Corporation and each of them
acting singly are hereby authorized, empowered and directed to
execute and deliver, in the name and on behalf of the Corporation,
such further agreements, instruments, documents, certificates and
filings, with such changes in the terms and provisions thereof as
the officer executing the same may; determine necessary or
appropriate, and to do and perform such other acts and deeds as they
or any of them determine necessary or appropriate, in order to
effectuate the purposes and intent of the foregoing resolutions."
and I do further certify that the above resolution has not been in any way
altered, amended or repealed, and is now in full force and effect.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed the corporate
seal of said Corporation this 29th day of October, 2003.
FirstChoice HealthPlans of Connecticut, Inc.
/s/ Xxxxxxxx Xxxxxxx
--------------------------------------------
By: Xxxxxxxx Xxxxxxx, Secretary
Chronic Inpatient
ICF/MR (Intermediate Care Facility for the Mentally Retarded)
SNF (Skilled Nursing Facility)
ICF (Intermediate Care Facility)
ICF-2
Super SNF
CDH Outpatient (Chronic Disease Hospital Outpatient)
Please be aware that Code 06 - Boarding Home may also be used to describe a
Non-ICF Group Home. Additionally, Code 05 - Rest Home is also used for a Home
for the Aged.
Some institutions are listed as a Multi-care institution since they consist of
segregated units each of which are devoted to various complexities of patient
care. An institution may be classified as a Boarding Home in one section and an
Intermediate Care Facility for the Mentally Retarded in another section. Again,
ASK AND CODE THE PATIENT LOCATION AS THE PRESCRIBER OR FACILITY DIRECTS.
AS A REMINDER, federal law under Section 1916(e) of the Social Security Act
requires that no provider enrolled in the Medicaid Program may deny care or
services to an individual eligible for such care or services because of an
inability to pay a copayment. If the client cannot pay the copayment, a provider
may not refuse to render the service or not fill the prescription for that
reason. However, a provider may ask for the unpaid copayment at a subsequent
visit or xxxx the client for the outstanding copayment. The client's own
declaration that he/she is unable to pay is the basis for determining when a
client is unable to pay.
This bulletin and other program information can be found at
XXX.XXXXXXXXXXXXXXXX.XXX. Questions regarding this bulletin may be directed to
the EDS Provider Assistance Center - Monday through Friday from 8:30 a.m. to
5:00 p.m. at:
In-state toll free.......... 000-000-0000 OR EDS
Out-of-state or in the XX Xxx 0000 [EDS LOGO]
local New Britain, CT area.. 860-832-9259 Xxxxxxxx, XX 00000
2 of 2
CONNECTICUT DEPARTMENT OF SOCIAL SERVICES
[LOGO] MEDICAL ASSISTANCE PROGRAM
PROVIDER BULLETIN
PB 2003-89 SEPTEMBER 2003
TO: SELECT PROVIDERS
SUBJECT: CO-PAY FOR OUTPATIENT SERVICES
The Department of Social Services is implementing a patient co-payment
requirement for recipients of Medicaid. Effective NOVEMBER 1, 2003 and forward,
Medicaid enrolled providers of certain outpatient services shall collect a $2.00
CO-PAYMENT per client, per date of service.
EXEMPTIONS:
The co-payment requirement does not apply to the following:
- children under 21 years of age;
- women who are pregnant or in the postpartum period. The postpartum period
is the 60 day period following child birth;
- family planning services and supplies;
- emergency services provided by a hospital for revenue center codes 450 -
452 and 459;
- clients who have Medicare as their primary insurance, provided Medicare
makes a payment towards the deductible;
- hospital outpatient laboratory services revenue center codes 300 - 309
only;
- clients residing in a nursing facility, chronic disease hospital or
intermediate care facility for the mentally retarded (ICF/MR).
CONDITIONS FOR CO-PAYMENT
Federal law under Section 1916(e) of the Social Security Act requires that no
provider enrolled in the Medicaid program may deny care or services to an
individual eligible for such care or services because of the inability to pay a
co-payment. Therefore, if the client cannot pay the co-payment, a provider may
not refuse to render the service for that reason. However, a provider may ask
for the unpaid co-payment at a subsequent visit or xxxx the client for the
outstanding co-payment. The client's own declaration that he/she is unable to
pay is the basis for determining when a client is unable to pay.
OUTPATIENT SERVICES/PROVIDERS THAT REQUIRE A CO-PAY
The following provider types shall collect the $2.00 co-payment from appropriate
clients if the services are performed in one of the designated facility types
identified below.
- Ambulatory Surgical Centers
- Dental & Dental Group
- Dental Clinic
- FQHC (Dental, Medical, Mental Health)
- Hospital Dental Clinic
- Hospital Outpatient
- Independent Radiology
- Medical Clinic
- Mental Health Clinic
- Methadone Maintenance Clinic
- Nurse Midwife & Nurse Midwife Group
- Nurse Practitioner & Nurse Practitioner Group
- Optician & Optician Group
- Optometrist & Optometrist Group
- Physician & Physician Group
- Psychiatric Hospital Outpatient
- Rehabilitation Center Clinic
DESIGNATED FACILITY TYPE
The co-payment requirement applies if the service provided by one of the above
referenced provider types is rendered in any of the following facility types.
The corresponding facility type code would be indicated on the claim form.
FACILITY TYPE FACILITY TYPE CODE
------------- ------------------
Office 11
Outpatient Hospital 22
Ambulatory Surgical Center 24
Independent Clinic 49
Federally Qualified Health Center (FQHC) 50
Psychiatric Facility Partial Hospitalization 52
Community Mental Health Center 53
Non-Residential Substance Abuse Treatment Facility 57
Comprehensive Outpatient Rehabilitation Facility 62
Public Health Clinic 71
CLAIMS PROCESSING INSTRUCTIONS
Providers should xxxx their usual and customary charge. The $2.00 co-payment
will be systematically deducted from the allowed amount once per provider, per
client, per date of service. If a claim is billed with span dates of service on
one detail line, then the claim detail will have $2.00 deducted for each date of
service. If a claim is submitted with multiple procedure codes for the same date
of service on separate details the $2.00 co-payment will be deducted from the
first paid detail.
Explanation of benefits (EOB) code 364, "Payment Reduced By Co-pay" will be
posted to each detail that a co-payment was deducted from. If both co-payment
and other insurance were deducted from the same detail, EOB 416, "Payment Amount
Reduced By Other Insurance And Co-pay" will be posted to the detail.
This bulletin and other program information can be found at
XXX.XXXXXXXXXXXXXXXX.XXX. Questions regarding this bulletin may be directed to
the EDS Provider Assistance Center - Monday through Friday from 8:30 a.m. to
5:00 p.m. at:
In-state toll free.......... 000-000-0000 or EDS
Out-of-state or in the XX Xxx 0000 [EDS LOGO]
local New Britain, CT area.. 860-832-9259 Xxxxxxxx, XX 00000
STATE OF CONNECTICUT
[QUI TRANSTULIT SUSTNET LOGO] DEPARTMENT OF SOCIAL SERVICES
CONTRACT AMENDMENT
AMENDMENT NUMBER: 8
CONTRACT #: 093-MED-FCHP-1
CONTRACT PERIOD: 08/11/2001 - 12/31/2003
CONTRACTOR NAME: FIRST CHOICE HEALTH PLAN OF CT
CONTRACTOR ADDRESS: 00 XXXXXX XXXX, XXXXX XXXXX, XX 00000-0000
Contract number 093-MED-FCHP-1 by and between the Department of Social Services
(the "Department") and Firstchoice Health Plan of CT (the "Contractor") for the
provision of services under the HUSKY A program as amended by Amendments 1, 2,
3, 4, 5, 6 and 7 is hereby further amended as follows:
1. PARAGRAPH 1 OF PART I AS AMENDED BY AMENDMENTS 1, 2, 3, 4, 5, 6 AND 7 IS
FURTHER AMENDED TO EXTEND THE CONTRACT END DATE FROM NOVEMBER 30, 2003 TO
DECEMBER 31, 2003.
2. THE CONTRACTOR AND THE DEPARTMENT FURTHER AGREE THAT THE PARTIES'
OBLIGATION TO COMPLY WITH PART II "GENERAL CONTRACT TERMS FOR MCOS" DATED
AUGUST 13, 2003 PAGES 1 THROUGH 115 OF AMENDMENT 5 SHALL TERMINATE ON THE
DATE THAT THIS AMENDMENT EXPIRES UNLESS THE PARTIES AGREE IN A SUBSEQUENT
AMENDMENT TO EXTEND THE EFFECTIVE DATE OF THE CONTRACT.
3. APPENDIX I IS HEREBY FURTHER AMENDED TO EXTEND THE EFFECTIVE DATE OF THE
CAPITATION RATES FROM 11/30/03 TO DECEMBER 31, 2003. IF, THROUGH THE
PASSAGE OF A BUDGET FOR STATE FISCAL YEAR ("SFY") 2004 THE CAPITATION
RATES ARE TO BE REVISED EFFECTIVE JULY 1, 2003, THE DEPARTMENT, IN THE
NEXT AMENDMENT TO THIS CONTRACT WHICH MAY BE ENTERED INTO PRIOR TO THE
EXPIRATION OF THIS AMENDMENT, SHALL AMEND THE CAPITATION RATES TO REFLECT
SUCH REVISIONS AND SHALL MAKE ANY NECESSARY ADJUSTMENTS TO CAPITATION
PAYMENTS MADE TO THE CONTRACTOR SINCE JULY 1, 2003 TO REFLECT THE REVISED
CAPITATION RATES.
ACCEPTANCES AND APPROVALS
This document constitutes an amendment to the above numbered contract. All
provisions of that contract and prior amendments, except those explicitly
changed or described above by this amendment, shall remain in full force and
effect.
Page 1 of 2
CONTRACTOR
FIRSTCHOICE HEALTH PLAN OF CT [APPROVED NOV 25 2003 WELLCARE LEGAL SERVICES]
/s/ Xxxx X. Xxxxx
------------------------------- ___________________
Signature (Authorized Official) Date
________________________________ ___________________
Typed Name (Authorized Official) Title
DEPARTMENT
DEPARTMENT OF SOCIAL SERVICES
_____________________________ ______________
Signature (Authorizd Official) Date
XXXXXXX X. XXXXXXXXXX DEPUTY COMMISSIONER
--------------------- -------------------
Typed Name (Authorized Official) Title
OFFICE OF THE ATTORNEY GENERAL
___________________________________________________________________
Attorney General (as to form) Date
( ) THIS CONTRACT DOES NOT REQUIRE THE SIGNATURE OF THE ATTORNEY GENERAL
PURSUANT TO AN AGREEMENT BETWEEN THE DEPARTMENT AND THE OFFICE OF THE ATTORNEY
GENERAL DATED:_____________________
Page 2 of 2
APPENDIX Amended
PLAN NAME:
FIRSTCHOICE
CAPITATION RATES
07/01/02 - 12/31/03
FAIRFIELD HARTFORD LITCHFIELD MIDDLESEX NEW HAVEN NEW LONDON TOLLAND XXXXXXX
--------- -------- ---------- --------- --------- ---------- ------- -------
UNDER ONE $536.44 $606.89 $605.12 $717.18 $602.97 $600.00 $724.78 $581.51
AGES 1 TO 14 $102.32 $110.46 $110.15 $130.10 $109.79 $109.23 $131.46 $107.71
MALE - AGES 15 TO 39 $127.22 $138.42 $138.03 $162.52 $137.60 $136.94 $164.18 $135.18
FEMALE - AGES 15 TO 39 $207.77 $231.48 $230.81 $273.76 $230.00 $228.84 $276.70 $223.07
MALE - AGES 40 AND OVER $227.33 $254.24 $253.48 $301.18 $252.59 $251.31 $304.41 $244.68
FEMALE - AGES 40 AND OVER $218.52 $244.15 $243.42 $289.20 $242.55 $241.32 $292.32 $235.04
PAGE 1 OF 1
Effective 7/1/02
SECRETARY'S CERTIFICATE
I, Xxxxxxxx Xxxxxxx, the duly elected Secretary of FirstChoice HealthPlans
of Connecticut, Inc., a corporation organized under the laws of the State of
Connecticut (the "Corporation"), do hereby certify that the following is a full
and true copy of a resolution adopted at a meeting of the Board of Directors of
said Corporation, duly held on the 23rd day of May, 2003:
"RESOLVED, that the officers of the Corporation be, and they hereby
are, authorized to sign and execute in the name of the Corporation
all applications contracts, leases and other deeds and documents or
instruments in writing of whatsoever nature that may be required in
the ordinary course of the business of the Corporation and that may
be necessary to secure for operation of the corporate affairs,
governmental permits and licenses for, and incidental to, the lawful
operations of the business of the Corporation, and to do such acts
and things as such officers deem necessary or advisable to fulfill
such legal requirements as are applicable to the Corporation and its
business."
"RESOLVED, that the officers of the Corporation and each of them
acting singly are hereby authorized, empowered and directed to
execute and deliver, in the name and on behalf of the Corporation,
such further agreements, instruments, documents, certificates and
filings, with such changes in the terms and provisions thereof as
the officer executing the same man determine necessary or
appropriate, and to do and perform such other acts and deeds as they
or any of them determine necessary or appropriate, in order to
effectuate the purposes and intent of the foregoing resolutions."
and I do further certify that the above resolution has not been in any way
altered, amended or repealed, and is now in full force and effect.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed the corporate
seal of said Corporation this 25th day of November, 2003.
FirstChoice HealthPlans of Connecticut, Inc.
/s/ Xxxxxxxx Xxxxxxx
-------------------------------------------
By: Xxxxxxxx Xxxxxxx, Secretary
