Common use of Provision of Contract Services Clause in Contracts

Provision of Contract Services. 1. Promptly provide or arrange for the provision of all services required under s. 49.46(2), Wis. Stats., and HFS 107 Wis. Adm. Code; as further clarified in all Wisconsin Medicaid Program Provider Handbooks and Bulletins, and HMO Contract Interpretation Bulletins (CIBs) and as otherwise specified in this Contract except: a. County Transportation by common carrier or private motor vehicle (except as required in Article III. B (10). HealthCheck). HMOs are required to arrange for transportation for HealthCheck visits. When authorized by the Department, the HMO may provide non-emergency transportation by common carrier or private motor vehicle for HealthCheck visits and be reimbursed by the County. HMOs may negotiate arrangements with local county Departments of Health and Social Services for common carrier or private vehicle transportation for HMO services in general and not just for HealthCheck visits. The Department will facilitate the development of such arrangements between the HMO and the county. HMOs interested in developing a transportation arrangement with one or more counties and interested in Department assistance should contact the following office either by mail or phone: Bureau of Managed Health Care Programs ▇.▇. ▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇- 0309 Phone Number: (▇▇▇) ▇▇▇-▇▇▇▇ or ▇▇▇-▇▇▇▇ Fax Number: (▇▇▇) ▇▇▇-▇▇▇▇ b. Milwaukee County HMOs will provide common carrier transportation to enrollees. Transportation services will be limited to: . Transporting Medicaid/BadgerCare HMO members only. . Transportation of Medicaid/BadgerCare HMO members to and from Medicaid covered services. HMO Contract for January 1, 2000 - December 31, ▇▇▇▇ ▇▇▇ ▇▇▇ is responsible for arranging for the common carrier transportation and providing monthly costs incurred to Milwaukee County Department of Human Services (DHS), of common carrier transportation arranged. HMO agrees to submit costs to the DHS within 15 days following the end of each month to: Milwaukee County DHS Financial Assistant, Division Administrator ▇▇▇▇ ▇. ▇▇▇▇▇ Street Milwaukee, WI 53206 The DHS is responsible for reimbursing the HMO for mileage and an administration fee. The State Department of Health and Family Services reserves the right to adjust these rates. The HMO shall maintain adequate records for each enrollee which include all pertinent and sufficient information relating to common carrier transportation, and make this information readily available to the Department of Health and Family Services (DHFS). HMO agrees to report suspected abuse by enrollees or providers to the DHFS. c. Dental, if Article XV and Addendum XX indicates dental is not covered. d. Prenatal Care Coordination. e. Targeted Case Management. f. School-Based Services. g. Milwaukee Childcare Coordination. h. Tuberculosis-related Services. 2. Cover chiropractic services, or in the alternative, enter into a subcontract for chiropractic services with the State as provided in Article XV. State law mandates coverage. 3. Remain liable for provision of care for that period for which capitation payment has been made in cases where medical status code changes occur subsequent to capitation payment. HMO Contract for January 1, 2000 - December 31, 2001 4. Be liable, where emergencies and HMO referrals to out-of-area or non-affiliated providers occur, for payment only to the extent that Medicaid pays, including Medicare deductibles, or would pay, its fee-for-service providers for services to the AFDC population. For inpatient hospital services, the Department will provide each HMO per diem rates based on the Medicaid fee-for-service equivalent. This condition does not apply to: (1) cases where prior payment arrangements were established; and (2) specific subcontract agreements. 5. Changes to Medicaid covered services mandated by Federal or State law subsequent to the signing of this Contract will not affect the contract services for the term of this Contract, unless (1) agreed to by mutual consent, or (2) unless the change is necessary to continue to receive federal funds or due to action of a court of law. The Department may incorporate any change in covered services mandated by Federal or State law into the Contract effective the date the law goes into effect, if it adjusts the capitation rate accordingly. The Department will give the HMO 30 days notice of any such change that reflects service increases, and the HMO may elect to accept or reject the service increases for the remainder of that contract year; the Department will give the HMO 60 days notice of any such change that reflects service decreases, with a right of the HMO to dispute the amount of the decrease within that 60 days. The HMO has the right to accept or reject service decreases for the remainder of the Contract year. The date of implementation of the change in coverage will coincide with the effective date of the increased or decreased funding. This section does not limit the Department's ability to modify the Medicaid/HMO Contract for changes in the State Budget. 6. Be responsible for payment of all contract services provided to all Medicaid/BadgerCare recipients listed as ADDs or CONTINUEs on either the Initial or Final Enrollment Reports (see Article IV. B and D) generated for the month of coverage. The HMO is also responsible for payment of services to all newborns meeting the criteria described in Article V. G. "Capitation

Provision of Contract Services. 1. Promptly provide or arrange for the provision of all services required under s. Section 49.46(2), Wis. Stats., and HFS 107 Wis. Adm. Code; as further clarified in all Wisconsin Medicaid Program Provider Handbooks and Bulletins, and HMO Contract Interpretation Bulletins (CIBs) and as otherwise specified in this Contract except: a. County Transportation by common carrier or private motor vehicle (except as required in Article III. B (10). HealthCheck). HMOs are required to arrange for transportation for HealthCheck visits. When authorized by the Department, the HMO may provide non-emergency transportation by common carrier or private motor vehicle for HealthCheck visits and be reimbursed by the County. HMOs may negotiate arrangements with local county Departments of Health and Social Services for common carrier or private vehicle transportation for HMO services in general and not just for HealthCheck visits. The Department will make a list of county transportation contacts available to HMOs upon request. The Department will facilitate the development of such arrangements between the HMO and the county. HMOs interested in developing a transportation arrangement with one or more counties and interested in Department assistance should contact the following office either by mail or phone: Bureau of Managed Health Care Programs ▇.▇. P.O. Box 309 Madison, WI 53701- 0309 ▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇- 0309 Phone Number: (▇▇▇) ▇▇▇-▇▇▇▇ or ▇▇ ▇▇▇-▇▇▇▇ Fax Number: (608) 261-▇▇▇) ▇ ▇▇▇ ▇▇▇-trac▇ ▇▇▇ ▇▇nuary 1, 2002 - December 31, 2003 -8- b. Milwaukee County HMOs will provide common carrier transportation to enrollees. Transportation services will be limited to: . Transporting o Transportation of Medicaid/BadgerCare HMO members only. . o Transportation of Medicaid/BadgerCare HMO members to and from Medicaid covered services. The HMO Contract for January 1, 2000 - December 31, ▇▇▇▇ ▇▇▇ ▇▇▇ is responsible for arranging for the common carrier transportation and providing monthly costs incurred to Milwaukee County Department of Human Services (DHSMCDHS), of for common carrier transportation arranged. HMO agrees to submit costs to the DHS within 15 days following the end of each month to: Milwaukee County DHS Financial Assistant, Division Administrator ▇▇▇▇ ▇. ▇▇▇▇▇ 1220 W. Vliet Street Milwaukee, WI 53206 The ▇▇▇ DHS is responsible for reimbursing the HMO for mileage and an administration fee. The State Department of Health and Family Services reserves the right to adjust these rates. The HMO shall maintain adequate records for each enrollee which include all pertinent and sufficient information relating to common carrier transportation, and make this information readily available to the Department of Health and Family Services (DHFS). HMO agrees to report suspected abuse by enrollees or providers to the DHFS. c. Dental, if Article XV and Addendum XX indicates unless the HMO is certified to provide dental is not coveredservices. d. Prenatal Care Coordination. e. Targeted Case Management. f. School-Based Services. g. Milwaukee Childcare Coordination. h. Tuberculosis-related Services.. HMO Contract for January 1, 2002 - December 31, 2003 2. Cover chiropractic services, or in the alternative, enter into a subcontract for chiropractic services with the State as provided in Article XV. State law mandates coverage. 3. Remain liable for provision of care for that period for which capitation payment has been made in cases where medical status code changes occur subsequent to capitation payment. HMO Contract for January 1, 2000 - December 31, 2001. 4. Be liable, where emergencies and HMO referrals to out-of-area or non-affiliated providers occur, for payment only to the extent that Medicaid pays, including Medicare deductibles, or would pay, its fee-for-service FFS providers for services to the AFDC AFDC/BadgerCare population. For inpatient hospital services, the Department will provide each HMO per diem rates based on the Medicaid fee-for-service FFS equivalent. This condition does not apply to: : (1) cases where prior payment arrangements were established; and (2) specific subcontract agreements. 5. Changes to Medicaid covered services mandated by Federal or State law subsequent to the signing of this Contract will not affect the contract services for the term of this Contract, unless (1) agreed to by mutual consent, or (2) unless the change is necessary to continue to receive federal funds or due to action of a court of law. The Department may incorporate any change in covered services mandated by Federal or State law into the Contract effective the date the law goes into effect, if it adjusts the capitation rate accordingly. The Department will give the HMO 30 days notice of any such change that reflects service increases, and the HMO may elect to accept or reject rejects the service increases for the remainder of that contract year; the Department will give the HMO 60 days notice of any such change that reflects service decreases, with a right of the HMO to dispute the amount of the decrease within that 60 days. The HMO has the right to accept or reject service decreases for the remainder of the Contract year. The date of implementation of the change in coverage will coincide with the effective date of the increased or decreased funding. This section does not limit the Department's ability to modify the Medicaid/HMO Contract for changes in the State Budget. 6. Be responsible for payment of all contract services provided to all Medicaid/BadgerCare recipients listed as ADDs or CONTINUEs on either the Initial or Final Enrollment Reports (see Article IV. B and D) generated for the month of coverage. The HMO is also responsible for payment of services to all newborns meeting the criteria described in Article V. G. V.G, "CapitationCapitation Payments for Newborns." Additionally, the HMO agrees to provide, or authorize provision of, services to all Medicaid enrollees with valid Forward cards indicating HMO enrollment without regard to disputes HMO Contract for January 1, 2002 - December 31, 2003 -10- about enrollment status and without regard to any other identification requirements. Any discrepancies between the cards and the reports will be reported to the Department for resolution. The HMO shall continue to provide and authorize provision of all contract services until the discrepancy is resolved. This includes recipients who were PENDING on the Initial Report and held a valid Forward card indicating HMO enrollment, but did not appear as an CONTINUE on the Final Report.