1
Exhibit 10.2
TDH Document No. 7526032317*2001-01
1999
CONTRACT FOR SERVICES
Between
THE TEXAS DEPARTMENT OF HEALTH
And
HMO
1999 Renewal Contract
Tarrant Service Area
August 9, 1999
2
TABLE OF CONTENTS
ARTICLE I PARTIES AND AUTHORITY TO CONTRACT....................................................1
ARTICLE II DEFINITIONS..........................................................................2
ARTICLE III PLAN ADMINISTRATIVE AND HUMAN RESOURCE REQUIREMENTS.................................14
3.1 ORGANIZATION AND ADMINISTRATION.................................................................14
-------------------------------
3.2 NON-PROVIDER SUBCONTRACTS.......................................................................15
-------------------------
3.3 MEDICAL DIRECTOR................................................................................17
----------------
3.4 PLAN MATERIALS AND DISTRIBUTION OF PLAN MATERIALS...............................................18
-------------------------------------------------
3.5 RECORDS REQUIREMENTS AND RECORDS RETENTION......................................................19
------------------------------------------
3.6 HMO REVIEW OF TDH MATERIALS.....................................................................20
---------------------------
3.7 HMO TELEPHONE ACCESS REQUIREMENTS...............................................................21
---------------------------------
ARTICLE IV FISCAL, FINANCIAL, CLAIMS AND INSURANCE REQUIREMENTS................................21
4.1 FISCAL SOLVENCY.................................................................................21
---------------
4.2 MINIMUM NET WORTH...............................................................................22
-----------------
4.3 PERFORMANCE BOND................................................................................22
----------------
4.4 INSURANCE.......................................................................................22
---------
4.5 FRANCHISE TAX...................................................................................23
-------------
4.6 AUDIT...........................................................................................23
-----
4.7 PENDING OR THREATENED LITIGATION................................................................23
--------------------------------
4.8 MISREPRESENTATION AND FRAUD IN RESPONSE TO RFA AND IN HMO OPERATIONS............................23
--------------------------------------------------------------------
4.9 THIRD PARTY RECOVERY............................................................................24
--------------------
4.10 CLAIMS PROCESSING REQUIREMENTS..................................................................25
------------------------------
4.11 INDEMNIFICATION.................................................................................27
---------------
ARTICLE V STATUTORY AND REGULATORY COMPLIANCE REQUIREMENTS....................................28
5.1 COMPLIANCE WITH FEDERAL, STATE, AND LOCAL LAWS..................................................28
----------------------------------------------
5.2 PROGRAM INTEGRITY...............................................................................28
-----------------
5.3 FRAUD AND ABUSE COMPLIANCE PLAN.................................................................28
-------------------------------
5.4 SAFEGUARDING INFORMATION........................................................................31
------------------------
5.5 NON-DISCRIMINATION..............................................................................31
------------------
5.6 HISTORICALLY UNDERUTILIZED BUSINESSES (HUBs)....................................................32
--------------------------------------------
5.7 BUY TEXAS.......................................................................................33
---------
5.8 CHILD SUPPORT...................................................................................33
-------------
5.9 REQUESTS FOR PUBLIC INFORMATION.................................................................33
-------------------------------
5.10 NOTICE AND APPEAL...............................................................................34
-----------------
ARTICLE VI SCOPE OF SERVICES...................................................................34
6.1 SCOPE OF SERVICES...............................................................................34
-----------------
6.2 PRE-EXISTING CONDITIONS.........................................................................37
-----------------------
6.3 SPAN OF ELIGIBILITY.............................................................................37
-------------------
6.4 CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS.................................................38
-----------------------------------------------
6.5 EMERGENCY SERVICES..............................................................................39
------------------
6.6 BEHAVIORAL HEALTH CARE SERVICES - SPECIFIC REQUIREMENTS.........................................40
-------------------------------------------------------
6.7 FAMILY PLANNING - SPECIFIC REQUIREMENTS.........................................................42
---------------------------------------
6.8 TEXAS HEALTH STEPS (EPSDT)......................................................................43
--------------------------
6.9 PERINATAL SERVICES..............................................................................46
------------------
6.10 EARLY CHILDHOOD INTERVENTION (ECI)..............................................................47
----------------------------------
1999 Renewal Contract
Tarrant Service Area
2
August 9, 1999
3
6.11 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN
-----------------------------------------------------------------------
(WIC) - SPECIFIC REQUIREMENTS...................................................................48
-----------------------------
6.12 TUBERCULOSIS (TB)...............................................................................49
-----------------
6.13 PEOPLE WITH DISABILITIES OR CHRONIC OR COMPLEX CONDITIONS.......................................50
---------------------------------------------------------
6.14 HEALTH EDUCATION AND WELLNESS AND PREVENTION PLANS..............................................52
--------------------------------------------------
6.15 SEXUALLY TRANSMITTED DISEASES (STDs) AND HUMAN IMMUNODEFICIENCY VIRUS (HIV).....................53
---------------------------------------------------------------------------
6.16 BLIND AND DISABLED MEMBERS......................................................................55
--------------------------
ARTICLE VII PROVIDER NETWORK REQUIREMENTS.......................................................56
7.1 PROVIDER ACCESSIBILITY..........................................................................56
----------------------
7.2 PROVIDER CONTRACTS..............................................................................57
------------------
7.3 PHYSICIAN INCENTIVE PLANS.......................................................................61
-------------------------
7.4 PROVIDER MANUAL AND PROVIDER TRAINING...........................................................63
-------------------------------------
7.5 MEMBER PANEL REPORTS............................................................................64
--------------------
7.6 PROVIDER COMPLAINT AND APPEAL PROCEDURE.........................................................64
---------------------------------------
7.7 PROVIDER QUALIFICATIONS - GENERAL...............................................................64
---------------------------------
7.8 PRIMARY CARE PROVIDERS..........................................................................66
----------------------
7.9 OB/GYN PROVIDERS................................................................................70
----------------
7.10 SPECIALTY CARE PROVIDERS........................................................................70
------------------------
7.11 SPECIAL HOSPITALS AND SPECIALTY CARE FACILITIES.................................................71
-----------------------------------------------
7.12 BEHAVIORAL HEALTH - LOCAL MENTAL HEALTH AUTHORITY (LMHA)........................................71
--------------------------------------------------------
7.13 SIGNIFICANT TRADITIONAL PROVIDERS (STPs)........................................................73
----------------------------------------
7.14 RURAL HEALTH PROVIDERS..........................................................................73
----------------------
7.15 FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) AND RURAL HEALTH CLINICS (RHC)........................74
------------------------------------------------------------------------
7.16 COORDINATION WITH PUBLIC HEALTH.................................................................75
-------------------------------
7.17 COORDINATION WITH TEXAS DEPARTMENT OF PROTECTIVE AND REGULATORY SERVICES........................79
-----------------------------------------------------------------------
7.18 DELEGATED NETWORKS (IPAs, LIMITED PROVIDER NETWORKS AND ANHCs)..................................80
--------------------------------------------------------------
ARTICLE VIII MEMBER SERVICES REQUIREMENTS........................................................82
8.1 MEMBER EDUCATION................................................................................82
----------------
8.2 MEMBER HANDBOOK.................................................................................82
---------------
8.3 ADVANCE DIRECTIVES..............................................................................82
------------------
8.4 MEMBER ID CARDS.................................................................................84
---------------
8.5 MEMBER HOTLINE..................................................................................85
--------------
8.6 MEMBER COMPLAINT PROCESS........................................................................85
------------------------
8.7 MEMBER NOTICE, APPEALS AND FAIR HEARINGS........................................................87
----------------------------------------
8.8 MEMBER ADVOCATES................................................................................89
----------------
8.9 MEMBER CULTURAL AND LINGUISTIC SERVICES.........................................................89
---------------------------------------
ARTICLE IX MARKETING AND PROHIBITED PRACTICES..................................................91
9.1 MARKETING MATERIAL MEDIA AND DISTRIBUTION.......................................................91
-----------------------------------------
9.2 MARKETING ORIENTATION AND TRAINING..............................................................92
----------------------------------
9.3 PROHIBITED MARKETING PRACTICES..................................................................92
------------------------------
9.4 NETWORK PROVIDER DIRECTORY......................................................................93
--------------------------
ARTICLE X MIS SYSTEM REQUIREMENTS.............................................................93
10.1 MODEL MIS REQUIREMENTS..........................................................................93
----------------------
10.2 SYSTEM-WIDE FUNCTIONS...........................................................................95
---------------------
10.3 ENROLLMENT/ELIGIBILITY SUBSYSTEM................................................................96
--------------------------------
10.4 PROVIDER SUBSYSTEM..............................................................................97
------------------
10.5 ENCOUNTER/CLAIMS PROCESSING SUBSYSTEM...........................................................98
-------------------------------------
10.6 FINANCIAL SUBSYSTEM.............................................................................99
-------------------
1999 Renewal Contract
Tarrant Service Area
3
August 9, 1999
4
10.7 UTILIZATION/QUALITY IMPROVEMENT SUBSYSTEM......................................................100
-----------------------------------------
10.8 REPORT SUBSYSTEM...............................................................................102
----------------
10.9 DATA INTERFACE SUBSYSTEM.......................................................................103
------------------------
10.10 TPR SUBSYSTEM..................................................................................104
-------------
10.11 YEAR 2000 (Y2K) COMPLIANCE.....................................................................105
--------------------------
ARTICLE XI QUALITY ASSURANCE AND QUALITY IMPROVEMENT PROGRAM..................................105
11.1 QUALITY IMPROVEMENT PROGRAM (QIP) SYSTEM.......................................................105
----------------------------------------
11.2 WRITTEN QIP PLAN...............................................................................105
----------------
11.3 QIP SUBCONTRACTING.............................................................................105
------------------
11.4 ACCREDITATION..................................................................................106
-------------
11.5 BEHAVIORAL HEALTH INTEGRATION INTO QIP.........................................................106
--------------------------------------
11.6 QIP REPORTING REQUIREMENTS.....................................................................106
--------------------------
ARTICLE XII REPORTING REQUIREMENTS.............................................................106
12.1 FINANCIAL REPORTS..............................................................................106
-----------------
12.2 STATISTICAL REPORTS............................................................................108
-------------------
12.3 ARBITRATION/LITIGATION CLAIMS REPORT...........................................................110
------------------------------------
12.4 SUMMARY REPORT OF PROVIDER COMPLAINTS..........................................................110
-------------------------------------
12.5 PROVIDER NETWORK REPORTS.......................................................................110
------------------------
12.6 MEMBER COMPLAINTS..............................................................................110
-----------------
12.7 FRAUDULENT PRACTICES...........................................................................111
--------------------
12.8 UTILIZATION MANAGEMENT REPORTS - BEHAVIORAL HEALTH.............................................111
--------------------------------------------------
12.9 UTILIZATION MANAGEMENT REPORTS - PHYSICAL HEALTH...............................................111
------------------------------------------------
12.10 QUALITY IMPROVEMENT REPORTS....................................................................111
---------------------------
12.11 HUB REPORTS....................................................................................113
-----------
12.12 THSTEPS REPORTS................................................................................113
---------------
ARTICLE XIII PAYMENT PROVISIONS.................................................................113
13.1 CAPITATION AMOUNTS.............................................................................113
------------------
13.2 EXPERIENCE REBATE TO STATE.....................................................................117
--------------------------
13.3 PERFORMANCE OBJECTIVES.........................................................................118
----------------------
13.4 ADJUSTMENTS TO PREMIUM.........................................................................119
----------------------
ARTICLE XIV ELIGIBILITY, ENROLLMENT, AND DISENROLLMENT.........................................119
14.1 ELIGIBILITY DETERMINATION......................................................................119
-------------------------
14.2 ENROLLMENT.....................................................................................121
----------
14.3 DISENROLLMENT..................................................................................122
-------------
14.4 AUTOMATIC RE-ENROLLMENT........................................................................122
-----------------------
14.5 ENROLLMENT REPORTS.............................................................................123
------------------
ARTICLE XV GENERAL PROVISIONS.................................................................123
15.1 INDEPENDENT CONTRACTOR.........................................................................123
----------------------
15.2 AMENDMENT......................................................................................123
---------
15.3 LAW, JURISDICTION AND VENUE....................................................................124
---------------------------
15.4 NON-WAIVER.....................................................................................124
----------
15.5 SEVERABILITY...................................................................................124
------------
15.6 ASSIGNMENT.....................................................................................124
----------
15.7 MAJOR CHANGE IN CONTRACTING....................................................................125
---------------------------
15.8 NON-EXCLUSIVE..................................................................................125
-------------
15.9 DISPUTE RESOLUTION.............................................................................125
------------------
15.10 DOCUMENTS CONSTITUTING CONTRACT................................................................125
-------------------------------
15.11 FORCE MAJEURE..................................................................................125
-------------
1999 Renewal Contract
Tarrant Service Area
4
August 9, 1999
5
15.12 NOTICES........................................................................................126
-------
15.13 SURVIVAL.......................................................................................126
--------
ARTICLE XVI DEFAULT AND REMEDIES...............................................................126
16.1 DEFAULT BY TDH.................................................................................126
--------------
16.2 REMEDIES AVAILABLE TO HMO FOR TDH's DEFAULT....................................................126
-------------------------------------------
16.3 DEFAULT BY HMO.................................................................................127
--------------
ARTICLE XVII NOTICE OF DEFAULT AND CURE OF DEFAULT..............................................135
ARTICLE XVIII EXPLANATION OF REMEDIES............................................................136
18.1 TERMINATION....................................................................................136
-----------
18.2 DUTIES OF CONTRACTING PARTIES UPON TERMINATION.................................................138
----------------------------------------------
18.3 SUSPENSION OF NEW ENROLLMENT...................................................................139
----------------------------
18.4 LIQUIDATED MONEY DAMAGES.......................................................................139
------------------------
18.5 APPOINTMENT OF TEMPORARY MANAGEMENT............................................................141
-----------------------------------
18.6 TDH-INITIATED DISENROLLMENT OF A MEMBER OR MEMBERS WITHOUT CAUSE...............................142
----------------------------------------------------------------
18.7 RECOMMENDATION TO HCFA THAT SANCTIONS BE TAKEN AGAINST HMO.....................................142
----------------------------------------------------------
18.8 CIVIL MONETARY PENALTIES.......................................................................142
------------------------
18.9 FORFEITURE OF ALL OR PART OF THE TDI PERFORMANCE BOND..........................................143
-----------------------------------------------------
18.10 REVIEW OF REMEDY OR REMEDIES TO BE IMPOSED.....................................................143
------------------------------------------
ARTICLE XIX TERM...............................................................................143
1999 Renewal Contract
Tarrant Service Area
5
August 9, 1999
6
APPENDICES
APPENDIX A
Standards For Quality Improvement Programs
APPENDIX B
HUB Progress Assessment Reports
APPENDIX C
Value-added Services
APPENDIX D
Required Critical Elements
APPENDIX E
Transplant Facilities
APPENDIX F
Trauma Facilities
APPENDIX G
Hemophilia Treatment Centers And Programs
APPENDIX H
Utilization Management Report - Behavioral Health
APPENDIX I
Managed Care Financial-Statistical Report
APPENDIX J
Utilization Management Report - Physical Health
APPENDIX K
Preventive Health Performance Objectives
APPENDIX L
Cost Principles For Administrative Expenses
APPENDIX M
Arbitration/Litigation Report
1999 Renewal Contract
Tarrant Service Area
6
August 9, 1999
7
1999
CONTRACT FOR SERVICES
Between
THE TEXAS DEPARTMENT OF HEALTH
And
HMO
This contract is entered into between the Texas Department of Health (TDH) and
AMERICAID TEXAS, INC., DBA AMERICAID COMMUNITY CARE (HMO). The purpose of this
contract is to set forth the terms and conditions for HMO's participation as a
managed care organization in the TDH STAR Program (STAR or STAR Program). Under
the terms of this contract HMO will provide comprehensive health care services
to qualified and Medicaid-eligible recipients through a managed care delivery
system. This is a risk-based contract. HMO was selected to provide services
under this contract under Health and Safety Code, Title 2, Section 12.011 and
Section 12.021, and Texas Government Code Section 533.001 et seq. HMO's
selection for this contract was based upon HMO's Application submitted in
response to TDH's Request for Application (RFA) in the service area.
Representations and responses contained in HMO's Application are incorporated
into and are enforceable provisions of this contract, except where changed by
this contract.
ARTICLE I PARTIES AND AUTHORITY TO CONTRACT
1.1 The Texas Legislature has designated the Texas Health and
Human Services Commission (THHSC) as the single State agency to
administer the Medicaid program in the State of Texas. THHSC has
delegated the authority to operate the Medicaid managed care
delivery system for acute care services to TDH. TDH has authority
to contract with HMO to carry out the duties and functions of the
Medicaid managed care program under Health and Safety Code, Title
2, Section 12.011 and Section 12.021 and Texas Government Code
Section 533.001 et seq.
1.2 HMO is a corporation with authority to conduct business in
the State of Texas and has a certificate of authority from the
Texas Department of Insurance (TDI) to operate as a Health
Maintenance Organization (HMO) under Chapter 20A of the Insurance
Code. HMO is in compliance with all TDI rules and laws that apply
to HMOs. HMO has been authorized to enter into this contract by
its Board of Directors or other governing body. HMO is an
authorized vendor with TDH and has received a Vendor
Identification number from the Texas Comptroller of Public
Accounts.
1999 Renewal Contract
Tarrant Service Area
7
August 9, 1999
8
1.3 This contract is subject to the approval and on-going
monitoring of the federal Health Care Financing Administration
(HCFA).
1.4 Renewal Review. TDH is required by Human Resources Code
Section 32.034(a) and Government Code 533.007 to conduct renewal
review of HMO's performance and compliance with this contract as a
condition for retention and renewal.
1.4.1 Renewal Review may include a review of HMO's past
performance and compliance with the requirements of this contract
and on-site inspection of any or all of HMO's systems or
processes.
1.4.2 TDH will provide HMO with at least 30 days written notice
prior to conducting an HMO renewal review. A report of the results
of the renewal review findings will be provided to HMO within 10
weeks from the completion of the renewal review. The renewal
review report will include any deficiencies which must be
corrected and the timeline within which the deficiencies must be
corrected.
1.4.3 TDH reserves the right to conduct on-site inspections of
any or all of HMO's systems and processes as often as necessary to
ensure compliance with contract requirements. TDH may conduct at
least one complete on-site inspection of all systems and processes
every three years. TDH will provide six weeks advance notice to
HMO of the three year on-site inspection, unless TDH enters into
an MOU with the Texas Department of Insurance to accept the TDI
report in lieu of a TDH on-site inspection. TDH will notify HMO
prior to conducting an onsite visit related to a regularly
scheduled review specifically described in this contract. Even in
the case of a regularly scheduled visit, TDH reserves the right to
conduct an onsite review without advance notice if TDH believes
there may be potentially serious or life-threatening deficiencies.
1.5 AUTHORITY OF HMO TO ACT ON BEHALF OF TDH. HMO is given
express, limited authority to exercise the State's right of
recovery as provided in Article 4.9, and to enforce provisions of
this contract which require providers or subcontractors to produce
records, reports, encounter data, public health data, and other
documents to comply with this contract and which TDH has authority
to require under State or federal laws.
ARTICLE II DEFINITIONS
Terms used throughout this Contract have the following meaning, unless the
context clearly
1999 Renewal Contract
Tarrant Service Area
8
August 9, 1999
9
indicates otherwise:
Abuse means provider practices that are inconsistent with sound fiscal,
business, or medical practices and result in an unnecessary cost to the Medicaid
program, or in reimbursement for services that are not medically necessary or
that fail to meet professionally recognized standards for health care. It also
includes Member practices that result in unnecessary cost to the Medicaid
program.
Action means a denial, termination, suspension, or reduction of covered services
or the failure of HMO to act upon request for covered services within a
reasonable time or a denial of a request for prior authorization for covered
services affecting a Member. This term does not include reaching the end of
prior authorized services.
Adjudicate means to deny or pay a clean claim.
Adverse determination means a determination by a 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 HMO; in which HMO owns or holds more than a five
percent (5%) interest; any parent entity; or subsidiary entity of HMO,
regardless of the organizational structure of the entity.
Allowable expenses means all expenses related to the Contract for Services
between TDH and HMO that are incurred during the term of the contract that are
not reimbursable or recovered from another source.
Allowable revenue means all Medicaid managed care revenue received by HMO for
the contract period, including retroactive adjustments made by TDH.
Appeal of adverse determination means the formal process by which a utilization
review agent offers a mechanism to address adverse determinations as defined in
Article 21.58A, Texas Insurance Code.
Auxiliary aids and services includes qualified interpreters or other effective
methods of making aurally delivered materials understood by persons with hearing
impairments; and, taped texts, large print, Braille, or other effective methods
to ensure visually delivered materials are available to individuals with visual
impairments. Auxiliary aids and services also includes effective methods to
ensure that materials (delivered both aurally and visually) are available to
those with cognitive or other disabilities affecting communication.
Behavioral health care services means covered services for the treatment of
mental or emotional
1999 Renewal Contract
Tarrant Service Area
9
August 9, 1999
10
disorders and treatment of chemical dependency disorders.
Benchmark means a target or standard based on historical data or an
objective/goal.
Capitation means a method of payment in which HMO or a health care provider
receives a fixed amount of money each month for each enrolled Member, regardless
of the amount of covered services used by the enrolled Member.
CHIP means Children's Health Insurance Program established by Title XXI of the
Social Security Act to assist state efforts to initiate and expand child health
assistance to uninsured, low-income children.
Chronic or complex condition means a physical, behavioral, or developmental
condition which may have no known cure and/or is progressive and/or can be
debilitating or fatal if left untreated or under-treated.
Clean claim means a TDH approved or identified claim format that contains all
data fields required by HMO and TDH for final adjudication of the claim. The
required data fields must be complete and accurate. Clean claim also includes
HMO-published requirements for adjudication, such as medical records, as
appropriate (see definition of Unclean Claim). The TDH required data fields are
identified in TDH's AHMO Encounter Data Claims Submission Manual.
CLIA means the federal legislation commonly known as the Clinical Laboratories
Improvement Act of 1988 as found at Section 353 of the federal Public Health
Services Act, and regulations adopted to implement the Act.
Community Management Team (CMT) means interagency groups responsible for
developing and implementing the Texas Children's Mental Health Plan (TCMHP) at
the local level. A CMT consists of local representatives from TXMHMR, the Mental
Health Association of Texas, Texas Commission on Alcohol and Drug Abuse, Texas
Department of Protective and Regulatory Services, Texas Department of Human
Services, Texas Department of Health, Juvenile Probation Commission, Texas Youth
Commission, Texas Rehabilitation Commission, Texas Education Agency, Council on
Early Childhood Intervention and a parent representative. This organizational
structure is also replicated in the State Management Team that sets overall
policy direction for the TCMHP.
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
1999 Renewal Contract
Tarrant Service Area
10
August 9, 1999
11
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 files the complaint.
Complaint means any dissatisfaction, expressed by a complainant orally or in
writing to HMO, with any aspect of HMO's operation, including, but not limited
to, dissatisfaction with plan administration; procedures related to review or
appeal of an adverse determination, as that term is defined by Texas Insurance
Code Article 20A.12, with the exception of the Independent Review Organization
requirements; the denial, reduction, or termination of a service for reasons not
related to medical necessity; the way a service is provided; or disenrollment
decisions, expressed by a complainant. 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 Member. The term also does
not include a provider's or enrollee's oral/written dissatisfaction or
disagreement with an adverse determination or a request for a Fair Hearing to
TDH.
Comprehensive Care Program: See definition for Texas Health Steps.
Continuity of care means care provided to a Member by the same primary care
provider or specialty provider to the greatest degree possible, so that the
delivery of care to the Member remains stable, and services are consistent and
unduplicated.
Contract means this contract between TDH and HMO and documents included by
reference and any of its written amendments, corrections or modifications.
Contract administrator means an entity contracting with TDH to carry out
specific administrative functions under the State's Medicaid managed care
program.
Contract anniversary date means September 1 of each year after the first year of
this contract, regardless of the date of execution or effective date of the
contract.
Contract period means the period of time starting with effective date of the
contract and ending on the termination date of the contract.
Court-ordered commitment means a commitment of a STAR 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.
Covered services means health care services HMO must arrange to provide to
Members, including all services required by this contract and state and federal
law, and all value-added
1999 Renewal Contract
Tarrant Service Area
11
August 9, 1999
12
services described by HMO in its response to the Request For Application (RFA)
for this contract.
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.
Day means calendar day unless specified otherwise.
Denied claim means a clean claim or a portion of a clean claim for which a
determination is made that the claim cannot be paid.
Disability means a physical or mental impairment that substantially limits one
or more of the major life activities of an individual.
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.
DSM-IV means the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, which is the American Psychiatric Association's official classification
of behavioral health disorders.
ECI means Early Childhood Intervention which is a federally mandated program for
infants and children under the age of three with or at risk for development
delays and/or disabilities. The federal ECI regulations are found at 34 C.F.R.
303.1 et seq. The State ECI rules are found at 25 TAC Section 621.21 et seq.
Effective date means the date on which TDH signs the contract following
signature of the contract by HMO.
Emergency behavioral health condition means any condition, without regard to the
nature or cause of the condition, which in the opinion of a prudent layperson
possessing an average knowledge of health and medicine requires immediate
intervention and/or medical attention without which Members would present an
immediate danger to themselves or others or which renders Members incapable of
controlling, knowing or understanding the consequences of their actions.
Emergency services means covered inpatient and outpatient services that are
furnished by a provider that is qualified to furnish such services under this
contract and are needed to evaluate or stabilize an emergency medical condition
and/or an emergency behavioral health condition.
1999 Renewal Contract
Tarrant Service Area
12
August 9, 1999
13
Emergency Medical Condition means a medical condition manifesting itself by
acute symptoms of sufficient severity (including severe pain), such that a
prudent layperson, who possesses an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical care could result in:
(a) placing the patient's health in serious jeopardy;
(b) serious impairment to bodily functions;
(c) serious dysfunction of any bodily organ or part;
(d) serious disfigurement; or
(e) in the case of a pregnant woman, serious jeopardy to the health of
the fetus.
Encounter means a covered service or group of services delivered by a provider
to a Member during a visit between the Member and provider. This also includes
value-added services.
Encounter data means data elements from fee-for-service claims or capitated
services proxy claims that are submitted to TDH by HMO in accordance with TDH's
"HMO Encounter Data Claims Submission Manual".
Enrollment Broker means an entity contracting with TDH to carry out specific
functions related to Member services (i.e., enrollment/disenrollment,
complaints, etc.) under TDH's Medicaid managed care program.
Enrollment report means the list of Medicaid recipients who are enrolled with an
HMO as Members for the month the report was issued.
EPSDT means the federally mandated Early and Periodic Screening, Diagnosis and
Treatment program contained at 42 USC 1396d(r) (see definition for Texas Health
Steps). The name has been changed to Texas Health Steps (THSteps) in the State
of Texas.
Experience Rebate means excess of allowable HMO STAR revenues over allowable HMO
STAR expenses.
Fair Hearing means the process adopted and implemented by the Texas Department
of Health, 25 TAC Chapter 1, in compliance with federal regulations and state
rules relating to Medicaid Fair Hearings found at 42 CFR Part 431, Subpart E,
and 1 TAC, Chapter 357.
FQHC means a Federally Qualified Health Center that has been certified by HCFA
to meet the requirements of '1861(aa)(3) of the Social Security Act as a
federally qualified health center and is enrolled as a provider in the Texas
Medicaid program.
Fraud means an intentional deception or misrepresentation made by a person with
the knowledge that the deception could result in some unauthorized benefit to
himself or some other person. It
1999 Renewal Contract
Tarrant Service Area
13
August 9, 1999
14
includes any act that constitutes fraud under applicable federal or state law.
HCFA means the federal Health Care Financing Administration.
Health care services means medically necessary physical medicine, behavioral
health care and health-related services which an enrolled population might
reasonably require in order to be maintained in good health, including, as a
minimum, emergency care and inpatient and outpatient services.
Implementation Date means the first date that Medicaid managed care services are
delivered to Members in a service area.
Inpatient stay means at least a 24-hour stay in a facility licensed to provide
hospital care.
JCAHO means Joint Commission on Accreditation of Health Care Organizations.
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 Section
121.031.
Local Mental Health Authority (LMHA) means an entity to which the TXMHMR board
delegates its authority and responsibility within a specified region 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 life activities means functions such as caring for oneself, performing
manual tasks, walking, seeing, hearing, speaking, breathing, learning, and
working.
Major population group means any population which represents at least
10% of the Medicaid population in any of the counties in the service area served
by the Contractor.
Medical home means a primary or specialty care provider who has accepted the
responsibility for providing accessible, continuous, comprehensive and
coordinated care to Members participating in TDH's Medicaid managed care
program.
Medically necessary behavioral health care services means those behavioral
health care services which:
1999 Renewal Contract
Tarrant Service Area
14
August 9, 1999
15
(a) are reasonable and necessary for the diagnosis or treatment of a mental
health or chemical dependency disorder or to improve or to maintain or to
prevent deterioration of functioning resulting from such a disorder;
(b) are in accordance with professionally accepted clinical guidelines and
standards of practice in behavioral health care;
(c) are furnished in the most appropriate and least restrictive setting in
which services can be safely provided;
(d) are the most appropriate level or supply of service which can safely be
provided; and
(e) could not be omitted without adversely affecting the Member=s mental
and/or physical health or the quality of care rendered.
Medically necessary health care services means health care services, other than
behavioral health care services which are:
(a) reasonable and necessary to prevent illnesses or medical conditions, or
provide early screening, interventions, and/or treatments for conditions
that cause suffering or pain, cause physical deformity or limitations in
function, threaten to cause or worsen a handicap, cause illness or
infirmity of a Member, or endanger life;
(b) provided at appropriate facilities and at the appropriate levels of care
for the treatment of a Member's 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; and
(e) no more intrusive or restrictive than necessary to provide a proper
balance of safety, effectiveness, and efficiency.
Member means a person who: is entitled to benefits under Title XIX of the Social
Security Act and the Texas Medical Assistance Program (Medicaid), is in a
Medicaid eligibility category included in the STAR Program, and is enrolled in
the STAR Program.
Member month means one Member enrolled with an HMO during any given month. The
total Member months for each month of a year comprise the annual Member months.
Mental health priority population means those individuals served by TXMHMR who
meet the
1999 Renewal Contract
Tarrant Service Area
15
August 9, 1999
16
definition of the priority population. The priority population for mental health
care services is defined as:
Children and adolescents under the age of 18 who have a diagnosis of
mental illness who exhibit severe emotional or social disabilities which
are life-threatening or require prolonged intervention.
Adults who have severe and persistent mental illnesses such as
schizophrenia, major depression, manic depressive disorder, or other
severely disabling mental disorders which require crisis resolution or
ongoing and long-term support and treatment.
MIS means management information system.
Non-provider subcontracts means contracts between HMO and a third party which
performs a function, excluding delivery of health care services, that HMO is
required to perform under its contract with TDH.
Pended claim means a claim for payment which requires additional information
before the claim can be adjudicated as a clean claim.
Performance premium means an amount which may be paid to a managed care
organization as a bonus for accomplishing a portion or all of the performance
objectives contained in this contract.
Premium means the amount paid by TDH to a managed care organization on a monthly
basis and is determined by multiplying the Member months times the capitation
amount for each enrolled Member.
Primary care physician or primary care provider (PCP) means a physician or
provider who has agreed with HMO to provide a medical home to Members and who is
responsible for providing initial and primary care to patients, maintaining the
continuity of patient care, and initiating referral for care (also see Medical
home).
Provider means an individual or entity and its employees and subcontractors that
directly provide health care services to HMO's Members under TDH's Medicaid
managed care program.
Provider contract means an agreement entered into by a direct provider of health
care services and HMO or an intermediary entity.
Proxy Claim Form means a form submitted by providers to document services
delivered to Medicaid Members under a capitated arrangement. It is not a claim
for payment.
Public information means information that is collected, assembled, or maintained
under a law or ordinance or in connection with the transaction of official
business by a governmental body or
1999 Renewal Contract
Tarrant Service Area
16
August 9, 1999
17
for a governmental body and the governmental body owns the information or has a
right of access.
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; and it is usually used to interpret
spoken English into text English but may be used to translate other spoken
languages into text.
Renewal Review means a review process conducted by TDH or its agent(s) to assess
HMO's capacity and capability to perform the duties and responsibilities
required under the Contract. This process is required by Texas Government Code
Section 533.007.
RFA means Request For Application issued by TDH for the initial procurement in
the service area and all RFA addenda, corrections or modifications.
Risk means the potential for loss as a result of expenses and costs of HMO
exceeding payments made by TDH under this contract.
Rural Health Clinic (RHC) means an entity that meets all of the requirements for
designation as a rural health clinic under Section 1861(aa)(1) of the Social
Security Act and approved for participation in the Texas Medicaid Program.
SED means severe emotional disturbance as determined by a local mental health
authority.
Service area means the counties included in a site selected for the STAR
Program, within which a participating HMO must provide services.
SPMI means severe and persistent mental illness as determined by the Local
Mental Health Authority.
Significant traditional provider (STP) means all hospitals receiving
disproportionate share hospital funds (DSH) in FY '95 and all other providers in
a county that, when listed by provider type in descending order by the number of
recipient encounters, provided the top 80 percent of recipient encounters for
each provider type in FY '95.
Special hospital means an establishment that:
(a) offers services, facilities, and beds for use for more than 24 hours for
two or more unrelated individuals who are regularly admitted, treated,
and discharged and who require services more intensive than room, board,
personal services, and general nursing care;
1999 Renewal Contract
Tarrant Service Area
17
August 9, 1999
18
(b) has clinical laboratory facilities, diagnostic x-ray facilities,
treatment facilities, or other definitive medical treatment;
(c) has a medical staff in regular attendance; and
(d) maintains records of the clinical work performed for each patient.
STAR Program is the name of the State of Texas Medicaid managed care program.
"STAR" stands for the State of Texas Access Reform.
State fiscal year means the 12-month period beginning on September 1 and ending
on August 31 of the next year.
Subcontract means any written agreement between HMO and other party to fulfill
the requirements of this contract. All subcontracts are required to be in
writing.
Subcontractor means any individual or entity which has entered into a
subcontract with HMO.
TAC means Texas Administrative Code.
TANF means Temporary Assistance to Needy Families.
TCADA means Texas Commission on Alcohol and Drug Abuse, the State agency
responsible for licensing chemical dependency treatment facilities. TCADA also
contracts with providers to deliver chemical dependency treatment services.
Texas Children's Mental Health Plan (TCMHP) means the interagency, State-funded
initiative that plans, coordinates, provides and evaluates service systems for
children and adolescents with behavioral health needs. The Plan is operated at a
state and local level by Community Management Teams representing the major
child-serving state agencies.
TDD means telecommunication device for the deaf. It is interchangeable with the
term Teletype machine or TTY.
TDH means the Texas Department of Health or its designees.
TDHS means the Texas Department of Human Services.
TDI means the Texas Department of Insurance.
TDMHMR means the Texas Department of Mental Health and Mental Retardation, which
is the State agency responsible for developing mental health policy for public
and private sector
1999 Renewal Contract
Tarrant Service Area
18
August 9, 1999
19
providers.
Temporary Assistance to Needy Families (TANF) means the federally funded program
that provides assistance to single-parent families with children who meet the
categorical requirements for aid. This program was formerly known as Aid to
Families with Dependent Children (AFDC) program.
Texas Health Steps (THSteps) is the name adopted by the State of Texas for the
federally mandated Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
program. It includes the State=s Comprehensive Care Program extension to EPSDT,
which adds benefits to the federal EPSDT requirements contained in 42 United
States Code Section 1396d(r), and defined and codified at 42 C.F.R. Section
440.40 and Section 441.56-62. TDH's rules are contained in 25 TAC, Chapter 33
(relating to Early and Periodic Screening, Diagnosis and Treatment).
Texas Medicaid Provider Procedures Manual means the policy and procedures manual
published by or on behalf of TDH which contains policies and procedures required
of all health care providers who participate in the Texas Medicaid program. The
manual is published annually and is updated bi-monthly by the Medicaid Bulletin.
Texas Medicaid Service Delivery Guide means an attachment to the Texas Medicaid
Provider Procedures Manual.
THHSC means the Texas Health and Human Services Commission.
Third Party Liability (TPL) means the legal responsibility of another individual
or entity to pay for all or part of the services provided to Members under this
contract (see 25 TAC, Subchapter 28, relating to Third Party Resources).
Third Party Recovery (TPR) means the recovery of payments made on behalf of a
Member by TDH or HMO from an individual or entity with the legal responsibility
to pay for the services.
TXMHMR means Texas Mental Health and Mental Retardation system which includes
the state agency, TDMHMR, and the Local Mental Health and Mental Retardation
Authorities.
Unclean claim means a claim that does not contain accurate and complete data in
all claim fields that are required by HMO and TDH and other HMO-published
requirements for adjudication, such as medical records, as appropriate (see
definition of Clean Claim).
Urgent behavioral health situations means conditions which require attention and
assessment within 24 hours but which do not place the Member in immediate danger
to themselves or others and the Member is able to cooperate with treatment.
Urgent condition means a health condition, including an urgent behavioral health
situation,
1999 Renewal Contract
Tarrant Service Area
19
August 9, 1999
20
which is not an emergency but is severe or painful enough to cause a prudent
layperson, possessing the average knowledge of medicine, to believe that his or
her condition requires medical treatment evaluation or treatment within 24 hours
by the Member's PCP or PCP designee to prevent serious deterioration of the
Member's condition or health.
Value-added services means a service that the state has approved to be included
in this contract for which HMO does not receive capitation.
ARTICLE III PLAN ADMINISTRATIVE AND HUMAN RESOURCE REQUIREMENTS
3.1 ORGANIZATION AND ADMINISTRATION
3.1.1 HMO must maintain the organizational and administrative
capacity and capabilities to carry out all duties and
responsibilities under this contract.
3.1.2 HMO must maintain assigned staff with the capacity and
capability to provide all services to all Members under this
contract.
3.1.3 HMO must maintain an administrative office in the service
area (local office). The local office must comply with the
American with Disabilities Act (ADA) requirements for public
buildings. Member Advocates for the service area must be located
in this office (see Article 8.8).
3.1.4 HMO must provide training and development programs to all
assigned staff to ensure they know and understand the service
requirements under this contract including the reporting
requirements, the policies and procedures, cultural and linguistic
requirements and the scope of services to be provided.
3.1.5 HMO must notify TDH no later than 30 days after the
effective date of this contract of any changes in its
organizational chart as previously submitted to TDH.
3.1.5.1 HMO must notify TDH within fifteen (15) working days of any
change in key managers or behavioral health subcontractors. This
information must be updated whenever there is a significant change
in organizational structure or personnel.
3.1.6 Participation in Regional Advisory Committee. HMO must
participate on a Regional Advisory Committee established in the
service area in compliance
1999 Renewal Contract
Tarrant Service Area
20
August 9, 1999
21
with the Texas Government Code, Sections 533.021-533.029. The
Regional Advisory Committee in each managed care service area must
include representatives from at least the following entities:
hospitals; managed care organizations; primary care providers;
state agencies; consumer advocates; Medicaid recipients; rural
providers; long-term care providers; specialty care providers,
including pediatric providers; and political subdivisions with a
constitutional or statutory obligation to provide health care to
indigent patients. THHSC and TDH will determine the composition of
each Regional Advisory Committee.
3.1.6.1 The Regional Advisory Committee is required to meet at
least quarterly for the first year after appointment of the
committee and at least annually in subsequent years. The actual
frequency may vary depending on the needs and requirements of the
committee.
3.2 NON-PROVIDER SUBCONTRACTS
3.2.1 HMO must enter into written contracts with all
subcontractors and maintain copies of the subcontracts in HMO's
administrative office. HMO must submit two copies of all
non-provider subcontracts to TDH for approval no later than 60
days after the effective date of this contract, unless the
subcontract has already been submitted to and approved by TDH.
Subcontracts entered into after the effective date of this
contract must be submitted no later than 30 days prior to the date
of execution of the subcontract. HMO must also make non-provider
subcontracts available to TDH upon request, at the time and
location requested by TDH.
3.2.1.1 TDH HAS 15 WORKING DAYS TO REVIEW THE SUBCONTRACT AND RECOMMEND
ANY SUGGESTIONS OR REQUIRED CHANGES. IF TDH HAS NOT RESPONDED TO
HMO BY THE FIFTEENTH DAY, HMO MAY EXECUTE THE SUBCONTRACT. TDH
RESERVES THE RIGHT TO REQUEST HMO TO MODIFY ANY SUBCONTRACT THAT
HAS BEEN DEEMED APPROVED.
3.2.1.2 HMO must notify TDH no later than 90 days prior to
terminating any subcontract affecting a major performance function
of this contract. All major subcontractor terminations or
substitutions require TDH approval (see Article 15.7). TDH may
require HMO to provide a transition plan describing how the
subcontracted function will continue to be provided. All
subcontracts are subject to the terms and conditions of this
contract and must contain the provisions of Article V, Statutory
and Regulatory Compliance, and the provisions contained in Article
3.2.4.
3.2.2 Subcontracts which are requested by any agency with
authority to
1999 Renewal Contract
Tarrant Service Area
21
August 9, 1999
22
investigate and prosecute fraud and abuse must be produced at the
time and in the manner requested by the requesting Agency.
Subcontracts requested in response to a Public Information request
must be produced within 3 working days from TDH's notification to
HMO of the request. All requested records must be provided
free-of-charge.
3.2.3 The form and substance of all subcontracts including
subsequent amendments are subject to approval by TDH. TDH retains
the authority to reject or require changes to any provisions of
the subcontract that do not comply with the requirements or duties
and responsibilities of this contract or create significant
barriers for TDH in carrying out its duty to monitor compliance
with the contract. HMO REMAINS RESPONSIBLE FOR PERFORMING ALL
DUTIES, RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT
REGARDLESS OF WHETHER THE DUTY, RESPONSIBILITY OR SERVICE IS
SUBCONTRACTED TO ANOTHER.
3.2.4 HMO and all intermediary entities must include the
following standard language in each subcontract and ensure that
this language is included in all subcontracts down to the actual
provider of the services. The following standard language is not
the only language that will be considered acceptable by TDH.
3.2.4.1 [Contractor] understands that services provided under this
contract are funded by state and federal funds under the Texas
Medical Assistance Program (Medicaid). [Contractor] is subject to
all state and federal laws, rules and regulations that apply to
persons or entities receiving state and federal funds.
[Contractor] understands that any violation by [Contractor] of a
state or federal law relating to the delivery of services under
this contract, or any violation of the TDH/HMO contract could
result in liability for contract money damages, and/or civil and
criminal penalties and sanctions under state and federal law.
3.2.4.2 [Contractor] understands and agrees that HMO has the sole
responsibility for payment of services rendered by the
[Contractor] under this contract. In the event of HMO insolvency
or cessation of operations, [Contractor's] sole recourse is
against HMO through the bankruptcy or receivership estate of HMO.
3.2.4.3 [Contractor] understands and agrees that TDH is not liable
or responsible for payment for any services provided under this
contract.
3.2.4.4 [Contractor] agrees that any modification, addition, or
deletion of the provisions of this agreement will become effective
no earlier than 30 days after HMO notifies TDH of the change. If
TDH does not provide written approval within 30 days from receipt
of notification from HMO, changes may be
1999 Renewal Contract
Tarrant Service Area
22
August 9, 1999
23
considered provisionally approved.
3.2.4.5 This contract is subject to state and federal fraud and
abuse statutes. [Contractor] will be required to cooperate in the
investigation and prosecution of any suspected fraud or abuse, and
must provide any and all requested originals and copies of records
and information, free-of-charge on request, to any state or
federal agency with authority to investigate fraud and abuse in
the Medicaid program.
3.2.5 The Texas Medicaid Fraud Control Unit must be allowed to
conduct private interviews of HMO personnel, subcontractors and
their personnel, witnesses, and patients. Requests for information
are to be complied with, in the form and the language requested.
HMO employees and Contractors and subcontractors and their
employees and Contractors must cooperate fully in making
themselves available in person for interviews, consultation, grand
jury proceedings, pretrial conference, hearings, trial and in any
other process, including investigations. Compliance with this
Article is at HMO's and subcontractors' own expense.
3.3 MEDICAL DIRECTOR
3.3.1 HMO must have the equivalent of a full-time Medical
Director licensed under the Texas State Board of Medical Examiners
(M.D. or D.O.). HMO must have a written job description describing
the Medical Director's authority, duties and responsibilities as
follows:
3.3.1.1 Ensure that medical necessity decisions, including prior
authorization protocols, are rendered by qualified medical
personnel and are based on TDH's definition of medical necessity,
and is in compliance with the Utilization Review Act and 21.58a of
the Texas Insurance Code.
3.3.1.2 Oversight responsibility of network providers to ensure
that all care provided complies with the generally accepted health
standards of the community.
3.3.1.3 Oversight of HMO's quality improvement process, including
establishing and actively participating in HMO's quality
improvement committee, monitoring Member health status, HMO
utilization review policies and standards and patient outcome
measures.
3.3.1.4 Identify problems and develop and implement corrective
actions to quality improvement process.
1999 Renewal Contract
Tarrant Service Area
23
August 9, 1999
24
3.3.1.5 Develop, implement and maintain responsibility for HMO's
medical policy.
3.3.1.6 Oversight responsibility for medically related complaints.
3.3.1.7 Participate and provide witnesses and testimony on behalf
of HMO in the TDH Fair Hearing process.
3.3.2 The Medical Director must exercise independent medical
judgement in all medical necessity decisions. HMO must ensure that
medical necessity decisions are not adversely influenced by fiscal
management decisions. TDH may conduct reviews of medical necessity
decisions by HMO Medical Director at any time.
3.4 PLAN MATERIALS AND DISTRIBUTION OF PLAN MATERIALS
3.4.1 HMO must receive written approval from TDH for all updated
written materials, produced or authorized by HMO, containing
information about the STAR Program prior to distribution to
Members, prospective Members, providers within HMO's network, or
potential providers who HMO intends to recruit as network
providers. This includes Member education materials.
3.4.2 Member materials must meet cultural and linguistic
requirements as stated in Article VIII. Unless otherwise required,
Member materials must be written at a 4th - 6th grade reading
comprehension level; and translated into the language of any major
population group, except when TDH requires HMO to use statutory
language (i.e., advance directives, medical necessity, etc.).
3.4.3 All materials regarding the STAR Program, including Member
education materials, must be submitted to TDH for approval prior
to distribution. TDH has 15 working days to review the materials
and recommend any suggestions or required changes. If TDH has not
responded to HMO by the fifteenth day, HMO may print and
distribute these materials. TDH reserves the right to request HMO
to modify plan materials that are deemed approved and have been
printed or distributed. These modifications can be made at the
next printing unless substantial non-compliance exists. An
exception to the 15 working day timeframe may be requested in
writing by HMO for written provider materials that require a quick
turn-around time (e.g., letters). These materials will be reviewed
by TDH within 5 working days.
3.4.4 HMO must forward approved English versions of their Member
Handbook, Member Provider Directory, newsletters, individual
Member letters, and any written information that applies to
Medicaid-specific services to DHS for
1999 Renewal Contract
Tarrant Service Area
24
August 9, 1999
25
DHS to translate into Spanish. DHS must provide the written and
approved translation into Spanish to HMO no later than 15 working
days after receipt of the English version by DHS. HMO must
incorporate the approved translation into these materials. If DHS
has not responded to HMO by the fifteenth day, HMO may print and
distribute these materials. TDH reserves the right to require
revisions to materials if inaccuracies are discovered or if
changes are required by changes in policy or law. These changes
can be made at the next printing unless substantial non-compliance
exists. HMO has the option of using the DHS translation unit or
their own translators for health education materials that do not
contain Medicaid-specific information and for other marketing
materials such as billboards, radio spots, and television and
newspaper advertisements.
3.4.5 HMO must reproduce all written instructional, educational,
and procedural documents required under this contract and
distribute them to its providers and Members. HMO must reproduce
and distribute instructions and forms to all network providers who
have reporting and audit requirements under this contract.
3.4.6 HMO must provide TDH with at least three paper copies and
one electronic copy of their Member Handbook, Provider Manual and
Member Provider Directory. If an electronic format is not
available, five paper copies are required.
3.4.7 Changes to the Required Critical Elements for the Member
Handbook, Provider Manual, and Provider Directory may be handled
as inserts until the next printing of these documents.
3.5 RECORDS REQUIREMENTS AND RECORDS RETENTION
3.5.1 HMO must keep all records required to be created and
retained under this contract. Records related to Members served in
this service area must be made available in HMO's local office
when requested by TDH. All records must be retained for a period
of five (5) years unless otherwise specified in this contract.
Original records must be kept in the form they were created in the
regular course of business for a minimum of two (2) years
following the end of the contract period. Microfilm, digital or
electronic records may be substituted for the original records
after the first two (2) years, if the retention system is reliable
and supported by a retrieval system which allows reasonable access
to the records. All copies of original records must be made using
guidelines and procedures approved by TDH, if the original
documents will no longer be available or accessible.
3.5.2 Availability and Accessibility. All records, documents and
data required to be created under this contract are subject to
audit, inspection and production. If
1999 Renewal Contract
Tarrant Service Area
25
August 9, 1999
26
an audit, inspection or production is requested by TDH, TDH's
designee or TDH acting on behalf of any agency with regulatory or
statutory authority over Medicaid Managed Care, the requested
records must be made available at the time and at the place the
records are requested. Copies of requested records must be
produced or provided free-of-charge to the requesting agency.
Records requested after the second year following the end of
contract term that have been stored or archived must be accessible
and made available within 10 calendar days from the date of a
request by TDH or the requesting agency or at a time and place
specified by the requesting entity.
3.5.3 Accounting Records. HMO must create and keep accurate and
complete accounting records in compliance with Generally Accepted
Accounting Principles (GAAP). Records must be created and kept for
all claims payments, refunds and adjustment payments to providers,
premium or capitation payments, interest income and payments for
administrative services or functions. Separate records must be
maintained for medical and administrative fees, charges, and
payments.
3.5.4 General Business Records. HMO must create and keep complete
and accurate general business records to reflect the performance
of duties and responsibilities, and compliance with the provisions
of this contract.
3.5.5 Medical Records. HMO must require, through contractual
provisions or provider manual, providers to create and keep
medical records in compliance with the medical records standards
contained in the Standards for Quality Improvement Programs in
Appendix A. All medical records must be kept for at least five (5)
years, except for records of rural health clinics, which must be
kept for a period of six (6) years from the date of service.
3.5.6 Matters in Litigation. HMO must keep records related to
matters in litigation for five (5) years following the termination
or resolution of the litigation.
3.5.7 On-line Retention of Claims History. HMO must keep
automated claims payment histories for a minimum of 18 months from
date of adjudication in an on-line inquiry system. HMO must also
keep sufficient history on-line to ensure all claim/encounter
service information is submitted to and accepted by TDH for
processing.
3.6 HMO REVIEW OF TDH MATERIALS
TDH will submit all studies or audits that relate or refer to HMO
for review and comment to HMO 10 working days prior to releasing
the report to the public or to
1999 Renewal Contract
Tarrant Service Area
26
August 9, 1999
27
Members.
3.7 HMO TELEPHONE ACCESS REQUIREMENTS
HMO must ensure that HMO has adequately-staffed telephone lines.
Telephone personnel must receive customer service telephone
training. HMO must ensure that telephone staffing is adequate to
fulfill the standards of promptness and quality listed below:
1. 80% of all telephone calls must be answered within an
average of 30 seconds;
2. The lost (abandonment) rate must not exceed 10%;
3. 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 or Provider.
ARTICLE IV FISCAL, FINANCIAL, CLAIMS AND INSURANCE REQUIREMENTS
4.1 FISCAL SOLVENCY
4.1.1 HMO must be and remain in full compliance with all state
and federal solvency requirements for HMOs, including but not
limited to all reserve requirements, net worth standards,
debt-to-equity ratios, or other debt limitations.
4.1.2 If HMO becomes aware of any impending changes to its
financial or business structure which could adversely impact its
compliance with these requirements or its ability to pay its debts
as they come due, HMO must notify TDH immediately in writing. If
HMO becomes aware of a take-over or assignment which would require
the approval of TDI or TDH, HMO must notify TDH immediately in
writing.
4.1.3 HMO must not have been placed under state conservatorship
or receivership or filed for protection under federal bankruptcy
laws. None of HMO's property, plant or equipment must have been
subject to foreclosure or repossession within the preceding
10-year period. HMO must not have any debt declared in default and
accelerated to maturity within the preceding 10-year period. HMO
represents that these statements are true as of the contract
effective date. HMO must inform TDH within 24 hours of a change in
any of the preceding representations.
1999 Renewal Contract
Tarrant Service Area
27
August 9, 1999
28
4.2 MINIMUM NET WORTH
4.2.1 HMO has 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 Medicaid 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 Article 1.39 of the Insurance Code.
4.2.2 The minimum equity must be maintained during the entire
contract period.
4.3 PERFORMANCE BOND
HMO has furnished TDH with a performance bond in the form
prescribed by TDH and approved by TDI, naming TDH as Obligee,
securing HMO's faithful performance of the terms and conditions of
this contract. The performance bond has been issued in the amount
of $100,000 for a two year period (contract period). If the
contract is renewed or extended under Article XVIII, a separate
bond will be required for each additional term of the contract.
The bond has been issued by a surety licensed by TDI, and
specifies cash payment as the sole remedy. Performance Bond
requirements under this Article must comply with Texas Insurance
Code Section 11.1805, relating to Performance and Fidelity Bonds.
The bond must be delivered to TDH at the same time the signed HMO
contract is delivered to TDH.
4.4 INSURANCE
4.4.1 HMO must maintain, or cause to be maintained, general
liability insurance in the amounts of at least $1,000,000 per
occurrence and $5,000,000 in the aggregate.
4.4.2 HMO must maintain or require professional liability
insurance on each of the providers in its network in the amount of
$100,000 per occurrence and $300,000 in the aggregate, or the
limits required by the hospital at which the network provider has
admitting privileges.
4.4.3 HMO must maintain an umbrella professional liability
insurance policy for the greater of $3,000,000 or an amount
(rounded to the next $100,000) which represents the number of STAR
Members enrolled in HMO in the first month of the contract year
multiplied by $150, not to exceed $10,000,000.
4.4.4 Any exceptions to the requirements of this Article must be
approved in
1999 Renewal Contract
Tarrant Service Area
28
August 9, 1999
29
writing by TDH prior to the effective date of this contract. HMOs
and providers who qualify as either state or federal units of
government are exempt from the insurance requirements of this
Article and are not required to obtain exemptions from these
provisions prior to the effective date of this contract. State and
federal units of government are required to comply with and are
subject to the provisions of the Texas or Federal Tort Claims Act.
4.5 FRANCHISE TAX
HMO certifies that its payment of franchise taxes is current or
that it is not subject to the State of Texas franchise tax.
4.6 AUDIT
4.6.1 TDH, TDI, or their designee have the right from time to
time to examine and audit books and records of HMO, or its
subcontractors, relating to: (1) HMO's capacity to bear the risk
of potential financial losses; (2) services performed or
determination of amounts payable under this contract; (3)
detection of fraud and abuse; and (4) other purposes TDH deems to
be necessary to perform its regulatory function and/or to enforce
the provisions of this contract.
4.6.2 TDH is required to conduct an audit of HMO at least once
every three years. HMO is responsible for paying the costs of an
audit conducted under this Article. The costs of the audit paid by
HMO are allowable costs under this contract.
4.7 PENDING OR THREATENED LITIGATION
HMO must require disclosure from subcontractors and network
providers of all pending or potential litigation or administrative
actions against the subcontractor or network provider and must
disclose this information to TDH, in writing, prior to the
execution of this contract. HMO must make reasonable investigation
and inquiry that there is not pending or potential litigation or
administrative action against the providers or subcontractors in
HMO's provider network. HMO must notify TDH of any litigation
which is initiated or threatened after the effective date of this
contract within seven days of receiving service or becoming aware
of the threatened litigation.
4.8 MISREPRESENTATION AND FRAUD IN RESPONSE TO RFA AND IN HMO
OPERATIONS
4.8.1 HMO was awarded this contract based upon the responses and
1999 Renewal Contract
Tarrant Service Area
29
August 9, 1999
30
representations contained in HMO's application submitted in
response to TDH's RFA. All responses and representations upon
which scoring was based were considered material to the decision
of whether to award the contract to HMO. RFA responses are
incorporated into this contract by reference. The provisions of
this contract control over any RFA response if there is a conflict
between the RFA and this contract, or if changes in law or policy
have changed the requirements of HMO contracting with TDH to
provide Medicaid Managed Care.
4.8.2 This contract was awarded in part based upon HMO's
representation of its current equity and financial ability to bear
the risks under this contract. TDH will consider any
misrepresentations of HMO's equity, HMO's ability to bear
financial risks of this contract or inflating the equity of HMO,
solely for the purpose of being awarded this contract, a material
misrepresentation and fraud under this contract.
4.8.3 Discovery of any material misrepresentation or fraud on the
part of HMO in HMO's application or in HMO's day-to-day activities
and operations may cause this contract to terminate and may result
in legal action being taken against HMO under this contract, and
state and federal civil and criminal laws.
4.9 THIRD PARTY RECOVERY
4.9.1 Third Party Recovery. All Members are required to assign
their rights to any benefits to the State and agree to cooperate
with the State in identifying third parties who may be liable for
all or part of the costs for providing services to the Member, as
a condition for participation in the Medicaid program. HMO is
authorized to act as the State's agent in enforcing the State's
rights to third party recovery under this contract.
4.9.2 Identification. HMO must develop and implement systems and
procedures to identify potential third parties who may be liable
for payment of all or part of the costs for providing medical
services to Members under this contract. Potential third parties
must include any of the sources identified in 42 C.F.R. 433.138,
relating to identifying third parties, except workers'
compensation, uninsured and underinsured motorist insurance, first
and third party liability insurance and tortfeasors. HMO must
coordinate with TDH to obtain information from other state and
federal agencies and HMO must cooperate with TDH in obtaining
information from commercial third party resources. HMO must
require all providers to comply with the provisions of 25 TAC
Section 28, relating to Third Party Recovery in the Medicaid
program.
4.9.3 Exchange of Identified Resources. HMO must forward
identified
1999 Renewal Contract
Tarrant Service Area
30
August 9, 1999
31
resources of uninsured and underinsured motorist insurance, first
and third party liability insurance and tortfeasors ("excepted
resources") to TDH for TDH to pursue collection and recovery from
these resources. TDH will forward information on all third party
resources identified by TDH to HMO. HMO must coordinate with TDH
to obtain information from other state and federal agencies,
including HCFA for Medicare and the Child Support Enforcement
Division of the Office of the Attorney General for medical
support. HMO must cooperate with TDH in obtaining and exchanging
information from commercial third party resources.
4.9.4 Recovery. HMO must actively pursue and collect from third
party resources which have been identified, except when the cost
of pursuing recovery reasonably exceeds the amount which may be
recovered by HMO. HMO is not required to, but may pursue recovery
and collection from the excepted resources listed in Article
4.9.3. HMO must report the identity of these resources to TDH,
even if HMO will pursue collection and recovery from the excepted
resources.
4.9.4.1 HMO must provide third party resource information to
network providers to whom individual Members have been assigned or
who provide services to Members. HMO must require providers to
seek recovery from potential third party resources prior to
seeking payment from HMO. If network providers are paid
capitation, HMO must either seek recovery from third party
resources or account to TDH for all amounts received by network
providers from third party resources.
4.9.4.2 HMO must prohibit network providers from interfering with
or placing liens upon the State's right or HMO's right, acting as
the State's agent, to recovery from third party resources. HMO
must prohibit network providers from seeking recovery in excess of
the Medicaid payable amount or otherwise violating state and
federal laws.
4.9.5 Retention. HMO may retain as income all amounts recovered
from third party sources as long as recoveries are obtained in
compliance with the contract and state and federal laws.
4.9.6 Accountability. HMO must report all third party recovery
efforts and amounts recovered as required in Article 12.1.12. If
HMO fails to pursue and recover from third parties no later than
180 days after the date of service, TDH may pursue third party
recoveries and retain all amounts recovered without accounting to
HMO for the amounts recovered. Amounts recovered by TDH will be
added to expected third party recoveries to reduce future
capitation rates, except recoveries from those excepted third
party resources listed in Article 4.9.3.
1999 Renewal Contract
Tarrant Service Area
31
August 9, 1999
32
4.10 CLAIMS PROCESSING REQUIREMENTS
4.10.1 HMO and claims processing subcontractors must comply with
TDH's Texas Managed Care Claims Manual (Claims Manual), which
contains TDH's claims processing requirements. HMO must comply
with any changes to the Claims Manual with appropriate notice of
changes from TDH.
4.10.2 HMO must forward claims submitted to HMO in error to
either: 1) the correct HMO if the correct HMO can be determined
from the claim or is otherwise known to HMO; 2) the State's claims
administrator; or 3) the provider who submitted the claim in
error, along with an explanation of why the claim is being
returned.
4.10.3 HMO must not pay any claim submitted by a provider who has
been excluded or suspended from the Medicare or Medicaid programs
for fraud and abuse when HMO has knowledge of the exclusion or
suspension.
4.10.4 All provider clean claims must be adjudicated (finalized as
paid or denied adjudicated) within 30 days from the date the claim
is received by HMO. HMO must pay providers interest on a clean
claim which is not adjudicated within 30 days from the date the
claim is received by HMO or becomes clean at a rate of 1.5% per
month (18% annual) for each month the clean claim remains
unadjudicated. HMO will be held to a minimum performance level of
90% of all clean claims paid or denied within 30 days of receipt
and 99% of all clean claims paid or denied within 90 days of
receipt. Failure to meet these performance levels is a default
under this contract and could lead to damages or sanctions as
outlined in Article XVII. The performance levels are subject to
changes if required to comply with federal and state laws or
regulations.
4.10.4.1 All claims and appeals submitted to HMO and claims processing
subcontractors must be paid-adjudicated (clean claims),
denied-adjudicated (clean claims), or denied for additional
information (unclean claims) to providers within 30 days from the
date the claim is received by HMO. Providers must be sent a
written notice for each claim that is denied for additional
information (unclean claims) identifying the claim, all reasons
why the claim is being denied, the date the claim was received by
HMO, all information required from the provider in order for HMO
to adjudicate the claim, and the date by which the requested
information must be received from the provider.
4.10.4.2 Claims that are suspended (pended internally) must be subsequently
paid-adjudicated, denied-adjudicated, or denied for additional
information (pended externally) within 30 days from date of
receipt. No claim can be suspended for a period exceeding 30 days
from date of receipt of the claim.
1999 Renewal Contract
Tarrant Service Area
32
August 9, 1999
33
4.10.4.3 HMO must identify each data field of each claim form that is
required from the provider in order for HMO to adjudicate the
claim. HMO must inform all network providers about the required
fields no later than 30 days prior to the effective date of the
contract or as a provision within HMO/provider contract.
Out-of-network providers must be informed of all required fields
if the claim is denied for additional information. The required
fields must include those required by HMO and TDH.
4.10.5 HMO is subject to Article XVI, Default and Remedies, for
claims that are not processed on a timely basis as required by
this contract and the Claims Manual. Notwithstanding the
provisions of Articles 4.10.4, 4.10.4.1 and 4.10.4.2, HMO's
failure to adjudicate (paid, denied, or external pended) at least
ninety percent (90%) of all claims within thirty (30) days of
receipt and ninety-nine percent (99%) within ninety (90) days of
receipt for the contract year to date is a default under Article
XVI of this contract.
4.10.6 HMO must comply with the standards adopted by the U.S.
Department of Health and Human Services under the Health Insurance
Portability and Accountability Act of 1996 submitting and
receiving claims information through electronic data interchange
(EDI) that allows for automated processing and adjudication of
claims within two or three years, as applicable, from the date the
rules promulgated under HIPAA are adopted.
4.10.7 For claims requirements regarding retroactive PCP changes
for mandatory Members, see Article 7.8.12.2.
4.11 INDEMNIFICATION
4.11.1 HMO/TDH: HMO must agree to indemnify TDH and its agents for
any and all claims, costs, damages and expenses, including court
costs and reasonable attorney's fees, which are related to or
arise out of:
4.11.1.1 Any failure, inability, or refusal of HMO or any of its network
providers or other subcontractors to provide covered services;
4.11.1.2 Claims arising from HMO's, HMO's network provider's or other
subcontractor's negligent or intentional conduct in not providing
covered services; and
4.11.1.3 Failure, inability, or refusal of HMO to pay any of its network
providers or subcontractors for covered services.
1999 Renewal Contract
Tarrant Service Area
33
August 9, 1999
34
4.11.2 HMO/Provider: HMO is prohibited from requiring providers to
indemnify HMO for HMO's own acts or omissions which result in
damages or sanctions being assessed against HMO either under this
contract or under state or federal law.
ARTICLE V STATUTORY AND REGULATORY COMPLIANCE REQUIREMENTS
5.1 COMPLIANCE WITH FEDERAL, STATE, AND LOCAL LAWS
5.1.1 HMO must know, understand and comply with all state and
federal laws and regulations relating to the Texas Medicaid
Program which have not been waived by HCFA. HMO must comply with
all rules relating to the Medicaid managed care program adopted by
TDH, TDI, THHSC, TDMHMR and any other state agency delegated
authority to operate or administer Medicaid or Medicaid managed
care programs.
5.1.2 HMO must require, through contract provisions, that all
network providers or subcontractors comply with all state and
federal laws and regulations relating to the Texas Medicaid
Program and all rules relating to the Medicaid managed care
program adopted by TDH, TDI, THHSC, TDMHMR and any other state
agency delegated authority to operate Medicaid or Medicaid Managed
Care programs.
5.1.3 HMO must comply with the provisions of the Clean Air Act
and the Federal Water Pollution Control Act, as amended, found at
42 C.F.R. 7401, et seq. and 33 U.S.C. 1251, et seq., respectively.
5.2 PROGRAM INTEGRITY
5.2.1 HMO has not been excluded, debarred, or suspended from
participation in any program under Title XVIII or Title XIX under
any of the provisions of Section 1128(a) or (b) of the Social
Security Act (42 USC Section 1320 a-7), or Executive Order 12549.
HMO must notify TDH within 3 days of the time it receives notice
that any action is being taken against HMO or any person defined
under the provisions of Section 1128(a) or (b) or any
subcontractor, which could result in exclusion, debarment, or
suspension of HMO or a subcontractor from the Medicaid program, or
any program listed in Executive Order 12549.
5.2.2 HMO must comply with the provisions of, and file the
certification of compliance required by the Xxxx Anti-Lobbying
Amendment, found at 31 U.S.C. 1352, relating to use of federal
funds for lobbying for or obtaining federal
1999 Renewal Contract
Tarrant Service Area
34
August 9, 1999
35
contracts.
5.3 FRAUD AND ABUSE COMPLIANCE PLAN
5.3.1 This contract is subject to all state and federal laws and
regulations relating to fraud and abuse in health care and the
Medicaid program. HMO must cooperate and assist TDH and THHSC and
any other state or federal agency charged with the duty of
identifying, investigating, sanctioning or prosecuting suspected
fraud and abuse. HMO must provide originals and/or copies of all
records and information requested and allow access to premises and
provide records to TDH or its authorized agent(s), THHSC, HCFA,
the U.S. Department of Health and Human Services, FBI, TDI, and
the Texas Attorney General's Medicaid Fraud Control Unit. All
copies of records must be provided free of charge.
5.3.2 Compliance Plan. HMO must submit to TDH for approval a
written fraud and abuse compliance plan which is based on the
Model Compliance Plan issued by the U.S. Department of Health and
Human Services, the Office of Inspector General (OIG), no later
than 30 days after the effective date of the contract. HMO must
designate an officer or director in its organization who has the
responsibility and authority for carrying out the provisions of
its compliance plan. HMO must submit any updates or modifications
in its compliance plan to TDH for approval at least 30 days prior
to the modifications going into effect. HMO's fraud and abuse
compliance plan must:
5.3.2.1 ensure that all officers, directors, managers and employees
know and understand the provisions of HMO's fraud and abuse
compliance plan.
5.3.2.2 contain procedures designed to prevent and detect potential
or suspected abuse and fraud in the administration and delivery of
services under this contract.
5.3.2.3 contain provisions for the confidential reporting of plan
violations to the designated person in HMO.
5.3.2.4 contain provisions for the investigation and follow-up of
any compliance plan reports.
5.3.2.5 ensure that the identity of individuals reporting
violations of the plan is protected.
5.3.2.6 contain specific and detailed internal procedures for
officers, directors,
1999 Renewal Contract
Tarrant Service Area
35
August 9, 1999
36
managers and employees for detecting, reporting, and investigating
fraud and abuse compliance plan violations.
5.3.2.7 require any confirmed or suspected fraud and abuse under
state or federal law be reported to TDH, the Medicaid Program
Integrity section of the Office of Investigations and Enforcement
of the Texas Health and Human Services Commission, and/or the
Medicaid Fraud Control Unit of the Texas Attorney General.
5.3.2.8 ensure that no individual who reports plan violations or
suspected fraud and abuse is retaliated against.
5.3.3 Training. HMO must designate executive and essential
personnel to attend mandatory training in fraud and abuse
detection, prevention and reporting. The training will be
conducted by the Office of Investigation and Enforcement, Health
and Human Services Commission, and will be provided free of
charge. HMO must schedule and complete training no later than 90
days after the effective date of any updates or modification of
the written Model Compliance Plan.
5.3.3.1 If HMO's personnel have attended OIE training prior to the
effective date of this contract, they are not required to attend
additional OIE training unless new training is required due to
changes in federal and/or state law or regulations. If additional
OIE training is required, TDH will notify HMO to schedule this
additional training.
5.3.3.2 If HMO updates or modifies its written fraud and abuse
compliance plan, 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.
5.3.3.3 If HMO's executive and essential personnel change or if HMO
employs additional executive and essential personnel, the new or
additional personnel must attend OIE training within 90 days of
employment by HMO.
5.3.4 HMO's failure to report potential or suspected fraud or
abuse may result in sanctions, contract cancellation, or exclusion
from participation in the Medicaid program.
5.3.5 HMO must allow the Texas Medicaid Fraud Control Unit and
THHSC's Office of Investigations and Enforcement, to conduct
private interviews of HMO's employees, subcontractors and their
employees, witnesses, and patients.
1999 Renewal Contract
Tarrant Service Area
36
August 9, 1999
37
Requests for information must be complied with in the form and the
language requested. HMO's employees and its subcontractors and
their employees must cooperate fully and be available in person
for interviews, consultation, grand jury proceedings, pre-trial
conference, hearings, trial and in any other process.
5.3.6 Subcontractors. HMO must submit the documentation
described in Articles 5.3.6.1 through 5.3.6.3, in compliance with
Texas Government Code Section 533.012, regarding any subcontractor
providing health care services under this contract except for
those providers who have re-enrolled as a provider in the Medicaid
program as required by Section 2.07, Chapter 1153, Acts of the
75th Legislature, Regular Session, 1997, or who modified a
contract in compliance with that section. HMO must submit
information in a format as specified by TDH. Documentation must be
submitted no later than 120 days after the effective date of this
contract. Subcontracts entered into after the effective date of
this contract must be submitted no later than 90 days after the
effective date of the subcontract. The required documentation
required under this provision is not subject to disclosure under
Chapter 552, Government Code.
5.3.6.1 a description of any financial or other business
relationship between HMO and its subcontractor;
5.3.6.2 a copy of each type of contract between HMO and its
subcontractor;
5.3.6.3 a description of the fraud control program used by any
subcontractor.
5.4 SAFEGUARDING INFORMATION
5.4.1 All Member information, records and data collected or
provided to HMO by TDH or another State agency is protected from
disclosure by state and federal law and regulations. HMO may only
receive and disclose information which is directly related to
establishing eligibility, providing services and conducting or
assisting in the investigation and prosecution of civil and
criminal proceedings under state or federal law. HMO must include
a confidentiality provision in all subcontracts with individuals.
5.4.2 HMO is responsible for informing Members and providers
regarding the provisions of 42 C.F.R. 431, Subpart F, relating to
Safeguarding Information on Applicants and Recipients, and HMO
must ensure that confidential information is protected from
disclosure except for authorized purposes.
5.4.3 HMO must assist network PCPs in developing and implementing
policies for protecting the confidentiality of AIDS and
HIV-related medical information
1999 Renewal Contract
Tarrant Service Area
37
August 9, 1999
38
and an anti-discrimination policy for employees and Members with
communicable diseases. Also see Health and Safety Code, Chapter
85, Subchapter E, relating to the Duties of State Agencies and
State Contractors.
5.4.4 HMO must require that subcontractors have mechanisms in
place to ensure Member's (including minor's) confidentiality for
family planning services.
5.5 NON-DISCRIMINATION
HMO agrees to comply with and to include in all subcontracts a
provision that the subcontractor will comply with each of the
following requirements:
5.5.1 Title VI of the Civil Rights Act of 1964, Section 504 of
the Rehabilitation Act of 1973, the Americans with Disabilities
Act of 1990, and all requirements imposed by the regulations
implementing these acts and all amendments to the laws and
regulations. The regulations provide in part that no person in the
United States shall on the grounds of race, color, national
origin, sex, age, disability, political beliefs or religion be
excluded from participation in, or denied, any aid, care, service
or other benefits, or be subjected to any discrimination under any
program or activity receiving federal funds.
5.5.2 Texas Health and Safety Code Section 85.113 (relating to
workplace and confidentiality guidelines regarding AIDS and HIV).
5.5.3 The provisions of Executive Order 11246, as amended by
11375, relating to Equal Employment Opportunity.
5.5.4 HMO shall not discriminate with respect to participation,
reimbursement, or indemnification as to any provider who is acting
within the scope of the provider's license or certification under
applicable State law, solely on the basis of such license or
certification. This requirement shall not be construed to prohibit
HMO from including providers only to the extent necessary to meet
the needs of HMO's Members or from establishing any measure
designed to maintain quality and control costs consistent with
HMO's responsibilities.
5.6 HISTORICALLY UNDERUTILIZED BUSINESSES (HUBS)
5.6.1 TDH is committed to providing procurement and contracting
opportunities to historically underutilized businesses (HUBs),
under the provisions of Texas Government Code, Title 10, Subtitle
D, Chapter 2161 and 1 TAC Section 111.11(b) and 111.13(c)(7). TDH
requires its Contractors and subcontractors to make a good faith
effort to assist HUBs in receiving a portion of the total contract
value of this
1999 Renewal Contract
Tarrant Service Area
38
August 9, 1999
39
contract.
5.6.2 The HUB good faith effort goal for this contract is 18.1%
of total premiums paid. HMO agrees to make a good faith effort to
meet or exceed this goal. HMO acknowledges it made certain good
faith effort representations and commitments to TDH during the HUB
good faith effort determination process. HMO agrees to use its
best efforts to abide by these representations and commitments
during the contract period.
5.6.3 HMO is required to submit HUB quarterly reports to TDH as
required in Article 12.11.
5.6.4 TDH will assist HMO in meeting the contracting and
reporting requirements of this Article.
5.7 BUY TEXAS
HMO agrees to "Buy Texas" products and materials when they are
available at a comparable price and in a comparable period of
time, as required by Section 48 of Article IX of the General
Appropriations Act of 1995.
5.8 CHILD SUPPORT
5.8.1 The Texas Family Code Section 231.006 requires TDH to
withhold contract payments from any for-profit entity or
individual who is at least 30 days delinquent in child support
obligations. It is HMO's responsibility to determine and verify
that no owner, partner, or shareholder who has at least at 25%
ownership interest is delinquent in child support obligations. HMO
must attach a list of the names and Social Security numbers of all
shareholders, partners or owners who have at least a 25% ownership
interest in HMO.
5.8.2 Under Section 231.006 of the Family Code, the contractor
certifies that the contractor is not ineligible to receive the
specified grant, loan, or payment and acknowledges that this
contract may be terminated and payment may be withheld if this
certification is inaccurate. A child support obligor who is more
than 30 days delinquent in paying child support or a business
entity in which the obligor is a sole proprietor, partner,
shareholder, or owner with an ownership interest of at least 25%
is not eligible to receive the specified grant, loan or payment.
5.8.3 If TDH is informed and verifies that a child support
obligor who is more than 30 days delinquent is a partner,
shareholder, or owner with at least a 25% ownership interest, it
will withhold any payments due under this contract until it
1999 Renewal Contract
Tarrant Service Area
39
August 9, 1999
40
has received satisfactory evidence that the obligation has been
satisfied or that the obligor has entered into a written repayment
request.
5.9 REQUESTS FOR PUBLIC INFORMATION
5.9.1 This contract and all network provider and subcontractor
contracts are subject to public disclosure under the Public
Information Act (Texas Government Code, Chapter 552). TDH may
receive Public Information requests related to this contract,
information submitted as part of the compliance of the contract
and HMO's application upon which this contract was awarded. TDH
agrees that it will promptly deliver a copy of any request for
Public Information to HMO.
5.9.2 TDH may, in its sole discretion, request a decision from
the Office of the Attorney General (AG opinion) regarding whether
the information requested is excepted from required public
disclosure. TDH may rely on HMO's written representations in
preparing any AG opinion request, in accordance with Texas
Government Code Section 552.305. TDH is not liable for failing to
request an AG opinion or for releasing information which is not
deemed confidential by law, if HMO fails to provide TDH with
specific reasons why the requested information is exempt from the
required public disclosure. TDH or the Office of the Attorney
General will notify all interested parties if an AG opinion is
requested.
5.9.3 If HMO believes that the requested information qualifies as
a trade secret or as commercial or financial information, HMO must
notify TDH--within three (3) working days of HMO's receipt of the
request--of the specific text, or portions of text, which HMO
claims is excepted from required public disclosure. HMO is
required to identify the specific provisions of the Public
Information Act which HMO believes are applicable, and is required
to include a detailed written explanation of how the exceptions
apply to the specific information identified by HMO as
confidential and excepted from required public disclosure.
5.10 NOTICE AND APPEAL
HMO must comply with the notice requirements contained in 25 TAC
Section 36.21, and the maintaining benefits and services contained
in 25 TAC Section 36.22, whenever HMO intends to take an action
affecting the Member benefits and services under this contract.
Also see the Member appeal requirements contained in Article 8.7
of this contract.
ARTICLE VI SCOPE OF SERVICES
1999 Renewal Contract
Tarrant Service Area
40
August 9, 1999
41
6.1 SCOPE OF SERVICES
HMO is paid capitation for all services included in the State of
Texas Title XIX State Plan and the 1915(b) waiver application for
the SDA currently filed and approved by HCFA, except those
services which are specifically excluded and listed in Article
6.1.8 (non-capitated services).
6.1.1 HMO must pay for or reimburse for all covered services
provided to mandatory-enrolled Members for whom HMO is paid
capitation.
6.1.2 TDH must pay for or reimburse for all covered services
provided to SSI voluntary Members who enroll with HMO on a
voluntary basis. It is at HMO's discretion whether to provide
value-added services to voluntary Members.
6.1.3 HMO must provide covered services described in the 1999
Texas Medicaid Provider Procedures Manual (Provider Procedures
Manual), subsequent editions of the Provider Procedures Manual
also in effect during the contract period, and all Texas Medicaid
Bulletins which update the 1999 Provider Procedures Manual and
subsequent editions of the Provider Procedures Manual published
during the contract period.
6.1.4 Covered services are subject to change due to changes in
federal law, changes in Texas Medicaid policy, and/or responses to
changes in Medicine, Clinical protocols, or technology.
6.1.5 The STAR Program has obtained a waiver to the State Plan to
include three enhanced benefits to all voluntary and mandatory
STAR Members. Two of these enhanced benefits removed restrictions
which previously applied to Medicaid eligible individuals 21 years
and older: the three-prescriptions per month limit; and, the
30-day spell of illness limit. One of these expanded the covered
benefits to add an annual adult well check.
6.1.6 Value-added Services. Value-added services that are
approved by TDH during the contracting process are included in the
Scope of Services under this contract. Value-added services are
listed in Appendix C.
6.1.6.1 The approval request must include:
6.1.6.1.1 A detailed description of the service to be offered;
6.1.6.1.2 Identification of the category or group of Members eligible to
receive the service if it is a type of service that is not
appropriate for all Members. (HMO has the
1999 Renewal Contract
Tarrant Service Area
41
August 9, 1999
42
discretion to determine if voluntary Members are eligible for the
value-added services);
6.1.6.1.3 Any limits or restrictions which apply to the service; and
6.1.6.1.4 A description of how a Member may obtain or access the service.
6.1.6.2 Value-added services can only be added or removed by
written amendment of this contract. HMO cannot include a
value-added service in any material distributed to Members or
prospective Members until this contract has been amended to
include that value-added service or HMO has received written
approval from TDH pending finalization of the contract amendment.
6.1.6.2.1 If a value-added service is deleted by amendment, HMO must notify
each Member that the service is no longer available through HMO,
and HMO must revise all materials distributed to prospective
Members to reflect the change in covered services.
6.1.6.3 Value-added services must be offered to all mandatory HMO
Members, as indicated in Article 6.1.6.1.2, unless the contract is
amended or the contract terminates.
6.1.7 HMO may offer additional benefits that are outside the
scope of services of this contract to individual Members on a
case-by-case basis, based on medical necessity,
cost-effectiveness, and satisfaction and improved
health/behavioral health status of the Member/Member family.
6.1.8 Non-Capitated Services. The following Texas Medicaid
program services have been excluded from the services included in
the calculation of HMO capitation rate:
THSteps Dental (including Orthodontia)
Early Childhood Intervention Case Management/Service
Coordination
MHMR Targeted Case Management
Mental Health Rehabilitation
Pregnant Women and Infants Case Management
THSteps Medical Case Management
Texas School Health and Related Services
Texas Commission for the Blind Case Management
Tuberculosis Services Provided by TDH-approved providers
(Directly Observed Therapy andContact Investigation)
Vendor Drugs (out-of-office drugs)
1999 Renewal Contract
Tarrant Service Area
42
August 9, 1999
43
Medical Transportation
TDHS Hospice Services
Refer to relevant chapters in the Provider Procedures Manual and
the Texas Medicaid Bulletins for more information.
Although HMO is not responsible for paying or reimbursing for
these non-capitated services, HMO remains responsible for
providing appropriate referrals for Members to obtain or access
these services.
6.1.8.1 HMO is responsible for informing providers that all
non-capitated services must be submitted to TDH for payment or
reimbursement.
6.2 PRE-EXISTING CONDITIONS
HMO is responsible for providing all covered services to each
eligible Member beginning on the effective date of the contract or
the Member's date of enrollment under the contract regardless of
pre-existing conditions, prior diagnosis and/or receipt of any
prior health care services.
6.3 SPAN OF ELIGIBILITY
The following outlines HMO's responsibilities for payment of
hospital and free-standing psychiatric facility (facility)
admissions:
6.3.1 Inpatient Admission Prior to Enrollment in HMO. HMO is
responsible for payment of physician and non-hospital/facility
charges for the period for which HMO is paid a capitation payment
for that Member. HMO is not responsible for hospital/facility
charges for Members admitted prior to the date of enrollment in
HMO.
6.3.2 Inpatient Admission After Enrollment in HMO. HMO is
responsible for all charges until the Member is discharged from
the hospital/facility or until the Member loses Medicaid
eligibility.
6.3.2.1 If a Member regains Medicaid eligibility and the Member was
enrolled in HMO at the time the Member was admitted to the
hospital, HMO is responsible for charges as follows:
6.3.2.1.1 Member Re-enrolls into HMO After Regaining Medicaid Eligibility.
HMO is responsible for all charges for the period for which HMO
receives a capitation payment for the Member or until the Member
is discharged or loses Medicaid eligibility.
1999 Renewal Contract
Tarrant Service Area
43
August 9, 1999
44
6.3.2.1.2 Member Re-enrolls in Another Health Plan After Regaining Medicaid
Eligibility. HMO is responsible for hospital/facility charges
until the Member is discharged or loses Medicaid eligibility.
6.3.3 Plan Change. A Member cannot change from one health plan to
another health plan during an inpatient hospital stay.
6.3.4 Hospital/Facility Transfer. Discharge from one acute care
hospital/facility and readmission to another acute care
hospital/facility within 24 hours for continued treatment is not a
discharge under this contract.
6.3.5 HMO insolvency or receivership. HMO is responsible for
payment of all services provided to a person who was a Member on
the date of insolvency or receivership to the same extent they
would otherwise be responsible under this Article 6.3.
6.4 CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS
6.4.1 HMO must ensure that the care of newly enrolled Members is
not disrupted or interrupted. HMO must take special care to
provide continuity in the care of newly enrolled Members whose
health or behavioral health condition has been treated by
specialty care providers or whose health could be placed in
jeopardy if care is disrupted or interrupted.
6.4.2 Pregnant Members with 12 weeks or less remaining before the
expected delivery date must be allowed to remain under the care of
the Member's current OB/GYN through the Member's postpartum
checkup, even if the provider is out-of-network. If Member wants
to change her OB/GYN to one who is in the plan, she must be
allowed to do so if the provider to whom she wishes to transfer
agrees to accept her in the last trimester.
6.4.3 HMO must pay a Member's existing out-of-network providers
for covered services until the Member's records, clinical
information and care can be transferred to a network provider.
Payment must be made within the time period required for network
providers. HMO may pay any out-of-network provider a reasonable
and customary amount determined by the HMO. This Article does not
extend the obligation of HMO to reimburse the Member's existing
out-of-network providers of on-going care for more than 90 days
after Member enrolls in HMO or for more than nine months in the
case of a Member who at the time of enrollment in HMO has been
diagnosed with and receiving treatment for a terminal illness. The
obligation of HMO to reimburse the Member's existing
out-of-network
1999 Renewal Contract
Tarrant Service Area
44
August 9, 1999
45
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.
6.4.4 HMO must provide or pay out-of-network providers who
provide covered services to Members who move out of the service
area through the end of the period for which capitation has been
paid for the Member.
6.5 EMERGENCY SERVICES
6.5.1 HMO must pay for the professional, facility, and ancillary
services that are medically necessary to perform the medical
screening examination and stabilization of HMO Member presenting
as 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 HMO's in-network or
out-of-network providers. HMO may elect to pay any emergency
services provider an amount negotiated between the emergency
provider and HMO, or a reasonable and customary amount determined
by the HMO.
6.5.2 HMO must ensure that its network primary care providers
(PCPs) have after-hours telephone availability 24 hours a day, 7
days a week throughout the service area.
6.5.3 HMO cannot require prior authorization as a condition for
payment for an emergency medical condition, an emergency
behavioral health condition, or labor and delivery.
6.5.4 Medical Screening Examination. A medical screening
examination may range from a relatively simple history, physical
examination, diagnosis, and treatment, to a complex examination,
diagnosis, and treatment that requires substantial use of hospital
emergency department and physician services. HMO must pay for the
emergency medical screening examination required to determine
whether an emergency condition exists, as required by 42 U.S.C.
1395dd. HMOs must reimburse for both the physician's services and
the hospital's emergency services, including the emergency room
and its ancillary services.
6.5.5 Stabilization Services. HMO must pay for emergency
services performed to stabilize the Member as documented by the
Emergency physician in the Member's medical record. HMOs must
reimburse for physician's services and hospital's emergency
services including the emergency room and its ancillary services.
With respect to an emergency medical condition, to stabilize is to
1999 Renewal Contract
Tarrant Service Area
45
August 9, 1999
46
provide such medical care as to assure within reasonable medical
probability that no deterioration of the condition is likely to
result from, or occur during discharge, transfer, or admission of
the Member from the emergency room.
6.5.6 Post-stabilization Services. Post-stabilization services
are services subsequent to an emergency that a treating physician
views as medically necessary after an emergency medical condition
has been stabilized. They are not "emergency services" and are
subject to HMO's prior authorization process. HMO must be
available to authorize or deny post-stabilization services within
one hour after being contacted by the treating physician.
6.5.7 HMO must provide access to the TDH-designated Level I and
Level II trauma centers within the State or hospitals meeting the
equivalent level of trauma care. HMOs may make out-of-network
reimbursement arrangements with the TDH-designated Level I and
Level II trauma centers to satisfy this access requirement.
6.6 BEHAVIORAL HEALTH CARE SERVICES - SPECIFIC REQUIREMENTS
6.6.1 HMO must provide or arrange to have provided to Members all
behavioral health care services included as covered services.
These services are described in detail in the Texas Medicaid
Provider Procedures Manual (Provider Procedures Manual) and the
Texas Medicaid Bulletins, which is the bi-monthly update to the
Provider Procedures Manual. Clinical information regarding covered
services are published by the Texas Medicaid program in the Texas
Medicaid Service Delivery Guide.
6.6.2 HMO must maintain a behavioral health provider network that
includes psychiatrists, psychologists and other behavioral health
providers. HMO must provide or arrange to have provided behavioral
health benefits described as covered services. These services are
indicated in the Provider Procedures Manual and the Texas Medicaid
Bulletins, which is the bi-monthly update to the Provider
Procedures Manual. Clinical information regarding covered services
are published by the Texas Medicaid Program in the Texas Medicaid
Service Delivery Guide. The network must include providers with
experience in serving children and adolescents to ensure
accessibility and availability of qualified providers to all
eligible children and adolescents in the service area. The list of
providers including names, addresses and phone numbers must be
available to TDH upon request.
6.6.3 HMO must maintain a Member education process to help
Members know where and how to obtain behavioral health care
services.
1999 Renewal Contract
Tarrant Service Area
46
August 9, 1999
47
6.6.4 HMO must implement policies and procedures to ensure that
Members who require routine or regular laboratory and ancillary
medical tests or procedures to monitor behavioral health
conditions are provided the services by the provider ordering the
procedure or at a lab located at or near the provider's office.
6.6.5 When assessing Members for behavioral health care services,
HMO and network behavioral health providers must use the DSM-IV
multi-axial classification and report axes I, II, III, IV, and V
to TDH. TDH may require use of other assessment instrument/outcome
measures in addition to the DSM-IV. Providers must document DSM-IV
and assessment/outcome information in the Member's medical record.
6.6.6 HMO must permit Members to self refer to any in-network
behavioral health care provider without a referral from the
Member's PCP. HMO must permit Members to participate in the
selection or assignment of the appropriate behavioral health
individual practitioner(s) who will serve them. HMO previously
submitted a written copy of its policies and procedures for
self-referral to TDH. Changes or amendments to those policies and
procedures must be submitted to TDH for approval at least 60 days
prior to their effective date.
6.6.7 HMO must require, through contract provisions, that PCPs
have screening and evaluation procedures for detection and
treatment of, or referral for, any known or suspected behavioral
health problems and disorders. PCPs may provide any clinically
appropriate behavioral health care services within the scope of
their practice. This requirement must be included in all Provider
Manuals.
6.6.8 HMO must require that behavioral health providers refer
Members with known or suspected physical health problems or
disorders to their PCP for examination and treatment. Behavioral
health providers may only provide physical health care services if
they are licensed to do so. This requirement must be included in
all Provider Manuals.
6.6.9 HMO must require that behavioral health providers send
initial and quarterly (or more frequently if clinically indicated)
summary reports of Members' behavioral health status to PCP. This
requirement must be included in all Provider Manuals.
6.6.10 HMO must require, through 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 7 days from
the date of discharge. HMO must ensure that behavioral
1999 Renewal Contract
Tarrant Service Area
47
August 9, 1999
48
health providers contact Members who have missed appointments
within 24 hours to reschedule appointments.
6.6.11 HMO must provide inpatient psychiatric services to Members
under the age of 21 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.
6.6.11.1 HMO cannot deny, reduce or controvert the medical necessity of any
court ordered inpatient psychiatric service for Members under age
21. Any modification or termination of services must be presented
to the court with jurisdiction over the matter for determination.
6.6.11.2 A Member who has been ordered to receive treatment under the
provisions of Chapter 573 or 574 of the Texas Health and Safety
Code cannot appeal the commitment through HMO's complaint or
appeals process.
6.6.12 HMO must comply with 28 TAC Sections 3.8001 et seq.,
regarding utilization review of chemical dependency treatment.
6.7 FAMILY PLANNING - SPECIFIC REQUIREMENTS
6.7.1 Counseling and Education. HMO must require, through
contract provisions, that Members requesting contraceptive
services or family planning services are also provided counseling
and education about family planning and family planning services
available to Members. HMO must develop outreach programs to
increase community support for family planning and encourage
Members to use available family planning services. HMO is
encouraged to include a representative cross-section of Members
and family planning providers who practice in the community in
developing, planning and implementing family planning outreach
programs.
6.7.2 Freedom of Choice. 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 HMO provider network. HMO must provide Members access to
information about the providers of family planning services
available and the Member's right to choose any Medicaid family
planning provider. HMO must provide access to confidential family
planning services.
6.7.3 Provider Standards and Payment. HMO must require all
1999 Renewal Contract
Tarrant Service Area
48
August 9, 1999
49
subcontractors who are family planning agencies to deliver family
planning services according to the TDH Family Planning Service
Delivery Standards. HMO must provide, at minimum, the full scope
of services available under the Texas Medicaid program for family
planning services. HMO will reimburse family planning agencies and
out-of-network family planning providers the Medicaid fee-for
service amounts for family planning services, including medically
necessary medications, contraceptives, and supplies.
6.7.4 HMO must provide medically-approved methods of
contraception to Members. Contraceptive methods must be
accompanied by verbal and written instructions on their correct
use. HMO must establish mechanisms to ensure all medically
approved methods of contraception are made available to the
Member, either directly or by referral to a subcontractor. The
following initial Member education content may vary according to
the educator's assessment of the Member's current knowledge:
6.7.4.1 general benefits of family planning services and contraception;
6.7.4.2 information on male and female basic reproductive anatomy and
physiology;
6.7.4.3 information regarding particular benefits and potential side
effects and complications of all available contraceptive methods;
6.7.4.4 information concerning all of the health care provider's available
services, the purpose and sequence of health care provider
procedures, and the routine schedule of return visits;
6.7.4.5 information regarding medical emergencies and where to obtain
emergency care on a 24-hour basis;
6.7.4.6 breast self-examination rationales and instructions unless
provided during physical exam (for females); and
6.7.4.7 information on HIV/STD infection and prevention and safer sex
discussion.
6.7.5 HMO must require, through contractual provisions, that
subcontractors have mechanisms in place to ensure Member's
(including minor's) confidentiality for family planning services.
6.7.6 HMO must develop, implement, monitor, and maintain
standards, policies and procedures for providing information
regarding family
1999 Renewal Contract
Tarrant Service Area
49
August 9, 1999
50
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.
6.7.7 HMO must report encounter data on family planning services
in accordance with Article 12.2.
6.8 TEXAS HEALTH STEPS (EPSDT)
6.8.1 THSteps Services. HMO must develop effective methods to
ensure that children under the age of 21 receive THSteps services
when due and according to the recommendations established by the
American Academy of Pediatrics and the THSteps periodicity
schedule for children. HMO must arrange for THSteps services to be
provided to all eligible Members except when a Member knowingly
and voluntarily declines or refuses services after the Member has
been provided information upon which to make an informed decision.
6.8.2 Member Education and Information. HMO must ensure that
Members are provided information and educational materials about
the services available through the THSteps program, and how and
when they can obtain the services. The information should tell the
Member how they can obtain dental benefits, transportation
services through the TDH Medical Transportation program, and
advocacy assistance from HMO.
6.8.3 Provider Education and Training. HMO must provide
appropriate training to all network providers and provider staff
in the providers' area of practice regarding the scope of benefits
available and the THSteps program. Training must include THSteps
benefits, the periodicity schedule for THSteps checkups and
immunizations, and Comprehensive Care Program (CCP) services
available under the THSteps program to Members under age 21 years.
Providers must also be educated and trained regarding the
requirements imposed upon the department and contracting HMOs
under the Consent Decree entered in Xxxx x. XxXxxxxx, et. al.,
Civil Action No. 3:93CV65, in the United States District Court for
the Eastern District of Texas, Paris Division. Providers should be
educated and trained to treat each THSteps visit as an opportunity
for a comprehensive assessment of the Member.
6.8.4 Member Outreach. HMO must provide an outreach unit that
works with Members to ensure they receive prompt services and are
effectively informed about available THSteps services. Each month
HMO must retrieve from the Enrollment Broker BBS a list of Members
who are due and overdue THSteps services. Using these lists and
their own internally generated lists, HMOs will
1999 Renewal Contract
Tarrant Service Area
50
August 9, 1999
51
contact Members and encourage Members who are periodically due or
overdue a THSteps service to obtain the service as soon as
possible. HMO outreach staff must coordinate with TDH THSteps
outreach staff to ensure that Members have access to the Medical
Transportation Program, and that any coordination with other
agencies is maintained.
6.8.5 Initial Checkups Upon Enrollment. HMO must have mechanisms
in place to ensure that all newly enrolled Members receive a
THSteps checkup within 90 days from enrollment, if one is due
according to the American Academy of Pediatrics periodicity
schedule, or if there is uncertainty regarding whether one is due.
HMO should make THSteps checkups a priority to all newly enrolled
Members.
6.8.6 Accelerated Services to Migrant Populations. HMO must
cooperate and coordinate with the department, outreach programs
and THSteps regional program staff and agents to ensure prompt
delivery of services to children of migrant farm workers and other
migrant populations who may transition into and out of HMOs
program more rapidly and/or unpredictably than the general
population.
6.8.7 Newborn Checkups. HMO must have mechanisms in place to
ensure that all newborn Members have an initial newborn checkup
before discharge from the hospital and again within two weeks from
the time of birth. HMO must require providers to send all THSteps
newborn screens to the TDH Bureau of Laboratories or a TDH
certified laboratory. Providers must include detailed identifying
information for all screened newborn Members and the Member's
mother to allow TDH to link the screens performed at the hospital
with screens performed at the two week follow-up.
6.8.7.1 Laboratory Tests: 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 TDH Laboratory for analysis. HMO must educate providers
about THSteps program requirements for submitting laboratory tests
to the TDH Bureau of Laboratories.
6.8.8 Coordination and Cooperation. HMO must make an effort to
coordinate and cooperate with existing community and school-based
health and education programs that offer services to school-aged
children in a location that is both familiar and convenient to the
Members. HMO must make a good faith effort to comply with Head
Start's requirement that Members participating in Head Start
receive their THSteps checkup no later than 45 days after
enrolling into either program.
1999 Renewal Contract
Tarrant Service Area
51
August 9, 1999
52
6.8.9 Immunizations. 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; and the AAP Periodicity Schedule.
6.8.9.1 ImmTrac Compliance. HMO must educate providers about and
require providers to comply with the requirements of Chapter 161,
Health and Safety Code, relating to the Texas Immunization
Registry (ImmTrac), to include parental consent on the Vaccine
Information Statement.
6.8.10 Claim Forms. HMO must require all THSteps providers to
submit claims for services paid (either on a capitated or fee-for
service basis) on the HCFA 1500 claim form and use the unique
procedure coding required by TDH.
6.8.11 Compliance with THSteps Performance Benchmark. TDH will
establish performance benchmarks against which HMO's full
compliance with the THSteps periodicity schedule will be measured.
The performance benchmarks will establish minimum compliance
measures which will increase over time. HMO must meet all
performance benchmarks required for THSteps services.
6.8.12 Validation of Encounter Data. Encounter data will be
validated by chart review of a random sample of THSteps eligible
enrollees against monthly encounter data reported by HMO. Chart
reviews will be conducted by TDH to validate that all screens are
performed when due and as reported, and that reported data is
accurate and timely. Substantial deviation between reported and
charted encounter data could result in HMO and/or network
providers being investigated for potential fraud and abuse without
notice to HMO or the provider.
6.9 PERINATAL SERVICES
6.9.1 HMO's perinatal health care services must ensure
appropriate care is provided to women and infants who are Members
of HMO, from the preconception period through the infant's first
year of life. HMO's perinatal health care system must comply with
the requirements of Health & Safety Code, Chapter 32 Maternal and
Infant Health Improvement Act and 25 TAC Section 37.233 et seq.
6.9.2 HMO shall have a perinatal health care system in place
that, at a minimum, provides the following services:
6.9.2.1 pregnancy planning and perinatal health promotion and
education for reproductive- age women;
1999 Renewal Contract
Tarrant Service Area
52
August 9, 1999
53
6.9.2.2 perinatal risk assessment of nonpregnant women, pregnant
and postpartum women, and infants up to one year of age;
6.9.2.3 access to appropriate levels of care based on risk
assessment, including emergency care;
6.9.2.4 transfer and care of pregnant women, newborns, and infants
to tertiary care facilities when necessary;
6.9.2.5 availability and accessibility of
obstetricians/gynecologists, anesthesiologists, and neonatologists
capable of dealing with complicated perinatal problems;
6.9.2.6 availability and accessibility of appropriate outpatient
and inpatient facilities capable of dealing with complicated
perinatal problems; and
6.9.2.7 compiles, analyzes and reports process and outcome data of
Members to TDH.
6.9.3 HMO must have procedures in place to assign a pediatrician
to an unborn child prior to birth of the child.
6.9.4 HMO must provide inpatient care for its pregnant/delivering
Members and newborn Members in a health care facility, if
requested by the mother or is determined to be medically necessary
by the Member's PCP, for a minimum of:
6.9.4.1 48 hours following an uncomplicated vaginal delivery; and
6.9.4.2 96 hours for an uncomplicated caesarian delivery.
6.9.5 HMO must establish mechanisms to ensure that medically
necessary inpatient care is provided to either the Member or the
newborn Member for complications following the birth of the
newborn using HMO's prior authorization procedures for a medically
necessary hospitalization.
1999 Renewal Contract
Tarrant Service Area
53
August 9, 1999
54
6.9.6 HMO is responsible for all covered services provided to
newborn Members. The State will enroll newborn children of STAR
Members in accordance with Section 533.0075 of the Texas
Government Code when changes to the DHS eligibility system that
are necessary to implement the law have been made. TDH will notify
HMO of the implementation date of the changes under Section
533.0075 of the Government Code. Section 533.0075 states that
newborn children of STAR Members will be enrolled in a STAR health
plan on the date on which DHS has completed the newborn's Medicaid
eligibility determination, including the assignment of a Medicaid
eligibility number to the newborn, or 60 days after the date of
birth, whichever is earlier.
6.10 EARLY CHILDHOOD INTERVENTION (ECI)
6.10.1 ECI Services. HMO must provide all federally mandated
services contained at 34 C.F.R. 303.1 et seq., and 25 TAC Section
621.21 et seq., relating to identification, referral and delivery
of health care services contained in the Member's Individual
Family Service Plan (IFSP). An IFSP is the written plan which
identifies a Member's disability or chronic or complex
condition(s) or developmental delay, and describes the course of
action developed to meet those needs, and identifies the person or
persons responsible for each action in the plan. The plan is a
mutual agreement of the Member's Primary Care Physician (PCP),
Case Manager, and the Member/family, and is part of the Member's
medical record.
6.10.2 ECI Providers. HMO must contract with qualified providers
to provide ECI services to Members under age 3 with developmental
delays. HMO may contract with local ECI programs or non-ECI
providers who meet qualifications for participation by the Texas
Interagency Council on Early Childhood Intervention to provide ECI
services.
6.10.3 Identification and Referral. HMO must ensure that network
providers are educated regarding the identification of Members
under age 3 who have or are at risk for having disabilities and/or
developmental delays. HMO must use written education material
developed or approved by the Texas Interagency Council on Early
Childhood Intervention. HMO must ensure that all providers refer
identified Members to ECI service providers within two working
days from the day the Member is identified. Eligibility for ECI
services is determined by the local ECI program using the criteria
contained in 25 TAC Section 621.21 et seq.
6.10.4 Coordination. HMO must coordinate and cooperate with local
ECI programs which perform assessment in the development of the
Individual Family Service Plan (IFSP), including on-going case
management and other non-
1999 Renewal Contract
Tarrant Service Area
54
August 9, 1999
55
capitated services required by the Member's IFSP. Cooperation
includes conducting medical diagnostic procedures and providing
medical records required to perform developmental assessments and
develop the IFSP within the time lines established at 34 C.F.R.
303.1 et seq. ECI case management is not an HMO capitated service.
6.10.5 Intervention. HMO must require, through contract
provisions, that all medically necessary health and behavioral
health care services contained in the Member's IFSP are provided
to the Member in amount, duration and scope established by the
IFSP. Medical necessity for health and behavioral health care
services is determined by the interdisciplinary team as approved
by the Member's PCP. HMO cannot modify the plan of care or alter
the amount, duration and scope of services required by the
Member's IFSP. HMO cannot create unnecessary barriers for the
Member to obtain IFSP services, including requiring prior
authorization for the ECI assessment and insufficient
authorization periods for prior authorized services.
6.11 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS,
AND CHILDREN (WIC) - SPECIFIC REQUIREMENTS
6.11.1 HMO must coordinate with WIC to provide certain medical
information which is necessary to determine WIC eligibility, such
as height, weight, hematocrit or hemoglobin (see Article
7.16.3.2).
6.11.2 HMO must direct all eligible Members to the WIC program
(Medicaid recipients are automatically income-eligible for WIC).
6.11.3 HMO must coordinate with existing WIC providers to ensure
Members have access to the Special Supplemental Nutrition Program
for Women, Infants and Children; or HMO must provide these
services.
6.11.4 HMO may use the nutrition education provided by WIC to
satisfy health education requirements described in this contract.
6.12 TUBERCULOSIS (TB)
6.12.1 Education, Screening, Diagnosis and Treatment. HMO must
provide Members and providers with education on the prevention,
detection and effective treatment of tuberculosis (TB). HMO must
establish mechanisms to ensure all procedures required to screen
at-risk Members and to form the basis for a diagnosis and proper
prophylaxis and management of TB are available to all Members,
except services referenced in Article 6.1.8 as non-capitated
services. HMO must develop policies and procedures to ensure that
Members who may be
1999 Renewal Contract
Tarrant Service Area
55
August 9, 1999
56
or are at risk for exposure to TB are screened for TB. An at-risk
Member refers to a person who is susceptible to TB because of the
association with certain risk factors, behaviors, drug resistance,
or environmental conditions. HMO must consult with the local TB
control program to ensure that all services and treatments
provided by HMO are in compliance with the guidelines recommended
by the American Thoracic Society (ATS), the Centers for Disease
Control and Prevention (CDC), and TDH policies and standards.
6.12.2 Reporting and Referral. HMO must implement policies and
procedures requiring providers to report all confirmed or
suspected cases of TB to the local TB control program within one
working day of identification of a suspected case, using the forms
and procedures for reporting TB adopted by TDH (25 TAC Section
97). HMO must require that in-state labs report mycobacteriology
culture results positive for M. Tuberculosis and M. Tuberculosis
antibiotic susceptibility to TDH as required for in-state labs by
25 TAC Section 97.5(a). Referral to state-operated hospitals
specializing in the treatment of tuberculosis should only be made
for TB-related treatment.
6.12.3 Medical Records. HMO must provide access to Member medical
records to TDH and the local TB control program for all confirmed
and suspected TB cases upon request.
6.12.4 Coordination and Cooperation with the Local TB Control
Program. HMO must coordinate with the local TB control program to
ensure that all Members with confirmed or suspected TB have a
contact investigation and receive Directly Observed Therapy (DOT).
HMO must require, through contract provisions, that providers
report any Member who is non-compliant, drug resistant, or who is
or may be posing a public health threat to TDH or the local TB
control program. HMO must cooperate with the local TB control
program in enforcing the control measures and quarantine
procedures contained in Chapter 81 of the Texas Health and Safety
Code.
6.12.4.1 HMO must have a mechanism for coordinating a post-discharge plan
for follow-up DOT with the local TB program.
6.12.4.2 HMO must coordinate with the TDH South Texas Hospital and Texas
Center for Infectious Disease for voluntary and court-ordered
admission, discharge plans, treatment objectives and projected
length of stay for Members with multi-drug resistant TB.
6.12.4.3 HMO may contract with the local TB control programs to perform any
of the capitated services required in Article 6.12.
1999 Renewal Contract
Tarrant Service Area
56
August 9, 1999
57
6.13 PEOPLE WITH DISABILITIES OR CHRONIC OR COMPLEX CONDITIONS
6.13.1 HMO shall provide the following services to persons with
disabilities or chronic or complex conditions. These services are
in addition to the covered services described in detail in the
Texas Medicaid Provider Procedures Manual (Provider Procedures
Manual) and the Texas Medicaid Bulletins which is the bi-monthly
update to the Provider Procedures Manual. Clinical information
regarding covered services are published by the Texas Medicaid
program in the Texas Medicaid Service Delivery Guide.
6.13.2 HMO must develop and maintain a system and procedures for
identifying Members who have disabilities or chronic or complex
medical and behavioral health conditions. Once identified, HMO
must have effective health delivery systems to provide the covered
services to meet the special preventive, primary acute, and
speciality health care needs appropriate for treatment of the
individual's condition. The guidelines and standards established
by the American Academy of Pediatrics, the American College of
Obstetrics/Gynecologists, the U.S. Public Health Service, and
other medical and professional health organizations and
associations' practice guidelines whose standards are recognized
by TDH must be used in determining the medically necessary
services and plan of care for each individual.
6.13.3 HMO must require that the PCP for all persons with
disabilities or chronic or complex conditions develops a plan of
care to meet the needs of the Member. The plan of care must be
based on health needs, specialist(s) recommendations, and periodic
reassessment of the Member's developmental and functional status
and service delivery needs. HMO must require providers to maintain
record keeping systems to ensure that each Member who has been
identified with a disability or chronic or complex condition has
an initial plan of care in the primary care provider's medical
records, Member agrees to that plan of care, and that the plan is
updated as often as the Member's needs change, but at least
annually.
6.13.4 HMO must provide primary care and specialty care provider
network for persons with disabilities or chronic or complex
conditions. Specialty and subspecialty providers serving all
Members must be Board Certified/Board Eligible in their specialty.
HMO may request exceptions from TDH for approval of traditional
providers who are not board-certified or board-eligible but who
otherwise meet HMO's credentialing requirements.
1999 Renewal Contract
Tarrant Service Area
57
August 9, 1999
58
6.13.5 HMO must have in its network PCPs and specialty care
providers that have documented experience in treating people with
disabilities or chronic or complex conditions, including children.
For services to children with disabilities or chronic or complex
conditions, HMO must have in its network PCPs and specialty care
providers that have demonstrated experience with children with
disabilities or chronic or complex conditions in pediatric
specialty centers such as children's hospitals, medical schools,
teaching hospitals and tertiary center levels.
6.13.6 HMO must provide information, education and training
programs to Members, families, PCPs, specialty physicians, and
community agencies about the care and treatment available in HMO's
plan for Members with disabilities or chronic or complex
conditions.
6.13.7 HMO must coordinate care and establish linkages, as
appropriate for a particular Member, with existing community-based
entities and services, including but not limited to: Maternal and
Child Health, Chronically Ill and Disabled Children's Services
(CIDC), the Medically Dependent Children Program (MDCP), Community
Resource Coordination Groups (CRCGs), Interagency Council on Early
Childhood Intervention (ECI), Home and Community-based Services
(HCS), Community Living Assistance and Support Services (CLASS),
Community Based Alternatives (CBA), In Home Family Support,
Primary Home Care, Day Activity and Health Services (DAHS),
Deaf/Blind Multiple Disabled waiver program and Medical
Transportation Program (MTP).
6.13.8 HMO must include TDH approved pediatric transplant centers,
TDH designated trauma centers, and TDH designated hemophilia
centers in its provider network (see Appendices E, F, and G for a
listing of these facilities).
6.13.9 HMO must ensure Members with disabilities or chronic or
complex conditions have access to treatment by a multidisciplinary
team when determined to be medically necessary for effective
treatment, or to avoid separate and fragmented evaluations and
service plans. The teams must include both physician and
non-physician providers determined to be necessary by the Member's
PCP for the comprehensive treatment of the Member. The team must:
6.13.9.1 Participate in hospital discharge planning;
6.13.9.2 Participate in pre-admission hospital planning for non-emergency
hospitalizations;
6.13.9.3 Develop specialty care and support service recommendations to be
incorporated into the primary care provider's plan of care;
1999 Renewal Contract
Tarrant Service Area
58
August 9, 1999
59
6.13.9.4 Provide information to the Member and the Member's family
concerning the specialty care recommendations; and
6.13.9.5 Develop and implement training programs for primary care
providers, community agencies, ancillary care providers, and
families concerning the care and treatment of a Member with a
disability or chronic or complex conditions.
6.13.10 HMO must identify coordinators of medical care to assist providers
who serve Members with disabilities and chronic or complex
conditions and the Members and their families in locating and
accessing appropriate providers inside and outside HMO's network.
6.13.11 HMO must assist, through information and referral, eligible
Members in accessing providers of non-capitated Medicaid services
listed in Article 6.1.8, as applicable.
6.13.12 HMO must ensure that Members who require routine or regular
laboratory and ancillary medical tests or procedures to monitor
disabilities or chronic or complex conditions are allowed by HMO
to receive the services from the provider in the provider's office
or at a contracted lab located at or near the provider's office.
6.14 HEALTH EDUCATION AND WELLNESS AND PREVENTION PLANS
6.14.1 Health Education Plan. HMO must develop and implement a
Health Education plan. The health education plan must tell Members
how HMO system operates, how to obtain services, including
emergency care and out-of-plan services. The plan must emphasize
the value of screening and preventive care and must contain
disease-specific information and educational materials.
6.14.2 Wellness Promotion Programs. HMO must conduct wellness
promotion programs to improve the health status of its Members.
HMO may cooperatively conduct Health Education classes for all
enrolled STAR Members with one or more HMOs also contracting with
TDH in the service area to provide services to Medicaid recipients
in all counties of the service area. Providers and HMO staff must
integrate health EDUCATION, wellness and prevention training into
the care of each Member. HMO must provide a range of health
promotion and wellness information and activities for Members in
formats that meet the needs of all Members. HMO must:
(1) develop, maintain and distribute health education services
standards,
1999 Renewal Contract
Tarrant Service Area
59
August 9, 1999
60
policies and procedures to providers;
(2) monitor provider performance to ensure the standards for
health education services are complied with;
(3) inform providers in writing about any non-compliance with
the plan standards, policies or procedures;
(4) establish systems and procedures that ensure that
provider's medical instruction and education on preventive
services provided to the Member are documented in the
Member's medical record; and
(5) establish mechanisms for promoting preventive care services
to Members who do not access care, e.g. newsletters,
reminder cards, and mail-outs.
6.14.3 Health Education Activities Report. HMO must submit, upon
request, a Health Education Activities Schedule to TDH or its
designee listing the time and location of classes, health fairs or
other events conducted during the time period of the request.
6.15 SEXUALLY TRANSMITTED DISEASES (STDS) AND HUMAN
IMMUNODEFICIENCY VIRUS (HIV)
HMO must provide STD services that include STD/HIV prevention,
screening, counseling, diagnosis, and treatment. HMO is
responsible for implementing procedures to ensure that Members
have prompt access to appropriate services for STDs, including
HIV.
6.15.1 HMO must allow Members access to STD services and HIV
diagnosis services without prior authorization or referral by PCP.
HMO must comply with Texas Family Code Section 32.003, relating to
consent to treatment by a child.
6.15.2 HMO must provide all covered services required to form the
basis for a diagnosis and treatment plan for STD/HIV by the
provider.
6.15.3 HMO must consult with TDH regional public health authority
to ensure that Members receiving clinical care of STDs, including
HIV, are managed according to a protocol which has been approved
by TDH (see Article 7.16.1 relating to cooperative agreements with
public health authorities).
6.15.4 HMO must make education available to providers and Members
on the prevention, detection and effective treatment of STDs,
including HIV.
1999 Renewal Contract
Tarrant Service Area
60
August 9, 1999
61
6.15.5 HMO must require providers to report all confirmed cases of
STDs, including HIV, to the local or regional health authority
according to 25 Texas Administrative Code, Sections 97.131 -
97.134, using the required forms and procedures for reporting
STDs.
6.15.6 HMO must coordinate with the TDH regional health authority
to ensure that Members with confirmed cases of syphilis,
chancroid, gonorrhea, chlamydia and HIV receive risk reduction and
partner elicitation/notification counseling. Coordination must be
included in the subcontract required by Article 7.16.1. HMO may
contract with local or regional health authorities to perform any
of the covered services required in Article 6.15.
6.15.7 HMO's PCPs may enter into contracts or agreements with
traditional HIV service providers in the service area to provide
services such as case management, psychosocial support and other
services. If the service provided is a covered service under this
contract, the contract or agreement must include payment
provisions.
6.15.8 The subcontract with the respective TDH regional offices
and city and county health departments, as described in Article
7.16.1, must include, but not be limited to, the following topics:
6.15.8.1 Access for Case Investigation. Procedures must be established to
make Member records available to public health agencies with
authority to conduct disease investigation, receive confidential
Member information, and follow up.
6.15.8.2 Medical Records and Confidentiality. HMO must require that
providers have procedures in place to protect the confidentiality
of Members provided STD/HIV services. These procedures must
include, but are not limited to, the manner in which medical
records are to be safeguarded; how employees are to protect
medical information; and under what conditions information can be
shared. HMO must inform and require its providers who provide
STD/HIV services to comply with all state laws relating to
communicable disease reporting requirements. HMO must implement
policies and procedures to monitor provider compliance with
confidentiality requirements.
6.15.8.3 Partner Referral and Treatment. Members who are named as contacts
to an STD, including HIV, should be evaluated and treated
according to HMO's protocol. All protocols must be approved by
TDH. HMO's providers must coordinate referral of non-Member
partners to local and regional health department STD staff.
1999 Renewal Contract
Tarrant Service Area
61
August 9, 1999
62
6.15.8.4 Informed Consent and Counseling. HMO must have policies and
procedures in place regarding obtaining informed consent and
counseling Members. The subcontracts with providers who treat HIV
patients must include provisions requiring the provider to refer
Members with HIV infection to public health agencies for in-depth
prevention counseling, on-going partner elicitation and
notification services and other prevention support services. The
subcontracts must also include provisions that require the
provider to direct-counsel or refer an HIV-infected Member about
the need to inform and refer all sex and/or needle-sharing
partners that might have been exposed to the infection for
prevention counseling and antibody testing.
6.16 BLIND AND DISABLED MEMBERS
6.16.1 HMO must arrange for all covered health and health-related
services required under this contract for all voluntarily enrolled
Blind and Disabled Members. HMO is not required to provide
value-added services to Blind and Disabled Members.
6.16.2 HMO must perform the same administrative services and
functions as are performed for mandatory Members under this
contract. These administrative services and functions include, but
are not limited to:
6.16.2.1 Prior authorization of services;
6.16.2.2 All customer services functions offered Members in mandatory
participation categories, including the complaint process,
enrollment services, and hotline services;
6.16.2.3 Linguistic services, including providing Member materials in
alternative formats for the blind and disabled;
6.16.2.4 Health education;
6.16.2.5 Utilization management using TDH Claims Administrator encounter
data to provide appropriate interventions for Members through
administrative case management;
6.16.2.6 Quality assurance activities as needed and Focused Studies as
required by TDH; and
6.16.2.7 Coordination to link Blind and Disabled Members with applicable
community resources and targeted case management programs (see
Non-Capitated Services in
1999 Renewal Contract
Tarrant Service Area
62
August 9, 1999
63
Article 6.1.8).
6.16.3 HMO must require network providers to submit claims for
health and health-related services to TDH's Claims Administrator
for claims adjudication and payment.
6.16.4 HMO must provide services to Blind and Disabled Members
within HMO's network unless necessary services are unavailable
within network. HMO must also allow referrals to out-of-network
providers if necessary services are not available within HMO's
network. Records must be forwarded to Member's PCP following a
referral visit.
ARTICLE VII PROVIDER NETWORK REQUIREMENTS
7.1 PROVIDER ACCESSIBILITY
7.1.1 HMO must enter into written contracts with properly
credentialed health care service providers. The names of all
providers must be submitted to TDH as part of HMO subcontracting
process. HMO must have its own credentialing process to review,
approve and periodically recertify the credentials of all
participating providers in compliance with 28 TAC 11.1902,
relating to credentialing of providers in HMOs.
7.1.2 HMO must require tax I.D. numbers from all providers. HMO
is required to do backup withholding from all payments to
providers who fail to give tax I.D. numbers or who give incorrect
numbers.
7.1.3 Timeframes for Access Requirements. HMO must have
sufficient network providers and establish procedures to ensure
Members have access to routine, urgent, and emergency services;
telephone appointments; advice and Member service lines. These
services must be accessible to Members within the following
timeframes:
7.1.3.1 Urgent Care within 24 hours of request;
7.1.3.2 Routine care within 2 weeks of request;
7.1.3.3 Physical/Wellness Exams for adults must be provided within
8 to 10 weeks of the request;
7.1.3.4 HMO must establish policies and procedures to ensure that
THSteps
1999 Renewal Contract
Tarrant Service Area
63
August 9, 1999
64
Checkups be provided within 90 days of new enrollment, except
newborn Members should be seen within 2 weeks of enrollment, and
in all cases for all Members be consistent with the American
Academy of Pediatrics and THSteps periodicity schedule which is
based on the American Academy of Pediatrics schedule and
delineated in the Texas Medicaid Provider Procedures Manual and
the Medicaid bi-monthly bulletins (see Article 6.1, Scope of
Services). If the Member does not request a checkup, HMO must
establish a procedure for contacting the Member to schedule the
checkup.
7.1.4 HMO is prohibited from requiring a provider or provider
group to enter into an exclusive contracting arrangement with HMO
as a condition for participation in its provider network.
7.2 PROVIDER CONTRACTS
7.2.1 All providers must have a written contract, either with an
intermediary entity or an HMO, to participate in the Medicaid
program (provider contract). HMO must make all contracts available
to TDH upon request, at the time and location requested by TDH.
All standard formats of provider contracts must be submitted to
TDH for approval no later than 60 days after the effective date of
this contract, unless previously filed with TDH. HMO must submit 1
paper copy and 1 electronic copy in a form specified by TDH. Any
change to the standard format must be submitted to TDH for
approval no later than 30 days prior to the implementation of the
new standard format. All provider contracts are subject to the
terms and conditions of this contract and must contain the
provisions of Article V, Statutory and Regulatory Compliance, and
the provisions contained in Article 3.2.4.
7.2.1.1 TDH has 15 working days to review the materials and
recommend any suggestions or required changes. If TDH has not
responded to HMO by the fifteenth day, HMO may execute the
contract. TDH reserves the right to request HMO to modify any
contract that has been deemed approved.
7.2.2 Primary Care Provider (PCP) contracts and specialty care
contracts must contain provisions relating to the requirements of
the provider types found in this contract. For example, PCP
contracts must contain the requirements of Article 7.8 relating to
Primary Care Providers.
7.2.3 Provider contracts that are requested by any agency with
authority to investigate and prosecute fraud and abuse must be
produced at the time and place required by TDH or the requesting
agency. Provider contracts requested in response to a Public
Information request must be produced within 48 hours of the
1999 Renewal Contract
Tarrant Service Area
64
August 9, 1999
65
request. Requested contracts and all related records must be
provided free-of-charge to the requesting agency.
7.2.4 The form and substance of all provider contracts are
subject to approval by TDH. TDH retains the authority to reject or
require changes to any contract that do not comply with the
requirements or duties and responsibilities of this contract. HMO
REMAINS RESPONSIBLE FOR PERFORMING AND FOR ANY FAILURE TO PERFORM
ALL DUTIES, RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT
REGARDLESS OF WHETHER THE DUTY, RESPONSIBILITY OR SERVICE IS
CONTRACTED TO ANOTHER FOR ACTUAL PERFORMANCE.
7.2.5 TDH reserves the right and retains the authority to make
reasonable inquiry and conduct investigations into patterns of
provider and Member complaints against HMO or any intermediary
entity with whom HMO contracts to deliver health care services
under this contract. TDH may impose appropriate sanctions and
contract remedies to ensure HMO compliance with the provisions of
this contract.
7.2.6 HMO must not restrict a provider's ability to provide
opinions or counsel to a Member with respect to benefits,
treatment options, and provider's change in network status.
7.2.7 To the extent feasible within HMO's existing claims
processing systems, HMO should have a single or central address to
which providers must submit claims. If a central processing center
is not possible within HMO's existing claims processing system,
HMO must provide each network provider a complete list of all
entities to whom the providers must submit claims for processing
and/or adjudication. The list must include the name of the entity,
the address to which claims must be sent, explanation for
determination of the correct claims payer based on services
rendered, and a phone number the provider may call to make claims
inquiries. HMO must notify providers in writing of any changes in
the claims filing list at least 30 days prior to effective date of
change. If HMO is unable to provide 30 days notice, providers must
be given a 30-day extension on their claims filing deadline to
ensure claims are routed to correct processing center.
7.2.8 HMO, all IPAs, and other intermediary entities must include
contract language which substantially complies with the following
standard contract provisions in each Medicaid provider contract.
This language must be included in each contract with an actual
provider of services, whether through a direct contract or through
intermediary provider contracts:
1999 Renewal Contract
Tarrant Service Area
65
August 9, 1999
66
7.2.8.1 [Provider] is being contracted to deliver Medicaid managed
care under the TDH STAR program. HMO must provide copies of the
TDH/HMO Contract to the [Provider] upon request. [Provider]
understands that services provided under this contract are funded
by State and federal funds under the Medicaid program. [Provider]
is subject to all state and federal laws, rules and regulations
that apply to all persons or entities receiving state and federal
funds. [Provider] understands that any violation by a provider of
a State or federal law relating to the delivery of services by the
provider under this HMO/Provider contract, or any violation of the
TDH/HMO contract could result in liability for money damages,
and/or civil or criminal penalties and sanctions under state
and/or federal law.
7.2.8.2 [Provider] understands and agrees that HMO has the sole
responsibility for payment of covered services rendered by the
provider under HMO/Provider contract. In the event of HMO
insolvency or cessation of operations, [Provider's] sole recourse
is against HMO through the bankruptcy, conservatorship, or
receivership estate of HMO.
7.2.8.3 [Provider] understands and agrees TDH is not liable or
responsible for payment for any Medicaid covered services provided
to mandatory Members under HMO/Provider contract. Federal and
State laws provide severe penalties for any provider who attempts
to collect any payment from or xxxx a Medicaid recipient for a
covered service.
7.2.8.4 [Provider] agrees that any modification, addition, or
deletion of the provisions of this contract will become effective
no earlier than 30 days after HMO notifies TDH of the change in
writing. If TDH does not provide written approval within 30 days
from receipt of notification from HMO, changes can be considered
provisionally approved, and will become effective. Modifications,
additions or deletions which are required by TDH or by changes in
state or federal law are effective immediately.
7.2.8.5 This contract is subject to all state and federal laws and
regulations relating to fraud and abuse in health care and the
Medicaid program. [Provider] must cooperate and assist TDH and any
state or federal agency that is charged with the duty of
identifying, investigating, sanctioning or prosecuting suspected
fraud and abuse. [Provider] must provide originals and/or copies
of any and all information, allow access to premises and provide
records to TDH or its authorized agent(s), THHSC, HCFA, the U.S.
Department of Health and Human Services, FBI, TDI, and the Texas
Attorney General's Medicaid Fraud Control Unit, upon request, and
free-of-charge. [Provider] must report any suspected fraud or
abuse including any suspected fraud and abuse committed by HMO or
a
1999 Renewal Contract
Tarrant Service Area
66
August 9, 1999
67
Medicaid recipient to TDH for referral to THHSC.
7.2.8.6 [Provider] is required to submit proxy claims forms to HMO
for services provided to all STAR Members that are capitated by
HMO in accordance with the encounter data submissions requirements
established by HMO and TDH.
7.2.8.7 HMO is prohibited from imposing restrictions upon the
[Provider's] free communication with Members about a Member's
medical conditions, treatment options, HMO referral policies, and
other HMO policies, including financial incentives or arrangements
and all STAR managed care plans with whom [Provider] contracts.
7.2.8.8 The Texas Medicaid Fraud Control Unit must be allowed to
conduct private interviews of [Providers] and the [Providers']
employees, contractors, and patients. Requests for information
must be complied with, in the form and language requested.
[Providers] and their employees and contractors must cooperate
fully in making themselves available in person for interviews,
consultation, grand jury proceedings, pre-trial conference,
hearings, trial and in any other process, including
investigations. Compliance with this Article is at HMO's and
[Provider's] own expense.
7.2.8.9 HMO must include the method of payment and payment amounts
in all provider contracts.
7.2.8.10 All provider clean claims must be adjudicated within 30 days. HMO
must pay provider interest on all clean claims that are not paid
within 30 days at a rate of 1.5% per month (18% annual) for each
month the claim remains unadjudicated.
7.2.8.11 HMO must prohibit network providers from interfering with or
placing liens upon the state's right or HMO's right, acting as the
state's agent, to recovery from third party resources. HMO must
prohibit network providers from seeking recovery in excess of the
Medicaid payable amount or otherwise violating state and federal
laws.
7.2.9 HMO must follow the procedures outlined in article 20A.18A
of the Texas Insurance Code if terminating a contract with a
provider, including an STP. At least 30 days before the effective
date of the proposed termination of the provider's contract, HMO
must provide a written explanation to the provider of the reasons
for termination. HMO may immediately terminate a provider contract
if the provider presents imminent harm to patient health, actions
against a license or practice, or fraud.
7.2.9.1 Within 60 days of the termination notice date, a provider
may request a
1999 Renewal Contract
Tarrant Service Area
67
August 9, 1999
68
review of HMO's proposed termination by an advisory review panel,
except in a case in which there is imminent harm to patient
health, an action against a private license, or fraud. The
advisory review panel must be composed of physicians and
providers, as those terms are defined in article 20A.02(r) and
(t), including at least one representative in the provider's
specialty or a similar specialty, if available, appointed to serve
on the standing quality assurance committee or utilization review
committee of HMO. The decision of the advisory review panel must
be considered by HMO but is not binding on HMO. HMO must provide
to the affected provider, on request, a copy of the recommendation
of the advisory review panel and HMO's determination.
7.2.9.2 A provider who is terminated is entitled to an expedited
review process by HMO on request by the provider. HMO must provide
notification of the provider's termination to HMO's Members
receiving care from the terminated provider at least 30 days
before the effective date of the termination. If a provider is
terminated for reasons related to imminent harm to patient health,
HMO may notify its Members immediately.
7.2.10 HMO must notify TDH no later than 90 days prior to
terminating any subcontract affecting a major performance function
of this contract. If HMO seeks to terminate a provider's contract
for imminent harm to patient health, actions against a license or
practice, or fraud, contract termination may be immediate. TDH
will require assurances that any contract termination will not
result in an interruption of an essential service or major
contract function.
7.2.11 HMO must include a complaint and appeals process which
complies with the requirements of Article 20A.12 of the Texas
Insurance Code relating to Complaint Systems in all provider
contracts. HMO's complaint and appeals process must be the same
for all providers.
7.3 PHYSICIAN INCENTIVE PLANS
7.3.1 HMO may operate a physician incentive plan only if: (1) no
specific payment may be made directly or indirectly under a
physician incentive plan to a physician or physician group as an
inducement to reduce or limit medically necessary services
furnished to a Member; and (2) the stop-loss protection, enrollee
surveys and disclosure requirements of this Article are met.
7.3.2 HMO must disclose to TDH information required by federal
regulations found at 42 C.F.R. Section 417.479. The information
must be disclosed in sufficient detail to determine whether the
incentive plan complies with the requirements at 42 C.F.R. Section
417.479. The disclosure must contain the following information:
1999 Renewal Contract
Tarrant Service Area
68
August 9, 1999
69
7.3.2.1 Whether services not furnished by a physician or physician
group (referral services) are covered by the incentive plan. If
only services furnished by the physician or physician group are
covered by the incentive plan, disclosure of other aspects of the
incentive plan are not required to be disclosed.
7.3.2.2 The type of incentive arrangement (e.g. withhold, bonus,
capitation).
7.3.2.3 The percent of the withhold or bonus, if the incentive plan
involves a withhold bonus.
7.3.2.4 Whether the physician or physician group has evidence of a
stop-loss protection, including the amount and type of stop-loss
protection.
7.3.2.5 The panel size and the method used for pooling patients, if
patients are pooled.
7.3.2.6 The results of Member and disenrollee surveys, if HMO is
required under 42 C.F.R. Section 417.479 to conduct Member and
disenrollee surveys.
7.3.3 HMO must submit the information required in Articles
7.3.2.1 - 7.3.2.5 to TDH by the effective date of this contract
and each anniversary date of the contract.
7.3.4 HMO must submit the information required in Article 7.3.2.6
one year after the effective date of initial contract or effective
date of renewal contract, and annually each subsequent year under
the contract. HMO's who put physicians or physician groups at
substantial financial risk must conduct a survey of all Members
who have voluntarily disenrolled in the previous year. A list of
voluntary disenrollees may be obtained from the Enrollment Broker.
7.3.5 HMO must provide Members with information regarding
Physician Incentive Plans upon request. The information must
include the following:
7.3.5.1 whether HMO uses a physician incentive plan that covers
referral services;
7.3.5.2 the type of incentive arrangement (i.e., withhold, bonus,
capitation);
7.3.5.3 whether stop-loss protection is provided; and
7.3.5.4 results of enrollee and disenrollee surveys, if required
under 42 C.F.R. Section 417.479.
1999 Renewal Contract
Tarrant Service Area
69
August 9, 1999
70
7.3.5.5 HMO must ensure that IPAs and ANHCs with whom HMO contracts
comply with the requirements above. HMO is required to meet the
requirements above for all levels of subcontracting.
7.4 PROVIDER MANUAL AND PROVIDER TRAINING
7.4.1 HMO must prepare and issue a Provider Manual(s), including
any necessary specialty manuals (e.g. behavioral health) to the
providers in the HMO network and to newly contracted providers in
the HMO network within five (5) working days from inclusion of the
provider into the network. The Provider Manual must contain
sections relating to special requirements of the STAR Program as
required under this contract. See Appendix D, Required Critical
Elements, for specific details regarding content requirements.
Provider Manual and any revisions must be approved by TDH prior to
publication and distribution to providers (see Article 3.4.1
regarding the process for plan materials review).
7.4.2 HMO must provide training to all network providers and
their staff regarding the requirements of the TDH/HMO contract and
special needs of STAR Members.
7.4.2.1 HMO training for all providers must be completed no later
than 30 days after placing a newly contracted provider on active
status. HMO must provide on-going training to new and existing
providers as required by HMO or TDH to comply with this contract.
7.4.2.2 HMO must include in all PCP training how to screen for and
identify behavioral health disorders, HMO's referral process to
behavioral health care services and clinical coordination
requirements for behavioral health. HMO must include in all
training for behavioral health providers how to identify physical
health disorders, HMO's referral process to primary care and
clinical coordination requirements between physical medicine and
behavioral health providers. HMO must include training on
coordination and quality of care such as behavioral health
screening techniques for PCPs and new models of behavioral health
interventions.
7.4.3 HMO must provide primary care and behavioral health
providers with screening tools and instruments approved by TDH.
7.4.4 HMO must maintain and make available upon request
enrollment or attendance rosters dated and signed by each attendee
or other written evidence of
1999 Renewal Contract
Tarrant Service Area
70
August 9, 1999
71
training of each network provider and their staff.
7.4.5 HMO must have its written policies and procedures for the
screening, assessment and referral processes between behavioral
health providers and physical medicine providers available for TDH
review prior to the effective date of the contract.
7.5 MEMBER PANEL REPORTS
HMO must furnish each PCP with a current list of enrolled Members
enrolled or assigned to that Provider no later than 5 days after
HMO receives the Enrollment File from the Enrollment Broker each
month. If the 5th day falls on a weekend or state holiday, the
file must be provided by the following working day.
7.6 PROVIDER COMPLAINT AND APPEAL PROCEDURES
7.6.1 HMO must develop, implement and maintain a provider
complaint system. The complaint and appeal procedures must be in
compliance with all applicable state and federal law or
regulations. All Member complaints and/or appeals of an adverse
determination requested by the enrollee, or any person acting on
behalf of the enrollee, or a physician or provider acting on
behalf of the enrollee must comply with the provisions of this
Article. Modifications and amendments to the complaint system must
be submitted to TDH no later than 30 days prior to the
implementation of the modification or amendment.
7.6.2 HMO must include the provider complaint and appeal
procedure in all network provider contracts or in the provider
manual.
7.6.3 HMO's complaint and appeal process cannot contain
provisions requiring a Member to submit a complaint or appeal to
TDH for resolution in lieu of the HMO's process.
7.6.4 HMO must establish mechanisms to ensure that network
providers have access to a person who can assist providers in
resolving issues relating to claims payment, plan administration,
education and training, and complaint procedures.
7.7 PROVIDER QUALIFICATIONS - GENERAL
The providers in HMO network must meet the following
qualifications:
1999 Renewal Contract
Tarrant Service Area
71
August 9, 1999
72
-----------------------------------------------------------------------------------
FQHC A Federally Qualified Health Center meets the standards
established by federal rules and procedures. The FQHC must also be
an eligible provider enrolled in the Medicaid program.
-----------------------------------------------------------------------------------
Physician An individual who is licensed to practice medicine as an M.D. or a
D.O. in the State of Texas either as a primary care provider or in
the area of specialization under which they will provide medical
services under contract with HMO; who is a provider enrolled in
the Medicaid program; and who has a valid Drug Enforcement Agency
registration number and a Texas Controlled Substance Certificate,
if either is required in their practice.
-----------------------------------------------------------------------------------
Hospital An institution licensed as a general or special hospital by the
State of Texas under Chapter 241 of the Health and Safety Code and
Private Psychiatric Hospitals under Chapter 577 of the Health and
Safety Code (or is a provider which is a component part of a State
or local government entity which does not require a license under
the laws of the State of Texas), which is enrolled as a provider
in the Texas Medicaid Program. HMO will require that all
facilities in the network used for acute inpatient specialty care
for people under age 21 with disabilities or chronic or complex
conditions will have a designated pediatric unit; 24-hour
laboratory and blood bank availability; pediatric radiological
capability; meet JCAHO standards; and have discharge planning and
social service units.
-----------------------------------------------------------------------------------
Non-Physician An individual holding a license issued by the applicable licensing
Practitioner agency of the State of Texas who is enrolled in the Texas Medicaid
Provider Program or an individual properly trained to provide behavioral
health support services who practices under the direct supervision
of an appropriately licensed professional.
-----------------------------------------------------------------------------------
Clinical An entity having a current certificate issued under the Federal
Laboratory Clinical Laboratory Improvement Act (CLIA), and enrolled in the
Texas Medicaid Program.
-----------------------------------------------------------------------------------
Rural Health An institution which meets all of the criteria for designation as
Clinic (RHC) a rural health clinic, and enrolled in the Texas Medicaid Program.
-----------------------------------------------------------------------------------
Local Health A local health department established pursuant to Health and
Department Safety Code, Title 2, Local Public Health Reorganization Act
Section 121.031ff.
-----------------------------------------------------------------------------------
1999 Renewal Contract
Tarrant Service Area
72
August 9, 1999
73
-----------------------------------------------------------------------------------
Local Mental Under Section 531.002(8) of the Health and Safety Code, the local
Health component of the TXMHMR system designated by TDMHMR to carry out
Authority the legislative mandate for planning, policy development,
(LMHA) coordination, and resource development/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.
-----------------------------------------------------------------------------------
Non-Hospital A provider of health care services which is licensed and
Facility credentialed to provide services, and enrolled in the Texas
Provider Medicaid Program.
-----------------------------------------------------------------------------------
School Based Clinics located at school campuses that provide on-site primary
Health and preventive care to children and adolescents.
Clinic (SBHC)
-----------------------------------------------------------------------------------
7.8 PRIMARY CARE PROVIDERS
7.8.1 HMO must have a system for monitoring Member enrollment
into its plan to allow HMO to effectively plan for future needs
and recruit network providers as necessary to ensure adequate
access to primary care and specialty care. The Member enrollment
monitoring system must include the length of time required for
Members to access care within the network. The monitoring system
must also include monitoring after-hours availability and
accessibility of PCPs.
7.8.2 HMO must maintain a primary care provider network in
sufficient numbers and geographic distribution to serve a minimum
of forty-five percent (45%) of the mandatory STAR eligibles in
each county of the service area. HMO is required to increase the
capacity of the network as necessary to accommodate enrollment
growth beyond the forty-fifth percentile (45%).
7.8.3 HMO must maintain a provider network that includes
pediatricians and physicians with pediatric experience in
sufficient numbers and geographic distribution to serve eligible
children and adolescents in the service area and provide timely
access to the full scope of benefits, especially THSteps checkups
and immunizations.
7.8.4 HMO must comply with the access requirements as established
by the Texas Department of Insurance for all HMOs doing business
in Texas, except as otherwise required by this contract.
7.8.5 HMO must have physicians with board
eligibility/certification in pediatrics available for referral for
Members under the age of 21.
1999 Renewal Contract
Tarrant Service Area
73
August 9, 1999
74
7.8.5.1 Individual PCPs may serve more than 2,000 Members. However,
if TDH determines that a PCP's Member enrollment exceeds the PCP's
ability to provide accessible, quality care, TDH may prohibit the
PCP from receiving further enrollments. TDH may direct HMOs to
assign or reassign Members to another PCP's panel.
7.8.6 HMO must have PCPs available throughout the service area to
ensure that no Member must travel more than 30 miles to access the
PCP, unless an exception to this distance requirement is made by
TDH.
7.8.7 HMO'S PRIMARY CARE PROVIDER NETWORK MAY INCLUDE PROVIDERS
FROM ANY OF THE FOLLOWING PRACTICE AREAS: GENERAL PRACTITIONERS;
FAMILY PRACTITIONERS; INTERNISTS; PEDIATRICIANS;
OBSTETRICIANS/GYNECOLOGISTS (OB/GYN); PEDIATRIC AND FAMILY
ADVANCED PRACTICE NURSES (APNs) AND CERTIFIED NURSE MIDWIVES WOMEN
HEALTH (CNMs) PRACTICING UNDER THE SUPERVISION OF A PHYSICIAN;
PHYSICIAN ASSISTANTS (PAs) 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; OR FEDERALLY QUALIFIED HEALTH CENTERS
(FQHCs), RURAL HEALTH CLINICS (RHCs) AND SIMILAR COMMUNITY
CLINICS; AND SPECIALISTS WHO ARE WILLING TO PROVIDE MEDICAL HOMES
TO SELECTED MEMBERS WITH SPECIAL NEEDS AND CONDITIONS (SEE ARTICLE
7.9.4).
7.8.8 The PCP for a Member with disabilities or chronic or
complex conditions may be a specialist who agrees to provide PCP
services to the Member. The specialty provider must agree to
perform all PCP duties required in the contract and PCP duties
must be within the scope of the specialist's license. Any
interested person may initiate the request for a specialist to
serve as a PCP for a Member with disabilities or chronic or
complex conditions.
7.8.9 PCPs must either have admitting privileges at a hospital,
which is part of HMO network of providers, or make referral
arrangements with an HMO provider who has admitting privileges to
a network hospital.
7.8.10 HMO must require, through contract provisions, that PCPs
are accessible to Members 24 hours a day, 7 days a week. The
following are acceptable and unacceptable phone arrangements for
contacting PCPs after normal business hours.
Acceptable:
1999 Renewal Contract
Tarrant Service Area
74
August 9, 1999
75
(1) Office phone is answered after-hours by an answering
service which meets language requirements of the major
population groups and which can contact the PCP or another
designated medical practitioner. All calls answered by an
answering service must be returned within 30 minutes.
(2) Office phone is answered after normal business hours by a
recording in the language of each of the major population
groups served directing the patient to call another number
to reach the PCP or another provider designated by the PCP.
Someone must be available to answer the designated
provider's phone. Another recording is not acceptable.
(3) Office phone is transferred after office hours to another
location where someone will answer the phone and be able to
contact the PCP or another designated medical practitioner,
who can return the call within 30 minutes.
Unacceptable:
(1) Office phone is only answered during office hours.
(2) Office phone is answered after-hours by a recording which
tells patients to leave a message.
(3) Office phone is answered after-hours by a recording which
directs patients to go to an Emergency Room for any
services needed.
(4) Returning after-hours calls outside of 30 minutes.
7.8.11 HMO must require PCPs, through contract provisions or
provider manual, to provide primary care services and continuity
of care to Members who are enrolled with or assigned to the PCP.
Primary care services are all services required by a Member for
the prevention, detection, treatment and cure of illness, trauma,
disease or disorder, which are covered and/or required services
under this contract. All services must be provided in compliance
with generally accepted medical and behavioral health standards
for the community in which services are rendered. HMO must require
PCPs, through contract provisions or provider manual, to provide
children under the age of 21 services in accordance with the
American Academy of Pediatric recommendations and the THSteps
periodicity schedule and provide adults services in accordance
with the U.S. Preventive Services Task Force's publication "Put
Prevention Into Practice".
7.8.11.1 HMO must require PCPs, through contract provisions or provider
manual, to assess the medical needs of Members for referral to
specialty care providers and
1999 Renewal Contract
Tarrant Service Area
75
August 9, 1999
76
provide referrals as needed. PCP must coordinate care with
specialty care providers after referral.
7.8.11.2 HMO must require PCPs, through contract provisions or provider
manual, to make necessary arrangements with home and community
support services to integrate the Member's needs. This integration
may be delivered by coordinating the care of Members with other
programs, public health agencies and community resources which
provide medical, nutritional, behavioral, educational and outreach
services available to Members.
7.8.11.3 HMO must require, through contract provisions or provider manual,
that the Member's PCP or HMO provider through whom PCP has made
arrangements, be the admitting or attending physician for
inpatient hospital care, except for emergency medical or
behavioral health conditions or when the admission is made by a
specialist to whom the Member has been referred by the PCP. HMO
must require, through contract provisions or provider manual, that
PCP assess the advisability and availability of outpatient
treatment alternatives to inpatient admissions. HMO must require,
through contract provisions or provider manual, that PCP provide
or arrange for pre-admission planning for non-emergency inpatient
admissions, and discharge planning for Members. PCP must call the
emergency room with relevant information about the Member. PCP
must provide or arrange for follow-up care after emergency or
inpatient care.
7.8.11.4 HMO must require PCPs for children under the age of 21 to provide
or arrange to have provided all services required under Article
6.8 relating to Texas Health Steps, Article 6.9 relating to
Perinatal Services, Article 6.10 relating to Early Childhood
Intervention, Article 6.11 relating to WIC, Article 6.13 relating
to People With Disabilities or Chronic or Complex Conditions, and
Article 6.14 relating to Health Education and Wellness and
Prevention Plans. PCP must cooperate and coordinate with HMO to
provide Member and the Member's family with knowledge of and
access to available services.
7.8.12 PCP Selection and Changes. All Medicaid recipients who are
eligible for participation in the STAR program have the right to
select their PCP and HMO. Medicaid recipients who are mandatory
STAR participants who do not select a PCP and/or HMO during the
time period allowed will be assigned to a PCP and/or HMO using the
TDH default process. Members may change PCPs at any time, but
these changes are limited to four (4) times per year.
7.8.12.1 Voluntary SSI Members. PCP changes cannot be performed
retroactively for voluntary SSI Members. If an SSI Member requests
a PCP change on or before the 15th of the month, the change will
be effective the first day of the next month.
1999 Renewal Contract
Tarrant Service Area
76
August 9, 1999
77
If an SSI Member requests a PCP change after the 15th of the
month, the change will be effective the first day of the second
month that follows. Exceptions to this policy will be allowed for
reasons of medical necessity or other extenuating circumstances.
7.8.12.2 Mandatory Members. Retroactive changes to a Member's PCP should
only be made if it is medically necessary or there are other
circumstances which necessitate a retroactive change. HMO must pay
claims for services provided by the original PCP. If the original
PCP is paid on a capitated basis and services were provided during
the period for which capitation was paid, HMO cannot recoup the
capitation.
7.9 OB/GYN PROVIDERS
HMO must allow a female Member to select an OB/GYN within its
provider network or within a limited provider network in addition
to a PCP, to provide health care services within the scope of the
professional specialty practice of a properly credentialed OB/GYN.
See Article 21.53D of the Texas Insurance Code and 28 TAC Sections
11.506, 11.1600 and 11.1608. A Member who selects an OB/GYN must
be allowed direct access to the health care services of the OB/GYN
without a referral by the woman's PCP or a prior authorization or
precertification from HMO. HMO must allow Members to change
OB/GYNs up to four times per year. Health care services must
include, but not be limited to:
7.9.1 One well-woman examination per year;
7.9.2 Care related to pregnancy;
7.9.3 Care for all active gynecological conditions; and
7.9.4 Diagnosis, treatment, and referral for any disease or
condition within the scope of the professional practice of a
properly credentialed obstetrician or gynecologist.
7.9.5 HMOs which allow its Members to directly access any OB/GYN
provider within its network, must ensure that the provisions of
Articles 7.9.1 through 7.9.4 continue to be met.
7.9.6 OB/GYN providers must comply with HMO's procedures
contained in HMO's provider manual or provider contract for OB/GYN
providers, including but not limited to prior authorization
procedures.
7.10 SPECIALTY CARE PROVIDERS
1999 Renewal Contract
Tarrant Service Area
77
August 9, 1999
78
7.10.1 HMO must maintain specialty providers, including pediatric
specialty providers, within the network in sufficient numbers and
areas of practice to meet the needs of all Members requiring
specialty care or services.
7.10.2 HMO must require, through contract provisions or provider
manual, that specialty providers send a record of consultation and
recommendations to a Member's PCP for inclusion in Member's
medical record and report encounters to the PCP and/or HMO.
7.10.3 HMO must ensure availability and accessibility to
appropriate specialists.
7.10.4 HMO must ensure that no Member is required to travel in
excess of 75 miles to secure initial contact with referral
specialists; special hospitals, psychiatric hospitals; diagnostic
and therapeutic services; and single service health care
physicians, dentists or providers. Exceptions to this requirement
may be allowed when an HMO has established, through utilization
data provided to TDH, that a normal pattern for securing health
care services within an area exists or HMO is providing care of a
higher skill level or specialty than the level which is available
within the service area such as, but not limited to, treatment of
cancer, xxxxx, and cardiac diseases.
7.11 SPECIAL HOSPITALS AND SPECIALTY CARE FACILITIES
7.11.1 HMO must include all medically necessary specialty services
through its network specialists, subspecialists and specialty care
facilities (e.g., children's hospitals, and tertiary care
hospitals).
7.11.2 HMO must include requirements for pre-admission and
discharge planning in its contracts with network hospitals.
Discharge plans for a Member must be provided by HMO or the
hospital to the Member/family, the PCP and specialty care
physicians.
7.11.3 HMO must have appropriate multidisciplinary teams for
people with disabilities or chronic or complex medical conditions.
These teams must include the PCP and any individuals or providers
involved in the day-to-day or on-going care of the Member.
7.11.4 HMO must include in its provider network a TDH-designated
perinatal care facility, as established by Section 32.042, Texas
Health and Safety Code, once the designated system is finalized
and perinatal care facilities have been approved for the service
area (see Article 6.9.1).
1999 Renewal Contract
Tarrant Service Area
78
August 9, 1999
79
7.12 BEHAVIORAL HEALTH - LOCAL MENTAL HEALTH AUTHORITY (LMHA)
7.12.1 Assessment to determine eligibility for rehabilitative and
targeted MHMR case management services is a function of the LMHA.
HMO must provide all covered services described in detail in the
Texas Medicaid Provider Procedures Manual (Provider Procedures
Manual) and the Texas Medicaid Bulletins which is the bi-monthly
update to the Provider Procedures Manual. Clinical information
regarding covered services are published by the Texas Medicaid
program in the Texas Medicaid Service Delivery Guide. Covered
services must be provided to Members with SPMI and SED, when
medically necessary, whether or not they are also receiving
targeted case management or rehabilitation services through the
LMHA.
7.12.2 HMO will coordinate with the 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.
7.12.3 HMO must enter into written agreements with all LMHAs in
the service area which describes the process(es) which HMO and
LMHA will use to coordinate services for STAR Members with SPMI or
SED. The agreement will contain the following provisions:
7.12.3.1 Describe the behavioral health covered services indicated in
detail in the Provider Procedures Manual and the Texas Medicaid
Bulletins which is the bi-monthly update to the Provider
Procedures Manual. Clinical information regarding covered services
are published by the Texas Medicaid program in the Texas Medicaid
Service Delivery Guide. Also include the amount, duration, and
scope of basic and value-added services, and HMO's responsibility
to provide these services;
7.12.3.2 Describe criteria, protocols, procedures and instrumentation for
referral of STAR Members from and to HMO and LMHA;
7.12.3.3 Describe processes and procedures for referring Members with SPMI
or SED to LMHA for assessment and determination of eligibility for
rehabilitation or targeted case management services;
7.12.3.4 Describe how the LMHA and HMO will coordinate providing behavioral
health care services to Members with SPMI or SED;
7.12.3.5 Establish clinical consultation procedures between HMO and LMHA
including
1999 Renewal Contract
Tarrant Service Area
79
August 9, 1999
80
consultation to effect referrals and on-going consultation
regarding the Member's progress;
7.12.3.6 Establish procedures to authorize release and exchange of clinical
treatment records;
7.12.3.7 Establish procedures for coordination of assessment,
intake/triage, utilization review/utilization management and care
for persons with SPMI or SED;
7.12.3.8 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;
7.12.3.9 Establish procedures for coordination of emergency and urgent
services to Members; and
7.12.3.10 Establish procedures for coordination of care and transition of
care for new HMO Members who are receiving treatment through the
LMHA.
7.12.4 HMO must offer licensed practitioners of the healing arts,
who are part of the Member's treatment team for rehabilitation
services, the opportunity to participate in HMO's network. The
practitioner must agree to accept the standard provider
reimbursement rate, meet the credentialing requirements, comply
with all the terms and conditions of the standard provider
contract of HMO.
7.12.5 Members receiving rehabilitation services must be allowed
to choose the licensed practitioners of the healing arts who are
currently a part of the Member's treatment team for rehabilitation
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, HMO must
reimburse the LMHA at current Medicaid fee-for-service amounts.
7.13 SIGNIFICANT TRADITIONAL PROVIDERS (STPS)
HMO must seek participation in its provider network from:
7.13.1 Each health care provider in the service area who has
traditionally provided care to Medicaid recipients;
7.13.2 Each hospital in the service area that has been designated
as a disproportionate share hospital under Medicaid; and
7.13.3 Each specialized pediatric laboratory in the service area,
including those
1999 Renewal Contract
Tarrant Service Area
80
August 9, 1999
81
laboratories located in children's hospitals.
7.14 RURAL HEALTH PROVIDERS
7.14.1 In rural areas of the service area, HMO must seek the
participation in its provider network of rural hospitals,
physicians, home and community support service agencies, and other
rural health care providers who:
7.14.1.1 are the only providers located in the service area; and
7.14.1.2 are Significant Traditional Providers.
7.14.2 In order to contract with HMO, rural health providers must:
7.14.2.1 agree to accept the prevailing provider contract rate of HMO based
on provider type; and
7.14.2.2 have the credentials required by HMO, provided that lack of board
certification or accreditation by JCAHO may not be the only
grounds for exclusion from the provider network.
7.14.3 HMO must reimburse rural hospitals with 100 or fewer
licensed beds in counties with fewer than 50,000 persons for acute
care services at a rate calculated using the higher of the
prospective payment system rate or the cost reimbursed methodology
authorized under the Tax Equity and Fiscal Responsibility Act of
1982 (TEFRA). Hospitals reimbursed under TEFRA cost principles
shall be paid without the imposition of the TEFRA cap.
7.14.4 HMO must reimburse physicians who practice in rural
counties with fewer than 50,000 persons at a rate using the
current Medicaid fee schedule, including negotiated
fee-for-service.
7.15 FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS) AND RURAL HEALTH
CLINICS (RHCS)
7.15.1 HMO must make reasonable efforts to include FQHCs and RHCs
(Freestanding and hospital-based) in its provider network.
7.15.2 FQHCs or RHCs will receive a cost settlement from TDH and
must agree to accept initial payments from HMO in an amount that
is equal to or greater than HMO's payment terms for other
providers providing the same or similar services.
1999 Renewal Contract
Tarrant Service Area
81
August 9, 1999
82
7.15.2.1 HMO must submit monthly FQHC and RHC encounter and payment reports
to all contracted FQHCs and RHCs, and FQHCs and RHCs with whom
there have been encounters, not later than 21 days from the end of
the month for which the report is submitted. The format will be
developed by TDH. The FQHC and RHC must validate the encounter and
payment information contained in the report(s). 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. HMO must submit the signed FQHC and RHC encounter and
payment reports to TDH not later than 45 days from the end of the
month for which the report is submitted.
7.15.2.2 For FQHCs, TDH will determine the amount of the interim settlement
based on the difference between: an amount equal to the number of
Medicaid allowable encounters multiplied by the rate per encounter
from the latest settled FQHC fiscal year cost report, and the
amount paid by HMO to the FQHC for the quarter. For RHCs, TDH will
determine the amount of the interim settlement based on the
difference between a reasonable cost amount methodology provided
by TDH and the amount paid by HMO to the RHC for the quarter. TDH
will pay the FQHC or the RHC the amount of the interim settlement,
if any, as determined by TDH or collect and retain the quarterly
recoupment amount, if any.
7.15.2.3 TDH will cost settle with each FQHC and RHC annually, based on the
FQHC or the RHC fiscal year cost report and the methodology
described in Article 7.15.2.2. TDH will make additional payments
or recoup payments from the FQHC or the RHC based on reasonable
costs less prior interim payment settlements.
7.15.2.4 Cost settlements for RHCs, and HMO's obligation to provide RHC
reporting described in Article 7.15, are retroactive to October 1,
1997.
7.16 COORDINATION WITH PUBLIC HEALTH
7.16.1 Reimbursed Arrangements. HMO must make a good faith effort
to enter into a subcontract for the covered health care services
as specified below with TDH Public Health Regions, city and/or
county health departments or districts in each county of the
service area that will be providing these services to the Members
(Public Health Entities), who will be paid for services by HMO,
including any or all of the following services or any covered
service which the public health department and HMO have agreed to
provide:
7.16.1.1 Sexually Transmitted Diseases (STDs) Services (see Article 6.15);
7.16.1.2 Confidential HIV Testing (see Article 6.15);
1999 Renewal Contract
Tarrant Service Area
82
August 9, 1999
83
7.16.1.3 Immunizations;
7.16.1.4 Tuberculosis (TB) Care (see Article 6.12);
7.16.1.5 Family Planning Services (see Article 6.7);
7.16.1.6 THSteps checkups (see Article 6.8); and
7.16.1.7 Prenatal services (see Article 6.9).
7.16.2 HMO must make a good faith effort to enter into
subcontracts with public health entities in the service area. The
subcontracts must be available for review by TDH or its designated
agent(s) on the same basis as all other subcontracts. If any
changes are made to the contract, it must be resubmitted to TDH.
If an HMO is unable to enter into a contract with public health
entities, HMO must document current and past efforts to TDH.
Documentation must be submitted no later than 120 days after the
execution of this contract. Public health subcontracts must
include the following areas:
7.16.2.1 The general relationship between HMO and the Public Health entity.
The subcontracts must specify the scope and responsibilities of
both parties, the methodology and agreements regarding billing and
reimbursements, reporting responsibilities, Member and provider
educational responsibilities, and the methodology and agreements
regarding sharing of confidential medical record information
between the public health entity and the PCP.
7.16.2.2 Public Health Entity responsibilities:
(1) Public health providers must inform Members that
confidential health care information will be provided to
the PCP.
(2) Public health providers must refer Members back to PCP for
any follow-up diagnostic, treatment, or referral services.
(3) Public health providers must educate Members about the
importance of having a PCP and accessing PCP services
during office hours rather than seeking care from Emergency
Departments, Public Health Clinics, or other Primary Care
Providers or Specialists.
(4) Public health entities must identify a staff person to act
as liaison to HMO to coordinate Member needs, Member
referral, Member and provider education, and the transfer
of confidential medical record information.
1999 Renewal Contract
Tarrant Service Area
83
August 9, 1999
84
7.16.2.3 HMO Responsibilities:
(1) HMO must identify care coordinators who will be available
to assist public health providers and PCPs in getting
efficient referrals of Members to the public health
providers, specialists, and health-related service
providers either within or outside HMO's network.
(2) HMO must inform Members that confidential healthcare
information will be provided to the PCP.
(3) HMO must educate Members on how to better utilize their
PCPs, public health providers, emergency departments,
specialists, and health-related service providers.
7.16.2.4 Existing contracts must include the provisions in Articles
7.16.2.1 through 7.16.2.3.
7.16.3 Non-Reimbursed Arrangements with Public Health Entities.
7.16.3.1 Coordination with Public Health Entities. HMOs must make a good
faith effort to enter into a Memorandum of Understanding (MOU)
with Public Health Entities in the service area regarding the
provision of services for essential public health care services.
These MOUs must be entered into in each service area and are
subject to TDH approval. If any changes are made to the MOU, it
must be resubmitted to TDH. If an HMO is unable to enter into an
MOU with a public health entity, HMO must document current and
past efforts to TDH. Documentation must be submitted no later than
120 days after the execution of this contract. MOUs must contain
the roles and responsibilities of HMO and the public health
department for the following services:
(1) Public health reporting requirements regarding communicable
diseases and/or diseases which are preventable by
immunization as defined by state law;
(2) Notification of and referral to the local Public Health
Entity, as defined by state law, of communicable disease
outbreaks involving Members;
(3) Referral to the local Public Health Entity for TB contact
investigation and evaluation and preventive treatment of
persons whom the Member has come into contact;
1999 Renewal Contract
Tarrant Service Area
84
August 9, 1999
85
(4) Referral to the local Public Health Entity for STD/HIV
contact investigation and evaluation and preventive
treatment of persons whom the Member has come into contact;
and,
(5) Referral for WIC services and information sharing;
(6) Coordination and follow-up of suspected or confirmed cases
of childhood lead exposure.
7.16.3.2 Coordination with Other TDH Programs. HMOs must make a good faith
effort to enter into a Memorandum of Understanding (MOU) with
other TDH programs regarding the provision of services for
essential public health care services. These MOUs must be entered
into in each service area and are subject to TDH approval. If any
changes are made to the MOU, it must be resubmitted to TDH. If an
HMO is unable to enter into an MOU with other TDH programs, HMO
must document current and past efforts to TDH. Documentation must
be submitted no later than 120 days after the execution of this
contract. MOUs must delineate the roles and responsibilities of
HMO and the TDH programs for the following services:
(1) Use of the TDH laboratory for THSteps newborn screens; lead
testing; and hemoglobin/hematocrit tests;
(2) Availability of vaccines through the Vaccines for Children
Program;
(3) Reporting of immunizations provided to the statewide
ImmTrac Registry including parental consent to share data;
(4) Referral for WIC services and information sharing;
(5) Pregnant, Women and Infant (PWI) Targeted Case Management;
(6) THSteps outreach, informing and Medical Case Management;
(7) Participation in the community-based coalitions with the
Medicaid-funded case management programs in MHMR, ECI, TCB,
and TDH (PWI, CIDC and THSteps Medical Case Management);
(8) Referral to the TDH Medical Transportation Program;
(9) Cooperation with activities required of public health
authorities to conduct the annual population and community
based needs assessment; and
1999 Renewal Contract
Tarrant Service Area
85
August 9, 1999
86
(10) Coordination and follow-up of suspected or confirmed cases
of childhood lead exposure.
7.16.4 All public health contracts must contain provider network
requirements in Article VII, as applicable.
7.17 COORDINATION WITH TEXAS DEPARTMENT OF PROTECTIVE AND
REGULATORY SERVICES
7.17.1 HMO must cooperate and coordinate with the Texas Department
of Protective and Regulatory Services (TDPRS) for the care of a
child who is receiving services from or has been placed in the
conservatorship of TDPRS.
7.17.2 HMO must comply with all provisions of a Court Order or
TDPRS Service Plan with respect to a child in the conservatorship
of TDPRS (Order) entered by a Court of Continuing Jurisdiction
placing a child under the protective custody of TDPRS or a Service
Plan voluntarily entered into by the parents or person having
legal custody of a minor and TDPRS, which relates to the health
and behavioral health care services required to be provided to the
Member.
7.17.3 HMO cannot deny, reduce, or controvert the medical
necessity of any health or behavioral health care services
included in an Order entered by a court. HMO may participate in
the preparation of the medical and behavioral care plan prior to
TDPRS submitting the health care plan to the Court. Any
modification or termination of court ordered services must be
presented and approved by the court with jurisdiction over the
matter.
7.17.4 A Member or the parent or guardian whose rights are subject
to an Order or Service Plan cannot appeal the necessity of the
services ordered through HMO's complaint or appeal processes, or
to TDH for a Fair Hearing.
7.17.5 HMO must include information in its provider training and
manuals regarding:
7.17.5.1 providing medical records;
7.17.5.2 scheduling medical and behavioral health appointments within 14
days unless requested earlier by TDPRS; and
7.17.5.3 recognition of abuse and neglect and appropriate referral to
TDPRS.
1999 Renewal Contract
Tarrant Service Area
86
August 9, 1999
87
7.17.6 HMO must continue to provide all covered services to a
Member receiving services from or in the protective custody of
TDPRS until the Member has been disenrolled from HMO as a result
of loss of eligibility in Medicaid managed care or placement into
xxxxxx care.
7.18 DELEGATED NETWORKS (IPAs, LIMITED PROVIDER NETWORKS AND
ANHCs)
7.18.1 All HMO contracts with any of the entities described in
Texas Insurance Code Article 20A.02(ee) and a group of providers
who are licensed to provide the same health care services or an
entity that is wholly-owned or controlled by one or more hospitals
and physicians including a physician-hospital organization
(delegated network contracts) must:
7.18.1.1 contain the mandatory contract provisions for all subcontractors
in Article 3.2 of this contract;
7.18.1.2 comply with the requirements, duties and responsibilities of this
contract;
7.18.1.3 not create a barrier for full participation to significant
traditional providers;
7.18.1.4 not interfere with TDH's oversight and audit responsibilities
including collection and validation of encounter data; or
7.18.1.5 be consistent with the federal requirement for simplicity in the
administration of the Medicaid program.
7.18.2 In addition to the mandatory provisions for all
subcontracts under Articles 3.2. and 7.2, all HMO/delegated
network contracts must include the following mandatory standard
provisions:
7.18.2.1 HMO is required to include subcontract provisions in its delegated
network contracts which require the UM protocol used by a
delegated network to produce substantially similar outcomes, as
approved by TDH, as the UM protocol employed by the contracting
HMO. The responsibilities of an HMO in delegating UM functions to
a delegated network will be governed by Article 16.3.11 of this
contract.
7.18.2.2 Delegated networks that are delegated claims payment
responsibilities by HMO must also have the responsibility to
submit encounter, utilization, quality, and financial data to HMO.
HMO remains responsible for integrating all delegated network data
reports into HMO's reports required under this contract. If HMO is
1999 Renewal Contract
Tarrant Service Area
87
August 9, 1999
88
not able to collect and report all delegated network data for HMO
reports required by this contract, HMO must not delegate claims
processing to the delegated network.
7.18.2.3 The delegated network must comply with the same records retention
and production requirements, including Open Records requirements,
as the HMO under this contract.
7.18.2.4 The delegated network is subject to the same marketing
restrictions and requirements as the HMO under this contract.
7.18.2.5 HMO is responsible for ensuring that delegated network contracts
comply with the requirements and provisions of the TDH/HMO
contract. TDH will impose appropriate sanctions and remedies upon
HMO for any default under the TDH/HMO contract which is caused
directly or indirectly by the acts or omissions of the delegated
network.
7.18.3 HMO cannot enter into contracts with delegated networks to
provide services under this contract which require the delegated
network to enter into exclusive contracts with HMO as a condition
for participation with HMO.
7.18.3.1 Article 17.18.3 does not apply to providers who are employees or
participants in limited provider networks.
7.18.4 All delegated networks that limit Member access to those
providers contracted with the delegated network (closed or limited
panel networks) with whom HMO contracts must either independently
meet the access provisions of 28 Texas Administrative Code Section
11.1607, relating to access requirements for those Members
enrolled or assigned to the delegated network, or HMO must provide
for access through other network providers outside the closed
panel delegated network.
7.18.5 HMO cannot delegate to a delegated network the enrollment,
re-enrollment, assignment or reassignment of a Member.
7.18.6 In addition to the above provision HMO and approved
Non-Profit Health Corporations must comply with all of the
requirements contained in 28 TAC Section 11.1604, relating to
Requirements of Certain Contracts between Primary HMOs and ANHCs
and Primary HMOs and Provider HMOs.
7.18.7 HMO REMAINS RESPONSIBLE FOR PERFORMING ALL DUTIES,
RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT
1999 Renewal Contract
Tarrant Service Area
88
August 9, 1999
89
REGARDLESS OF WHETHER THE DUTY, RESPONSIBILITY OR SERVICE IS
CONTRACTED OR DELEGATED TO ANOTHER. HMO MUST PROVIDE A COPY OF THE
CONTRACT PROVISIONS THAT SET OUT HMO'S DUTIES, RESPONSIBILITIES,
AND SERVICES TO ANY PROVIDER NETWORK OR GROUP WITH WHOM HMO
CONTRACTS TO PROVIDE HEALTH CARE SERVICES ON A RISK SHARING OR
CAPITATED BASIS OR TO PROVIDE HEALTH CARE SERVICES.
ARTICLE VIII MEMBER SERVICES REQUIREMENTS
8.1 MEMBER EDUCATION
HMO must provide the Member education requirements as contained in
Article VI at 6.5, 6.6, 6.7, 6.8, 6.9, 6.10, 6.11, 6.12, 6.13, and
6.14, and this Article of the contract.
8.2 MEMBER HANDBOOK
8.2.1 HMO must mail each newly enrolled Member a Member Handbook
no later than five (5) days after HMO receives the Enrollment
File. If the 5th day falls on a weekend or state holiday, the
Member Handbook must be mailed by the following working day. The
Member Handbook must be written at a 4th - 6th grade reading
comprehension level. The Member Handbook must contain all critical
elements specified by TDH. See Appendix D, Required Critical
Elements, for specific details regarding content requirements. HMO
must submit a Member Handbook to TDH for approval prior to the
effective date of the contract unless previously approved (see
Article 3.4.1 regarding the process for plan materials review).
8.2.2 Member Handbook Updates. HMO must provide updates to the
Handbook to all Members as changes are made to the Required
Critical Elements in Appendix D. HMO must make the Member Handbook
available in the languages of the major population groups and the
visually impaired served by HMO.
8.2.3 THE MEMBER HANDBOOK AND ANY REVISIONS OR CHANGES MUST BE
APPROVED BY TDH PRIOR TO PUBLICATION AND DISTRIBUTION TO MEMBERS
(see Article 3.4.1 regarding the process for plan materials
review).
8.3 ADVANCE DIRECTIVES
1999 Renewal Contract
Tarrant Service Area
89
August 9, 1999
90
8.3.1 Federal and state law require HMOs and providers to
maintain written policies and procedures for informing and
providing written information to all adult Members 18 years of age
and older about their rights under state and federal law, in
advance of their receiving care (Social Security Act Section
1902(a)(57) and Section 1903(m)(1)(A)). The written policies and
procedures must contain procedures for providing written
information regarding the Member's right to refuse, withhold or
withdraw medical treatment advance directives. HMO's policies and
procedures must comply with provisions contained in 42 CFR Section
434.28 and 42 CFR Section 489, SubPart I, relating to advance
directives for all hospitals, critical access hospitals, skilled
nursing 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:
8.3.1.1 a Member's right to self-determination in making health
care decisions; and
8.3.1.2 the Advance Directives Act, Chapter 166, Texas Health and
Safety Code, which includes:
8.3.1.2.1 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;
8.3.1.2.2 a Member's right to make written and non-written Out-of-Hospital
Do-Not-Resuscitate Orders; and
8.3.1.2.3 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.
8.3.2 HMO must maintain written policies for implementing a
Member's advance directive. Those policies must include a clear
and precise statement of limitation if HMO or a participating
provider cannot or will not implement a Member's advance
directive.
8.3.2.1 A statement of limitation on implementing a Member's
advance directive should include at least the following
information:
8.3.2.1.1 a clarification of any differences between HMO's conscience
objections and those which may be raised by the Member's PCP or
other providers;
1999 Renewal Contract
Tarrant Service Area
90
August 9, 1999
91
8.3.2.1.2 identification of the state legal authority permitting HMO's
conscience objections to carrying out an advance directive; and
8.3.2.1.3 a description of the range of medical conditions or procedures
affected by the conscience objection.
8.3.3 HMO cannot require a Member to execute or issue an advance
directive as a condition for receiving health care services.
8.3.4 HMO cannot discriminate against a Member based on whether
or not the Member has executed or issued an advance directive.
8.3.5 HMO's policies and procedures must require HMO and
subcontractor to comply with the requirements of state and federal
law relating to advance directives. HMO must provide education and
training to employees, Members, and the community on issues
concerning advance directives.
8.3.6 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. HMO must submit to TDH any revisions to existing
approved advance directive materials.
8.3.7 HMO must notify Members of any changes in state or federal
laws relating to advance directives within 90 days from the
effective date of the change, unless the law or regulation
contains a specific time requirement for notification.
8.4 MEMBER ID CARDS
8.4.1 A Medicaid Identification Form (Form 3087) is issued
monthly by the TDHS. The form includes the "STAR" Program logo and
the name and toll free number of the Member's health plan. A
Member may have a temporary Medicaid Identification (Form 1027-A)
which will include a STAR indicator.
8.4.2 HMO must issue a Member Identification Card (ID) to the
Member within five (5) days from receiving the Enrollment File
from the Enrollment Broker. If the 5th day falls on a weekend or
state holiday, the ID Card must be issued by the following working
day. The ID Card must include, at a minimum, the following:
Member's name; Member's Medicaid number; either the issue date of
the card or
1999 Renewal Contract
Tarrant Service Area
91
August 9, 1999
92
effective date of the PCP assignment; PCP's name, address, and
telephone number; name of HMO; name of IPA to which the Member's
PCP belongs, if applicable; the 24-hour, seven (7) day a week
toll-free telephone number operated by HMO; the toll-free number
for behavioral health care services; and directions for what to do
in an emergency. The ID Card must be reissued if the Member
reports a lost card, there is a Member name change, if Member
requests a new PCP, or for any other reason which results in a
change to the information disclosed on the ID Card.
8.5 MEMBER HOTLINE
HMO must maintain a toll-free Member telephone hotline 24 hours a
day, seven days a week for Members to obtain assistance in
accessing services under this contract. Telephone availability
must be demonstrated through an abandonment rate of less than 10%.
8.6 MEMBER COMPLAINT PROCESS
8.6.1 HMO must develop, implement and maintain a Member complaint
system that complies with the requirements of Article 20A.12 of
the Texas Insurance Code, relating to the Complaint System, except
where otherwise provided in this contract and in applicable
federal law. The complaint and appeals procedure must be the same
for all Members and must comply with Texas Insurance Code, Article
20A.12 or applicable federal law. Modifications and amendments
must be submitted to TDH at least 30 days prior to the
implementation of the modification or amendment.
8.6.2 HMO must have written policies and procedures for
receiving, tracking, reviewing, and reporting and resolving of
Member complaints. The procedures must be reviewed and approved in
writing by TDH. Any changes or modifications to the procedures
must be submitted to TDH for approval thirty (30) days prior to
the effective date of the amendment.
8.6.3 HMO must designate an officer of HMO who has primary
responsibility for ensuring that complaints are resolved in
compliance with written policy and within the time required. An
"officer" of HMO means a president, vice president, secretary,
treasurer, or chairperson of the board for a corporation, the sole
proprietor, the managing general partner of a partnership, or a
person having similar executive authority in the organization.
8.6.4 HMO must have a routine process to detect patterns of
complaints and disenrollments and involve management and
supervisory staff to develop policy and procedural improvements to
address the complaints. HMO must cooperate
1999 Renewal Contract
Tarrant Service Area
92
August 9, 1999
93
with TDH and TDH's Enrollment Broker in Member complaints relating
to enrollment and disenrollment.
8.6.5 HMO's complaint procedures must be provided to Members in
writing and in alternative communication formats. A written
description of HMO's complaint procedures must be in appropriate
languages and easy for Members to understand. HMO must include a
written description in the Member Handbook. HMO must maintain at
least one local and one toll-free telephone number for making
complaints.
8.6.6 HMO's process must require that every complaint received in
person, by telephone or in writing, is recorded in a written
record and is logged with the following details: date;
identification of the individual filing the complaint;
identification of the individual recording the complaint; nature
of the complaint; disposition of the complaint; corrective action
required; and date resolved.
8.6.7 HMO's process must include a requirement that the Governing
Body of HMO reviews the written records (logs) for complaints and
appeals.
8.6.8 HMO is prohibited from discriminating against a Member
because that Member is making or has made a complaint.
8.6.9 HMO cannot process requests for disenrollments through
HMO's complaint procedures. Requests for disenrollments must be
referred to TDH within five (5) business days after the Member
makes a disenrollment request.
8.6.10 HMO must develop, implement and maintain an appeal of
adverse determination procedure that complies with the
requirements of Article 21.58A of the Texas Insurance Code,
relating to the utilization review, except where otherwise
provided in this contract and in applicable federal law. The
appeal of an adverse determination procedure must be the same for
all Members and must comply with Texas Insurance Code, Article
21.58A or applicable federal law. Modifications and amendments
must be submitted to TDH no less than 30 days prior to the
implementation of the modification or amendment. When an enrollee,
a person acting on behalf of an enrollee, or an enrollee's
provider of record expresses orally or in writing any
dissatisfaction or disagreement with an adverse determination, HMO
or UR agent must regard the expression of dissatisfaction as a
request to appeal an adverse determination.
8.6.11 If a complaint or appeal of an adverse determination
relates to the denial, delay, reduction, termination or suspension
of covered services by either HMO or
1999 Renewal Contract
Tarrant Service Area
93
August 9, 1999
94
a utilization review agent contracted to perform utilization
review by HMO, HMO must inform Members they have the right to
access the TDH Fair Hearing process at any time in lieu of the
internal complaint system provided by HMO. HMO is required to
comply with the requirements contained in 1 TAC Chapter 357,
relating to notice and Fair Hearings in the Medicaid program,
whenever an action is taken to deny, delay, reduce, terminate or
suspend a covered service.
8.6.12 If Members utilize HMO's internal complaint or appeal of
adverse determination system and the complaint relates to the
denial, delay, reduction, termination or suspension of covered
services by either HMO or a utilization review agent contracted to
perform utilization review by HMO, HMO must inform the Member that
they continue to have a right to appeal the decision through the
TDH Fair Hearing process.
8.6.13 The provisions of Article 21.58A, Texas Insurance Code,
relating to a Member's right to appeal an adverse determination
made by HMO or a utilization review agent by an independent review
organization, do not apply to a Medicaid recipient. Federal fair
hearing requirements (Social Security Act Section 1902a(3),
codified at 42 C.F.R. 431.200 et. seq.) require the agency to make
a final decision after a fair hearing, which conflicts with the
State requirement that the IRO make a final decision. Therefore,
the State requirement is pre-empted by the federal requirement.
8.6.14 HMO will cooperate with the Enrollment Broker and TDH to
resolve all Member complaints. Such cooperation may include, but
is not limited to, participation by HMO or Enrollment Broker
and/or TDH internal complaint committees.
8.6.15 HMO must have policies and procedures in place outlining
the role of HMO's Medical Director in the Member Complaint System
and appeal of an adverse determination. The Medical Director must
have a significant role in monitoring, investigating and hearing
complaints.
8.6.16 HMO must provide Member Advocates to assist Members in
understanding and using HMO's complaint system and appeal of an
adverse determination.
8.6.17 HMO's Member Advocates must assist Members in writing or
filing a complaint or appeal of an adverse determination and
monitoring the complaint or appeal through the Contractor's
complaint or appeal of an adverse determination process until the
issue is resolved.
8.7 MEMBER NOTICE, APPEALS AND FAIR HEARINGS
1999 Renewal Contract
Tarrant Service Area
94
August 9, 1999
95
8.7.1 HMO must send Members the notice required by 1 Texas
Administrative Code Section 357.5, whenever HMO takes an action to
deny, delay, reduce or terminate covered services to a Member. The
notice must be mailed to the Member no less than 10 days before
HMO intends to take an action. If an emergency exists, or if the
time within which the service must be provided makes giving 10
days notice impractical or impossible, notice must be provided by
the most expedient means reasonably calculated to provide actual
notice to the Member, including by phone, direct contact with the
Member, or through the provider's office.
8.7.2 The notice must contain the following information:
8.7.2.1 Member's right to immediately access TDH's Fair Hearing
process;
8.7.2.2 a statement of the action HMO will take;
8.7.2.3 the date the action will be taken;
8.7.2.4 an explanation of the reasons HMO will take the action;
8.7.2.5 a reference to the state and/or federal regulations which
support HMO's action;
8.7.2.6 an address where written requests may be sent and a
toll-free number Member can call to: request the assistance of a
Member representative, or file a complaint, or request a Fair
Hearing;
8.7.2.7 a procedure by which Member may appeal HMO's action through
either HMO's complaint process or TDH's Fair Hearings process;
8.7.2.8 an explanation that Members may represent themselves, or be
represented by HMO's representative, a friend, a relative, legal
counsel or another spokesperson;
8.7.2.9 an explanation of whether, and under what circumstances,
services may be continued if a complaint is filed or a Fair
Hearing requested;
8.7.2.10 a statement that if the Member wants a TDH Fair Hearing on the
action, 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;
8.7.2.11 a statement explaining that HMO must make its decision within 30
days from the
1999 Renewal Contract
Tarrant Service Area
95
August 9, 1999
96
date the complaint is received by HMO; and
8.7.2.12 a statement explaining that a final decision must be made by TDH
within 90 days from the date a Fair Hearing is requested.
8.8 MEMBER ADVOCATES
8.8.1 HMO must provide Member Advocates to assist Members. Member
Advocates must be physically located within the service area.
Member Advocates must inform Members of their rights and
responsibilities, the complaint process, the health education and
the services available to them, including preventive services.
8.8.2 Member Advocates must assist Members in writing complaints
and are responsible for monitoring the complaint through HMO's
complaint process until the Member's issues are resolved or a TDH
Fair Hearing requested (see Articles 8.6.15, 8.6.16, and 8.6.17).
8.8.3 Member Advocates are responsible for making recommendations
to management on any changes needed to improve either the care
provided or the way care is delivered. Member Advocates are also
responsible for helping or referring Members to community
resources available to meet Member needs that are not available
from HMO as Medicaid covered services.
8.8.4 Member Advocates must provide outreach to Members and
participate in TDH-sponsored enrollment activities.
8.9 MEMBER CULTURAL AND LINGUISTIC SERVICES
8.9.1 Cultural Competency Plan. HMO must have a comprehensive
written Cultural Competency Plan describing how HMO will ensure
culturally competent services, and provide linguistic and
disability-related access. The Plan must describe how the
individuals and systems within HMO will effectively provide
services to people of all cultures, races, ethnic backgrounds, and
religions 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. HMO
must submit a written plan to TDH prior to the effective date of
this contract unless previously submitted. Modifications and
amendments to the written plan must be submitted to TDH no later
than 30 days prior to implementation of the modification or
amendment. The Plan must also be made available to HMO's network
of providers.
1999 Renewal Contract
Tarrant Service Area
96
August 9, 1999
97
8.9.2 The Cultural Competency Plan must include the following:
8.9.2.1 HMO's written policies and procedures for ensuring
effective communication through the provision of linguistic
services following Title VI of the Civil Rights Act guidelines and
the provision of auxiliary aids and services, in compliance with
the Americans with Disabilities Act, Title III, Department of
Justice Regulation 36.303. HMO must disseminate these policies and
procedures to ensure that both Staff and subcontractors are aware
of their responsibilities under this provision of the contract.
8.9.2.2 A description of how HMO will educate and train its staff
and subcontractors on culturally competent service delivery, and
the provision of linguistic and/or disability-related access as
related to the characteristics of its Members;
8.9.2.3 A description of how HMO will implement the plan in its
organization, identifying a person in the organization who will
serve as the contact with TDH on the Cultural Competency Plan;
8.9.2.4 A description of how HMO will develop standards and
performance requirements for the delivery of culturally competent
care and linguistic access, and monitor adherence with those
standards and requirements;
8.9.2.5 A description of how HMO will provide outreach and health
education to Members, including racial and ethnic minorities,
non-English speakers or limited-English speakers, and those with
disabilities; and
8.9.2.6 A description of how HMO will help Members access
culturally and linguistically appropriate community health or
social service resources;
8.9.3 Linguistic, Interpreter Services, and Provision of
Auxiliary Aids and Services. HMO must provide experienced,
professional interpreters when technical, medical, or treatment
information is to be discussed. See Title VI of the Civil Rights
Act of 1964, 42 U.S.C. Sections 2000d, et seq. HMO must ensure the
provision of auxiliary aids and services necessary for effective
communication, as per the Americans with Disabilities Act, Title
III, Department of Justice Regulations 36.303.
8.9.3.1 HMO must adhere to and provide to Members the Member Xxxx
of Rights and Responsibilities as adopted by the Texas Health and
Human Services Commission and contained at 1 Texas Administrative
Code (TAC) Sections 353.202-
1999 Renewal Contract
Tarrant Service Area
97
August 9, 1999
98
353.203. The Member Xxxx of Rights and Responsibilities assures
Members the right "to have interpreters, if needed, during
appointments with their providers and when talking to their health
plan. Interpreters include people who can speak in their native
language, assist with a disability, or help them understand the
information."
8.9.3.2 HMO must have in place policies and procedures that outline
how Members can access face-to-face interpreter services in a
provider's office if necessary to ensure the availability of
effective communication regarding treatment, medical history or
health education for a Member. HMOs must inform its providers on
how to obtain an updated list of participating, qualified
interpreters.
8.9.3.3 A competent interpreter is defined as someone who is:
8.9.3.4 proficient in both English and the other language;
8.9.3.5 has had orientation or training in the ethics of
interpreting; and
8.9.3.6 has the ability to interpret accurately and impartially.
8.9.3.7 HMO must provide 24-hour access to interpreter services for
Members to access emergency medical services within HMO's network.
8.9.3.8 Family Members, especially minor children, should not be used as
interpreters in assessments, therapy or other medical situations
in which impartiality and confidentiality are critical, unless
specifically requested by the Member. However, a family member or
friend may be used as an interpreter if they can be relied upon to
provide a complete and accurate translation of the information
being provided to the Member; provided that the Member is advised
that a free interpreter is available; and the Member expresses a
preference to rely on the family member or friend.
8.9.4 All Member orientation presentations education classes and
materials must be presented in the languages of the major
population groups making up 10% or more of the Medicaid population
in the service area, as specified by TDH. HMO must provide
auxiliary aids and services, as needed, including materials in
alternative formats (i.e., large print, tape or Braille), and
interpreters or real-time captioning to accommodate the needs of
persons with disabilities that affect communication.
8.9.5 HMO must provide or arrange access to TDD to Members who
are deaf or
1999 Renewal Contract
Tarrant Service Area
98
August 9, 1999
99
hearing impaired.
8.10 On the date of the new Member's enrollment, TDH will
provide HMOs with the Member's Medicaid certification date.
ARTICLE IX MARKETING AND PROHIBITED PRACTICES
9.1 MARKETING MATERIAL MEDIA AND DISTRIBUTION
HMOs may present their marketing materials to eligible Medicaid
recipients through any method or media determined to be acceptable
by TDH. The media may include but are not limited to: written
materials, such as brochures, posters, or fliers which can be
mailed directly to the Member or left at Texas Department of Human
Services eligibility offices; TDH-sponsored community enrollment
events; and paid or public service announcements on radio. All
marketing materials must be approved by TDH prior to distribution
(see Article 3.4).
9.2 MARKETING ORIENTATION AND TRAINING
HMO must require that all HMO staff having direct contact with
Members as part of their job duties and their supervisors
satisfactorily complete TDH's marketing orientation and training
program prior to engaging in marketing activities on behalf of
HMO. TDH will notify HMO of scheduled orientations.
9.3 PROHIBITED MARKETING PRACTICES
9.3.1 HMO and its agents, subcontractors and providers are
prohibited from engaging in the following marketing practices:
9.3.1.1 conducting any direct-contact marketing to prospective
Members except through TDH-sponsored enrollment events;
9.3.1.2 making any written or oral statement containing material
misrepresentations of fact or law relating to HMO's plan or the
STAR program;
9.3.1.3 making false, misleading or inaccurate statements relating
to services or benefits of HMO or the STAR program;
9.3.1.4 offering prospective Members anything of material or
financial value as an incentive to enroll with a particular PCP or
HMO; and
1999 Renewal Contract
Tarrant Service Area
99
August 9, 1999
100
9.3.1.5 discriminating against an eligible Member because of race,
creed, age, color, sex, religion, national origin, ancestry,
marital status, sexual orientation, physical or mental handicap,
health status, or requirements for health care services.
9.3.2 HMO may offer nominal gifts with a retail value of no more
than $10 and/or free health screens to potential Members, as long
as these gifts and free health screenings are offered whether or
not the potential Member enrolls in their HMO. Free health
screenings cannot be used to discourage less healthy potential
Members from joining HMO. All gifts must be approved by TDH prior
to distribution to Members. The results of free screenings must be
shared with the Member's PCP if the Member enrolls with HMO
providing the screen.
9.3.3 Marketing representatives may not conduct or participate in
marketing activities for more than one HMO.
9.4 NETWORK PROVIDER DIRECTORY
9.4.1 The provider directory and any revisions must be approved
by TDH prior to publication and distribution to prospective
Members (see Article 3.4.1 regarding the process for plan
materials review). The directory must contain all critical
elements specified by TDH. See Appendix D, Required Critical
Elements, for specific details regarding content requirements.
9.4.2 If HMO contracts with limited provider networks, the
provider directory must comply with the requirements of 28 TAC
11.1600(b)(11), relating to the disclosure and notice of limited
provider networks.
9.4.3 Updates to the provider directory must be provided to the
Enrollment Broker at the beginning of each State fiscal year
quarter. This includes the months of September, December, March
and June. HMO is responsible for submitting draft updates to TDH
only if changes other than PCP information are incorporated. HMO
is responsible for sending three final paper copies and one
electronic copy of the updated provider directory to TDH each
quarter. If an electronic format is not available, five paper
copies must be sent. TDH will forward two updated provider
directories, along with its approval notice, to the Enrollment
Broker to facilitate the distribution of the directories.
ARTICLE X MIS SYSTEM REQUIREMENTS
1999 Renewal Contract
Tarrant Service Area
100
August 9, 1999
101
10.1 MODEL MIS REQUIREMENTS
10.1.1 HMO must maintain an MIS that will provide support for all
functions of HMO's processes and procedures related to the flow
and use of data within HMO. The MIS must enable HMO to meet the
requirements of this contract. The MIS must have the capacity and
capability of capturing and utilizing various data elements to
develop information for HMO administration.
10.1.2 HMO must maintain a claim retrieval service processing
system that can identify date of receipt, action taken on all
provider claims or encounters (i.e., paid, denied, other), and
when any action was taken in real time.
10.1.3 HMO must have a system that can be adapted to the change in
Business Practices/Policies within a short period of time.
10.1.4 HMO is required to submit and receive data as specified in
this contract and HMO Encounter Data Submissions Manual. HMO must
provide complete encounter data of all capitated services within
the scope of services of the contract between HMO and TDH.
Encounter data must follow the format, data elements and method of
transmission specified in the contract and HMO Encounter Data
Submissions Manual. HMO must submit encounter data, including
adjustments to encounter data. The Encounter transmission will
include all encounter data and encounter data adjustments
processed by HMO for the previous month. Data quality validation
will incorporate assessment standards developed jointly by HMO and
TDH. Original records will be made available for inspection by TDH
for validation purposes. Data which do not meet quality standards
must be corrected and returned within a time period specified by
TDH.
10.1.5 HMO must use the procedure codes, diagnosis codes, and
other codes used for reporting encounters and fee-for-service
claims in the most recent edition of the Medicaid Provider
Procedures Manual or as otherwise directed by TDH. Any exceptions
will be considered on a code-by-code basis after TDH receives
written notice from HMO requesting an exception. HMO must also use
the provider numbers as directed by TDH for both encounter and
fee-for-service claims submissions.
10.1.6 HMO must have hardware, software, network and
communications system with the capability and capacity to handle
and operate all MIS subsystems.
10.1.7 HMO must notify TDH of any changes to HMO's MIS department
dedicated to or supporting this contract by Phase I of Renewal
Review. Any
1999 Renewal Contract
Tarrant Service Area
101
August 9, 1999
102
updates to the organizational chart and the description of
responsibilities must be provided to TDH at least 30 days prior to
the effective date of the change. Official points of contact must
be provided to TDH on an on-going basis. An Internet E-mail
address must be provided for each point of contact.
10.1.8 HMO must operate and maintain a MIS that meets or exceeds
the requirements outlined in the Model MIS Guidelines that follow:
10.1.8.1 The Contractor's system must be able to meet all eight MIS Model
Guidelines as listed below. The eight subsystems are used in the
Model MIS Requirements to identify specific functions or features
required by HMO's MIS. These subsystems focus on the individual
systems functions or capabilities to support the following
operational and administrative areas:
(1) Enrollment/Eligibility Subsystem
(2) Provider Subsystem
(3) Encounter/Claims Processing Subsystem
(4) Financial Subsystem
(5) Utilization/Quality Improvement Subsystem
(6) Reporting Subsystem
(7) Interface Subsystem
(8) TPR Subsystem
10.2 SYSTEM-WIDE FUNCTIONS
HMO MIS system must include functions and/or features which must
apply across all subsystems as follows:
(1) Ability to update and edit data.
(2) Maintain a history of changes and adjustments and audit
trails for current and retroactive data. Audit trails will
capture date, time, and reasons for the change, as well as
who made the change.
(3) Allow input mechanisms through manual and electronic
transmissions.
1999 Renewal Contract
Tarrant Service Area
102
August 9, 1999
103
(4) Have procedures and processes for accumulating, archiving,
and restoring data in the event of a system or subsystem
failure.
(5) Maintain automated or manual linkages between and among all
MIS subsystems and interfaces.
(6) Ability to relate Member and provider data with
utilization, service, accounting data, and reporting
functions.
(7) Ability to relate and extract data elements into summary
and reporting formats attached as Appendices to contract.
(8) Must have written process and procedures manuals which
document and describe all manual and automated system
procedures and processes for all the above functions and
features, and the various subsystem components.
(9) Maintain and cross-reference all Member-related information
with the most current Medicaid number.
10.3 ENROLLMENT/ELIGIBILITY SUBSYSTEM
The Enrollment/Eligibility Subsystem is the central processing
point for the entire MIS. It must be constructed and programmed to
secure all functions which require Membership data. It must have
functions and/or features which support requirements as follows:
(1) Identify other health coverage available or third party
liability (TPL), including type of coverage and effective
dates.
(2) Maintain historical data (files) as required by TDH.
(3) Maintain data on enrollments/disenrollments and complaint
activities. The data must include reason or type of
disenrollment, complaint, and resolution--by incident.
(4) Receive, translate, edit and update files in accordance
with TDH requirements prior to inclusion in HMO's MIS.
Updates will be received from TDH's agent and processed
within two working days after receipt.
(5) Provide error reports and a reconciliation process between
new data and data existing in MIS.
1999 Renewal Contract
Tarrant Service Area
103
August 9, 1999
104
(6) Identify enrollee changes in primary care provider and the
reason(s) for those changes and effective dates.
(7) Monitor PCP capacity and limitations prior to connecting
the enrollee to PCP in the system, and provide a kick-out
report when capacity and limitations are exceeded.
(8) Verify enrollee eligibility for medical services rendered
or for other enrollee inquiries.
(9) Generate and track referrals, e.g., Hospitals/Specialists.
(10) Search records by a variety of fields (e.g., name, unique
identification numbers, date of birth, SSN, etc.) for
eligibility verification.
(11) Send PCP assignment updates to TDH in the format as
specified by TDH.
10.4 PROVIDER SUBSYSTEM
The provider subsystem must accept, process, store and retrieve
current and historical data on providers, including services,
payment methodology, license information, service capacity, and
facility linkages.
Functions and Features:
(1) Identify specialty(s), admission privileges, enrollee
linkage, capacity, facility linkages, emergency
arrangements or contact, and other limitations,
affiliations, or restrictions.
(2) Maintain provider history files to include audit trails and
effective dates of information.
(3) Maintain provider fee schedules/remuneration agreements to
permit accurate payment for services based on the financial
agreement in effect on the date of service.
(4) Support HMO credentialing, recredentialing, and credential
tracking processes; incorporates or links information to
provider record.
(5) Support monitoring activity for physician to enrollee
ratios (actual to maximum) and total provider enrollment to
physician and HMO capacity.
1999 Renewal Contract
Tarrant Service Area
104
August 9, 1999
105
(6) Flag and identify providers with restrictive conditions
(e.g., limits to capacity, type of patient, age
restrictions, and other services if approved out-
of-network).
(7) Support national provider number format (UPIN, NPIN, CLIA,
etc., as required by TDH).
(8) Provide provider network files 90 days prior to
implementation and updates monthly. Format will be provided
by TDH to contracted entities.
(9) Support the national CLIA certification numbers for
clinical laboratories.
(10) Exclude providers from participation that have been
identified by TDH as ineligible or excluded. Files must be
updated to reflect period and reason for exclusion.
10.5 ENCOUNTER/CLAIMS PROCESSING SUBSYSTEM
The encounter/claims processing subsystem must collect, process,
and store data on all health care services delivered for which HMO
is responsible. The functions of these subsystems are
claims/encounter processing and capturing health service
utilization data. The subsystem must capture all health care
services, including medical supplies, using standard codes (e.g.
CPT-4, HCPCS, ICD9-CM, UB92 Revenue Codes), rendered by
health-care providers to an eligible enrollee regardless of
payment arrangement (e.g. capitation or fee-for-service). It
approves, prepares for payment, or may reject or deny claims
submitted. This subsystem may integrate manual and automated
systems to validate and adjudicate claims and encounters. HMO must
use encounter data validation methodologies prescribed by TDH.
Functions and Features:
(1) Accommodate multiple input methods: electronic submission,
tape, claim document, and media.
(2) Support entry and capture of a minimum of all required data
elements specified in the Encounter Data Submission Manual.
(3) Edit and audit to ensure allowed services are provided by
eligible providers for Members.
1999 Renewal Contract
Tarrant Service Area
105
August 9, 1999
106
(4) Interface with Member and provider subsystems.
(5) Capture and report TPL potential, reimbursement or denial.
(6) Edit for utilization and service criteria, medical policy,
fee schedules, multiple contracts, contract periods and
conditions.
(7) Submit data to TDH through electronic transmission using
specified formats.
(8) Support multiple fee schedule benefit packages and
capitation rates for all contract periods for individual
providers, groups, services, etc. A claim encounter must be
initially adjudicated and all adjustments must use the fee
applicable to the date of service.
(9) Provide timely, accurate, and complete data for monitoring
claims processing performance.
(10) Provide timely, accurate, and complete data for reporting
medical service utilization.
(11) Maintain and apply prepayment edits to verify accuracy and
validity of claims data for proper adjudication.
(12) Maintain and apply edits and audits to verify timely,
accurate, and complete encounter data reporting.
(13) Submit reimbursement to non-contracted providers for
emergency care rendered to enrollees in a timely and
accurate fashion.
(14) Validate approval and denials of precertification and prior
authorization requests during adjudication of
claims/encounters.
(15) Track and report the exact date a service was performed.
Use of date ranges must have State approval.
(16) Receive and capture claim and encounter data from TDH.
(17) Receive and capture value-added services codes.
(18) Capability of identifying adjustments and linking them to
the original claims/encounters.
1999 Renewal Contract
Tarrant Service Area
106
August 9, 1999
107
10.6 FINANCIAL SUBSYSTEM
The financial subsystem must provide the necessary data for 100%
of all accounting functions including cost accounting, inventory,
fixed assets, payroll, general ledger, accounts receivable,
accounts payable, financial statement presentation, and any
additional data required by TDH. The financial subsystem must
provide management with information that can demonstrate that the
proposed or existing HMO is meeting, exceeding, or falling short
of fiscal goals. The information must also provide management with
the necessary data to spot the early signs of fiscal distress, far
enough in advance to allow management to take corrective action
where appropriate.
Functions and Features:
(1) Provide information on HMO's economic resources, assets,
and liabilities and present accurate historical data and
projections based on historical performance and current
assets and liabilities.
(2) Produce financial statements in conformity with Generally
Accepted Accounting Principles (GAAP) and in the format
prescribed by TDH.
(3) Provide information on potential third party payers;
information specific to the Member; claims made against
third party payers; collection amounts and dates; denials,
and reasons for denials.
(4) Track and report savings by category as a result of cost
avoidance activities.
(5) Track payments per Member made to network providers
compared to utilization of the provider's services.
(6) Generate Remittance and Status Reports.
(7) Make claim and capitation payments to providers or groups.
(8) Reduce/increase accounts payable/receivable based on
adjustments to claims or recoveries from third party
resources.
10.7 UTILIZATION/QUALITY IMPROVEMENT SUBSYSTEM
The quality management/quality improvement/utilization review
subsystem combines data from other subsystems, and/or external
systems, to produce reports
1999 Renewal Contract
Tarrant Service Area
107
August 9, 1999
108
for analysis which focus on the review and assessment of quality
of care given, detection of over and under utilization, and the
development of user defined reporting criteria and standards. This
system profiles utilization of providers and enrollees and
compares them against experience and norms for comparable
individuals. This system also supports the quality assessment
function.
The subsystem tracks utilization control function(s) and
monitoring inpatient admissions, emergency room use, ancillary,
and out-of-area services. It provides provider profiles,
occurrence reporting, and monitoring and evaluation studies. The
subsystem may integrate HMO's manual and automated processes or
incorporate other software reporting and/or analysis programs.
The subsystem incorporates and summarizes information from
enrollee surveys, provider and enrollee complaints, and appeal
processes.
Functions and Features:
(1) Supports provider credentialing and recredentialing
activities.
(2) Supports HMO processes to monitor and identify deviations
in patterns of treatment from established standards or
norms. Provides feedback information for monitoring
progress toward goals, identifying optimal practices, and
promoting continuous improvement.
(3) Supports development of cost and utilization data by
provider and service.
(4) Provides aggregate performance and outcome measures using
standardized quality indicators similar to HEDIS or as
specified by TDH.
(5) Supports quality-of-care Focused Studies.
(6) Supports the management of referral/utilization control
processes and procedures, including prior authorization and
precertifications and denials of services.
(7) Monitors primary care provider referral patterns.
(8) Supports functions of reviewing access, use and
coordination of services (i.e. actions of Peer Review and
alert/flag for review and/or follow-up; laboratory, x-ray
and other ancillary service utilization per visit).
(9) Stores and reports patient satisfaction data through use of
enrollee surveys.
1999 Renewal Contract
Tarrant Service Area
108
August 9, 1999
109
(10) Provides fraud and abuse detection, monitoring and
reporting.
(11) Meets minimum report/data collection/analysis functions of
Article XI and Appendix A - Standards For Quality
Improvement Programs.
(12) Monitors and tracks provider and enrollee complaints and
appeals from receipt to disposition or resolution by
provider.
10.8 REPORT SUBSYSTEM
The reporting subsystem supports reporting requirements of all HMO
operations to HMO management and TDH. It allows HMO to develop
various reports to enable HMO management and TDH to make decisions
regarding HMO activity.
Functions and Capabilities:
(1) Produces standard, TDH-required reports and ad hoc reports
from the data available in all MIS subsystems. All reports
will be submitted as a paper copy or electronically in a
format approved by TDH.
(2) Have system flexibility to permit the development of
reports at irregular periods as needed.
(3) Generate reports that provide unduplicated counts of
enrollees, providers, payments and units of service unless
otherwise specified.
(4) Generate an alphabetic Member listing.
(5) Generate a numeric Member listing.
(6) Generate a Member eligibility listing by PCP (panel
report).
(7) Report on PCP change by reason code.
(8) Report on TPL (COB) information to TDH.
(9) Report on provider capacity and assignment from date of
service to date received.
(10) Generate or produce an aged outstanding liability report.
1999 Renewal Contract
Tarrant Service Area
109
August 9, 1999
110
(11) Produce a Member ID Card.
(12) Produce Member/provider mailing labels.
10.9 DATA INTERFACE SUBSYSTEM
10.9.1 The interface subsystem supports incoming and outgoing data
from and to other organizations. It allows HMO to maintain
enrollee, benefit package, eligibility, disenrollment/enrollment
status, and medical services received outside of capitated
services and associated cost. All interfaces must follow the
specifications frequencies and formats listed in the Interface
Manual.
10.9.2 HMO must obtain access to the TexMedNet BBS. Some file
transfers and E-mail will be handled through this mechanism.
10.9.3 Provider Network File. The provider file shall supply
Network Provider data between an HMO and TDH. This process shall
accomplish the following:
(1) Provide identifying information for all managed care
providers (e.g. name, address, etc.).
(2) Maintain history on provider enrollment/disenrollment.
(3) Identify PCP capacity.
(4) Identify any restrictions (e.g., age, sex, etc.).
(5) Identify number and types of specialty providers available
to Members.
10.9.4 Eligibility/Enrollment Interface. The enrollment interface
must provide eligibility data between TDH and HMOs.
(1) Provides benefit package data to HMOs in accordance with
capitated services.
(2) Provides PCP assignments.
(3) Provides Member eligibility status data.
(4) Provides Member demographics data.
(5) Provides HMOs with cross-reference data to identify
duplicate Members.
1999 Renewal Contract
Tarrant Service Area
110
August 9, 1999
111
10.9.5 Encounter/Claim Data Interface. The encounter/claim
interface must transfer paid fee-for-service claims data to HMOs
and capitated services/encounters from HMO, including adjustments.
This file will include all service types, such as inpatient,
outpatient, and medical services. TDH's agent will process claims
for non-capitated services.
10.9.6 Capitation Interface. The capitation interface must
transfer premium and Member information to HMO. This interface's
basic purpose is to balance HMO's Members and premium amount.
10.9.7 TPR Interface. TDH will provide a data file that contains
information on enrollees that have other insurance. Because
Medicaid is the payer of last resort, all services and encounters
should be billed to the other insurance companies for recovery.
TDH will also provide an insurance company data file which
contains the name and address of each insurance company.
10.9.8 TDH will provide a diagnosis file which will give the code
and description of each diagnosis permitted by TDH.
10.9.9 TDH will provide a procedure file which contains the
procedures which must be used on all claims and encounters. This
file contains HCPCS, revenue, and ICD9-CM surgical procedure
codes.
10.9.10 TDH will provide a provider file that contains the Medicaid
provider numbers, and the provider's names and addresses. The
provider number authorized by TDH must be submitted on all claims,
encounters, and network provider submissions.
10.10 TPR SUBSYSTEM
HMO's third party recovery system must have the following
capabilities and capacities:
(1) Identify, store, and use other health coverage available to
eligible Members or third party liability (TPL) including
type of coverage and effective dates.
(2) Provide changes in information to TDH as specified by TDH.
(3) Receive TPL data from TDH to be used in claim and encounter
processing.
1999 Renewal Contract
Tarrant Service Area
111
August 9, 1999
112
10.11 YEAR 2000 (Y2K) COMPLIANCE
10.11.1 HMO must take all appropriate measures to make all software which
will record, store, and process and present calendar dates falling
on or after January 1, 2000, perform in the same manner and with
the same functionality, data integrity and performance, as dates
falling on or before December 31, 1999, at no added cost to TDH.
HMO must take all appropriate measures to ensure that the software
will not lose, alter or destroy records containing dates falling
on or after January 1, 2000. HMO will ensure that all software
will interface and operate with all TDH, or its agent's, data
systems which exchange data, including but not limited to
historical and archived data. In addition, HMO guarantees that the
year 2000 leap year calculations will be accommodated and will not
result in software, firmware or hardware failures.
10.11.2 TDH and all subcontracted entities are required by state and
federal law to meet Y2K compliance standards. Failure of TDH or a
TDH contractor other than an HMO to meet Y2K compliance standards
which results in an HMO's failure to meet the Y2K requirements of
this contract is a defense of an HMO against a declaration by TDH
of default by an HMO under this contract.
ARTICLE XI QUALITY ASSURANCE AND QUALITY IMPROVEMENT PROGRAM
11.1 QUALITY IMPROVEMENT PROGRAM (QIP) SYSTEM
HMO must develop, maintain, and operate a Quality Improvement
Program (QIP) system which complies with federal regulations
relating to Quality Assurance systems, found at 42 C.F.R. Section
434.34. The system must meet the Standards for Quality Improvement
Programs contained in Appendix A.
11.2 WRITTEN QIP PLAN
HMO must have on file with TDH an approved plan describing its
Quality Improvement Plan (QIP), including how HMO will accomplish
the activities pertaining to each Standard (I-XVI) in Appendix A.
Modifications and amendments must be submitted to TDH no later
than 60 days prior to the implementation of the modification or
amendment.
11.3 QIP SUBCONTRACTING
1999 Renewal Contract
Tarrant Service Area
112
August 9, 1999
113
If HMO subcontracts any of the essential functions or reporting
requirements of QIP to another entity, HMO must maintain a file of
the subcontractors. The file must be available for review by TDH
or its designee upon request. HMO must notify TDH no later than 90
days prior to terminating any subcontract affecting a major
performance function of this contract (see Article 3.2.1.2).
11.4 ACCREDITATION
If HMO is accredited by an external accrediting agency,
documentation of accreditation must be provided to TDH. HMO must
provide TDH with their accreditation status upon request.
11.5 BEHAVIORAL HEALTH INTEGRATION INTO QIP
HMO must integrate behavioral health into its QIP system and
include a systematic and on-going process for monitoring,
evaluating, and improving the quality and appropriateness of
behavioral health care services provided to Members. HMO's QIP
must enable HMO to collect data, monitor and evaluate for
improvements to physical health outcomes resulting from behavioral
health integration into the overall care of the Member.
11.6 QIP REPORTING REQUIREMENTS
HMO must meet all of the QIP Reporting Requirements contained in
Article XII.
ARTICLE XII REPORTING REQUIREMENTS
12.1 FINANCIAL REPORTS
12.1.1 Monthly MCFS Report. HMO must submit the Managed Care
Financial-Statistical Report (MCFS) included in Appendix I. The
report must be submitted to TDH no later than 30 days after the
end of each state fiscal year quarter (i.e., Dec. 30, March 30,
June 30, Sept. 30) and must include complete financial and
statistical information for each month. The MCFS Report must be
submitted for each claims processing subcontractor in accordance
with this Article. HMO must incorporate financial and statistical
data received by its delegated networks (IPAs, ANHCs, Limited
Provider Networks) in its MCFS Report.
12.1.2 For any given month in which an HMO has a net loss of
$200,000 or more
1999 Renewal Contract
Tarrant Service Area
113
August 9, 1999
114
for the contract period to date, HMO must submit an MCFS Report
for that month by the 30th day after the end of the reporting
month. The MCFS Report must be completed in accordance with the
Instructions for Completion of the Managed Care
Financial-Statistical Report developed by TDH.
12.1.3 An HMO must submit monthly reports for each of the first 6
months following the Implementation Date. If the cumulative net
loss for the contract period to date after the 6th month is less
than $200,000, HMO may submit quarterly reports in accordance with
the above provisions unless the condition in Article 12.1.2
exists, in which case monthly reports must be submitted.
12.1.4 Final MCFS Reports. HMO must file two Final Managed Care
Financial-Statistical Reports. The first final report must reflect
expenses incurred through the 90th day after the end of the
contract year. The first final report must be filed on or before
the 120th day after the end of the contract year. The second final
report must reflect data completed through the 334th day after the
end of the contract year and must be filed on or before the 365th
day following the end of the contract year.
12.1.5 Administrative expenses reported in the monthly and Final
MCFS Reports must be reported in accordance with Appendix L, Cost
Principles for Administrative Expenses. Indirect administrative
expenses must be based on an allocation methodology for Medicaid
managed care activities and services that is developed or approved
by TDH.
12.1.6 Affiliate Report. HMO must submit an Affiliate Report to
TDH if this information has changed since the last report was
submitted. The report must contain the following information:
12.1.6.1 A listing of all Affiliates; and
12.1.6.2 A schedule of all transactions with Affiliates which, under the
provisions of this Contract, will be allowable as expenses in
either Line 4 or Line 5 of Part 1 of the MCFS Report for services
provided to HMO by the Affiliates for the prior approval of TDH.
Include financial terms, a detailed description of the services to
be provided, and an estimated amount which will be incurred by HMO
for such services during the Contract period.
12.1.7 Annual Audited Financial Report. On or before June 30th of
each year, HMO must submit to TDH a copy of the annual audited
financial report filed with TDI.
1999 Renewal Contract
Tarrant Service Area
114
August 9, 1999
115
12.1.8 Form HCFA-1513. HMO must file an updated Form HCFA-1513
regarding control, ownership, or affiliation of HMO 30 days prior
to the end of the contract year. An updated Form HCFA 1513 must
also be filed no later than 30 days after any change in control,
ownership, or affiliation of HMO. Forms may be obtained from TDH.
12.1.9 Section 1318 Financial Disclosure Report. HMO must file an
updated HCFA Public Health Service (PHS) "Section 1318 Financial
Disclosure Report" no later than 30 days after the end of the
contract year and no later than 30 days after entering into,
renewing, or terminating a relationship with an affiliated party.
These forms may be obtained from TDH.
12.1.10 TDI Examination Report. HMO must furnish a copy of any TDI
Examination Report no later than 10 days after receipt of the
final report from TDI.
12.1.11 IBNR Plan. HMO must furnish a written IBNR Plan to manage
incurred-but-not-reported (IBNR) expenses, and a description of
the method of insuring against insolvency, including information
on all existing or proposed insurance policies. The Plan must
include the methodology for estimating IBNR. The plan and
description must be submitted to TDH no later than 60 days after
the effective date of this contract, unless previously submitted
to TDH. Changes to the IBNR plan and description must be submitted
to TDH no later than 30 days before changes to the plan are
implemented by HMO.
12.1.12 Third Party Recovery (TPR) Reports. HMO must file quarterly Third
Party Recovery (TPR) Reports in accordance with the format
developed by TDH. TPR reports must include total dollars recovered
from third party payers for services to HMO's Members for each
month and the total dollars recovered through coordination of
benefits, subrogation, and worker's compensation.
12.1.13 Each report required under this Article must be mailed to: Bureau
of Managed Care; Texas Dept. of Health; 0000 Xxxx 00xx Xxxxxx;
Xxxxxx, XX 00000-0000 (Exception: The MCFS Report may be submitted
to TDH via E-mail). HMO must also mail a copy of the reports,
except for items in Article 12.1.7 and Article 12.1.10 to Texas
Department of Insurance, Mail Code 106-3A, HMO Division,
Attention: HMO Division Director, X.X. Xxx 000000, Xxxxxx, XX
00000-0000.
12.2 STATISTICAL REPORTS
12.2.1 HMO must electronically file the following monthly reports:
(1) encounter; (2) encounter detail; (3) institutional; (4)
institutional detail; and (5) claims detail for cost-reimbursed
services filed, if any, with HMO. Encounter
1999 Renewal Contract
Tarrant Service Area
115
August 9, 1999
116
data must include the data elements, follow the format, and use
the transmission method specified by TDH in the Encounter Data
Submission Manual. Encounters must be submitted by HMO to TDH no
later than 45 days after the date of adjudication (finalization)
of the claims.
12.2.2 Monthly reports must include current month encounter data
and encounter data adjustments to the previous month's data.
12.2.3 Data quality standards will be developed jointly by HMO and
TDH. Encounter data must meet or exceed data quality standards.
Data that does not meet quality standards must be corrected and
returned within the period specified by TDH. Original records must
be made available to validate all encounter data.
12.2.4 HMO must require providers to submit claims and encounter
data to HMO no later than 95 days after the date services are
provided.
12.2.5 HMO must use the procedure codes, diagnosis codes and other
codes contained in the most recent edition of the Texas Medicaid
Provider Procedures Manual and as otherwise provided by TDH.
Exceptions or additional codes must be submitted for approval
before HMO uses the codes.
12.2.6 HMO must use its TDH-specified identification numbers on
all encounter data submissions. Please refer to the TDH Encounter
Data Submission Manual for further specifications.
12.2.7 HMO must validate all encounter data using the encounter
data validation methodology prescribed by TDH prior to submission
of encounter data to TDH.
12.2.8 All Claims Summary Report. HMO must submit the "All Claims
Summary Report" identified in the Texas Managed Care Claims Manual
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 TDH in a format specified
by TDH.
12.2.9 Medicaid Disproportionate Share Hospital (DSH) Reports. HMO
must file preliminary and final Medicaid Disproportionate Share
Hospital (DSH) reports, required by TDH to identify and reimburse
hospitals that qualify for Medicaid DSH funds. The preliminary and
final DSH reports must include the data elements and be submitted
in the form and format specified by TDH. The preliminary DSH
reports are due on or before June 1 of the year following the
state fiscal year for which data is being reported. The final DSH
reports are due on or before August 15 of the year following the
state fiscal year for which data is
1999 Renewal Contract
Tarrant Service Area
116
August 9, 1999
117
being reported.
12.3 ARBITRATION/LITIGATION CLAIMS REPORT
HMO must submit an Arbitration/Litigation Claims Report in a
format provided by TDH (see Appendix M) identifying all provider
or HMO requests for arbitration or matters in litigation. The
report must be submitted within 30 days from the date the matter
is referred to arbitration or suit is filed, or whenever there is
a change of status in a matter referred to arbitration or
litigation.
12.4 SUMMARY REPORT OF PROVIDER COMPLAINTS
HMO must submit a Summary Report of Provider Complaints. HMO must
also report complaints submitted to its subcontracted risk groups
(e.g., IPAs). The complaint report must be submitted in two paper
copies and one electronic copy on or before the 45 days following
the end of the state fiscal quarter using a form specified by TDH.
12.5 PROVIDER NETWORK REPORTS
12.5.1 Provider Network Report. HMO must submit to the Enrollment
Broker an electronic file summarizing changes in HMO's provider
network including PCPs, specialists, ancillary providers and
hospitals. The file must indicate if the PCPs and specialists
participate in a closed network and the name of the delegated
network. The electronic file must be submitted in the format
specified by TDH and can be submitted as often as daily but must
be submitted at least weekly.
12.5.2 Provider Termination Report. HMO must submit a monthly
report which identifies any providers who cease to participate in
HMO's provider network, either voluntarily or involuntarily. The
report must be submitted to TDH in the format specified by TDH.
HMO will submit the report no later than thirty (30) days after
the end of the reporting month. The information must include the
provider's name, Medicaid number, the reason for the provider's
termination, and whether the termination was voluntary or
involuntary.
12.6 MEMBER COMPLAINTS
HMO must submit a quarterly summary report of Member complaints.
HMO must also report complaints submitted to its subcontracted
risk groups (e.g., IPAs). The complaint report format must be
submitted to TDH as two paper copies and one electronic copy on or
before 45 days following the end of the state fiscal quarter using
a form specified by TDH.
1999 Renewal Contract
Tarrant Service Area
117
August 9, 1999
118
12.7 FRAUDULENT PRACTICES
HMO must report all fraud and abuse enforcement actions or
investigations taken against HMO and/or any of its subcontractors
or providers by any state or federal agency for fraud or abuse
under Title XVIII or Title XIX of the Social Security Act or any
State law or regulation and any basis upon which an action for
fraud or abuse may be brought by a State or federal agency as soon
as such information comes to the attention of HMO.
12.8 UTILIZATION MANAGEMENT REPORTS - BEHAVIORAL HEALTH
Behavioral health (BH) utilization management reports are required
on a semi-annual basis with submission of data files that are, at
a minimum, due to TDH or its designee, on a quarterly basis no
later than 150 days following the end of the period. Refer to
Appendix H for the standardized reporting format for each report
and detailed instructions for obtaining the specific data required
in the report and for data file submission specifications. The BH
utilization report and data file submission instructions may
periodically be updated by TDH to facilitate clear communication
to the health plan.
12.9 UTILIZATION MANAGEMENT REPORTS - PHYSICAL HEALTH
Physical health (PH) utilization management reports are required
on a semi-annual basis with submission of data files that are, at
a minimum, due to TDH or its designee on a quarterly basis no
later than 150 days following the end of the period. Refer to
Appendix J for the standardized reporting format for each report
and detailed instructions for obtaining specific data required in
the report and for data file submission specifications. The PH
Utilization Management Report and data file submission
instructions may periodically be updated by TDH to facilitate
clear communication to the health plan.
12.10 QUALITY IMPROVEMENT REPORTS
12.10.1 HMO must conduct health Focused Studies in well child and
pregnancy, and a study chosen by HMO that may be performed in the
areas of behavioral health care, asthma, or other chronic
conditions. Well child and pregnancy studies shall be conducted
and data collected using criteria and methods developed by TDH.
The following format shall be utilized:
(1) Executive Summary.
(2) Definition of the population and health areas of concern.
1999 Renewal Contract
Tarrant Service Area
118
August 9, 1999
119
(3) Clinical guidelines/standards, quality indicators, and
audit tools.
(4) Sources of information and data collection methodology.
(5) Data analysis and information/results.
(6) Corrective actions if any, implementation, and follow-up
plans including monitoring, assessment of effectiveness,
and methods for provider feedback.
12.10.2 Annual Focused Studies. Focused Studies on well child , pregnancy,
and a study chosen by the plan, must be submitted to TDH according
to due dates established by TDH.
12.10.3 Annual QIP Summary Report. An annual QIP summary report must be
conducted yearly based on the state fiscal year. The annual QIP
summary report must be submitted by March 31 of each year. This
report must provide summary information on HMO's QIP system and
include the following:
(1) Executive summary of QIP - include results of all QI
reports and interventions.
(2) Activities pertaining to each standard (I through XVI) in
Appendix A. Report must list each standard.
(3) Methodologies for collecting, assessing data and measuring
outcomes.
(4) Tracking and monitoring quality of care.
(5) Role of health professionals in QIP review.
(6) Methodology for collection data and providing feedback to
provider and staff.
(7) Outcomes and/or action plan.
12.10.4 Provider Medical Record Audit and Report. HMO is required to
conform to commonly accepted medical record standards such as
those used by, NCQA, JCAHO, or those used for credentialing review
such as the Texas Environment of Care Assessment Program (TECAP),
and have documentation on file at HMO for review by TDH or its
designee during an on-site review.
1999 Renewal Contract
Tarrant Service Area
119
August 9, 1999
120
12.11 HUB REPORTS
HMO must submit quarterly reports documenting HMO's HUB program
efforts and accomplishments. The report must include a narrative
description of HMO's program efforts and a financial report
reflecting payments made to HUB. HMO must use the format included
in Appendix B for HUB quarterly reports. For HUB Certified
Entities: HMO must include the General Service Commission (GSC)
Vendor Number and the ethnicity/gender under which a contracting
entity is registered with GSC. For HUB Qualified (but not
certified) Entities: HMO must include the ethnicity/gender of the
major owner(s) (51%) of the entity. Any entities for which HMO
cannot provide this information, cannot be included in the HUB
report. For both types of entities, an entity will not be included
in the HUB report if HMO does not list ethnicity/gender
information.
12.12 THSTEPS REPORTS
Minimum reporting requirements. HMO must submit, at a minimum, 80%
of all THSteps checkups on HCFA 1500 claim forms as part of the
encounter file submission to the TDH Claims Administrator no later
than thirty (30) days after the date of final adjudication
(finalization) of the claims. Failure to comply with these minimum
reporting requirements will result in Article XVIII sanctions and
money damages.
ARTICLE XIII PAYMENT PROVISIONS
13.1 CAPITATION AMOUNTS
13.1.1 TDH will pay HMO monthly premiums calculated by multiplying
the number of Member months by Member risk group times the monthly
capitation amount by Member risk group. HMO and network providers
are prohibited from billing or collecting any amount from a Member
for health care services covered by this contract, in which case
the Member must be informed of such costs prior to providing
non-covered services.
1999 Renewal Contract
Tarrant Service Area
120
August 9, 1999
121
13.1.2 DELIVERY SUPPLEMENTAL PAYMENT (DSP). TDH HAS SUBMITTED THE
DELIVERY SUPPLEMENTAL PAYMENT METHODOLOGY TO HCFA FOR APPROVAL.
THE MONTHLY CAPITATION AMOUNTS FOR SEPTEMBER 1, 1999, THROUGH
AUGUST 31, 2000, AND THE DSP AMOUNT ARE LISTED BELOW. THESE
AMOUNTS ARE EFFECTIVE SEPTEMBER 1, 1999. THE MONTHLY CAPITATION
AMOUNTS ESTABLISHED FOR EACH RISK GROUP IN THE TARRANT SERVICE
AREA USING THE STANDARD METHODOLOGY (LISTED IN ARTICLE 13.1.3)
WILL APPLY IF THE DSP METHODOLOGY IS NOT APPROVED BY HCFA.
--------------------------------------------------------------------------------
RISK GROUP MONTHLY CAPITATION AMOUNTS
September 1, 1999 - August 31,
2000
--------------------------------------------------------------------------------
TANF Adults $154.34
--------------------------------------------------------------------------------
TANF Children > 12 $61.86
Months of Age
--------------------------------------------------------------------------------
Expansion Children > $83.41
12 Months of Age
--------------------------------------------------------------------------------
Newborns <= 12 Months $425.28
of Age
--------------------------------------------------------------------------------
TANF Children <= 12 $425.28
Months of Age
--------------------------------------------------------------------------------
Expansion Children <= 12 $425.28
Months of Age
--------------------------------------------------------------------------------
Federal Mandate Children $50.27
--------------------------------------------------------------------------------
CHIP Phase I $75.06
--------------------------------------------------------------------------------
Pregnant Women $151.51
--------------------------------------------------------------------------------
Disabled/Blind $14.00
Administration
--------------------------------------------------------------------------------
Delivery Supplemental Payment: A one-time per pregnancy
supplemental payment for each delivery shall be paid to HMO as
provided below in the following amount: $3,164.40.
1999 Renewal Contract
Tarrant Service Area
121
August 9, 1999
122
13.1.2.1 HMO will receive a DSP for each live or still birth. The one-time
payment is made regardless of whether there is a single or
multiple births at time of delivery. A delivery is the birth of a
liveborn infant, regardless of the duration of the pregnancy, or a
stillborn (fetal death) infant of 20 weeks or more gestation. A
delivery does not include a spontaneous or induced abortion,
regardless of the duration of the pregnancy.
13.1.2.2 For an HMO Member who is classified in the Pregnant Women, TANF
Adults, TANF Children >12 months, Expansion Children >12 months,
Federal Mandate Children, or CHIP risk group, HMO will be paid the
monthly capitation amount identified in Article 13.1.2 for each
month of classification, plus the DSP amount identified in Article
13.1.2.
13.1.2.3 HMO must submit a monthly DSP Report (report) that includes the
data elements specified by TDH. TDH will consult with contracted
HMOs prior to revising the report data elements and requirements.
The reports must be submitted to TDH in the format and time
specified by TDH. The report must include only unduplicated
deliveries. The report must include only deliveries for which HMO
has made a payment for the delivery, to either a hospital or other
provider. No DSP will be made for deliveries which are not
reported by HMO to TDH within 210 DAYS AFTER THE DATE OF DELIVERY,
or within 30 days from the date of discharge from the hospital for
the stay related to the delivery, whichever is later.
13.1.2.4 HMO must maintain complete claims and adjudication disposition
documentation, including paid and denied amounts for each
delivery. HMO must submit the documentation to TDH within five (5)
days from the date of a TDH request for documents.
13.1.2.5 The DSP will be made by TDH to HMO within twenty (20) state
working days after receiving an accurate report from HMO.
13.1.2.6 All infants of age equal to or less than twelve months (Newborns)
in the TANF Children, Expansion Children, and Newborns risk groups
will be capitated at the Newborns classification capitation amount
in Article 13.1.2.
13.1.3 Standard Methodology. If the DSP methodology is not
approved by HCFA, the monthly capitation amounts established for
each risk group in the Tarrant Service Area using the Methodology
set forth in Article 13.1.1, without the DSP, are as follows:
1999 Renewal Contract
Tarrant Service Area
122
August 9, 1999
123
---------------------------------------------------------------
RISK GROUP MONTHLY CAPITATION AMOUNTS
September 1, 1999 - August 31,
2000
---------------------------------------------------------------
TANF Adults $187.16
---------------------------------------------------------------
TANF Children $75.97
---------------------------------------------------------------
Expansion Children $96.73
---------------------------------------------------------------
Newborns $477.64
---------------------------------------------------------------
Federal Mandate Children $50.84
---------------------------------------------------------------
CHIP Phase I $83.54
---------------------------------------------------------------
Pregnant Women $621.93
---------------------------------------------------------------
Disabled/Blind $14.00
Administration
---------------------------------------------------------------
13.1.4 TDH will re-examine the capitation rates paid to HMO under
this contract during the first year of the contract period and
will provide HMO with capitation rates for the second year of the
contract period no later than 30 days before the date of the
one-year anniversary of the contract's effective date. Capitation
rates for state fiscal year 2001 will be re-examined based on the
most recent available traditional Medicaid cost data for the
contracted risk groups in the service area, trended forward and
discounted.
13.1.4.1 Once HMO has received their capitation rates established by TDH
for the second year of this contract, HMO may terminate this
contract as provided in Article 18.1.6 of this contract. HMO MAY
ALSO TERMINATE THIS CONTRACT AS PROVIDED IN ARTICLE 18.1.6 IF HCFA
DOES NOT APPROVE THE DELIVERY SUPPLEMENTAL PAYMENT METHODOLOGY
DESCRIBED IN ARTICLE 13.1.2.
13.1.5 The monthly premium payment to HMO is based on monthly
enrollments adjusted to reflect money damages set out in Article
18.8 and adjustments to premiums in Article 13.5.
13.1.6 The monthly premium payments will be made to HMO no later
than the 10th working day of the month for which premiums are
paid. HMO must accept payment for premiums by direct deposit into
an HMO account.
1999 Renewal Contract
Tarrant Service Area
123
August 9, 1999
124
13.1.7 Payment of monthly capitation amounts is subject to
availability of appropriations. If appropriations are not
available to pay the full monthly capitation amounts, TDH will
equitably adjust capitation amounts for all participating HMOs,
and reduce scope of service requirements as appropriate.
13.1.8 HMO renewal rates reflect program increases appropriated by
the 76th legislature for physician (to include THSteps providers)
and outpatient facility services. HMO must report to TDH any
change in rates for participating physicians (to include THSteps
providers) and outpatient facilities resulting from this increase.
The report must be submitted to TDH at the end of the first
quarter of the FY2000 and FY2001 contract years according to the
deliverables matrix schedule set for HMO.
13.2 EXPERIENCE REBATE TO STATE
13.2.1 For fiscal year 2000, HMO must pay to TDH an experience
rebate calculated in accordance with the tiered rebate method
listed below based on the excess of allowable HMO STAR revenues
over allowable HMO STAR expenses as measured by any positive
amount on Line 7 of "Part 1: Financial Summary, All Coverage
Groups Combined" of the annual Managed Care Financial-Statistical
Report set forth in Appendix I, as reviewed and confirmed by TDH.
TDH reserves the right to have an independent audit performed to
verify the information provided by HMO.
---------------------------------------------------------------------------------------
Graduated Rebate Method
---------------------------------------------------------------------------------------
Experience Rebate as a HMO Share State Share
Percentage of
Revenues
---------------------------------------------------------------------------------------
0% - 3% 100% 0%
---------------------------------------------------------------------------------------
Over 3% - 7% 75% 25%
---------------------------------------------------------------------------------------
Over 7% - 10% 50% 50%
---------------------------------------------------------------------------------------
Over 10% - 15% 25% 75%
---------------------------------------------------------------------------------------
Over 15% 0% 100%
---------------------------------------------------------------------------------------
13.2.2 Carry Forward of Prior Contract Period Losses: Losses incurred for
one
1999 Renewal Contract
Tarrant Service Area
124
August 9, 1999
125
contract period can only be carried forward to the next contract
period.
13.2.2.1 Carry Forward of Loss from one Service Delivery Area to Another:
If HMO operates in multiple Service Delivery Areas (SDAs), losses
in one SDA cannot be used to offset net income before taxes in
another SDA.
13.2.3 Experience rebate will be based on a pre-tax basis.
13.2.4 Population-Based Initiatives (PBIs) and Experience Rebates:
HMO may subtract from an experience rebate owed to the State,
expenses for population-based health initiatives that have been
approved by TDH. A population-based initiative (PBI) is a project
or program designed to improve some aspect of quality of care,
quality of life, or health care knowledge for the community as a
whole. Value-added service does not constitute a PBI.
Contractually required services and activities do not constitute a
PBI.
13.2.5 There will be two settlements for payment(s) of the state share of
the experience rebate. The first settlement shall equal 100
percent of the state share of the experience rebate as derived
from Line 7 of Part 1 (Net Income Before Taxes) of the FINAL
Managed Care Financial Statistical (MCFS) Report and shall be paid
on the same day the first FINAL MCFS Report is submitted to TDH.
The second settlement shall be an adjustment to the first
settlement and shall be paid to TDH on the same day that the
second FINAL MCFS Report is submitted to TDH if the adjustment is
a payment from HMO to TDH. TDH or its agent may audit or review
the MCFS reports. If TDH determines that corrections to the MCFS
reports are required, based on a TDH audit/review or other
documentation acceptable to TDH, to determine an adjustment to the
amount of the second settlement, then final adjustment shall be
made within two years from the date that HMO submits the second
FINAL MCFS report. HMO must pay the first and second settlements
on the due dates for the first and second FINAL MCFS reports
respectively as identified in Article 12.1.5. TDH may adjust the
experience rebate if TDH determines HMO has paid affiliates
amounts for goods or services that are higher than the fair market
value of the goods and services in the service area. Fair market
value may be based on the amount HMO pays a non-affiliate(s) or
the amount another HMO pays for the same or similar service in the
service area AND WILL BE DETERMINED ON A CASE-BY-CASE BASIS. TDH
has final authority in auditing and determining the amount of the
experience rebate.
1999 Renewal Contract
Tarrant Service Area
125
August 9, 1999
126
13.3 PERFORMANCE OBJECTIVES
13.3.1 Preventive Health Performance Objectives are contained in
this contract at Appendix K. These reports are submitted annually
and must be submitted no later than 150 days after the end of the
State fiscal year.
13.4 ADJUSTMENTS TO PREMIUM
13.4.1 TDH may recoup premiums paid to HMO in error. Error may be
either human or machine error on the part of TDH or an agent or
contractor of TDH. TDH may recoup premiums paid to HMO if a Member
is enrolled into HMO in error, and HMO provided no covered
services to Member for the period of time for which premium was
paid. If services were provided to Member as a result of the
error, recoupment will not be made.
13.4.2 TDH may recoup premium paid to HMO if a Member for whom
premium is paid moves outside the United States, and HMO has not
provided covered services to the Member for the period of time for
which premium has been paid. TDH will not recoup premium if HMO
has provided covered services to the Member during the period of
time for which premium has been paid.
13.4.3 TDH may recoup premium paid to HMO if a Member for whom
premium is paid dies before the first day of the month for which
premium is paid.
13.4.4 TDH may recoup or adjust premium paid to HMO for a Member
if the Member's eligibility status or program type is changed,
corrected as a result of error, or is retroactively adjusted.
13.4.5 Recoupment or adjustment of premium under Articles 13.4.1
through 13.4.4 may be appealed using the TDH dispute resolution
process.
13.4.6 TDH may adjust premiums for all Members within an
eligibility status or program type if adjustment is required by
reductions in appropriations and/or if a benefit or category of
benefits is excluded or included as a covered service. Adjustment
must be made by amendment as required by Article 15.2. Adjustment
to premium under this subsection may not be appealed using the TDH
dispute resolution process.
ARTICLE XIV ELIGIBILITY, ENROLLMENT, AND DISENROLLMENT
1999 Renewal Contract
Tarrant Service Area
126
August 9, 1999
127
14.1 ELIGIBILITY DETERMINATION
14.1.1 TDH will identify Medicaid recipients who are eligible for
participation in the STAR program using the eligibility status
described below.
14.1.2 Individuals in the following categories who reside in any
part of the Service Area must enroll in one of the health plans
providing services in the Service Areas:
14.1.2.1 TANF ADULTS - Individuals age 21 and over who are eligible for the
TANF program. This category may also include some pregnant women.
14.1.2.2 TANF CHILDREN - Individuals under age 21 who are eligible for the
TANF program. This category may also include some pregnant women
and some children less than one year of age.
14.1.2.3 PREGNANT WOMEN receiving Medical Assistance Only (MAO) - Pregnant
women whose families' income is below 185% of the Federal Poverty
Level (FPL).
14.1.2.4 NEWBORN (MAO) - Children under age one born to Medicaid-eligible
mothers.
14.1.2.5 EXPANSION CHILDREN (MAO) - Children under age 18, ineligible for
TANF because of the applied income of their stepparents or
grandparents.
14.1.2.6 EXPANSION CHILDREN (MAO) - Children under age 1 whose families'
income is below 185% FPL.
14.1.2.7 EXPANSION CHILDREN MAO - Children age 1- 5 whose families' income
is at or below 133% of FPL.
14.1.2.8 FEDERAL MANDATE CHILDREN (MAO) - Children under age 19 born before
October 10, 1983, whose families' income is below the TANF income
limit.
14.1.2.9 CHIP PHASE I - Children's Health Insurance Program Phase I
(Federal Mandate Acceleration) Children under age nineteen (19)
born before October 1, 1983, with family income below 100% Federal
Poverty Income Level.
14.1.3 The following individuals are eligible for the STAR Program
and are not required to enroll in a health plan but have the
option to enroll in a plan. HMO will be required to accept
enrollment of those Medicaid recipients from this group who elect
to enroll in HMO.
1999 Renewal Contract
Tarrant Service Area
127
August 9, 1999
128
14.1.3.1 DISABLED AND BLIND INDIVIDUALS WITHOUT MEDICARE Recipients with
Supplemental Security Income (SSI) benefits who are not eligible
for Medicare may elect to participate in the STAR program on a
voluntary basis.
14.1.3.2 Certain blind or disabled individuals who lose SSI eligibility
because of Title II income and who are not eligible for Medicare.
14.1.4 During the period after which the Medicaid eligibility
determination has been made but prior to enrollment in HMO,
Members will be enrolled under the traditional Medicaid program.
All Medicaid-eligible recipients will remain in the
fee-for-service Medicaid program until enrolled in or assigned to
an HMO.
14.2 ENROLLMENT
14.2.1 TDH has the right and responsibility to enroll and
disenroll eligible individuals into the STAR program. TDH will
conduct continuous open enrollment for Medicaid recipients and HMO
must accept all persons who chose to enroll as Members in HMO or
who are assigned as Members in HMO by TDH, without regard to the
Member's health status or any other factor.
14.2.2 All enrollments are subject to the accessibility and
availability limitations and restrictions contained in the Section
1915(b) waiver obtained by TDH. TDH has the authority to limit
enrollment into HMO if the number and distance limitations are
exceeded.
14.2.3 TDH makes no guarantees or representations to HMO regarding
the number of eligible Medicaid recipients who will ultimately be
enrolled as STAR Members of HMO.
14.2.4 HMO must cooperate and participate in all TDH sponsored and
announced enrollment activities. HMO must have a representative at
all TDH enrollment activities unless an exception is given by TDH.
The representative must comply with HMO's cultural and linguistic
competency plan (see Cultural and Linguistic requirements in
Article 8.9). HMO must provide marketing materials, HMO pamphlets,
Member Handbooks, a list of network providers, HMO's linguistic
and cultural capabilities and other information requested or
required by TDH or its Enrollment Broker to assist potential
Members in making informed choices.
14.2.5 TDH will provide HMO with at least 10 days written notice
of all TDH planned activities. Failure to participate in, or send
a representative to a TDH
1999 Renewal Contract
Tarrant Service Area
128
August 9, 1999
129
sponsored enrollment activity is a default of the terms of the
contract. Default may be excused if HMO can show that TDH failed
to provide the required notice, or if HMO's absence is excused by
TDH.
14.3 DISENROLLMENT
14.3.1 HMO has a limited right to request a Member be disenrolled
from HMO without the Member's consent. TDH must approve any HMO
request for disenrollment of a Member for cause. Disenrollment of
a Member may be permitted under the following circumstances:
14.3.1.1 Member misuses or loans Member's HMO membership card to another
person to obtain services.
14.3.1.2 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.
14.3.1.3 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).
14.3.2 HMO must take reasonable measures to correct Member
behavior prior to requesting disenrollment. Reasonable measures
may include providing education and counseling regarding the
offensive acts or behaviors.
14.3.3 HMO must notify the Member of HMO's decision to disenroll
the Member if all reasonable measures have failed to remedy the
problem.
14.3.4 If the Member disagrees with the decision to disenroll the
Member from HMO, HMO must notify the Member of the availability of
the complaint procedure and TDH's Fair Hearing process.
14.3.5 HMO CANNOT REQUEST A DISENROLLMENT BASED ON ADVERSE CHANGE
IN THE MEMBER'S HEALTH STATUS OR UTILIZATION OF SERVICES WHICH ARE
MEDICALLY NECESSARY FOR TREATMENT OF A MEMBER'S CONDITION.
14.4 AUTOMATIC RE-ENROLLMENT
14.4.1 Members who are disenrolled because they are temporarily
ineligible for
1999 Renewal Contract
Tarrant Service Area
129
August 9, 1999
130
Medicaid will be automatically re-enrolled into the same health
plan. Temporary loss of eligibility is defined as a period of 6
months or less.
14.4.2 HMO must inform its Members of the automatic re-enrollment
procedure. Automatic re-enrollment must be included in the Member
Handbook (see Article 8.2.1).
14.5 ENROLLMENT REPORTS
14.5.1 TDH will provide HMO enrollment reports listing all STAR
Members who have enrolled in or were assigned to HMO during the
initial enrollment period.
14.5.2 TDH will provide monthly HMO Enrollment Reports to HMO on
or before the first of the month.
14.5.3 TDH will provide Member verification to HMO and network
providers through telephone verification or TexMedNet.
ARTICLE XV GENERAL PROVISIONS
15.1 INDEPENDENT CONTRACTOR
HMO, its agents, employees, network providers, and subcontractors
are independent contractors and do not perform services under this
contract as employees or agents of TDH. HMO is given express,
limited authority to exercise the State's right of recovery as
provided in Article 4.9.
15.2 AMENDMENT
15.2.1 This contract must be amended by TDH if amendment is
required to comply with changes in state or federal laws, rules,
or regulations.
15.2.2 TDH and HMO may amend this contract if reductions in
funding or appropriations make full performance by either party
impracticable or impossible, and amendment could provide a
reasonable alternative to termination. If HMO does not agree to
the amendment, contract may be terminated under Article XVIII.
15.2.3 This contract must be amended if either party discovers a
material
1999 Renewal Contract
Tarrant Service Area
130
August 9, 1999
131
omission of a negotiated or required term, which is essential to
the successful performance or maintaining compliance with the
terms of the contract. The party discovering the omission must
notify the other party of the omission in writing as soon as
possible after discovery. If there is a disagreement regarding
whether the omission was intended to be a term of the contract,
the parties must submit the dispute to dispute resolution under
Article 15.9.
15.2.4 This contract may be amended by mutual agreement at any
time.
15.2.5 All amendments to this contract must be in writing and
signed by both parties.
15.2.6 No agreement shall be used to amend this contract unless it
is made a part of this contract by specific reference, and is
numbered sequentially by order of its adoption.
15.3 LAW, JURISDICTION AND VENUE
Venue and jurisdiction shall be in the state and federal district
courts of Xxxxxx County, Texas. The laws of the State of Texas
shall be applied in all matters of state law.
15.4 NON-WAIVER
Failure to enforce any provision or breach shall not be taken by
either party as a waiver of the right to enforce the provision or
breach in the future.
15.5 SEVERABILITY
Any part of this contract which is found to be unenforceable,
invalid, void, or illegal shall be severed from the contract. The
remainder of the contract shall be effective.
15.6 ASSIGNMENT
This contract was awarded to HMO based on HMO's qualifications to
perform personal and professional services. HMO cannot assign this
contract without the written consent of TDI and TDH. This
provision does not prevent HMO from subcontracting duties and
responsibilities to qualified subcontractors. If TDI and TDH
consent to an assignment of this contract, a transition period of
90 days will run from the date the assignment is approved by TDI
and TDH so that Members' services are not interrupted and, if
necessary, the notice provided for in Article
1999 Renewal Contract
Tarrant Service Area
131
August 9, 1999
132
15.7 can be sent to Members. The assigning HMO must also submit a
transition plan, as set out in Article 18.2.1, subject to TDH's
approval.
15.7 MAJOR CHANGE IN CONTRACTING
TDH may send notice to Members when a major change affecting HMO
occurs. A "major change" includes, but is not limited to, a
substantial change of subcontractors and assignment of this
contract. The notice letter to Members may permit the Members to
re-select their plan and PCP. TDH will bear the cost of preparing
and sending the notice letter in the event of an approved
assignment of the contract. For any other major change in
contracting, HMO will prepare the notice letter and submit it to
TDH for review and approval. After TDH has approved the letter for
distribution to Members, HMO will bear the cost of sending the
notice letter.
15.8 NON-EXCLUSIVE
This contract is a non-exclusive agreement. Either party may
contract with other entities for similar services in the same
service area.
15.9 DISPUTE RESOLUTION
The dispute resolution process adopted by TDH in accordance with
Chapter 2260, Texas Government Code, will be used to attempt to
resolve all disputes arising under this contract. All disputes
arising under this contract shall be resolved through TDH's
dispute resolution procedures, except where a remedy is provided
for through TDH's administrative rules or processes. All
administrative remedies must be exhausted prior to other methods
of dispute resolution.
15.10 DOCUMENTS CONSTITUTING CONTRACT
This contract includes this document and all amendments and
appendices to this document, the Request for Application, the
Application submitted in response to the Request for Application,
the Texas Medicaid Provider Procedures Manual and Texas Medicaid
Bulletins addressed to HMOs, contract interpretation memoranda
issued by TDH for this contract, and the federal waiver granting
TDH authority to contract with HMO. If any conflict in provisions
between these documents occurs, the terms of this contract and any
amendments shall prevail. The documents listed above constitute
the entire contract between the parties.
15.11 FORCE MAJEURE
1999 Renewal Contract
Tarrant Service Area
132
August 9, 1999
133
TDH and HMO are excused from performing the duties and obligations
under this contract for any period that they are prevented from
performing their services as a result of a catastrophic
occurrence, or natural disaster, clearly beyond the control of
either party, including but not limited to an act of war, but
excluding labor disputes.
15.12 NOTICES
Notice may be given by any means which provides for verification
of receipt. All notices to TDH shall be addressed to Bureau Chief,
Texas Department of Health, Bureau of Managed Care, 0000 X. 00xx
Xxxxxx, Xxxxxx, XX 00000-0000, with a copy to the Contract
Administrator. Notices to HMO shall be addressed to
President/CEO, _______JAMES X. XXXXXXX, XX._____________________
_______2730 X. XXXXXXXX FREEWAY SUITE 608 WEST TOWER____________
_______DALLAS, TX 75207________________________________________.
15.13 SURVIVAL
The provisions of this contract which relate to the obligations of
HMO to maintain records and reports shall survive the expiration
or earlier termination of this contract for a period not to exceed
six (6) years unless another period may be required by record
retention policies of the State of Texas or HCFA.
ARTICLE XVI DEFAULT AND REMEDIES
16.1 DEFAULT BY TDH
16.1.1 FAILURE TO MAKE CAPITATION PAYMENTS
Failure by TDH to make capitation payments when due is a default
under this contract.
16.1.2 FAILURE TO PERFORM DUTIES AND RESPONSIBILITIES
Failure by TDH to perform a material duty or responsibility as set
out in this contract is a default under this contract.
16.2 REMEDIES AVAILABLE TO HMO FOR TDH'S DEFAULT
1999 Renewal Contract
Tarrant Service Area
133
August 9, 1999
134
HMO may terminate this contract as set out in Article 18.1.5 of
this contract if TDH commits either of the events of default set
out in Article 16.1.
16.3 DEFAULT BY HMO
16.3.1 FAILURE TO PERFORM AN ADMINISTRATIVE FUNCTION
Failure of HMO to perform an administrative function is a default
under this contract. Administrative functions are any requirements
under this contract that are not direct delivery of health care
services, including claims payment; encounter data submission;
filing any report when due; cooperating in good faith with TDH, an
entity acting on behalf of TDH, or an agency authorized by statute
or law to require the cooperation of HMO in carrying out an
administrative, investigative, or prosecutorial function of the
Medicaid program; providing or producing records upon request; or
entering into contracts or implementing procedures necessary to
carry out contract obligations.
16.3.1.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and
may be exercised concurrently or consecutively. Exercise of any
remedy in whole or in part does not limit TDH in exercising all or
part of any remaining remedies.
For HMO=s failure to perform an administrative function under this
contract, TDH may:
- Terminate the contract if the applicable conditions set out in
Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Assess liquidated money damages as set out in Article 18.4;
and/or
- Require forfeiture of all or part of the TDI performance bond as
set out in Article 18.9.
16.3.2 ADVERSE ACTION AGAINST HMO BY TDI
Termination or suspension of HMO's TDI Certificate of Authority or
any adverse action taken by TDI that TDH determines will affect
the ability of HMO to provide health care services to Members is a
default under this contract.
16.3.2.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
1999 Renewal Contract
Tarrant Service Area
134
August 9, 1999
135
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and
may be exercised concurrently or consecutively. Exercise of any
remedy in whole or in part does not limit TDH in exercising all or
part of any remaining remedies.
For an adverse action against HMO by TDI, TDH may:
- Terminate the contract if the applicable conditions set out in
Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance bond as
set out in Article 18.9.
16.3.3 INSOLVENCY
Failure of HMO to comply with state and federal solvency standards
or incapacity of HMO to meet its financial obligations as they
come due is a default under this contract.
16.3.3.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and
may be exercised concurrently or consecutively. Exercise of any
remedy in whole or in part does not limit TDH in exercising all or
part of any remaining remedies.
For HMO's insolvency, TDH may:
- Terminate the contract if the applicable conditions set out in
Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance bond as
set out in Article 18.9.
16.3.4 FAILURE TO COMPLY WITH FEDERAL LAWS AND REGULATIONS
Failure of HMO to comply with the federal requirements for
Medicaid, including, but not limited to, federal law regarding
misrepresentation, fraud, or abuse; and, by incorporation,
Medicare standards, requirements, or prohibitions, is a default
under this contract.
1999 Renewal Contract
Tarrant Service Area
135
August 9, 1999
136
The following events are defaults under this contract pursuant to
42 U.S.C. Sections 1396b(m)(5), 1396u-2(e)(1)(A):
16.3.4.1 HMO's substantial failure to provide medically necessary items and
services that are required under this contract to be provided to
Members;
16.3.4.2 HMO's imposition of premiums or charges on Members in excess of
the premiums or charge permitted by federal law;
16.3.4.3 HMO's acting to discriminate among Members on the basis of their
health status or requirements for health care services, including
expulsion or refusal to enroll an individual, except as permitted
by federal law, or engaging in any practice that would reasonably
be expected to have the effect of denying or discouraging
enrollment with HMO by eligible individuals whose medical
condition or history indicates a need for substantial future
medical services;
16.3.4.4 HMO's misrepresentation or falsification of information that is
furnished to HCFA, TDH, a Member, a potential Member, or a health
care provider;
16.3.4.5 HMO's failure to comply with the physician incentive requirements
under 42 U.S.C. Section 1396b(m)(2)(A)(x); or
16.3.4.6 HMO's distribution, either directly or through any agent or
independent contractor, of marketing materials that contain false
or misleading information, excluding materials prior approved by
TDH.
16.3.5 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and
may be exercised concurrently or consecutively. If HMO repeatedly
fails to meet the requirements of Articles 16.3.4.1 through and
including 16.3.4.6, TDH must, regardless of what other sanctions
are provided, appoint temporary management and permit Members to
disenroll without cause. Exercise of any remedy in whole or in
part does not limit TDH in exercising all or part of any remaining
remedies.
For HMO's failure to comply with federal laws and regulations, TDH
may:
- Terminate the contract if the applicable conditions set out in
Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Appoint temporary management as set out in Article 18.5;
1999 Renewal Contract
Tarrant Service Area
136
August 9, 1999
137
- Initiate disenrollment of a Member of Members without cause as
set out in Article 18.6;
- Suspend or default all enrollment of individuals;
- Suspend payment to HMO;
- Recommend to HCFA that sanctions be taken against HMO as set out
in Article 18.7;
- Assess civil monetary penalties as set out in Article 18.8;
and/or
- Require forfeiture of all or part of the TDI performance bond as
set out in Article 18.9.
16.3.6 FAILURE TO COMPLY WITH APPLICABLE STATE LAW
HMO's failure to comply with Texas law applicable to Medicaid,
including, but not limited to, Article 32.039 of the Texas Human
Resources Code and state law regarding misrepresentation, fraud,
or abuse, is a default under this contract.
16.3.6.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and
may be exercised concurrently or consecutively. Exercise of any
remedy in whole or in part does not limit TDH in exercising all or
part of any remaining remedies.
For HMO's failure to comply with applicable state law, TDH may:
- Terminate the contract if the applicable conditions set out in
Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Assess administrative penalties as set out in Article 32.039,
Government Code, with the opportunity for notice and appeal as
required by Article 32.039; and/or
- Require forfeiture of all or part of the TDI performance bond
as set out in Article 18.9.
16.3.7 MISREPRESENTATION OR FRAUD UNDER ARTICLE 4.8
HMO's misrepresentation or fraud under Article 4.8 of this
contract is a default under this contract.
16.3.7.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by
1999 Renewal Contract
Tarrant Service Area
137
August 9, 1999
138
law or in equity, are joint and several, and may be exercised
concurrently or consecutively. Exercise of any remedy in whole or
in part does not limit TDH in exercising all or part of any
remaining remedies.
For HMO's misrepresentation or fraud under Article 4.8, TDH may:
- Terminate the contract if the applicable conditions set out in
Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance bond as
set out in Article 18.9.
16.3.8 EXCLUSION FROM PARTICIPATION IN MEDICARE OR MEDICAID
16.3.8.1 Exclusion of HMO or any of the managing employees or persons with
an ownership interest whose disclosure is required by Section
1124(a) of the Social Security Act (the Act) from the Medicaid or
Medicare program under the provisions of Section 1128(a) and/or
(b) of the Act is a default under this contract.
16.3.8.2 Exclusion of any provider or subcontractor or any of the managing
employees or persons with an ownership interest of the provider or
subcontractor whose disclosure is required by Section 1124(a) of
the Social Security Act (the Act) from the Medicaid or Medicare
program under the provisions of Section 1128(a) and/or (b) of the
Act is a default under this contract if the exclusion will
materially affect HMO's performance under this contract.
16.3.8.3 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and
may be exercised concurrently or consecutively. Exercise of any
remedy in whole or in part does not limit TDH in exercising all or
part of any remaining remedies.
For HMO's exclusion from Medicare or Medicaid, TDH may:
- Terminate the contract if the applicable conditions set out in
Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance bond as
set out in Article 18.9.
16.3.9 FAILURE TO MAKE PAYMENTS TO NETWORK PROVIDERS AND
1999 Renewal Contract
Tarrant Service Area
138
August 9, 1999
139
SUBCONTRACTORS
HMO's failure to make timely and appropriate payments to network
providers and subcontractors is a default under this contract.
Withholding or recouping capitation payments as allowed or
required under other articles of this contract is not a default
under this contract.
16.3.9.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and
may be exercised concurrently or consecutively. Exercise of any
remedy in whole or in part does not limit TDH in exercising all or
part of any remaining remedies.
For HMO's failure to make timely and appropriate payments to
network providers and subcontractors, TDH may:
- Terminate the contract if the applicable conditions set out in
Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Assess liquidated money damages as set out in Article 18.4;
and/or
- Require forfeiture of all or part of the TDI performance bond as
set out in Article 18.9.
16.3.10 FAILURE TO TIMELY ADJUDICATE CLAIMS
Failure of HMO to adjudicate (paid, denied, or external pended) at
least ninety (90%) of all claims within thirty (30) days of
receipt and ninety-nine percent (99%) of all claims within ninety
days of receipt for the contract year is a default under this
contract.
16.3.10.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and
may be exercised concurrently or consequently. Exercise of any
remedy in whole or in part does not limit TDH in exercising all or
part of any remaining remedies.
For HMO's failure to timely adjudicate claims, TDH may:
- Terminate the contract if the applicable conditions set out in
Article 18.1.1 are met;
1999 Renewal Contract
Tarrant Service Area
139
August 9, 1999
140
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance bond as
set out in Article 18.9.
16.3.11 FAILURE TO DEMONSTRATE THE ABILITY TO PERFORM CONTRACT FUNCTIONS
Failure to pass any of the mandatory system or delivery functions
of the Readiness Review required in Article I of this contract is
a default under the contract.
16.3.11.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and
may be exercised concurrently or consecutively. Exercise of any
remedy in whole or in part does not limit TDH in exercising all or
part of any remaining remedies.
For HMO's failure to demonstrate the ability to perform contract
functions, TDH may:
- Terminate the contract if the applicable conditions set out in
Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance bond as
set out in Article 18.9.
16.3.12 FAILURE TO MONITOR AND/OR SUPERVISE ACTIVITIES OF CONTRACTORS OR
NETWORK PROVIDERS
16.3.12.1 Failure of HMO to audit, monitor, supervise, or enforce functions
delegated by contract to another entity that results in a default
under this contract or constitutes a violation of state or federal
laws, rules, or regulations is a default under this contract.
16.3.12.2 Failure of HMO to properly credential its providers, conduct
reasonable utilization review, or conduct quality monitoring is a
default under this contract.
16.3.12.3 Failure of HMO to require providers and contractors to provide
timely and accurate encounter, financial, statistical, and
utilization data is a default under this contract.
16.3.12.4 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
1999 Renewal Contract
Tarrant Service Area
140
August 9, 1999
141
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and
may be exercised concurrently or consecutively. Exercise of any
remedy in whole or in part does not limit TDH in exercising all or
part of any remaining remedies.
For HMO's failure to monitor and/or supervise activities of
contractors or network providers, TDH may:
- Terminate the contract if the applicable conditions set out in
Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance bond as
set out in Article 18.9.
16.3.13 PLACING THE HEALTH AND SAFETY OF MEMBERS IN JEOPARDY
HMO's placing the health and safety of the Members in jeopardy is
a default under this contract.
16.3.13.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and
may be exercised concurrently or consecutively. Exercise of any
remedy in whole or in part does not limit TDH in exercising all or
part of any remaining remedies.
For HMO's placing the health and safety of Members in jeopardy,
TDH may:
- Terminate the contract if the applicable conditions set out in
Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance bond as
set out in Article 18.9.
16.3.14 FAILURE TO MEET ESTABLISHED BENCHMARK
Failure of HMO to meet any benchmark established by TDH under this
contract is a default under this contract.
16.3.14.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
1999 Renewal Contract
Tarrant Service Area
141
August 9, 1999
142
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and
may be exercised concurrently or consecutively. Exercise of any
remedy in whole or in part does not limit TDH in exercising all or
part of any remaining remedies.
For HMO's failure to meet any benchmark established by TDH under
this contract, TDH may:
- Remove the THSteps component from the capitation paid to HMO if
the benchmark(s) missed is for THSteps;
- Terminate the contract if the applicable conditions set out in
Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Assess liquidated money damages as set out in Article 18.4;
and/or
- Require forfeiture of all or part of the TDI performance bond as
set out in Article 18.9.
ARTICLE XVII NOTICE OF DEFAULT AND CURE OF DEFAULT
17.1 TDH will provide HMO with written notice of default (Notice
of Default) under this contract. The Notice of Default may be
given by any means that provides verification of receipt. The
Notice of Default must contain the following information:
17.1.1 A clear and concise statement of the circumstances or
conditions that constitute a default under this contract;
17.1.2 The contract provision(s) under which default is being
declared;
17.1.3 A clear and concise statement of how and/or whether the
default may be cured;
17.l.4 A clear and concise statement of the time period during
which HMO may cure the default if HMO is allowed to cure;
17.1.5 The remedy or remedies TDH is electing to pursue and when
the remedy or remedies will take effect;
17.1.6 If TDH is electing to impose money damages and/or civil
monetary penalties, the amount that TDH intends to withhold or
impose and the factual basis on which TDH is imposing the chosen
remedy or remedies;
1999 Renewal Contract
Tarrant Service Area
142
August 9, 1999
143
17.l.7 Whether any part of money damages or civil monetary
penalties, if TDH elects to pursue one or both of those remedies,
may be passed through to an individual or entity who is or may be
responsible for the act or omission for which default is declared;
17.1.8 Whether failure to cure the default within the given time
period, if any, will result in TDH pursuing an additional remedy
or remedies, including, but not limited to, additional damages or
sanctions, referral for investigation or action by another agency,
and/or termination of the contract.
ARTICLE XVIII EXPLANATION OF REMEDIES
18.1 TERMINATION
18.1.1 TERMINATION BY TDH
TDH may terminate this contract if:
18.1.1.1 HMO substantially fails or refuses to provide medically necessary
services and items that are required under this contract to be
provided to Members after notice and opportunity to cure;
18.1.1.2 HMO substantially fails or refuses to perform administrative
functions under this contract after notice and opportunity to
cure;
18.1.1.3 HMO materially defaults under any of the provisions of Article
XVI;
18.1.1.4 Federal or state funds for the Medicaid program are no longer
available; or
18.1.1.5 TDH has a reasonable belief that HMO has placed the health or
welfare of Members in jeopardy.
18.1.2 TDH must give HMO 90 days written notice of intent to
terminate this contract if termination is the result of HMO's
substantial failure or refusal to perform administrative functions
or a material default under any of the provisions of Article XVI.
TDH must give HMO reasonable notice under the circumstances if
termination is the result of federal or state funds for the
Medicaid program no longer being available. TDH must give the
notice required under TDH's formal hearing procedures set out in
Section 1.2.1 in Title 25 of the Texas Administrative
1999 Renewal Contract
Tarrant Service Area
143
August 9, 1999
144
Code if termination is the result of HMO's substantial failure or
refusal to provide medically necessary services and items that are
required under the contract to be provided to Members or TDH's
reasonable belief that HMO has placed the health or welfare of
Members in jeopardy.
18.1.2.1 Notice may be given by any means that gives verification of
receipt.
18.1.2.2 Unless termination is the result of HMO's substantial failure or
refusal to provide medically necessary services and items that are
required under this contract to be provided to Members or is the
result of TDH's reasonable belief that HMO has placed the health
or welfare of Members in jeopardy, the termination date is 90 days
following the date that HMO receives the notice of intent to
terminate. For HMO's substantial failure or refusal to provide
services and items, HMO is entitled to request a pre-termination
hearing under TDH's formal hearing procedures set out in Section
1.2.1 of Title 25, Texas Administrative Code.
18.1.3 TDH may, for termination for HMO's substantial failure or
refusal to provide medically necessary services and items, notify
HMO's Members of any hearing requested by HMO and permit Members
to disenroll immediately without cause. Additionally, if TDH
terminates for this reason, TDH may enroll HMO's Members with
another HMO or permit HMO's Members to receive Medicaid-covered
services other than from an HMO.
18.1.4 HMO must continue to perform services under the transition
plan described in Article 18.2.1 until the last day of the month
following 90 days from the date of receipt of notice if the
termination is for any reason other than TDH's reasonable belief
that HMO is placing the health and safety of the Members in
jeopardy. If termination is due to this reason, TDH may prohibit
HMO's further performance of services under the contract.
18.1.5 If TDH terminates this contract, HMO may appeal the
termination under Section 32.034, Texas Human Resources Code.
18.1.6 TERMINATION BY HMO
HMO may terminate this contract if TDH fails to pay HMO as
required under Article XIII of this contract or otherwise
materially defaults in its duties and responsibilities under this
contract, or by giving notice no later than 30 days after
receiving the capitation rates for the second contract year.
Retaining premium, recoupment, sanctions, or penalties that are
allowed under this contract or that result from HMO's failure to
perform or HMO's default under the terms of this
1999 Renewal Contract
Tarrant Service Area
144
August 9, 1999
145
contract is not cause for termination.
18.1.7 HMO must give TDH 90 days written notice of intent to
terminate this contract. Notice may be given by any means that
gives verification of receipt. The termination date will be
calculated as the last day of the month following 90 days from the
date the notice of intent to terminate is received by TDH.
18.1.8 TDH must be given 30 days from the date TDH receives HMO's
written notice of intent to terminate for failure to pay HMO to
pay all amounts due. If TDH pays all amounts then due within this
30-day period, HMO cannot terminate the contract under this
article for that reason.
18.1.9 TERMINATION BY MUTUAL CONSENT
This contract may be terminated at any time by mutual consent of
both HMO and TDH.
18.2 DUTIES OF CONTRACTING PARTIES UPON TERMINATION
When termination of the contract occurs, TDH and HMO must meet the
following obligations:
18.2.1 TDH and HMO must prepare a transition plan, which is
acceptable to and approved by TDH, to ensure that Members are
reassigned to other plans without interruption of services. That
transition plan will be implemented during the 90-day period
between receipt of notice and the termination date unless
termination is the result of TDH's reasonable belief that HMO is
placing the health or welfare of Members in jeopardy.
18.2.2 If the contract is terminated by TDH for any reason other
than federal or state funds for the Medicaid program no longer
being available or if HMO terminates the contract based on lower
capitation rates for the second contract year as set out in
Article 00.0.0.0:
18.2.2.1 TDH is responsible for notifying all Members of the date of
termination and how Members can continue to receive contract
services;
18.2.2.2 HMO is responsible for all expenses related to giving notice to
Members; and
18.2.2.3 HMO is responsible for all expenses incurred by TDH in
implementing the transition plan.
1999 Renewal Contract
Tarrant Service Area
145
August 9, 1999
146
18.2.3 If the contract is terminated by HMO for any reason other
than based on lower capitation rates for the second contract year
as set out in Article 00.0.0.0:
18.2.3.1 TDH is responsible for notifying all Members of the date of
termination and how Members can continue to receive contract
services;
18.2.3.2 TDH is responsible for all expenses related to giving notice to
Members; and.
18.2.3.3 TDH is responsible for all expenses it incurs in implementing the
transition plan.
18.2.4 If the contract is terminated by mutual consent:
18.2.4.1 TDH is responsible for notifying all Members of the date of
termination and how Members can continue to receive contract
services
18.2.4.2 HMO is responsible for all expenses related to giving notice to
Members; and
18.2.4.3 TDH is responsible for all expenses it incurs in implementing the
transition plan.
18.3 SUSPENSION OF NEW ENROLLMENT
18.3.1 TDH must give HMO 30 days notice of intent to suspend new
enrollment in the Notice of Default other than for default for
fraud and abuse or imminent danger to the health or safety of
Members. The suspension date will be calculated as 30 days
following the date that HMO receives the Notice of Default.
18.3.2 TDH may immediately suspend new enrollment into HMO for a
default declared as a result of fraud and abuse or imminent danger
to the health and safety of Members.
18.3.3 The suspension of new enrollment may be for any duration,
up to the termination date of the contract. TDH will base the
duration of the suspension upon the type and severity of the
default and HMO's ability, if any, to cure the default.
18.4 LIQUIDATED MONEY DAMAGES
18.4.1 The measure of damages in the event that HMO fails to
perform its obligations under this contract may be difficult or
impossible to calculate or quantify. Therefore, should HMO fail to
perform in accordance with the terms and conditions of this
contract, TDH may require HMO to pay sums as specified
1999 Renewal Contract
Tarrant Service Area
146
August 9, 1999
147
below as liquidated damages. The liquidated damages set out in
this Article are not intended to be in the nature of a penalty but
are intended to be reasonable estimates of TDH's financial loss
and damage resulting from HMO's non-performance.
18.4.2 If TDH imposes money damages, TDH may collect those damages
by reducing the amount of any monthly premium payments otherwise
due to HMO by the amount of the damages. Money damages that are
withheld from monthly premium payments are forfeited and will not
be subsequently paid to HMO upon compliance or cure of default
unless a determination is made after appeal that the damages
should not have been imposed.
18.4.3 Failure to file or filing incomplete or inaccurate annual,
semi-annual or quarterly reports may result in money damages of
not more than $11,000.00 for every month from the month the report
is due until submitted in the form and format required by TDH.
These money damages apply separately to each report.
18.4.4 Failure to produce or provide records and information
requested by TDH, an entity acting on behalf of TDH, or an agency
authorized by statute or law to require production of records at
the time and place the records were required or requested may
result in money damages of not more than $5,000.00 per day for
each day the records are not produced as required by the
requesting entity or agency if the requesting entity or agency is
conducting an investigation or audit relating to fraud or abuse,
and not more than $1,000.00 per day for each day records are not
produced if the requesting entity or agency is conducting routine
audits or monitoring activities.
18.4.5 Failure to file or filing incomplete or inaccurate
encounter data may result in money damages of not more than
$25,000 for each month HMO fails to submit encounter data in the
form and format required by TDH. TDH will use the encounter data
validation methodology established by TDH to determine the number
of encounter data and the number of months for which damages will
be assessed.
18.4.6 Failing or refusing to cooperate with TDH, an entity acting
on behalf of TDH, or an agency authorized by statute or law to
require the cooperation of HMO in carrying out an administrative,
investigative, or prosecutorial function of the Medicaid program
may result in money damages of not more than $8,000.00 per day for
each day HMO fails to cooperate.
18.4.7 Failure to enter into a required or mandatory contract or
failure to contract for or arrange to have all services required
under this contract provided may result
1999 Renewal Contract
Tarrant Service Area
147
August 9, 1999
148
in money damages of not more than $1,000.00 per day that HMO
either fails to negotiate in good faith to enter into the required
contract or fails to arrange to have required services delivered.
18.4.8 Failure to meet the benchmark for benchmarked services
under this contract may result in money damages of not more than
$25,000 for each month that HMO fails to meet the established
benchmark.
18.4.9 TDH may also impose money damages for a default under
Article 16.3.9, Failure to Make Payments to Network Providers and
subcontractors, of this contract. These money damages are in
addition to the interest HMO is required to pay to providers under
the provisions of Articles 4.10.4 and 7.2.7.10 of this contract.
18.4.9.1 If TDH determines that HMO has failed to pay a provider for a
claim or claims for which the provider should have been paid, TDH
may impose money damages of $2 per day for each day the claim is
not paid from the date the claim should have been paid (calculated
as 30 days from the date a clean claim was received by HMO) until
the claim is paid by HMO.
18.4.9.2 If TDH determines that HMO has failed to pay a capitation amount
to a provider who has contracted with HMO to provide services on a
capitated basis, TDH may impose money damages of $10 per day, per
Member for whom the capitation is not paid, from the date on which
the payment was due until the capitation amount is paid.
18.5 APPOINTMENT OF TEMPORARY MANAGEMENT
18.5.1 TDH may appoint temporary management to oversee the
operation of HMO upon a finding that there is continued egregious
behavior by HMO or there is a substantial risk to the health of
the Members.
18.5.2 TDH may appoint temporary management to assure the health
of HMO's Members if there is a need for temporary management
while:
18.5.2.1 there is an orderly termination or reorganization of HMO; or
18.5.2.2 are made to remedy violations found under Article 16.3.4.
18.5.3 Temporary management will not be terminated until TDH has
determined that HMO has the capability to ensure that the
violations that triggered appointment of temporary management will
not recur.
1999 Renewal Contract
Tarrant Service Area
148
August 9, 1999
149
18.5.4 TDH is not required to appoint temporary management before
terminating this contract.
18.5.5 No pre-termination hearing is required before appointing
temporary management.
18.5.6 As with any other remedy provided under this contract, TDH
will provide notice of default as is set out in Article XVII to
HMO. Additionally, as with any other remedy provided under this
contract, under Article 18.1 of this contract, HMO may dispute the
imposition of this remedy and seek review of the proposed remedy.
18.6 TDH-INITIATED DISENROLLMENT OF A MEMBER OR MEMBERS WITHOUT
CAUSE
TDH must give HMO 30 days notice of intent to initiate
disenrollment of a Member of Members in the Notice of Default. The
TDH-initiated disenrollment date will be calculated as 30 days
following the date that HMO receives the Notice of Default.
18.7 RECOMMENDATION TO HCFA THAT SANCTIONS BE TAKEN AGAINST HMO
18.7.1 If HCFA determines that HMO has violated federal law or
regulations and that federal payments will be withheld, TDH will
deny and withhold payments for new enrollees of HMO.
18.7.2 HMO must be given notice and opportunity to appeal a
decision of TDH and HCFA pursuant to 42 CFR '434.67.
18.8 CIVIL MONETARY PENALTIES
18.8.1 For a default under Article 16.3.4.1, TDH may assess not more than
$25,000 for each default;
18.8.2 For a default under Article 16.3.4.2, TDH may assess double the
excess amount charged in violation of the federal requirements for
each default. The excess amount shall be deducted from the penalty
and returned to the Member concerned.
18.8.3 For a default under Article 16.3.4.3, TDH may assess not more than
$100,000 for
1999 Renewal Contract
Tarrant Service Area
149
August 9, 1999
150
each default, including $15,000 for each individual not enrolled
as a result of the practice described in Article 16.3.4.3.
18.8.4 For a default under Article 16.3.4.4, TDH may assess not more than
$100,000 for each default if the material was provided to HCFA or
TDH and not more than $25,000 for each default if the material was
provided to a Member, a potential Member, or a health care
provider.
18.8.5 For a default under Article 16.3.4.5, TDH may assess not more than
$25,000 for each default.
18.8.6 For a default under Article 16.3.4.6, TDH may assess not more than
$25,000 for each default.
18.8.7 HMO may be subject to civil money penalties under the provisions
of 42 CFR 1003 in addition to or in place of withholding payments
for a default under Article 16.3.4.
18.9 FORFEITURE OF ALL OR A PART OF THE TDI PERFORMANCE BOND
TDH may require forfeiture of all or a portion of the face amount
of the TDI performance bond if TDH determines that an event of
default has occurred. Partial payment of the face amount shall
reduce the total bond amount available pro rata.
18.10 REVIEW OF REMEDY OR REMEDIES TO BE IMPOSED
18.10.1 HMO may dispute the imposition of any sanction under this
contract. HMO notifies TDH of its dispute by filing a written
response to the Notice of Default, clearly stating the reason HMO
disputes the proposed sanction. With the written response, HMO
must submit to TDH any documentation that supports HMO's position.
HMO must file the review within 15 days from HMO's receipt of the
Notice of Default. Filing a dispute in a written response to the
Notice of Default suspends imposition of the proposed sanction.
18.10.2 HMO and TDH must attempt to informally resolve the dispute. If
HMO and TDH are unable to informally resolve the dispute, HMO must
notify the Bureau Chief of Managed Care that HMO and TDH cannot
agree. The Bureau Chief will refer the dispute to the Associate
Commissioner for Health Care Financing who will appoint a
committee to review the dispute under TDH's dispute resolution
procedures. The decision of the dispute resolution committee will
be TDH's final administrative decision.
1999 Renewal Contract
Tarrant Service Area
150
August 9, 1999
151
ARTICLE XIX TERM
19.1 The effective date of this contract is _AUGUST 30_______, 1999.
This contract will terminate on August 31, 2001, unless terminated
earlier as provided for elsewhere in this contract.
19.2 This contract may be renewed for an additional one-year period by
written amendment to the contract executed by the parties prior to
the termination date of the present contract. TDH will notify HMO
no later than 90 days before the end of the contract period of its
intent not to renew the contract.
19.3 If either party does not intend to renew the contract beyond its
contract period, the party intending not to renew must submit a
written notice of its intent not to renew to the other party no
later than 90 days before the termination date set out in Article
19.1.
19.4 If either party does not intend to renew the contract beyond its
contract period and sends the notice required in Article 19.3, a
transition period of 90 days will run from the date the notice of
intent not to renew is received by the other party. By signing
this contract, the parties agree that the terms of this contract
shall automatically continue during any transition period.
19.5 The party that does not intend to renew the contract beyond its
contract period and sends the notice required by Article 19.3 is
responsible for sending notices to all Members on how the Member
can continue to receive covered services. The expense of sending
the notices will be paid by the non-renewing party. If TDH does
not intend to renew and sends the required notice, TDH is
responsible for any costs it incurs in ensuring that Members are
reassigned to other plans without interruption of services. If HMO
does not intend to renew and sends the required notice, HMO is
responsible for any costs TDH incurs in ensuring that Members are
reassigned to other plans without interruption of services. If
both parties do not intend to renew the contract beyond its
contract period, TDH will send the notices to Members and the
parties will share equally in the cost of sending the notices and
of implementing the transition plan.
19.6 Non-renewal of this contract is not a contract termination for
purposes of appeal rights under the Human Resources Code Section
32.034.
1999 Renewal Contract
Tarrant Service Area
151
August 9, 1999
152
SIGNED 30TH day of August , 1999.
----------------------------- ---------------------------
TEXAS DEPARTMENT OF HEALTH HMO Name
BY: BY:
---------------------------- ------------------------------
Xxxxxxx X. Xxxxxx III, M.D. Printed Name: XXXXX X. XXXXXXX, XX.
Commissioner of Health ------------------------------
Title: PRESIDENT AND CEO
------------------------------
Approved as to Form:
Office of General Counsel
APPENDICES
Copies of the Appendices A-M will be available in the Regulatory Department upon
request.
OR# 024804
7526032317 * 2001 01A
AMENDMENT NO. 1
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
THE TEXAS DEPARTMENT OF HEALTH AND HMO
This Amendment No. 1 is entered into between the Texas Department of Health and
AMERICAID Texas, Inc. dba AMERICAID Community Care (HMO), to amend the Contract
for Services between the Texas Deparment of Health and HMO, in the Tarrant
Service Area, dated August 26, 1999. The effective date of this Amendment is
September 1, 1999. All other contract provisions remain in full force and
effect.
(The amended sections which have been BOLDED are shown throughout the entire
contract)
1999 Renewal Contract
Tarrant Service Area
152
August 9, 1999
153
1999 Renewal Contract
Tarrant Service Area
153
August 9, 1999
