STATE OF ILLINOIS DEPARTMENT OF PUBLIC AID AMENDMENT NO. 3 TO THE CONTRACT FOR FURNISHING HEALTH SERVICES BY A MANAGED CARE ORGANIZATION
Exhibit
10.1
STATE
OF ILLINOIS DEPARTMENT OF PUBLIC AID
AMENDMENT
NO. 3 TO THE
2004-24-001-KA3
whereas, the
parties to the Contract for Furnishing Health Services by a Managed Care
Organization ("CONTRACT"), the
Illinois Department of Healthcare & Family Services (formerly Public
Aid),
000
Xxxxx Xxxxx Xxxxxx Xxxx, Xxxxxxxxxxx, Xxxxxxxx 00000-0000 (herein referred
to as
"Department"), acting by and through its Director, and
Harmony Health Plan of Illinois, Inc.,
000
Xxxxx Xxxxxx Xxxxx, Xxxxx 0000, Xxxxxxx, XX 00000 (hereinafter referred to
as
"Contractor"), desire to amend the CONTRACT; and
WHEREAS,
the
Department is statutorily obligated to amend this Contract to achieve net
liability savings in its managed care appropriation, and;
WHEREAS,
the
Department's actuary has certified that the Contract and rates resulting
from
this amendment are actuarially sound;
NOW
THEREFORE,
the
parties agree to amend the contract as follows:
1.
Article V, Section 5.1 of the contract is amended to read as follows effective
for dates of service August 1, 2005, and later;
5.1
Services.
(a)
Amount,
Duration and Scope of Coverage.
The
Contractor shall comply with the terms of 42 C.F.R. §438.206(b) and provide or
arrange to have provided to all Enrollees all services described in 89 111.
Adm.
Code, Part 140 as amended from time to time and not specifically excluded
therein or in this Article V, Section 5.1 in accordance with the terms of
this
Contract. Covered Services shall be provided in the amount, duration and
scope
as set forth in 89 111. Adm. Code, Part 140 and this Contract, and shall
be
sufficient to achieve the purposes for which such Covered Services are
furnished. This duty shall commence at the time of initial coverage as to
each
Enrollee. The Contractor shall, at all times, cover the appropriate level
of
service (i.e., triage, urgent) for all Emergency Services provided in an
emergency room setting. The Contractor shall notify the Department in writing
within five (5) days following a change in the Contractor's network of
Affiliated Providers that renders the Contractor unable to provide one (1)
or
more Covered Service(s) in any Contracting Area. The Contractor shall not
refer
Enrollees to publicly supported health care entities to receive Covered
Services, for which the Contractor receives payment from the Department,
unless
such entities are Affiliated with the Contractor's Plan. Such publicly supported
health care entities include, but are not limited to, Chicago Department
of
Public Health and its clinics, Xxxx County Bureau of Health Services, and
local
health departments. The Contractor shall provide a mechanism for an Enrollee
to
Page
l
obtain
a
second opinion from a qualified Provider, whether Affiliated or non-Affiliated,
at no cost to the Enrollee.
(b)
Enumerated
Covered Services.
The
Contractor shall have a sufficient number of Affiliated Providers (including
Tertiary Care hospital(s) and, where appropriate, advanced practice nurses)
in
place to provide all of the following services and benefits (which shall
be
specifically included as Covered Services under this Contract) to Enrollees
at
all times during the term of this Contract, whenever Medically Necessary,
except
to the extent services are identified as excluded services pursuant to
subsection (e) of this Section 5.1:
•
Assistive/augmentative communication devices;
•
Audiology services, physical therapy, occupational therapy and speech
therapy;
•
Behavioral health services, including subacute alcohol and substance abuse
services and mental health services, in accordance with subsection (c)
hereof;
•
Blood,
blood components and the administration thereof;
•
Certified hospice services;
•
Chiropractic services;
•
Clinic
services (as described in 89 111. Adm. Code, Part 140.460);
•
Diagnosis and treatment of medical conditions of the eye;
•
Durable
and nondurable medical equipment and supplies;
•
Emergency Services;
•
Family
planning services;
•
Home
health care services;
•
Inpatient hospital services (including dental hospitalization in case of
trauma
or when related to a medical condition and acute medical
detoxification);
•
Inpatient psychiatric care;
•
Laboratory and x-ray services; The drawing of blood for lead screening shall
take place within the Contractor's Affiliated facilities or elsewhere at
the
Contractor's expense.**
_______________________
*Covered
Services may be provided by an optometrist operating within the scope of
his
license.
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2
•
Medical
procedures performed by a dentist;
•
Nurse
midwives services;
•
Nursing
facility services for the first ninety (90) days;
•
Orthotic/prosthetic devices, including prosthetic devices or reconstructive
surgery incident to a mastectomy;
•
Outpatient hospital services (excluding outpatient behavioral health
services);
•
Physicians' services, including psychiatric care;
•
Podiatric services;
•
Routine
care in conjunction with certain investigational cancer treatments, as provided
in Public Act 91-0406;
•
Services required to treat a condition diagnosed as a result ofEPSDT services,
in accordance with 89 111. Adm. Code 140.485;
•
Services to Prevent Illness and Promote Health in accordance with subsection
(d)
hereof;
•
Transplants covered under 89 111. Adm. Code 148.82 (using transplant providers
certified by the Department, if the procedure is performed in the State);
and
•
Transportation to secure Covered Services.
(c)
Behavioral
Health Services.
(1)
The Contractor
will provide the following behavioral health services, which are Covered
Services:
•
Inpatient psychiatric or substance abuse services that are provided in general
hospital medical units;
_________________________________
**A11
laboratory tests for children being screened for lead must be sent for analysis
to the Illinois Department of Public Health's laboratory.
***
Contractors will be responsible for covering up to a maximum of ninety (90)
days
nursing facility care (or equivalent care provided at home because a skilled
nursing facility is not available) annually per Enrollee. Periods in excess
of
ninety (90) days annually will be paid by the Department according to its
prevailing reimbursement system.
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3
•
Inpatient psychiatric services provided in a hospital that is a psychiatric
hospital or a distinct psychiatric unit, as defined in 89 111. Adm. Code
148.40(a)(l);
•
Inpatient
acute
alcoholism and substance abuse treatment (detoxification);
•
Hospital-based organized clinic services referred to as outpatient treatment
psychiatric services for Type A and Type B Psychiatric Clinic Services, as
defined in 89 111. Adm. Code 148.140(b)(l)(E);
•
Behavioral health services provided
by
Physicians, including psychiatrists;
and
•
Laboratory services provided on an outpatient basis for behavioral health,
even
if ordered by a behavioral health provider in connection with the provision
of
treatment that is excluded from Covered Services.
(2)
If an
Enrollee presents himself to the Contractor for behavioral health services,
or
is referred through a third party, the Contractor will complete a behavioral
health assessment.
| • |
If
the assessment indicates that all services needed are within the
scope of
Covered Services, the Contractor will arrange for the provision
of all
such Covered Services.
|
| • |
If
the assessment indicates that outpatient services are needed beyond
the
scope of Covered Services, the Contractor will explain to the Enrollee
the
services needed and the importance of obtaining them and provide
the
Enrollee with a list of Community Behavioral Health Providers (CBHP).
The
Contractor will assist the Enrollee in contacting a CBHP chosen
by the
Enrollee, unless the Enrollee
objects.
|
| • |
If
a Enrollee obtains needed comprehensive services through a CBHP,
the
Contractor will be responsible for payment for laboratory services
in
connection with the comprehensive services provided by the CBHP.
The
Contractor shall not be liable for other Covered Services provided
by the
CBHP. The Contractor may require that laboratory services are provided
by
Providers that are Affiliated with
Contractor.
|
(d)
Services
to Prevent Illness and Promote Health.
The
Contractor shall make documented efforts to provide initial health screenings
and preventive care to all Enrollees. The Contractor shall provide, or arrange
to provide, the following Covered Services to all Enrollees, as appropriate,
to
prevent illness and promote health:
(1)
EPSDT
services in accordance with 89 111. Adm. Code 140.485 and described in this
Article V, Section 5.12(a);
Page
4
(2)
Preventive Medicine Schedule which shall address preventive health care issues
for Enrollees twenty-one (21) years of age or older (Article V, Section
5.12(b));
(3)
Maternity care for pregnant Enrollees (Article V, Section 5.12(c));
and
(4)
Family planning services and supplies, including physical examination and
counseling provided during the visit, annual physical examination for family
planning purposes, pregnancy testing, voluntary sterilization, insertion
or
injection of contraceptive drugs or devices, and related laboratory and
diagnostic testing (except to the extent an Enrollee has chosen to obtain
such
services and supplies from a non-Affiliated Provider, in which case the
Department shall be responsible for providing payment for such
services).
(e)
Exclusions
from Covered Services.
In
addition to those services and benefits excluded from Covered Services by
89
111. Adm. Code, Part 140, as amended from time to time, the following services
and benefits shall NOT be included as Covered Services:
(1)
Dental services;
(2)
Mental health clinic services as provided through a community behavioral
health
provider as identified in 89 111. Adm. Code 140.452 and 140.454 and further
defined in 59 111. Adm. Code, Part 132 "Medicaid Community Mental Health
Services Program.";
(3)
Subacute alcoholism and substance abuse treatment services as provided through
a
community behavioral health provider as identified in 89 111. Adm. Code
148.340(a) and further defined in 77 111. Adm. Code 2090;
(4)
Routine examinations to determine visual acuity and the refractive state
of the
eye, eyeglasses, other devices to correct vision, and any associated supplies
and equipment. The Contractor shall refer Enrollees needing such services
to
Providers participating in the Medical Assistance Program able to provide
such
services, or to a central referral entity that maintains a list of such
Providers;
(5)
Nursing facility services, or equivalent care provided at home because a
skilled
nursing facility is unavailable, beginning on the ninety-first (91st) day
of
service in a calendar year;
(6)
Services provided in an Intermediate Care Facility for the Mentally
Retarded/Developmentally Disabled and services provided in a nursing facility
to
mentally retarded or developmentally disabled Participants;
(7)
Early
intervention services, including case management, provided pursuant to the
Early
Intervention Services System Act (325 ILCS 20 et seq.);
(8)
Services provided through school-based clinics as such clinics are defined
by
the Department;
Page
5
(9)
Services provided through local education agencies that are enrolled with
the
Department under an approved individual education plan (IEP);
(10)
Services provided under Section 1915(c) home and community-based
waivers;
(11)
Services funded through the Juvenile Rehabilitation Services Medicaid Matching
Fund;
(12)
Services that are experimental and/or investigational in nature;
(13)
Services provided by a non-Affiliated Provider and not authorized by the
Contractor, unless this Contract specifically requires that such services
be
covered;
(14)
Services that are provided without first obtaining a required referral or
prior
authorization as set forth in the Enrollee handbook;
(15)
Medical and/or surgical services provided solely for cosmetic
purposes;
(16)
Diagnostic and/or therapeutic procedures related to infertility/sterility;
and
(17)
Pharmacy services.
(f)
Limitations
on Covered Services.
The
following services and benefits shall be limited as Covered
Services:
(1)
Termination of pregnancy shall be provided only as allowed by applicable
State
and federal law (42 C.F.R. Part 441, Subpart E). In any such case, the
requirements of such laws must be fully complied with and DPA Form 2390 must
be
completed and filed in the Enrollee's medical record. Termination of pregnancy
shall not be provided to KidCare Enrollees.
(2)
Sterilization services may be provided only as allowed by State and federal
law
(see 42 C.F.R. Part 441, Subpart F). In any such case, the requirements of
such
laws must be fully complied with and a DPA Form 2189 must be completed and
filed
in the Enrollee's medical record.
(3)
If a
hysterectomy is provided, a DPA Form 1977 must be completed and filed in
the
Enrollee's medical record.
(g)
Right
of Conscience.
The
parties acknowledge that pursuant to 745 ILCS 70/1 et seq.,
a
Contractor may choose to exercise a right of conscience by not rendering
certain
Covered Services. Should the Contractor choose to
exercise this right, the Contractor must promptly notify the Department of
its
intent to exercise its right of conscience in writing. Such notification
shall
contain the services that the Contractor is unable to render pursuant to
the
exercise of the right of conscience. The parties agree that at that time
the
Department shall adjust the Capitation payment to the Contractor and amend
the
contract accordingly.
Page
6
Should
the Contractor choose to exercise this right, the Contractor must notify
Potential Enrollees, Prospective Enrollees and Enrollees that it has chosen
to
not render certain Covered Services, as follows:
(1)
To
Potential Enrollees, prior to Enrollment;
(2)
To
Prospective Enrollees, during Enrollment; and
(3)
To
Enrollees, within ninety (90) days after adopting a policy with respect to
any
particular service that previously was a Covered Service.
(h)
Emergency
Services.
(1)
The
Contractor shall cover Emergency Services for all Enrollees whether the
Emergency Services are provided by an Affiliated or non-Affiliated
Provider.
(2)
The
Contractor shall not impose any requirements for prior approval of Emergency
Services. If an Enrollee calls the Contractor to request Emergency Services,
such call shall receive an immediate response.
(3)
The
Contractor shall cover Emergency Services for Enrollees who are temporarily
away
from their residence and outside the Contracting Area for all Emergency Services
to which they would be entitled within the Contracting Area.
(4)
The
Contractor shall have no obligation to cover medical services provided on
an
emergency basis that are not Covered Services under this Contract.
(5)
Elective care or care required as a result of circumstances that could
reasonably have been foreseen prior to the Enrollee's departure from the
Contracting Area are not covered. Unexpected hospitalization due to
complications of pregnancy shall be covered. Routine delivery at term outside
the Contracting Area, however, shall not be covered if the Enrollee is outside
the Contracting Area against medical advice unless the Enrollee is outside
of
the Contracting Area due to circumstances beyond her control. The Contractor
must educate the Enrollee of the medical and financial implications of leaving
the Contracting Area and the importance of staying near the treating Provider
throughout the last month of pregnancy.
(6)
The
Contractor shall provide ongoing education to Enrollees regarding the
appropriate use of Emergency Services.
(7)
The
Contractor shall not condition coverage for Emergency Services on the treating
Provider notifying the Contractor of the Enrollee's screening and treatment
within ten (10) calendar days of presentation for Emergency
Services.
(8)
The
determination of whether or not an Enrollee is sufficiently Stabilized for
discharge or transfer to another facility shall be binding on the
Contractor.
(i)
Post-Stabilization
Services.
The
Contractor shall cover Post-Stabilization Services provided by an Affiliated
or
non-Affiliated Provider in any the following situations: (a)
Page
7
the
Contractor authorized such services; (b) such services were administered
to
maintain the Enrollee's stabilized condition within one (1) hour of a request
to
the Contractor for authorization of further Post-Stabilization Services;
or (c)
the Contractor does not respond to a request to authorize further
Post-Stabilization Services within one (1) hour, the Contractor could not
be
contacted, or the Contractor and the treating Provider cannot reach an agreement
concerning the Enrollee's care and an Affiliated Provider is unavailable
for a
consultation, in which case the treating Provider must be permitted to continue
the care of the Enrollee until an Affiliated Provider is reached and either
concurs with the treating Provider's plan of care or assumes responsibility
for
the Enrollee's care.
(j)
Additional
Services or Benefits.
The
Contractor shall obtain prior approval from the Department before offering
any
additional service or benefit not required under this Contract to all Enrollees.
The Contractor shall notify Enrollees before discontinuing an additional
service
or benefit. The notice to Enrollees must be approved in advance by the
Department. The Contractor shall continue any ongoing course of treatment
for an
Enrollee then receiving such service or benefit.
(k)
Telephone
Access.
The
Contractor shall establish a toll-free twenty-four (24) hour telephone number
to
confirm eligibility for benefits and seek prior approval for treatment where
required under the Plan, and shall assure twenty-four (24) hour access, via
telephone(s), to medical professionals, either to the Plan directly or to
the
Primary Care Providers, for consultation to obtain medical care. The Contractor
must also make a toll-free number available, at a minimum during the business
hours of 9:00 a.m. until 5:00 p.m. on regular business days. This number
also
will be used to confirm eligibility for benefits, for approval for non-emergency
services and for Enrollees to call to request Site, Primary Care Provider,
or
Women's Health Care Provider changes, to make complaints or grievances, to
request disenrollment and to ask questions. The Contractor may use one toll-free
number for these purposes or may establish two separate numbers.
2.
Any
references in the contract to pharmacy services inconsistent with the changes
in
Article V, Section 5.1 for dates of service August 1, 2005 or later shall
be
read in a manner consistent with the changes in Article V, Section
5.1.
3.
The
following provision is added to the contract at Article VII, Section
7.12:
7.12
Medical
Loss Ratio Guarantee
(a)
For
each calendar quarter that this contract is in effect, effective with the
quarter beginning April 1, 2005, if the Contractor's Medical Loss Ratio (MLR)
is
less than 82%, the Department will recover by deduction from future payments
a
percentage of the quarter's premium revenue equal to the difference between
the
reported MLR and 82%.
(b)
Medical Loss Ratio shall be calculated by dividing total hospital and medical
expenses incurred in Illinois by premium revenue paid by the Department.
Premium
revenue for a quarter shall be the premium revenue accrued, including Hospital
Delivery Case Rate Payments. Expenses reported as Incurred But Not Reported
(IBNR) shall be subject to review by the Department for actuarial soundness.
All
elements of reports used to calculate MLR are subject to audit by the
Department. Audits may be ordered by the Department within
Page
8
30
days
of Departmental receipt of each quarterly report, and audits shall encompass
the
total subject matter of that report.
(c)
Hospital and medical expenses are the incurred costs of providing direct
care to
Enrollees for Covered Services. Outreach and general education are not included
in medical expenses.
(d)
At
the end of the four quarters ending March 31, 2006, the Department will review
the Contractor's MLR for the full four quarters and recover or reconcile
previous recoveries so that the Department has recovered the percentage of
the
total premium revenue for the four quarters equal to the difference between
the
cumulative MLR below 82% and 82%. Reconciliation shall consist of payment
by the
Contractor of any difference below the annualized 82% MLR not previously
deducted, or repayment to the Contractor of deductions over the annualized
82%
MLR previously made by the Department. A similar reconciliation will be
performed at the end of each four quarters or the termination of any contractual
relationship between the parties. Notwithstanding the provisions of section
7.12(b), the Department may order an audit of the reporting for the full
four
quarters within 45 days of Departmental receipt of a cumulative report of
the
four quarters.
(e)
The
Contractor shall report all information necessary to effectuate this section
in
a format and on a schedule consistent with NAIC guidelines. The Department
may
request additional supporting information necessary to effectuate this section,
and the Contractor shall report this information to the Department in a timely
manner.
(f)
For
purposes of calculating the Contractor's MLR, for the quarter beginning April
1,
2005, and for the month of July 2005, premium revenue will be adjusted to
remove
premium revenue for pharmacy services in excess of Contractor's costs for
pharmacy services.
4.
First
Amended Attachment I shall be deleted and replaced by the attached
Second
Amended
Attachment I. Each
reference to Attachment I or First Amended Attachment I in the Contract shall
be
replaced with a reference to Second Amended Attachment I.
All
other
terms and conditions of the CONTRACT shall remain in full force and
effect.
Page
9
IN
WITNESS WHEREOF,
the
parties have hereunto caused this agreement to amend the CONTRACT to be executed
by their duly authorized representatives, effective August 1, 2005.
|
DEPARTMENT
OF
HEALTHCARE & FAMILY SERVICES
By:
/s/
Xxxxx X. Xxxxx
Xxxxx
X. Xxxxx
Title:
Director
Date:7/29/05
|
HARMONY
HEALTH PLAN OF ILLINOIS, INC.
By:
/s/ Xxxx X. Xxxxx
Printed
Name: Xxxx
X. Xxxxx
Title:
President
and CEO
Date:
7/27/05
Fein:
00-0000000
|
Page
10
SECOND
AMENDED ATTACHMENT I RATE SHEETS
(a)
Contractor Name: Harmony Health Plan of Illinois, me.
Address:
000 Xxxxx Xxxxxx Xxxxx, Xxxxx 0000
Xxxxxxx,
XX 00000
(b)
Contracting Area(s) Covered by the Contractor and Enrollment Limit:
|
Contracting
Area
|
Enrollment
Limit
|
|
The
following counties in Region III:
Franklin
(effective 03/15/04 through 8/31/05) Xxxxxxx (effective 09/01/03
through
8/31/05) Xxxxxxx Xxxxx (effective 09/01/03)
Xxxxxxxx
(effective 09/01/03)
St.
Xxxxx Xxxxxxxxxx (effective 09/01/03) Xxxxxxxxxx (effective 09/01/03
through 8/31/05)
|
50,000
|
|
Region
IV
|
100,000
|
(c)
Total
Enrollment Limit for all Contracting Areas: 150,000
(d)
Threshold Review Levels: Counties listed above in Region III: 40,000
Region
IV 80,000
(e)
Standard Capitation Rates for Enrollees, effective
August 1,2003
through
July 31,2005:
|
Age/Gender
Mo = month Yr == year
|
Region
I (N.W. Illinois) PMPM
|
Region
II (Central Illinois) PMPM
|
Region
III (Southern Illinois) PMPM
|
Region
IV (Xxxx County) PMPM
|
Region
V (Collar Counties) PMPM
|
|
0-3Mo
|
$1,152.25
|
$1,178.77
|
$1,242.71
|
$1,244.64
|
$854.58
|
|
4Mo-lYr
|
127.81
|
117.63
|
165.94
|
125.04
|
108.35
|
|
2Yr-5Yr
|
63.77
|
67.81
|
71.74
|
58.67
|
56.28
|
|
6Yr-13Yr
|
72.08
|
79.78
|
75.18
|
58.18
|
57.47
|
|
14Yr-20Yr,
Male
|
115.93
|
135.96
|
131.18
|
90.67
|
142.60
|
|
14Yr-20Y,
Female
|
148.51
|
157.40
|
155.15
|
112.48
|
119.82
|
|
21Yr-44Yr,
Male
|
161.79
|
216.53
|
201.90
|
164.23
|
159.43
|
|
21Yr-44Yr,
Female
|
217.61
|
228.14
|
237.13
|
185.81
|
184.20
|
|
00Xxx
Xxxx and Female
|
437.86
|
486.40
|
476.29
|
359.61
|
409.17
|
Att.
I -1
Standard
Capitation Rates for Enrollees, effective
August 1, 2005
through
July 31, 2006:
|
Age/Gender
Mo = month Yr = year
|
Region
I
(N.W.
Illinois) PMPM
|
Region
II (Central Illinois) PMPM
|
Region
III (Southern Illinois) PMPM
|
Region
IV (Xxxx County) PMPM
|
Region
V (Collar Counties) PMPM
|
|
0-3Mo
|
$1,342.61
|
$1,178.83
|
$1,271.32
|
$1,369.28
|
$948.46
|
|
4Mo-lYr
|
121.62
|
109.83
|
154.41
|
117.41
|
99.27
|
|
2Yr-5Yr
|
53.51
|
57.02
|
59.41
|
51.49
|
49.60
|
|
6Yr-13Yr
|
49.37
|
51.29
|
52.22
|
45.53
|
42.00
|
|
14Yr-20Yr,
Male
|
85.90
|
92.02
|
85.37
|
70.16
|
100.73
|
|
14Yr-20Y,
Female
|
127.53
|
128.58
|
123.97
|
94.84
|
98.76
|
|
21Yr-44Yr,Male
|
113.28
|
161.06
|
139.13
|
121.91
|
110.33
|
|
21Yr-44Yr,
Female
|
164.91
|
167,03
|
168.42
|
148.97
|
141.81
|
|
00Xxx
Xxxx and Female
|
277.48
|
310.00
|
275.75
|
258.08
|
273.13
|
(f) Hospital
Delivery Case Rate, effective August 1, 2003 through July 31, 2005:
|
Hospital
Delivery Case Rate
(per
delivery)
|
$3,196.12
|
$3,104.66
|
$3,281.22
|
$3,748.33
|
$3,276.03
|
Hospital
Delivery Case Rate, effective
August 1, 2005
through
July 31,2006:
|
Hospital
Delivery Case Rate (per delivery)
|
$3,008.88
|
$2,900.77
|
$3,100.59
|
$3,431.08
|
$3,113.07
|
Alt.
I -
2
