Policies and Procedures for Core Functions. The Contractor shall develop, maintain, and provide to EOHHS upon request, policies and procedures for all core functions necessary to manage the MassHealth population effectively and efficiently and meet the requirements outlined in this Contract. All policies and procedures requiring EOHHS approval shall be documented and shall include the dates of approval by EOHHS. These policies and procedures shall include, but are not limited to, the following topics: a. Response to violations of Enrollees’ privacy rights by staff or Subcontractors; b. Non-discrimination of MassHealth Enrollees; c. Enrollee cooperation with those providing health care services; d. Marketing activities and the Contractor’s procedures for monitoring these activities; e. Advance Directives; f. Assisting Enrollees in understanding their benefits and how to access them; g. Enrollees’ right to be free from restraint or seclusion used as a means of coercion or retaliation; h. The provision of Culturally and Linguistically Appropriate Services; i. Practice guidelines in quality measurement and improvement activities; j. Handling of complaints/Grievances sent directly to EOHHS; k. Process used to monitor PCP and Subcontractor implementation of amendments and improvements; l. Retention of medical records; m. Engagement and coordination with BH CPs and LTSS CPs, as described in Section 2.4.E; n. Care Management; o. Public health emergencies; and p. Risk stratification. D. Readiness Review Overview 1. Contract Readiness Workplan a. No later than five business days following the Contract Effective Date, or other date as specified by EOHHS, the Contractor shall submit to EOHHS, for its review and approval, a workplan which shall be used by EOHHS to monitor the Contractor’s progress toward achieving Contract readiness, as detailed in Section 2.5.D below, in accordance with timelines specified by EOHHS. The workplan shall: 1) Address all of the items listed in Section 2.5.D.3, at a minimum; 2) List each task, the date by which it will be completed, how it will be completed, and the documentation that will be provided to EOHHS as evidence that the task has been completed. b. EOHHS may, in its discretion, modify or reject any such workplan, in whole or in part; c. The Contractor shall modify its workplan as specified by EOHHS and resubmit for approval. 2. EOHHS will conduct a Readiness Review of the Contractor that may include, at a minimum, one on-site review, as determined appropriate by EOHHS. This Readiness Review shall be conducted prior to enrollment of Members into the Contractor, and at other times during the Contract period at the discretion of EOHHS. EOHHS will conduct the Readiness Review to verify the Contractor’s assurances that the Contractor is ready and able to meet its obligations under the Contract. EOHHS reserves the right to conduct an additional Readiness Review in the event that additional populations become eligible for enrollment with the Contractor. 3. The scope of the Readiness Review will include, but is not limited to, a review of the following elements: a. Operational and Administration, specifically: 1) Staffing and resources, including Key Personnel and functions directly impacting on Enrollees (e.g., adequacy of Enrollee Services staffing), in accordance with Section 2.5.A; 2) Delegation and oversight of Contractor responsibilities, including but not limited to capabilities of Material Subcontractors in accordance with Section 5.17; 3) Enrollee and Provider communications; 4) Internal Grievance policies and procedures, in accordance with Section 2.9; b. Service Delivery 1) Case management, care coordination, and service planning in accordance with 2) Quality improvement, including comprehensiveness of quality management/quality improvement strategies, in accordance with Section 2.10; and c. A review of other items specified in the Contract, including but not limited to: 1) Marketing Materials, in accordance with Section 2.7; 2) Content of Participating PCP and Affiliated Provider contracts in accordance with Sections 2.2.A and 2.2.D; 3) Content of Material Subcontracts with Community Partners, in accordance with Sections 2.4.F; and
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Policies and Procedures for Core Functions. The Contractor shall develop, maintain, and provide to EOHHS upon request, policies and procedures for all core functions necessary to effectively and efficiently manage the MassHealth population effectively and efficiently and meet the requirements outlined in this Contract. All policies and procedures requiring EOHHS approval shall be documented and shall include the dates of approval by EOHHS. These policies and procedures shall include, but are not limited to, the following topics:
a. : Response to violations of Enrollees’ privacy rights by staff staff, Providers or Subcontractors;
b. subcontractors; Non-discrimination of MassHealth Enrollees;
c. Enrollee cooperation with those providing health care services;
d. ; Non-restriction of Providers advising or advocating on an Enrollee’s behalf; Appeal rights for certain minors who under the law may consent to medical procedures without parental consent; Marketing activities that apply to the Plan, Providers and subcontractors as well as the Contractor’s procedures for monitoring these activities;
e. ; Cost-sharing by Enrollees; Advance Directives;
f. directives; Assisting Enrollees in understanding their benefits and how to access them;
g. ; Access and availability standards; Enrollees’ right to be free from restraint or seclusion used as a means of coercion or retaliation;
h. ; The provision of Culturally and Linguistically Appropriate Services;
i. ; Practice guidelines in quality measurement and improvement activities;
j. Handling ; Compliance with Emergency Services and Poststabilization Care Services requirements as identified in 42 CFR 438.114; Procedures for tracking appeals when Enrollees become aware of complaints/Grievances sent directly to EOHHS;
k. the Adverse Action, in the event that no notice had been sent; Process used to monitor PCP Provider and Subcontractor subcontractor implementation of amendments and improvements;
l. ; Retention of medical records;
m. ; Engagement and coordination with BH CPs and LTSS CPs, as described in Section 2.4.E;
n. Sections 2.5.F and 2.5.G; Care Management;
o. Public health emergencies; Risk stratification; and p. Risk stratification.
D. Readiness Review OverviewClaims processing. Other Contract Management Requirements
1. Customer Service Center (CSC) Enrollment Vendor Education The Contractor shall participate in educational sessions, at the request of EOHHS, to update EOHHS staff and its designated CSC Enrollment Vendor regarding information which would assist prospective Enrollees in evaluating the Contractor’s Plan. These educational activities may include multiple presentations per Contract Readiness WorkplanYear at EOHHS, Plan sites and CSC Enrollment Vendor offices.
a. No 2. Material Subcontracts/Subcontractors Prior to contracting with a Material Subcontractor, the Contractor shall evaluate the prospective Material Subcontractor’s ability to perform the activities to be subcontracted. All Material Subcontracts must be prior approved by EOHHS. To obtain such approval, the Contractor shall make a request in writing and submit with that request a completed Material Subcontractor checklist using the template provided by EOHHS and attached hereto as Appendix I, as may be modified by EOHHS from time-to-time, at least 60 days prior to the date the Contractor expects to execute the Material Subcontract. For Material Subcontractors who are pharmacy benefit managers, the Contractor shall submit the above information 90 days prior to the date the Contractor expects to execute the Material Subcontract. Among other things required in the checklist, the Contractor must describe the process for selecting the Material Subcontractor, including the selection criteria used. The Contractor shall provide EOHHS with any additional information requested by EOHHS in addition to the information required in the checklist. For Material Subcontractors who are pharmacy benefit managers, the Contractor shall provide a network adequacy report at EOHHS’ request. The Material Subcontract shall:
1) Be a written agreement;
2) Specify, and require compliance with, all applicable requirements of this Contract and the activities and reporting responsibilities the Material Subcontractor is obligated to provide;
3) Provide for imposing sanctions, including contract termination, if the Material Subcontractor’s performance is inadequate;
4) Require the Material Subcontractor to comply with all applicable Medicaid laws, regulations, and applicable subregulatory guidance;
5) Comply with the audit and inspection requirements set forth in 42 CFR 438.230(c)(3), such that the Material Subcontract requires the Material Subcontractor to agree as follows. See also Section 5.4.
a) The State, CMS, HHS Inspector General, the Comptroller General, or their designees, have the right to audit, evaluate, and inspect any records or systems that pertain to any activities performed or amounts payable under this Contract. This right exists through 10 years from the final date of the contract or from the date of completion of any audit, whichever is later; provided, however that if any of the entities above determine that there is a reasonable possibility of fraud or similar risk, they may audit, evaluate, and inspect at any time; and
b) The Material Subcontractor will make its premises, facilities, equipment, records, and systems available for the purposes of any audit, evaluation, or inspection described immediately above; The Contractor shall monitor any Material Subcontractor’s performance on an ongoing basis and perform a formal review annually. If any deficiencies or areas for improvement are identified, the Contractor shall require the Material Subcontractor to take corrective action. Upon request, the Contractor shall provide EOHHS with a copy of the annual review and any corrective action plans developed as a result. Upon notifying any Material Subcontractor, or being notified by such Material Subcontractor, of the intention to terminate such subcontract, the Contractor shall notify EOHHS in writing no later than five business days following the Contract Effective Datesame day as such notification, and shall otherwise support any necessary member transition or other date related activities as specified by EOHHSdescribed in Section 2.2 and elsewhere in this Contract. In accordance with Appendix A, the Contractor shall submit to EOHHS, for EOHHS an annual list of all Material Subcontractors. Such annual report shall include notification if any of its review and approval, Material Subcontractors are a workplan which business enterprise (for-profit) or non-profit organization certified by the Commonwealth’s Supplier Diversity Office. The Contractor shall be used by EOHHS to monitor the Contractor’s progress toward achieving Contract readinesssubmit ad hoc reports, as detailed in Section 2.5.D belowfrequently as necessary or as directed by ▇▇▇▇▇, in accordance with timelines specified by EOHHSany changes to the above-mentioned list and report. The workplan Contractor shall make best efforts to ensure that all Material Subcontracts stipulate that Massachusetts general law or Massachusetts regulation will prevail if there is a conflict between the state law or state regulation where the Material Subcontractor is based. The Contractor shall:
1) Address , pursuant to the Acts of 2014, c. 165, Section 188, file with MassHealth any contracts or subcontracts for the management and delivery of behavioral health services by specialty behavioral health organizations to MassHealth members and MassHealth shall disclose such contracts upon request. Notwithstanding any relationship the Contractor may have with a subcontractor, including Material subcontractors, the Contractor shall maintain ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of this Contract; and The Contractor shall remain fully responsible for meeting all of the items listed in Section 2.5.D.3, at a minimum;
2terms and requirements (including all applicable state and federal regulations) List each task, the date by which it will be completed, how it will be completed, and the documentation that will be provided to EOHHS as evidence that the task has been completed.
b. EOHHS may, in its discretion, modify or reject any such workplan, in whole or in part;
c. The Contractor shall modify its workplan as specified by EOHHS and resubmit for approval.
2. EOHHS will conduct a Readiness Review of the Contractor that may include, at a minimum, one on-site review, as determined appropriate by EOHHS. This Readiness Review shall be conducted prior to enrollment Contract regardless of Members into the Contractor, and at other times during the Contract period at the discretion of EOHHS. EOHHS will conduct the Readiness Review to verify the Contractor’s assurances that whether the Contractor is ready and able subcontracts for performance of any Contract responsibility. No subcontract will operate to meet relieve the Contractor of its obligations legal responsibilities under the Contract. EOHHS reserves the right to conduct an additional Readiness Review in the event that additional populations become eligible for enrollment with the Contractor.
3. The scope of the Readiness Review will include, but is not limited to, a review of the following elements:
a. Operational and Administration, specifically:
1) Staffing and resources, including Key Personnel and functions directly impacting on Enrollees (e.g., adequacy Contractor shall inform all Material Subcontractors of Enrollee Services staffing), grievance and appeal rights as described in accordance with Section 2.5.A;
2) Delegation 2.8.A.7 and oversight of Contractor responsibilities, including but not limited to capabilities of Material Subcontractors in accordance with Section 5.17;
3) Enrollee and Provider communications;
4) Internal Grievance policies and procedures, in accordance with Section 2.9;
b. Service Delivery
1) Case management, care coordination, and service planning in accordance with
2) Quality improvement, including comprehensiveness of quality management/quality improvement strategies, in accordance with Section 2.10; and
c. A review of other items specified in the Contract, including but not limited to:
1) Marketing Materials, in accordance with Section 2.7;
2) Content of Participating PCP and Affiliated Provider contracts in accordance with Sections 2.2.A and 2.2.D; 3) Content of Material Subcontracts with Community Partners, in accordance with Sections 2.4.F; and2.12.
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