EXHIBIT 10.4a
AMENDMENT NO. 7
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
THE HEALTH AND HUMAN SERVICES COMMISSION AND HMO
This Amendment No. 7 is entered into between the Health and Human Services
Commission (HHSC) and Superior Health Plan, Inc. (HMO) in El Paso Service Area,
to amend the 1999 Contract for Services between the Health and Human Services
Commission and HMO. The effective date of this Amendment is the date HHSC Signs
this Amendment. All other contract provisions remain in full force and effect.
The Parties agree to amend the Contract as follows:
1. ARTICLE XVIII IS AMENDED TO READ AS FOLLOWS:
15.2 AMENDMENT AND CHANGE REQUEST PROCESS
15.2.1 HHSC 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, the contract may be terminated under Article
XVIII.
15.2.2 This contract must be amended if either party discovers a
material omission of a negotiated or required term, which is
essential to the successful performance or maintaining
compliance with the terms of the contract. The party discovering
the omission must notify the other party of the omission in
writing as soon as possible after discovery. If there is a
disagreement regarding whether the omission was intended to be a
term of the contract, the parties must submit the dispute to
dispute resolution under Article 15.9.
15.2.3 This contract may be amended at any time by mutual agreement.
15.2.4 All amendments to this contract must be in writing and signed by
both parties.
15.2.5 Any change in either party's obligations under this contract
("Change") requires a written amendment to the contract that is
negotiated using the process outlined in Article 15.2.6.
15.2.6 Change Request Process.
October 30, 2001 1 of 3
15.2.6.1 If federal or state laws, rules, regulations, policies or
guidelines are adopted, promulgated, judicially interpreted or
changed, or if contracts are entered into or changed, the effect
of which is to alter the ability of either party to fulfill its
obligations under this contract, the parties will promptly
negotiate in good faith, using the process outlined in Article
15.2.6, appropriate modifications or alterations to the contract
and any appendix (appendices) or attachments(s) made a part of
this contract.
15.2.6.2 Change Order Approval Procedure
15.2.6.2.1 During the term of this contract, HHSC or HMO may propose
changes in the services, deliverables, or other aspects of this
contract ("Changes"), pursuant to the procedures set forth in
this article.
15.2.6.2.2 If HHSC proposes a Change, it shall deliver to the HMO a written
notice describing the proposed Change which includes the State's
estimated fiscal impact on the HMO, if available ("Change Order
Request"). HMO must respond to such proposal within 30 calendar
days of receipt by preparing and delivering to HHSC, at no
additional cost to HHSC a written document (a "Change Order
Response"), that specifies:
15.2.6.2.2.1 The financial impact, if any, of the Change Order Request on the
HMO and the manner in which such impact was calculated;
15.2.6.2.2.2 The effect, if any, of the Change Order Request on HMO's
performance of its obligations under this contract, including
the effect on the services or deliverables;
15.2.6.2.2.3 The anticipated time schedule for implementing the Change Order
Request; and
15.2.6.2.2.4 Any other information requested in the Change Order Request or
which is reasonably necessary for HHSC to make an informed
decision regarding the proposal.
15.2.6.2.3 If HMO proposes a Change, it must deliver a HMO Change Order
Request to HHSC that includes the proposed Change and
information described in Articles 15.2.6.2.2.1 - 15.2.6.2.2.4
for a Change Order Response. HHSC must respond to HMO within 30
calendar days of receipt of this information.
15.2.6.2.4 Upon HHSC's receipt of a Change Order Request or a Change Order
Response, the Parties shall negotiate a resolution of the
requested Change in good faith. The parties will exchange
information in good faith in an attempt to agree upon the
requested Change.
October 30, 2001 2 of 3
15.2.6.3 No Change to the services or deliverables or any other aspect of
this contract will become effective without the written approval
and execution of a mutually agreeable written amendment to this
contract by HHSC and the HMO. Under no circumstances will the
HMO be entitled to payment for any work or services rendered
under a Change Order that has not been approved by HHSC in
accordance with the Change Order Procedures.
15.2.7 The implementation of an amendment to this contract is subject
to the approval of the Centers for Medicare and Medicaid
Services (CMS, formerly called HCFA).
2. APPENDIX C: Appendix C is deleted in its entirety and is replaced by a new
Appendix C which is Attachment No. 1 to this amendment. This amendment
provides for the addition of "Special Programs for Illness" for gestational
diabetes and the modification of the "Prenatal Program with Gifts".
AGREED AND SIGNED by an authorized representative of the parties on
_________________ 2001.
Health and Human Services Commission Superior Health Plan, Inc.
By: /s/ Xxx X. Xxxxxxx By: /s/ Xxxxxxx Xxxxxxxx
--------------------------- ----------------------------------
Don. A Xxxxxxx Xxxxxxx Xxxxxxxx
President & CEO, Centene
Approved as to Form:
-----------------------------
Office of General Counsel
October 30, 2001 3 of 3
AMENDMENT NO. 8
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
HEALTH AND HUMAN SERVICES COMMISSION AND HMO
This Amendment No. 8 is entered into between the Health and Human Services
Commission (HHSC) and Superior Health Plan, Inc. (HMO), to amend the Contract
for Services between the Health and Human Services Commission and HMO in the El
Paso Service Area. The effective date of this amendment is January 1, 2002. The
Parties agree to amend the Contract as follows:
1. Article XIII is amended to read as follows:
ARTICLE XIII PAYMENT PROVISIONS
13.1 CAPITATION AMOUNTS
13.1.2 HMO capitation rates listed below reflect program increases
appropriated by the 76th and 77th legislatures for physician
services (to include THSteps providers) and outpatient
facility services. Rates will be increased starting January 1,
2002, to reflect increases in traditional fee-for-service
payments for 1) Evaluation and Management Level 3 services
(procedure code 99213), and 2) high-volume providers. The
methodology for determining high-volume providers will be
distributed to HMO by HHSC ("High-volume Provider
Methodology"). The first rate increase will be effective
January 1, 2002, and will reflect increases for procedure code
99213. Rate increases for high volume providers will be
effective the first day of the month after the "High-volume
Provider Methodology" is released by HHSC. The Methodology
will state the amount of each increase (99213 and high-volume
provider). Final rates with all increases included are shown
in the table below.
13.1.2. HMO must submit reports to HHSC indicating the methodology
used and must certify that the funds provided to the HMO for
the pass through have been passed through to providers. HMO
must use the reporting format specified by HHSC and follow the
reporting schedule indicated on the HHSC deliverables matrix.
PPAC Rate Increase Amendment 12/12/01
13.1.2.2 Capitation Rates
Risk Group Monthly Capitation Amounts
---------- --------------------------
TANF Adults $ 178.98
TANF Children > 12 Months $ 84.24
of Age
Expansion Children > 12 $ 72.77
Months of Age
Newborns (12 Months of $ 363.27
Age)
TANF Children 12 Months $ 363.27
of Age
Expansion Children 12 $ 363.27
Months of Age
Federal Mandate Children $ 47.90
CHIP Phase I $ 62.04
Pregnant Women $ 216.51
Disabled/Blind $ 14.00
Administration
13.1.2.3 Delivery Supplemental Payment. A one-time per pregnancy
supplemental payment for each delivery shall be paid to HMO in
the following amount: $2,992.02. 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.
13.1.2.4 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.
13.1.2.5 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
PPAC Rate Increase Amendment 12/12/01
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.
13.1.2.6 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.
13.1.2.7 The DSP will be made by TDH to HMO within twenty (20) state
working days after receiving an accurate report from HMO.
13.1.2.8 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.
AGREED AND SIGNED by an authorized representative of the parties on
______________________________2001.
Health and Human Services Commission Superior Health Plan, Inc.
By: /s/ Xxx X. Xxxxxxx By: /s/ Xxxxxxx Xxxxxxxx
-------------------------- -------------------------------
Xxx X. Xxxxxxx Xxxxxxx Xxxxxxxx
President & CEO, Centene
Approved as to Form:
------------------------------------
Office of General Counsel
PPAC Rate Increase Amendment 12/12/01
AMENDMENT 9
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
SUPERIOR HEALTH PLAN, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR PROGRAM
IN THE
EL PASO SERVICE DELIVERY AREA
AMENDMENT 9
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
SUPERIOR HEALTH PLAN, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR PROGRAM IN THE EL PASO SDA
ARTICLE 1. PURPOSE................................................................................................... 1
SECTION 1.01 AUTHORIZATION......................................................................................... 1
SECTION 1.02 GENERAL EFFECTIVE DATE OF CHANGES..................................................................... 1
ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES............................................................... 1
SECTION 2.01 GENERAL............................................................................................... 1
SECTION 2.02 MODIFICATION OF SECTION 1.4, RENEWAL REVIEWS.......................................................... 1
SECTION 2.03 MODIFICATION OF ARTICLE 2, DEFINITIONS................................................................ 2
SECTION 2.04 MODIFICATION OF SECTION 3.4, PLAN MATERIALS AND DISTRIBUTION OF PLAN MATERIALS........................ 3
SECTION 2.05 MODIFICATION OF SECTION 3.5, RECORDS REQUIREMENT AND RECORDS RETENTION................................ 3
SECTION 2.06 MODIFICATION OF SECTION 3.7, HMO TELEPHONE ACCESS REQUIREMENTS........................................ 3
SECTION 2.07 MODIFICATION OF SECTION 4.3, PERFORMANCE BOND......................................................... 4
SECTION 2.08 MODIFICATION OF SECTION 4.6, AUDIT.................................................................... 4
SECTION 2.09 MODIFICATION OF SECTION 4.9, THIRD PARTY RECOVERY..................................................... 4
SECTION 2.10 MODIFICATION OF SECTION 4.10, CLAIMS PROCESSING REQUIREMENTS.......................................... 4
SECTION 2.11 MODIFICATION TO SECTION 5.4, SAFEGUARDING INFORMATION................................................. 5
SECTION 2.12 MODIFICATION OF SECTION 5.6, HISTORICALLY UNDERUTILIZED BUSINESSES (HUBS)............................. 5
SECTION 2.13 MODIFICATION OF SECTION 5.10, NOTICE AND APPEAL....................................................... 6
SECTION 2.14 MODIFICATION OF SECTION 6.3, SPAN OF ELIGIBILITY...................................................... 6
SECTION 2.15 MODIFICATION OF SECTION 6.4, CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS.......................... 7
SECTION 2.16 MODIFICATION OF SECTION 6.5, EMERGENCY SERVICES....................................................... 8
SECTION 2.17 MODIFICATION OF SECTION 6.6, BEHAVIORAL HEALTH CARE SERVICES - SPECIFIC REQUIREMENTS.................. 8
SECTION 2.18 MODIFICATION TO SECTION 6.16, BLIND AND DISABLED MEMBERS.............................................. 9
SECTION 2.19 MODIFICATION OF SECTION 8.4, MEMBER ID CARDS.......................................................... 9
SECTION 2.20 MODIFICATION OF SECTION 10.1, MODEL MIS REQUIREMENTS.................................................. 9
SECTION 2.21 MODIFICATION OF SECTION 10.4, PROVIDER SUBSYSTEM...................................................... 9
SECTION 2.22 MODIFICATION OF SECTION 10.9, DATA INTERFACE SUBSYSTEM................................................ 9
SECTION 2.23 MODIFICATION OF SECTION 10.11, YEAR 2000 (Y2K) COMPLIANCE.............................................10
SECTION 2.24 ADDITION OF SECTION 10.12, HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
(HIPAA) COMPLIANCE.............................................................................................. 10
SECTION 2.25 MODIFICATION OF SECTION 12.1., FINANCIAL REPORTS..................................................... 10
SECTION 2.26 MODIFICATION OF SECTION 12.4, SUMMARY REPORT OF PROVIDER COMPLAINTS.................................. 11
SECTION 2.27 MODIFICATION OF SECTION 12.6, MEMBER COMPLAINTS...................................................... 12
SECTION 2.28 MODIFICATION OF SECTION 12.13, EXPEDITED PRENATAL OUTREACH REPORT.................................... 12
SECTION 2.29 ADDITION OF SECTION 12.14, MEMBER HOTLINE PERFORMANCE REPORT......................................... 12
SECTION 2.30 ADDITION OF SECTION 12.15, SUBMISSION OF STAR DELIVERABLES/REPORTS................................... 12
SECTION 2.31 MODIFICATIONS TO SECTION 13.1, CAPITATION AMOUNTS.................................................... 13
SECTION 2.32 MODIFICATION OF SECTION 13.2, EXPERIENCE REBATE TO THE STATE......................................... 14
SECTION 2.33 SECTION 13.3, PERFORMANCE OBJECTIVES................................................................. 15
SECTION 2.34 MODIFICATION OF SECTION 13.5, NEWBORN AND PREGNANT WOMEN PAYMENT PROVISIONS.......................... 15
SECTION 2.35 MODIFICATION OF SECTION 14.3, NEWBORN ENROLLMENT..................................................... 16
SECTION 2.36 MODIFICATION OF SECTION 15.12, NOTICES............................................................... 16
SECTION 2.37 MODIFICATION OF SECTION 18.1.6, TERMINATION BY HMO................................................... 16
SECTION 2.38 MODIFICATION OF SECTION 18.10, REVIEW OF REMEDY OR REMEDIES TO BE IMPOSED.............................16
SECTION 2.39 MODIFICATION OF SECTION 19.1, CONTRACT TERM...........................................................17
SECTION 2.40 MODIFICATIONS TO CONTRACT APPENDICES..................................................................17
ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES..............................................................17
i
HHSC XXXXXXXX XX. 000-00-000
XXXXX XX XXXXX
XXXXXX OF XXXXXX
AMENDMENT 9
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
SUPERIOR HEALTH PLAN, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR PROGRAM
IN THE
EL PASO SERVICE DELIVERY AREA
THIS CONTRACT AMENDMENT (the "Amendment") is entered into between the
HEALTH & HUMAN SERVICES COMMISSION ("HHSC"), an administrative agency within the
executive department of the State of Texas, and Superior Health Plan, Inc.
("HMO"), a health maintenance organization organized under the laws of the State
of Texas, possessing a certificate of authority issued by the Texas Department
of Insurance to operate as a health maintenance organization, and having its
principal office at: 0000 X. XX-00, Xxxxx 000, Xxxxxx, XX 00000. HHSC and HMO
may be referred to in this Amendment individually as a "Party" and collectively
as the "Parties."
The Parties hereby agree to amend their Agreement as set forth in Article 2
of this Amendment.
ARTICLE 1. PURPOSE.
SECTION 1.01 AUTHORIZATION.
This Amendment is executed by the Parties in accordance with Section 15.2
of the Agreement.
SECTION 1.02 GENERAL EFFECTIVE DATE OF CHANGES.
This Amendment is effective SEPTEMBER 1, 2002, and terminates on August 31,
2003, unless extended or terminated sooner in accordance with the Agreement.
ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES
SECTION 2.01 GENERAL
The Health Care Financing Administration (HCFA) has had a name change to
the Centers for Medicare and Medicaid Services (CMS). All references to HCFA in
the Agreement should be replaced with CMS.
SECTION 2.02 MODIFICATION OF SECTION 1.4, RENEWAL REVIEWS
Section 1.4 is replaced with the following language:
"Renewal Review. At its sole discretion, HHSC may choose
to conduct a renewal review of HMO's performance and
compliance with this contract as a condition for retention and
renewal."
HHSC Contract 529-03-044l
Page 1 of 17
SECTION 2.03 MODIFICATION OF ARTICLE 2, DEFINITIONS
(a) The following terms amend and modify the definitions set forth in
Article 2:
"CMS means the Centers for Medicare and Medicaid
Services, formerly known as the Health Care Financing
Administration (HCFA), which is the federal agency responsible
for administering Medicare and overseeing state administration
of Medicaid.
EMERGENCY MEDICAL CONDITION means a medical condition
manifesting itself by acute symptoms of recent onset and
sufficient severity (including severe pain), such that a
prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of
immediate medical care could result in: (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. FAIR HEARING means the process adopted and implemented
by the Texas Health and Human Services Commission, 25 TAC
Chapter 1, in compliance with federal regulations and state
rules relating to Medicaid Fair Hearings.
HEDS means the HMO/EPO/Dental Services Division of
the Texas Health and Human Services Commission.
HHSC means the Texas Health and Human Services
Commission or its designees.
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 1 TAC, Subchapter 354.2301 et seq., relating to
Third Party Resources).
TP 40 means Type Program 40, which is a TDHS Medicaid
program eligibility type assigned to pregnant women under 185%
of the federal poverty level (FPL).
TP 45 means Type Program 45, which is a TDHS Medicaid
program eligibility code assigned to newborns (under 12
months) who are born to mothers who are Medicaid eligible at
the time of the child's birth.
TEXMEDNET means Texas Medical Network, which is the
State's information system that processes claims and
encounters. TexMedNet's functions include, but are not limited
to eligibility verification, claims and encounters
submissions, e-mail communications, and electronic funds
transfers."
(b) The term "HHSCS" is deleted and replaced with "TDHS" as defined in
Article 2 of the Contract.
(c) The term "THHSC" is deleted and replaced with "HHSC" as defined above.
HHSC Contract 000-00-000
Page 2 of 17
SECTION 2.04 MODIFICATION OF SECTION 3.4, PLAN MATERIALS AND DISTRIBUTION OF
PLAN MATERIALS
Section 3.4.3 is replaced with the following language:
"3.4.3 All plan materials regarding the STAR Program,
including Member education materials, must be submitted to
HHSC for approval prior to distribution. HHSC has fifteen (15)
working days to review the materials and recommend any
suggestions or required changes. If HHSC has not responded to
HMO by the fifteenth (15th) day, HMO may print and distribute
these materials. HHSC 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 fifteen (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 generally be reviewed by HHSC within five (5)
working days. HHSC 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, as determined by HHSC.
SECTION 2.05 MODIFICATION OF SECTION 3.5, RECORDS REQUIREMENT AND RECORDS
RETENTION
Section 3.5.1 is replaced with the following language:
"3.5.1 HMO must keep all records required to be
created and retained under this Agreement in accordance with
the standards set forth herein. Records related to Members
served in the HMO's service area(s) must be made available in
HMO's local office when requested by HHSC.
Original records, except paper claims, must be kept
in the form they were created in the regular course of
business for a minimum of three (3) years following the
expiration of the contract period, including any extensions.
Paper claims may be digitally copied from the time of initial
receipt, if the HMO: 1) receives HHSC prior written approval;
2) certifies that an unaltered copy of the original claim
received can be produced upon request; 3) the retention system
is reliable and supported by a retrieval system that allows
reasonable accurate records. HHSC may require the HMO to
retain the records for an additional period if an audit,
litigation or administrative action involving the records
exists."
SECTION 2.06 MODIFICATION OF SECTION 3.7, HMO TELEPHONE ACCESS REQUIREMENTS
Section 3.7.1 is replaced with the following language:
3.7.1 For all HMO telephone access (including
Behavioral Health telephone services), HMO must ensure
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%;
HHSC Contract 000-00-000
Page 3 of 17
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.
4. Telephone services must meet cultural competency
requirements (see Article 8.8) and provide "linguistic access"
to all members as defined in Article II. This would include
the provision of interpretive services required for effective
communication for Members and providers.
SECTION 2.07 MODIFICATION OF SECTION 4.3, PERFORMANCE BOND
Section 4.3 is replaced with the following language:
"4.3 HMO has furnished HHSC with a performance bond
in the form prescribed by HHSC and approved by TDI, naming
HHSC as Obligee, securing HMO's faithful performance of the
terms and conditions of this Agreement. The performance bond
must be issued in the amount of $100,000 for the Contract
Period, plus an additional 12 months after the expiration of
the Contract Period. If the Contract Period is renewed or
extended pursuant to Article 15, the HMO must replace the
performance bond with a separate bond covering performance
during the renewal or extension period, plus an additional 12
months. The bond must be issued by a surety licensed by TDI,
and specify cash payment as the sole remedy. HMO must deliver
the bond to HHSC at the same time the signed HMO contract,
renewal or extension is delivered to HHSC."
SECTION 2.08 MODIFICATION OF SECTION 4.6, AUDIT
Section 4.6.2 is replaced with the following language:
"4.6.2 HHSC or its designee will conduct an audit of
HMO at least once every two 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
Agreement."
SECTION 2.09 MODIFICATION OF SECTION 4.9, THIRD PARTY RECOVERY
Section 4.9.2 is replaced with the following language:
"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
HHSC to obtain information from other state and federal
agencies and HMO must cooperate with HHSC in obtaining
information from commercial third party resources. HMO must
require all providers to comply with the provisions of 1 TAC
Section 354.2301, et seq., relating to Third Party Recovery in
the Medicaid program."
SECTION 2.10 MODIFICATION OF SECTION 4.10, CLAIMS PROCESSING REQUIREMENTS
Section 4.10.8 is replaced with the following language:
HHSC Contract 000-00-000
Page 4 of 17
"4.10.8 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
(HIPAA), Public Law 104-191, regarding 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 (see 45 CFR parts 160 through 164).
SECTION 2.11 MODIFICATION TO SECTION 5.4, SAFEGUARDING INFORMATION
Section 5.4.1 is replaced with the following language:
"5.4.1 The use and disclosure of all Member
information, records, and data (Member Information) collected
or provided to HMO by HHSC or another state agency is
protected by state and federal law and regulations, including,
but not limited to, the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), Public law 104-191, and 45
CFR parts 160 through 164. HMO agrees to ensure that any of
its agents, including subcontractors, to whom HMO discloses
Member Information agrees to the same restrictions and
conditions that apply to HMO with respect to Member
Information.
SECTION 2.12 MODIFICATION OF SECTION 5.6, HISTORICALLY UNDERUTILIZED BUSINESSES
(HUBS)
Sections 5.6.1 through 5.6.3 are replaced with the following language:
"5.6.1 In accordance with Texas Government Code
Chapter 2161 and 1 TAC Section 111.11 et seq. and ss.392.100
state agencies are required to make a good faith effort to
assist Historically Underutilized Businesses (HUBs) in
receiving contract awards issued by the State. The goal of
this program is to promote full and equal business opportunity
for all businesses in contracting with the state. It is HHSC's
intent that all contractors make a good faith effort to
subcontract with HUBs during the performance of their
contracts.
IMPORTANT NOTE: The Health and Human Services
Commission has concluded that HUB subcontracting opportunities
may exist in connection with this contract. See Appendix B to
the Agreement for the following instructions and form:
"Grant/Contract Applicants Client Services HUB Subcontracting
Plan Instructions" (C-IGA), and Determination of Good Faith
Effort for Grant Contracts (C-DGFE). If an approved HUB
subcontracting plan is not already on file with HHSC, THE HMO
SHALL SUBMIT A COMPLETED C-DGFE FORM ALONG WITH THE SIGNED
CONTRACT OR RENEWAL.
If HMO responds, `yes' to question two on Form
C-DGFE, HMO shall document good faith efforts to develop a HUB
Subcontracting Plan by completing and documenting the steps on
form C-DGFE. Additionally, quarterly reports on HUB
subcontracting are required according to the schedule on Form
C-QSR. Quarterly Report forms are included in Appendix B of
this amendment.
HHSC Contract 000-00-000
Page 5 of 17
If HMO decides after the award to subcontract any
part of the contract, the HMO shall notify the contract
manager prior to entering into any subcontract. The HMO shall
comply with the good faith effort requirements relating to
developing and submitting a subcontracting plan.
5.6.2 HMO is required to submit HUB quarterly reports
to HHSC as required in Article 12.11.
5.6.3 HHSC will assist HMO in meeting the contracting
and reporting requirements of this Article."
SECTION 2.13 MODIFICATION OF SECTION 5.10, NOTICE AND APPEAL
Section 5.10 is replaced with the following:
"5.10 HMO must comply with the notice requirements
contained in 1 TAC Section 354.2211, and the maintaining
benefits and services contained in 1 TAC Section 354.2213,
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 8.6 of this
Agreement."
SECTION 2.14 MODIFICATION OF SECTION 6.3, SPAN OF ELIGIBILITY
Section 6.3 and its subparts are replaced with the following language"
"6.3 The following outlines HMO's responsibilities
for payment of hospital and freestanding psychiatric facility
(facility) admissions:
6.3.1 The payor responsible for the hospital/facility
charges at the start of an inpatient stay remains responsible
for hospital/facility charges until the time of discharge, or
until such time that there is a loss of Medicaid eligibility.
6.3.2 HMO is responsible for professional charges
during every month for which the payor receives a full
capitation payment.
6.3.3 HMO is not responsible for any services after
effective date of loss of Medicaid eligibility
6.3.4 Plan Change. A Member cannot change from one
STAR health plan to another STAR health plan during an
inpatient hospital stay.
6.3.5 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.
6.3.6 HMO insolvency or receivership. HMO is
responsible for payment of all services provided to a person
who was a Member on the date of insolvency or receivership to
the same extent they would otherwise be responsible under this
Article 6.3.
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6.3.7 For purposes of this Section 6.3, a Member
"loses Medicaid eligibility" when:
6.3.7.1 Medicaid eligibility is terminated and never
regained under one Medicaid Type Program with no subsequent
transfer of eligibility to another Medicaid Type Program; or
6.3.7.2 Medicaid eligibility is terminated and there
is a lapse of at least one month in regular Medicaid coverage.
The term "regular Medicaid coverage" refers to either
traditional fee-for-service Medicaid or Medicaid managed care
coverage; or
6.3.7.3 A client re-applies for Medicaid eligibility
and is certified for prior Medicaid coverage, as defined by
TDHS, for any month(s) prior to the month of application. The
term "prior Medicaid coverage" refers to Applicants who are
eligible for Medicaid coverage during the three-month period
before the month they apply for TANF or Medical Programs.
Prior Medicaid coverage may be continuous or there may be
interrupted periods of eligibility involving all or some of
the certified Members.
Administrative process limitations within the State's
application and recertification process do not constitute a
"loss of Medicaid eligibility".
SECTION 2.15 MODIFICATION OF SECTION 6.4, CONTINUITY OF CARE AND OUT-OF-NETWORK
PROVIDERS
Section 6.4.3 is replaced with the following language:
"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. This Article
does not extend the obligation of HMO to reimburse the
Member's existing out-of-network providers for 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 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.
6.4.3.1 HMO will pay reasonable and customary rates
for all out-of-network provider claims with dates of service
between September 1, 2002 and November 30, 2002. HMO must
forward any complaints submitted by out-of-network providers
during this time to HHSC. HHSC will review all complaints and
determine whether payments were reasonable and customary. HHSC
will direct the HMO to pay a reasonable and customary amount,
as determined by HHSC, if it concludes that the payments were
not reasonable and customary for the provider. Failure to
comply with this provision constitutes a default under Article
XVI, Default and Remedies.
6.4.3.2 For all out-of-network provider claims with
dates of service on or after December 1, 2002, HMO must pay
providers a reasonable and
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customary amount consistent with a methodology approved by
HHSC. HMO must submit its methodology, along with any
supporting documentation, to HHSC by September 30, 2002. HHSC
will review and respond to the information by November 15,
2002. HMO must forward any complaints by out-of-network
providers submitted after December 1, 2002 to HHSC, which will
review all complaints. If HHSC determines that payment is not
consistent with the HMO's approved methodology, the HMO must
pay the provider a rate, using the approved reasonable and
customary methodology, as determined by HHSC. Failure to
comply with this provision constitutes a default under Article
XVI, Default and Remedies.
SECTION 2.16 MODIFICATION OF SECTION 6.5, EMERGENCY SERVICES
Section 6.5.1 is replaced with the following language:
"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.
6.5.1.1 For all out-of-network providers, HMO will pay a
reasonable and customary amount for emergency services.
HMO will pay a reasonable and customary amount for
services for all out-of-network emergency services provider
claims with dates of service between September 1, 2002 and
November 30, 2002. HMO must forward any complaints submitted
by out-of-network emergency services providers during this
time to HHSC. HHSC will review all complaints and determine
whether payments were reasonable and customary. HHSC will
direct the HMO to pay a reasonable and customary amount, as
determined by HHSC, if it concludes that the payments were not
reasonable and customary for the provider.
6.5.1.2 For all out-of-network emergency services
provider claims with dates of service on or after December 1,
2002, HMO must pay providers a reasonable and customary amount
consistent with a methodology approved by HHSC. HMO must
submit its methodology, along with any supporting
documentation, to HHSC by September 30, 2002. HHSC will review
and respond to the information by November 15, 2002. HMO must
forward any complaints by out-of-network emergency services
providers submitted after December 1, 2002 to HHSC, which will
review all complaints. If HHSC determines that payment is not
consistent with the HMO's approved methodology, the HMO must
pay the emergency services provider a rate, using the approved
reasonable and customary methodology, as determined by HHSC.
Failure to comply with this provision constitutes a default
under Article XVI, Default and Remedies.
SECTION 2.17 MODIFICATION OF SECTION 6.6, BEHAVIORAL HEALTH CARE SERVICES -
SPECIFIC REQUIREMENTS
Section 6.6.5 is replaced with the following language:
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"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. HHSC may
require use of other assessment instrument/outcome measures in
addition to the DSM-IV. Providers must document DSM-IV and
assessment/outcome information in the Member's medical
record."
SECTION 2.18 MODIFICATION TO SECTION 6.16, BLIND AND DISABLED MEMBERS
Section 6.16.1 is replaced with the following language:
"6.16.1 Blind and disabled Members' SSI status is
effective the date of State's eligibility system, SAVERR,
identifies the Member as Type Program 13 (TP13). On this
effective date, the Member becomes a voluntary STAR enrollee.
The State is responsible for updating the State's
eligibility system within 45 days of official notice of the
Members' federal SSI eligibility by the Social Security
Administration (SSA).
SECTION 2.19 MODIFICATION OF SECTION 8.4, MEMBER ID CARDS
Section 8.4.1 is replaced with the following language:
"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."
SECTION 2.20 MODIFICATION OF SECTION 10.1, MODEL MIS REQUIREMENTS
Section 10.1.3.6 is replaced with the following language:
"10.1.3.6 HMO is required to provide representation
to attend and participate in the HHSC Systems Workgroup as a
part of the Systems Scan Call."
SECTION 2.21 MODIFICATION OF SECTION 10.4, PROVIDER SUBSYSTEM
Subparts 7 and 8 of Section 10.4 are replaced with the following language:
"7. Support national provider number format (UPIN,
NPIN, CLIA, TPI, etc., as required by HHSC).
8. Provide Provider Network and Affiliation files 90
days prior to implementation and updates monthly. Format will
be provided by HHSC to contracted entities."
SECTION 2.22 MODIFICATION OF SECTION 10.9, DATA INTERFACE SUBSYSTEM
Section 10.9.3 is replaced with the following language:
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Page 9 of 17
"10.9.3 Provider Network and Affiliation Files. The
HMO will supply network provider data to the Enrollment Broker
and Claims Administrator. This data will consist of a Provider
Network File and a Provider Affiliation File. The HMO will
submit the Provider Network File to the Enrollment Broker and
the Provider Affiliation File to the Claims Administrator.
Both files shall accomplish the following objectives:
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.
6. Provide other (Master Provider File) information
identified by HHSC."
SECTION 2.23 MODIFICATION OF SECTION 10.11, YEAR 2000 (Y2K) COMPLIANCE
Section 10.11 is deleted in its entirety.
SECTION 2.24 ADDITION OF SECTION 10.12, HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT (HIPAA) COMPLIANCE.
Section 10.12 is added as follows:
"10.12 Health Insurance Portability and
Accountability Act (HIPAA) Compliance. HMO's system must
comply with applicable certificate of coverage and data
specification and reporting requirements promulgated pursuant
to the Health Insurance Portability and Accountability Act
(HIPPA) of 1996, P.L. 104-191 (August 21, 1996), as amended or
modified.
SECTION 2.25 MODIFICATION OF SECTION 12.1., FINANCIAL REPORTS
Sections 12.1.4, 12.1.11, and 12.13 are replaced with the following
language, and Section 12.14 is added.
Sections 12.1.2, 12.1.3, 12.1.7 and 12.1.10 are deleted in their entirety.
12.1.2 [Deleted]
12.1.3 [Deleted]
12.1.4 Final MCFS Reports. HMO must file two final
MCFS Reports for each of the following:
- The initial two-year contract period (SFY
2000-2001),
- The first one-year contract extension period
(SFY 2002), and
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o This second one-year contract extension
period (SFY 2003).
The first final report must reflect expenses incurred
during each contract period and paid through the 90th day
after the end of the contract period. The first final report
must be filed on or before the 120th day after the end of each
contract period. The second final report must reflect expenses
incurred during each contract period and paid through the
334th day after the end of the contract period. The second
final report must be filed on or before the 365th day after
the end of each contract period.
. . . .
12.1.7 [Deleted]
. . . .
12.1.10 [Deleted]
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 HHSC no
later than 60 days after the effective date of this contract.
Changes to the IBNR plan and description must be submitted to
HHSC no later than 30 days before changes to the plan are
implemented by HMO.
. . . .
12.1.13 Each report required under this Article must
be mailed to: Medicaid HMO Contract Deliverables Manager, HEDS
Division, Texas Health and Human Services Commission, X.X. Xxx
00000, Xxxxxx, Xxxxx 00000-0000 (Exception: The MCFS Report
may be submitted to HHSC via E-mail to
xxxxxxx@xxxx.xxxxx.xx.xx).
12.1.14 Bonus and/or Incentive Payment Plan. The HMO
must furnish a written Bonus and/or Incentive Payments Plan to
HHSC to determine whether such payments are allowable
administrative expenses in accordance with Appendix L, "Cost
Principles for Administrative Expenses, 11. Compensation for
Personnel Services, i. Bonuses and Incentive Payments." The
written plan must include a description of the plan's criteria
for establishing bonus and/or incentive payments, the
methodology to calculate bonus and/or incentive payments, and
the timing as to when these bonus and/or incentive payments
are to be paid. The plan and description must be submitted to
HHSC for approval no later than 30 days after the execution of
the contract and any contract renewal. If the HMO revises the
Bonus and/or Incentive Payment Plan, the HMO must submit the
revised plan to HHSC for approval prior to implementing the
plan."
SECTION 2.26 MODIFICATION OF SECTION 12.4, SUMMARY REPORT OF PROVIDER COMPLAINTS
Section 12.4 is replaced with the following language:
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"12.4 HMO must submit a Summary Report of Provider
Complaints. HMO must also reports complaints submitted to its
subcontracted risk groups (e.g., IPAs). The complaint report
format must be submitted not later than 45 days following the
end of the state fiscal quarter in a format specified by
HHSC."
SECTION 2.27 MODIFICATION OF SECTION 12.6, MEMBER COMPLAINTS
Section 12.6 is replaced with the following language:
"12.6 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 must be submitted not later than 45 days following the
end of the state fiscal quarter in a format specified by
HHSC."
SECTION 2.28 MODIFICATION OF SECTION 12.13, EXPEDITED PRENATAL OUTREACH REPORT
Section 12.13 is deleted in its entirety.
SECTION 2.29 ADDITION OF SECTION 12.14, MEMBER HOTLINE PERFORMANCE REPORT
Section 12.14 is added as follows:
"12.14 MEMBER HOTLINE PERFORMANCE REPORT
HMO must submit, on a monthly basis, a Member Hotline
Performance Report that contains all required elements set out
in Article 3.7 of this Agreement in a formant approved by
HHSC. The report is due on the 30th of the month following the
end of each month."
SECTION 2.30 ADDITION OF SECTION 12.15, SUBMISSION OF STAR DELIVERABLES/REPORTS
Section 12.15 is added as follows:
"12.15 SUBMISSION OF STAR DELIVERABLES/REPORTS
12.15.1 Electronic Mail. STAR deliverables and
reports should be submitted to HHSC via electronic mail unless
HHSC expressly provides that they must be submitted in a
different manner. Reports and deliverables that may not be
submitted electronically include, but are not limited to:
Encounter Data, Supplemental Delivery Payment data, UDT data,
and certain Member Materials.
12.15.1.1 The e-mail address for deliverables
submission is xxxxxxx@xxxx.xxxxx.xx.xx.
12.15.1.2 Electronic Mail Restrictions:
File Size: E-mail file size is limited to 2.5 MB.
Files larger than that will need to be compressed (zip file)
or split into multiple files for submission.
HHSC Contract 000-00-000
Page 12 of 17
Confidentiality: Routine STAR deliverables/reports
should not contain any member specific data that would be
considered confidential.
12.15.2 FQHC and RHC Deliverables. HMO may submit
FQHC and RHC deliverables by uploading the required
information to the Claims Administrator's Bulleting Board
System (BBS). The uploaded data must contain a unique 8-digit
control number. HMO should format the 8-digit control number
as follows:
o 2 digit plan code identification number;
o Julian date; and then
o HMO's 3-digit report number (i.e., HMO's
first report will be 001).
After uploading the data to the BBS, the HMO must
notify HHSC via e-mail that it has uploaded the data, and
include the name of the file and recipient directory. HMO must
also mail signed original report summaries, including the
corresponding 8-digit control number, to HHSC within three (3)
business days after uploading the data to the BBS.
12.15.3 Special Submission Needs. In special cases
where other submission methods are necessary, HMO must contact
the assigned Health Plan Manager for authorization and
instructions.
12.15.4 Deliverables due via Mail. HMO should mail
reports and deliverables that must be submitted by mail to the
following address: General Mail: Texas Health & Human Services
Commission HEDS Contract Deliverables X.X. Xxx 00000 Xxxxxx,
Xxxxx 00000-0000
Overnight Mail:
Texas Health & Human Services Commission
HEDS Contract Deliverables
00000 Xxxxx Xxxxx Xxxxxx
Xxxxxx, XX 00000
12.15.5 Texas Department of Insurance (TDI). The
submission of deliverables/reports to HHSC does not relieve
the Plan of any reporting requirements/responsibility with
TDI. The Plan should continue to report to TDI as they have in
the past."
SECTION 2.31 MODIFICATIONS TO SECTION 13.1, CAPITATION AMOUNTS
Section 13.1.7.1 is added:
"13.1.7.1 HMO rates for FY 2002 and FY 2003 include
pass through funds for providers, as appropriated by the 77th
Texas Legislature. HMO must file reports on pass through
methodology expenditures as requested by HHSC."
HHSC Contract 000-00-000
Page 13 of 17
SECTION 2.32 MODIFICATION OF SECTION 13.2, EXPERIENCE REBATE TO THE STATE
Sections 13.2.1, 13.2.2.1, 13.2.3, and 13.2.5 are replaced with the
following language:
"13.2.1 For the Contract Period, HMO must pay to HHSC
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 set
forth in Appendix I, as reviewed and confirmed by HHSC. HHSC
reserves the right to have an independent audit performed to
verify the information provided by HMO.
GRADUATED REBATE METHOD
--------------------------------------------------------------------------------
NET INCOME BEFORE TAXES
AS A PERCENTAGE OF
REVENUES HMO SHARE STATE SHARE
----------------------- ----------------------- ---------------------
0% - 3% 100% 0%
Over 3% - 7% 75% 25%
Over 7% - 10% 50% 50%
Over 10% - 15% 25% 75%
Over 15% 0% 100%
13.2.2.1 The experience rebate for the HMO shall be
calculated by applying the experience rebate formula in
Article 13.2.1 to the sum of the net income before taxes for
all STAR Medicaid service areas contracted between the State
and HMO.
13.2.3 Experience rebate will be based on a pre-tax
basis. Expenses for value-added services are excluded from the
determination of Net Income Before Taxes reported in the Final
MCFS Report; however, HMO may subtract from Net Income Before
Taxes, expenses incurred for value added services for the
experience rebate calculations.
13.2.5 There will be two settlements for payment(s)
of the experience rebate for SFY 2000-2001, two settlements
for payment(s) for the experience rebate for SFY 2002, and two
settlements for payment(s) for the experience rebate for SFY
2003. The first settlement for the specified contract period
shall equal 100 percent of the experience rebate as derived
from Net Income Before Taxes less the value-added services
expenses in the first final MCFS Report and shall be paid on
the same day the first final MCFS Report is submitted to HHSC
for the specified time period. The second settlement shall be
an adjustment to the first settlement and shall be paid to
HHSC on the same day that the second final MCFS Report is
submitted to HHSC for that specified time period if the
adjustment is a payment from HMO to HHSC. If the adjustment is
a payment from HHSC to HMO, HHSC shall pay such adjustment to
HMO within thirty (30) days of receipt of the second final
MCFS Report. HHSC or its agent may audit the MCFS report. If
HHSC determines that corrections to the MCFS reports are
required, based on a audit of other documentation acceptable
to HHSC, to determine an adjustment to the amount of the
second settlement, then
HHSC Contract 000-00-000
Page 14 of 17
final adjustment shall be made within three 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 12.1.4. HHSC may adjust the experience rebate if
HHSC 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. HHSC has final authority in auditing and
determining the amount of the experience rebate."
SECTION 2.33 SECTION 13.3, PERFORMANCE OBJECTIVES
Section 13.3.9 is replaced with the following language:
"13.3.9 The performance objective allocation for HMO
shall be assigned to each performance objective, described in
Appendix K, in accordance with the following percentages:
EPSDT SCREENS INCENTIVE PERCENT OF PERFORMANCE OBJECTIVE FUND
------------------------------------ ------------------------------------------
1. <12 months 12%
2. 12 to 24 months 12%
3. 25 months - 20 years 20%
IMMUNIZATIONS PERCENT OF PERFORMANCE OBJECTIVE INCENTIVE FUND
--------------------------------- -------------------------------------------------
4. <12 months 17%
5. 12 to 24 months 12%
PREGNANCY VISITS PERCENT OF PERFORMANCE OBJECTIVE INCENTIVE FUND
---------------------------------- ----------------------------------------------------
6. Initial prenatal exam 15%
7. Postpartum visit 12%
SECTION 2.34 MODIFICATION OF SECTION 13.5, NEWBORN AND PREGNANT WOMEN PAYMENT
PROVISIONS
Sections 13.5.1.1, 13.5.3 and 13.5.6 are replaced with the following
language:
"13.5.1.1 The mother of the newborn Member may
request that the newborn's health plan coverage be changed to
another HMO during the first 90 days following the date of
birth, but may only do so through the Medicaid managed care
Enrollment Broker.
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13.5.3 All non-TP45 newborns whose mothers are HMO
Members at the time of the birth will be retroactively
enrolled into the HMO by TDHS Data Control except as outlined
in Article 13.5.4.
13.5.6 HMO is responsible for payment for all covered
services provided to TP40 members by in-network or
out-of-network providers from the date of enrollment in HMO,
but prior to HMO receiving TP40 Member on monthly capitation
file. HMO must waive requirement for prior authorization (or
grant retroactive prior authorization) for medically necessary
services provided from the date of enrollment in HMO, but
prior to HMO receiving TP40 member on monthly capitation
file."
SECTION 2.35 MODIFICATION OF SECTION 14.3, NEWBORN ENROLLMENT
Section 14.3.1.1 is replaced with the following language:
"14.3.1.1 A mother of a newborn Member may request a
plan change for her newborn during the first 90 days by
contacting the Enrollment Broker. If a change is approved, the
Enrollment Broker will notify both plans involved in the
process. If no alternative to the plan change can be reached,
the Enrollment Broker will notify the HMO of the newborn plan
change request received from the mother."
SECTION 2.36 MODIFICATION OF SECTION 15.12, NOTICES
Section 15.12 is replaced with the following language:
"Notice may be given by registered mail, facsimile,
and/or hand delivery. All notices to HHSC shall be addressed
to: Medicaid HMO Contract Deliverables Manager, HEDS Division,
Texas Health and Human Services Commission, X.X. Xxx 00000,
Xxxxxx, Xxxxx 00000-0000, with a copy to the Contract
Administrator. Notices to HMO shall be addressed to
President/CEO, 0000 X. XX-00, Xxxxx 000, Xxxxxx, XX 00000."
SECTION 2.37 MODIFICATION OF SECTION 18.1.6, TERMINATION BY HMO
Section 18.1.6 is replaced with the following language:
"18.1.6 HMO may terminate this contract if HHSC fails
to pay HMO as required under Article 13 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 Contract Period. 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 contract is not cause for termination."
SECTION 2.38 MODIFICATION OF SECTION 18.10, REVIEW OF REMEDY OR REMEDIES TO BE
IMPOSED
Section 18.10 is replaced with the following language:
"18.10.2 HMO and HHSC must attempt to informally
resolve a dispute. If HMO and HHSC are unable to informally
resolve a dispute,
HHSC Contract 000-00-000
Page 16 of 17
HMO must notify the HEDS Manager and Director of Medicaid/CHIP
Operations that HMO and HHSC cannot agree. The Director of
Medicaid/CHIP Operations will refer the dispute to the State
Medicaid Director who will appoint a committee to review the
dispute under HHSC's dispute resolution procedures. The
decision of the dispute resolution committee will be HHSC's
final administrative decision."
SECTION 2.39 MODIFICATION OF SECTION 19.1, CONTRACT TERM
Section 19.1 is replaced with the following language:
"19.1 The effective date of this contract is August
31, 1999. This contract will terminate on August 31, 2003
unless extended or terminated earlier as provided for
elsewhere in this contract."
SECTION 2.40 MODIFICATIONS TO CONTRACT APPENDICES.
The following appendices are replaced with the versions attached to
this Amendment:
- Appendix B, HUB
- Appendix C, Value-added Services (for
certain HMOs)
- Appendix F, Texas Trauma Facilities
- Appendix G, Texas Hemophilia Centers
- Appendix I, Financial Statistical Report
- Appendix K, Preventive Health Performance
Objectives
ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES
The Parties contract and agree that the terms of the Agreement will remain
in effect and continue to govern except to the extent modified in this
Amendment.
By signing this Amendment, the Parties expressly understand and agree that
this Amendment is hereby made a part of the Agreement as though it were set out
word for word in the Agreement.
IN WITNESS HEREOF, HHSC AND THE HMO HAVE EACH CAUSED THIS AMENDMENT TO BE
SIGNED AND DELIVERED BY ITS DULY AUTHORIZED REPRESENTATIVE.
SUPERIOR HEALTH PLAN, INC. HEALTH & HUMAN SERVICES COMMISSION
By: /s/ Xxxxxxxxxxx Xxxxxx By:
---------------------------------- -----------------------------------
Xxxxxxxxxxx Xxxxxx Xxx Xxxxxxx
President & CEO Commissioner
Date: 8/22/02 Date:
------------------------------- ---------------------------------
HHSC Contract 000-00-000
Page 17 of 17
HHSC XXXXXXXX XX. 000-00-000
XXXXX XX XXXXX
XXXXXX OF XXXXXX
AMENDMENT 10
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
SUPERIOR HEALTH PLAN, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR PROGRAM
IN THE
EL PASO SERVICE DELIVERY AREA
THIS CONTRACT AMENDMENT (the "Amendment") is entered into between the
HEALTH & HUMAN SERVICES COMMISSION ("HHSC"), an administrative agency within the
executive department of the State of Texas, and SUPERIOR HEALTH PLAN, INC.
("CONTRACTOR"), a health maintenance organization organized under the laws of
the State of Texas, possessing a certificate of authority issued by the Texas
Department of Insurance to operate as a health maintenance organization, and
having its principal office at 0000 X. XX-00, Xxxxx 000, Xxxxxx, Xxxxx 00000.
HHSC and CONTRACTOR may be referred to in this Amendment individually as a
"Party" and collectively as the "Parties."
The Parties hereby agree to amend their Agreement as set forth in Article 2
of this Amendment.
ARTICLE 1. PURPOSE.
SECTION 1.01 AUTHORIZATION.
This Amendment is executed by the Parties in accordance with Article 15.2
of the Agreement.
SECTION 1.02 GENERAL EFFECTIVE DATE OF CHANGES.
This Amendment is effective November 1, 2002.
ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES
SECTION 2.01 MODIFICATION OF ARTICLE 2 DEFINITIONS
The following term is added to amend the definitions set forth in
Article 2:
"EXPERIENCE REBATE PERIOD means each period within
the Contract Period related to the calculations and
settlements of Experience Rebates to HHSC described in Section
13.2. The Contract Period consists of the following Experience
Rebate Periods:
- September 1, 1999 through August 31, 2001
(1st Experience Rebate Period)
- September 1, 2001 through August 31, 2002
(2nd Experience Rebate Period)
- September 1, 2002 through August 31, 2003
(3rd Experience Rebate Period)"
Page 1 of 4
HHSC Contract 000-00-000
SECTION 2.02 MODIFICATION TO SECTION 13.2, EXPERIENCE REBATE TO STATE
Section 13.2 is replaced with the following language:
"13.2.1 HMO must pay to HHSC an experience rebate for
each Experience Rebate Period. HMO will calculate the
experience rebate in accordance with the tiered rebate formula
listed below based on Net Income Before Taxes (excess of
allowable revenues over allowable expenses) as set forth in
Appendix I. The HMO's calculations are subject to HHSC
approval, and HHSC reserves the right to have an independent
audit performed to verify the information provided by HMO.
GRADUATED REBATE FORMULA
--------------------------------------------------------------------------------
NET INCOME BEFORE TAXES
AS A PERCENTAGE OF TOTAL
REVENUES HMO SHARE HHSC SHARE
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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 Experience Rebate
Period Losses: Losses incurred for one Experience Rebate
Period can only be carried forward as an offset to Net Income
Before Taxes in the next Experience Rebate Period.
13.2.2.1 HMO shall calculate the experience rebate by
applying the experience rebate formula in Article 13.2.1 as
follows:
For the 1st Experience Rebate Period, to the Net
Income Before Taxes for each STAR Medicaid service area
contracted between HHSC and HMO. The HMO will separately
calculate the experience rebate for each service area, and
losses in one service area cannot be used to offset Net Income
Before Taxes in another service area. Losses from the 1st
Experience Rebate Period can be carried forward to the 2nd
Experience Rebate Period for the same service area.
For the 2nd Experience Rebate Period, to the sum of
the Net Income Before Taxes for all STAR Medicaid service
areas contracted between HHSC and HMO. Losses from the 2nd
Experience Rebate Period can be carried forward to the 3rd
Experience Rebate Period.
For the 3rd Experience Rebate Period, to the sum of
the Net Income Before Taxes for all CHIP, STAR Medicaid, and
STAR+PLUS Medicaid service areas contracted between HHSC or
TDHS and HMO.
13.2.3 Experience rebate will be based on a pre-tax
basis. Expenses for value-added services are excluded from the
determination
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HHSC Contract 000-00-000
of Net Income Before Taxes reported in the Final MCFS Report;
however, HMO may subtract from Net Income Before Taxes,
expenses incurred for value added services for the experience
rebate calculations.
13.2.4 Population-Based Initiatives (PBIs) and
Experience Rebates: HMO may subtract from an experience rebate
owed to HHSC, expenses for population-based health initiatives
that have been approved by HHSC. A PBI is a project or program
designed to improve some aspect of quality of care, quality of
life, or health care knowledge for the Medicaid population
that may also benefit 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 experience rebate for the 1st Experience Rebate Period,
two settlements for payment(s) of the experience rebate for
the 2nd Experience Rebate Period, and two settlements for
payment(s) of the experience rebate for the 3rd Experience
Rebate Period. Settlement payments are payable to HHSC. The
first settlement for the specified Experience Rebate Period
shall equal 100 percent of the experience rebate as derived
from Net Income Before Taxes reduced by any value-added
services expenses in the first Final MCFS Report and shall be
paid on the same day that the first Final MCFS Report is
submitted to HHSC for the specified time period. The second
settlement shall be an adjustment to the first settlement and
shall be paid on the same day that the second Final MCFS
Report is submitted to HHSC for that specified time period if
the adjustment is a payment from HMO to HHSC. If the
adjustment is a payment from HHSC to HMO, HHSC shall pay such
adjustment to HMO within thirty (30) days of receipt of the
second Final MCFS Report. HHSC or its agent may audit the MCFS
Reports. If HHSC determines that corrections to the MCFS
Reports are required, based on an audit of other documentation
acceptable to HHSC, to determine an adjustment to the amount
of the second settlement, then final adjustment shall be made
within three (3) 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 12.1.4.
HHSC may adjust the experience rebate if HHSC determines HMO
has paid (an) affiliate(s) 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 goods and services in
the service area. HHSC has final authority in auditing and
determining the amount of the experience rebate."
ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES
The Parties contract and agree that the terms of the Agreement will remain
in effect and continue to govern except to the extent modified in this
Amendment.
By signing this Amendment, the Parties expressly understand and agree that
this Amendment is hereby made a part of the Agreement as though it were set out
word for word in the Agreement.
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HHSC Contract 000-00-000
IN WITNESS HEREOF, HHSC AND THE CONTRACTOR HAVE EACH CAUSED THIS AMENDMENT
TO BE SIGNED AND DELIVERED BY ITS DULY AUTHORIZED REPRESENTATIVE.
SUPERIOR HEALTH PLAN, INC. HEALTH & HUMAN SERVICES COMMISSION
By: /s/ Xxxxxxxxxxx Xxxxxx By:
--------------------------------- ----------------------------------
Xxxxxxxxxxx Xxxxxx Xxx X. Xxxxxxx
President and CEO Commissioner
Date: 11/8/02 Date:
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HHSC Contract 000-00-000
