1
Exhibit 10.4
TDH Document No. 7526032317 * 2000-01
1999
CONTRACT FOR SERVICES
Between
THE TEXAS DEPARTMENT OF HEALTH
And
HMO
AMERICAID Texas, Inc.
Dallas Service Area
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TABLE OF CONTENTS
APPENDICES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
ARTICLE I PARTIES AND AUTHORITY TO CONTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ARTICLE II DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ARTICLE III PLAN ADMINISTRATIVE AND HUMAN RESOURCE REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.1 ORGANIZATION AND ADMINISTRATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.2 NON-PROVIDER SUBCONTRACTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.3 MEDICAL DIRECTOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.4 PLAN MATERIALS AND DISTRIBUTION OF PLAN MATERIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.5 RECORDS REQUIREMENTS AND RECORDS RETENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.6 HMO REVIEW OF TDH MATERIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ARTICLE IV FISCAL, FINANCIAL, CLAIMS AND INSURANCE REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . 18
4.1 FISCAL SOLVENCY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
4.2 MINIMUM EQUITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
4.3 PERFORMANCE BOND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.4 INSURANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.5 FRANCHISE TAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.6 AUDIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4.7 PENDING OR THREATENNG LITIGATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4.8 MISREPRESENTATION AND FRAUD IN RESPONSE TO RFA AND IN HMO OPERATIONS . . . . . . . . . . . . . . . . . . . . . . 20
4.9 THIRD PARTY RECOVERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
4.10 CLAIMS PROCESSING REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.11 INDEMNIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
ARTICLE V STATUTORY AND REGULATORY COMPLIANCE REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
5.1 COMPLIANCE WITH FEDERAL, STATE, AND LOCAL LAWS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
5.2 PROGRAM INTEGRITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
5.3 FRAUD AND ABUSE COMPLIANCE PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
5.4 SAFEGUARDING INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
5.5 NON-DISCRIMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
5.6 HISTORICALLY UNDERUTILIZED BUSINESSES (HUBs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
5.7 BUY TEXAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
5.8 CHILD SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
5.9 REQUESTS FOR PUBLIC INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
5.10 NOTICE AND APPEAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
ARTICLE VI SCOPE OF SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
6.1 SCOPE OF SERVICES - GENERAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
6.2 PRE-EXISTING CONDITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
6.3 SPAN OF ELIGIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
6.4 CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
6.5 EMERGENCY SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
6.6 BEHAVIORAL HEALTH SERVICES - SPECIFIC REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
6.7 FAMILY PLANNING - SPECIFIC REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
6.8 TEXAS HEALTH STEPS (EPSDT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
6.9 PERINATAL SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
6.10 EARLY CHILDHOOD INTERVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
6.11 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) - SPECIFIC REQUIREMENTS . . . . . . 40
6.12 TUBERCULOSIS (TB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
6.13 PEOPLE WITH DISABILITIES OR CHRONIC OR COMPLEX CONDITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
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6.14 HEALTH EDUCATION AND WELLNESS AND PREVENTION PLANS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
6.15 SEXUALLY TRANSMITTED DISEASES (STDs) AND HUMAN IMMUNODEFICIENCY VIRUS (HIV) . . . . . . . . . . . . . . . . . . . 46
6.16 BLIND AND DISABLED MEMBERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
ARTICLE VII PROVIDER NETWORK REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
7.1 PROVIDER ACCESSIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
7.2 PROVIDER CONTRACTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
7.3 PHYSICIAN INCENTIVE PLANS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
7.4 PROVIDER MANUAL AND PROVIDER TRAINING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
7.5 MEMBER PANEL REPORTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
7.6 PROVIDER COMPLAINT AND APPEAL PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
7.7 PROVIDER QUALIFICATIONS - GENERAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
7.8 PRIMARY CARE PROVIDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
7.9 OB/GYN PROVIDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
7.10 SPECIALTY CARE PROVIDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
7.11 SPECIAL HOSPITALS AND SPECIALTY CARE FACILITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
7.12 SIGNIFICANT TRADITIONAL PROVIDERS (STPs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
7.13 RURAL HEALTH PROVIDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
7.14 FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) AND RURAL HEALTH CLINICS (RHC) . . . . . . . . . . . . . . . . . . . . 63
7.15 COORDINATION WITH PUBLIC HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
7.16 COORDINATION WITH TEXAS DEPARTMENT OF PROTECTIVE AND REGULATORY SERVICES..... . . . . . . . . . . . . . . . . . . 67
7.17 PROVIDER NETWORKS (IPAs, LIMITED PROVIDER NETWORKS AND ANHCs) . . . . . . . . . . . . . . . . . . . . . . . . . . 68
ARTICLE VIII MEMBER SERVICES REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
8.1 MEMBER EDUCATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
8.2 MEMBER HANDBOOK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
8.3 ADVANCE DIRECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
8.4 MEMBER ID CARDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
8.5 MEMBER HOTLINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
8.6 MEMBER COMPLAINT PROCESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
8.7 MEMBER NOTICE, APPEALS AND FAIR HEARINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
8.8 MEMBER ADVOCATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
8.9 MEMBER CULTURAL AND LINGUISTIC SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
ARTICLE IX MARKETING AND PROHIBITED PRACTICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
9.1 MARKETING MATERIAL MEDIA AND DISTRIBUTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
9.2 MARKETING ORIENTATION AND TRAINING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
9.3 PROHIBITED MARKETING PRACTICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
9.4 NETWORK PROVIDER DIRECTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
ARTICLE X MIS SYSTEM REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
10.1 MODEL MIS REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
10.2 SYSTEM-WIDE FUNCTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
10.3 ENROLLMENT/ELIGIBILITY SUBSYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
10.4 PROVIDER SUBSYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
10.5 ENCOUNTER/CLAIMS PROCESSING SUBSYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
10.6 FINANCIAL SUBSYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
10.7 UTILIZATION/QUALITY IMPROVEMENT SUBSYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
10.8 REPORT SUBSYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
10.9 DATA INTERFACE SUBSYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
10.10 TPR SUBSYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
10.11 YEAR 2000 COMPLIANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
ARTICLE XI QUALITY ASSURANCE AND QUALITY IMPROVEMENT PROGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . 92
11.1 QUALITY IMPROVEMENT PROGRAM (QIP) SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
11.2 WRITTEN QIP PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
11.3 QIP SUBCONTRACTING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
11.4 ACCREDITATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
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11.5 BEHAVIORAL HEALTH INTEGRATION INTO QIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
11.6 QIP REPORTING REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
ARTICLE XII REPORTING REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
12.1 FINANCIAL REPORTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
12.2 STATISTICAL REPORTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
12.3 ARBITRATION/LITIGATION CLAIMS REPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
12.4 SUMMARY REPORT OF PROVIDER COMPLAINTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
12.5 PROVIDER NETWORK REPORTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
12.6 MEMBER COMPLAINTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
12.7 FRAUDULENT PRACTICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
12.8 UTILIZATION MANAGEMENT REPORTS - BEHAVIORAL HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
12.9 UTILIZATION MANAGEMENT REPORTS - PHYSICAL HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
12.10 QUALITY IMPROVEMENT REPORTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
12.11 HUB REPORTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
12.12 THSTEPS REPORTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
12.13 REPORTING REQUIREMENTS DUE DATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
ARTICLE XIII PAYMENT PROVISIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
13.1 CAPITATION AMOUNTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
13.2 EXPERIENCE REBATE TO STATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
13.3 PERFORMANCE OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
13.4 PAYMENT OF PERFORMANCE OBJECTIVE BONUSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
13.5 ADJUSTMENTS TO PREMIUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
ARTICLE XIV ELIGIBILITY, ENROLLMENT, AND DISENROLLMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
14.1 ELIGIBILITY DETERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
14.2 ENROLLMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
14.3 DISENROLLMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
14.4 AUTOMATIC RE-ENROLLMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
14.5 ENROLLMENT REPORTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
ARTICLE XV GENERAL PROVISIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
15.1 INDEPENDENT CONTRACTOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
15.2 AMENDMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
15.3 LAW, JURISDICTION AND VENUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
15.4 NON-WAIVER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
15.5 SEVERABILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
15.6 ASSIGNMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
15.7 NON-EXCLUSIVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
15.8 DISPUTE RESOLUTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
15.9 DOCUMENTS CONSTITUTING CONTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
15.10 FORCE MAJEURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
15.11 NOTICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
15.12 SURVIVAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
ARTICLE XVI DEFAULT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
16.1 FAILURE TO PROVIDE COVERED SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
16.2 FAILURE TO PERFORM AN ADMINISTRATIVE FUNCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
16.3 HMO CERTIFICATE OF AUTHORITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
16.4 INSOLVENCY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
16.5 FAILURE TO COMPLY WITH FEDERAL LAWS AND REGULATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
16.6 EXCLUSION FROM PARTICIPATION IN MEDICARE OR MEDICAID . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
16.7 MISREPRESENTATION, FRAUD OR ABUSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
16.8 FAILURE TO MAKE CAPITATION PAYMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
16.9 FAILURE TO MAKE PAYMENTS TO NETWORK PROVIDERS AND SUBCONTRACTORS . . . . . . . . . . . . . . . . . . . . . . 115
16.10 FAILURE TO DEMONSTRATE THE ABILITY TO PERFORM CONTRACT FUNCTIONS . . . . . . . . . . . . . . . . . . . . . . 115
16.11 FAILURE TO MONITOR AND/OR SUPERVISE ACTIVITIES OF CONTRACTORS OR NETWORK PROVIDERS . . . . . . . . . . . . . 115
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ARTICLE XVII NOTICE OF DEFAULT AND CURE OF DEFAULT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
ARTICLE XVIII REMEDIES AND SANCTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
18.1 TERMINATION BY TDH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
18.2 TERMINATION BY HMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
18.3 TERMINATION BY MUTUAL CONSENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
18.4 DUTIES UPON TERMINATION OF CONTRACTING PARTIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
18.5 STATE AND FEDERAL DAMAGES, PENALTIES AND SANCTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
18.6 SUSPENSION OF NEW ENROLLMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
18.7 TDH INITIATED DISENROLLMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
18.8 LIQUIDATED MONEY DAMAGES - WITHHOLDING PAYMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
18.9 FORFEITURE OF TDI PERFORMANCE BOND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
ARTICLE XIX TERM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
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APPENDICES
APPENDIX A
Standards For Quality Improvement Programs
APPENDIX B
HUB Progress Assessment Reports
APPENDIX C
Scope of Services
APPENDIX D
Family Planning Providers
APPENDIX E
Transplant Facilities
APPENDIX F
Trauma Facilities
APPENDIX G
Hemophilia Treatment Centers And Programs
APPENDIX H
Utilization Management Report - Behavioral Health
APPENDIX I
Managed Care Financial-Statistical Report
APPENDIX J
Utilization Management Report - Physical Health
APPENDIX K
Preventive Health Performance Objectives
APPENDIX L
Cost Principles For Administrative Expenses
APPENDIX M
Required Critical Elements
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TDH Document No. ________
1999
CONTRACT FOR SERVICES
Between
THE TEXAS DEPARTMENT OF HEALTH
And
HMO
This contract is entered into between the Texas Department of Health (TDH) and
AMERICAID Texas, Inc. (HMO). The purpose of this contract is to set forth the
terms and conditions for HMO's participation as a managed care organization in
the TDH STAR Program (STAR or STAR Program). Under the terms of this contract
HMO will provide comprehensive health care services to qualified and eligible
Medicaid recipients through a managed care delivery system. This is a
risk-based contract. HMO was selected to provide services under this contract
under the Professional Services Procurement Act, Government Code, Title 10,
Section 2254.001 et. seq. HMO's selection for this contract was based upon
HMO's Application submitted in response to TDH's 1998 Request for Application
(RFA). Representations and responses contained in HMO's Application are
incorporated into and are enforceable provisions of this contract.
Terms used throughout this Contract have the following meaning, unless the
context clearly indicates otherwise.
ARTICLE I PARTIES AND AUTHORITY TO CONTRACT
1.1 The Texas Legislature has designated the Texas Health and
Human Services Commission (THHSC) as the single State agency
to administer the Medicaid program in the State of Texas.
THHSC has delegated the authority to operate the Medicaid
managed care delivery system for acute care services to TDH.
TDH has authority to contract with HMO to carry out the duties
and functions of the Medicaid managed care program under
Health and Safety Code, Title 2, Section 12.011 and Section
12.021 and Texas Government Code Section 533.001 et. seq.
1.2 HMO is a corporation with authority to conduct business in the
State of Texas and has a certificate of authority from the
Texas Department of Insurance (TDI) to operate as a Health
Maintenance Organization (HMO) under Chapter 20A of the
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Insurance Code. HMO is in compliance with all TDI rules and
laws that apply to HMOs. HMO has been authorized to enter
into this contract by its Board of Directors or other
governing body. HMO is an enrolled provider in the Texas
Medical Assistance Program (Medicaid).
1.3 This contract is subject to the approval and ongoing
monitoring of the federal Health Care Financing Administration
(HCFA).
1.4 Readiness Review. This contract is subject to TDH's Readiness
Review of HMO. Under the provisions of Human Resources Code
Section 32.043(a), TDH is required to review all HMOs with
whom it contracts to determine whether HMO has complied with
the TDH/HMO contract and/or can continue to meet all contract
obligations.
1.4.1 Readiness review will be conducted through: on-site
inspection of service authorization, claims payment systems,
complaint-processing systems, and other processes or systems
required by the contract, as determined by TDH; and, by review
of HMO's compliance with contract requirements in the
preceding and existing contract, including claims payment,
complaints received/resolved, encounter data submission and
other required reports.
1.4.2 TDH will provide HMO with written notice of the elements and
scheduling of the reviews, any deficiencies which must be
corrected, and the timeline by which deficiencies must be
corrected.
1.4.3 TDH may discontinue enrollment of Members into HMO if the
Readiness Review reveals that HMO is not currently prepared to
meet its contractual obligations or has failed to correct or
cure defaults under the provisions of Article XVII.
1.5 Implementation Plan. Texas Government Code Section 533.007(b)
requires that each HMO that contracts with TDH to provide
health care services to recipients in a service area must
submit an implementation plan not later than the 90th day
before the Implementation Date in the service area.
1.5.1 The implementation plan must include, but not be limited to:
1) staffing patterns by function for all operations, including
enrollment, information systems, member services, quality
improvement, claims management, case management, and provider
and recipient training, and, 2) specific time frames for
demonstrating preparedness for implementation before the
Implementation Date in the service area.
1.5.2 TDH will respond to an implementation plan not later than the
10th day after the date HMO submits the plan if the plan does
not adequately meet preparedness guidelines.
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1.5.3 HMO must submit status reports on the implementation plan not
later than the 60th day and the 30th day before the
Implementation Date in the service area every 30th day after
the Implementation Date, until the 180th day after the
Implementation Date.
1.6 AUTHORITY OF HMO TO ACT ON BEHALF OF TDH. HMO is given
express, limited authority to exercise the State's right of
recovery as provided in Article 4.9, and to enforce provisions
of this contract which require providers or subcontractors to
produce records, reports, encounter data, public health data,
and other documents to comply with this contract and which TDH
has authority to require under State or federal laws.
ARTICLE II DEFINITIONS
Abuse means provider practices that are inconsistent with sound fiscal,
business, or medical practices and result in an unnecessary cost to the
Medicaid program, or in reimbursement for services that are not medically
necessary or that fail to meet professionally recognized standards for health
care. It also includes recipient practices that result in unnecessary cost to
the Medicaid program.
Action means a denial, termination, suspension, or reduction of covered
services or the failure of HMO to act upon request for covered services within
a reasonable time or a denial of a request for prior authorization for covered
services affecting a Member. This term does not include reaching the end of
prior authorized services.
Adjudicate means to deny or pay a clean claim.
AFDC and AFDC-related means the federally funded program that provides
financial assistance to single-parent families with children who meet the
categorical requirements for aid. This program is now called Temporary
Assistance to Needy Families (TANF).
Affiliate means any individual or entity owning or holding more than a five
percent (5%) interest in HMO; in which HMO owns or holds more than a five
percent (5%) interest; any parent entity; or subsidiary entity of HMO,
regardless of the organizational structure of the entity.
Allowable expenses means all expenses related to the Contract for Services
between TDH and HMO that are incurred during the term of the contract that are
not reimbursable or recovered from another source.
Allowable revenue means all Medicaid managed care revenue received by HMO for
the contract period, including retroactive adjustments made by TDH.
Behavioral health services means covered services for the treatment of mental
or emotional disorders and treatment of chemical dependency disorders.
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10
Capitation means a method of payment in which HMO or a health care provider
receives a fixed amount of money each month for each enrolled Member,
regardless of the services used by the enrolled Member.
CHIP means Children's Health Insurance Program established by Title XXI of the
Social Security Act to assist state efforts to initiate and expand child health
assistance to uninsured, low-income children.
Chronic or complex condition means a physical, behavioral, or developmental
condition which may have no known cure and/or is progressive and/or can be
debilitating or fatal if left untreated or under-treated.
Clean claim means a TDH approved or identified claim format that contains all
data fields required by HMO and TDH for final adjudication of the claim. The
required data fields must be complete and accurate. Clean claim also includes
HMO-published requirements for adjudication, such as medical records, as
appropriate. (See definition of Unclean Claim.) The TDH required data fields
are identified in TDH's "HMO Encounter Data Claims Submission Manual."
CLIA means the federal legislation commonly known as the Clinical Laboratories
Improvement Act of 1988 as found at Section 353 of the federal Public Health
Services Act, and regulations adopted to implement the Act.
Complainant means a Member or a treating provider or other individual
designated to act on behalf of the Member who files the complaint.
Complaint means any dissatisfaction, expressed by a complainant orally or in
writing to HMO, with any aspect of HMO's operation, including but not limited
to dissatisfaction with plan administration; an appeal of an adverse
determination to HMO; the way a service is provided; or disenrollment decisions
expressed by a complainant. A complaint is not a misunderstanding or
misinformation that is resolved promptly by supplying the appropriate
information or clearing up the misunderstanding to the satisfaction of the
Member, or a request for a fair hearing to TDH.
Continuity of care means care provided to a Member by the same primary care
provider or specialty provider to the greatest degree possible, so that the
delivery of care to the Member remains stable, and services are consistent and
unduplicated.
Contract means this contract between TDH and HMO and documents included by
reference and any of its written amendments, corrections or modifications.
Contract administrator means an entity contracting with TDH to carry out
specific administrative functions under the State's Medicaid managed care
program.
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Contract anniversary date means September 1 of each year after the first year
of this contract, regardless of the date of execution or effective date of the
contract.
Contract period means the period of time starting with effective date of the
contract and ending on the termination date of the contract.
Covered services means health care services and health related services HMO
must provide to Members, including all services required by this contract and
state and federal law, and all value-added services described by HMO in its
response to the Request For Application (RFA) for this contract.
Day means calendar day unless specified otherwise.
Denied claim means a clean claim or a portion of a clean claim for which a
determination is made that the claim cannot be paid.
Disability means a physical or mental impairment that substantially limits one
or more of the major life activities of an individual.
DSM-IV means the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, which is the American Psychiatric Association's official
classification of behavioral health disorders.
ECI means Early Childhood Intervention which is a federally mandated program
for infants and children under the age of three with or at risk for development
delays and/or disabilities. The federal ECI regulations are found at 34 C.F.R.
303.1 et. seq. The State ECI rules are found at 25 TAC Section 621.21 et. seq.
Effective date of the contract means the day on which this contract is signed
and the parties are bound by the terms and conditions of this contract.
Emergency behavioral health condition means any condition, without regard to
the nature or cause of the condition, which in the opinion of a prudent
layperson possessing an average knowledge of health and medicine requires
immediate intervention and/or medical attention without which Members would
present an immediate danger to themselves or others or which renders Members
incapable of controlling, knowing or understanding the consequences of their
actions.
Emergency services means covered inpatient and outpatient services that are
furnished by a provider that is qualified to furnish such services under this
contract and are needed to evaluate or stabilize an emergency medical
condition.
Emergency Medical Condition means 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 care could result in:
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Dallas Service Area Contract
12
(a) placing the patient's health in serious jeopardy;
(b) serious impairment to bodily functions;
(c) serious dysfunction of any bodily organ or part; or
(d) serious disfigurement; or
(e) in the case of a pregnant woman, serious jeopardy to the health of
the fetus.
Encounter means a covered service or group of services delivered by a provider
to a Member during a visit between the Member and provider. This also includes
value-added services.
Encounter data means data elements from fee-for-service claims or capitated
services proxy claims that are submitted to TDH by HMO in accordance with TDH's
"HMO Encounter Data Claims Submission Manual".
Enrollment Broker means an entity contracting with TDH to carry out specific
functions related to Member services (i.e. enrollment/disenrollment,
complaints, etc.) under TDH's Medicaid managed care program.
Enrollment report means the list of Medicaid recipients who are enrolled with
an HMO as Members for the month the report was issued.
EPSDT means the federally mandated Early and Periodic Screening, Diagnosis and
Treatment program contained at 42 USC 1396d(r). (See definition for Texas
Health Steps.) The name has been changed to Texas Health Steps (THSteps) in
the State of Texas.
Execution date means the date this contract is signed by persons with the
authority to contract for TDH and HMO.
Fair hearing means a due process hearing conducted by the Texas Department of
Health that complies with 25 TAC Section 1.51 et. seq. and federal rules found
at 42 CFR Subpart E, relating to Fair Hearings for Applicants and Recipients.
FQHC means a Federally Qualified Health Center that has been certified by HCFA
to meet the requirements of Section 1861(aa)(3) of the Social Security Act as a
federally qualified health center and is enrolled as a provider in the Texas
Medicaid Program.
Fraud means an intentional deception or misrepresentation made by a person with
the knowledge that the deception could result in some unauthorized benefit to
himself or some other person. It includes any act that constitutes fraud under
applicable federal or state law.
HCFA means the federal Health Care Financing Administration.
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Dallas Service Area Contract
13
Health care services or health services means physical medicine and
health-related services which an enrolled population might reasonably require
in order to be maintained in good health, including, as a minimum, emergency
services and inpatient and outpatient services.
Implementation Date means the first date that Medicaid managed care services
are delivered to Members in each of the counties in a service area.
Inpatient stay means at least a 24-hour stay in a facility licensed to provide
hospital care.
JCAHO means Joint Commission on Accreditation of Health Care Organizations.
Local Health Department means a local health department established pursuant to
Health and Safety Code, Title 2, Local Public Health Reorganization Act Section
121.031.
Local tuberculosis control program means a tuberculosis program that is managed
by a local or regional health department.
Major life activities means functions such as caring for oneself, performing
manual tasks, walking, seeing, hearing, speaking, breathing, learning, and
working.
Major population group is defined by federal guidelines as a group comprising
10% or more of HMO's Medicaid service population.
Medical education refers to the State-supported allopathic medical schools and
schools of osteopathic medicine, their teaching institutions and faculties,
those entities that have Primary Care Residency Programs approved by the
Accreditation Council for Graduate Medical Education.
Medical home means a primary or specialty care provider who has accepted the
responsibility for providing accessible, continuous, comprehensive and
coordinated care to Members participating in TDH's Medicaid managed care
program.
Medically necessary behavioral health services means those behavioral health
services which:
(a) are reasonable and necessary for the diagnosis or treatment of a
mental health or chemical dependency disorder or to improve or to
maintain or to prevent deterioration of functioning resulting from
such a disorder;
(b) are in accordance with professionally accepted clinical guidelines and
standards of practice in behavioral health care;
(c) are furnished in the most appropriate and least restrictive setting in
which services can be safely provided;
(d) are the most appropriate level or supply of service which can safely
be provided; and
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Dallas Service Area Contract
14
(e) could not be omitted without adversely affecting the Member's mental
and/or physical health or the quality of care rendered.
Medically necessary health care services means health care services, other than
behavioral health services which are:
(a) reasonable and necessary to prevent illnesses or medical conditions,
or provide early screening, interventions, and/or treatments for
conditions that cause suffering or pain, cause physical deformity or
limitations in function, threaten to cause or worsen a handicap, cause
illness or infirmity of a Member, or endanger life;
(b) provided at appropriate facilities and at the appropriate levels of
care for the treatment of a Member's medical conditions;
(c) consistent with health care practice guidelines and standards that are
issued by professionally recognized health care organizations or
governmental agencies;
(d) consistent with the diagnoses of the conditions; and
(e) no more intrusive or restrictive than necessary to provide a proper
balance of safety, effectiveness, and efficiency.
Member means a person who: is entitled to benefits under Title XIX of the
Social Security Act and the Texas Medical Assistance Program (Medicaid), is in
a Medicaid eligibility category included in the STAR Program, and is enrolled
in the STAR Program.
Member month means one Member enrolled with an HMO during any given month. The
total Member months for each month of a year comprise the annual Member months.
MIS means management information system.
NorthSTAR means a behavioral health carve-out program operating only in the
Dallas Service Area and administered by the Texas Commission on Alcohol and
Drug Abuse and the Texas Department of Mental Health and Mental Retardation.
Pended claim means a claim for payment which requires additional information
before the claim can be adjudicated as a clean claim.
Performance premium means an amount which may be paid to a managed care
organization as a bonus for accomplishing a portion or all of the performance
objectives contained in this contract.
Premium means the amount paid by TDH to a managed care organization on a
monthly basis and is determined by multiplying the Member months times the
capitation amount for each enrolled Member.
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15
Primary care physician or primary care provider (PCP) means a physician or
provider who has agreed with HMO to provide a medical home to Members and who
is responsible for providing initial and primary care to patients, maintaining
the continuity of patient care, and initiating referral for care (also see
Medical home).
Provider means an individual or entity and its employees and subcontractors
that directly provide health care services to HMO's Members under TDH's
Medicaid managed care program.
Provider contract means an agreement entered into by a direct provider of
health services and HMO or an intermediary entity.
Public information means information that is collected, assembled, or
maintained under a law or ordinance or in connection with the transaction of
official business by a governmental body or for a governmental body and the
governmental body owns the information or has a right of access.
Readiness review means a review process conducted by TDH or its agent(s) to
assess HMO's capacity and capability to perform the duties and responsibilities
required under the Contract. This process is required by Texas Government Code
Section 533.007.
RFA means Request For Application issued by TDH on June 17, 1998, and all RFA
addenda, corrections or modifications.
Risk means the potential for loss as a result of expenses and costs of HMO
exceeding payments made by TDH under this contract.
Rural Health Clinic (RHC) means an entity that meets all of the requirements
for designation as a rural health clinic under Section 1861(aa)(1) of the
Social Security Act and approved for participation in the Texas Medicaid
Program.
Service area means the counties included in a site selected for the STAR
Program, within which a participating HMO must provide services.
Significant traditional provider (STP) means all hospitals receiving
disproportionate share hospital funds (DSH) in FY '95 and all other providers
in a county that, when listed by provider type in descending order by the
number of recipient encounters, provided the top 80 percent of recipient
encounters for each provider type in FY '95.
Special hospital means an establishment that:
(a) offers services, facilities, and beds for use for more than 24 hours
for two or more unrelated individuals who are regularly admitted,
treated, and discharged and who require services more intensive than
room, board, personal services, and general nursing care;
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Dallas Service Area Contract
16
(b) has clinical laboratory facilities, diagnostic x-ray facilities,
treatment facilities, or other definitive medical treatment;
(c) has a medical staff in regular attendance; and
(d) maintains records of the clinical work performed for each patient.
STAR Program is the name of the State of Texas Medicaid managed care program.
"STAR" stands for the State of Texas Access Reform.
State fiscal year means the 12-month period beginning on September 1 and ending
on August 31 of the next year.
Subcontract means any written agreement between HMO and other party to fulfill
the requirements of this contract. All subcontracts are required to be in
writing.
Subcontractor means any individual or entity which has entered into a
subcontract with HMO.
TAC means Texas Administrative Code.
TANF means Temporary Assistance to Needy Families.
TCADA means Texas Commission on Alcohol and Drug Abuse. State agency
responsible for licensing chemical dependency treatment facilities. TCADA also
contracts with providers to deliver chemical dependency treatment services.
TDD means telecommunication device for the deaf. It is interchangeable with
the term Teletype machine or TTY.
TDH means the Texas Department of Health or its designees.
TDHS means the Texas Department of Human Services.
TDI means the Texas Department of Insurance.
TDMHMR means the Texas Department of Mental Health and Mental Retardation,
which is the State agency responsible for developing mental health policy for
public and private sector providers.
Temporary Assistance to Needy Families (TANF) means the federally funded
program that provides assistance to single-parent families with children who
meet the categorical requirements for aid. This program was formerly known as
Aid to Families with Dependent Children (AFDC) program.
Texas Health Steps (THSteps) is the name adopted by the State of Texas for the
federally mandated Early and Periodic Screening, Diagnosis and Treatment
(EPSDT) program. It includes the State's Comprehensive Care Program extension
to EPSDT, which adds benefits to the federal EPSDT
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Dallas Service Area Contract
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requirements contained in 42 United States Code Section 1396d(r), and defined
and codified at 42 C.F.R. Section 440.40 and Sections 441.56-62. TDH's rules
are contained in 25 TAC, Chapter 33 (relating to Early and Periodic Screening,
Diagnosis and Treatment).
Texas Medicaid Provider Procedures Manual means the policy and procedures
manual published by or on behalf of TDH which contains policies and procedures
required of all health care providers who participate in the Texas Medicaid
program. The manual is updated by the Medicaid Bulletin which is published
bi-monthly.
Texas Medicaid Service Delivery Guide means an attachment to the Texas Medicaid
Provider Procedures Manual.
THHSC means the Texas Health and Human Services Commission.
THSteps means Texas Health Steps.
Third Party Liability (TPL) means the legal responsibility of another
individual or entity to pay for all or part of the services provided to Members
under this contract. (See 25 TAC, Subchapter 28, relating to Third Party
Resources.)
Third Party Recovery (TPR) means the recovery of payments made on behalf of a
Member by TDH or HMO from an individual or entity with the legal responsibility
to pay for the services.
TXMHMR means Texas Mental Health and Mental Retardation system which includes
the state agency, TDMHMR, and the Local Mental Health and Mental Retardation
Authorities.
Unclean claim means a claim that does not contain accurate and complete data in
all claim fields that are required by HMO and TDH and other HMO-published
requirements for adjudication, such as medical records, as appropriate. (See
definition of Clean Claim.)
Urgent behavioral health situations means conditions which require attention
and assessment within 24 hours but which do not place the Member in immediate
danger to themselves or others and the Member is able to cooperate with
treatment.
Urgent condition means a health condition which is not an emergency but is
severe or painful enough to cause a prudent layperson possessing the average
knowledge of medicine to believe that his or her condition requires medical
treatment evaluation or treatment within 24 hours by the Member's PCP or PCP
designee to prevent serious deterioration of the Member's condition or health.
Value-added services means services which were not included in the RFA as
mandatory covered services, but which were submitted by HMO with its response
to the RFA and which have been approved by TDH to be included in this contract
as value-added services in Appendix C - Scope of Services. These services must
be provided to all mandatory Members as part of the covered services
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under this contract. No additional capitation will be paid for these services,
under the current capitation rate.
ARTICLE III PLAN ADMINISTRATIVE AND HUMAN RESOURCE REQUIREMENTS
3.1 ORGANIZATION AND ADMINISTRATION
3.1.1 HMO must maintain the organizational and administrative
capacity and capabilities to carry out all duties and
responsibilities under this contract.
3.1.2 HMO must maintain assigned staff with the capacity and
capability to provide all services to all Members under this
contract.
3.1.3 HMO must maintain an administrative office in the service area
(local office). The local office must comply with the
American with Disabilities Act requirements for public
buildings. Member Advocates for the service area must be
located in this office. (See Article 8.8.)
3.1.4 HMO must provide training and development programs to all
assigned staff to ensure they know and understand the service
requirements under this contract including the reporting
requirements, the policies and procedures, cultural and
linguistic requirements and the scope of services to be
provided.
3.1.5 By Phase I of Readiness Review, HMO submit a current
organizational chart showing basic functions, the number of
employees for those functions, and a list of key managers in
HMO who are responsible for the basic functions of the
organization. HMO must notify TDH within fifteen (15) working
days of any change in key managers or Subcontractors. This
information must be updated annually or when there is a
significant change in organizational structure or personnel.
HMO shall submit a description and organizational chart which
illustrates how physical health services administration will
be coordinated with behavioral health administration in
NorthStar plans, including individuals assigned to be liaisons
to NorthSTAR plans.
3.1.6 Participation in Regional Advisory Committee. HMO must
participate on a Regional Advisory Committee established in
the service area in compliance with the Texas Government Code,
Sections 533.021-533.029. The Regional Advisory Committee in
each managed care service area must include representatives
from at least the following entities: hospitals; managed care
organizations; primary care providers; state agencies;
consumer advocates; Medicaid recipients; rural providers;
long-term care
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providers; specialty care providers, including pediatric
providers; and political subdivisions with a constitutional or
statutory obligation to provide health care to indigent
patients. HHSC and TDH will determine the composition of each
Regional Advisory Committee.
3.1.6.1 The Regional Advisory Committee is required to meet at least
quarterly for the first year after appointment of the
committee and at least annually in subsequent years. The
actual frequency may vary depending on the needs and
requirements of the committee.
3.2 NON-PROVIDER SUBCONTRACTS
3.2.1 HMO must enter into written contracts with all Subcontractors
and maintain copies of the subcontracts in HMO's
administrative office. HMO must make non-provider
subcontracts available to TDH upon request, at the time and
location requested by TDH. Additionally, all HMO non-provider
subcontracts, including all intermediary subcontracts down to
the actual provider of services, relating to the delivery or
payment of covered health services must be submitted to TDH no
later than 120 days prior to the Implementation Date.
3.2.1.1 HMO must notify TDH not less than 90 days prior to terminating
any subcontract affecting a major performance function of this
contract. All major Subcontractor terminations or
substitutions require TDH approval. TDH may require HMO to
provide a transition plan describing how care will continue to
be provided to Members. All subcontracts are subject to the
terms and conditions of this contract and must contain the
provisions of Article V, Statutory and Regulatory Compliance,
and the provisions contained in 3.2.4
3.2.2 Subcontracts, which are requested by any agency with authority
to investigate and prosecute fraud and abuse, must be produced
at the time and in the manner requested by the requesting
Agency. Subcontracts requested in response to a public
information request must be produced with 48 hours of the
request. All requested records must be provided free of
charge.
3.2.3 The form and substance of all Subcontracts including
subsequent amendments are subject to approval by TDH. TDH
retains the authority to reject or require changes to any
provisions of the subcontract that do not comply with the
requirements or duties and responsibilities of this contract
or create significant barriers for TDH in carrying out its
duty to monitor compliance with the contract. HMO REMAINS
RESPONSIBLE FOR PERFORMING ALL DUTIES, RESPONSIBILITIES AND
SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER THE DUTY,
RESPONSIBILITY OR SERVICE IS SUBCONTRACTED TO ANOTHER.
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3.2.4 HMO and all intermediary entities must include the following
standard language in each subcontract and ensure that this
language is included in all subcontracts down to the actual
provider of the services. The following standard language is
not the only language that will be considered acceptable by
TDH.
3.2.4.1 Contractor understands that services provided under this
contract are funded by state and federal funds under the Texas
Medical Assistance Program (Medicaid). Contractor is subject
to all state and federal laws, rules and regulations that
apply to persons or entities receiving state and federal
funds. Contractor understands that any violation by
Contractor of a state or federal law relating to the delivery
of services under this contract, or any violation of the
TDH/HMO contract could result in liability for contract money
damages, and/or civil and criminal penalties and sanctions
under state and federal law.
3.2.4.2 Contractor understands and agrees that HMO has the sole
responsibility for payment of services rendered by the
Contractor under this contract. In the event of HMO
insolvency or cessation of operations, Contractor's sole
recourse is against HMO through the bankruptcy or receivership
estate of HMO.
3.2.4.3 Contractor understands and agrees that TDH is not liable or
responsible for payment for any services provided under this
contract.
3.2.4.4 Contractor agrees that any modification, addition, or deletion
of the provisions of this agreement will become effective no
earlier than 30 days after HMO notifies TDH of the change. If
TDH does not provide written approval within 30 days from
receipt of notification from HMO, changes may be considered
provisionally approved.
3.2.4.5 This contract is subject to state and federal fraud and abuse
statutes. The Contractor will be required to cooperate in the
investigation and prosecution of any suspected fraud or abuse,
and must provide any and all requested originals and copies of
records and information, free of charge on request, to any
state or federal agency with authority to investigate fraud
and abuse in the Medicaid program.
3.2.5 The Texas Medicaid Fraud Control Unit must be allowed to
conduct private interviews of HMO personnel, Subcontractors
and their personnel, witnesses, and patients. Requests for
information are to be complied within the form and the
language requested. HMO employees and contractors and
Subcontractors and their employees and contractors must
cooperate fully in making themselves available in person for
interviews, consultation, grand jury proceedings, pretrial
conference, hearings, trial and in any other process,
including investigations. Compliance with this Article is at
HMO's and subcontractors' own expense.
3.2.6 HMO must include a complaint and appeals process which
complies with the requirements of Article 20A.12 of the Texas
Insurance Code relating to Complaint
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System in all non-provider subcontracts. HMO's complaint and
appeals process must be the same for all Contractors.
3.3 MEDICAL DIRECTOR
3.3.1 HMO must have a full-time physician (M.D. or D.O.) licensed in
Texas, to serve as Medical Director. HMO must enter into a
written contract or written employment agreement with the
Medical Director describing the following authority, duties
and responsibilities:
3.3.1.1 Ensure that medical decisions, including prior authorization
protocols, are rendered by qualified medical personnel and are
based on TDH's definition of medical necessity.
3.3.1.2 Oversight responsibility of network providers to ensure that
all care provided complies with the generally accepted health
standards of the community.
3.3.1.3 Oversight of HMO's quality improvement process, including
establishing and actively participating in HMO's quality
improvement committee, monitoring Member health status, HMO
utilization review policies and standards and patient outcome
measures.
3.3.1.4 Identify problems and develop and implement corrective actions
to quality improvement process.
3.3.1.5 Develop, implement and maintain responsibility for HMO's
medical policy.
3.3.1.6 Oversight responsibility for medically related complaints.
3.3.1.7 Participate and provide witnesses and testimony on behalf of
HMO in the TDH fair hearing process.
3.3.2 The Medical Director must exercise independent medical
judgement in all medical decisions. HMO must ensure that
medical decisions are not adversely influenced by fiscal
management decisions. TDH may conduct reviews of medical
decisions by HMO Medical Director at any time.
3.4 PLAN MATERIALS AND DISTRIBUTION OF PLAN MATERIALS
3.4.1 HMO and its subcontractors must receive written approval from
TDH for all written materials containing information about the
STAR Program prior to distribution to Members, prospective
Members, providers within HMO's network, or potential
providers who HMO intends to recruit as network providers.
3.4.2 Member materials must meet cultural and linguistic
requirements as stated in Article VIII. Unless otherwise
required, Member materials must:
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3.4.2.1 be written at a 4th - 6th grade reading comprehension level;
and
3.4.2.2 be translated into the language of any major population group.
3.4.3 All materials regarding the STAR Program must be submitted to
TDH for approval prior to distribution. TDH has 15 working
days to review the materials and recommend any suggestions or
required changes. If TDH has not responded to HMO by the
fifteenth day, HMO may submit a written request for deemed
approval. Requests for deemed approval must clearly identify
the materials for which deemed approval is requested by title
of document, date of submission, and the timelines for
publication and distribution. TDH must respond in writing
within two working days from the date a deemed approval
request is received. TDH reserves the right to request HMO to
modify plan materials.
3.4.4 HMO must reproduce all written instructional, educational, and
procedural documents required under this contract and
distribute them to its providers and Members. HMO must
reproduce and distribute instructions and forms to all network
providers who have reporting and audit requirements under this
contract.
3.4.5 HMO must provide TDH with at least five copies of all written
materials that HMO is required to submit under this contract,
unless otherwise specified by TDH.
3.5 RECORDS REQUIREMENTS AND RECORDS RETENTION
3.5.1 HMO must keep all records required to be created and retained
under this contract. Records related to Members served in this
service area must be made available in HMO's local office when
requested by TDH. All records must be retained for a period
of five (5) years unless otherwise specified in this contract.
Original records must be kept in the form they were created in
the regular course of business for a minimum of two (2) years
following the end of the contract period. Microfilm, digital
or electronic records may be substituted for the original
records after the first two (2) years, if the retention system
is reliable and is supported by a retrieval system which
allows reasonable access to the records. All copies of
original records must be made using guidelines and procedures
approved by TDH, if the original documents will no longer be
available or accessible.
3.5.2 Availability and Accessibility. All records, documents and
data required to be created under this contract are subject to
audit, inspection and production. If an audit, inspection or
production is requested by TDH, TDH's designee or TDH acting
on behalf of any agency with regulatory or statutory authority
over Medicaid Managed Care, the requested records must be made
available at the time and at the place the records are
requested. Copies of requested records must be produced or
provided free of charge to the requesting agency. Records
requested after the second year following the end of contract
term, which have been stored or archived must be
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accessible and made available within 10 calendar days from the
date of a request by TDH or the requesting agency or at a time
and place specified by the requesting entity.
3.5.3 Accounting Records. HMO must create and keep accurate and
complete accounting records in compliance with to Generally
Accepted Accounting Principles (GAAP). Records must be created
and kept for all claims payments, refunds and adjustment
payments to providers, premium or capitation payments,
interest income and payments for administrative services or
functions. Separate records must be maintained for medical and
administrative fees, charges and payments.
3.5.4 General Business Records. HMO must create and keep complete
and accurate general business records to reflect the
performance of duties and responsibilities, and compliance
with the provisions of this contract.
3.5.5 Medical records. HMO must require, through contractual
provisions, providers to create and keep medical records in
compliance with the medical records standards contained in the
Standards for Quality Improvement Programs in Appendix A. All
medical records must be kept for at least five (5) years,
except for records of rural health clinics, which must be kept
for a period of six (6) years from the date of service.
3.5.6 Matters in Litigation. HMO must keep records related to
matters in litigation for five (5) years following the
termination or resolution of the litigation.
3.5.7 On-line Retention of Claims History. HMO must keep automated
claims payment histories for a minimum of 18 months, from date
of adjudication, in an on-line inquiry system. HMO must also
keep sufficient history on-line to ensure all claim/encounter
service information is submitted to and accepted by TDH for
processing.
3.6 HMO REVIEW OF TDH MATERIALS
TDH will submit all studies or audits that relate or refer to
HMO for review and comment to HMO 15 days prior to releasing
the report to the public or to Members.
ARTICLE IV FISCAL, FINANCIAL, CLAIMS AND INSURANCE REQUIREMENTS
4.1 FISCAL SOLVENCY
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4.1.1 HMO must be and remain in full compliance with all state and
federal solvency requirements for HMOs, including but not
limited to all reserve requirements, net worth standards,
debt- to-equity ratios, or other debt limitations.
4.1.2 If HMO becomes aware of any impending changes to its financial
or business structure which could adversely impact its
compliance with these requirements or its ability to pay its
debts as they come due, provide services under this contract,
or if HMO becomes aware of a take-over or assignment which
would require approval of TDI or TDH, HMO must notify TDH
immediately in writing.
4.1.3 HMO must not have been placed under state conservatorship or
receivership or filed for protection under federal bankruptcy
laws. None of HMO's property, plant or equipment must have
been subject to foreclosure or repossession within the
preceding 10-year period. HMO must not have any debt declared
in default and accelerated to maturity within the preceding
10-year period. HMO represents that these statements are true
as of the contract execution date. HMO must inform TDH within
24 hours of a change in any of the preceding representations.
4.2 MINIMUM EQUITY
4.2.1 HMO has minimum equity equal to the greater of (a) $1,500,000;
(b) an amount equal to the sum of twenty five dollars ($25)
times the number of all enrollees including Medicaid Members;
or (c) an amount that complies with standards adopted by TDI.
Equity is calculated by subcontracting accrued liabilities
from admitted assets, as those terms are defined in 28 TAC
Section 11.806 and Section 11.2(b) respectively.
4.2.2 The minimum equity must be maintained during the entire
contract period.
4.3 PERFORMANCE BOND
HMO has furnished TDH a performance bond in the form
prescribed by TDH and approved by TDI, naming TDH as Obligee,
securing HMO's faithful performance of the terms and
conditions of this contract. The performance bond has been
issued in the amount of $100,000. If the contract is renewed
or extended under Article XVIII, a separate bond will be
required for each additional term of the contract. The bond
has been issued by a surety licensed by TDI, and specifies
cash payment as the sole remedy. Performance Bond
requirements under this Article must comply with Texas
Insurance Code Section 11.1805, relating to Performance and
Fidelity Bonds. The bond must be delivered to TDH at the same
time the signed HMO contract is delivered to TDH.
4.4 INSURANCE
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4.4.1 HMO must maintain or cause to be maintained general liability
insurance in the amounts of at least $1,000,000 per occurrence
and $5,000,000 in the aggregate.
4.4.2 HMO must maintain or require professional liability insurance
on each of the providers in its network in the amount of
$100,000 per occurrence and $300,000 in the aggregate, or the
limits required by the hospital at which the network provider
has admitting privileges.
4.4.3 HMO must maintain an umbrella professional liability insurance
policy for the greater of $3,000,000 or an amount (rounded to
the next $100,000) which represents the number of STAR Members
enrolled in HMO in the first month of the contract year
multiplied by $150, not to exceed $10,000,000.
4.4.4 Any exceptions to the requirements of this Article must be
approved in writing by TDH prior to the contract
Implementation Date. HMOs and providers who qualify as either
state or federal units of government are exempt from the
insurance requirements of this Article and are not required to
obtain exemptions from these provisions prior to the contract
Implementation Date. State and federal units of government
are required to comply with and are subject to the provisions
of the Texas or Federal Tort Claims Act.
4.5 FRANCHISE TAX
HMO certifies that its payment of franchise taxes is current
or that it is not subject to the State of Texas franchise tax.
4.6 AUDIT
4.6.1 TDH, TDI or their designee have the right from time to time to
examine and audit books and records of HMO or of its
Subcontractors relating to: (1) HMO's capacity to bear the
risk of potential financial losses; (2) services performed or
determination of amounts payable under this contract; (3)
detection of fraud and abuse; and (4) other purposes TDH deems
to be necessary to perform its regulatory function and/or to
enforce the provisions of this contract.
4.6.2 TDH is required to conduct an audit of HMO at least once every
three years. HMO is responsible for paying the costs of an
audit conducted under this Article. The costs of the audit
may be allowed as a credit against premium taxes paid by HMO
under the provisions of the Texas Insurance Code.
4.7 PENDING OR THREATENING LITIGATION
HMO must require disclosure from Subcontractors and network
providers of all pending or potential litigation or
administrative actions against the Subcontractor or network
provider and must disclose this information to TDH, in
writing, prior to the
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execution of prior contracts and this renewal. HMO must make
reasonable investigation and inquiry that there is not pending
or potential litigation or administrative action against the
providers or Subcontractors in HMO's provider network. HMO
must notify TDH of any litigation which is initiated or
threatened after the Implementation Date within seven days of
receiving service or becoming aware of the threatened
litigation.
4.8 MISREPRESENTATION AND FRAUD IN RESPONSE TO RFA AND IN HMO
OPERATIONS
4.8.1 HMO was awarded this contract based upon the responses and
representations contained in HMO's application submitted in
response to TDH's RFA. All responses and representations upon
which scoring was based were considered material to the
decision of whether to award the contract to HMO. RFA
responses are incorporated into this contract by reference.
The provisions of this contract control over any RFA response
if there is a conflict between the RFA and this contract, or
if changes in law or policy have changed the requirements of
HMO contracting with TDH to provide Medicaid Managed Care.
4.8.2 This contract was awarded in part based upon HMO's
representation of its current equity and financial ability to
bear the risks under this contract. TDH will consider any
misrepresentations of HMO's equity, HMO's ability to bear
financial risks of this contract or inflating the equity of
HMO, solely for the purpose of being awarded this contract, a
material misrepresentation and fraud under this contract.
4.8.3 Discovery of any material misrepresentation or fraud on the
part of HMO in HMO's application or in HMO's day-to-day
activities and operations may cause this contract to terminate
and may result in legal action being taken against HMO under
this contract, and state and federal civil and criminal laws.
4.9 THIRD PARTY RECOVERY
4.9.1 Third Party Recovery. All Members are required to assign
their rights to any benefits to the State and agree to
cooperate with the State in identifying third parties who may
be liable for all or part of the costs for providing services
to the Member, as a condition for participation in the
Medicaid program. HMO is authorized to act as the State's
agent in enforcing the State's rights to third party recovery
under this contract.
4.9.2 Identification. HMO must develop and implement systems and
procedures to identify potential third parties who may be
liable for payment of all or part of the costs for providing
medical services to Members under this contract. Potential
third parties must include any of the sources identified in 42
C.F.R. 433.138, relating to identifying third parties, except
workers' compensation, uninsured and underinsured motorist
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insurance, first and third party liability insurance and
tortfeasors. HMO must coordinate with TDH to obtain
information from other state and federal agencies and HMO must
cooperate with TDH in obtaining information from commercial
third party resources. HMO must require all providers to
comply with the provisions of 25 TAC Section 28, relating to
Third Party Recovery in the Medicaid program.
4.9.3 Exchange of identified resources. HMO must forward identified
resources of uninsured and underinsured motorist insurance,
first and third party liability insurance and tortfeasors
("excepted resources") to TDH for TDH to pursue collection and
recovery from these resources. TDH will forward information
on all third party resources identified by TDH to HMO. HMO
must coordinate with TDH to obtain information from other
state and federal agencies, including HCFA for Medicare and
the Child Support Enforcement Division of the Office of the
Attorney General for medical support. HMO must cooperate with
TDH in obtaining and exchanging information from commercial
third party resources.
4.9.4 Recovery. HMO must actively pursue and collect from third
party resources which have been identified, except when the
cost of pursuing recovery reasonably exceeds the amount which
may be recovered by HMO. HMO is not required to, but may
pursue recovery and collection from the excepted resources
listed in 4.9.3. HMO must report the identity of these
resources to TDH, even if HMO will pursue collection and
recovery from the excepted resources.
4.9.4.1 HMO must provide third party resource information to network
providers to whom individual Members have been assigned or who
provide services to Members. HMO must require providers to
seek recovery from potential third party resources prior to
seeking payment from HMO. If network providers are paid
capitation, HMO must either seek recovery from third party
resources or account to TDH for all amounts received by
network providers from third party resources.
4.9.4.2 HMO must prohibit network providers from interfering with or
placing liens upon the State's right or HMO's right, acting as
the State's agent, to recovery from third party resources. HMO
must prohibit network providers from seeking recovery in
excess of the Medicaid payable amount or otherwise violating
state and federal laws.
4.9.5 Retention. HMO may retain as income all amounts recovered
from third party sources as long as recoveries are obtained in
compliance with the contract and state and federal laws.
4.9.6 Accountability. HMO must report all third party recovery
efforts and amounts recovered as required in 12.1.10. If HMO
fails to pursue and recover from third parties no later 180
days after the date of service, TDH may pursue third party
recoveries and retain all amounts recovered without accounting
to HMO for the amounts recovered. Amounts recovered by TDH
will be added to expected third
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party recoveries to reduce future capitation rates, except
recoveries from those excepted third party resources listed in
4.9.3.
4.10 CLAIMS PROCESSING REQUIREMENTS
4.10.1 HMO and claims processing subcontractors must comply with
TDH's Texas Managed Care Claims Manual (Claims Manual), which
contains TDH's claims processing requirements.
4.10.2 HMO must forward claims submitted to HMO in error to either
the correct HMO if the correct HMO can be determined from the
claim or is otherwise known to HMO or the State's claims
administrator; or to the provider who submitted the claim in
error, along with an explanation of why the claim is being
returned.
4.10.3 HMO must not pay any claim submitted by a provider who is
under investigation for or has been excluded or suspended from
the Medicare or Medicaid programs for fraud and abuse when HMO
is on actual or constructive notice of the investigation,
exclusion or suspension.
4.10.4 All provider clean claims must be adjudicated (finalized as
paid or denied adjudicated) within 30 days from the date the
claim is received by HMO. HMO must pay providers interest on
a clean claim which is not adjudicated within 30 days from the
date the claim is received by HMO or becomes clean at a rate
of 1.5% per month (18% annual) for each month the clean claim
remains unadjudicated.
4.10.4.1 All claims and appeals submitted to HMO and claims processing
subcontractors must be paid- adjudicated (clean claims),
denied-adjudicated (clean claims), or denied for additional
information (unclean claims) to providers within 30 days from
the date the claim is received by HMO. Providers must be sent
a written notice for each claim that is denied for additional
information (unclean claims) identifying the claim, all
reasons why the claim is being denied, the date the claim was
received by HMO, all information required from the provider in
order for HMO to adjudicate the claim, and the date by which
the requested information must be received from the provider.
4.10.4.2 Claims that are suspended (pended internally) must be
subsequently paid-adjudicated, denied- adjudicated, or denied
for additional information (pended externally) within 30 days
from date of receipt. No claim can be suspended for a period
exceeding 30 days from date of receipt of the claim.
4.10.4.3 HMO must identify each data field of each claim form that is
required from the provider in order for HMO to adjudicate the
claim. HMO must inform all network providers about the
required fields at least 30 days prior to the service area
Implementation Date or as a provision within HMO/provider
contract. Out of network providers must be informed of all
required fields if the claim is denied for
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additional information. The required fields must include
those required by HMO and TDH.
4.10.5 HMO is subject to the Remedies and Sanctions Article of this
Contract for claims that are not processed on a timely basis
as required by this Contract and the Claims Manual.
4.10.6 HMO must offer to its Subcontractors the option of submitting
and receiving claims information through electronic data
interchange (EDI) that allows for automated processing and
adjudication of claims. EDI processing must be offered as an
alternative to the filing of paper claims.
4.11 INDEMNIFICATION
4.11.1 HMO/TDH: HMO must agree to indemnify TDH and its agents for
any and all claims, costs, damages and expenses, including
court costs and reasonable attorney's fees, which are related
to or arise out of:
4.11.1.1 Any failure, inability, or refusal of HMO or any of its
network providers or other Subcontractors to provide contract
services;
4.11.1.2 Claims arising from HMO's, HMO's network provider's or other
Subcontractor's negligent or intentional conduct in providing
services under this contract.
4.11.1.3 Failure, inability or refusal of HMO to pay any of its network
providers or Subcontractors for services.
4.11.2 HMO/Provider: HMO is prohibited from requiring any providers
to indemnify HMO for HMO's own acts or omissions which result
in damages or sanctions being assessed against HMO either
under this contract or under state or federal law.
ARTICLE V STATUTORY AND REGULATORY COMPLIANCE REQUIREMENTS
5.1 COMPLIANCE WITH FEDERAL, STATE, AND LOCAL LAWS
5.1.1 HMO must know, understand and comply with all state and
federal laws and regulations relating to the Texas Medicaid
Program which have not been waived by HCFA. HMO must comply
with all rules relating to the Medicaid managed care program
adopted by TDH,TDI,THHSC, TDMHMR and any other state agency
delegated authority to operate or administer Medicaid or
Medicaid managed care programs.
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5.1.2 HMO must require, through contract provisions, that all
network providers or Subcontractors comply with all state and
federal laws and regulations relating to the Texas Medicaid
Program and all rules relating to the Medicaid managed care
program adopted by TDH, TDI, THHSC, TDMHMR and any other state
agency delegated authority to operate Medicaid or Medicaid
Managed Care programs.
5.1.3 HMO must comply with the provisions of the Clean Air Act and
the Federal Water Pollution Control Act, as amended, found at
42 C.F.R. 7401, et. seq. and 33 U.S.C. 1251, et. seq.,
respectively.
5.2 PROGRAM INTEGRITY
5.2.1 HMO has not been excluded, debarred, or suspended from
participation in any program under Title XVIII or Title XIX
under any of the provisions of Section 1128(a) or (b) of the
Social Security Act (42 USC Section 1320 a-7), or Executive
Order 12549. HMO must notify TDH within 3 days of the time it
receives notice that any action is being taken against HMO or
any person defined under the provisions of section 1128(a) or
(b) or any Subcontractor, which could result in exclusion,
debarment, or suspension of HMO or a Subcontractor from the
Medicaid program, or any program listed in Executive Order
12549.
5.2.2 HMO must comply with the provisions of, and file the
certification of compliance required by the Xxxx Anti-Lobbying
Amendment, found at 31 U.S.C. 1352, relating to use of federal
funds for lobbying for or obtaining federal contracts.
5.3 FRAUD AND ABUSE COMPLIANCE PLAN
5.3.1 This contract is subject to all state and federal laws and
regulations relating to fraud and abuse in health care and the
Medicaid program. HMO must cooperate and assist TDH and any
state or federal agency charged with the duty of identifying,
investigating, sanctioning or prosecuting suspected fraud and
abuse. HMO must provide originals and/or copies of all
records and information requested and allow access to premises
and provide records to TDH or its authorized agent(s), THHSC,
HCFA, the U.S. Department of Health and Human Services, FBI,
TDI, and the Texas Attorney General's Medicaid Fraud Control
Unit. All copies of records must be provided free of charge.
5.3.2 HMO must submit a written compliance plan to TDH for approval
at least 150 days prior to the Implementation Date. HMO must
submit any updates or modifications to TDH for approval at
least 30 days prior to modifications going into effect.
5.3.2.1 The plan must ensure that all officers, directors, managers
and employees know and understand the provisions of HMO's
fraud and abuse compliance plan. The written
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plan must contain procedures designed to prevent and detect
potential or suspected abuse and fraud in the administration
and delivery of services under this contract. The plan must
contain provisions for the confidential reporting of plan
violations to the designated person. The plan must contain
provisions for the investigation and follow-up of any
compliance plan reports. The fraud and abuse compliance plan
must ensure that the identity of individuals reporting
violations of the plan is protected. The plan must contain
specific and detailed internal procedures for officers,
directors, managers and employees for detecting, reporting,
and investigating fraud and abuse compliance plan violations.
The compliance plan must require that confirmed violations be
reported to TDH.
5.3.2.2 The plan must require any confirmed or suspected fraud and
abuse under state or federal law be reported to TDH, the
Medicaid Program Integrity section of the Office of
Investigations and Enforcement of the Texas Health and Human
Services Commission, and/or the Medicaid Fraud Control Unit of
the Texas Attorney General. The written plan must ensure
that no individual who reports plan violations or suspected
fraud and abuse is retaliated against.
5.3.3 HMOs must comply with the requirements of the Model Compliance
Plan for HMOs when this model plan is issued by the U.S.
Department of Health and Human Services, the Office of
Inspector General (OIG). HMO must designate executive and
essential personnel to attend mandatory training in fraud and
abuse detection, prevention and reporting. The training will
be conducted by the Office of Investigation and Enforcement,
Health and Human Services Commission and will be provided free
of charge. Training must be scheduled not later than 150 days
before the Implementation Date, and completed by all
designated personnel not later than 60 days before the
Implementation Date.
5.3.4 HMO must designate an officer or director in its organization
who has the responsibility and authority for carrying out the
provisions of the fraud and abuse compliance plan.
5.3.5 HMO's failure to report potential or suspected fraud or abuse
may result in sanctions, cancellation of contract, or
exclusion from participation in the Medicaid program.
5.3.6 HMO must allow the Texas Medicaid Fraud Control Unit to
conduct private interviews of HMO's employees, Subcontractors
and their employees, witnesses, and patients. Requests for
information must be complied with in the form and the language
requested. HMO's employees and its Subcontractors and their
employees must cooperate fully and be available in person for
interviews, consultation, grand jury proceedings, pre-trial
conference, hearings, trial and in any other process.
5.4 SAFEGUARDING INFORMATION
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5.4.1 All Member information, records and data collected or provided
to HMO by TDH or another State agency is protected from
disclosure by state and federal law and regulations. HMO may
only receive and disclose information which is directly
related to establishing eligibility, providing services and
conducting or assisting in the investigation and prosecution
of civil and criminal proceedings under state or federal law.
HMO must include a confidentiality provision in all
subcontracts with individuals.
5.4.2 HMO is responsible for informing Members and providers
regarding the provisions of 42 C.F.R. 431, Subpart F, relating
to Safeguarding Information on Applicants and Recipients, and
HMO must ensure that confidential information is protected
from disclosure except for authorized purposes.
5.4.3 HMO is responsible for educating Members and providers
concerning the Human Immunodeficiency Virus (HIV) and its
related conditions including Acquired Immunodeficiency
Syndrome (AIDS). PCP must develop and implement a policy for
protecting the confidentiality of AIDS and HIV- related
medical information and an anti-discrimination policy for
employees and Members with communicable diseases. See also
Health and Safety Code, Chapter 85, Subchapter E relating to
Duties of State Agencies and State Contractors.
5.4.4 HMO must require, through contractual provisions, that
subcontractors have mechanisms in place to ensure Member's
(including minor's) confidentiality for family planning
services.
5.5 NON-DISCRIMINATION
HMO agrees to comply with and to include in all Subcontracts a
provision that the Subcontractor will comply with each of the
following requirements:
5.5.1 Title VI of the Civil Rights Act of 1964, Section 504 of the
Rehabilitation Act of 1973, the Americans with Disabilities
Act of 1990, and all requirements imposed by the regulations
implementing these acts and all amendments to the laws and
regulations. The regulations provide in part that no person
in the United States shall on the grounds of race, color,
national origin, sex, age, disability, political beliefs or
religion be excluded from participation in, or denied, any
aid, care, service or other benefits, or be subjected to any
discrimination under any program or activity receiving federal
funds.
5.5.2 Texas Health and Safety Code Section 85.113 (relating to
workplace and confidentiality guidelines regarding AIDS and
HIV).
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5.5.3 The provisions of Executive Order 11246, as amended by 11375,
relating to Equal Employment Opportunity.
5.5.4 HMO SHALL NOT DISCRIMINATE WITH RESPECT TO PARTICIPATION,
REIMBURSEMENT, OR INDEMNIFICATION AS TO ANY PROVIDER WHO IS
ACTING WITHIN THE SCOPE OF THE PROVIDER'S LICENSE OR
CERTIFICATION UNDER APPLICABLE STATE LAW, SOLELY ON THE BASIS
OF SUCH LICENSE OR CERTIFICATION. THIS REQUIREMENT SHALL NOT
BE CONSTRUED TO PROHIBIT HMO FROM INCLUDING PROVIDERS ONLY TO
THE EXTENT NECESSARY TO MEET THE NEEDS OF THE HMO'S MEMBERS OR
FROM ESTABLISHING ANY MEASURE DESIGNED TO MAINTAIN QUALITY AND
CONTROL COSTS CONSISTENT WITH HMO'S RESPONSIBILITIES.
5.6 HISTORICALLY UNDERUTILIZED BUSINESSES (HUBS)
5.6.1 TDH is committed to providing procurement and contracting
opportunities to historically underutilized businesses (HUBs),
under the provisions of Texas Government Code, Title 10,
Subtitle D, Chapter 2161 and 1 TAC Section 111.11(b) and
111.13(c)(7). TDH requires its Contractors and Subcontractors
to make a good faith effort to assist HUBs in receiving a
portion of the total contract value of this contract.
5.6.2 The HUB good faith effort goal for this contract is 18.1% of
total premiums paid. HMO agrees to make a good faith effort
to meet or exceed this goal. HMO acknowledges it made certain
good faith effort representations and commitments to TDH
during the HUB good faith effort determination process. HMO
agrees to use its best efforts to abide by these
representations and commitments during the contract period.
5.6.3 HMO is required to submit HUB quarterly reports to TDH as
required in Article 12.11.
5.6.4 TDH will assist HMO in meeting the contracting and reporting
requirements of this Article.
5.7 BUY TEXAS
HMO agrees to "Buy Texas" products and materials when they are
available at a comparable price and in a comparable period of
time, as required by Section 48 of Article IX of the General
Appropriations Act of 1995.
5.8 CHILD SUPPORT
5.8.1 The Texas Family Code Section 231.006 requires TDH to withhold
contract payments from any for-profit entity or individual who
is at least 30 days delinquent in child support obligations.
It is HMO's responsibility to determine and verify that no
owner, partner, or shareholder who has at least at 25%
ownership interest is delinquent in
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child support obligations. HMO must attach a list of the
names and Social Security numbers of all shareholders,
partners or owners who have at least a 25% ownership interest
in HMO.
5.8.2 Under Section 231.006 of the Family Code, the vendor or
applicant certifies that the individual or business entity
named in this contract, bid, or application is not ineligible
to receive the specified grant, loan, or payment and
acknowledges that this contract may be terminated and payment
may be withheld if this certification is inaccurate. A child
support obligor who is more than 30 days delinquent in paying
child support or a business entity in which the obligor is a
sole proprietor, partner, shareholder, or owner with an
ownership interest of at least 25% is not eligible to receive
the specified grant, loan or payment.
5.8.3 If TDH is informed and verifies that a child support obligor
who is more than 30 days delinquent is a partner, shareholder,
or owner with at least a 25% ownership interest, it will
withhold any payments due under this contract until it has
received satisfactory evidence that the obligation has been
satisfied or that the obligor has entered into a written
repayment request.
5.9 REQUESTS FOR PUBLIC INFORMATION
5.9.1 This contract and all network provider and Subcontractor
contracts are subject to public disclosure under the Public
Information Act (Texas Government Code, Chapter 552). TDH may
receive Public Information requests related to this contract,
information submitted as part of the compliance of the
contract and HMO's application upon which this contract was
awarded. TDH agrees that it will promptly deliver a copy of
any request for public information to HMO.
5.9.2 If HMO believes that the requested information qualifies as a
trade secret, commercial or financial information, HMO must,
within two (2) working days of HMO's receipt of the request,
notify TDH of the specific text, or portion of text, which HMO
claims is excepted from required public disclosure. HMO is
required to identify the specific provisions of the Act which
HMO believes are applicable, and is required to include a
detailed written explanation of how the exceptions apply to
the specific information identified by HMO as confidential and
excepted from required public disclosure.
5.9.3 TDH may, in its sole discretion, request a decision from the
Office of the Attorney General (AG opinion) regarding whether
the information requested is excepted from required public
disclosure. TDH may rely on HMO's written representations in
preparing any AG opinion request, in accordance with Texas
Government Code Section 552.305. TDH is not liable for
failing to request an AG opinion or for releasing information
which is not deemed confidential by law, if HMO fails to
provide TDH
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with specific reasons why the requested information is exempt
from the required public disclosure. TDH or the Office of the
Attorney General will notify all interested parties if an AG
opinion is requested.
5.10 NOTICE AND APPEAL
HMO must comply with the notice requirements contained in 25
TAC Section 36.21, and the maintaining benefits and services
contained in 25 TAC Section 36.22, whenever HMO intends to
take an action affecting the Member benefits and services
under this contract. See also the Member appeal requirements
contained in Article 8.7 of this contract.
ARTICLE VI SCOPE OF SERVICES
6.1 SCOPE OF SERVICES - GENERAL
HMO must provide or arrange to have provided to Members all
health care services listed in Appendix C - Scope of Services,
which is attached and incorporated into this contract. HMO
must also provide or arrange to have provided to mandatory
Members all value-added services listed in HMO's response to
the RFA for this contract. The RFA and responses are
incorporated into this contract by reference.
6.2 PRE-EXISTING CONDITIONS
HMO is responsible for providing all covered services to each
eligible Member beginning on the Implementation Date or the
Member's date of enrollment under the contract regardless of
pre-existing conditions, prior diagnosis and/or receipt of any
prior health care services.
6.3 SPAN OF ELIGIBILITY
HMO must provide all services to Members assigned to HMO under
this contract for all periods for which HMO has received
payment, except as follows:
6.3.1 Inpatient admission prior to enrollment in HMO. HMO is
responsible for payment of physician and non-hospital services
from the date of enrollment in HMO. HMO is not responsible for
hospital charges for Members admitted prior to enrollment.
6.3.2 Inpatient admission after enrollment in HMO. HMO is
responsible for all services until the Member is discharged
from the hospital, unless the Member loses Medicaid or STAR
eligibility. In such cases, HMO is liable for all services
during the period HMO is paid capitation for the Member.
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6.3.3 Discharge after voluntary disenrollment from HMO and
re-enrollment into a new HMO. HMO remains responsible for
payment of hospital charges until the Member is discharged.
HMO to whom Member transfers is responsible for payment of all
physician and non-hospital charges beginning on the effective
date of enrollment into the new HMO.
6.3.4 Newborns. HMO is responsible for all costs, including
hospital, physician and non-hospital costs attributed to the
care to a newborn child if the mother was enrolled in HMO on
the date of birth.
6.3.5 Hospital Transfer. Discharge from one hospital and
readmission or admission to another hospital within 24 hours
for continued treatment shall not be considered discharge
under this Article.
6.3.6 HMO insolvency or receivership. HMO is responsible for
payment of all services provided to a person who was a Member
on the date of insolvency or receivership to the same extent
they would otherwise be responsible under this Article 6.3.
6.4 CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS
6.4.1 HMO must ensure that the care of newly enrolled Members is not
disrupted or interrupted. HMO must take special care to
provide continuity in the care of newly enrolled Members whose
health or behavioral health condition has been treated by
specialty care providers or whose health could be placed in
jeopardy if care is disrupted or interrupted.
6.4.2 Pregnant Members with 12 weeks or less remaining before the
expected delivery date must be allowed to remain under the
care of the Member's current OB/GYN through the Member's
postpartum checkup even if the provider is out-of-network. If
the Member wants to change her OB/GYN to one who is in the
plan, she must be allowed to do so if the provider to whom she
wishes to transfer agrees to accept her in the last trimester.
6.4.3 HMO must pay a Member's existing out-of-network providers for
covered services until the Member's records, clinical
information and care can be transferred to a network provider.
Payment must be made within the time period required for
network providers. Payment amounts must be the amount HMO
pays a comparable network provider, an amount negotiated
between the out-of-network provider and HMO, or the Medicaid
fee-for-service amount. This Article does not extend the
obligation of HMO to reimburse existing out-of-network
providers of ongoing care for more than 90 days after Member
enrolls in HMO or for more than nine months in the case of
Member who at the time of enrollment in HMO, have been
diagnosed with a terminal illness. However, the obligation of
HMO to reimburse the existing out-of-network provider for
services provided to a pregnant Member with 12 weeks or less
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remaining before the expected delivery date extends through
delivery of the child, immediate postpartum care, and the
follow-up checkup within the first six weeks of delivery.
6.4.4 HMO must provide or pay out-of-network providers who provide
covered services to Members who move out of the service area
through the end of the period for which capitation has been
paid.
6.5 EMERGENCY SERVICES
6.5.1 HMO must provide or arrange to have provided, and pay for
emergency services. Emergency services includes all emergency
facility charges related to behavioral health diagnoses except
those charges by specialized behavioral health emergency
facilities. HMO cannot require prior authorization as a
condition for payment for emergency services. HMO must have a
system for providers to verify Member enrollment in HMO 24
hours a day, 7 days a week.
6.5.2 HMO must provide emergency services 24 hours a day, 7 days a
week, at a hospital, by access to physician consultation or
emergency medical care through HMO's own facilities or through
arrangements approved by TDH with other providers. HMO must
provide conveniently located emergency services sites for
providing after-hour emergency services.
6.5.3 HMO must have emergency and crisis hotline services available
24 hours a day, 7 days a week toll-free throughout the service
area. Staff must be qualified to assess the immediate health
care needs and determine whether an emergency condition exists
and provide triage, advice, and referral and, if necessary,
arrange for treatment of the Member. Crisis hotline staff
must include or have access to qualified behavioral health
professionals to assess behavioral health emergencies. It is
not acceptable for an emergency intake line to be answered by
an answering machine.
6.5.4 HMO must develop and maintain an educational program to ensure
that Members understand what is an emergency medical condition
and know where and how to obtain medically necessary services
in emergency situations, 24 hours a day, seven days a week.
6.5.5 HMO must include in its provider network TDH designated trauma
centers which are within the service area.
6.5.6 HMO must coordinate with emergency response systems in the
community, including the police, fire and EMS departments,
child protective services, and chemical dependency emergency
services.
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6.5.7 HMO must pay for emergency services provided to Members inside
or outside of HMO's provider network and service area. HMO
must pay reasonable and customary reimbursement amounts for
providers and emergency services required to assess whether an
emergency exists, and deliver emergency services required.
6.5.8 HMO may establish reasonable deadlines for providers to submit
claims for out-of-network and out of service area emergency
services. HMO must pay out-of-network and service-area
provider clean claims within 30 days from HMO's receipt of a
clean claim.
6.5.9 HMO must provide a written copy of its policies and procedures
for emergency admissions to TDH for approval not later than 90
days prior to the Implementation Date. Modifications or
amendments to policies and procedures must be submitted to TDH
for approval at least 60 days prior to the implementation of
the modification or amendment.
6.6 BEHAVIORAL HEALTH SERVICES - SPECIFIC REQUIREMENTS
6.6.1 HMO must provide or arrange to provide to Members all
Behavioral Health Services listed in Appendix C - Scope of
Services, which is attached and incorporated into this
contract.
6.6.2 HMO must maintain a Member education process to help Members
know where and how to obtain behavioral health services.
6.6.3 HMO must require its PCPs to have medical history, screening
and evaluation procedures for behavioral health problems and
disorders and either treat or refer the Member for evaluation
and treatment of known or suspected behavioral health problems
and disorders. PCPs may provide any clinically appropriate
behavioral health services within the scope of their practice.
6.6.4 HMO must establish policies and procedures that require PCP
and behavioral health providers to coordinate HMO and
behavioral health organization (BHO) covered services.
6.6.5 HMO must have policies and procedures which allow confidential
information to be shared by the PCP and the primary behavioral
health care provider.
6.6.6 HMO must execute a Memorandum of Agreement (MOA) with
NorthStar-contracted BHOs in the service area. The MOA must
contain provisions for coordination of care and must address
the following:
6.6.6.1 How HMO and BHO will provide education to Members regarding
the services that each will provide and how the Member can
access the services;
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6.6.6.2 How HMO and BHO will provide education and information to
providers regarding which entity is responsible for claims
processing and payment;
6.6.6.3 How emergency services will be paid and coordinated;
6.6.6.4 Guidelines and procedures to monitor accessibility,
availability, referral and coordination to medically necessary
and appropriate physical and behavioral health care for
Members with both physical and behavioral health problems; and
how claims will be processed and paid;
6.6.6.5 Members utilization of prescribed medicines from both HMO and
BHO to monitor psychopharmacological medications and prevent
adverse drug reactions;
6.6.6.6 Identify persons in HMO and BHO to coordinate services and
provide assistance to their respective providers;
6.6.6.7 How each entity will provide guidelines and education to
providers regarding the exchange of confidential medical
record information, with Member permission, between the PCPs
and the primary behavioral health providers, including
mechanisms to protect confidentiality of medical records;
6.6.6.8 Collaboration on any joint Quality Improvement studies,
reviews or other State required projects.
6.6.7 HMO must establish and implement policies and procedures to
allow its network PCPs to refer Members for BHO services by
contacting HMO's contact person with the BHO.
6.6.8 When assessing Members for behavioral health services, HMO
must use the DSM-IV multi-axial classification and report axes
I, II, III, IV, and V to TDH. TDH may require use of other
assessment instrument/outcome measures in addition to the
DSM-IV. Providers must document DSM-IV and assessment/outcome
information in the Member's medical record.
6.7 FAMILY PLANNING - SPECIFIC REQUIREMENTS
6.7.1 Counseling and Education. HMO must require, through contract
provisions, that Members requesting contraceptive services or
family planning services are provided counseling and
education. HMO must provide education about family planning
and family planning services available to Members. HMO must
develop outreach programs to increase community support for
family planning and encourage Members to use available family
planning services. HMO is encouraged to include a
representative cross-section of Members and family planning
providers of the
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community in developing, planning and implementing family
planning outreach programs.
6.7.2 Freedom of Choice. HMO must ensure that the Member has the
right to choose any Medicaid participating family planning
provider in or out of its network (family planning providers
are listed in Appendix D). HMO must provide Member access to
information about the providers of family planning services
available in the network and the Member's right to choose any
Medicaid family planning provider. HMO must provide access to
confidential family planning services.
6.7.3 Provider Standards and Payment. HMO must require all
Subcontractors who are family planning agencies to deliver
family planning services according to the TDH Family Planning
Service Delivery Standards. HMO must provide, at minimum, the
full scope of services available under the Texas Medicaid
program for family planning services. HMO will reimburse
out-of- network family planning providers the Medicaid fee-for
service amounts for family planning services only.
6.7.4 HMO must provide medically approved methods of contraception
to Members. Contraceptive methods must be accompanied by
verbal and written instructions on their correct use. HMO
must establish mechanisms to ensure all medically approved
methods of contraception are made available to the Member,
either directly or by referral to a Subcontractor. The
following initial Member education content may vary according
to the educator's assessment of the Member's current
knowledge:
6.7.4.1 general benefits of family planning services and
contraception;
6.7.4.2 information on male and female basic reproductive anatomy and
physiology;
6.7.4.3 information regarding particular benefits and potential side
effects and complications of all available contraceptive
methods;
6.7.4.4 information concerning all of the health care provider's
available services, the purpose and sequence of health care
provider procedures, and the routine schedule of return
visits;
6.7.4.5 information regarding medical emergencies and where to obtain
emergency care on a 24-hour basis;
6.7.4.6 breast self-examination rationales and instructions unless
provided during physical exam (for females); and
6.7.4.7 information on HIV/STD infection and prevention and safer sex
discussion.
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6.7.5 HMO must require, through contractual provisions, that
subcontractors have mechanisms in place to ensure Member's
(including minor's) confidentiality for family planning
services.
6.7.6 HMO must develop, implement, monitor, and maintain standards,
policies and procedures for providing information regarding
family planning to providers and Members, specifically
regarding State and federal laws governing Member
confidentiality (including minors).
6.7.7 HMO must report encounter data on family planning services in
accordance with Article 12.2.
6.8 TEXAS HEALTH STEPS (THSteps - formerly EPSDT)
6.8.1 THSteps Services. HMO must develop effective methods to
ensure that children under the age of 21 receive THSteps
services when due and according to the recommendations
established by the American Academy of Pediatrics and the
THSteps periodicity schedule for children. HMO must provide
THSteps services to all eligible Members except when a Member
knowingly and voluntarily declines or refuses services after
the Member has been provided information upon which to make an
informed decision.
6.8.2 Member Education and Information. HMO must ensure that
Members are provided information and educational materials
about the services available through the THSteps program, and
how and when they can obtain the services. The information
should tell the Member how they can obtain dental benefits,
transportation services through the TDH Medical Transportation
program, and advocacy assistance from HMO.
6.8.3 Provider education and training. HMO must provide appropriate
training to all network providers and provider staff in the
providers' area of practice regarding the scope of benefits
available and the THSteps program. Training must include
THSteps benefits, the periodicity schedule for THSteps
checkups and immunizations, and services available under the
THSteps program which are not available to all Medicaid
recipients and are available to ensure that Members can comply
with the periodicity schedule, including but not limited to
transportation, dental checkups, and CCP. Providers must also
be educated and trained regarding the requirements imposed
upon the department and contracting HMOs under the Consent
Decree entered in Xxxx x. XxXxxxxx, et. al., Civil Action No.
3:93CV65, in the United States District Court for the Eastern
District of Texas, Paris Division. Providers should be
educated and trained to treat each THSteps visit as an
opportunity for a comprehensive assessment of the Member.
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6.8.4 Member Outreach. HMO must provide an outreach unit that works
with Members to ensure they receive prompt services and are
knowledgeable about available Texas Health Step services.
Outreach staff must coordinate with TDH Texas Health Step
outreach staff to ensure that Members have access to the
Medical Transportation Program, and that any coordination with
other agencies is maintained. MTP will not transport Members
to value-added services offered by HMO.
6.8.5 Initial Checkups upon enrollment. HMO must have mechanisms in
place to ensure that all newly enrolled Members receive a
THSteps checkup within 90 days from enrollment, if one is due
according to the American Academy of Pediatrics periodicity
schedule, or if there is uncertainty regarding whether one is
due. HMO should make THSteps checkups a priority to all newly
enrolled Members.
6.8.6 Accelerated Services to Migrant Populations. HMO must
cooperate and coordinate with the department, outreach
programs and THSteps regional program staff and agents to
ensure prompt delivery of services to children of migrant farm
workers and other migrant populations who may transition into
and out of HMOs program more rapidly and/or unpredictably than
the general population.
6.8.7 Newborn checkups. HMO must have mechanisms in place to ensure
that all newborn children of Members have an initial newborn
checkup before discharge from the hospital and again within
two weeks from the time of birth. HMO must require providers
to send all THSteps newborn screens to the TDH Bureau of
Laboratories or a TDH certified laboratory. Providers must
include detailed identifying information for all screened
newborns and the Member's mother to allow TDH to link the
screens performed at the hospital with screens performed at
the two week follow-up.
6.8.8 Coordination and Cooperation. HMO must make an effort to
coordinate and cooperate with existing community and
school-based health and education programs that offer services
to school-aged children in a location that is both familiar
and convenient to the Members. HMO must make a good faith
effort to comply with Head Start's requirement that members
participating in Head Start receive their THSteps checkup no
later than 45 days after enrolling into either program.
6.8.9 Immunizations and Laboratory Tests. HMO must require
providers to comply with the THSteps program requirements for
submitting laboratory tests to the TDH Bureau of Laboratories
or the Texas Center for Infectious Disease Cytopathology
Laboratory Department.
6.8.9.1 ImmTrac Compliance. HMO must educate providers about and
require providers to comply with the requirements of Chapter
161, Health and Safety Code, relating to the Texas
Immunization Registry (ImmTrac).
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6.8.9.2 Vaccines for Children Program. Registered providers can also
receive the vaccines free from TDH through the Vaccines for
Children Program (VFC). These vaccines are supplied to
provider offices through local and state public health
departments. (Please refer to Texas Medicaid Service Delivery
Guide, pages 4-9.)
6.8.10 Claim forms. HMO must require all THSteps providers to submit
claims for services paid (either on a capitated or fee-for
service basis) on the HCFA 1500 claim form and use the unique
procedure coding required by TDH.
6.8.11 Compliance with THSteps performance milestones. TDH will
establish performance milestones against which HMO's full
compliance with the THSteps periodicity schedule will be
measured. The performance milestones will establish minimum
compliance measures which will increase over time. HMO must
meet all performance milestones required for THSteps services.
HMO must submit all THSteps reports and encounters as required
under this contract. Failure to meet or exceed the
performance milestones may result in: removal of THSteps
component of the capitation amounts paid to HMO; or any of the
Remedies contained in Article XVIII. Repeated non-compliance
with the THSteps performance milestones is a major breach of
the terms of this contract and could result in termination of
the contract, or non-renewal of the contract, in addition to
all money damages and sanctions assessed against HMO for non-
compliance with reporting administrative requirements.
6.8.12 Validation of Encounter Data. Encounter data will be
validated by chart review of a random sample of THSteps
eligible enrollees against monthly encounter data reported by
HMO. Chart reviews will be conducted by TDH to validate that
all screens are performed when due and as reported, and that
reported data is accurate and timely. Substantial deviation
between reported and charted encounter data could result in
HMO and/or network providers being investigated for potential
fraud and abuse without notice to HMO or the provider.
6.9 PERINATAL SERVICES
6.9.1 HMO's perinatal health care services must ensure appropriate
care is provided to women and infants, from the preconception
period through the infant's first year of life. HMO's
perinatal health care system must comply with the requirements
of Health & Safety Code, Chapter 32 Maternal and Infant Health
Improvement Act and 25 TAC Section 37.233 et. seq.
6.9.2 HMO shall have a perinatal health care system in place that,
at a minimum, provides the following services:
6.9.2.1 pregnancy planning and perinatal health promotion and
education for reproductive age women;
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6.9.2.2 perinatal risk assessment of nonpregnant women, pregnant and
postpartum women, and infants up to one year of age;
6.9.2.3 access to appropriate levels of care based on risk assessment,
including emergency care;
6.9.2.4 transfer and care of pregnant women, newborns, and infants to
tertiary care facilities when necessary;
6.9.2.5 availability and accessibility of obstetricians/gynecologists;
anesthesiologists, and neonatologists capable of dealing with
complicated perinatal problems;
6.9.2.6 availability and accessibility of appropriate outpatient and
inpatient facilities capable of dealing with complicated
perinatal problems; and
6.9.2.7 compiles, analyzes and reports process and outcome data of
Members to TDH.
6.9.3 HMO must have procedures in place to assign a pediatrician to
an unborn child prior to birth of the child.
6.9.4 HMO must provide inpatient care for a Member and a newborn
child in a health care facility, if requested by the mother or
is determined to be medically necessary by the Member's PCP,
for a minimum of:
6.9.4.1 48 hours following an uncomplicated vaginal delivery and,
6.9.4.2 96 hours for an uncomplicated caesarian delivery.
6.9.5 HMO must establish mechanisms to ensure that medically
necessary inpatient care is provided to either the Member or
the newborn child for complications following the birth of
newborn using HMO's prior authorization procedures for a
medically necessary hospitalization.
6.9.6 HMO is responsible for all services provided to the newborn
unless and until the newborn is enrolled into another plan.
6.10 EARLY CHILDHOOD INTERVENTION
6.10.1 ECI Services. HMO must provide all federally mandated
services contained at 34 C.F.R. 303.1 et. seq., and 25 TAC
Section 621.21 et. seq., relating to identification, referral
and delivery of health care services contained in the Member's
Individual Family Service Plan (IFSP). An IFSP is the written
plan which identifies a Member's disability or chronic or
complex conditions(s) or developmental delay, and describes
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the course of action developed to meet those needs, and
identifies the person or persons responsible for each action
in the plan. The plan is a mutual agreement of the Member's
Primary Care Physician (PCP), Case Manager, and the
Member/family, and is part of the Member's medical record.
6.10.2 ECI Providers. HMO must contract with qualified providers to
provide ECI services to Members under age 3 with developmental
delays. HMO may contract with local ECI programs or non-ECI
providers who meet qualifications for participation by the
Texas Interagency Council on Early Childhood Intervention to
provide ECI services.
6.10.3 Identification and Referral. HMO must ensure that network
providers are educated regarding the identification of Members
under age 3 who have or are at risk for having disabilities
and/or developmental delays. HMO must use written education
material developed or approved by the Texas Interagency
Council on Early Childhood Intervention. HMO must ensure that
all providers refer identified Members to ECI service
providers within two working days from the day the Member is
identified. Eligibility for ECI services is determined by the
local ECI program using the criteria contained in 25 TAC
Section 621.21 et. seq.
6.10.4 Coordination. HMO must coordinate and cooperate with local
ECI programs which perform assessment in the development of
the Individual Family Service Plan (IFSP), including ongoing
case management and other non-capitated services required by
the Member's IFSP. Cooperation includes conducting medical
diagnostic procedures and providing medical records required
to perform developmental assessments and develop the IFSP
within the time lines established at 34 C.F.R. 303.1 et. seq.
ECI case management is not an HMO capitated service.
6.10.5 Intervention. HMO must require, through contract provisions,
that all medically necessary health and behavioral health
services contained in the Member's IFSP are provided to the
Member in amount, duration and scope established by the IFSP.
Medical necessity for health and behavioral health services is
determined by the interdisciplinary team as approved by the
Member's PCP. HMO cannot modify the plan of care or alter the
amount, duration and scope of services required by the
Member's IFSP. HMO cannot create unnecessary barriers for the
Member to obtain IFSP services, including requiring prior
authorization for the ECI assessment and insufficient
authorization periods for prior authorized services.
6.11 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND
CHILDREN (WIC) - SPECIFIC REQUIREMENTS
6.11.1 HMO must coordinate with WIC to provide certain medical
information, which is necessary to determine WIC eligibility,
such as height, weight, hematocrit or hemoglobin (See Article
7.15.4.2).
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6.11.2 HMO must direct all eligible Members to the WIC program
(Medicaid recipients are automatically income-eligible for
WIC).
6.11.3 HMO must coordinate with existing WIC providers to ensure
Members have access to the special supplemental nutrition
program for women, infants and children (WIC), or HMO must
provide these services.
6.11.4 HMO may use the nutrition education provided by WIC to satisfy
health education and promotion requirements described in this
contract.
6.12 TUBERCULOSIS (TB)
6.12.1 Education, screening, diagnosis and treatment. HMO must
provide Members and providers with education on the
prevention, detection and effective treatment of tuberculosis
(TB). HMO must establish mechanisms to ensure all procedures
required to screen at-risk Members and to form the basis for a
diagnosis and proper prophylaxis and management of TB are
available to all Members, except services listed in Appendix C
as non-capitated services. HMO must develop policies and
procedures to ensure that Members who may be or are at risk
for exposure to TB are screened for TB. An at-risk Member
refers to a person who is susceptible to TB because of the
association with certain risk factors, behaviors or
environmental conditions. HMO must consult with the local TB
control program to ensure that all services and treatments
provided by HMO are in compliance with the guidelines
recommended by the American Thoracic Society (ATS) and the
Centers for Disease Control and Prevention (CDC) and TDH
policies and standards.
6.12.2 Reporting and referral. HMO must implement policies and
procedures requiring providers to report all confirmed or
suspected cases of TB to the local TB control program within
one working day of identification of a suspected case, using
the forms and procedures for reporting TB adopted by TDH (25
TAC Section 97). HMO must require, through contract
provisions, that in-state or out-of-state labs report positive
mycobacteriology results to the health department as required
for in-state labs by 25 TAC Section 97.5(a). Referral to
state-operated hospitals specializing in the treatment of
tuberculosis should only be made for TB-related treatment.
6.12.3 Medical records. HMO must provide access to Member medical
records to TDH and the local TB control program for all
confirmed and suspected TB cases upon request.
6.12.4 Coordination and cooperation with the local TB control
program. HMO must coordinate with the local TB control
program to ensure that Members with confirmed or suspected TB
have a contact investigation and receive directly observed
therapy. HMO must require, through contract provisions, that
providers report any Member who is non-compliant, drug
resistant, or who is or may be posing a public health threat
to TDH or the local TB control program. HMO must cooperate
with local TB
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control program in enforcing the control measures and
quarantine procedures contained in Chapter 81 of the Texas
Health and Safety Code.
6.12.4.1 HMO must have a mechanism for coordinating a post-discharge
plan for follow-up DOT with the local TB program.
6.12.4.2 HMO must coordinate with the TDH South Texas Hospital and
Texas Center for Infectious Disease for voluntary and
court-ordered admission, discharge plans, treatment objectives
and projected length of stay for Members with multi-drug
resistant TB.
6.12.4.3 HMO may contract with the local TB control programs to perform
any of the capitated services required in this Article.
6.13 PEOPLE WITH DISABILITIES OR CHRONIC OR COMPLEX CONDITIONS
6.13.1 HMO shall provide the following services to persons with
disabilities or chronic or complex conditions. These services
are in addition to the services listed in Appendix C - Scope
of Services.
6.13.2 HMO must develop and maintain a system and procedures for
identifying Members who have disabilities or chronic or
complex medical and behavioral health conditions. Once
identified, HMO must have effective health delivery systems to
provide the covered services to meet the special preventive,
primary acute, and speciality health care needs appropriate
for treatment of the individual's condition. The guidelines
and standards established by the American Academy of
Pediatrics, the American College of Obstetrics/Gynecologists,
the U.S. Public Health Service, and other medical and
professional health organizations and associations' practice
guidelines whose standards are recognized by TDH must be used
in determining the medically necessary services and plan of
care for each individual.
6.13.3 HMO must require, through contract provisions, that the PCP
for all persons with disabilities or chronic or complex
conditions develops a plan of care to meet the needs of the
Member. The plan of care must be based on health needs,
specialist(s) recommendations, and periodic reassessment of
the Member's functional status and service delivery needs.
HMO must require providers to maintain record keeping systems
to ensure that each Member who has been identified with a
disability or chronic or complex condition has an initial plan
of care in the primary care provider's medical records; and
that the plan is updated as often as the Member's needs
change, but at least annually.
6.13.4 HMO must provide primary care and specialty care provider
network for persons with disabilities or chronic or complex
conditions. Specialty and subspecialty providers serving all
Members must be Board Certified/Board Eligible in their
specialty. HMO
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may request exceptions from TDH for approval of traditional
providers who are not board-certified or board-eligible but
who otherwise meet HMO's credentialing requirements.
6.13.5 When treating Members with disabilities or chronic or complex
conditions, HMO must ensure that PCPs and specialty care
providers have documented experience in treating people with
similar disabilities or chronic or complex conditions. For
services to children with disabilities or chronic or complex
conditions, HMO must ensure that PCPs and specialty care
providers have demonstrated experience with children with
disabilities or chronic or complex conditions in pediatric
specialty centers such as children's hospitals, medical
schools, teaching hospitals and tertiary center levels.
6.13.6 HMO must provide information, education and training programs
to Members, families, PCPs , specialty physicians, and
community agencies about the care and treatment available in
HMO's plan for Members with disabilities or chronic or complex
conditions.
6.13.7 HMO must coordinate care and establish linkages, as
appropriate for a particular Member, with existing
community-based entities and services, including but not
limited to Maternal and Child Health, Chronically Ill and
Disabled Children's Services (CIDC), the Medically Dependent
Children Program (MDCP), Community Resource Coordination
Groups (CRCGs), Interagency Council on Early Childhood
Intervention (ECI), Home and Community-based Services (HCS and
HCS-O), Community Living Assistance and Support Services
(CLASS), Community Based Alternatives (CBA), In Home Family
Support, Primary Home Care, Day Activity and Health Services
(DAHS), Deaf/Blind Multiple Disabled waiver program and
Medical Transportation Program.
6.13.8 HMO must include TDH approved pediatric transplant centers,
TDH designated trauma centers, and TDH designated hemophilia
centers in its provider network. (See Appendices E, F, G for
a listing of these facilities.)
6.13.9 HMO must ensure Members with disabilities or chronic or
complex conditions have access to treatment by a
multidisciplinary team when determined to be medically
necessary for effective treatment, or to avoid separate and
fragmented evaluations and service plans. The teams must
include both physician and non-physician providers determined
to be necessary by the Member's PCP for the comprehensive
treatment of the Member. The team must:
6.13.9.1 Participate in hospital discharge planning;
6.13.9.2 Participate in pre-admission hospital planning for
non-emergency hospitalizations;
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6.13.9.3 Develop specialty care and support service recommendations to
be incorporated into the primary care provider's plan of care;
6.13.9.4 Provide information to the Member and the Member's family
concerning the specialty care recommendations; and
6.13.9.5 Develop and implement training programs for primary care
providers, community agencies, ancillary care providers, and
families concerning the care and treatment of a Member with a
disability or chronic or complex conditions.
6.13.10 HMO must identify coordinators of medical care to assist
providers who serve Members with disabilities and chronic or
complex conditions and the Members and their families in
locating and accessing appropriate providers inside and
outside HMO's network.
6.13.11 HMO must assist eligible Members in accessing providers of
non-capitated Medicaid services listed in Appendix C, as
applicable.
6.13.12 HMO must require, through contract provisions, that Members
who require routine or regular laboratory and ancillary
medical tests or procedures to monitor disabilities or chronic
or complex conditions are provided the services by the
provider ordering the procedure or at a lab located at or near
the provider's office.
6.14 HEALTH EDUCATION AND WELLNESS AND PREVENTION PLANS
6.14.1 Group Needs Assessment. HMO must conduct a group needs
assessment of enrolled STAR Members to determine Member health
education needs and literacy levels. HMO may cooperatively
conduct a group needs assessment of all enrolled STAR Members
with one or more HMOs also contracting with TDH in the service
area to provide services to Medicaid recipients.
6.14.2 Group Needs Assessment Report. The Group Needs Assessment
Report is due six months after the Implementation Date. The
Needs Assessment Report would include, but not be limited to,
demographic information, prevalence of health conditions, and
stated preferences for health education.
6.14.2.1 Group Needs Assessment Methodology Report and Preliminary
Health Education Plan. The Group Needs Assessment Methodology
Report and the Preliminary Health Education Plan are due no
later than 30 days following the Implementation Date. They
should be combined into one document.
6.14.2.1.1 Group Needs Assessment Methodology Report. HMO must submit a
report to TDH summarizing the methodology, key activities,
timeline for implementation and HMO personnel responsible for
analyzing and interpreting results of the assessment and
establishing health education priorities. The Group Needs
Assessment Methodology
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must evidence use or planned use of local and/or state public
health department information resources and how HMO will
coordinate with the TDH regional office.
6.14.2.1.2 Preliminary Health Education Plan. The Group Needs Assessment
Methodology Report must also include a preliminary health
education plan that uses local and/or state public health
department information resources.
6.14.3 Health Education Plan. The health education plan must tell
Members how HMO system operates, how to obtain services,
including emergency care and out-of-plan services. The plan
must emphasize the value of screening and preventive care and
must contain disease-specific information and educational
materials. HMO must submit health education plan updates
annually. The final Health Education Plan is due 30 days
after the Group Needs Assessment Report has been completed and
filed with TDH.
6.14.3.1 Member Education Materials. Member education materials must
be approved in advance by TDH and must meet language and
reading level requirements. Materials must be submitted to
TDH for approval not later than 90 days prior to the
Implementation Date. Modifications or amendments to these
materials must be submitted for approval within 60 days prior
to their implementation.
6.14.3.2 Wellness Promotion Programs. HMO must conduct wellness
promotion programs to improve the health status of its
Members. HMO may cooperatively conduct Health Education
classes of all enrolled STAR members with one or more HMOs
also contracting with TDH in the service area to provide
services to Medicaid recipients in contiguous counties of the
service area. Providers and HMO staff must integrate health
education wellness and prevention training into the care of
each Member. HMO must provide a range of health promotion and
wellness information and activities for Members in formats
that meet the needs of all Members.
HMO must: (1) develop, maintain and distribute health
education services standards, policies and procedures to
providers; (2) monitor provider performance to ensure the
standards for health education services are complied with; (3)
inform providers in writing about any non-compliance with the
plan standards, policies or procedures; (4) establish systems
and procedures that ensure that provider's medical instruction
and education on preventive services provided to the Member
are documented in the Member's medical record; and (5)
establish mechanisms for promoting preventive care services to
Members who do not access care, e.g. newsletters, reminder
cards, and mail-outs.
6.14.4 Implementation of Health Education and Wellness Plan. HMO
must implement its health education and wellness plan. The
plan could include health education classes targeted to the
needs of the Members, distribution of health education and
wellness promotion pamphlets, audiovisual programs, health
fairs, case management and one-
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on-one education. HMO staff has the option to provide the
education directly or through contracted vendors and/or
referrals to community agencies. HMO may use the nutrition
education provided to WIC participants to satisfy nutrition
counseling requirements.
6.14.5 Health Education Activities Schedule. HMO must submit a
proposed Health Education Activities Schedule to TDH or its
designee on the last day of the month prior to the beginning
of each State fiscal year quarter. The schedule should
include the time and location of classes, health fairs or
other events covering all areas of the service area. HMO must
submit quarterly summary reports of health education
activities. HMO must coordinate and integrate the health
education system with the quality improvement program.
HMO may cooperatively conduct Health Education classes of all
enrolled STAR members with one or more HMOs also contracting
with TDH in the service area to provide services to Medicaid
recipients in contiguous counties of the service area.
6.15 SEXUALLY TRANSMITTED DISEASES (STDS) AND HUMAN
IMMUNODEFICIENCY VIRUS (HIV)
HMO must provide STD services that include STD/HIV prevention,
screening, counseling, diagnosis, and treatment. HMO is
responsible for implementing procedures to ensure that Members
have prompt access to appropriate services for STDs, including
HIV.
6.15.1 HMO must allow Members access to STD services and HIV
diagnosis services without prior authorization or referral by
PCP. HMO must comply with Texas Family Code Section 32.003,
relating to consent to treatment by a child.
6.15.2 HMO must provide all covered services required to form the
basis for a diagnosis and treatment plan for STD/HIV by the
provider.
6.15.3 HMO must consult with TDH regional public health authority to
ensure that Members receiving clinical care of STDs, including
HIV, are managed according to a protocol which has been
approved by TDH. (Also see Article 7.16.1, relating to
cooperative agreements with public health authorities.)
6.15.4 HMO must make education available to providers and Members on
the prevention, detection and effective treatment of STDs,
including HIV.
6.15.5 HMO must require providers to report all confirmed cases of
STDs, including HIV, to the local or regional health authority
according to 25 Texas Administrative Code, Sections
97.131-97.134, using the required forms and procedures for
reporting STDs.
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6.15.6 HMO must coordinate with the TDH regional health authority to
ensure that Members with confirmed cases of syphilis,
chancroid, gonorrhea, chlamydia and HIV receive risk reduction
and partner elicitation/notification counseling. Coordination
must be included in the subcontract required by Article
7.16.1. HMO may contract with local or regional health
authorities to perform any of the covered services required in
this subsection.
6.15.7 HMO's PCPs may enter into contracts or agreements with
traditional HIV service providers in the service area to
provide services such as case management, psychosocial support
and other services. If the service provided is a covered
service under this contract, the contract or agreement must
include payment provisions.
6.15.8 The subcontract with the respective TDH regional offices and
city and county health departments, as described in Article
7.16.1, must include, but not be limited to, the following
topics:
6.15.8.1 Access for Case Investigation. Procedures must be established
to make Member records available to public health agencies
with authority to conduct disease investigation, receive
confidential Member information, and follow up.
6.15.8.2 Medical Records and Confidentiality. HMO must require,
through contract provisions, that providers have procedures in
place to protect the confidentiality of Members provided
STD/HIV services. These procedures must include, but are not
limited to, the manner in which medical records are to be
safeguarded; how employees are to protect medical information;
and under what conditions information can be shared. HMO must
inform and require its providers, who provide STD/HIV
services, to comply with all state laws relating to
communicable disease reporting requirements. HMO must
implement policies and procedures to monitor provider
compliance with confidentiality requirements.
6.15.8.3 Partner referral and treatment. Members who are named as
contacts to an STD, including HIV, should be evaluated and
treated according to HMO's protocol. All protocols must be
approved by TDH. HMO's providers must coordinate referral of
non-Member partners to local and regional health department
STD staff.
6.15.8.4 Informed consent and counseling. HMO must have policies and
procedures in place regarding obtaining informed consent and
counseling Members. The Subcontracts with providers who treat
HIV patients must include provisions requiring the provider to
refer Members with HIV infection to public health agencies for
in-depth prevention counseling, ongoing partner elicitation
and notification services and other prevention support
services. The Subcontracts must also include provisions that
require the provider to direct counsel or refer an HIV
infected member about the need to inform and refer all sex
and/or needle- sharing partners that might have been exposed
to the infection for prevention counseling and antibody
testing.
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6.16 BLIND AND DISABLED MEMBERS
6.16.1 HMO must arrange for all covered health and health related
services required under this contract for all voluntarily
enrolled Blind and Disable Members. HMO is not required to
provide value-added services to Blind and Disabled Members.
6.16.2 HMO must perform the same administrative services and
functions as are performed for mandatory Members under this
contract. These administrative services and functions include
but are not limited to:
6.16.2.1 Prior authorization of services;
6.16.2.2 All customer services functions offered Members in Mandatory
participation categories, including complaint process,
enrollment services, and hotline services;
6.16.2.3 Linguistic services, including providing Member materials in
alternative formats for the blind and disabled;
6.16.2.4 Health education;
6.16.2.5 Utilization management using TDH Claims Administrator
encounter data to provide appropriate interventions for
Members through administrative case management;
6.16.2.6 Quality assurance activities as needed and focused studies as
required by TDH;
6.16.2.7 Coordination to link Blind and Disabled Members with
applicable community resources and targeted case management
programs (see Non-Capitated Services in Scope of Services,
Appendix C).
6.16.3 HMO must require network providers to submit claims for health
and health-related services to TDH's Claims Administrator for
claims adjudication and payment.
6.16.4 HMO must provide services to Blind and Disabled Members within
HMO's network unless necessary services are unavailable within
network. HMO must also allow referrals to out-of network
providers if necessary services are not available within HMO's
network. Records must be forwarded to Member's PCP following
a referral visit.
ARTICLE VII PROVIDER NETWORK REQUIREMENTS
7.1 PROVIDER ACCESSIBILITY
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7.1.1 HMO must enter into written contracts with properly
credentialed health care service providers. The names of all
providers must be submitted to TDH as part of HMO
subcontracting process. HMO must have its own credentialing
process to review, approve and periodically recertify the
credentials of all participating providers in compliance with
28 TAC 11.1902, relating to credentialing of providers in
HMOs.
7.1.2 HMO must require tax I.D. numbers from all providers. HMO is
required to do backup withholding from all payments to
providers who fail to give tax I.D. numbers, or who give
incorrect numbers.
7.1.3 Timeframes for Access Requirements. HMO must have sufficient
network providers and establish procedures to ensure Members
have access to routine, urgent, and emergency services;
telephone appointments; advice and Member service lines.
These services must be accessible to Members within the
following timeframes:
7.1.3.1 Urgent Care within 24 hours of request;
7.1.3.2 Routine care within 2 weeks of request;
7.1.3.3 Physical/Wellness Exams for adults must be provided within 8
to 10 weeks of the request;
7.1.3.4 HMO must establish policies and procedures to ensure that
THSteps Checkups be provided within 90 days of new enrollment,
except newborns should be seen within 2 weeks of enrollment,
and in all cases be consistent with the American Academy of
Pediatrics and/or THSteps periodicity schedule. If the Member
does not request a checkup, HMO must establish a procedure for
contacting the Member to schedule the checkup.
7.1.4 HMO is prohibited from requiring a provider or provider group
to enter into an exclusive contracting arrangement with HMO as
a condition for participation in its provider network.
7.2 PROVIDER CONTRACTS
7.2.1 HMO must enter into written contracts with all providers
(provider contracts) and maintain copies of the contracts at
HMO's administrative office. Provider contracts include all
contracts between intermediary entities and the direct
provider of health services. HMO must make all contracts
available to TDH, at the time and location requested by TDH.
All standard formats of provider contracts must be submitted
to TDH for approval no later than 120 days prior to the
Implementation Date. Standard formats of provider contracts
that are executed
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later than the 120 days prior to the Implementation Date must
be submitted to TDH within 5 working days after the date of
execution of the provider contract. All contracts are
subject to the terms and conditions of this contract and must
contain the provisions of Article V, Statutory and Regulatory
Compliance, and the provisions contained in 3.2.4. HMO must
notify TDH not less than 90 days prior to terminating any
subcontract affecting a major performance function of this
contract. All major Subcontractor terminations and/or
substitutions require TDH approval.
7.2.2 Primary Care Provider (PCP) contracts and specialty care
contracts must contain provisions relating to the requirements
of the provider types found in this contract. For example, PCP
contracts must contain the requirements of Article 7.8 of this
contract relating to Primary Care Providers.
7.2.3 Provider contracts that are requested by any agency with
authority to investigate and prosecute fraud and abuse must be
produced at the time and the place required by TDH or the
requesting agency. Provider contracts requested in response to
public information request must be produced within 48 hours of
the request. Requested contracts and all related records must
be provided free of charge to the requesting agency.
7.2.4 The form and substance of all provider contracts are subject
to approval by TDH. TDH retains the authority to reject or
require changes to any contract that do not comply with the
requirements or duties and responsibilities of this contract.
HMO REMAINS RESPONSIBLE FOR PERFORMING AND FOR ANY FAILURE TO
PERFORM ALL DUTIES, RESPONSIBILITIES AND SERVICES UNDER THIS
CONTRACT REGARDLESS OF WHETHER THE DUTY, RESPONSIBILITY OR
SERVICE IS CONTRACTED TO ANOTHER FOR ACTUAL PERFORMANCE.
7.2.5 TDH reserves the right and retains the authority to make
reasonable inquiry and conduct investigations into patterns of
provider and Member complaints against HMO or any intermediary
entity with whom HMO contracts to deliver health services
under this contract. TDH may impose appropriate sanctions and
contract remedies to ensure HMO compliance with the provisions
of this contract.
7.2.6 HMO must not restrict a provider's ability to provide opinions
or counsel to a Member with respect to benefits, treatment
options, and provider's change in network status.
7.2.7 HMO, all IPAs, and other intermediary entities must include
contract language which substantially complies with the
following standard contract provisions in each Medicaid
provider contract. This language must be included in each
contract with an actual provider of services, whether through
a direct contract or through intermediary provider contracts:
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7.2.7.1 [Provider] is being contracted to deliver Medicaid managed
care under the TDH STAR program. HMO must provide copies of
the TDH/HMO Contract to the provider upon request. [Provider]
understands that services provided under this contract are
funded by State and federal funds under the Medicaid program.
Provider is subject to all state and federal laws, rules and
regulations that apply to all persons or entities receiving
state and federal funds. [Provider] understands that any
violation by a provider of a State or federal law relating to
the delivery of services by the provider under this
HMO/Provider contract, or any violation of the TDH/HMO
contract could result in liability for money damages, and or
civil or criminal penalties and sanctions under state and/or
federal law.
7.2.7.2 [Provider] understands and agrees that HMO has the sole
responsibility for payment of covered services rendered by the
provider under HMO/Provider contract. In the event of HMO
insolvency or cessation of operations,[Provider's] sole
recourse is against HMO through the bankruptcy,
conservatorship, or receivership estate of HMO.
7.2.7.3 [Provider] understands and agrees TDH is not liable or
responsible for payment for any Medicaid covered services
provided to mandatory Members under HMO/Provider contract.
Federal and State laws provide severe penalties for any
provider who attempts to collect any payment from or xxxx a
recipient for a covered service.
7.2.7.4 [Provider] agrees that any modification, addition, or deletion
of the provisions of this contract will become effective no
earlier than 30 days after HMO notifies TDH of the change in
writing. If TDH does not provide written approval within 45
days from receipt of notification from HMO, changes can be
considered provisionally approved, and will become effective.
Modifications, additions or deletions which are required by
TDH or by changes in state or federal law are effective
immediately.
7.2.7.5 This contract is subject to all state and federal laws and
regulations relating to fraud and abuse in health care and the
Medicaid program. [Provider] must cooperate and assist TDH and
any state or federal agency that is charged with the duty of
identifying, investigating, sanctioning or prosecuting
suspected fraud and abuse. [Provider] must provide originals
and/or copies of any and all information, allow access to
premises and provide records to TDH or its authorized
agent(s), THHSC, HCFA, the U.S. Department of Health and Human
Services, FBI, TDI, and the Texas Attorney General's Medicaid
Fraud Control Unit, upon request, and free of charge.
[Provider] must report any suspected fraud or abuse including
any suspected fraud and abuse committed by HMO or a recipient
to TDH for referral to THHSC.
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7.2.7.6 [Provider] is required to submit proxy claims forms to HMO for
services provided to all STAR Members that are capitated by
HMO in accordance with the encounter data submissions
requirements established by HMO and TDH.
7.2.7.7 HMO is prohibited from imposing restrictions upon the
provider's free communication with Members about a Member's
medical conditions, treatment options, HMO referral policies,
and other HMO policies, including financial incentives or
arrangements and all STAR managed care plans with whom
Provider contracts.
7.2.7.8 The Texas Medicaid Fraud Control Unit must be allowed to
conduct private interviews of [Provider] and its employees,
contractors, and patients. Requests for information must be
complied within the form and the language requested.
[Provider] and its employees and contractors must cooperate
fully in making themselves available in person for interviews,
consultation, grand jury proceedings, pre-trial conference,
hearings, trial and in any other process, including
investigations. Compliance with this Article is at HMO's and
provider's own expense.
7.2.7.9 HMO must include the method of payment and payment amounts in
all provider contracts.
7.2.7.10 All provider clean claims must be adjudicated within 30 days.
HMO must pay provider interest on all clean claims that are
not paid within 30 days at a rate of 1.5% per month (18%
annual) for each month the claim remains unadjudicated.
7.2.7.11 HMO must prohibit network providers from interfering with or
placing liens upon the state's right or HMOs right, acting as
the state's agent, to recovery from third party resources.
HMO must prohibit network providers from seeking recovery in
excess of the Medicaid payable amount or otherwise violating
state and federal laws.
7.2.8 HMO must comply with the provisions of Chapter 20A Section 18A
of HMO Act relating to Physician and Provider contracts,
except Subpart (e), which relates to capitation payments.
7.2.9 HMO must include a complaint and appeals process which
complies with the requirements of Article 20A.12 of the Texas
Insurance Code relating to Complaint System in all
subcontracts. HMO's complaint and appeals process must be the
same for all Contractors.
7.3 PHYSICIAN INCENTIVE PLANS
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7.3.1 HMO may operate a physician incentive plan only if 1) no
specific payment may be made directly or indirectly under a
physician incentive plan to a physician or physician group as
an inducement to reduce or limit medically necessary services
furnished to a Member, and 2) the stop-loss protection,
enrollee surveys and disclosure requirements of this Article
are met.
7.3.2 HMO must disclose to TDH information required by federal
regulations found at 42 C.F.R. Section 417.479. The
information must be disclosed in sufficient detail to
determine whether the incentive plan complies with the
requirements at 42 C.F.R. Section 417.479. The disclosure must
contain the following information:
7.3.2.1 Whether services not furnished by a physician or physician
group (referral services) are covered by the incentive plan.
If only services furnished by the physician or physician group
are covered by the incentive plan, disclosure of other aspects
of the incentive plan are not required to be disclosed.
7.3.2.2 The type of incentive arrangement (e.g. withhold, bonus,
capitation).
7.3.2.3 The percent of the withhold or bonus, if the incentive plan
involves a withhold bonus.
7.3.2.4 Whether the physician or physician group has evidence of a
stop-loss protection, including the amount and type of
stop-loss protection.
7.3.2.5 The panel size and the method used for pooling patients, if
patients are pooled.
7.3.2.6 The results of Member and disenrollee surveys, if HMO is
required under 42 C.F.R. Section 417.479 to conduct Member and
disenrollee surveys.
7.3.3 HMO must submit the information required in 7.3.2.1 - 7.3.2.5
to TDH 90 days prior to the Implementation Date of the program
in the service area and each anniversary date of the contract.
7.3.4 HMO must submit the information required in 7.3.2.6 one year
after the effective date of initial contract or effective date
of renewal contract, and annually each subsequent year under
the contract.
7.3.5 HMO must provide Members with information regarding Physician
Incentive Plans upon request. The information must include the
following:
7.3.5.1 whether HMO uses physician incentive plan that covers referral
services;
7.3.5.2 the type of incentive arrangement (i.e., withhold, bonus,
capitation);
7.3.5.3 whether stop-loss protection is provided; and,
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7.3.5.4 results of enrollee and disenrollee surveys, if required under
42 C.F.R. Section 417.479.
7.3.5.5 HMO must ensure that IPAs and ANHCs with whom HMO contracts
comply with the above requirements. HMO is required to meet
above requirements for all levels of subcontracting.
7.4 PROVIDER MANUAL AND PROVIDER TRAINING
7.4.1 HMO must prepare and issue a Provider Manual(s), including any
necessary specialty manuals, to the providers in HMO network
and to newly contracted providers in HMO network within five
(5) working days from inclusion of the provider into the
network. The Provider Manual must contain sections relating
to special requirements of the STAR Program as required under
this contract. See Appendix M, Required Critical Elements,
for specific details regarding content requirements
HMO must submit a Provider Manual to TDH for approval 120 days
prior to the Implementation Date. (See Article 3.4.1
regarding process for plan materials review.)
7.4.2 HMO must provide training to all network providers and their
staff regarding the requirements of the TDH/HMO contract and
special needs of STAR Members.
7.4.2.1 HMO training for all providers must be completed within 30
days of placing a newly contracted provider on active status.
HMO must provide on-going training to new and existing
providers as required by HMO or TDH to comply with this
contract.
7.4.2.2 HMO must include in all PCP training how to screen for and
identify behavioral health disorders, HMO's referral process
to behavioral health services and clinical coordination
requirements for behavioral health. HMO must include training
on coordination and quality of care such as behavioral health
screening techniques for PCPs and new models of behavioral
health interventions.
7.4.3 HMO must provide primary care providers with screening tools
and instruments approved by TDH.
7.4.4 HMO must maintain and make available upon request enrollment
or attendance rosters dated and signed by each attendee or
other written evidence of training of each network provider
and their staff.
7.4.5 HMO must have its written policies and procedures for the
screening, assessment and referral processes between
behavioral health providers and physical medicine providers
available for TDH review not later than 120 days before the
Implementation Date.
7.5 MEMBER PANEL REPORTS
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HMO must furnish each Provider with a current list of enrolled
Members enrolled or assigned to that Provider within 5 days
from HMO receiving the Member list from the Enrollment Broker
each month.
7.6 PROVIDER COMPLAINT AND APPEAL PROCEDURES
7.6.1 HMO must establish a written provider complaint and appeal
procedure for network providers. HMO must submit the written
complaint and appeal procedure to TDH by Phase II of Readiness
Review. The complaint and appeals procedure must be the same
for all providers and must comply with Texas Insurance Code,
Art. 20A.12.
7.6.2 HMO must include the provider complaint and appeal procedure
in all network provider contracts.
7.6.3 HMO's complaint and appeal process cannot contain provisions
referring the complaint or appeal to TDH for resolution.
7.6.4 HMO must establish mechanisms to ensure that network providers
have access to a person who can assist providers in resolving
issues relating to claims payment, plan administration,
education and training, and complaint procedures.
7.7 PROVIDER QUALIFICATIONS - GENERAL
The providers in HMO network must meet the following
qualifications:
FQHC A Federally Qualified Health Center meets the standards established by federal rules and procedures. The
FQHC must also be an eligible provider enrolled in the Medicaid.
Physician An individual who is licensed to practice medicine as an MD or a DO in the State of Texas either as a
primary care provider or in the area of specialization under which they will provide medical services
under contract with HMO; who is a provider enrolled in the Medicaid; who has a valid Drug Enforcement
Agency registration number, and a Texas Controlled Substance Certificate, if either is required in their
practice.
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Hospital An institution licensed as a general or special hospital by the State of Texas under Chapter 241 of the
Health and Safety Code which is enrolled as a provider in the Texas Medicaid Program. HMO will require
that all facilities in the network used for acute inpatient specialty care for people under age 21 with
disabilities or chronic or complex conditions will have a designated pediatric unit; 24 hour laboratory
and blood bank availability; pediatric radiological capability; meet JCAHO standards; and have discharge
planning and social service units.
Non-Physician An individual holding a license issued by the applicable licensing agency of the State of Texas who is
Practitioner enrolled in the Texas Medicaid Program.
Provider
Clinical An entity having a current certificate issued under the Federal Clinical Laboratory Improvement Act
Laboratory (CLIA), and is enrolled in the Texas Medicaid Program.
Rural Health An institution which meets all of the criteria for designation as a rural health clinic and is enrolled in
Clinic (RHC) the Texas Medicaid Program.
Local Health A local health department established pursuant to Health and Safety Code, Title 2, Local Public Health
Department Reorganization Act Section 121.031ff.
Non-Hospital A provider of health care services which is licensed and credentialed to provide services and is enrolled
Facility Provider in the Texas Medicaid Program.
School Based Clinics located at school campuses that provide on site primary and preventive care to children and
Health Clinic adolescents.
(SBHC)
7.8 PRIMARY CARE PROVIDERS
7.8.1 HMO must have a system for monitoring Member enrollment into
its plan to allow HMO to effectively plan for future needs and
recruit network providers as necessary to ensure adequate
access to primary care and specialty care. The Member
enrollment monitoring system must include the length of time
required for Members to access care within the network. The
monitoring system must also include monitoring after-hours
availability and accessibility of PCPs.
7.8.2 HMO must maintain a primary care provider network in
sufficient numbers and geographic distribution to serve a
minimum of forty-five percent (45%) of the mandatory STAR
eligibles in each county of the service area. HMO is required
to increase the capacity of the network as necessary to
accommodate enrollment growth beyond the forty-fifth
percentile (45%).
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7.8.3 HMO must maintain a provider network that includes
pediatricians and physicians with pediatric experience in
sufficient numbers and geographic distribution to serve
eligible children and adolescents in the service area and
provide timely access to the full scope of benefits,
especially THSteps checkups and immunizations.
7.8.4 HMO must comply with the access requirements as established by
the Texas Department of Insurance for all HMOs doing business
in Texas, except as otherwise required by this contract.
7.8.5 HMO must have the equivalent of one full-time equivalent (FTE)
primary care provider (PCP) for every 2,000 Members. HMO must
have one FTE PCP with pediatric training or experience for
every 2,500 Members under the age of 21. Each PCP may be
assigned no more than 1,500 Members across all participating
managed care plans in the service area.
7.8.5.1 Exceptions to this requirement may be made by TDH when a
provider can demonstrate a capacity and capability to provide
access to quality managed care to more than 1,500 managed care
Members. TDH will notify a PCP directly when the PCP is
approaching the 1,500 STAR Member limitation. The PCP must
then request an exception to the 1,500 Member limitation by
submitting certain information to TDH:
(1) Names, Medicaid provider numbers (if required), Texas
professional licensure and general responsibilities
of any providers supplementing the PCP's practice
such as other physicians; Pediatric, Women's Health
Care and Family Advanced Nurse Practitioners;
Certified Nurse mid-wives; Physician Assistants
specializing in Family Medicine, Internal Medicine,
Pediatrics or Obstetrics/Gynecology;
(2) Patient office hours and office locations, and
(3) A description for after-hours coverage arrangements
and a telephone number available for their STAR
patients. If the PCP does not provide the
information or if TDH cannot verify the information
provided by the PCP, then TDH will deny the increased
capacity. If TDH determines that the PCP does not
have or fails to maintain the capacity of providing
quality accessible care, the number of Members will
be reduced through a freeze on new enrollments for
that PCP. TDH may disenroll Members if required
accessibility and quality of care to all Members is
jeopardized.
7.8.6 HMO must have PCPs available throughout the service area to
ensure that no Member must travel more than 30 miles, or 45
minutes, whichever is less, to access the PCP, unless an
exception to this distance or time requirement is made by the
TDH.
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7.8.7 HMO's primary care provider network may include providers from
any of the following practice areas: General Practitioners;
Family Practitioners; Internists; Pediatricians;
Obstetricians/Gynecologists (OB/GYN); Pediatric and Family
Advanced Practice Nurses (APNs); Certified Nurse Midwives
Women Health (CNMs); Physician Assistants (PAs) practicing
under the supervision of a specialist in Internal Medicine,
Pediatric or Obstetric/Gynecology provider; or Federally
Qualified Health Centers (FQHCs); Rural Health Clinics (RHCs)
and similar community clinics; and specialists who are willing
to provide medical homes to selected Members with special
needs and conditions (see 7.8.8).
7.8.8 The PCP for a Member with disabilities or chronic or complex
conditions may be a specialist who agrees to provide PCP
services to the Member. The specialty provider must agree to
perform all PCP duties required in the contract and PCP duties
must be within the scope of the specialist's license. Any
interested person may initiate the request for a specialist to
serve as a PCP for a Member with disabilities or chronic or
complex conditions.
7.8.9 PCPs must either have admitting privileges at a hospital,
which is part of HMO network of providers, or make referral
arrangements with an HMO provider who has admitting privileges
to a network hospital.
7.8.10 HMO must require, through contract provisions, that PCPs are
accessible to Members 24 hours a day, 7 days a week. The
following are acceptable and unacceptable phone arrangements
for contacting PCPs after normal business hours.
Acceptable:
(1) Office phone is answered after hours by an answering
service which meets language requirements of the
major population groups and which can contact the PCP
or another designated medical practitioner. All
calls answered by an answering service must be
returned within 30 minutes.
(2) Office phone is answered after normal business hours
by a recording in the language of each of the major
population groups served directing the patient to
call another number to reach the PCP or another
provider designated by the PCP. Someone must be
available to answer the designated provider's phone.
Another recording is not acceptable.
(3) Office phone is transferred after office hours to
another location where someone will answer the phone
and be able to contact the PCP or another designated
medical practitioner, who can return the call within
30 minutes.
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Unacceptable:
(1) Office phone is only answered during office hours.
(2) Office phone is answered after hours by a recording
which tells patients to leave a message.
(3) Office phone is answered after hours by a recording
which directs patients to go to an Emergency Room for
any services needed.
(4) Returning after-hour calls outside of 30 minutes.
7.8.11 HMO must require PCPs, through contract provisions, to provide
primary care services and continuity of care to Members who
are enrolled with or assigned to the PCP. Primary care
services are all services required by a Member for the
prevention, detection, treatment and cure of illness, trauma,
disease or disorder, which are covered and/or required
services under this contract. All services must be provided
in compliance with generally accepted medical and behavioral
health standards for the community in which services are
rendered. HMO must require PCPs, through contract provisions,
to provide children under the age of 21 services in accordance
with the American Academy of Pediatric recommendations and the
THSteps periodicity schedule and provide adults services in
accordance with the U.S. Preventive Services Task Force's
publication Put Prevention Into Practice.
7.8.11.1 HMO must require PCPs, through contract provisions, to assess
the medical needs of Members for referral to specialty care
providers and provide referrals as needed. PCP must coordinate
care with specialty care providers after referral.
7.8.11.2 HMO must require PCPs, through contract provisions, to make
necessary arrangements with home and community support
services to integrate the Member's needs. This integration
may be delivered by coordinating the care of Members with
other programs, public health agencies and community resources
which provide medical, nutritional, behavioral, educational
and outreach services available to Members.
7.8.11.3 HMO must require, through contract provisions, that the
Member's PCP or HMO provider through whom PCP has made
arrangements, be the admitting or attending physician for
inpatient hospital care, except for emergency medical or
behavioral health conditions or when the admission is made by
a specialist to whom the Member has been referred by the PCP.
HMO must require, through contract provisions, that PCP assess
the advisability and availability of outpatient treatment
alternatives to inpatient admissions. HMO must require,
through contract provisions, that PCP provide or arrange for
pre-admission planning for non- emergency inpatient
admissions, and discharge planning for Members. PCP must call
the emergency room
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with relevant information about the Member. PCP must provide
or arrange for follow-up care after emergency or inpatient
care.
7.8.11.4 HMO must require PCPs for children under the age of 21 to
provide or arrange to have provided all services required
under Article 6.8 relating to Texas Health Steps, Article 6.9
relating to Perinatal Services, Article 6.10 relating to Early
Childhood Intervention, Article 6.11 relating to WIC, Article
6.13 relating to persons with disabilities or chronic or
complex conditions, and Article 6.14 relating to Health
Education and Wellness are provided to Members who qualify for
the services. PCP must cooperate and coordinate with HMO to
provide Member and the Member's family with knowledge of and
access to available services.
7.8.12 All Medicaid recipients who are eligible for participation in
the STAR program have the right to select the PCP and HMO to
whom they will be assigned. Female recipients also have the
right to select an OB/GYN in addition to a PCP. Recipients
who are mandatory STAR participants who do not select a PCP or
HMO during the time period allowed will be defaulted to a PCP
and/or HMO using the TDH default process. Members may change
PCPs at any time, but these changes are limited to four (4)
times per year. If a PCP or OB/GYN who has been selected by
or assigned to a Member is no longer in HMO's provider
network, HMO must contact the Member and provide them an
opportunity to reselect. If the Member does not want to
change the PCP or OB/GYN to another provider in HMO network,
the Member must be directed to Enrollment Broker for
resolution or reselection. If a PCP or OB/GYN who has been
selected by or assigned to a Member is no longer in an IPA's
provider network but continues to participate in HMO network,
HMO or IPA may not change the Member's PCP or OB/GYN.
7.9 OB/GYN PROVIDERS
HMO must allow a female Member to select an OB/GYN within its
network or a limited provider network in addition to a PCP, to
provide health care services within the scope of the
professional specialty practice of a properly credentialed
OB/GYN, in accordance with Article 21.53D of the Texas
Insurance Code and rules promulgated under the law. A Member
who selects an OB/GYN must have direct access to the health
care services of the OB/GYN without a referral by the woman's
PCP or prior authorization or precertification from HMO.
Health care services must include, but not be limited to:
7.9.1 One well-woman examination per year;
7.9.2 Care related to pregnancy;
7.9.3 Care for all active gynecological conditions; and
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7.9.4 Diagnosis, treatment, and referral for any disease or
condition within the scope of the professional practice of a
properly credentialed obstetrician or gynecologist.
7.9.5 HMO must allow Members to change OB/GYNs up to four times per
year.
7.10 SPECIALTY CARE PROVIDERS
7.10.1 HMO must maintain specialty providers, including pediatric
specialty providers, within the network in sufficient numbers
and areas of practice to meet the needs of all Members
requiring specialty care or services.
7.10.2 HMO must require, through contract provisions, that specialty
providers send a record of consultation and recommendations to
a Member's PCP for inclusion in Member's medical record and
report encounters to the PCP and/or HMO.
7.10.3 HMO must ensure availability and accessibility to appropriate
specialists.
7.10.4 HMO must ensure that no Member is required to travel in excess
of 75 miles to secure initial contact with referral
specialists; special hospitals; diagnostic and therapeutic
services; and single service health care physicians, dentists
or providers. Exceptions to this requirement may be allowed
when an HMO has established, through utilization data provided
to TDH, that a normal pattern for securing health care
services within an area exists or HMO is providing care of a
higher skill level or specialty than the level which is
available within the service area such as, but not limited to,
treatment of cancer, xxxxx, and cardiac diseases.
7.11 SPECIAL HOSPITALS AND SPECIALTY CARE FACILITIES
7.11.1 HMO must include all medically necessary specialty services
through its network specialists, subspecialists and specialty
care facilities (e.g., children's hospitals, and tertiary care
hospitals).
7.11.2 HMO must include requirements for pre-admission and discharge
planning in its contracts with network hospitals. Discharge
plans for a Member must be provided by HMO or the hospital to
the Member/family, the PCP and specialty care physicians.
7.11.3 HMO must have appropriate multidisciplinary teams for people
with disabilities or chronic or complex medical conditions.
These teams must include the PCP and any individuals or
providers involved in the day-to-day or ongoing care of the
Member.
7.11.4 HMO must include in its provider network a TDH-designated
perinatal care facility, as established by Section 32.042,
Texas Health and Safety Code, once the designated system is
finalized and perinatal care facilities have been approved for
the service area. Also see Article 6.9.1 of this contract.
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7.12 SIGNIFICANT TRADITIONAL PROVIDERS (STPS)
7.12.1 HMO must include significant traditional providers as
designated by TDH in its provider network to provide primary
care and specialty care services. HMO must include STPs in
its provider network for at least three (3) years following
the Implementation Date in the service area.
7.12.2 STPs must agree to the contract requirements contained in
Article 7.2, unless exempted from a requirement by law or
rule. STPs must also agree to the following contract
requirements:
7.12.2.1 STP must agree to accept the standard reimbursement rate
offered by HMO to other providers for the same or similar
services.
7.12.2.2 STP must meet the credentialing requirements of HMO. HMO must
not require STPs to meet a different or higher credentialing
standard than is required of other providers providing the
same or similar services. HMO may not require STPs to
contract with a subcontractor which requires a different or
higher credentialing standard than HMO, if the application of
the higher standard results in a disproportionate number of
STPs being excluded from the subcontractor, if the STP would
not be excluded using the credentialing standards of HMO.
7.12.2.3 HMO must demonstrate a good faith effort to include STPs in
its provider network. HMO's compliance with the TDH's good
faith effort requirement for STPs must be reported using
report requirements defined by TDH. HMO must submit quarterly
reports, in a format provided by TDH, documenting HMOs
compliance with TDH's good faith effort requirement for STPs.
7.12.3 Failure to demonstrate a good faith effort to meet TDH's
compliance objectives to include STPs in HMO's provider
network, or failure to report efforts and compliance as
required in 7.12.2.3, are defaults under this contract and may
result in any or all of the sanctions and remedies included in
Article XVIII of this contract.
7.13 RURAL HEALTH PROVIDERS
7.13.1 In rural areas of the service area, HMO must seek the
participation in its provider network of rural hospitals,
physicians, home and community support service agencies, and
other rural health care providers who:
7.13.1.1 are the only providers located in the service area; and
7.13.1.2 are Significant Traditional Providers.
7.13.2 In order to contract with HMO, rural health providers must
also:
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7.13.2.1 agree to accept the prevailing provider contract rate of HMO
based on provider type; and
7.13.2.2 have the credentials required by HMO, provided that lack of
board certification or accreditation by JCAHO may not be the
only grounds for exclusion from the provider network.
7.13.3 HMO must reimburse rural hospitals with 100 or fewer licensed
beds in counties with fewer than 50,000 persons for acute care
services at a rate calculated using the higher of the
prospective payment system rate or the cost reimbursed
methodology authorized under the Tax Equity and Fiscal
Responsibility Act of 1982 (TEFRA). Hospitals reimbursed under
TEFRA cost principles shall be paid without the imposition of
the TEFRA cap.
7.13.4 HMO must reimburse physicians who practice in rural counties
with fewer than 50,000 at a rate using the current Medicaid
fee schedule, including negotiated fee for service.
7.14 FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) AND RURAL HEALTH
CLINICS (RHC)
7.14.1 HMO must make reasonable efforts to include FQHCs and RHCs
(Freestanding and hospital-based) in its provider network.
7.14.2 FQHCs or RHCs will receive a cost settlement from TDH and must
agree to accept initial payments from HMO in an amount that is
equal to or greater than HMO's payment terms for other
providers providing the same or similar services.
7.14.2.1 HMO must submit monthly FQHC and RHC encounter and payment
reports to all contracted FQHCs and RHCs, and FQHCs and RHCs
with whom there have been encounters, not later than 21 days
from the end of the month for which the report is submitted.
The format will be developed by TDH. The FQHC and RHC must
validate the encounter and payment information contained in
the report(s). Both HMO and the FQHC/RHC must sign the
report(s) after each party agrees that it accurately reflects
encounters and payments for the month reported. HMO must
submit the signed FQHC and RHC encounter and payment reports
to TDH not later than 45 days from the end of the month for
which the report is submitted.
7.14.2.2 For FQHCs, TDH will determine the amount of the interim
settlement based on the difference between: an amount equal
to the number of Medicaid allowable encounters multiplied by
the rate per encounter from the latest settled FQHC fiscal
year cost report; and, the amount paid by HMO to the FQHC for
the quarter. For RHCs, TDH will determine the amount of the
interim settlement based on the difference between a
reasonable cost amount methodology provided by TDH and the
amount paid by
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HMO to the RHC for the quarter. TDH will pay the FQHC or the
RHC the amount of the interim settlement, if any, as
determined by TDH or collect and retain the quarterly
recoupment amount, if any.
7.14.2.3 TDH will cost settle with each FQHC and RHC annually, based on
the FQHC or the RHC fiscal year cost report and the
methodology described in paragraph 7.14.2.2. TDH will make
additional payments or recoup payments from the FQHC or the
RHC based on reasonable costs less prior interim payment
settlements.
7.15 COORDINATION WITH PUBLIC HEALTH
7.15.1 Reimbursed Arrangements. HMO must make a good faith effort to
enter into a subcontract for the covered health care services
as specified below with TDH Public Health Regions, city and/or
county health departments or districts in each county of the
service area that will be providing these services to the
Members (Public Health Entities), who will be paid for
services by HMO, including any or all of the following
services:
7.15.1.1 Sexually Transmitted Diseases (STDs) Services (See Article
6.15);
7.15.1.2 Confidential HIV Testing (See Article 6.15);
7.15.1.3 Immunizations (See relevant paragraphs in Article 6.8.9); and,
7.15.1.4 Tuberculosis (TB) Care (See Article 6.12).
7.15.2 The subcontract must include any covered services, which the
public health department has agreed to provide:
7.15.2.1 Family Planning Services (See Article 6.7);
7.15.2.2 THSteps checkups (See Article 6.8);
7.15.2.3 Prenatal services.
7.15.3 HMO must enter into subcontracts with public health entities
at least 90 days prior to the Implementation Date for the
service area. The subcontracts must be available for review
by TDH or its designated agent(s) on the same basis as all
other subcontracts. If an HMO is unable to enter into a
contract with any of the public health entities, HMO must
submit documentation substantiating its reasonable efforts to
enter into such an agreement, to TDH. The subcontracts must
include the following areas:
7.15.3.1 The general relationship between HMO and the Public Health
entity. The subcontracts must specify the scope and
responsibilities of both parties, the methodology and
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agreements regarding billing and reimbursements, reporting
responsibilities, Member and provider educational
responsibilities, and the methodology and agreements regarding
sharing of confidential medical record information between the
public health entity and the PCP.
7.15.3.2 Public Health Entity responsibilities:
(1) Public health providers must inform Members that
confidential health care information will be provided
to the PCP.
(2) Public health providers must refer Members back to
PCP for any follow-up diagnostic, treatment, or
referral services.
(3) Public health providers must educate Members about
the importance of having a PCP and assessing PCP
services during office hours rather than seeking care
from Emergency Departments, Public Health Clinics, or
other Primary Care Providers or Specialists.
(4) Public health entities must identify a staff person
to act as liaison to HMO to coordinate Member needs,
Member referral, Member and provider education, and
the transfer of confidential medical record
information.
7.15.3.3 HMO Responsibilities:
(1) HMO must identify care coordinators who will be
available to assist public health providers and PCPs
in getting efficient referrals of Members to the
public health providers, specialists, and
health-related service providers either within or
outside HMO's network.
(2) HMO must inform Members that confidential healthcare
information will be provided to the PCP.
(3) HMO must educate Members on how to better utilize
their PCPs, public health providers, emergency
departments, specialists, and health-related service
providers.
7.15.4 Non-Reimbursed Arrangements with Public Health Entities.
7.15.4.1 Coordination with Public Health Entities. HMOs must enter
into a Memorandum of Understanding (MOU) with Public Health
Entities regarding the provision of services for essential
public health services. These MOUs must be entered into at
least 90 days before the Implementation Date in the service
area and are subject to TDH approval. These MOUs must contain
the roles and responsibilities of HMO and the public health
department for the following services:
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(1) Public health reporting requirements regarding
communicable diseases and/or diseases which are
preventable by immunization as defined by state law;
(2) Notification of and referral to the local Public
Health Entity, as defined by state law, of
communicable disease outbreaks involving Members;
(3) Referral to the local Public Health Entity for TB
contact investigation and evaluation and preventive
treatment of persons whom the Member has come into
contact;
(4) Referral to the local Public Health Entity for
STD/HIV contact investigation and evaluation and
preventive treatment of persons whom the Member has
come into contact; and,
(5) Referral for WIC services and information sharing;
(6) Coordination and follow-up of suspected or confirmed
cases of childhood lead exposure.
7.15.4.2 Coordination with Other TDH Programs. HMOs must enter into a
Memorandum of Understanding (MOU) with other TDH programs
regarding the provision of services for essential public
health services. These MOUs must be entered into at least 90
days before the Implementation Date in the service area and
are subject to TDH approval. These MOUs must delineate the
roles and responsibilities of HMO and the public health
department for the following services:
(1) Use of the TDH laboratory for THSteps newborn
screens; lead testing; and hemoglobin/hematocrit
tests;
(2) Availability of immunizations through the Vaccines
for Children Program;
(3) Reporting of immunizations provided to the statewide
ImmTrac Registry including parental consent to share
data;
(4) Referral for WIC services and information sharing;
(5) Pregnant, Women and Infant (PWI) Targeted Case
Management;
(6) THSteps outreach, informing and Medical Case
Management;
(7) Participation in the community-based coalitions with
the Medicaid-funded case management programs in MHMR,
ECI, TCB, and TDH (PWI, CIDC and THSteps Medical Case
Management);
(8) Referral to the TDH Medical Transportation Program;
and,
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(9) Cooperation with activities required of public health
authorities to conduct the annual population and
community based needs assessment.
(10) Coordination and follow-up of suspected or confirmed
cases of childhood lead exposure.
7.15.5 All public health contracts must contain provider network
requirements in Article VII, as applicable.
7.16 COORDINATION WITH TEXAS DEPARTMENT OF PROTECTIVE AND
REGULATORY SERVICES
7.16.1 HMO must cooperate and coordinate with the Texas Department of
Protective and Regulatory Services (TDPRS) for the care of a
child who is receiving services from or has been placed in the
conservatorship of TDPRS.
7.16.2 HMO must comply with all provisions of a court order or TDPRS
service plan with respect to a child in the conservatorship of
TDPRS (Order) entered by a Court of continuing jurisdiction
placing a child under the protective custody of the TDPRS or a
service plan voluntarily entered into by the parents or person
having legal custody of a minor and TDPRS, which relates to
the health and behavioral health services required to be
provided to the Member.
7.16.3 HMO cannot deny, reduce, or controvert the medical necessity
of any health services included in an Order. Any modification
or termination of ordered services must be presented and
approved by the court with jurisdiction over the matter for
decision.
7.16.4 A Member or the parent or guardian whose rights are subject to
an Order or Service Plan cannot appeal the necessity of the
services ordered through HMO's complaint or appeal processes,
or to TDH for a fair hearing.
7.16.5 HMO must include information in its provider training and
manuals regarding:
7.16.5.1 providing medical records,
7.16.5.2 scheduling medical and behavioral health appointments within
14 days unless requested earlier by TDPRS,
7.16.5.3 recognition of abuse and neglect and appropriate referral to
TDPRS.
7.16.6 HMO must continue to provide all covered services to a Member
receiving services from or in the protective custody of TDPRS
until the Member has been disenrolled
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from HMO as a result of loss of eligibility in Medicaid
managed care or placement into xxxxxx care.
7.17 PROVIDER NETWORKS (IPAS, LIMITED PROVIDER NETWORKS AND ANHCS)
7.17.1 All HMO contracts with independent physician, provider
associations or similar provider groups, organizations, or
networks (IPA contracts) and standard IPA contracts with
contracted providers (IPA/Provider contracts) must be
submitted to TDH no later than 120 days prior to the
Implementation Date. The form and substance of all HMO/IPA
and IPA/Provider contracts are subject to approval by TDH.
TDH retains the authority to reject and require changes to any
HMO/IPA or IPA/Provider contract which:
7.17.1.1 does not contain the mandatory contract provisions for all
subcontractors in this contract,
7.17.1.2 does not comply with the requirements, duties and
responsibilities of this contract,
7.17.1.3 creates a barrier for full participation to significant
traditional providers,
7.17.1.4 interferes with TDH's oversight and audit responsibilities
including collection and validation of encounter data, or
7.17.1.5 is inconsistent with the federal requirement for simplicity in
the administration of the Medicaid program.
7.17.1.6 HMO must include this contract as an attachment to any IPA
contract for Medicaid managed care services.
7.17.2 HMO cannot delegate claims payment to an IPA, even under a
capitated partial or full risk arrangement. This provision
does not apply to single limited or basic service HMOs.
7.17.3 In addition to the mandatory provisions for all subcontracts
under Articles 3.2 and 7.2, all HMO/IPA contracts must include
the following mandatory standard provisions:
7.17.3.1 HMO is required to include subcontract provisions in its IPA
contracts which require the UM protocol used by an IPA to
produce substantially similar outcomes, as approved by TDH, as
the UM protocol employed by the contracting HMO. The
responsibilities of an HMO in delegating UM functions to an
IPA will be governed by Article 16.11 of this contract.
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7.17.3.2 The IPA must comply with the same encounter, utilization,
quality, and financial reporting requirements as HMO under
this contract. The IPA must comply with the same report
filing timelines and include the same information and use the
same format as HMO under this contract.
7.17.3.3 The IPA must comply with the same records retention and
production requirements as HMO under this contract, including
public information requests.
7.17.3.4 The IPA is subject to the same marketing restrictions and
requirements as HMO under this contract.
7.17.3.5 HMO is responsible for ensuring that IPAs comply with the
requirements and provisions of the TDH/HMO contract. TDH will
impose appropriate sanctions and remedies upon HMO for any
default under the TDH/HMO contract which is caused directly or
indirectly by the acts or omissions of the IPA. Sanctions
imposed by TDH upon HMO cannot be passed through or recouped
from the IPA or network providers unless specifically allowed
by TDH in the Notice of Default and the pass through or
recoupment is disclosed as a HMO/IPA contract provision.
7.17.4 HMO cannot enter into contracts with IPAs to provide services
under this contract which require the participating providers
to enter into exclusive contracts with the IPA as a condition
for participation in the IPA.
7.17.4.1 Provision 7.17.4 does not apply to providers who are employees
or participants in limited or closed panel provider networks.
7.17.5 All limited provider or closed panel IPA networks with whom
HMO contracts must either independently meet the access
provisions of 28 Texas Administrative Code Section 11.1607,
relating to access requirements, or HMO must provide for
access through other network providers outside the closed
panel IPA.
7.17.6 HMO cannot delegate to an IPA the enrollment, reenrollment,
assignment or reassignment of a Member.
7.17.7 In addition to the above provision HMO and approved Non-Profit
Health Corporations must comply with all of the requirements
contained in 28 TAC Section 11.1604, relating to Requirements
of Certain Contracts between Primary HMOs and ANHCs and
Primary HMOs and Provider HMOs.
7.17.8 HMO REMAINS RESPONSIBLE FOR PERFORMING ALL DUTIES,
RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT REGARDLESS
OF WHETHER THE DUTY, RESPONSIBILITY OR SERVICE IS CONTRACTED
OR DELEGATED TO ANOTHER. HMO MUST PROVIDE A COMPLETE COPY OF
THIS CONTRACT TO ANY PROVIDER NETWORK
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OR GROUP WITH WHOM HMO CONTRACTS TO PROVIDE HEALTH CARE
SERVICES ON A RISK SHARING OR CAPITATED BASIS OR TO PROVIDE
HEALTH CARE SERVICES OTHER THAN MEDICAL CARE SERVICE OR
ANCILLARY SERVICES.
ARTICLE VIII MEMBER SERVICES REQUIREMENTS
8.1 MEMBER EDUCATION
HMO must provide the Member education requirements as
contained in Article VI at 6.5, 6.6, 6.7, 6.8, 6.9, 6.10,
6.11, 6.12, 6.13, 6.14 and this Article of the contract.
8.2 MEMBER HANDBOOK
8.2.1 HMO must mail each Member a Member Handbook within five (5)
days from the date that the Member's name appears on the
Enrollment Report. The Member Handbook must be written at a
4th - 6th grade reading comprehension level. The Member
Handbook must contain all critical elements specified by TDH.
See Appendix M, Required Critical Elements, for specific
details regarding content requirements. HMO must submit a
Member Handbook to TDH for approval not later than 90 days
before the Implementation Date. (See Article 3.4.1 regarding
the process for plan materials review.)
8.2.2 Member Handbook Updates. HMO must provide updates to the
Handbook to all Members as changes are made to the above
policies. HMO must make the Member Handbook available in the
languages of the major populations and in a format accessible
to blind or visually impaired Members.
8.2.3 THE MEMBER HANDBOOK AND ANY REVISIONS OR CHANGES MUST BE
APPROVED BY TDH PRIOR TO PUBLICATION AND DISTRIBUTION TO
MEMBERS.
8.3 ADVANCE DIRECTIVES
8.3.1 Federal law requires HMOs and providers to maintain written
policies and procedures for informing and providing written
information to all adult Members about their rights under
state and federal law, in advance of their receiving care
(Social Security Act Section 1902(a)(57) and Section
1903(m)(1)(A). These must contain procedures for providing
written information regarding the Member's right to refuse,
withhold or withdraw medical treatment advance directives.
HMO's policies and procedures must comply with provisions
contained in 42 CFR Section 434.28 and 42 CFR Section 489,
SubPart I, relating to advance directives for all hospitals,
critical access hospitals, skilled nursing
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facilities, home health agencies, providers of home health
care, providers of personal care services and hospices, as
well as following state laws and rules:
8.3.1.1 the Member's right to self-determination in making health care
decisions;
8.3.1.2 the Member's rights under the Natural Death Act (Texas Health
and Safety Code, Chapter 672) to execute an advance written
Directive to Physicians, or to make a non-written directive
regarding their right to withhold or withdraw life sustaining
procedures in the event of a terminal condition;
8.3.1.3 the Member's rights under Texas Health and Safety Code,
Chapter 674, relating to written and non-written
Out-of-Hospital Do-Not-Resuscitate Orders;
8.3.1.4 the Member's right to execute a Durable Power of Attorney for
Health Care regarding their right to appoint an agent to make
medical treatment decisions on their behalf if the Member
becomes incapacitated (Civil Practice and Remedies Code,
Chapter 135); and
8.3.1.5 HMO's policies for implementing a Member's advance directives,
including a clear and concise statement of limitations if HMO
or a participating provider cannot or will not be able to
carry out a Member's advance directive.
8.3.2 A statement of limitation on implementing a Member's advance
directive should include at least the following information:
8.3.2.1 clarify any differences between HMO's conscience objections
and those which may be raised by the Member's PCP or other
providers;
8.3.2.2 identify the state legal authority permitting HMO's conscience
objections to carrying out an advance directive;
8.3.2.3 describe the range of medical conditions or procedures
affected by the conscience objection.
8.3.3 The policies and procedures must require HMO and Subcontractor
to comply with the requirements of state and federal laws
relating to advance directives. HMO must provide education
and training to employees, Members and the community on issues
concerning advance directives.
8.3.4 All materials provided to Members regarding advance directives
must be written at a 7th - 8th grade reading comprehension
level, except where a provision is required by state or
federal law, and the provision cannot be reduced or modified
to a 0xx- 0xx xxxxx xxxxxxx xxxxx, xxxxxxx it is a reference
to the law or is required to be included
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"xx xxxxxxx" in the state or federal law. HMO must submit any
revisions to existing approved advanced directive materials.
8.3.5 HMO must notify Members of any changes in state or federal
laws relating to advance directives within 90 days from the
effective date of the change, unless the law or regulation
contains a specific time requirement for notification.
8.4 MEMBER ID CARDS
8.4.1 A Medicaid Identification Form (Form 3087) is issued monthly
by the TDHS and includes the "STAR" Program the name of the
Member's PCP and health plan. A Member may have a temporary
Medicaid Identification (Form 1027-A) which will include a
STAR indicator.
8.4.2 HMO must issue a Member Identification Card to the Member
within five (5) days from receiving notice of enrollment of
the Member into HMO. The Member Identification Card must
include, at a minimum, the following: Member's name; Member's
Medicaid number; the effective date of the card; PCP's name,
address, and telephone number; name of HMO; name of IPA to
which the Member's PCP belongs, if applicable; the 24-hour,
seven (7) day a week toll-free telephone number operated by
HMO; and directions for what to do in an emergency.
Identification Card must be reissued if the Member reports a
lost card, there is a Member name change, if Member requests a
new PCP, or for any other reason which results in a change to
the information disclosed on the Identification Card.
8.5 MEMBER HOTLINE
HMO must maintain a toll-free Member telephone hotline 24
hours a day, seven days a week for Members to obtain
assistance in accessing services under this contract.
Telephone availability must be demonstrated through an
abandonment rate of less than 10%.
8.6 MEMBER COMPLAINT PROCESS
8.6.1 HMO must develop, implement and maintain a Member complaint
system that complies with the requirements of Article 20A.12
of the Texas Insurance Code, relating to the Complaint System,
except where otherwise provided in this contract or in federal
law.
8.6.2 HMO must have written policies and procedures for taking,
tracking, reviewing, and reporting and resolving of member
complaints. The procedures must be reviewed and approved in
writing by TDH before Phase I of Readiness Review. Any
amendments to the procedures must be submitted to TDH for
approval thirty (30) days prior to the effective date of the
amendment.
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8.6.3 HMO must designate an officer of HMO who has primary
responsibility for ensuring that complaints are resolved in
compliance with written policy and within the time required.
An "officer" of HMO means a president, vice president,
secretary, treasurer, or chairperson of the board for a
corporation, the sole proprietor, the managing general partner
of a partnership, or a person having similar executive
authority in the organization.
8.6.4 HMO must have a routine process to detect patterns of
complaints and disenrollments and involve management and
supervisory staff to develop policy and procedural
improvements to address the complaints. HMO must cooperate
with TDH and TDH's enrollment broker in addressing Member
complaints relating to enrollment and disenrollment.
8.6.5 HMO's complaint procedures must be provided to Members in
writing and in alternative communications formats. A written
description of HMO's complaint procedures must be in
appropriate languages and easy for Members to understand. HMO
must include a written description of the complaint procedures
in the Member Handbook. HMO must maintain at least one local
and one toll-free telephone number for making complaints.
8.6.6 HMO's process must require that every complaint received in
person, by telephone or in writing, is recorded in a written
record and is logged with the following details: date,
identification of the individual filing the complaint,
identification of the individual recording the complaint,
disposition of the complaint, corrective action required, and
date resolved.
8.6.7 HMO's process must include a requirement that the Governing
Body of HMO reviews the written records (logs) for complaints
and appeals. An officer of the HMO must be designated to have
direct responsibility for the complaint system.
8.6.8 HMO is prohibited from discriminating against a Member because
that Member is making or has made a complaint.
8.6.9 HMO cannot process requests for disenrollments through HMO's
complaint procedures. Requests for disenrollments must be
referred to TDH within five (5) business days after the Member
makes a disenrollment request.
8.6.10 If a complaint relates to the denial, delay, reduction,
termination or suspension of covered services by either HMO or
a utilization review agent contracted to perform utilization
review by HMO, HMO must inform Members they have the right to
access the TDH fair hearing process at any time in lieu of the
internal complaint system provided by HMO. HMO is required to
comply with the notice requirements
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contained in 25 TAC Chapter 36, relating to notice and fair
hearings in the Medicaid program, whenever an action is taken
to deny, delay, reduce, terminate or suspend a covered
service.
8.6.11 If Members utilize HMO's internal complaint system and the
complaint relates to the denial, delay, reduction, termination
or suspension of covered services by either HMO or a
utilization review agent contracted to perform utilization
review by HMO, HMO must inform the Member that they continue
to have a right to appeal the decision through the TDH fair
hearing process.
8.6.12 The provisions of Article 21.58A, Texas Insurance Code,
relating to a Member's right to appeal an adverse
determination made by HMO or a utilization review agent by an
independent review organization, do not apply to a Medicaid
recipient. Federal fair hearing requirements (Social Security
Act Section 1902a(3), codified at 42 C.F.R. 431.200 et. seq.)
require the agency to make a final decision, after a fair
hearing which conflicts with the State requirement that the
IRO make a final decision, therefore the State requirement is
pre-empted by the federal requirement.
8.6.13 HMO will cooperate with the Enrollment Broker and TDH to
resolve all Member complaints. Such cooperation may include,
but is not limited to, participation by HMO or Enrollment
Broker and/or TDH internal complaint committees.
8.6.14 HMO must have policies and procedures in place outlining the
role of HMO's Medical Director in the Member Complaint System.
The Medical Director must have a significant role in
monitoring, investigating and hearing complaints.
8.6.15 HMO must provide Member Advocates to assist Members in
understanding and using HMO's complaint system.
8.6.16 HMO's Member Advocates must assist Members in writing or
filing a complaint and monitoring the complaint through the
Contractor's complaint process until the issue is resolved.
8.6.17 Member Advocates must file a Member Advocate Report of their
review and participation in the complaint procedure for each
complaint brought by a Member and a summary of each complaint
resolution. A copy of the Member Advocate Report must be
included in HMO's quarterly report. (See Article 12.6.)
8.7 MEMBER NOTICE, APPEALS AND FAIR HEARINGS
8.7.1 HMO must send Members the notice required by 25 TAC, Chapter
36, whenever HMO takes an action to deny, delay, reduce or
terminate covered services to a Member. The notice must be
mailed to the Member no less than 10 days before HMO intends
to take an action. If an emergency exists, or if the time
within which the service must be provided makes giving 10 days
notice impractical or impossible,
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notice must be provided by the most expedient means reasonably
calculated to provide actual notice to the Member, including
by phone, or through the provider's office.
8.7.2 The notice must contain the following information:
8.7.2.1 the Member's right to immediately access TDH's Fair Hearing
process;
8.7.2.2 a statement of the action HMO will take;
8.7.2.3 an explanation of the reasons HMO will take the action;
8.7.2.4 a reference to the state and/or federal regulations which
support HMO's action;
8.7.2.5 a procedure by which the Member may appeal HMO's action
through either HMO's complaint process or TDH's fair hearings
process and include an address where a written request may be
sent and toll-free number the Member can call to request the
assistance of a Member representative or to file a complaint
or request a fair hearing;
8.7.2.6 an explanation that the Member may represent themselves, or be
represented by HMO's representative, a friend, a relative,
legal counsel or another spokesperson;
8.7.2.7 an explanation of whether and under what circumstances
services may be continued if a complaint is filed or a fair
hearing requested;
8.7.2.8 a statement that if the Member wants a TDH Fair Hearing on the
action, the Member must make the request for a Fair Hearing
within 90 days of the date the notice was mailed;
8.7.2.9 an explanation that the Member may request that resolution
through HMO complaint process or TDH Fair Hearing be conducted
based on written information without the necessity of taking
oral testimony; and
8.7.2.10 a statement explaining that HMO must make a decision or a
final decision must be made by TDH within 90 days from the
date the complaint is filed or a Fair Hearing requested.
8.8 MEMBER ADVOCATES
8.8.1 HMO must provide Member Advocates to assist Members. The
Member Advocates must be physically located within the Service
Area. Member Advocates must inform Members of their rights
and responsibilities, the complaint process, the health
education and the services available to them, including
preventive services.
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8.8.2 The Member Advocates must assist Members in writing complaints
and are responsible for monitoring the complaint through HMO's
complaint process until the Member's issues are resolved or a
TDH Fair Hearing requested. (See Articles 8.6.15, 8.6.16 and
8.6.17.)
8.8.3 Member Advocates are responsible for making recommendations to
management on any changes needed to improve either the care
provided or the way care is delivered. Advocates are also
responsible for helping or referring Members to community
resources available to meet Member needs that are not
available from HMO as Medicaid covered services.
8.8.4 Member Advocates must provide outreach to Members and
participate in TDH-sponsored enrollment activities and
participate in the Group Needs Assessment process.
8.9 MEMBER CULTURAL AND LINGUISTIC SERVICES
8.9.1 Linguistic Services and Cultural Competency Plan. HMO must
have a comprehensive written Linguistic Services and Cultural
Competency Plan describing how HMO will meet the linguistic
and cultural needs of Members. The Plan must describe how the
individuals and systems within HMO will effectively provide
services to people of all cultures, races, ethnic backgrounds,
and religions in a manner that recognizes, values, affirms,
and respects the worth of the individuals and protects and
preserves the dignity of each. HMO must submit a written plan
to TDH not later than 90 days prior to the Implementation
Date. The Plan must also be made available to HMO's network
of providers.
8.9.2 HMO must develop and implement written policies and procedures
for the provision of linguistic services following Title VI of
the Civil Rights Act guidelines and must monitor the
performance of the individuals who provide linguistic
services. HMO must disseminate these policies and procedures
to ensure that both Staff and subcontractors are aware of
their responsibilities under Title VI.
8.9.3 The Linguistic Services and Cultural Competency Plan must
include but not be limited to the following:
8.9.3.1 A description of how HMO will educate its staff on linguistic
and cultural needs and the characteristics of its Members;
8.9.3.2 A description of how HMO will implement the plan in its
organization, including the designation of staff responsible
for carrying out all portions of the Linguistic Services and
Cultural Competency Plan;
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8.9.3.3 A description of how HMO will develop standards and
performance requirements for the delivery of linguistic
services and culturally competent care, and monitor adherence
with those standards and requirements;
8.9.3.4 A description of how HMO will assist Members in writing/filing
a complaint and monitoring the complaint through the
Contractor's complaint process until the issue is resolved;
8.9.3.5 Recommendations to HMO management on any changes needed to
improve either the care provided or the way care is delivered;
8.9.3.6 A description of how HMO will provide outreach to Members and
participate in TDH-sponsored enrollment activities;
8.9.3.7 A description of how HMO will help Members access community
health or social services resources that are not covered under
the contract with TDH;
8.9.3.8 A description of how HMO will participate in the Group Needs
Assessment process.
8.9.4 HMO must provide the following types of linguistic services:
interpreters, translated signage, and referrals to culturally
and linguistically appropriate community services programs.
8.9.5 HMO must forward all approved English versions of materials to
DHS for DHS to translate into Spanish. DHS must provide the
written and approved translation into Spanish to HMO within 15
days from receipt of the English version. HMO must
incorporate the approved translations into all materials
distributed to Members. TDH reserves the right to require
revisions to materials if inaccuracies are discovered, or if
changes are required by changes in policy or law.
8.9.6 Interpreter Services. HMO must provide trained, professional
interpreters when technical, medical, or treatment information
is to be discussed.
8.9.6.1 HMO must adhere to and provide to Members the Member Xxxx of
Rights and Responsibilities as adopted by the Texas Health and
Human Services Commission and contained at 1 Texas
Administrative Code (TAC) Sections 353.202-353.203. The
Member Xxxx of Rights and Responsibilities assures Members the
right "to have interpreters, if needed, during appointments
with [their] providers and when talking to [their] health
plan. Interpreters include people who can speak in [their]
native language, assist with a disability, or help [them]
understand the information."
8.9.6.2 HMO must have in place policies and procedures that outline
how Members can access face-to-face interpreter services in a
provider's office if necessary to ensure the
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availability of effective communication regarding treatment,
medical history or health education for a Member.
8.9.6.3 A current copy of the list of interpreters must be provided to
each provider in HMO's provider network and updated as
necessary. This list must be available to Members and TDH or
its agent(s) upon request. A competent interpreter is defined
as someone who is:
8.9.6.3.1 proficient in both English and the other language, and
8.9.6.3.2 has had orientation or training in the ethics of interpreting,
and
8.9.6.3.3 has fundamental knowledge in both languages of any specialized
medical terms and concepts.
8.9.6.4 HMO must provide 24-hour access to interpreter services for
Members to access emergency medical services within HMO's
network.
8.9.6.5 Family Members, especially minor children, should not be used
as interpreters in assessments, therapy or other medical
situations in which impartiality and confidentiality are
critical, unless specifically requested by the Member.
However, a family member or friend may be used as an
interpreter if they can be relied upon to provide a complete
and accurate translation of the information being provided to
the Member; the Member is advised that a free interpreter is
available; and the Member expresses a preference to rely on
the family member or friend.
8.9.7 All Member orientation presentations and education classes
must be conducted in the languages of the major population
groups, as specified by TDH, in the service area(s) as the
identified need arises.
8.9.8 HMO must provide TDD access to Members who are deaf or hearing
impaired.
ARTICLE IX MARKETING AND PROHIBITED PRACTICES
9.1 MARKETING MATERIAL MEDIA AND DISTRIBUTION
HMOs may present their marketing materials to eligible
Medicaid recipients through any method or media determined to
be acceptable by TDH. The media may include but are not
limited to: written materials, such as brochures, posters, or
fliers which can be mailed directly to the client or left at
Texas Department of Human Services eligibility offices; TDH
sponsored community enrollment events; and paid or public
service announcements on radio. All marketing materials must
be approved by TDH prior to distribution (see Article 3.4).
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9.2 MARKETING ORIENTATION AND TRAINING
HMO must require that all HMO staff having direct contact with
Members as part of their job duties and their supervisors have
satisfactorily completed TDH's marketing orientation and
training program prior to engaging in marketing activities on
behalf of HMO. TDH will notify HMO of scheduled orientations.
9.3 PROHIBITED MARKETING PRACTICES
9.3.1 HMO and its agents, subcontractors and providers are
prohibited from engaging in the following marketing practices:
9.3.1.1 conducting any direct contact marketing to prospective Members
except through TDH-sponsored enrollment events;
9.3.1.2 making any written or oral statement containing material
misrepresentations of fact or law relating to HMO's plan or
the STAR program;
9.3.1.3 making false, misleading or inaccurate statements relating to
services or benefits of HMO or the STAR program;
9.3.1.4 offering prospective Members anything of material or financial
value as an incentive to enroll with a particular PCP or HMO;
and
9.3.1.5 discriminating against an eligible Member because of race,
creed, age, color, sex, religion, national origin, ancestry,
marital status, sexual orientation, physical or mental
handicap, health status, or requirements for health care
services.
9.3.2 HMO may offer nominal gifts with a retail value of no more
than $10 and/or free health screens to potential Members, as
long as these gifts and free health screenings are offered
whether or not the client enrolls in HMO. Free health
screenings cannot be used to discourage less healthy potential
Members from joining HMO. All gifts must be approved by TDH
prior to distribution to Members. The results of free
screenings must be shared with the Member's PCP if the Member
enrolls with HMO providing the screen.
9.3.3 Marketing representatives may not conduct or participate in
marketing activities for more than one HMO.
9.4 NETWORK PROVIDER DIRECTORY
9.4.1 HMO must submit a provider directory to TDH no later than 180
days prior to the Implementation Date. HMO must provide the
provider directory to the Enrollment
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Broker for prospective members. The directory must contain
all critical elements specified by TDH. See Appendix M,
Required Critical Elements, for specific details regarding
content requirements.
9.4.2 If HMO contracts with limited provider networks, the provider
directory must comply with the requirements of 28 TAC
11.1600(b)(11), relating to the disclosure and notice of
limited provider networks.
9.4.3 Updates to the provider directory must be provided to the
Enrollment Broker at the beginning of each state fiscal year
quarter. This includes the months of September, December,
March and June. HMO is responsible for submitting draft
updates to TDH only if changes other than PCP information are
incorporated. HMO is responsible for sending five final
copies of the updated provider directory to TDH each quarter.
TDH will forward two updated provider directories, along with
its approval notice, to the Enrollment Broker to facilitate
their distribution.
ARTICLE X MIS SYSTEM REQUIREMENTS
10.1 MODEL MIS REQUIREMENTS
10.1.1 HMO must maintain a MIS that will provide support for all
functions of HMO's processes and procedures related to the
flow and use of data within HMO. The MIS must enable HMO to
meet the requirements of this contract. The MIS must have the
capacity and capability of capturing and utilizing various
data elements to develop information for HMO administration.
10.1.2 HMO must maintain a claim retrieval service processing system
that can identify date of receipt, action taken on all
provider claims or encounters (i.e., paid, denied, other), and
when any action was taken in real time.
10.1.3 HMO must have a system that can be adapted to the change in
Business Practices/Policies within a short period of time.
10.1.4 HMO is required to submit and receive data as specified in
this contract and HMO Encounter Data Submissions Manual. The
MIS must provide encounter data for all capitated services
within the scope of services of the contract between HMO and
TDH. Encounter data must follow the format, data elements and
method of transmission specified in the contract and HMO
Encounter Data Submissions Manual. HMO must submit encounter
data, including adjustments to encounter data, by the 10th day
of each month. The Encounter transmission will include all
encounter data and encounter data adjustments processed by HMO
for the previous month. Data quality validation will
incorporate assessment standards developed jointly by HMO and
TDH. Original records will be made available for inspection
by TDH for
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validation purposes. Data which does not meet quality
standards must be corrected and returned within a time period
specified by TDH.
10.1.5 HMO must use the procedure codes, diagnosis codes, and other
codes used for reporting encounters and fee-for-service claims
in the most recent edition of the Medicaid Provider Procedures
Manual or as otherwise directed by TDH. Any exceptions will
be considered on a code-by-code basis after TDH receives
written notice from HMO requesting an exception. HMO must
also use the provider numbers as directed by TDH for both
encounter and fee-for-service claims submission.
10.1.6 HMO must maintain accounting records for all claim payments,
refunds and adjustments of payments to providers, and all
premium payments, interest income and any administrative fees
paid to Subcontractors for services under this contract.
Provider payments for health or health related services must
be reported separately from administrative payments. HMO must
submit periodic reports and data to TDH as required by TDH.
10.1.7 HMO must have hardware, software, network and communications
system with the capability and capacity to handle and operate
all MIS subsystems.
10.1.8 HMO must provide an organizational chart and description of
responsibilities of HMO's MIS department dedicated to or
supporting this Contract by Phase I of Readiness Review. Any
updates to the organizational chart and the description of
responsibilities must be provided to TDH at least 30 days
prior to the effective date of the change. Official points of
contact must be provided to TDH on an ongoing basis. An
Internet E-mail address must be provided for each point of
contact.
10.1.9 HMO must operate and maintain a MIS that meets or exceeds the
requirements outlined in the Model MIS Guidelines that follow:
10.1.9.1 Eight subsystems are used in the Model MIS Requirements to
identify specific functions or features required by HMO's MIS.
These subsystems focus on the individual systems functions or
capabilities to support the following operational and
administrative areas:
(1) Enrollment/Eligibility Subsystem
(2) Provider Subsystem
(3) Encounter/Claims Processing Subsystem
(4) Financial Subsystem
(5) Utilization/Quality Improvement Subsystem
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(6) Reporting Subsystem
(7) Interface Subsystem
(8) TPR Subsystem
10.2 SYSTEM-WIDE FUNCTIONS
HMO MIS system must include functions and/or features which
must apply across all subsystems as follows:
(1) Ability to update and edit data.
(2) Maintain a history of changes and adjustments and
audit trails for current and retroactive data. Audit
trails will capture date, time, and reasons for the
change, as well as who made the change.
(3) Allow input mechanisms through manual and electronic
transmissions.
(4) Have procedures and processes for accumulating,
archiving, and restoring data in the event of a
system or subsystem failure.
(5) Maintain automated or manual linkages between and
among all MIS subsystems and interfaces.
(6) Ability to relate Member and provider data with
utilization, service, accounting data, and reporting
functions.
(7) Ability to relate and extract data elements into
summary and reporting formats attached as Appendices
to contract.
(8) Must have written process and procedures manuals
which document and describe all manual and automated
system procedures and processes for all the above
functions and features, and the various subsystem
components.
(9) Maintain and cross-reference all Member-related
information with the most current Medicaid number.
10.3 ENROLLMENT/ELIGIBILITY SUBSYSTEM
The Enrollment/Eligibility Subsystem is the central processing
point for the entire MIS. It must be constructed and
programmed to secure all functions which require
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Membership data. It must have function and/or features which
support requirements as follows:
(1) Identify other health coverage available or third
party liability (TPL), including type of coverage and
effective dates.
(2) Maintain historical data (files) as required by TDH.
(3) Maintain data on enrollments/disenrollments and
complaint activities. This data must include reason
or type of disenrollment, complaint and resolution by
incidence.
(4) Receive, translate, edit and update files in
accordance with TDH requirements prior to inclusion
in HMO's MIS. Updates will be received from TDH's
agent and processed within two working days after
receipt.
(5) Provide error reports and a reconciliation process
between new data and data existing in MIS.
(6) Identify enrollee changes in primary care provider
and the reason(s) for those changes and effective
dates.
(7) Monitor PCP capacity and limitations prior to
connecting the enrollee to PCP in the system, and
provide a kick-out report when capacity and
limitations are exceeded.
(8) Verify enrollee eligibility for medical services
rendered or for other enrollee inquiries.
(9) Generate and track referrals, e.g.,
Hospitals/Specialists.
(10) Search records by a variety of fields (e.g., name,
unique identification numbers, date of birth, SSN,
etc.) for eligibility verification.
(11) Send PCP assignment updates to TDH in the format as
specified by TDH.
10.4 PROVIDER SUBSYSTEM
The provider subsystem must accept, process, store and
retrieve current and historical data on providers, including
services, payment methodology, license information, service
capacity, and facility linkages.
Functions and Features:
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(1) Identify specialty(s), admission privileges, enrollee
linkage, capacity, facility linkages, emergency
arrangements or contact, and other limitations,
affiliations, or restrictions.
(2) Maintain provider history files to include audit
trails and effective dates of information.
(3) Maintain provider fee schedules/remuneration
agreements to permit accurate payment for services
based on the financial agreement in effect on the
date of service.
(4) Support HMO credentialing, recredentialing, and
credential tracking processes; incorporates or links
information to provider record.
(5) Support monitoring activity for physician to enrollee
ratios (actual to maximum) and total provider
enrollment to physician and HMO capacity.
(6) Flag and identify providers with restrictive
conditions (e.g., limits to capacity, type of
patient, and other services if approved out of
network, to include age restrictions).
(7) Support national provider number format (UPIN, NPIN,
CLIA, etc. as required by TDH).
(8) Provide provider network files 90 days prior to
implementation and updates monthly. Format will be
provided by TDH to contracted entities.
(9) Support the national CLIA certification numbers for
clinical laboratories.
(10) Exclude providers from participation that have been
identified by TDH as ineligible or excluded. Files
must be updated to reflect period and reason for
exclusion.
10.5 ENCOUNTER/CLAIMS PROCESSING SUBSYSTEM
The encounter/claims processing subsystem must collect,
process, and store data on all health services delivered for
which HMO is responsible. The functions of these subsystems
are claims/encounter processing and capturing health service
utilization data. The subsystem must capture all health
related services, including medical supplies, using standard
codes (e.g. CPT-4, HCPCS, ICD9-CM, UB92 Revenue Codes)
rendered by health-care providers to an eligible enrollee
regardless of payment arrangement (e.g. capitation or fee-
for-service). It approves, prepares for payment, or may
return or deny claims submitted. This subsystem may integrate
manual and
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automated systems to validate and adjudicate claims and
encounters. HMO must use encounter data validation
methodologies prescribed by TDH.
Functions and Features:
(1) Accommodate multiple input methods - electronic
submission, tape, claim document, and media.
(2) Support entry and capture of a minimum of two
diagnosis codes for each individual service as
defined by TDH.
(3) Edit and audit to ensure allowed services are
provided by eligible providers for eligible
recipients.
(4) Interface with Member and provider subsystems.
(5) Capture and report TPL potential, reimbursement or
denial.
(6) Edit for utilization and service criteria, medical
policy, fee schedules, multiple contracts, contract
periods and conditions.
(7) Submit data to TDH through electronic transmission
using specified formats.
(8) Support multiple fee schedule benefit packages and
capitation rates for all contract periods for
individual providers, groups, services, etc. A claim
encounter must be initially adjudicated and all
adjustments must use the fee applicable to the date
of service.
(9) Provide timely, accurate, and complete data for
monitoring claims processing performance.
(10) Provide timely, accurate, and complete data for
reporting medical service utilization.
(11) Maintain and apply prepayment edits to verify
accuracy and validity of claims data for proper
adjudication.
(12) Maintain and apply edits and audits to verify timely,
accurate, and complete encounter data reporting.
(13) Submit reimbursement to non-contracted providers for
emergency care rendered to enrollees in a timely and
accurate fashion.
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(14) Validate approval and denials of precertification and
prior authorization requests during adjudication of
claims/encounters.
(15) Track and report the exact date a service was
performed. Use of date ranges must have State
approval.
(16) Receive and capture claim and encounter data from
TDH.
(17) Receive and capture value-added services codes.
10.6 FINANCIAL SUBSYSTEM
The financial subsystem must provide the necessary data for all
accounting functions including cost accounting, inventory,
fixed assets, payroll, general ledger, accounts receivable and
payable, financial statement presentation, and any additional
data required by TDH. The financial subsystem must provide
management with information that can demonstrate that the
proposed or existing HMO is meeting, exceeding, or falling
short of fiscal goals. The information must also provide
management with the necessary data to spot the early signs of
fiscal distress, far enough in advance to allow management to
take corrective action where appropriate.
Functions and Features:
(1) Provide information on HMO's economic resources,
assets, and liabilities and present accurate
historical data and projections based on historical
performance and current assets and liabilities.
(2) Produce financial statements in conformity with
Generally Accepted Accounting Principles and in the
format prescribed by TDH.
(3) Provide information on potential third party payers;
information specific to the client; claims made
against third party payers; collection amounts and
dates; denials, and reasons for denials.
(4) Track and report savings by category as a result of
cost avoidance activities.
(5) Track payments per Member made to network providers
compared to utilization of the provider's services.
(6) Generate Remittance and Status Reports.
(7) Make claim and capitation payments to providers or
groups.
(8) Reduce/increase accounts payable/receivable based on
adjustments to claims or recoveries from third party
resources.
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10.7 UTILIZATION/QUALITY IMPROVEMENT SUBSYSTEM
The quality management/quality improvement/utilization review
subsystem combines data from other subsystems, and/or external
systems, to produce reports for analysis which focus on the
review and assessment of quality of care given, detection of
over and under utilization, and the development of user
defined reporting criteria and standards. This system
profiles utilization of providers and enrollees and compares
them against experience and norms for comparable individuals.
This system also supports the quality assessment function.
The subsystem tracks utilization control function(s) and
monitoring inpatient admissions, emergency room use,
ancillary, and out-of-area services. It provides provider
profiles, occurrence reporting, monitoring and evaluation
studies, and enrollee satisfaction survey compilations. The
subsystem may integrate HMO's manual and automated processes
or incorporate other software reporting and/or analysis
programs.
The subsystem incorporates and summarizes information from
enrollee surveys, provider and enrollee complaints, and appeal
processes.
Functions and Features:
(1) Supports provider credentialing and recredentialing
activities.
(2) Supports HMO processes to monitor and identify
deviations in patterns of treatment from established
standards or norms. Provides feedback information
for monitoring progress toward goals, identifying
optimal practices, and promoting continuous
improvement.
(3) Supports development of cost and utilization data by
provider and service.
(4) Provides aggregate performance and outcome measures
using standardized quality indicators similar to
HEDIS or as specified by TDH.
(5) Supports focused quality of care studies.
(6) Supports the management of referral/utilization
control processes and procedures, including prior
authorization and precertifications and denials of
services.
(7) Monitors primary care provider referral patterns.
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(8) Supports functions of reviewing access, use and
coordination of services (i.e. actions of Peer Review
and alert/flag for review and/or follow-up;
laboratory, x-ray and other ancillary service
utilization per visit).
(9) Stores and reports patient satisfaction data through
use of enrollee surveys.
(10) Provides fraud and abuse detection, monitoring and
reporting.
(11) Meets minimum report/data collection/analysis
functions of Article XI and Appendix A of this
Contract.
(12) Monitors and tracks provider and enrollee complaints
and appeals from receipt to disposition or resolution
by provider.
10.8 REPORT SUBSYSTEM
The reporting subsystem supports reporting requirements of all
HMO operations to HMO management and TDH. It allows HMO to
develop various reports to enable HMO management and TDH to
make decisions regarding HMO activity.
Functions and Capabilities:
(1) Produces standard, TDH-required reports and ad hoc
reports from the data available in all MIS
subsystems. All reports will be submitted on hard
copy or electronically in a format approved by TDH.
(2) Have system flexibility to permit the development of
reports at irregular periods as needed.
(3) Generate reports that provide unduplicated counts of
enrollees, providers, payments and units of service
unless otherwise specified.
(4) Generate an alphabetic Member listing.
(5) Generate a numeric Member listing.
(6) Generate a client eligibility listing by PCP (panel
report).
(7) Report on PCP change by reason code.
(8) Report on TPL (COB) information to TDH.
(9) Report on provider capacity and assignment from date
of service to date received.
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(10) Generate or produce an aged outstanding liability
report.
(11) Produce a Member ID Card.
(12) Produce client/provider mailing labels.
10.9 DATA INTERFACE SUBSYSTEM
10.9.1 The interface subsystem supports incoming and outgoing data
from and to other organizations. It allows HMO to maintain
enrollee, benefit package, eligibility,
disenrollment/enrollment status, and medical services received
outside of capitated services and associated cost. All
interfaces must follow the specifications frequencies and
formats listed in the Interface Manual.
10.9.2 HMO must obtain access to the TexMedNet BBS. Some file
transfers and E-mail will be handled through this mechanism.
10.9.3 Provider Network File. The provider file shall supply Network
Provider data between an HMO and TDH. This process shall
accomplish the following:
(1) Provide identifying information for all managed care
providers (e.g. name, address, etc.).
(2) Maintain history on provider enrollment/disenrollment.
(3) Identify PCP capacity.
(4) Identify any restrictions (e.g., age, sex, etc.).
(5) Identify number and types of specialty providers
available to Members.
10.9.4 Eligibility/Enrollment Interface. The enrollment interface
must provide eligibility data between TDH and HMOs.
(1) Provides benefit package data to HMOs in accordance
with capitated services.
(2) Provides PCP assignments.
(3) Provides Member eligibility status data.
(4) Provides Member demographics data.
(5) Provides HMOs with cross-reference data to identify
duplicate Members.
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10.9.5 Encounter/Claim Data Interface. The encounter/claim interface
must transfer paid fee-for-service claims data to HMOs and
capitated services/encounters from HMO, including adjustments.
This file will include all service types, such as inpatient,
outpatient, and medical services. TDH's agent will process
claims for non-capitated services.
10.9.6 Capitation Interface. The capitation interface must transfer
premium and Member information to HMO. This interface's basic
purpose is to balance HMO's Members and premium amount.
10.9.7 TPR Interface. TDH will provide a data file that contains
information on enrollees that have other insurance. Because
Medicaid is the payer of last resort, all services and
encounters should be billed to the other insurance companies
for recovery. TDH will also provide an insurance company data
file which contains the name and address of each insurance
company.
10.9.8 TDH will provide a diagnosis file which will give the code and
description of each diagnosis permitted by TDH.
10.9.9 TDH will provide a procedure file which contains the
procedures which must be used on all claims and encounters.
This file contains HCPCS, revenue, and ICD9-CM surgical
procedure codes.
10.9.10 TDH will provide a provider file that will contain the
Medicaid provider numbers, name, and address of each Medicaid
provider. The Medicaid number authorized by TDH will be
submitted on all claims, encounters, and network provider
submissions.
10.10 TPR SUBSYSTEM
HMO's third party recovery system must have the following
capabilities and capacities:
(1) Identify, store, and use other health coverage
available to eligible Members or third party
liability (TPL) including type of coverage and
effective dates.
(2) Provide changes in information to TDH as specified by
TDH.
(3) Receive TPL data from TDH to be used in claim and
encounter processing.
10.11 YEAR 2000 COMPLIANCE
HMO must take all appropriate measures to make all software
which will record, store, and process and present calendar
dates falling on or after January 1, 2000,
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perform in the same manner and with the same functionality,
data integrity and performance, as dates falling on or before
December 31, 1999, at no added cost to TDH. HMO must take all
appropriate measures to ensure that the software will not
lose, alter or destroy records containing dates falling on or
after January 1, 2000. HMO will ensure that all software will
interface and operate with all TDH, or its agent's, data
systems which exchange data, including but not limited to
historical and archived data. In addition, HMO guarantees
that the year 2000 leap year calculations will be accommodated
and will not result in software, firmware or hardware
failures.
ARTICLE XI QUALITY ASSURANCE AND QUALITY IMPROVEMENT PROGRAM
11.1 QUALITY IMPROVEMENT PROGRAM (QIP) SYSTEM
HMO must develop, maintain, and operate a Quality Improvement
Program (QIP) system which complies with federal regulations
relating to Quality Assurance systems, found at 42 C.F.R.
Section 434.34. The system must meet the Standards for
Quality Improvement Programs contained in Appendix A.
11.2 WRITTEN QIP PLAN
HMO must have an approved plan describing its Quality
Improvement Plan (QIP), including how HMO will accomplish the
activities pertaining to each Standard (I-XVI) in Appendix A
on file with TDH.
11.3 QIP SUBCONTRACTING
If HMO subcontracts any of the essential functions or
reporting requirements of QIP to another entity, HMO must
submit a list of the subcontractors and a description of how
the Subcontractor will meet the standards and reporting
requirements of this contract 60 days prior to the
Implementation Date. HMO must notify TDH no later than 90
days prior to terminating any subcontract affecting a major
performance function of this contract (see Article 3.2).
11.4 ACCREDITATION
If HMO is accredited by an external accrediting agency,
documentation of accreditation must be provided to TDH. HMO
must provide TDH with their accreditation status upon request.
11.5 BEHAVIORAL HEALTH INTEGRATION INTO QIP
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HMO must integrate behavioral health into its QIP system and
include a systematic and on-going process for monitoring,
evaluating, and improving the quality and appropriateness of
behavioral health services provided to Members. HMO's QIP
must enable HMO to collect data, monitor and evaluate for
improvements to physical health outcomes resulting from
behavioral health integration into the overall care of the
Member.
11.6 QIP REPORTING REQUIREMENTS
HMO must meet all of the QIP Reporting Requirements contained
in Article XII.
ARTICLE XII REPORTING REQUIREMENTS
12.1 FINANCIAL REPORTS
12.1.1 Monthly MCFS Report. HMO must submit the Managed Care
Financial Statistical Report (MCFS) included in Appendix I as
may be modified or amended by TDH. The report must be
submitted to TDH 30 days after the end of each state fiscal
year quarter and must include complete financial and
statistical information for each month. The MCFS Report must
be submitted for each claims processing subcontractor in
accordance with this Article. HMO must incorporate financial
and statistical data received by its provider networks (IPAs,
ANHCs, Limited Provider Networks) in its MCFS Report.
12.1.2 For any given month in which an HMO has a net loss of $200,000
or more for the contract period to date, HMO must submit an
MCFS Report for that month by the 30th day after the end of
the reporting month. The MCFS Report must be completed in
accordance with the Instructions for Completion of the Managed
Care Financial-Statistical Report developed by TDH.
12.1.3 An HMO must submit monthly reports for each of the first 6
months following the Implementation Date of the contract
between TDH and HMO. If the cumulative net loss for the
contract period to date after the 6th month is less than
$200,000, HMO may submit quarterly reports in accordance with
the above provisions unless conditions 12.1.2 or 12.1.3 exist,
in which case monthly reports must be submitted.
12.1.4 Annual MCFS Report. HMO must file two annual Managed Care
Financial Statistical Reports. The first annual report must
reflect expenses incurred through the 90th day after the end
of the contract year. The first annual report must be filed
on or before the 120th day after the end of the contract year.
The second annual report must reflect data completed through
the 334th day after the end of the contract year and must be
filed on or before the 365th day following the end of the
contract year.
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12.1.5 Administrative expenses reported in the monthly and annual
MCFS Reports must be reported in accordance with Appendix L,
Cost Principles for Administrative Expenses. Indirect
administrative expenses must be based on an allocation
methodology for Medicaid managed care activities and services
that is developed or approved by TDH.
12.1.6 Affiliated Related Parties Report. HMO must submit an
Affiliated Related Parties Report to TDH not later than 90
days prior to the Implementation Date. The report must
contain the following information:
12.1.6.1 A listing of all Affiliates/Related parties;
12.1.6.2 A schedule of all transactions with Affiliates which, under
the provisions of this Contract, will be allowable as expenses
in either Line 4 or Line 5 of Part 1 of the MCFS Report for
services provided to HMO by the Affiliate, including financial
terms, a detailed description of the services to be provided
and an estimated amount which will be incurred by HMO for such
services during the Contract period for the prior approval of
TDH.
12.1.7 Annual Audited Financial Report. On or before June 30th of
each year, HMO must submit to TDH a copy of the annual audited
financial report filed with TDI.
12.1.8 Form HCFA-1513. HMO must file an updated Form HCFA-1513
regarding control, ownership, or affiliation of HMO 30 days
prior to the end of the contract year. An updated Form
HCFA-1513 must also be filed within 30 days of any change in
control, ownership, or affiliation of HMO. Forms may be
obtained from TDH.
12.1.9 Section 1318 Financial Disclosure Report. HMO must file an
updated HCFA Public Health Service (PHS) "Section 1318
Financial Disclosure Report" within 30 days from the end of
the contract year and within 30 days of entering into,
renewing, or terminating a relationship with an affiliated
party. These forms may be obtained from TDH.
12.1.10 TDI Examination Report. HMO must furnish a copy of any TDI
Examination Report within 10 days after receipt from TDI.
12.1.11 IBNR Plan. HMO must furnish a written IBNR Plan to manage
incurred-but-not-reported (IBNR) expenses, and a description
of the method of insuring against insolvency, including
information on all existing or proposed insurance policies.
The Plan must include the methodology for estimating IBNR.
The plan and description must be submitted to TDH not later
than 60 days prior to the Implementation Date of this
contract.
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12.1.12 Third Party Recovery (TPR) Reports. HMO must file quarterly
Third Party Recovery (TPR) Reports in accordance with the
format developed by TDH. TPR reports must include total
dollars recovered from third party payers for services to
HMO's Members for each month and the total dollars recovered
through coordination of benefits, subrogation, and worker's
compensation.
12.1.13 Pre-implementation Expenses. Pre-implementation expenses
(i.e., expenses incurred between the effective date of the
contract and the Implementation Date) will be allowable
expenses as determined by TDH. Such expenses must be reported
for each month in which the expenses were incurred. Such
expenses shall be counted toward the calculation of total
expenses for the first contract year for purposes of
calculating the net income before taxes. Such expenses shall
not be allocated or amortized beyond the first contract year.
12.1.14 Each report required under this Article must be mailed to:
Bureau of Managed Care; Texas Dept. of Health; 0000 Xxxx 00xx
Xxxxxx; Xxxxxx, XX 00000-0000. HMO must also mail a copy of
the reports, except for items in Article 12.1.7 and Article
12.1.10, to Texas Department of Insurance, Mail Code 106-3A,
HMO Division, Attention: HMO Division Director, X.X. Xxx
000000, Xxxxxx, XX 00000-0000.
12.2 STATISTICAL REPORTS
12.2.1 HMO must electronically file the following monthly reports:
(1) encounter; (2) encounter detail; (3) institutional; (4)
institutional detail; and (5) claims detail for cost-
reimbursed services filed, if any, with HMO. Monthly reports
must be submitted by the 10th day following the end of the
reporting month. Encounter data must include the data
elements, follow the format, and use the transmission method
specified by TDH.
12.2.2 Monthly reports must include current month encounter data and
encounter data adjustments to the previous month's data.
12.2.3 Data quality standards will be developed jointly by HMO and
TDH. Encounter data must meet or exceed data quality
standards. Data that does not meet quality standards must be
corrected and returned within the period specified by TDH.
Original records must be made available to validate all
encounter data.
12.2.4 HMO must require providers to submit claims and encounter data
to HMO within 95 days from the date services are provided.
12.2.5 HMO must use the procedure codes, diagnosis codes and other
codes contained in the most recent edition of the Texas
Medicaid Provider Procedures Manual and as otherwise provided
by TDH. Exceptions or additional codes must be submitted for
approval before HMO uses the codes.
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12.2.6 HMO must use Medicaid provider numbers on all encounter and
fee-for-service claim submissions. Any exceptions must be
approved by TDH.
12.2.7 Claims Aging and Summary Report. HMO must submit the monthly
Claims Aging and Summary Reports identified in the Texas
Managed Care Claims Manual by the third Monday of the month
following the reporting period. The reports must be submitted
to TDH in a format using the instructions specified by TDH.
12.2.8 HMO must validate all encounter data using the encounter data
validation methodology prescribed by TDH prior to submission
of encounter data to TDH.
12.2.9 Medicaid Disproportionate Share Hospital (DSH) Reports. HMO
must file preliminary and final Medicaid Disproportionate
Share Hospital (DSH) reports, required by TDH to identify and
reimburse hospitals that qualify for Medicaid DSH funds. The
preliminary and final DSH reports must include the data
elements and be submitted in the form and format specified by
TDH. The preliminary DSH reports are due on or before June 1
of the year following the state fiscal year for which data is
being reported. The final DSH reports are due on or before
August 15 of the year following the state fiscal year for
which data is being reported.
12.3 ARBITRATION/LITIGATION CLAIMS REPORT
HMO must submit a monthly Arbitration/Litigation Claims Report
in a form developed by TDH identifying all provider complaints
that are in arbitration or litigation. The report is to be
submitted by the last working day of the month following the
reporting month.
12.4 SUMMARY REPORT OF PROVIDER COMPLAINTS
HMO must submit a Summary Report of Provider Complaints. The
report must include a copy of any complaints submitted to
either HMO or an arbitrator, or both. The report must also
include a copy of the provider complaint log. HMO must also
report complaints submitted to its subcontracted risk groups
(e.g., IPAs). The report must be submitted on or before the
fifteenth of the month following the end of the state fiscal
quarter using a form specified by TDH.
12.5 PROVIDER NETWORK REPORTS
12.5.1 Provider Network Change Reports. HMO must submit a monthly
report summarizing changes in HMO's provider network. The
report must be submitted to TDH in the format specified by
TDH. HMO will submit the report thirty (30) days following the
end of the reporting month. The report must identify provider
additions and deletions and the impact to the following:
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(1) geographic access for the Members;
(2) cultural and linguistic services;
(3) the ethnic composition of providers;
(4) the number of Member assigned to PCPs;
(5) the change in the ratio of providers with pediatric
experience to the number of Members under age 21; and
(6) number of specialists serving as PCPs.
12.5.1.1 Provider Termination Report. HMO must also include in the
Provider Network Change Report information identifying any
providers who cease to participate in HMO's provider network,
either voluntarily or involuntarily. The information must
include the provider's name, Medicaid number, the reason for
the provider's termination, and whether the termination was
voluntary or involuntary.
12.5.2 PCP Network and Capacity Report. HMO must submit
electronically to Enrollment Broker a weekly report that shows
changes to the PCP network and PCP capacity.
12.6 MEMBER COMPLAINTS
HMO must submit a quarterly summary report of Member
complaints. The report must show the date upon which each
complaint was filed, a summary of the facts surrounding the
complaint, the date of the resolution of the complaint, an
explanation of the procedure followed, and the outcome of the
complaint process. It should also include the Member Advocate
Report (refer to Article 8.6.17). The complaint report format
must be approved by TDH and submitted in hard copy and
diskette. HMO must also report complaints submitted to its
subcontracted risk groups (e.g., IPAs).
12.7 FRAUDULENT PRACTICES
HMO must report all fraud and abuse enforcement actions or
investigations taken against HMO and/or any of its
Subcontractors or providers by any state or federal agency for
fraud or abuse under Title XVIII or Title XIX of the Social
Security Act or any State law or regulation and any basis upon
which an action for fraud or abuse may be brought by a State
or federal agency as soon as such information comes to the
attention of HMO.
12.8 UTILIZATION MANAGEMENT REPORTS - BEHAVIORAL HEALTH
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HMO will be required to report behavioral health (BH)
utilization information in a format specified by TDH on a
quarterly basis. This report is due 120 days following the
end of the State Fiscal Quarter. The utilization report
instructions may periodically be updated by TDH to include new
codes and to facilitate clear communication to the health
plan.
12.9 UTILIZATION MANAGEMENT REPORTS - PHYSICAL HEALTH
Physical health (PH) utilization management reports are
required on a quarterly basis and are due 120 days following
the end of the State Fiscal Quarter and are to be provided in
hard copy and in a format specified by TDH. Refer to Appendix
J for the standardized reporting format for each report and
detailed instructions for obtaining specific data required in
the report. The PH Utilization Management Report instructions
may periodically be updated by TDH to include new codes and to
facilitate clear communication to the health plan.
12.10 QUALITY IMPROVEMENT REPORTS
12.10.1 HMO must conduct focused health studies in pregnancy and
prenatal care, THSteps, asthma (or another chronic disease as
required by TDH). HMO will be required to conduct no more
than two focused studies, as instructed by TDH. These studies
shall be conducted and data collected using criteria and
methods developed by TDH. The following format shall be
utilized:
(1) Executive Summary.
(2) Definition of the population and health areas of
concern.
(3) Clinical guidelines/standards, quality indicators,
and audit tools.
(4) Sources of information and data collection
methodology.
(5) Data analysis and information/results.
(6) Corrective actions if any, implementation, and follow
up plans including monitoring, assessment of
effectiveness, and methods for provider feedback.
12.10.2 Annual Focus Studies. Focus studies on well child, asthma and
ADHD must be submitted to TDH no later than March 1, 2000.
Focus studies on pregnancy and substance abuse in pregnancy
must be submitted no later than June 1, 2000.
12.10.3 Annual QIP Summary Report. An annual QIP summary report must
be conducted yearly based on the state fiscal year. The
annual QIP summary report must be
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submitted by December 31 of each year. This report must
provide summary information on HMO's QIP system and include
the following:
(1) Executive summary of QIP - include results of all QI
reports and interventions.
(2) Activities pertaining to each standard (I through
XVI) in Appendix A. Report must list each standard.
(3) Methodologies for collecting, assessing data and
measuring outcomes.
(4) Tracking and monitoring quality of care.
(5) Role of health professionals in QIP review.
(6) Methodology for collection data and providing
feedback to provider and staff.
(7) Outcomes and/or action plan.
12.10.4 HMO must submit an annual provider medical record audit of its
PCPs that conform to the medical record requirements found in
Standard XII in Appendix A.
12.10.4.1 HMO must submit a written plan for correcting the
noncompliance (<80% compliance rate) and a time line for
achieving compliance if audits reveal noncompliance with TDH
medical records standards.
12.10.5 HMO must submit to TDH semi-annual reports on its subspecialty
network.
12.11 HUB REPORTS
HMO must submit quarterly reports documenting HMO's HUB
program efforts and accomplishments. The report must include a
narrative description of HMO's program efforts and a financial
report reflecting payments made to HUB. HMO must use the
format included in Appendix B for HUB quarterly reports.
12.12 THSTEPS REPORTS
Minimum reporting requirements. HMO must submit, at a
minimum, 80% of all THSteps checkups on HCFA 1500 claim forms
as part of the encounter file submission to the TDH Claims
Administrator within 120 days from the date of service.
Failure to comply with these minimum reporting requirements
will result in Article XVIII sanctions and money damages.
12.13 REPORTING REQUIREMENTS DUE DATES
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TDH will provide HMO with a matrix of all contract
deliverables with due dates. The due dates for deliverables
may be changed by TDH. TDH will provide HMO with 30 days
notice of any deliverable due date change.
ARTICLE XIII PAYMENT PROVISIONS
13.1 CAPITATION AMOUNTS
13.1.1 TDH will pay HMO monthly premiums calculated by multiplying
the number of Member months by Member risk group times the
monthly capitation amount by Member risk group. HMO and
network providers are prohibited from billing or collecting
any amount from a Member for health care services covered by
this contract, in which case the Member must be informed of
such costs prior to providing non-covered services.
13.1.2 Delivery Supplemental Payment (DSP). TDH has submitted the
delivery supplemental payment methodology to HCFA for
approval. THE MONTHLY CAPITATION AMOUNTS FOR SEPTEMBER 1,
1999, THROUGH AUGUST 31, 2000 AND THE DSP AMOUNT ARE LISTED
BELOW. THESE AMOUNTS ARE EFFECTIVE SEPTEMBER 1, 1999. THE
MONTHLY CAPITATION AMOUNTS ESTABLISHED FOR EACH RISK GROUP IN
THE DALLAS SERVICE AREA USING THE STANDARD METHODOLOGY (LISTED
IN ARTICLE 13.1.3) WILL APPLY IF THE DSP METHODOLOGY IS NOT
APPROVED BY HCFA.
------------------------------------------------------------------------------
RISK GROUP MONTHLY CAPITATION AMOUNTS
SEPTEMBER 1, 1999 - AUGUST 31, 2000
------------------------------------------------------------------------------
TANF ADULTS $131.03
------------------------------------------------------------------------------
TANF CHILDREN > 12 $57.99
MONTHS OF AGE -
------------------------------------------------------------------------------
EXPANSION CHILDREN > 12 $136.81
MONTHS OF AGE
------------------------------------------------------------------------------
NEWBORNS (< 12 MONTHS OF $276.74
AGE) -
------------------------------------------------------------------------------
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------------------------------------------------------------------------------
TANF CHILDREN < 12 $276.74
MONTHS OF AGE -
------------------------------------------------------------------------------
EXPANSION CHILDREN < 12 $276.74
MONTHS OF AGE -
------------------------------------------------------------------------------
FEDERAL MANDATE CHILDREN $55.40
------------------------------------------------------------------------------
CHIP PHASE 1 $94.27
------------------------------------------------------------------------------
PREGNANT WOMEN $232.66
------------------------------------------------------------------------------
DISABLED/BLIND $14.00
ADMINISTRATION
------------------------------------------------------------------------------
DELIVERY SUPPLEMENTAL PAYMENT: A ONE-TIME PER PREGNANCY
SUPPLEMENTAL PAYMENT FOR EACH DELIVERY SHALL BE PAID TO HMO AS
PROVIDED BELOW IN THE FOLLOWING AMOUNT: $3,076.23.
13.1.2.1 HMO will receive a DSP for each live or still birth. The
one-time payment is made regardless of whether there is a
single or multiple births at time of delivery. A delivery is
the birth of a liveborn infant, regardless of the duration of
the pregnancy or, a stillborn (fetal death) infant of 20 weeks
or more gestation. A delivery does not include a spontaneous
or induced abortion, regardless of the duration of the
pregnancy.
13.1.2.2 For an HMO Member who is classified in the Pregnant Women,
TANF Adults, or TANF CHILDREN > 12 MONTHS, EXPANSION CHILDREN
>12 MONTHS, FEDERAL MANDATE CHILDREN, OR CHIP risk group, HMO
will be paid the monthly capitation amount identified in
section 13.1.2 for each month of classification, plus the DSP
amount identified in Article 13.1.2.
13.1.2.3 HMO must submit a MONTHLY DSP Report (report) that includes
the data elements specified by TDH TDH will consult with
contracted HMOs prior to revising the report data elements and
requirements. The reports must be submitted to TDH in the
format and time specified by TDH. The report must include
only unduplicated deliveries. The report must include only
deliveries for which HMO has made a payment for the delivery,
to either a hospital or other provider. No DSP will be made
for deliveries which are not reported BY HMO TO TDH within 210
days AFTER the date of delivery, or WITHIN
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30 DAYS FROM THE DATE OF discharge from the hospital FOR THE
STAY RELATED TO THE DELIVERY, whichever is later.
13.1.2.4 HMO must maintain complete claims and adjudication disposition
documentation, including paid and denied amounts for each
delivery. HMO must submit the documentation to TDH within
five (5) days from the date of a TDH request for documents.
13.1.2.5 The DSP will be made by TDH to HMO within TWENTY (20) STATE
WORKING days after receiving an accurate report from HMO.
13.1.2.6 All infants of age equal to or less than twelve months
(Newborns) IN THE TANF CHILDREN, EXPANSION CHILDREN, AND
NEWBORNS RISK GROUPS will be capitated at the Newborns
classification capitation amount in paragraph 13.1.2
13.1.3 Standard Methodology. If the DSP methodology is not approved
by HCFA, the monthly capitation amounts established for each
risk group in the Dallas Service Area using the methodology
set forth in 13.1.1, without the DSP, are as follows:
--------------------------------------------------------------------------
RISK GROUP MONTHLY CAPITATION AMOUNTS
SEPTEMBER 1, 1999 - AUGUST 31, 2000
--------------------------------------------------------------------------
TANF ADULTS $155.91
--------------------------------------------------------------------------
TANF CHILDREN $68.09
--------------------------------------------------------------------------
EXPANSION CHILDREN $136.73
--------------------------------------------------------------------------
NEWBORNS $322.45
--------------------------------------------------------------------------
FEDERAL MANDATE CHILDREN $55.72
--------------------------------------------------------------------------
CHIP PHASE 1 $99.35
--------------------------------------------------------------------------
PREGNANT WOMEN $646.38
--------------------------------------------------------------------------
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--------------------------------------------------------------------------
DISABLED/BLIND ADMINISTRATION $14.00
--------------------------------------------------------------------------
13.1.4 The monthly premium payment to HMO is based on monthly
enrollments adjusted to reflect money damages set out in
Article 18.8 and adjustments to premiums in Article 13.5.
13.1.5 The monthly premium payments will be made to HMO no later than
the 10th working day of the month for which premiums are paid.
HMO must accept payment for premiums by direct deposit into an
HMO account.
13.1.6 Payment of monthly capitation amounts is subject to
availability of appropriations. If appropriations are not
available to pay the full monthly capitation amounts, TDH will
equitably adjust capitation amounts for all participating
HMOs, and reduce scope of service requirements as appropriate.
13.2 EXPERIENCE REBATE TO STATE
13.2.1 HMO must pay to TDH an experience rebate equal to fifty
percent (50%) of the excess of allowable HMO STAR revenues
over allowable HMO STAR expenses as measured by any positive
amount on Line 7 of "Part 1: Financial Summary, All Coverage
Groups Combined" of the annual Managed Care Financial
Statistical Report set forth in Appendix I, as audited and
confirmed by TDH.
13.2.2 There will be two settlements for payment of the experience
rebate. The first settlement shall equal 100 percent of the
experience rebate as derived from Line 7 of Part 1 (Net Income
Before Taxes) of the annual Managed Care Financial Statistical
(MCFS) Report. The second settlement shall be an adjustment to
the first settlement and shall be paid to TDH on the same day
that the second annual MCFS Report is submitted to TDH if the
adjustment is a payment from HMO to TDH. TDH or its agent may
audit or review the MCFS reports. If TDH determines that
corrections to the MCFS reports are required, based on a TDH
audit/review or other documentation acceptable to TDH, to
determine an adjustment to the amount of the second
settlement, then final adjustment shall be made within two
years from the date that HMO submits the second annual MCFS
report. HMO must pay the first and second settlements on the
due dates for the first and second MCFS reports respectively
as identified in Article 12.1.5. TDH may adjust the
experience rebate if TDH determines HMO has paid affiliates
amounts for goods or services that are higher than the fair
market value of the goods and services in the service area.
Fair market value may be based on the amount HMO pays a
non-affiliate(s) or the amount another HMO pays for the same
or similar service in the service area. TDH will have final
authority in assessing the amount of the experience rebate.
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13.3 PERFORMANCE OBJECTIVES
13.3.1 Preventive Health Performance Objectives are contained in this
contract at Appendix K. HMO must accomplish the performance
objectives or a designated percentage in order to be eligible
for payment of financial incentives. Performance objectives
are subject to change. TDH will consult with HMO prior to
revising performance objectives.
13.3.2 HMO will receive credit for accomplishing a performance
objective upon receipt of accurate encounter data required
under paragraphs 10.5 and 12.2 of this contract and/or a
Detailed Data Element Report from HMO with report format as
determined by TDH and aggregate data reported by HMO in
accordance with a report format as determined by TDH
(Performance Objectives Report). Accuracy and completeness of
the detailed data element report and the aggregate data
Performance Objectives Report will be determined by TDH
through a TDH audit of HMO claims processing system. If TDH
determines that the Detailed Data Element Report and
Performance Objectives Report are sufficiently supported by
the results of the TDH audit, the payment of financial
incentives will be made to HMO. Conversely, if the audit
results do not support the reports as determined by TDH, HMO
will not receive payment of the financial incentive. TDH may
conduct provider chart reviews to validate the accuracy of the
claims data related to HMO accomplishment of performance
objectives. If the results of the chart review do not support
HMO claims system data or HMO Detailed Data Element Report and
the Performance Objectives Report, TDH may recoup payments
made to HMO for performance objectives incentives.
13.3.3 HMO will also receive credit for performance objectives
performed by other organizations if a network primary care
provider or HMO retains documentation from the performing
organization which satisfies the requirements contained in
Appendix K of this contract.
13.3.4 HMO will receive performance objective bonuses for
accomplishing the following percentages of performance
objectives:
----------------------------------------------------------------------------
Percent of Each Performance Percent of Performance Objective
Objective Accomplished Allocations Paid to HMO
----------------------------------------------------------------------------
60% to 65% 20%
----------------------------------------------------------------------------
65% to 70% 30%
----------------------------------------------------------------------------
70% to 75% 40%
----------------------------------------------------------------------------
75% to 80% 50%
----------------------------------------------------------------------------
80% to 85% 60%
----------------------------------------------------------------------------
85% to 90% 70%
----------------------------------------------------------------------------
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----------------------------------------------------------------------------
90% to 95% 80%
----------------------------------------------------------------------------
95% to 100% 90%
----------------------------------------------------------------------------
100% 100%
----------------------------------------------------------------------------
13.3.5 HMO must submit the Detailed Data Element Report and the
Performance Objectives Report regardless of whether or not HMO
intends to claim payment of performance objective bonuses.
13.4 PAYMENT OF PERFORMANCE OBJECTIVE BONUSES
13.4.1 Payment of performance objective bonus is contingent upon
availability of appropriations. If appropriations are not
available to pay performance objective bonuses as set out below,
TDH will equitably distribute all available funds to each HMO
that has accomplished the performance objectives.
13.4.2 In addition to the capitation amounts set forth in Article
13.1.2, a performance premium of two dollars ($2.00) per Member
month will be allocated by TDH for the accomplishment of
performance objectives.
13.4.3 HMO must submit the Performance Objectives Report and the
Detailed Data Element Report as referenced in Article 13.3.2,
within 150 days from the end of each State fiscal year.
Performance premiums will be paid to HMO within 120 days after
the State receives and validates the data contained in each
required Performance Objectives Report.
13.4.4 The performance objective allocation for HMO shall be assigned
to each performance objective, described in Appendix K, in
accordance with the following percentages:
-------------------------------------------------------------------------
EPSDT SCREENS PERCENT OF PERFORMANCE
OBJECTIVE INCENTIVE FUND
-------------------------------------------------------------------------
1. <12 months 7%
-------------------------------------------------------------------------
2. 12 to 24 months 7%
-------------------------------------------------------------------------
3. 25 months - 20 years 19%
-------------------------------------------------------------------------
4. <12 months = 3.8 screens 21%
-------------------------------------------------------------------------
5. 12 to 24 months = 2.8 screens 14%
-------------------------------------------------------------------------
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-------------------------------------------------------------------------
IMMUNIZATIONS PERCENT OF PERFORMANCE
OBJECTIVE INCENTIVE FUND
-------------------------------------------------------------------------
6. <12 months 6%
-------------------------------------------------------------------------
7. 12 to 24 months 3%
-------------------------------------------------------------------------
-------------------------------------------------------------------------
ADULT ANNUAL VISITS Percent of Performance
Objective Incentive Fund
-------------------------------------------------------------------------
8. Adult Annual Visits 2%
-------------------------------------------------------------------------
-------------------------------------------------------------------------
PREGNANCY VISITS Percent of Performance
Objective Incentive Fund
-------------------------------------------------------------------------
9. Initial prenatal exam 6%
-------------------------------------------------------------------------
10. Visits by Gestational Age 10%
-------------------------------------------------------------------------
11. Postpartum visit 5%
-------------------------------------------------------------------------
13.5 ADJUSTMENTS TO PREMIUM
13.5.1 TDH may recoup premiums paid to HMO in error. Error may be
either human or machine error on the part of TDH or an agent or
contractor of TDH. TDH may recoup premiums paid to HMO if a
Member is enrolled into HMO in error, and HMO provided no
covered services to Member for the period of time for which
premium was paid. If services were provided to Member as a
result of the error, recoupment will not be made.
13.5.2 TDH may recoup premium paid to HMO if a Member for whom premium
is paid moves outside the United States, and HMO has not
provided covered services to the Member for the period of time
for which premium has been paid. TDH will not recoup premium if
HMO has provided covered services to the Member during the
period of time for which premium has been paid.
13.5.3 TDH may recoup premium paid to HMO if a Member for whom premium
is paid dies before the first day of the month for which premium
is paid.
13.5.4 TDH may recoup or adjust premium paid to HMO for a Member if the
Member's eligibility status or program type is changed,
corrected as a result of error, or is retroactively adjusted.
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13.5.5 Recoupment or adjustment of premium under 13.5.1 through 13.5.4
may be appealed using the TDH dispute resolution process.
13.5.6 TDH may adjust premiums for all Members within an eligibility
status or program type if adjustment is required by reductions
in appropriations and/or if a benefit or category of benefits is
excluded or included as a covered service. Adjustment must be
made by amendment as required by Article 15.2. Adjustment to
premium under this subsection may not be appealed using the TDH
dispute resolution process.
ARTICLE XIV ELIGIBILITY, ENROLLMENT, AND DISENROLLMENT
14.1 ELIGIBILITY DETERMINATION
14.1.1 TDH will identify Medicaid recipients who are eligible for
participation in the STAR program using the eligibility status
described below.
14.1.2 Individuals in the following categories who reside in any part
of the Service Area MUST enroll in one of the health plans
providing services in the Service Areas:
14.1.2.1 TANF ADULTS - Individuals age 21 and over who are eligible for
the TANF program. This category may also include some pregnant
women.
14.1.2.2 TANF CHILDREN - Individuals under age 21 who are eligible for
the TANF program. This category may also include some pregnant
women and some children less than one year of age.
14.1.2.3 PREGNANT WOMEN receiving Medical Assistance Only (MAO) -
Pregnant women whose families' income is below 185% of the
Federal Poverty Level (FPL).
14.1.2.4 NEWBORN (MAO) - Children under age one born to Medicaid-eligible
mothers.
14.1.2.5 EXPANSION CHILDREN (MAO) - Children under age 18, ineligible for
TANF because of the applied income of their stepparents or
grandparents.
14.1.2.6 EXPANSION CHILDREN (MAO) - Children under age 1 whose families'
income is below 185% FPL.
14.1.2.7 EXPANSION CHILDREN MAO - Children age 1- 5 whose families'
income is at or below 133% of FPL.
14.1.2.8 FEDERAL MANDATE CHILDREN (MAO) - Children under age 19 born
before October 10, 1983, whose families' income is below the
TANF income limit.
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14.1.2.9 CHILDREN'S HEALTH INSURANCE PROGRAM (MAO) - Children under age
19, born on or after October 1, 1979, whose families' income is
between the medically needy standards limit and 100% FPL.
14.1.2.10 CHIP PHASE I - Children's Health Insurance Program Phase I
(Federal Mandate Acceleration) Children are children under age
nineteen (19) born before October 1, 1983, with family income
below 100% Federal Poverty Income Level.
14.1.3 The following individuals are eligible for the STAR Program and
ARE NOT required to enroll in a health plan, but have the option
to enroll in a plan. HMO will be required to accept enrollment
of those recipients from this group who elect to enroll in HMO.
14.1.3.1 DISABLED AND BLIND INDIVIDUALS WITHOUT MEDICARE - Recipients
with Supplemental Security Income (SSI) benefits who are not
eligible for Medicare may elect to participate in the STAR
program on a voluntary basis.
14.1.3.2 Certain blind or disabled individuals who lose SSI eligibility
because of Title II income and who are not eligible for
Medicare.
14.1.3.3 Non-institutionalized blind and disabled people enrolled in
1915(c) waivers whose income is above SSI limits, whose
eligibility was determined using the institutional cap (300%),
and who are not Medicare eligible. (TDH will be phasing out
this population during FY 99.)
14.1.4 During the period after which the Medicaid eligibility
determination has been made but prior to enrollment in HMO,
Members will be enrolled under the traditional Medicaid program.
All Medicaid eligible recipients will remain in the
fee-for-service Medicaid program until enrolled in or assigned
to an HMO.
14.2 ENROLLMENT
14.2.1 TDH has the right and responsibility to enroll and disenroll
eligible individuals into the STAR program. TDH will conduct
continuous open enrollment for Medicaid recipients and HMO must
accept all persons who chose to enroll as Members in HMO or who
are assigned as Members in HMO by TDH, without regard to the
Member's health status or any other factor.
14.2.2 All enrollments are subject to the accessibility and
availability limitations and restrictions contained in the
Section 1915(b) waiver obtained by TDH. TDH has the authority
to limit enrollment into HMO if the number and distance
limitations are exceeded.
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14.2.3 TDH makes no guarantees or representations to HMO regarding the
number of eligible Medicaid recipients who will ultimately be
enrolled as STAR Members of HMO.
14.2.4 HMO must cooperate and participate in all TDH sponsored and
announced enrollment activities. HMO must have a representative
at all TDH enrollment activities unless an exception is given by
TDH. The representative must comply with HMO's cultural and
linguistic competency plan (see Cultural and Linguistic
requirements in Paragraph 8.9 of this contract). HMO must
provide marketing materials, HMO pamphlets, Member handbooks, a
list of network providers, HMO's linguistic and cultural
capabilities and other information requested or required by TDH
or its Enrollment Broker to assist potential Members in making
informed choices.
14.2.5 TDH will provide HMO with at least 10 days written notice of all
TDH planned activities. Failure to participate in, or send a
representative to a TDH sponsored enrollment activity is a
default of the terms of the contract. Default may be excused if
HMO can show that TDH failed to provide the required notice, or
if HMO's absence is excused by TDH.
14.3 DISENROLLMENT
14.3.1 HMO has a limited right to request a Member be disenrolled from
HMO without the Member's consent. TDH must approve any HMO
request for disenrollment of a Member for cause. Disenrollment
of a Member may be permitted under the following circumstances:
14.3.1.1 The Member misuses or loans the Member's HMO membership card to
another person to obtain services.
14.3.1.2 The Member is disruptive, unruly, threatening or uncooperative
to the extent that the Member's membership seriously impairs
HMO's or provider's ability to provide services to the Member or
to obtain Members, and the Member's behavior is not caused by a
physical or behavioral health condition.
14.3.1.3 The Member steadfastly refuses to comply with managed care, such
as repeated emergency room use combined with refusal to allow
HMO to treat the underlying medical condition.
14.3.2 HMO must take reasonable measures to correct Member behavior
prior to requesting disenrollment. Reasonable measures may
include providing education and counseling regarding the
offensive acts or behaviors.
14.3.3 HMO must notify the Member of HMO's decision to disenroll the
Member if all reasonable measures have failed to remedy the
problem.
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14.3.4 If the Member disagrees with the decision to disenroll the
Member from HMO, HMO must notify the Member of the availability
of the complaint procedure and TDH's fair hearing process.
14.3.5 HMO CANNOT REQUEST A DISENROLLMENT BASED ON ADVERSE CHANGE IN
THE MEMBER'S HEALTH STATUS OR UTILIZATION OF SERVICES WHICH ARE
MEDICALLY NECESSARY FOR TREATMENT OF A MEMBER'S CONDITION.
14.4 AUTOMATIC RE-ENROLLMENT
14.4.1 Members who are disenrolled because they are temporarily
ineligible for Medicaid will be automatically re-enrolled into
the same health plan. Temporary loss of eligibility is defined
as a period of 3 months or less.
14.4.2 HMO must inform its Members of the automatic re-enrollment
procedure. Automatic re- enrollment must be included in the
Member Handbook (See Article 8.2.1).
14.5 ENROLLMENT REPORTS
14.5.1 TDH will provide HMO enrollment reports listing all STAR Members
who have enrolled in or were assigned to HMO during the initial
enrollment period.
14.5.2 TDH will provide monthly HMO Enrollment Reports to HMO on or
before the first of the month.
14.5.3 TDH will provide Member verification to HMO and network
providers through telephone verification or TexMedNet.
ARTICLE XV GENERAL PROVISIONS
15.1 INDEPENDENT CONTRACTOR
HMO, its agents, employees, network providers and subcontractors
are independent contractors, and do not perform services under
this contract as employees or agents of TDH. HMO is given
express, limited authority to exercise the State's right of
recovery as provided in 4.9.
15.2 AMENDMENT
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15.2.1 This contract must be amended by TDH if amendment is required to
comply with changes in state or federal laws, rules, or
regulations.
15.2.2 TDH and HMO may amend this contract if reductions in funding or
appropriations make full performance of either party
impracticable or impossible, and amendment could provide a
reasonable alternative to termination. If HMO does not agree to
the amendment, contract may be terminated under Article XVIII.
15.2.3 This contract must be amended if either party discovers a
material omission of a negotiated or required term, which is
essential to the successful performance or maintaining
compliance with the terms of the contract. The party
discovering the omission must notify the other party of the
omission in writing as soon as possible after discovery. If
there is a disagreement regarding whether the omission was
intended to be a term of the contract, the parties must submit
the dispute to dispute resolution under paragraph 15.8 of this
contract.
15.2.4 This contract may be amended by mutual agreement at any time.
15.2.5 All amendments to this contract must be in writing and signed by
both parties.
15.2.6 No agreement shall be used to amend this contract unless it is
made a part of this contract by specific reference, and is
numbered sequentially by order of its adoption.
15.3 LAW, JURISDICTION AND VENUE
Venue and jurisdiction shall be in the state and federal
district courts of Xxxxxx County, Texas. The laws of the State
of Texas shall be applied in all matters of state law.
15.4 NON-WAIVER
Failure to enforce any provision or breach shall not be taken by
either party as a waiver of the right to enforce the provision
or breach in the future.
15.5 SEVERABILITY
Any part of this contract which is found to be unenforceable,
invalid, void, or illegal shall be severed from the contract.
The remainder of the contract shall be effective.
15.6 ASSIGNMENT
This contract was awarded to HMO based on HMO's qualifications
to perform personal and professional services. HMO cannot
assign this contract without the written consent of TDI and TDH.
This provision does not prevent HMO from
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subcontracting duties and responsibilities to qualified
subcontractors. All subcontracts, which would affect the
delivery of medical care or services to TDH STAR Health Plan
Members, must be approved by TDH.
15.7 NON-EXCLUSIVE
This contract is a non-exclusive agreement. Either party may
contract with other entities for similar services in the same
service area.
15.8 DISPUTE RESOLUTION
All disputes arising under this contract shall be resolved
through TDH's dispute resolution procedures, except where a
remedy is provided for through TDH's administrative rules or
processes. All administrative remedies must be exhausted prior
to other methods of dispute resolution.
15.9 DOCUMENTS CONSTITUTING CONTRACT
This contract includes this document and all amendments and
appendices to this document, the Request for Application, the
Application submitted in response to the Request for
Application, the Texas Medicaid Provider Procedures Manual and
Texas Medicaid Bulletins addressed to HMOs, contract
interpretation memoranda issued by TDH for this contract, and
the federal waiver granting TDH authority to contract with HMO.
If any conflict in provisions between these documents occurs,
the terms of this contract and any amendments shall prevail.
The documents listed above constitute the entire contract
between the parties.
15.10 FORCE MAJEURE
TDH and HMO are excused from performing the duties and
obligations under this contract for any period that they are
prevented from performing their services as a result of a
catastrophic occurrence, or natural disaster, clearly beyond the
control of either party, including but not limited to an act of
war, but excluding labor disputes.
15.11 NOTICES
Notice may be given by any means which provides for verification
of receipt. All notices to TDH shall be addressed to Bureau
Chief, Texas Department of Health, Bureau of Managed Care, 0000
X. 00xx Xxxxxx, Xxxxxx, XX 00000-0000, with a copy to the
Contract Administrator. Notices to HMO shall be addressed to
CEO/President,
AMERICAID Texas, Inc.
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000 Xxxxxxx Xxxxxx, 2nd Floor
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Xxxx Xxxxx, XX 00000
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15.12 SURVIVAL
The provisions of this contract which relate to the obligations
of HMO to maintain records and reports shall survive the
expiration or earlier termination of this contract for a period
not to exceed six (6) years unless another period may be
required by record retention policies of the State of Texas or
HCFA.
ARTICLE XVI DEFAULT
16.1 FAILURE TO PROVIDE COVERED SERVICES
If a member requests a fair hearing before the department
because the HMO has failed to provide a covered service, the
Bureau of Managed Care may recommend to the hearing officer that
a determination be made to impose sanctions upon the HMO, in
addition to any remedy entered for an on behalf of the Member.
The recommendation to impose sanctions must include an amount of
recommended sanctions. The amount of the sanction may be in any
amount of not less than $1000 or more than $25,000 depending
upon the nature of the denial and the hardship or health threat
that the denial placed upon the Member.
16.2 FAILURE TO PERFORM AN ADMINISTRATIVE FUNCTION
Failure of HMO to perform an administrative function is a
default under this contract. Administrative functions are any
requirements under this contract which are not direct delivery
of health or health-related services, including claims payment,
encounter date submission, filing any report when due, providing
or producing records upon request or failing to enter into
contracts or implementing procedures necessary to carry out
contract obligations.
16.3 HMO CERTIFICATE OF AUTHORITY
Termination or suspension of HMO's TDI Certificate of Authority
or any adverse action taken by TDI which TDH determines will
affect the ability of HMO to provide health care services to
Members is a default under this contract.
16.4 INSOLVENCY
Failure of HMO to maintain against fiscal insolvency as required
under State or federal law or incapacity of HMO to meet its
financial obligation as they come due is a default under this
contract.
16.5 FAILURE TO COMPLY WITH FEDERAL LAWS AND REGULATIONS
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Xxxxxxx xx XXX to comply with the federal requirements for
Medicaid, or by incorporation, Medicare standards, requirements,
or prohibitions, is a default of this contract.
16.6 EXCLUSION FROM PARTICIPATION IN MEDICARE OR MEDICAID
16.6.1 Exclusion of HMO or any of the managing employees or persons
with an ownership interest whose disclosure is required by
Section 1124(a) of the Social Security Act (the Act), under the
provisions of Section 1128(a) and/or (b) of the Act, is a
default of this contract.
16.6.2 Exclusion of any provider or Subcontractor or any of the
managing employees or persons with an ownership interest of the
provider or Subcontractor whose disclosure is required by
Section 1124(a) of the Social Security Act (the Act), under the
provisions of Section 1128(a) and/or (b) of the Act, is a
default of this contract if the exclusion will materially affect
HMO's performance under this contract.
16.7 MISREPRESENTATION, FRAUD OR ABUSE
Misrepresentation or fraud under the provisions of Article 4.8
of this contract is a default under this contract.
Misrepresentation or fraud and abuse under any state or federal
law, regulation or rule or under the common law of the State of
Texas, is a default under this contract.
16.8 FAILURE TO MAKE CAPITATION PAYMENTS
Failure by TDH to make capitation payments when due is a default
under this contract.
16.9 FAILURE TO MAKE PAYMENTS TO NETWORK PROVIDERS AND SUBCONTRACTORS
Failure to make timely and appropriate payments to network
providers and Subcontractors is a default under this contract.
Withholding or recouping capitation payments as allowed or
required under other Articles of this contract is not a default
under this contract.
16.10 FAILURE TO DEMONSTRATE THE ABILITY TO PERFORM CONTRACT FUNCTIONS
Failure to pass any of the mandatory system or delivery
functions of the Readiness Review required in Article I is a
default under the contract.
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16.11 FAILURE TO MONITOR AND/OR SUPERVISE ACTIVITIES OF CONTRACTORS OR
NETWORK PROVIDERS
16.11.1 Failure of HMO to audit, monitor, supervise, or enforce
functions delegated by contract to another entity which results
in a default under this contract or constitutes a violation of
state or federal laws, rules, or regulations is a default under
this contract.
16.11.2 Failure of HMO to properly credential, conduct reasonable
utilization review, and quality monitoring is a default under
this contract.
16.11.3 Failure of HMO to require providers and contractors to provide
timely and accurate encounter, financial, statistical and
utilization data is a default under this contract.
ARTICLE XVII NOTICE OF DEFAULT AND CURE OF DEFAULT
17.1 TDH will provide HMO with written notice of default under this
contract. The written notice must contain the following
information:
17.1.1 A clear and concise statement of the circumstances or conditions
which constitute a default under this contract;
17.1.2 The contract provision(s) under which default is being declared;
17.1.3 A clear and concise statement of how and/or whether the default
may be cured;
17.l.4 A clear and concise statement of the time period HMO will be
allowed to cure the default;
17.1.5 The amount of damages or the types of sanctions which are being
or will be imposed pending cure, and the date they began or will
begin;
17.l.6 Whether any part of the damages or sanctions may be equipped or
passed through to an individual or entity who is or may be
responsible for the act or omission for which default is
declared;
17.1.7 Whether failure to cure within the given time period will result
in additional damages or sanctions and/or referral for
investigation or action by another agency, and/or termination of
the contract.
17.2 Sanctions and damages for acts or omissions which are events of
default under Article XVI will be imposed from the date of
occurrence until cured, unless otherwise stated in the notice of
default.
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ARTICLE XVIII REMEDIES AND SANCTIONS
18.l TERMINATION BY TDH
18.1.1 TDH may terminate this contract if:
18.1.1.1 HMO repeatedly fails or refuses to provide services and perform
administrative functions under this contract after notice and
opportunity to cure;
18.1.1.2 HMO materially defaults under any of the provisions of Article
XVI, or;
18.1.1.3 Federal or state funds for the Medicaid program are no longer
available, or;
18.1.1.4 TDH has a reasonable belief that HMO has placed the health or
welfare of Members in jeopardy.
18.1.2 TDH must give HMO 30 days written notice of intent to terminate
this contract if termination is a result of HMO's failure to
cure a default under Article XVIII. If termination is a result
of 18.1.1.3, TDH will provide HMO with reasonable notice under
the circumstances. If termination is a result of 18.1.1.4, TDH
will give the notice required under the provisions of the
department's formal hearing procedures in 25 Texas
Administrative Code Section 1.2.1. Notice may be given by any
means that gives verification of receipt. The termination date
will be calculated as 30 days following the date that HMO
receives the notice of intent to terminate.
18.1.3 HMO must continue to perform services until the last day of the
month following 30 days from the date of receipt of notice if
the termination is a result of 18.1.1.1, 18.1.1.2, or 18.1.1.3
above. TDH may prohibit HMO's further performance of services
under the contract if the reason for termination is 18.1.1.4
above.
18.1.4 HMO may appeal the termination of this contract under the
provision of the Texas Human Resources Code, Section 32.034.
18.1.5 The remedies available to TDH set forth above are in addition to
all other remedies available to TDH by law or in equity, are
joint and several, and may be exercised concurrently or
consecutively. Exercise of any remedy in whole or in part shall
not limit TDH in exercising all or part of any remaining
remedies.
18.2 TERMINATION BY HMO
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18.2.1 HMO may terminate this contract if TDH fails to pay HMO as
required under Article XIII or otherwise materially defaults in
its duties and responsibilities under this contract. Retaining
premium, recoupment, sanctions, or penalties which are allowed
under this contract or which result from HMO's failure to
perform or a default under the terms of the contract are not
cause for termination.
18.2.2 HMO must give TDH 60 days written notice of intent to terminate
this contract. Notice may be given by any means that gives
verification of receipt. The termination date will be
calculated as the last day of the month following 60 days from
the date the notice of intent to termination is received by TDH.
18.2.3 TDH must be given 30 days to pay all amounts due. If TDH pays
all amounts then due, HMO cannot terminate the contract under
this Article.
18.2.4 This agreement may be terminated at any time and without cause
by either party, upon at least (90) days prior written notice.
During said ninety day notice period, both HMO and TDH shall use
each of their best efforts to accommodate the smooth transition
of health care services being rendered to HMO Members at time of
termination of the Agreement, as outlined in Section 18.4
18.3 TERMINATION BY MUTUAL CONSENT
This contract may be terminated at any time by mutual consent of
both HMO and TDH.
18.4 DUTIES UPON TERMINATION OF CONTRACTING PARTIES
When termination of the contract occurs, TDH and HMO must meet
the following obligations:
18.4.1 If the contract is terminated unilaterally by TDH, because of
failure of HMO to perform duties and obligations required by the
contract or by mutual consent with termination initiated by HMO:
18.4.1.1 TDH is responsible for notifying all Members of the date of
termination and how Members can continue to receive contract
services; and
18.4.1.2 HMO is responsible for all expenses related to giving notice to
Members.
18.4.2 If the contract is terminated for any reason other than those
included in 18.4.1:
18.4.2.1 TDH is responsible for notifying all Members of the date of
termination and how Members can continue to receive contract
services; and
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18.4.2.2 TDH is responsible for all expenses related to giving notice to
Members.
18.5 STATE AND FEDERAL DAMAGES, PENALTIES AND SANCTIONS
18.5.1 TDH may recommend to HCFA that sanctions be taken against HMO
for violations of 42 C.F.R. 434.67(a), relating to sanctions
against HMOs with risk comprehensive contracts. These
violations are also defaults of Article XVI of this contract.
If HCFA determines that HMO has violated one or more of these
provisions of the regulations and determines that federal
payments will be withheld, TDH will deny and withhold payments
for new enrollees of HMO.
18.5.1.1 HMO must be given notice and opportunity to appeal a decision of
TDH and HCFA as required in 42 C.F.R. 434.67(c) and (d).
18.5.1.2 HMO may be subject to civil money penalties under the provisions
of 42 C.F.R. 1003 in addition to or in place of withholding
payments under 18.5.1.
18.5.2 HMO may be subject to damages and penalties under the Human
Resources Code, Section 32.039, relating to damages and
penalties for events of default under this contract and
violations of the provisions of Section 32.039.
18.5.2.1 HMO will be given notice of the default or violation upon which
damages or penalties are based and an opportunity to appeal
under the provision of Section 32.039.
18.6 SUSPENSION OF NEW ENROLLMENT
18.6.1 TDH may suspend new enrollment into HMO for any default under
this contract.
18.6.2 TDH must give HMO 30 days written notice of intent to suspend
new enrollment other than for defaults which are imposed as a
result of fraud and abuse or imminent danger to the health or
safety of Members. Notice may be given by any means which gives
verification of receipt. The suspension date will be calculated
as 30 days following the date that HMO receives the notice of
intent to suspend new enrollment. During the 30-day notice
period, HMO will be given an opportunity to cure the defaults,
if a cure is possible.
18.6.3 TDH may immediately suspend new enrollment into HMO for a
default declared as a result of fraud and abuse or imminent
danger to the health and safety of Members or investigation,
prosecution, or suspension by an agency charged with the duty of
investigation of state and federal laws.
18.6.4 The suspension of new enrollment may be for any duration, up to
the termination date of the contract. TDH will impose a
duration of suspension based upon the type and severity of the
default and HMO's ability to cure the default.
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18.7 TDH INITIATED DISENROLLMENT
18.7.1 TDH may initiate disenrollment of a Member or reduce the total
number of Members enrolled in HMO through disenrollment if HMO
fails to provide covered services to a Member or if TDH
determines that HMO has a pattern or practice of failing to
provide covered services to Members.
18.7.2 TDH must give HMO 30 days written notice of intent to initiate
disenrollment of a Member. Notice may be given by any means
which gives verification of receipt. The TDH initiated
disenrollment date will be calculated as 30 days following the
date that HMO receives the notice of intent to disenroll. HMO
will not be given an opportunity to cure the default unless the
right to cure is expressly authorized in the notice letter.
18.7.3 TDH may continue to reduce the number of Members enrolled in HMO
until HMO demonstrates that it can and/or will provide covered
services as required under this contract.
18.8 LIQUIDATED MONEY DAMAGES - WITHHOLDING PAYMENTS
18.8.1 TDH may impose liquidated money damages in addition to other
remedies and sanctions provided under this contract. If money
damages are imposed, TDH may reduce the amount of any monthly
premium payments otherwise due to HMO by the amount of the
damages. Money damages, which are withheld, are forfeited and
will not be subsequently paid to HMO upon compliance or cure of
default, unless a determination is made after appeal that the
damages should not have been imposed.
18.8.2 Failure to perform or comply with an administrative function.
TDH may impose and withhold the following money damages for each
event of default:
18.8.2.1 Failure to file or filing incomplete or inaccurate annual or
quarterly reports will result in money damages of not less than
$3,000.00 or more than $11,000.00 for every month from the month
the report is due until submitted in the form and format
required by TDH. These money damages apply separately to each
report.
18.8.2.2 Failure to produce or provide records and information requested
by TDH, or an entity acting on behalf of TDH, or an agency
authorized by statute or law to require production of records at
the time and place the records were required or requested, will
result in money damages of not less than $1,000.00 per day for
each day the records are not produced as required by the
requesting entity or agency if the requesting entity or agency
is conducting an investigation or audit relating to fraud or
abuse, and $500.00 per day for each day records are not produced
if the requesting entity or agency is conducting routine audits
or monitoring activities.
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18.8.2.3 Failure to file or filing incomplete or inaccurate encounter
data will result in money damages of not less than $10,000 nor
more than $25,000 for each month HMO fails to submit encounter
data in the form and format required by TDH. These damages are
in addition to the damages contained in 18.8.2.1 above. TDH
will use the encounter data validation methodology established
by TDH to determine the numbers of encounter data and the number
of days for which damages will be assessed.
18.8.2.4 Failing or refusing to cooperate with TDH, an entity acting on
behalf of TDH, or an agency authorized by statute or law to
require the cooperation of HMO, in carrying out an
administrative, investigative, or prosecutorial function of the
Medicaid program, will result in money damages of not less than
$1,000.00 per day for each day HMO fails to cooperate.
18.8.3 Failure to provide or pay for covered services. TDH will impose
and withhold the following money damages for each event of
default:
18.8.3.1 Failure to provide mandatory and/or benchmarked services. If
HMO fails to deliver services or to report encounter data
documenting the delivery of services which are mandated by
federal law or for which a benchmark is established under this
contract, TDH will impose money damages. Damages imposed will
be not less than $10,000 nor more than $25,000 for each month
that HMO substantially fails to deliver the services and/or
report the encounter data documenting the delivery of the
services, or fails to meet the established benchmark. These
damages are in addition to failure to document or submit
encounter data and reports required elsewhere in this contract.
18.8.3.2 Failure to provide a covered service requested or required by a
Member. If a Member requests a fair hearing before TDH because
HMO has substantially failed to provide a covered service, the
Bureau of Managed Care may make a recommendation to the hearing
officer conducting the fair hearing to impose sanctions upon
HMO. The recommendation of the Bureau of Managed Care to impose
sanctions must include an amount of recommended sanctions, and
the justification for entering a finding that HMO has
substantially failed to deliver the requested service. The
amount of the sanction may be in any amount of not less than
$1,000.00 nor more than $25,000.00 depending upon the nature of
the denial and the hardship or health threat that the denial
placed upon the Member.
18.8.3.3 If TDH has provided or paid for a service requested by a Member
pending a decision after a fair hearing and the decision is
adverse to HMO, TDH will withhold the entire amount TDH paid for
the service in addition to the damages under 18.8.3.
18.8.3.4 Failure to enter into a required or mandatory contract or
failure to contract for or arrange to have all services required
under this contract provided will result in money damages of
$1,000.00 per day that HMO either fails to negotiate in good
faith to enter into the required contract or fails to arrange to
have required services delivered.
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18.8.3.5 Failing to pay providers claims for covered services. TDH will
impose and withhold the following money damages for each event
of default. These money damages are in addition to the interest
HMO is required to pay to providers under the provisions of
7.2.7.10, above.
18.8.3.6 If TDH determines that HMO has failed to pay a provider for a
claim or claims for which provider should have been paid, TDH
will impose money damages of $2 per day for each day the claim
is not paid from the date the claim should have been paid
(calculated as 30 days from the date a clean claim was received
by HMO) until the claim is paid by HMO.
18.8.3.7 If TDH determines that HMO has failed to pay a capitation amount
to a provider who has contracted with HMO to provide services on
a capitated basis, TDH will impose money damages of $10 per day,
per Member for whom the capitation is not paid, from the date on
which the payment was due until the capitation amount is paid.
18.8.4 TDH must provide HMO with 7 days written notice of intent to
withhold capitation amounts under this Article 18.8. The notice
will include the reason for the withhold, the amount that TDH
intends to withhold, and facts and detail sufficient for HMO to
determine the accuracy of the proposed withhold. Notice may be
given by any means that gives verification of receipt.
18.8.5 HMO may appeal the decision of TDH to withhold capitation
amounts by filing a written response to the notice clearly
stating the reason HMO disputes the withhold, and include any
supporting documentation with the response. HMO must file the
appeal within 15 days from HMO's receipt of the notice. Filing
an appeal will not pend or suspend the withhold.
18.8.6 HMO and TDH must attempt to informally resolve the dispute. If
HMO and TDH are unable to informally resolve the dispute, HMO
must notify the Bureau Chief of Managed Care that they are
unable to come to an agreement. The Bureau Chief will refer the
dispute to the Associate Commissioner for Health Care Financing
who will appoint a committee to review the dispute under the
department's dispute resolution procedures. The decision of the
dispute resolution committee will be a final administrative
decision of the department.
18.9 FORFEITURE OF TDI PERFORMANCE BOND
TDH may require forfeiture of all or a portion of the face
amount of the TDI performance bond if TDH determines that an
event of default has occurred. Partial payment of the face
amount shall reduce the total bond amount available pro rata.
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ARTICLE XIX TERM
19.1 The effective date of this contract is July 1, 1999. This
contract will terminate on August 31, 2000, unless terminated
earlier as provided elsewhere in this contract.
19.2 The contract will not automatically renew beyond the initial
term. TDH will notify HMO not less than 60 days before the end
of the contract term of its intent not to renew the contract.
19.3 If HMO does not intend to renew beyond the initial term of the
contract, HMO must submit a written Notice of Intent Not to
Renew, along with a transition plan for its existing Members,
not less than 90 days before the end of the contract term in
19.1. HMO will be responsible for paying all costs of providing
notice to Members and any additional costs incurred by TDH to
ensure that Members are reassigned to other plans without
interruption of services.
19.4 HMO may enter into a new contract to continue to provide managed
care services under the following terms and conditions:
19.4.1 HMO submits a written Request to Continue Operations Without
Interruption not less than 90 days before the end of the
contract term in 19.1;
19.4.2 HMO submits to a Readiness Review by TDH under the provisions of
Gov. Code Section 533.107;
19.4.3 HMO cures any past default or deficiencies or submits a written
plan documenting how past defaults or deficiencies will be
avoided under a future contract, and the written plan is
approved by TDH;
19.4.4 HMO submits all reports and encounter data currently due or past
due under this contract before the termination date of this
contract.
19.4.5 If HMO submits a Request to Continue Operations Without
Interruption but either fails to meet the requirements of this
Article or decides prior to execution of a renewal contract not
to continue operations, HMO will be responsible for paying all
costs of providing notice to Members and any additional costs
incurred by TDH to ensure that Members are reassigned to other
plans without interruption of services. HMO must continue to
provide services to Members for 60 days or until all Members
have been reassigned to other plans.
19.5 This contract may be extended on a temporary basis if the
requirements of this section have been initiated but the
requirements of 19.3 have not been completed and/or evaluated by
TDH before the termination date.
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19.6 Non-renewal of this contract is not a contract termination for
purposes of appeal rights under the Human Resources Code Section
32.034.
SIGNED 8th day of February , 1999.
--------------------------------- ------------------------
TEXAS DEPARTMENT OF HEALTH HMO NAME
BY: BY:
---------------------------- ------------------------------
Xxxxxxx X. Xxxxxx III, M.D. Printed Name:
Commissioner of Health ------------------------------
Title:
------------------------------
Approved as to Form:
Office of General Counsel
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APPENDICES
Copies of the Appendices A-M will be available in the Regulatory Department
upon request.
--------------------------------------------------------------------------------
AMENDMENT NO.1
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
THE TEXAS DEPARTMENT OF HEALTH AND HMO
This Amendment No.1 is entered into between the Texas Department of Health and
AMERICAID Texas, Inc. (HMO), to amend the Contract for Services between the
Texas Department of Health and HMO in the Dallas Service Area, dated February
8, 1999. The effective date of this Amendment is September 1, 1999. All other
contract provisions remain in full force and effect.
(The amended sections, BOLD AND ITALICIZED, are shown throughout the entire
contract)
AGREED AND SIGNED by an authorized representative of the parties on November 1,
1999.
TEXAS DEPARTMENT OF HEALTH AMERICAID Texas, Inc.
By: Xxxxxxx X. Xxxxxx, III., M.D. By: Xxxxx X. Xxxxxxx, Xx.
----------------------------- ---------------------
Commissioner of Health President & CEO
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