Common use of Contractor Requirements for State Operations Clause in Contracts

Contractor Requirements for State Operations. Through this Capitated Financial Alignment Model initiative, CMS and RI EOHHS will work in partnership to offer Eligible Beneficiaries the option of enrolling into Contractor’s MMP, which consists of a comprehensive network of Health Care Professionals and social service providers. The Contractor will deliver and coordinate all components of Medicare and Medicaid Covered Services for Enrollees. Licensure and Certification 2.1.1.2.1. Contractor certifies that it is licensed in Rhode Island as an Health Maintenance Organization (HMO) under the provisions of Rhode Island General Laws R.I. Gen. Laws §27-41-1 et. seq., “the Health Maintenance Organization Act.” If Contractor is not a licensed HMO in Rhode Island, Contractor certifies that it is either a nonprofit hospital service corporation that is licensed by the RI Department of Business Regulation (RI DBR) under R.I. Gen. Laws §27-19-1 et. seq., a nonprofit medical service corporation that is licensed by RI DBR under R.I. Gen. Laws §27-20-1 et. seq., or another health insurance entity licensed by RI DBR, and that it meets the following requirements: 2.1.1.2.1.1. Is certified by the Rhode Island Department of Health (RI DOH) as a Health Plan under the Rules and Regulations for the Certification of Health Plans (R23-17.13-CHP); and 2.1.1.2.1. 2. Meets the requirements of R23-17.13-CHP §§ 3.4, 5.2, 6.1.4, and 6.4.7; and

Contractor Requirements for State Operations. Through this Capitated Financial Alignment Model initiative, CMS and RI EOHHS will work in partnership to offer Eligible Beneficiaries the option of enrolling into Contractor’s MMP, which consists of a comprehensive network of Health Care Professionals and social service providers. The Contractor will deliver and coordinate all components of Medicare and Medicaid Covered Services for Enrollees. Licensure and Certification 2.1.1.2.1. Contractor certifies that it is licensed in Rhode Island as an Health Maintenance Organization (HMO) under the provisions of Rhode Island General Laws R.I. Gen. Laws §27-41-1 et. seq., “the Health Maintenance Organization Act.” If Contractor is not a licensed HMO in Rhode Island, Contractor certifies that it is either a nonprofit hospital service corporation that is licensed by the RI Department of Business Regulation (RI DBR) under R.I. Gen. Laws §27-19-1 et. seq., a nonprofit medical service corporation that is licensed by RI DBR under R.I. Gen. Laws §27-20-1 et. seq., or another health insurance entity licensed by RI DBR, and that it meets the following requirements: 2.1.1.2.1.1. Is certified by the Rhode Island Department of Health (RI DOH) as a Health Plan under the Rules and Regulations for the Certification of Health Plans (R23-17.13-CHP); and 2.1.1.2.1. 22.1.1.2.1.2. Meets the requirements of R23-17.13-CHP §§ 3.4, 5.2, 6.1.4, and 6.4.7; and 2.1.1.2.1.3. Meets the requirements under the RI DOH Rules and Regulations for the Utilization Review of Health Care Services (R23-17.12). 2.1.1.2.2. Contractor agrees to provide to RI EOHHS, or its designees, any information requested pertaining to its licensure or certification. 2.1.1.2.3. Contractor agrees to provide a copy to RI EOHHS of any correspondence to RI DBR and/or RI DOH concerning its license, Contract status with any institution or provider group and/or certification. Contractor agrees to provide RI EOHHS a copy of any complaints, decisions, orders or notices from RI DBR, RI DOH or any other regulatory or oversight entities (e.g., Rhode Island Department of Attorney General) within thirty (30) Days of Contractor’s receipt of any complaints, decisions, orders or notices. Accreditation 2.1.1.3.1. The Contractor is accredited by the NCQA as a Medicaid managed care organization. 2.1.1.3.2. The Contractor must submit to RI EOHHS a PDF copy of its current NCQA accreditation certificate for a Medicaid managed care organization and must maintain such accreditation for the duration of this Contract. 2.1.1.3.3. The Contractor must report to RI EOHHS any deficiencies noted by the NCQA for the Contractor’s Medicare and/or Medicaid product lines within thirty (30) Days of being notified of the deficiencies, or on the earliest date permitted by NCQA, whichever is earliest. The Contractor agrees to authorize NCQA to provide EOHHS and CMS with a copy of the most recent accreditation review, including status, survey type and level; any recommendation for actions or improvements; any corrective action plans; summaries of findings; and the expiration date of the accreditation. 2.1.1.3.4. Achievement of provisional accreditation status shall require a corrective action plan within thirty (30) Days of receipt of the final report from the NCQA and may result in termination of CMS’ and RI EOHHS’s Contract with the Contractor in accordance with the termination provisions of the Contract as outlined in Section 5.5 herein. 2.1.1.3.5. Contractor agrees to forward to RI EOHHS any complaints received from NCQA within thirty (30) Days of Contractor’s receipt of a complaint. 2.1.1.3.6. Contractor agrees to provide to the RI EOHHS, or its designees, any information requested pertaining to its accreditation including communication to and from the NCQA. Such information shall include any communications pertaining to Contractor’s accreditation by NCQA as well as actual HEDIS® and CAHPS® data, transmittals, and reports. Mergers and Acquisition 2.1.1.4.1. In addition to the requirements at 42 C.F.R. § 422 Subpart L, the Contractor must adhere to the NCQA notification requirements regarding mergers and acquisitions and must notify RI EOHHS and CMS of any action by NCQA that is prompted by a merger or acquisition (including, but not limited to change in accreditation status, loss of accreditation, etc.).