Responsible Office: HHSC Office of General Counsel (OGC) Subject: HHSC Managed Care Contract HHSC Contract No. 529-06-0280-00014-G
Exhibit
10.2
Contractual
Document (CD)
|
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Responsible
Office: HHSC Office of General Counsel (OGC)
|
||||
Subject:
HHSC Managed Care Contract
|
HHSC
Contract No. 529-06-0280-00014-G
|
Part
1: Parties to the Contract:
|
|||
This
Contract Amendment (the “Amendment”) is between the Texas Health and Human
Services Commission (HHSC), an administrative agency within the executive
department of the State of Texas, having its principal office at
0000
Xxxxx Xxxxx Xxxxxxxxx, Xxxxxx, Xxxxx 00000, and Superior HealthPlan,
Inc.
(HMO) a corporation organized under the laws of the State of Texas,
having
its principal place of business at: 0000 Xxxxx XX-00, Xxxxx 000,
Xxxxxx,
Xxxxx 00000. HHSC and HMO may be referred to in this Amendment
individually as a “Party” and collectively as the “Parties.”
The
Parties hereby agree to amend their original contract, HHSC contract
number 529-06-0280-00014 (the “Contract”) as set forth
herein. The Parties agree that the terms of the Contract will
remain in effect and continue to govern except to the extent modified
in
this Amendment.
This
Amendment is executed by the Parties in accordance with the authority
granted in Attachment A to the HHSC Managed Care Contract document,
“HHSC
Uniform Managed Care Contract Terms & Conditions,” Article 8,
“Amendments and Modifications.”
|
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Part
2: Effective Date of Amendment:
|
Part
3: Contract Expiration Date
|
Part
4: Operational Start Date:
|
|
CHIP
Perinatal rates effective April 1, 2007.
STAR+PLUS
rates and inpatient behavioral health services for Xxxxxx Service
Area
effective June 1, 2007.
All
other provisions effective July 1, 2007.
|
August
31, 2008
|
STAR
and CHIP HMOs: September 1, 2006
STAR+PLUS
HMOs: February 1, 2007
CHIP
Perinatal HMOs: January 1, 2007
|
|
Part
5: Project Managers:
|
|||
HHSC:
Xxxxx
Xxxxxxxxx
Director
of Medicaid/CHIP Health Plan Operations
00000
Xxxxxx Xxxxxxxxx, Xxxxxxxx X
Xxxxxx,
Xxxxx 00000
Phone: 000-000-0000
Fax: 000-000-0000
|
HMO:
Xxxxxx
Xxxx
Vice
President of Regulatory Affairs
0000
Xxxxx XX-00, Xxxxx 000
Xxxxxx,
Xxxxx 00000
Phone:
000-000-0000
Fax: 000-000-0000
E-mail:
xxxxx@xxxxxxx.xxx
|
||
Part
6: Deliver Legal Notices to:
|
|||
HHSC:
General
Counsel
0000
Xxxxx Xxxxx Xxxxxxxxx, 0xx
Xxxxx
Xxxxxx,
Xxxxx 00000
Fax: 000-000-0000
|
HMO:
Superior
HealthPlan
0000
Xxxxx XX-00, Xxxxx 000
Xxxxxx,
Xxxxx 00000
Fax: 000-000-0000
|
Contractual
Document (CD)
|
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Responsible
Office: HHSC Office of General Counsel (OGC)
|
||||
Subject:
HHSC Managed Care Contract
|
HHSC
Contract No. 529-06-0280-00014-G
|
Part
7: HMO Programs and Service Areas:
|
||||
This
Contract applies to the following HHSC HMO Programs and Service Areas
(check all that apply). All references in the Contract
Attachments to HMO Programs or Service Areas that are not checked
are
superfluous and do not apply to the HMO.
|
||||
x Medicaid
STAR HMO Program
|
||||
Service
Areas
|
x
Bexar
|
x
Lubbock
|
||
¨
Dallas
|
x
Nueces
|
|||
x
El
Paso
|
¨
Tarrant
|
|||
¨
Harris
|
x
Travis
|
|||
See
attachment B-6, "Map of Counties with HMO Program Services Areas,"
for
listing of counties included within the STAR Services
Areas.
|
||||
x Medicaid
STAR+PLUS HMO Program
|
||||
Service
Areas
|
x
Bexar
|
x Nueces
|
||
¨
Xxxxxx
|
¨ Xxxxxx
|
|||
See
Attachment B-6.1 "Map of Counties with STAR+PLUS HMO Program Service
Areas," for listing of counties included within the STAR+PLUS Service
Areas.
|
||||
x CHIP
HMO Program
|
||||
Core
Service Areas:
|
x
Bexar
|
x Nueces
|
||
¨ Dallas
|
¨
Tarrant
|
|||
x El
Paso
|
xTravis
|
|||
¨
Xxxxxx
|
¨
Xxxx
|
|||
x Lubbock
|
||||
Optional
Service Areas:
|
x
Bexar
|
x Lubbock
|
||
x El
Paso
|
x Nueces
|
|||
¨
Harris
|
x
Travis
|
|||
See
Attachment B-6, "Map of Counties with HMO Program Service Areas,
"for
listing of counties included within the CHIP Core Services Areas
and Chip
Optional Service Areas.
|
x CHIP
Perinatal Program
|
||||
Core
Service Areas:
|
x
Bexar
|
x Nueces
|
||
¨ Dallas
|
¨
Tarrant
|
|||
x El
Paso
|
xTravis
|
|||
¨
Xxxxxx
|
¨
Xxxx
|
|||
x Lubbock
|
||||
Optional
Service Areas:
|
x
Bexar
|
x
Lubbock
|
||
x El
Paso
|
x Nueces
|
|||
¨
Harris
|
x
Travis
|
|||
See Attachment B:6.2, "Map of Counties with CHIOP Perinatal HMO Program Service Areas,: for a list of counties included within the CHIP Perinatal Service Areas. | ||||
Part
8: Payment
|
Part
8 of
the HHSC Managed Care Contract document, “Payment,” is modified to add the
capitation rates for Rate Period 1.
x
Medicaid
STAR HMO PROGRAM
|
||||||
Capitation:
See Attachment A, “HHSC Uniform Managed Care Contract Terms and
Conditions,” Article 10, for a description of the Capitation Rate-setting
methodology and the Capitation Payment requirements for the STAR
Program.
The following Rate Cells and Capitation Rates will apply to Rate
Period
1:
|
||||||
Service
Area: BEXAR
|
||||||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
|||||
1
|
TANF
Adult
|
$261.68
|
||||
2
|
TANF
Child >
12 months
|
$87.11
|
||||
3
|
Expansion
Child >12 months
|
$87.41
|
||||
4
|
Newborn
< 12 months
|
$650.47
|
||||
5
|
TANF
child <12 months
|
$280.34
|
||||
6
|
Expansion
Child <12 months
|
$184.41
|
||||
7
|
Federal
Mandate child
|
$67.40
|
||||
8
|
Pregnant
Woman
|
$399.99
|
||||
9
|
Delivery
Supplemental Payment
|
$3,166.59
|
Contractual
Document (CD)
|
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|||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||||
Subject:
HHSC Managed Care Contract
|
HHSC
Contract No. 529-06-0280-00014-G
|
Service
Area: EL PASO
|
|||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
||
1
|
TANF
Adult
|
$219.32
|
|
2
|
TANF
Child>12 months
|
$75.90
|
|
3
|
Expansion
Child>12 months
|
$90.95
|
|
4
|
Newborn
< 12 months
|
$556.63
|
|
5
|
TANF
child <12 months
|
$238.42
|
|
6
|
Expansion
Child <12 months
|
$181.32
|
|
7
|
Federal
Mandate child
|
$66.95
|
|
8
|
Pregnant
Woman
|
$380.91
|
|
9
|
Delivery
Supplemental Payment
|
$3,343.04
|
Service
Area: LUBBOCK
|
|||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
||
1
|
TANF
Adult
|
$253.16
|
|
2
|
TANF
Child>12 months
|
$86.38
|
|
3
|
Expansion
Child>12 months
|
$88.21
|
|
4
|
Newborn
< 12 months
|
$416.38
|
|
5
|
TANF
child <12 months
|
$207.08
|
|
6
|
Expansion
Child <12 months
|
$238.86
|
|
7
|
Federal
Mandate child
|
$76.09
|
|
8
|
Pregnant
Woman
|
$510.74
|
|
9
|
Delivery
Supplemental Payment
|
$3,130.39
|
Contractual
Document (CD)
|
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|||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||||
Subject:
HHSC Managed Care Contract
|
HHSC
Contract No. 529-06-0280-00014-G
|
Service
Area: NUECES
|
|||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
||
1
|
TANF
Adult
|
$230.50
|
|
2
|
TANF
Child>12 months
|
$88.46
|
|
3
|
Expansion
Child>12 months
|
$92.31
|
|
4
|
Newborn
< 12 months
|
$670.99
|
|
5
|
TANF
child <12 months
|
$322.76
|
|
6
|
Expansion
Child <12 months
|
$322.76
|
|
7
|
Federal
Mandate child
|
$67.25
|
|
8
|
Pregnant
Woman
|
$292.08
|
|
9
|
Delivery
Supplemental Payment
|
$3,103.82
|
Service
Area: XXXXXX
|
|||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
||
1
|
TANF
Adult
|
$195.85
|
|
2
|
TANF
Child>12 months
|
$73.05
|
|
3
|
Expansion
Child>12 months
|
$86.18
|
|
4
|
Newborn
< 12 months
|
$740.08
|
|
5
|
TANF
child <12 months
|
$213.76
|
|
6
|
Expansion
Child <12 months
|
$215.26
|
|
7
|
Federal
Mandate child
|
$64.06
|
|
8
|
Pregnant
Woman
|
$417.81
|
|
9
|
Delivery
Supplemental Payment
|
$3,147.49
|
STAR
SSI Administrative Fee: HHSC will pay a STAR HMO a monthly
Administrative Fee of $14.00 per SSI Beneficiary who voluntarily enrolls in
the
HMO in accordance with Attachment A, "HHSC Uniform Managed Care Contract Terms
and Conditions," Article 10.
Delivery
Supplemental Payment: See Attachment A, "HHSC Uniform Managed Care
Contract Terms and Conditions," Article 10, for a description of the methodology
for establishing the Delivery Supplemental Payment for the STAR
Program
Contractual
Document (CD)
|
![]() |
|||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||||
Subject:
HHSC Managed Care Contract
|
HHSC
Contract No. 529-06-0280-00014-G
|
xMedicaid
STAR+PLUS HMO Program
Capitation:See
Attachment A, "HHSC Uniform Managed Care Contract Terms and Conditions," Article
10, for a description of the Capitation Rate-setting methodology and the
Capitation Payment requirements for the STAR+PLUS Program. The
following Rate Cells and Capitation Rates will apply to Rate Periods 1 and
2.
STAR+PLUS
Service Area: BEXAR
|
||||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
Rate
Period 2 Capitation Rates
|
||
1.
|
Medicaid
Only Standard Rate
|
$388.93
|
$403.69
|
|
2.
|
Medicaid
Only 1915 (C)Nursing Facility Waiver Rate
|
$2,755.92
|
$2,873.79
|
|
3.
|
Dual
Eligible Standard Rate
|
$251.00
|
$259.76
|
|
4.
|
Dual
Eligible 1915 (C) Nursing Facility Waiver Rate
|
$1,704.74
|
$1,776.84
|
|
5.
|
Nursing
Facility - Medicaid Only
|
$388.93
|
$403.69
|
|
6.
|
Nursing
Facility - Dual Eligible
|
$251.00
|
$259.76
|
STAR+PLUS
Service Area: NUECES
|
||||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
Rate
Period 2 Capitation Rates
|
||
1.
|
Medicaid
Only Standard Rate
|
$453.61
|
$471.19
|
|
2.
|
Medicaid
Only 1915 (C) Nursing Facility Waiver Rate
|
$2,689.23
|
$2,804.20
|
|
3.
|
Dual
Eligible Standard Rate
|
$311.35
|
$322.73
|
|
4.
|
Dual
Eligible 1915 (C) Nursing Facility Waiver Rate
|
$1,666.27
|
$1,736.68
|
|
5.
|
Nursing
Facility - Medicaid Only
|
$453.61
|
$471.19
|
|
6.
|
Nursing
Facility - Dual Eligible
|
$311.35
|
$322.73
|
Contractual
Document (CD)
|
![]() |
|||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||||
Subject:
HHSC Managed Care Contract
|
HHSC
Contract No. 529-06-0280-00014-G
|
xCHIP
HMO
PROGRAM
Capitation: See
Attachment A, "HHSC Uniform Managed Care Contract Terms and Conditions," Article
10, for a description of the Capitation Rate-setting methodology and the
Capitation Payment requirements for the CHIP Program. The following
Rate Cells and Capitation Rates will apply to Rate Period 1:
Service
Area: BEXAR
|
|||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
||
1
|
<
Age 1
|
$100.58
|
|
2
|
Ages
1 through 5
|
$78.71
|
|
3
|
Ages
6 through 14
|
$61.06
|
|
4
|
Ages 15
through 18
|
$84.70
|
Service
Area: EL PASO
|
|||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
||
1
|
<
Age 1
|
$61.24
|
|
2
|
Ages
1 through 5
|
$73.74
|
|
3
|
Ages
6 through 14
|
$57.09
|
|
4
|
Ages 15
through 18
|
$67.88
|
Service
Area: LUBBOCK
|
|||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
||
1
|
<
Age 1
|
$56.26
|
|
2
|
Ages
1 through 5
|
$76.79
|
|
3
|
Ages
6 through 14
|
$68.04
|
|
4
|
Ages 15
through 18
|
$93.75
|
Contractual
Document (CD)
|
![]() |
|||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||||
Subject:
HHSC Managed Care Contract
|
HHSC
Contract No. 529-06-0280-00014-G
|
Service
Area: NUECES
|
|||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
||
1
|
<
Age 1
|
$89.40
|
|
2
|
Ages
1 through 5
|
$93.77
|
|
3
|
Ages
6 through 14
|
$78.78
|
|
4
|
Ages 15
through 18
|
$97.60
|
Service
Area: XXXXXX
|
|||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
||
1
|
<
Age 1
|
$63.15
|
|
2
|
Ages
1 through 5
|
$90.64
|
|
3
|
Ages
6 through 14
|
$83.08
|
|
4
|
Ages
15 through 18
|
$124.32
|
Delivery
Supplemental Payment: See Attachment A, "HHSC Uniform Managed Care
Contract Terms and Conditions," Article 10, for a description of the methodology
for establishing the Delivery Supplemental Payment for the CHIP Program. The
Chip Delivery Supplement Payment is $3,000.00 for all Service
Areas.
xCHIP
Perinatal
Program
|
||||||
Capitation:
See Attachment A, "HHSC Uniform Managed Care Contract Terms and
Conditions," Article 10, for a description of the Capitation Rate-setting
methodology and the Capitation Payment requirements for the CHIP
Perinatal
Program.
|
||||||
Service
Area: BEXAR
|
||||||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
|||||
1
|
Perinate
0% - 185%
|
$417.19
|
||||
2
|
Perinate
186% - 200%
|
$152.35
|
||||
3
|
Perinate
Newborn 0% - 185%
|
$335.90
|
||||
4
|
Perinate
Newborn 186% - 200%
|
$683.52
|
Contractual
Document (CD)
|
![]() |
|||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||||
Subject:
HHSC Managed Care Contract
|
HHSC
Contract No. 529-06-0280-00014-G
|
Service
Area: EL PASO
|
|||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
||
1
|
Perinate
0% - 185%
|
$417.19
|
|
2
|
Perinate
186% - 200%
|
$152.35
|
|
3
|
Perinate
Newborn 0% - 185%
|
$287.45
|
|
4
|
Perinate
Newborn 186% - 200%
|
$584.91
|
Service
Area: LUBBOCK
|
|||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
||
1
|
Perinate
0% - 185%
|
$417.19
|
|
2
|
Perinate
186% - 200%
|
$152.35
|
|
3
|
Perinate
Newborn 0% - 185%
|
$215.02
|
|
4
|
Perinate
Newborn 186% - 200%
|
$437.53
|
Service
Area: NUECES
|
|||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
||
1
|
Perinate
0% - 185%
|
$417.19
|
|
2
|
Perinate
186% - 200%
|
$152.35
|
|
3
|
Perinate
Newborn 0% - 185%
|
$346.50
|
|
4
|
Perinate
Newborn 186% - 200%
|
$705.08
|
Service
Area: XXXXXX
|
|||
Rate
Cell
|
Rate
Period 1 Capitations Rates
|
||
1
|
Perinate
0% - 185%
|
$417.19
|
|
2
|
Perinate
186% - 200%
|
$152.35
|
|
3
|
Perinate
Newborn 0% - 185%
|
$380.66
|
|
4
|
Perinate
Newborn 186% - 200%
|
$774.58
|
Delivery
Supplemental Payment: See Attachment A, “HHSC
Uniform Managed Care Contract Terms and Conditions,” Article 10, for a
description of the methodology for establishing the Delivery Supplemental
Payment for the CHIP Perinatal Program. The CHIP Perinatal Delivery Supplemental
Payment is $3,000.00 for Perinates between 186% and 200% of the Federal Poverty
Level for all Service Areas.
Contractual
Document (CD)
|
![]() |
|||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||||
Subject:
HHSC Managed Care Contract
|
HHSC
Contract No. 529-06-0280-00014-G
|
Part
9: Contract Attachments:
|
Modifications
to Part 9 of the HHSC Managed Care Contract document, “Contract
Attachments,” are italicized below:
A: HHSC
Uniform Managed Care Contract Terms & Conditions - Version 1.6 is
replaced with Version 1.7
B: Scope
of Work/Performance Measures – Version 1.6 is replaced with Version
1.7 for all attachments, except if noted.
B-1: HHSC
RFP 000-00-000, Sections 6-9
B-2: Covered
Services
B-2.1
STAR+PLUS Covered Services
B-2.2
CHIP Perinatal Program Covered Services
B-3: Value-added
Services
B-3.1
STAR+PLUS Value-added Services
B-3.2
CHIP Perinatal Program Value-added Services
B-4: Performance
Improvement Goals
B-4.1
SFY 2008 Performance Improvement Goals
B-5: Deliverables/Liquidated
Damages Matrix
B-6: Map
of Counties with STAR and CHIP HMO Program Service Areas
B-6.1
STAR+PLUS Service Areas
B-6.2
CHIP Perinatal Program Service Areas
B-7: STAR+PLUS
Attendant Care Enhanced Payment Methodology
C: HMO’s
Proposal and Related Documents
C-1: HMO’s
Proposal
C-2: HMO
Supplemental Responses
C-3: Agreed
Modifications to HMO’s Proposal
|
Part
10: Signatures:
|
||||
The
Parties have executed this Contract Amendment in their capacities
as
stated below with authority to bind their organizations on the dates
set
forth by their signatures. By signing this Amendment, the
Parties expressly understand and agree that this Amendment is hereby
made
part of the Contract as though it were set out word for word in the
Contract.
|
||||
Texas
Health and Human Services Commission
|
Superior
HealthPlan, Inc.
|
|||
Xxxxxxx
X. Xxxx, M.D.
|
By: Xxxxxxxxxxx
Xxxxxx
|
|||
Deputy
Executive Commissioner for Health Services
|
Title:
President and CEO
|
|||
Date:
|
Date:
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions
|
Version
1.7
|

Texas
Health & Human Services Commission
Uniform
Managed Care Contract Terms & Conditions
Version
1.7
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions
|
Version
1.7
|
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version of the Uniform Managed Care Contract Terms &
Conditions
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
version of the Uniform Managed Care Contract Terms & Conditions that
includes provisions applicable to MCOs participating in the STAR+PLUS
Program.
Article
2, “Definitions,” is amended to add or modify the following
definitions: 1915(c) Nursing Facility Waiver; Community-based
Long Term Care Services; Court-ordered Commitment; Default Enrollment;
Dual Eligibles; Eligibles; Functionally Necessary Covered Services;
HHSC
Administrative Services Contractor; HHSC HMO Programs or HMO Programs;
Medicaid HMOs; Medical Assistance Only; Member; Minimum Data Set
For Home
Care (MSD-HC); Nursing Facility Cost Ceiling; Nursing Facility Level
of
Care; Outpatient Hospital Service; Qualified and Disabled Working
Individual (QDWI); Qualified Medicare Beneficiary; Service Coordination;
Service Coordinator; Specified Low-income Medicare Beneficiary (SMBL);
STAR+PLUS or STAR+PLUS Program; STAR+PLUS HMO; Supplemental Security
Income (SSI).
Article
4, “Contract Administration and Management,” is amended to add Sections
4.02(a)(12) and 4.04.1, relating to the STAR+PLUS Service
Coordinator.
Article
8, “Amendments and Modifications,” Section 8.06 is amended to clarify that
CMS must approve all amendments to STAR and STAR+PLUS HMO
contracts.
Article
10, “Terms and Conditions of Payment,” Section 10.05.1 is added to include
the Capitation Rate structure provisions relating to STAR+PLUS. Section
10.11 is modified to apply only to STAR and CHIP. Section
10.11.1 is added to include the Experience Rebate provisions relating
to
STAR+PLUS.
|
Revision
|
1.2
|
September
1, 2006
|
Revised
version of the Uniform Managed Care Contract Terms & Conditions that
includes provisions applicable to MCOs participating in the STAR
and CHIP
Programs.
Section
4.04(a) is amended to change the reference from “Texas Board of Medical
Examiners” to “Texas Medical Board”.
Article
5 is amended to clarify the following sections: 5.02(e)(5), regarding
disenrollment of Members; 5.02(i), regarding disenrollment of xxxxxx
care
children; and 5.04(b), regarding CHIP eligibility and enrollment
for
babies of CHIP Members
Article
10 is amended to clarify the following sections: 10.01(d), regarding
the
fixed monthly Capitation Rate components; 10.10(c), regarding updating
the
state
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Contractual
Document (CD)
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Responsible
Office: HHSC Office of General Counsel (OGC)
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Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions
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Version
1.7
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system
for Members who become eligible for SSI. Section 10.17 is added
regarding recoupment for federal disallowance.
Article
17 is amended to clarify the following section: 17.01, naming HHSC
as an
additional insured.
|
|||
Revision
|
1.3
|
September
1, 2006
|
Article
2 is amended to modify and add the following definitions to include
the
CHIP Perinatal Program- Appeal, CHIP Perinatal Program, CHIP Perinatal
HMO, CHIP Perinate, CHIP Perinate Newborn, Covered Services, Complaint,
Delivery Supplemental Payment, Eligibles, Experience Rebate, HHSC
Administrative Services Contractor, Major Population Group, Member,
Optional Service Area, and Service Management.
Article
5 is amended to add the following sections: 5.04.1 CHIP Perinatal
eligibility and enrollment; 5.05(c) CHIP Perinatal HMOs.
Article
10 is amended to apply to the CHIP Perinatal Program. Section 10.06(a)
is
amended to add the Capitation Rates Structure for CHIP Perinates
and CHIP
Perinate Newborns. Section 10.06(e) is added to include a
description of the rate-setting methodology for the CHIP Perinatal
Program. 10.09(b) is modified to include CHIP Perinatal Program;
Section
10.11 is amended to add the CHIP Perinatal Program to the STAR and
CHIP
Experience Rebate. Section 10.12(c) amended to clarify cost
sharing for the CHIP Perinatal Program.
|
Revision
|
1.4
|
September,
1 2006
|
Contract
amendment did not revise Attachment A HHSC Uniform Managed Care Terms
and
Conditions
|
Revision
|
1.5
|
January
1, 2007
|
Revised
version of the Uniform Managed Care Contract Terms & Conditions that
includes provisions applicable to MCOs participating in the STAR,
STAR+PLUS, CHIP, and CHIP Perinatal Programs.
Section
5.04(a) is amended to clarify the period of CHIP continuous
coverage.
Section
5.04.1 is amended to clarify the process for a CHIP Perinatal Newborn
to
move into CHIP at the end of the 12-month CHIP Perinatal Program
eligibility.
Section
5.08 is added to include STAR+PLUS special default language.
Section
10.06.1 is amended to correct the FPL percentages for CHIP Perinates
and
CHIP Perinate Newborns.
Section
17.01 is amended to clarify the insurance requirements for the HMOs
and
Network Providers and to remove the insurance requirements for
Subcontractors.
Section
17.02(b) is added to clarify that a separate Performance Bond is
not
needed for the CHIP Perinatal Program.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment A HHSC Uniform Managed Care Terms
and
Conditions
|
Revision
|
1.7
|
July
1, 2007
|
Article
2 is modified to correct and align definition for “Clean Claim” with the
UMCM.
Section
4.08(c) is modified to add a cross-reference
to
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions
|
Version
1.7
|
new
Attachment B-1, Section 8.1.1.2.
Section
5.05(a), Medicaid HMOs, is amended to clarify provisions regarding
enrollment into Medicaid Managed Care from Medicaid Fee-for-Service
while
in the hospital, changing HMOs while in the hospital, and addressing
which
HMO is responsible for professional and hospital charges during the
hospital stay.
New
Section 10.05.1 (c) is added to clarify capitation payments (delays
in
payment and levels of capitation) for Members certified to receive
STAR+PLUS Waiver Services.
Section
10.06.1 is modified to include the CHIP Perinatal pass through for
delivery physician services for women under 185% FPL.
Section
10.11 is modified to include treatment of the new Incentives and
Disincentives (within the Experience Rebate
determination); additionally, several clarifications are added
with respect to the continuing accrual of any unpaid interest,
etc.
Section
10.11.1 is modified to include treatment of the new Incentives and
Disincentives (within the Experience Rebate determination); additionally,
several clarifications are added with respect to the continuing accrual
of
any unpaid interest, etc.
|
|||
1
Status should
be represented as “Baseline” for initial issuances, “Revision” for changes
to the Baseline version, and “Cancellation” for withdrawn
versions
2
Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3
Brief
description of the changes to the document made in the
revision.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions
|
Version
1.7
|
TABLE
OF CONTENTS
Article1.Introduction
|
2
|
Section
1.01 Purpose
|
2
|
Section
1.02 Risk-based contract
|
2
|
Section
1.03 Inducements
|
2
|
Section
1.04 Construction of the Contract
|
2
|
Section
1.05 No implied authority
|
3
|
Section
1.06 Legal Authority
|
3
|
Article
2. Definitions
|
3
|
Article
3. General Terms & Conditions
|
15
|
Section
3.01 Contract elements
|
15
|
Section
3.02 Term of the Contract
|
15
|
Section
3.03 Funding
|
15
|
Section
3.04 Delegation of authority
|
15
|
Section
3.05 No waiver of sovereign immunity
|
15
|
Section
3.06 Force majeure
|
15
|
Section
3.07 Publicity
|
15
|
Section
3.08 Assignment
|
16
|
Section
3.09 Cooperation with other vendors and prospective
vendors
|
16
|
Section
3.10 Renegotiation and reprocurement rights
|
16
|
Section
3.11 RFP errors and omissions
|
16
|
Section
3.12 Attorneys’ fees
|
16
|
Section
3.13 Preferences under service contracts
|
17
|
Section
3.14 Time of the essence
|
17
|
Section
3.15 Notice
|
17
|
Article
4. Contract Administration & Management
|
17
|
Section
4.01 Qualifications, retention and replacement of HMO
employees
|
17
|
Section
4.02 HMO’s Key Personnel
|
17
|
Section
4.03 Executive Director
|
17
|
Section
4.04 Medical Director
|
18
|
Section
4.04.1 STAR+PLUS Service Coordinator
|
18
|
Section
4.05 Responsibility for HMO personnel and Subcontractors
|
19
|
Section
4.06 Cooperation with HHSC and state administrative
agencies
|
19
|
Section
4.07 Conduct of HMO personnel
|
19
|
Section
4.08 Subcontractors
|
20
|
Section
4.09 HHSC’s ability to contract with Subcontractors
|
21
|
Section
4.10 HMO Agreements with Third Parties
|
21
|
Article
5. Member Eligibility & Enrollment
|
21
|
Section
5.01 Eligibility Determination
|
21
|
Section
5.02 Member Enrollment & Disenrollment
|
21
|
Section
5.03 STAR enrollment for pregnant women and infants
|
22
|
Section
5.04 CHIP eligibility and enrollment
|
22
|
Section
5.05 Span of Coverage
|
23
|
Section
5.06 Verification of Member Eligibility
|
23
|
Section
5.07 Special Temporary STAR Default Process
|
23
|
Section
5.08 Special Temporary STAR+PLUS Default Process
|
24
|
Article
6. Service Levels & Performance Measurement
|
24
|
Section
6.01 Performance measurement
|
24
|
Article
7. Governing Law & Regulations
|
24
|
Section
7.01 Governing law and venue
|
24
|
Section
7.02 HMO responsibility for compliance with laws and
regulations
|
24
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Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions
|
Version
1.7
|
Section
7.03 TDI licensure/ANHC certification and solvency
|
25
|
Section
7.04 Immigration Reform and Control Act of 1986
|
25
|
Section
7.05 Compliance with state and federal anti-discrimination
laws
|
25
|
Section
7.06 Environmental protection laws
|
25
|
Section
7.07 HIPAA
|
26
|
Article
8. Amendments & Modifications
|
26
|
Section
8.01 Mutual agreement
|
26
|
Section
8.02 Changes in law or contract
|
26
|
Section
8.03 Modifications as a remedy
|
26
|
Section
8.04 Modifications upon renewal or extension of Contract
|
26
|
Section
8.05 Modification of HHSC Uniform Managed Care Manual
|
26
|
Section
8.06 CMS approval of Medicaid amendments
|
27
|
Section
8.07 Required compliance with amendment and modification
procedures
|
27
|
Article
9. Audit & Financial Compliance
|
27
|
Section
9.01 Financial record retention and audit
|
27
|
Section
9.02 Access to records, books, and documents
|
27
|
Section
9.03 Audits of Services, Deliverables and inspections
|
27
|
Section
9.04 SAO Audit
|
28
|
Section
9.05 Response/compliance with audit or inspection findings
|
28
|
Article
10. Terms & Conditions of Payment
|
28
|
Section
10.01 Calculation of monthly Capitation Payment
|
28
|
Section
10.02 Time and Manner of Payment
|
29
|
Section
10.03 Certification of Capitation Rates
|
29
|
Section
10.04 Modification of Capitation Rates
|
29
|
Section
10.05 STAR Capitation Structure
|
29
|
Section
10.05.1STAR+PLUS Capitation Structure
|
30
|
Section
10.06 CHIP Capitation Rates Structure
|
30
|
Section
10.07 HMO input during rate setting process
|
31
|
Section
10.08 Adjustments to Capitation Payments
|
31
|
Section
10.09 Delivery Supplemental Payment for CHIP, CHIP Perinatal and
STAR
HMOs
|
31
|
Section
10.10 Administrative Fee for SSI Members
|
32
|
Section
10.11 STAR, CHIP, and CHIP Perinatal Experience Rebate
|
32
|
Section
10.11.1 STAR+PLUS Experience Rebate
|
34
|
Section
10.12 Payment by Members
|
36
|
Section
10.13 Restriction on assignment of fees
|
36
|
Section
10.14 Liability for taxes
|
36
|
Section
10.15 Liability for employment-related charges and
benefits
|
36
|
Section
10.16 No additional consideration
|
37
|
Section
10.17 Federal Disallowance
|
37
|
Article
11. Disclosure & Confidentiality of
Information
|
37
|
Section
11.01 Confidentiality
|
37
|
Section
11.02 Disclosure of HHSC’s Confidential Information
|
38
|
Section
11.03 Member Records
|
38
|
Section
11.04 Requests for public information
|
38
|
Section
11.05 Privileged Work Product
|
38
|
Section
11.06 Unauthorized acts
|
39
|
Section
11.07 Legal action
|
39
|
Article
12. Remedies & Disputes
|
39
|
Section
12.01 Understanding and expectations
|
39
|
Section
12.02 Tailored remedies
|
39
|
Section
12.03 Termination by HHSC
|
41
|
Section
12.04 Termination by HMO
|
43
|
Section
12.05 Termination by mutual agreement
|
43
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions
|
Version
1.7
|
Section
12.06 Effective date of termination
|
43
|
Section
12.07 Extension of termination effective date
|
43
|
Section
12.08 Payment and other provisions at Contract termination
|
43
|
Section
12.09 Modification of Contract in the event of remedies
|
43
|
Section
12.10 Turnover assistance
|
43
|
Section
12.11 Rights upon termination or expiration of Contract
|
44
|
Section
12.12 HMO responsibility for associated costs
|
44
|
Section
12.13 Dispute resolution
|
44
|
Section
12.14 Liability of HMO
|
44
|
Article
13. Assurances & Certifications
|
45
|
Section
13.01 Proposal certifications
|
45
|
Section
13.02 Conflicts of interest
|
45
|
Section
13.03 Organizational conflicts of interest
|
45
|
Section
13.04 HHSC personnel recruitment prohibition
|
46
|
Section
13.05 Anti-kickback provision
|
46
|
Section
13.06 Debt or back taxes owed to State of Texas
|
46
|
Section
13.07 Certification regarding status of license, certificate, or
permit
|
46
|
Section
13.08 Outstanding debts and judgments
|
46
|
Article
14. Representations & Warranties
|
46
|
Section
14.01 Authorization
|
46
|
Section
14.02 Ability to perform
|
46
|
Section
14.03 Minimum Net Worth
|
46
|
Section
14.04 Insurer solvency
|
46
|
Section
14.05 Workmanship and performance
|
47
|
Section
14.06 Warranty of deliverables
|
47
|
Section
14.07 Compliance with Contract
|
47
|
Section
14.08 Technology Access
|
47
|
Article
15. Intellectual Property
|
47
|
Section
15.01 Infringement and misappropriation
|
47
|
Section
15.02 Exceptions
|
48
|
Section
15.03 Ownership and Licenses
|
48
|
Article
16. Liability
|
49
|
Section
16.01 Property damage
|
49
|
Section
16.02 Risk of Loss
|
49
|
Section
16.03 Limitation of HHSC’s Liability
|
49
|
Article
17. Insurance & Bonding
|
49
|
Section
17.01 Insurance Coverage
|
49
|
Section
17.02 Performance Bond
|
50
|
Section
17.03 TDI Fidelity Bond
|
51
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions
|
Version
1.7
|
Article
1 Introduction
Section
1.01Purpose.
The
purpose of this Contract is to set
forth the terms and conditions for the HMO’s participation as a managed care
organization in one or more of the HMO Programs administered by
HHSC. Under the terms of this Contract, HMO will provide
comprehensive health care services to qualified Program recipients through
a
managed care delivery system.
Section
1.02Risk-based contract.
This
is a Risk-based
contract.
Section
1.03Inducements.
In
making the award of this Contract,
HHSC relied on HMO’s assurances of the following:
(1)
HMO
is an established health maintenance organization that arranges for the delivery
of health care services, is currently licensed as such in the State of Texas
and
is fully authorized to conduct business in the Service Areas;
(2)
HMO
and the HMO Administrative Service Subcontractors have the skills,
qualifications, expertise, financial resources and experience necessary to
provide the Services and Deliverables described in the RFP, HMO’s Proposal, and
this Contract in an efficient, cost-effective manner, with a high degree of
quality and responsiveness, and has performed similar services for other public
or private entities;
(3)
HMO
has thoroughly reviewed, analyzed, and understood the RFP, has timely raised
all
questions or objections to the RFP, and has had the opportunity to review and
fully understand HHSC’s current program and operating environment for the
activities that are the subject of the Contract and the needs and requirements
of the State during the Contract term;
(4)
HMO
has had the opportunity to review and understand the State’s stated objectives
in entering into this Contract and, based on such review and understanding,
HMO
currently has the capability to perform in accordance with the terms and
conditions of this Contract;
(5)
HMO
also has reviewed and understands the risks associated with the HMO Programs
as
described in the RFP, including the risk of non-appropriation of
funds.
Accordingly,
on the basis of the terms
and conditions of this Contract, HHSC desires to engage HMO to perform the
Services and provide the Deliverables described in this Contract under the
terms
and conditions set forth in this Contract.
Section
1.04Construction of the Contract.
(a)
Scope
of Introductory Article.
The
provision of any introductory
article to the Contract are intended to be a general introduction and are not
intended to expand the scope of the Parties' obligations under the Contract
or
the alter the plain meaning of the terms and conditions of the
Contract
(b)
References to the “State.”
References
in the Contract to the
“State” shall mean the State of Texas unless otherwise specifically indicated
and shall be interpreted, as appropriate, to mean or include HHSC and other
agencies of the State of Texas that may participate in the administration of
the
HMO Programs, provided, however, that no provision will be interpreted to
include any entity other than HHSC as the contracting agency.
(c)
Severability.
If
any provision of this Contract is
construed to be illegal or invalid, such interpretation will not affect the
legality or validity of any of its other provisions. The illegal or invalid
provision will be deemed stricken and deleted to the same extent and effect
as
if never incorporated in this Contract, but all other provisions will remain
in
full force and effect.
(d)
Survival of terms.
Termination
or expiration of this
Contract for any reason will not release either Party from any liabilities
or
obligations set forth in this Contract that:
(1)
The Parties have expressly agreed
shall survive any such termination or expiration; or
(2)
Arose prior to the effective date
of termination and remain to be performed or by their nature would be intended
to be applicable following any such termination or expiration.
(e)
Headings.
The
article, section and paragraph
headings in this Contract are for reference and convenience only and may not
be
considered in the interpretation of this Contract.
(f)
Global drafting conventions.
(1)
The terms “include,” “includes,”
and “including” are terms of inclusion, and where used in this Contract, are
deemed to be followed by the words “without limitation.”
(2)
Any references to “sections,”
“appendices,” “exhibits” or “attachments” are deemed to be references to
sections, appendices, exhibits or attachments to this Contract.
(3)
Any references to laws, rules,
regulations, and manuals in this Contract are deemed references to these
documents as amended, modified, or supplemented from time to time during the
term of this Contract.
2
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions
|
Version
1.7
|
Section
1.05No implied authority.
The
authority delegated to HMO by HHSC
is limited to the terms of this Contract. HHSC is the state agency designated
by
the Texas Legislature to administer the HMO Programs, and no other agency of
the
State grants HMO any authority related to this program unless directed through
HHSC. HMO may not rely upon implied authority, and specifically is
not delegated authority under this Contract to:
(1)
make public policy;
(2)
promulgate, amend or disregard
administrative regulations or program policy decisions made by State and federal
agencies responsible for administration of HHSC Programs; or
(3)
unilaterally communicate or
negotiate with any federal or state agency or the Texas Legislature on behalf
of
HHSC regarding the HHSC Programs.
HMO
is required to cooperate to the
fullest extent possible to assist HHSC in communications and negotiations with
state and federal governments and agencies concerning matters relating to the
scope of the Contract and the HMO Program(s), as directed by HHSC.
Section
1.06Legal Authority.
(a)
HHSC is authorized to enter into
this Contract under Chapters 531 and 533, Texas Government Code; Section
2155.144, Texas Government Code; and/or Chapter 62, Texas Health & Safety
Code. HMO is authorized to enter into this Contract pursuant to the
authorization of its governing board or controlling owner or
officer.
(b)
The person or persons signing and
executing this Contract on behalf of the Parties, or representing themselves
as
signing and executing this Contract on behalf of the Parties, warrant and
guarantee that he, she, or they have been duly authorized to execute this
Contract and to validly and legally bind the Parties to all of its terms,
performances, and provisions.
Article
2. Definitions
As
used in this Contract, the following
terms and conditions shall have the meanings assigned below:
1915(c)
Nursing Facility
Waiver means the HHSC waiver program that provides home and
community based services to aged and disabled adults as cost-effective
alternatives to institutional care in nursing homes.
Abuse
means
provider practices that are inconsistent with sound fiscal, business, or medical
practices and result in an unnecessary cost to the Medicaid or CHIP 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
Member practices that result in unnecessary cost to the Medicaid or CHIP
Program.
Account
Name
means the name of the individual who lives with the child(ren) and who applies
for the Children’s Health Insurance Program coverage on behalf of the
child(ren).
Action
(Medicaid only) means:
(1)
the
denial or limited authorization of a requested Medicaid service, including
the
type or level of service;
(2)
the
reduction, suspension, or termination of a previously authorized
service;
(3)
the
denial in whole or in part of payment for service;
(4)
the
failure to provide services in a timely manner;
(5)
the
failure of an HMO to act within the timeframes set forth in the Contract and
42
C.F.R. §438.408(b); or
(6)
for a
resident of a rural area with only one HMO, the denial of a Medicaid Members’
request to obtain services outside of the Network.
An
Adverse Determination is one type of Action.
Acute
Care
means preventive care, primary care, and other medical care provided under
the
direction of a physician for a condition having a relatively short
duration.
Acute
Care
Hospital means a hospital that provides acute care
services
Adjudicate
means to deny or pay a clean claim.
Administrative
Services
see HMO Administrative Services.
Administrative
Services
Contractor see HHSC Administrative Services
Contractor.
Adverse
Determination means a determination by an HMO or Utilization Review
agent that the Health Care Services furnished, or proposed to be furnished
to a
patient, are not Medically Necessary or not appropriate.
Affiliate
means
any individual or entity owning or holding more than a five percent (5%)
interest in the HMO or in which the HMO owns or holds more than a five percent
(5%) interest; any parent entity; or subsidiary entity of the HMO, regardless
of
the organizational structure of the entity.
Agreement
or Contract means this
formal, written, and legally enforceable contract and amendments thereto between
the Parties.
Allowable
Expenses means all expenses related to the Contract between HHSC
and the HMO that are incurred during the Contract Period, are not reimbursable
or recovered from another source, and that conform with the HHSC Uniform Managed
Care Manual’s “Cost Principles for Administrative Expenses.”
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AAP
means
the
American Academy of Pediatrics.
Approved
Non-Profit Health
Corporation (ANHC) means an organization formed in compliance with
Chapter 844 of the Texas Insurance Code and licensed by TDI. See also
HMO.
Appeal
(Medicaid
only) means the formal process by which a Member or his or her
representative request a review of the HMO’s Action, as defined
above.
Appeal
(CHIP and CHIP
Perinatal Program only) means the formal process by which a
Utilization Review agent addresses Adverse Determinations.
Auxiliary
Aids and
Services includes:
(1)
qualified interpreters or other
effective methods of making aurally delivered materials understood by persons
with hearing impairments;
(2)
taped texts, large print, Braille,
or other effective methods to ensure visually delivered materials are available
to individuals with visual impairments; and
(3)
other effective methods to ensure
that materials (delivered both aurally and visually) are available to those
with
cognitive or other Disabilities affecting communication.
Behavioral
Health Services
means Covered Services for the treatment of mental, emotional,
or
chemical dependency disorders.
Benchmark
means
a target or standard based on historical data or an objective/goal.
Business
Continuity Plan or
BCP means a plan that provides for a quick and smooth restoration
of MIS operations after a disruptive event. BCP includes business
impact analysis, BCP development, testing, awareness, training, and
maintenance. This is a day-to-day plan.
Business
Day
means any day other than a Saturday, Sunday, or a state or federal
holiday on which HHSC’s offices are closed, unless the context clearly indicates
otherwise.
CAHPS
means the
Consumer Assessment of Health Plans Survey. This survey is conducted annually
by
the EQRO.
Call
Coverage
means arrangements made by a facility or an attending physician
with an appropriate level of health care provider who agrees to be available
on
an as-needed basis to provide medically appropriate services for routine, high
risk, or Emergency Medical Conditions or Emergency Behavioral Health Conditions
that present without being scheduled at the facility or when the attending
physician is unavailable.
Capitation
Rate
means a fixed predetermined fee paid by HHSC to the HMO each month
in accordance with the Contract, for each enrolled Member in a defined Rate
Cell, in exchange for the HMO arranging for or providing a defined set of
Covered Services to such a Member, regardless of the amount of Covered Services
used by the enrolled Member.
Capitation
Payment means the aggregate amount paid by HHSC to the HMO on a
monthly basis for the provision of Covered Services to enrolled Members in
accordance with the Capitation Rates in the Contract.
Case
Head means
the head of the household that is applying for Medicaid.
C.F.R.
means
the Code of Federal Regulations.
Chemical Dependency Treatment means treatment provided for a
chemical dependency condition by a Chemical Dependency Treatment facility,
chemical dependency counselor or hospital.
Children’s
Health Insurance
Program or CHIP means the health insurance
program authorized and funded pursuant to Title XXI, Social Security Act (42
U.S.C. §§ 1397aa-1397jj) and administered by HHSC.
Child
(or Children) with
Special Health Care Needs(CSHCN) means a
child (or children) who:
(1)
ranges in age from birth up to age
nineteen (19) years;
(2)
has a serious ongoing illness, a
complex chronic condition, or a disability that has lasted or is anticipated
to
last at least twelve (12) continuous months or more;
(3)
has an illness, condition or
disability that results (or without treatment would be expected to result)
in
limitation of function, activities, or social roles in comparison with accepted
pediatric age-related milestones in the general areas of physical, cognitive,
emotional, and/or social growth and/or development;
(4)
requires regular, ongoing
therapeutic intervention and evaluation by appropriately trained health care
personnel; and
(5)
has a need for health and/or
health-related services at a level significantly above the usual for the child’s
age.
CHIP
HMO Program, or CHIP
Program, means the State of Texas program in which HHSC contracts
with HMOs to provide, arrange for, and coordinate Covered Services for enrolled
CHIP Members.
CHIP
HMOs means
HMOs participating in the CHIP HMO Program.
CHIP
Perinatal HMOs
means HMOs participating in the CHIP Perinatal
Program.
CHIP
Perinatal
Program means the State of Texas program in which
HHSC contracts with HMOs to provide, arrange for, and coordinate Covered
Services for enrolled CHIP Perinate and CHIP Perinate Newborn
Members. Although the CHIP
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Perinatal
Program is part of the CHIP Program, for Contract administration purposes it
is
identified independently in this Contract. An HMO must specifically contract
with HHSC as a CHIP Perinatal HMO in order to participate in this part of the
CHIP Program.
CHIP
Perinate
means a CHIP Perinatal Program Member identified prior to
birth.
CHIPPerinate
Newborn means a CHIP Perinate who has been born alive.
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 claim submitted by a physician or provider for medical care or health
care services rendered to a Member, with the data necessary for the MCO or
subcontracted claims processor to adjudicate and accurately report the claim.
A
Clean Claim must meet all requirements for accurate and complete data as defined
in the appropriate 837-(claim type) encounter guides as follows:
(1)
837 Professional Combined
Implementation Guide
(2)
837 Institutional Combined
Implementation Guide
(3)
837 Professional Companion
Guide
(4)
837 Institutional Companion
Guide
The
HMO may not require a physician or
provider to submit documentation that conflicts with the requirements of Texas
Administrative Code, Title 28, Part 1, Chapter 21, Subchapters C and
T.
CMS
means
the
Centers for Medicare and Medicaid Services, formerly known as the Health Care
Financing Administration (HCFA), which is the federal agency responsible for
administering Medicare and overseeing state administration of Medicaid and
CHIP.
COLA
means the
Cost of Living Adjustment.
Community-based
Long Term
Care Services means services provided to STAR+PLUS Members in their
home or other community based settings necessary to provide assistance with
activities of daily living to allow the Member to remain in the most integrated
setting possible. Community-based Long-term Care includes services available
to
all STAR+PLUS Members as well as those services available only to STAR+PLUS
Members who qualify under the 1915(c) Nursing Facility Waiver
services.
Community
Resource
Coordination Groups (CRCGs) means a statewide system of local
interagency groups, including both public and private providers, which
coordinate services for ”multi-need” children and youth. CRCGs develop
individual service plans for children and adolescents whose needs can be met
only through interagency cooperation. CRCGs address Complex Needs in a model
that promotes local decision-making and ensures that children receive the
integrated combination of social, medical and other services needed to address
their individual problems.
Complainant
means a Member or a treating provider or other individual designated to act
on
behalf of the Member who filed the Complaint.
Complaint
(CHIP and CHIP
Perinatal Programs only) means any dissatisfaction, expressed by a
Complainant, orally or in writing to the HMO, with any aspect of the HMO’s
operation, including, but not limited to, dissatisfaction with plan
administration, procedures related to review or Appeal of an Adverse
Determination, as defined in Texas Insurance Code, Chapter 843, Subchapter
G;
the denial, reduction, or termination of a service for reasons not related
to
medical necessity; the way a service is provided; or disenrollment
decisions. The term does not include misinformation that is resolved
promptly by supplying the appropriate information or clearing up the
misunderstanding to the satisfaction of the CHIP Member.
Complaint
(Medicaid
only) means an expression of dissatisfaction expressed by a
Complainant, orally or in writing to the HMO, about any matter related to the
HMO other than an Action. As provided by 42 C.F.R. §438.400, possible subjects
for Complaints include, but are not limited to, the quality of care of services
provided, and aspects of interpersonal relationships such as rudeness of a
provider or employee, or failure to respect the Medicaid Member’s
rights.
Complex
Need
means a condition or situation resulting in a need for coordination or access
to
services beyond what a PCP would normally provide, triggering the HMO's
determination that Care Coordination is required.
Comprehensive
Care
Program: See definition for Texas Health Steps.
Confidential
Information means any communication or record (whether oral,
written, electronically stored or transmitted, or in any other form) consisting
of:
(1)
Confidential Client information, including HIPAA-defined protected health
information;
(2)
All
non-public budget, expense, payment and other financial
information;
(3)
All
Privileged Work Product;
(4)
All
information designated by HHSC or any other State agency as confidential, and
all information designated as confidential under the
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Texas
Public Information Act, Texas Government Code, Chapter 552;
(5)
The
pricing, payments, and terms and conditions of the Contract, unless disclosed
publicly by HHSC or the State; and
(6)
Information utilized, developed, received, or maintained by HHSC, the HMO,
or
participating State agencies for the purpose of fulfilling a duty or obligation
under this Contract and that has not been disclosed publicly.
Consumer-Directed
Services means the Member or his legal guardian is the employer of
and retains control over the hiring, management, and termination of an
individual providing personal assistance or respite.
Continuity
of
Care means care provided to a Member by the same PCP or specialty
provider to ensure that the delivery of care to the Member remains stable,
and
services are consistent and unduplicated.
Contract
or
Agreement means this formal, written, and legally
enforceable contract and amendments thereto between the Parties.
Contract
Period
or Contract Term means the Initial Contract Period plus
any and all Contract extensions.
Contractor
or
HMO means the HMO that is a party to this Contract and
is an insurer licensed by TDI as an HMO or as an ANHC formed in compliance
with
Chapter 844 of the Texas Insurance Code.
Core
Service Area
(CSA) means the core set Service Area counties defined by HHSC for
the STAR and/or CHIP HMO Programs in which Eligibles will be required to enroll
in an HMO. (See Attachment B-6 to the HHSC Managed Care Contract document for
detailed information on the Service Area counties.)
Copayment
(CHIP
only) means the amount that a Member is required to pay when
utilizing certain benefits within the health care plan. Once the
copayment is made, further payment is not required by the Member.
Corrective
Action
Plan means the detailed written plan that may be required by HHSC
to correct or resolve a deficiency or event causing the assessment of a remedy
or damage against HMO.
Court-Ordered
Commitment means a commitment of a STAR, STAR+PLUS or CHIP Member
to a psychiatric facility for treatment ordered by a court of law pursuant
to
the Texas Health and Safety Code, Title VII Subtitle C.
Covered
Services means Health Care Services the HMO must arrange to provide
to Members, including all services required by the Contract and state and
federal law, and all Value-added Services negotiated by the Parties (see
Attachments B-2, B-2.1, B-2.2 and B-3 of the HHSC
Managed Care Contract relating to “Covered Services” and “Value-added
Services”). Covered Services include Behavioral Health
Services.
Credentialing
means the process of collecting, assessing, and validating qualifications and
other relevant information pertaining to a health care provider to determine
eligibility and to deliver Covered Services.
Cultural
Competency means the ability of individuals and systems to provide
services effectively to people of various cultures, races, ethnic backgrounds,
and religions in a manner that recognizes, values, affirms, and respects the
worth of the individuals and protects and preserves their dignity.
Date
of
Disenrollment means the last day of the last month for which HMO
receives payment for a Member.
Day
means a
calendar day unless specified otherwise.
Default
Enrollment means the process established by HHSC to assign a
mandatory STAR, STAR+PLUS, or CHIP Perinate enrollee who has not selected an
MCO
to an MCO.
Deliverable
means a written or recorded work product or data prepared, developed, or
procured by HMO as part of the Services under the Contract for the use or
benefit of HHSC or the State of Texas.
Delivery
Supplemental
Payment means a one-time per pregnancy supplemental payment for
STAR, CHIP and CHIP Perinatal HMOs.
DADS
means
the
Texas Department of Aging and Disability Services or its successor agency
(formerly Department of Human Services).
DSHS
means the
Texas Department of State Health Services or its successor agency (formerly
Texas Department of Health and Texas Department of Mental Health and Mental
Retardation).
Disease
Management
means a system of coordinated healthcare interventions and
communications for populations with conditions in which patient self-care
efforts are significant.
Disproportionate
Share
Hospital (DSH) means a hospital that serves a higher than average
number of Medicaid and other low-income patients and receives additional
reimbursement from the State.
Disabled
Person or Person
with Disability means a person under sixty-five (65) years of age,
including a child, who qualifies for Medicaid services because of a
disability.
Disability
means a physical or mental impairment that substantially limits one or more
of
an individual’s major life activities, such as caring for oneself, performing
manual tasks, walking, seeing,
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hearing,
speaking, breathing, learning, and/or working.
Disability-related
Access means that facilities are readily accessible to and usable
by individuals with disabilities, and that auxiliary aids and services are
provided to ensure effective communication, in compliance with Title III of
the
Americans with Disabilities Act.
Disaster
Recovery
Plan means the document developed by the HMO that outlines details
for the restoration of the MIS in the event of an emergency or
disaster.
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.
Dual
Eligibles
means Medicaid recipients who are also eligible for Medicare.
ECI
means Early
Childhood Intervention, a federally mandated program for infants and children
under the age of three with or at risk for developmental 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 §621.21 et seq.
EDI
means
electronic data interchange.
Effective
Date means the effective date of this Contract, as specified in the HHSC Managed
Care Contract document.
Effective
Date
of Coverage means the first day of the month for which the HMO has received
payment for a Member.
Eligibles
means
individuals residing in one of the Service Areas and eligible to enroll in
a
STAR, STAR+PLUS, CHIP, or CHIP Perinatal HMO, as applicable.
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:
(1)
requires immediate intervention
and/or medical attention without which Members would present an immediate danger
to themselves or others, or
(2)
which renders Members incapable of
controlling, knowing or understanding the consequences of their
actions.
Emergency
Services means covered inpatient and outpatient services furnished
by a provider that is qualified to furnish such services under the Contract
and
that are needed to evaluate or stabilize an Emergency Medical Condition and/or
an Emergency Behavioral Health Condition, including Post-stabilization Care
Services.
Emergency
Medical
Condition means a medical condition manifesting itself by acute
symptoms of recent onset and 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:
(1)
placing the patient’s health in serious jeopardy;
(2)
serious impairment to bodily functions;
(3)
serious dysfunction of any bodily organ or part;
(4)
serious disfigurement; or
(5)
in
the case of a pregnant women, serious jeopardy to the health of
a woman or her unborn child.
Encounter
means
a Covered Service or group of Covered 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 HHSC by the HMO in accordance with HHSC’s required
format for Medicaid and CHIP HMOs.
Enrollment
Report/Enrollment
File means the daily or monthly list of Eligibles that are enrolled
with an HMO as Members on the day or for the month the report is
issued.
EPSDT
means the
federally mandated Early and Periodic Screening, Diagnosis and Treatment program
contained at 42 U.S.C. 1396d(r). The name has been changed to Texas Health
Steps
(THSteps) in the State of Texas.
ExclusiveProvider
Organization (EPO) means the vendor contracted with HHSC to operate
the CHIP EPO in Texas.
Expansion
Area
means a county or Service Area that has not previously provided healthcare
to
HHSC’s HMO Program Members utilizing a managed care model.
Expansion
Children means children who are generally at least one, but under
age 6, and live in a family whose income is at or below 133 percent of the
federal poverty level (FPL). Children in thiscoverage group have
either elected to bypass TANF or are not eligible for TANF in
Texas.
Experience
Rebate means the portion of the HMO’s net income before taxes that
is returned to the State in accordance with Section 10.11 for the STAR, CHIP
and
CHIP Perinatal Programs and 10.11.1 for the STAR+PLUS Program (“Experience
Rebate”).
Expedited
Appeal means an appeal to the HMO in which the decision is required
quickly based on the Member's health status, and the amount of
time
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necessary
to participate in a standard appeal could jeopardize the Member's life or health
or ability to attain, maintain, or regain maximum function.
Expiration
Date
means the expiration date of this Contract, as specified in HHSC’s Managed Care
Contract document.
External
Quality Review
Organization (EQRO) means the entity that contracts with HHSC to
provide external review of access to and quality of healthcare provided to
Members of HHSC’s HMO Programs.
Fair
Hearing
means the process adopted and implemented by HHSC in 25 T.A.C. Chapter 1, in
compliance with federal regulations and state rules relating to Medicaid Fair
Hearings.
Fee-for-Service
means the traditional Medicaid Health Care Services payment system under which
providers receive a payment for each unit of service according to rules adopted
pursuant to Chapter 32, Texas Human Resources Code.
Force
Majeure
Event means any failure or delay in performance of a duty by a
Party under this Contract that is caused by fire, flood, hurricane, tornadoes,
earthquake, an act of God, an act of war, riot, civil disorder, or any similar
event beyond the reasonable control of such Party and without the fault or
negligence of such Party.
FQHC
means a
Federally Qualified Health Center, certified by CMS to meet the requirements
of
§1861(aa)(3) of the Social Security Act as a federally qualified health
center, that is enrolled as a provider in the Texas Medicaid
program.
FPL means
the Federal Poverty Level.
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.
FSR
means
Financial Statistical Report.
Functionally
Necessary
Covered Services means Community-based Long Term Care services
provided to assist STAR+PLUS Members with activities of daily living based
on a
functional assessment of the Member’s activities of daily living and a
determination of the amount of supplemental supports necessary for the STAR+PLUS
Member to remain independent or in the most integrated setting
possible.
Habilitative
and
Rehabilitative Services means Health Care Services described in
Attachment B-2 that may be required by children who fail to
reach (habilitative) or have lost (rehabilitative) age appropriate developmental
milestones.
Health
Care
Services means the Acute Care, Behavioral Health Care and
health-related services that an enrolled population might reasonably require
in
order to be maintained in good health.
Health
and Human Services
Commission or HHSC means the administrative
agency within the executive department of Texas state government established
under Chapter 531, Texas Government Code, or its designee, including, but not
limited to, the HHS Agencies.
Health-related
Materials are materials developed by the HMO or obtained from a
third party relating to the prevention, diagnosis or treatment of a medical
condition.
HEDIS,
the
Health Plan Employer Data and Information Set, is a registered trademark of
NCQA. HEDIS is a set of standardized performance measures designed to reliably
compare the performance of managed health care plans. HEDIS is sponsored,
supported and maintained by NCQA.
HHS
Agency
means the Texas health and human service agencies subject to HHSC’s oversight
under Chapter 531, Texas Government Code, and their successor
agencies.
HHSC
Administrative Services
Contractor (ASC) means an entity performing HMO administrative
services functions, including member enrollment functions, for STAR, STAR+PLUS,
CHIP, or CHIP Perinatal HMO Programs under contract with HHSC.
HHSC
HMO Programs or HMO
Programs mean the STAR, STAR+PLUS, CHIP, and CHIP Perinatal HMO
Programs.
HHSC
Uniform Managed Care
Manual means the manual published by or on behalf of HHSC that
contains policies and procedures required of all HMOs participating in the
HHSC
Programs.
HIPAA
means
the
Health Insurance Portability and Accountability Act of 1996, P.L. 104-191
(August 21, 1996), as amended or modified.
HMO
or
Contractor means the HMO that is a party to this
Contract, and is either:
(1)
an
insurer licensed by TDI as a Health Maintenance Organization in accordance
with
Chapter 843 of the Texas Insurance Code, or
(2)
a
certified Approved Non-Profit Health Corporation (ANHC) formed in compliance
with Chapter 844 of the Texas Insurance Code.
HMO
Administrative
Services means the performance of services or functions, other than
the direct delivery of Covered Services, necessary for the management of the
delivery of and payment for Covered Services, including but not limited to
Network, utilization, clinical and/or quality management, service authorization,
claims processing, management information systems operation and
reporting.
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HMO’s
Service Area
means all the counties included in any HHSC-defined Core or
Optional Service Area, as applicable to each HMO Program and within which the
HMO has been selected to provide HMO services.
Home
and Community Support
Services Agency or HCSS means an entity licensed to provide home
health, hospice, or personal assistance services provided to individuals in
their own home or independent living environment as prescribed by a physician
or
individualized service plan. Each HCSS must provide clients with a plan of
care
that includes specific services the agency agrees to perform. The agencies
are
licensed and monitored by DADS or its successor.
Hospital
means
a licensed public or private institution as defined by Chapter 241, Texas Health
and Safety Code, or in Subtitle C, Title 7, Texas Health and Safety
Code.
I
ICF-MR
means
an
intermediate care facility for the mentally retarded.
Individual
Family Service
Plan (IFSP) means the plan for services required by the Early
Childhood Intervention (ECI) Program and developed by an interdisciplinary
team.
Initial
Contract Period
means the Effective Date of the Contract through August 31,
2008.
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.
Joint
Interface Plan (JIP)
means a document used to communicate basic system interface
information. This information includes: file structure, data elements,
frequency, media, type of file, receiver and sender of the file, and file I.D.
The JIP must include each of the HMO’s interfaces required to conduct business
under this Contract. The JIP must address the coordination with each of the
HMO’s interface partners to ensure the development and maintenance of the
interface; and the timely transfer of required data elements between contractors
and partners.
Key
HMO Personnel
means the critical management and technical positions identified
by
the HMO in accordance with Article 4.
Linguistic
Access
means translation and interpreter services, for written and spoken
language to ensure effective communication. Linguistic access includes sign
language interpretation, and the provision of other auxiliary aids and services
to persons with disabilities.
Local
Health Department
means a local health department established pursuant to Health
and
Safety Code, Title 2, Local Public Health Reorganization Act
§121.031.
Local
Mental Health
Authority (LMHA) means an entity within a specified region
responsible for planning, policy development, coordination, and resource
development and allocation and for supervising and ensuring the provision of
mental health care services to persons with mental illness in one or more local
service areas.
Major
Population Group
means any population, which represents at least 10% of the
Medicaid, CHIP, and/or CHIP Perinatal Program population in any of the counties
in the Service Area served by the HMO.
Material
Subcontractor
or Major Subcontractor means any entity
that contracts with the HMO for all or part of the HMO Administrative Services,
where the value of the subcontracted HMO Administrative Service(s) exceeds
$100,000, or is reasonablyexpected to exceed $100,000, per State Fiscal
Year. Providers in the HMO’s Provider Network are not Material
Subcontractors.
Mandated
or
Required Services means services that a state is required to offer
to categorically needy clients under a state Medicaid plan.
Marketing
means
any communication from the HMO to a Medicaid or CHIP Eligible who is not
enrolled with the HMO that can reasonably be interpreted as intended to
influence the Eligible to:
(1) enroll
with the HMO; or
(2) not
enroll in, or to disenroll from, another MCO.
Marketing
Materials
means materials that are produced in any medium by or on behalf
of
the HMO and can reasonably be interpreted as intending to market to potential
Members. Health-related Materials are not Marketing
Materials.
MCO
means
managed care organization.
Medicaid
means
the medical assistance entitlement program authorized and funded pursuant to
Title XIX, Social Security Act (42 U.S.C. §1396 et seq.) and administered by
HHSC.
Medicaid
HMOs
means contracted HMOs participating in STAR and/or STAR+PLUS.
Medical
Assistance
Only (MAO) means a person that does not receive SSI
benefits but qualifies financially and functionally for limited Medicaid
assistance.
Medical
Home
means a PCP or specialty care Provider who has accepted the responsibility
for
providing accessible, continuous, comprehensive and coordinated care to Members
participating in a HHSC HMO Program.
Medically
Necessary
means:
(1)
Non-behavioral health related Health Care Services that are:
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(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 health conditions;
(c)
consistent with health care practice guidelines and standards that are endorsed
by professionally recognized health care organizations or governmental
agencies;
(d)
consistent with the diagnoses of the conditions;
(e)
no
more intrusive or restrictive than necessary to provide a proper balance of
safety, effectiveness, and efficiency;
(f)
are
not experimental or investigative; and
(g)
are
not primarily for the convenience of the Member or Provider; and
(2)
Behavioral Health Services that are:
(a)
are
reasonable and necessary for the diagnosis or treatment of a mental health
or
chemical dependency disorder, or to improve, maintain, or 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 that can safely be
provided;
(e)
could
not be omitted without adversely affecting the Member’s mental and/or physical
health or the quality of care rendered;
(f)
are
not experimental or investigative; and
(g)
are
not primarily for the convenience of the Member or Provider.
Member
means a
person who:
(1)
is
entitled to benefits under Title XIX of the Social Security Act and Medicaid,
is
in a Medicaid eligibility category included in the STAR or STAR+PLUS Program,
and is enrolled in the STAR or STAR+PLUS Program and the HMO’s STAR or STAR+PLUS
HMO;
(2)
is
entitled to benefits under Title XIX of the Social Security Act and Medicaid,
is
in a Medicaid eligibility category included as a voluntary participant in the
STAR or STAR+PLUS Program, and is enrolled in the STAR or STAR+PLUS Program
and
the HMO’s STAR or STAR+PLUS HMO;
(3)
has
met CHIP eligibility criteria and is enrolled in the HMO’s CHIP HMO;
or
(4)
has
met CHIP Perinatal Program eligibility criteria and is enrolled in the HMO’s
CHIP Perinatal Program.
Member
Materials means all written materials produced or authorized by the
HMO and distributed to Members or potential members containing information
concerning the HMO Program(s). Member Materials include, but are not limited
to,
Member ID cards, Member handbooks, Provider directories, and Marketing
Materials.
Member
Month
means one Member enrolled with the HMO during any given month. The total Member
Months for each month of a year comprise the annual Member Months.
Member(s)
with Special Health Care Needs (MSHCN) includes a Child or Children
with a Special Health Care Need (CSHCN) and any adult Member who:
(1)
has a
serious ongoing illness, a Chronic or Complex Condition, or a Disability that
has lasted or is anticipated to last for a significant period of time,
and
(2)
requires regular, ongoing therapeutic intervention and evaluation by
appropriately trained health care personnel.
Minimum
Data Set for Home
Care (MDS-HC) means the assessment instrument included in the
Uniform Managed Care Manual that is used to collect data such
as health, social support and service use information on persons receiving
long
term care services outside of an institutional setting.
MIS
means
Management Information System.
National
Committee for
Quality Assurance (NCQA) means the independent organization that
accredits HMOs, managed behavioral health organizations, and accredits and
certifies disease management programs. HEDIS and the Quality Compass are
registered trademarks of NCQA.
Net
Income before
Taxes means an aggregate excess of Revenues over Allowable
Expenses.
Network
or Provider
Network means all Providers that have a contract with the HMO, or
any Subcontractor, for the delivery of Covered Services to the HMO’s Members
under the Contract.
Network
Provider or
Provider means an appropriately credentialed and licensed
individual,
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facility,
agency, institution, organization or other entity, and its employees and
subcontractors, that has a contract with the HMO for the delivery of Covered
Services to the HMO’s Members.
Non-capitated
Services means those Medicaid services identified in Attachment
B-1, Section 8.2.2.8.
Non-provider
Subcontracts means contracts between the HMO and a third party that
performs a function, excluding delivery of health care services, that the HMO
is
required to perform under its Contract with HHSC.
Nursing
Facility Cost
Ceiling means the annualized cost of serving a client in a nursing
facility. A per diem cost is established for each Medicaid nursing facility
resident based on the level of care needed. This level of care is
referred to as the Texas Index for Level of Effort or the TILE
level. The per diem cost is annualized to achieve the nursing
facility ceiling.
Nursing
Facility Level of
Care means the determination that the level of care required to
adequately serve a STAR+PLUS Member is at or above the level of care provided
by
a nursing facility.
OB/GYN
means
obstetrician-gynecologist.
Open
Panel
means Providers who are accepting new patients for the HMO Program(s)
served.
Operational
Start
Date means the first day on which an HMO is responsible for
providing Covered Services to Members of an HMO Program in a Service Area in
exchange for a Capitation Payment under the Contract. The Operational
Start Date may vary per HMO Program and Service Area. The Operational
Start Date(s) applicable to this Contract are set forth in the HHSC Managed
Care
Contract document.
Optional
Service Area
(OSA) means an HHSC defined county or counties, contiguous to a
CSA, in which CHIP or CHIP Perinatal HMOs provide health care coverage to CHIP
Eligibles. The CHIP or CHIP Perinatal HMO must serve the associated Core Service
Area in order to provide coverage in the OSA. The HHSC Managed Care
Contract document includes OSAs, if applicable.
Operations
Phase means the period of time when HMO is responsible for
providing the Covered Services and all related Contract functions for a Service
Area. The Operations Phase begins on the Operational Start Date, and
may vary by HMO Program and Service Area.
Outpatient
Hospital
Services means diagnostic, therapeutic, and rehabilitative services
that are provided to Members in an organized medicalfacility, for less than
a
24-hour period, by or under the direction of a physician. To distinguish between
the types of services being billed, hospitals must indicate a three-digit type
of xxxx (TOB) code in block 4 of the UB-92 claim form. Most commonly for
hospitals, this code will be 131 for an outpatient hospital claims.
Out-of-Network
(OON) means an appropriately licensed individual, facility, agency,
institution, organization or other entity that has not entered into a contract
with the HMO for the delivery of Covered Services to the HMO’s
Members.
Parties
means
HHSC and HMO, collectively.
Party
means
either HHSC or HMO, individually.
Pended
Claim
means a claim for payment, which requires additional information before the
claim can be adjudicated as a clean claim.
Population
Risk
Group means a distinct group of members identified by age, age
range, gender, type of program, or eligibility category.
Post-stabilization
Care
Services means Covered Services, related to an Emergency Medical
Condition that are provided after a Medicaid Member is stabilized in order
to
maintain the stabilized condition, or, under the circumstances described in
42
§§C.F.R. 438.114(b)&(e) and 42 C.F.R. §422.113(c)(iii) to improve or resolve
the Medicaid Member’s condition.
Primary
Care Physician or
Primary Care Provider (PCP) means a physician or provider who has
agreed with the 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.
Provider
types that can be PCPs are
from any of the following practice areas: General Practice, Family Practice,
Internal Medicine, Pediatrics, Obstetrics/Gynecology (OB/GYN), Pediatric and
Family Advanced Practice Nurses (APNs) and Physician Assistants (when practicing
under the supervision of a physician specializing in Family Practice, Internal
Medicine, Pediatrics or Obstetrics/Gynecology who also qualifies as a PCP under
this contract), , Federally Qualified Health Centers (FQHCs), Rural Health
Clinics (RHCs) and similar community clinic s; and specialist physicians who
are
willing to provide a Medical Home to selected Members with special needs and
conditions.
Proposal
means
the proposal submitted by the HMO in response to the RFP.
Provider
or Network
Provider means an appropriately credentialed and licensed
individual, facility, agency, institution, organization or other entity, and
its
employees and subcontractors, that has a contract with the HMO for the delivery
of Covered Services to the HMO’s Members.
Provider
Contract means a contract entered into by a direct provider of
health care services and the HMO or an intermediary entity.
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Provider
Network or Network
means all Providers that have contracted with the HMO for the
applicable HMO Program.
Proxy
Claim
Form means a form submitted by Providers to document services
delivered to Members under a capitated arrangement. It is not a claim for
payment.
Public
Health
Entity means a HHSC Public Health Region, a Local Health
Department, or a hospital district.
Public
Information means information that:
(1)
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
(2)
The governmental body owns or has a
right of access to.
Qualified
and Disabled
Working Individual (QDWI) means an individual whose only Medicaid
benefit is payment of the Medicare Part A premium.
Qualified
Medicare
Beneficiary (QMB) means a Medicare beneficiary whose only Medicaid
benefits are payment of Medicare premiums, deductibles, and coinsurance for
individuals who are entitled to Medicare Part A, whose income does not exceed
100% of the federal poverty level, and whose resources do not exceed twice
the
resource limit of
the
SSI
program.
Quality
Improvement means a system to continuously examine, monitor and
revise processes and systems that support and improve administrative and
clinical functions.
Rate
Cell means
a Population Risk Group for which a Capitation Rate has been
determined.
Rate
Period 1
means the period of time beginning on the Operational Start Date and ending
on
August 31, 2007.
Rate
Period 2
means the period of time beginning on September 1, 2007 and ending on August
31,
2008.
Real-Time
Captioning (also known as CART, Communication Access Real-Time
Translation) means a process by which a trained individual uses a shorthand
machine, a computer, and real-time translation software to type and
simultaneously translate spoken language into text on a computer screen. Real
Time Captioning is provided for individuals who are deaf, have hearing
impairments, or have unintelligible speech. It is usually used to interpret
spoken English into text English but may be used to translate other spoken
languages into text.
Readiness
Review means the assurances made by a selected HMO and the
examination conducted by HHSC, or its agents, of HMO’s ability, preparedness,
and availability to fulfill its obligations under the Contract.
Request
for Proposals
or RFP means the procurement solicitation
instrument issued by HHSC under which this Contract was awarded and all RFP
addenda, corrections or modifications, if any.
Revenue
means
all managed care revenue received by the HMO pursuant to this Contract during
the Contract Period, including retroactive adjustments made by HHSC. This would
include any funds earned on Medicaid or CHIP managed care funds such as
investment income, earned interest, or third party administrator earnings from
services to delegated Networks.
Risk
means the
potential for loss as a result of expenses and costs of the HMO exceeding
payments made by HHSC under the Contract.
Routine
Care
means health care for covered preventive and medically necessary Health Care
Services that are non-emergent or non-urgent.
Rural
Health Clinic
(RHC) means an entity that meets all of the requirements for
designation as a rural health clinic under 1861(aa)(1) of the Social Security
Act and approved for participation in the Texas Medicaid Program.
Service
Coordination means a specialized care management service that is
performed by a Service Coordinator and that includes but is not limited
to:
(1)
identification of needs, including
physical health, mental health services and for STAR+PLUS Members, long term
support services,
(2)
development of a Service Plan to
address those identified needs;
(3)
assistance to ensure timely and a
coordinated access to an array of providers and Covered Services;
(4)
attention to addressing unique
needs of Members; and
(5)
coordination of Plan services with
social and other services delivered outside the Plan, as necessary and
appropriate.
Service
Coordinator
means the person with primary responsibility for providing service
coordination and care management to STAR+PLUS Members.
Scope
of Work
means the description of Services and Deliverables specified in
this Contract, the RFP, the HMO’s Proposal, and any agreed modifications to
these documents.
SDX
means State
Data Exchange.
SED
means
severe emotional disturbance as determined by a Local Mental Health
Authority.
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Service
Area
means the counties included in any HHSC-defined Core and Optional Service Area
as applicable to each HMO Program.
Service
Management is an administrative service in the STAR, CHIP and CHIP
Perinatal Programs performed by the HMO to facilitate development of a Service
Plan and coordination of services among a Member’s PCP, specialty providers and
non-medical providers to ensure Members with Special Health Care Needs and/or
Members needing high-cost treatment have access to, and appropriately utilize,
Medically Necessary Covered Services, Non-capitated Services, and other services
and supports.
Service
Plan
(SP) means an individualized plan developed with and for Members
with Special Health Care Needs, including persons with disabilities or chronic
or complex conditions. The SP includes, but is not limited to, the
following:
(1)
the Member’s history;
(2)
summary of current medical and
social needs and concerns;
(3)
short and long term needs and
goals;
(4)
a list of services required, their
frequency, and
(5)
a description of who will provide
such services.
The
Service Plan should incorporate as
a component of the plan the Individual Family Service Plan (IFSP) for members
in
the Early Childhood Intervention (ECI) Program
The
Service Plan may include
information for services outside the scope of covered benefits such as how
to
access affordable, integrated housing.
Services
means
the tasks, functions, and responsibilities assigned and delegated to the HMO
under this Contract.
Significant
Traditional
Provider or STP (for Medicaid) means primary care providers and
long-term care providers, identified by HHSC as having provided a significant
level of care to Fee-for-Service clients. Disproportionate Share Hospitals
(DSH)
are also Medicaid STPs.
Significant
Traditional
Provider or STP (for CHIP) means primary care providers
participating in the CHIP HMO Program prior to May 2004, and Disproportionate
Share Hospitals (DSH).
Skilled
Nursing Facility
Services (CHIP only) Services provided in a facility that provides
nursing or rehabilitation services and Medical supplies and use of appliances
and equipment furnished by the facility.
Software
means
all operating system and applications software used by the HMO to provide the
Services under this Contract.
SPMI
means
severe and persistent mental illness as determined by the Local Mental Health
Authority.
Specialty
Hospital
means any inpatient hospital that is not a general Acute Care
hospital.
Specialty
Therapy means physical therapy, speech therapy or occupational
therapy.
Specified
Low-Income
Medicare Beneficiary (SLMB) means a Medicare beneficiary whose only
Medicaid benefit is payment of the Medicare Part B premium.
SSA
means the
Social Security Administration.
SSI
Administrative
Fee means the monthly per member per month fee paid to an HMO to
provide administrative services to manage the healthcare of the HMO’s voluntary
SSI beneficiaries. These services are described in more detail under Section
10.10 of this document.
Stabilize
means
to provide such medical care as to assure within reasonable medical probability
that no deterioration of the condition is likely to result from, or occur from,
or occur during discharge, transfer, or admission of the Member.
STAR+PLUS
or STAR+PLUS
Program means the State of Texas Medicaid managed care program in
which HHSC contracts with HMOs to provide, arrange, and coordinate preventive,
primary, acute and long term care Covered Services to adult persons with
disabilities and elderly persons age 65 and over who qualify for Medicaid
through the SSI program and/or the MAO program. Children under age 21, who
qualify for Medicaid through the SSI program, may voluntarily participate in
the
STAR+PLUS program.
STAR+PLUS
HMOs
means contracted HMOs participating in the STAR+PLUS Program.
State Fiscal Year (SFY) means a 12-month period beginning on
September 1 and ending on August 31 the following year.
Subcontract means
any agreement between the HMO and other party to fulfill the requirements of
the
Contract.
Subcontractor
means any individual or entity, including an Affiliate, that has
entered into a Subcontract with HMO.
Subsidiary
means an Affiliate controlled by such person or entity directly or indirectly
through one or more intermediaries.
Supplemental
Security Income
(SSI) means a Federal income supplement program funded by general
tax revenues (not Social Security taxes) designed to help aged, blind and
disabled people with little or no income by providing cash to meet basic needs
for food, clothing and shelter.
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T.A.C.
means
Texas Administrative Code.
TDD
means telecommunication device for the deaf. It is interchangeable with the
term
Teletype machine
or TTY.
TDI
means the
Texas Department of Insurance.
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 the Aid
to
Families with Dependent Children (AFDC) program.
Texas
Health Network (THN)
is the name of the Medicaid primary care case management program
in
Texas.
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 requirements contained in 42 U.S.C.
§1396d(r), and defined and codified at 42 C.F.R. §§440.40 and 441.56-62. HHSC’s
rules are contained in 25 T.A.C., Chapter 33 (relating to Early and Periodic
Screening, Diagnosis and Treatment).
Texas
Medicaid Bulletin
means the bi-monthly update to the Texas Medicaid Provider
Procedures Manual.
Texas
Medicaid Provider
Procedures Manual means the policy and procedures manual published
by or on behalf of HHSC that contains policies and procedures required of all
health care providers who participate in the Texas Medicaid program. The manual
is published annually and is updated bi-monthly by the Texas Medicaid
Bulletin.
Texas
Medicaid Service
Delivery Guide means an attachment to the Texas Medicaid Provider
Procedures Manual.
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 the
Contract (see 1 TAC §354.2301 et seq., relating to Third Party
Resources).
Third
Party Recovery
(TPR) means the recovery of payments on behalf of a Member by HHSC
or the HMO from an individual or entity with the legal responsibility to pay
for
the Covered Services.
TP
40 means
Type Program 40, which is a Medicaid program eligibility type assigned to
pregnant women under 185% of the federal poverty level (FPL).
TP
45 means
Type Program 45, which is a Medicaid program eligibility code assigned to
newborns (under 12 months of age) who are born to mothers who are Medicaid
eligible at the time of the child’s birth.
Transition
Phase includes all activities the HMO is required to perform
between the Contract Effective Date and the Operational Start Date for a Service
Area.
Turnover
Phase
includes all activities the HMO is required to perform in order to close out
the
Contract and/or transition Contract activities and operations for a Service
Area
to HHSC or a subsequent contractor.
Turnover
Plan
means the written plan developed by HMO, approved by HHSC, to be employed during
the Turnover Phase. The Turnover Plan describes HMO’s policies and procedures
that will assure:
(1)
The least disruption in the
delivery of Health Care Services to those Members who are enrolled with the
HMO
during the transition to a subsequent health plan;
(2)
Cooperation with HHSC and the
subsequent health plan in notifying Members of the transition and of their
option to select a new plan, as requested and in the form required or approved
by HHSC; and
(3)
Cooperation with HHSC and the
subsequent health plan in transferring information to the subsequent health
plan, as requested and in the form required or approved by HHSC.
URAC
/American Accreditation
Health Care Commission means the independent organization that
accredits Utilization Review functions and offers a variety of other
accreditation and certification programs for health care
organizations.
Urgent
Behavioral Health
Situation means a behavioral health condition that requires
attention and assessment within twenty-four (24) hours but which does not place
the Member in immediate danger to himself or herself or others and the Member
is
able to cooperate with treatment.
Urgent
Condition means a health condition including an Urgent Behavioral
Health Situation that 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 twenty-four (24) hours by the Member’s PCP or PCP designee to
prevent serious deterioration of the Member’s condition or health.
Utilization
Review means the system for retrospective, concurrent, or
prospective review of the medical necessity and appropriateness of Health Care
Services provided, being provided, or proposed to be provided to a
Member. The term does not include elective requests for clarification
of coverage.
Value-added
Services means additional services for coverage beyond those
specified in the
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RFP. Value-added
Services must be actual health care services or benefits rather than gifts,
incentives, health assessments or educational classes. Temporary phones, cell
phones, additional transportation benefits, and extra home health services
may
be Value-added Services, if approved by HHSC. Best practice
approaches to delivering Covered Services are not considered Value-added
Services.
Waste
means
practices that are not cost-efficient.
Article
3. General Terms &
Conditions
Section
3.01Contract
elements.
(a)
Contract documentation.
The
Contract between the Parties will
consist of the HHSC Managed Care Contract document and all attachments and
amendments.
(b)
Order
of documents.
In
the event of any conflict or
contradiction between or among the contract documents, the documents shall
control in the following order of precedence:
(1)
The final executed HHSC
Managed Care Contract document, and all amendments
thereto;
(2)
HHSC Managed Care Contract
Attachment A– “HHSC’s Uniform Managed Care Contract Terms and
Conditions,” and all amendments thereto;
(3)
HHSC Managed Care Contract
Attachment B– “Scope of Work/Performance Measures,” and all
attachments and amendments thereto;
(4)
The HHSC Uniform Managed
Care Manual, and all attachments and amendments thereto;
(5)
HHSC Managed Care Contract
Attachment C-3– “Agreed Modifications to HMO’s
Proposal;”
(6)
HHSC Managed Care Contract
Attachment C-2, “HMO Supplemental Responses,” and
(7)
HHSC Managed Care Contract
Attachment C-1– “HMO’s Proposal.”
Section
3.02 Term of the Contract.
The
term of the Contract will begin on
the Effective Date and will conclude on the Expiration Date. The Parties may
renew the Contract for an additional period or periods, but the Contract Term
may not exceed a total of eight (8) years. All reserved contract
extensions beyond the Expiration Date will be subject to good faith negotiations
between the Parties and mutual agreement to the extension(s).
Section
3.03Funding.
This
Contract is expressly conditioned
on the availability of state and federal appropriated funds. HMO will have
no
right of action against HHSC in the event that HHSC is unable to perform its
obligations under this Contract as a result of the suspension, termination,
withdrawal, or failure of funding to HHSC or lack of sufficient funding of
HHSC
for any activities or functions contained within the scope of this Contract.
If
funds become unavailable, the provisions of Article 12
(“Remedies and Disputes”) will apply. HHSC will use all reasonable efforts to
ensure that such funds are available, and will negotiate in good faith with
HMO
to resolve any HMO claims for payment that represent accepted Services or
Deliverables that are pending at the time funds become
unavailable. HHSC shall make best efforts to provide reasonable
written advance notice to HMO upon learning that funding for this Contract
may
be unavailable.
Section
3.04Delegation of authority.
Whenever,
by any provision of this
Contract, any right, power, or duty is imposed or conferred on HHSC, the right,
power, or duty so imposed or conferred is possessed and exercised by the
Commissioner unless any such right, power, or duty is specifically delegated
to
the duly appointed agents or employees of HHSC. The Commissioner will reduce
any
such delegation of authority to writing and provide a copy to HMO on
request.
Section
3.05No waiver of sovereign
immunity.
The
Parties expressly agree that no
provision of this Contract is in any way intended to constitute a waiver by
HHSC
or the State of Texas of any immunities from suit or from liability that HHSC
or
the State of Texas may have by operation of law.
Section
3.06Force majeure.
Neither
Party will be liable for any
failure or delay in performing its obligations under the Contract if such
failure or delay is due to any cause beyond the reasonable control of such
Party, including, but not limited to, unusually severe weather, strikes, natural
disasters, fire, civil disturbance, epidemic, war, court order, or acts of
God. The existence of such causes of delay or failure will extend the
period of performance in the exercise of reasonable diligence until after the
causes of delay or failure have been removed. Each Party must inform
the other in writing with proof of receipt within five (5) Business Days of
the
existence of a force majeure event or otherwise waive this right as a
defense.
Section
3.07Publicity.
(a)
HMO may use the name of HHSC, the
State of Texas, any HHS Agency, and the name of the HHSC HMO Program in any
media release, public announcement, or public disclosure relating to
the
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Contract
or its subject matter only if, at least seven (7) calendar days prior to
distributing the material, the HMO submits the information to HHSC for review
and comment. If HHSC has not responded within seven (7) calendar days, the
HMO
may use the submitted information. HHSC reserves the right to object
to and require changes to the publication if, at HHSC’s sole discretion, it
determines that the publication does not accurately reflect the terms of the
Contract or the HMO’s performance under the Contract. .
(b)
HMO will provide HHSC with one (1)
electronic copy of any information described in Subsection 3.07(a) prior to
public release. HMO will provide additional copies, including hard
copies, at the request of HHSC.
(c)
The requirements of Subsection
3.07(a) do not apply to:
(1)
proposals or reports submitted to HHSC, an administrative agency of the State
of
Texas, or a governmental agency or unit of another state or the federal
government;
(2)
information concerning the Contract’s terms, subject matter, and estimated
value:
(a)
in
any report to a governmental body to which the HMO is required by law to report
such information, or
(b)
that
the HMO is otherwise required by law to disclose; and
(3)
Member Materials (the HMO must comply with the Uniform Managed Care
Manual’s provisions regarding the review and approval of Member
Materials).
Section
3.08Assignment.
(a)
Assignment by HMO.
HMO
shall not assign all or any portion
of its rights under or interests in the Contract or delegate any of its duties
without prior written consent of HHSC. Any written request for assignment or
delegation must be accompanied by written acceptance of the assignment or
delegation by the assignee or delegation by the delegate. Except
where otherwise agreed in writing by HHSC, assignment or delegation will not
release HMO from its obligations pursuant to the Contract. An HHSC-approved
Material Subcontract will not be considered to be an assignment or delegation
for purposes of this section.
(b)
Assignment by HHSC.
HMO
understands and agrees HHSC may in
one or more transactions assign, pledge, transfer, or hypothecate the
Contract. This assignment will only be made to another State agency
or a non-State agency that is contracted to perform agency support.
(c)
Assumption.
Each
party to whom a transfer is made
(an "Assignee") must assume all or any part of HMO’S or HHSC's interests in the
Contract, the product, and any documents executed with respect to the Contract,
including, without limitation, its obligation for all or any portion of the
purchase payments, in whole or in part.
Section
3.09Cooperation with other vendors and prospective
vendors.
HHSC
may award supplemental contracts
for work related to the Contract, or any portion thereof. HMO will
reasonably cooperate with such other vendors, and will not commit or permit
any
act that may interfere with the performance of work by any other
vendor.
Section
3.10Renegotiation and reprocurement
rights.
(a)
Renegotiation of Contract terms.
Notwithstanding
anything in the
Contract to the contrary, HHSC may at any time during the term of the Contract
exercise the option to notify HMO that HHSC has elected to renegotiate certain
terms of the Contract. Upon HMO’s receipt of any notice pursuant to this
Section, HMO and HHSC will undertake good faith negotiations of the subject
terms of the Contract, and may execute an amendment to the Contract in
accordance with Article 8.
(b)
Reprocurement of the services or procurement of additional
services.
Notwithstanding
anything in the
Contract to the contrary, whether or not HHSC has accepted or rejected HMO’s
Services and/or Deliverables provided during any period of the Contract, HHSC
may at any time issue requests for proposals or offers to other potential
contractors for performance of any portion of the Scope of Work covered by
the
Contract or Scope of Work similar or comparable to the Scope of Work performed
by HMO under the Contract.
(c)
Termination rights upon reprocurement.
If
HHSC elects to procure the Services
or Deliverables or any portion of the Services or Deliverables from another
vendor in accordance with this Section, HHSC will have the termination rights
set forth in Article 12 (“Remedies and Disputes”).
Section
3.11 RFP errors and
omissions.
HMO
will not take advantage of any
errors and/or omissions in the RFP or the resulting Contract. HMO
must promptly notify HHSC of any such errors and/or omissions that are
discovered.
Section
3.12Attorneys’ fees.
In
the event of any litigation, appeal,
or other legal action to enforce any provision of the Contract, HMO agrees
to
pay all reasonable expenses of such action, including attorneys' fees and costs,
if HHSC is the prevailing Party.
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Section
3.13Preferences under service
contracts.
HMO
is required in performing the
Contract to purchase products and materials produced in the State of Texas
when
they are available at a price and time comparable to products and materials
produced outside the State.
Section
3.14Time of the essence.
In
consideration of the need to ensure uninterrupted and continuous HHSC HMO
Program performance, time is of the essence in the performance of the Scope
of
Work under the Contract.
Section
3.15Notice
(a)
Any notice or other legal
communication required or permitted to be made or given by either Party pursuant
to the Contract will be in writing and in English, and will be deemed to have
been given:
(1)
Three
(3) Business Days after the date of mailing if sent by registered or certified
U.S. mail, postage prepaid, with return receipt requested;
(2)
When
transmitted if sent by facsimile, provided a confirmation of transmission is
produced by the sending machine; or
(3)
When
delivered if delivered personally or sent by express courier
service.
(b)
The notices described in this
Section may not be sent by electronic mail.
(c)
All notices must be sent to the
Project Manager identified in the HHSC Managed
CareContract document. In addition, legal
notices must be sent to the Legal Contact identified in the HHSC Managed
Care Contract document.
(d)
Routine communications that are
administrative in nature will be provided in a manner agreed to by the
Parties.
Article
4. Contract Administration &
Management
Section
4.01Qualifications, retention and replacement of HMO
employees.
HMO
agrees to maintain the
organizational and administrative capacity and capabilities to carry out all
duties and responsibilities under this Contract. The personnel HMO
assigns to perform the duties and responsibilities under this Contract will
be
properly trained and qualified for the functions they are to perform.
Notwithstanding transfer or turnover of personnel, HMO remains obligated to
perform all duties and responsibilities under this Contract without degradation
and in accordance with the terms of this Contract.
Section
4.02 HMO’s Key Personnel.
(a)
Designation of Key Personnel.
HMO
must designate key management and
technical personnel who will be assigned to the Contract. For the purposes
of
this requirement, Key Personnel are those with management responsibility or
principal technical responsibility for the following functional areas for each
HMO Program included within the scope of the Contract:
(1)
Member Services;
(2)
Management Information
Systems;
(3)
Claims Processing,
(4)
Provider Network Development and
Management;
(5)
Benefit Administration and
Utilization and Care Management;
(6)
Quality Improvement;
(7)
Behavioral Health
Services;
(8)
Financial Functions;
(9)
Reporting;
(10)
Executive Director(s) for
applicable HHSC HMO Program(s) as defined in Section 4.03
(“Executive Director”);
(11)
Medical Director(s) for applicable
HHSC HMO Program(s) as defined in Section 4.04 (“Medical
Director”); and
(12)
STAR+PLUS Service Coordinators for
STAR+PLUS HMOs as defined in Section 4.04.1 (“STAR+PLUS Service
Coordinator.”)
(b)
Support and Replacement of Key Personnel.
The
HMO must maintain, throughout the
Contract Term, the ability to supply its Key Personnel with the required
resources necessary to meet Contract requirements and comply with applicable
law. The HMO must ensure project continuity by timely replacement of Key
Personnel, if necessary, with a sufficient number of persons having the
requisite skills, experience and other qualifications. Regardless of
specific personnel changes, the HMO must maintain the overall level of
expertise, experience, and skill reflected in the Key HMO Personnel job
descriptions and qualifications included in the HMO’s proposal.
(c)
Notification of replacement of Key Personnel.
HMO
must notify HHSC within fifteen
(15) Business Days of any change in Key Personnel. Hiring or replacement of
Key
Personnel must conform to all Contract requirements. If HHSC determines that
a
satisfactory working relationship cannot be established between certain Key
Personnel and HHSC, it will notify the HMO in writing. Upon receipt
of HHSC’s notice, HHSC and HMO will attempt to resolve HHSC’s concerns on a
mutually agreeable basis.
Section
4.03Executive Director.
(a)
The HMO must employ a qualified
individual to serve as the Executive Director for its HHSC HMO Program(s).
Such
Executive Director must be
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employed
full-time by the HMO, be primarily dedicated to HHSC HMO Program(s), and must
hold a Senior Executive or Management position in the HMO’s organization, except
that the HMO may propose an alternate structure for the Executive Director
position, subject to HHSC’s prior review and written approval.
(b)
The Executive Director must be
authorized and empowered to represent the HMO regarding all matters pertaining
to the Contract prior to such representation. The Executive Director must act
asliaison between the HMO and the HHSC and must have responsibilities that
include, but are not limited to, the following:
(1)
ensuring the HMO’s compliance with
the terms of the Contract, including securing and coordinating resources
necessary for such compliance;
(2)
receiving and responding to all
inquiries and requests made by HHSC related to the Contract, in the time frames
and formats specified by HHSC. Where practicable, HHSC must consult with the
HMO
to establish time frames and formats reasonably acceptable to the
Parties;
(3)
attending and participating in
regular HHSC HMO Executive Director meetings or conference calls;
(4)
attending and participating in
regular HHSC Regional Advisory Committees (RACs) for managed care (the Executive
Director may designate key personnel to attend a RAC if the Executive Director
is unable to attend);
(5)
making best efforts to promptly
resolve any issues identified either by the HMO or HHSC that may arise and
are
related to the Contract;
(6)
meeting with HHSC representative(s)
on a periodic or as needed basis to review the HMO’s performance and resolve
issues, and
(7)
meeting with HHSC at the time and
place requested by HHSC, if HHSC determines that the HMO is not in compliance
with the requirements of the Contract.
Section
4.04Medical Director.
(a)
The HMO must have a qualified
individual to serve as the Medical Director for its HHSC HMO Program(s). The
Medical Director must be currently licensed in Texas under the Texas Medical
Board as an M.D. or D.O. with no restrictions or other licensure limitations.
The Medical Director must comply with the requirements of 28 T.A.C. §11.1606 and
all applicable federal and state statutes and regulations.
(b)
The Medical Director, or his or her
physician designee meeting the same Contract qualifications that apply to the
Medical Director, must be available by telephone 24 hours a day, seven days
a
week, for Utilization Review decisions. The Medical Director, and his/her
designee, must either possess expertise with Behavioral Health Services, or
ready access to such expertise to ensure timely and appropriate medical
decisions for Members, including after regular business hours.
(c)
The Medical Director, or his or her
physician designee meeting the same Contract qualifications that apply to the
Medical Director, must be authorized and empowered to represent the HMO
regarding clinical issues, Utilization Review and quality of care inquiries.
The
Medical Director, or his or her physician designee, must exercise independent
medical judgment in all decisions relating to medical necessity. The HMO must
ensure that its decisions relating to medical necessity are not adversely
influenced by fiscal management decisions. HHSC may conduct reviews of decisions
relating to medical necessity upon reasonable notice.
Section
4.04.1STAR+PLUS Service
Coordinator
(a)
STAR+PLUS HMOs must employ as
Service Coordinators persons experienced in meeting the needs of people with
disabilities, old and young, and vulnerable populations who have Chronic or
Complex Conditions. A Service Coordinator must have an undergraduate and/or
graduate degree in social work or a related field, or be a Registered Nurse,
Licensed Vocational Nurse, Advanced Nurse Practitioner, or a Physician
Assistant.
(b)
The STAR+PLUS HMO must monitor the
Service Coordinator’s workload and performance to ensure that he or she is able
to perform all necessary Service Coordination functions for the STAR+PLUS
Members in a timely manner.
(c)
The Service Coordinator must be
responsible for working with the Member or his or her representative, the PCP
and other Providers to develop a seamless package of care in which primary,
Acute Care, and long-term care service needs are met through a single,
understandable, rational plan. Each Member’s Service Plan must also be well
coordinated with the Member’s family and community support systems, including
Independent Living Centers, Area Agencies on Aging and Mental Retardation
Authorities. The Service Plan should be agreed to and signed by the Member
or
the Member’s representative to indicate agreement with the plan. The plan should
promote consumer direction and self-determination and may include information
for services outside the scope of Covered Services such as how to access
affordable, integrated housing. For dual eligible Members, the STAR+PLUS HMO
is
responsible for meeting the Member’s Community Long- term Care Service
needs.
(d)
The STAR+PLUS HMO must empower its
Service Coordinators to authorize the provision and
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delivery
of Covered Services, including Community Long-term Care Covered
Services.
Section
4.05Responsibility for HMO personnel and
Subcontractors.
(a)
HMO’s employees and Subcontractors
will not in any sense be considered employees of HHSC or the State of Texas,
but
will be considered for all purposes as the HMO’s employees or its
Subcontractor’s employees, as applicable.
(b)
Except as expressly provided in
this Contract, neither HMO nor any of HMO’s employees or Subcontractors may act
in any sense as agents or representatives of HHSC or the State of
Texas.
(c)
HMO agrees that anyone employed by
HMO to fulfill the terms of the Contract is an employee of HMO and remains
under
HMO’s sole direction and control. HMO assumes sole and full responsibility for
its acts and the acts of its employees and Subcontractors.
(d)
HMO agrees that any claim on behalf
of any person arising out of employment or alleged employment by the
HMO (including, but not limited to, claims of discrimination against
HMO, its officers, or its agents) is the sole responsibility of HMO and not
the
responsibility of HHSC. HMO will indemnify and hold harmless the
State from any and all claims asserted against the State arising out of such
employment or alleged employment by the HMO. HMO understands that any
person who alleges a claim arising out of employment or alleged employment
by
HMO will not be entitled to any compensation, rights, or benefits from HHSC
(including, but not limited to, tenure rights, medical and hospital care, sick
and annual/vacation leave, severance pay, or retirement benefits).
(e)
HMO agrees to be responsible for
the following in respect to its employees:
(1)
Damages incurred by HMO’s employees
within the scope of their duties under the Contract; and
(2)
Determination of the hours to be
worked and the duties to be performed by HMO’s employees.
(f)
HMO agrees and will inform its
employees and Subcontractor(s) that there is no right of subrogation,
contribution, or indemnification against HHSC for any duty owed to them by
HMO
pursuant to this Contract or any judgment rendered against the HMO. HHSC’s
liability to the HMO’s employees, agents and Subcontractors, if any, will be
governed by the Texas Tort Claims Act, as amended or modified (TEX. CIV. PRACT.
& REM. CODE §101.001et seq.).
(g)
HMO understands that HHSC does not
assume liability for the actions of, or judgments rendered against, the HMO,
its
employees, agents or Subcontractors. HMO agrees that it has no right
to indemnification or contribution from HHSC for any such judgments rendered
against HMO or its Subcontractors.
Section
4.06Cooperation with HHSC and state administrative
agencies.
(a)
Cooperation with Other MCOs.
HMO
agrees to reasonably cooperate with
and work with the other MCOs in the HHSC HMO Programs, Subcontractors, and
third-party representatives as requested by HHSC. To the extent permitted by
HHSC’s financial and personnel resources, HHSC agrees to reasonably cooperate
with HMO and to use its best efforts to ensure that other HHSC contractors
reasonably cooperate with the HMO.
(b)
Cooperation with state and federal administrative agencies.
HMO
must ensure that HMO personnel will
cooperate with HHSC or other state or federal administrative agency personnel
at
no charge to HHSC for purposes relating to the administration of HHSC programs
including, but not limited to the following purposes:
(1)
The
investigation and prosecution of fraud, abuse, and waste in the HHSC
programs;
(2)
Audit, inspection, or other investigative purposes; and
(3)
Testimony in judicial or quasi-judicial proceedings relating to the Services
and/or Deliverables under this Contract or other delivery of information to
HHSC
or other agencies’ investigators or legal staff.
Section
4.07Conduct of HMO
personnel.
(a)
While performing the Scope of Work,
HMO’s personnel and Subcontractors must:
(1)
Comply with applicable State rules and regulations and HHSC’s requests regarding
personal and professional conduct generally applicable to the service locations;
and
(2)
Otherwise conduct themselves in a businesslike and professional
manner.
(b)
If HHSC determines in good faith
that a particular employee or Subcontractor is not conducting himself or herself
in accordance with this Contract, HHSC may provide HMO with notice and
documentation concerning such conduct. Upon receipt of such notice,
HMO must promptly investigate the matter and take appropriate action that may
include:
(1)
Removing the employee from the project;
(2)
Providing HHSC with written notice of such removal; and
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(3)
Replacing the employee with a similarly qualified individual acceptable to
HHSC.
(c)
Nothing in the Contract will
prevent HMO, at the request of HHSC, from replacing any personnel who are not
adequately performing their assigned responsibilities or who, in the reasonable
opinion of HHSC’s Project Manager, after consultation with HMO, are unable to
work effectively with the members of the HHSC’s staff. In such event, HMO will
provide replacement personnel with equal or greater skills and qualifications
as
soon as reasonably practicable. Replacement of Key Personnel will be
subject to HHSC review. The Parties will work together in the event of any
such
replacement so as not to disrupt the overall project schedule.
(d)
HMO agrees that anyone employed by
HMO to fulfill the terms of the Contract remains under HMO’s sole direction and
control.
(e)
HMO shall have policies regarding
disciplinary action for all employees who have failed to comply with federal
and/or state laws and the HMO’s standards of conduct, policies and procedures,
and Contract requirements. HMO shall have policies regarding
disciplinary action for all employees who have engaged in illegal or unethical
conduct.
Section
4.08Subcontractors.
(a)
HMO remains fully responsible for
the obligations, services, and functions performed by its Subcontractors to
the
same extent as if such obligations, services, and functions were performed
by
HMO’s employees, and for purposes of this Contract such work will be deemed work
performed by HMO. HHSC reserves the right to require the replacement
of any Subcontractor found by HHSC to be unacceptable and unable to meet the
requirements of the Contract, and to object to the selection of a
Subcontractor.
(b)
HMO must:
(1)
actively monitor the quality of care and services, as well as the quality of
reporting data, provided under a Subcontract;
(2)
notify HHSC in writing at least 60 days prior to reprocurement of services
provided by any Material Subcontractor;
(3)
notify HHSC in writing within three (3) Business Days after making a
decision to terminate a Subcontract with a Material Subcontractor or
upon receiving notification from the Material Subcontractor of its intent to
terminate such Subcontract;
(4)
notify HHSC in writing within one (1) Business Day of making a decision to
enter
into a Subcontract with a new Material Subcontractor, or a new Subcontract
for
newly procured services of an existing Material Subcontractor; and
(5)
provide HHSC with a copy of TDI filings of delegation agreements.
(c)
During the Contract Period,
Readiness Reviews by HHSC or its designated agent may occur if:
(1)
a new
Material Subcontractor is employed by HMO;
(2)
an
existing Material Subcontractor provides services in a new Service
Area;
(3)
an
existing Material Subcontractor provides services for a new HMO
Program;
(4)
an
existing Material Subcontractor changes locations or changes its MIS and or
operational functions;
(5)
an
existing Material Subcontractor changes one or more of its MIS subsystems,
claims processing or operational functions; or
(6)
a
Readiness Review is requested by HHSC.
The
HMO
must submit information required by HHSC for each proposed Material
Subcontractor as indicated in Attachment B-1, Section 7. Refer
to Attachment B-1, Sections 8.1.1.2 and
8.1.18
for additional information regarding HMO Readiness Reviews during the Contract
Period.
(d)
HMO must not disclose Confidential
Information of HHSC or the State of Texas to a Subcontractor unless and until
such Subcontractor has agreed in writing to protect the confidentiality of
such
Confidential Information in the manner required of HMO under this
Contract.
(e)HMO
must identify any Subcontractor
that is a subsidiary or entity formed after the Effective Date of the Contract,
whether or not an Affiliate of HMO, substantiate the proposed Subcontractor’s
ability to perform the subcontracted Services, and certify to HHSC that no
loss
of service will occur as a result of the performance of such
Subcontractor. The HMO will assume responsibility for all contractual
responsibilities whether or not the HMO performs them. Further, HHSC considers
the HMO to be the sole point of contact with regard to contractual matters,
including payment of any and all charges resulting from the
Contract.
(f)
Except as provided herein, all
Subcontracts must be in writing and must provide HHSC the right to examine
the
Subcontract and all Subcontractor records relating to the Contract and the
Subcontract. This requirement does not apply to agreements with
utility or mail service providers.
(g)
A Subcontract whereby HMO receives
rebates, recoupments, discounts, payments, or other consideration from a
Subcontractor (including without
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limitation
Affiliates) pursuant to or related to the execution of this Contract must be
in
writing and must provide HHSC the right to examine the Subcontract and all
records relating to such consideration.
(h)
All Subcontracts described in
subsections (f) and (g) must show the dollar amount, the percentage
of money, or the value of any consideration that HMO pays to or receives from
the Subcontractor.
(i)
HMO must submit a copy of each
Material Subcontract executed prior to the Effective Date of the Contract to
HHSC no later than thirty (30) days after the Effective Date of the
Contract. For Material Subcontracts executed after the Effective Date
of the Contract, HMO must submit a copy to HHSC no later than five (5) Business
Days after execution.
(j)
Network Provider Contracts must
include the mandatory provisions included in the HHSC Uniform Managed
Care Manual.
(k)
HHSC reserves the right to reject
any Subcontract or require changes to any provisions that do not comply with
the
requirements or duties and responsibilities of this Contract or create
significant barriers for HHSC in monitoring compliance with this
Contract.
Section
4.09HHSC’s ability to contract with
Subcontractors.
The
HMO may not limit or restrict,
through a covenant not to compete, employment contract or other contractual
arrangement, HHSC’s ability to contract with Subcontractors or former employees
of the HMO.
Section
4.10HMO Agreements with Third
Parties
(a)
If the HMO intends to report
compensation paid to a third party (including without limitation an Affiliate)
as an Allowable Expense under this Contract, and the compensation paid to the
third party exceeds $100,000, or is reasonably anticipated to exceed $100,000,
in a State Fiscal Year, then the HMO’s agreement with the third party must be in
writing. The agreement must provide HHSC the right to examine the
agreement and all records relating to the agreement.
(b)
All agreements whereby HMO receives
rebates, recoupments, discounts, payments, or other consideration from a third
party (including without limitation Affiliates) pursuant to or related to the
execution of this Contract, must be in writing and must provide HHSC the right
to examine the agreement and all records relating to such consideration.
(c)
All agreements described in
subsections (a) and (b) must show the dollar amount, the percentage of money,
or
the value of any consideration that HMO pays to or receives from the third
party.
(d)
HMO must submit a copy of each
third party agreement described in subsections (a) and (b) to HHSC. If the
third
party agreement is entered into prior to the Effective Date of the Contract,
HMO
must submit a copy no later than thirty (30) days after the Effective Date
of
the Contract. If the third party agreement is executed after the
Effective Date of the Contract, HMO must submit a copy no later than five (5)
Business Days after execution. (e) For third party agreements valued under
$100,000 per State Fiscal Year that are reported as Allowable Expenses, the
HMO
must maintain financial records and data sufficient to verify the accuracy
of
such expenses in accordance with the requirements of Article
9.
(f)
HHSC reserves the right to reject
any third party agreement or require changes to any provisions that do not
comply with the requirements or duties and responsibilities of this Contract
or
create significant barriers for HHSC in monitoring compliance with this
Contract.
(g)
This section shall not apply to
Provider Contracts, or agreements with utility or mail service
providers.
Article
5. Member Eligibility & Enrollment
Section
5.01Eligibility
Determination
The
State or its designee will make
eligibility determinations for each of the HHSC HMO Programs.
Section
5.02Member Enrollment &
Disenrollment.
(a)
The HHSC Administrative Services
Contractor will enroll and disenroll eligible individuals in the HMO Program.
To
enroll in an HMO, the Member’s permanent residence must be located within the
HMO’s Service Area. The HMO is not allowed to induce or accept disenrollment
from a Member. The HMO must refer the Member to the HHSC Administrative Services
Contractor.
(b)
HHSC makes no guarantees or
representations to the HMO regarding the number of eligible Members who will
ultimately be enrolled into the HMO or the length of time any such enrolling
Members remain enrolled with the HMO beyond the minimum mandatory enrollment
periods established for each HHSC HMO Program.
(c)
The HHSC Administrative Services
Contractor will electronically transmit to the HMO new Member information and
change information applicable to active Members.
(d)
As described in the following
Sections, depending on the HMO Program, special conditions may also apply to
enrollment and span of coverage for the HMO.
(e)
HMO has a limited right to request
a Member be disenrolled from HMO without the Member’s consent. HHSC must approve
any HMO request for disenrollment of a Member for cause. HHSC
may
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permit
disenrollment of a Member under the following circumstances:
(1)
Member misuses or loans Member’s HMO membership card to another person to obtain
services.
(2)
Member is disruptive, unruly, threatening or uncooperative to the extent that
Member’s membership seriously impairs HMO’s or Provider’s ability to provide
services to Member or to obtain new Members, and Member’s behavior is not caused
by a physical or behavioral health condition.
(3)
Member steadfastly refuses to comply with managed care restrictions (e.g.,
repeatedly using emergency room in combination with refusing to allow HMO to
treat the underlying medical condition).
(4)
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.
(5)
For
STAR+PLUS HMOs, under limited conditions, the HMO may request disenrollment
of
members who are totally dependent on a ventilator or who have been diagnosed
with End Stage Renal Disease.
(f)
HHSC must notify the Member of
HHSC’s decision to disenroll the Member if all reasonable measures have failed
to remedy the problem.
(g)
If the Member disagrees with the
decision to disenroll the Member from HMO, HHSC must notify the Member of the
availability of the Complaint procedure and, for Medicaid Members, HHSC’s Fair
Hearing process.
(h)
HMO cannot request a disenrollment
based on adverse change in the member’s health status or utilization of services
that are Medically Necessary for treatment of a member’s condition.
(i)
Upon implementation of the
Comprehensive Healthcare Program for Xxxxxx Care, STAR and CHIP Members taken
into conservatorship by the Department of Family and Protective Services (DFPS)
will be disenrolled effective the date of conservatorship.
Section
5.03STAR enrollment for pregnant women and
infants.
(a)
The HHSC Administrative Services
Contractor will retroactively enroll some pregnant Members in a Medicaid HMO
based on their date of eligibility.
(b)
The HHSC Administrative Services
Contractor will enroll newborns born to Medicaid eligible mothers who are
enrolled in a STAR HMO in the same HMO for 90 days following the date of birth,
unless the mother requests a plan change as a special exception. The
Administrative Service Contractor will consider such requests on a case-by-case
basis. The HHSC Administrative Services Contractor will retroactively, to date
of birth, enroll newborns in the applicable STAR HMO.
Section
5.04 CHIP eligibility and
enrollment.
(a)
Continuous coverage.
Except
as provided in 1 T.A.C.
§370.307, a child who is CHIP-eligible will have six (6) months of continuous
coverage. Children enrolling in CHIP for the first time, or returning to CHIP
after disenrollment, will be subject to a waiting period before coverage
actually begins, except as provided in 1 T.A.C. §370.46. The waiting period for
a child is determined by the date on which he/she is found eligible for CHIP,
and extends for a duration of three months. If the child is found
eligible for CHIP on or before the 15th day of a month, then the waiting period
begins on the first day of that same month. If the child is found
eligible on or after the 16th day of a month, then the waiting period begins
on
the first day of the next month.
(b)
Pregnant Members and Infants.
(1)
The HHSC Administrative Contractor
will refer pregnant CHIP Members, with the exception of Legal Permanent
Residents and other legally qualified aliens barred from Medicaid due to federal
eligibility restrictions, to Medicaid for eligibility determinations. Those
CHIP
Members who are determined to be Medicaid Eligible will be disenrolled from
HMO’s CHIP plan. Medicaid coverage will be coordinated to begin after CHIP
eligibility ends to avoid gaps in health care coverage.
(2)
In the event the HMO remains
unaware of a Member’s pregnancy until delivery, the delivery will be covered by
CHIP. Babies are automatically enrolled in the mother’s CHIP health
plan at birth with CHIP eligibility and re-enrollment following the timeframe
as
that of the mother. The HHSC Administrative Services Contractor will then set
the Member’s eligibility expiration date at the later of (1) the end of the
second month following the month of the baby’s birth or (2) the Member’s
original eligibility expiration date.
Section
5.04.1CHIP Perinatal eligibility, enrollment, and
disenrollment
(a)
The HHSC Administrative Contractor
will electronically transmit to the HMO new CHIPPerinate Member information
based on the appropriate CHIP Perinate or CHIP Perinate Newborn Rate
Cell. There is no waiting period for CHIP Perinatal Program
Members.
(b)
CHIP Perinate Newborns are eligible
for 12 months continuous enrollment, beginning with the month of enrollment
as a
CHIP Perinate (month of enrollment plus 11 months). A CHIP
Perinate
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Newborn
will maintain coverage in his or her CHIP Perinatal health plan.
(c)
If only one CHIP Perinatal HMO
operates in a Service Area, HHSC will automatically enroll a prospective member
in that CHIP Perinatal HMO. If multiple CHIP Perinatal HMOs offer
coverage in the Service Area, HHSC will send an enrollment packet to the
prospective Member’s household. If the household of a prospective
member does not make a selection within 15 calendar days, the HHSC
Administrative Services Contractor will notify the household that the
prospective member has been assigned to a CHIP Perinatal HMO (“Default
Enrollment”). When this occurs the household has 30 calendar days to
select another CHIP Perinatal HMO for the Member.
(d)
HHSC’s Administrative Services
Contractor will assign prospective members to CHIP Perinatal HMOs in a Service
Area in a rotational basis. Should HHSC implement one or more administrative
rules governing the Default Enrollment processes, such administrative rules
will
take precedence over the Default Enrollment process set forth
herein.
(e)
When a member of a household
enrolls in the CHIP Perinatal Program, all traditional CHIP members in the
household will be disenrolled from their current health plans and prospectively
enrolled in the CHIP Perinatal Program Member’s health plan. All
members of the household must remain in the same health plan through the end
of
the CHIP Perinatal Program Member’s enrollment period.
(f)
In the 10th month of the CHIP
Perinate Newborn’s coverage, the family will receive a CHIP renewal
form. The family must complete and submit the renewal form, which
will be pre-populated to include the CHIP Perinate Newborn’s and the CHIP
Program Members’ information. Once the child’s CHIP Perinatal Program
coverage expires, the child will be added to his or her siblings’ existing CHIP
program case.
Section
5.05Span of Coverage
(a)
Medicaid HMOs.
(1)
HHSC will conduct continuous open
enrollment for Medicaid Eligibles and the HMO must accept all persons who choose
to enroll as Members in the HMO or who are assigned as Members in the HMO by
HHSC, without regard to the Member’s health status, inpatient status, or any
other factor.
(2)
Members who are disenrolled because
they are temporarily ineligible for Medicaid will be automatically re-enrolled
into the same health plan, if available. Temporary loss of
eligibility is defined as a period of six months or less.
(3)
A Member cannot change from one
Medicaid HMO to another Medicaid HMO during an inpatient hospital
stay. Medicaid HMOs are responsible for professional charges during
every month for which the HMO receives a full capitation for a
Member.
(4)
The payor responsible for the
hospital charges at the start of an Inpatient Stay remains responsible for
hospital charges until the time of discharge, or until such time that there
is a
loss of Medicaid eligibility. Medicaid HMOs are not responsible for
any services after the effective date of loss of Medicaid
eligibility.
(b)
CHIP
HMOs.
If
a CHIP Member’s Effective Date of
Coverage occurs while the CHIP Member is confined in a hospital, HMO is
responsible for the CHIP Member’s costs of Covered Services beginning on the
Effective Date of Coverage. If a CHIP Member is disenrolled while the
CHIP Member is confined in a hospital, HMO’s responsibility for the CHIP
Member’s costs of Covered Services terminates on the Date of
Disenrollment.
(c)
CHIP
Perinatal HMOs.
If
a CHIP Perinate’s Effective Date of
Coverage occurs while the CHIP Perinate is confined in a Hospital, HMO is
responsible for the CHIP Perinate’s costs of Covered Services beginning on the
Effective Date of Coverage. If a CHIP Perinate is disenrolled while the CHIP
Perinate is confined in a Hospital, the HMO’s responsibility for the CHIP
Perinate’s costs of Covered Services terminates on the Date of
Disenrollment.
Section
5.06Verification of Member
Eligibility.
Medicaid
MCOs are prohibited from
entering into an agreement to share information regarding their Members with
an
external vendor that provides verification of Medicaid recipients’ eligibility
to Medicaid providers. All such external vendors must contract with
the State and obtain eligibility information from the State.
Section
5.07Special Temporary STAR Default
Process
(a)
STAR HMOs that did not contract
with HHSC prior to the Effective Date of the Contract to provide Medicaid Health
Care Services will be assigned a limited number of Medicaid-eligibles, who
have
not actively made a STAR HMO choice, for a finite period. The number
will vary by Service Area as set forth below. To the extent possible,
the special default assignment will be based on each eligible’s prior history
with a PCP and geographic proximity to a PCP.
(b)
For the Bexar, Dallas, El Paso,
Harris, Tarrant, and Xxxxxx Service Areas, the special default process will
begin with the Operational Start Date and conclude when the HMO has achieved
an
enrollment
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of
15,000
mandatory STAR members, or at the end of six months, whichever comes
first.
(c)
For the Lubbock Service Area, the
special default process will begin with the Operational Start Date and conclude
when the HMO has achieved an enrollment of 5,000 mandatory STAR members, or
at
the end of six months, whichever comes first.
(d)
Special default periods may be
extended for one or more Service Areas if consistent with HHSC administrative
rules.
(e)
This Section does not apply to the
Nueces Service Area.
Section
5.08Special Temporary STAR+PLUS Default
Process
(a)
STAR+PLUS HMOs that did not
contract with HHSC to provide STAR+PLUS services in Xxxxxx County prior to
the
Effective Date of the Contract will be assigned a limited number of STAR+PLUS
Medicaid-eligibles in Xxxxxx County, who have not actively made a STAR+PLUS
HMO
choice, for a finite period. To the extent possible, the special default
assignment will be based on each eligible's prior history with a PCP and
geographic proximity to a PCP.
(b)
For the Xxxxxx Service Area, the
special default process will begin on the Operational Start Date. All defaults
for Xxxxxx County will be awarded to the new HMO during the special default
process. The special default process will conclude at the end of the first
6-month period following the Operational Start Date, or when the HMO has
achieved a total enrollment of 8,000 STAR+PLUS Members for the entire Xxxxxx
Service Area (includes Xxxxxx and Xxxxxx Contiguous counties), whichever comes
first.
(c)The
special default process will
apply to Xxxxxx County only. The Xxxxxx Contiguous counties will follow the
standard default process.
(d)This
Section does not apply to the
Bexar, Nueces or Xxxxxx Service Areas for STAR+PLUS.
Article
6. Service Levels & Performance Measurement
Section
6.01Performance measurement.
Satisfactory
performance of this
Contract will be measured by:
(a)
Adherence to this Contract,
including all representations and warranties;
(b)
Delivery of the Services and
Deliverables described in Attachment B;
(c)
Results of audits performed by HHSC
or its representatives in accordance with Article 9 (“Audit and Financial
Compliance”);
(d)
Timeliness, completeness, and
accuracy of required reports; and
(e)
Achievement of performance measures
developed by HMO and HHSC and as modified from time to time by written agreement
during the term of this Contract.
Article
7. Governing Law & Regulations
Section
7.01Governing law and venue.
This
Contract is governed by the laws
of the State of Texas and interpreted in accordance with Texas
law. Provided HMO first complies with the procedures set forth in
Section 12.13 (“Dispute Resolution,”) proper venue for claims arising from this
Contract will be in the State District Court of Xxxxxx County,
Texas.
Section
7.02HMO responsibility for compliance with laws and
regulations.
(a)
HMO must comply, to the
satisfaction of HHSC, with all provisions set forth in this Contract, all
applicable provisions of state and federal laws, rules, regulations, federal
waivers, policies and guidelines, and any court-ordered consent decrees,
settlement agreements, or other court orders that govern the performance of
the
Scope of Work including, but not limited to:
(1)
Titles XIX and XXI of the Social
Security Act;
(2)
Chapters 62 and 63, Texas Health
and Safety Code;
(3)
Chapters 531 and 533, Texas
Government Code;
(4)
42 C.F.R. Parts 417 and 457, as
applicable;
(5)
45 C.F.R. Parts 74 and
92;
(6)
48 C.F.R. Part 31, or OMB Circular
A-122, based on whether the entity is for-profit or nonprofit;
(7)
1 T.A.C. Part 15, Chapters 361,
370, 3491, and 392; and
(8)
all State and Federal tax laws,
State and Federal employment laws, State and Federal regulatory requirements,
and licensing provisions.
(b)
The Parties acknowledge that the
federal and/or state laws, rules, regulations, policies, or guidelines, and
court-ordered consent decrees, settlement agreements, or other court orders
that
affect the performance of the Scope of Work may change from time to time or
be
added, judicially interpreted, or amended by competent authority. HMO
acknowledges that the HMO Programs will be subject to continuous change during
the term of the Contract and, except as provided in Section 8.02, HMO has
provided for or will provide for adequate resources, at no additional charge
to
HHSC, to reasonably accommodate such changes. The Parties further
acknowledge that HMO was selected, in part, because of its expertise,
experience, and knowledge concerning applicable Federal and/or state
laws,
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regulations,
policies, or guidelines that affect the performance of the Scope of
Work. In keeping with HHSC’s reliance on this knowledge and
expertise, HMO is responsible for identifying the impact of changes in
applicable Federal or state legislative enactments and regulations that affect
the performance of the Scope of Work or the State’s use of the Services and
Deliverables. HMO must timely notify HHSC of such changes and must work with
HHSC to identify the impact of such changes on how the State uses the Services
and Deliverables.
(c)
HHSC will notify HMO of any changes
in applicable law, regulation, policy, or guidelines that HHSC becomes aware
of
in the ordinary course of its business.
(d)
HMO is responsible for any fines,
penalties, or disallowances imposed on the State or HMO arising from any
noncompliance with the laws and regulations relating to the delivery of the
Services or Deliverables by the HMO, its Subcontractors or agents.
(e)
HMO is responsible for ensuring
each of its employees, agents or Subcontractors who provide Services under
the
Contract are properly licensed, certified, and/or have proper permits to perform
any activity related to the Services.
(f)
HMO warrants that the Services and
Deliverables will comply with all applicable Federal, State, and County laws,
regulations, codes, ordinances, guidelines, and policies. HMO will
indemnify HHSC from and against any losses, liability, claims, damages,
penalties, costs, fees, or expenses arising from or in connection with HMO’s
failure to comply with or violation of any such law, regulation, code,
ordinance, or policy.
Section
7.03TDI licensure/ANHC certification and
solvency.
(a)
Licensure
HMO
must be either licensed by the TDI
as an HMO or a certified ANHC in all counties for the Service
Areas included within the scope of the Contract.
(b)
Solvency
HMO
must maintain compliance with the
Texas Insurance Code and rules promulgated and administered by the TDI requiring
a fiscally sound operation. HMO must have a plan and takeappropriate
measures to ensure adequate provision against the risk of insolvency as required
by TDI. Such provision must be adequate to provide for the following in the
event of insolvency:
(1)
continuation of benefits, until the time of discharge, to Members who are
confined on the date of insolvency in a Hospital or other inpatient
facility;
(2)
payment to unaffiliated health care providers and affiliated health care
providers whose agreements do not contain member “hold harmless” clauses
acceptable to TDI, and
(3)
continuation of benefits for the duration of the Contract period for which
HHSC
has paid a Capitation Payment.
Provision
against the risk of insolvency must be made by establishing adequate reserves,
insurance or other guarantees in full compliance with all financial requirements
of TDI.
Section
7.04Immigration Reform and Control Act of
1986.
HMO
shall comply with the requirements
of the Immigration Reform and Control Act of 1986 and the Immigration Act of
1990 (8 X.X.X. §0000, et seq.) regarding employment verification and retention
of verification forms for any individual(s) hired on or after November 6, 1986,
who will perform any labor or services under this Contract.
Section
7.05Compliance with state and federal
anti-discrimination laws.
HMO
shall comply with Title VI of the
Civil Rights Act of 1964, Executive Order 11246 (Public Law 88-352), Section
504
of the Rehabilitation Act of 1973 (Public Law 93-112), the Americans with
Disabilities Act of 1990 (Public Law 101-336), and all amendments to each,
and
all requirements imposed by the regulations issued pursuant to these
Acts. In addition, HMO shall comply with Title 40, Chapter 73 of the
Texas Administrative Code, “Civil Rights,” to the extent applicable to this
Contract. These provide in part that no persons in the United States
must, 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 provided by Federal or State funding,
or otherwise be subjected to any discrimination.
Section
7.06Environmental protection
laws.
HMO
shall comply with the applicable
provisions of federal environmental protection laws as described in this
Section:
(a)
Pro-Children Act of 1994.
HMO
shall comply with the Pro-Children
Act of 1994 (20 X.X.X. §0000 et seq.), as applicable, regarding the provision of
a smoke-free workplace and promoting the non-use of all tobacco
products.
(b)
National Environmental Policy Act of 1969.
HMO
shall comply with any applicable
provisions relating to the institution of environmental quality control measures
contained in the National Environmental Policy Act of 1969 (42 X.X.X. §0000 et
seq.) and Executive Order 11514 (“Protection and Enhancement of Environmental
Quality”).
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(c)
Clean
Air Act and Water Pollution Control Act regulations.
HMO
shall comply with any applicable
provisions relating to required notification of facilities violating the
requirements of Executive Order 11738 (“Providing for Administration of the
Clean Air Act and the Federal Water Pollution Control Act with Respect to
Federal Contracts, Grants, or Loans”).
(d)
State
Clean Air Implementation Plan.
HMO
shall comply with any applicable
provisions requiring conformity of federal actions to State (Clean Air)
Implementation Plans under §176(c) of the Clean Air Act of 1955, as amended (42
U.S.C. §740 et seq.).
(e)
Safe
Drinking Water Act of 1974.
HMO
shall comply with applicable
provisions relating to the protection of underground sources of drinking water
under the Safe Drinking Water Act of 1974, as amended (21 U.S.C. § 349; 42
U.S.C. §§ 300f to 300j-9).
Section
7.07HIPAA.
HMO
shall comply with applicable
provisions of HIPAA. This includes, but is not limited to, the requirement
that
the HMO’s MIS system comply with applicable certificate of coverage and data
specification and reporting requirements promulgated pursuant to HIPAA. HMO
must
comply with HIPAA EDI requirements.
Article
8. Amendments & Modifications
Section
8.01Mutual agreement.
This
Contract may be amended at any
time by mutual agreement of the Parties. The amendment must be in
writing and signed by individuals with authority to bind the
Parties.
Section
8.02Changes in law or
contract.
If
Federal or State laws, rules,
regulations, policies or guidelines are adopted, promulgated, judicially
interpreted or changed, or if contracts are entered or changed, the effect
of
which is to alter the ability of either Party to fulfill its obligations under
this Contract, the Parties will promptly negotiate in good faith appropriate
modifications or alterations to the Contract and any schedule(s) or
attachment(s) made a part of this Contract. Such modifications or alterations
must be in writing and signed by individuals with authority to bind the parties,
equitably adjust the terms and conditions of this Contract, and must be limited
to those provisions of this Contract affected by the change.
Section
8.03Modifications as a remedy.
This
Contract may be modified under the
terms of Article 12 ( “Remedies and Disputes”).
Section
8.04Modifications upon renewal or extension of
Contract.
(a)
If HHSC seeks modifications to the
Contract as a condition of any Contract extension, HHSC’s notice to HMO will
specify those modifications to the Scope of Work, the Contract pricing terms,
or
other Contract terms and conditions.
(b)
HMO must respond to HHSC’s proposed
modification within the timeframe specified by HHSC, generally within thirty
(30) days of receipt. Upon receipt of HMO’s response to the proposed
modifications, HHSC may enter into negotiations with HMO to arrive at mutually
agreeable Contract amendments. In the event that HHSC determines that the
Parties will be unable to reach agreement on mutually satisfactory contract
modifications, then HHSC will provide written notice to HMO of its intent not
to
extend the Contract beyond the Contract Term then in effect.
Section
8.05Modification of HHSC Uniform Managed Care
Manual.
(a)
HHSC will provide HMO with at least
thirty (30)
days
advance written notice before implementing a substantive and material change
in
the HHSC Uniform Managed Care Manual (a change that materially and substantively
alters the HMO’s ability to fulfill its obligations under the
Contract). The Uniform Managed Care Manual, and all modifications
thereto made during the Contract Term, are incorporated by reference into this
Contract. HHSC will provide HMO with a reasonable amount of time to
comment on such changes, generally at least ten (10) Business
Days. HHSC is not required to provide advance written notice of
changes that are not material and substantive in nature, such as corrections
of
clerical errors or policy clarifications.
(b)
The Parties agree to work in good
faith to resolve disagreements concerning material and substantive changes
to
the HHSC Uniform Managed Care Manual. If the Parties are unable to
resolve issues relating to material and substantive changes, then either Party
may terminate the agreement in accordance with Article 12
(“Remedies and Disputes”).
(c)
Changes will be effective on the
date specified in HHSC’s written notice, which will not be earlier than the
HMO’s response deadline, and such changes will be incorporated into the HHSC
Uniform Managed Care Manual. If the HMO has raised an objection to a
material and substantive change to the HHSC Uniform Managed Care Manual and
submitted a notice of termination in accordance with Section
12.04(d), HHSC will not enforce the policy change during the period of
time between the receipt of the notice and the date of Contract
termination.
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Section
8.06 CMS approval of Medicaid amendments
The
implementation of amendments,
modifications, and changes to STAR and STAR+PLUS HMO contracts is subject to
the
approval of the Centers for Medicare and Medicaid Services (“CMS.”)
Section
8.07Required compliance with amendment and modification
procedures.
No
different or additional services,
work, or products will be authorized or performed except as authorized by this
Article. No waiver of any term, covenant, or condition of this
Contract will be valid unless executed in compliance with this
Article. HMO will not be entitled to payment for any services, work
or products that are not authorized by a properly executed Contract amendment
or
modification.
Article
9. Audit & Financial
Compliance
Section
9.01Financial record retention and audit.
HMO
agrees to maintain, and require its
Subcontractors to maintain, supporting financial information and documents
that
are adequate to ensure that payment is made and the Experience Rebate is
calculated in accordance with applicable Federal and State requirements, and
are
sufficient to ensure the accuracy and validity of HMO invoices. Such documents,
including all original claims forms, will be maintained and retained by HMO
or
its Subcontractors for a period of five (5) years after the Contract Expiration
Date or until the resolution of all litigation, claim, financial management
review or audit pertaining to this Contract, whichever is longer.
Section
9.02 Access to records, books, and documents.
(a)
Upon reasonable notice, HMO must
provide, and cause its Subcontractors to provide, the officials and entities
identified in this Section with prompt, reasonable, and adequate access to
any
records, books, documents, and papers that are related to the performance of
the
Scope of Work.
(b)
HMO and its Subcontractors must
provide the access described in this Section upon HHSC’s
request. This request may be for, but is not limited to, the
following purposes:
(1)
Examination;
(2)
Audit;
(3)
Investigation;
(4)
Contract administration; or
(5)
The
making of copies, excerpts, or transcripts.
(c)
The access required must be
provided to the following officials and/or entities:
(1)
The
United States Department of Health and Human Services or its
designee;
(2)
The
Comptroller General of the United States or its designee;
(3)
HMO
Program personnel from HHSC or its designee;
(4)
The
Office of Inspector General;
(5)
Any
independent verification and validation contractor or quality assurance
contractor acting on behalf of HHSC;
(6)
The
Office of the State Auditor of Texas or its designee;
(7)
A
State or Federal law enforcement agency;
(8)
A
special or general investigating committee of the Texas Legislature or its
designee; and
(9)
Any
other state or federal entity identified by HHSC, or any other entity engaged
by
HHSC.
(d)
HMO agrees to provide the access
described wherever HMO maintains such books, records, and supporting
documentation. HMO further agrees to provide such access in
reasonable comfort and to provide any furnishings, equipment, and other
conveniences deemed reasonably necessary to fulfill the purposes described
in
this Section. HMO will require its Subcontractors to provide
comparable access and accommodations.
Section
9.03Audits of Services, Deliverables and
inspections.
(a)
Upon reasonable notice from HHSC,
HMO will provide, and will cause its Subcontractors to provide, such auditors
and inspectors as HHSC may from time to time designate, with access
to:
(1)
HMO
service locations, facilities, or installations; and
(2)
HMO
Software and Equipment.
(b)
The access described in this
Section will be for the purpose of examining, auditing, or
investigating:
(1)
HMO’s
capacity to bear the risk of potential financial losses;
(2)
the
Services and Deliverables provided;
(3)
a
determination of the amounts payable under this Contract;
(4)
detection of fraud, waste and/or abuse; or
(5)
other
purposes HHSC deems necessary to perform its regulatory function and/or enforce
the provisions of this Contract.
(c)
HMO must provide, as part of the
Scope of Work, any assistance that such auditors and inspectors reasonably
may
require to complete such audits or inspections.
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(d)
If, as a result of an audit or
review of payments made to the HMO, HHSC discovers a payment error or
overcharge, HHSC will notify the HMO of such error or
overcharge. HHSC will be entitled to recover such funds as an offset
to future payments to the HMO, or to collect such funds directly from the HMO.
HMO must return funds owed to HHSC within thirty (30) days after receiving
notice of the error or overcharge, or interest will accrue on the amount
due. HHSC will calculate interest at the Department of Treasury’s
Median Rate (resulting from the Treasury’s auction of 13-week bills) for the
week in which liability is assessed. In the event that an audit reveals that
errors in reporting by the HMO have resulted in errors in payments to the HMO
or
errors in the calculation of the Experience Rebate, the HMO will indemnify
HHSC
for any losses resulting from such errors, including the cost of
audit.
Section
9.04SAO Audit
The
HMO
understands that acceptance of funds under this Contract acts as acceptance
of
the authority of the State Auditor’s Office (“SAO”), or any successor agency, to
conduct an investigation in connection with those funds. The HMO
further agrees to cooperate fully with the SAO or its successor in the conduct
of the audit or investigation, including providing all records
requested. The HMO will ensure that this clause concerning the
authority to audit funds received indirectly by Subcontractors through HMO
and
the requirement to cooperate is included in any Subcontract it awards, and
in
any third party agreements described in Section 4.10 (a-b).
Section
9.05Response/compliance with audit or inspection
findings.
(a)
HMO must take action to ensure its
or a Subcontractor’s compliance with or correction of any finding of
noncompliance with any law, regulation, audit requirement, or generally accepted
accounting principle relating to the Services and Deliverables or any other
deficiency contained in any audit, review, or inspection conducted under this
Article. This action will include HMO’S delivery to HHSC, for HHSC’S
approval, a Corrective Action Plan that addresses deficiencies identified in
any
audit(s), review(s), or inspection(s) within thirty (30)calendar days of the
close of the audit(s), review(s), or inspection(s).
(b)
HMO must bear the expense of
compliance with any finding of noncompliance under this Section that
is:
(1)
Required by Texas or Federal law, regulation, rule or other audit requirement
relating to HMO's business;
(2)
Performed by HMO as part of the Services or Deliverables; or
(3)
Necessary due to HMO's noncompliance with any law, regulation, rule or audit
requirement imposed on HMO.
(c)
As part of the Scope of Work, HMO
must provide to HHSC upon request a copy of those portions of HMO's and its
Subcontractors' internal audit reports relating to the Services and Deliverables
provided to HHSC under the Contract.
Article
10. Terms & Conditions of
Payment
Section
10.01 Calculation of monthly
Capitation Payment.
(a)
This is a Risk-based
contract. For each applicable HMO Program, HHSC will pay the HMO
fixed monthly Capitation Payments based on the number of eligible and enrolled
Members. HHSC will calculate the monthly Capitation Payments by multiplying
the
number of Members by each applicable Member Rate Cell. In
consideration of the Monthly Capitation Payment(s), the HMO agrees to provide
the Services and Deliverables described in this Contract.
(b)
HMO will be required to provide
timely financial and statistical information necessary in the Capitation Rate
determination process. Encounter Data provided by HMO must conform to
all HHSC requirements. Encounter Data containing non-compliant information,
including, but not limited to, inaccurate client or member identification
numbers, inaccurate provider identification numbers, or diagnosis or procedures
codes insufficient to adequately describe the diagnosis or medical procedure
performed, will not be considered in the HMO’s experience for rate-setting
purposes.
(c)
Information or data, including
complete and accurate Encounter Data, as requested by HHSC for rate-setting
purposes, must be provided to HHSC: (1) within thirty (30) days of receipt
of
the letter from HHSC requesting the information or data; and (2) no later than
March 31st of each year.
(d)
The fixed monthly Capitation Rate
consists of the following components:
(1)
an
amount for Health Care Services performed during the month;
(2)
an
amount for administering the program,
(3)
an
amount for the HMO’s Risk margin, and
(4)
with
respect to the Medicaid program,pass through funds for high-volume
providers.
Capitation
Rates for each HMO Program may vary by Service Area and MCO. HHSC
will employ or retain qualified actuaries to perform data analysis and calculate
the Capitation Rates for each Rate Period.
(e)
HMO understands and expressly
assumes the risks associated with the performance of the duties and
responsibilities under this Contract, including the failure, termination or
suspension of funding to HHSC, delays or denials of required
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approvals,
and cost overruns not reasonably attributable to HHSC.
Section
10.02Time and Manner of
Payment.
(a)
During the Contract Term and
beginning after the Operational Start Date, HHSC will pay the monthly Capitation
Payments by the 10th Business Day of each month.
(b)
The HMO must accept Capitation
Payments by direct deposit into the HMO’s account.
(c)
HHSC may adjust the monthly
Capitation Payment to the HMO in the case of an overpayment to the HMO, for
Experience Rebate amounts due and unpaid, and if money damages are assessed
in
accordance with Article 12 (“Remedies and
Disputes”).
(d)
HHSC’s payment of monthly
Capitation Payments is subject to availability of federal and state
appropriations. If appropriations are not available to pay the full monthly
Capitation Payment, HHSC may:
(1)
equitably adjust Capitation Payments for all participating Contractors, and
reduce scope of service requirements as appropriate in accordance with
Article 8, or
(2)
terminate the Contract in accordance with Article 12 (“Remedies
and Disputes”).
Section
10.03Certification of Capitation
Rates.
HHSC
will employ or retain a qualified
actuary to certify the actuarial soundness of the Capitation Rates contained
in
this Contract. HHSC will also employ or retain a qualified actuary to
certify all revisions or modifications to the Capitation Rates.
Section
10.04Modification of Capitation
Rates.
The
Parties expressly understand and
agree that the agreed Capitation Rates are subject to modification in accordance
with Article 8 (“Amendments and Modifications,”) if changes in state or federal
laws, rules, regulations or policies affect the rates or the actuarial soundness
of the rates. HHSC will provide the HMO notice of a modification to
the Capitation Rates 60 days prior to the effective date of the change, unless
HHSC determines that circumstances warrant a shorter notice
period. If the HMO does not accept the rate change, either Party may
terminate the Contract in accordance with Article 12 (“Remedies
and Disputes”).
Section
10.05STAR Capitation
Structure.
(a)
STAR
Rate Cells.
STAR
Capitation Rates are defined on a
per Member per month basis by Rate Cells and Service Areas. STAR Rate Cells
are:
(1)
TANF
adults;
(2)
TANF
children over 12 months of age;
(3)
Expansion children over 12 months of age;
(4)
Newborns less than or equal to 12 months of age;
(5)
TANF
children less than or equal to 12 months of age;
(6)
Expansion children less than or equal to 12 months of age;
(7)
Federal mandate children; and
(8)
Pregnant women.
(b)
STAR
Capitation Rate development:
(1)
Capitation Rates for Rate Periods 1 and 2 for Service Areas with historical
STAR
Program participation.
For
Service Areas where HHSC operated the STAR Program prior to the Effective Date
of this Contract, HHSC will develop base Capitation Rates by analyzing
historical STAR Encounter Data and financial data for the Service
Area. This analysis will apply to all MCOs in the Service Area,
including MCOs that have no historical STAR Program participation in the Service
Area. The analysis will include a review of historical enrollment and
claims experience information; any changes to Covered Services and covered
populations; rate changes specified by the Texas Legislature; and any other
relevant information. If the HMO participated in the STAR Program in the Service
Area prior to the Effective Date of this Contract, HHSC may modify the Service
Area base Capitation Rates using diagnosis-based risk adjusters to yield the
final Capitation Rates.
(2)
Capitation Rates for Rate Periods 1 and 2 for Service Areas with no historical
STAR Program participation.
For
Service Areas where HHSC has not operated the STAR Program prior to the
Effective Date of this Contract, HHSC will establish base Capitation Rates
for
Rate Periods 1 and 2 by analyzing Fee-for-Service claims data for the Service
Area. This analysis will include a review of historical enrollment
and claims experience information; any changes to Covered Services and covered
populations; rate changes specified by the Texas Legislature; and any other
relevant information.
(3)
Capitation Rates for subsequent Rate Periods for Service Areas with no
historical STAR Program participation.
For
Service Areas where HHSC has not operated the STAR Program prior to the
Effective Date of this Contract, HHSC will establish base Capitation Rates
for
the Rate Periods following Rate Period 2 by analyzing historical STAR Encounter
Data and financial data for the Service Area. This analysis will
include a review of historical enrollment and
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claims
experience information; any changes to Covered Services and covered populations;
rate changes specified by the Texas Legislature; and any other relevant
information.
(c)
Acuity adjustment.
HHSC
may evaluate and implement an
acuity adjustment methodology, or alternative reasonable methodology, that
appropriately reimburses the HMO for acuity and cost differences that deviate
from that of the community average, if HHSC in its sole discretion determines
that such a methodology is reasonable and appropriate. The community
average is a uniform rate for all HMOs in a Service Area, and is determined
by
combining all the experience for all HMOs in a Service Area to get an average
rate for the Service Area.
Value-added
Services will not be included in the rate-setting process.
Section
10.05.1 STAR+PLUS Capitation
Structure.
(a)
STAR+PLUS Rate Cells.
STAR+PLUS
Capitation Rates are defined
on a per Member per month basis by Rate Cells.
STAR+PLUS
Rate Cells are based on client category as follows:
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(1)
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Medicaid
Only Standard Rate
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(2)
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Medicaid
Only 1915 (c) Nursing Facility Waiver
Rate
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(3)
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Dual
Eligible Standard Rate
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(4)
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Dual
Eligible 1915(c) Nursing Facility Waiver
Rate
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(5)
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Nursing
Facility – Medicaid only
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(6)
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Nursing
Facility - Dual Eligible
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These
Rate Cells are subject to change after Rate Period 2.
(b)
STAR+PLUS Capitation Rates
For
All Service Areas, HHSC
will establish base Capitation Rates by Service Area based on fee-for-service
experience in the counties included in the Service Area. For the base Capitation
Rate in the Xxxxxx Service Area, the encounter data from existing STAR+PLUS
plans in Xxxxxx County will be blended with the fee-for-service experience
from
the balance of counties in the Xxxxxx Service Area. HHSC may adjust the base
Capitation Rate by the HMO’s Case Mix Index to yield the final Capitation
Rates.
HHSC
reserves the right to trend
forward these rates until sufficient Encounter Data is available to base
Capitation Rates on Encounter Data.
(c)
Delay
in Increased Capitation Level for Certain Members Receiving Waiver
Services
Once
a current HMO Member has been
certified to receive STAR+PLUS Waiver (SPW) services, there is a two-month
delay
before the HMO will begin receiving the higher capitation payment.
Non-Waiver
Members who qualify for
STAR+PLUS based on eligibility for SPW services and Waiver recipients who
transfer from another region will not be subject to this two-month delay in
the
increased capitation payment.
All
SPW recipients will be registered
into Service Authorization System Online (SASO). The Premium Payment
System (PPS) will process data from the SASO system in establishing a Member’s
correct capitation payment.
Section
10.06CHIP Capitation Rates
Structure.
(a)
CHIP
Rate Cells.
CHIP
Capitation Rates are defined on a
per Member per month basis by the Rate Cells applicable to a Service
Area. CHIP Rate Cells are based on the Member’s age group as
follows:
(1)
under
age one (1);
(2)
ages
one (1) through five (5);
(3)
ages
six (6) through fourteen (14); and
(4)
ages
fifteen (15) through eighteen (18).
(b)
CHIP
Capitation Rate development:
HHSC
will establish base Capitation
Rates by analyzing Encounter Data and financial data for each Service
Area. This analysis will include a review of historical enrollment
and claims experience information; any changes to Covered Services and covered
populations; rate changes specified by the Texas Legislature; and any other
relevant information. HHSC may modify the Service Area base
Capitation Rate using diagnosis based risk adjusters to yield the final
Capitation Rates.
(c)
Acuity adjustment.
HHSC
may evaluate and implement an
acuity adjustment methodology, or alternative reasonable methodology, that
appropriately reimburses the HMO for acuity and cost differences that deviate
from that of the community average, if HHSC in its sole discretion determines
that such a methodology is reasonable and appropriate. The community
average is a uniform rate for all HMOs in a Service Area, and is determined
by
combining all the experience for all HMOs in a Service Area to get an average
rate for the Service Area.
(d)
Value-added Services will not be included in the rate-setting
process.
Section
10.06.1 CHIP Perinatal Program Capitation
Structure.
(a)
CHIP
Perinatal Program Rate Cells.
CHIP
Perinatal Capitation Rates are
defined on a per Member per month basis by the Rate Cells applicable to a
Service Area. CHIP Perinatal Rate
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Cells
are
based on the Member’s birth status and household income as follows:
(1)
CHIP Perinate 0% - 185% of
FPL;
(2)
CHIP Perinate 186% - 200% of
FPL;
(3)
CHIP Perinate Newborn 0% - 185% of
FPL; and
4)
CHIP Perinate Newborn 186% - 200% of
FPL.
(b)
CHIP
Perinatal Program Capitation Rate Development
(1)
Until such time as adequate
encounter data is available to set rates, CHIP Perinatal Program
capitation
rates will be established based on experience from comparable populations in
the
Medicaid Fee-for-Service and STAR programs. This analysis will
include: a review of historical enrollment and claims experience information;
changes to Covered Services and covered populations; rate changes specified
by
the Texas Legislature; and any other relevant information. HHSC may
modify the Service Area based Capitation Rate using diagnosis-based risk
adjusters to yield the final Capitation Rates.
(2)
Effective 4/1/07, on a prospective
basis, the monthly premium rate for Perinatal expectant mothers at or below
185%
of FPL has been increased. The rate increase is to be passed on to all
physicians involved in the labor with delivery for members at or below 185%
FPL.
The average increase for the fee schedule for the procedure codes related to
labor with delivery is 26.1%.
(c)
Value-added Services will not be included in the rate-setting
process.
Section
10.07 HMO input during rate setting process.
(1)
In Service Areas with historical
STAR or CHIP Program participation, HMO must provide certified Encounter Data
and financial data as prescribed in HHSC’s Uniform Managed Care
Manual. Such information may include, without limitation: claims lag
information by Rate Cell, capitation expenses, and stop loss reinsurance
expenses. HHSC may request clarification or for additional financial
information from the HMO. HHSC will notify the HMO of the deadline
for submitting a response, which will include a reasonable amount of time for
response.
(2)
HHSC will allow the HMO to review
and comment on data used by HHSC to determine base Capitation
Rates. In Service Areas with no historical STAR Program
participation, this will include Fee-for-Service data for Rate Periods 1 and
2. HHSC will notify the HMO of deadline for submitting comments,
which will include a reasonable amount of time for response. HHSC
will not consider comments received after the deadline in its rate
analysis.
(3)
During the rate setting process,
HHSC will conduct at least two (2) meetings with the HMO. HHSC may
conduct the meetings in person, via teleconference, or by another method deemed
appropriate by HHSC. Prior to the first meeting, HHSC will provide
the HMO with proposed Capitation Rates. During the first meeting, HHSC will
describe the process used to generate the proposed Capitation Rates, discuss
major changes in the rate setting process, and receive input from the
HMO. HHSC will notify the HMO of the deadline for submitting
comments, which will include a reasonable amount of time to review and comment
on the proposed Capitation Rates and rate setting process. After
reviewing such comments, HHSC will conduct a second meeting to discuss the
final
Capitation Rates and changes resulting from HMO comments, if any.
Section
10.08 Adjustments to
CapitationPayments.
(a)
Recoupment.
HHSC
may recoup a payment made to the
HMO for a Member if:
(1)
the Member is enrolled into the HMO
in error, and the HMO provided no Covered Services to the Member during the
month for which the payment was made;
(2)
the Member moves outside the United
States, and the HMO has not provided Covered Services to the Member during
the
month for which the payment was made;
(3)
the Member dies before the first
day of the month for which the payment was made; or
(4)
a Medicaid Member’s eligibility
status or program type is changed, corrected as a result of error, or is
retroactively adjusted.
(b)
Appeal of recoupment.
The
HMO may appeal the recoupment
or adjustment of capitations in the above circumstances using the HHSC dispute
resolution process set forth in Section 12.13, (“Dispute
Resolution”).
Section
10.09Delivery Supplemental Payment for CHIP, CHIP
Perinatal and STAR HMOs.
(a)
The Delivery Supplemental Payment
(DSP) is a function of the average delivery cost in each Service
Area. Delivery costs include facility and professional
charges.
(b)
CHIP and STAR HMOs will receive a
Delivery Supplemental Payment (DSP) from HHSC for each live or stillbirth by
a
Member. CHIP Perinatal HMOs will receive a DSP from HHSC for each live or
stillbirth by a mother of a CHIP Perinatal Program Member in the 186% to 200%
FPL (measured at the time of enrollment in the CHIP Perinatal
Program). CHIP Perinatal HMOs will not receive a DSP
from
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for
a live or stillbirth by the mother of a CHIP Perinatal Program Member in the
100%-185% FPL. For STAR, CHIP and CHIP Perinatal Program HMOs, the
one-time DSP payment is made in the amount identified in the HHSC Managed Care
Contract document regardless of whether there is a single birth or there are
multiple births at time of delivery. A delivery is the birth of a
live born infant, regardless of the duration of the pregnancy, or a stillborn
(fetal death) infant of twenty (20) weeks or more of gestation. A
delivery does not include a spontaneous or induced abortion, regardless of
the
duration of the pregnancy.
(c)
HMO must submit a monthly DSP
Report as described in Attachment B-1, Section 8 to the
HHSC Managed Care Contract document, in the format prescribed
in HHSC’s Uniform Managed Care Manual.
(d)
HHSC will pay the Delivery
Supplemental Payment within twenty (20) Business Days after receipt of a
complete and accurate report from the HMO.
(e)
The HMO will not be entitled to
Delivery Supplemental Payments for deliveries that are not reported to HHSC
within 210 days after the date of delivery, or within thirty (30) days from
the
date of discharge from the hospital for the stay related to the delivery,
whichever is later.
(f)
HMO must maintain complete claims
and adjudication disposition documentation, including paid and denied amounts
for each delivery. The HMO must submit the documentation to HHSC within five
(5)
Business Days after receiving a request for such information from
HHSC.
Section
10.10Administrative Fee for SSI
Members
(a)
Administrative Fee.
STAR
HMOs will receive a monthly fee
for administering benefits to each SSI Beneficiary who voluntarily enrolls
in
the HMO (a “Voluntary SSI Member”), in the amount identified in the HHSC
Managed Care Contract document. The HHSC will pay for Health Care
Services for such Voluntary SSI Members under the Medicaid Fee-for-Services
program. SSI Beneficiaries in all Service Areas except Nueces may
voluntarily participate in the STAR Program; however, HHSC reserves the right
to
discontinue such voluntary participation.
(b)
Administrative services and functions.
(1)
HMO must perform the same
administrative services and functions for Voluntary SSI Members as are performed
for other Members under this contract. These administrative services and
functions include, but are not limited to:
(i)
prior
authorization of services; (ii) all Member services functions, including
linguistic services and Member materials in alternative formats for the blind
and disabled;
(iii)
health education;
(iv)
utilization management using HHSC Administrative Services Contractor encounter
data to provide service management and appropriate interventions;
(v)
quality assessment and performance improvement activities;
(vi)
coordination to link Voluntary SSI Members with applicable community resources
and Non-capitated services.
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(2)
HMO must require Network Providers to submit claims for health and
health-related services to the HHSC Administrative Services Contractor
for
claims adjudication and payment.
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(3)
HMO must provide services to
Voluntary SSI Members within the 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 the HMO’s Network.
Records must be forwarded to Member’s PCP following a referral
visit.
(c)
Members who become eligible for SSI
A
Member’s SSI status is effective the
date the State’s eligibility system identifies the Member as Type Program 13
(TP13). On this effective date, the Member becomes a voluntary STAR
enrollee. The State is responsible for updating the State's
eligibility system within 45 days of official notice of the Member’s Federal SSI
eligibility by the Social Security Administration (SSA).
Section
10.11STAR, CHIP, and CHIP Perinatal Experience
Rebate
(a)
HMO’s
duty to pay.
At
the end of each Rate Year beginning
with Rate Year 1, the HMO must pay an Experience Rebate for the STAR, CHIP,
and
CHIP Perinatal Programs to HHSC if the HMO’s Net Income before Taxes is greater
than 3% of the total Revenue for the period. The Experience Rebate is
calculated in accordance with the tiered rebate method set forth below based
on
the consolidated Net Income before Taxes for all of the HMO’s STAR, CHIP, and
CHIP Perinatal Service Areas included within the scope of the Contract, as
measured by any positive amount on the Financial-Statistical Report (FSR) as
reviewed and confirmed by HHSC.
(b)
Graduated Experience Rebate Sharing Method.
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Experience
Rebate as a % of Revenues
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HMO
Share
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HHSC
Share
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≤
3%
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100%
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0%
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>
3% and ≤ 7%
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75%
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25%
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>
7% and ≤ 10%
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50%
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50%
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>
10% and ≤ 15%
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25%
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75%
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>
15%
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0%
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100%
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HHSC
and
the HMO will share the Net Income before Taxes for the STAR, CHIP, and CHIP
Perinatal Programs as follows, unless HHSC provides the HMO an Experience Rebate
Reward in accordance with Section 6 of Attachment B-1 to the
HHSC Managed Care Contract document and HHSC’s Uniform
Managed Care Manual:
(1)
The HMO will retain all Net Income
before Taxes that is equal to or less than 3% of the total Revenues received
by
the HMO.
(2)
HHSC and the HMO will share that
portion of the Net Income before Taxes that is over 3% but less than or equal to
7% of the total Revenues received with 75% to the HMO and 25% to
HHSC.
(3)
HHSC and the HMO will share that
portion of the Net Income before Taxes that is over 7% but less than or equal
to
10% of the total Revenues received with 50% to the HMO and 50% to
HHSC.
(4)
HHSC and the HMO will share that
portion of the Net Income before Taxes that is over 10% but less than or equal
to 15% of the total Revenues received with 25% to the HMO and 75% to
HHSC.
(5)
HHSC will be paid the entire
portion of the Net Income before Taxes that exceeds 15% of the total
Revenues.
(c)
Net
income before taxes.
(1)
The HMO must compute the Net Income
before Taxes in accordance with the HHSC Uniform Managed Care Manual’s
“Cost Principles for Administrative Expenses” and “FSR
Instructions for Completion” and applicable federal regulations. The
Net Income before Taxes will be confirmed by HHSC or its agent for the Rate
Year
relating to all revenues and expenses incurred pursuant to the Contract. HHSC
reserves the right to modify the “Cost Principles for Administrative
Expenses” and “FSR Instructions for Completion” found
in HHSC’s Uniform Managed Care Manual in accordance with
Section 8.05.
(2)
For purposes of calculating Net
Income before Taxes, the following items are not Allowable
Expenses:
(i)
the
payment of an Experience Rebate;
(ii)
any
interest expense associated with late or underpayment of the Experience
Rebate;
(iii)
financial incentives, including without limitation the Quality Challenge Award
described in Attachment B-1, Section 6.3.2.3; and
(iv)
financial disincentives, including without limitation: the Performance-based
Capitation Rate described in Attachment B-1, Section 6.3.2.2; and the liquidated
damages described in Attachment B-5.
(3)
Financial incentives are true net
bonuses and shall not be reduced by the potential increased Experience Rebate
payments. Financial disincentives are true net disincentives, and
shall not be offset in whole or part by potential decreases in Experience Rebate
payments.
(4)
For FSR reporting purposes,
financial incentives incurred shall not be reported as an increase in Revenues
or as an offset to costs, and any award of such will not increase reported
income. Financial disincentives incurred shall not be included as
reported expenses, and shall not reduce reported income. The
reporting or recording of any of these incurred items will be done on a memo
basis, which is below the income line, and will be listed as separate
items.
(d)
Carry
forward of prior Rate Year losses.
Losses
incurred by a STAR, CHIP, or
CHIP Perinatal HMO for one Rate Year may be carried forward to the next Rate
Year, and applied as an offset against a STAR, CHIP, or CHIP Perinatal
Experience Rebate. Prior losses may be carried forward for only one Rate Year
for this purpose. If the HMO offsets a loss against another STAR,
CHIP, or CHIP Perinatal Service Area, only that portion of the loss that was
not
used as an offset may be carried forward to the next Rate Year. Losses incurred
by a
STAR,
CHIP, CHIP Perinatal HMO cannot be offset against the STAR+PLUS
Program.
(e)
Settlements for payment.
(1)
There will be at least two
settlements for HMO payment(s) of the State share of the Experience Rebate
for
the STAR, CHIP, and CHIP Perinatal Programs. The first scheduled settlement
shall equal 100% of the State share of the Experience Rebate as derived from
the
FSR, and shall be paidon the same day the 90-day FSR Report is submitted to
HHSC, accompanied by an actuarial opinion certifying the reserve.
(2)
The second scheduled settlement
shall be an adjustment to the first settlement and shall be paid by the HMO
to
HHSC on the same day that the 334-day FSR Report is submitted to HHSC if the
adjustment is a payment from the HMO to HHSC.
(3)
HHSC or its agent may audit or
review the FSRs. If HHSC determines that corrections to the
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FSRs
are
required, based on an HHSC audit/review or other documentation acceptable to
HHSC, to determine an adjustment to the amount of the second settlement, then
final adjustment shall be made by HHSC within three years from the date that
the
HMO submits the 334-day FSR. Any settlement payment resulting from an
audit or final adjustment shall be due from the HMO within 30 days of the
earlier of:
(i)
the
date of the management representation letter resulting from the audit;
or
(ii)
the
date of any invoice issued by HHSC.
Payment
within the 30-day timeframe will not relieve the HMO of any interest payment
obligation that may exist under Section 10.11(f).
(4)
HHSC may offset any Experience
Rebates and/or corresponding interest payments owed to the State from any future
Capitation Payments, or collect such sums directly from the HMO. HHSC must
receive the settlements by their due dates or HHSC will assess interest on
the
amounts due at the current prime interest rate as set forth below. HHSC may
adjust the Experience Rebate if HHSC determines the HMO has paid amounts for
goods or services that are not reasonable, necessary, and allowable in
accordance with the HHSC Uniform Managed Care Manual’s “Cost Principles
for Administrative Expenses” and “FSR Instructions for
Completion” and applicable federal regulations. HHSC has final
authority in auditing and determining the amount of the Experience
Rebate.
(f)
Interest on Experience Rebate.
(1)
Interest on any Experience Rebate
owed to HHSC shall be charged beginning thirty (30) days after the due date
for
each settlement, as described in Section 10.11(e). In addition, if
any adjusted amount is owed to HHSC at the final settlement date, then interest
will be charged on the adjusted amount owed beginning thirty (30) days after
the
second settlement date to the date of the final settlement
payment. HHSC will calculate interest at the Department of Treasury’s
Median Rate (resulting from the Treasury’s auction of 13-week bills) for the
week in which the liability is assessed.
(2)
If an audit or adjustment
determines a downward revision of income after an interest payment has
previously been required for the same State Fiscal Year, then HHSC will
recalculate the interest and, if necessary, issue a full or partial refund
or
credit to the HMO.
(3)
Any interest obligations that are
incurred pursuant to Section 10.11 that are not timely paid will be subject
to
accumulation of interest as well, at the same rate as applicable to the
underlying Experience Rebate.
(4)
All interest assessed pursuant to
Section 10.11
will continue to accrue until such point as a payment is received by HHSC,
at
which point interest on the amount received will stop accruing. If a
balance remains at that point that is subject to interest, then the balance
shall continue to accrue interest. If interim payments are made, such as between
the first and second settlements, then any interest that may be due will only
be
charged on amounts for the time period during which they remained
unpaid. By way of example only, if $100,000 is subject to interest
commencing on a given day, and a payment is received for $75,000 35 days after
the start of interest, then the $75,000 will be subject to 35 days of interest,
and the $25,000 balance will continue to accrue interest until
paid.
Section
10.11.1STAR+PLUS Experience
Rebate
(a)
HMO’s
duty to pay.
At
the end of each Rate Year beginning
with Rate Year 1, the HMO must pay an Experience Rebate to HHSC for the
STAR+PLUS Program if the HMO produces a positive Net Income in STAR+PLUS. The
STAR+PLUS Experience Rebate is calculated in accordance with the tiered rebate
method set forth below based on the consolidated Net Income before Taxes for
all
of the HMO’s STAR+PLUS Service Areas included within the scope of the Contract,
as measured by any positive amount on the Financial-Statistical Report (FSR)
as
reviewed and confirmed by HHSC.
(b)
Graduated STAR+PLUS Experience Rebate Sharing Method.
Experience
Rebate as a % of Revenues
|
HMO
Share
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HHSC
Share
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≤
3%
|
50%
|
50%
|
>
3%
|
75%
|
25%
|
HHSC
and the HMO will share the Net
Income before Taxes for the STAR+PLUS Program as follows, unless HHSC provides
the HMO an Experience Rebate Reward in accordance with Section 6 of
Attachment B-1 to the HHSC Managed Care Contract
document and HHSC’s Uniform Managed Care
Manual:
(1)
HHSC and the STAR+PLUS HMO will
share that portion of the Net Income before Taxes that is equal to or less
than
3% of the total STAR+PLUS Revenues received with 50% to the HMO and 50% to
HHSC.
(2)
HHSC and the STAR+PLUS HMO will
share that portion of the Net Income before Taxes that is over 3% of the total
STAR+PLUS Revenues received with 75% to the HMO and 25% to HHSC.
(c)
Net
income before taxes.
1)
The HMO must compute the Net Income
before Taxes in accordance with the HHSC Uniform Managed Care Manual’s
“Cost Principles for Administrative Expenses” and “FSR
Instructions
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for
Completion” and applicable federal regulations. The Net Income before
Taxes will be confirmed by HHSC or its agent for the Rate Year relating to
all
revenues and expenses incurred pursuant to the Contract. HHSC reserves the
right
to modify the “Cost Principles for Administrative Expenses” and
“FSR Instructions for Completion” found in HHSC’s
Uniform Managed Care Manual in accordance with Section
8.05.
(2)
For purposes of calculating Net
Income before Taxes, the following items are not Allowable
Expenses:
(i)
the payment of an Experience
Rebate;
(ii)
any interest expense associated
with late or underpayment of the Experience Rebate;
(iii)
financial incentives, including
without limitation the Quality Challenge Award described in Attachment B-1,
Section 6.3.2.3, and the STAR+PLUS Hospital Inpatient Incentive Shared Savings
Award described in Attachment B-1, Section 6.3.2.5.2; and
(iv)
financial disincentives, including
without limitation: the Performance-based Capitation Rate described in
Attachment B-1, Section 6.3.2.2; the STAR+PLUS Hospital Inpatient Disincentive
Administrative Fee at Risk described in Attachment B-1, Section 6.3.2.5.1;
and
the liquidated damages described in Attachment B-5.
(3)
Financial incentives are true net
bonuses and shall not be reduced by the potential increased Experience Rebate
payments. Financial disincentives are true net disincentives, and
shall not be offset in whole or part by potential decreases in Experience Rebate
payments.
(4)
For FSR reporting purposes,
financial incentives incurred shall not be reported as an increase in Revenues
or as an offset to costs, and any award of such will not increase reported
income. Financial disincentives incurred shall not be included as
reported expenses, and shall not reduce reported income. The
reporting or recording of any of these incurred items will be done on a memo
basis, which is below the income line, and will be listed as separate
items.
(d)
Carry
forward of prior Rate Year losses.
Losses
incurred by a STAR+PLUS HMO for one Rate Year may be carried forward to the
next
Rate Year, and applied as an offset against a STAR+PLUS Experience
Rebate. Prior losses may be carried forward for only one Rate Year
for this purpose. If the HMO offsets a loss against another STAR+PLUS
Service Area, only that portion of the loss that was not used as an offset
may
be carried forward to the next Rate Year. Losses incurred by a STAR+PLUS HMO
cannot be offset against the STAR or CHIP Programs.
(e)
Settlements for payment.
(1)
There will be at least two
settlements for HMO payment(s) of the State share of the Experience Rebate
for
the STAR, CHIP, and CHIP Perinatal Programs. The first scheduled settlement
shall equal 100% of the State share of the Experience Rebate as derived from
the
FSR, and shall be paid on the same day the 90-day FSR Report is submitted to
HHSC, accompanied by an actuarial opinion certifying the reserve.
(2)
The second scheduled settlement
shall be an adjustment to the first settlement and shall be paid by the HMO
to
HHSC on the same day that the 334-day FSR Report is submitted to HHSC if the
adjustment is a payment from the HMO to HHSC.
(3)
HHSC or its agent may audit or
review the FSRs. If HHSC determines that corrections to the FSRs are required,
based on an HHSC audit/review or other documentation acceptable to HHSC, to
determine an adjustment to the amount of the second settlement, then final
adjustment shall be made by HHSC within three years from the date that the
HMO
submits the 334-day FSR. Any settlement payment resulting from an
audit or final adjustment shall be due from the HMO within 30 days of the
earlier of:
(i)
the
date of the management representation letter resulting from the audit;
or
(ii)
the
date of any invoice issued by HHSC. Payment within the 30-day timeframe will
not
relieve the HMO of any interest payment obligation that may exist under Section
10.11.1(f).
(4)
HHSC may offset any Experience
Rebates and/or corresponding interest payments owed to the State from any future
Capitation Payments, or collect such sums directly from the HMO. HHSC
must receive settlements by their due dates or HHSC will assess interest on
the
amounts due at the current prime interest rate as set forth below. HHSC may
adjust the Experience Rebate if HHSC determines the HMO has paid amounts for
goods or services that are not reasonable, necessary, and allowable in
accordance with the HHSC Uniform Managed Care Manual’s “Cost Principles
for Administrative Expenses” and “FSR Instructions for
Completion” and applicable federal regulations. HHSC has final
authority in auditing and determining the amount of the Experience
Rebate.
(f)
Interest on Experience Rebate.
(1)
Interest on any Experience Rebate
owed to HHSC shall be charged beginning thirty (30) days after the due date
for
each settlement, as described in Section 10.11.1(e). In addition, if
any adjusted amount is owed to HHSC at the final settlement date, then interest
will be charged on the adjusted amount owed beginning thirty (30) days after
the
second settlement date to the date of the final settlement
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payment. HHSC
will calculate interest at the Department of Treasury’s Median Rate (resulting
from the Treasury’s auction of 13-week bills) for the week in which the
liability is assessed.
(2)
If an audit or adjustment
determines a downward revision of income after an interest payment has
previously been required for the same State Fiscal Year, then HHSC will
recalculate the interest and, if necessary, issue a full or partial refund
or
credit to the HMO.
(3)
Any interest obligations that are
incurred pursuant to Section 10.11.1 that are not timely paid will be subject
to
accumulation of interest as well, at the same rate as applicable to the
underlying Experience Rebate.
(4)
All interest assessed pursuant to
Section 10.11.1 will continue to accrue until such point as a payment is
received by HHSC, at which point interest on the amount received will stop
accruing. If a balance remains at that point that is subject to
interest, then the balance shall continue to accrue interest. If interim
payments are made, such as between the first and second settlements, then any
interest that may be due will only be charged on amounts for the time period
during which they remained unpaid. By way of example only, if
$100,000 is subject to interest commencing on a given day, and a payment is
received for $75,000 35 days after the start of interest, then the $75,000
will
be subject to 35 days of interest, and the $25,000 balance will continue to
accrue interest until paid.
Section
10.12Payment by Members.
(a)
Medicaid HMOs
Medicaid
HMOs and their Network
Providers are prohibited from billing or collecting any amount from a Member
for
Health Care Services covered by this Contract. HMO must inform Members of costs
for non-covered services, and must require its Network Providers
to:
(1)
inform Members of costs for non-covered services prior to rendering such
services; and
(2)
obtain a signed Private Pay form from such Members.
(b)
CHIP
HMOs.
(1)
Families that meet the enrollment
period cost share limit requirement must report it to the HHSC Administrative
Services Contractor. The HHSC Administrative Service Contractor notifies the
HMO
that a family’s cost share limit has been reached. Upon notification from the
HHSC Administrative Services Contractor that a family has reached its
cost-sharing limit for the term of coverage, the HMO will generate and mail
to
the CHIP Member a new Member ID card within five days, showing that the CHIP
Member’s cost-sharing obligation for that term of coverage has been
met. No cost-sharing may be collected from these CHIP Members for the
balance of their term of coverage.
(2)
Providers are responsible for
collecting all CHIP Member co-payments at the time of service. Co-payments
that
families must pay vary according to their income level. No co-payments apply,
at
any income level, to well-child or well-baby visits or immunizations. Except
for
costs associated with unauthorized non-emergency services provided to a Member
by Out-of-Network providers and for non-covered services, the co-payments
outlined in the CHIP Cost Sharing table in the HHSC Uniform Managed Care
Manual are the only amounts that a provider may collect from a
CHIP-eligible family.
(3)
Federal law prohibits charging
cost-sharing or deductibles to CHIP Members of Native Americans or Alaskan
Natives. The HHSC Administrative Services Contractor will notify the HMO of
CHIP
Members who are not subject to cost-sharing requirements. The HMO is
responsible for educating Providers regarding the cost-sharing waiver for this
population.
(4)
An HMO’s monthly Capitation Payment
will not be reduced for a family’s failure to make its CHIP premium
payment. There is no relationship between the per Member/per month
amount owed to the HMO for coverage provided during a month and the family’s
payment of its CHIP premium obligation for that month.
(c)
CHIP
Perinatal HMOs
Cost-sharing
does not apply to CHIP
Perinatal Program Members. The exemption from cost-sharing applies
through the end of the original 12-month enrollment period.
Section
10.13 Restriction on assignment of
fees.
During
the term of the Contract, HMO
may not, directly or indirectly, assign to any third party any beneficial or
legal interest of the HMO in or to any payments to be made by HHSC pursuant
to
this Contract. This restriction does not apply to fees paid to
Subcontractors.
Section
10.14 Liability for taxes.
HHSC
is not responsible in any way for
the payment of any Federal, state or local taxes related to or incurred in
connection with the HMO’s performance of this Contract. HMO must pay and
discharge any and all such taxes, including any penalties and interest. In
addition, HHSC is exempt from Federal excise taxes, and will not pay any
personal property taxes or income taxes levied on HMO or any taxes levied on
employee wages.
Section
10.15Liability for employment-related charges and
benefits.
HMO
will perform work under this
Contract as an independent contractor and not as agent or representative of
HHSC. HMO is solely and exclusively liable for payment of all
employment-
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related
charges incurred in connection with the performance of this Contract, including
but not limited to salaries, benefits, employment taxes, workers compensation
benefits, unemployment insurance and benefits, and other insurance or fringe
benefits for Staff.
Section
10.16No additional
consideration.
(a)
HMO will not be entitled to nor
receive from HHSC any additional consideration, compensation, salary, wages,
charges, fees, costs, or any other type of remuneration for Services and
Deliverables provided under the Contract, except by properly authorized and
executed Contract amendments.
(b)
No other charges for tasks,
functions, or activities that are incidental or ancillary to the delivery of
the
Services and Deliverables will be sought from HHSC or any other state agency,
nor will the failure of HHSC or any other party to pay for such incidental
or
ancillary services entitle the HMO to withhold Services and Deliverables due
under the Agreement.
(c)
HMO will not be entitled by virtue
of the Contract to consideration in the form of overtime, health insurance
benefits, retirement benefits, disability retirement benefits, sick leave,
vacation time, paid holidays, or other paid leaves of absence of any type or
kind whatsoever.
Section
10.17Federal Disallowance
If
the federal government recoups money
from the state for expenses and/or costs that are deemed unallowable by the
federal government, the state has the right to, in turn, recoup payments made
to
the HMOs for these same expenses and/or costs, even if they had not been
previously disallowed by the state and were incurred by the HMO, and any such
expenses and/or costs would then be deemed unallowable by the
state. If the state retroactively recoups money from the HMOs due to
a federal disallowance, the state will recoup the entire amount paid to the
HMO
for the federally disallowed expenses and/or costs, not just the federal
portion.
Article
11. Disclosure & Confidentiality of Information
Section
11.01Confidentiality.
(a)
HMO and all Subcontractors,
consultants, or agents under the Contract must treat all information that is
obtained through performance of the Services under the Contract, including,
but
not limited to, information relating to applicants or recipients of HHSC
Programs as Confidential Information to the extent that confidential treatment
is provided under law and regulations.
(b)
HMO is responsible for
understanding the degree to which information obtained through performance
of
this Contract is confidential under State and Federal law, regulations, or
administrative rules.
(c)
HMO and all Subcontractors,
consultants, or agents under the Contract may not use any information obtained
through performance of this Contract in any manner except as is necessary for
the proper discharge of obligations and securing of rights under the
Contract.
(d)
HMO must have a system in effect to
protect all records and all other documents deemed confidential under this
Contract maintained inconnection with the activities funded under the Contract.
Any disclosure or transfer of Confidential Information by HMO, including
information required by HHSC, will be in accordance with applicable law. If
the
HMO receives a request for information deemed confidential under this Contract,
the HMO will immediately notify HHSC of such request, and will make reasonable
efforts to protect the information from public disclosure.
(e)
In addition to the requirements
expressly stated in this Section, HMO must comply with any policy, rule, or
reasonable requirement of HHSC that relates to the safeguarding or disclosure
of
information relating to Members, HMO’S operations, or HMO’s performance of the
Contract.
(f)
In the event of the expiration of
the Contract or termination of the Contract for any reason, all Confidential
Information disclosed to and all copies thereof made by the HMOI shall be
returned to HHSC or, at HHSC’s option, erased or destroyed. HMO shall
provide HHSC certificates evidencing such destruction.
(g)
The obligations in this Section
shall not restrict any disclosure by the HMO pursuant to any applicable law,
or
by order of any court or government agency, provided that the HMO shall give
prompt notice to HHSC of such order.
(h)
With the exception of confidential
Member information, Confidential Information shall not be afforded the
protection of the Contract if such data was:
(1)
Already known to the receiving Party without restrictions at the time of its
disclosure by the furnishing Party;
(2)
Independently developed by the receiving Party without reference to the
furnishing Party’s Confidential Information;
(3)
Rightfully obtained by the other Party without restriction from a third party
after its disclosure by the furnishing Party;
(4)
Publicly available other than through the fault or negligence of the other
Party; or
(5)
Lawfully released without restriction to anyone.
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Section
11.02 Disclosure of HHSC’s Confidential Information.
(a)
HMO will immediately report to HHSC
any and all unauthorized disclosures or uses of HHSC’s Confidential Information
of which it or its Subcontractor(s), consultant(s), or agent(s) is aware or
has
knowledge. HMO acknowledges that any publication or disclosure of
HHSC’s Confidential Information to others may cause immediate and irreparable
harm to HHSC and may constitute a violation of State or federal
laws. If HMO, its Subcontractor(s), consultant(s), or agent(s) should
publish or disclose such Confidential Information to others without
authorization, HHSC will immediately be entitled to injunctive relief or any
other remedies to which it is entitled under law or equity. HHSC will
have the right to recover from HMO all damages and liabilities caused by or
arising from HMO’s, its Subcontractors’, consultants’, or agents’ failure to
protect HHSC’s Confidential Information. HMO will defend with counsel
approved by HHSC, indemnify and hold harmless HHSC from all damages, costs,
liabilities, and expenses (including without limitation reasonable attorneys’
fees and costs) caused by or arising from HMO’s or its Subcontractors’,
consultants’ or agents’ failure to protect HHSC’s Confidential
Information. HHSC will not unreasonably withhold approval of counsel
selected by the HMO.
(b)
HMO will require its
Subcontractor(s), consultant(s), and agent(s) to comply with the terms of this
provision.
Section
11.03Member Records
(a)
HMO must comply with the
requirements of state and federal laws, including the HIPAA requirements set
forth in Section 7.07, regarding the transfer of Member Records.
(b)
If at any time during the Contract
Term this Contract is terminated, HHSC may require the transfer of Member
Records, upon written notice to HMO, to another entity, as consistent with
federal and state laws and applicable releases.
(c)
The term “Member Record” for this
Section means only those administrative, enrollment, case management and other
such records maintained by HMO and is not intended to include patient records
maintained by participating Network Providers.
Section
11.04Requests for public
information.
(a)
HHSC agrees that it will promptly
notify HMO of a request for disclosure of information filed in accordance with
the Texas Public Information Act, Chapter 552 of the Texas Government Code,
that
consists of the HMO’S confidential information, including without limitation,
information or data to which HMO has a proprietary or commercial
interest. HHSC will deliver a copy of the request for public
information to HMO.
(b)
With respect to any information
that is the subject of a request for disclosure, HMO is required to demonstrate
to the Texas Office of Attorney General the specific reasons why the requested
information is confidential or otherwise excepted from required public
disclosure under law. HMO will provide HHSC with copies of all such
communications.
(c)
To the extent authorized under the
Texas Public Information Act, HHSC agrees to safeguard from disclosure
information received from HMO that the
HMO
believes to be confidential information. HMO must clearly xxxx such
information as confidential information or provide written notice to HHSC that
it considers the information confidential.
Section
11.05Privileged Work
Product.
(a)
HMO acknowledges that HHSC asserts
that privileged work product may be prepared in anticipation of litigation
and
that HMO is performing the Services with respect to privileged work product
as
an agent of HHSC, and that all matters related thereto are protected from
disclosure by the Texas Rules of Civil Procedure, Texas Rules of Evidence,
Federal Rules of Civil Procedure, or Federal Rules of Evidence.
(b)
HHSC will notify HMO of any
privileged work product to which HMO has or may have access. After
the HMO is notified or otherwise becomes aware that such documents, data,
database, or communications are privileged work product, only HMO personnel,
for
whom such access is necessary for the purposes of providing the Services, may
have access to privileged work product.
(c)
If HMO receives notice of any
judicial or other proceeding seeking to obtain access to HHSC’s privileged work
product, HMO will:
(1)
Immediately notify HHSC; and
(2)
Use
all reasonable efforts to resist providing such access.
(d)
If HMO resists disclosure of HHSC’s
privileged work product in accordance with this Section, HHSC will, to the
extent authorized under Civil Practices and Remedies Code or other applicable
State law, have the right and duty to:
(1)
represent HMO in such resistance;
(2)
to
retain counsel to represent HMO; or
(3)
to
reimburse HMO for reasonable attorneys' fees and expenses incurred in resisting
such access.
(e)
If a court of competent
jurisdiction orders HMO to produce documents, disclose data, or otherwise breach
the confidentiality obligations imposed in the Contract, or otherwise with
respect to maintaining the confidentiality, proprietary nature, and secrecy
of
privileged work product, HMO will not be liable for breach of such
obligation.
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Section
11.06Unauthorized acts.
Each
Party agrees to:
(1)
Notify the other Party promptly of
any unauthorized possession, use, or knowledge, or attempt thereof, by any
person or entity that may become known to it, of any HHSC Confidential
Information or any information identified by the HMO as confidential or
proprietary;
(2)
Promptly furnish to the other Party
full details of the unauthorized possession, use, or knowledge, or attempt
thereof, and use reasonable efforts to assist the other Party in investigating
or preventing the reoccurrence of any unauthorized possession, use, or
knowledge, or attempt thereof, of Confidential Information;
(3)
Cooperate with the other Party in
any litigation and investigation against third Parties deemed necessary by
such
Party to protect its proprietary rights; and
(4)
Promptly prevent a reoccurrence of
any such unauthorized possession, use, or knowledge such
information.
Section
11.07Legal action.
Neither
party may commence any legal
action or proceeding in respect to any unauthorized possession, use, or
knowledge, or attempt thereof by any person or entity of HHSC’s Confidential
Information or information identified by the HMO as confidential or proprietary,
which action or proceeding identifies the other Party such information without
such Party’s consent.
Article
12. Remedies &
Disputes
Section
12.01Understanding and expectations.
The
remedies described in this Section
are directed to HMO’s timely and responsive performance of the Services and
production of Deliverables, and the creation of a flexible and responsive
relationship between the Parties. The HMO is expected to meet or
exceed all HHSC objectives and standards, as set forth in the
Contract. All areas of responsibility and all Contract requirements
will be subject to performance evaluation by HHSC. Performance
reviews may be conducted at the discretion of HHSC at any time and may relate
to
any responsibility and/or requirement. Any and all responsibilities
and/or requirements not fulfilled may be subject to remedies set forth in the
Contract.
Section
12.02 Tailored
remedies.
(a)
Understanding of the Parties.
HMO
agrees and understands that HHSC
may pursue tailored contractual remedies for noncompliance with the
Contract. At any time and at its discretion, HHSC may impose or
pursue one or
more
remedies for each item of noncompliance and will determine remedies on a
case-by-case basis. HHSC’s
pursuit or non-pursuit of a tailored remedy does not constitute a waiver of
any
other remedy that HHSC may have at law or equity.
(b)
Notice and opportunity to cure for non-material breach.
(1)
HHSC will notify HMO in writing of
specific areas of HMO performance that fail to meet performance expectations,
standards, or schedules set forth in the Contract, but that, in the
determination of HHSC, do not result in a material deficiency or
delay
in
the implementation or operation of the Services.
(2)
HMO will, within five (5) Business
Days (or another date approved by HHSC) of receipt of written notice of a
non-material deficiency, provide the HHSC Project Manager a written response
that:
(A)
Explains the reasons for the deficiency, HMO’s plan to address or cure the
deficiency, and the date and time by which the deficiency will be cured;
or
(B)
If
HMO disagrees with HHSC’s findings, its reasons for disagreeing with HHSC’s
findings.
(3)
HMO’s proposed cure of a
non-material deficiency is subject to the approval of HHSC. HMO’s repeated
commission of non-material deficiencies or repeated failure to resolve any
such
deficiencies may be regarded by HHSC as a material deficiency and entitle HHSC
to pursue any other remedy provided in the Contract or any other appropriate
remedy HHSC may have at law or equity.
(c)
Corrective action plan.
(1)
At its option, HHSC may require HMO
to submit to HHSC a written plan (the “Corrective Action Plan”) to correct or
resolve a material breach of this Contract, as determined by HHSC.
(2)
The Corrective Action Plan must
provide:
(A)
A
detailed explanation of the reasons for the cited deficiency;
(B)
HMO’s
assessment or diagnosis of the cause; and
(C)
A
specific proposal to cure or resolve the deficiency.
(3)
The Corrective Action Plan must be
submitted by the deadline set forth in HHSC’s request for a Corrective Action
Plan. The Corrective Action Plan is subject to approval by HHSC,
which will not unreasonably be withheld.
(4)
HHSC will notify HMO in writing of
HHSC’s final disposition of HHSC’s concerns. If HHSC accepts HMO’s
proposed Corrective Action Plan, HHSC may:
(A)
Condition such approval on completion of tasks in the order or priority that
HHSC may reasonably prescribe;
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(B)
Disapprove portions of HMO’s proposed Corrective Action Plan; or
(C)
Require additional or different corrective action(s).
Notwithstanding
the submission and
acceptance of a Corrective Action Plan, HMO remains responsible for achieving
all written performance criteria.
(5)
HHSC’s acceptance of a Corrective
Action Plan under this Section will not:
(A)
Excuse HMO’s prior substandard performance;
(B)
Relieve HMO of its duty to comply with performance standards; or
(C)
Prohibit HHSC from assessing additional tailored remedies or pursuing other
appropriate remedies for continued substandard performance.
(d)
Administrative remedies.
(1)
At its discretion, HHSC may impose
one or more of the following remedies for each item of material noncompliance
and will determine the scope and severity of the remedy on a case-by-case
basis:
(A)
Assess liquidated damages in accordance with Attachment B-5 to
the HHSC Managed Care Contract, “Liquidated Damages
Matrix;”
(B)
Conduct accelerated monitoring of the HMO. Accelerated monitoring includes
more
frequent or more extensive monitoring by HHSC or its agent;
(C)
Require additional, more detailed, financial and/or programmatic reports to
be
submitted by HMO;
(D)
Decline to renew or extend the Contract;
(E)
Appoint temporary management;
(F)
Initiate disenrollment of a Member or Members;
(G)
Suspend enrollment of Members;
(H)
Withhold or recoup payment to HMO;
(I)
Require forfeiture of all or part of the HMO’s bond; or
(J)
Terminate the Contract in accordance with Section 12.03,
(“Termination by HHSC”).
(2)
For purposes of the Contract, an
item of material noncompliance means a specific action of HMO that:
(A)
Violates a material provision of the Contract;
(B)
Fails
to meet an agreed measure of performance; or
(C)
Represents a failure of HMO to be reasonably responsive to a reasonable request
of HHSC relating to the Services for information, assistance, or support within
the timeframe specified by HHSC.
(3)
HHSC will provide notice to HMO of
the imposition of an administrative remedy in accordance with this Section,
with
the exception of accelerated monitoring, which may be
unannounced. HHSC may require HMO to file a written response in
accordance with this Section.
(4)
The Parties agree that a State or
Federal statute, rule, regulation, or Federal guideline will prevail over the
provisions of this Section unless the statute, rule, regulation, or guidelines
can be read together with this Section to give effect to both.
(e)
Damages.
(1)
HHSC will be entitled to actual and
consequential damages resulting from the HMO’S failure to comply with any of the
terms of the Contract. In some cases, the actual damage to HHSC or
State of Texas as a result of HMO’S failure to meet any aspect of the
responsibilities ofthe Contract and/or to meet specific performance standards
set forth in the Contract are difficult or impossible to determine with precise
accuracy. Therefore, liquidated damages will be assessed in writing
against and paid by the HMO in accordance with and for failure to meet any
aspect of the responsibilities of the Contract and/or to meet the specific
performance standards identified by the HHSC in Attachment B-5 to the
HHSC Managed Care Contract, “Deliverables/Liquidated Damages Matrix.”
Liquidated damages will be assessed if HHSC determines such failure
is the fault
of the HMO (including the HMO’S Subcontractors and/or consultants) and is not
materially caused or contributed to by HHSC or its agents. If at any
time, HHSC determines the HMO has not met any aspect of the responsibilities
of
the Contract and/or the specific performance standards due to mitigating
circumstances, HHSC reserves the right to waive all or part of the liquidated
damages. All such waivers must be in writing, contain the reasons for
the waiver, and be signed by the appropriate executive of HHSC.
(2)
The liquidated damages prescribed
in this Section are not intended to be in the nature of a penalty, but are
intended to be reasonable estimates of HHSC’s projected financial loss and
damage resulting from the HMO’s nonperformance, including financial loss as a
result of project delays. Accordingly, in the event HMO fails to
perform in accordance with the Contract, HHSC may assess liquidated damages
as
provided in this Section.
(3)
If HMO fails to perform any of the
Services described in the Contract, HHSC may assess
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liquidated
damages for each occurrence of a liquidated damages event, to the extent
consistent with HHSC's tailored approach to remedies and Texas law.
(4)
HHSC may elect to collect
liquidated damages:
(A)
Through direct assessment and demand for payment delivered to HMO;
or
(B)
By
deduction of amounts assessed as liquidated damages as set-off against payments
then due to HMO or that become due at any time after assessment of the
liquidated damages. HHSC will make deductions until the full amount payable
by
the HMO is received by HHSC.
(f)
Equitable Remedies
(1)
HMO acknowledges that, if HMO
breaches (or attempts or threatens to breach) its material obligation under
this
Contract, HHSC may be irreparably harmed. In such a circumstance,
HHSC may proceed directly to court to pursue equitable remedies.
(2)
If a court of competent
jurisdiction finds that HMO breached (or attempted or threatened to breach)
any
such obligations, HMO agrees that without any additional findings of irreparable
injury or other conditions to injunctive relief, it will not oppose the entry
of
an appropriate order compelling performance by HMO and restraining it from
any
further breaches (or attempted or threatened breaches).
(g)
Suspension of Contract
(1)
HHSC may suspend performance of all
or any part of the Contract if:
(A)
HHSC
determines that HMO has committed a material breach of the
Contract;
(B)
HHSC
has reason to believe that HMO has committed, assisted in the commission of
Fraud, Abuse, Waste, malfeasance, misfeasance, or nonfeasance by any party
concerning the Contract;
(C)
HHSC
determines that the HMO knew, or should have known of, Fraud, Abuse, Waste,
malfeasance, or nonfeasance by any party concerning the Contract, and the HMO
failed to take appropriate action; or
(D)
HHSC
determines that suspension of the Contract in whole or in part is in the best
interests of the State of Texas or the HHSC Programs.
(2)
HHSC will notify HMO in writing of
its intention to suspend the Contract in whole or in part. Such
notice will:
(A)
Be
delivered in writing to HMO;
(B)
Include a concise description of the facts or matter leading to HHSC’s decision;
and
(C)
Unless HHSC is suspending the contract for convenience, request a Corrective
Action Plan from HMO or describe actions that HMO may take to avoid the
contemplated suspension of the Contract.
Section
12.03Termination by HHSC.
This
Contract will terminate upon the
Expiration Date. In addition, prior to completion of the Contract Term, all
or a
part of this Contract may be terminated for any of the following
reasons:
(a)
Termination in the best interest of HHSC.
HHSC
may terminate the Contract without
cause at any time when, in its sole discretion, HHSC determines that termination
is in the best interests of the State of Texas. HHSC will provide
reasonable advance written notice of the termination, as it deems appropriate
under the circumstances. The termination will be effective on the
date specified in HHSC’s notice of termination.
(b)
Termination for cause.
HHSC
reserves the right to terminate this Contract, in whole or in part, upon the
following conditions:
(1)
Assignment for the benefit of creditors, appointment of receiver, or inability
to pay debts. HHSC may terminate this Contract at any time if HMO:
(A)
Makes
an assignment for the benefit of its creditors;
(B)
Admits in writing its inability to pay its debts generally as they become due;
or
(C)
Consents to the appointment of a receiver, trustee, or liquidator of HMO or
of
all or any part of its property.
(2)
Failure to adhere to laws, rules, ordinances, or orders.
HHSC
may
terminate this Contract if a court of competent jurisdiction finds HMO failed
to
adhere to any laws, ordinances, rules, regulations or orders of any public
authority having jurisdiction and such violation prevents or substantially
impairs performance of HMO’s duties under this Contract. HHSC will
provide at least thirty (30) days advance written notice of such
termination.
(3)
Breach of confidentiality.
HHSC
may
terminate this Contract at any time if HMO breaches confidentiality laws
with
respect
to the Services and Deliverables provided under this Contract.
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(4)
Failure to maintain adequate personnel or resources.
HHSC
may
terminate this Contract if, after providing notice and an opportunity to
correct, HHSC determines that HMO has failed to supply personnel or resources
and such failure results in HMO’s inability to fulfill its duties under this
Contract. HHSC will provide at least thirty (30) days advance written notice
of
such termination.
(5)
Termination for gifts and gratuities.
(A)
HHSC
may terminate this Contract at any time following the determination by a
competent judicial or quasi-judicial authority and HMO’s exhaustion of all legal
remedies that HMO, its employees, agents or representatives have either offered
or given any thing of value to an officer or employee of HHSC or the State
of
Texas in violation of state law.
(B)
HMO
must include a similar provision in each of its Subcontracts and shall enforce
this provision against a Subcontractor who has offered or given any thing of
value to any of the persons or entities described in this Section, whether
or
not the offer or gift was in HMO’s behalf.
(C)
Termination of a Subcontract by HMO pursuant to this provision will not be
a
cause for termination of the Contract unless:
(1)
HMO
fails to replace such terminated Subcontractor within a reasonable time;
and
(2)
Such
failure constitutes cause, as described in this Subsection
12.03(b).
(D)
For
purposes of this Section, a “thing of value” means any item of tangible or
intangible property that has a monetary value of more than $50.00 and includes,
but is not limited to, cash, food, lodging, entertainment, and charitable
contributions. The term does not include contributions to holders of
public office or candidates for public office that are paid and reported in
accordance with State and/or Federal law.
(6)
Termination for non-appropriation of funds.
Notwithstanding
any other provision of this Contract, if funds for the continued fulfillment
of
this Contract by HHSC are at any time not forthcoming or are insufficient,
through failure of any entity to appropriate funds or otherwise, then HHSC
will
have the right to terminate this Contract at no additional cost and with no
penalty whatsoever by giving prior written notice documenting the lack of
funding. HHSC will provide at least thirty (30) days advance written
notice of such termination. HHSC will use reasonable efforts to
ensure appropriated funds are available.
(7)
Judgment and execution.
(A)
HHSC
may terminate the Contract at any time if judgment for the payment of money
in
excess of $500,000.00 that is not covered by insurance, is rendered by any
court
or governmental body against HMO, and HMO does not:
(1)
Discharge the judgment or provide for its discharge in accordance with the
terms
of the judgment;
(2)
Procure a stay of execution of the judgment within thirty (30) days from the
date of entry thereof; or
(3)
Perfect an appeal of such judgment and cause the execution of such judgment
to
be stayed during the appeal, providing such financial reserves as may be
required under generally accepted accounting principles.
(B)
If a
writ or warrant of attachment or any similar process is issued by any court
against all or any material portion of the property of HMO, and such writ or
warrant of attachment or any similar process is not released or bonded within
thirty (30) days after its entry, HHSC may terminate the Contract in accordance
with this Section.
(8)
Termination for insolvency.
(A)
HHSC
may terminate the Contract at any time if HMO:
(1)
Files
for bankruptcy;
(2)
Becomes or is declared insolvent, or is the subject of any proceedings related
to its liquidation, insolvency, or the appointment of a receiver or similar
officer for it;
(3)
Makes
an assignment for the benefit of all or substantially all of its creditors;
or
(4)
Enters into an Contract for the composition, extension, or readjustment of
substantially all of its obligations.
(B)
HMO
agrees to pay for all reasonable expenses of HHSC including the cost of counsel,
incident to:
(1)
The
enforcement of payment of all obligations of the HMO by any action or
participation in, or in connection with a case or proceeding under Chapters
7,
11, or 13 of the United States Bankruptcy Code, or any successor
statute;
(2)
A
case or proceeding involving a receiver or other similar officer duly appointed
to handle the HMO's business; or
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(3)
A
case or proceeding in a State court initiated by HHSC when previous collection
attempts have been unsuccessful.
(9)
Termination for HMO’S material breach of the Contract.
HHSC
will
have the right to terminate the Contract in whole or in part if HHSC determines,
at its sole discretion, that HMO has materially breached the
Contract. HHSC will provide at least thirty (30) days advance written
notice of such termination.
Section
12.04Termination by HMO.
(a)
Failure to pay.
HMO
may terminate this Contract if HHSC
fails to pay the HMO undisputed charges when due as required under this
Contract. Retaining premium, recoupment, sanctions, or penalties that
are allowed under this Contract or that result from the HMO’s failure to perform
or the HMO’s default under the terms of this Contract is not cause for
termination. Termination for failure to pay does not release HHSC
from the obligation to pay undisputed charges for services provided prior to
the
termination date.
If
HHSC fails to pay undisputed charges
when due, then the HMO may submit a notice of intent to terminate for failure
to
pay in accordance with the requirements of Subsection 12.04(d).
If HHSC pays all undisputed amounts then due within thirty (30)-days after
receiving the notice of intent to terminate,the HMO cannot proceed with
termination of the Contract under this Article.
(b)
Change to HHSC Uniform Managed Care Manual.
HMO
may terminate this agreement if the
Parties are unable to resolve a dispute concerning a material and substantive
change to the HHSC Uniform Managed Care Manual (a change that materially and
substantively alters the HMO’s ability to fulfill its obligations under the
Contract). HMO must submit a notice of intent to terminate due to a
material and substantive change in the HHSC Uniform Managed Care Manual no
later
than thirty (30) days after the effective date of the policy
change. HHSC will not enforce the policy change during the period of
time between the receipt of the notice of intent to terminate and the effective
date of termination.
(c)
Change to Capitation Rate.
If
HHSC
proposes a modification to the Capitation Rate that is unacceptable to the
HMO,
the HMO may terminate the Contract. HMO must submit a written notice
of intent to terminate due to a change in the Capitation Rate no later than
thirty (30) days after HHSC’s notice of the proposed change. HHSC will not
enforce the rate change during the period of time between the receipt of the
notice of intent to terminate and the effective date of
termination.
(d)
Notice of intent to terminate.
In
order to terminate the Contract
pursuant to this Section, HMO must give HHSC at least ninety
(90)
days
written notice of intent to terminate. The termination date will be
calculated as the last day of the month following ninety (90) days from the
date
the notice of intent to terminate is received by HHSC.
Section
12.05Termination by mutual
agreement.
This
Contract may be terminated by
mutual written agreement of the Parties.
Section
12.06Effective date of
termination.
Except
as otherwise provided in this
Contract, termination will be effective as of the date specified in the notice
of termination.
Section
12.07Extension of termination effective
date.
The
Parties may extend the effective
date of termination one or more times by mutual written agreement.
Section
12.08Payment and other provisions at Contract
termination.
(a)
In the event of termination
pursuant to this Article, HHSC will pay the Capitation Payment for Services
and
Deliverables rendered through the effective date of termination. All
pertinent provisions of the Contract will form the basis of
settlement.
(b)
HMO must provide HHSC all
reasonable access to records, facilities, and documentation as is required
to
efficiently and expeditiously close out the Services and Deliverables provided
under this Contract.
(c)
HMO must prepare a Turnover Plan,
which is acceptable to and approved by HHSC. The Turnover Plan will
be implemented during the time period between receipt of notice and the
termination date.
Section
12.09Modification of Contract in the event of
remedies.
HHSC
may propose a modification of this
Contract in response to the imposition of a remedy under this Article. Any
modifications under this Section must be reasonable, limited to the matters
causing the exercise of a remedy, in writing, and executed in accordance with
Article 8. HMO must negotiate such proposed modifications in good
faith.
Section
12.10Turnover assistance.
Upon
receipt of notice of termination
of the Contract by HHSC, HMO will provide any turnover assistance reasonably
necessary to enable HHSC or its designee to effectively close out the Contract
and move the work to another vendor or to perform the work
itself.
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Section
12.11Rights upon termination or expiration of
Contract.
In
the event that the Contract is
terminated for any reason, or upon its expiration, HHSC will, at HHSC's
discretion, retain ownership of any and all associated work products,
Deliverables and/or documentation in whatever form that they exist.
Section
12.12HMO responsibility for associated
costs.
If
HHSC terminates the Contract for
Cause, the HMO will be responsible to HHSC for all reasonable costs incurred
by
HHSC, the State of Texas, or any of its administrative agencies to replace
the
HMO. These costs include, but are not limited to, the costs of
procuring a substitute vendor and the cost of any claim or litigation that
is
reasonably attributable to HMO’s failure to perform any Service in accordance
with the terms of the Contract
Section
12.13 Dispute resolution.
(a)
General agreement of the Parties.
The
Parties mutually agree that the
interests of fairness, efficiency, and good business practices are best served
when the Parties employ all reasonable and informal means to resolve any dispute
under this Contract. The Parties express their mutual commitment to using all
reasonable and informal means of resolving disputes prior to invoking a remedy
provided elsewhere in this Section.
(b)
Duty
to negotiate in good faith.
Any
dispute that in the judgment of any
Party to this Contract may materially or substantially affect the performance
of
any Party will be reduced to writing and delivered to the other Party. The
Parties must then negotiate in good faith and use every reasonable effort to
resolve such dispute and the Parties shall not resort to any formal proceedings
unless they have reasonably determined that a negotiated resolution is not
possible. The resolution of any dispute disposed of by Contract between the
Parties shall be reduced to writing and delivered to all Parties within ten
(10)
Business Days.
(c)
Claims for breach of Contract.
(1)
General requirement. HMO’s claim
for breach of this Contract will be resolved in accordance with the dispute
resolution process established by HHSC in accordance with Chapter 2260, Texas
Government Code.
(2)
Negotiation of claims. The Parties
expressly agree that the HMO’s claim for breach of this Contract that the
Parties cannot resolve in the ordinary course of business or through the use
of
all reasonable and informal means will be submitted to the negotiation process
provided in Chapter 2260, Subchapter B, Texas Government Code.
(A)
To
initiate the process, HMO must submit written notice to HHSC that specifically
states that HMO invokes the provisions of Chapter 2260, Subchapter B, Texas
Government Code. The notice must comply with the requirements of
Title 1, Chapter 392, Subchapter B of the Texas Administrative
Code.
(B)
The
Parties expressly agree that the HMO’s compliance with Chapter 2260, Subchapter
B, Texas Government Code, will be a condition precedent to the filing of a
contested case proceeding under Chapter 2260, Subchapter C, of the Texas
Government Code.
(3)
Contested case proceedings. The contested case process provided in Chapter
2260,
Subchapter C, Texas Government Code, will be HMO’s sole and exclusive process
for seeking a remedy for any and all alleged breaches of contract by HHSC if
the
Parties are unable to resolve their disputes under Subsection (c)(2) of this
Section.
The
Parties expressly agree that
compliance with the contested case process provided in Chapter 2260, Subchapter
C, Texas Government Code, will be a condition precedent to seeking consent
to
xxx from the Texas Legislature under Chapter 107, Civil Practices & Remedies
Code. Neither the execution of this Contract by HHSC nor any other conduct
of
any representative of HHSC relating to this Contract shall be considered a
waiver of HHSC’s sovereign immunity to suit.
(4)
HHSC rules. The submission,
processing and resolution of HMO’s claim is governed by the rules adopted by
HHSC pursuant to Chapter 2260, Texas Government Code, found at Title 1, Chapter
392, Subchapter B of the Texas Administrative Code.
(5)
HMO’s duty to perform. Neither the
occurrence of an event constituting an alleged breach of contract nor the
pending status of any claim for breach of contract is grounds for the suspension
of performance, in whole or in part, by HMO of any duty or obligation with
respect to the performance of this Contract. Any changes to the Contract as
a
result of a dispute resolution will be implemented in accordance with
Article 8 (“Amendments and Modifications”).
Section
12.14 Liability of
HMO.
(a)
HMO bears all risk of loss or
damage to HHSC or the State due to:
(1)
Defects in Services or Deliverables;
(2)
Unfitness or obsolescence of Services or Deliverables; or
(3)
The
negligence or intentional misconduct of HMO or its employees, agents,
Subcontractors, or representatives.
(b)
HMO must, at the HMO’s own expense,
defend with counsel approved by HHSC, indemnify, and hold harmless HHSC and
State employees, officers, directors, contractors and agents from
and
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against
any losses, liabilities, damages, penalties, costs, fees, including without
limitation reasonable attorneys' fees, and expenses from any claim or action
for
property damage, bodily injury or death, to the extent caused by or arising
from
the negligence or intentional misconduct of the HMO and its employees, officers,
agents, or Subcontractors. HHSC will not unreasonably withhold
approval of counsel selected by HMO.
(c)
HMO will not be liable to HHSC for
any loss, damages or liabilities attributable to or arising from the failure
of
HHSC or any state agency to perform a service or activity in connection with
this Contract.
Article
13. Assurances &
Certifications
Section
13.01Proposal certifications.
HMO
acknowledges its continuing
obligation to comply with the requirements of the following certifications
contained in its Proposal, and will immediately notify HHSC of any changes
in
circumstances affecting these certifications:
(1)
Federal lobbying;
(2)
Debarment and
suspension;
(3)
Child support; and
(4)
Nondisclosure
statement.
Section
13.02Conflicts of interest.
(a)
Representation.
HMO
agrees to comply with applicable
state and federal laws, rules, and regulations regarding conflicts of interest
in the performance of its duties under this Contract. HMO warrants that it
has
no interest and will not acquire any direct or indirect interest that would
conflict in any manner or degree with its performance under this
Contract.
(b)
General duty regarding conflicts of interest.
HMO
will establish safeguards to
prohibit employees from using their positions for a purpose that constitutes
or
presents the appearance of personal or organizational conflict of interest,
or
personal gain. HMO will operate with complete independence and objectivity
without actual, potential or apparent conflict of interest with respect to
the
activities conducted under this Contract with the State of Texas.
Section
13.03Organizational conflicts of
interest.
(a)
Definition.
An
organizational conflict of interest
is a set of facts or circumstances, a relationship, or other situation under
which a HMO, or a Subcontractor has past, present, or currently planned personal
or financial
activities or interests that either directly or indirectly:
(1)
Impairs or diminishes the HMO’s, or Subcontractor’s ability to render impartial
or objective assistance or advice to HHSC; or
(2)
Provides the HMO or Subcontractor an unfair competitive advantage in future
HHSC
procurements (excluding the award of this Contract).
(b)
Warranty.
Except
as otherwise disclosed and
approved by HHSC prior to the Effective Date of the Contract, HMO warrants
that,
as of the Effective Date and to the best of its knowledge and belief, there
are
no relevant facts or circumstances that could give rise to an organizational
conflict of interest affecting this Contract. HMO affirms that it has neither
given, nor intends to give, at any time hereafter, any economic opportunity,
future employment, gift, loan, gratuity, special discount, trip, favor, or
service to a public servant or any employee or representative of same, at any
time during the procurement process or in connection
with the procurement process except as allowed under relevant state and federal
law.
(c)
Continuing duty to disclose.
(1)
HMO
agrees that, if after the Effective Date, HMO discovers or is made aware of
an
organizational conflict of interest, HMO will immediately and fully disclose
such interest in writing to the HHSC project manager. In addition,
HMO must promptly disclose any relationship that might be perceived or
represented as a conflict after its discovery by HMO or by HHSC as a potential
conflict. HHSC reserves the right to make a final determination
regarding the existence of conflicts of interest, and HMO agrees to abide by
HHSC’s decision.
(2)
The
disclosure will include a description of the action(s) that HMO has taken or
proposes to take to avoid or mitigate such conflicts.
(d)
Remedy.
If
HHSC determines that an
organizational conflict of interest exists, HHSC may, at its discretion,
terminate the Contract pursuant to Subsection 12.03(b)(9). If HHSC determines
that HMO was aware of an organizational conflict of interest before the award
of
this Contract and did not disclose the conflict to the contracting officer,
such
nondisclosure will be considered a material breach of the
Contract. Furthermore, such breach may be submitted to the Office of
the Attorney General, Texas Ethics Commission, or appropriate State or Federal
law enforcement officials for further action.
(e)
Flow
down obligation.
HMO
must include the provisions of this
Section in all Subcontracts for work to be performed similar to the service
provided by HMO, and the terms
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"Contract,"
"HMO," and "project manager" modified appropriately to preserve the State's
rights.
Section
13.04HHSC personnel recruitment
prohibition.
HMO
has not retained or promised to
retain any person or company, or utilized or promised to utilize a consultant
that participated in HHSC’s development of specific criteria of the RFP or who
participated in the selection of the HMO for this Contract.
Unless
authorized in writing by HHSC,
HMO will not recruit or employ any HHSC professional or technical personnel
who
have worked on projects relating to the subject matter of this Contract, or
who
have had any influence on decisions affecting the subject matter of this
Contract, for two (2) years following the completion of this
Contract.
Section
13.05Anti-kickback
provision.
HMO
certifies that it will comply with
the Anti-Kickback Act of 1986, 41 U.S.C. §51-58 and Federal Acquisition
Regulation 52.203-7, to the extent applicable.
Section
13.06Debt or back taxes owed to State of
Texas.
In
accordance with Section 403.055 of
the Texas Government Code, HMO agrees that any payments due to HMO under the
Contract will be first applied toward any debt and/or back taxes HMO owes State
of Texas. HMO further agrees that payments will be so applied until
such debts and back taxes are paid in full.
Section
13.07 Certification regarding status of license, certificate, or
permit.
Article
IX, Section 163 of the General
Appropriations Act for the 1998/1999 state fiscal biennium prohibits an agency
that receives an appropriation under either Article II or V of the General
Appropriations Act from awarding a contract with the owner, operator, or
administrator of a facility that has had a license, certificate, or permit
revoked by another Article II or V agency. HMO certifies it is not ineligible
for an award under this provision.
Section
13.08 Outstanding debts and
judgments.
HMO
certifies that it is not presently
indebted to the State of Texas, and that HMO is not subject to an outstanding
judgment in a suit by State of Texas against HMO for collection of the balance.
For purposes of this Section, an indebtedness is any amount sum of money that
is
due and owing to the State of Texas and is not currently under dispute. A false
statement regarding HMO’s status will be treated as a material breach of this
Contract and may be grounds for termination at the option of HHSC.
Article
14. Representations & Warranties
Section
14.01Authorization.
(a)
The execution, delivery and
performance of this Contract has been duly authorized by HMO and no additional
approval, authorization or consent of any governmental or regulatory agency
is
required to be obtained in order for HMO to enter into this Contract and perform
its obligations under this Contract.
(b)
HMO has obtained all licenses,
certifications, permits, and authorizations necessary to perform the Services
under this Contract and currently is in good standing with all regulatory
agencies that regulate any or all aspects of HMO’s performance of this Contract.
HMO will maintain all required certifications, licenses, permits, and
authorizations during the term of this Contract.
Section
14.02Ability to perform.
HMO
warrants that it has the financial
resources to fund the capital expenditures required under the Contract without
advances by HHSC or assignment of any payments by HHSC to a financing
source.
Section
14.03Minimum Net Worth.
The
HMO has, and will maintain
throughout the life of this Contract, minimum net worth 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 Members; or (c) an amount that complies
with standards adopted by TDI. Minimum net worth means the excess total admitted
assets over total liabilities, excluding liability for subordinated debt issued
in compliance with Chapter 843 of the Texas Insurance Code.
Section
14.04 Insurer solvency.
(a)
The HMO must be and remain in full
compliance with all applicable state and federal solvency requirements for
basic-service health maintenance organizations, including but not limited to,
all reserve requirements, net worth standards, debt-to-equity ratios, or other
debt limitations. In the event the HMO fails to maintain such compliance, HHSC,
without limiting any other rights it may have by law or under the Contract,
may
terminate the Contract.
(b)
If the HMO becomes aware of any
impending changes to its financial or business structure that could adversely
impact its compliance with the requirements of the Contract or its ability
to
pay its debts as they come due, the HMO must notify HHSC immediately in
writing.
(c)
The HMO must have a plan and take
appropriate measures to ensure adequate provision against the risk of insolvency
as required by TDI. Such provision must be adequate to provide for the following
in the event of insolvency:
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(1)
continuation of Covered Services, until the time of discharge, to Members who
are confined on the date of insolvency in a hospital or other inpatient
facility;
(2)
payments to unaffiliated health care providers and affiliated healthcare
providers whose Contracts do not contain Member “hold harmless” clauses
acceptable to the TDI;
(3)
continuation of Covered Services for the duration of the Contract Period for
which a capitation has been paid for a Member;
(4)
provision against the risk of insolvency must be made by establishing adequate
reserves, insurance or other guarantees in full compliance with all financial
requirements of TDI and the Contract.
Should
TDI determine that there is an
immediate risk of insolvency or the HMO is unable to provide Covered Services
to
its Members, HHSC, without limiting any other rights it may have by law, or
under the Contract, may terminate the Contract.
Section
14.05Workmanship and performance.
(a)
All Services and Deliverables
provided under this Contract will be provided in a manner consistent with the
standards of quality and integrity as outlined in the Contract.
(b)
All Services and Deliverables must
meet or exceed the required levels of performance specified in or pursuant
to
this Contract.
(c)
HMO will perform the Services and
provide the Deliverables in a workmanlike manner, in accordance with best
practices and high professional standards used in well-managed operations
performing services similar to the services described in this
Contract.
Section
14.06Warranty of
deliverables.
HMO
warrants that Deliverables
developed and delivered under this Contract will meet in all material respects
the specifications as described in the Contract during the period following
its
acceptance by HHSC, through the term of the Contract, including any subsequently
negotiated by HMO and HHSC. HMO will promptly repair or replace any such
Deliverables not in compliance with this warranty at no charge to
HHSC.
Section
14.07Compliance with
Contract.
HMO
will not take any action
substantially or materially inconsistent with any of the terms and conditions
set forth in this Contract without the express written approval of
HHSC.
Section
14.08Technology Access
(a)
HMO expressly acknowledges that
State funds may not be expended in connection with the purchase of an automated
information system unless that system meets certain statutory requirements
relating to accessibility by persons with visual
impairments. Accordingly, HMO represents and warrants to HHSC that
this technology is capable, either by virtue of features included within the
technology or because it is readily adaptable by use with other technology,
of:
(1)
Providing equivalent access for effective use by both visual and non-visual
means;
(2)
Presenting information, including prompts used for interactive communications,
in formats intended for non-visual use; and
(3)
Being
integrated into networks for obtaining, retrieving, and disseminating
information used by individuals who are not blind or visually
impaired.
(b)
For purposes of this Section, the
phrase "equivalent access" means a substantially similar ability to communicate
with or make use of the technology, either directly by features incorporated
within the technology or by other reasonable means such as assistive devices
or
services that would constitute reasonable accommodations under the Americans
with Disabilities Act or similar State or Federal laws. Examples of
methods by which equivalent access may be provided include, but are not limited
to, keyboard alternatives to mouse commands and other means of navigating
graphical displays, and customizable display appearance.
(c)
In addition, all technological
solutions offered by the HMO must comply with the requirements
of Texas Government Code §531.0162. This includes, but is
not limited to providing technological solutions that meet federal accessibility
standards for persons with disabilities, as applicable.
Article
15. Intellectual
Property
Section
15.01Infringement and
misappropriation.
(a)
HMO warrants that all Deliverables
provided by HMO will not infringe or misappropriate any right of, and will
be
free of any claim of, any third person or entity based on copyright, patent,
trade secret, or other intellectual property rights.
(b)
HMO will, at its expense, defend
with counsel approved by HHSC, indemnify, and hold harmless HHSC, its employees,
officers, directors, contractors, and agents from and against any losses,
liabilities, damages, penalties, costs, fees, including without limitation
reasonable attorneys’ fees and expenses, from any claim or action against HHSC
that is based on a claim of breach of the warranty set forth in the preceding
paragraph. HHSC will promptly notify HMO in writing of the claim,
provide HMO a copy of all information received by HHSC with respect to the
claim, and cooperate with HMO in defending or settling the
claim. HHSC will not unreasonably
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withhold,
delay or condition approval of counsel selected by the HMO.
(c)
In case the Deliverables, or any
one or part thereof, is in such action held to constitute an infringement or
misappropriation, or the use thereof is enjoined or restricted or if a
proceeding appears to HMO to be likely to be brought, HMO will, at its own
expense, either:
(1)
Procure for HHSC the right to continue using the Deliverables; or
(2)
Modify or replace the Deliverables to comply with the Specifications and to
not
violate any intellectual property rights.
If
neither of the alternatives set
forth in (1) or (2) above are available to the HMO on commercially reasonable
terms, HMO may require that HHSC return the allegedly infringing Deliverable(s)
in which case HMO will refund all amounts paid for all such
Deliverables.
Section
15.02Exceptions.
HMO
is not responsible for any claimed
breaches of the warranties set forth in Section 15.01 to the extent caused
by:
(a)
Modifications made to the item in
question by anyone other than HMO or its Subcontractors, or modifications made
by HHSC or its contractors working at HMO’s direction or in accordance with the
specifications; or
(b)
The combination, operation, or use
of the item with other items if HMO did not supply or approve for use with
the
item; or
(c)
HHSC’s failure to use any new or
corrected versions of the item made available by HMO.
Section
15.03Ownership and Licenses
(a)
Definitions.
For
purposes of this Section 15.03, the following terms have the meanings set forth
below:
(1) “Custom
Software” means any software developed by the HMO:
for HHSC; in connection with the Contract; and with funds received from
HHSC. The term does not include HMO Proprietary Software or Third
Party Software.
(2) “HMO
Proprietary Software” means software:(i) developed
by the HMO prior to the Effective Date of the Contract, or (ii) software
developed by the HMO after the Effective Date of the Contract that is not
developed: for HHSC; in connection with the Contract; and with funds received
from HHSC.
(3) “Third
Party
Software” means software that is: developed for
general commercial use; available to the public; or not developed for
HHSC. Third Party Software includes without limitation: commercial
off-the-shelf software; operating system software; and application software,
tools, and utilities.
(b)
Deliverables.
The
Parties agree that any Deliverable, including without limitation the Custom
Software, will be the exclusive property of HHSC.
(c)
Ownership rights.
(1)
HHSC will own all right, title, and
interest in and to its Confidential Information and the Deliverables provided
by
the HMO, including without limitation the Custom Software and associated
documentation. For purposes of this Section 15.03, the Deliverables
will not include HMO Proprietary Software or Third Party
Software. HMO will take all actions necessary and transfer ownership
of the Deliverables to HHSC, including, without limitation, the Custom Software
and associated documentation prior to Contract termination.
(2)
HMO will furnish such Deliverables,
upon request of HHSC, in accordance with applicable State law. All Deliverables,
in whole and in part, will be deemed works made for hire of HHSC for all
purposes of copyright law, and copyright will belong solely to HHSC. To the
extent that any such Deliverable does not qualify as a work for hire under
applicable law, and to the extent that the Deliverable includes materials
subject to copyright, patent, trade secret, or other proprietary right
protection, HMO agrees to assign, and hereby assigns, all right, title, and
interest in and to Deliverables, including without limitation all copyrights,
inventions, patents, trade secrets, and other proprietary rights therein
(including renewals thereof) to HHSC.
(3)
HMO will, at the expense of HHSC,
assist HHSC or its nominees to obtain copyrights, trademarks, or patents for
all
such Deliverables in the United States and any other countries. HMO
agrees to execute all papers and to give all facts known to it necessary to
secure United States or foreign country copyrights and patents, and to transfer
or cause to transfer to HHSC all the right, title, and interest in and to such
Deliverables. HMO also agrees not to assert any moral rights under applicable
copyright law with regard to such Deliverables.
(d)
License Rights HHSC will have a
royalty-free and non-exclusive license to access the HMO Proprietary Software
and associated documentation during the term of the Contract. HHSC will also
have ownership and unlimited rights to use, disclose, duplicate, or publish
all
information and data developed, derived, documented, or furnished by HMO under
or resulting from the Contract. Such data will include all results,
technical information, and materials developed for and/or obtained by HHSC
from
HMO in the performance of the Services hereunder, including but not limited
to
all reports, surveys, plans, charts, recordings (video and/or sound), pictures,
drawings, analyses, graphic representations computer,
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printouts,
notes and memoranda, and documents whether finished or unfinished, which result
from or are prepared in connection with the Services performed as a result
of
the Contract.
(e)
Proprietary Notices
HMO
will reproduce and include HHSC’s
copyright and other proprietary notices and product identifications provided
by
HMO on such copies, in whole or in part, or on any form of the
Deliverables.
(f)
State
and Federal Governments
In
accordance with 45 C.F.R. §95.617,
all appropriate State and Federal agencies will have a royalty-free,
nonexclusive, and irrevocable license to reproduce, publish, translate, or
otherwise use, and to authorize others to use for Federal Government purposes
all materials, the Custom Software and modifications thereof, and associated
documentation designed, developed, or installed with federal financial
participation under the Contract, including but not limited to those materials
covered by copyright, all software source and object code, instructions, files,
and documentation.
Article
16.
Liability
Section
16.01 Property
damage.
(a)
HMO will protect HHSC’s real and
personal property from damage arising from HMO’s, its agent’s, employees’ and
Subcontractors’ performance of the Contract, and HMO will be responsible for any
loss, destruction, or damage to HHSC’s property that results from or
is caused by HMO’s, its agents’, employees’ or Subcontractors’ negligent or
wrongful acts or omissions. Upon the loss of, destruction of, or
damage to any property of HHSC, HMO will notify the HHSC Project Manager thereof
and, subject to direction from the Project Manager or her or his designee,
will
take all reasonable steps to protect that property from further
damage.
(b)
HMO agrees to observe and encourage
its employees and agents to observe safety measures and proper operating
procedures at HHSC sites at all times.
(c)
HMO will distribute a policy
statement to all of its employees and agents that directs the employee or agent
to promptly report to HHSC or to HMO any special defect or unsafe condition
encountered while on HHSC premises. HMO will promptly report to HHSC
any special defect or an unsafe condition it encounters or otherwise learns
about.
Section
16.02Risk of Loss.
During
the period Deliverables are in
transit and in possession of HMO, its carriers or HHSC prior to being accepted
by HHSC, HMO will bear the risk of loss or damage thereto, unless such loss
or
damage is caused by the negligence or intentional misconduct of HHSC. After
HHSC
accepts a Deliverable, the risk of loss or damage to the Deliverable will be
borne by HHSC, except loss or damage attributable to the negligence or
intentional misconduct of HMO’s agents, employees or
Subcontractors.
Section
16.03Limitation of HHSC’s
Liability.
HHSC
WILL NOT BE LIABLE FOR ANY
INCIDENTAL, INDIRECT, SPECIAL, OR CONSEQUENTIAL DAMAGES UNDER CONTRACT, TORT
(INCLUDING NEGLIGENCE), OR OTHER LEGAL THEORY. THIS WILL APPLY
REGARDLESS OF THE CAUSE OF ACTION AND EVEN IF HHSC HAS BEEN ADVISED OF THE
POSSIBILITY OF SUCH DAMAGES.
HHSC’S
LIABILITY TO HMO UNDER THE
CONTRACT WILL NOT EXCEED THE TOTAL CHARGES TO BE PAID BY HHSC TO HMO UNDER
THE
CONTRACT, INCLUDING CHANGE ORDER PRICES AGREED TO BY THE PARTIES OR OTHERWISE
ADJUDICATED.
HMO’s
remedies are governed by the
provisions in Article 12.
Article
17. Insurance &
Bonding
Section
17.01Insurance Coverage.
(a)
Statutory and General Coverage
HMO
will maintain the following
insurance coverage.
(1)
Standard Worker's Compensation Insurance coverage;
(2)
Automobile Liability;
(3)
Comprehensive Liability Insurance including Bodily Injury coverage of
$100,000.00 per each occurrence and Property Damage Coverage of $25,000.00
per
each occurrence; and
(4)
General Liability Insurance of at least $1,000,000.00 per occurrence and
$5,000,000.00 in the aggregate.
If
HMO’s current Comprehensive General
Liability insurance coverage does not meet the above stated requirements, HMO
will obtain excess liability insurance to compensate for the difference in
the
coverage amounts.
(b)
Professional Liability Coverage.
(1)
HMO
must maintain, or cause its Network Providers to maintain, Professional
Liability Insurance for each Network Provider of $100,000.00 per occurrence
and
$300,000.00 in the aggregate, or the limits required by the hospital at which
the Network Provider has admitting privileges.
(2)
HMO
must maintain an Umbrella Professional Liability Insurance Policy for
the
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greater
of $3,000,000.00 or an amount (rounded to the nearest $100,000.00) that
represents the number of Members enrolled in the HMO in the first month of
the
applicable State Fiscal Year multiplied by $150.00, not to exceed
$10,000,000.00.
(c)
General Requirements for All Insurance Coverage
(1)
Except as provided herein, all exceptions to the Contract’s insurance
requirements must be approved in writing by HHSC. HHSC’s written approval is not
required in the following situations:
(A)
An
HMO or a Network Provider is not required to obtain the insurance coverage
described in Section 17.01 if the HMO or Network Provider qualifies as a state
governmental unit or municipality under the Texas Tort Claims Act, and is
required to comply with, and subject to the provisions of, the Texas Tort Claims
Act.
(B)
An
HMO may waive the Professional Liability Insurance requirement described in
Section 17.01(b)(1) for a Network Provider of Community-based Long Term Care
Services. An HMO may not waive this requirement if the Network
Provider provides other Covered Services in addition to Community-based Long
Term Care Services, or if a Texas licensing entity requires the Network Provider
to carry such Professional Liability coverage. An HMO that
waives the Professional Liability Insurance requirement for a Network Provider
pursuant to this provision is not required to obtain such coverage on behalf
of
the Network Provider.
(2)
HMO
or the Network Provider is responsible for any and all deductibles stated in
the
insurance policies.
(3)Insurance
coverage must be issued by insurance companies authorized to conduct business
in
the State of Texas.
(4)
Insurance coverage must name HHSC as an additional insured with the following
exceptions: Standard Workers’ Compensation Insurance maintained by the HMO, and
Professional Liability Insurance maintained by Network Providers.
(5)
Insurance coverage kept by the HMO must be maintained throughout the Term of
the
Contract, and until HHSC’s final acceptance of all Services and Deliverables.
Failure to maintain such insurance coverage will constitute a material breach
of
this Contract.
(6)
With
the exception of Professional Liability Insurance maintained by Network
Providers, the insurance policies described in this Section must have extended
reporting periods of two years. When policies are renewed or
replaced, the policy retroactive date must coincide with, or precede, the
Contract Effective Date.
(7)
With
the exception of Professional Liability Insurance maintained by Network
Providers, the insurance policies described in this Section must provide that
prior written notice to be given to HHSC at least thirty (30) calendar days
before coverage is substantially changed, canceled, or
non-renewed. HMO must submit a new coverage binder to HHSC to ensure
no break in coverage.
(8)
The
Parties expressly understand and agree that any insurance coverages and limits
furnished by HMO will in no way expand or limit HMO’s liabilities and
responsibilities specified within the Contract documents or by applicable
law.
(9)
HMO
expressly understands and agrees that any insurance maintained by HHSC will
apply in excess of and not contribute to insurance provided by HMO under the
Contract.
(10)
If
HMO, or its Network Providers, desire additional coverage, higher limits of
liability, or other modifications for its own protection, HMO or its Network
Providers will be responsible for the acquisition and cost of such additional
protection. Such additional protection will not be an Allowable
Expense under this Contract.
(d)
Proof
of Insurance Coverage
(1)
Except as provided in Section 17.01(d)(2), the HMO must furnish the HHSC Project
Manager original Certificates of Insurance evidencing the required insurance
coverage on or before theEffective Date of the Contract. If insurance
coverage is renewed during the Term of the Contract, the HMO must furnish the
HHSC Project Manager renewal certificates of insurance, or such similar
evidence, within five (5) Business Days of renewal. The failure of
HHSC to obtain such evidence from HMO will not be deemed to be a waiver by
HHSC
and HMO will remain under continuing obligation to maintain and provide proof
of
insurance coverage.
(2)
The
HMO is not required to furnish the HHSC Project Manager proof of Professional
Liability Insurance maintained by Network Providers on or before the Effective
Date of the Contract, but must provide such information upon HHSC’s request
during the Term of the Contract.
Section
17.02 Performance Bond.
(a)
Beginning on the Operational Start Date of the Contract, and each year
thereafter, the HMO must
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obtain
a
performance bond with a one (1) year term. The performance bond must
continue to be in effect for one (1) year following the expiration of the one
(1) year term. HMO must obtain and maintain the annual performance
bonds in the form prescribed by HHSC and approved by TDI, naming HHSC as
Obligee, securing HMO’s faithful performance of the terms and conditions of this
Contract. The annual performance bonds must comply with Chapter 843 of the
Texas
Insurance Code and 28 T.A.C. §11.1805. The annual performance bond(s)
must be issued in the amount of $100,000.00 for each applicable HMO Program
within each Service Area that the HMO covers under this Contract. All
performance bonds must be issued by a surety licensed by TDI, and specify cash
payment as the sole remedy. HMO must deliver the initial performance
bond to HHSC prior to the Operational Start Date of the Contract, and each
renewal performance bond prior to the first day of the State Fiscal
Year.
(b)
Since the CHIP Perinatal Program is
a sub-program of the CHIP Program, neither a separate performance bond for
the
CHIP Perinatal Program nor a combined performance bond for the CHIP and CHIP
Perinatal Programs is required. The same bond that the HMO obtains
for its CHIP Program within a particular Service Area also will cover the HMO’s
CHIP Perinatal Program, if applicable, in that same Service Area.
Section
17.03TDI Fidelity Bond
The
HMO will secure and maintain
throughout the life of the Contract a fidelity bond in compliance with Chapter
843 of the Texas Insurance Code and 28 T.A.C. §11.1805. The HMO must
promptly provide HHSC with copies of the bond and any amendments or renewals
thereto.
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DOCUMENT
HISTORY LOG
STATUS1
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DOCUMENT
REVISION2
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EFFECTIVE
DATE
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DESCRIPTION3
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Baseline
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n/a
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Initial
version Attachment B-1, Section 6
|
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Revision
|
1.1
|
June
30, 2006
|
Revised
version of the Attachment B-1, Section 6, that includes provisions
applicable to MCOs participating in the STAR+PLUS Program.
Section
6.3.2.1, Experience Rebate Reward, is modified to delete references
to the
selected performance indicators and the Quality Challenge
Pool.
Section
6.3.2.2, Performance-Based Capitation Rate, is modified to include
STAR+PLUS and to add Additional STAR+PLUS Performance Indicators.
Section
6.3.2.3, Quality Challenge Award, is modified to include STAR+PLUS.
Section 6.3.2.5, STAR+PLUS Hospital Inpatient Performance Based Capitation
Rate: Hospital Inpatient Stay Cost Incentives and Disincentives,
is
added.
Section
6.3.2.5.1, STAR+PLUS Hospital Inpatient Disincentive – Administrative Fee
at Risk, is added.
Section
6.3.2.5.2, STAR+PLUS Hospital Inpatient Incentive – Shared Savings Award,
is added.
|
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1.2
|
September
1, 2006
|
Revised
version of the Attachment B-1, Section 6, that includes provisions
applicable to MCOs participating in the STAR and CHIP
Programs.
Section
6.3.2.2, Performance-Based Capitation Rate, modifies the standard
performance indicator for the Behavioral Health Hotline to change
the
maximum abandonment rate from 5% to 7% (except in the Dallas Core
Service
Area).
Section
6.3.2.3, Quality Challenge Award, is modified to reflect the new
start
date for the Quality Challenge Award, which will not be implemented
until
State Fiscal Year 2008.
|
Revision
|
1.3
|
September
1, 2006
|
Revised
version of the Attachment B-1, Section 6 that includes provisions
applicable to MCOs participating in the CHIP Perinatal
Program.
Section
6.3.2.1 modified to clarify that the Experience Rebate Reward incentive
may apply to the CHIP Perinatal Program at a later date.
Section
6.3.2.2 modified to clarify that the Performance-based Capitation
Rate
will not apply for the CHIP Perinatal Program in SFY
2007.
|
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1.4
|
September
1, 2006
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Contract
amendment did not revise Attachment B-1 Section 6 – Premium Payment,
Incentives, and Disincentives
|
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Revision
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1.5
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Contract
amendment did not revise Attachment B-1 Section 6 – Premium Payment,
Incentives, and Disincentives
|
Revision
|
1.6
|
February
1, 2007
|
Revised
version of the Attachment B-1, Section 6, that
includes
provisions applicable to MCOs participating in the STAR+PLUS
Program.
Section
6.3.2.5 is modified to clarify the months included in Rate Period
1.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-1 Section 6 – Premium Payment,
Incentives, and Disincentives
|
1
Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn
versions
2
Revisions
should be
numbered in accordance according to the version of the issuance and
sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3
Brief
description of the
changes to the document made in the
revision.
|
6-2
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
6
|
Version
1.7
|
6.
|
Premium
Payment, Incentives, and
Disincentives
|
This
section documents how the Capitation Rates are developed and describes
performance incentives and disincentives related to HHSC’s value-based
purchasing approach. For further information, HMOs should refer to the HHSC
Uniform Managed Care Contract Terms and
Conditions.
Under
the
HMO Contracts, health care coverage for Members will be provided on a fully
insured basis. The HMO must provide the Services and Deliverables, including
Covered Services to enrolled Members in order for monthly Capitation Payments
to
be paid by HHSC. Attachment B- 1, Section 8 includes the HMO’s
financial responsibilities regarding out-of-network Emergency Services and
Medically Necessary Covered Services not available through Network
Providers.
6.1
|
Capitation
Rate Development
|
Refer
to
Attachment A, HHSC Uniform Managed Care Contract Terms
& Conditions, Article 10, “Terms & Conditions of Payment,” for
information concerning Capitation Rate development.
6.2
|
Financial
Payment Structure and
Provisions
|
HHSC
will
pay the HMO monthly Capitation Payments based on the number of eligible and
enrolled Members. HHSC will calculate the monthly Capitation Payments by
multiplying the number of Member Months times the applicable monthly Capitation
Rate by Member Rate Cell. The HMO must provide the Services and Deliverables,
including Covered Services to Members, described in the Contract for monthly
Capitation Payments to be paid by HHSC.
The
HMO
must understand and expressly assume the risks associated with the performance
of the duties and responsibilities under the Contract, including the failure,
termination, or suspension of funding to HHSC, delays or denials of required
approvals, cost of claims incorrectly paid by the HMO, and cost overruns not
reasonably attributable to HHSC. The HMO must further agree that no other
charges for tasks, functions, or activities that are incidental or ancillary
to
the delivery of the Services and Deliverables will be sought from HHSC or any
other state agency, nor will the failure of HHSC or any other party to pay
for
such incidental or ancillary services entitle the HMO to withhold Services
or
Deliverables due under the Contract.
6.2.1
|
Capitation
Payments
|
The
HMO
must refer to the HHSC Uniform Managed Care Contract Terms &
Conditions for information and Contract requirements on
the:
6-3
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
6
|
Version
1.7
|
1)
Time
and Manner of Payment,
2)
Adjustments to Capitation Payments,
3)
Delivery Supplemental Payment, and
4)
Experience Rebate.
6.3
|
Performance
Incentives and
Disincentives
|
HHSC
introduces several financial and non-financial performance incentives and
disincentives through this Contract. These incentives and disincentives are
subject to change by HHSC over the course of the Contract Period. The
methodologies required to implement these strategies will be refined by HHSC
after collaboration with contracting HMOs through a new incentives workgroup
to
be established by HHSC.
6.3.1
|
Non-financial
Incentives
|
6.3.1.1
|
Performance
Profiling
|
HHSC
intends to distribute information on key performance indicators to HMOs on
a
regular basis, identifying an HMO’s performance, and comparing that performance
to other HMOs, and HHSC standards and/or external Benchmarks. HHSC will
recognize HMOs that attain superior performance and/or improvement by
publicizing their achievements. For example, HHSC may post information
concerning exceptional performance on its website, where it will be available
to
both stakeholders and members of the public.
6.3.1.2
|
Auto-assignment
Methodology for Medicaid
HMOs
|
HHSC
may
also revise its auto-assignment methodology during the Contract Period for
new
Medicaid Members who do not select an HMO (Default Members). The new assignment
methodology would reward those HMOs that demonstrate superior performance and/or
improvement on one or more key dimensions of performance. In establishing the
assignment methodology, HHSC will employ a subset of the performance indicators
contained within the Performance Indicator Dashboard. At
present, HHSC intends to recognize those HMOs that exceed the minimum geographic
access standards defined within Attachment B-1, Section 8 and the
Performance Indicator Dashboard. HHSC may also use its assessment of
HMO performance on annual quality improvement goals (described in
Attachment B-1, Section 8) in developing the assignment
methodology. The methodology would disproportionately assign Default Members
to
the HMO(s) in a given Service Area that performed comparably favorably on the
selected performance indicators.
HHSC
anticipates that it will not implement a performance-based auto-assignment
algorithm before September 1, 2007. HHSC will invite HMO comments on potential
approaches prior to implementation of the new performance-based auto-assignment
algorithm.
6-4
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
6
|
Version
1.7
|
6.3.2
|
Financial
Incentives and
Disincentives
|
6.3.2.1
|
Experience
Rebate Reward
|
HHSC
historically has required HMOs to provide HHSC with an Experience Rebate (see
the Uniform Managed Care Contract Terms and Conditions, Article 10.11)
when there has been an aggregate excess of Revenues over Allowable
Expenses. During the Contract Period, should the HMO experience an aggregate
excess of Revenues over Allowable Expenses across STAR and CHIP HMO Programs
and
Service Areas, HHSC will allow the HMO to retain that portion of the aggregate
excess of Revenues over Allowable Expenses that is equal to or less than 3.5%
of
the total Revenue for the period should the HMO demonstrate superior performance
on selected performance indicators. The retention of 3.5% of revenue exceeds
the
retention of 3.0% of revenue that would otherwise be afforded to a HMO without
demonstrated superior performance on these performance indicators relative
to
other HMOs. HHSC will develop the methodology for determining the level of
performance necessary for an HMO to retain the additional 0.5% of revenue after
consultation with HMOs. The finalized methodology will be added to the
Uniform Managed Care Manual.
HHSC
will
calculate the Experience Rebate Reward after it has calculated the HMO’s at-risk
Capitation Rate payment, as described below in Section 6.3.2.2.
HHSC will calculate whether a HMO is eligible for the Experience Rebate Reward
prior to the 90-day Financial Statistical Report (FSR) filing.
HHSC
anticipates that it will not implement the incentive for Rate Period 1 of the
Contract. HHSC will invite HMO comments on potential approaches prior to
implementation of the new performance-based Experience Rebate Reward. HHSC
may
also implement this incentive option for the STAR+PLUS and CHIP Perinatal
programs in the future.
6.3.2.2
|
Performance-Based
Capitation Rate
|
Beginning
in State Fiscal Year 2007 of the Contract, HHSC will place each STAR and CHIP
HMO at risk for 1% of the Capitation Rate(s). Beginning in State Fiscal Year
2008 of the Contract, HHSC will also place each STAR+PLUS HMO at risk for 1%
of
the Capitation Rate(s). HHSC retains the right to vary the percentage of the
Capitation Rate placed at risk in a given RatePeriod. HHSC will not place CHIP
Perinatal HMOs at risk for 1% of the Capitation Rate(s) in State Fiscal Year
2007, but reserves this right in subsequent State Fiscal Years.
As
noted
in Section 6.2, HHSC will pay the HMO monthly Capitation Payments based on
the
number of eligible and enrolled Members. HHSC will calculate the monthly
Capitation Payments by multiplying the number of Member months times the
applicable monthly Capitation Rate by Member rate cell. At the end of each
Rate
Period, HHSC will evaluate if the HMO has demonstrated that it has fully met
the
performance expectations for which the HMO is at risk. Should the HMO fall
short
on some or all of the performance expectations, HHSC will adjust a future
monthly Capitation Payment by an appropriate portion of the 1% at-risk amount.
HMOs will be able to earn variable percentages up to 100% of the 1% at-risk
Capitation Rate. HHSC’s objective is that all HMOs achieve performance levels
that enable them to receive the full at-risk amount.
6-5
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
6
|
Version
1.7
|
HHSC
will
determine the extent to which the HMO has met the performance expectations
by
assessing the HMO’s performance for each applicable HMO Program relative to
performance targets for the rate period. HHSC will conduct separate accounting
for each HMO Program’s at-risk Capitation Rate amount.
HHSC
will
identify no more than 10 performance indicators for each HMO Program. Some
of
the
performance
indicators will be standard across the HMO Programs while others may apply
to
only
one
of the HMO Programs.
HHSC’s
performance indicators may include some or all of the following measures. The
specific performance indicators, periods of data collection, and associated
points are detailed in the HHSC Uniform Managed Care Manual.
The minimum percentage targets identified in this section
were
developed based, in part, on the HHSC HMO Program objective of ensuring access
to care and quality of care, past performance of the HHSC HMOs, and performance
of Medicaid and CHIP HMOs nationally on HEDIS and CAHPS measures of plan
performance. The Performance Indicator Dashboard includes a
more detailed explanation.
Standard
Performance Indicators:
|
1.
|
98%
of Clean Claims are properly Adjudicated within 30 calendar
days.
|
|
2.
|
The
Member Services Hotline abandonment rate does not exceed
7%.
|
|
3.
|
The
Behavioral Health Hotline
abandonment rate does not exceed
7%.1
|
|
4.
|
The
Provider Services Hotline abandonment rate does not exceed
7%.
|
Additional
STAR Performance Indicators
|
1.
|
90%
of child Members have access to at least one child-appropriate PCP
with an
Open Panel within 30 miles travel
distance.
|
|
2.
|
90%
of adult Members have access to at least one adult-appropriate PCP
with an
Open Panel within 30 miles travel
distance.
|
|
3.
|
36%
of age-qualified child Members receive six or more well-child visits
(in
the first 15 months of life.
|
|
4.
|
56%
of age-qualified child Members receive at least one well-child visit
in
the 3rd, 4th, 5th, or 6th year of
life.
|
|
5.
|
72%
of pregnant women Members receive a prenatal care visit in the first
trimester or within 42 days of
enrollment.
|
Additional
CHIP Performance Indicators
|
1.
|
90%
of child Members have access to at least one child-appropriate PCP
with an
Open Panel within 30 miles travel
distance.
|
|
2.
|
90%
of child Members have access to at least one otolaryngologist (ENT)
within
75 miles travel distance.
|
_______________________
1Will
not apply in
the Dallas Core Service Area. Points will be allocated proportionately over
the
remaining standard performance indicators.
6-6
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
6
|
Version
1.7
|
|
3.
|
56%
of age-qualified child Members receive at least one well-child visit
in
the 3rd, 4th, 5th, or 6th year of
life
|
|
4.
|
38%
of adolescents receive an annual well
visit.
|
Additional
STAR+PLUS Performance Indicators
|
1.
|
57%
of adult Members report no problem with delays in getting approval
from
the HMO
|
|
2.
|
90%
of adult Members have access to at least one adult-appropriate PCP
with an
Open Panel within 30 miles travel
distance
|
|
3.
|
62%
of adult Members report no problem in getting a referral to a Specialty
Physician
|
|
4.
|
47%
of adult Members report no problem getting needed Special Therapy
(physical therapy, occupational therapy, and speech therapy) from
the
HMO
|
|
5.
|
57%
of adult Members report no problem getting needed Behavioral Health
Services from the HMO
|
Failure
to timely provide HHSC with necessary data related to the calculation of the
performance indicators will result in HHSC’s assignment of a zero percent
performance rate for each related performance indicator.
Should
Member survey-based indicators yield response rates deemed by HHSC to be too
low
to yield credible data, HHSC will reapportion points across the remaining
measures.
Actual
plan rates will be rounded to the nearest whole number. HHSC will calculate
performance assessment for the at-risk portion of the capitation payments by
summing all earned points and converting them to a percentage. For example,
an
HMO that earns 92 points will earn 92% of the at-risk Capitation Rate. HHSC
will
apply the premium assessment of 8% of the at-risk Capitation Rate as a reduction
to the monthly Capitation Payment ninety days after the end of the contract
period.
HMOs
will
report actual Capitation Payments received on the Financial Statistical Report
(FSR). Actual Capitation Payments received include all of the at-risk Capitation
Payment paid to the HMO. Any performance assessment based on performance for
a
contract period will appear on the second final (334-day) FSR for that contract
period.
HHSC
will
evaluate the performance-based Capitation Rate methodology annually in
consultation with HMOs. HHSC may then modify the methodology it deems necessary
and appropriate to motivate, recognize, and reward HMOs for performance. The
methodologies for Rate Periods 1 and 2 will be included in the HHSC
Uniform Managed Care Manual.
6.3.2.3
|
Quality
Challenge Award
|
Data
collection for the Quality Challenge Award will begin on September 1, 2006;
however, the Quality Challenge Award will not be implemented until State Fiscal
Year 2008. Should one or more HMOs be unable to earn the full amount of the
performance-based at-risk portion of the Capitation Rate, HHSC will reallocate
the funds through the HMO Program’s Quality Challenge Award. HHSC will use these
funds to reward HMOs that demonstrate superior clinical quality. HHSC will
determine the number of HMOs that will receive Quality Challenge Award funds
annually based on the amount of the funds to be reallocated. Separate Quality
Challenge Award
6-7
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
6
|
Version
1.7
|
payments
will be made for each of the HMO programs. As with the performance-based
Capitation Rate, each HMO will be evaluated separately for each HMO Program.
HHSC intends to evaluate HMO performance annually on some combination of the
following performance indicators in order to determine which HMOs demonstrate
superior clinical quality. In no event will a distribution from the Quality
Challenge Award, plus any other incentive payments made in accordance with
the
HMO Contract, when combined with the Capitation Rate payments, exceed 105%
of
the Capitation Rate payments to an HMO.
Information
about the data collection period to be used for each indicator is found in
the
HHSC
Uniform
Managed Care Manual.
6.3.2.4
|
Remedies
and Liquidated Damages
|
All
areas
of responsibility and all requirements in the Contract will be subject to
performance evaluation by HHSC. Any and all responsibilities or requirements
not
fulfilled may have remedies and HHSC will assess either actual or liquidated
damages. Refer to Attachment A, HHSC Uniform Managed Care Contract Terms
and Conditions and Attachment B-5 for performance
standards that carry liquidated damage values.
6.3.2.5
|
STAR+PLUS
Hospital Inpatient Performance-Based Capitation Rate: Hospital Inpatient
Stay Cost Incentives &
Disincentives
|
Effective
as of the STAR+PLUS Operational Start Date, HHSC will place at-risk a portion
of
the HMO’s Medicaid-Only Capitation Rate. Settlements for Inpatient Stay costs
will be calculated by the State after the end of each State Fiscal Year (SFY)
using three (3) months of completed Hospital paid data for the preliminary
settlement and 11 months of completed data for the final settlement. The SFY
2006 Fee-for-Service (FFS) Inpatient Hospital per-member-per-month (PMPM) rate
will be projected for Rate Period 1 (February 1, 2007 through August 31, 2007)
for the first settlement. Adjustments for the projection will include trending
and risk adjustment. The base and final inpatient hospital PMPM rate will be
calculated separately for each HMO, Service Area, and Rate Cell. Xxxxxx County
is excluded from the Xxxxxx Service Area calculations.
6.3.2.5.1
|
STAR+PLUS
Hospital Inpatient Disincentive - Administrative Fee at
Risk
|
HHSC
has
assumed that STAR+PLUS HMOs will achieve a 22% reduction in projected FFS
Hospital Inpatient Stay costs, for the Medicaid-Only population, through the
implementation of the STAR+PLUS model. HMOs achieving savings beyond 22% will
be
eligible for the STAR+PLUS Shared Savings Award described in Section
6.3.2.5.2. The HMO will be at-risk for savings less than
22%.
The
maximum risk to the HMO will be equal to 50% of the difference between 15%
Hospital inpatient savings and 22% Hospital inpatient savings. The disincentive
for savings above 15%, but still less than 22% will be equal to 50% of the
difference between the level of achieved savings and 22%. HHSC retains the
right
to vary the disincentive percentage in a given Rate Period by Contract
amendment.
6-8
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
6
|
Version
1.7
|
6.3.2.5.2
|
STAR+PLUS
Hospital Inpatient Incentive – Shared Savings
Award
|
HMOs
that
exceed the 22% reduction in Inpatient Stay costs incurred by STAR+PLUS Members
specified in Section 6.3.2.5.1 will be eligible to obtain a 20%
share of the savings achieved beyond the 22% target. HHSC will determine the
extent to which the HMO has met and exceeded the performance expectation in
the
manner described within Section 6.3.2.5. Should HHSC determine
that the HMO exceeded the 22% target, HHSC will adjust a future monthly
Capitation Payment upward by 20% of the calculated savings. This shared savings
award is limited to 5% of the HMO’s capitation in accordance with Federal
Balance Budget Act requirements and is calculated off of total of STAR+PLUS
Capitation Payment. An HMO will be subject to contractual remedies and
determined ineligible for the award, if a HHSC audit reveals that the HMO has
inappropriately averted Medically Necessary Inpatient Stay admissions and
potentially endangered Member safety.
6-9
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
7
|
Version
1.7
|
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version Attachment B-1, Section 7
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
version of the Attachment B-1, Section 7, that
includes
provisions applicable to MCOs participating in the
STAR+PLUS
Program.
Sections
7.1 to 7.3 modified to include STAR+PLUS.
|
Revision
|
1.2
|
September
1, 2006
|
Revised
version of the Attachment B-1, Section 7, that
includes
provisions applicable to MCOs participating in the
STAR
and CHIP Programs.
Section
7.3.1.7, Operations Readiness, changes reference
from
“Operational Date” to “Effective Date.”
|
Revision
|
1.3
|
September
1, 2006
|
Revised
version of the Attachment B-1, Section 7, that
includes
provisions applicable to MCOs participating in the
CHIP
Perinatal Program.
Sections
7.2, 7.3, and 7.3.1.2 through 7.3.1.7 modified to
include
the CHIP Perinatal Program.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-1
Section
7 – Transition Phase Requirements
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-1
Section
7 – Transition Phase Requirements
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-1
Section
7 – Transition Phase Requirements
|
Revision
|
1.7
|
July
1, 2007
|
Section
7.3.1.9 is modified to add a cross-reference to
Attachment
B-1, Sections 8.1.1.2 and 8.1.18.
|
1Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and
“Cancellation”
for withdrawn versions
2 Revisions
should be
numbered in accordance according to the version of the issuance
and
sequential numbering of the
revision—e.g.,
“1.2” refers to the first version of the document and the second
revision.
3 Brief
description of
the changes to the document made in the revision.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
7
|
Version
1.7
|
7.
|
Transition
Phase Requirements
|
7.1
|
Introduction
|
This
Section presents the scope of work for the Transition Phase of the Contract,
which includes those activities that must take place between the time of
Contract award and the Operational Start Date.
The
Transition Phase will include a Readiness Review of each HMO, which must
be
completed successfully prior to a HMO’s Operational Start Date for each
applicable HMO Program. HHSC may, at its discretion, postpone the Operational
Start Date of the Contract for any such HMO that fails to satisfy all Transition
Phase requirements.
If
for
any reason, a HMO does not fully meet the Readiness Review prior to the
Operational Start Date, and HHSC has not approved a delay in the Operational
Start Date or approved a delay in the HMO’s compliance with the applicable
Readiness Review requirement, then HHSC shall impose remedies and either
actual
or liquidated damages. If the HMO is a current HMO Contractor, HHSC may also
freeze enrollment into the HMO’s plan for any of its HMO Programs. Refer to the
HHSC Uniform Managed Care Contract Terms and Conditions (Attachment
A)
and the Liquidated Damages Matrix (Attachment B-5) for
additional information.
7.2
|
Transition
Phase Scope for HMOs
|
STAR,
STAR+PLUS and CHIP HMOs must meet the Readiness Review requirements established
by HHSC no later than 90 days prior to the Operational Start Date for each
applicable HMO Program. CHIP Perinatal HMOS must meet the Readiness Review
requirements established by HHSC not later than 60 days prior to the Operational
Start Date for the CHIP Perinatal Program. HMO agrees to provide all materials
required to complete the readiness review by the dates established by HHSC
and
its Contracted Readiness Review Vendor.
7.3
|
Transition
Phase Schedule and Tasks
|
The
Transition Phase will begin after both Parties sign the Contract. The start
date
for the STAR and CHIP Transition Phase is November 15, 2005. The start date
for
the STAR+PLUS Transition Phase is June 30, 2006. The start date for the CHIP
Perinate Transition Phase is September 1, 2006.
The
Transition Phase must be completed no later than the agreed upon Operational
Start Date(s) for each HMO Program and Service Area. The HMO may be subject
to
liquidated damages for failure to meet the agreed upon Operational Start
Date
(see Attachment B-5).
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
7
|
Version
1.7
|
7.3.1
|
Transition
Phase Tasks
|
The
HMO
has overall responsibility for the timely and successful completion of each
of
the Transition Phase tasks. The HMO is responsible for clearly specifying
and
requesting information needed from HHSC, other HHSC contractors, and Providers
in a manner that does not delay the schedule or work to be
performed.
7.3.1.1
|
Contract
Start-Up and Planning
|
HHSC
and
the HMO will work together during the initial Contract start-up phase
to:
|
•
|
define
project management and reporting
standards;
|
|
•
|
establish
communication protocols between HHSC and the
HMO;
|
|
•
|
establish
contacts with other HHSC
contractors;
|
|
•
|
establish
a schedule for key activities and milestones;
and
|
|
•
|
clarify
expectations for the content and format of Contract
Deliverables.
|
The
HMO
will be responsible for developing a written work plan, referred to as the
Transition/Implementation Plan, which will be used to monitor progress
throughout the Transition Phase. An updated and detailed Transition
/Implementation Plan will be due to HHSC.
7.3.1.2
|
Administration
and Key HMO Personnel
|
No
later
than the Effective Date of the Contract, the HMO must designate and identify
Key
HMO Personnel that meet the requirements in HHSC Uniform Managed Care
Contract Terms & Conditions, Article 4. The HMO will supply HHSC
with resumes of each Key HMO Personnel as well as organizational information
that has changed relative to the HMO’s Proposal, such as updated job
descriptions and updated organizational charts, (including updated Management
Information System (MIS) job descriptions and an updated MIS staff
organizational chart), if applicable. If the HMO is using a Material
Subcontractor(s), the HMO must also provide the organizational chart for
such
Material Subcontractor(s).
No
later
than the Contract execution date, STAR+PLUS HMOs must update the information
above and provide any additional information as it relates to the STAR+PLUS
Program.
No
later
than the Contract execution date, CHIP Perinatal HMOs must update the
information above and provide any additional information as it relates to
the
CHIP Perinatal Program.
7.3.1.3
|
Financial
Readiness Review
|
In
order
to complete a Financial Readiness Review, HHSC will require that HMOs update
information submitted in their proposals. Note: STAR+PLUS and/or CHIP Perinatal
HMOs who have already submitted proposal updates for HHSC’s review for STAR
and/or CHIP, must either verify that the information has not changed and
that it
applies to STAR+PLUS and/or the CHIP
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
7
|
Version
1.7
|
Perinatal
Program or provide updated information for STAR+PLUS by July 10, 2006 and
for
the CHIP Perinatal Program by September 1, 2006. This information will include
the following:
Contractor
Identification and Information
1.
|
The
Contractor’s legal name, trade name, or any other name under which the
Contractor does business, if any.
|
2.
|
The
address and telephone number of the Contractor’s headquarters
office.
|
3.
|
A
copy of its current Texas Department of Insurance Certificate of
Authority
to provide HMO or ANHC services in the applicable Service Area(s).
The
Certificate of Authority must include all counties in the Service
Area(s)
for which the Contractor is proposing to serve HMO
Members.
|
4.
|
Indicate
with a “Yes-HMO”, “Yes-ANHC” or “No” in the applicable cell(s) of the
Column B of the following chart whether the Contractor is currently
certified by TDI as an HMO or ANHC in allcounties
in each of the CSAs in which the Contractor proposes to participate
in one
or more of the HHSC HMO Programs. If the Contractor is not proposing
to
serve a CSA for a particular HMO Program, the Contractor should
leave the
applicable cells in the table
empty.
|
Table
2: TDI Certificate of Authority in Proposed HMO Program
CSAs
Column
A
|
Column
B
|
Column
C
|
Core
Service
Area
(CSA)
|
TDI
Certificate of Authority
|
Counties/Partial
Counties without a
TDI
Certificate of Authority
|
Bexar
|
||
Dallas
|
||
El
Paso
|
||
Xxxxxx
|
||
Lubbock
|
||
Nueces
|
||
Tarrant
|
||
Xxxxxx
|
||
Xxxx
|
If
the
Contractor is not currently certified by TDI as an HMO
or ANHC in any one or more counties in a proposed CSA, the Contractor must
identify such entire counties in Column C for each CSA. For each county listed
in Column C, the Contractor must document that it applied to TDI for such
certification of authority prior to the submission of a Proposal for this
RFP.
The Contractor shall indicate the date that it applied for such certification
and the status of its application to get TDI certification in the relevant
counties in this section of its submission to HHSC.
5.
|
For
Contractors serving any CHIP and CHIP Perinatal OSAs, indicate
with a
“Yes-HMO”, “Yes-ANHC” or “No” in the applicable cell(s) of the Column C of
the following chart whether the Contractor is currently certified
by TDI
as an HMO or ANHC in the entire county in the OSA. If the Contractor
is
not proposing to serve an OSA, the Contractor should leave the
applicable
cells in the table empty.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
7
|
Version
1.7
|
Table
3: TDI Certificate of Authority in Proposed HMO Program
OSAs
CHIP
Program
|
||
Column
A
|
Column
B
|
Column
C
|
Core
Service Area
(CSA)
|
Affiliated
CHIP OSA
|
TDI
Certificate of Authority
|
Bexar
|
||
El
Paso
|
||
Xxxxxx
|
||
Lubbock
|
||
Nueces
|
||
Travis
|
CHIP
Perinatal Program
|
||
Column
A
|
Column
B
|
Column
C
|
Core
Service Area
(CSA)
|
Affiliated
CHIP OSA
|
TDI
Certificate of Authority
|
Bexar
|
||
El
Paso
|
||
Xxxxxx
|
||
Lubbock
|
||
Nueces
|
||
Xxxxxx
|
For
each
county listed in Column C, the Contractor must document that it applied to
TDI
for such certification of authority prior to the submission of a Proposal
for
this RFP. The Contractor shall indicate the date that it applied for such
certification and the status of its application to get TDI certification
in the
relevant counties in this section of its submission to HHSC.
6.
|
|
If
the Contractor proposes to participate in STAR or STAR+PLUS and
seeks to
be considered as an organization meeting the requirements of Section
§533.004(a) or (e) of the Texas Government Code, describe how the
Contractor meets the requirements of §§533.004(a)(1), (a)(2), (a)(3), or
(e) for each proposed Service
Areas.
|
7.
|
|
The
type of ownership (proprietary, partnership,
corporation).
|
8.
|
|
The
type of incorporation (for profit, not-for-profit, or non-profit)
and
whether the Contractor is publicly or privately
owned.
|
9.
|
|
If
the Contractor is an Affiliate or Subsidiary, identify the parent
organization.
|
10.
|
If
any change of ownership of the Contractor’s company is anticipated during
the 12 months following the Proposal due date, the Contractor must
describe the circumstances of such change and indicate when the
change is
likely to occur.
|
11.
|
The
name and address of any sponsoring corporation or others who provide
financial support to the Contractor and type of support, e.g.,
guarantees,
letters of credit, etc. Indicate if there are maximum limits of
the
additional financial support.
|
12.
|
The
name and address of any health professional that has at least a
five
percent financial interest in the Contractor and the type of financial
interest.
|
13.
|
The
names of officers and directors.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
7
|
Version
1.7
|
14.
|
The
state in which the Contractor is incorporated and the state(s)
in which
the Contractor is licensed to do business as an HMO. The Contractor
must
also indicate the state where it is commercially domiciled, if
applicable.
|
15.
|
The
Contractor’s federal taxpayer identification
number.
|
16.
|
The
Contractor’s Texas Provider Identifier (TPI) number if the Contractor is
Medicaidenrolled in Texas.
|
17.
|
Whether
the Contractor had a contract terminated or not renewed for
non-performance or poor performance within the past five years.
In such
instance, the Contractor must describe the issues and the parties
involved, and provide the address and telephone number of the principal
terminating party. The Contractor must also describe any corrective
action
taken to prevent any future occurrence of the problem leading to
the
termination.
|
18.
|
A
current Certificate of Good Standing issued by the Texas Comptroller
of
Public Accounts, or an explanation for why this form is not applicable
to
the Contractor.
|
19.
|
Whether
the Contractor has ever sought, or is currently seeking, National
Committee for Quality Assurance (NCQA) or American Accreditation
HealthCare Commission (URAC) accreditation status, and if it has
or is,
indicate:
|
|
•
|
its
current NCQA or URAC accreditation
status;
|
|
•
|
if
NCQA or URAC accredited, its accreditation term effective dates;
and
|
|
•
|
if
not accredited, a statement describing whether and when NCQA or
URAC
accreditation status was ever denied the
Contractor.
|
Material
Subcontractor Information
A
Material Subcontractor means any entity retained by the HMO to provide all
or
part of the HMO Administrative Services where the value of the subcontracted
HMO
Administrative Service(s) exceeds $100,000 per fiscal year. HMO Administrative
Services are those services or functions other than the direct delivery of
Covered Services necessary to manage the delivery of and payment for Covered
Services. HMO Administrative Services include but are not limited to Network,
utilization, clinical and/or quality management, service authorization, claims
processing, Management Information System (MIS) operation and reporting.
The
term Material Subcontractor does not include Providers in the HMO’s Provider
Network.
Contractors
must submit the following for each proposed Material Subcontractor, if
any:
1.
|
A
signed letter of commitment from each Material Subcontractor that
states
the Material Subcontractor’s willingness to enter into a Subcontractor
agreement with the Contractor and a statement of work for activities
to be
subcontracted. Letters of Commitment must be provided on the Material
Subcontractor’s official company letterhead and signed by an official with
the authority to bind the company for the subcontracted work. The
Letter
of Commitment must state, if applicable, the company’s certified HUB
status.
|
2.
|
The
Material Subcontractor’s legal name, trade name, or any other name under
which the Material Subcontractor does business, if
any.
|
3.
|
The
address and telephone number of the Material Subcontractor’s headquarters
office.
|
4.
|
The
type of ownership (e.g., proprietary, partnership,
corporation).
|
5.
|
The
type of incorporation (i.e., for profit, not-for-profit, or non-profit)
and whether the Material Subcontractor is publicly or privately
owned.
|
6.
|
If
a Subsidiary or Affiliate, the identification of the parent
organization.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
7
|
Version
1.7
|
7.
|
|
The
name and address of any sponsoring corporation or others who provide
financial support to the Material Subcontractor and type of support,
e.g.,
guarantees, letters of credit, etc. Indicate if there are maximum
limits
of the additional financial
support.
|
8.
|
|
The
name and address of any health professional that has at least a
five
percent (5%) financial interest in the Material Subcontractor and
the type
of financial interest.
|
9. |
|
The
state in which the Material Subcontractor is incorporated, commercially
domiciled, and the state(s) in which the organization is licensed
to do
business.
|
10.
|
The
Material Subcontractor’s Texas Provider Identifier if Medicaid-enrolled in
Texas.
|
11.
|
The
Material Subcontractor’s federal taxpayer identification
number.
|
12.
|
Whether
the Material Subcontractor had a contract terminated or not renewed
for
nonperformance or poor performance within the past five years.
In such
instance, the Contractor must describe the issues and the parties
involved, and provide the address and telephone number of the principal
terminating party. The Contractor must also describe any corrective
action
taken to prevent any future occurrence of the problem leading to
the
termination.
|
13.
|
Whether
the Material Subcontractor has ever sought, or is currently seeking,
National Committee for Quality Assurance (NCQA) or American Accreditation
HealthCare Commission (URAC) accreditation or certification status,
and if
it has or is, indicate:
|
|
•its
current NCQA or
URAC accreditation or certification
status;
|
|
•if
NCQA or URAC
accredited or certified, its accreditation or certification term
effective
dates; and
|
|
•if
not accredited,
a statement describing whether and when NCQA or URAC accreditation
status
was ever denied the Material
Subcontractor.
|
Organizational
Overview
1.
|
Submit
an organizational chart (labeled Chart A), showing the corporate
structure
and lines of responsibility and authority in the administration
of the
Bidder’s business as a health plan.
|
2.
|
Submit
an organizational chart (labeled Chart B) showing the Texas organizational
structure and how it relates to the proposed Service Area(s), including
staffing and functions performed at the local level. If Chart A
represents
the entire organizational structure, label the submission as Charts
A and
B.
|
3.
|
Submit
an organizational chart (labeled Chart C) showing the Management
Information System (MIS) staff organizational structure and how
it relates
to the proposed Service Area(s) including staffing and functions
performed
at the local level.
|
4.
|
If
the Bidder is proposing to use a Material Subcontractor(s), the
Bidder
shall include an organizational chart demonstrating how the Material
Subcontractor(s) will be managed within the Bidder’s Texas organizational
structure, including the primary individuals at the Bidder’s organization
and at each Material Subcontractor organization responsible for
overseeing
such Material Subcontract. This information may be included in
Chart B, or
in a separate organizational
chart(s).
|
5.
|
Submit
a brief narrative explaining the organizational charts submitted,
and
highlighting the key functional responsibilities and reporting
requirements of each organizational unit relating to the Bidder’s proposed
management of the HMO Program(s), including its management of any
proposed
Material Subcontractors.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
7
|
Version
1.7
|
Other
Information
1.
|
Briefly
describe any regulatory action, sanctions, and/or fines imposed
by any
federal or Texas regulatory entity or a regulatory entity in another
state
within the last 3 years, including a description of any letters
of
deficiencies, corrective actions, findings of noncompliance, and/or
sanctions. Please indicate which of these actions or fines, if
any, were
related to Medicaid or CHIP programs. HHSC may, at its option,
contact
these clients or regulatory agencies and any other individual or
organization whether or not identified by the
Contractor.
|
2.
|
No
later than ten (10) days after the Contract Effective Date, submit
documentation that demonstrates that the HMO has secured the required
insurance and bonds in accordance with TDI requirements and Attachment
B-1, Section 8.
|
3.
|
Submit
annual audited financial statement for fiscal years 2004 and 2005
(2005 to
be submitted no later than six months after the close of the fiscal
year).
|
4.
|
Submit
an Affiliate Report containing a list of all Affiliates and for
HHSC’s
prior review and approval, a schedule of all transactions with
Affiliates
that, under the provisions of the Contract, will be allowable as
expenses
in the FSR Report for services provided to the HMO by the Affiliate.
Those
should include financial terms, a detailed description of the services
to
be provided, and an estimated amount that will be incurred by the
HMO for
such services during the Contract
Period.
|
7.3.1.4
|
System
Testing and Transfer of
Data
|
The
HMO
must have hardware, software, network and communications systems with the
capability and capacity to handle and operate all MIS systems and subsystems
identified in Attachment B-1, Section 8.1.18. For example, the
HMO’s MIS system must comply with the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) as indicated in
Section
8.1.18.4.
During
this Readiness Review task, the HMO will accept into its system any and all
necessary data files and information available from HHSC or its contractors.
The
HMO will install and test all hardware, software, and telecommunications
required to support the Contract. The HMO will define and test modifications
to
the HMO’s system(s) required to support the business functions of the
Contract.
The
HMO
will produce data extracts and receive all electronic data transfers and
transmissions. STAR and CHIP HMOs must be able to demonstrate the ability
to
produce an EQRO (currently, Institute for Child Health Policy (ICHP)) encounter
file by April 1, 2006, and the 837-encounter file by August 1, 2006. STAR+PLUS
HMOs must be able to demonstrate the ability to produce the STAR+PLUS encounter
file by the STAR+PLUS Operational Start Date and the 837- encounter file
by
September 1, 2007. CHIP Perinatal HMOs who have already demonstrated the
ability
to produce an EQRO encounter file and 837-encounter file for the CHIP Program
are not required to produce separate files for the CHIP Perinatal
Program.
If
any
errors or deficiencies are evident, the HMO will develop resolution procedures
to address problems identified. The HMO will provide HHSC, or a designated
vendor, with test data files for systems and interface testing for all external
interfaces. This includes testing of the required
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
7
|
Version
1.7
|
telephone
lines for Providers and Members and any necessary connections to the HHSC
Administrative Services Contractor and the External Quality Review Organization.
The HHSC Administrative Services Contractor will provide enrollment test
files
to new HMOs that do not have previous HHSC enrollment files. The HMO will
demonstrate its system capabilities and adherence to Contract specifications
during readiness review.
7.3.1.5
|
System
Readiness Review
|
The
HMO
must assure that systems services are not disrupted or interrupted during
the
Operations Phase of the Contract. The HMO must coordinate with HHSC and other
contractors to ensure the business and systems continuity for the processing
of
all health care claims and data as required under this contract.
The
HMO
must submit to HHSC, descriptions of interface and data and process flow
for
each key business processes described in Section 8.1.18.3,
System-wide Functions.
The
HMO
must clearly define and document the policies and procedures that will be
followed to support day-to-day systems activities. The HMO must develop,
and
submit for State review and approval, the following information by December
14,
2005 for STAR and CHIP, by July 31, 2006 for STAR+PLUS:
|
1.
|
Joint
Interface Plan.
|
|
2.
|
Disaster
Recovery Plan
|
|
3.
|
Business
Continuity Plan
|
|
4.
|
Risk
Management Plan, and
|
|
5.
|
Systems
Quality Assurance Plan.
|
Separate
plans are not required for CHIP Perinatal HMOs.
7.3.1.6
|
Demonstration
and Assessment of System
Readiness
|
The
HMO
must provide documentation on systems and facility security and provide evidence
or demonstrate that it is compliant with HIPAA. The HMO shall also provide
HHSC
with a summary of all recent external audit reports, including findings and
corrective actions, relating to the HMO’s proposed systems, including any SAS70
audits that have been conducted in the past three years. The HMO shall promptly
make additional information on the detail of such system audits available
to
HHSC upon request.
In
addition, HHSC will provide to the HMO a test plan that will outline the
activities that need to be performed by the HMO prior to the Operational
Start
Date of the Contract. The HMO must be prepared to assure and demonstrate
system
readiness. The HMO must execute system readiness test cycles to include all
external data interfaces, including those with Material
Subcontractors.
HHSC,
or
its agents, may independently test whether the HMO’s MIS has the capacity to
administer the STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO business,
as
applicable to the HMO. This Readiness Review of a HMO’s MIS may include a desk
review and/or an
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
7
|
Version
1.7
|
onsite
review. HHSC may request from the HMO additional documentation to support
the
provision of STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO Services, as
applicable to the HMO. Based in part on the HMO’s assurances of systems
readiness, information contained in the Proposal, additional documentation
submitted by the HMO, and any review conducted by HHSC or its agents, HHSC
will
assess the HMO’s understanding of its responsibilities and the HMO’s capability
to assume the MIS functions required under the Contract.
The
HMO
is required to provide a Corrective Action Plan in response to any Readiness
Review deficiency no later than ten (10) calendar days after notification
of any
such deficiency by HHSC. If the HMO documents to HHSC’s satisfaction that the
deficiency has been corrected within ten (10) calendar days of such deficiency
notification by HHSC, no Corrective Action Plan is required.
7.3.1.7
|
Operations
Readiness
|
The
HMO
must clearly define and document the policies and procedures that will be
followed to support day-to-day business activities related to the provision
of
STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO Services, including
coordination with contractors. The HMO will be responsible for developing
and
documenting its approach to quality assurance.
Readiness
Review. Includes all plans to be implemented in one or more Service
Areas on the anticipated Operational Start Date. At a minimum, the HMO shall,
for each HMO Program:
|
1.
|
Develop
new, or revise existing, operations procedures and associated
documentation to support the HMO’s proposed approach to conducting
operations activities in compliance with the contracted scope of
work.
|
|
2.
|
Submit
to HHSC, a listing of all contracted and credentialed Providers,
in a HHSC
approved format including a description of additional contracting
and
credentialing activities scheduled to be completed before the Operational
Start Date.
|
|
3.
|
Prepare
and implement a Member Services staff training curriculum and a
Provider
training curriculum.
|
|
4.
|
Prepare
a Coordination Plan documenting how the HMO will coordinate its
business
activities with those activities performed by HHSC contractors
and the
HMO’s Material Subcontractors, if any. The Coordination Plan will include
identification of coordinated activities and protocols for the
Transition
Phase.
|
|
5.
|
Develop
and submit to HHSC the draft Member Handbook, draft Provider Manual,
draft
Provider Directory, and draft Member Identification Card for HHSC’s review
and approval. The materials must at a minimum meet the requirements
specified in Section 8.1.5 and include the Critical
Elements to be defined in the HHSC Uniform Managed Care
Manual.
|
|
6.
|
Develop
and submit to HHSC the HMO’s proposed Member complaint and appeals
processes for Medicaid, CHIP, and CHIP Perinatal as applicable
to the
HMO’s Program participation.
|
|
7.
|
Provide
sufficient copies of the final Provider Directory to the HHSC
Administrative Services Contractor in sufficient time to meet the
enrollment schedule.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
7
|
Version
1.7
|
|
8.
|
Demonstrate
toll-free telephone systems and reporting capabilities for the
Member
Services Hotline, the Behavioral Health Hotline, and the Provider
Services
Hotline.
|
|
9.
|
Submit
a written Fraud and Abuse Compliance Plan to HHSC for approval
no later
than 30 days after the Contract Effective Date. See Section
8.1.19, Fraud and Abuse, for the requirements of the plan,
including new requirements for special investigation units. As
part of the
Fraud and Abuse Compliance Plan, the HMO
shall:
|
|
•
|
designate
executive and essential personnel to attend mandatory training
in fraud
and abuse detection, prevention and reporting. Executive and essential
fraud and abuse personnel means HMO staff persons who supervise
staff in
the following areas: data collection, provider enrollment or
disenrollment, encounter data, claims processing, utilization review,
appeals or grievances, quality assurance and marketing, and who
are
directly involved in the decision-making and administration of
the fraud
and abuse detection program within the HMO. The training will be
conducted
by the Office of Inspector General, Health and Human Services Commission,
and will be provided free of charge. The HMO must schedule and
complete
training no later than 90 days after the Effective
Date.
|
|
•
|
designate
an officer or director within the organization responsible for
carrying
out the provisions of the Fraud and Abuse Compliance
Plan.
|
|
•
|
The
HMO is held to the same requirements and must ensure that, if this
function is subcontracted to another entity, the subcontractor
also meets
all the requirements in this section and the Fraud and Abuse section
as
stated in Attachment B-1, Section
8.
|
|
•
|
Note:
STAR+PLUS HMOs who have already submitted and received HHSC’s approval for
their Fraud and Abuse Compliance Plans must submit acknowledgement
that
the HMO’s approved Fraud and Abuse Compliance Plan also applies to the
STAR+PLUS program, or submit a revised Fraud and Abuse Compliance
Plan for
HHSC’s approval, with an explanation of changes to be made to incorporate
the STAR+PLUS program into the plan, by July 10,
2006.
|
|
•
|
CHIP
Perinatal HMOs who have already submitted and received HHSC’s approval for
their Fraud and Abuse Compliance Plans must submit acknowledgement
that
the HMO’s approved Fraud and Abuse Compliance Plan also applies to the
CHIP Perinatal Program, or submit a revised Fraud and Abuse Compliance
Plan for HHSC’s approval, with an explanation of changes to be made to
incorporate the CHIP Perinatal program into the plan, by September
15,
2006.
|
|
•
|
Complete
hiring and training of STAR+PLUS Service Coordination staff, no
later than
45 days prior to the STAR+PLUS Operational Start
Date.
|
During
the Readiness Review, HHSC may
request from the HMO certain operating procedures and updates to documentation
to support the provision of STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal
HMO
Services. HHSC will assess the HMO’s understanding of its responsibilities and
the HMO’s capability to assume the functions required under the Contract, based
in part on the HMO’s assurances of operational readiness, information contained
in the Proposal, and in Transition Phase documentation submitted by the
HMO.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
7
|
Version
1.7
|
The
HMO
is required to promptly provide a Corrective Action Plan and/or Risk Mitigation
Plan as requested by HHSC in response to Operational Readiness Review
deficiencies identified by the HMO or by HHSC or its agent. The HMO must
promptly alert HHSC of deficiencies, and must correct a deficiency or provide
a
Corrective Action Plan and/or Risk Mitigation Plan no later than ten (10)
calendar days after HHSC’s notification of deficiencies. If the Contractor
documents to HHSC’s satisfaction that the deficiency has been corrected within
ten (10) calendar days of such deficiency notification by HHSC, no Corrective
Action Plan is required.
7.3.1.8
|
Assurance
of System and Operational
Readiness
|
In
addition to successfully providing the Deliverables described in Section
7.3.1, the HMO must assure HHSC that all processes, MIS systems, and
staffed functions are ready and able to successfully assume responsibilities
for
operations prior to the Operational Start Date. In particular, the HMO must
assure that Key HMO Personnel, Member Services staff, Provider Services staff,
and MIS staff are hired and trained, MIS systems and interfaces are in place
and
functioning properly, communications procedures are in place, Provider Manuals
have been distributed, and that Provider training sessions have occurred
according to the schedule approved by HHSC.
7.3.1.9
|
Post-Transition
|
The
HMO
will work with HHSC, Providers, and Members to promptly identify and resolve
problems identified after the Operational Start Date and to communicate to HHSC,
Providers, and Members, as applicable, the steps the HMO is taking to resolve
the problems.
If
a HMO
makes assurances to HHSC of its readiness to meet Contract requirements,
including MIS and operational requirements, but fails to satisfy requirements
set forth in this Section, or as otherwise required pursuant to the Contract,
HHSC may, at its discretion do any of the following in accordance with the
severity of the non-compliance and the potential impact on Members and
Providers:
|
1.
|
freeze
enrollment into the HMO’s plan for the affected HMO Program(s) and Service
Area(s);
|
|
2.
|
freeze
enrollment into the HMO’s plan for all HMO Programs or for all Service
Areas of an affected HMO Program;
|
|
3.
|
impose
contractual remedies, including liquidated damages;
or
|
|
4.
|
pursue
other equitable, injunctive, or regulatory
relief.
|
Refer
to
Attachment B-1, Sections 8.1.1.2 and 8.1.18
for additional information regarding
HMO Readiness Reviews during the
Operations Phase.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version Attachment B-1, Section 8
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
version of the Attachment B-1, Section 8, that includes provisions
applicable to MCOs participating in the STAR+PLUS Program.
Section
8.1.1.1, Performance Evaluation, is modified to include STAR+PLUS
Performance Improvement Goals.
Section
8.1.2, Covered Services, is modified to include Functionally Necessary
Community Long-term Care Services for STAR+PLUS.
Section
8.1.2.1 Value-Added Services, is modified to add language allowing
for the
HMO to distinguish between the Dual Eligible and non-Dual Eligible
populations.
Section
8.1.2.2 Case-by-Case Added Services, is modified to clarify for STAR+Plus
members it is based on functionality.
Section
8.1.3, Access to Care, is modified to include STAR+PLUS Functional
Necessity and 1915(c) Nursing Facility Waiver clarifications.
Section
8.1.4, Provider Network, is modified to include STAR+PLUS.
Section
8.1.4.2, Primary Care Providers, is modified to include
STAR+PLUS
Section
8.1.4.8, Provider Reimbursement, is modified to include Functionally
Necessary Long-term care services for STAR+PLUS.
Section
8.1.7.7, Provider Profiling, is modified to include
STAR+PLUS.
Sections
8.1.12 and 8.1.12.2, Services for People with Special Health Care
Needs,
are modified to include STAR+PLUS.
Section
8.1.13, Service Management for Certain Populations, is modified to
include
STAR+PLUS.
Section
8.1.14, Disease Management, is modified to include STAR+PLUS.
Section
8.2, Additional Medicaid HMO Scope of Work, is modified to include
STAR+PLUS.
Section
8.3, Additional STAR+PLUS Scope of Work, is added.
|
Revision
|
1.2
|
September
1, 2006
|
Revised
version of Attachment B-1, Section 8, that includes provisions applicable
to MCOs participating in the STAR and CHIP Programs.
Section
8.1.1.1, Performance Evaluation, is modified to clarify that the
HMOs
goals are Service Area and Program specific; when the percentages
for
Goals 1 and 2 are to be negotiated; and when Goal 3 is to be
negotiated.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Section
8.1.2.1, Value-Added Services, is modified to add language allowing
for
the addition of two Value-added Services during the Transition Phase
of
the Contract and to clarify the effective dates for Value Added Services
for the Transition Phase and the Operation Phase of the
Contract.
Section
8.1.3.2, Access to Network Providers, is modified to delete references
to
Open Panels.
Section
8.1.4, Provider Network, is modified to clarify that “Out-of- Network
reimbursement arrangements” with certain providers must be in
writing.
Section
8.1.5.1, Member Materials, is modified to clarify the date that the
member
ID card and the member handbook are to be sent to members.
Section
8.1.5.6, Member Hotline, is modified to clarify the hotline performance
requirements.
Section
8.1.17.2, Financial Reporting Requirements, is modified to clarify
that
the Bonus Incentive Plan refers to the Employee Bonus Incentive Plan.
It
has also been modified to clarify the reports and deliverable due
dates
and to change the name of the Claims Summary Lag Report and clarify
that
the report format has been moved to the Uniform Managed Care
Manual.
Section
8.1.18.5, Claims Processing Requirements, is modified to revise the
claims
processing requirements and move many of the specifics to the Uniform
Managed Care Manual.
Section
8.1.20, Reporting Requirements, is modified to clarify the reports
and
deliverable due dates.
Section
8.1.20.2, Reports, is modified to delete the Claims Data Specifications
Report, amend the All Claims Summary Report, and add two new
provider-related reports to the contract.
Section
8.2.2.10, Cooperation with Immunization Registry, is added to comply
with
legislation, SB 1188 sec. 6(e)(1), 79th Legislature,
Regular
Session, 2005.
Section
8.2.2.11, Case Management for Children and Pregnant Women, is
added.
Section
8.2.5.1, Provider Complaints, is modified to include the 30- day
resolution requirement.
Section
8.2.10.2, Non-Reimbursed Arrangements with Local Public Health Entities,
is modified to update the requirements and delete the requirement
for an
MOU.
Section
8.2.11, Coordination with Other State Health and Human Services (HHS)
Programs, is modified to update the requirements and delete the
requirement for an MOU.
Section
8.4.2, CHIP Provider Complaint and Appeals, is modified to include
the
30-day resolution requirement.
|
|||
Revision
|
1.3
|
September
1, 2006
|
Revised
version of Attachment B-1, Section 8, that includes provisions applicable
to MCOs participating in the CHIP Perinatal
Program.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Section
8.1.1.1, Performance Evaluation, is modified to clarify that HHSC
will
negotiate and implement Performance Improvement Goals for the first
full
State Fiscal Year following the CHIP Perinatal Operational Start
Date
Section
8.1.2, Covered Services is amended to: (a) clarify that Fee For Service
will pay the Hospital costs for CHIP Perinate Newborns; (b) add a
reference to new Attachment B-2.2 concerning covered services; (c)
add
CHIP Perinate references where appropriate.
Section
8.1.2.2 Case-by-Case Added Services, is modified to clarify that
this does
not apply to the CHIP Perinatal Program.
Section
8.1.3, Access to Care, is amended to include emergency services
limitations.
Section
8.1.3.2, Access to Network Providers, is amended to include the Provider
access standards for the CHIP Perinatal Program.
Section
8.1.4.2 Primary Care Providers, is modified to clarify the development
of
the PCP networks between the CHIP Perinates and the CHIP Perinate
Newborns.
Section
8.1.4.6 Provider Manual, Materials and Training, modified to include
the
CHIP Perinatal Program
Section
8.1.4.9 Termination of Provider Contracts modified to include the
CHIP
Perinatal Program.
Section
8.1.5.2 Member Identification (ID) Card, modified to include the
CHIP
Perinatal Program.
Section
8.1.5.3 Member Handbook, modified to include the CHIP Perinatal
Program.
Section
8.1.5.4 Provider Directory, modified to include the CHIP Perinatal
Program.
Section
8.1.5.6 Member Hotline, modified to include the CHIP Perinatal
Program.
Section
8.1.5.7 Member Education, modified to include the CHIP Perinatal
Program.
Section
8.1.5.9 Member Complaint and Appeal Process, modified to include
the CHIP
Perinatal Program.
Section
8.1.7.7, Provider Profiling, is modified to include the CHIP Perinatal
Program.
Section
8.1.12, Services for People with Special Health Care Needs, modified
to
clarify between CHIP Perinatal Program and CHIP Perinatal
Newborn.
Section
8.1.13, Service Management for Certain Populations, modified to clarify
the CHIP Perinatal Program.
Section
8.1.15, Behavioral Health (BH) Network and Services, modified to
clarify
between CHIP Perinatal and Perinate members.
Section
8.1.17.2, Financial Reporting Requirements, modified to include the
CHIP
Perinatal Program.
Section
8.1.18.3, System-wide Functions, modified to include the CHIP Perinatal
Program.
Section
8.1.18.5, Claims Processing Requirements, modified to include the
CHIP
Perinatal Program.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Section
8.1.19, Fraud and Abuse, modified to include the CHIP Perinatal
Program
Section
8.1.20.2, Provider Termination Report and Provider Network Capacity
Report, is modified to include the CHIP Perinatal Program.
Section
8.5, Additional Scope of Work for CHIP Perinatal Program HMOs, is
added to
Attachment B-1
|
|||
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment did not revise Attachment X-0, Xxxxxxx 0- Xxxxxxxxxx Xxxxx
Requirements.
|
Revision
|
1.5
|
January
1, 2007
|
Revised
version of the Attachment B-1, Section 8, that includes provisions
applicable to MCOs participating in the STAR and STAR+PLUS
Program.
Section
8.1.2 is modified to include a reference to STAR and STAR+PLUS covered
services.
Section
8.1.20.2 is modified to update the references to the Uniform Managed
Care
Manual for the “Summary Report of Member Complaints and Appeals” and the
“Summary Report of Provider Complaints.”
Section
8.2.2.5 is modified to require the Provider to coordinate with the
Regional Health Authority.
Section
8.2.4 is amended to clarify cost settlements and encounter rates
for
Federally Qualified Health Centers (FQHCs) and Rural Health Clinics
(RHCs)
for STAR and STAR+PLUS service areas.
Section
8.3.2.4 is amended to clarify the timeframe for initial STAR+PLUS
assessments.
Section
8.3.3 is amended to: (1) clarify the use of the DHS Form 2060; (2)
require
the HMO to complete the Individual Service Plan (ISP), Form 3671
for each
Member receiving 1915(c) Nursing Facility Waiver Services; (3) require
HMOs to complete Form 3652 and Form 3671annually at reassessment;
(4)
allow the HMOs to administer the Minimum Data Set for Home Care (MDS-HC)
instrument for nonwaiver STAR+PLUS Members over the course of the
first
year of operation; (5) allow HMOs to submit other supplemental assessment
instruments.
Section
8.3.4 is modified to include the criteria for participation in 1915(c)
nursing facility waiver services.
Section
8.3.4.3 is amended to remove the six-month timeframe for Nursing
Facility
Cost Ceiling. Deletes provision stating DADS Commissioner may grant
exceptions in individual cases.
Section
8.3.5 is amended to delete the requirement that HMOs use the Consumer
Directed Services option for the delivery of Personal Attendant Services.
The new language provides HMOs with three options for delivering
these
services. The options are described in the following new subsections:
8.3.5.1, Personal Attendant Services Delivery Option – Self-Directed
Model; 8.3.5.2, Personal Attendant Services Delivery Option – Agency
Model, Self-Directed; and 8.3.5.3, Personal Attendant Services Delivery
Option – Agency Model.
Section
8.3.7.3 is modified to reflect the changes made by the HMO workgroup
regarding enhanced payments for attendant care. The section also
includes
a reference to new Attachment B-7,
which
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
contains
the HMO’s methodology for implementing and paying the enhanced
payments.
|
|||
Revision
|
1.6
|
February
1, 2007
|
Revised
version of the Attachment B-1, Section 8, that includes provisions
applicable to MCOs participating in the STAR+PLUS and CHIP Perinatal
Programs.
Section
8.1 is modified to clarify the Operational Start Date of the STAR+PLUS
Program.
Section
8.1.3.2 is modified to allow exceptions to hospital access standards
on a
case-by-case basis only for HMOs participating in the CHIP Perinatal
Program.
Section
8.3.3 is modified to clarify when the 12-month period begins for
the
STAR+PLUS HMOs to complete the MDS-HC instruments for non-1915(c)
Nursing
Facility Waiver Members who are receiving Community-based Long-term
Care
Services.
|
Revision
|
1.7
|
July
1, 0000
|
Xxx
Xxxxxxx 8.1.1.2 is added to require the HMOs to pay for any additional
readiness reviews beyond the original ones conducted before the
Operational Start Date.
Section
8.1.5.5 is modified to add a requirement that all HMOs must list
Home
Health Ancillary providers on their websites, with an indicator for
Pediatric services.
Section
8.1.17.2 is modified to remove the requirement that the Claims Lag
Report
separate claims by service categories.
Section
8.1.18 is modified to update the cross-references to sections of
the
contract addressing remedies and damages and to add crossreferences
to
sections of the contract addressing Readiness Reviews. Section 8.1.18.5
is
modified to require the HMO to make an electronic funds transfer
payment
process available when processing claims for Medically Necessary
covered
STAR+PLUS services.
Section
8.1.19 is modified to comply with a new federal law that requires
entities
that receive or make Medicaid payments of at least $5 million annually
to
educate employees, contractors and agents and to implement policies
and
procedures for detecting and preventing fraud, waste and abuse. Section
8.1.20.2 is modified to require Provider Termination Reports for
STAR+PLUS
as required by the Dashboard. The amendment also requires Claims
Summary
Reports be submitted by claim type.
Section
8.2.7.5 is modified to comply with the settlement agreement in the
Xxxxxxx X. litigation.
Section
8.3.4.3 is modified to remove references to the cost cap for 1915(c)
Nursing Facility Waiver services.
|
1Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn
versions
2Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision— e.g., “1.2” refers to the first
version of the document and the second revision.
3Brief
description of the changes to the document made in the
revision.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.
|
OPERATIONS
PHASE REQUIREMENTS
|
This
Section is designed to provide HMOs with sufficient information to understand
the HMOs' responsibilities. This Section describes scope of work requirements
for the Operations Phase of the Contract.
Section
8.1 includes the general scope of work that applies to the STAR,
STAR+PLUS, CHIP, and CHIP Perinatal HMO Programs.
Section
8.2 includes the additional Medicaid scope of work that applies only to
the STAR and STAR+PLUS HMOs.
Section
8.3 includes the additional scope of work that applies only to
STAR+PLUS HMOs.
Section
8.4 includes the additional scope of work that applies only to CHIP
HMOs.
Section
8.5 includes the additional scope of work that applies only to CHIP
Perinatal HMOs.
The
Section does not include detailed information on the STAR, STAR+PLUS, CHIP,
and
CHIP Perinatal HMO Program requirements, such as the time frame and format
for
all reporting requirements. HHSC has included this information in the
Uniform Managed Care Contract Terms and Conditions
(Attachment A) and the Uniform Managed Care
Manual. HHSC reserves the right to modify these documents as it deems
necessary using the procedures set forth in the Uniform Managed Care
Contract Terms and Conditions.
8.1
|
General
Scope of Work
|
In
each
HMO Program Service Area, HHSC will select HMOs for each HMO Program to provide
health care services to Members. The HMO must be licensed by the Texas
Department of Insurance (TDI) as an HMO or an ANHC in all zip codes in the
respective Service Area(s).
Coverage
for benefits will be available to enrolled Members effective on the Operational
Start Date. The Operational Start Date is September 1, 2006 for STAR and CHIP
HMOs, January 1, 2007 for CHIP Perinatal HMOs, and February 1, 2007 for the
STAR+PLUS HMOs.
8.1.1
|
Administration
and Contract Management
|
The
HMO
must comply, to the satisfaction of HHSC, with (1) all provisions set forth
in
this Contract, and (2) all applicable provisions of state and federal laws,
rules, regulations, and waivers.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.1.1.1
|
Performance
Evaluation
|
The
HMO
must identify and propose to HHSC, in writing, no later than May 1st of each
State Fiscal Year (SFY) after the Operational Start Date, annual HMO Performance
Improvement Goals for the next fiscal year, as well as measures and time frames
for demonstrating that such goals are being met. Performance Improvement Goals
must be based on HHSC priorities and identified opportunities for improvement
(see Attachment B-4, Performance Improvement Goals). The
Parties will negotiate such Performance Improvement Goals, the measures that
will be used to assess goal achievement, and the time frames for completion,
which will be incorporated into the Contract. If HHSC and the HMO cannot agree
on the Performance Improvement Goals, measures, or time frames, HHSC will set
the goals, measures, or time frames.
For
State
Fiscal Year 2007, HHSC has established three overarching goals for each Program.
These overarching goals are as follows:
Goal
1
|
(STAR
and CHIP) Improve Access to Primary Care Services for
Members
|
Goal
2
|
(STAR
and CHIP) Improve Access to Behavioral Health Services for
Members,
|
Goal
3
|
(STAR
Only) Improve Access to Clinically Appropriate Alternatives to Emergency
Room Services Outside of Regular Office Hours (CHIP Only) Improve
Current
Member Understanding About the CHIP Benefit Renewal
Processes
|
Note:
The HMO is required to propose customized sub-goals specific to the
HMO’s Service Areas and Programs for all overarching goals. The sub-goals must
be approved by HHSC as part of the negotiation process.
The
specific percentages of expected achievement for each sub-goal will be
negotiated by HHSC
and
the
HMO before the Operational Start Date.
For
STAR+PLUS HMOs, HHSC will negotiate and implement Performance Improvement Goals
for the first full fiscal year following the STAR+PLUS Operational Start Date.
One standard STAR+PLUS goal will relate to Consumer-Directed Services. STAR+PLUS
improvement goals for SFY2008 will be included in Attachment
B-4.1.
For
CHIP
Perinatal HMOs, HHSC will negotiate and implement Performance Improvement Goals
for the first full State Fiscal Year following the CHIP Perinatal Operational
Start Date.
The
HMO
must participate in semi-annual Contract Status Meetings (CSMs) with HHSC for
the primary purpose of reviewing progress toward the achievement of annual
Performance Improvement Goals and Contract requirements. HHSC may request
additional CSMs, as it deems necessary to address areas of noncompliance. HHSC
will provide the HMO with reasonable advance notice of additional CSMs,
generally at least five (5) business days.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
must provide to HHSC, no later than 14 business days prior to each semi-annual
CSM, one electronic copy of a written update, detailing and documenting the
HMO’s progress toward meeting the annual Performance Improvement Goals or other
areas of noncompliance.
HHSC
will
track HMO performance on Performance Improvement Goals. It will also track
other
key facets of HMO performance through the use of a Performance Indicator
Dashboard (see HHSC’s Uniform Managed Care Manual). HHSC will compile
the Performance Indicator Dashboard based on HMO submissions, data from the
External Quality Review Organization (EQRO), and other data available to HHSC.
HHSC will share the Performance Indicator Dashboard with the HMO on a quarterly
basis.
8.1.1.2
|
Additional
HMO Readiness Reviews
|
During
the Operations Phase, a HMO that chooses to make a change to any operational
system or undergo any major transition may be subject to an additional Readiness
Review(s). HHSC will determine whether the proposed changes will require a
desk
review and/or an onsite review. The HMO is responsible for all costs incurred
by
HHSC or its authorized agent to conduct an onsite Readiness Review.
Refer
to
Attachment X-0, Xxxxxxx 0 xxx Xxxxxxxxxx X-0, Section
8.1.18 for additional information regarding HMO Readiness Reviews.
Refer to Attachment A, Section 4.08(c) for information
regarding Readiness Reviews of the HMO’s Material Subcontractors.
8.1.2
|
Covered
Services
|
The
HMO
is responsible for authorizing, arranging, coordinating, and providing Covered
Services in accordance with the requirements of the Contract. The HMO must
provide Medically Necessary Covered Services to all Members beginning on the
Member’s date of enrollment regardless of pre-existing conditions, prior
diagnosis and/or receipt of any prior health care services. STAR+PLUS HMOs
must
also provide Functionally Necessary Community Long-term Care Services to all
Members beginning on the Member’s date of enrollment regardless of preexisting
conditions, prior diagnosis and/or receipt of any prior health care services.
The HMO must not impose any pre-existing condition limitations or exclusions
or
require Evidence of Insurability to provide coverage to any Member.
The
HMO
must provide full coverage for Medically Necessary Covered Services to all
Members and, for STAR+PLUS Members, Functionally Necessary Community Long-term
Care Services, without regard to the Member’s:
|
1.
|
previous
coverage, if any, or the reason for termination of such
coverage;
|
|
2.
|
health
status;
|
|
3.
|
confinement
in a health care facility; or
|
|
4.
|
for
any other reason.
|
Please
Note:
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
(STAR
HMOs): A Member cannot change from one STAR HMO to another STAR HMO during
an
inpatient hospital stay. The STAR HMO responsible for the hospital charges
for
STAR Members at the start of an Inpatient Stay remains responsible for hospital
charges until the time of discharge or until such time that there is a loss
of
Medicaid eligibility. STAR HMOs are responsible for professional charges during
every month for which the HMO receives a full capitation for a
Member.
(STAR+PLUS
HMOs): A Member cannot change from one STAR+PLUS HMO to another STAR+PLUS HMO
during an inpatient hospital stay. The STAR+PLUS HMO is responsible for
authorization and management of the inpatient hospital stay until the time
of
discharge, or until such time that there is a loss of Medicaid eligibility.
STAR+PLUS HMOs are responsible for professional charges during every month
for
which the HMO receives a full capitation for a Member.
A
Member
cannot change from one STAR+PLUS HMO to another STAR+PLUS HMO during a nursing
facility stay.
(CHIP
HMOs): If a CHIP Member’s Effective Date of Coverage occurs while the CHIP
Member is confined in a hospital, HMO is responsible for the CHIP Member’s costs
of Covered Services beginning on the Effective Date of Coverage. If a CHIP
Member is disenrolled while the CHIP Member is confined in a hospital, HMO’s
responsibility for the CHIP Member’s costs of Covered Services terminates on the
Date of Disenrollment.
(CHIP
Perinatal HMOs): If a CHIP Perinate’s Effective Date of Coverage occurs while
the CHIP Perinate is confined in a Hospital, HMO is responsible for the CHIP
Perinate’s costs of Covered Services beginning on the Effective Date of
Coverage. If a CHIP Perinate is disenrolled while the CHIP Perinate is confined
in a Hospital, HMO’s responsibility for the CHIP Perinate’s costs of Covered
Services terminates on the Date of Disenrollment.
The
HMO
must not practice discriminatory selection, or encourage segregation among
the
total group of eligible Members by excluding, seeking to exclude, or otherwise
discriminating against any group or class of individuals.
Covered
Services for all Medicaid HMO Members are listed in Attachments B-2 and
B-2.1 of the Contract (STAR and STAR+PLUS Covered Services). As noted
in Attachments B-2 and B-2.1, all Medicaid HMOs must provide
Covered Services described in the most recent Texas Medicaid Provider
Procedures Manual (Provider Procedures Manual), the THSteps
Manual (a supplement to the Provider Procedures Manual), and in all
Texas Medicaid Bulletins, which update the Provider Procedures
Manual except for those services identified in Section 8.2.2.8
as non-capitated services. A description of CHIP Covered
Services and
exclusions is provided in Attachment B-2 of the Contract. A
description of CHIP Perinatal Program Covered Services and exclusions is
provided in Attachment B-2.2 of the Contract. Covered Services
are subject to change due to changes in federal and state law, changes in
Medicaid, CHIP or CHIP Perinatal Program policy, and changes in medical
practice, clinical protocols, or technology.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.1.2.1
|
Value-added
Services
|
HMOs
may
propose additional services for coverage. These are referred to as “Value-added
Services.” Value-added Services must be actual health care services or benefits
rather than gifts, incentives, educational classes or health assessments.
Temporary phones, cell phones, additional transportation benefits, and extra
home health services may be Value-added Services, if approved by HHSC. Best
practice approaches to delivering Covered Services are not considered
Value-added Services.
If
offered, Value-added Services must be offered to all mandatory STAR, and CHIP
and CHIP Perinatal HMO Members within the applicable HMO Program and Service
Area. For STAR+PLUS Acute Care services, the HMO may distinguish between the
Dual Eligible and non-Dual Eligible populations. Value-added Services do not
need to be consistent across more than one HMO Program or across more than
one
Service Area. Value-added Services that are approved by HHSC during the
contracting process will be included in the Contract’s scope of
services.
The
HMO
must provide Value-added Services at no additional cost to HHSC. The HMO must
not pass on the cost of the Value-added Services to Providers. The HMO must
specify the conditions and parameters regarding the delivery of the Value-added
Services in the HMO’s Marketing Materials and Member Handbook, and must clearly
describe any limitations or conditions specific to the Value-added
Services.
Transition
Phase. During the Transition Phase, HHSC will offer a one-time
opportunity for the HMO to propose two additional Value-added Services to its
list of current, approved Value-added Services. (See Attachment B-3,
Value-Added Services). HHSC will establish the requirements and the
timeframes for submitting the two additional proposed Value-added
Services.
During
this HHSC-designated opportunity, the HMO may propose either to add new
Value-added Services or to enhance its current, approved Value-added Services.
The HMO may propose two additional Value-added Services per HMO Program, and
the
services do not have to be the same for each HMO Program. HHSC will review
the
proposed additional services and, if appropriate, will approve the additional
Value-added Services, which will be effective on the Operational Start Date.
The
HMO’s Contract will be amended to reflect the additional, approved Value-added
Services.
The
HMO
does not have to add Value-added Services during the HHSC-designated
opportunity, but this will be the only time during the Transition Phase for
the
HMO to add Value-added Services. At no time during the Transition Phase will
the
HMO be allowed to delete, limit or restrict any of its current, approved
Value-added Services.
Operations
Phase. During the Operations Phase, Value-added Services can be added
or removed only by written amendment of the Contract one time per fiscal year
to
be effective September 1 of the fiscal year, except when services are amended
by
HHSC during the fiscal year. This will allow HHSC to coordinate with annual
revisions to HHSC’s HMO Comparison Charts for Members. A HMO’s request to add or
delete a Value-added Service must be submitted to HHSC by May 1 of each year
to
be effective September 1 for the following contract period. (For STAR and CHIP,
see Attachment B-3, Value-Added Services. For STAR+PLUS,
see
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
Attachment
B-3.1, STAR+PLUS Value-Added Services. For CHIP Perinatal, see
Attachment B-3.2, CHIP Perinatal Value-Added
Services.)
A
HMO’s
request to add a Value-added Service must:
|
a.
|
Define
and describe the proposed Value-added
Service;
|
|
b.
|
Specify
the Service Areas and HMO Programs for the proposed Value-added
Service;
|
|
c.
|
Identify
the category or group of mandatory Members eligible to receive the
Value-added Service if it is a type of service that is not appropriate
for
all mandatory Members;
|
|
d.
|
Note
any limits or restrictions that apply to the Value-added
Service;
|
|
e.
|
Identify
the Providers responsible for providing the Value-added
Service;
|
|
f.
|
Describe
how the HMO will identify the Value-added Service in administrative
(Encounter) data;
|
|
g.
|
Propose
how and when the HMO will notify Providers and mandatory Members
about the
availability of such Value-added
Service;
|
|
h.
|
Describe
how a Member may obtain or access the Value-added Service;
and
|
|
i.
|
Include
a statement that the HMO will provide such Value-added Service for
at
least 12 months from the September 1 effective
date.
|
A
HMO
cannot include a Value-added Service in any material distributed to mandatory
Members or prospective mandatory Members until the Parties have amended the
Contract to include that Value-added Service. If a Value-added Service is
deleted by amendment, the HMO must notify each mandatory Member that the service
is no longer available through the HMO. The HMO must also revise all materials
distributed to prospective mandatory Members to reflect the change in
Value-added Services.
8.1.2.2
|
Case-by-Case
Added Services
|
Except
as
provided below, the HMO may offer additional benefits that are outside the
scope
of services to individual Members on a case-by-case basis, based on Medical
Necessity, cost-effectiveness, the wishes of the Member/Member’s family, the
potential for improved health status of the Member, and for STAR+PLUS Members
based on functional necessity.
Section
8.1.2.2, Case-by-Case Added Services, does not apply to the CHIP Perinatal
Program.
8.1.3
|
Access
to Care
|
All
Covered Services must be available to Members on a timely basis in accordance
with medically appropriate guidelines, and consistent with generally accepted
practice parameters, requirements in this Contract. The HMO must comply with
the
access requirements as established by the Texas Department of Insurance (TDI)
for all HMOs doing business in Texas, except as otherwise required by this
Contract. Medicaid HMOs must be responsive to the possibility of increased
Members due to the phase-out of the PCCM model in Service Areas where adequate
HMO coverage exists.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
must provide coverage for Emergency Services to Members 24 hours a day and
7
days a week, without regard to prior authorization or the Emergency Service
provider’s contractual relationship with the HMO. The HMO’s policy and
procedures, Covered Services, claims adjudication methodology, and reimbursement
performance for Emergency Services must comply with all applicable state and
federal laws and regulations, whether the provider is in-network or
Out-of-Network. A HMO is not responsible for payment for unauthorized
non-emergency services provided to a Member by Out-of-Network
providers.
The
HMO
must also have an emergency and crisis Behavioral Health Services Hotline
available 24 hours a day, 7 days a week, toll-free throughout the Service Area.
The Behavioral Health Services Hotline must meet the requirements described
in
Section 8.1.15. For Medicaid Members, a HMO must provide
coverage for Emergency Services in compliance with 42 C.F.R. §438.114, and as
described in more detail in Section 8.2.2.1. The HMO may
arrange Emergency Services and crisis Behavioral Health Services through mobile
crisis teams.
For
CHIP
Members, Emergency Services, including emergency Behavioral Health Services,
must be provided in accordance with the Texas Insurance Code and TDI
regulations.
For
the
CHIP Perinatal Program, refer to Attachment B-2.2 for description of emergency
services for CHIP Perinates and CHIP Perinate Newborns.
For
the
STAR, STAR+PLUS, and CHIP Programs, and for CHIP Perinate Newborns, HMO must
require, and make best efforts to ensure, that PCPs are accessible to Members
24
hours a day, 7 days a week and that its Network Primary Care Providers (PCPs)
have after-hours telephone availability that is consistent with, Section
8.1.4. CHIP Perinatal HMOs are not required to establish PCP Networks
for CHIP Perinates.
The
HMO
must provide that if Medically Necessary Covered Services are not available
through Network physicians or other Providers, the HMO must, upon the request
of
a Network physician or other Provider, within the time appropriate to the
circumstances relating to the delivery of the services and the condition of
the
patient, but in no event to exceed five business days after receipt of
reasonably requested documentation, allow a referral to a non-network physician
or provider. The HMO must fully reimburse the non-network provider in accordance
with the Out-of-Network methodology for Medicaid as defined by HHSC, and for
CHIP, at the usual and customary rate defined by TDI in 28 T.A.C. Section
11.506.
The
Member will not be responsible for any payment for Medically Necessary Covered
Services, including Functionally Necessary Covered Services, other
than:
(1)
|
HHSC-specified
co-payments for CHIP Members, where applicable;
and
|
(2) STAR+PLUS
Members who qualify for 1915(c) Nursing Facility Waiver services and enter
a
24-hour setting will be required to pay the provider of care room and board
costs and any income in excess of the personal needs allowance, as established
by HHSC. If the HMO provides Members who do not qualify for the 1915(c) Nursing
Facility Waiver services in a 24-hour setting as an alternative to nursing
facility or hospitalization, the Member will be required to pay the provider
of
care room and board costs and any income in excess of the personal needs
allowance, as established by HHSC.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.1.3.1
|
Waiting
Times for Appointments
|
Through
its Provider Network composition and management, the HMO must ensure that
appointments for the following types of Covered Services are provided within
the
time frames specified below. In all cases below, “day” is defined as a calendar
day.
|
1.
|
Emergency
Services must be provided upon Member presentation at the service
delivery
site, including at non-network and out-of-area
facilities;
|
|
2.
|
Urgent
care, including urgent specialty care, must be provided within 24
hours of
request.
|
|
3.
|
Routine
primary care must be provided within 14 days of
request;
|
|
4.
|
Initial
outpatient behavioral health visits must be provided within 14 days
of
request;
|
|
5.
|
Routine
specialty care referrals must be provided within 30 days of
request;
|
|
6.
|
Pre-natal
care must be provided within 14 days of request, except for high-risk
pregnancies or new Members in the third trimester, for whom an appointment
must be offered within five days, or immediately, if an emergency
exists;
|
|
7.
|
Preventive
health services for adults must be offered to a Member within 90
days of
request; and
|
|
8.
|
Preventive
health services for children, including well-child check-ups should
be
offered to Members in accordance with the American Academy of Pediatrics
(AAP) periodicity schedule. Please note that for Medicaid Members,
HMOs
should use the THSteps Program modifications to the AAP periodicity
schedule. For newly enrolled Members under age 21, overdue or upcoming
well-child checkups, including THSteps medical checkups, should be
offered
as soon as practicable, but in no case later than 14 days of enrollment
for newborns, and no later than 60 days of enrollment for all other
eligible child Members.
|
8.1.3.2
|
Access
to Network Providers
|
The
HMO’s
Network shall have within its Network, PCPs in sufficient numbers, and with
sufficient capacity, to provide timely access to regular and preventive
pediatric care and THSteps services to all child Members in accordance with
the
waiting times for appointments in Section 8.1.3.1.
PCP
Access: At a minimum, the HMO must ensure that all Members have access
to an age-appropriate PCP in the Provider Network with an Open Panel within
30
miles of the Member’s residence. For the purposes of assessing compliance with
this requirement, an internist who provides primary care to adults only is
not
considered an age-appropriate PCP choice for a Member under age 21, and a
pediatrician is not considered an age-appropriate choice for a Member age 21
and
over. Note: This provision does not apply to CHIP Perinates, but it does apply
to CHIP Perinate Newborns.
OB/GYN
Access and CHIP Perinatal Program Provider Access: STAR, STAR+PLUS and
CHIP Program Network: at a minimum, STAR, STAR+PLUS and CHIP HMOs must ensure
that all female Members have access to an OB/GYN in the Provider Network within
75 miles of the Member’s residence. (If the OB/GYN is acting as the Member’s
PCP, the HMO must follow the access requirements for the PCP.) The HMO must
allow female Members to select an OB/GYN within its Provider Network. A female
Member who selects an OB/GYN must be allowed direct access to the OB/GYN’s
health care services without a referral from the Member’s PCP or a
prior
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
authorization.
A pregnant Member with 12 weeks or less remaining before the expected delivery
date must be allowed to remain under the Member’s current OB/GYN care though the
Member’s post-partum checkup, even if the OB/GYN provider is, or becomes,
Out-of-Network.
CHIP
Perinatal Program Network: At a minimum, CHIP Perinatal HMOs must ensure that
CHIP Perinates have access to a Provider of perinate services within 75 miles
of
the Member’s residence if the Member resides in an urban area and within 125
miles of the Member’s residence if the Member resides in a rural
area.
Outpatient
Behavioral Health Service Provider Access: At a minimum, the HMO must
ensure that all Members except CHIP Perinates have access to an outpatient
Behavioral Health Service Provider in the Network within 75 miles of the
Member’s residence. Outpatient Behavioral Health Service Providers must include
Masters and Doctorate-level trained practitioners practicing independently
or at
community mental health centers, other clinics or at outpatient hospital
departments. A Qualified Mental Health Provider (QMHP), as defined and
credentialed by the Texas Department of State Health Services standards (T.A.C.
Title 25, Part I, Chapter 412), is an acceptable outpatient behavioral health
provider as long as the QMHP is working under the authority of an MHMR entity
and is supervised by a licensed mental health professional or
physician.
Other
Specialist Physician Access: At a minimum, the HMO must ensure that all
Members except CHIP Perinates have access to a Network specialist physician
within 75 miles of the Member’s residence for common medical specialties. For
adult Members, common medical specialties shall include general surgery,
cardiology, orthopedics, urology, and ophthalmology. For child Members, common
medical specialties shall include orthopedics and otolaryngology.
Hospital
Access: The HMO must ensure that all Members have access to an Acute
Care hospital in the Provider Network within 30 miles of the Member’s residence.
For HMOs participating in the CHIP Perinatal Program, exceptions to this access
standard may be requested on a case-by-case basis and must have HHSC
approval.
All
other Covered Services, except for services provided in the Member’s
residence: At a minimum, the HMO must ensure that all Members have
access to at least one Network Provider for each of the remaining Covered
Services described in Attachment B-2, within 75 miles of the
Member’s residence. This access requirement includes, but is not limited to,
specialists, specialty hospitals, psychiatric hospitals, diagnostic and
therapeutic services, and single or limited service health care physicians
or
Providers, as applicable to the HMO Program.
The
HMO
is not precluded from making arrangements with physicians or providers outside
the HMO’s Service Area for Members to receive a higher level of skill or
specialty than the level available within the Service Area, including but not
limited to, treatment of cancer, xxxxx, and cardiac diseases. HHSC may consider
exceptions to the above access-related requirements when an HMO has established,
through utilization data provided to HHSC, that a normal pattern for securing
health care services within an area does not meet these standards, or when
an
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.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.1.3.3
|
Monitoring
Access
|
The
HMO
is required to systematically and regularly verify that Covered Services
furnished by Network Providers are available and accessible to Members in
compliance with the standards described in Sections 8.1.3.1 and
8.1.3.2, and for Covered Services furnished by PCPs, the standards
described in Section 8.1.4.2.
The
HMO
must enforce access and other Network standards required by the Contract and
take appropriate action with Providers whose performance is determined by the
HMO to be out of compliance.
8.1.4
|
Provider
Network
|
The
HMO
must enter into written contracts with properly credentialed Providers as
described in this Section. The Provider contracts must comply with the
Uniform Managed Care Manual’s requirements.
The
HMO
must maintain a Provider Network sufficient to provide all Members with access
to the full range of Covered Services required under the Contract. The HMO
must
ensure its Providers and subcontractors meet all current and future state and
federal eligibility criteria, reporting requirements, and any other applicable
rules and/or regulations related to the Contract.
The
Provider Network must be responsive to the linguistic, cultural, and other
unique needs of any minority, elderly, or disabled individuals, or other special
population in the Service Areas and HMO Programs served by the HMO, including
the capacity to communicate with Members in languages other than English, when
necessary, as well as with those who are deaf or hearing impaired.
The
HMO
must seek to obtain the participation in its Provider Network of qualified
providers currently serving the Medicaid and CHIP Members in the HMO’s proposed
Service Area(s).
NOTE:
The following Provider descriptions do not require STAR+PLUS HMOs to contract
with Hospital providers for Inpatient Stay services. STAR+PLUS HMOs are
required, however, to contract with Hospitals for Outpatient Hospital
Services.
All
Providers: All Providers must be licensed in the State of Texas to
provide the Covered Services for which the HMO is contracting with the Provider,
and not be under sanction or exclusion from the Medicaid program. All Acute
Care
Providers serving Medicaid Members must be enrolled as Medicaid providers and
have a Texas Provider Identification Number (TPIN). Long-term Care Providers
are
not required to have a TPIN but must have a LTC Provider number. Providers
must
also have a National Provider Identifier (NPI) in accordance with the timelines
established in 45 C.F.R. Part 162, Subpart D (for most Providers, the NPI must
be in place by May 23, 2007.)
Inpatient
hospital and medical services: The HMO must ensure that Acute Care
hospitals and specialty hospitals are available and accessible 24 hours per
day,
seven days per week, within the HMO’s Network to provide Covered Services to
Members throughout the Service Area.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
Children’s
Hospitals/hospitals with specialized pediatric services: The HMO must
ensure Members access to hospitals designated as Children’s Hospitals by
Medicare and hospitals with specialized pediatric services, such as teaching
hospitals and hospitals with designated children’s wings, so that these services
are available and accessible 24 hours per day, seven days per week, to provide
Covered Services to Members throughout the Service Area. The HMO must make
Out-of-Network reimbursement arrangements with a designated Children’s Hospital
and/or hospital with specialized pediatric services in proximity to the Member’s
residence, and such arrangements must be in writing, if the HMO does not include
such hospitals in its Provider Network. Provider Directories, Member materials,
and Marketing materials must clearly distinguish between hospitals designated
as
Children’s Hospitals and hospitals that have designated children’s
units.
Trauma:
The HMO must ensure Members access to Texas Department of State Health
Services (TDSHS) designated Level I and Level II trauma centers within the
State
or hospitals meeting the equivalent level of trauma care in the HMO’s Service
Area, or in close proximity to such Service Area. The HMO must make
Out-of-Network reimbursement arrangements with the DSHS-designated Level I
and
Level II trauma centers or hospitals meeting equivalent levels of trauma care,
and such arrangements must be in writing, if the HMO does not include such
a
trauma center in its Provider Network.
Transplant
centers: The HMO must ensure Member access to HHSC-designated
transplant centers or centers meeting equivalent levels of care. A list of
HHSC-designated transplant centers can be found in the Procurement Library
in
Attachment H. The HMO must make Out-of-Network reimbursement arrangements with
a
designated transplant center or center meeting equivalent levels of care in
proximity to the Member’s residence, and such arrangements must be in writing,
if the HMO does not include such a center in its Provider Network.
Hemophilia
centers: The HMO must ensure Member access to hemophilia centers
supported by the Centers for Disease Control (CDC). A list of these hemophilia
centers can be found at xxxx://xxx.xxx.xxx/xxxxxx/xxx/xxx_xxxx.xxx. The HMO
must
make Out-of-Network reimbursement arrangements with a CDC-supported hemophilia
center, and such arrangements must be in writing, if the HMO does not include
such a center in its Provider Network.
Physician
services: The HMO must ensure that Primary Care Providers are available
and accessible 24 hours per day, seven days per week, within the Provider
Network. The HMO must contract with a sufficient number of participating
physicians and specialists within each Service Area to comply with the access
requirements throughout Section 8.1.3 and meet the needs of
Members for all Covered Services.
The
HMO
must ensure that an adequate number of participating physicians have admitting
privileges at one or more participating Acute Care hospitals in the Provider
Network to ensure that necessary admissions are made. In no case may there
be
less than one in-network PCP with admitting privileges available and accessible
24 hours per day, seven days per week for each Acute Care hospital in the
Provider Network.
The
HMO
must ensure that an adequate number of participating specialty physicians have
admitting privileges at one or more participating hospitals in the HMO’s
Provider Network to
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
ensure
necessary admissions are made. The HMO shall require that all physicians who
admit to hospitals maintain hospital access for their patients through
appropriate call coverage.
Laboratory
services: The HMO must ensure that in-network reference laboratory
services must be of sufficient size and scope to meet the non-emergency and
emergency needs of the enrolled population and the access requirements in
Section 8.1.3. Reference laboratory specimen procurement
services must facilitate the provision of clinical diagnostic services for
physicians, Providers and Members through the use of convenient reference
satellite labs in each Service Area, strategically located specimen collection
areas in each Service Area, and the use of a courier system under the management
of the reference lab. For Medicaid Members, THSteps requires that laboratory
specimens obtained as part of a THSteps medical checkup visit must be sent
to
the TDSHS Laboratory.
Diagnostic
imaging: The HMO must ensure that diagnostic imaging services are
available and accessible to all Members in each Service Area in accordance
with
the access standards in Section 8.1.3. The HMO must ensure that
diagnostic imaging procedures that require the injection or ingestion of
radiopaque chemicals are performed only under the direction of physicians
qualified to perform those procedures.
Home
health services: The HMO must have a contract(s) with a home health
Provider so that all Members living within the HMO’s Service Area will have
access to at least one such Provider for home health Covered Services. (These
services are provided as part of the Acute Care Covered Services, not the
Community Long-term Care Services.)
Community
Long-term Care services: STAR+PLUS HMOs must have contracts with
Community Long-term Care service Providers, so that all Members living within
the Contractor’s Service Area will have access to Medically Necessary and
Functionally Necessary Covered Services.
8.1.4.1
|
Provider
Contract Requirements
|
The
HMO
is prohibited from requiring a provider or provider group to enter into an
exclusive contracting arrangement with the HMO as a condition for participation
in its Provider Network.
The
HMO’s
contract with health care Providers must be in writing, must be in compliance
with applicable federal and state laws and regulations, and must include minimum
requirements specified in the Uniform Managed Care Contract Terms and
Conditions (Attachment A) and HHSC’s Uniform Managed Care
Manual.
The
HMO
must submit model Provider contracts to HHSC for review during Readiness Review.
HHSC retains the right to reject or require changes to any model Provider
contract that does not comply with HMO Program requirements or the HHSC-HMO
Contract.
8.1.4.2
|
Primary
Care Providers
|
The
HMO’s
PCP Network may include Providers from any of the following practice areas:
General Practice; Family Practice; Internal Medicine; Pediatrics;
Obstetrics/Gynecology
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
(OB/GYN);
Certified Nurse Midwives (CNM) and Physician Assistants (PAs) practicing under
the supervision of a physician; Federally Qualified Health Centers (FQHCs),
Rural Health Clinics (RHCs), and similar community clinics; and specialist
physicians who are willing to provide a Medical Home to selected Members with
special needs and conditions. Section 533.005(a)(13), Government Code, requires
the HMO to use Pediatric and Family Advanced Practice Nurses practicing under
the supervision of a physician as PCPs in its Provider Network for STAR and
STAR+PLUS.
CHIP
Perinatal HMOs are not required to develop PCP Networks for CHIP Perinates.
CHIP
Perinatal HMOs may use the same PCP Network for CHIP Members and CHIP Perinatal
Newborns.
An
internist or other Provider who provides primary care to adults only is not
considered an age-appropriate PCP choice for a Member under age 21. An internist
or other Provider who provides primary care to adults and children may be a
PCP
for children if:
|
1.
|
the
Provider assumes all HMO PCP responsibilities for such Members in
a
specific age group under age 21,
|
|
2.
|
the
Provider has a history of practicing as a PCP for the specified age
group
as evidenced by the Provider’s primary care practice including an
established patient population under age 20 and within the specified
age
range, and
|
|
3.
|
the
Provider has admitting privileges to a local hospital that includes
admissions to pediatric units.
|
A
pediatrician is not considered an age-appropriate choice for a Member age 21
and
over.
The
PCP
for a Member with disabilities, Special Health Care Needs, or Chronic or Complex
Conditions may be a specialist physician who agrees to provide PCP services
to
the Member. The specialty physician 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 through the
HMO for a specialist to serve as a PCP for a Member with disabilities, Special
Health Care Needs, or Chronic or Complex Conditions. The HMO shall handle such
requests in accordance with 28 T.A.C. Part 1, Chapter 11, Subchapter
J.
PCPs
who
provide Covered Services for STAR, CHIP, and CHIP Perinatal Newborns must either
have admitting privileges at a Hospital that is part of the HMO’s Provider
Network or make referral arrangements with a Provider who has admitting
privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting
privileges at a Medicaid Hospital or make referral arrangements with a Provider
who has admitting privileges to a Medicaid Hospital.
The
HMO
must require, through contract provisions, that PCPs are accessible to Members
24 hours a day, 7 days a week. The HMO is encouraged to include in its Network
sites that offer primary care services during evening and weekend hours. The
following are acceptable and unacceptable telephone arrangements for contacting
PCPs after their normal business hours.
Acceptable
after-hours coverage:
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
|
1.
|
The
office telephone 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.
|
The
office telephone 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 telephone. Another recording is not acceptable;
and
|
|
3.
|
The
office telephone is transferred after office hours to another location
where someone will answer the telephone and be able to contact the
PCP or
another designated medical practitioner, who can return the call
within 30
minutes.
|
Unacceptable
after-hours coverage:
|
1.
|
The
office telephone is only answered during office
hours;
|
|
2.
|
The
office telephone is answered after-hours by a recording that tells
patients to leave a message;
|
|
3.
|
The
office telephone is answered after-hours by a recording that directs
patients to go to an Emergency Room for any services needed;
and
|
|
4.
|
Returning
after-hours calls outside of 30
minutes.
|
The
HMO
must require PCPs, through contract provisions or Provider Manual, to provide
children under the age of 21 with preventive services in accordance with the
AAP
recommendations for CHIP Members and CHIP Perinate Newborns, and the THSteps
periodicity schedule published in the THSteps Manual for Medicaid Members.
The
HMO must require PCPs, through contract provisions or Provider Manual, to
provide adults with preventive services in accordance with the U.S. Preventive
Services Task Force requirements. The HMO must make best efforts to ensure
that
PCPs follow these periodicity requirements for children and adult Members.
Best
efforts must include, but not be limited to, Provider education, Provider
profiling, monitoring, and feedback activities.
The
HMO
must require PCPs, through contract provisions or Provider Manual, to assess
the
medical needs of Members for referral to specialty care providers and provide
referrals as needed. PCPs must coordinate Members’ care with specialty care
providers after referral. The HMO must make best efforts to ensure that PCPs
assess Member needs for referrals and make such referrals. Best efforts must
include, but not be limited to, Provider education activities and review of
Provider referral patterns.
8.1.4.3
|
PCP
Notification
|
The
HMO
must furnish each PCP with a current list of enrolled Members enrolled or
assigned to that Provider no later than five (5) working days after the HMO
receives the Enrollment File from the HHSC Administrative Services Contractor
each month. The HMO may offer and provide such enrollment information in
alternative formats, such as through access to a secure Internet site, when
such
format is acceptable to the PCP.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.1.4.4
|
Provider
Credentialing and
Re-credentialing
|
The
HMO
must review, approve and periodically recertify the credentials of all
participating physician Providers and all other licensed Providers who
participate in the HMO’s Provider Network. The HMO may subcontract with another
entity to which it delegates such credentialing activities if such delegated
credentialing is maintained in accordance with the National Committee for
Quality Assurance (NCQA) delegated credentialing requirements and any comparable
requirements defined by HHSC.
At
a
minimum, the scope and structure of a HMO’s credentialing and re-credentialing
processes must be consistent with recognized HMO industry standards such as
those provided by NCQA and relevant state and federal regulations including
28
T.A.C. §11.1902, relating to credentialing of providers in HMOs, and as an
additional requirement for Xxxxxxxx XXXx, 00 C.F.R. §438.214(b). The initial
credentialing process, including application, verification of information,
and a
site visit (if applicable), must be completed before the effective date of
the
initial contract with the physician or Provider. The re-credentialing process
must occur at least every three years.
The
re-credentialing process must take into consideration Provider performance
data
including, but not be limited to, Member Complaints and Appeals, quality of
care, and utilization management.
8.1.4.5
|
Board
Certification Status
|
The
HMO
must maintain a policy with respect to Board Certification for PCPs and
specialty physicians that encourage participation of board certified PCPs and
specialty physicians in the Provider Network. The HMO must make information
on
the percentage of Board-certified PCPs in the Provider Network and the
percentage of Board-certified specialty physicians, by specialty, available
to
HHSC upon request.
8.1.4.6
|
Provider
Manual, Materials and
Training
|
The
HMO
must prepare and issue a Provider Manual(s), including any necessary specialty
manuals (e.g., behavioral health) to all existing Network Providers. For newly
contracted Providers, the HMO must issue copies of the Provider Manual(s) 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
HMO Program(s) and the enrolled populations in compliance with the requirements
of this Contract.
HHSC
or
its designee must approve the Provider Manual, and any substantive revisions
to
the Provider Manual, prior to publication and distribution to Providers. The
Provider Manual must contain the critical elements defined in the
Uniform Managed Care Manual. HHSC’s initial review of the
Provider Manual is part of the Operational Readiness Review described in
Attachment B-1, Section 7.
The
HMO
must provide training to all Providers and their staff regarding the
requirements of the Contract and special needs of Members. The HMO’s Medicaid,
CHIP and/or CHIP Perinatal Program training must be completed within 30 days
of
placing a newly contracted Provider on active status. The HMO must provide
on-going training to new and existing Providers as required
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
by
the
HMO or HHSC to comply with the Contract. The 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 Provider and their
staff.
The
HMO
must establish ongoing Provider training that includes, but is not limited
to,
the following issues:
|
1.
|
Covered
Services and the Provider’s responsibilities for providing and/or
coordinating such services. Special emphasis must be placed on areas
that
vary from commercial coverage rules (e.g., Early Intervention services,
therapies and DME/Medical Supplies); and for Medicaid, making referrals
and coordination with Non-capitated
Services;
|
|
2.
|
Relevant
requirements of the Contract;
|
|
3.
|
The
HMO’s quality assurance and performance improvement program and the
Provider’s role in such a program;
and
|
|
4.
|
The
HMO’s policies and procedures, especially regarding in-network and Out-of-
Network referrals.
|
Provider
Materials produced by the HMO, relating to Medicaid Managed Care, the CHIP
Program, and/or the CHIP Perinatal Program must be in compliance with State
and
Federal laws and requirements of the HHSC Uniform Managed Care Contract
Terms and Conditions. HMO must make available any provider materials to
HHSC upon request.
8.1.4.7
|
Provider
Hotline
|
The
HMO
must operate a toll-free telephone line for Provider inquiries from 8 a.m.
to 5
p.m. local time for the Service Area, Monday through Friday, except for
State-approved holidays. The Provider Hotline must be staffed with personnel
who
are knowledgeable about Covered Services and each applicable HMO Program, and
for Medicaid, about Non-capitated Services.
The
HMO
must ensure that after regular business hours the line is answered by an
automated system with the capability to provide callers with operating hours
information and instructions on how to verify enrollment for a Member with
an
Urgent Condition or an Emergency Medical Condition. The HMO must have a process
in place to handle after-hours inquiries from Providers seeking to verify
enrollment for a Member with an Urgent Condition or an Emergency Medical
Condition, provided, however, that the HMO and its Providers must not require
such verification prior to providing Emergency Services.
The
HMO
must ensure that the Provider Hotline meets the following minimum performance
requirements for all HMO Programs and Service Areas:
|
1.
|
99%
of calls are answered by the fourth ring or an automated call pick-up
system is used;
|
|
2.
|
no
more than one percent of incoming calls receive a busy
signal;
|
|
3.
|
the
average hold time is 2 minutes or less;
and
|
|
4.
|
the
call abandonment rate is 7% or
less.
|
The
HMO
must conduct ongoing call quality assurance to ensure these standards are met.
The Provider Hotline may serve multiple HMO Programs if Hotline staff is
knowledgeable about all of the HMO’s Programs. The Provider Hotline may serve
multiple Service Areas if the Hotline
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
staff
is
knowledgeable about all such Service Areas, including the Provider Network
in
such Service Areas.
The
HMO
must monitor its performance regarding Provider Hotline standards and submit
performance reports summarizing call center performance for the Hotline as
indicated in Section 8.1.20. If the HMO subcontracts with a
Behavioral Health Organization (BHO) that is responsible for Provider Hotline
functions related to Behavioral Health Services, the BHO’s Provider Hotline must
meet the requirements in Section 8.1.4.7.
8.1.4.8
|
Provider
Reimbursement
|
The
HMO
must make payment for all Medically Necessary Covered Services provided to
all
Members for whom the HMO is paid a capitation. A STAR+PLUS HMO must also make
payment for all Functionally Necessary Covered Services provided to all Members
for whom the HMO is paid a capitation. The HMO must ensure that claims payment
is timely and accurate as described in Section 8.1.18.5. The
HMO must require tax identification numbers from all participating Providers.
The HMO is required to do back-up withholding from all payments to Providers
who
fail to give tax identification numbers or who give incorrect
numbers.
8.1.4.9
|
Termination
of Provider Contracts
|
Unless
prohibited or limited by applicable law, at least 15 days prior to the effective
date of the HMO’s termination of contract of any participating Provider the HMO
must notify the HHSC Administrative Services Contractor and notify affected
current Members in writing. Affected Members include all Members in a PCP’s
panel and all Members who have been receiving ongoing care from the terminated
Provider, where ongoing care is defined as two or more visits for home-based
or
office-based care in the past 12 months.
For
the
CHIP and CHIP Perinatal Programs, the HMO’s process for terminating Provider
contracts must comply with the Texas Insurance Code and TDI
regulations.
8.1.5
|
Member
Services
|
The
HMO
must maintain a Member Services Department to assist Members and Members’ family
members or guardians in obtaining Covered Services for Members. The HMO must
maintain employment standards and requirements (e.g., education, training,
and
experience) for Member Services Department staff and provide a sufficient number
of staff for the Member Services Department to meet the requirements of this
Section, including Member Hotline response times, and Linguistic Access
capabilities, see 8.1.5.6 Member Hotline Requirements.
8.1.5.1
|
Member
Materials
|
The
HMO
must design, print and distribute Member identification (ID) cards and a Member
Handbook to Members. Within five business days following the receipt of an
Enrollment File from the HHSC Administrative Services Contractor, the HMO must
mail a Member’s ID card and Member Handbook to the Case Head or Account Name for
each new Member. When the Case Head or Account Name is on behalf of two or
more
new Members, the HMO is only
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
required
to send one Member Handbook. The HMO is responsible for mailing materials only
to those Members for whom valid address data are contained in the Enrollment
File.
The
HMO
must design, print and distribute a Provider Directory to the HHSC
Administrative Services Contractor as described in Section
8.1.5.4.
Member
materials must be at or below a 6th grade reading level as measured by the
appropriate score on the Xxxxxx reading ease test. Member materials must be
available in English, Spanish, and the languages of other Major Population
Groups making up 10% or more of the managed care eligible population in the
HMO’s Service Area, as specified by HHSC. HHSC will provide the HMO with
reasonable notice when the enrolled population reaches 10% within the HMO’s
Service Area. All Member materials must be available in a format accessible
to
the visually impaired, which may include large print, Braille, and
audiotapes.
The
HMO
must submit member materials to HHSC for approval prior to use or mailing.
HHSC
will identify any required changes to the Member materials within 15 business
days. If HHSC has not responded to the Contractor by the fifteenth day, the
Contractor may proceed to use the submitted materials. HHSC reserves the right
to require discontinuation of any Member materials that violate the terms of
the
Uniform Managed Care Terms and Conditions, including but not
limited to “Marketing Policies and Procedures” as described in the
Uniform Managed Care Manual.
8.1.5.2
|
Member
Identification (ID) Card
|
All
Member ID cards must, at a minimum, include the following
information:
|
1.
|
the
Member’s name;
|
|
2.
|
the
Member’s Medicaid, CHIP or CHIP Perinatal Program
number;
|
|
3.
|
the
effective date of the PCP assignment (excluding CHIP
Perinates);
|
|
4.
|
the
PCP’s name, address (optional for all products), and telephone number
(excluding CHIP Perinates);
|
|
5.
|
the
name of the HMO;
|
|
6.
|
the
24-hour, seven (7) day a week toll-free Member services telephone
number
and BH Hotline number operated by the HMO;
and
|
|
7.
|
any
other critical elements identified in the Uniform Managed Care
Manual.
|
The
HMO
must reissue the Member ID card if a Member reports a lost card, there is a
Member name change, if the Member requests a new PCP, or for any other reason
that results in a change to the information disclosed on the ID card. CHIP
Perinatal HMOs must issue Member ID cards to both CHIP Perinates and CHIP
Perinate Newborns.
8.1.5.3
|
Member
Handbook
|
HHSC
must
approve the Member Handbook, and any substantive revisions, prior to publication
and distribution. As described in Attachment B-1, Section 7,
the HMO must develop and submit to HHSC the draft Member Handbook for approval
during the Readiness Review and must submit a final Member Handbook
incorporating changes required by HHSC prior to the Operational Start
Date.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
Member Handbook for each applicable HMO Program must, at a minimum, meet the
Member materials requirements specified by Section 8.1.5.1
above and must include critical elements in the Uniform Managed
Care Manual. CHIP Perinatal HMOs must issue Member Handbooks to both
CHIP Perinates and CHIP Perinate Newborns. The Member Handbook for CHIP Perinate
Newborns may be the same as that used for CHIP.
The
HMO
must produce a revised Member Handbook, or an insert informing Members of
changes to Covered Services upon HHSC notification and at least 30 days prior
to
the effective date of such change in Covered Services. In addition to modifying
the Member materials for new Members, the HMO must notify all existing Members
of the Covered Services change during the time frame specified in this
subsection.
8.1.5.4
|
Provider
Directory
|
The
Provider Directory for each applicable HMO Program, and any substantive
revisions, must be approved by HHSC prior to publication and distribution.
The
HMO is responsible for submitting draft Provider directory updates to HHSC
for
prior review and approval if changes other than PCP information or clerical
corrections are incorporated into the Provider Directory.
As
described in Attachment B-1, Section 7, during the Readiness
Review, the HMO must develop and submit to HHSC the draft Provider Directory
template for approval and must submit a final Provider Directory incorporating
changes required by HHSC prior to the Operational Start Date. Such draft and
final Provider Directories must be submitted according to the deadlines
established in Attachment B-1, Section 7.
The
Provider Directory for each applicable HMO Program must, at a minimum, meet
the
Member Materials requirements specified by Section 8.1.5.1
above and must include critical elements in the Uniform Managed
Care Manual. The Provider Directory must include only Network Providers
credentialed by the HMO in accordance with Section 8.1.4.4. If
the HMO contracts with limited Provider Networks, the Provider Directory must
comply with the requirements of 28 T.A.C. §11.1600(b)(11), relating to the
disclosure and notice of limited Provider Networks.
CHIP
Perinatal HMOs must develop Provider Directories for both CHIP Perinates and
CHIP Perinate Newborns. The Provider Directory for CHIP Perinate Newborns may
be
the same as that used for the CHIP Program.
The
HMO
must update the Provider Directory on a quarterly basis. The HMO must make
such
update available to existing Members on request, and must provide such update
to
the HHSC Administrative Services Contractor at the beginning of each state
fiscal quarter. HHSC will consult with the HMOs and the HHSC Administrative
Services Contractors to discuss methods for reducing the HMO’s administrative
costs of producing new Provider Directories, including considering submission
of
new Provider Directories on a semi-annual rather than a quarterly basis if
a HMO
has not made major changes in its Provider Network, as determined by HHSC.
HHSC
will establish weight limits for the Provider Directories. Weight limits may
vary by Service Area. HHSC will require HMOs that exceed the weight limits
to
compensate HHSC for postage fees in excess of the weight limits.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
must send the most recent Provider Directory, including any updates, to
Members
upon
request. The HMO must, at least annually, include written and verbal offers
of
such
Provider
Directory in its Member outreach and education materials.
8.1.5.5
|
Internet
Website
|
The
HMO
must develop and maintain, consistent with HHSC standards and Section 843.2015
of
the
Texas
Insurance Code and other applicable state laws, a website to provide
general
information
about the HMO’s Program(s), its Provider Network, its customer services, and
its
Complaints
and Appeals process. The HMO may develop a page within its existing website
to
meet
the
requirements of this section. The HMO must maintain a Provider Directory for
its
HMO
Program(s)
on the HMO’s website with designation of open versus closed panels. All
HMOs
must
list
Home Health Ancillary providers on their websites, with an indicator for
Pediatric
services
if provided. The HMO’s website must comply with the Marketing Policies
and
Procedures
for each applicable HHSC HMO Program.
The
website’s HMO Program content must be:
|
1.
|
Written
in Major Population Group languages (which under this contract include
only English and Spanish);
|
|
2.
|
Culturally
appropriate;
|
|
3.
|
Written
for understanding at the 6th grade reading level;
and
|
|
4.
|
Be
geared to the health needs of the enrolled HMO Program
population.
|
To
minimize download and “wait times,” the website must avoid tools or techniques
that require
significant
memory or disk resources or require special intervention on the customer side
to
install
plug-ins or additional software. Use of proprietary items that would require
a
specific
browser
are not allowed. HHSC strongly encourages the use of tools that take advantage
of
efficient
data access methods and reduce the load on the server or bandwidth.
8.1.5.6
|
Member
Hotline
|
The
HMO
must operate a toll-free hotline that Members can call 24 hours a day, seven
(7)
days a
week.
The
Member Hotline must be staffed with personnel who are knowledgeable about
its
HMO
Program(s) and Covered Services, between the hours of 8:00 a.m. to 5:00 p.m.
local time
for
the
Service Area, Monday through Friday, excluding state-approved
holidays.
The
HMO
must ensure that after hours, on weekends, and on holidays the Member
Services
Hotline
is answered by an automated system with the capability to provide callers with
operating
hours
and
instructions on what to do in cases of emergency. All recordings must be in
English
and
in
Spanish. A voice mailbox must be available after hours for callers to leave
messages. The
HMO’s
Member Services representatives must return member calls received by the
automated
system
on
the next working day.
If
the
Member Hotline does not have a voice-activated menu system, the HMO must have
a
menu
system
that will accommodate Members who cannot access the system through other
physical
means,
such as pushing a button.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
must ensure that its Member Service representatives treat all callers with
dignity and respect the callers’ need for privacy. At a minimum, the HMO’s
Member Service representatives must be:
|
1.
|
Knowledgeable
about Covered Services;
|
|
2.
|
Able
to answer non-technical questions pertaining to the role of the PCP,
as
applicable;
|
|
3.
|
Able
to answer non-clinical questions pertaining to referrals or the process
for receiving authorization for procedures or
services;
|
|
4.
|
Able
to give information about Providers in a particular
area;
|
|
5.
|
Knowledgeable
about Fraud, Abuse, and Waste and the requirements to report any
conduct
that, if substantiated, may constitute Fraud, Abuse, or Waste in
the HMO
Program;
|
|
6.
|
Trained
regarding Cultural Competency;
|
|
7.
|
Trained
regarding the process used to confirm the status of persons with
Special
Health Care Needs;
|
|
8.
|
For
Medicaid members, able to answer non-clinical questions pertaining
to
accessing Non-capitated Services;
and
|
|
9.
|
For
CHIP Members, able to give correct cost-sharing information relating
to
premiums, co-pays or deductibles, as applicable. (Cost-sharing does
not
apply to CHIP Perinates or CHIP Perinate
Newborns.)
|
Hotline
services must meet Cultural Competency requirements and must appropriately
handle calls from non-English speaking (and particularly, Spanish-speaking)
callers, as well as calls from individuals who are deaf or hard-of-hearing.
To
meet these requirements, the HMO must employ bilingual Spanish-speaking Member
Services representatives and must secure the services of other contractors
as
necessary to meet these requirements.
The
HMO
must process all incoming Member correspondence and telephone inquiries in a
timely and responsive manner. The HMO cannot impose maximum call duration limits
but must allow calls to be of sufficient length to ensure adequate information
is provided to the Member. The HMO must ensure that the toll-free Member Hotline
meets the following minimum performance requirements for all HMO Programs and
Service Areas:
|
1.
|
99%
of calls are answered by the fourth ring or an automated call pick-up
system;
|
|
2.
|
no
more than one percent (1%) of incoming calls receive a busy
signal;
|
|
3.
|
at
least 80% of calls must be answered by toll-free line staff within
30
seconds measured from the time the call is placed in queue after
selecting
an option; and
|
|
4.
|
the
call abandonment rate is 7% or
less.
|
The
HMO
must conduct ongoing quality assurance to ensure these standards are
met.
The
Member Services Hotline may serve multiple HMO Programs if Hotline staff is
knowledgeable about all of the HMO’s Medicaid and/or CHIP Programs. The Member
Services Hotline may serve multiple Service Areas if the Hotline staff is
knowledgeable about all such Service Areas, including the Provider Network
in
each Service Area.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
must monitor its performance regarding HHSC Member Hotline standards and submit
performance reports summarizing call center performance for the Member Hotline
as indicated in Section 8.1.20 and the Uniform Managed
Care Manual.
8.1.5.7
|
Member
Education
|
The
HMO
must, at a minimum, develop and implement health education initiatives that
educate Members about:
|
1.
|
How
the HMO system operates, including the role of the
PCP;
|
|
2.
|
Covered
Services, limitations and any Value-added Services offered by the
HMO;
|
|
3.
|
The
value of screening and preventive care,
and
|
|
4.
|
How
to obtain Covered Services,
including:
|
|
a.
|
Emergency
Services;
|
|
b.
|
Accessing
OB/GYN and specialty care;
|
|
c.
|
Behavioral
Health Services;
|
|
d.
|
Disease
Management programs;
|
|
e.
|
Service
Coordination, treatment for pregnant women, Members with Special
Health
Care Needs, including Children with Special Health Care Needs; and
other
special populations;
|
|
f.
|
Early
Childhood Intervention (ECI)
Services;
|
|
g.
|
Screening
and preventive services, including well-child care (THSteps medical
checkups for Medicaid Members);
|
|
h.
|
For
CHIP Members, Member co-payments
|
|
i.
|
Suicide
prevention; and
|
|
j.
|
Identification
and health education related to
Obesity.
|
The
HMO
must provide a range of health promotion and wellness information and activities
for Members in formats that meet the needs of all Members. The HMO must propose,
implement, and assess innovative Member education strategies for wellness care
and immunization, as well as general health promotion and prevention. The HMO
must conduct wellness promotion programs to improve the health status of its
Members. The HMO may cooperatively conduct health education classes for all
enrolled Members with one or more HMOs also contracting with HHSC in the Service
Area. The HMO must work with its Providers to integrate health education,
wellness and prevention training into the care of each Member.
The
HMO
also must provide condition and disease-specific information and educational
materials to Members, including information on its Service Management and
Disease Management programs described in Section 8.1.13 and Section 8.1.
Condition- and disease-specific information must be oriented
to various
groups within the managed care eligible population, such as children, the
elderly, persons with disabilities and non-English speaking Members, as
appropriate to the HMO’s Medicaid, CHIP and/or CHIP Perinatal
Program(s).
8.1.5.8
|
Cultural
Competency Plan
|
The
HMO
must have a comprehensive written Cultural Competency Plan describing how the
HMO will ensure culturally competent services, and provide Linguistic Access
and
Disability-related Access. The Cultural Competency Plan must describe how the
individuals and systems
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
within
the HMO will effectively provide services to people of all cultures, races,
ethnic backgrounds, and religions as well as those with disabilities in a manner
that recognizes, values, affirms, and respects the worth of the individuals
and
protects and preserves the dignity of each. The HMO must submit the Cultural
Competency Plan to HHSC for Readiness Review. Modifications and amendments
to
the plan must be submitted to HHSC no later than 30 days prior to
implementation. The Plan must also be made available to the HMO’s Network of
Providers.
8.1.5.9
|
Member
Complaint and Appeal
Process
|
The
HMO
must develop, implement and maintain a system for tracking, resolving, and
reporting Member Complaints regarding its services, processes, procedures,
and
staff. The HMO must ensure that Member Complaints are resolved within 30
calendar days after receipt. The HMO is subject to remedies, including
liquidated damages, if at least 98 percent of Member Complaints are not resolved
within 30 days of receipt of the Complaint by the HMO. Please see the
Uniform Managed Care Contract Terms & Conditions and
Attachment B-5, Deliverables/Liquidated Damages
Matrix.
The
HMO
must develop, implement and maintain a system for tracking, resolving, and
reporting Member Appeals regarding the denial or limited authorization of a
requested service, including the type or level of service and the denial, in
whole or in part, of payment for service. Within this process, the HMO must
respond fully and completely to each Appeal and establish a tracking mechanism
to document the status and final disposition of each Appeal.
The
HMO
must ensure that Member Appeals are resolved within 30 calendar days, unless
the
HMO can document that the Member requested an extension or the HMO shows there
is a need for additional information and the delay is in the Member's interest.
The HMO is subject to liquidated damages if at least 98 percent of Member
Appeals are not resolved within 30 days of receipt of the Appeal by the HMO.
Please see the Uniform Managed Care Contract Terms & Conditions
and Attachment B-5, Deliverables/Liquidated Damages
Matrix.
Medicaid
HMOs must follow the Member Complaint and Appeal Process described in
Section 8.2.6. CHIP and CHIP Perinatal HMOs must comply with
the CHIP Complaint and Appeal Process described in Sections 8.4.2
and 8.5.2, respectively.
8.1.6
|
Marketing
and Prohibited Practices
|
The
HMO
and its Subcontractors must adhere to the Marketing Policies and Procedures
as
set forth by HHSC in the Contract, and the HHSC Uniform Managed Care
Manual.
8.1.7
|
Quality
Assessment and Performance
Improvement
|
The
HMO
must provide for the delivery of quality care with the primary goal of improving
the health status of Members and, where the Member’s condition is not amenable
to improvement, maintain the Member’s current health status by implementing
measures to prevent any further decline in condition or deterioration of health
status. The HMO must work in collaboration with Providers to actively improve
the quality of care provided to Members, consistent with the
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
Quality
Improvement Goals and all other requirements of the Contract. The HMO must
provide mechanisms for Members and Providers to offer input into the HMO’s
quality improvement activities.
8.1.7.1
|
QAPI
Program Overview
|
The
HMO
must develop, maintain, and operate a quality assessment and performance
improvement (QAPI) Program consistent with the Contract, and TDI requirements,
including 28 T.A.C. §11.1901(a)(5) and §11.1902. Medicaid HMOs must also meet
the requirements of 42 C.F.R. §438.240.
The
HMO
must have on file with HHSC an approved plan describing its QAPI Program,
including how the HMO will accomplish the activities required by this section.
The HMO must submit a QAPI Program Annual Summary in a format and timeframe
specified by HHSC or its designee. The HMO must keep participating physicians
and other Network Providers informed about the QAPI Program and related
activities. The HMO must include in Provider contracts a requirement securing
cooperation with the QAPI.
The
HMO
must approach all clinical and non-clinical aspects of quality assessment and
performance improvement based on principles of Continuous Quality Improvement
(CQI)/Total Quality Management (TQM) and must:
|
1.
|
Evaluate
performance using objective quality
indicators;
|
|
2.
|
Xxxxxx
data-driven decision-making;
|
|
3.
|
Recognize
that opportunities for improvement are
unlimited;
|
|
4.
|
Solicit
Member and Provider input on performance and QAPI
activities;
|
|
5.
|
Support
continuous ongoing measurement of clinical and non-clinical effectiveness
and Member satisfaction;
|
|
6.
|
Support
programmatic improvements of clinical and non-clinical processes
based on
findings from on-going measurements;
and
|
|
7.
|
Support
re-measurement of effectiveness and Member satisfaction, and continued
development and implementation of improvement interventions as
appropriate.
|
8.1.7.2
|
QAPI
Program Structure
|
The
HMO
must maintain a well-defined QAPI structure that includes a planned systematic
approach to improving clinical and non-clinical processes and outcomes. The
HMO
must designate a senior executive responsible for the QAPI Program and the
Medical Director must have substantial involvement in QAPI Program activities.
At a minimum, the HMO must ensure that the QAPI Program structure:
|
1.
|
Is
organization-wide, with clear lines of accountability within the
organization;
|
|
2.
|
Includes
a set of functions, roles, and responsibilities for the oversight
of QAPI
activities that are clearly defined and assigned to appropriate
individuals, including physicians, other clinicians, and
non-clinicians;
|
|
3.
|
Includes
annual objectives and/or goals for planned projects or activities
including clinical and non-clinical programs or initiatives and
measurement activities; and
|
|
4.
|
Evaluates
the effectiveness of clinical and non-clinical
initiatives.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.1.7.3
|
Clinical
Indicators
|
The
HMO
must engage in the collection of clinical indicator data. The HMO must use
such
clinical indicator data in the development, assessment, and modification of
its
QAPI Program.
8.1.7.4
|
QAPI
Program Subcontracting
|
If
the
HMO subcontracts any of the essential functions or reporting requirements
contained within the QAPI Program to another entity, the HMO must maintain
a
file of the subcontractors. The file must be available for review by HHSC or
its
designee upon request.
8.1.7.5
|
Behavioral
Health Integration into QAPI
Program
|
If
the
HMO provides Behavioral Health Services within the Covered Services as defined
in Attachments B-2, B-2.1, and B-2.2, it must integrate
behavioral health into its QAPI Program and include a systematic and on-going
process for monitoring, evaluating, and improving the quality and
appropriateness of Behavioral Health Services provided to Members. The HMO
must
collect data, and monitor and evaluate for improvements to physical health
outcomes resulting from behavioral health integration into the Member’s overall
care.
8.1.7.6
|
Clinical
Practice Guidelines
|
The
HMO
must adopt not less than two evidence-based clinical practice guidelines for
each applicable HMO Program. Such practice guidelines must be based on valid
and
reliable clinical evidence, consider the needs of the HMO’s Members, be adopted
in consultation with contracting health care professionals, and be reviewed
and
updated periodically, as appropriate. The HMO must develop practice guidelines
based on the health needs and opportunities for improvement identified as part
of the QAPI Program.
The
HMO
may coordinate the development of clinical practice guidelines with other HHSC
HMOs to avoid providers in a Service Area receiving conflicting practice
guidelines from different HMOs.
The
HMO
must disseminate the practice guidelines to all affected Providers and, upon
request, to Members and potential Members.
The
HMO
must take steps to encourage adoption of the guidelines, and to measure
compliance with the guidelines, until such point that 90% or more of the
Providers are consistently in compliance, based on HMO measurement findings.
The
HMO must employ substantive Provider motivational incentive strategies, such
as
financial and non-financial incentives, to improve Provider compliance with
clinical practice guidelines. The HMO’s decisions regarding utilization
management, Member education, coverage of services, and other areas included
in
the practice guidelines must be consistent with the HMO’s clinical practice
guidelines.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.1.7.7
|
Provider
Profiling
|
The
HMO
must conduct PCP and other Provider profiling activities at least annually.
As
part of its QAPI Program, the HMO must describe the methodology it uses to
identify which and how many Providers to profile and to identify measures to
use
for profiling such Providers.
Provider
profiling activities must include, but not be limited to:
|
1.
|
Developing
PCP and Provider-specific reports that include a multi-dimensional
assessment of a PCP or Provider’s performance using clinical,
administrative, and Member satisfaction indicators of care that are
accurate, measurable, and relevant to the enrolled
population;
|
|
2.
|
Establishing
PCP, Provider, group, Service Area or regional Benchmarks for areas
profiled, where applicable, including STAR, STAR+PLUS, CHIP and CHIP
Perinatal Program-specific Benchmarks, where appropriate;
and
|
|
3.
|
Providing
feedback to individual PCPs and Providers regarding the results of
their
performance and the overall performance of the Provider
Network.
|
8.1.7.8
|
Network
Management
|
The
HMO
must:
|
1.
|
Use
the results of its Provider profiling activities to identify areas
of
improvement for individual PCPs and Providers, and/or groups of
Providers;
|
|
2.
|
Establish
Provider-specific quality improvement goals for priority areas in
which a
Provider or Providers do not meet established HMO standards or improvement
goals;
|
|
3.
|
Develop
and implement incentives, which may include financial and non-financial
incentives, to motivate Providers to improve performance on profiled
measures; and
|
|
4.
|
At
least annually, measure and report to HHSC on the Provider Network
and
individual Providers’ progress, or lack of progress, towards such
improvement goals.
|
8.1.7.9
|
Collaboration
with the EQRO
|
The
HMO
will collaborate with HHSC’s external quality review organization (EQRO) to
develop studies, surveys, or other analytical approaches that will be carried
out by the EQRO. The purpose of the studies, surveys, or other analytical
approaches is to assess the quality of care and service provided to Members
and
to identify opportunities for HMO improvement. To facilitate this process,
the
HMO will supply claims data to the EQRO in a format identified by HHSC in
consultation with HMOs, and will supply medical records for focused clinical
reviews conducted by the EQRO. The HMO must also work collaboratively with
HHSC
and the EQRO to annually measure selected HEDIS measures that require chart
reviews. During the first year of operations, HHSC anticipates that the selected
measures will include, at a minimum, well-child visits and immunizations,
appropriate use of asthma medications, measures related to Members with
diabetes, and control of high blood pressure.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.1.8
|
Utilization
Management
|
The
HMO
must have a written utilization management (UM) program description, which
includes, at a minimum:
|
1.
|
Procedures
to evaluate the need for Medically Necessary Covered
Services;
|
|
2.
|
The
clinical review criteria used, the information sources, the process
used
to review and approve the provision of Covered
Services;
|
|
3.
|
The
method for periodically reviewing and amending the UM clinical review
criteria; and
|
|
4.
|
The
staff position functionally responsible for the day-to-day management
of
the UM function.
|
The
HMO
must make best efforts to obtain all necessary information, including pertinent
clinical information, and consult with the treating physician as appropriate
in
making UM determinations.
The
HMO
must issue coverage determinations, including adverse determinations, according
to the following timelines:
|
•
|
Within
three (3) business days after receipt of the request for authorization
of
services;
|
|
•
|
Within
one (1) business day for concurrent hospitalization decisions;
and
|
|
•
|
Within
one (1) hour for post-stabilization or life-threatening conditions,
except
that for Emergency Medical Conditions and Emergency Behavioral Health
Conditions, the HMO must not require prior
authorization.
|
The
HMO’s
UM Program must include written policies and procedures to ensure:
|
1.
|
Consistent
application of review criteria that are compatible with Members’ needs and
situations;
|
|
2.
|
Determinations
to deny or limit services are made by physicians under the direction
of
the Medical Director;
|
|
3.
|
Appropriate
personnel are available to respond to utilization review inquiries
8:00
a.m. to 5:00 p.m., Monday through Friday, with a telephone system
capable
of accepting utilization review inquiries after normal business hours.
The
HMO must respond to calls within one business
day;
|
|
4.
|
Confidentiality
of clinical information; and
|
|
5.
|
Quality
is not adversely impacted by financial and reimbursement-related
processes
and decisions.
|
For
HMOs
with preauthorization or concurrent review programs, qualified medical
professionals must supervise preauthorization and concurrent review
decisions.
The
HMO
UM Program must include polices and procedures to:
|
1.
|
Routinely
assess the effectiveness and the efficiency of the UM
Program;
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
|
2.
|
Evaluate
the appropriate use of medical technologies, including medical
procedures, drugs and devices;
|
|
3.
|
target
areas of suspected inappropriate service
utilization;
|
|
4.
|
Detect
over- and under-utilization;
|
|
5.
|
Routinely
generate Provider profiles regarding utilization patterns and compliance
with utilization review criteria and
policies;
|
|
6.
|
Compare
Member and Provider utilization with norms for comparable
individuals;
|
|
7.
|
Routinely
monitor inpatient admissions, emergency room use, ancillary, and
out-of-area services;
|
|
8.
|
Ensure
that when Members are receiving Behavioral Health Services from the
local mental health authority that the HMO is using the same UM
guidelines as those prescribed for use by Local Mental Health
Authorities by MHMR which are published
at: xxxx://xxx.xxxx.xxxxx.xx.xx/xxxxxxxxxxxxx/xxxxxxxxxxxxxxxxxxxxxxxx/XXXXxxxXxxxx.xxxx ;
and
|
|
9.
|
Refer
suspected cases of provider or Member Fraud, Abuse, or Waste to the
Office
of Inspector General (OIG) as required by Section
8.1.19.
|
8.1.9
|
Early
Childhood Intervention
(ECI)
|
The
HMO
must ensure that Network Providers are educated regarding their responsibility
under federal laws (e.g., 20 U.S.C. §1435 (a)(5); 34 C.F.R. §303.321(d)) to
identify and refer any Member age three (3) or under suspected of having a
developmental disability or delay, or who is at risk of delay, to the
designated ECI program for screening and assessment within two (2) working
days from the day the Provider identifies the Member. The HMO must use
written educational materials developed or approved by the Department of
Assistive and Rehabilitative Services – Division for Early Childhood
Intervention Services for these “child find” activities. Eligibility for
ECI services will be determined by the local ECI program using the
criteria contained in 40 T.A.C. §108.25.
The
HMO
must contract with qualified ECI Providers to provide ECI services to Members
under age three who have been determined eligible for ECI services. The HMO
must permit Members to self refer to local ECI Service Providers without
requiring a referral from the Member’s PCP. The HMO’s policies and
procedures, including its Provider Manual, must include written
policies and procedures for allowing such self-referral to ECI
providers.
The
HMO
must coordinate and cooperate with local ECI programs in the development
and implementation of the Individual Family Service Plan (IFSP), including
on-going case management and other non-capitated services required by the
Member’s IFSP. The IFSP is an agreement developed by the interdisciplinary
team that consists of the ECI Case Manager/Service Coordinator, the
Member/family, and other professionals who participated in the
Member’s evaluation or are providing direct services to the Member, and may
include the Member’s Primary Care Physician (PCP) with parental consent.
The IFSP identifies the Member’s present level of development based on
assessment, describes the services to be provided to the child to meet the
needs of the child and the family, and identifies the person or persons
responsible for each service required by the plan. The IFSP shall be
transmitted by the ECI Provider to the HMO and the PCP with parental
consent to enhance coordination of the plan of care. The IFSP may
be included in the Member’s medical record.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
Cooperation
with the ECI program includes covering medical diagnostic procedures and
providing medical records required to perform developmental assessments and
developing the IFSP within the 45-day timeline established in federal rule
(34
C.F.R. §303.342(a)). The HMO must require compliance with these requirements
through Provider contract provisions. The HMO must not withhold authorization
for the provision of such medical diagnostic procedures. The HMO must promptly
provide to the ECI program, relevant medical records available to the
HMO.
The
interdisciplinary team will determine Medical Necessity for health and
Behavioral Health Services as approved by the Member’s PCP. The 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 the amount, duration, scope and service setting established by the
IFSP. The HMO must allow services to be provided by a non-network provider
if a
Network Provider is not available to provide the services in the amount,
duration, scope and service setting as required by the IFSP. The HMO cannot
modify the plan of care or alter the amount, duration, scope, or service setting
required by the Member’s IFSP. The HMO cannot create unnecessary barriers for
the Member to obtain IFSP services, including requiring prior authorization
for
the ECI assessment or establishing insufficient authorization periods for prior
authorized services.
8.1.10
|
Special
Supplemental Nutrition Program for Women, Infants, and Children (WIC)
-
Specific Requirements
|
The
HMO
must, by contract, require its Providers to coordinate with the Special
Supplemental Nutrition Program for Women, Infants, and Children (WIC) to provide
medical information necessary for WIC eligibility determinations, such as
height, weight, hematocrit or hemoglobin. The HMO must make referrals to WIC
for
Members potentially eligible for WIC. The HMO may use the nutrition education
provided by WIC to satisfy certain health education requirements of the
Contract.
8.1.11
|
Coordination
with Texas Department of Family and Protective
Services
|
The
HMO
must cooperate and coordinate with the Texas Department of Family and Protective
Services (TDFPS) (formerly the Department of Protective and Regulatory Services)
for the care of a child who is receiving services from or has been placed in
the
conservatorship of TDFPS.
The
HMO
must comply with all provisions related to Covered Services, including
Behavioral Health Services, in the following documents:
|
•
|
A
court order (Order) entered by a Court of Continuing Jurisdiction
placing
a child under the protective custody of
TDFPS.
|
|
•
|
A
TDFPS Service Plan entered by a Court of Continuing Jurisdiction
placing a
child under the protective custody of
TDFPS.
|
|
•
|
A
TDFPS Service Plan voluntarily entered into by the parents or person
having legal custody of a Member and
TDFPS.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
cannot deny, reduce, or controvert the Medical Necessity of any health or
Behavioral Health Services included in an Order. The HMO may participate in
the
preparation of the medical and behavioral care plan prior to TDFPS submitting
the health care plan to the Court. Any modification or termination of
court-ordered services must be presented and approved by the court having
jurisdiction over the matter.
A
Member
or the parent or guardian whose rights are subject to an Order or Service Plan
cannot use the HMO’s Complaint or Appeal processes, or the HHSC Fair Hearing
process to Appeal the necessity of the Covered Services.
The
HMO
must include information in its Provider Manuals and training materials
regarding:
|
1.
|
Providing
medical records to TDFPS;
|
|
2.
|
Scheduling
medical and Behavioral Health Services appointments within 14 days
unless
requested earlier by TDFPS; and
|
|
3.
|
Recognition
of abuse and neglect, and appropriate referral to
TDFPS.
|
The
HMO
must continue to provide all Covered Services to a Member receiving services
from, or in the protective custody of, TDFPS until the Member has been
disenrolled from the HMO due to loss of Medicaid managed care eligibility or
placed into xxxxxx care.
8.1.12
|
Services
for People with Special Health Care
Needs
|
This
section applies to STAR, STAR+PLUS, CHIP HMOs. It applies to CHIP Perinatal
HMOs
with respect to their Perinate Newborn Members only.
8.1.12.1
|
Identification
|
The
HMO
must develop and maintain a system and procedures for identifying Members with
Special Health Care Needs (MSHCN), including people with disabilities or chronic
or complex medical and behavioral health conditions and Children with Special
Health Care Needs (CSHCN)1.
The
HMO
must contact Members pre-screened by the HHSC Administrative Services Contractor
as MSHCN to determine whether they meet the HMO’s MSHCN assessment criteria, and
to determine whether the Member requires special services described in this
section. The HMO must provide information to the HHSC Administrative Services
Contractor that identifies Members who the HMO has assessed to be MSHCN,
including any Members pre-screened by the HHSC Administrative Services
Contractor and confirmed by the HMO as a MSHCN. The information must be
provided, in a format and on a timeline to be specified by HHSC in the
Uniform
________________
1
CSHCN
is a term often used to refer to a services program for children with special
health care needs administered by DSHS, and described in 25 TAC, Part 1, Section
38.1. Although children served through this program may also be served by
Medicaid or CHIP, the reference to “CSHCN” in this Contract does not refer to
children served through this program.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
Managed
Care Manual, and updated with newly identified MSHCN by the 10th day of
each month. In the event that a MSHCN changes HMOs, the HMO must provide the
receiving contractor information concerning the results of the HMO’s
identification and assessment of that Member’s needs, to prevent duplication of
those activities.
8.1.12.2
|
Access
to Care and Service
Management
|
Once
identified, the HMO must have effective systems to ensure the provision of
Covered Services to meet the special preventive, primary Acute Care, and
specialty health care needs appropriate for treatment of the individual Member’s
condition(s). All STAR+PLUS Members are considered to be MSHCN.
The
HMO
must provide access to identified PCPs and specialty care Providers with
experience serving MSHCN. Such Providers must be board-qualified or
board-eligible in their specialty. The HMO may request exceptions from HHSC
for
approval of traditional providers who are not board-qualified or board-eligible
but who otherwise meet the HMO’s credentialing requirements.
For
services to CSHCN, the HMO must have Network PCPs and specialty care Providers
that have demonstrated experience with CSHCN in pediatric specialty centers
such
as children’s hospitals, teaching hospitals, and tertiary care
centers.
The
HMO
is responsible for working with MSHCN, their families and legal guardians if
applicable, and their health care providers to develop a seamless package of
care in which primary, Acute Care, and specialty service needs are met through
a
Service Plan that is understandable to the Member, or, when applicable, the
Member’s legal guardian.
The
HMO
is responsible for providing Service Management to develop a Service Plan and
ensure MSHCN, including CSHCN, have access to treatment by a multidisciplinary
team when the Member’s PCP determines the treatment is Medically Necessary, or
to avoid separate and fragmented evaluations and service plans. The team must
include both physician and nonphysician providers determined to be necessary
by
the Member’s PCP for the comprehensive treatment of the Member. The team
must:
|
1.
|
Participate
in hospital discharge planning;
|
|
2.
|
Participate
in pre-admission hospital planning for non-emergency
hospitalizations;
|
|
3.
|
Develop
specialty care and support service recommendations to be incorporated
into
the Service Plan; and
|
|
4.
|
Provide
information to the Member, or when applicable, the Member’s legal guardian
concerning the specialty care
recommendations.
|
MSHCN,
their families, or their health providers may request Service Management from
the HMO. The HMO must make an assessment of whether Service Management is needed
and furnish Service Management when appropriate. The HMO may also recommend
to a
MSHCN, or to a CSHCN’s family, that Service Management be furnished if the HMO
determines that Service Management would benefit the Member.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
must provide information and education in its Member Handbook and Provider
Manual about the care and treatment available in the HMO’s plan for Members with
Special Health Care Needs, including the availability of Service
Management.
The
HMO
must have a mechanism in place to allow Members with Special Health Care Needs
to have direct access to a specialist as appropriate for the Member’s condition
and identified needs, such as a standing referral to a specialty physician.
The
HMO must also provide MSHCN with access to non-primary care physician
specialists as PCPs, as required by 28 T.A.C. §11.900 and Section
8.1.
The
HMO
must implement a systematic process to coordinate Non-capitated Services, and
enlist the involvement of community organizations that may not be providing
Covered Services but are otherwise important to the health and wellbeing of
Members. The HMO also must make a best effort to establish relationships with
State and local programs and community organizations, such as those listed
below, in order to make referrals for MSHCN and other Members who need community
services:
|
•
|
Community
Resource Coordination Groups
(CRCGs);
|
|
•
|
Early
Childhood Intervention (ECI)
Program;
|
|
•
|
Local
school districts (Special
Education);
|
|
•
|
Texas
Department of Transportation’s Medical Transportation Program
(MTP);
|
|
•
|
Texas
Department of Assistive and Rehabilitative Services (DARS) Blind
Children’s Vocational Discovery and Development
Program;
|
|
•
|
Texas
Department of State Health (DSHS) services, including community mental
health programs, the Title V Maternal and Child Health and Children
with
Special Health Care Needs (CSHCN) Programs, and the Program for
Amplification of Children of Texas
(PACT);
|
|
•
|
Other
state and local agencies and programs such as food stamps, and the
Women,
Infants, and Children’s (WIC)
Program;
|
|
•
|
Civic
and religious organizations and consumer and advocacy groups, such
as
United Cerebral Palsy, which also work on behalf of the MSHCN
population.
|
8.1.13
|
Service
Management for Certain
Populations
|
The
HMO
must have service management programs and procedures for the following
populations, as applicable to the HMO’s Medicaid and/or CHIP Program(s) (See
CHIP Perinatal Program Covered Services, Attachment B-2.2, for
the applicability of these services to the CHIP Perinatal Program):
1.
|
High-cost
catastrophic cases;
|
2.
|
Women
with high-risk pregnancies (STAR and STAR+PLUS Programs only);
and
|
3.
|
Individuals
with mental illness and co-occurring substance
abuse.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.1.14
|
Disease
Management (DM)
|
The
HMO
must provide, or arrange to have provided to Members, comprehensive disease
management services consistent with state statutes and regulations. Such DM
services must be part of person-based approach to DM and holistically address
the needs of persons with multiple chronic conditions. The HMO must develop
and
implement DM services that relate to chronic conditions that are prevalent
in
HMO Program Members. In the first year of operations, STAR, STAR+PLUS and CHIP
HMOs must have DM Programs that address Members with chronic conditions to
be
identified by HHSC and included within the Uniform Managed Care
Manual. HHSC will not identify the Members with chronic conditions. The
HMO must implement policies and procedures to ensure that Members that require
DM services are identified and enrolled in a program to provide such DM
services. The HMO must develop and maintain screening and evaluation procedures
for the early detection, prevention, treatment, or referral of participants
at
risk for or diagnosed with chronic conditions identified by HHSC and included
within the Uniform Managed Care Manual. The HMO must ensure
that all Members identified for DM are enrolled into a DM Program with the
opportunity to opt out of these services within 30 days while still maintaining
access to all other Covered Services.
The
DM
Program(s) must include:
1.
|
Patient
self-management education;
|
2.
|
Provider
education;
|
3.
|
Evidence-based
models and minimum standards of
care;
|
4.
|
Standardized
protocols and participation
criteria;
|
5.
|
Physician-directed
or physician-supervised care;
|
6.
|
Implementation
of interventions that address the continuum of
care;
|
7.
|
Mechanisms
to modify or change interventions that are not proven effective;
and
|
8.
|
Mechanisms
to monitor the impact of the DM Program over time, including both
the
clinical and the financial impact.
|
The
HMO
must maintain a system to track and monitor all DM participants for clinical,
utilization, and cost measures.
The
HMO
must provide designated staff to implement and maintain DM Programs and to
assist participating Members in accessing DM services. The HMO must educate
Members and Providers about the HMO’s DM Programs and activities. Additional
requirements related to the HMO’s Disease Management Programs and activities are
found in the HHSC Uniform Managed Care Manual.
8.1.14.1
|
DM
Services and Participating
Providers
|
At
a
minimum, the HMO must:
1.
|
Implement
a system for Providers to request specific DM
interventions;
|
2.
|
Give
Providers information, including differences between recommended
prevention and treatment and actual care received by Members enrolled
in a
DM Program, and information concerning such Members’ adherence to a
service plan; and
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
3.
|
For
Members enrolled in a DM Program, provide reports on changes in a
Member’s
health status to their PCP.
|
8.1.14.2
|
HMO
DM Evaluation
|
HHSC
or
its EQRO will evaluate the HMO’s DM Program.
8.1.15
|
Behavioral
Health (BH) Network and
Services
|
The
requirements in this sub-section pertain to all HMOs except: (1) the STAR HMOs
in the Dallas CSA, whose Members receive Behavioral Health Services through
the
NorthSTAR Program, and (2) the CHIP Perinatal Program HMOs with respect to
their
Perinate Members.
The
HMO
must provide, or arrange to have provided, to Members all Medically Necessary
Behavioral Health (BH) Services as described in Attachments B-2, B-2.1,
and B-2.2. All BH Services must be provided in conformance with the
access standards included in Section 8.1.3. For Medicaid HMOs,
BH Services are described in more detail in the Texas Medicaid Provider
Procedures Manual and the Texas Medicaid Bulletins.
When assessing Members for BH Services, the HMO and its Network Behavioral
Health Service Providers must use the DSM-IV multi-axial classification. HHSC
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.
8.1.15.1
|
BH
Provider Network
|
The
HMO
must maintain a Behavioral Health Services Provider Network that includes
psychiatrists, psychologists, and other Behavioral Health Service Providers.
The
Provider Network must include Behavioral Health Service Providers with
experience serving special populations among the HMO Program(s)’ enrolled
population, including, as applicable, children and adolescents, persons with
disabilities, the elderly, and cultural or linguistic minorities, to ensure
accessibility and availability of qualified Providers to all Members in the
Service Area.
8.1.15.2
|
Member
Education and Self-referral for Behavioral Health
Services
|
The
HMO
must maintain a Member education process to help Members know where and how
to
obtain Behavioral Health Services.
The
HMO
must permit Members to self refer to any in-network Behavioral Health Services
Provider without a referral from the Member’s PCP. The HMOs’ policies and
procedures, including its Provider Manual, must include written policies and
procedures for allowing such self- referral to BH services.
The
HMO
must permit Members to participate in the selection of the appropriate
behavioral health individual practitioner(s) who will serve them and must
provide the Member with information on accessible in-network Providers with
relevant experience.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.1.15.3
|
Behavioral
Health Services Hotline
|
This
Section includes Hotline functions pertaining to Members. Requirements for
Provider Hotlines are found in Section 8.1.4.7. The HMO must
have an emergency and crisis Behavioral Health Services Hotline staffed by
trained personnel 24 hours a day, 7 days a week, toll-free throughout the
Service Area. Crisis hotline staff must include or have access to qualified
Behavioral Health Services professionals to assess behavioral health
emergencies. Emergency and crisis Behavioral Health Services may be arranged
through mobile crisis teams. It is not acceptable for an emergency intake line
to be answered by an answering machine.
The
HMO
must operate a toll-free hotline as described in Section 8.1.5.6
to handle Behavioral Health-related calls. The HMO may operate
one
hotline to handle emergency and crisis calls and routine Member calls. The
HMO
cannot impose maximum call duration limits and must allow calls to be of
sufficient length to ensure adequate information is provided to the Member.
Hotline services must meet Cultural Competency requirements and provide
linguistic access to all Members, including the interpretive services required
for effective communication.
The
Behavioral Health Services Hotline may serve multiple HMO Programs Hotline
staff
is knowledgeable about all of the HMO Programs. The Behavioral Health Services
Hotline may serve multiple Service Areas if the Hotline staff is knowledgeable
about all such Service Areas, including the Behavioral Health Provider Network
in each Service Area. The HMO must ensure that the toll-free Behavioral Health
Services Hotline meets the following minimum performance requirements for all
HMO Programs and Service Areas:
|
1.
|
99%
of calls are answered by the fourth ring or an automated call pick-up
system;
|
|
2.
|
No
incoming calls receive a busy
signal;
|
|
3.
|
At
least 80% of calls must be answered by toll-free line staff within
30
seconds measured from the time the call is placed in queue after
selecting
an option; and
|
|
4.
|
The
call abandonment rate is 7% or
less.
|
The
HMO
must conduct on-going quality assurance to ensure these standards are
met.
The
HMO
must monitor the HMO’s performance against the Behavioral Health Services
Hotline standards and submit performance reports summarizing call center
performance as indicated in Section 8.1.20 and the
Uniform Managed Care Manual.
8.1.15.4
|
Coordination
between the BH Provider and the
PCP
|
The
HMO
must require, through contract provisions, that PCPs have screening and
evaluation procedures for the detection and treatment of, or referral for,
any
known or suspected behavioral health problems and disorders. PCPs may provide
any clinically appropriate Behavioral Health Services within the scope of their
practice.
The
HMO
must provide training to network PCPs on how to screen for and identify
behavioral health disorders, the HMO’s referral process for Behavioral Health
Services and clinical coordination requirements for such services. The 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.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
shall develop and disseminate policies regarding clinical coordination between
Behavioral Health Service Providers and PCPs. The HMO must require that
Behavioral Health Service Providers refer Members with known or suspected and
untreated physical health problems or disorders to their PCP for examination
and
treatment, with the Member’s or the Member’s legal guardian’s consent.
Behavioral Health Providers may only provide physical health care services
if
they are licensed to do so. This requirement must be specified in all Provider
Manuals.
The
HMO
must require that behavioral health Providers send initial and quarterly (or
more frequently if clinically indicated) summary reports of a Members’
behavioral health status to the PCP, with the Member’s or the Member’s legal
guardian’s consent. This requirement must be specified in all Provider
Manuals.
8.1.15.5
|
Follow-up
after Hospitalization for Behavioral Health
Services
|
The
HMO
must require, through Provider contract provisions, that all Members receiving
inpatient psychiatric services are scheduled for outpatient follow-up and/or
continuing treatment prior to discharge. The outpatient treatment must occur
within seven (7) days from the date of discharge. The HMO must ensure that
Behavioral Health Service Providers contact Members who have missed appointments
within 24 hours to reschedule appointments.
8.1.15.6
|
Chemical
Dependency
|
The
HMO
must comply with 28 T.A.C. §3.8001 et seq., regarding utilization
review for Chemical Dependency Treatment. Chemical Dependency Treatment must
conform to the standards set forth in 28 T.A.C. Part 1, Chapter 3, Subchapter
HH.
8.1.15.7
|
Court-Ordered
Services
|
“Court-Ordered
Commitment” means a commitment of a Member to a psychiatric facility for
treatment that is ordered by a court of law pursuant to the Texas Health and
Safety Code, Title VII, Subtitle C.
The
HMO
must provide inpatient psychiatric services to Members under the age of 21,
up
to the annual limit, who have been ordered to receive the services by a court
of
competent jurisdiction under the provisions of Chapters 573 and 574 of the
Texas
Health and Safety Code, relating to Court-Ordered Commitments to psychiatric
facilities. The HMO is not obligated to cover placements as a condition of
probation, authorized by the Texas Family Code.
The
HMO
cannot deny, reduce or controvert the Medical Necessity of inpatient psychiatric
services provided pursuant to a Court-ordered Commitment for Members under
age
21. Any modification or termination of services must be presented to the court
with jurisdiction over the matter for determination.
A
Member
who has been ordered to receive treatment under the provisions of Chapter 573
or
574 of the Texas Health and Safety Code can only Appeal the commitment through
the court system.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.1.15.8
|
Local
Mental Health Authority
(LMHA)
|
The
HMO
must coordinate with the Local Mental Health Authority (LMHA) and state
psychiatric facility regarding admission and discharge planning, treatment
objectives and projected length of stay for Members committed by a court of
law
to the state psychiatric facility.
Medicaid
HMOs are required to comply with additional Behavioral Health Services
requirements relating to coordination with the LMHA and care for special
populations. These Medicaid HMO requirements are described in Section
8.2.8.
8.1.16
|
Financial
Requirements for Covered
Services
|
The
HMO
must pay for or reimburse Providers for all Medically Necessary Covered Services
provided to all Members. The HMO is not liable for cost incurred in connection
with health care rendered prior to the date of the Member’s Effective Date of
Coverage in that HMO. A Member may receive collateral health benefits under
a
different type of insurance such as workers compensation or personal injury
protection under an automobile policy. If a Member is entitled to coverage
for
specific services payable under another insurance plan and the HMO paid for
such
Covered Services, the HMO may obtain reimbursement from the responsible
insurance entity not to exceed 100% of the value of Covered Services
paid.
8.1.17
|
Accounting
and Financial Reporting
Requirements
|
The
HMO’s
accounting records and supporting information related to all aspects of the
Contract must be accumulated in accordance with Generally Accepted Accounting
Principles (GAAP) and the cost principles contained in the Cost Principles
Document in the Uniform Managed Care Manual. The State will not
recognize or pay services that cannot be properly substantiated by the HMO
and
verified by HHSC.
The
HMO
must:
|
1.
|
Maintain
accounting records for each applicable HMO Program separate and apart
from
other corporate accounting records;
|
|
2.
|
Maintain
records for all claims payments, refunds and adjustment payments
to
providers, capitation payments, interest income and payments for
administrative services or functions and must maintain separate records
for medical and administrative fees, charges, and
payments;
|
|
3.
|
Maintain
an accounting system that provides an audit trail containing sufficient
financial documentation to allow for the reconciliation of xxxxxxxx,
reports, and financial statements with all general ledger accounts;
and
|
|
4.
|
Within
60 days after Contract execution, submit an accounting policy manual
that
includes all proposed policies and procedures the HMO will follow
during
the duration of the Contract. Substantive modifications to the accounting
policy manual must be approved by
HHSC.
|
The
HMO
agrees to pay for all reasonable costs incurred by HHSC to perform an
examination, review or audit of the HMO’s books pertaining to the
Contract.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.1.17.1
|
General
Access to Accounting
Records
|
The
HMO
must provide authorized representatives of the Texas and federal government
full
access to all financial and accounting records related to the performance of
the
Contract.
The
HMO
must:
|
1.
|
Cooperate
with the State and federal governments in their evaluation, inspection,
audit, and/or review of accounting records and any necessary supporting
information;
|
|
2.
|
Permit
authorized representatives of the State and federal governments full
access, during normal business hours, to the accounting records that
the
State and the Federal government determine are relevant to the Contract.
Such access is guaranteed at all times during the performance and
retention period of the Contract, and will include both announced
and
unannounced inspections, on-site audits, and the review, analysis,
and
reproduction of reports produced by the
HMO;
|
|
3.
|
Make
copies of any accounting records or supporting documentation relevant
to
the Contract available to HHSC or its agents within ten (10) business
days
of receiving a written request from HHSC for specified records or
information. If such documentation is not made available as requested,
the
HMO agrees to reimburse HHSC for all costs, including, but not limited
to,
transportation, lodging, and subsistence for all State and federal
representatives, or their agents, to carry out their inspection,
audit,
review, analysis, and reproduction functions at the location(s) of
such
accounting records; and
|
|
4.
|
Pay
any and all additional costs incurred by the State and federal government
that are the result of the HMO’s failure to provide the requested
accounting records or financial information within ten (10) business
days
of receiving a written request from the State or federal
government.
|
8.1.17.2
|
Financial
Reporting Requirements
|
HHSC
will
require the HMO to provide financial reports by HMO Program and by Service
Area
to support Contract monitoring as well as State and Federal reporting
requirements. HHSC will consult with HMOs regarding the format and frequency
of
such reporting. All financial information and reports that are not
Member-specific are property of HHSC and will be public record. Any deliverable
or report in Section 8.1.17.2 without a specified due date is due quarterly
on
the last day of the month. Where the due date states 30 days, the HMO is to
provide the deliverable by the last day of the month following the end of the
reporting period. Where the due date states 45 days, the HMO is to provide
the
deliverable by the 15th day of the second month following the end of the
reporting period.
CHIP
Perinatal Program data must be reported, and the data will be integrated into
existing CHIP Program financial reports. Except for the Financial Statistical
Report, no separate CHIP Perinatal Program reports are required. For all other
CHIP financial reports, where appropriate, HHSC will designate specific
attributes within the CHIP Program financial reports that the CHIP Perinatal
HMOs must complete to allow HHSC to extract financial data particular to the
CHIP Perinatal Program.
HHSC’s
Uniform Managed Care Manual will govern the timing, format and
content for the following reports.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
Audited
Financial Statement –The HMO must provide the annual audited financial
statement, for each year covered under the Contract, no later than June 30.
The
HMO must provide the most recent annual financial statements, as required by
the
Texas Department of Insurance for each year covered under the Contract, no
later
than March 1.
Affiliate
Report – The HMO must submit an Affiliate Report to HHSC if this
information has changed since the last report submission. The report must
contain the following:
|
1.
|
A
list of all Affiliates, and
|
|
2.
|
For
HHSC’s prior review and approval, a schedule of all transactions with
Affiliates that, under the provisions of the Contract, will be allowable
as expenses in the FSR Report for services provided to the HMO by
the
Affiliate. Those should include financial terms, a detailed description
of
the services to be provided, and an estimated amount that will be
incurred
by the HMO for such services during the Contract
Period.
|
Employee
Bonus and/or Incentive Payment Plan – If a HMO intends to include
Employee Bonus or Incentive Payments as allowable administrative expenses,
the
HMO must furnish a written Employee Bonus and/or Incentive Payments Plan to
HHSC
so it may determine whether such payments are allowable administrative expenses
in accordance with Cost Principles Document in the Uniform Managed Care
Manual. The written plan must include a description of the HMO’s
criteria for establishing bonus and/or incentive payments, the methodology
to
calculate bonus and/or incentive payments, and the timing of bonus and/or
incentive payments. The Bonus and/or Incentive Payment Plan and description
must
be submitted to HHSC for approval no later than 30 days after the Effective
Date
of the Contract and any Contract renewal. If the HMO substantively revises
the
Employee Bonus and/or Incentive Payment Plan, the HMO must submit the revised
plan to HHSC for prior review and approval.
Claims
Lag Report - The HMO must submit Claims Lag Report as a Contract
year-to-date report. The report must be submitted quarterly by the last day
of
the month following the reporting period. The report must be submitted to HHSC
in a format specified by HHSC. The report format is contained in the
Uniform Managed Care Manual Chapter 5, Section 5.6.2. The
report must disclose the amount of incurred claims each month and the amount
paid each month.
DSP
Report - The HMO must submit a monthly Delivery Supplemental Payment
(DSP) Report that includes the data elements specified by HHSC in the format
specified by HHSC. HHSC will consult with contracted HMOs prior to revising
the
DSP Report data elements and requirements. The DSP Report must include only
unduplicated deliveries and only deliveries for which the HMO has made a
payment, to either a hospital or other provider.
Form
CMS-1513 - The HMO must file an original Form CMS-1513 prior to
beginning operations regarding the HMO’s control, ownership, or affiliations. An
updated Form CMS-1513 must also be filed no later than 30 days after any change
in control, ownership, or affiliations.
FSR
Reports – The HMO must file quarterly and annual Financial-Statistical
Reports (FSR) in the format and timeframe specified by HHSC. HHSC will include
FSR format and directions in the Uniform Managed Care Manual.
The HMO must incorporate financial and statistical data of delegated networks
(e.g., IPAs, ANHCs, Limited Provider Networks), if any, in its FSR Reports.
Administrative expenses reported in the FSRs must be reported in accordance
with
the
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
Cost
Principles Document in the Uniform Managed Care Manual.
Quarterly FSR reports are due no later than 30 days after the end of the quarter
and must provide information for the current quarter and year-to-date
information through the current quarter. The first annual FSR report must
reflect expenses incurred through the 90th day after the end of the fiscal
year.
The first annual report must be filed on or before the 120th day after the
end
of each fiscal year and accompanied by an actuarial opinion by a qualified
actuary who is in good standing with the American Academy of Actuaries.
Subsequent annual reports must reflect data completed through the 334th day after
the end
of each fiscal year and must be filed on or before the 365th day following
the
end of each fiscal year.
CHIP
Perinatal HMOs are required to submit separate FSRs for the CHIP Perinatal
Program following the instructions outlined above and in the Uniform
Managed Care Manual.
Out-of-Network
Utilization Reports – The HMO must file quarterly Out-of Network
Utilization Reports in the format and timeframe specified by HHSC. HHSC will
include the report format and directions in the Uniform Managed Care
Manual. Quarterly reports are due 30 days after the end of each
quarter.
HUB
Reports – Upon contract award, the HMO must attend a post award meeting
in Austin, Texas, at a time specified by HHSC, to discuss the development and
submission of a Client Services HUB Subcontracting Plan for inclusion and the
HMO’s good faith efforts to notify HUBs of subcontracting opportunities. The HMO
must maintain its HUB Subcontracting Plan and submit monthly reports documenting
the HMO’s Historically Underutilized Business (HUB) program efforts and
accomplishments to the HHSC HUB Office. The report must include a narrative
description of the HMO’s program efforts and a financial report reflecting
payments made to HUBs. HMOs must use the formats included in HHSC’s
Uniform Managed Care Manual for the HUB monthly reports. The
HMO must comply with HHSC’s standard Client Services HUB Subcontracting Plan
requirements for all subcontractors.
IBNR
Plan - The 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 HHSC no later than 60 days after
the Effective Date of the Contract. Substantive changes to a HMO’s IBNR plan and
description must be submitted to HHSC no later than 30 days before the HMO
implements changes to the IBNR plan.
Medicaid
Disproportionate Share Hospital (DSH) Reports – Medicaid HMOs must file
preliminary and final Medicaid DSH reports, required by HHSC 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 HHSC in the Uniform Managed Care
Manual. The preliminary DSH reports are due on or before June 1 of the
year following the state fiscal reporting year. The final DSH reports are due
no
later than July 15 of the year following the state fiscal reporting year. This
reporting requirement does not apply to CHIP or CHIP Perinatal Program HMOs.
For
STAR+PLUS, HMOs will include only outpatient services in the DSH
report.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
TDI
Examination Report - The HMO must furnish a copy of any TDI Examination
Report, including the financial, market conduct, target exam, quality of care
components, and corrective action plans and responses, no later than 10 days
after receipt of the final report from TDI.
TDI
Filings – The HMO must submit annual figures for controlled risk-based
capital, as well as its quarterly financial statements, both as required by
TDI.
Registration
Statement (also known as the “Form B”) - If the HMO is a part of an
insurance holding company system, the HMO must submit to HHSC a complete
registration statement, also known as Form B, and all amendments to this form,
and any other information filed by such insurer with the insurance regulatory
authority of its domiciliary jurisdiction.
Section
1318 Financial Disclosure Report - The HMO must file an original CMS
Public Health Service (PHS) Section 1318 Financial Disclosure Report prior
to
the start of Operations and an updated CMS PHS Section 1318 Financial Disclosure
Report no later than 30 days after the end of each Contract Year and no later
than 30 days after entering into, renewing, or terminating a relationship with
an affiliated party.
Third
Party Recovery (TPR) Reports - The HMO must file TPR Reports in
accordance with the format developed by HHSC in the Uniform Managed Care
Manual. HHSC will require the HMO to submit TPR reports no more often
than quarterly. TPR reports must include total dollars recovered from third
party payers for each HMO Program for services to the HMO’s Members, and the
total dollars recovered through coordination of benefits, subrogation, and
worker’s compensation. For CHIP HMOs, the TPR Reports only apply if the HMO
chooses to engage in TPR activities.
8.1.18
|
Management
Information System
Requirements
|
The
HMO
must maintain a Management Information System (MIS) that supports all functions
of the HMO’s processes and procedures for the flow and use of HMO data. The HMO
must have hardware, software, and a network and communications system with
the
capability and capacity to handle and operate all MIS subsystems for 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;
|
|
6.
|
Reporting
Subsystem;
|
|
7.
|
Interface
Subsystem; and
|
|
8.
|
TPR
Subsystem, as applicable to each HMO
Program.
|
The
MIS
must enable the HMO to meet the Contract requirements, including all applicable
state and federal laws, rules, and regulations. The MIS must have the capacity
and capability to capture and utilize various data elements required for HMO
administration.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
HHSC
will
provide the HMO with pharmacy data on the HMO’s Members on a weekly basis
through the HHSC Vendor Drug Program, or should these services be outsourced,
through the Pharmacy Benefit Manager. HHSC will provide a sample format of
pharmacy data to contract awardees.
The
HMO
must have a system that can be adapted to changes in Business Practices/Policies
within the timeframes negotiated by the Parties. The HMO is expected to cover
the cost of such systems modifications over the life of the
Contract.
The
HMO
is required to participate in the HHSC Systems Work Group.
The
HMO
must provide HHSC prior written notice of major systems changes, generally
within 90 days, and implementations, including any changes relating to Material
Subcontractors, in accordance with the requirements of this Contract and the
Uniform Managed Care Terms and Conditions.
The
HMO
must provide HHSC any updates to the HMO’s organizational chart relating to MIS
and the description of MIS responsibilities at least 30 days prior to the
effective date of the change. The HMO must provide HHSC official points of
contact for MIS issues on an on-going basis.
HHSC,
or
its agent, may conduct a Systems Readiness Review to validate the HMO’s ability
to meet the MIS requirements as described in Attachment B-1, Section
7. The System Readiness Review may include a desk review and/or an
onsite review and must be conducted for the following events:
|
1.
|
A
new plan is brought into the HMO
Program;
|
|
2.
|
An
existing plan begins business in a new Service
Area;
|
|
3.
|
An
existing plan changes location;
|
|
4.
|
An
existing plan changes its processing system, including changes in
Material
Subcontractors performing MIS or claims processing functions;
and
|
|
5.
|
An
existing plan in one or two HHSC HMO Programs is initiating a Contract
to
participate in any additional HMO
Programs.
|
If
for
any reason, a HMO does not fully meet the MIS requirements, then the HMO must,
upon request by HHSC, either correct such deficiency or submit to HHSC a
Corrective Action Plan and Risk Mitigation Plan to address such deficiency
as
requested by HHSC. Immediately upon identifying a deficiency, HHSC may impose
remedies and either actual or liquidated damages according to the severity
of
the deficiency. HHSC may also freeze enrollment into the HMO’s plan for any of
its HMO Programs until such deficiency is corrected. Refer to Attachment
A, Article 12 and Attachment B-5 for additional
information regarding remedies and damages. Refer to Attachment X-0,
Xxxxxxx 0 xxx Xxxxxxxxxx X-0, Section 8.1.1.2 for
additional information regarding HMO Readiness Reviews. Refer to
Attachment A, Section 4.08(c) for information regarding
Readiness Reviews of the HMO’s Material Subcontractors.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.1.18.1
|
Encounter
Data
|
The
HMO
must provide complete Encounter Data for all Covered Services, including Value
added Services. Encounter Data must follow the format, and data elements as
described in the HIPAA-compliant 837 format. HHSC will specify the method of
transmission, and the submission schedule, in the Uniform Managed Care
Manual. The HMO must submit monthly Encounter Data transmissions, and
include all Encounter Data and Encounter Data adjustments processed by the
HMO.
Encounter Data quality validation must incorporate assessment standards
developed jointly by the HMO and HHSC. The HMO must make original records
available for inspection by HHSC for validation purposes. Encounter Data that
do
not meet quality standards must be corrected and returned within a time period
specified by HHSC.
In
addition to providing Encounter Data in the 837 format described above, HMOs
must submit an Encounter Data file to HHSC's EQRO, in the format provided in
the
Uniform Managed Care Manual. This additional submission
requirement is time-limited and may not be required for the entire term of
the
Contract.
For
reporting Encounters and fee-for-service claims to HHSC, the HMO must use the
procedure codes, diagnosis codes, and other codes as directed by HHSC. Any
exceptions will be considered on a code-by-code basis after HHSC receives
written notice from the HMO requesting an exception. The HMO must also use
the
provider numbers as directed by HHSC for both Encounter and fee-for-service
claims submissions, as applicable.
8.1.18.2
|
HMO
Deliverables related to MIS
Requirements
|
At
the
beginning of each state fiscal year, the HMO must submit for HHSC’s review and
approval any modifications to the following documents:
|
1.
|
Joint
Interface Plan;
|
|
2.
|
Disaster
Recovery Plan;
|
|
3.
|
Business
Continuity Plan;
|
|
4.
|
Risk
Management Plan; and
|
|
5.
|
Systems
Quality Assurance Plan.
|
The
HMO
must submit such modifications to HHSC according to the format and schedule
identified the HHSC Uniform Managed Care Manual.
8.1.18.3
|
System-wide
Functions
|
The
HMO’s
MIS system must include key business processing functions and/or features,
which
must apply across all subsystems as follows:
|
1.
|
Process
electronic data transmission or media to add, delete or modify membership
records with accurate begin and end
dates;
|
|
2.
|
Track
Covered Services received by Members through the system, and accurately
and fully maintain those Covered Services as HIPAA-compliant Encounter
transactions;
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
3.
|
|
Transmit
or transfer Encounter Data transactions on electronic media in the
HIPAA
format to the contractor designated by HHSC to receive the Encounter
Data;
|
4.
|
|
Maintain
a history of changes and adjustments and audit trails for current
and
retroactive data;
|
5.
|
|
Maintain
procedures and processes for accumulating, archiving, and restoring
data
in the event of a system or subsystem
failure;
|
6.
|
|
Employ
industry standard medical billing taxonomies (procedure codes, diagnosis
codes) to describe services delivered and Encounter transactions
produced;
|
7.
|
|
Accommodate
the coordination of benefits;
|
8.
|
|
Produce
standard Explanation of Benefits
(EOBs);
|
9.
|
|
Pay financial transactions to Providers in compliance
with
federal and state laws, rules and
regulations;
|
10.
|
Ensure
that all financial transactions are auditable according to GAAP
guidelines.
|
11.
|
Relate
and extract data elements to produce report formats (provided within
the
Uniform Managed Care Manual) or otherwise required by
HHSC;
|
12.
|
Ensure
that written process and procedures manuals document and describe
all
manual and automated system procedures and processes for the
MIS;
|
13.
|
Maintain
and cross-reference all Member-related information with the most
current
Medicaid, CHIP or CHIP Perinatal Program Provider number;
and
|
14.
|
Ensure
that the MIS is able to integrate pharmacy data from HHSC’s Drug Vendor
file (available through the Virtual Private Network (VPN)) into the
HMO’s
Member data.
|
8.1.18.4
|
Health
Insurance Portability and Accountability Act (HIPAA)
Compliance
|
The
HMO’s
MIS system must comply with applicable certificate of coverage and data
specification and reporting requirements promulgated pursuant to the Health
Insurance Portability and Accountability Act (HIPAA) of 1996, P.L. 104-191
(August 21, 1996), as amended or modified. The HMO must comply with HIPAA EDI
requirements. HMO’s enrollment files must be in the 834 HIPAA-compliant format.
Eligibility inquiries must be in the 270/271 format and all claims and
remittance transactions in the 837/835 format.
The
HMO
must provide its Members with a privacy notice as required by HIPAA. The HMO
must provide HHSC with a copy of its privacy notice for filing.
8.1.18.5
|
Claims
Processing Requirements
|
The
HMO
must process and adjudicate all provider claims for Medically Necessary Covered
Services that are filed within the time frames specified in the Uniform
Managed Care Manual. The HMO is subject to remedies, including
liquidated damages and interest, if the HMO does not process and adjudicate
claims within the timeframes listed in the Uniform Managed Care
Manual.
The
HMO
must administer an effective, accurate, and efficient claims payment process
in
compliance with federal laws and regulations, applicable state laws and rules,
the Contract, and the Uniform Managed Care Manual. In addition,
a Medicaid HMO must be able to accept and process provider claims in compliance
with the Medicaid Provider Procedures Manual and The Texas Medicaid
Bulletin.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
must maintain an automated claims processing system that registers the date
a
claim is received by the MCO, the detail of each claim transaction (or action)
at the time the transaction occurs, and has the capability to report each claim
transaction by date and type to include interest payments. The claims system
must maintain information at the claim and line detail level. The claims system
must maintain adequate audit trails and report accurate claims performance
measures to HHSC.
The
HMO’s
claims system must maintain online and archived files. The HMO must keep online
automated claims payment history for the most current 18 months. The HMO must
retain other financial information and records, including all original claims
forms, for the time period established in Attachment A, Section
9.01. All claims data must be easily sorted and produced in formats as
requested by HHSC.
The
HMO
must offer its Providers/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. Electronic claims must use
HIPAA-compliant electronic formats.
The
HMO
must make an electronic funds transfer (EFT) payment process (for direct
deposit) available to in-network providers when processing claims for Medically
Necessary covered STAR+PLUS services.
The
HMO
may deny a claim submitted by a provider for failure to file in a timely manner
as provided for in the Uniform Managed Care Manual. The HMO
must not pay any claim submitted by a provider excluded or suspended from the
Medicare, Medicaid, CHIP or CHIP Perinatal programs for Fraud, Abuse, or Waste.
The HMO must not pay any claim submitted by a Provider that is on payment hold
under the authority of HHSC or its authorized agent(s), or who has pending
accounts receivable with HHSC.
The
HMO
is subject to the requirements related to coordination of benefits for secondary
payors in the Texas Insurance Code Section 843.349 (e) and (f).
The
HMO
must notify HHSC of major claim system changes in writing no later than 90
days
prior to implementation. The HMO must provide an implementation plan and
schedule of proposed changes. HHSC reserves the right to require a desk or
on-site readiness review of the changes.
The
HMO
must inform all Network Providers about the information required to submit
a
claim at least 30 days prior to the Operational Start Date and as a provision
within the HMO/Provider contract. The HMO must make available to Providers
claims coding and processing guidelines for the applicable provider type.
Providers must receive 90 days notice prior to the HMO’s implementation of
changes to claims guidelines.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.1.19
|
Fraud
and Abuse
|
A
HMO is
subject to all state and federal laws and regulations relating to Fraud, Abuse,
and Waste in health care and the Medicaid and CHIP programs. The HMO must
cooperate and assist HHSC and any state or federal agency charged with the
duty
of identifying, investigating, sanctioning or prosecuting suspected Fraud,
Abuse
or Waste. The HMO must provide originals and/or copies of all records and
information requested and allow access to premises and provide records to the
Inspector General for the Texas Health and Human Services System, HHSC or its
authorized agent(s), the Centers for Medicare and Medicaid Services (CMS),
the
U.S. Department of Health and Human Services (DHHS), Federal Bureau of
Investigation, TDI, or other units of state government. The HMO must provide
all
copies of records free of charge.
The
HMO
must submit a written Fraud and Abuse compliance plan to the Office of Inspector
General at HHSC for approval (See Attachment B-1, Section 7 for
requirements regarding timeframes for submitting the original plan.) The plan
must ensure that all officers, directors, managers and employees know and
understand the provisions of the HMO’s Fraud and Abuse compliance plan. The plan
must include the name, address, telephone number, electronic mail address,
and
fax number of the individual(s) responsible for carrying out the
plan.
The
written Fraud and Abuse compliance plan must:
|
1.
|
Contain
procedures designed to prevent and detect potential or suspected
Abuse,
Fraud and Waste in the administration and delivery of services under
the
Contract;
|
|
2.
|
Contain
a description of the HMO’s procedures for educating and training personnel
to prevent Fraud, Abuse, or Waste;
|
|
3.
|
Include
provisions for the confidential reporting of plan violations to the
designated person within the HMO’s organization and ensure that the
identity of an individual reporting violations is protected from
retaliation;
|
|
4.
|
Include
provisions for maintaining the confidentiality of any patient information
relevant to an investigation of Fraud, Abuse, or
Waste;
|
|
5.
|
Provide
for the investigation and follow-up of any allegations of Fraud,
Abuse, or
Waste and contain specific and detailed internal procedures for officers,
directors, managers and employees for detecting, reporting, and
investigating Fraud and Abuse compliance plan
violations;
|
|
6.
|
Require
that confirmed violations be reported to the Office of Inspector
General
(OIG); and
|
|
7.
|
Require
any confirmed violations or confirmed or suspected Fraud, Abuse,
or Waste
under state or federal law be reported to
OIG.
|
If
the
HMO contracts for the investigation of allegations of Fraud, Abuse, or Waste
and
other types of program abuse by Members or Providers, the plan must include
a
copy of the subcontract; the names, addresses, telephone numbers, electronic
mail addresses, and fax numbers of the principals of the subcontracted entity;
and a description of the qualifications of the subcontracted entity. Such
subcontractors must be held to the requirements stated in this
Section.
The
HMO
must designate executive and essential personnel to attend mandatory training
in
Fraud and Abuse detection, prevention and reporting. Designated executive and
essential personnel
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
means
the
HMO staff persons who supervise staff in the following areas: data collection,
provider enrollment or disenrollment, encounter data, claims processing,
utilization review, appeals or grievances, quality assurance and marketing,
and
who are directly involved in the decision-making and administration of the
Fraud
and Abuse detection program within the HMO. The training will be conducted
by
the OIG free of charge. The HMO must schedule and complete training no later
than 90 days after the Effective Date of the Contract. If the HMO updates or
modifies its written Fraud and Abuse compliance plan, the HMO must train its
executive and essential personnel on these updates or modifications no later
than 90 days after the effective date of the updates or
modifications.
The
HMO
must designate an officer or director in its organization with responsibility
and authority to carry out the provisions of the Fraud and Abuse compliance
plan. A HMO’s failure to report potential or suspected Fraud or Abuse may result
in sanctions, cancellation of the Contract, and/or exclusion from participation
in the Medicaid, CHIP or CHIP Perinatal HMO Programs. The HMO must allow the
OIG, HHSC, its agents, or other governmental units to conduct private interviews
of the HMO’s personnel, subcontractors and their personnel, witnesses, and
Members with regard to a confirmed violation. The HMO’s personnel and it
subcontractors must reasonably cooperate, to the satisfaction of HHSC, by being
available in person for interviews, consultation, grand jury proceedings,
pre-trial conferences, hearings, trials and in any other process, including
investigations, at the HMO’s and subcontractors’ own expense.
Additional
Requirements for STAR and STAR+PLUS HMOs:
In
accordance with Section 1902(a)(68) of the Social Security Act, STAR and
STAR+PLUS HMOs that receive or make annual Medicaid payments of at least $5
million must:
|
1.
|
Establish
written policies for all employees, managers, officers, contractors,
subcontractors, and agents of the HMO, which provide detailed information
about the False Claims Act, administrative remedies for false claims
and
statements, any state laws pertaining to civil or criminal penalties
for
false claims, and whistleblower protections under such laws, as described
in Section 1902(a)(68)(A).
|
|
2.
|
Include
as part of such written policies, detailed provisions regarding the
HMO’s
policies and procedures for detecting and preventing fraud, waste,
and
abuse.
|
|
3.
|
Include
in any employee handbook a specific discussion of the laws described
in
Section 1902(a)(68)(A), the rights of employees to be protected as
whistleblowers, and the HMO’s policies and procedures for detecting and
preventing fraud, waste, and abuse.
|
8.1.20
|
Reporting
Requirements
|
The
HMO
must provide and must require its subcontractors to provide:
|
1.
|
All
information required under the Contract, including but not limited
to, the
reporting requirements or other information related to the performance
of
its responsibilities hereunder as reasonably requested by the HHSC;
and
|
|
2.
|
Any
information in its possession sufficient to permit HHSC to comply
with the
Federal Balanced Budget Act of 1997 or other Federal or state laws,
rules,
and regulations. All information must be provided in accordance with
the
timelines, definitions, formats and
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
instructions
as specified by HHSC. Where practicable, HHSC may consult with HMOs to establish
time frames and formats reasonably acceptable to both parties.
Any
deliverable or report in Section 8.1.20 without a specified due date is due
quarterly on the last day of the month following the end of the reporting
period. Where the due date states 30 days, the HMO is to provide the deliverable
by the last day of the month following the end of the reporting period. Where
the due date states 45 days, the HMO is to provide the deliverable by the 15th
day of the second month following the end of the reporting period.
The
HMO’s
Chief Executive and Chief Financial Officers, or persons in equivalent
positions, must certify that financial data, Encounter Data and other
measurement data has been reviewed by the HMO and is true and accurate to the
best of their knowledge after reasonable inquiry.
8.1.20.1
|
HEDIS
and Other Statistical Performance
Measures
|
The
HMO
must provide to HHSC or its designee all information necessary to analyze the
HMO’s provision of quality care to Members using measures to be determined by
HHSC in consultation with the HMO. Such measures must be consistent with HEDIS
or other externally based measures or measurement sets, and involve collection
of information beyond that present in Encounter Data. The Performance
Indicator Dashboard, found in the Uniform Managed Care Manual
provides additional information on the role of the
HMO and the EQRO in
the collection and calculation of HEDIS, CAHPS, and other performance
measures.
8.1.20.2
|
Reports
|
The
HMO
must provide the following reports, in addition to the Financial Reports
described in Section 8.1.17 and those reporting requirements
listed elsewhere in the Contract. The HHSC Uniform Managed Care Manual
will include a list of all required reports, and a description
of the
format, content, file layout and submission deadlines for each
report.
For
the
following reports, CHIP Perinatal Program data will be integrated into existing
CHIP Program reports. Generally, no separate CHIP Perinatal Program reports
are
required. Where appropriate, HHSC will designate specific attributes within
the
CHIP Program reports that the CHIP Perinatal HMOs must complete to allow HHSC
to
extract data particular to the CHIP Perinatal Program.
Claims
Summary Report - The HMO must submit quarterly Claims Summary Reports
to HHSC by HMO Program, Service Area and claim type by the 30th day following
the end of the reporting period unless otherwise specified. Claim Types include
facility and/or professional services for Acute Care, Behavioral Health, Vision,
and Long Term Services and Supports. Within each claim type, claims data must
be
reported separately on the UB and CMS 1500 claim forms. The format for the
Claims Summary Report is contained in Chapter 5, Section 5.6.1 of the
Uniform Managed Care Manual.
QAPI
Program Annual Summary Report - The HMO must submit a QAPI Program
Annual Summary in a format and timeframe as specified in the Uniform Managed
Care Manual.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
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Version
1.7
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Fraudulent
Practices Report - Utilizing the HHSC-Office of Inspector General (OIG)
fraud referral form, the HMO’s assigned officer or director must report and
refer all possible acts of waste, abuse or fraud to the HHSC-OIG within 30
working days of receiving the reports of possible acts of waste, abuse or fraud
from the HMO’s Special Investigative Unit (SIU). The report and referral must
include: an investigative report identifying the allegation,
statutes/regulations violated or considered, and the results of the
investigation; copies of program rules and regulations violated for the time
period in question; the estimated overpayment identified; a summary of the
interviews conducted; the encounter data submitted by the provider for the
time
period in question; and all supporting documentation obtained as the result
of
the investigation. This requirement applies to all reports of possible acts
of
waste, abuse and fraud.
Additional
reports required by the Office of the Inspector General relating to waste,
abuse
or fraud are listed in the HHSC Uniform Managed Care
Manual.
Provider
Termination Report: (CHIP (including integrated CHIP Perinatal Program data),
STAR, and STAR+PLUS)
MCO
must
submit a quarterly report that identifies any providers who cease to participate
in MCO's provider network, either voluntarily or involuntarily. The report
must
be submitted to HHSC in the format specified by HHSC, no later than 30 days
after the end of the reporting period.
PCP
Network & Capacity Report: (CHIP only (including integrated CHIP Perinatal
Program data))
For
the
CHIP Program, MCO must submit a quarterly report listing all unduplicated PCPs
in the MCO's Provider Network. For the CHIP Perinatal Program, the Perinatal
Newborns are assigned PCPs that are part of the CHIP PCP Network. The report
must be submitted to HHSC in the format specified by HHSC, no later than 30
days
after the end of the reporting quarter.
Summary
Report of Member Complaints and Appeals - The HMO must submit quarterly
Member Complaints and Appeals reports. The HMO must include in its reports
Complaints and Appeals submitted to its subcontracted risk groups (e.g., IPAs)
and any other subcontractor that provides Member services. The HMO must submit
the Complaint and Appeals reports electronically on or before 45 days following
the end of the state fiscal quarter, using the format specified by HHSC in
the
HHSC Uniform Managed Care Manual, Chapter 5.4.2.
HHSC
may
direct the CHIP Perinatal HMOs to provide segregated Member Complaints and
Appeals reports on an as-needed basis.
Summary
Report of Provider Complaints - The HMO must submit Provider complaints
reports on a quarterly basis. The HMO must include in its reports complaints
submitted by providers to its subcontracted risk groups (e.g., IPAs) and any
other subcontractor that provides Provider services. The complaint reports
must
be submitted electronically on or before 45 days following the end of the state
fiscal quarter, using the format specified by HHSC in the HHSC Uniform
Managed Care Manual, Chapter 5.4.2.
HHSC
may
direct the CHIP Perinatal HMOs to provide segregated Provider Complaints and
Appeals reports on an as-needed basis.
Contractual
Document (CD)
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|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
Hotline
Reports - The HMO must submit, on a quarterly basis, a status report
for the Member Hotline, the Behavioral Health Services Hotline, and the Provider
Hotline in comparison with the performance standards set out in Sections
8.1.5.6, 8.1.14.3, and 8.1.4.7. The HMO shall submit such reports using
a format to be prescribed by HHSC in consultation with the HMOs.
If
the
HMO is not meeting a hotline performance standard, HHSC may require the HMO
to
submit monthly hotline performance reports and implement corrective actions
until the hotline performance standards are met. If a HMO has a single hotline
serving multiple Service Areas, multiple HMO Programs, or multiple hotline
functions, (i.e. Member, Provider, Behavioral Health Services hotlines), HHSC
may request on an annual basis that the HMO submit certain hotline response
information by HMO Program, by Service Area, and by hotline function, as
applicable to the HMO. HHSC may also request this type of hotline information
if
a HMO is not meeting a hotline performance standard.
The
HMO
must follow all applicable Joint Interface Plans (JIPs) and all required file
submissions for HHSC’s Administrative Services Contractor, External Quality
Review Organization (EQRO) and HHSC Medicaid Claims Administrator. The JIPs
can
be accessed through the Uniform Managed Care Manual.
8.2
|
Additional
Medicaid HMO Scope of Work
|
The
following provisions apply to any HMO participating in the STAR or STAR+PLUS
HMO
Program.
8.2.1
|
Continuity
of Care and Out-of-Network
Providers
|
The
HMO
must ensure that the care of newly enrolled Members is not disrupted or
interrupted. The 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 Medically Necessary Covered Services are disrupted or
interrupted.
The
HMO
must allow pregnant Members with 12 weeks or less remaining before the expected
delivery date 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 a
Member wants to change her OB/GYN to one who is in the Network, she must be
allowed to do so if the Provider to whom she wishes to transfer agrees to accept
her in the last trimester of pregnancy.
The
HMO
must pay a Member’s existing Out-of-Network providers for Medically Necessary
Covered Services until the Member’s records, clinical information and care can
be transferred to a Network Provider, or until such time as the Member is no
longer enrolled in that HMO, whichever is shorter. Payment to Out-of-Network
providers must be made within the time period required for Network Providers.
The HMO must comply with out-of-network provider reimbursement rules as adopted
by HHSC.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
This
Article does not extend the obligation of the HMO to reimburse the Member’s
existing Out-of- Network providers for on-going care for:
|
1.
|
More
than 90 days after a Member enrolls in the HMO’s Program,
or
|
|
2.
|
For
more than nine (9) months in the case of a Member who, at the time
of
enrollment in the HMO, has been diagnosed with and receiving treatment
for
a terminal illness and remains enrolled in the
HMO.
|
The
HMO’s
obligation to reimburse the Member’s existing Out-of-Network provider for
services provided to a pregnant Member with 12 weeks or less 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.
The
HMO
must provide or pay Out-of-Network providers who provide Medically Necessary
Covered Services to Members who move out of the Service Area through the end
of
the period for which capitation has been paid for the Member.
The
HMO
must provide Members with timely and adequate access to Out-of-Network services
for as long as those services are necessary and covered benefits not available
within the network, in accordance with 42 C.F.R. §438.206(b)(4). The HMO will
not be obligated to provide a Member with access to Out-of-Network services
if
such services become available from a Network Provider.
The
HMO
must ensure that each Member has access to a second opinion regarding the use
of
any Medically Necessary Covered Service. A Member must be allowed access to
a
second opinion from a Network Provider or Out-of-Network provider if a Network
Provider is not available, at no cost to the Member, in accordance with 42
C.F.R. §438.206(b)(3).
8.2.2
|
Provisions
Related to Covered Services for Medicaid
Members
|
8.2.2.1
|
Emergency
Services
|
HMO
policy and procedures, Covered Services, claims adjudication methodology, and
reimbursement performance for Emergency Services must comply with all applicable
state and federal laws, rules, and regulations including 42 C.F.R. §438.114,
whether the provider is in-network or Out-of-Network. HMO policies and
procedures must be consistent with the prudent layperson definition of an
Emergency Medical Condition and the claims adjudication processes required
under
the Contract and 42 C.F.R. §438.114.
The
HMO
must pay for the professional, facility, and ancillary services that are
Medically Necessary to perform the medical screening examination and
stabilization of a Member presenting with an Emergency Medical Condition or
an
Emergency Behavioral Health Condition to the hospital emergency department,
24
hours a day, 7 days a week, rendered by either the HMO's Network or
Out-of-Network providers.
The
HMO
cannot require prior authorization as a condition for payment for an Emergency
Medical Condition, an Emergency Behavioral Health Condition, or labor and
delivery. The HMO
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
cannot
limit what constitutes an Emergency Medical Condition on the basis of lists
of
diagnoses or symptoms. The HMO cannot refuse to cover Emergency Services based
on the emergency room provider, hospital, or fiscal agent not notifying the
Member’s PCP or the HMO of the Member’s screening and treatment within 10
calendar days of presentation for Emergency Services. The HMO may not hold
the
Member who has an Emergency Medical Condition liable for payment of subsequent
screening and treatment needed to diagnose the specific condition or stabilize
the patient. The HMO must accept the emergency physician or provider’s
determination of when the Member is sufficiently stabilized for transfer or
discharge.
A
medical
screening examination needed to diagnose an Emergency Medical Condition must
be
provided in a hospital based emergency department that meets the requirements
of
the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 C.F.R.
§§489.20, 489.24 and 438.114(b)&(c)). The HMO must pay for the emergency
medical screening examination, as required by 42 U.S.C. §1395dd. The HMO must
reimburse for both the physician's services and the hospital's Emergency
Services, including the emergency room and its ancillary services.
When
the
medical screening examination determines that an Emergency Medical Condition
exists, the HMO must pay for Emergency Services performed to stabilize the
Member. The emergency physician must document these services in the Member's
medical record. The HMO must reimburse for both the physician's and hospital's
emergency stabilization services including the emergency room and its ancillary
services.
The
HMO
must cover and pay for Post-Stabilization Care Services in the amount, duration,
and scope necessary to comply with 42 C.F.R. §438.114(b)&(e) and 42 C.F.R.
§422.113(c)(iii). The HMO is financially responsible for post-stabilization
care
services obtained within or outside the Network that are not pre-approved by
a
Provider or other HMO representative, but administered to maintain, improve,
or
resolve the Member’s stabilized condition if:
|
1.
|
The
HMO does not respond to a request for pre-approval within 1
hour;
|
|
2.
|
The
HMO cannot be contacted; or
|
|
3.
|
The
HMO representative and the treating physician cannot reach an agreement
concerning the Member’s care and a Network physician is not available for
consultation. In this situation, the HMO must give the treating physician
the opportunity to consult with a Network physician and the treating
physician may continue with care of the patient until an HMO physician
is
reached. The HMO’s financial responsibility ends as follows: the HMO
physician with privileges at the treating hospital assumes responsibility
for the Member’s care; the HMO physician assumes responsibility for the
Member’s care through transfer; the HMO representative and the treating
physician reach an agreement concerning the Member’s care; or the Member
is discharged.
|
8.2.2.2
|
Family
Planning - Specific
Requirements
|
The
HMO
must require, through Provider contract provisions, that Members requesting
contraceptive services or family planning services are also provided counseling
and education about the family planning and family planning services available
to Members. The HMO must develop outreach programs to increase community support
for family planning and encourage Members to use available family planning
services.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
must ensure that Members have the right to choose any Medicaid participating
family planning provider, whether the provider chosen by the Member is in or
outside the Provider Network. The HMO must provide Members access to information
about available providers of family planning services and the Member’s right to
choose any Medicaid family planning provider. The HMO must provide access to
confidential family planning services.
The
HMO
must provide, at minimum, the full scope of services available under the Texas
Medicaid program for family planning services. The HMO will reimburse family
planning agencies the Medicaid fee-for service amounts for family planning
services, including Medically Necessary medications, contraceptives, and
supplies not covered by the Vendor Drug Program and will reimburse
Out-of-Network family planning providers in accordance with HHSC’s
administrative rules.
The
HMO
must provide medically approved methods of contraception to Members, provided
that the methods of contraception are Covered Services. Contraceptive methods
must be accompanied by verbal and written instructions on their correct use.
The
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
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). Providers and family planning agencies
cannot require parental consent for minors to receive family planning services.
The HMO must require, through contractual provisions, that subcontractors have
mechanisms in place to ensure Member’s (including minor’s) confidentiality for
family planning services.
8.2.2.3
|
Texas
Health Steps (EPSDT)
|
The
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 AAP and the THSteps periodicity schedule for children. The
HMO must arrange for THSteps services for all eligible Members except when
a
Member knowingly and voluntarily declines or refuses services after receiving
sufficient information to make an informed decision.
HMO
must
have mechanisms in place to ensure that all newly enrolled newborns receive
an
appointment for a THSteps checkup within 14 days of enrollment and all other
eligible child Members receive a THSteps checkup within 60 days of enrollment,
if one is due according to the AAP periodicity schedule.
The
HMO
must ensure that Members are provided information and educational materials
about the services available through the THSteps Program, and how and when
they
may obtain the services. The information should tell the Member how they can
obtain dental benefits, transportation services through the Texas Department
of
Transportation’s Medical Transportation Program, and advocacy assistance from
the HMO.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
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:
|
1.
|
THSteps
benefits,
|
|
2.
|
The
periodicity schedule for THSteps medical checkups and
immunizations,
|
|
3.
|
The
required elements of THSteps medical
checkups,
|
|
4.
|
Providing
or arranging for all required lab screening tests (including lead
screening), and Comprehensive Care Program (CCP) services available
under
the THSteps program to Members under age 21
years.
|
HMO
must
also educate and train Providers regarding the requirements imposed on HHSC
and
contracting HMOs under the Consent Decree entered in Xxxx x. Xxxxxxx, 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.
The
HMO
must provide outreach to Members to ensure they receive prompt services and
are
effectively informed about available THSteps services. Each month, the HMO
must
retrieve from the HHSC Administrative Services Contractor Bulletin Board System
a list of Members who are due and overdue THSteps services. Using these lists
and its own internally generated list, the HMO will contact such Members to
obtain the service as soon as possible. The HMO outreach staff must coordinate
with DSHS THSteps outreach staff to ensure that Members have access to the
Medical Transportation Program, and that any coordination with other agencies
is
maintained.
The
HMO
must cooperate and coordinate with the State, 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 the HMO’s Program more rapidly and/or unpredictably
than the general population.
The
HMO
must have mechanisms in place to ensure that all newborn Members have an initial
newborn checkup before discharge from the hospital and again within two weeks
from the time of birth. The HMO must require Providers to send all THSteps
newborn screens to the DSHS Bureau of Laboratories or a DSHS certified
laboratory. Providers must include detailed identifying information for all
screened newborn Members and the Member’s mother to allow DSHS to link the
screens performed at the hospital with screens performed at the two-week
follow-up.
All
laboratory specimens collected as a required component of a THSteps checkup
(see
Medicaid Provider Procedures Manual for age-specific requirements) must be
submitted to the DSHS Laboratory for analysis. The HMO must educate Providers
about THSteps Program requirements for submitting laboratory tests to the DSHS
Bureau of Laboratories.
The
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.
The
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.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
must educate Providers on the Immunization Standard Requirements set forth
in
Chapter 161, Health and Safety Code; the standards in the ACIP Immunization
Schedule; the AAP Periodicity Schedule for CHIP Members; and the DSHS
Periodicity Schedule for Medicaid Members. The HMO shall educate Providers
that
Medicaid Members under age 21 must be immunized during the THSteps checkup
according to the DSHS routine immunization schedule. The HMO shall also educate
Providers that the screening provider is responsible for administration of
the
immunization and should not refer children to Local Health Departments to
receive immunizations.
The
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), to include parental consent on the Vaccine
Information Statement.
The
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
HIPAA compliant code set required by HHSC.
Encounter
Data will be validated by chart review of a random sample of THSteps eligible
enrollees against monthly Encounter Data reported by the HMO. HHSC or its
designee will conduct chart reviews 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 the HMO and/or Network Providers being investigated for potential Fraud,
Abuse, or Waste without notice to the HMO or the Provider.
8.2.2.4
|
Perinatal
Services
|
The
HMO’s
perinatal health care services must ensure appropriate care is provided to
women
and infant Members of the HMO from the preconception period through the infant’s
first year of life. The HMO’s perinatal health care system must comply with the
requirements of the Texas Health and Safety Code, Chapter 32 (the Maternal
and
Infant Health Improvement Act) and administrative rules codified at 25 T.A.C.
Chapter 37, Subchapter M.
The
HMO
must have a perinatal health care system in place that, at a minimum, provides
the following services:
|
1.
|
Pregnancy
planning and perinatal health promotion and education for reproductive-
age women;
|
|
2.
|
Perinatal
risk assessment of non-pregnant women, pregnant and postpartum women,
and
infants up to one year of age;
|
|
3.
|
Access
to appropriate levels of care based on risk assessment, including
emergency care;
|
|
4.
|
Transfer
and care of pregnant women, newborns, and infants to tertiary care
facilities when necessary;
|
|
5.
|
Availability
and accessibility of OB/GYNs, anesthesiologists, and neonatologists
capable of dealing with complicated perinatal problems;
and
|
|
6.
|
Availability
and accessibility of appropriate outpatient and inpatient facilities
capable of dealing with complicated perinatal
problems.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
must have a process to expedite scheduling a prenatal appointment for an
obstetrical exam for a TP40 Member no later than two weeks after receiving
the
daily Enrollment File verifying the Member’s enrollment into the
HMO.
The
HMO
must have procedures in place to contact and assist a pregnant/delivering Member
in selecting a PCP for her baby either before the birth or as soon as the baby
is born.
The
HMO
must provide inpatient care and professional services relating to labor and
delivery for its pregnant/delivering Members, and neonatal care for its newborn
Members at the time of delivery and for up to 48 hours following an
uncomplicated vaginal delivery and 96 hours following an uncomplicated Caesarian
delivery.
The
HMO
must Adjudicate provider claims for services provided to a newborn Member in
accordance with HHSC’s claims processing requirements using the proxy ID number
or Stateissued Medicaid ID number. The HMO cannot deny claims based on a
provider’s non-use of State-issued Medicaid ID number for a newborn Member. The
HMO must accept provider claims for newborn services based on mother’s name
and/or Medicaid ID number with accommodations for multiple births, as specified
by the HMO.
The
HMO
must notify providers involved in the care of pregnant/delivering women and
newborns (including Out-of-Network providers and hospitals) of the HMO’s prior
authorization requirements. The HMO cannot require a prior authorization for
services provided to a pregnant/delivering Member or newborn Member for a
medical condition that requires Emergency Services, regardless of when the
emergency condition arises.
8.2.2.5
|
Sexually
Transmitted Diseases (STDs) and Human Immunodeficiency Virus
(HIV)
|
The
HMO
must provide STD services that include STD/HIV prevention, screening,
counseling, diagnosis, and treatment. The HMO is responsible for implementing
procedures to ensure that Members have prompt access to appropriate services
for
STDs, including HIV. The HMO must allow Members access to STD services and
HIV
diagnosis services without prior authorization or referral by a
PCP.
The
HMO
must comply with Texas Family Code Section 32.003, relating to consent to
treatment by a child. The HMO must provide all Covered Services required to
form
the basis for a diagnosis by the Provider as well as the STD/HIV treatment
plan.
The
HMO
must make education available to Providers and Members on the prevention,
detection and effective treatment of STDs, including HIV.
The
HMO
must require Providers to report all confirmed cases of STDs, including HIV,
to
the local or regional health authority according to 25 T.A.C. §§97.131 - 97.134,
using the required forms and procedures for reporting STDs. The HMO must require
the Providers to coordinate with the HHSC 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.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
must have established procedures to make Member records available to public
health agencies with authority to conduct disease investigation, receive
confidential Member information, and provide follow up activities.
The
HMO
must require 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. The HMO must inform and require its
Providers who provide STD/HIV services to comply with all state laws relating
to
communicable disease reporting requirements. The HMO must implement policies
and
procedures to monitor Provider compliance with confidentiality
requirements.
The
HMO
must have policies and procedures in place regarding obtaining informed consent
and counseling Members provided STD/HIV services.
8.2.2.6
|
Tuberculosis
(TB)
|
The
HMO
must provide Members and Providers with education on the prevention, detection
and effective treatment of tuberculosis (TB). The 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 referenced in Section 8.2.2.8
as Non-Capitated Services. The 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 means a person who is susceptible to TB because of
the
association with certain risk factors, behaviors, drug resistance, or
environmental conditions. The HMO must consult with the local TB control program
to ensure that all services and treatments are in compliance with the guidelines
recommended by the American Thoracic Society (ATS), the Centers for Disease
Control and Prevention (CDC), and DSHS policies and standards.
The
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, using the most recent DSHS forms and procedures
for reporting TB. The HMO must provide access to Member medical records to
DSHS
and the local TB control program for all confirmed and suspected TB cases upon
request.
The
HMO
must coordinate with the local TB control program to ensure that all Members
with confirmed or suspected TB have a contact investigation and receive Directly
Observed Therapy (DOT). The HMO must require, through contract provisions,
that
Providers report to DSHS or the local TB control program any Member who is
non-compliant, drug resistant, or who is or may be posing a public health
threat. The HMO must cooperate with the local TB control program in enforcing
the control measures and quarantine procedures contained in Chapter 81 of the
Texas Health and Safety Code.
The
HMO
must have a mechanism for coordinating a post-discharge plan for follow-up
DOT
with the local TB program. The HMO must coordinate with the DSHS 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.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.2.2.7
|
Objection
to Provide Certain
Services
|
In
accordance with 42 C.F.R. §438.102, the HMO may file an objection to providing,
reimbursing for, or providing coverage of, a counseling or referral service
for
a Covered Service based on moral or religious grounds. The HMO must work with
HHSC to develop a work plan to complete the necessary tasks and determine an
appropriate date for implementation of the requested changes to the requirements
related to Covered Services. The work plan will include timeframes for
completing the necessary Contract and waiver amendments, adjustments to
Capitation Rates, identification of the HMO and enrollment materials needing
revision, and notifications to Members.
In
order
to meet the requirements of this section, the HMO must notify HHSC of grounds
for and provide detail concerning its moral or religious objections and the
specific services covered under the objection, no less than 120 days prior
to
the proposed effective date of the policy change.
8.2.2.8
|
Medicaid
Non-capitated Services
|
The
following Texas Medicaid programs and services have been excluded from HMO
Covered Services. Medicaid Members are eligible to receive these Non-capitated
Services on a Fee-for- Service basis from Texas Medicaid providers. HMOs should
refer to relevant chapters in the Provider Procedures Manual
and the Texas Medicaid Bulletins for more
information.
|
1.
|
THSteps
dental (including orthodontia);
|
|
2.
|
Early
Childhood Intervention (ECI) case management/service
coordination;
|
|
3.
|
DSHS
targeted case management;
|
|
4.
|
DSHS
mental health rehabilitation;
|
|
5.
|
DSHS
case management for Children and Pregnant
Women;
|
|
6.
|
Texas
School Health and Related Services
(SHARS);
|
|
7.
|
Department
of Assistive and Rehabilitative Services Blind Children’s Vocational
Discovery and Development Program;
|
|
8.
|
Tuberculosis
services provided by DSHS-approved providers (directly observed therapy
and contact investigation);
|
|
9.
|
Vendor
Drug Program (out-of-office drugs);
|
10.
|
Texas
Department of Transportation Medical
Transportation;
|
11.
|
DADS
hospice services (all Members are disenrolled from their health plan
upon
enrollment into hospice except STAR+PLUS members receiving 1915(c)
Nursing
Facility Waiver services that are not covered by the Hospice
Program);
|
12.
|
Audiology
services and hearing aids for children (under age 21) (hearing screening
services are provided through the THSteps Program and are capitated)
through PACT (Program for Amplification for Children of
Texas).
|
13.
|
For
STAR+PLUS, Inpatient Stays are Non-capitated
Services.
|
8.2.2.9
|
Referrals
for Non-capitated Services
|
Although
Medicaid HMOs are not responsible for paying or reimbursing for Non-capitated
Services, HMOs are responsible for educating Members about the availability
of
Non-capitated Services, and for providing appropriate referrals for Members
to
obtain or access these services.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
is responsible for informing Providers that bills for all Non-capitated Services
must be submitted to HHSC’s Claims Administrator for
reimbursement.
8.2.2.10
|
Cooperation
with Immunization Registry
|
The
HMO
must work with HHSC and health care providers to improve the immunization rate
of Medicaid clients and the reporting of immunization information for
inclusion in the Texas Immunization Registry, called
“ImmTrac.”
8.2.2.11
|
Case
Management for Children and Pregnant
Women
|
The
HMO
must educate Members and Providers on the services available through
Case Management for Children and Pregnant Women (CPW) as described on the
program’s website
at xxxx://xxx.xxxx.xxxxx.xx.xx/xxxxxxx/xxxxxxx.xxxx. An HMO may
provide information about CPW’s website and basic information about CPW
services in order to meet this requirement. CPW information and materials
must be included in the HMO’s Provider Manual, Member Handbook and Provider
orientations. The information and materials must also inform Providers that
the disclosure of medical records or information between Providers, HMO’s and
CPW case managers does not require a medical release form from the
Member.
The
HMO
must coordinate services with CPW regarding a Member’s health care needs that
are identified by CPW and referred to the HMO. Upon receipt of a referral
or assessment from a CPW case manager, the HMO’s designated staff are
required to review the assessment and determine, based on the HMO’s
policies, the appropriate level of health care and services. The HMO’s
staff must also coordinate with the Member’s family, Member’s Primary Care
Provider (PCP), in and Out-of-Network Providers, agencies, and the HMO’s
utilization management staff to ensure that the health care and services
identified are properly referred, authorized, scheduled and provided within
a timely manner.
The
HMO
must ensure that access to medically necessary health care needed by the Member
is available within the standards established by HHSC for respective care.
HMOs are not required to arrange or provide for any covered or non-covered
services identified in the CPW assessment. The decision whether to
authorize these services is made by the HMO. Within five (5) business days
of identifying any non-covered health care services or other services that
the
Member may need, the HMO’s staff must report to the CPW case manager which
items/services will not be performed by the HMO. Additionally, within ten
(10) business days after all of the authorized services have been provided,
the HMO’s staff must follow-up with CPW case manager to report the
provision of services. The HMO’s staff must ensure that all services provided to
a Member by an HMO Provider are reported to the Member’s PCP.
The
CPW
program requires its contracted case managers to coordinate with the HMO and
the HMO’s PCPs. The HMO should report problems regarding CPW referrals,
assessments or coordination activities to HHSC for follow-up with CPW
program staff.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.2.3
|
Medicaid
Significant Traditional
Providers
|
In
the
first three (3) years of a Medicaid HMO Program operating in a Service Area,
the
HMO must seek participation in its Network from all Medicaid Significant
Traditional Providers (STPs) defined by HHSC in the applicable Service Area
for
the applicable HMO Program. For STAR HMOs, the Medicaid STP requirements only
apply in the Nueces Service Area. For STAR+PLUS HMOs, the Medicaid STP
requirements apply to all Service Areas, except Xxxxxx County within the Xxxxxx
Service Area.
Medicaid
STPs are defined as PCPs and, for STAR+PLUS, Community-based Long Term Care
providers in a county, that, when listed by provider type by county in
descending order by unduplicated number of clients, served the top 80% of
unduplicated clients. Hospitals receiving Disproportionate Share Hospital (DSH)
funds are also considered STPs in the Service Area in which they are located.
Note that STAR+PLUS HMOs are not required to contract with Hospitals for
Inpatient Stays, but are required to contract with Hospitals for Outpatient
Hospital Services. The HHSC website includes a list of Medicaid STPs by Service
Area.
Because
the STP lists were produced in FY2005, HHSC has developed an updated list for
Long Term Care Providers. The list will be provided to HMOs and posted on HHSC’s
website.
The
STP
requirement will be in place for three years after the program has been
implemented. During that time, providers who believe they meet the STP
requirements may contact HHSC request HHSC’s consideration for STP status.
STAR+PLUS HMOs will be notified when Providers are added to the list of STPs
for
a Service Area.
The
HMO
must give STPs the opportunity to participate in its Network for at least three
(3) years commencing on the implementation date of Medicaid managed care in
the
Service Area. However, the STP provider must:
|
1.
|
Agree
to accept the HMO’s Provider reimbursement rate for the provider type;
and
|
|
2.
|
Meet
the standard credentialing requirements of the HMO, provided that
lack of
board certification or accreditation by the Joint Commission on
Accreditation of Health Care Organizations (JCAHO) is not the sole
grounds
for exclusion from the Provider
Network.
|
8.2.4
|
Federally
Qualified Health Centers (FQHCs) and Rural Health Clinics
(RHCs)
|
The
HMO
must make reasonable efforts to include FQHCs and RHCs (freestanding and
hospital-based) in its Provider Network. The HMO must reimburse FQHCs and RHCs
for health care services provided outside of regular business hours, as defined
by HHSC in rules, including weekend days or holidays, at a rate that is equal
to
the allowable rate for those services as determined under Section 32.028, Human
Resources Code, if the Member does not have a referral from their PCP. FQHCs
or
RHCs will receive a cost settlement from HHSC and must agree to accept initial
payments from the HMO in an amount that is equal to or greater than the HMO’s
payment terms for other Providers providing the same or similar services. Cost
settlements will not be applicable to the Nueces Service Area and the STAR+PLUS
Service Areas. The HMOs serving those Areas will pay the full encounter rates
to
the FQHCs and RHCs when claims payments are made.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
must submit monthly FQHC and RHC encounter and payment reports to all contracted
FQHCs and RHCs, and FQHCs and RHCs with which 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 HHSC and provided in the Uniform Managed
Care Manual. The FQHC and RHC must validate the encounter and payment
information contained in the report(s). The HMO and the FQHC/RHC must both
sign
the report(s) after each party agrees that it accurately reflects encounters
and
payments for the month reported. The HMO must submit the signed FQHC and RHC
encounter and payment reports to HHSC not later than 45 days from the end of
the
reported month. Encounter and payment reports will not be necessary for the
Nueces Service Area and the STAR+PLUS Service Areas since the HMOs in those
Areas will be paying the full encounter rates to the FQHCs and
RHCs.
8.2.5
|
Provider
Complaints and Appeals
|
8.2.5.1
|
Provider
Complaints
|
Medicaid
HMOs must develop, implement, and maintain a system for tracking and resolving
all Medicaid Provider complaints. Within this process, the HMO must respond
fully and completely to each complaint and establish a tracking mechanism to
document the status and final disposition of each Provider complaint. The HMO
must resolve Provider Complaints within 30 days from the date the Complaint
is
received.
8.2.5.2
|
Appeal
of Provider Claims
|
Medicaid
HMOs must develop, implement, and maintain a system for tracking and resolving
all Medicaid Provider appeals related to claims payment. Within this process,
the Provider must respond fully and completely to each Medicaid Provider’s
claims payment appeal and establish a tracking mechanism to document the status
and final disposition of each Medicaid Provider’s claims payment
appeal.
Medicaid
HMOs must contract with physicians who are not Network Providers to resolve
claims disputes related to denial on the basis of medical necessity that remain
unresolved subsequent to a Provider appeal. The determination of the physician
resolving the dispute must be binding on the HMO and the Provider. The physician
resolving the dispute must hold the same specialty or a related specialty as
the
appealing Provider. HHSC reserves the right to amend this process to include
an
independent review process established by HHSC for final determination on these
disputes.
8.2.6
|
Member
Rights and
Responsibilities
|
In
accordance with 42 C.F.R. §438.100, all Medicaid HMOs must maintain written
policies and procedures for informing Members of their rights and
responsibilities, and must notify their Members of their right to request a
copy
of these rights and responsibilities. The Member Handbook must include
notification of Member rights and responsibilities.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.2.7
|
Medicaid
Member Complaint and Appeal
System
|
The
HMO
must develop, implement, and maintain a Member Complaint and Appeal system
that
complies with the requirements in applicable federal and state laws and
regulations, including 42 C.F.R. §431.200, 42 C.F.R. Part 438, Subpart F,
“Grievance System,” and the provisions of 1 T.A.C. Chapter 357 relating to
Medicaid managed care organizations.
The
Complaint and Appeal system must include a Complaint process, an Appeal process,
and access to HHSC’s Fair Hearing System. The procedures must be the same for
all Members and must be reviewed and approved in writing by HHSC or its
designee. Modifications and amendments to the Member Complaint and Appeal system
must be submitted for HHSC’s approval at least 30 days prior to the
implementation.
8.2.7.1
|
Member
Complaint Process
|
The
HMO
must have written policies and procedures for receiving, tracking, responding
to, reviewing, reporting and resolving Complaints by Members or their authorized
representatives. For purposes of this Section 8.2.7, an
“authorized representative” is any person or entity acting on behalf of the
Member and with the Member’s written consent. A Provider may be an authorized
representative.
The
HMO
must resolve Complaints within 30 days from the date the Complaint is received.
The HMO is subject to remedies, including liquidated damages, if at least 98
percent of Member Complaints are not resolved within 30 days of receipt of
the
Complaint by the HMO. Please see the Uniform Managed Care Contract Terms
& Conditions and Attachment B-5, Deliverables/Liquidated
Damages Matrix. The Complaint procedure must be the same for all
Members under the Contract. The Member or Member’s authorized representative may
file a Complaint either orally or in writing. The HMO must also inform Members
how to file a Complaint directly with HHSC, once the Member has exhausted the
HMO’s complaint process.
The
HMO
must designate an officer of the HMO who has primary responsibility for ensuring
that Complaints are resolved in compliance with written policy and within the
required timeframe. For purposes of Section 8.2.7.2, an
“officer” of the 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.
The
HMO
must have a routine process to detect patterns of Complaints. Management,
supervisory, and quality improvement staff must be involved in developing policy
and procedure improvements to address the Complaints.
The
HMO’s
Complaint procedures must be provided to Members in writing and through oral
interpretive services. A written description of the HMO’s Complaint procedures
must be available in prevalent non-English languages for Major Population Groups
identified by HHSC, at no more than a 6th grade reading level.
The
HMO
must include a written description of the Complaint process in the Member
Handbook. The HMO must maintain and publish in the Member Handbook, at least
one
local and one toll-
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
free
telephone number with TeleTypewriter/Telecommunications Device for the Deaf
(TTY/TDD) and interpreter capabilities for making Complaints.
The
HMO’s
process must require that every Complaint received in person, by telephone,
or
in writing must be acknowledged and recorded in a written record and logged
with
the following details:
|
1.
|
Date;
|
|
2.
|
Identification
of the individual filing the
Complaint;
|
|
3.
|
Identification
of the individual recording the
Complaint;
|
|
4.
|
Nature
of the Complaint;
|
|
5.
|
Disposition
of the Complaint (i.e., how the HMO resolved the
Complaint);
|
|
6.
|
Corrective
action required; and
|
|
7.
|
Date
resolved.
|
The
HMO
is prohibited from discriminating or taking punitive action against a Member
or
his or her representative for making a Complaint.
If
the
Member makes a request for disenrollment, the HMO must give the Member
information on the disenrollment process and direct the Member to the HHSC
Administrative Services Contractor. If the request for disenrollment includes
a
Complaint by the Member, the Complaint will be processed separately from the
disenrollment request, through the Complaint process.
The
HMO
will cooperate with the HHSC’s Administrative Services Contractor and HHSC or
its designee to resolve all Member Complaints. Such cooperation may include,
but
is not limited to, providing information or assistance to internal Complaint
committees.
The
HMO
must provide designated Member Advocates to assist Members in understanding
and
using the HMO’s Complaint system as described in Section
8.2.7.9. The HMO’s Member Advocates must assist Members in writing or
filing a Complaint and monitoring the Complaint through the HMO’s Complaint
process until the issue is resolved.
8.2.7.2
|
Medicaid
Standard Member Appeal
Process
|
The
HMO
must develop, implement and maintain an Appeal procedure that complies with
state and federal laws and regulations, including 42 C.F.R.§ 431.200 and 42
C.F.R. Part 438, Subpart F, “Grievance System.” An Appeal is a disagreement with
an HMO Action as defined in HHSC’s Uniform Contract Terms and
Conditions. The Appeal procedure must be the same for all Members. When
a Member or his or her authorized representative expresses orally or in writing
any dissatisfaction or disagreement with an Action, the HMO must regard the
expression of dissatisfaction as a request to Appeal an Action.
A
Member
must file a request for an Appeal with the HMO within 30 days from receipt
of
the notice of the Action. The HMO is subject to remedies, including liquidated
damages, if at least 98 percent of Member Appeals are not resolved within 30
days of receipt of the Appeal by the HMO. Please see the Uniform Managed
Care Contract Terms & Conditions and Attachment B-5, Deliverables/Liquidated
Damages Matrix. To ensure continuation of currently authorized
services, however, the Member must file the Appeal on or before the later of
10
days following
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
the
HMO’s
mailing of the notice of the Action, or the intended effective date of the
proposed Action. The HMO must designate an officer who has primary
responsibility for ensuring that Appeals are resolved in compliance with written
policy and within the 30-day time limit.
The
provisions of Article 21.58A, Texas Insurance Code, (to be recodified as Texas
Insurance Code, Title 14, Chapter 4201), relating to a Member’s right to Appeal
an Adverse Determination made by the HMO or a utilization review agent to an
independent review organization, do not apply to a Medicaid recipient. Article
21.58A is pre-empted by federal Fair Hearings requirements.
The
HMO
must have policies and procedures in place outlining the Medical Director’s role
in an Appeal of an Action. The Medical Director must have a significant role
in
monitoring, investigating and hearing Appeals. In accordance with 42 C.F.R.§
438.406, the HMO’s policies and procedures must require that individuals who
make decisions on Appeals are not involved in any previous level of review
or
decision-making, and are health care professionals who have the appropriate
clinical expertise in treating the Member’s condition or disease.
The
HMO
must provide designated Member Advocates, as described in Section
8.2.7.9, to assist Members in understanding and using the Appeal
process. The HMO’s Member Advocates must assist Members in writing or filing an
Appeal and monitoring the Appeal through the HMO’s Appeal process until the
issue is resolved.
The
HMO
must have a routine process to detect patterns of Appeals. Management,
supervisory, and quality improvement staff must be involved in developing policy
and procedure improvements to address the Appeals.
The
HMO’s
Appeal procedures must be provided to Members in writing and through oral
interpretive services. A written description of the Appeal procedures must
be
available in prevalent non-English languages identified by HHSC, at no more
than
a 6th grade reading level. The HMO must include a written description of the
Appeals process in the Member Handbook. The HMO must maintain and publish in
the
Member Handbook at least one local and one toll-free telephone number with
TTY/TDD and interpreter capabilities for requesting an Appeal of an
Action.
The
HMO’s
process must require that every oral Appeal received must be confirmed by a
written, signed Appeal by the Member or his or her representative, unless the
Member or his or her representative requests an expedited resolution. All
Appeals must be recorded in a written record and logged with the following
details:
|
1)
|
Date
notice is sent;
|
|
2)
|
Effective
date of the Action;
|
|
3)
|
Date
the Member or his or her representative requested the
Appeal;
|
|
4)
|
Date
the Appeal was followed up in
writing;
|
|
5)
|
Identification
of the individual filing;
|
|
6)
|
Nature
of the Appeal; and
|
|
7)
|
Disposition
of the Appeal, and notice of disposition to
Member.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
must send a letter to the Member within five (5) business days acknowledging
receipt of the Appeal request. Except for the resolution of an Expedited Appeal
as provided in Section 8.2.7.3, the HMO must complete the
entire standard Appeal process within 30 calendar days after receipt of the
initial written or oral request for Appeal. The timeframe for a standard Appeal
may be extended up to 14 calendar days if the Member or his or her
representative requests an extension; or the HMO shows that there is a need
for
additional information and how the delay is in the Member’s interest. If the
timeframe is extended, the HMO must give the Member written notice of the reason
for delay if the Member had not requested the delay. The HMO must designate
an
officer who has primary responsibility for ensuring that Appeals are resolved
within these timeframes and in accordance with the HMO’s written
policies.
During
the Appeal process, the HMO must provide the Member a reasonable opportunity
to
present evidence and any allegations of fact or law in person as well as in
writing. The HMO must inform the Member of the time available for providing
this
information and that, in the case of an expedited resolution, limited time
will
be available.
The
HMO
must provide the Member and his or her representative opportunity, before and
during the
Appeal process, to examine the Member’s case file, including medical records and
any other documents considered during the Appeal process. The HMO must include,
as parties to the Appeal, the Member and his or her representative or the legal
representative of a deceased Member’s estate.
In
accordance with 42 C.F.R.§ 438.420, the HMO must continue the Member’s benefits
currently being received by the Member, including the benefit that is the
subject of the Appeal, if all of the following criteria are met:
|
1.
|
The
Member or his or her representative files the Appeal timely as defined
in
this Contract:
|
|
2.
|
The
Appeal involves the termination, suspension, or reduction of a previously
authorized course of treatment;
|
|
3.
|
The
services were ordered by an authorized
provider;
|
|
4.
|
The
original period covered by the original authorization has not expired;
and
|
|
5.
|
The
Member requests an extension of the
benefits.
|
If,
at
the Member’s request, the HMO continues or reinstates the Member’s benefits
while the Appeal is pending, the benefits must be continued until one of the
following occurs:
|
1.
|
The
Member withdraws the Appeal;
|
|
2.
|
Ten
(10) days pass after the HMO mails the notice resolving the Appeal
against
the Member, unless the Member, within the 10-day timeframe, has requested
a Fair Hearing with continuation of benefits until a Fair Hearing
decision
can be reached; or
|
|
3.
|
A
state Fair Hearing officer issues a hearing decision adverse to the
Member
or the time period or service limits of a previously authorized service
has been met.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
In
accordance with 42 C.F.R.§ 438.420(d), if the final resolution of the Appeal is
adverse to the Member and upholds the HMO’s Action, then to the extent that the
services were furnished to comply with the Contract, the HMO may recover such
costs from the Member.
If
the
HMO or State Fair Hearing Officer reverses a decision to deny, limit, or delay
services that were not furnished while the Appeal was pending, the HMO must
authorize or provide the disputed services promptly and as expeditiously as
the
Member’s health condition requires.
If
the
HMO or State Fair Hearing Officer reverses a decision to deny authorization
of
services and the Member received the disputed services while the Appeal was
pending, the HMO is responsible for the payment of services.
The
HMO
is prohibited from discriminating or taking punitive action against a Member
or
his or her representative for making an Appeal.
8.2.7.3
|
Expedited
Medicaid HMO Appeals
|
In
accordance with 42 C.F.R. §438.410, the HMO must establish and maintain an
expedited review process for Appeals, when the HMO determines (for a request
from a Member) or the provider indicates (in making the request on the Member’s
behalf or supporting the Member’s request) that taking the time for a standard
resolution could seriously jeopardize the Member’s life or health. The HMO must
follow all Appeal requirements for standard Member Appeals as set forth in
Section 8.2.7.2), except where differences are specifically
noted. The HMO must accept oral or written requests for Expedited
Appeals.
Members
must exhaust the HMO’s Expedited Appeal process before making a request for an
expedited Fair Hearing. After the HMO receives the request for an Expedited
Appeal, it must hear an approved request for a Member to have an Expedited
Appeal and notify the Member of the outcome of the Expedited Appeal within
3
business days, except that the HMO must complete investigation and resolution
of
an Appeal relating to an ongoing emergency or denial of continued
hospitalization: (1) in accordance with the medical or dental immediacy of
the
case; and (2) not later than one (1) business day after receiving the Member’s
request for Expedited Appeal is received.
Except
for an Appeal relating to an ongoing emergency or denial of continued
hospitalization, the timeframe for notifying the Member of the outcome of the
Expedited Appeal may be extended up to 14 calendar days if the Member requests
an extension or the HMO shows (to the satisfaction of HHSC, upon HHSC’s request)
that there is a need for additional information and how the delay is in the
Member’s interest. If the timeframe is extended, the HMO must give the Member
written notice of the reason for delay if the Member had not requested the
delay.
If
the
decision is adverse to the Member, the HMO must follow the procedures relating
to the notice in Section 8.2.7.5. The HMO is responsible for
notifying the Member of his or her right to access an expedited Fair Hearing
from HHSC. The HMO will be responsible for providing documentation to the State
and the Member, indicating how the decision was made, prior to HHSC’s expedited
Fair Hearing.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
is prohibited from discriminating or taking punitive action against a Member
or
his or her representative for requesting an Expedited Appeal. The HMO must
ensure that punitive action is neither taken against a provider who requests
an
expedited resolution or supports a Member’s request.
If
the
HMO denies a request for expedited resolution of an Appeal, it
must:
(1)
|
Transfer
the Appeal to the timeframe for standard resolution,
and
|
(2)
|
Make
a reasonable effort to give the Member prompt oral notice of the
denial,
and follow up within two (2) calendar days with a written
notice.
|
8.2.7.4
|
Access
to Fair Hearing for Medicaid
Members
|
The
HMO
must inform Members that they have the right to access the Fair Hearing process
at any time during the Appeal system provided by the HMO. In the case of an
expedited Fair Hearing process, the HMO must inform the Member that he or she
must first exhaust the HMO’s internal Expedited Appeal process prior to filing
an Expedited Fair Hearing. The HMO must notify Members that they may be
represented by an authorized representative in the Fair Hearing
process.
8.2.7.5
|
Notices
of Action and Disposition of Appeals for Medicaid
Members
|
The
HMO
must notify the Member, in accordance with 1 T.A.C. Chapter 357, whenever the
HMO takes an Action. The notice must, at a minimum, include any information
required by 1 T.A.C. Chapter 357 that relates to a managed care organization’s
notice of Action and any information required by 42 C.F.R. §438.404 as directed
by HHSC, including but not limited to:
|
1.
|
The
dates, types and amount of service
requested;
|
|
2.
|
The
Action the HMO has taken or intends to
take;
|
|
3.
|
The
reasons for the Action (If the Action taken is based upon a determination
that the requested service is not medically necessary, the HMO must
provide an explanation of the medical basis for the decision, application
of policy or accepted standards of medical practice to the individuals
medical circumstances, in it’s notice to the
member.);
|
|
4.
|
The
Member’s right to access the HMO’s Appeal
process.
|
|
5.
|
The
procedures by which the Member may Appeal the HMO’s
Action;
|
|
6.
|
The
circumstances under which expedited resolution is available and how
to
request it;
|
|
7.
|
The
circumstances under which a Member may continue to receive benefits
pending resolution of the Appeal, how to request that benefits be
continued, and the circumstances under which the Member may be required
to
pay the costs of these services;
|
|
8.
|
The
date the Action will be taken;
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
9.
|
|
A
reference to the HMO policies and procedures supporting the HMO’s
Action;
|
10.
|
An
address where written requests may be sent and a toll-free number
that the
Member can call to request the assistance of a Member representative,
file
an Appeal, or request a Fair
Hearing;
|
11.
|
An
explanation that Members may represent themselves, or be represented
by a
provider, a friend, a relative, legal counsel or another
spokesperson;
|
12.
|
A
statement that if the Member wants a Fair Hearing on the Action,
the
Member must make the request for a Fair Hearing within 90 days of
the date
on the notice or the right to request a hearing is
waived;
|
13.
|
A
statement explaining that the HMO must make its decision within 30
days
from the date the Appeal is received by the HMO, or 3 business days
in the
case of an Expedited Appeal; and
|
14.
|
A
statement explaining that the hearing officer must make a final decision
within 90 days from the date a Fair Hearing is
requested.
|
8.2.7.6
|
Timeframe
for Notice of Action
|
In
accordance with 42 C.F.R.§ 438.404(c), the HMO must mail a notice of Action
within the following timeframes:
|
1.
|
For
termination, suspension, or reduction of previously authorized
Medicaid-covered services, within the timeframes specified in 42
C.F.R.§§
431.211, 431.213, and 431.214;
|
|
2.
|
For
denial of payment, at the time of any Action affecting the
claim;
|
|
3.
|
For
standard service authorization decisions that deny or limit services,
within the timeframe specified in 42 C.F.R.§
438.210(d)(1);
|
|
4.
|
If
the HMO extends the timeframe in accordance with 42 C.F.R. §438.210(d)(1),
it must:
|
|
5.
|
give
the Member written notice of the reason for the decision to extend
the
timeframe and inform the Member of the right to file an Appeal if
he or
she disagrees with that decision;
and
|
|
6.
|
issue
and carry out its determination as expeditiously as the Member’s health
condition requires and no later than the date the extension
expires;
|
|
7.
|
For
service authorization decisions not reached within the timeframes
specified in 42 C.F.R.§ 438.210(d) (which constitutes a denial and is thus
an adverse Action), on the date that the timeframes expire;
and
|
|
8.
|
For
expedited service authorization decisions, within the timeframes
specified
in 42 C.F.R. 438.210(d).
|
8.2.7.7
|
Notice
of Disposition of Appeal
|
In
accordance with 42 C.F.R.§ 438.408(e), the HMO must provide written notice of
disposition of all Appeals including Expedited Appeals. The written resolution
notice must include the results
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
and
date
of the Appeal resolution. For decisions not wholly in the Member’s favor, the
notice must contain:
|
1.
|
The
right to request a Fair Hearing;
|
|
2.
|
How
to request a Fair Hearing;
|
|
3.
|
The
circumstances under which the Member may continue to receive benefits
pending a Fair Hearing;
|
|
4.
|
How
to request the continuation of
benefits;
|
|
5.
|
If
the HMO’s Action is upheld in a Fair Hearing, the Member may be liable for
the cost of any services furnished to the Member while the Appeal
is
pending; and
|
|
6.
|
Any
other information required by 1 T.A.C. Chapter 357 that relates to
a
managed care organization’s notice of disposition of an
Appeal.
|
8.2.7.8
|
Timeframe
for Notice of Resolution of
Appeals
|
In
accordance with 42 C.F.R.§ 438.408, the HMO must provide written notice of
resolution of Appeals, including Expedited Appeals, as expeditiously as the
Member’s health condition requires, but the notice must not exceed the timelines
as provided in this Section for Standard or Expedited Appeals. For expedited
resolution of Appeals, the HMO must make reasonable efforts to give the Member
prompt oral notice of resolution of the Appeal, and follow up with a written
notice within the timeframes set forth in this Section for Expedited Appeals.
If
the HMO denies a request for expedited resolution of an Appeal, the HMO must
transfer the Appeal to the timeframe for standard resolution as provided in
this
Section, and make reasonable efforts to give the Member prompt oral notice
of
the denial, and follow up within two calendar days with a written
notice.
8.2.7.9
|
Medicaid
Member Advocates
|
The
HMO
must provide Member Advocates to assist Members. Member Advocates must be
physically located within the Service Area unless an exception is approved
by
HHSC. Member Advocates must inform Members of the following:
|
1.
|
Their
rights and responsibilities,
|
|
2.
|
The
Complaint process,
|
|
3.
|
The
Appeal process,
|
|
4.
|
Covered
Services available to them, including preventive services,
and
|
|
5.
|
Non-capitated
Services available to them.
|
Member
Advocates must assist Members in writing Complaints and are responsible for
monitoring the Complaint through the HMO’s Complaint process.
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.
Member Advocates are also responsible for helping or referring Members to
community resources available to meet Member needs that are not available from
the HMO as Medicaid Covered Services.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.2.8
|
Additional
Medicaid Behavioral Health
Provisions
|
8.2.8.1
|
Local
Mental Health Authority
(LMHA)
|
Assessment
to determine eligibility for rehabilitative and targeted DSHS case
management services is a function of the LMHA. Covered Services must be
provided to Members with severe and persistent mental illness (SPMI) and
severe emotional disturbance (SED), when Medically Necessary, whether or
not they are also receiving targeted case management or
rehabilitation services through the LMHA.
The
HMO
must enter into written agreements with all LMHAs in the Service Area that
describe the process(es) that the HMO and LMHAs will use to coordinate
services for Medicaid Members with SPMI or SED. The agreements
will:
|
1.
|
Describe
the Behavioral Health Services indicated in detail in the Provider
Procedures Manual and in
the Texas Medicaid Bulletin, include the amount,
duration, and scope of basic and Value-added Services, and the HMO’s
responsibility to provide these
services;
|
|
2.
|
Describe
criteria, protocols, procedures and instrumentation for referral
of
Medicaid Members from and to the HMO and the
LMHA;
|
|
3.
|
Describe
processes and procedures for referring Members with SPMI or SED to
the LMHA for assessment and determination of eligibility for
rehabilitation or targeted case management
services;
|
|
4.
|
Describe
how the LMHA and the HMO will coordinate providing Behavioral
Health Services to Members with SPMI or
SED;
|
|
5.
|
Establish
clinical consultation procedures between the HMO and LMHA
including consultation to effect referrals and on-going consultation
regarding the
Member’s progress;
|
|
6.
|
Establish
procedures to authorize release and exchange of clinical treatment
records;
|
|
7.
|
Establish
procedures for coordination of assessment, intake/triage,
utilization review/utilization management and care for persons with
SPMI or SED;
|
|
8.
|
Establish
procedures for coordination of inpatient psychiatric services (including
Court-ordered Commitment of Members under 21) in state psychiatric
facilities within the LMHA’s catchment
area;
|
|
9.
|
Establish
procedures for coordination of emergency and urgent services to
Members;
|
10.
|
Establish
procedures for coordination of care and transition of care for new
Members who are receiving treatment through the LMHA;
and
|
11.
|
Establish
that when Members are receiving Behavioral Health Services from the
Local Mental Health Authority that the HMO is using the same UM
guidelines as those prescribed for use by local mental health
authorities by DSHS which are published
at: xxxx://xxx.xxxx.xxxxx.xx.xx/xxxxxxxxxxxxx/xxxxxxxxxxxxxxxxxxxxxxxx/XXXXxxxXxxxx.xxxx.
|
The
HMO
must offer licensed practitioners of the healing arts (defined in 25 T.A.C.,
Part 2, Chapter 419, Subchapter L), who are part of the Member’s treatment
team for rehabilitation services, the opportunity to participate in the
HMO’s Network. The practitioner must agree to accept the HMO’s Provider
reimbursement rate, meet the credentialing requirements, and comply with
all the terms and conditions of the HMO’s standard Provider
contract.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
HMOs
must
allow Members receiving rehabilitation services to choose the licensed
practitioners of the healing arts who are currently a part of the Member’s
treatment team for rehabilitation services to provide Covered Services. If
the
Member chooses to receive these services from licensed practitioners of the
healing arts who are part of the Member’s rehabilitation services treatment team
but are not part of the HMO’s Network, the HMO must reimburse the Local Mental
Health Authority through Out-of-Network reimbursement arrangements.
Nothing
in this section diminishes the potential for the Local Mental Health Authority
to seek best value for rehabilitative services by providing these services
under
arrangement, where possible, as specified is 25 T.A.C. §419.455.
8.2.9
|
Third
Party Liability and
Recovery
|
Medicaid
HMOs are responsible for establishing a plan and process for recovering costs
for services that should have been paid through a third party in accordance
with
State and Federal law and regulations. To recognize this requirement, capitation
payments to the HMOs are reduced by the projected amount of TPR that the HMO
is
expected to recover.
The
HMOs
must provide required reports as stated in Section 8.1.17.2,
Financial Reporting Requirements.
After
120-days from the date of service on any claim, encounter, or other Medicaid
related payment by the HMO subject to Third Party Recovery, HHSC may attempt
recovery independent of any HMO action. HHSC will retain, in full, all funds
received as a result of the state initiated recovery or subrogation
action.
HMOs
shall provide a Member quarterly file, which contains the following information
if available to the HMO: the Member name, address, claim submission address,
group number, employer's mailing address, social security number, and date
of
birth for each subscriber or policyholder and each dependent of the subscriber
or policyholder covered by the insurer. The file shall be used for the purpose
of matching the Texas Medicaid eligibility file against the HMO Member file
to
identify Medicaid clients enrolled in the HMO, which may not be known the
Medicaid Program.
8.2.10
|
Coordination
With Public Health
Entities
|
8.2.10.1
|
Reimbursed
Arrangements with Public Health
Entities
|
The
HMO
must make a good faith effort to enter into a subcontract for Covered Services
with Public Health Entities. Possible Covered Services that could be provided
by
Public Health Entities include, but are not limited to, the following
services:
|
1.
|
Sexually
Transmitted Diseases (STDs)
services;
|
|
2.
|
Confidential
HIV testing;
|
|
3.
|
Immunizations;
|
|
4.
|
Tuberculosis
(TB) care;
|
|
5.
|
Family
Planning services;
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
|
6.
|
THSteps
medical checkups, and
|
|
7.
|
Prenatal
services.
|
These
subcontracts must be available for review by HHSC or its designated agent(s)
on
the same basis as all other subcontracts. If the HMO is unable to enter into
a
contract with Public Health Entities, the HMO must document efforts to contract
with Public Health Entities, and make such documentation available to HHSC
upon
request.
HMO
Contracts with Public Health Entities must specify the scope of responsibilities
of both parties, the methodology and 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
HMO or PCP.
The
HMO
must:
|
1.
|
Identify
care managers who will be available to assist public health providers
and
PCPs in efficiently referring Members to the public health providers,
specialists, and health-related service providers either within or
outside
the HMO’s Network; and
|
|
2.
|
Inform
Members that confidential healthcare information will be provided
to the
PCP, and educate Members on how to better utilize their PCPs, public
health providers, emergency departments, specialists, and health-related
service providers.
|
8.2.10.2
|
Non-Reimbursed
Arrangements with Local Public Health
Entities
|
The
HMO
must coordinate with Public Health Entities in each Service Area regarding
the
provision of essential public health care services. In addition to the
requirements listed above in Section 8.2.2, or otherwise required under state
law or this contract, the HMO must meet the following requirements:
|
1.
|
Report
to public health entities regarding communicable diseases and/or
diseases
that are preventable by immunization as defined by state
law;
|
|
2.
|
Notify
the local Public Health Entity, as defined by state law, of communicable
disease outbreaks involving
Members;
|
|
3.
|
Educate
Members and Providers regarding WIC services available to Members;
and
|
|
4.
|
Coordinate
with local public health entities that have a child lead program,
or with
DSHS regional staff when the local public health entity does not
have a
child lead program, for follow-up of suspected or confirmed cases
of
childhood lead exposure.
|
8.2.11
|
Coordination
with Other State Health and Human Services (HHS)
Programs
|
The
HMO
must coordinate with other state HHS Programs in each Service Area regarding
the
provision of essential public health care services. In addition to the
requirements listed above in Section 8.2.2. or otherwise required under state
law or this contract, the HMO must meet the following requirements:
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
|
1.
|
Require
Providers to use the DSHS Bureau of Laboratories for specimens obtained
as
part of a THSteps medical checkup, including THSteps newborn screens,
lead
testing, and hemoglobin/hematocrit
tests;
|
|
2.
|
Notify
Providers of the availability of vaccines through the Texas Vaccines
for
Children Program;
|
|
3.
|
Work
with HHSC and Providers to improve the reporting of immunizations
to the
statewide ImmTrac Registry;
|
|
4.
|
Educate
Providers and Members about the Department of State Health Services
(DSHS)
Case Management for Children and Pregnant Women (CPW) services
available;
|
|
5.
|
Coordinate
services with CPW specifically in regard to an HMO Member’s health care
needs that are identified by CPW and referred to the
HMO;
|
|
6.
|
Participate,
to the extent practicable, in the community-based coalitions with
the
Medicaid-funded case management programs in the Department of Assistive
and Rehabilitative Services (DARS), the Department of Aging and Disability
Services (DADS), and DSHS;
|
|
7.
|
Cooperate
with activities required of state and local public health authorities
necessary to conduct the annual population and community based needs
assessment; and
|
|
8.
|
Report
all blood lead results, coordinate and follow-up of suspected or
confirmed
cases of childhood lead exposure with the Childhood Lead Poisoning
Prevention Program in DSHS.
|
8.2.12
|
Advance
Directives
|
Federal
and state law require HMOs and providers to maintain written policies and
procedures for informing all adult Members 18 years of age and older about
their
rights to refuse, withhold or withdraw medical treatment and mental health
treatment through advance directives (see Social Security Act §1902(a)(57) and
§1903(m)(1)(A)). The HMO’s policies and procedures must include written
notification to Members and comply with provisions contained in 42 C.F.R.
§434.28 and 42 C.F.R. § 489, Subpart I, relating to advance directives for all
hospitals, critical access hospitals, skilled nursing facilities, home health
agencies, providers of home health care, providers of personal care services
and
hospices, as well as the following state laws and rules:
|
1.
|
A
Member’s right to self-determination in making health care
decisions;
|
|
2.
|
The
Advance Directives Act, Chapter 166, Texas Health and Safety Code,
which
includes:
|
|
a.
|
A
Member’s right to execute an advance written directive to physicians and
family or surrogates, or to make a non-written directive to administer,
withhold or withdraw life-sustaining treatment in the event of a
terminal
or irreversible condition;
|
|
b.
|
A
Member’s right to make written and non-written out-of-hospital
do-not-resuscitate (DNR) orders;
|
|
c.
|
A
Member’s right to execute a Medical Power of Attorney to appoint an agent
to make health care decisions on the Member’s behalf if the Member becomes
incompetent; and
|
|
3.
|
The
Declaration for Mental Health Treatment, Chapter 137, Texas Civil
Practice
and Remedies Code, which includes: a Member’s right to execute a
Declaration for Mental Health Treatment in a document making a declaration
of preferences or instructions regarding mental health
treatment.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
must maintain written policies for implementing a Member’s advance directive.
Those policies must include a clear and precise statement of limitation if
the
HMO or a Provider cannot or will not implement a Member’s advance
directive.
The
HMO
cannot require a Member to execute or issue an advance directive as a condition
of receiving health care services. The HMO cannot discriminate against a Member
based on whether or not the Member has executed or issued an advance
directive.
The
HMO’s
policies and procedures must require the HMO and subcontractors to comply with
the requirements of state and federal law relating to advance directives. The
HMO must provide education and training to employees and Members on issues
concerning advance directives.
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 7th - 8th
grade
reading level because it is a reference to the law or is required to be included
“as written” in the state or federal law.
The
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.
8.3
|
Additional
STAR+PLUS Scope of Work
|
8.3.1
|
Covered
Community-Based Long-Term Care
Services
|
The
HMO
must ensure that STAR+PLUS Members needing Community Long-term Care Services
are
identified and that services are referred and authorized in a timely manner.
The
HMO must ensure that Providers of Community Long-term Care Services are licensed
to deliver the service they provide. The inclusion of Community Long-term Care
Services in a managed care model presents challenges, opportunities and
responsibilities.
Community
Long-term Care Services may be necessary as a preventative service to avoid
more
expensive hospitalizations, emergency room visits, or institutionalization.
Community Long-term Care Services should also be made available to Members
to
assure maintenance of the highest level of functioning possible in the least
restrictive setting. A Member’s need for Community Long-term Care Services to
assist with the activities of daily living must be considered as important
as
needs related to a medical condition. HMOs must provide Functionally Necessary
Covered Services to Community Long-term Care Service Members.
8.3.1.1
|
Community
Based Long-Term Care Services Available to All
Members
|
The
HMO
shall enter into written contracts with Providers of Personal Assistance
Services and Day Activity and Health Services (DAHS) to make them available
to
all STAR+PLUS Members. These Providers must at a minimum, meet all of the
following state licensure and certification requirements for providing the
services in Attachment B-2.1, Covered Services.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
Community
Long-Term Care Services Available to All
Members
|
|
Service
|
Licensure
and Certification Requirements
|
Personal
Attendant Services
|
The
Provider must be licensed by the Texas Department of Human Services
as a
Home and Community Support Services Agency. The level of licensure
required depends on the type of service delivered.
NOTE:
For primary home care and client managed attendant care, the agency
may
have only the Personal Assistance Services level of
licensure.
|
Day
Activity and Health Services (DAHS)
|
The
Provider must be licensed by the Texas Department of Human Services,
Long
Term Care Regulatory Division, as an adult day care provider. To
provide
DAHS, the Provider must provide the range of services required for
DAHS.
|
8.3.1.2
|
1915(c)
Nursing Facility Waiver Services Available to Members Who Qualify
for 1915
(c) Nursing Facility Waiver
Services
|
The
1915(c) Nursing Facility Waiver provides Community Long-term Care Services
to
Medicaid Eligibles who are elderly and to adults with disabilities as a
cost-effective alternative to living in a nursing facility. These Members must
be age 21 or older, be a Medicaid recipient or be otherwise financially eligible
for waiver services. To be eligible for 1915(c) Nursing Facility Waiver
Services, a Member must meet income and resource requirements for Medicaid
nursing facility care, and receive a determination from HHSC on the medical
necessity of the nursing facility care. The HMO must make available to STAR+PLUS
Members who meet the eligibility requirements the array of services allowable
through HHSC’s CMS-approved 1915(c) Nursing Facility Waiver (see
Appendix B-2.1, STAR+PLUS Covered Services).
Community
Long-Term Care Services Under the 1915(c) Nursing Facility
Waiver
|
|
Service
|
Licensure
and Certification Requirements
|
Personal
Attendant Services
|
The
Provider must be licensed by the Texas Department of Human Services
as a
Home and Community Support Services Agency. The level of licensure
required depends on the type of service delivered. For Primary Home
Care
and Client Managed Attendant Care, the agency may have only the Personal
Assistance Services level of licensure.
|
Assisted
Living
|
The
Provider must be licensed by the Texas Department of Aging and Disability
Services, Long Term Care Regulatory Division. The type of licensure
determines what services may be provided.
|
Emergency
Response Service Provider
|
Texas
Department of Aging and Disability Services (DADS) Standards for
Emergency
Response Services at 40 T.A.C. §52.201(a), and be licensed by the Texas
Board of Private Investigators and Private Security Agencies, unless
exempt from licensure.
|
Adult
Xxxxxx Home
|
TDSHS
Provider standards for Adult Xxxxxx Care and TDSHS Rules at 40 T.A.C.
§48.6032. Four bed homes also licensed under
TDSHS
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
Community
Long-Term Care Services Under the 1915(c) Nursing Facility
Waiver
|
|
Service
|
Licensure
and Certification Requirements
|
Rules
at 40 T.A.C. §481.8906.
DFPS
licensure in accordance with 24-hour Care Licensing requirements
found in
T.A.C., Title 40, Part 19, Chapter 720.
|
|
Home
Delivered Meals
|
T.A.C.,
Title 40, Part 1, Chapter 55.
|
Physical
Therapy
|
Licensed
Physical Therapist through the Texas Board of Physical Therapy Examiners,
Chapter 453.
|
Occupational
Therapy
|
Licensed
Occupational Therapist through the Texas Board of Occupational Therapy
Examiners, Chapter 454.
|
Speech
Therapy
|
Licensed
Speech Therapist Through the Department of State Health
Services.
|
Consumer
Directed Services
|
Home
and Community Support Services Agency (HCSSA)
|
Transition
Assistance Services
|
No
licensure or certification requirements.
|
Minor
Home Modification
|
No
licensure or certification requirements.
|
Adaptive
Aids and Medicaid Equipment
|
No
licensure or certification requirements.
|
Medical
supplies
|
No
licensure or certification
requirements.
|
8.3.2
|
Service
Coordination
|
The
HMO
must furnish a Service Coordinator to all STAR+PLUS Members who request one.
The
HMO should also furnish a Service Coordinator to a STAR+PLUS Member when the
HMO
determines one is required through an assessment of the Member’s health and
support needs. The HMO must ensure that each STAR+PLUS Member has a qualified
PCP who is responsible for overall clinical direction and, in conjunction with
the Service Coordinator, serves as a central point of integration and
coordination of Covered Services, including primary, Acute Care, long-term
care
and Behavioral Health Services.
The
Service Coordinator must work as a team with the PCP, and coordinate all
STAR+PLUS Covered Services and any applicable Non-capitated Services with the
PCP. This requirement applies whether or not the PCP is in the HMO’s Network, as
some STAR+PLUS Members dually eligible for Medicare may have a PCP that is
not
in the HMO’s Provider Network. In order to integrate the Member’s Acute Care and
primary care, and stay abreast of the Member’s needs and condition, the Service
Coordinator must also actively involve and coordinate with the Member’s primary
and specialty care providers, including Behavioral Health Service providers,
and
providers of Non-capitated Services.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
STAR+PLUS
Members dually eligible for Medicare will receive most prescription drug
services through Medicare rather than Medicaid. The Texas Vendor Drug Program
will pay for a limited number of medications not covered by
Medicare.
The
HMO
must identify and train Members or their families to coordinate their own care,
to the extent of the Member’s or the family’s capability and willingness to
coordinate care.
8.3.2.1
|
Service
Coordinators
|
The
HMO
must employ as Service Coordinators persons experienced in meeting the needs
of
vulnerable populations who have Chronic or Complex Conditions. Such Service
Coordinators are Key HMO Personnel as described in Attachment
A, HHSC’s Uniform Managed Care Contract Terms and Conditions,
Section 4.02, and must meet the requirements set forth in
Section 4.04.1 of HHSC’s Uniform Managed Care Contract
Terms and Conditions.
8.3.2.2
|
Referral
to Community Organizations
|
The
HMO
must provide information about and referral to community organizations that
may
not be providing STAR+PLUS Covered Services, but are otherwise important to
the
health and well being of Members. These organizations include, but are not
limited to:
|
1.
|
State/federal
agencies (e.g., those agencies with jurisdiction over aging, public
health, substance abuse, mental health/retardation, rehabilitation,
developmental disabilities, income support, nutritional assistance,
family
support agencies, etc.);
|
|
2.
|
social
service agencies (e.g., Area Agencies on Aging, residential support
agencies, independent living centers, supported employment agencies,
etc.);
|
|
3.
|
city
and county agencies (e.g., welfare departments, housing programs,
etc.);
|
|
4.
|
civic
and religious organizations; and
|
|
5.
|
consumer
groups, advocates, and councils (e.g., legal aid offices, consumer/family
support groups, permanency planning,
etc.).
|
8.3.2.3
|
Discharge
Planning
|
The
HMO
must have a protocol for quickly assessing the needs of Members discharged
from
a Hospital or other care or treatment facility.
The
HMO’s
Service Coordinator must work with the Member’s PCP, the hospital discharge
planner(s), the attending physician, the Member, and the Member’s family to
assess and plan for the Member’s discharge. When long-term care is needed, the
HMO must ensure that the Member’s discharge plan includes arrangements for
receiving community-based care whenever possible. The HMO must ensure that
the
Member, the Member’s family, and the Member’s PCP are all well informed of all
service options available to meet the Member’s needs in the
community.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.3.2.4
|
Transition
Plan for New STAR+PLUS
Members
|
The
HMO
must provide a transition plan for Members enrolled in the STAR+PLUS Program.
HHSC, and/or the previous STAR+PLUS HMO contractor, will provide the HMO with
detailed Care Plans, names of current providers, etc., for newly enrolled
Members already receiving long-term care services at the time of enrollment.
The
HMO must ensure that current providers are paid for Medically Necessary Covered
Services that are delivered in accordance with the Member’s existing
treatment/long-term care services plan after the Member has become enrolled
in
the HMO and until the transition plan is developed.
The
transition planning process must include, but is not limited to, the
following:
|
1.
|
review
of existing DADS long-term care services
plans;
|
|
2.
|
preparation
of a transition plan that ensures continuous care under the Member’s
existing Care Plan during the transfer into the HMO’s Network while the
HMO conducts an appropriate assessment and development of a new plan,
if
needed;
|
|
3.
|
if
durable medical equipment or supplies had been ordered prior to enrollment
but have not been received by the time of enrollment, coordination
and
follow-through to ensure that the Member receives the necessary supportive
equipment and supplies without undue delay;
and
|
|
4.
|
payment
to the existing provider of service under the existing authorization
until
the HMO has completed the assessment and service plans and issued
new
authorizations.
|
The
HMO
must review any existing care plan and develop a transition plan within 30
days
of receiving the Member’s enrollment. The transition plan will remain in place
until the HMO contacts the Member and coordinates modifications to the Member’s
current treatment/long-term care services plan. The HMO must ensure that the
existing services continue and that there are no breaks in services. For initial
implementation of the STAR+PLUS program in a Service Area, the HMO must complete
this process within 90-days of the Member’s enrollment.
The
HMO
must ensure that the Member is involved in the assessment process and fully
informed about options, is included in the development of the care plan, and
is
in agreement with the plan when completed.
8.3.2.5
|
Centralized
Medical Record and
Confidentiality
|
The
Service Coordinator shall be responsible for maintaining a centralized record
related to Member contacts, assessments and service authorizations. The HMO
shall ensure that the organization of and documentation included in the
centralized Member record meets all applicable professional standards ensuring
confidentiality of Member records, referrals, and documentation of
information.
The
HMO
must have a systematic process for generating or receiving referrals and sharing
confidential medical, treatment, and planning information across
providers.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.3.2.6
|
Nursing
Facilities
|
Nursing
facility care, although a part of the care continuum, presents a challenge
for
managed care. Because of the process for becoming eligible for Medicaid
assistance in a nursing facility, there is frequently a significant time gap
between entry into the nursing home and determination of Medicaid eligibility.
During this gap from entry to Medicaid eligibility, the resident has “nested” in
the facility and many of the community supports are no longer available. To
require participation of all nursing facility residents would result in the
HMO
maintaining a Member in the nursing facility without many options for managing
their health. For this reason, persons who qualify for Medicaid as a result
of
nursing facility residency are not enrolled in STAR+PLUS.
The
STAR+PLUS HMO must participate in the Promoting Independence initiative for
such
individuals. Promoting Independence (PI) is a philosophy that aged and disabled
individuals remain in the most integrated setting to receive long-term care
services. PI is Texas' response to the U.S. Supreme Court ruling in Xxxxxxxx
v. X.X. that requires states to provide community-based services for
persons with disabilities who would otherwise be entitled to institutional
services, when:
|
•
|
the
state's treatment professionals determine that such placement is
appropriate;
|
|
•
|
the
affected persons do not oppose such treatment;
and
|
|
•
|
the
placement can be reasonably accommodated, taking into account the
resources available to the state and the needs of others who are
receiving
state supported disability
services.
|
In
accordance with legislative direction, the HMO must designate a point of contact
to receive referrals for nursing facility residents who may potentially be
able
to return to the community through the use of 1915(c) Nursing Facility Waiver
services. To be eligible for this option, an individual must reside in a nursing
facility until a written plan of care for safely moving the resident back into
a
community setting has been developed and approved.
A
STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member
for a total of four months. The nursing facility will xxxx the state directly
for covered nursing facility services delivered while the Member is in the
nursing facility. See Section 8.3.2.7 for further
information.
The
HMO
is responsible for the Member at the time of nursing facility entry and must
utilize the Service Coordinator staff to complete an assessment of the Member
within 30 days of entry in the nursing facility, and develop a plan of care
to
transition the Member back into the community if possible. If at this initial
review, return to the community is possible, the Service Coordinator will work
with the resident and family to return the Member to the community using 1915(c)
Waiver Services.
If
the
initial review does not support a return to the community, the Service
Coordinator will conduct a second assessment 90 days after the initial
assessment to determine any changes in the individual’s condition or
circumstances that would allow a return to the community. The Service
Coordinator will develop and implement the transition plan.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
The
HMO
will provide these services as part of the Promoting Independence initiative.
The HMO must maintain the documentation of the assessments completed and make
them available for state review at any time.
It
is
possible that the STAR+PLUS HMO will be unaware of the Member’s entry into a
nursing facility. It is the responsibility of the nursing facility to review
the
Member’s Medicaid card upon entry into the facility and notify the HMO. The
nursing facility is also required to notify HHSC of the entry of a new
resident.
8.3.2.7
|
HMO
Four-Month Liability for Nursing Facility
Care
|
A
STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member
for a total of four months. The four months do not have to be consecutive.
Upon
completion of four months of nursing facility care, the individual will be
disenrolled from the STAR+PLUS Program and the Medicaid Fee-for-Service program
will provide Medicaid benefits. A STAR+PLUS Member may not change HMOs while
in
a nursing facility.
Tracking
the four months of liability is done through a counter system. The four-month
counter starts with the Medicaid admission or on the 21st day of a Medicare
stay. A partial month counts as a full month. In other words, the month in
which
the Medicaid admission occurs or the month on which the 21st day of the Medicare
stay occurs, is counted as one of the four months.
An
amount
will be included in the capitation rates to cover the cost of four months of
nursing facility services (based upon experience from STAR+PLUS in Xxxxxx
County) for the historical average number of admissions to nursing facilities.
Nursing facility costs for STAR+PLUS in Xxxxxx County have accounted for less
than one percent of premiums in recent years. HHSC believes that these costs
will not deviate substantially from this experience.
The
HMO
will be liable for the cost of care in a nursing facility care and, for
Medicaid-only Members, the cost of all other Covered Services. The HMO will
not
maintain nursing facilities in its Network and will not reimburse the nursing
facilities directly. Nursing facilities will use the traditional Fee-for-Service
system of billing HHSC rather than billing the HMO. The HMO's liability will
be
established based on the amount paid through the Fee-for-Service billing system
on behalf of the Member. HHSC will recoup those costs from the HMO by an offset
to the monthly Capitation Payment. The offset will be recognized as a nursing
facility expense.. The HMO will record the nursing facility liability recoupment
as nursing facility expense on its Financial-Statistical Reports (FSR). The
HMO
will be responsible for direct payment of all non-nursing facility Medicaid
expenses on behalf of the Member.
8.3.3
|
STAR+PLUS
Assessment Instruments
|
The
HMO
must have and use functional assessment instruments to identify Members with
significant health problems, Members requiring immediate attention, and Members
who need or are at risk of needing long-term care services. The HMO, a
subcontractor, or a Provider may complete assessment instruments, but the HMO
remains responsible for the data recorded.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
HMOs
must
use the DHS Form 2060, as amended or modified, to assess a Member’s need for
Functionally Necessary Personal Attendant Services. The HMO may adapt the form
to reflect the HMO’s name or distribution instructions, but the elements must be
the same and instructions for completion must be followed without
amendment.
The
DHS
Form 2060 must be completed if a need or a change in Personal Attendant Services
is warranted at the initial contact, at the annual reassessment, and anytime
a
Member requests the services or requests a change in services. The DHS Form
2060
must also be completed if the HMO determines the Member requires the services
or
requires a change in the Personal Attendant Services that are
authorized.
For
Members and applicants seeking or needing the 1915(c) Nursing Facility Waiver
services, the HMOs must use the DADS CARE Form 3652, as amended or modified,
to
assess Members and to supply current medical information for Medical Necessity
determinations. The HMO must also complete the Individual Service Plan (ISP),
Form 3671 for each Member receiving 1915(c) Nursing Facility Waiver Services.
The ISP is established for a one-year period. After the initial ISP is
established, the ISP must be completed on an annual basis and the end date
or
expiration date does not change. Both of these forms (Form 3652 and Form 3671)
must be completed annually at reassessment. The HMO is responsible for tracking
the end dates of the ISP to ensure that the Member is reassessed prior to the
expiration date. Note that the DADS CARE Form 3652 cannot be submitted earlier
than 90 days prior to the expiration date of the ISP.
HHSC
has
adopted a Minimum Data Set for Home Care (MDS-HC), which can be found in the
HHSC Uniform Managed Care Manual. HHSC may adopt new versions of this instrument
as appropriate or as directed by CMS. The MDS-HC instrument must be completed
and electronically submitted to HHSC in the specified format within 30 days
of
enrollment for every Member receiving Community-based Long-term Care Services,
and then each year by the anniversary of the Member’s date of
enrollment.
The
MDS-HC instrument must be completed and electronically submitted to HHSC in
the
specified format within 30 days of enrollment for every Member receiving
Community-based Long-term Care Services. Because of the large number of Members
the HMOs will be receiving initially during the implementation period of the
STAR+PLUS Program, HHSC is allowing the following:
|
•
|
For
the 1915(c) Nursing Facility Waiver Members, the MDS-HC instrument
must be
completed in conjunction with the annual reassessment. The MDS-HC
instrument must be completed annually at the time of reassessment
for
these Members.
|
|
•
|
For
the non-1915(c) Nursing Facility Waiver Members that are receiving
Community-based Long-term Care Services, the HMO must submit a schedule
for HHSC’s approval that provides a plan of how the MDS-HC instruments
will be completed for these Members over a twelve-month period beginning
on February 1, 2007.
|
In
addition to submitting the MDS-HC instrument to HHSC, the HMO may also submit
other supplemental assessment instruments it elects to use. As specialized
MDS
instruments are developed or adopted by HHSC for other living arrangements
(e.g., assisted living), HHSC will notify HMO of the availability of the
instrument and the date the HMO is required to begin using
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
such
instrument in the HHSC Uniform Managed Care Manual. Any additional assessment
instruments used by the HMO must be approved by HHSC.
8.3.4
|
1915(c)
Nursing Facility Waiver Service
Eligibility
|
Recipients
of 1915(c) Nursing Facility Waiver services must meet nursing facility criteria
for participation in the waiver and must have a plan of care at initial
determination of eligibility in which the plan’s annualized cost is equal to or
less than the annualized cost of care if the individual were to enter a nursing
facility.
8.3.4.1
|
For
Members
|
The
HMO
must notify HHSC when it initiates 1915(c) Nursing Facility Waiver eligibility
testing on a STAR+PLUS Member. The HMO must apply risk criteria, complete the
Form 3652 for Medical Necessity determination, complete the assessment
documentation, and prepare a 1915(c) Nursing Facility Waiver Individual Service
Plan (ISP) for each Member requesting 1915(c) Nursing Facility Waiver services
and for Members the HMO has identified as needing 1915(c) Nursing Facility
Waiver services. The HMO must provide HHSC the results of the assessment
activities within 45 days of initiating the assessment process.
HHSC
will
notify the Member and the HMO of the eligibility determination, which will
be
based on the information provided by the HMO. If the STAR+PLUS Member is
eligible for 1915(c) Nursing Facility Waiver services, HHSC will notify the
Member of the effective date of eligibility. If the Member is not eligible
for
1915(c) Nursing Facility Waiver services, HHSC will provide the Member
information on right to Appeal the Adverse Determination. Regardless of the
1915(c) Nursing Facility Waiver eligibility determination, HHSC will send a
copy
of the Member notice to the HMO.
8.3.4.2
|
For
Medical Assistance Only (MAO) Non-Member
Applicants
|
Non-Member
persons who are not eligible for Medicaid in the community may apply for
participation in the 1915(c) Nursing Facility Waiver program under the financial
and functional eligibility requirements for MAO. HHSC will inform the applicant
that services are provided through an HMO and allow the applicant to select
the
HMO. HHSC will authorize the selected HMO to initiate pre-enrollment assessment
services required under the 1915(c) Nursing Facility Waiver for the non-member.
The HMO must complete Form 3652 for Medical Necessity determination, complete
the assessment documentation, and prepare a 1915(c) Nursing Facility Waiver
service plan for each applicant referred by HHSC. The initial home visit with
the applicant must occur within 14 days of the receipt of the referral. The
HMO
must provide HHSC the results of the assessment activities within 45 days of
the
receipt of the referral.
HHSC
will
notify the applicant and the HMO of the results of its eligibility
determination. If the applicant is eligible, HHSC will notify the applicant
and
the HMO will be notified of the effective date of eligibility, which will be
the
first day of the month following the determination of eligibility. The HMO
must
initiate the Individual Service Plan (ISP) on the date of
enrollment.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
If
the
applicant is not eligible, the HHSC notice will provide information on the
applicant’s right to Appeal the Adverse Determination. HHSC will also send
notice to the HMO if the applicant is not eligible for 1915(c) Nursing Facility
Waiver services.
8.3.4.3
|
Annual
Reassessment
|
Prior
to
the end date of the annual ISP, the HMO must initiate an annual reassessment
to
determine and validate continued eligibility for 1915(c) Nursing Facility Waiver
services for each Member receiving such services. The HMO will be expected
to
complete the same activities for the annual reassessment as required for the
initial eligibility determination, with the following exception: the HMO does
not need to obtain a physician’s signature on the Form 3652 for the annual
reassessment. Existing 1915(c) Nursing Facility Waiver clients may not be denied
1915(c) Nursing Facility Waiver services solely on the basis that the proposed
cost of the ISP will exceed the cost of care if the Member were in a nursing
home if the following conditions are met:
|
1.
|
those
services are required for that individual to live in the most integrated
setting appropriate to his or her needs;
and
|
|
2.
|
HHSC
continues to comply with the cost-effectiveness requirements from
the
CMS.
|
Individuals
receiving waiver services through the Medically Dependent Children Program
are
covered by the provisions in this Section when they apply for transition to
the
1915(c) waiver program at age 21.
8.3.5
|
Personal
Attendant Services
|
There
are
three options available to STAR+PLUS Members desiring the delivery of Personal
Attendant Services (PAS): 1) Self-Directed; 2) Agency Model, Self-Directed;
and
3) Agency Model. The HMO must provide information to all eligible Members on
the
three options and must provide Member orientation in the option selected by
the
Member. The HMO will provide the information to any STAR+PLUS Member receiving
Personal Attendant Services:
|
•
|
at
initial assessment;
|
|
•
|
at
annual reassessment or annual contact with the STAR+PLUS
Member;
|
|
•
|
at
any time when a STAR+PLUS Member receiving PAS requests the information;
and
|
|
•
|
in
the Member Handbook.
|
The
HMO
must contract with providers who are able to offer PAS and must also
educate/train the HMO Network Providers regarding the three PAS options. To
participate as a PAS Network Provider, the Provider must have a contract with
DADS for the delivery of PAS. The HMO must assure compliance with the Texas
Administrative Code in Title 40, Part 1, Chapter 41, Sections 41.101, 41.103,
and 41.105. The HMO must include the requirements in the Provider Manual and
in
the STAR+PLUS Provider training.
8.3.5.1
|
Personal
Attendant Services Delivery Option – Self-Directed
Model
|
In
the
Self-Directed Model, the Member or the Member’s legal guardian is the employer
of record and retains control over the hiring, management, and termination
of an
individual
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
providing
Personal Attendant Services. The Member is responsible for assuring that the
employee meets the requirements for Personal Attendant Services, including
the
criminal history check. The Member uses a Home and Community Support Services
(HCSS) agency to handle the employer-related administrative functions such
as
payroll, substitute (back-up), and filing tax-related reports of Personal
Attendant Services.
8.3.5.2
|
Personal
Attendant Services Delivery Option – Agency Model,
Self-Directed
|
In
the
Agency Model, Self-Directed, the Member or the Member’s legal guardian chooses a
Home and Community Support Services (HCSS) agency in the HMO Provider Network
who is the employer of record. In this model, the Member selects the personal
attendant from the HCSS agency’s personal attendant employees. The personal
attendant’s schedule is set up based on the Member input, and the Member manages
the Personal Attendant Services. The Member retains the right to supervise
and
train the personal attendant. The Member may request a different personal
attendant and the HCSS agency would be expected to honor the request. The HCSS
agency establishes the payment rate, benefits, and provides all administrative
functions such as payroll, substitute (back-up), and filing tax-related reports
of personal attendant services.
8.3.5.3
|
Personal
Attendant Services Delivery Option – Agency
Model
|
In
the
Agency Model, the Member chooses a Home and Community Support Services (HCSS)
agency to hire, manage, and terminate the individual providing Personal
Attendant Services. The HCSS agency is selected by the Member from the HCSS
agencies in the HMO Provider Network. The Service Coordinator and Member develop
the schedule and send it to the HCSS agency. The Member retains the right to
supervise and train the personal attendant. The Member may request a different
personal attendant and the HCSS agency would be expected to honor the request.
The HCSS agency establishes the payment rate, benefits, and provides all
administrative functions such as payroll, substitute (back-up), and filing
tax-related reports of personal attendant services.
8.3.6
|
Community
Based Long-term Care Service
Providers
|
8.3.6.1
|
Training
|
The
HMO
must comply with Section 8.1.4.6 regarding Provider Manual and Provider training
specific to the STAR+PLUS Program. The HMO must train all Community Long-term
Care Service Providers regarding the requirements of the Contract and special
needs of STAR+PLUS Members. The HMO must establish ongoing STAR+PLUS Provider
training addressing the following issues at a minimum:
|
1.
|
Covered
Services and the Provider’s responsibilities for providing such services
to STAR+PLUS Members and billing the HMO for such services. The HMO
must
place special emphasis on Community Long-term Care Services and STAR+PLUS
requirements, policies, and procedures that vary from Medicaid
Fee-for-Service and commercial coverage rules, including payment
policies
and procedures.
|
|
2.
|
Inpatient
Stay hospital services and the authorization and billing of such
services
for STAR+PLUS Members.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
|
3.
|
Relevant
requirements of the STAR+PLUS Contract, including the role of the
Service
Coordinator;
|
|
4.
|
Processes
for making referrals and coordinating Non-capitated
Services;
|
|
5.
|
The
HMO’s quality assurance and performance improvement program and the
Provider’s role in such programs;
and
|
|
6.
|
The
HMO’s STAR+PLUS policies and procedures, including those relating to
Network and Out-of-Network
referrals.
|
8.3.7.2
|
LTC
Provider Billing
|
Long-term
care providers are not required to utilize the billing systems that most medical
facilities use on a regular basis. For this reason, the HMO must make
accommodations to the claims processing system for such providers to allow
for a
smooth transition from traditional Medicaid to Managed Care
Medicaid.
HHSC
will
meet with HMOs to develop a standardized method long-term care billing. All
STAR+PLUS HMOs will be required to utilize the standardized method, which will
be incorporated into the HHSC Uniform Managed Care
Manual.
8.3.7.3
|
Rate
Enhancement Payments for Agencies Providing Attendant
Care
|
All
HMOs
participating in the STAR+PLUS program must allow their Long-term Support
Services (LTSS) Providers to participate in the STAR+PLUS Attendant Care
Enhancement Program if the providers are currently participating in the enhanced
payment program with the Department of Aging and Disability Services (DADS).
HMOs may choose not to offer participation to DADS-contracted providers who
do
not currently participate in the enhancement program. Additionally, HMOs may
choose to include Providers in the network who do not participate in the
enhanced payment program.
Attachment
B-7, STAR+PLUS Attendant Care Enhanced Payment Methodology explains the
methodology that the STAR+PLUS HMO will use to implement and pay the enhanced
payments, including a description of the timing of the payments, in accordance
with the requirements in the Uniform Managed Care Manual and
the intent of the 2000-01 General Appropriations Act (Rider 27, House Xxxx
1,
76th Legislature, Regular Session, 1999) and T.A.C. Title 1, Part 15, Chapter
355.
8.3.7.4
|
Payment
for 1915(c) Nursing Facility Waiver Services for Non-
Members
|
Disenrolled
Members: Occasionally, the Social Security Administration will place
SSI recipients on hold for a short period of time, usually due failure to
provide timely updates required for the continuation of SSI benefits. During
this period, the recipients will not appear to be eligible for Medicaid or
1915(c) Nursing Facility Waiver services. Often the Social Security
Administration reinstates these Medicaid Eligibles retroactively without a
break
in Medicaid coverage. To deal with this situation, for at least thirty (30)
days
after disenrollment, the HMO will continue to authorize and pay for 1915(c)
Nursing Facility Waiver services for disenrolled STAR+PLUS Members who appear
to
lose eligibility due to an administrative problem related to
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
SSI.
If
at the end of the thirty (30) days, the Medicaid Eligible’s 1915(c) Nursing
Facility Waiver eligibility is reinstated, the Medicaid Eligible will be
manually enrolled into the STAR+PLUS HMO back to the date of disenrollment
and
the retroactive adjustment system will properly reimburse the HMO. If after
thirty (30) days, the former STAR+PLUS Member continues to be ineligible for
Medicaid, the individual will not be retroactively enrolled, and the HMO will
xxxx HHSC for 1915(c) Nursing Facility Waiver services rendered during this
time.
8.4
|
Additional
CHIP Scope of Work
|
The
following provisions only apply to HMOs participating in CHIP.
8.4.1
|
CHIP
Provider Network
|
In
each
Service Area, the HMO must seek to obtain the participation in its Provider
Network of CHIP Significant Traditional Providers (STPs), defined by HHSC as
PCP
Providers currently serving the CHIP population and DSH hospitals. The
Procurement Library includes CHIP STPs by Service Area.
The
HMO
must give STPs the opportunity to participate in its Network if the
STPs:
|
1.
|
Agree
to accept the HMO’s Provider reimbursement rate for the provider type;
and
|
|
2.
|
Meet
the standard credentialing requirements of the HMO, provided that
lack of
board certification or accreditation by the Joint Commission on
Accreditation of Health Care Organizations (JCAHO) is not the sole
grounds
for exclusion from the Provider
Network.
|
8.4.2
|
CHIP
Provider Complaint and
Appeals
|
CHIP
Provider Complaints and Appeals are subject to disposition consistent with
the
Texas Insurance Code and any applicable TDI regulations. The HMO must resolve
Provider Complaints within 30 days from the date the Complaint is
received.
8.4.3
|
CHIP
Member Complaint and Appeal
Process
|
CHIP
Member Complaints and Appeals are subject to disposition consistent with the
Texas Insurance Code and any applicable TDI regulations. HHSC will require
the
HMO to resolve Complaints and Appeals (that are not elevated to TDI) within
30
days from the date the Complaint or Appeal is received. The HMO is subject
to
remedies, including liquidated damages, if at least 98 percent of Member
Complaints or Member Appeals are not resolved within 30 days of receipt of
the
Complaint or Appeal by the HMO. Please see the Uniform Managed Care
Contract Terms & Conditions and Attachment B-5,
Deliverables/Liquidated Damages Matrix. Any person, including those
dissatisfied with a HMO’s resolution of a Complaint or Appeal, may report an
alleged violation to TDI.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
8
|
Version
1.7
|
8.4.4 Dental
Coverage for CHIP Members
The
HMO
is not responsible for reimbursing dental providers for preventive and
therapeutic dental services obtained by CHIP Members. However, medical and/or
hospital charges, such as anesthesia, that are necessary in order for CHIP
Members to access standard therapeutic dental services, are Covered Services
for
CHIP Members. The HMO must provide access to facilities and physician services
that are necessary to support the dentist who is providing dental services
to a
CHIP Member under general anesthesia or intravenous (IV) sedation.
The
HMO
must inform Network facilities, anesthesiologists, and PCPs what authorization
procedures are required, and how Providers are to be reimbursed for the
preoperative evaluations by the PCP and/or anesthesiologist and for the facility
services. For dental-related medical Emergency Services, the HMO must reimburse
in-network and Out-of-Network providers in accordance with federal and state
laws, rules, and regulations.
8.5
|
Additional
CHIP Perinatal Scope of
Work
|
The
following provisions only apply to HMOs participating in CHIP Perinatal
Program.
8.5.1
|
CHIP
Perinatal Provider Network
|
In
each
Service Area, the CHIP Perinatal HMO must seek to obtain the participation
of
Providers for CHIP Perinate Members. CHIP Perinatal HMOs are encouraged to
obtain the participation of Obstetricians/Gynecologists (OB/GYNs), Family
Practice Physicians with experience in prenatal care, or other qualified health
care Providers as CHIP Perinate Providers. See Sections 8.1.3.2, Access to
Network Providers, and 8.1.4.2, Primary Care Providers, regarding distinctions
in the provider networks for CHIP Perinates and CHIP Perinate
Newborns.
8.5.2
|
CHIP
Perinatal Program Provider Complaint and
Appeals
|
CHIP
Perinatal Program Provider Complaints and Appeals are subject to disposition
consistent with the Texas Insurance Code and any applicable TDI regulations.
The
HMO must resolve Provider Complaints within 30 days from the date the Complaint
is received.
8.5.3
|
CHIP
Perinatal Program Member Complaint and Appeal
Process
|
CHIP
Perinatal Program Member Complaints and Appeals are subject to disposition
consistent with the Texas Insurance Code and any applicable TDI regulations.
HHSC will require the HMO to resolve Complaints and Appeals (that are not
elevated to TDI) within 30 days from the date the Complaint or Appeal is
received. Any person, including those dissatisfied with a HMO’s resolution of a
Complaint or Appeal, may report an alleged violation to TDI.
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
9
|
Version
1.7
|
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version Attachment B-1, Section 7
|
|
Revision
|
1.1
|
June
30, 2006
|
Contract
amendment to include STAR+PLUS program. No change to this
Section.
|
Revision
|
1.2
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-1 Section 9 – Turnover
Requirements
|
Revision
|
1.3
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-1 Section 9 – Turnover
Requirements
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-1 Section 9 – Turnover
Requirements
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-1 Section 9 – Turnover
Requirements
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-1 Section 9 – Turnover
Requirements
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-1 Section 9 – Turnover
Requirements
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the
Baseline
version, and “Cancellation” for withdrawn versions
2 Revisions
should be numbered in accordance according to the version of the
issuance
and sequential
numbering
of the revision—e.g., “1.2” refers to the first version of the document
and the second
revision.
3 Brief
description of the changes to the document made in the
revision.
|
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
9
|
Version
1.7
|
9.
Turnover
Requirements
9.1
Introduction
This
section presents the Turnover Requirements to which the HMO must agree. Turnover
is defined as those activities that are required for the HMO to perform upon
termination of the Contract in situations in which the HMO must transition
Contract operations to HHSC or a subsequent Contractor.
9.2
Transfer of Data
The
HMO
must transfer all data regarding the provision of Covered Services to Members
to
HHSC or a new HMO, at the sole discretion of HHSC and as directed by HHSC.
All
transferred data must be compliant with HIPAA.
All
relevant data must be received and verified by HHSC or the subsequent
Contractor. If HHSC determines that not all of the data regarding the provision
of Covered Services to Members was transferred to HHSC or the subsequent
Contractor, as required, or the data is not HIPAA compliant, HHSC reserves
the
right to hire an independent contractor to assist HHSC in obtaining and
transferring all the required data and to ensure that all the data are HIPAA
compliant. The reasonable cost of providing these services will be the
responsibility of the HMO.
9.3
Turnover Services
Six
months prior to the end of the Contract Period, including any extensions to
such
Period, the HMO must propose a Turnover Plan covering the possible turnover
of
the records and information maintained to either the State or a successor HMO.
The Turnover Plan must be a comprehensive document detailing the proposed
schedule, activities, and resource requirements associated with the turnover
tasks. The Turnover Plan must be approved by HHSC.
As
part
of the Turnover Plan, the HMO must provide HHSC with copies of all relevant
Member and service data, documentation, or other pertinent information
necessary, as determined by the HHSC, for HHSC or a subsequent Contractor to
assume the operational activities successfully. This includes correspondence,
documentation of ongoing outstanding issues, and other operations support
documentation. The plan will describe the HMO’s approach and schedule for
transfer of all data and operational support information, as applicable. The
information must be supplied in media and format specified by the State and
according to the schedule approved by the State.
HHSC
is
not limited or restricted in the ability to require additional information
from
the HMO or modify the turnover schedule as necessary.
9.4
Post-Turnover Services
Thirty
(30) days following turnover of operations, the HMO must provide HHSC with
a
Turnover Results report documenting the completion and results of each step
of
the Turnover Plan. Turnover will not be considered complete until this document
is approved by HHSC.
If
the
HMO does not provide the required relevant data and reference tables,
documentation, or other pertinent information necessary for HHSC or the
subsequent Contractor to assume the operational activities successfully, the
HMO
agrees to reimburse the State for all reasonable costs, including, but
not
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
9
|
Version
1.7
|
limited
to, transportation, lodging, and subsistence for all state and federal
representatives, or their agents, to carry out their inspection, audit, review,
analysis, reproduction and transfer functions at the location(s) of such
records.
The
HMO
also agrees to pay any and all additional costs incurred by the State that
are
the result of the HMO’s failure to provide the requested records, data or
documentation within the time frames agreed to in the Turnover
Plan.
The
HMO
must maintain all files and records related to Members and Providers for five
years after the date of final payment under the Contract or until the resolution
of all litigation, claims, financial management review or audit pertaining
to
the Contract, whichever is longer. The HMO agrees to repay any valid, undisputed
audit exceptions taken by HHSC in any audit of the Contract.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2 – Covered Services
|
Version
1.7
|
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version Attachment B-2, Covered Services
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
Covered Services.
|
Revision
|
1.2
|
September
1. 2006
|
Revised
Attachment B-2 to include provisions applicable to MCOs participating
in
the STAR and CHIP Programs.
STAR
Covered Services, Services Included under the HMO Capitation Payment,
is
modified to clarify the STAR covered services related to “optometry” and
“vision.”
CHIP
Covered Services is modified to correct services related to artificial
aids including surgical implants.
|
Revision
|
1.3
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-2, Covered
Services.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-2, Covered
Services.
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-2, Covered
Services.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-2, Covered
Services.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-2, Covered
Services.
|
1Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn
versions
2Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3Brief
description of the changes to the document made in the
revision.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2 – Covered Services
|
Version
1.7
|
STAR
Covered Services
The
following is a non-exhaustive, high-level listing of Acute Care Covered Services
included under the STAR Medicaid managed care program.
Medicaid
HMO Contractors are responsible for providing a benefit package to Members
that
includes all medically necessary services covered under the traditional,
fee-for-service Medicaid programs except for Non-capitated Services provided
to
STAR Members outside of the HMO capitation and listed in Attachment B-1,
Section 8.2.2.8. Medicaid HMO Contractors must coordinate care
for Members for these Non-capitated Services so that Members have access
to a
full range of medically necessary Medicaid services, both capitated and
non-capitated. A Contractor may elect to offer additional acute care Value-added
Services.
The
STAR
Members are provided with three enhanced benefits compared to the traditional,
fee-forservice Medicaid coverage:
|
1)
|
waiver
of the three-prescription per month
limit;
|
|
2)
|
waiver
of the 30-day spell-of-illness limitation under fee-for-services;
and
|
|
3)
|
inclusion
of an annual adult well check for patients 21 years of age and
over.
|
Medicaid
HMO Contractors are responsible for providing a benefit package to Members
that
includes the waiver of the 30-day spell-of-illness limitation under
fee-for-service and the inclusion of an annual adult well check for patients
21
years of age and over. Prescription drug benefits to Medicaid HMO Members
are
provided outside of the HMO capitation.
Bidders
and Contractors should refer to the current Texas Medicaid Provider
Procedures Manual and the bi-monthly Texas Medicaid
Bulletin for a more inclusive listing of limitations and
exclusions that apply to each Medicaid benefit category. (These documents
can be
accessed online at: xxxx://xxx.xxxx.xxx.)
The
services listed in this Attachment are subject to modification based on Federal
and State laws and regulations and Programs policy updates.
Services
included under the HMO capitation payment
|
—
|
Ambulance
services
|
|
—
|
Audiology
services, including hearing aids for adults (hearing aids for children
are
provided through the PACT program and are a non-capitated
service)
|
|
—
|
Behavioral
Health Services, including:
|
|
Ø
|
Inpatient
and outpatient mental health services for children (under age
21)
|
|
Ø
|
Outpatient
chemical dependency services for children (under age
21)
|
|
Ø
|
Detoxification
services
|
|
Ø
|
Psychiatry
services
|
|
Ø
|
Counseling
services for adults (21 years of age and
over)
|
|
—
|
Birthing
center services
|
|
—
|
Chiropractic
services
|
|
—
|
Dialysis
|
|
—
|
Durable
medical equipment and supplies
|
|
—
|
Emergency
Services
|
|
—
|
Family
planning services
|
|
—
|
Home
health care services
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2 – Covered Services
|
Version
1.7
|
|
—
|
Hospital
services, including inpatient and
outpatient
|
|
—
|
Laboratory
|
|
—
|
Medical
check-ups and Comprehensive Care Program (CCP) Services for children
(under age 21)vthrough the Texas Health Steps
Program
|
|
—
|
Podiatry
|
|
—
|
Prenatal
care
|
|
—
|
Primary
care services
|
|
—
|
Radiology,
imaging, and X-rays
|
|
—
|
Specialty
physician services
|
|
—
|
Therapies
– physical, occupational and speech
|
|
—
|
Transplantation
of organs and tissues
|
—
|
Vision
(Includes optometry and glasses. Contact lenses are only covered
if they
are medically necessary for vision correction, which can not be
accomplished by glasses.)
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2 – Covered Services
|
Version
1.7
|
CHIP
Covered Services
Covered
CHIP services must meet the CHIP definition of Medically Necessary Covered
Services as defined in this Contract. There is no lifetime
maximum on benefits; however, 12-month period, enrollment period (a 6-month
period), or lifetime limitations do apply to certain services, as specified
in
the following chart. Please note that if services with a 12-month annual
limit
are all used within one 6-month enrollment period, these particular services
are
not available during the second 6-month enrollment period within that annual
period. Co-pays apply until a family reaches its specific cost-sharing
maximum.
Covered
Benefit
|
Description
|
Inpatient
General Acute and
Inpatient Rehabilitation Hospital
Services
|
Services
include, but are not limited to, the following:
nHospital-provided
Physician or Provider services
nSemi-private
room
and board (or private if medically necessary as certified by
attending)
nGeneral
nursing
care
nSpecial
duty
nursing when medically necessary
nICU
and
services
nPatient
meals and
special diets
nOperating,
recovery and other treatment rooms
nAnesthesia
and
administration (facility technical component)
nSurgical
dressings, trays, casts, splints
nDrugs,
medications
and biologicals
nBlood
or blood
products that are not provided free-of-charge to the patient and
their
administration
nX-rays,
imaging
and other radiological tests (facility technical component)
nLaboratory
and
pathology services (facility technical component)
nMachine
diagnostic
tests (EEGs, EKGs, etc.)
nOxygen
services
and inhalation therapy
nRadiation
and
chemotherapy
nAccess
to
DSHS-designated Level III perinatal centers or Hospitals meeting
equivalent levels of care
nIn-network
or
out-of-network facility and Physician services for a mother and
her
newborn(s) for a minimum of 48 hours following an uncomplicated
vaginal
delivery and 96 hours following an uncomplicated delivery by caesarian
section.
nHospital,
physician and related medical services, such as anesthesia, associated
with dental care
nSurgical
implants
nOther
artificial
aids including surgical implants
nImplantable
devices are covered under Inpatient and Outpatient services and
do not
count towards the DME 12-month period limit
|
Skilled
Nursing
Facilities
(Includes
Rehabilitation
Hospitals)
|
Services
include, but are not limited to, the following:
nSemi-private
room
and board
nRegular
nursing
services
nRehabilitation
services
nMedical
supplies
and use of appliances and equipment furnished by the
facility
|
Outpatient Hospital,
Comprehensive Outpatient Rehabilitation Hospital, Clinic
(Including Health Center) and
Ambulatory Health Care Center
|
Services
include, but are not limited to, the following services provided
in a
hospital clinic or emergency room, a clinic or health center,
hospital-based emergency department or an ambulatory health care
setting:
nX-ray,
imaging,
and radiological tests (technical component)
nLaboratory
and
pathology services (technical component)
nMachine
diagnostic
tests
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2 – Covered Services
|
Version
1.7
|
Covered
Benefit
|
Description
|
nAmbulatory
surgical facility services
nDrugs,
medications
and biologicals
nCasts,
splints,
dressings
nPreventive
health
services
nPhysical,
occupational and speech therapy
nRenal
dialysis
nRespiratory
services
nRadiation
and
chemotherapy
nBlood
or blood
products that are not provided free-of-charge to the patient and
the
administration of these products
nFacility
and
related medical services, such as anesthesia, associated with dental
care,
when provided in a licensed ambulatory surgical facility.
nSurgical
implants
nOther
artificial
aids including surgical implants
nImplantable
devices are covered under Inpatient and Outpatient services and
do not
count towards the DME 12-month period limit
|
|
Physician/Physician
Extender Professional Services
|
Services
include, but are not limited to, the following:
nAmerican Academy
of Pediatrics recommended well-child exams and preventive health
services (including, but not limited to, vision and hearing screening
and immunizations)
nPhysician
office
visits, in-patient and out-patient services
nLaboratory,
x-rays, imaging and pathology services, including technical component
and/or professional interpretation
nMedications,
biologicals and materials administered in Physician’s office
nAllergy
testing,
serum and injections
nProfessional
component (in/outpatient) of surgical services, including:
-Surgeons
and assistant surgeons for surgical procedures including appropriate
follow-up care
-Administration
of anesthesia by Physician (other than surgeon) or CRNA
-Second
surgical opinions
-Same-day
surgery performed in a Hospital without an over-night stay
-Invasive
diagnostic procedures such as endoscopic examinations
nHospital-based
Physician services (including Physician-performed technical and
interpretive components)
nIn-network
and
out-of-network Physician services for a mother and her newborn(s) for
a minimum of 48 hours following an uncomplicated vaginal delivery and
96 hours following an uncomplicated delivery by
caesarian section.
nPhysician
services
medically necessary to support a dentist providing dental services to
a CHIP member such as general anesthesia or intravenous
(IV) sedation.
|
Durable
Medical Equipment (DME), Prosthetic Devices and Disposable Medical
Supplies
|
$20,000
12-month period limit for DME, prosthetics, devices and disposable
medical
supplies (diabetic supplies and equipment are not counted against
this ccap). Services include DME (equipment which can withstand
repeated use and is primarily and customarily used to serve a medical
purpose, generally is not useful to a person in the absence of
Illness, Injury, or Disability, and is appropriate for use in the
home), including devices and supplies that are medically necessary
and necessary for one or more activities of daily living
and appropriate to assist in the treatment of a medical condition,
including:
nOrthotic
braces
and orthotics
nProsthetic
devices
such as artificial eyes, limbs, and braces
nProsthetic
eyeglasses and contact lenses for the management of
severe
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2 – Covered Services
|
Version
1.7
|
Covered
Benefit
|
Description
|
ophthalmologic
disease
nHearing
aids
nDiagnosis-specific
disposable medical supplies, including diagnosis-specific prescribed
specialty formula and dietary supplements. (See Attachment
A)
|
|
Home
and Community Health Services
|
Services
that are provided in the home and community, including, but not
limited
to:
nHome
infusion
nRespiratory
therapy
nVisits
for private
duty nursing (R.N., L.V.N.)
nSkilled
nursing
visits as defined for home health purposes (may include R.N. or
L.V.N.).
nHome
health aide
when included as part of a plan of care during a period that skilled
visits have been approved.
nSpeech,
physical
and occupational therapies.
nServices
are not
intended to replace the CHILD'S caretaker or to provide relief for
the caretaker
nSkilled
nursing
visits are provided on intermittent level and not intended to provide
24-hour skilled nursing services
nServices
are not
intended to replace 24-hour inpatient or skilled nursing facility
services
|
Inpatient
Mental Health
Services
|
Mental
health services, including for serious mental illness, furnished
in a
freestanding psychiatric hospital, psychiatric units of general acute
care hospitals and state-operated facilities, including, but not
limited to:
nNeuropsychological
and psychological testing.
nInpatient
mental
health services are limited to:
n45
days 12-month
inpatient limit
nIncludes
inpatient
psychiatric services, up to 12-month period limit, ordered by a court
of competent jurisdiction under the provisions of Chapters 573 and
574 of the Texas Health and Safety Code, relating to court
ordered commitments to psychiatric facilities. Court order serves as
binding determination of medical necessity. Any modification or
termination of services must be presented to the court with
jurisdiction over the matter for determination
n25
days of the
inpatient benefit can be converted to residential
treatment, therapeutic xxxxxx care or other 24-hour therapeutically
planned and structured services or sub-acute outpatient (partial
hospitalization or rehabilitative day treatment) mental health
services on the basis of financial equivalence against the inpatient
per diem cost
n20
of the
inpatient days must be held in reserve for inpatient use only
nDoes
not require
PCP referral
|
Outpatient
Mental Health Services
|
Mental
health services, including for serious mental illness, provided
on an
outpatient basis, including, but not limited to:
nMedication
management visits do not count against the outpatient visit
limit.
nThe
visits can be
furnished in a variety of community-based settings (including school
and
home-based) or in a state-operated facility
nUp
to 60 days
12-month period limit for rehabilitative day treatment
n60
outpatient
visits 12-month period limit
n60
rehabilitative
day treatment days can be converted to outpatient visits on the
basis of
financial equivalence against the day treatment per diem cost
n60
outpatient
visits can be converted to skills training (psycho educational
skills
development) or rehabilitative day treatment on the basis of
financial equivalence against the outpatient visit
cost
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2 – Covered Services
|
Version
1.7
|
Covered
Benefit
|
Description
|
nIncludes
outpatient psychiatric services, up to 12-month period limit, ordered
by a
court of competent jurisdiction under the provisions of Chapters 573
and 574 of the Texas Health and Safety Code, relating to
court ordered commitments to psychiatric facilities. Court order
serves as binding determination of medical necessity. Any
modification or termination of services must be presented to the
court with jurisdiction over the matter
for determination
nInpatient
days
converted to sub-acute outpatient services are in addition to the
outpatient limits and do not count towards those limits
nA
Qualified Mental
Health Professional (QMHP), as defined by and credentialed through
Texas
Department of State Health Services (DSHS) standards (TAC Title 25,
Part II, Chapter 412), is a Local Mental Health Authorities provider.
A QMHP must be working under the authority of an DSHS entity and be
supervised by a licensed mental health professional or physician.
QMHPs are acceptable providers as long as the services would
be within the scope of the services that are typically provided by
QMHPs. Those services include individual and group skills training
(which can be components of interventions such as day treatment and
in-home services), patient and family education, and crisis
services
nDoes
not require
PCP referral
|
|
Inpatient
Substance Abuse Treatment Services
|
Services
include, but are not limited to:
nInpatient
and
residential substance abuse treatment services
including detoxification and crisis stabilization, and 24-hour
residential rehabilitation programs
nDoes
not require
PCP referral
nMedically
necessary detoxification/stabilization services, limited to 14
days per
12-month period.
n24-hour
residential rehabilitation programs, or the equivalent, up to 60
days per
12-month period
n30
days may be
converted to partial hospitalization or intensive
outpatient rehabilitation, on the basis of financial equivalence
against the inpatient per diem cost
n30
days must be
held in reserve for inpatient use only.
|
Outpatient
Substance Abuse Treatment Services
|
nServices
include,
but are not limited to, the following:
nPrevention
and
intervention services that are provided by physician and nonphysician
providers, such as screening, assessment and referral for
chemical dependency disorders.
nIntensive
outpatient services is defined as an organized non-residential
service
providing structured group and individual therapy,
educational services, and life skills training which consists of at
least 10 hours per week for four to 12 weeks, but less than 24
hours per
day
nOutpatient
treatment service is defined as consisting of at least one to two
hours
per week providing structured group and individual
therapy, educational services, and life skills training
nOutpatient
treatment services up to a maximum of:
nIntensive
outpatient program (up to 12 weeks per 12-month period)
nOutpatient
services (up to six-months per 12-month period)
nDoes
not require
PCP referral
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2 – Covered Services
|
Version
1.7
|
Covered
Benefit
|
Description
|
Rehabilitation
Services
|
Services
include, but are not limited to, the following:
nHabilitation
(the
process of supplying a child with the means to reach
ageappropriate developmental milestones through therapy or treatment)
and rehabilitation services include, but are not limited to the
following:
nPhysical,
occupational and speech therapy
nDevelopmental
assessment
|
Hospice
Care Services
|
Services
include, but are not limited to:
nPalliative
care,
including medical and support services, for those children who have
six months or less to live, to keep patients comfortable during
the last
weeks and months before death
nTreatment
for
unrelated conditions is unaffected
nUp
to a maximum of
120 days with a 6 month life expectancy
nPatients
electing
hospice services waive their rights to treatment related to their
terminal
illnesses; however, they may cancel this election at anytime
nServices
apply to
the hospice diagnosis
|
Emergency
Services, including Emergency Hospitals, Physicians, and
Ambulance Services
|
HMO
cannot require authorization as a condition for payment for emergency
conditions or labor and delivery.
Covered
services include, but are not limited to, the following:
nEmergency
services
based on prudent lay person definition of emergency health
condition
nHospital
emergency
department room and ancillary services and physician services 24
hours a
day, 7 days a week, both by in-network and
out-of-network providers
nMedical
screening
examination
nStabilization
services
nAccess
to DSHS
designated Xxxxx 0 and Level II trauma centers or hospitals meeting
equivalent levels of care for emergency services
nEmergency
ground,
air and water transportation
nEmergency
dental
services, limited to fractured or dislocated jaw, traumatic damage to
teeth, and removal of cysts.
|
Transplants
|
Services
include, but are not limited to, the following:
nUsing
up-to-date
FDA guidelines, all non-experimental human organ and tissue transplants
and all forms of non-experimental corneal, bone marrow and peripheral
stem cell transplants, including donor medical
expenses.
|
Vision
Benefit
|
The
health plan may reasonably limit the cost of the
frames/lenses.
Services
include:
nOne
examination of
the eyes to determine the need for and prescription for corrective
lenses
per 12-month period, without authorization
nOne
pair of
non-prosthetic eyewear per 12-month period
|
Chiropractic
Services
|
Services
do not require physician prescription and are limited to
spinal subluxation
|
Tobacco
Cessation
Program
|
Covered
up to $100 for a 12- month period limit for a plan- approved
program
nHealth
Plan
defines plan-approved program.
nMay
be subject to
formulary requirements.
|
[Value-added
services]
|
See
Attachment B-3
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2 – Covered Services
|
Version
1.7
|
CHIP
EXCLUSIONS FROM COVERED SERVICES
n
|
Inpatient
and outpatient infertility treatments or reproductive services
other than
prenatal care, labor and delivery, and care related to disease,
illnesses, or abnormalities related to the reproductive
system
|
n
|
Personal
comfort items including but not limited to personal care kits provided
on
inpatient admission, telephone, television, newborn infant
photographs, meals for guests of patient, and other articles which
are not required for the specific treatment of sickness or
injury
|
n
|
Experimental
and/or investigational medical, surgical or other health care procedures
or services which are not generally employed or recognized within
the
medical community
|
n
|
Treatment
or evaluations required by third parties including, but not limited
to,
those for schools, employment, flight clearance, camps, insurance or
court
|
n
|
Private
duty nursing services when performed on an inpatient basis or in
a skilled
nursing facility.
|
n
|
Mechanical
organ replacement devices including, but not limited to artificial
heart
|
n
|
Hospital
services and supplies when confinement is solely for diagnostic
testing
purposes, unless otherwise pre-authorized by Health
Plan
|
n
|
Prostate
and mammography screening
|
n
|
Elective
surgery to correct vision
|
n
|
Gastric
procedures for weight loss
|
n
|
Cosmetic
surgery/services solely for cosmetic
purposes
|
n
|
Out-of-network
services not authorized by the Health Plan except for emergency
care
and physician services for a mother and her newborn(s) for a minimum
of 48 hours following an uncomplicated vaginal delivery and 96 hours
following an uncomplicated delivery by caesarian
section
|
n
|
Services,
supplies, meal replacements or supplements provided for weight
control or
the treatment of obesity, except for the services associated with the
treatment for morbid obesity as part of a treatment plan approved by
the Health Plan
|
n
|
Acupuncture
services, naturopathy and
hypnotherapy
|
n
|
Immunizations
solely for foreign travel
|
n
|
Routine
foot care such as hygienic care
|
n
|
Diagnosis
and treatment of weak, strained, or flat feet and the cutting or
removal
of corns, calluses and toenails (this does not apply to the removal
of nail roots or surgical treatment of conditions underlying corns,
calluses or ingrown toenails)
|
n
|
Replacement
or repair of prosthetic devices and durable medical equipment due
to
misuse, abuse or loss when confirmed by the Member or the
vendor
|
n
|
Corrective
orthopedic shoes
|
n
|
Convenience
items
|
n
|
Orthotics
primarily used for athletic or recreational
purposes
|
n
|
Custodial
care (care that assists a child with the activities of daily living,
such
as assistance in walking, getting in and out of bed, bathing,
dressing, feeding, toileting, special diet preparation, and
medication supervision that is usually self-administered or provided
by
a parent. This care does not require the continuing attention of
trained medical or paramedical personnel.) This exclusion does not
apply to hospice services.
|
n
|
Housekeeping
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2 – Covered Services
|
Version
1.7
|
n
|
Public
facility services and care for conditions that federal, state,
or local
law requires be provided in a public facility or care provided while
in the custody of legal authorities
|
n
|
Services
or supplies received from a nurse, which do not require the skill
and
training of a nurse
|
n
|
Vision
training and vision therapy
|
n
|
Reimbursement
for school-based physical therapy, occupational therapy, or speech
therapy services are not covered except when ordered by a
Physician/PCP
|
n
|
Donor
non-medical expenses
|
n
|
Charges
incurred as a donor of an organ when the recipient is not covered
under
this health plan
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2 – Covered Services
|
Version
1.7
|
CHIP
DME/SUPPLIES
SUPPLIES
|
COVERED
|
EXCLUDED
|
COMMENTS/MEMBER
CONTRACT
PROVISIONS
|
Ace
Bandages
|
X
|
Exception:
If provided by and billed through the clinic or home care agency it
is covered as an incidental supply.
|
|
Alcohol,
rubbing
|
X
|
Over-the-counter
supply.
|
|
Alcohol,
swabs
(diabetic)
|
X
|
Over-the-counter
supply not covered, unless RX provided at time
of dispensing.
|
|
Alcohol,
swabs
|
X
|
Covered
only when received with IV therapy or central
line kits/supplies.
|
|
Xxx
Kit Epinephrine
|
X
|
A
self-injection kit used by patients highly allergic to bee
stings.
|
|
Arm
Sling
|
X
|
Dispensed
as part of office visit.
|
|
Attends
(Diapers)
|
X
|
Coverage
limited to children age 4 or over only when prescribed by a physician
and
used to provide care for a covered diagnosis as outlined in a treatment
care plan
|
|
Bandages
|
X
|
||
Basal
Thermometer
|
X
|
Over-the-counter
supply.
|
|
Batteries
– initial
|
X
|
For
covered DME items
|
|
Batteries
– replacement
|
X
|
For
covered DME when replacement is necessary due to normal
use.
|
|
Betadine
|
X
|
See
IV therapy supplies.
|
|
Books
|
X
|
||
Clinitest
|
X
|
For
monitoring of diabetes.
|
|
Colostomy
Bags
|
See
Ostomy Supplies.
|
||
Communication
Devices
|
X
|
||
Contraceptive
Jelly
|
X
|
Over-the-counter
supply. Contraceptives are not covered under
the plan.
|
|
Cranial
Head Mold
|
X
|
||
Diabetic
Supplies
|
X
|
Monitor
calibrating solution, insulin syringes, needles, lancets, lancet
device,
and glucose strips.
|
|
Diapers/Incontinent
Briefs/Chux
|
X
|
Coverage
limited to children age 4 or over only when prescribed by a physician
and
used to provide care for a covered diagnosis as outlined in a
treatment care plan
|
|
Diaphragm
|
X
|
Contraceptives
are not covered under the plan.
|
|
Diastix
|
X
|
For
monitoring diabetes.
|
|
Diet,
Special
|
X
|
||
Distilled
Water
|
X
|
||
Dressing
Supplies/Central
Line
|
X
|
Syringes,
needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape.
Many
times these items are dispensed in a kit when includes all necessary
items for one dressing site change.
|
|
Dressing
Supplies/Decubitus
|
X
|
Eligible
for coverage only if receiving covered home care for
wound care.
|
|
Dressing
Supplies/Peripheral
IV
Therapy
|
X
|
Eligible
for coverage only if receiving home IV therapy.
|
|
Dressing
Supplies/Other
|
X
|
||
Dust
Mask
|
X
|
||
Ear
Molds
|
X
|
Custom
made, post inner or middle ear surgery
|
|
Electrodes
|
X
|
Eligible
for coverage when used with a covered DME.
|
|
Enema
Supplies
|
X
|
Over-the-counter
supply.
|
|
Enteral
Nutrition
|
X
|
Necessary
supplies (e.g., bags, tubing, connectors, catheters, etc.)
are
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2 – Covered Services
|
Version
1.7
|
SUPPLIES
|
COVERED
|
EXCLUDED
|
COMMENTS/MEMBER
CONTRACT
PROVISIONS
|
Supplies
|
eligible
for coverage. Enteral nutrition products are not covered except
for those
prescribed for hereditary metabolic disorders, a nonfunction or
disease of the structures that normally permit food to reach the
small bowel, or malabsorption due to disease
|
||
Eye
Patches
|
X
|
Covered
for patients with amblyopia.
|
|
Formula
|
X
|
Exception:
Eligible for coverage only for chronic hereditary metabolic disorders
a
non-function or disease of the structures that normally permit food
to reach the small bowel; or malabsorption due to disease (expected
to last longer than 60 days when prescribed by the physician and
authorized by plan.) Physician documentation to
justify
prescription of formula must include:
•Identification
of a metabolic disorder, dysphagia that results in a medical need for
a liquid diet, presence of a gastrostomy, or disease resulting in
malabsorption that requires a medically necessary nutritional
product
Does
not include formula:
•For
members who could be sustained on an
age-appropriate diet.
•Traditionally
used for infant feeding
•In
pudding form (except for clients with documented oropharyngeal motor
dysfunction who receive greater than 50 percent of their daily
caloric intake from this product)
•For
the primary diagnosis of failure to thrive, failure to gain weight,
or lack of growth or for infants less than twelve months of age
unless medical necessity is documented and other criteria, listed
above, are met.
Food
thickeners, baby food, or other regular grocery products that can
be
blenderized and used with an enteral system that are
not medically necessary, are not covered, regardless of
whether these regular food products are taken orally or
parenterally.
|
|
Gloves
|
X
|
Exception:
Central line dressings or wound care provided by home care
agency.
|
|
Hydrogen
Peroxide
|
X
|
Over-the-counter
supply.
|
|
Hygiene
Items
|
X
|
||
Incontinent
Pads
|
X
|
Coverage
limited to children age 4 or over only when prescribed by a physician
and
used to provide care for a covered diagnosis as outlined in a
treatment care plan
|
|
Insulin
Pump (External) Supplies
|
X
|
Supplies
(e.g., infusion sets, syringe reservoir and dressing, etc.)
are eligible for coverage if the pump is a covered
item.
|
|
Irrigation
Sets, Wound Care
|
X
|
Eligible
for coverage when used during covered home care for wound
care.
|
|
Irrigation
Sets, Urinary
|
X
|
Eligible
for coverage for individual with an indwelling
urinary catheter.
|
|
IV
Therapy Supplies
|
X
|
Tubing,
filter, cassettes, IV pole, alcohol swabs, needles, syringes and any
other related supplies necessary for home IV therapy.
|
|
K-Y
Jelly
|
X
|
Over-the-counter
supply.
|
|
Lancet
Device
|
X
|
Limited
to one device only.
|
|
Lancets
|
X
|
Eligible
for individuals with diabetes.
|
|
Med
Ejector
|
X
|
||
Needles
and
|
See
Diabetic Supplies
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2 – Covered Services
|
Version
1.7
|
SUPPLIES
|
COVERED
|
EXCLUDED
|
COMMENTS/MEMBER
CONTRACT
PROVISIONS
|
Syringes/Diabetic
|
|||
Needles
and Syringes/IV and Central Line
|
See
IV Therapy and Dressing Supplies/Central Line.
|
||
Needles
and Syringes/Other
|
X
|
Eligible
for coverage if a covered IM or SubQ medication is being administered
at home.
|
|
Normal
Saline
|
See
Saline, Normal
|
||
Novopen
|
X
|
||
Ostomy
Supplies
|
X
|
Items
eligible for coverage include: belt, pouch, bags, wafer, face plate,
insert, barrier, filter, gasket, plug, irrigation kit/sleeve,
tape, skin prep, adhesives, drain sets, adhesive remover, and pouch
deodorant.
Items
not eligible for coverage include: scissors, room
deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and
lotions.
|
|
Parenteral Nutrition/Supplies
|
X
|
Necessary
supplies (e.g., tubing, filters, connectors, etc.) are eligible
for
coverage when the Health Plan has authorized the parenteral
nutrition.
|
|
Saline,
Normal
|
X
|
Eligible
for coverage:
a)
when used to dilute medications for nebulizer treatments;
b)
as part of covered home care for wound care;
c)
for indwelling urinary catheter irrigation.
|
|
Xxxxx
Sleeve
|
X
|
||
Xxxxx
Socks
|
X
|
||
Suction
Catheters
|
X
|
||
Syringes
|
See
Needles/Syringes.
|
||
Tape
|
See
Dressing Supplies, Ostomy Supplies, IV Therapy
Supplies.
|
||
Tracheostomy
Supplies
|
X
|
Cannulas,
Tubes, Ties, Holders, Cleaning Kits, etc. are eligible
for coverage.
|
|
Under
Pads
|
See
Diapers/Incontinent Briefs/Chux.
|
||
Unna
Boot
|
X
|
Eligible
for coverage when part of wound care in the home setting. Incidental
charge when applied during office visit.
|
|
Urinary,
External Catheter & Supplies
|
X
|
Exception:
Covered when used by incontinent male where injury to the urethra
prohibits use of an indwelling catheter ordered by the PCP and
approved by the plan
|
|
Urinary,
Indwelling Catheter & Supplies
|
X
|
Cover
catheter, drainage bag with tubing, insertion tray, irrigation
set and
normal saline if needed.
|
|
Urinary,
Intermittent
|
X
|
Cover
supplies needed for intermittent or straight
catherization.
|
|
Urine
Test Kit
|
X
|
When
determined to be medically necessary.
|
|
Urostomy
supplies
|
See
Ostomy Supplies.
|
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-2.1 – STAR+PLUS Covered Services
|
Version
1.7
|
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version of Attachment B-2, Covered Services.
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
Covered Services. This is the initial version of Attachment B-2.1,
STAR+PLUS Covered Services, which lists the Acute Care Services
and the
Community Based Long Term Care Services.
|
Revision
|
1.2
|
September
1, 2006
|
Contract
Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
Services.
|
Revision
|
1.3
|
September
1, 2006
|
Contract
Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
Services.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
Services.
|
Revision
|
1.5
|
January
1, 2007
|
Revised
Attachment B-2.1, STAR+PLUS Covered Services, to include inpatient
and
outpatient mental health services for adults.
|
Revision
|
1.6
|
February
1, 2007
|
Revised
Attachment B-2.1, STAR+PLUS Covered Services, to exclude inpatient
mental
health services for adults and children, and to establish monetary
limits
on Transition Assistance Services.
Personal
Attendant Services is clarified to include the three service delivery
options described in Attachment B-1, Section 8.3.5. Consumer
Directed Personal Attendant Services is deleted from the list since
it is
one of the three service delivery options under Personal Attendant
Services.
|
Revision
|
1.7
|
June
1, 2007
|
Revised
Attachment B-2.1, STAR+PLUS Covered Services, to include inpatient
mental
health services for adults and children and to include effective
dates by
service area.
|
1
Status
should
be represented as “Baseline” for initial issuances, “Revision” for changes
to the Baseline version, and “Cancellation” for withdrawn
versions
2 Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3
Brief
description of the changes to the document made in the
revision.
|
1
of
4
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-2.1 – STAR+PLUS Covered Services
|
Version
1.7
|
STAR+PLUS
Covered Services
Acute
Care Services
The
following is a non-exhaustive, high-level listing of Acute Care Covered Services
included under the STAR+PLUS Medicaid managed care program.
Medicaid
HMO Contractors are responsible for providing a benefit package to Members
that
includes all medically necessary services covered under the traditional,
fee-for-service Medicaid programs except for Non-capitated Services provided
to
Medicaid Members outside of the HMO capitation and listed in Attachment B-1,
Section 8.2.2.8. In addition to the non-capitated services listed in Attachment
B-1, Section 8.2.2.8, Hospital Inpatient Stays are excluded from the capitation
payment to STAR+PLUS HMOs and are paid through HHSC’s Administrative Contractor
responsible for payment of Traditional Medicaid fee-for-service claims. Medicaid
HMO Contractors must coordinate care for Members for these Non-capitated
Services so that Members have access to a full range of medically necessary
Medicaid services, both capitated and non-capitated. A Contractor may elect
to
offer additional acute care Value-added Services.
The
STAR+PLUS Members are provided with two enhanced benefits compared to the
traditional, fee-for-service Medicaid coverage:
1) waiver
of the three-prescription per month limit, for members not covered by
Medicare;
2) inclusion
of an annual adult well check for patients 21 years of age and
over.
Medicaid
HMO Contractors are responsible for providing a benefit package to Members
that
includes an annual adult well check for patients 21 years of age and
over. Prescription drug benefits to HMO Members are provided outside
of the HMO capitation.
STAR+PLUS
HMO Contractors should refer to the current Texas Medicaid Provider
Procedures Manual and the bi-monthly Texas Medicaid
Bulletin for a more inclusive listing of limitations and
exclusions that apply to each Medicaid benefit category. (These documents
can be
accessed online at: xxxx://xxx.xxxx.xxx.)
The
services listed in this Attachment are subject to modification based on Federal
and State laws and regulations and Programs policy updates.
Services
included under the HMO capitation payment
•
|
Ambulance
services
|
•
|
Audiology
services, including hearing aids for adults (hearing aids for children
are
provided through the PACT program and are a non-capitated
service)
|
•
|
Behavioral
Health Services, including:
|
|
o
|
Inpatient
mental health services for Adults and Children (Effective 6/01/07
in the
Xxxxxx Service Area; and effective 9/01/07 in the Bexar, Nueces
and Xxxxxx
Service Areas.)
|
|
o
|
Outpatient
mental health services for Adults and
Children
|
|
o
|
Outpatient
chemical dependency services for children (under age
21)
|
|
o
|
Detoxification
services
|
|
o
|
Psychiatry
services
|
|
o
|
Counseling
services for adults (21 years of age and
over)
|
•
|
Birthing
center services
|
•
|
Chiropractic
services
|
2
of 4
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-2.1 – STAR+PLUS Covered Services
|
Version
1.7
|
•
|
Dialysis
|
•
|
Durable
medical equipment and supplies
|
•
|
Emergency
Services
|
•
|
Family
planning services
|
•
|
Home
health care services
|
•
|
Hospital
services, outpatient
|
•
|
Laboratory
|
•
|
Medical
check-ups and Comprehensive Care Program (CCP) Services for children
(under age 21) through the Texas Health Steps
Program
|
•
|
Optometry,
glasses, and contact lenses, if medically
necessary
|
•
|
Podiatry
|
•
|
Prenatal
care
|
•
|
Primary
care services
|
•
|
Radiology,
imaging, and X-rays
|
•
|
Specialty
physician services
|
•
|
Therapies
– physical, occupational and speech
|
•
|
Transplantation
of organs and tissues
|
•
|
Vision
|
Community
Based Long Term Care Services
The
following is a non-exhaustive, high-level listing of Community Based Long
Term
Care Covered Services included under the STAR+PLUS Medicaid managed care
program.
• Community
Based Long Term Care Services for all Members
|
o
|
Personal
Attendant Services – All Members of a STAR+PLUS HMO may receive medically
and functionally necessary personal attendant services
(PAS).
|
|
o
|
Day
Activity and Health Services – All Members of a STAR+PLUS HMO may receive
medically and functionally necessary Day Activity and Health Care
Services
(DAHS).
|
•
|
1915
(c) Nursing Facility Waiver Services for those Members who qualify
for
such services
|
The
state
provides an enriched array of services to clients who would otherwise qualify
for nursing facility care through a Home and Community Based Medicaid
Waiver. In traditional Medicaid, this is known as the Community Based
Alternatives (CBA) waiver. The STAR+PLUS HMO must also provide the
services that are available to clients through the CBA waiver in traditional
Medicaid to those clients that meet the functional and financial eligibility
for
the 1915 (c) Nursing Facility Waiver Services.
|
o
|
Personal
Attendant Services (including the three service delivery options:
Self-Directed; Agency Model, Self Directed; and Agency
Model)
|
|
o
|
Nursing
Services (in home)
|
|
o
|
Emergency
Response Services (Emergency call
button)
|
|
o
|
Home
Delivered Meals
|
|
o
|
Minor
Home Modifications
|
|
o
|
Adaptive
Aids and Medical Equipment
|
|
o
|
Medical
Supplies
|
|
o
|
Physical
Therapy, Occupational Therapy, Speech
Therapy
|
|
o
|
Adult
Xxxxxx Care
|
|
o
|
Assisted
Living
|
3
of
4
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-2.1 – STAR+PLUS Covered Services
|
Version
1.7
|
|
o
|
Transition
Assistance Services (These services are limited to a maximum of
$2,500.00. If the HMO determines that no other resources are
available to pay for the basic services/items needed to assist
a Member,
who is leaving a nursing facility, with setting up a household,
the HMO
may authorize up to $2,500.00 for Transition Assistance Services
(TAS). The $2,500.00 TAS benefit is part of the expense ceiling
when determining the Total Annual Individual Service Plan (ISP)
Cost.)
|
4
of
4
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version of Attachment B-2, Covered Services
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
Covered Services.
|
Revision
|
1.2
|
September
1, 2006
|
Revised
Attachment B-2, Covered Services, by updating provisions applicable
to
MCOs participating in the STAR and CHIP Programs.
|
Revision
|
1.3
|
September
1, 2006
|
Revised
Attachment B-2, Covered Services, by adding Attachment B-2.2, CHIP
Perinatal Covered Services. This is the initial version of Attachment
B-2.2, which lists the CHIP Perinatal Covered Services, exclusions
and
DME/Supplies.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
Services.
|
Revision
|
1.5
|
January
1, 2007
|
Contract
Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
Services.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
Services.
|
Revision
|
1.7
|
June
1, 2007
|
Contract
Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
Services.
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn
versions
2 Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3 Brief
description of the changes to the document made in the
revision.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
CHIP
Perinatal Program Covered Services
Covered
CHIP Perinatal Program services must meet the definition of Medically Necessary
Covered Services as defined in this Contract. There is no
lifetime maximum on benefits; however, 12-month enrollment period or lifetime
limitations do apply to certain services, as specified in the following chart.
Co-pays do not apply to CHIP Perinatal Program Members. CHIP Perinatal Program
Members are eligible for 12-months continuous coverage following enrollment
in
the program.
Covered
Benefit
|
CHIP
Perinate Newborn
|
CHIP
Perinate
|
Inpatient
General Acute and Inpatient Rehabilitation Hospital
Services
|
For
CHIP Perinate Newborns in families with incomes at or below 185%
of the
Federal Poverty Level, the facility charges are not a covered benefit
for
the initial Perinate Newborn admission; however, facility charges
are a
covered benefit after the initial Perinate Newborn admission. "Initial
Perinate Newborn admission" means the hospitalization associated
with the
birth.
For
CHIP Perinate Newborns in families with incomes at or below 185%
of the
Federal Poverty Level, professional service charges are a covered
benefit
for the initial Perinate Newborn admission and subsequent admissions.
"Initial Perinate Newborn admission" means the hospitalization
associated
with the birth.
Services
include, but are not limited to, the following:
§Hospital-provided
Physician or Provider services
§Semi-private
room
and board (or private if medically necessary as certified by
attending)
§General
nursing
care
§Special
duty
nursing when medically necessary
§ICU
and
services
§Patient
meals and
special diets
§Operating,
recovery and other treatment rooms
§Anesthesia
and
administration (facility technical component)
|
For
CHIP Perinates in families with incomes at or below 185% of the
Federal
Poverty Level, the facility charges are not a covered benefit;
however,
professional services charges associated with labor with delivery
are a
covered benefit.
For
CHIP Perinates in families with incomes between 186% and 200% of
the
Federal Poverty Level, benefits are limited to professional service
charges and facility charges associated with labor with
delivery.
Covered
medically necessary Hospital-provided services are limited to labor
with
delivery until birth.
Services
include:
§Operating,
recovery and other treatment rooms
§Anesthesia
and
administration (facility technical component
§Medically
necessary surgical services are limited to services that directly
relate
to the delivery of the unborn
child.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
Covered
Benefit
|
CHIP
Perinate Newborn
|
CHIP
Perinate
|
§Surgical
dressings, trays, casts, splints
§Drugs,
medications
and biologicals
§Blood
or blood
products that are not provided free-of-charge to the patient and
their
administration
§X-rays,
imaging
and other radiological tests (facility technical component)
§Laboratory
and
pathology services (facility technical component)
§Machine
diagnostic
tests (EEGs, EKGs, etc.)
§Oxygen
services
and inhalation therapy
§Radiation
and
chemotherapy
§Access
to
DSHS-designated Level III perinatal centers or Hospitals meeting
equivalent levels of care
§In-network
or
out-of-network facility and Physician services for a mother and
her
newborn(s) for a minimum of 48 hours following an uncomplicated
vaginal
delivery and 96 hours following an uncomplicated delivery by caesarian
section.
§Hospital,
physician and related medical services, such as anesthesia, associated
with dental care
§Surgical
implants
§Other
artificial
aids including surgical implants
§Implantable
devices are covered under Inpatient and Outpatient services and
do not
count towards the DME 12- month period limit
|
||
Skilled
Nursing Facilities (Includes Rehabilitation
Hospitals)
|
Services
include, but are not limited
to,
the following:
§Semi-private
room
and board
§Regular
nursing
services
§Rehabilitation
services
§Medical
supplies
and use of
|
Not
a covered benefit.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
Covered
Benefit
|
CHIP
Perinate Newborn
|
CHIP
Perinate
|
appliances
and equipment furnished by the facility
|
||
Outpatient
Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic
(Including Health Center) and Ambulatory Health Care
Center
|
Services
include, but are not limited to, the following services provided
in a
hospital clinic or emergency room, a clinic or health center,
hospital-based emergency department or an ambulatory health care
setting:
§X-ray,
imaging,
and radiological tests (technical component)
§Laboratory
and
pathology services (technical component)
§Machine
diagnostic
tests
§Ambulatory
surgical facility services
§Drugs,
medications
and biologicals
§Casts,
splints,
dressings
§Preventive
health
services
§Physical,
occupational and speech therapy
§Renal
dialysis
§Respiratory
services
§Radiation
and
chemotherapy
§Blood
or blood
products that are not provided free-of-charge to the patient and
the
administration of these products
§Facility
and
related medical services, such as anesthesia, associated with dental
care,
when provided in a licensed ambulatory surgical facility.
§Surgical
implants
§Other
artificial
aids including surgical implants
§Implantable
devices are covered under Inpatient and Outpatient services and
do not
count towards the DME 12- month period limit.
|
Services
include, the following services provided in a hospital clinic or
emergency
room, a clinic or health center, hospital-based emergency department
or an
ambulatory health care setting:
§X-ray,
imaging,
and radiological tests (technical component)
§Laboratory
and
pathology services (technical component)
§Machine
diagnostic
tests
§Drugs,
medications
and biologicals that are medically necessary prescription and injection
drugs.
(1)
Laboratory and radiological services are limited to services that
directly
relate to ante partum care and/or the delivery of the covered CHIP
Perinate until birth.
(2)
Ultrasound of the pregnant uterus is a covered benefit when medically
indicated. Ultrasound may be indicated for suspected genetic defects,
high-risk pregnancy, fetal growth retardation, or gestational age
confirmation.
(3)
Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion (FIUT)
and
Ultrasonic Guidance for Cordocentesis, FIUT are covered benefits
with an
appropriate diagnosis.
(4)
Laboratory tests are limited to: nonstress testing, contraction,
stress
testing, hemoglobin or hematocrit repeated once a trimester and
at 32-36
weeks of pregnancy; or complete blood count (CBC), urinanalysis
for
protein and glucose every visit, blood type and RH antibody screen;
repeat
antibody screen for Rh negative women at 28 weeks followed by RHO
immune
globulin
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
Covered
Benefit
|
CHIP
Perinate Newborn
|
CHIP
Perinate
|
administration
if indicated; rubella antibody titer, serology for syphilis, hepatitis
B
surface antigen, cervical cytology, pregnancy test, gonorrhea test,
urine
culture, sickle cell test, tuberculosis (TB) test, human immunodeficiency
virus (HIV) antibody screen, Chlamydia test, other laboratory tests
not
specified but deemed medically necessary, and multiple marker screens
for
neural tube defects (if the client initiates care between 16 and
20
weeks); screen for gestational diabetes at 24-28 weeks of pregnancy;
other
lab tests as indicated by medical condition of client.
|
||
Physician/Physician
Extender Professional Services
|
Services
include, but are not limited to, the following:
§American
Academy
of Pediatrics recommended well-child exams and preventive health
services
(including, but not limited to, vision and hearing screening and
immunizations)
§Physician
office
visits, in-patient and out-patient services
§Laboratory,
x-rays, imaging and pathology services, including technical component
and/or professional interpretation
§Medications,
biologicals and materials administered in Physician’s office
§Allergy
testing,
serum and injections
§Professional
component (in/outpatient) of surgical services, including:
-Surgeons
and assistant surgeons for surgical procedures including appropriate
follow-up care
-Administration
of anesthesia by Physician (other than surgeon) or CRNA
-Second
surgical opinions
-Same-day
surgery
|
Services
include, but are not limited to the following:
§Medically
necessary physician services are limited to prenatal and postpartum
care
and/or the delivery of the covered unborn child until birth
§Physician
office
visits, inpatient and out-patient services
§Laboratory,
x-rays, imaging and pathology services including technical component
and
/or professional interpretation
§Medically
necessary medications, biologicals and materials administered in
Physician’s office
§Professional
component (in/outpatient) of surgical services, including:
OSurgeons
and assistant surgeons for surgical procedures directly related
to the
labor with delivery of the covered unborn child until birth.
OAdministration
of anesthesia by Physician (other than surgeon) or CRNA
OInvasive
diagnostic procedures directly related to the labor-with
delivery
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
Covered
Benefit
|
CHIP
Perinate Newborn
|
CHIP
Perinate
|
performed
in a Hospital
without
an over-night stay
-Invasive
diagnostic procedures such as endoscopic
examinations
§Hospital-based
Physician services
(including
Physician-performed technical and interpretive components)
§In-network
and out-of-network
Physician services for a mother and her newborn(s) for a minimum
of 48
hours following an uncomplicated vaginal delivery and 96 hours
following
an uncomplicated delivery by caesarian
section.
§Physician
services
medically necessary to support a dentist providing dental services
to a
CHIP member such as general anesthesia or intravenous (IV)
sedation.
|
of
the unborn child.
§Hospital-based
Physician
services
(including Physician
performed
technical and
interpretive
components)
§Professional
component of the
ultrasound
of the pregnant
uterus
when medically
indicated
for suspected genetic
defects,
high-risk pregnancy,
fetal
growth retardation, or
gestational
age confirmation.
§Professional
component of
Amniocentesis,
Cordocentesis,
Fetal
Intrauterine Transfusion
(FIUT)
and Ultrasonic
Guidance
for Amniocentesis,
Cordocentrsis,
and FIUT.
|
|
Prenatal
Care and Pre-Pregnancy Family Services and
Supplies
|
Not
a covered benefit.
|
Services
are limited to an initial
visit
and subsequent prenatal (ante
partum)
care visits that include:
(1)
One visit every four weeks for the first 28 weeks or
pregnancy;
(2)
one visit every two to three weeks from 28 to 36 weeks of
pregnancy;
and
(3)
one visit per week from 36 weeks to delivery.
More
frequent visits are allowed as Medically Necessary. Benefits are
limited
to:
Limit
of 20 prenatal visits and 2 postpartum visits (maximum within 60
days)
without documentation of a complication of pregnancy. More frequent
visits
may be necessary for high-risk pregnancies. High-risk prenatal
visits are
not limited to 20 visits per pregnancy. Documentation supporting
medical
necessity must be maintained in the physician’s files and is subject to
retrospective review.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
Covered
Benefit
|
CHIP
Perinate Newborn
|
CHIP
Perinate
|
Visits
after the initial visit must
include:
§interim
history
(problems, marital status, fetal status);
§physical
examination (weight, blood pressure, fundalheight, fetal position
and
size, fetal heart rate, extremities) and
§laboratory
tests
(urinanalysis for protein and glucose every visit; hematocrit or
hemoglobin repeated once a trimester and at 32-36 weeks of pregnancy;
multiple marker screen for fetal abnormalities offered at 16-20
weeks of
pregnancy; repeat antibody screen for Rh negative women at 28 weeks
followed by Rho immune globulin administration if indicated; screen
for
gestational diabetes at 24-28 weeks of pregnancy; and other lab
tests as
indicated by medical condition of client).
|
||
Durable
Medical Equipment (DME), Prosthetic Devices and Disposable Medical
Supplies
|
$20,000
12-month period limit for DME, prosthetics, devices and disposable
medical
supplies (diabetic supplies and equipment are not counted against
this
cap). Services include DME (equipment which can withstand repeated
use and
is primarily and customarily used to serve a medical purpose, generally
is
not useful to a person in the absence of Illness, Injury, or Disability,
and is appropriate for use in the home), including devices and
supplies
that are medically necessary and necessary for one or more activities
of daily living and appropriate to assist in the treatment of a
medical
condition, including:
§Orthotic
braces
and orthotics
§Prosthetic
devices
such as artificial eyes, limbs, and braces
§Prosthetic
eyeglasses and contact lenses for the management of severe ophthalmologic
disease
§Hearing
aids
§Diagnosis-specific
disposable
|
Not
a covered benefit.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
Covered
Benefit
|
CHIP
Perinate Newborn
|
CHIP
Perinate
|
medical
supplies, including diagnosis-specific prescribed specialty formula
and
dietary supplements. (See Attachment A)
|
||
Home
and Community Health Services
|
Services
that are provided in the
home
and community, including,
but
not limited to:
§Home
infusion
§Respiratory
therapy
§Visits
for private
duty nursing (R.N.,
L.V.N.)
§Skilled
nursing
visits as defined for
home health purposes (may include
R.N. or L.V.N.).
§Home
health aide
when included
as part of a plan of care
during a period that skilled visits
have been approved.
§Speech,
physical
and occupational therapies.
§Services
are not
intended to replace the CHILD'S caretaker or to provide relief
for the
caretaker
§Skilled
nursing
visits are provided on intermittent level and not intended to provide
24-hour skilled nursing services
§Services
are not
intended to replace 24-hour inpatient or skilled nursing facility
services
|
Not
a covered benefit.
|
Inpatient
Mental Health Services
|
Mental
health services, including for serious mental illness, furnished in a
free-standing psychiatric hospital, psychiatric units of general
acute
care hospitals and state-operated facilities, including, but not
limited
to:
§Neuropsychological
and psychological testing.
§Inpatient
mental
health services are limited to:
§45
days 12-month
inpatient limit
§Includes
inpatient
psychiatric services, up to 12-month period limit, ordered by a
court
of
|
Not
a covered benefit.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
Covered
Benefit
|
CHIP
Perinate Newborn
|
CHIP
Perinate
|
competent
jurisdiction under the provisions of Chapters 573 and 574 of the
Texas
Health and Safety Code, relating to court ordered commitments to
psychiatric facilities. Court order serves as binding determination
of
medical necessity. Any modification or termination of services
must be
presented to the court with jurisdiction over the matter for
xxxxxxxxxxxxx
§00
days of the
inpatient benefit can be converted to residential treatment, therapeutic
xxxxxx care or other 24-hour therapeutically planned and structured
services or sub-acute outpatient (partial hospitalization or
rehabilitative day treatment) mental health services on the basis
of
financial equivalence against the inpatient per diem cost
§20
of the
inpatient days must be held in reserve for inpatient use only
§Does
not require
PCP referral
|
||
Outpatient
Mental Health
Services
|
Mental
health services, including for serious mental illness, provided
on an
outpatient basis, including, but not limited to:
§Medication
management visits do not count against the outpatient visit
limit.
§The
visits can be
furnished in a variety of community-based settings (including school
and
home-based) or in a state-operated facility
§Up
to 60 days
12-month period limit for rehabilitative day treatment
§60
outpatient
visits 12-month period limit
§60
rehabilitative
day treatment days can be converted to outpatient visits on the
basis of
financial equivalence against the day treatment per diem
cost
|
Not
a covered benefit.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
Covered
Benefit
|
CHIP
Perinate Newborn
|
CHIP
Perinate
|
§60
outpatient
visits can be converted to skills training (psycho educational
skills
development) or rehabilitative day treatment on the basis of financial
equivalence against the outpatient visit cost
§Includes
outpatient psychiatric services, up to 12-month period limit, ordered
by a
court of competent jurisdiction under the provisions of Chapters
573 and
574 of the Texas Health and Safety Code, relating to court ordered
commitments to psychiatric facilities. Court order serves as binding
determination of medical necessity. Any modification or termination
of
services must be presented to the court with jurisdiction over
the matter
for determination
§Inpatient
days
converted to sub-acute outpatient services are in addition to the
outpatient limits and do not count towards those limits
§A
Qualified Mental
Health Professional (QMHP), as defined by and credentialed through
Texas
Department of State Health Services (DSHS) standards (TAC Title
25, Part
II, Chapter 412), is a Local Mental Health Authorities provider.
A QMHP
must be working under the authority of an DSHS entity and be supervised
by
a licensed mental health professional or physician. QMHPs are acceptable
providers as long as the services would be within the scope of
the
services that are typically provided by QMHPs. Those services include
individual and group skills training (which can be components of
interventions such as day treatment and in-home services), patient
and
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
Covered
Benefit
|
CHIP
Perinate Newborn
|
CHIP
Perinate
|
family
education, and crisis services
§Does
not require
PCP referral
|
||
Inpatient
Substance Abuse Treatment Services
|
Services
include, but are not limited
to:
§Inpatient
and
residential substance abuse treatment services including detoxification
and crisis stabilization, and 24-hour residential rehabilitation
programs
§Does
not require
PCP referral
§Medically
necessary detoxification/stabilization services, limited to 14
days per
12-month period.
§24-hour
residential rehabilitation programs, or the equivalent, up to 60
days per
12-month period.
§30
days may be
converted to partial hospitalization or intensive outpatient
rehabilitation, on the basis of financial equivalence against the
inpatient per diem cost
§30
days must be
held in reserve for inpatient use only.
|
Not
a covered benefit.
|
Outpatient
Substance Abuse Treatment Services
|
§Services
include,
but are not limited to, the following:
§Prevention
and
intervention services that are provided by physician and non-physician
providers, such as screening, assessment and referral for chemical
dependency disorders.
§Intensive
outpatient services is defined as an organized non-residential
service
providing structured group and individual therapy, educational
services,
and life skills training which consists of at least 10 hours per
week for
four to 12 weeks, but less than 24 hours per day
§Outpatient
treatment service is defined as consisting of at least one to two
hours
per week
|
Not
a covered benefit.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
Covered
Benefit
|
CHIP
Perinate Newborn
|
CHIP
Perinate
|
providing
structured group and individual therapy, educational services,
and life
skills training
§Outpatient
treatment services up to a maximum of:
§Intensive
outpatient program (up to 12 weeks per 12-month period)
§Outpatient
services (up to six-months per 12-month period)
§Does
not require
PCP referral
|
||
Rehabilitation
Services
|
Services
include, but are not limited to, the following:
§Habilitation
(the
process of supplying a child with the means to reach age-appropriate
developmental milestones through therapy or treatment) and rehabilitation
services include, but are not limited to the following:
§Physical,
occupational and speech therapy
§Developmental
assessment
|
Not
a covered benefit.
|
Hospice
Care Services
|
Services
include, but are not limited to:
§Palliative
care,
including medical and support services, for those children who
have six
months or less to live, to keep patients comfortable during the
last weeks
and months before death
§Treatment
for
unrelated conditions is unaffected
§Up
to a maximum of
120 days with a 6 month life expectancy
§Patients
electing
hospice services waive their rights to treatment related to their
terminal
illnesses; however, they may cancel this election at anytime
§Services
apply to
the hospice diagnosis
|
Not
a covered benefit.
|
Emergency
Services, including Emergency Hospitals, Physicians, and Ambulance
Services
|
HMO
cannot require authorization as a condition for payment for emergency
conditions labor and
|
HMO
cannot require authorization as a condition for payment for emergency
conditions related to
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
Covered
Benefit
|
CHIP
Perinate Newborn
|
CHIP
Perinate
|
delivery.
Covered
services include, but are not limited to, the following:
§Emergency
services
based on prudent lay person definition of emergency health
condition
§Hospital
emergency
department room and ancillary services and physician services 24
hours a
day, 7 days a week, both by in-network and out-of-network
providers
§Medical
screening
examination
§Stabilization
services
§Access
to DSHS
designated Xxxxx 0 and Level II trauma centers or hospitals meeting
equivalent levels of care for emergency services
§Emergency
ground,
air and water transportation
§Emergency
dental
services, limited to fractured or dislocated jaw, traumatic damage
to
teeth, and removal of cysts.
|
labor
with delivery.
Covered
services are limited to those emergency services that are directly
related
to the delivery of the unborn child until birth.
§Emergency
services
based on prudent lay person definition of emergency health
condition
§Medical
screening
examination to determine emergency when directly related to the
delivery
of the covered unborn child.
§ Stabilization
services related to the labor with delivery of the covered unborn
child.
§Emergency
ground,
air and water transportation for labor and threatened labor is
a covered
benefit
Benefit
limits: Post-delivery services or complications resulting in the
need for
emergency services for the mother of the CHIP Perinate are not
a covered
benefit.
|
|
Transplants
|
Services
include, but are not limited to, the following:
§Using
up-to-date
FDA guidelines, all non-experimental human organ and tissue transplants
and all forms of non-experimental corneal, bone marrow and peripheral
stem
cell transplants, including donor medical expenses.
|
Not
a covered benefit.
|
Vision
Benefit
|
The
health plan may reasonably limit the cost of the frames/lenses.
Services
include:
§One
examination of
the eyes to determine the need for and prescription for corrective
lenses
per 12-month period, without authorization
§One
pair of
non-prosthetic eyewear per 12-month period
|
Not
a covered benefit.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
Covered
Benefit
|
CHIP
Perinate Newborn
|
CHIP
Perinate
|
Chiropractic
Services
|
§Services
do not
require physician prescription and are limited to spinal
subluxation.
|
Not
a covered benefit.
|
Tobacco
Cessation Program
|
Covered
up to $100 for a 12- month period limit for a plan- approved program
.
§Health
Plan
defines plan-approved program.
§May
be subject to
formulary requirements.
|
Not
a covered benefit.
|
Case
Management and Care Coordination Services
|
These
services include outreach informing, case management, care coordination
and community referral.
|
Covered
benefit.
|
Value-added
services
|
See
Attachment B-3.2
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
CHIP
PERINATAL PROGRAM EXCLUSIONS FROM COVERED
SERVICES
FOR CHIP
PERINATES
|
·
|
For
CHIP Perinates in families with incomes at or below 185% of the
Federal
Poverty Level, inpatient facility charges are not a covered benefit
for
the initial Perinatal Newborn admission. "Initial Perinatal Newborn
admission" means the hospitalization associated with the
birth.
|
|
·
|
Inpatient
and outpatient treatments other than prenatal care, labor with
delivery,
and postpartum care related to the covered unborn child until
birth.
|
|
·
|
Inpatient
mental health services.
|
|
·
|
Outpatient
mental health services.
|
|
·
|
Durable
medical equipment or other medically related remedial
devices.
|
|
·
|
Disposable
medical supplies.
|
|
·
|
Home
and community-based health care
services.
|
|
·
|
Nursing
care services.
|
|
·
|
Dental
services.
|
|
·
|
Inpatient
substance abuse treatment services and residential substance abuse
treatment services.
|
|
·
|
Outpatient
substance abuse treatment services.
|
|
·
|
Physical
therapy, occupational therapy, and services for individuals with
speech,
hearing, and language disorders.
|
|
·
|
Hospice
care.
|
|
·
|
Skilled
nursing facility and rehabilitation hospital
services.
|
|
·
|
Emergency
services other than those directly related to the labor with delivery
of
the covered unborn child.
|
|
·
|
Transplant
services.
|
|
·
|
Tobacco
Cessation Programs.
|
|
·
|
Chiropractic
Services.
|
|
·
|
Medical
transportation not directly related to the labor or threatened
labor
and/or delivery of the covered unborn
child.
|
|
·
|
Personal
comfort items including but not limited to personal care kits provided
on
inpatient admission, telephone, television, newborn infant photographs,
meals for guests of patient, and other articles which are not required
for
the specific treatment related to labor with delivery or post partum
care.
|
|
·
|
Experimental
and/or investigational medical, surgical or other health care procedures
or services which are not generally employed or recognized within
the
medical community
|
|
·
|
Treatment
or evaluations required by third parties including, but not limited
to,
those for schools, employment, flight clearance, camps, insurance
or
court
|
|
·
|
Private
duty nursing services when performed on an inpatient basis or in
a skilled
nursing facility.
|
|
·
|
Mechanical
organ replacement devices including, but not limited to artificial
heart
|
|
·
|
Hospital
services and supplies when confinement is solely for diagnostic
testing
purposes and not a part of labor with
delivery
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
|
·
|
Prostate
and mammography screening
|
|
·
|
Elective
surgery to correct vision
|
|
·
|
Gastric
procedures for weight loss
|
|
·
|
Cosmetic
surgery/services solely for cosmetic
purposes
|
|
·
|
Out-of-network
services not authorized by the Health Plan except for emergency
care
related to the labor with delivery of the covered unborn
child.
|
|
·
|
Services,
supplies, meal replacements or supplements provided for weight
control or
the treatment of obesity
|
|
·
|
Acupuncture
services, naturopathy and
hypnotherapy
|
|
·
|
Immunizations
solely for foreign travel
|
|
·
|
Routine
foot care such as hygienic care
|
|
·
|
Diagnosis
and treatment of weak, strained, or flat feet and the cutting or
removal
of corns, calluses and toenails (this does not apply to the removal
of
nail roots or surgical treatment of conditions underlying corns,
calluses
or ingrown toenails)
|
|
·
|
Corrective
orthopedic shoes
|
|
·
|
Convenience
items
|
|
·
|
Orthotics
primarily used for athletic or recreational
purposes
|
|
·
|
Custodial
care (care that assists with the activities of daily living, such
as
assistance in walking, getting in and out of bed, bathing, dressing,
feeding, toileting, special diet preparation, and medication supervision
that is usually self-administered or provided by a caregiver. This
care
does not require the continuing attention of trained medical or
paramedical personnel.)
|
|
·
|
Housekeeping
|
|
·
|
Public
facility services and care for conditions that federal, state,
or local
law requires be provided in a public facility or care provided
while in
the custody of legal authorities
|
|
·
|
Services
or supplies received from a nurse, which do not require the skill
and
training of a nurse
|
|
·
|
Vision
training, vision therapy, or vision
services
|
|
·
|
Reimbursement
for school-based physical therapy, occupational therapy, or speech
therapy
services are not covered
|
|
·
|
Donor
non-medical expenses
|
|
·
|
Charges
incurred as a donor of an
organ
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
CHIP
PERINATAL PROGRAM EXCLUSIONS FROM COVERED
SERVICES
FOR CHIP PERINATE
NEWBORNS
With
the
exception of the first bullet, all the following exclusions match those found
in
the
CHIP
Program.
|
·
|
For
CHIP Perinate Newborns in families with incomes at or below 185%
of the
Federal Poverty Level, inpatient facility charges are not a covered
benefit for the initial Perinate Newborn admission. "Initial Perinate
Newborn admission" means the hospitalization associated with the
birth.
|
|
·
|
Inpatient
and outpatient infertility treatments or reproductive services
other than
prenatal care, labor and delivery, and care related to disease,
illnesses,
or abnormalities related to the reproductive
system
|
|
·
|
Personal
comfort items including but not limited to personal care kits provided
on
inpatient admission, telephone, television, newborn infant photographs,
meals for guests of patient, and other articles which are not required
for
the specific treatment of sickness or
injury
|
|
·
|
Experimental
and/or investigational medical, surgical or other health care procedures
or services which are not generally employed or recognized within
the
medical community
|
|
·
|
Treatment
or evaluations required by third parties including, but not limited
to,
those for schools, employment, flight clearance, camps, insurance
or
court
|
|
·
|
Private
duty nursing services when performed on an inpatient basis or in
a skilled
nursing facility.
|
|
·
|
Mechanical
organ replacement devices including, but not limited to artificial
heart
|
|
·
|
Hospital
services and supplies when confinement is solely for diagnostic
testing
purposes, unless otherwise pre-authorized by Health
Plan
|
|
·
|
Prostate
and mammography screening
|
|
·
|
Elective
surgery to correct vision
|
|
·
|
Gastric
procedures for weight loss
|
|
·
|
Cosmetic
surgery/services solely for cosmetic
purposes
|
|
·
|
Out-of-network
services not authorized by the Health Plan except for emergency
care and
physician services for a mother and her newborn(s) for a minimum
of 48
hours following an uncomplicated vaginal delivery and 96 hours
following
an uncomplicated delivery by caesarian
section
|
|
·
|
Services,
supplies, meal replacements or supplements provided for weight
control or
the treatment of obesity, except for the services associated with
the
treatment for morbid obesity as part of a treatment plan approved
by the
Health Plan
|
|
·
|
Acupuncture
services, naturopathy and
hypnotherapy
|
|
·
|
Immunizations
solely for foreign travel
|
|
·
|
Routine
foot care such as hygienic care
|
|
·
|
Diagnosis
and treatment of weak, strained, or flat feet and the cutting or
removal
of corns, calluses and toenails (this does not apply to the removal
of
nail roots or surgical treatment of conditions underlying corns,
calluses
or ingrown toenails)
|
|
·
|
Replacement
or repair of prosthetic devices and durable medical equipment due
to
misuse, abuse or loss when confirmed by the Member or the
vendor
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
|
·
|
Corrective
orthopedic shoes
|
|
·
|
Convenience
items
|
|
·
|
Orthotics
primarily used for athletic or recreational
purposes
|
|
·
|
Custodial
care (care that assists a child with the activities of daily living,
such
as assistance in walking, getting in and out of bed, bathing, dressing,
feeding, toileting, special diet preparation, and medication supervision
that is usually self-administered or provided by a parent. This
care does
not require the continuing attention of trained medical or paramedical
personnel.) This exclusion does not apply to hospice
services.
|
|
·
|
Housekeeping
|
|
·
|
Public
facility services and care for conditions that federal, state,
or local
law requires be provided in a public facility or care provided
while in
the custody of legal authorities
|
|
·
|
Services
or supplies received from a nurse, which do not require the skill
and
training of a nurse
|
|
·
|
Vision
training and vision therapy
|
|
·
|
Reimbursement
for school-based physical therapy, occupational therapy, or speech
therapy
services are not covered except when ordered by a
Physician/PCP
|
|
·
|
Donor
non-medical expenses
|
|
·
|
Charges
incurred as a donor of an organ when the recipient is not covered
under
this health plan
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
CHIP
& CHIP PERINATAL PROGRAM DME/SUPPLIES
Note:
DME/SUPPLIES are not a covered benefit for CHIP Perinate
Members
but
are a benefit for CHIP Perinate Newborns.
SUPPLIES
|
COVERED
|
EXCLUDED
|
COMMENTS/MEMBER
CONTRACT
PROVISIONS
|
Ace
Bandages
|
X
|
Exception:
If provided by and billed through the clinic or home care
agency
it is covered as an incidental supply.
|
|
Alcohol,
rubbing
|
X
|
Over-the-counter
supply.
|
|
Alcohol,
swabs
(diabetic)
|
X
|
Over-the-counter
supply not covered, unless RX provided at time of
dispensing.
|
|
Alcohol,
swabs
|
X
|
Covered
only when received with IV therapy or central line
kits/supplies.
|
|
Xxx
Kit Epinephrine
|
X
|
A
self-injection kit used by patients highly allergic to bee
stings.
|
|
Arm
Sling
|
X
|
Dispensed
as part of office visit.
|
|
Attends
(Diapers)
|
X
|
Coverage
limited to children age 4 or over only when prescribed by
a
physician and used to provide care for a covered diagnosis as
outlined
in a treatment care plan.
|
|
Bandages
|
X
|
||
Basal
Thermometer
|
X
|
Over-the-counter
supply.
|
|
Batteries
– initial
|
X
|
.
|
For
covered DME items
|
Batteries
– replacement
|
X
|
For
covered DME when replacement is necessary due to normal
use.
|
|
Betadine
|
X
|
See
IV therapy supplies.
|
|
Books
|
X
|
||
Clinitest
|
X
|
For
monitoring of diabetes.
|
|
Colostomy
Bags
|
See
Ostomy Supplies.
|
||
Communication
Devices
|
X
|
||
Contraceptive
Jelly
|
X
|
Over-the-counter
supply. Contraceptives are not covered under the
plan.
|
|
Cranial
Head Mold
|
X
|
||
Diabetic
Supplies
|
X
|
Monitor
calibrating solution, insulin syringes, needles, lancets,
lancet
device, and glucose strips.
|
|
Diapers/Incontinent
Briefs/Chux
|
X
|
Coverage
limited to children age 4 or over only when prescribed by
a
physician and used to provide care for a covered diagnosis as
outlined
in a treatment care plan
|
|
Diaphragm
|
X
|
Contraceptives
are not covered under the plan.
|
|
Diastix
|
X
|
For
monitoring diabetes.
|
|
Diet,
Special
|
X
|
||
Distilled
Water
|
X
|
||
Dressing
Supplies/Central
Line
|
X
|
Syringes,
needles, Tegaderm, alcohol swabs, Betadine swabs or
ointment,
tape. Many times these items are dispensed in a kit when
includes
all necessary items for one dressing site change.
|
|
Dressing
Supplies/Decubitus
|
X
|
Eligible
for coverage only if receiving covered home care for wound
care.
|
|
Dressing
Supplies/Peripheral
IV
Therapy
|
X
|
Eligible
for coverage only if receiving home IV therapy.
|
|
Dressing
Supplies/Other
|
X
|
||
Dust
Mask
|
X
|
||
Ear
Molds
|
X
|
Custom
made, post inner or middle ear
surgery
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
SUPPLIES
|
COVERED
|
EXCLUDED
|
COMMENTS/MEMBER
CONTRACT
PROVISIONS
|
Electrodes
|
X
|
Eligible
for coverage when used with a covered DME.
|
|
Enema
Supplies
|
X
|
Over-the-counter
supply.
|
|
Enteral
Nutrition
Supplies
|
X
|
Necessary
supplies (e.g., bags, tubing, connectors, catheters, etc.)
are
eligible
for coverage. Enteral nutrition products are not covered
except
for those prescribed for hereditary metabolic disorders, a
non-
function
or disease of the structures that normally permit food to
reach
the small bowel, or malabsorption due to disease
|
|
Eye
Patches
|
X
|
Covered
for patients with amblyopia.
|
|
Formula
|
X
|
Exception:
Eligible for coverage only for chronic hereditary metabolic disorders
a
non-function or disease of the structures that normally permit
food to
reach the small bowel; or malabsorption due to disease (expected
to last
longer than 60 days when prescribed by the physician and authorized
by
plan.) Physician documentation to justify prescription of formula
must
include:
·Identification
of a metabolic disorder, dysphagia that results in a medical need
for a
liquid diet, presence of a gastrostomy, or disease resulting in
malabsorption that requires a medically necessary nutritional
product
Does
not include formula:
·For
members
who could be sustained on an age-appropriate diet.
·Traditionally
used for infant feeding
·In
pudding
form (except for clients with documented oropharyngeal motor dysfunction
who receive greater than 50 percent of their daily caloric intake
from
this product)
·For
the
primary diagnosis of failure to thrive, failure to gain weight,
or lack of
growth or for infants less than twelve months of age unless medical
necessity is documented and other criteria, listed above, are
met.
Food
thickeners, baby food, or other regular grocery products that
can
be blenderized and used with an enteral system that are not
medically
necessary, are not covered, regardless of whether these
regular
food products are taken orally or parenterally.
|
|
Gloves
|
X
|
Exception:
Central line dressings or wound care provided by home care
agency.
|
|
Hydrogen
Peroxide
|
X
|
Over-the-counter
supply.
|
|
Hygiene
Items
|
X
|
||
Incontinent
Pads
|
X
|
Coverage
limited to children age 4 or over only when prescribed by
a
physician and used to provide care for a covered diagnosis as outlined
in
a treatment care plan
|
|
Insulin
Pump (External)
Supplies
|
X
|
Supplies
(e.g., infusion sets, syringe reservoir and dressing, etc.)
are
eligible
for coverage if the pump is a covered item.
|
|
Irrigation
Sets, Wound
Care
|
X
|
Eligible
for coverage when used during covered home care for
wound
care.
|
|
Irrigation
Sets, Urinary
|
X
|
Eligible
for coverage for individual with an indwelling urinary
catheter.
|
|
IV
Therapy Supplies
|
X
|
Tubing,
filter, cassettes, IV pole, alcohol swabs, needles, syringes
and
any other related supplies necessary for home IV
therapy.
|
|
K-Y
Jelly
|
X
|
Over-the-counter
supply.
|
|
Lancet
Device
|
X
|
Limited
to one device only.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-2.2 – CHIP Perinatal Covered
Services
|
Version
1.7
|
SUPPLIES
|
COVERED
|
EXCLUDED
|
COMMENTS/MEMBER
CONTRACT
PROVISIONS
|
Lancets
|
X
|
Eligible
for individuals with diabetes.
|
|
Med
Ejector
|
X
|
||
Needles
and
Syringes/Diabetic
|
See
Diabetic Supplies
|
||
Needles
and
Syringes/IV
and
Central
Line
|
See
IV Therapy and Dressing Supplies/Central Line.
|
||
Needles
and
Syringes/Other
|
X
|
Eligible
for coverage if a covered IM or SubQ medication is being
administered
at home.
|
|
Normal
Saline
|
See
Saline, Normal
|
||
Novopen
|
X
|
||
Ostomy
Supplies
|
X
|
Items
eligible for coverage include: belt, pouch, bags, wafer, face plate,
insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape,
skin
prep, adhesives, drain sets, adhesive remover, and pouch
deodorant.
Items
not eligible for coverage include: scissors, room deodorants, cleaners,
rubber gloves, gauze, pouch covers, soaps, and lotions.
|
|
Parenteral
Nutrition/Supplies
|
X
|
Necessary
supplies (e.g., tubing, filters, connectors, etc.) are
eligible
for
coverage when the Health Plan has authorized the parenteral
nutrition.
|
|
Saline,
Normal
|
X
|
Eligible
for coverage:
a)
when used to dilute medications for nebulizer treatments;
b)
as part of covered home care for wound care;
c)
for indwelling urinary catheter irrigation.
|
|
Xxxxx
Sleeve
|
X
|
||
Xxxxx
Socks
|
X
|
||
Suction
Catheters
|
X
|
||
Syringes
|
See
Needles/Syringes.
|
||
Tape
|
See
Dressing Supplies, Ostomy Supplies, IV Therapy
Supplies.
|
||
Tracheostomy
Supplies
|
X
|
Cannulas,
Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for
coverage.
|
|
Under
Pads
|
See
Diapers/Incontinent Briefs/Chux.
|
||
Unna
Boot
|
X
|
Eligible
for coverage when part of wound care in the home setting.
Incidental
charge when applied during office visit.
|
|
Urinary,
External
Catheter
& Supplies
|
X
|
Exception:
Covered when used by incontinent male where injury to
the
urethra prohibits use of an indwelling catheter ordered by
the
PCP
and approved by the plan
|
|
Urinary,
Indwelling
Catheter
& Supplies
|
X
|
Cover
catheter, drainage bag with tubing, insertion tray,
irrigation
set
and normal saline if needed.
|
|
Urinary,
Intermittent
|
X
|
Cover
supplies needed for intermittent or straight
catherization.
|
|
Urine
Test Kit
|
X
|
When
determined to be medically necessary.
|
|
Urostomy
supplies
|
See
Ostomy Supplies.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3 – Value-added Services
|
Version
1.7
|
DOCUMENT
HISTORY LOG
|
|||
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version of Attachment B-3, Value-added Services.
|
|
Revision
|
1.1
|
June
30, 2006
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.2
|
September
1. 2006
|
Revised
Physical Health Value-added Services to include Home Visits to New
Mothers. Revised the certification provision by changing the start
date
for the 12-month provision of services.
|
Revision
|
1.3
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment removed the separate signature requirement for Attachment
B-3,
Value-added Services. By signing the Contract and/or Contract Amendment,
the HMO certifies that it will provide the Value-added Services from
September 1, 2006 through August 31, 2007.
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
1
Status should be represented as “Baseline” for initial issuances,
“Revision” for changes to the Baseline version, and “Cancellation” for
withdrawn versions
2
Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3
Brief
description of the changes to the document made in the
revision.
|
1 of
5
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3 – Value-added Services
|
Version
1.7
|
ATTACHMENT
B-3: VALUE-ADDED SERVICES
September
1, 2006 – August 31, 2007
HMO:
|
Superior
HealthPlan, Inc.
|
HMO
PROGRAM:
|
CHIP
|
SERVICE
AREA(S):
|
Bexar,
El Paso, Lubbock, Nueces, and Xxxxxx
|
Physical
Health Value-added Services
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Vision
|
20%
discount off of Upgraded Hardware- The Member will receive a 20%
discount
on upgraded hardware.
|
There
is no limitation on the number of times the discount can be
utilized.
|
TVHP
contracted providers.
|
Pharmacy
|
Provides
members with a $15.00 per household per quarter credit toward over
the
counter medications and supplies.
|
Services
must be sought from contracted pharmacies only. Items eligible for
purchase under this benefit are over-the-counter, health related
items
only.
|
Pharmacy
Data Management contracted
providers.
|
2
of
5
Contractual
Document (CD)
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
Subject:
Attachment B-3 – Value-added Services
|
Version
1.7
|
Physical
Health Value-added Services
Physical
Health Value-added Services
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Transportation
|
For
Members in need of transportation that cannot access transportation
in a
timely manner, Superior will provide bus tokens to ensure that Members
have a means of accessing their provider appointment.
|
Members
in the Nueces Service Area. The Transportation Authority in this
area will
not agree to allow the plan to purchase bus vouchers or tokens. The
bus
tokens must be requested in advance of a provider visit and authorized
by
Superior’s Member Services Department.
|
Transit
Authorities in applicable Service Area.
|
NurseWise
|
Twenty-four
hour nurse advice line
|
Available
to all members by calling the Member Services toll-free
number
|
NurseWise,
an affiliate of Centene Corporation
|
Home
Visits to New Mothers
|
Superior
Social Work and/or CONNECTIONS staff will make home visits to any
Member
with a new baby. This visit provides for resource and education
coordination as identified in the visit, [what does this mean?] and
ensures Members and the new babies are keeping all post natal and
newborn
doctor visits. This benefit is available to all Superior
Members who have delivered a baby.
|
Only
that a member consent to the home visit.
|
Superior’s
CONNECTIONS and Social Work staff provide this
service.
|
3
of
5
Contractual
Document (CD)
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
Subject:
Attachment B-3 – Value-added Services
|
Version
1.7
|
Behavioral
Health Value-added Services for Members Under
21
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Behavioral Health
Value-added Services for Members 21 and Over
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
ADDITIONAL
INFORMATION:
1.
|
Explain
how and when Providers and Members will be notified about the availability
of the value-added services to be
provided.
|
Value
Added Services information will be included in the Superior Provider
Manual and also during training sessions. Members will receive this
information via the Plan Comparison Chart, in the Member Handbook,
with
New Member Packets and during orientations. Periodically, Superior
will
also highlight Value Added Services in the Provider and Member
Newsletters
|
4
of 5
Contractual
Document (CD)
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
Subject:
Attachment B-3 – Value-added Services
|
Version
1.7
|
2.
|
Describe
how a Member may obtain or access the value-added services to be
provided.
|
See
explanations provided above for accessing services.
|
A
Member may access the Home Visits to New Mothers service by accepting
a
home visit appointment from a Superior Social Work or CONNECTIONS
staff
member.
|
3.
|
Describe
how the HMO will identify the Value-added Service in administrative
(encounter) data.
|
Superior
will track the value added services through our claims system for
those
value-adds that HIPAA-compliant procedural codes are available (vision,
behavioral health, flu shots). Superior will create a specific benefit
category to track and report the value added services 'separately'
from
our 'capitated' service data. In addition, Superior will have the
ability
to pass this information to the State utilizing the encounter submission
process, as long as the State is able to segregate the value adds
data
from the capitated services data.
|
For
pharmacy services, Superior will receive a data file from the pharmacy
vendor to capture all utilization of the pharmacy value-add
benefit.
|
For
transportation services, Superior will maintain an electronic file
of
transportation services provided for Superior’s
membership.
|
Home
visits to new mothers are tracked through Superior’s case management
system. Each staff member logs each member visit and the outcome/findings
of the visit in Superior’s computer system. Superior will work with HHSC
to establish the most efficient transmission of the
data.
|
4.
|
By
signing the Contract and/or Contract Amendment HMO certifies that
it will
provide the approved Value-added Services described herein from September
1, 2006 through August 31, 2007.
|
5
of
5
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3 – Value-added Service
|
Version
1.7
|
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version of Attachment B-3, Value-added Services.
|
|
Revision
|
1.1
|
June
30, 2006
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.2
|
September
1, 2006
|
Revised
the Physical Health Value-added Services to include Home Visits to
New Mothers. Revised the certification provision by changing the
start
date for the 12-month provision of services.
|
Revision
|
1.3
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment removed the separate signature requirement for Attachment
B-3,
Value-added Services. By signing the Contract and/or Contract Amendment,
the HMO certifies that it will provide the Value-added Services
from
September 1, 2006 through August 31, 2007.
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-3, Value-added
Services.
|
1
Status should be represented as “Baseline” for initial
issuances, “Revision” for changes to the Baseline version, and
“Cancellation” for withdrawn versions
2
Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3
Brief
description of the changes to the document made in the
revision.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3 – Value-added Service
|
Version
1.7
|
ATTACHMENT
B-3: VALUE-ADDED SERVICES
September
1, 2006 – August 31, 2007
HMO:
|
Superior
HealthPlan, Inc.
|
HMO
PROGRAM:
|
Medicaid
|
SERVICE
AREA(S):
|
Bexar,
El Paso, Lubbock, Nueces, and
Xxxxxx
|
Physical
Health Value-added Services
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Vision
|
Members
are allowed to purchase any prescription eyewear and apply a $100
allowance toward the purchase of that eyewear.
|
Members
are responsible for any charges that exceed the $100 allowance.
Disposable
contact lenses are excluded from this $100 allowance. This Value-Added
benefit is only allowed one time per benefit period (i.e.
24-months).
|
TVHP
contracted providers.
|
Pharmacy
|
Provides
members with a $15.00 per household per quarter credit toward over
the
counter medications and supplies.
|
Services
must be sought from contracted pharmacies only. Items eligible
for
purchase under this benefit are over-the-counter, health related
items
only.
|
Pharmacy
Data Management contracted
providers.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3 – Value-added Service
|
Version
1.7
|
Physical
Health Value-added Services
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Transportation
|
HMO
will offer tokens or vouchers for bus services to HMO members that
have
trouble accessing the State's Medical Transportation Program in
a timely
manner to ensure access to their provider appointments. In addition,
HMO
will provide transportation to non-medical services such as health
education programs, nutrition classes, and birth preparation classes.
HMO's member service staff will approve and coordinate the transportation
service".
|
Members
in the Nueces Service Area. The Transportation Authority in this
area will
not agree to allow the plan to purchase bus vouchers or
tokens.
The
bus tokens must be requested in advance of a provider visit and
authorized
by Superior’s Member Services Department.
|
Transit
Authorities in applicable Service Area.
|
Adult
Flu Shot
|
During
the flu season months of October through December, Members age
21 or older
will be provided with a flu shot through their Primary Care Provider
(PCP).
|
This
benefit is available to all STAR Adult Members age 21 and over.
These
services must be obtained from the Member’s Primary Care
Provider.
|
It
is anticipated that the Member’s designated Primary Care Provider (PCP)
will render this service.
|
NurseWise
|
Twenty-four
hour nurse advice line
|
Available
to all members by calling the Member Services toll-free
number
|
NurseWise,
an affiliate of Centene Corporation
|
Home
visits to New Mothers
|
Superior
Social Work and/or CONNECTIONS staff will make home visits to any
Member
with a new baby. This visit provides for resource and education
coordination as identified in the visit, and ensures Members and
the new
babies are keeping all post natal and newborn doctor visits. This
benefit
is available to all Superior Members who have delivered a
baby.
|
Only
that a member consent to the home visit.
|
Superior’s
CONNECTIONS and Social Work staff provide this
service.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3 – Value-added Service
|
Version
1.7
|
Behavioral
Health Value-added Services for Members Under
21
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Behavioral
Health
|
Rehabilitation/skills
training. These are services provided to pregnant and parenting
substance
abusers at MHMR centers or in other treatment settings, focusing
both on
substance abuse and parenting issues. An augmentation of standard
substance abuse treatment to focus on the special needs of this
population. Authorized in increments of 15 minutes, with amount,
duration,
and scope based on medical necessity. This benefit is available
to all
Members. It is geared to pregnant women and parenting
Members.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
In addition, the service will be authorized for15-minute increments.
The
amount, duration, and scope are based on medical
necessity.
|
It
is anticipated that Superior’s contracted MHMR providers specializing in
Rehabilitation/Skills training in each Service Area will render
this
service.
|
Behavioral
Health
|
Superior’s
Behavioral Health Subcontractor will authorize Behavioral Health
practitioners in medical settings to provide health psychology
interventions focused on the effective management of chronic medical
conditions. These might include psycho-educational groups for chronic
conditions, individual coaching for patients with chronic disease
states,
or skills training activities.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
The authorization will be tied to medical necessity.
|
It
is anticipated that these services will be rendered by Superior’s
behavioral health practitioners located in Superior’s contracted Federally
Qualified Health Centers.
|
Behavioral
Health
|
Partial
Hospitalization/Extended Day Treatment- An alternative to, or a
step down
from, inpatient care.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
Services are authorized for a minimum of five hours, but for less
than
24-hours per day. The amount, duration, and scope will be based
on
medical
|
It
is anticipated that Superior’s contracted Behavioral Health Providers such
as its’ MHMR facilities and other contracted facilities in
each
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3 – Value-added Service
|
Version
1.7
|
Behavioral
Health Value-added Services for Members Under
21
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
necessity
|
Service
Area will render this service.
|
||
Behavioral
Health
|
Intensive
Outpatient Treatment/Day Treatment (IOP)- Used as an alternative
to or
step down from more restrictive levels of care.
|
These
services must be authorized by Superior’s Behavioral Health Material
Subcontractor. In addition, the service will be authorized for
greater
than one and one half hours, but less than five hours per day.
Amount,
duration, and scope are based on medical necessity.
|
It
is anticipated that Superior’s contracted Behavioral Health Providers such
as the MHMR or other facilities in each Service Area will render
this
service.
|
Behavioral
Health Value-added Services for Members 21 and
Over
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Behavioral
Health
|
Rehabilitation/skills
training. These are services provided to pregnant and parenting
substance
abusers at MHMR centers or in other treatment settings, focusing
both on
substance abuse and parenting issues. An augmentation of standard
substance abuse treatment to focus on the special needs of this
population. This benefit is available to all Members. It is geared
to
pregnant women and parenting Members.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
In addition, the service will be authorized for15-minute increments.
The
amount, duration, and scope are based on medical
|
It
is anticipated that Superior’s contracted MHMR providers specializing in
Rehabilitation/Skills training in each Service Area will render
this
service.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3 – Value-added Service
|
Version
1.7
|
Behavioral
Health Value-added Services for Members 21 and
Over
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
necessity
|
|||
Behavioral
Health
|
Partial
Hospitalization/Extended Day Treatment- An alternative to, or a
step down
from, inpatient care.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
Services are authorized for a minimum of five hours, but for less
than
24-hours per day. The amount, duration, and scope will be based
on medical
necessity.
|
It
is anticipated that Superior’s contracted Behavioral Health Providers such
as its’ MHMR facilities and other contracted facilities in each Service
Area will render this service.
|
Behavioral
Health
|
Superior’s
Behavioral Health Subcontractor, will authorize Behavioral Health
practitioners in medical settings to provide health psychology
interventions focused on the effective management of chronic medical
conditions. These might include psycho-educational groups for chronic
conditions, individual coaching for patients with chronic disease
states,
or skills training activities.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
The authorization will be tied to medical necessity.
|
It
is anticipated that these services will be rendered by Superior’s
behavioral health practitioners located in Superior’s contracted Federally
Qualified Health Centers.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3 – Value-added Service
|
Version
1.7
|
Behavioral
Health Value-added Services for Members 21 and
Over
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Behavioral
Health
|
Intensive
Outpatient Treatment/Day Treatment (IOP)- Used as an alternative
to or
step down from more restrictive levels of care.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
In addition, the service will be authorized for greater than one
and one
half hours, but less than five hours per day. Amount, duration,
and scope
are based on medical necessity.
|
It
is anticipated that Superior’s contracted Behavioral Health Providers such
as the MHMR or other facilities in each Service Area will render
this
service.
|
Behavioral
Health
|
Off-site
Services such as home-based services, , mobile crisis, intensive
case
management. It should be noted that staff must go off-site to provide
such
services. These services are provided to Members to help reduce
or avoid
inpatient admissions by a community based, mobile, multi-disciplinary
team
of licensed clinicians and trained, unlicensed workers working
under the
direction of a licensed professional.
|
These
services must be authorized by Superior’s Behavioral Health Subcontractor.
The amount, duration and scope are based on medical
necessity.
|
It
is anticipated that Superior’s contracted Behavioral Health Providers such
as the MHMR in each Service Area will render this
service.
|
ADDITIONAL
INFORMATION:
1.
|
Explain
how and when Providers and Members will be notified about the availability
of the value-added services to be
provided.
|
Value
Added Services information will be included in the Superior Provider
Manual and also during training sessions. Members will receive
this
information via the Plan Comparison Chart, in the Member Handbook,
with
New Member Packets and during orientations.
Periodically,
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3 – Value-added Service
|
Version
1.7
|
Superior
will also highlight Value Added Services in the Provider and Member
Newsletters.
2.
|
Describe
how a Member may obtain or access the value-added services to be
provided.
|
See
explanations provided above for accessing services.
A
Member may access the Home Visits to New Mothers service by accepting
a
home visit appointment from a Superior Social Work or CONNECTIONS
staff
member.
|
3.
|
Describe
how the HMO will identify the Value-added Service in administrative
(encounter) data.
|
Superior
will track the value added services through our claims system for
those
value-adds that HIPAA-compliant procedural codes are available
(vision,
behavioral health, flu shots). Superior will create a specific
benefit
category to track and report the value added services 'separately'
from
our 'capitated' service data. In addition, Superior will have the
ability
to pass this information to the State utilizing the encounter submission
process, as long as the State is able to segregate the value adds
data
from the capitated services data. For pharmacy services,
Superior will receive a data file from the pharmacy vendor to capture
all
utilization of the pharmacy value-add benefit
For
transportation services, Superior will maintain an electronic file
of
transportation services provided for Superior’s membership.
Home
visits to new mothers are tracked through Superior’s case management
system. Each staff member logs each member visit and the outcome/findings
of the visit in Superior’s computer system. Superior will work with HHSC
to establish the most efficient transmission of the
data.
|
4.
|
By
signing the Contract and/or Contract Amendment HMO certifies that
it will
provide the approved Value-added Services described herein from
September
1, 2006 through August 31, 2007
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3.1 – STAR+PLUS Value-added Services
|
Version
1.7
|
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
1.0
|
Initial
version of Attachment B-3, Value-added Services
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
Attachment B-3, Value Added Services, by adding Attachment B-3.1,
STAR+PLUS Value Added Services. This is the initial version of Attachment
B-3.1, STAR+PLUS Value Added Services.
|
Revision
|
1.2
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-3.1, STAR+PLUS Value Added
Services
|
Revision
|
1.3
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-3.1, STAR+PLUS Value Added
Services
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment removed the separate signature requirement for Attachment
B-3.1,
STAR+PLUS Value-added Services. By signing the Contract and/or
Contract Amendment, the HMO certifies that it will provide the Value-added
Services from January 1, 2007 through August 31, 2007.
|
Revision
|
1.5
|
January
1, 2007
|
Revised
Attachment B-3.1, STAR+PLUS Value Added Services to state that only
non-dual members are eligible for dental benefits and to clarify
description of Out-of-Home Respite.
|
Revision
|
1.6
|
February
1, 2007
|
Revised
Attachment B-3.1, Value Added Services, to clarify the coverage period
for
the VAS.
|
Revision
|
1.7
|
July
1, 2007
|
Revised
Attachment B-3.1, Value Added Services, to clarify the coverage period
for
the VAS.
|
1 Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn
versions
2
Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3 Brief
description of the changes to the document made in the
revision.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3.1 – STAR+PLUS Value-added Services
|
Version
1.7
|
ATTACHMENT
B-3.1: STAR+PLUS VALUE-ADDED SERVICES
February
1, 2007 through August 31, 2007
HMO: Superior
HealthPlan, Inc.
SERVICE
AREA(S):
Bexar
& Nueces
Physical
Health Value-added Services
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Pharmacy
|
Provides
members with a $15.00 per household quarter credit toward over the
counter
medications and supplies.
|
Services
must be sought from contracted pharmacies only. Items eligible
for purchase under this benefit are over-the-counter health related
items
only.
|
Pharmacy
Data Management contracted providers.
|
Dental
|
Basic
dental coverage, which includes the following CPT codes: 0140-
Emergency Evaluation; 0120- Periodic Oral Evaluation; 0220- Intra-oral
Periapaical First Film; 0230- Intraoral Periapical- Each Additional;
0240-
Intra-oral Occlusal Film; 0270- Bitewings- single film; 0272- Bitewings-
two films; 07110- Extraction- Single Tooth/Routine to Difficult;
and 07120
Extraction- Each Additional.
|
If
a Member receives services that are outside of the scope of the CPT
Codes
listed, the Member will be subject to a co-payment of 75% of the
dentists’
usual and customary charges for those services.
Only
non-dual members are eligible for dental benefits.
|
OraQuest
Dental Network
|
Adult
Flu Shot
|
During
the flu season months of October through December, Members age
21 or older will be provided with a flu shot through their Primary
Care
Provider (PCP).
|
This
benefit is limited to non-dual STAR+PLUS Adult members age 21 and
over. Members may self-refer for this service.
|
Designated
Primary Care Provider
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3.1 – STAR+PLUS Value-added Services
|
Version
1.7
|
Physical
Health Value-added Services
|
|||
NurseWise
|
Twenty-four
hour nurse advice line
|
Available
to all members by calling the Member Services toll-free
number
|
NurseWise,
an affiliate of Centene Corporation
|
Community
Based Long Term Care Value-added Services
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Out-of-Home
Respite
|
Respite
services for a caretaker who needs relief from their care-giving
responsibilities because of severe physical or mental stress or who
is
temporarily unable to provide care because of illness, hospitalization,
family emergency or other obligation. Services will be provided in
the
setting most appropriate to the Member's needs including assisted
living
facilities, adult xxxxxx care homes, or adult day activity
centers.
|
This
benefit is limited to non-dual Adult non-Waiver Members age 21 and
over. Must be prior authorized. Limited to up to ten hours per
month of in home respite services.
|
Network
providers.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3.1 – STAR+PLUS Value-added Services
|
Version
1.7
|
Behavioral
Health Value-added Services for Members 21 and
Over
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Behavioral
Health
|
Health
Psychology Interventions provided by a behavioral health practitioner
in a
medical setting that focuses on the effective management of chronic
medical conditions. This might include psycho-educational
groups for chronic conditions, individual coaching for patients with
chronic disease states, or skills training activities.
|
Limited
to non-dual Members only. Services must be authorized and is
based on medical necessity.
|
Network
Federally Qualified Health Centers (FQHCs)
|
Behavioral
Health
|
Intensive
Outpatient Treatment/Day Treatment (IOP)- Used as an alternative
to step
down from more restrictive levels of care.
|
Limited
to non-dual Members only. Services must be authorized and is
based on medical necessity. Services will be authorized for
greater than one and one half hours, but less than five hours per
day.
|
It
is anticipated that behavioral health providers such as the MHMR
or other
facilities within the Service Area will render this
service.
|
Behavioral
Health
|
Partial
Hospitalization/Extended Day Treatment- An alternative to, or a step
down
from, inpatient care.
|
Limited
to non-dual Members only. Services must be authorized and is
based on medical necessity. Services will be authorized for a
minimum of five hours, but for less than 24-hours per day.
|
It
is anticipated that behavioral health providers such as the MHMR
or other
facilities within the Service Area will render this
service.
|
Behavioral
Health
|
Off-site
services such as intensive case management. It should be noted
that staff must go off-site to provide such services. These
services are provided to Members to help reduce or avoid inpatient
admissions by a community based, mobile, multi-disciplinary team
of
licensed clinicians and trained, unlicensed workers working under
the
direction of a licensed professional.
|
Limited
to non-dual Members only. Services must be authorized and is
based on medical necessity.
|
It
is anticipated that behavioral health providers such as the MHMR
or other
facilities within the Service Area will render this
service.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3.1 – STAR+PLUS Value-added Services
|
Version
1.7
|
ADDITIONAL
INFORMATION:
1.
|
Explain
how and when Providers and Members will be notified about the availability
of the value-added services to be
provided.
|
Value
added services information will be included in the Superior Provider
Manual and also during training sessions. Members will receive
this information via the Plan Comparison Chart, in the Member Handbook,
with New Member Packets and during orientations. Periodically,
Superior will also highlight Value Added Services in the Provider
and
member Newsletters.
|
2.
|
Describe
how a Member may obtain or access the value-added services to be
provided.
|
See
explanations provided above for accessing
services.
|
3.
|
Describe
how the HMO will identify the Value-added Service in administrative
(encounter) data.
|
Superior
will track value added services through our claims system for those
value
–adds that are IIPAA-compliant procedural codes are available (flu
shots,
podiatry, etc.). Superior will create specific benefit
categories to track and report the value added services “separately” from
our “capitated” service data. In addition, Superior will have
the ability to pass this information to the State utilizing the encounter
submission process, as long as the Sate is able to segregate the
value
adds data from the capitated services data. For pharmacy
services, Superior will receive a data file from the pharmacy vendor
to
capture all utilization of pharmacy value added benefits. The same
is true
for dental services.
|
4.
|
By
signing the Contract and/or Contract Amendment HMO certifies that
it will
provide the approved Value-added Services described herein from February
1, 2007 through August 31, 2007.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3.2 – CHIP Perinatal Program Value-added
Services
|
Version
1.7
|
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
1.0
|
Initial
version of Attachment B-3, Value-added Services
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
Attachment B-3, Value Added Services, by addingAttachment B-3.1,
STAR+PLUS
Value Added Services.
|
Revision
|
1.2
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-3, Value Added
Services
|
Revision
|
1.3
|
September
1, 2006
|
Revised
Attachment B-3, Value Added Services, by adding Attachment B-3.2,
CHIP
Perinatal Program Value Added Services. This is the initial version
of
Attachment B-3.2, CHIP Perinatal Program Value Added
Services.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment removed the separate signature requirement for Attachment
B-3.2,
CHIP Perinatal Program Value-added Services. By signing the Contract
and/or Contract Amendment, the HMO certifies that it will provide
the
Value-added Services from January 1, 2007 through August 31,
2007.
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-3.2, CHIP Perinatal Program
Value
Added Services.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-3.2, CHIP Perinatal Program
Value
Added Services.
|
Revision
|
1.7
|
July
1, 2007.
|
Contract
amendment did not revise Attachment B-3.2, CHIP Perinatal Program
Value
Added Services
|
1
Status should be represented as “Baseline” for initial issuances,
“Revision” for changes to the Baseline version,
and “Cancellation” for withdrawn versions
2
Revisions should be numbered in accordance according to the version
of the
issuance and sequential numbering of the revision—e.g.,
“1.2” refers to the first version of the document and the second
revision.
3
Brief description of the changes to the document made in the
revision.
|
1
of
4
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3.2 – CHIP Perinatal Program Value-added
Services
|
Version
1.7
|
ATTACHMENT
B-3.2: CHIP PERINATAL PROGRAM VALUE-ADDED SERVICES
January
1, 2007 through August 31, 2007
HMO:
|
|
SERVICE
AREA(S):
|
Physical
Health Value-added Services
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
Behavioral
Health Value-added Services for Members Under 21
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
2
of
4
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3.2 – CHIP Perinatal Program Value-added
Services
|
Version
1.7
|
Behavioral
Health Value-added Services for Members 21 and
Over
|
|||
Value-added
Service
|
Description
of Value-added Services and Members Eligible to Receive the
Services
|
Limitations
or Restrictions
|
Provider(s)
responsible for providing this service
|
ADDITIONAL
INFORMATION:
1.
|
Explain
how and when Providers and Members will be notified about the availability
of the value-added services to be
provided.
|
2.
|
Describe
how a Member may obtain or access the value-added services to be
provided.
|
3
of
4
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-3.2 – CHIP Perinatal Program Value-added
Services
|
Version
1.7
|
3.
|
Describe
how the HMO will identify the Value-added Service in administrative
(encounter) data.
|
4.
|
By
signing the Contract and/or Contract Amendment HMO certifies that
it will
provide the approved Value-added Services described herein from January
1,
2007 through August 31, 2007.
|
4 of
4
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-4 –Performance Improvement Goals
|
Version
1.7
|
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version Attachment B-4, Performance Improvement Goals.
|
|
Revision
|
1.1
|
June
30, 2006
|
Contract
amendment to include STAR+PLUS program (Attachment B-4.1). No change
to
this Section.
|
Revision
|
1.2
|
September
1, 2006
|
Revised
version of Attachment B-4 that includes provisions applicable to
MCOs
participating in the STAR and CHIP Programs.
Updates
the attachment to reflect the changes made in Attachment B-1, Section
8.1.1.1.
|
Revision
|
1.3
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-4, Performance Improvement
Goals.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amended to include Attachment B-4, Performance Improvement Goals
for
SFY2007 and format change.
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-4, Performance Improvement
Goals.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-4, Performance Improvement
Goals.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-4, Performance Improvement
Goals.
|
1Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn
versions
2
Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3Brief
description of the changes to the document made in the
revision.
|
Texas
Health and Human Services Commission
STAR
and CHIP HMO
Performance
Improvement Goals
SFY
2007
(September
1, 2006 – August 31, 2007)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: CHIP
HMO
Service Delivery Area: Bexar SDA
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1:
Improve
Access to Primary Care Services for Members
|
§90%
of Pediatricians will have open panels
§90%
of initial credentialing of PCPs will be finalized within 90 days
of
receipt of application
|
Goal
2:
Improve
Access to Behavioral Health Services for Members
|
§Increase
urgent care appointment availability by 5 percentage points over
the
baseline
§Improve
the percent of psychiatrists accepting new member referrals by 5
percentage points over the baseline
|
Goal
3:
Improve
Current Member Understanding About the CHIP Benefit Renewal
Processes
|
§Member
Services staff will provide verbal reminders about re-enrollment
to 90% of
members
§Member
Services will research 100% of undelivered member mail
for updated and valid demographic
information
|
Additional
information related to the Performance Improvement Goals can be found in
Attachment B-1,
Section
8.1.1.1, to the Contract.
Texas
Health and Human Services Commission
STAR
and CHIP HMO
Performance
Improvement Goals
SFY
2007
(September
1, 2006 – August 31, 2007)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: CHIP
HMO
Service Delivery Area: El Paso SDA
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1:
Improve
Access to Primary Care Services for Members
|
§90%
of
Pediatricians will have open panels
§90%
of
initial credentialing of PCPs will be finalized within 90 days of
receipt
of application
|
Goal
2:
Improve
Access to Behavioral Health Services for Members
|
§Increase
urgent care appointment availability by 5 percentage points over
the
baseline
§Improve
the percent of psychiatrists accepting new member referrals by 5
percentage points over the baseline
|
Goal
3:
Improve
Current Member Understanding About the CHIP Benefit Renewal
Processes
|
§Member
Services staff will provide verbal reminders about re-enrollment
to 90% of
members
§Member
Services will research 100% of undelivered member mail
for updated and valid demographic
information
|
Additional
information related to the Performance Improvement Goals can be found in
Attachment B-1,
Section
8.1.1.1, to the Contract.
Texas
Health and Human Services Commission
STAR
and CHIP HMO
Performance
Improvement Goals
SFY
2007
(September
1, 2006 – August 31, 2007)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: CHIP
HMO
Service Delivery Area: Lubbock SDA
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1:
Improve
Access to Primary Care Services for Members
|
§90%
of
Pediatricians will have open panels
§90%
of
initial credentialing of PCPs will be finalized within 90 days of
receipt
of application
|
Goal
2:
Improve
Access to Behavioral Health Services for Members
|
§Increase
urgent care appointment availability by 5 percentage points over
the
baseline
§Improve
the percent of psychiatrists accepting new member referrals by 5
percentage points over the baseline
|
Goal
3:
Improve
Current Member Understanding About the CHIP Benefit Renewal
Processes
|
§Member
Services staff will provide verbal reminders about re-enrollment
to 90% of
members
§Member
Services will research 100% of undelivered member mail
for updated and valid demographic
information
|
Additional
information related to the Performance Improvement Goals can be found in
Attachment B-1,
Section
8.1.1.1, to the Contract.
Texas
Health and Human Services Commission
STAR
and CHIP HMO
Performance
Improvement Goals
SFY
2007
(September
1, 2006 – August 31, 2007)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: CHIP
HMO
Service Delivery Area: Nueces SDA
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1:
Improve
Access to Primary Care Services for Members
|
§90%
of
Pediatricians will have open panels
§90%
of
initial credentialing of PCPs will be finalized within 90 days of
receipt
of application
|
Goal
2:
Improve
Access to Behavioral Health Services for Members
|
§Increase
urgent care appointment availability by 5 percentage points over
the
baseline
§Improve
the percent of psychiatrists accepting new member referrals by 5
percentage points over the baseline
|
Goal
3:
Improve
Current Member Understanding About the CHIP Benefit Renewal
Processes
|
§Member
Services staff will provide verbal reminders about re-enrollment
to 90% of
members
§Member
Services will research 100% of undelivered member mail
for updated and valid demographic
information
|
Additional
information related to the Performance Improvement Goals can be found in
Attachment B-1,
Section
8.1.1.1, to the Contract.
Texas
Health and Human Services Commission
STAR
and CHIP HMO
Performance
Improvement Goals
SFY
2007
(September
1, 2006 – August 31, 2007)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: CHIP
HMO
Service Delivery Area: Xxxxxx SDA
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1:
Improve
Access to Primary Care Services for Members
|
§90%
of
Pediatricians will have open panels
§90%
of
initial credentialing of PCPs will be finalized within 90 days of
receipt
of application
|
Goal
2:
Improve
Access to Behavioral Health Services for Members
|
§Increase
urgent care appointment availability by 5 percentage points over
the
baseline
§Improve
the percent of psychiatrists accepting new member referrals by 5
percentage points over the baseline
|
Goal
3:
Improve
Current Member Understanding About the CHIP Benefit Renewal
Processes
|
§Member
Services staff will provide verbal reminders about re-enrollment
to 90% of
members
§Member
Services will research 100% of undelivered member mail
for updated and valid demographic
information
|
Additional
information related to the Performance Improvement Goals can be found in
Attachment B-1,
Section
8.1.1.1, to the Contract.
Texas
Health and Human Services Commission
STAR
and CHIP HMO
Performance
Improvement Goals
SFY
2007
(September
1, 2006 – August 31, 2007)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: STAR
HMO
Service Delivery Area: Bexar SDA
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1:
Improve
Access to Primary Care Services for Members
|
§90%
of
Pediatricians will have open panels
§90%
of
initial credentialing of PCPs will be finalized within 90 days of
receipt
of application
|
Goal
2:
Improve
Access to Behavioral Health Services for Members
|
§Increase
urgent care appointment availability by 5 percentage points over
the
baseline
§Improve
the percent of psychiatrists accepting new member referrals by 5
percentage points over the baseline
|
Goal
3:
Improve
Access to Clinically Appropriate Alternatives to Emergency Room Services
Outside of Regular Office Hours
|
§Increase
the number of providers, including urgent care clinics offering after
hour
appointments, by 5% over baseline
§Target
outreach and education 90% of members who have utilized the emergency
room
for primary care services > 2
times
|
Additional
information related to the Performance Improvement Goals can be found in
Attachment B-1,
Section
8.1.1.1, to the Contract.
Texas
Health and Human Services Commission
STAR
and CHIP HMO
Performance
Improvement Goals
SFY
2007
(September
1, 2006 – August 31, 2007)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: STAR
HMO
Service Delivery Area: El Paso SDA
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1:
Improve
Access to Primary Care Services for Members
|
§90%
of
Pediatricians will have open panels
§90%
of
initial credentialing of PCPs will be finalized within 90 days of
receipt
of application
|
Goal
2:
Improve
Access to Behavioral Health Services for Members
|
§Increase
urgent care appointment availability by 5 percentage points over
the
baseline
§Improve
the percent of psychiatrists accepting new member referrals by 5
percentage points over the baseline
|
Goal
3:
Improve
Access to Clinically Appropriate Alternatives to Emergency Room Services
Outside of Regular Office Hours
|
§Increase
the number of providers, including urgent care clinics offering after
hour
appointments, by 5% over baseline
§Target
outreach and education 90% of members who have utilized the emergency
room
for primary care services > 2
times
|
Additional
information related to the Performance Improvement Goals can be found in
Attachment B-1,
Section
8.1.1.1, to the Contract.
Texas
Health and Human Services Commission
STAR
and CHIP HMO
Performance
Improvement Goals
SFY
2007
(September
1, 2006 – August 31, 2007)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: STAR
HMO
Service Delivery Area: Lubbock SDA
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1:
Improve
Access to Primary Care Services for Members
|
§90%
of
Pediatricians will have open panels
§90%
of
initial credentialing of PCPs will be finalized within 90 days of
receipt
of application
|
Goal
2:
Improve
Access to Behavioral Health Services for Members
|
§Increase
urgent care appointment availability by 5 percentage points over
the
baseline
§Improve
the percent of psychiatrists accepting new member
referrals by 5 percentage points
over the baseline
|
Goal
3:
Improve
Access to Clinically Appropriate Alternatives to Emergency Room Services
Outside of Regular Office Hours
|
§Increase
the number of providers, including urgent care clinics offering after
hour
appointments, by 5% over baseline
§Target
outreach and education to 90% of members who have
utilized the emergency room for
primary care services ≥2 times
|
Additional
information related to the Performance Improvement Goals can be found in
Attachment B-1,
Section
8.1.1.1, to the Contract.
Texas
Health and Human Services Commission
STAR
and CHIP HMO
Performance
Improvement Goals
SFY
2007
(September
1, 2006 – August 31, 2007)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: STAR
HMO
Service Delivery Area: Nueces SDA
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1:
Improve
Access to Primary Care Services for Members
|
§90%
of
Pediatricians will have open panels
§90%
of
initial credentialing of PCPs will be finalized within 90 days of
receipt
of application
|
Goal
2:
Improve
Access to Behavioral Health Services for Members
|
§Increase
urgent care appointment availability by 5 percentage points over
the
baseline
§Improve
the percent of psychiatrists accepting new member
referrals by 5 percentage points
over the baseline
|
Goal
3:
Improve
Access to Clinically Appropriate Alternatives to Emergency Room Services
Outside of Regular Office Hours
|
§Increase
the number of providers, including urgent care clinics offering after
hour
appointments, by 5% over baseline
§Target
outreach and education to 90% of members who have
utilized the emergency room for
primary care services ≥2 times
|
Additional
information related to the Performance Improvement Goals can be found in
Attachment B-1,
Section
8.1.1.1, to the Contract.
Texas
Health and Human Services Commission
STAR
and CHIP HMO
Performance
Improvement Goals
SFY
2007
(September
1, 2006 – August 31, 2007)
A.
Health Plan Information
Plan
Name: Superior HealthPlan
HMO
Program: STAR
HMO
Service Delivery Area: Xxxxxx SDA
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1:
Improve
Access to Primary Care Services for Members
|
§90%
of
Pediatricians will have open panels
§90%
of
initial credentialing of PCPs will be finalized within 90 days of
receipt
of application
|
Goal
2:
Improve
Access to Behavioral Health Services for Members
|
§Increase
urgent care appointment availability by 5 percentage points over
the
baseline
§Improve
the percent of psychiatrists accepting new member
referrals by 5 percentage points
over the baseline
|
Goal
3:
Improve
Access to Clinically Appropriate Alternatives to Emergency Room Services
Outside of Regular Office Hours
|
§Increase
the number of providers, including urgent care clinics offering after
hour
appointments, by 5% over baseline
§Target
outreach and education to 90% of members who have
utilized the emergency room for
primary care services ≥2 times
|
Additional
information related to the Performance Improvement Goals can be found in
Attachment B-1,
Section
8.1.1.1, to the Contract.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-4.1 – FY2008 Performance Improvement
Goals
|
Version
1.7
|
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
1.0
|
Initial
version of Attachment B-4, Performance Improvement
Goals.
|
|
Revision
|
1.1
|
June
30, 2006
|
Revised
Attachment B-4, Performance Improvement Goals Template, by adding
Attachment B-4.1, FY2008 Performance Improvement Goals Template.
This is
the initial version of Attachment B-4.1, FY2008 Performance Improvement
Goals.
|
Revision
|
1.2
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
Goals.
|
Revision
|
1.3
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
Goals.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
Goals, but did change format.
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
Goals.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
Goals.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
Goals.
|
1
Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and
“Cancellation”
for withdrawn versions
2
Revisions
should be
numbered in accordance according to the version of the issuance and
sequential numbering of the
revision—e.g.,
“1.2” refers to the first version of the document and the second
revision.
3
Brief
description of the
changes to the document made in the
revision.
|
Additional
information related to the Performance Improvement Goals can be found in
Attachment B-1, Section 8.1.1.1, to the Contract
1
of
2
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-4.1 – FY2008 Performance Improvement
Goals
|
Version
1.7
|
Texas
Health and Human Services Commission
HMO
Performance Improvement Goal Template
for
State Fiscal Year 2008
(September
1, 2007 – August 31, 2008)
A.
Health Plan Information
Plan
Name:
HMO
Program:
HMO
Service Delivery Area:
|
|
B.
Overarching Goal
|
C.
Sub Goals:
|
Goal
1-5:
Three
to five Goals for all applicable HMO Programs to be determined
and negotiated prior to FY2008.
|
To
be determined for FY2008.
|
Goal
6:
(STAR+PLUS
HMOs) Increase the use of the Consumer
Directed
Services (CDS)
Program
|
Increase
the percentage of enrollees receiving Personal Assistance Services
(PAS)
through the Consumer Directed Services (CDS) Program by 15% as compared
to
the baseline rate of ____
|
Specific
percentages for Sub-Goals will be negotiated by HHSC and the HMO before the
beginning
of FY2008.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-5 –Deliverables/Liquidated Damages
Matrix
|
Version
1.6
|
DOCUMENT
HISTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
Initial
version of Attachment B-5, Deliverables/Liquidated Damage
Matrix.
|
|
Revision
|
1.1
|
June
30, 2006
|
Contract
amendment did not revise Attachment B-5, Deliverables/Liquidated
Damage
Matrix.
|
Revision
|
1.2
|
September
1, 2006
|
Amended
Attachment B-5, Deliverables/Liquidated Damages Matrix, to add a
footnote
clarifying the deliverable due dates. Also amended the provisions
regarding Claims Processing Requirements and the Reporting Requirements
for the Claims Summary Report.
|
Revision
|
1.3
|
September
1, 2006
|
Amended
Attachment B-5, Deliverables/Liquidated Damages Matrix, performance
standard for Provider Directories for the CHIP Perinatal
Program.
|
Revision
|
1.4
|
September
1, 2006
|
Contract
amendment did not revise Attachment B-5, Deliverables/Liquidated
Damage
Matrix.
|
Revision
|
1.5
|
January
1, 2007
|
Contract
amendment did not revise Attachment B-5, Deliverables/Liquidated
Damage
Matrix.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-5, Deliverables/Liquidated
Damage
Matrix.
|
Revision
|
1.7
|
July
1, 2007
|
Amended
Attachment B-5, Deliverables/Liquidated Damages Matrix, to add
clarifications to the provisions addressing Claims Processing Requirements
and the Reporting Requirements for the Claims Summary Report.
|
1Status
should be represented as “Baseline” for initial issuances, “Revision” for
changes to the Baseline version, and “Cancellation” for withdrawn
versions
2Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—e.g., “1.2” refers to the first
version of the document and the second revision.
3Brief
description of the changes to the document made in the
revision.
|
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-5 –Deliverables/Liquidated Damages
Matrix
|
Version
1.6
|
Deliverables/Liquidated
Damages Matrix
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
Contract
Attachment B-1, RFP §7.3 --Transition Phase Schedule
Contract
Attachment B-1, RFP §7.3.1 -- Transition Phase Tasks
Contract
Attachment B-1, RFP §8.1 -- General Scope
|
The
HMO must be operational no later than the agreed upon Operations
Start
Date. HHSC, or its agent, will determine when the HMO is considered
to be
operational based on the requirements in Section 7 and 8 of Attachment
B-1
|
Operations
Start Date
|
Each
calendar day of non-compliance, per HMO Program, per Service Area
(SA).
|
HHSC
may assess up to $10,000 per calendar day for each day beyond the
Operations Start date that the HMO is not operational until the day
that
the HMO is operational, including all systems.
|
Contract
Attachment B-1 RFP §7.3.1.5 – Systems Readiness Review
|
The
HMO must submit to HHSC or to the designated Readiness Review Contractor
the following plans for review, by December 14, 2005 for STAR and
CHIP,
and by July 31, 2006 for STAR+PLUS:
•Joint
Interface
Plan;
•Disaster
Recovery
Plan;
|
Transition
Period
|
Each
calendar day of non-compliance, per report, per HMO Program, and
per
SA.
|
HHSC
may assess up to $1,000 per calendar day for each day a deliverable
is
late, inaccurate or incomplete.
|
1
Derived
from the Contract or HHSC’s Uniform Managed Care Manual.
2 Standard
specified in the Contract. Note: Where the due date states 30 days, the HMO
is
to provide the deliverable by the last day of the month following the end of
the
reporting period. Where the due date states 45 days, the HMO is to provide
the
deliverable by the 15th day of the second month following the end of the
reporting period.
3
Period
during which HHSC will evaluate service for purposes of tailored
remedies.
4
Measure
against which HHSC will apply remedies.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-5 –Deliverables/Liquidated Damages
Matrix
|
Version
1.6
|
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
•Business
Continuity
Plan;
•Risk
Management Plan;
and
•Systems
Quality Assurance
Plan.
|
||||
Contract
Attachment
B-1
RFP
§7.3.1.7 –
Operations
Readiness
|
Final
versions of the Provider Directory must be submitted to the Administrative
Services Contractor no later than 95 days prior to the Operational
Start
Date for the CHIP, STAR, and STAR+PLUS HMOs, and no later than 30
days
prior to the Operational Start Date for the CHIP Perinatal
HMOs.
|
Transition
Period
|
Each
calendar day of non-compliance, per directory, per HMO Program and
per
SA.
|
HHSC
may assess up to $1,000 per calendar day for each day the directory
is
late, inaccurate or incomplete.
|
Contract
Attachment B-1 RFP §§ 6, 7, 8 and 9
Uniform
Managed Care Manual
|
All
reports and deliverables as specified in Sections 6, 7, 8 and 9 of
Attachment B-1 must be submitted according to the timeframes and
requirements stated in the Contract (including all attachments) and
HHSC’s
Uniform Managed Care Manual. (Specific Reports or deliverables listed
separately in this matrix are subject to the specified liquidated
damages.)
|
Transition
Period, Quarterly during Operations Period
|
Each
calendar day of non-compliance, per HMO Program, per SA.
|
HHSC
may assess up to $250 per calendar day if the report/deliverable
is late,
inaccurate, or incomplete.
|
Contract
|
The
HMO may not engage in
|
Transition,
|
Per
incident of non-
|
HHSC
may assess up to $1,000 per
|
1
Derived
from the Contract or HHSC’s Uniform Managed Care Manual.
2 Standard
specified in the Contract. Note: Where the due date states 30 days, the HMO
is
to provide the deliverable by the last day of the month following the end of
the
reporting period. Where the due date states 45 days, the HMO is to provide
the
deliverable by the 15th day of the second month following the end of the
reporting period.
3
Period
during which HHSC will evaluate service for purposes of tailored
remedies.
4
Measure
against which HHSC will apply remedies.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-5 –Deliverables/Liquidated Damages
Matrix
|
Version
1.6
|
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
Attachment
B-1 RFP §8.1.6 --Marketing & Prohibited Practices
Uniform
Managed Care Manual
|
prohibited
marketing practices.
|
Measured
Quarterly during the Operations Period
|
compliance.
|
incident
of non-compliance.
|
Contract
Attachment B-1 RFP §8.1.17.2 --Financial Reporting
Requirements
Uniform
Managed Care Manual – Chapter 5
|
Financial
Statistical Reports (FSR): For each SA, the HMO must file quarterly
and
annual FSRs. Quarterly reports are due no later than 30 days after
the
conclusion of each State Fiscal Quarter (SFQ). The first annual report
is
due no later than 120 days after the end of each Contract Year and
the
second annual report is due no later than 365 days after the end
of each
Contract Year.
|
Quarterly
during the Operations Period
|
Per
calendar day of non-compliance, per HMO Program, per SA.
|
HHSC
may assess up to $1,000 per calendar day a quarterly or annual report
is
late, inaccurate or incomplete.
|
Contract
Attachment B-1 RFP §8.1.17.2 -- Financial Reporting
Requirements:
|
Medicaid
Disproportionate Share Hospital (DSH) Reports: The Medicaid HMO must
submit, on an annual basis, preliminary and final DSH Reports. The
Preliminary report is due no later than June 1st after each reporting
year, and the
|
Measured
during 4th Quarter of the Operations Period (6/1–8/31)
|
Per
calendar day of non-compliance, per HMO Program, per SA.
|
HHSC
may assess up to $1,000 per calendar day, per program, per service
area,
for each day the report is late, incorrect, inaccurate or
incomplete.
|
1
Derived
from the Contract or HHSC’s Uniform Managed Care Manual.
2 Standard
specified in the Contract. Note: Where the due date states 30 days, the HMO
is
to provide the deliverable by the last day of the month following the end of
the
reporting period. Where the due date states 45 days, the HMO is to provide
the
deliverable by the 15th day of the second month following the end of the
reporting period.
3
Period
during which HHSC will evaluate service for purposes of tailored
remedies.
4
Measure
against which HHSC will apply remedies.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-5 –Deliverables/Liquidated Damages
Matrix
|
Version
1.6
|
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
Uniform
Managed Care Manual – Chapter 5
|
final
report is due no later than July 15th after each reporting year.
This
standard does not apply to CHIP HMOs.
|
|||
Contract
Attachment B-1 RFP §8.1.18 – Management Information System (MIS)
Requirements
|
The
HMO’s MIS must be able to resume operations within 72 hours of employing
its Disaster Recovery Plan.
|
Measured
Quarterly during the Operations Period
|
Per
calendar day of non-compliance, per HMO Program, per SA.
|
HHSC
may assess up to $5,000 per calendar day of
non-compliance
|
Contract
Attachment B-1 RFP §8.1.18.3 – Management Information System (MIS)
Requirements: System-Wide Functions
|
The
HMO’s MIS system must meet all requirements in Section 8.1.18.3 of
Attachment B-1.
|
Measured
Quarterly during the Operations Period
|
Per
calendar day of non-compliance, per HMO Program, per SA.
|
HHSC
may assess up to $5,000 per calendar day of
non-compliance.
|
Contract
Attachment B-1 RFP §8.1.18.5 -- Claims Processing
Requirements
|
The
HMO must adjudicate all provider Clean Claims within 30 days of receipt
by
the HMO. The HMO must pay providers interest at an 18% per annum,
calculated daily for the full period in which the Clean
|
Measured
Quarterly during the Operations Period
|
Per
incident of non-compliance.
|
HHSC
may assess up to $1,000 per claim if the HMO fails to timely pay
interest.
|
1
Derived
from the Contract or HHSC’s Uniform Managed Care Manual.
2 Standard
specified in the Contract. Note: Where the due date states 30 days, the HMO
is
to provide the deliverable by the last day of the month
following
the end of the reporting period. Where the due date states 45 days, the HMO
is
to provide the deliverable by the 15th day of the second
month
following the end of the reporting period.
3
Period
during which HHSC will evaluate service for purposes of tailored
remedies.
4
Measure
against which HHSC will apply remedies.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-5 –Deliverables/Liquidated Damages
Matrix
|
Version
1.6
|
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
Uniform
Managed Care Manual Chapter 2
|
Claim
remains unadjudicated beyond the 30-day claims processing deadline.
Interest owed the provider must be paid on the same date that the
claim is
adjudicated.
|
|||
Contract
Attachment B-1 RFP §8.1.18.5 -- Claims Processing
Requirements
Uniform
Managed Care Manual – Chapter 2
|
The
HMO must comply with the claims processing requirements and standards
as
described in Section 8.1.18.5 of Attachment B-1 and in Chapter 2
of the
Uniform Managed Care Manual.
|
Measured
Quarterly during the Operations Period
|
Per
quarterly reporting period, per HMO Program, per Service Area, per
claim
type.
|
HHSC
may assess liquidated damages of up to $5,000 for the first quarter
that
an HMO’s Claims Performance percentages by claim type, by Program, and by
service area, fall below the performance standards. HHSC may assess
up to
$25,000 per quarter for each additional quarter that the Claims
Performance percentages by claim type, by Program, and by service
area,
fall below the performance standards.
|
Contract
Attachment B-1 RFP §8.1.20.2-- Reporting Requirements
Uniform
Managed Care
|
Claims
Summary Report: The HMO must submit quarterly, Claims Summary Reports
to
HHSC by HMO Program, by Service Area, and by claim type, by the 30th
day
following the reporting period unless otherwise specified.
|
Measured
Quarterly during the Operations Period
|
Per
calendar day of non-compliance, per HMO Program, per Service Area,
per
claim type.
|
HHSC
may assess up to $1,000 per calendar day the report is late, inaccurate,
or incomplete.
|
1
Derived
from the Contract or HHSC’s Uniform Managed Care Manual.
2 Standard
specified in the Contract. Note: Where the due date states 30 days, the HMO
is
to provide the deliverable by the last day of the month
following
the end of the reporting period. Where the due date states 45 days, the HMO
is
to provide the deliverable by the 15th day of the second
month
following the end of the reporting period.
3
Period
during which HHSC will evaluate service for purposes of tailored
remedies.
4
Measure
against which HHSC will apply remedies.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-5 –Deliverables/Liquidated Damages
Matrix
|
Version
1.6
|
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
Manual
Chapters 2 and 5
|
||||
Contract
Attachment B-1 RFP §8.1.5.9—Member Complaint and Appeal
Process
Contract
Attachment B-1 RFP §8.2.7.1 – Member Complaint Process
Contract
Attachment B-1 RFP §8.4.3 – CHIP Member Complaint and Appeal
Process
|
The
HMO must resolve at least 98% of Member Complaints within 30 calendar
days
from the date the Complaint is received by the HMO
|
Measured
Quarterly during the Operations Period
|
Per
reporting period, per HMO Program, per SA.
|
HHSC
may assess up to $250 per reporting period if the HMO fails to meet
the
performance standard.
|
Contract
Attachment B-1 RFP §8.3.3 – STAR+PLUS Assessment Instruments
Uniform
|
The
MDS-HC instrument must be completed and electronically submitted
to HHSC
in the specified format within 30 days of enrollment for every Member
receiving Community-based Long-term Care Services, and then each
year by
the
|
Operations,
Turnover
|
Per
calendar day of non-compliance, per Service Area.
|
HHSC
may assess up to $500 per calendar day per Service Area, for
each day a report is late, inaccurate or
incomplete.
|
1
Derived
from the Contract or HHSC’s Uniform Managed Care Manual.
2 Standard
specified in the Contract. Note: Where the due date states 30 days, the HMO
is
to provide the deliverable by the last day of the month following the end of
the
reporting period. Where the due date states 45 days, the HMO is to provide
the
deliverable by the 15th day of the second month following the end of the
reporting period.
3
Period
during which HHSC will evaluate service for purposes of tailored
remedies.
4
Measure
against which HHSC will apply remedies.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-5 –Deliverables/Liquidated Damages
Matrix
|
Version
1.6
|
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
Managed
Care Manual
|
anniversary
of the Member’s date of enrollment.
|
|||
Contract
Attachment B-1 RFP §8.1.5.9— Member Complaint and Appeal
Process
Contract
Attachment B-1 RFP §8.2.7.2 -- Medicaid Standard Member Appeal
Process
Contract
Attachment B-1 RFP § 8.4.3 CHIP Member Complaint and Appeal
Process
|
The
HMO must resolve at least 98% of Member Appeals within 30 calendar
days
from the date the Appeal is filed with the HMO.
|
Measured
Quarterly during the Operations Period
|
Per
reporting period, per HMO Program, per SA.
|
HHSC
may assess up to $500 per reporting period if the HMO fails to meet
the
performance standard.
|
Contract
Attachment B-1 RFP §9.2 --Transfer of Data
|
The
HMO must transfer all data regarding the provision of Covered Services
to
Members to HHSC or a new HMO, at the sole discretion of HHSC and
as
directed by HHSC. All transferred data must comply with the Contract
requirements,
|
Measured
at Time of Transfer of Data and ongoing after the Transfer of Data
until
satisfactorily completed
|
Per
incident of noncompliance (failure to provide data and/or failure
to
provide data in required format), per HMO Program, per SA.
|
HHSC
may assess up to $10,000 per calendar day the data is late, inaccurate
or
incomplete.
|
1
Derived
from the Contract or HHSC’s Uniform Managed Care Manual.
2 Standard
specified in the Contract. Note: Where the due date states 30 days, the HMO
is
to provide the deliverable by the last day of the month following the end of
the
reporting period. Where the due date states 45 days, the HMO is to provide
the
deliverable by the 15th day of the second month following the end of the
reporting period.
3
Period
during which HHSC will evaluate service for purposes of tailored
remedies.
4
Measure
against which HHSC will apply remedies.
Contractual
Document (CD)
|
|
Responsible
Office: HHSC Office of General Counsel (OGC)
|
|
Subject:
Attachment B-5 –Deliverables/Liquidated Damages
Matrix
|
Version
1.6
|
Service/
Component1
|
Performance
Standard2
|
Measurement
Period3
|
Measurement
Assessment4
|
Liquidated
Damages
|
including
HIPAA.
|
||||
Contract
Attachment B-1 RFP §9.3 --Turnover Services
|
Six
months prior to the end of the contract period or any extension thereof,
the HMO must propose a Turnover Plan covering the possible turnover
of the
records and information maintained to either the State (HHSC) or
a
successor HMO.
|
Measured
at Six Months prior to the end of the contract period or any extension
thereof and ongoing until satisfactorily completed
|
Each
calendar day of non-compliance, per HMO Program, per SA.
|
HHSC
may assess up to $1,000 per calendar day the Plan is late, inaccurate,
or
incomplete.
|
Contract
Attachment B-1 RFP §9.4 --Post-Turnover Services
|
The
HMO must provide the State (HHSC) with a Turnover Results report
documenting the completion and results of each step of the Turnover
Plan
30 days after the Turnover of Operations.
|
Measured
30 days after the Turnover of Operations
|
Each
calendar day of non-compliance, per HMO program, per SA.
|
HHSC
may assess up to $250 per calendar day the report is late, inaccurate
or
incomplete.
|
Contract
Attachment A HHSC Uniform Managed Care Contract Terms and Conditions,
Section 4.08 Subcontractors
|
The
HMO must notify HHSC in writing immediately upon making a decision
to
terminate a subcontract with a Material Subcontractor or upon receiving
notification from the Material Subcontractor of its intent to terminate
such subcontract.
|
Transition,
Measured Quarterly during the Operations Period
|
Each
calendar day of non-compliance, per HMO Program, per SA.
|
HHSC
may assess up to $5,000 per calendar day of
non-compliance.
|
1
Derived
from the Contract or HHSC’s Uniform Managed Care Manual.
2 Standard
specified in the Contract. Note: Where the due date states 30 days, the HMO
is
to provide the deliverable by the last day of the month following the end of
the
reporting period. Where the due date states 45 days, the HMO is to provide
the
deliverable by the 15th day of the second month following the end of the
reporting period.
3
Period
during which HHSC will evaluate service for purposes of tailored
remedies.
4
Measure
against which HHSC will apply remedies.




Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-7 – STAR+PLUS Attendant Care Enhanced Payments
Methodology
|
Version
1.7
|
DOCUMENT
HOSTORY LOG
STATUS1
|
DOCUMENT
REVISION2
|
EFFECTIVE
DATE
|
DESCRIPTION3
|
Baseline
|
n/a
|
January
1, 2007
|
Initial
version of Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments
Methodology, was incorporated into Version 1.5 of the
Contract.
|
Revision
|
1.6
|
February
1, 2007
|
Contract
amendment did not revise Attachment B-7, STAR+PLUS Attendant Care
Enhanced
Payments Methodology.
|
Revision
|
1.7
|
July
1, 2007
|
Contract
amendment did not revise Attachment B-7, STAR+PLUS Attendant Care
Enhanced
Payments Methodology.
|
1
Status should
be represented as “Baseline” for initial issuances, “Revision” for changes
to the Baseline version, and “Cancellation” for
withdrawn
versions
2
Revisions
should be numbered in accordance according to the version of the
issuance
and sequential numbering of the revision—
e.g.,
“1.2” refers to the first version of the document and the second
revision.
3
Brief
description of the changes to the document made in the
revision.
|
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-7 – STAR+PLUS Attendant Care Enhanced Payments
Methodology
|
Version
1.7
|
ATTACHMENT
B-7: STAR+PLUS ATTENDANT CARE ENHANCED PAYMENTS
METHODOLOGY
HMO:
|
Superior
Health Plan
|
SERVICE
AREA(S):
|
Bexar
& Nueces
|
I.Provider
Contracting
|
(a)
Description of criteria the HMO will use to allow participation in
the
STAR+PLUS Attendant Care Enhanced Payments. Will the HMO have a
enrollment period that corresponds to the DADS enrollment period
to allow
new providers to participate in the HMO's Attendant Care Enhanced
Payments, or will the HMO have it's own enrollment period that is
separate
and not tied to the DADS enrollment?
(b)
Description of any limitations or
restrictions.
|
Superior
HealthPlan will only allow those providers that are currently
participating in the DADS Attendant Compensation Rate Enhancements
to
participate in the STAR+PLUS Attendant Care Enhanced Payments. SHP
will
have an enrollment period corresponding to the DADS enrollment period
to
allow new providers to participate in the SHP Attendant Care Enhanced
Payments.
|
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-7 – STAR+PLUS Attendant Care Enhanced Payments
Methodology
|
Version
1.7
|
II.Payment
for STAR+PLUS Attendant Care Enhanced Payments
|
Description
of methodology the HMO will use to pay for the Attendant Care Enhanced
Payments. Provide sufficient detail to fully explain the
planned methodology.
|
Superior
will not use the DADS rates. SHP will establish an additional amount
to be
added on to the unit rate by type of service.
|
|
III. Timing
of the Attendant Care Enhanced Payments
|
Description
of when the payments will be made to the Providers and the frequency
of
payments. Also include timeframes for Providers complaints and
appeals regarding enhanced payments.
|
The
enhanced rate payment amount will be paid at the time of claims payment
so
the frequency will depend on the frequency with which providers file
their
claims. Provider complaints and appeals will be handled through the
normal
complaint and appeal process and finalized within 30 days from
receipt.
|
Contractual
Document (CD)
|
||
Responsible
Office: HHSC Office of General Counsel (OGC)
|
||
Subject:
Attachment B-7 – STAR+PLUS Attendant Care Enhanced Payments
Methodology
|
Version
1.7
|
IV. Assurances
from Participating Providers
|
Description
of how the HMO will ensure that the participating Providers are using
the
enhancement funds to compensate direct care workers as intended by
the
2000-01 General Appropriations Act (Rider 27, House Xxxx 1, 76th
Legislature, Regular Session, 1999) and by T.A.C. Title 1, Part 15,
Chapter 355.
|
Participating
Providers will be required by contract to complete and submit an
affidavit
annually stating they applied the enhancement funds to the compensation
for direct care staff. Compensation may include increased hourly
rates,
bonuses, paid holidays or additional benefits such as employer paid
insurance.
|
|
V. Monitoring
of Attendant Care Enhanced Payments
|
Explanation
of the Monitoring Process that the HMO will use to monitor whether
the
Attendant Care Enhanced Payments are used for the purposes intended
by the
Texas Legislature.
|
Each
Provider’s compliance with the attendant compensation spending requirement
for the reporting period will be monitored on an annual basis via the
submission of the affidavit stating they applied the enhancement
funds to
the compensation for direct care staff. Compensation may include
increased
hourly rates, bonuses, paid holidays or additional benefits such
as
employer paid insurance. In addition, providers may be audited on
as
as-needed basis to ensure financial records support the pass through
of
the enhanced funds. Enhanced payments could potentially be recouped
for
those Providers who fail to pass the funds to their direct care
staff.
|
By
signing the Contract and/or Contract Amendment, HMO certifies that the approved
STAR+PLUS Attendant Care Enhanced Payments Methodology described herein is
the
methodology the HMO will use to make the legislatively mandated payments to
its
Long Term Services and Support (LTSS) Providers participating in the Attendant
Care Enhanced Payments.
Additional
information related to the Attendant Care Enhanced Payments can be found in
Attachment B-1, Section 8.3.7.3 of the Contract.