1
EXHIBIT 10.4
TDH Document No. 7526032317*2001 02
2000
CONTRACT FOR SERVICES
Between
THE TEXAS DEPARTMENT OF HEALTH
And
HMO
Americaid
2000 Renewal Contract
Dallas Service Area
August 28, 2000
2
TABLE OF CONTENTS
APPENDICES .................................................................. V
ARTICLE I PARTIES AND AUTHORITY TO CONTRACT ............................ 1
ARTICLE II DEFINITIONS .................................................. 2
ARTICLE III PLAN ADMINISTRATIVE AND HUMAN RESOURCE REQUIREMENTS .......... 13
3.1 ORGANIZATION AND ADMINISTRATION ....................................... 13
3.2 NON-PROVIDER SUBCONTRACTS ............................................. 14
3.3 MEDICAL DIRECTOR ...................................................... 16
3.4 PLAN MATERIALS AND DISTRIBUTION OF PLAN MATERIALS ..................... 17
3.5 RECORDS REQUIREMENTS AND RECORDS RETENTION ............................ 18
3.6 HMO REVIEW OF TDH MATERIALS ........................................... 19
3.7 HMO TELEPHONE ACCESS REQUIREMENTS ..................................... 19
ARTICLE IV FISCAL, FINANCIAL, CLAIMS AND INSURANCE REQUIREMENTS ........ 20
4.1 FISCAL SOLVENCY ....................................................... 20
4.2 MINIMUM NET WORTH ..................................................... 21
4.3 PERFORMANCE BOND ...................................................... 21
4.4 INSURANCE ............................................................. 21
4.5 FRANCHISE TAX ......................................................... 22
4.6 AUDIT ................................................................. 22
4.7 PENDING OR THREATENED LITIGATION ...................................... 22
4.8 MISREPRESENTATION AND FRAUD IN RESPONSE TO RFA AND IN HMO OPERATIONS .. 23
4.9 THIRD PARTY RECOVERY .................................................. 23
4.10 CLAIMS PROCESSING REQUIREMENTS ........................................ 25
4.11 INDEMNIFICATION ....................................................... 26
ARTICLE V STATUTORY AND REGULATORY COMPLIANCE REQUIREMENTS ............ 26
5.1 COMPLIANCE WITH FEDERAL, STATE, AND LOCAL LAWS ........................ 27
5.2 PROGRAM INTEGRITY ..................................................... 27
5.3 FRAUD AND ABUSE COMPLIANCE PLAN ....................................... 27
5.4 SAFEGUARDING INFORMATION .............................................. 30
5.5 NON-DISCRIMINATION .................................................... 30
5.6 HISTORICALLY UNDERUTILIZED BUSINESSES (HUBs) .......................... 31
5.7 BUY TEXAS ............................................................. 31
5.8 CHILD SUPPORT ......................................................... 31
5.9 REQUESTS FOR PUBLIC INFORMATION ....................................... 32
5.10 NOTICE AND APPEAL ..................................................... 33
ARTICLE VI SCOPE OF SERVICES ........................................... 33
6.1 SCOPE OF SERVICES ..................................................... 33
6.2 PRE-EXISTING CONDITIONS ............................................... 35
6.3 SPAN OF ELIGIBILITY ................................................... 35
6.4 CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS ....................... 36
6.5 EMERGENCY SERVICES .................................................... 37
6.6 BEHAVIORAL HEALTH SERVICES - SPECIFIC REQUIREMENTS .................... 38
6.7 FAMILY PLANNING - SPECIFIC REQUIREMENTS ............................... 40
6.8 TEXAS HEALTH STEPS (EPSDT) ............................................ 41
6.9 PERINATAL SERVICES .................................................... 44
6.10 EARLY CHILDHOOD INTERVENTION .......................................... 46
6.11 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN
(WIC) - SPECIFIC REQUIREMENTS .......................................... 47
6.12 TUBERCULOSIS (TB) ...................................................... 47
6.13 PEOPLE WITH DISABILITIES OR CHRONIC OR COMPLEX CONDITIONS .............. 48
i Dallas Service Area Contract
3
6.14 HEALTH EDUCATION AND WELLNESS AND PREVENTION PLANS ...................50
6.15 SEXUALLY TRANSMITTED DISEASES (STDs) AND HUMAN IMMUNODEFICIENCY VIRUS
(HIV) ................................................................51
6.16 BLIND AND DISABLED MEMBERS ...........................................53
ARTICLE VII PROVIDER NETWORK REQUIREMENTS ................................54
7.1 PROVIDER ACCESSIBILITY ...............................................54
7.2 PROVIDER CONTRACTS ...................................................55
7.3 PHYSICIAN INCENTIVE PLANS ............................................59
7.4 PROVIDER MANUAL AND PROVIDER TRAINING ................................60
7.5 MEMBER PANEL REPORTS .................................................61
7.6 PROVIDER COMPLAINT AND APPEAL PROCEDURES .............................61
7.7 PROVIDER QUALIFICATIONS - GENERAL ....................................62
7.8 PRIMARY CARE PROVIDERS ...............................................63
7.9 OB/GYN PROVIDERS .....................................................66
7.10 SPECIALTY CARE PROVIDERS .............................................67
7.11 SPECIAL HOSPITALS AND SPECIALTY CARE FACILITIES ......................68
7.12 SIGNIFICANT TRADITIONAL PROVIDERS (STPs) .............................68
7.13 RURAL HEALTH PROVIDERS ...............................................69
7.14 FEDERALLY QUALIFIED HEALTH CENTERS (FOHC) AND RURAL HEALTH
CLINICS (RHC) ........................................................70
7.15 COORDINATION WITH PUBLIC HEALTH ......................................71
7.16 COORDINATION WITH TEXAS DEPARTMENT OF PROTECTIVE AND
REGULATORY SERVICES ..................................................74
7.17 DELEGATED NETWORKS (IPAs, LIMITED PROVIDER NETWORKS AND ANHCs) .......75
ARTICLE VIII MEMBER SERVICES REQUIREMENTS ................................77
8.1 MEMBER EDUCATION .....................................................77
8.2 MEMBER HANDBOOK ......................................................77
8.3 ADVANCE DIRECTIVES ...................................................77
8.4 MEMBER ID CARDS ......................................................79
8.5 MEMBER COMPLAINT PROCESS .............................................80
8.6 MEMBER NOTICE, APPEALS AND FAIR HEARINGS .............................82
8.7 MEMBER ADVOCATES .....................................................83
8.8 MEMBER CULTURAL AND LINGUISTIC SERVICES ..............................84
8.9 CERTIFICATION DATE ...................................................86
ARTICLE IX MARKETING AND PROHIBITED PRACTICES ..........................86
9.1 MARKETING MATERIAL MEDIA AND DISTRIBUTION ............................86
9.2 MARKETING ORIENTATION AND TRAINING ...................................86
9.3 PROHIBITED MARKETING PRACTICES .......................................86
9.4 NETWORK PROVIDER DIRECTORY ...........................................87
ARTICLE X MIS SYSTEM REQUIREMENTS .........................................88
10.1 MODEL MIS REQUIREMENTS ...............................................88
10.2 SYSTEM-WIDE FUNCTIONS ................................................90
10.3 ENROLLMENT/ELIGIBILITY SUBSYSTEM .....................................91
10.4 PROVIDER SUBSYSTEM ...................................................92
10.5 ENCOUNTER/CLAIMS PROCESSING SUBSYSTEM ................................93
10.6 FINANCIAL SUBSYSTEM ..................................................94
10.7 UTILIZATION/QUALITY IMPROVEMENT SUBSYSTEM ............................95
10.8 REPORT SUBSYSTEM .....................................................96
10.9 DATA INTERFACE SUBSYSTEM .............................................96
10.10 TPR SUBSYSTEM ........................................................98
ARTICLE XI QUALITY ASSURANCE AND QUALITY IMPROVEMENT PROGRAM ...........98
11.1 QUALITY IMPROVEMENT PROGRAM (QIP) SYSTEM ..............................98
11.2 WRITTEN QIP PLAN ......................................................98
11.3 QIP SUBCONTRACTING ....................................................98
11.4 ACCREDITATION .........................................................98
ii Dallas Service Area Contract
4
11.5 BEHAVIORAL HEALTH INTEGRATION INTO QIP.......................... 99
11.6 QIP REPORTING REQUIREMENTS...................................... 99
ARTICLE XII REPORTING REQUIREMENTS..................................... 99
12.1 FINANCIAL REPORTS............................................... 99
12.2 STATISTICAL REPORTS............................................. 102
12.3 ARBITRATION/LITIGATION CLAIMS REPORT............................ 102
12.4 SUMMARY REPORT OF PROVIDER COMPLAINTS........................... 103
12.5 PROVIDER NETWORK REPORTS........................................ 103
12.6 MEMBER COMPLAINTS............................................... 103
12.7 FRAUDULENT PRACTICES............................................ 103
12.8 UTILIZATION MANAGEMENT REPORTS -- BEHAVIORAL HEALTH............. 104
12.9 UTILIZATION MANAGEMENT REPORTS -- PHYSICAL HEALTH............... 104
12.10 QUALITY IMPROVEMENT REPORTS..................................... 104
12.11 HUB REPORTS..................................................... 105
12.12 THSTEPS REPORTS................................................. 106
ARTICLE XIII PAYMENT PROVISIONS......................................... 106
13.1 CAPITATION AMOUNTS.............................................. 106
13.2 EXPERIENCE REBATE TO STATE...................................... 108
13.3 PERFORMANCE OBJECTIVES.......................................... 110
13.4 PAYMENT OF PERFORMANCE OBJECTIVE BONUSES........................ 111
13.5 ADJUSTMENTS TO PREMIUM.......................................... 112
13.6 NEWBORN AND PREGNANT WOMEN PAYMENT PROVISIONS................... 113
ARTICLE XIV ELIGIBILITY, ENROLLMENT AND DISENROLLMENT.................. 114
14.1 ELIGIBILITY DETERMINATION....................................... 114
14.2 ENROLLMENT...................................................... 115
14.3 NEWBORN ENROLLMENT.............................................. 116
14.4 DISENROLLMENT................................................... 117
14.5 AUTOMATIC RE-ENROLLMENT......................................... 118
14.6 ENROLLMENT REPORTS.............................................. 118
ARTICLE XV GENERAL PROVISIONS......................................... 118
15.1 INDEPENDENT CONTRACTOR.......................................... 118
15.2 AMENDMENT....................................................... 118
15.3 LAW, JURISDICTION AND VENUE..................................... 119
15.4 NON-WAIVER...................................................... 119
15.5 SEVERABILITY.................................................... 119
15.6 ASSIGNMENT...................................................... 119
15.7 MAJOR CHANGE IN CONTRACTING..................................... 120
15.8 NON-EXCLUSIVE................................................... 120
15.9 DISPUTE RESOLUTION.............................................. 120
15.10 DOCUMENTS CONSTITUTING CONTRACT................................. 120
15.11 FORCE MAJEURE................................................... 121
15.12 NOTICE.......................................................... 121
15.13 SURVIVAL........................................................ 121
ARTICLE XVI DEFAULT.................................................... 121
16.1 DEFAULT BY TDH.................................................. 121
16.2 REMEDIES AVAILABLE TO HMO FOR TDH's DEFAULT..................... 121
16.3 DEFAULT BY HMO.................................................. 121
ARTICLE XVII NOTICE OF DEFAULT AND CURE OF DEFAULT...................... 129
ARTICLE XVIII REMEDIES AND SANCTIONS..................................... 130
18.1 TERMINATION..................................................... 130
18.2 DUTIES OF CONTRACTING PARTIES UPON TERMINATION.................. 132
iii Dallas Service Area Contract
5
18.3 SUSPENSION OF NEW ENROLLMENT.........................................133
18.4 LIQUIDATED MONEY DAMAGES.............................................133
18.5 APPOINTMENT OF TEMPORARY MANAGEMENT..................................135
18.6 TDH-INITIATED DISENROLLMENT OF A MEMBER OR MEMBERS WITHOUT CAUSE.....136
18.7 RECOMMENDATION TO HCFA THAT SANCTIONS BE TAKEN AGAINST HMO...........136
18.8 CIVIL MONETARY PENALTIES.............................................136
18.9 FORFEITURE OF ALL OR PART OF THE TDI PERFORMANCE BOND................137
18.10 REVIEW OF REMEDY OR REMEDIES TO BE IMPOSED...........................137
ARTICLE XIX TERM.......................................................137
Dallas Service Area Contract
iv
6
APPENDICES
APPENDIX A
Standards For Quality Improvement Programs
APPENDIX B
HUB Progress Assessment Reports
APPENDIX C
Value-added Services
APPENDIX D
Required Critical Elements
APPENDIX E
Transplant Facilities
APPENDIX F
Trauma Facilities
APPENDIX G
Hemophilia Treatment Centers And Programs
APPENDIX H
Utilization Management Report - Behavioral Health
APPENDIX I
Managed Care Financial-Statistical Report
APPENDIX J
Utilization Management Report - Physical Health
APPENDIX K
Preventive Health Performance Objectives
APPENDIX L
Cost Principles For Administrative Expenses
APPENDIX M
Arbitration/Litigation Report
TDH Document No. _____________
v Dallas Service Area Contract
7
2000
CONTRACT FOR SERVICES
Between
THE TEXAS DEPARTMENT OF HEALTH
And
HMO
This contract is entered into between the Texas Department of Health (TDH) and
Americaid Texas, Inc. dba Americaid Community Care (HMO). The purpose of this
contract is to set forth the terms and conditions for HMO's participation as a
managed care organization in the TDH STAR Program (STAR or STAR Program). Under
the terms of this contract HMO will provide comprehensive health care services
to qualified and eligible Medicaid recipients through a managed care delivery
system. This is a risk-based contract. HMO was selected to provide services
under this contract under the Professional Services Procurement Act, Government
Code, Title 10, Section 2254.001 et. seq. HMO's selection for this contract was
based upon HMO's Application submitted in response to TDH's 1998 Request for
Application (RFA). Representations and responses contained in HMO's Application
are incorporated into and are enforceable provisions of this contract.
Terms used throughout this Contract have the following meaning, unless the
context clearly indicates otherwise.
ARTICLE I PARTIES AND AUTHORITY TO CONTRACT
1.1 The Texas Legislature has designated the Texas Health and Human
Services Commission (THHSC) as the single State agency to administer
the Medicaid program in the State of Texas. THHSC has delegated the
authority to operate the Medicaid managed care delivery system for
acute care services to TDH. TDH has authority to contract with HMO to
carry out the duties and functions of the Medicaid managed care
program under Health and Safety Code, Title 2, Section 12.011 and
Section 12.021 and Texas Government Code Section 533.001 et. seq.
1.2 HMO is a corporation with authority to conduct business in the State
of Texas and has a certificate of authority from the Texas Department
of Insurance (TDI) to operate as a Health Maintenance Organization
(HMO) under Chapter 20A of the Insurance Code. HMO is in compliance
with all TDI rules and laws that apply to HMOs. HMO has been
authorized to enter into this contract by its Board of Directors or
other governing body. HMO is an authorized vendor with TDH and has
received a Vendor Identification number from the Texas Comptroller of
Public Accounts.
1 Dallas Service Area Contract
8
1.3 This contract is subject to the approval and ongoing monitoring of the
Federal Health Care Financing Administration (HCFA).
1.4 Renewal Review TDH is required by Human Resources Code Section
32.043(a) and Government Code 533.007 to conduct renewal review of
HMO's performance and compliance with this contract as a condition for
retention and renewal.
1.4.1 Renewal Review may include a review of HMO's past performance and
compliance with the requirements of this contract and on-site
inspection of any or all of HMO's systems or processes.
1.4.2 TDH will provide HMO with at least 30 days written notice prior to
conducting an HMO renewal review. A report of the results of the
renewal review findings will be provided to HMO within 10 weeks from
the completion of the renewal review. The renewal review report will
include any deficiencies which must be corrected and the time line
within which the deficiencies must be corrected.
1.4.3 TDH reserves the right to conduct on-site inspections of any or all of
HMO's systems and processes as often as necessary to ensure compliance
with contract requirements. TDH may conduct at least one complete
on-site inspection of all systems and processes every three years. TDH
will provide six weeks advance notice to HMO of the three year on-site
inspection, unless TDH enters into an MOU with the Texas Department of
Insurance to accept the TDI report in lieu of a TDH on-site inspection.
TDH will notify HMO prior to conducting an on-site visit related to a
regularly scheduled review specifically described in this contract.
Even in the case of a regularly scheduled visit, TDH reserves the right
to conduct an on-site review without advance notice if TDH believes
there may be potentially serious or life threatening deficiencies.
1.5 AUTHOR OF HMO TO ACT ON BEHALF OF TDH. HMO is given express, limited
authority to exercise the State's right of recovery as provided in
Article 4.9 and to enforce provisions of this contract which require
providers or subcontractors to produce records; reports, encounter
data; public health data, and other documents to comply with this
contract and which TDH has authority to require under State or federal
laws.
ARTICLE II DEFINITIONS
2 Dallas Service Area Contract
9
Abuse means provider practices that are inconsistent with sound fiscal,
business, or medical practices and result in an unnecessary cost to the Medicaid
programs, reimbursement for services that are not medically necessary or that
fail to meet professionally recognized standards for health care. It also
includes recipient practices that result in unnecessary cost to the Medicaid
program.
Action means a denial, termination, suspension, or reduction of covered services
or the failure of HMO to act upon request for covered services within a
reasonable time or a denial of a request for prior authorization for covered
services affecting a Member. This term does not include reaching the end of
prior authorized services.
Adjudicate means to deny or pay a clean claim.
Adverse determination means a determination by a utilization review agent that
the health care services furnished, or proposed to be furnished to a patient,
are not medically necessary or not appropriate.
Affiliate means any individual or entity owning or holding more than a five
percent (5%) interest in HMO; in which HMO owns or holds more than a five
percent (5%) interest; any parent entity; or subsidiary entity of HMO,
regardless of the organizational structure of the entity.
Allowable expenses means all expenses related to the Contract for Services
between TDH and HMO that are incurred during the term of the contract that are
not reimbursable or recovered from another source.
Allowable revenue means all Medicaid managed care revenue received by HMO for
the contract period, including retroactive adjustments made by TDH.
Appeal of adverse determination means the format process by which a utilization
review agent offers a mechanism to address adverse determination as defined in
Article 21.58A, Texas Insurance Code.
Auxiliary aids and services includes qualified interpreters or other effective
methods of making aurally delivered materials understood by persons with hearing
impairments; and, taped texts, large print, Braille, or other effective methods
to ensure visually delivered materials are available to individuals with visual
impairments. Auxiliary aids and services also includes effective methods to
ensure that materials (delivered both aurally and visually) are available to
those with cognitive or other disabilities affecting communication.
Behavioral health services means covered services for the treatment of mental or
emotional disorders and treatment of chemical dependency disorders.
Benchmark means a target or standard based on historical data or an
objective/goal.
3 Dallas Service Area Contract
10
Call coverage means arrangements made by a facility or an attending physician
with an appropriate level of health care provider who agrees to be available on
an as-needed basis to provide medically appropriate services for routine/high
risk/or emergency medical conditions or emergency Behavioral Health conditions
that present without being scheduled at the facility or when the attending
physician is unavailable.
Capitation means a method of payment in which HMO or a health care provider
receives a fixed amount of money each month for each enrolled Member, regardless
of the services used by the enrolled Member.
CHIP means Children's Health Insurance Program established by Title XXI of the
Social Security Act to assist state efforts to initiate and expand child health
assistance to uninsured, low-income children.
Chronic or complex condition means a physical, behavioral, or developmental
condition which may have no known cure and/or is progressive and/or can be
debilitating or fatal if left untreated or under-treated.
Clean claim means a TDH approved or identified claim format that contains all
data fields required by HMO and TDH for final adjudication of the claim. The
required data fields must be complete and accurate. Clean claim also includes
HMO-published requirements for adjudication, such as medical records, as
appropriate. (See definition of Unclean Claim.) The TDH required data fields are
identified in TDH's "HMO Encounter Data Claims Submission Manual."
CLIA means the federal legislation commonly known as the Clinical Laboratories
Improvement Act of 1988 as found at Section 353 of the federal Public Health
Services Act, and regulations adopted to implement the Act.
Community Resource Coordination Groups (CRCGs) means a state wide system of
local interagency groups, including both public and private providers, which
coordinate services for "multi-need" children and youth. CRCGs develop
individual service plans for children and adolescents whose needs can be met
only through interagency cooperation. CRCGs address complex needs in a model
that promotes local decision-making and ensures that children receive the
integrated combination of social, medical and other services needed to address
their individual problems.
Complainant means a Member or a treating provider or other individual designated
to act on behalf of the Member who files the complaint.
Complaint means any dissatisfaction, expressed by a complainant orally or in
writing to HMO, with any aspect of HMO's operation, including but not limited
to dissatisfaction with plan administration's procedures related to review or
appeal of an adverse determination, as that term is defined by the Texas
Insurance Code Article 20A.12, with the exception of the Independent Review
Organization requirements; the denial, reduction, or termination of a service
for reasons not related to medical
4 Dallas Service Area Contract
11
necessity; the way a service is provided; or disenrollment decisions expressed
by a complainant. The term does not include misinformation that is resolved
promptly by supplying the appropriate information or clearing up the
misunderstanding to the satisfaction of the Member. The term also does not
include a provider's or enrollee's oral/written dissatisfaction or disagreement
with an adverse determination or a request for a fair hearing to TDH.
Comprehensive Care Program: See definition for Texas Health Steps.
Continuity of care means care provided to a Member by the same primary care
provider or specialty provider to the greatest degree possible, so that the
delivery of care to the Member remains stable, and services are consistent and
unduplicated.
Contract means this contract between TDH and HMO and documents included by
reference and any of its written amendments, corrections or modifications.
Contract administrator means an entity contracting with TDH to carry out
specific administrative functions under the State's Medicaid managed care
program.
Contract anniversary date means September 1 of each year after the first year of
this contract, regardless of the date of execution or effective date of the
contract.
Contract period means the period of time starting with effective date of the
contract and ending on the termination date of the contract.
Court-ordered commitment means a commitment of a STAR Member to a psychiatric
facility for treatment that is ordered by a court of law pursuant to the Texas
Health and Safety Code, Title VII Subtitle C.
Covered services means health care services HMO must arrange to provide to
Members, including all services required by this contract and state and federal
law, and all value-added services described by HMO in its response to the
Request For Application (RFA) for this contract.
Cultural competency means the ability of individuals and systems to provide
services effectively to people of various cultures, races, ethnic backgrounds,
and religions in a manner that recognizes, values, affirms, and respects the
worth of the individuals and protects and preserves their dignity.
Day means calendar day unless specified otherwise.
Denied claim means a clean claim or a portion of a clean claim for which a
determination is made that the claim cannot be paid.
Disability means a physical or mental impairment that substantially limits one
or more of the major life activities of an individual.
5 Dallas Service Area Contract
12
Disability-related access means that facilities are readily accessible to and
usable by individuals with disabilities, and that auxiliary aids and services
are provided to ensure effective communication, in compliance with Title III of
the Americans with Disabilities Act.
DSM-IV means the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, which is the American Psychiatric Association's official classification
of behavioral health disorders.
ECI means Early Childhood Intervention which is a federally mandated program for
infants and children under the age of three with or at risk for development
delays and/or disabilities. The federal ECI regulations are found at 34 C.F.R.
303.1 et. seq. The State ECI rules are found at 25 TAC Section 621.21 et. seq.
Effective date means the date on which TDH signs the contract following
signature of the contract by HMO.
Emergency behavioral health condition means any condition, without regard to the
nature or cause of the condition, which in the opinion of a prudent layperson
possessing an average knowledge of health and medicine requires immediate
intervention and/or medical attention without which Members would present an
immediate danger to themselves or others or which renders Members incapable of
controlling, knowing or understanding the consequences of their actions.
Emergency services means covered inpatient and outpatient services that are
furnished by a provider that is qualified to furnish such services under this
contract and are needed to evaluate or stabilize an emergency medical condition
and/or an emergency behavioral health condition.
Emergency Medical Condition means a medical condition manifesting itself by
acute symptoms of sufficient severity (including severe pain), such that a
prudent layperson, who possesses an average knowledge of health and medicine
could reasonably expect the absence of immediate medical care could result in:
(a) placing the patient's health in serious jeopardy;
(b) serious impairment to bodily functions;
(c) serious dysfunction of any bodily organ or part; or
(d) serious disfigurement; or
(e) in the case of a pregnant woman, serious jeopardy to the health of
the fetus.
Encounter means a covered service or group of services delivered by a provider
to a Member during a visit between the Member and provider. This also includes
value-added services.
Encounter data means data elements from fee-for-service claims or capitated
services proxy claims that are submitted to TDH by HMO in accordance with TDH's
"HMO Encounter Data Claims Submission Manual".
6 Dallas Service Area Contract
13
Enrollment Broker means an entity contracting with TDH to carry out specific
functions related to Member services (i.e. enrollment/disenrollment,
complaints, etc.) under TDH's Medicaid managed care program.
Enrollment report/enrollment file means the daily or monthly list of Medicaid
recipients who are enrolled with an HMO as Members on the day or for the month
the report is issued.
EPSDT means the federally mandated Early and Periodic Screening, Diagnosis and
Treatment program contained at 42 USC 1396d(r). (See definition for Texas Health
Steps.) The name has been changed to Texas Health Steps (THSteps) in the State
of Texas.
Experience Rebate means excess of allowable HMO STAR revenues over allowable
HMO STAR expenses.
Fair hearing means the process adopted and implemented by the Texas Department
of Health 25 TAC Chapter 1, in compliance with federal regulations and state
rules relating to Medicaid Fair Hearings Part 431, found at 42 C.F.R Subpart E,
and 1 TAC, Chapter 357.
FQHC means a Federally Qualified Health Center that has been certified by HCFA
to meet the requirements of Section 1861(aa)(3) of the Social Security Act as a
federally qualified health center and is enrolled as a provider in the Texas
Medicaid Program.
Fraud means an intentional deception or misrepresentation made by a person with
the knowledge that the deception could result in some unauthorized benefit to
himself or some other person. It includes any act that constitutes fraud under
applicable federal or state law.
HCFA means the federal Health Care Financing Administration.
Health care services means medically necessary physical medicine and
health-related services which an enrolled population might reasonably require in
order to be maintained in good health, including, as a minimum, emergency
services and inpatient and outpatient services.
Implementation Date means the first date that Medicaid managed care services are
delivered to Members in a service area.
Inpatient stay means at least a 24-hour stay in a facility licensed to provide
hospital care.
JCAHO means Joint Commission on Accreditation of Health Care Organizations.
Linguistic access means translation and interpreter services, for written and
spoken language to ensure effective communication. Linguistic access includes
sign language interpretation and the provision of other auxiliary aids and
services to persons with disabilities.
7 Dallas Service Area Contract
14
Local Health Department means a local health department established pursuant to
Health and Safety Code, Title 2, Local Public Health Reorganization Act Section
121.031.
Major life activities means functions such as caring for oneself, performing
manual tasks, walking, seeing, hearing, speaking, breathing, learning, and
working.
Major population group is defined by federal guidelines as a group comprising
10% or more of HMO's Medicaid service population.
Medical home means a primary or specialty care provider who has accepted the
responsibility for providing accessible, continuous, comprehensive and
coordinated care to Members participating in TDH's Medicaid managed care
program.
Medically necessary behavioral health services means those behavioral health
services which:
(a) are reasonable and necessary for the diagnosis or treatment of a
mental health or chemical dependency disorder or to improve or to
maintain or to prevent deterioration of functioning resulting from
such a disorder;
(b) are in accordance with professionally accepted clinical guidelines
and standards of practice in behavioral health care;
(c) are furnished in the most appropriate and least restrictive
setting in which services can be safely provided;
(d) are the most appropriate level or supply of service which can
safely be provided; and
(e) could not be omitted without adversely affecting the Member's
mental and/or physical health or the quality of care rendered.
Medically necessary health care services means health care services, other than
behavioral health services which are:
(a) reasonable and necessary to prevent illnesses or medical
conditions, or provide early screening, interventions, and/or
treatments for conditions that cause suffering or pain, cause
physical deformity or limitations in function, threaten to cause
or worsen a handicap, cause illness or infirmity of a Member, or
endanger life;
(b) provided at appropriate facilities and at the appropriate levels
of care for the treatment of a Member's health conditions;
(c) consistent with health care practice guidelines and standards that
are endorsed by professionally recognized health care
organizations or governmental agencies;
8 Dallas Service Area Contract
15
(d) consistent with the diagnoses of the conditions; and
(e) no more intrusive or restrictive than necessary to provide a
proper balance of safety, effectiveness, and efficiency.
Member means a person who: is entitled to benefits under Title XIX of the Social
Security Act and the Texas Medical Assistance Program (Medicaid), is in a
Medicaid eligibility category included in the STAR Program, and is enrolled in
the STAR Program.
Member month means one Member enrolled with an HMO during any given month. The
total Member months for each month of a year comprise the annual Member months.
MIS means management information system.
Non-provider subcontract means a contract between HMO and a third party which
performs a function, excluding delivery of health care services, that HMO is
required to perform under its contract with TDH.
NorthSTAR means a behavioral health carve-out program operating only in the
Dallas Service Area and administered by the Texas Commission on Alcohol and Drug
Abuse and the Texas Department of Mental Health and Mental Retardation.
Pended claim means a claim for payment which requires additional information
before the claim can be adjudicated as a clean claim.
Performance premium means an amount which may be paid to a managed care
organization as a bonus for accomplishing a portion or all of the performance
objectives contained in this contract.
Premium means the amount paid by TDH to a managed care organization on a monthly
basis and is determined by multiplying the Member months times the capitation
amount for each enrolled Member.
Primary care physician or primary care provider (PCP) means a physician or
provider who has agreed with HMO to provide a medical home to Members and who is
responsible for providing initial and primary care to patients, maintaining the
continuity of patient care, and initiating referral for care (also see Medical
home).
Provider means an individual or entity and its employees and subcontractors that
directly provide health care services to HMO's Members under TDH's Medicaid
managed care program.
Provider contract means an agreement entered into by a direct provider of health
services and HMO or an intermediary entity.
9 Dallas Service Area Contract
16
Proxy Claim Form means a form submitted by providers to document services
delivered to Medicaid Members under capitation arrangement. It is not a claim
for payment.
Public information means information that is collected, assembled, or maintained
under a law or ordinance or in connection with the transaction of official
business by a governmental body or for a governmental body and the governmental
body owns the information or has a right of access.
Real Time Captioning (also known as CART, Communication Access Real-Time
Translation) means a process by which a trained individual uses a shorthand
machine, a computer, and real-time translation software to type simultaneously
translated spoken language into text on a computer screen. Real Time Captioning
is provided for individuals who are deaf, have hearing impairments, or have
unintelligible speech; it is usually used to interpret spoken English into text
English, but may be used to translate other spoken language into text.
Renewal review means a review process conducted by TDH or its agent(s) to assess
HMO's capacity and capability to perform the duties and responsibilities
required under the Contract. This process is required by Texas Government Code
Section 533.007.
RFA means Request For Application issued by TDH on June 17,1998, and all RFA
addenda, corrections or modifications.
Risk means the potential for loss as a result of expenses and costs of HMO
exceeding payments made by TDH under this contract.
Rural Health Clinic (RHC) means an entity that meets all of the requirements for
designation as a rural health clinic under Section 1861(aa)(1) of the Social
Security Act and approved for participation in the Texas Medicaid Program.
Service area means the counties included in a site selected for the STAR
Program, within which a participating HMO must provide services.
Significant traditional provider (STP) means all hospitals receiving
disproportionate share hospital funds (DSH) in FY `95 and all other providers in
a county that, when listed by provider type in descending order by the number of
recipient encounters, provided the top 80 percent of recipient encounters for
each provider type in FY `95.
Special hospital means an establishment that:
(a) offers services, facilities, and beds for use for more than 24
hours for two or more unrelated individuals who are regularly
admitted, treated, and discharged and who require services more
intensive than room, board, personal services, and general nursing
care;
10 Dallas Service Area Contract
17
(b) has clinical laboratory facilities, diagnostic x-ray facilities,
treatment facilities, or other definitive medical treatment;
(c) has a medical staff in regular attendance; and
(d) maintains records of the clinical work performed for each patient.
STAR Program is the name of the State of Texas Medicaid managed care program.
"STAR" stands for the State of Texas Access Reform.
State fiscal year means the 12-month period beginning on September 1 and ending
on August 31 of the next year.
Subcontract means any written agreement between HMO and other party to fulfill
the requirements of this contract. All subcontracts are required to be in
writing.
Subcontractor means any individual or entity which has entered into a
subcontract with HMO.
TAC means Texas Administrative Code.
TANF means Temporary Assistance to Needy Families.
TCADA means Texas Commission on Alcohol and Drug Abuse. State agency responsible
for licensing chemical dependency treatment facilities. TCADA also contracts
with providers to deliver chemical dependency treatment services.
TDD means telecommunication device for the deaf. It is interchangeable with the
term Teletype machine or TTY.
TDH means the Texas Department of Health or its designees.
TDHS means the Texas Department of Human Services.
TDI means the Texas Department of Insurance.
TDMHMR means the Texas Department of Mental Health and Mental Retardation, which
is the State agency responsible for developing mental health policy for public
and private sector providers.
Temporary Assistance to Needy Families (TANF) means the federally funded program
that provides assistance to single-parent families with children who meet the
categorical requirements for aid. This program was formerly known as Aid to
Families with Dependent Children (AFDC) program.
11 Dallas Service Area Contract
18
Texas Health Steps (THSteps) is the name adopted by the State of Texas for the
federally mandated Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
program. It includes the State's Comprehensive Care Program extension to EPSDT,
which adds benefits to the federal EPSDT requirements contained in 42 United
States Code Section 1396d(r), and defined and codified at 42 C.F.R. Section
440.40 and Sections 441.56-62. TDH's rules are contained in 25 TAC, Chapter 33
(relating to Early and Periodic Screening, Diagnosis and Treatment).
Texas Medicaid Provider Procedures Manual means the policy and procedures manual
published by or on behalf of TDH which contains policies and procedures required
of all health care providers who participate in the Texas Medicaid program. The
manual is published annually and is updated bi-monthly by the Medicaid Bulletin.
THHSC means the Texas Health and Human Services Commission.
Third Party Liability (TPL) means the legal responsibility of another individual
or entity to pay for all or part of the services provided to Members under this
contract. (See 25 TAC, Subchapter 28, relating to Third Party Resources.)
Third Party Recovery (TPR) means the recovery of payments made on behalf of a
Member by TDH or HMO from an individual or entity with the legal responsibility
to pay for the services.
TP40 (Type Program 40) means Pregnant women receiving Medical Assistance Only
(MOA)-Pregnant women whose families' income is below 185% of the Federal Poverty
Level (FPL)
TP45 (Type Program 45) means Newborn (MAO) - Children under age one born to
Medicaid-eligible mothers.
TXMHMR means Texas Mental Health and Mental Retardation system which includes
the state agency, TDMHMR, and the Local Mental Health and Mental Retardation
Authorities.
Unclean claim means a claim that does not contain accurate and complete data in
all claim fields that are required by HMO and TDH and other HMO-published
requirements for adjudication, such as medical records, as appropriate. (See
definition of Clean Claim.)
Urgent behavioral health situations means conditions which require attention and
assessment within 24 hours but which do not place the Member in immediate danger
to themselves or others and the Member is able to cooperate with treatment.
Urgent condition means a health condition which is not an emergency but is
severe or painful enough to cause a prudent layperson possessing the average
knowledge of medicine to believe that his or her condition requires medical
treatment evaluation or treatment within 24 hours by the Member's PCP or PCP
designee to prevent serious deterioration of the Member's condition or health.
12 Dallas Service Area Contract
19
Value-added services means a service that the state has approved to be included
in this contract for which HMO does not receive capitation.
ARTICLE III PLAN ADMINISTRATIVE AND HUB RESOURCE REQUIREMENTS
3.1 ORGANIZATION AND ADMINISTRATION
3.1.1 HMO must maintain the organizational and administrative capacity and
capabilities to carry out all duties and responsibilities under this
contract.
3.1.2 HMO must maintain assigned staff with the capacity and capability to
provide all services to all Members under this contract.
3.1.3 HMO must maintain an administrative office in the service area (local
office). The local office must comply with the American with
Disabilities Act requirements for public buildings. Member Advocates
for the service area must be located in this office. (See Article 8.8.)
3.1.4 HMO must provide training and development programs to all assigned
staff to ensure they know and understand the service requirements under
this contract including the reporting requirements, the policies and
procedures, cultural and linguistic requirements and the scope of
services to be provided.
3.1.5 HMO must notify TDH no later than 30 days after the effective date of
this contract of any changes in its organizational chart as previously
submitted to TDH.
3.1.5.1 HMO must notify TDH within fifteen (15) working days of any change in
key managers or behavioral health subcontractors. This information must
be updated whenever there is a significant change in organizational
structure or personnel.
3.1.5.2 HMO shall submit a description and organizational chart, unless
previously submitted, which illustrates how physical health services
administration will be coordinated with behavioral health
administration in NorthStar plans, including individuals assigned to be
liaisons to NorthSTAR plans.
3.1.6 Participation in Regional Advisory Committee. HMO must participate on a
Regional Advisory Committee established in the service area in
compliance with the Texas Government Code, Sections
533.021-533.029. The Regional Advisory Committee in each managed care
service area must include representatives from at least the following
entities: hospitals; managed care organizations; primary care
providers; state agencies; consumer advocates; Medicaid recipients;
rural providers; long-term care providers; specialty care providers,
including pediatric providers; and political
13 Dallas Service Area Contract
20
subdivisions with a constitutional or statutory obligation to provide
health care to indigent patients. HHSC and TDH have authority to
determine the composition of each Regional Advisory Committee.
3.1.6.1 The Regional Advisory Committee is required to meet at least quarterly
for the first year after appointment of the committee and at least
annually in subsequent years. The actual frequency may vary depending
on the needs and requirements of the committee.
3.2 NON-PROVIDER SUBCONTRACTS
3.2.1 HMO must enter into written contracts with all Subcontractors and
maintain copies of the subcontracts in HMO's administrative office. HMO
must submit two copies of all non-provider subcontracts to TDH for
approval no later than 60 days after the effective date of this
contract, unless the subcontract has already been submitted to and
approved by TDH. Subcontracts entered into after the effective date of
this contract must be submitted no later than 30 days prior to the date
of execution of the subcontract. HMO must make non-provider
subcontracts available to TDH upon request, at the time and location
requested by TDH.
3.2.1.1 TDH has 15 working days to review the subcontract and recommend any
suggestions or required changes. If TDH has not responded to HMO by the
fifteenth day, HMO may execute the subcontract. TDH reserves the right
to request HMO to modify any subcontract that has been deemed approved.
.
3.2.1.2 HMO must notify TDH no later than 90 days prior to terminating any
subcontract affecting a major performance function of this contract.
All major Subcontractor terminations or substitutions require TDH
approval (see Article 15.7). TDH may require HMO to provide a
transition plan describing how the subcontracted function will continue
to be provided. All subcontracts are subject to the terms and
conditions of this contract and must contain the provisions of Article
V, Statutory and Regulatory Compliance, and the provisions contained in
3.2.4
3.2.2 Subcontracts, which are requested by any agency with authority to
investigate and prosecute fraud and abuse, must be produced at the time
and in the manner requested by the requesting Agency. Subcontracts
requested in response to a public information request must be produced
with 3 working days from TDH's notification to HMO of the request. All
requested records must be provided free of charge.
3.2.3 The form and substance of all Subcontracts including subsequent
amendments are subject to approval by TDH. TDH retains the authority to
reject or require changes to any provisions of the subcontract that do
not comply with the requirements or
14 Dallas Service Area Contract
21
duties and responsibilities of this contract or create significant
barriers for TDH in carrying out its duty to monitor compliance with
the contract. HMO REMAINS RESPONSIBLE FOR PERFORMING ALL DUTIES,
RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER
THE DUTY, RESPONSIBILITY OR SERVICE IS SUBCONTRACTED TO ANOTHER
3.2.4 HMO and all intermediary entities must include the following standard
language in each subcontract and ensure that this language is included
in all subcontracts down to the actual provider of the services. The
following standard language is not the only language that will be
considered acceptable by TDH.
3.2.4.1 Contractor understands that services provided under this contract are
funded by state and federal funds under the Texas Medical Assistance
Program (Medicaid). Contractor is subject to all state and federal
laws, rules and regulations that apply to persons or entities receiving
state and federal funds. Contractor understands that any violation by
Contractor of a state or federal law relating to the delivery of
services under this contract, or any violation of the TDH/HMO contract
could result in liability for contract money damages, and/or civil and
criminal penalties and sanctions under state and federal law.
3.2.4.2 Contractor understands and agrees that HMO has the sole responsibility
for payment of services rendered by the Contractor under this contract.
In the event of HMO insolvency or cessation of operations, Contractor's
sole recourse is against HMO through the bankruptcy or receivership
estate of HMO.
3.2.4.3 Contractor understands and agrees that TDH is not liable or responsible
for payment for any services provided under this contract.
3.2.4.4 Contractor agrees that any modification, addition, or deletion of the
provisions of this agreement will become effective no earlier than 30
days after HMO notifies TDH of the change. If TDH does not provide
written approval within 30 days from receipt of notification from HMO,
changes may be considered provisionally approved.
3.2.4.5 This contract is subject to state and federal fraud and abuse statutes.
The Contractor will be required to cooperate in the investigation and
prosecution of any suspected fraud or abuse, and must provide any and
all requested originals and copies of records and information, free of
charge on request, to any state or federal agency with authority to
investigate fraud and abuse in the Medicaid program.
3.2.5 The Texas Medicaid Fraud Control Unit must be allowed to conduct
private interviews of HMO personnel, Subcontractors and their
personnel, witnesses, and patients. Requests for information are to be
complied within the form and the language requested. HMO employees and
contractors and Subcontractors and their
15 Dallas Service Area Contract
22
employees and contractors must cooperate fully in making themselves
available in person for interviews, consultation, grand jury
proceedings, pretrial conference, hearings, trial and in any other
process, including investigations. Compliance with this Article is at
HMO's and subcontractors' own expense.
3.3 MEDICAL DIRECTOR
3.3.1 HMO must have at least one a full-time Medical Director licensed under
the Texas State Board of Medical Examiners (M.D. or D.O.). The Medical
Director may oversee other product line of the HMO but must fulfill all
duties and responsibilities as Medical Director for the Medicaid
Program. HMO must have a written job description describing the Medical
Director's authority, duties and responsibilities as follows:
3.3.1.1 Ensure that medical decisions, including prior authorization protocols,
are rendered by qualified medical personnel and are based on TDH's
definition of medical necessity, and is in compliance with the
Utilization Review Act and 21.58a of the Texas Insurance Code.
3.3.1.2 Oversight responsibility of network providers to ensure that all care
provided complies with the generally accepted health standards of the
community.
3.3.1.3 Oversight of HMO's quality improvement process, including establishing
and actively participating in HMO's quality improvement committee,
monitoring Member health status, HMO utilization review policies and
standards and patient outcome measures.
3.3.1.4 Identify problems and develop and implement corrective actions to
quality improvement process.
3.3.1.5 Develop, implement and maintain responsibility for HMO's medical
policy.
3.3.1.6 Oversight responsibility for medically related complaints.
3.3.1.7 Participate and provide witnesses and testimony on behalf of HMO in the
TDH fair hearing process.
3.3.2 The Medical Director must exercise independent medical judgement in all
medical decisions. HMO must ensure that medical decisions are not
adversely influenced by fiscal management decisions. TDH may conduct
reviews of medical decisions by HMO Medical Director at any time.
16 Dallas Service Area Contract
23
3.4 PLAN MATERIALS AND DISTRIBUTION OF PLAN MATERIALS
3.4.1 HMO must receive written approval from TDH for all written materials,
produced or authorized by HMO, containing information about the STAR
Program prior to distribution to Members, prospective Members,
providers within HMO's network, or potential providers who HMO intends
to recruit as network providers. This includes Member education
materials.
3.4.2 Member materials must meet cultural and linguistic requirements as
stated in Article VIII. Unless otherwise required, Member materials
must be written at a 4th - 6th grade reading comprehension level; and
be translated into the language of any major population group, except
when TDH requires HMO to use statutory language (i.e., advance
directives, medical necessity, etc.).
3.4.3 All materials regarding the STAR Program including Member education
materials, must be submitted to TDH for approval prior to distribution.
TDH has 15 working days to review the materials and recommend any
suggestions or required changes. If TDH has not responded to HMO by the
fifteenth day, HMO print and distribute STAR Program materials. TDH
reserves the right to request HMO to modify plan materials that are
deemed approved and have been printed or distributed. TDH-requested
modifications of previously approved, printed or distributed materials
can be made at the next printing unless substantial non-compliance
exists. An exception to the 15 working day timeframe may be requested
in writing by HMO for written provider materials that require a quick
turn-around time (e.g., letters). Materials requiring a quick
turn-around time will be reviewed by TDH within 5 working days.
3.4.4 HMO must forward TDH-approved English versions of their Member
Handbook, Member Provider Directory, newsletters, individual Member
letters, and any written information that applies to Medicaid-specific
services to DHS for DHS to translate into Spanish. DHS must provide the
written and approved translation into Spanish to HMO no later than 15
working days after receipt of the English version by DHS. HMO must
incorporate the approved translation into Member materials. If DHS has
not responded to HMO by the fifteenth day, HMO may print and distribute
the Member materials, with the translation provided by HMO's outside
translation source, rather than DHS's translation. TDH reserves the
right to require revisions to materials if inaccuracies are discovered
or if changes are required by changes in policy or law. Any changes
required by policy or law can be made at the next printing unless
substantial non-compliance exists. HMO has the option of using the DHS
translation unit or their own translators for health education
materials that do not contain Medicaid-specific information and for
other marketing materials such as billboards, radio spots, and
television and newspaper advertisements.
17 Dallas Service Area Contract
24
3.4.5 HMO must reproduce all written instructional; educational, and
procedural documents required under this contract and distribute them
to its providers and Members. HMO must reproduce and distribute
instructions and forms to all network providers who have reporting and
audit requirements under this contract.
3.4.6 HMO must provide TDH with at least three paper copies and one
electronic copy of HMO's Member Handbook, Provider Manual and Member
Provider Directory. If an electronic format is not available, five
paper copies are required.
3.4.7 Changes to the Required Critical Elements for the Member Handbook,
Provider Manual, and Provider Directory may be included as inserts into
handbooks, manuals and directories until the next printing of these
documents.
3.5 RECORDS REQUIREMENTS AND RECORDS RETENTION
3.5.1 HMO must keep all records required to be created and retained under
this contract. Records related to Members served in this service area
must be made available in HMO's local office when requested by TDH. All
records must be retained for a period of five (5) years unless
otherwise specified in this contract. Original records must be kept in
the form they were created in the regular course of business for a
minimum of two (2) years following the end of the contract period.
Microfilm, digital or electronic records may be substituted for the
original records after the first two (2) years, if the retention system
is reliable and is supported by a retrieval system which allows
reasonable access to the records. All copies of original records must
be made using guidelines and procedures approved by TDH, if the
original documents will no longer be available or accessible.
3.5.2 Availability and Accessibility. All records, documents and data
required to be created under this contract are subject to audit,
inspection and production. If an audit, inspection or production is
requested by TDH, TDH's designee or TDH acting on behalf of any agency
with regulatory or statutory authority over Medicaid Managed Care, the
requested records must be made available at the time and at the place
the records are requested. Copies of requested records must be produced
or provided free of charge to the requesting agency. Records requested
after the second year following the end of contract term, which have
been stored or archived must be accessible and made available within 10
calendar days from the date of a request by TDH or the requesting
agency or at a time and place specified by the requesting entity.
3.5.3 Accounting Records. HMO must create and keep accurate and complete
accounting records in compliance with to Generally Accepted Accounting
Principles (GAAP). Records must be created and kept for all claims
payments, refunds and adjustment payments to providers, premium or
capitation payments, interest income and
18 Dallas Service Area Contract
25
payments for administrative services or functions. Separate records
must be maintained for medical and administrative fees, charges and
payments.
3.5.4 General Business Records. HMO must create and keep complete and
accurate general business records to reflect the performance of duties
and responsibilities and compliance with the provisions of this
contract.
3.5.5 Medical records. HMO must require, through contractual provisions,
providers to create and keep medical records in compliance with the
medical records standards contained in the Standards for Quality
Improvement Programs in Appendix A. All medical records must be kept
for at least five (5) years, except for records of rural health
clinics, which must be kept for a period of six (6) years from the date
of service.
3.5.6 Matters in Litigation. HMO must keep records related to matters in
litigation for five (5) years following the termination or resolution
of the litigation.
3.5.7 On-line Retention of Claims History. HMO must keep automated claims
payment histories for a minimum of 18 months, from date of
adjudication, in an on-line inquiry system. HMO must also keep
sufficient history on-line to ensure all claim/encounter service
information is submitted to and accepted by TDH for processing.
3.6 HMO REVIEW OF TDH MATERIALS
TDH will submit all studies or audits that relate or refer to HMO for
review and comment to HMO 10 working days prior to releasing the report
to the public or to Members.
3.7 HMO TELEPHONE ACCESS REQUIREMENTS
3.7.1 For all HMO telephone access, 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%;
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 8.9) and provide "linguistic access" to all
members as defined in Article 11.
19 Dallas Service Area Contract
26
* This would include the provision of interpretive services
required for effective communication for Members and
providers:
3.7.2 Member Helpline: The HMO must furnish a toll free phone line which
members may call 24 hours a day, 7 days a week. An answering service or
other similar mechanism, which allows callers to obtain information
from a live person, may be used for after-hours and weekend coverage.
3.7.2.1 HMO must provide coverage for the following services at least during
HMO's regular business hours (a minimum of 9 hours a days between 8
a.m. and 6 p.m.) Monday through Friday:
1. Member ID information
2. PCP Change
3. Benefit understanding
4. PCP verification
5. Access issues (including referrals to specialists)
6. Unavailability of PCP
7. Member eligibility
8. Complaints
9. Service area issues (including when member is temporarily
out-of-service area)
10. Other services covered by member services.
3.7.2.2 HMO must provide TDH with policies and procedures indicating how the
HMO will meet the needs of members who are unable to contact HMO during
regular business hours.
3.7.3 HMO must ensure that PCPs are available 24 hours a day, 7 days a week
(see Article 7.8). This includes PCP telephone coverage (see 28 TAC
11.2001(a)lA).
ARTICLE IV FISCAL, FINANCIAL, CLAIMS AND INSURANCE REQUIREMENTS
4.1 FISCAL SOLVENCY
4.1.1 HMO must be and remain in full compliance with all state and federal
solvency requirements for HMOs, including but not limited to all
reserve requirements, net worth standards, debt-to-equity ratios, or
other debt limitations.
4.1.2 If HMO becomes aware of any impending changes to its financial or
business structure which could adversely impact its compliance with
these requirements or its ability to pay its debts as they come due,
provide services under this contract, or if HMO becomes aware of a
take-over or assignment which would require approval of TDI or TDH, HMO
must notify TDH immediately in writing.
20 Dallas Service Area Contract
27
4.1.3 HMO must not have been placed under state conservatorship or
receivership or filed for protection under federal bankruptcy laws.
None of HMO's property, plant or equipment must have been subject to
foreclosure or repossession within the preceding 10-year period. HMO
must not have any debt declared in default and accelerated to maturity
within the preceding 10-year period. HMO represents that these
statements are true as of the contract effective date. HMO must inform
TDH within 24 hours of a change in any of the preceding
representations.
4.2 MINIMUM NET WORTH
4.2.1 HMO has minimum net worth to the greater of (a) $1,500,000; (b) an
amount equal to the sum of twenty five dollars ($25) times the number
of all enrollees including Medicaid Members; or (c) an amount that
complies with standards adopted by TDI. Minimum net worth means the
excess total admitted assets over total liabilities, excluding
liability for subordinated debt issued in compliance with Article 1.39
of the Insurance Code.
4.2.2 The minimum equity must be maintained during the entire contract
period.
4.3 PERFORMANCE BOND
HMO has furnished TDH a performance bond in the form prescribed by TDH
and approved by TDI, naming TDH as Obligee, securing HMO's faithful
performance of the terms and conditions of this contract. The
performance bond has been issued in the amount of $100,000. If the
contract is renewed or extended under Article XVIII, a separate bond
will be required for each additional term of the contract. The bond has
been issued by a surety licensed by TDI, and specifies cash payment as
the sole remedy. Performance Bond requirements under this Article must
comply with Texas Insurance Code Section 11.1805, relating to
Performance and Fidelity Bonds. The bond must be delivered to TDH at
the same time the signed HMO contract is delivered to TDH.
4.4 INSURANCE
4.4.1 HMO must maintain or cause to be maintained general liability insurance
in the amounts of at least $1,000,000 per occurrence and $5,000,000 in
the aggregate.
4.4.2 HMO must maintain or require professional liability insurance on each
of the providers in its network in the amount of $100,000 per
occurrence and $300,000 in the aggregate, or the limits required by the
hospital at which the network provider has admitting privileges.
21 Dallas Service Area Contract
28
4.4.3 HMO must maintain an umbrella professional liability insurance policy
for the greater of $3,000,000 or an amount (rounded to the next
$100,000) which represents the number of STAR Members enrolled in HMO
in the first month of the contract year multiplied by $150, not to
exceed $10,000,000.
4.4.4 Any exceptions to the requirements of this Article must be approved in
writing by TDH prior to the effective date of this contract. HMOs and
providers who qualify as either state or federal units of government
are exempt from the insurance requirements of this Article and are not
required to obtain exemptions from these provisions prior to the
effective date of this contract. State and federal units of government
are required to comply with and are subject to the provisions of the
Texas or Federal Tort Claims Act.
4.5 FRANCHISE TAX
HMO certifies that its payment of franchise taxes is current or that
it is not subject to the State of Texas franchise tax.
4.6 AUDIT
4.6.1 TDH, TDI or their designee have the right from time to time to examine
and audit books and records of HMO or of its Subcontractors relating
to: (1) HMO's capacity to bear the risk of potential financial losses;
(2) services performed or determination of amounts payable under this
contract; (3) detection of fraud and abuse; and (4) other purposes TDH
deems to be necessary to perform its regulatory function and/or to
enforce the provisions of this contract.
4.6.2 TDH is required to conduct an audit of HMO at least once every three
years. HMO is responsible for paying the costs of an audit conducted
under this Article. The costs of the audit by HMO are allowable costs
under this contract.
4.7 PENDING OR THREATENED LITIGATION
HMO must require disclosure from Subcontractors and network providers
of all pending or potential litigation or administrative actions
against the Subcontractor or network provider and must disclose this
information to TDH, in writing, prior to the execution of prior
contracts and this renewal. HMO must make reasonable investigation and
inquiry that there is not pending or potential litigation or
administrative action against the providers or subcontractors in HMO's
provider network. HMO must notify TDH of any litigation which is
initiated or threatened after the effective date of this contract
within seven days of receiving service or becoming aware of the
threatened litigation.
22 Dallas Service Area Contract
29
4.8 MISREPRESENTATION AND FRAUD IN RESPONSE TO RFA AND IN HMO OPERATIONS
4.8.1 HMO was awarded this contract based upon the responses and
representations contained in HMO's application submitted in response
to TDH's RFA. All responses and representations upon which scoring was
based were considered material to the decision of whether to award the
contract to HMO. RFA responses are incorporated into this contract by
reference. The provisions of this contract control over any RFA
response if there is a conflict between the RFA and this contract, or
if changes in law or policy have changed the requirements of HMO
contracting with TDH to provide Medicaid Managed Care.
4.8.2 This contract was awarded in part based upon HMO's representation of
its current equity and financial ability to bear the risks under this
contract. TDH will consider any misrepresentations of HMO's equity,
HMO's ability to bear financial risks of this contract or inflating
the equity of HMO, solely for the purpose of being awarded this
contract, a material misrepresentation and fraud under this contract.
4.8.3 Discovery of any material misrepresentation or fraud on the part of
HMO in HMO's application or in HMO's day-to-day activities and
operations may cause this contract to terminate and may result in
legal action being taken against HMO under this contract, and state
and federal civil and criminal laws.
4.9 THIRD PARTY RECOVERY
4.9.1 Third Party Recovery. All Members are required to assign their rights
to any benefits to the State and agree to cooperate with the State in
identifying third parties who may be liable for all or part of the
costs for providing services to the Member, as a condition for
participation in the Medicaid program. HMO is authorized to act as the
State's agent in enforcing the State's rights to third party recovery
under this contract.
4.9.2 Identification. HMO must develop and implement systems and procedures
to identify potential third parties who may be liable for payment of
all or part of the costs for providing medical services to Members
under this contract. Potential third parties must include any of the
sources identified in 42 C.F.R. 433.138, relating to identifying third
parties, except workers' compensation, uninsured and underinsured
motorist insurance, first and third party liability insurance and
tortfeasors. HMO must coordinate with TDH to obtain information from
other state and federal agencies and HMO must cooperate with TDH in
obtaining information from commercial third party resources. HMO must
require all providers to comply with the provisions of 25 TAC Section
28, relating to Third Party Recovery in the Medicaid program.
23 Dallas Service Area Contract
30
4.9.3 Exchange of identified resources. HMO must forward identified
resources of uninsured and underinsured motorist insurance, first and
third party liability insurance and tortfeasors ("excepted resources")
to TDH for TDH to pursue collection and recovery from these resources.
TDH will forward information on all third party resources identified
by TDH to HMO. HMO must coordinate with TDH to obtain information from
other state and federal agencies, including HCFA for Medicare and the
Child Support Enforcement Division of the Office of the Attorney
General for medical support. HMO must cooperate with TDH in obtaining
and exchanging information from commercial third party resources.
4.9.4 Recovery. HMO must actively pursue and collect from third party
resources which have been identified, except when the cost of pursuing
recovery reasonably exceeds the amount which may be recovered by HMO.
HMO is not required to, but may pursue recovery and collection from
the excepted resources listed in 4.9.3. HMO must report the identity
of these resources to TDH, even if HMO will pursue collection and
recovery from the excepted resources.
4.9.4.1 HMO must provide third party resource information to network providers
to whom individual Members have been assigned or who provide services
to Members. HMO must require providers to seek recovery from potential
third party resources prior to seeking payment from HMO. If network
providers are paid capitation, HMO must either seek recovery from
third party resources or account to TDH for all amounts received by
network providers from third party resources.
4.9.4.2 HMO must prohibit network providers from interfering with or placing
liens upon the State's right or HMO's right, acting as the State's
agent, to recovery from third party resources. HMO must prohibit
network providers from seeking recovery in excess of the Medicaid
payable amount or otherwise violating state and federal laws.
4.9.5 Retention. HMO may retain as income all amounts recovered from third
party sources as long as recoveries are obtained in compliance with
the contract and state and federal laws.
4.9.6 Accountability. HMO must report all third party recovery efforts and
amounts recovered as required in 12.1.10. If HMO fails to pursue and
recover from third parties no later 180 days after the date of
service, TDH may pursue third party recoveries and retain all amounts
recovered without accounting to HMO for the amounts recovered. Amounts
recovered by TDH will be added to expected third party recoveries to
reduce future capitation rates, except recoveries from those excepted
third party resources listed in 4.9.3.
24 Dallas Service Area Contract
31
4.10 CLAIMS PROCESSING REQUIREMENTS
4.10.1 HMO and claims processing subcontractors must comply with TDH's Texas
Managed Care Claims Manual (Claims Manual), which contains TDH's
claims processing requirements. HMO must comply with any changes to
the Claims Manual with appropriate notice of changes from TDH.
4.10.2 HMO must forward claims submitted to HMO in error to either the
correct HMO if the correct HMO can be determined from the claim or is
otherwise known to HMO or the State's claims administrator; or to the
provider who submitted the claim in error, along with an explanation
of why the claim is being returned.
4.10.3 HMO must not pay any claim submitted by a provider who has been
excluded or suspended from the Medicare or Medicaid programs for fraud
and abuse when HMO has knowledge of the exclusion or suspension.
4.10.4 All provider clean claims must be adjudicated (finalized as paid or
denied adjudicated) within 30 days from the date the claim is received
by HMO as required by the Claims Manual. HMO must pay providers
interest on a clean claim which is not adjudicated within 30 days from
the date the claim is received by HMO or becomes clean at a rate of
1.5% per month (18% annual) for each month the clean claim remains
unadjudicated (see Section 2.8 of the Texas Medicaid Managed Care
Claims Manual to calculate the interest payment to providers). HMO
will be held to a minimum performance level of 90% of all clean claims
paid or denied within 30 days of receipt and 99% of all clean claims
paid or denied within 90 days of receipt. Failure to meet these
performance levels is a default under Article XVI Default and Remedies
of this contract and could lead to damages or sanctions under Article
XVII. Performance levels are subject to change if required to comply
with federal and state laws or regulations.
4.10.4.1 All claims and appeals submitted to HMO and claims processing
subcontractors must be paid-adjudicated (clean claims),
denied-adjudicated (clean claims), or denied for additional
information (unclean claims) to providers within 30 days from the date
the claim is received by HMO. Providers must be sent a written notice
for each claim that is denied for additional information (unclean
claims) identifying the claim, all reasons why the claim is being
denied, the date the claim was received by HMO, all information
required from the provider in order for HMO to adjudicate the claim,
and the date by which the requested information must be received from
the provider.
4.10.4.2 Claims that are suspended (pended internally) must be subsequently
paid adjudicated, denied-adjudicated, or denied for additional
information (pended
25 Dallas Service Area Contract
32
externally) within 30 days from date of receipt. No claim can be
suspended for a period exceeding 30 days from date of receipt of the
claim.
4.10.4.3 HMO must identify each data field of each claim form that is required
from the provider in order for HMO to adjudicate the claim. HMO must
inform all network providers about the required fields at least 30
days prior to the effective date of this contract or as a provision
within HMO/provider contract. Out of network providers must be
informed of all required fields if the claim is denied for additional
information. The required fields must include those required by HMO
and TDH.
4.10.5 HMO 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 regarding the submission and receipt of
claims information through electronic data interchange (EDI) that
allows for automated processing and adjudication of claims within two
or three years, as applicable, from the date the rules promulgated
under HIPAA are adopted.
4.10.6 For claims requirements regarding retroactive PCP changes for
mandatory Members, see Article 7.8.12.2.
4.11 INDEMNIFICATION
4.11.1 HMO/TDH: HMO must agree to indemnify TDH and its agents for any and
all claims, costs, damages and expenses, including court costs and
reasonable attorney's fees, which are related to or arise out of:
4.11.1.1 Any failure, inability, or refusal of HMO or any of its network
providers or other Subcontractors to provide contract services;
4.11.1.2 Claims arising from HMO's, HMO's network provider's or other
Subcontractor's negligent or intentional conduct in providing services
under this contract.
4.11.1.3 Failure, inability or refusal of HMO to pay any of its network
providers or Subcontractors for services.
4.11.2 HMO/Provider: HMO is prohibited from requiring any providers to
indemnify HMO for HMO's own acts or omissions which result in damages
or sanctions being assessed against HMO either under this contract or
under state or federal law.
ARTICLE V STATUTORY AND REGULATORY COMPLIANCE REQUIREMENTS
26 Dallas Service Area Contract
33
5.1 COMPLIANCE WITH FEDERAL, STATE, AND LOCAL LAWS
5.1.1 HMO must know, understand and comply with all state and federal laws
and regulations relating to the Texas Medicaid Program which have not
been waived by HCFA. HMO must comply with all rules relating to the
Medicaid managed care program adopted by TDH, TDI, THHSC, TDMHMR and
any other state agency delegated authority to operate or administer
Medicaid or Medicaid managed care programs.
5.1.2 HMO must require, through contract provisions, that all network
providers or Subcontractors comply with all state and federal laws and
regulations relating to the Texas Medicaid Program and all rules
relating to the Medicaid managed care program adopted by TDH, TDI,
THHSC, TDMHMR and any other state agency delegated authority to
operate Medicaid or Medicaid Managed Care programs.
5.1.3 HMO must comply with the provisions of the Clean Air Act and the
Federal Water Pollution Control Act, as amended, found at 42 C.F.R.
7401, et. seq. and 33 USC 1251, et. seq., respectively.
5.2 PROGRAM INTEGRITY
5.2.1 HMO has not been excluded, debarred, or suspended from participation
in any program under Title XVIII or Title XIX under any of the
provisions of Section 1128(a) or (b) of the Social Security Act (42
USC Section 1320 a-7), or Executive Order 12549. HMO must notify TDH
within 3 days of the time it receives notice that any action is being
taken against HMO or any person defined under the provisions of
section 1128(a) or (b) or any Subcontractor, which could result in
exclusion, debarment, or suspension of HMO or a Subcontractor from the
Medicaid program, or any program listed in Executive Order 12549.
5.2.2 HMO must comply with the provisions of, and file the certification of
compliance required by the ββββ Anti-Lobbying Amendment, found at 31
USC 1352, relating to use of federal funds for lobbying for or
obtaining federal contracts.
5.3 FRAUD AND ABUSE COMPLIANCE PLAN
5.3.1 This contract is subject to all state and federal laws and regulations
relating to fraud and abuse in health care and the Medicaid program.
HMO must cooperate and assist TDH and THHSC and any other state or
federal agency charged with the duty of identifying, investigating,
sanctioning or prosecuting suspected fraud and abuse. HMO must provide
originals and/or copies of all records and information requested and
allow access to premises and provide records to TDH or its authorized
agent(s), THHSC, HCFA, the U.S. Department of Health and Human
Services, FBI, TDI, and
27 Dallas Service Area Contract
34
the Texas Attorney General's Medicaid Fraud Control Unit. All copies
of records must be provided free of charge.
5.3.2 Compliance Plan. HMO must submit to TDH for approval a written fraud
and abuse compliance plan which is based on the Model Compliance Plan
issued by the U.S. Department of Health and Human Services, the Office
of Inspector General (OIG), no later than 30 days after the effective
date of this contract. HMO must designate an officer or director in
its organization who has the responsibility and authority for carrying
out the provisions of its compliance plan. HMO must submit any updates
or modifications in its compliance plan to TDH for approval at least
30 days prior to the modifications going into effect. HMO's fraud and
abuse compliance plan must:
5.3.2.1 ensure that all officers, directors, managers and employees know and
understand the provisions of HMO's fraud and abuse compliance plan.
5.3.2.2 contain procedures designed to prevent and detect potential or
suspected abuse and fraud in the administration and delivery of
services under this contract.
5.3.2.3 contain provisions for the confidential reporting of plan violations
to the designated person in HMO.
5.3.2.4 contain provisions for the investigation and follow-up of any
compliance plan reports.
5.3.2.5 ensure that the identity of individuals reporting violations of the
plan is protected.
5.3.2.6 contain specific and detailed internal procedures for officers,
directors, managers and employees for detecting, reporting, and
investigating fraud and abuse compliance plan violations.
5.3.2.7 require any confirmed or suspected fraud and abuse under state or
federal law be reported to TDH, the Medicaid Program Integrity section
of the Office of Investigations and Enforcement of the Texas Health
and Human Services Commission, and/or the Medicaid Fraud Control Unit
of the Texas Attorney General.
5.3.2.8 ensure that no individual who reports plan violations or suspected
fraud and abuse is retaliated against.
5.3.3 Training. HMO must designate executive and essential personnel to
attend mandatory training in fraud and abuse detection, prevention and
reporting. The training will be conducted by the Office of
Investigation and Enforcement, Health and Human Services Commission,
and will be provided free of charge. HMO must
28 Dallas Service Area Contract
35
schedule and complete training no later than 90 days after the
effective date of any updates or modification of the written Model
Compliance Plan.
5.3.3.1 If HMO's executive and essential personnel change or if HMO employs
additional executive and essential personnel, the new or additional
personnel must attend OIE training within 90 days of employment by
HMO.
5.3.4 HMO's failure to report potential or suspected fraud or abuse may
result in sanctions, contract cancellation, or exclusion from
participation in the Medicaid program.
5.3.5 HMO must allow the Texas Medicaid Fraud Control Unit and THHSC's
Office of Investigations and Enforcement, to conduct private
interviews of HMO's employees, subcontractors and their employees,
witnesses, and patients. Requests for information must be complied
with in the form and the language requested. HMO's employees and its
Subcontractors and their employees must cooperate fully and be
available in person for interviews, consultation, grand jury
proceedings, pre-trial conference, hearings, trial and in any other
process.
5.3.6 Subcontractors. HMO must submit the documentation described in
Articles 5.3.6.1 through 5.3.6.3, in compliance with Texas Government
Code Section 533.012, regarding any subcontractor providing health
care services under this contract except for those providers who have
re-enrolled as a provider in the Medicaid program as required by
Section 2.07, Chapter 1153, Acts of the 75th Legislature, Regular
Session, 1997, or who modified a contract in compliance with that
section. HMO must submit information in a format as specified by TDH.
Documentation must be submitted no later than 120 days after the
effective date of this contract. Subcontracts entered into after the
effective date of this contract must be submitted no later than 90
days after the effective date of the subcontracts. The documentation
required under this provision is not subject to disclosure under
Chapter 552, Government Code. The information which must be submitted
must include:
5.3.6.1 a description of any financial or other business relationship between
HMO and its subcontractor;
5.3.6.2 a copy of each type of contract between HMO and its subcontractor;
5.3.6.3 a description of the fraud control program used by any subcontractor.
5.4 SAFEGUARDING INFORMATION
5.4.1 All Member information, records and data collected or provided to HMO
by TDH or another State agency is protected from disclosure by state
and federal law and regulations. HMO may only receive and disclose
information which is directly
29 Dallas Service Area Contract
36
related to establishing eligibility, providing services and conducting
or assisting in the investigation and prosecution of civil and
criminal proceedings under state or federal law. HMO must include a
confidentiality provision in all subcontracts with individuals.
5.4.2 HMO is responsible for informing Members and providers regarding the
provisions of 42 C.F.R. 431, Subpart F, relating to Safeguarding
Information on Applicants and Recipients, and HMO must ensure that
confidential information is protected from disclosure except for
authorized purposes.
5.4.3 HMO must assist network PCPs in developing and implementing a policies
for protecting the confidentiality of AIDS and HIV-related medical
information and an anti-discrimination policy for employees and
Members with communicable diseases. See also Health and Safety Code,
Chapter 85, Subchapter E relating to Duties of State Agencies and
State Contractors.
5.4.4 HMO must require, through contractual provisions, that subcontractors
have mechanisms in place to ensure Member's (including minor's)
confidentiality for family planning services.
5.5 NON-DISCRIMINATION
HMO agrees to comply with and to include in all Subcontracts a
provision that the Subcontractor will comply with each of the
following requirements:
5.5.1 Title VI of the Civil Rights Act of 1964, Section 504 of the
Rehabilitation Act of 1973, the Americans with Disabilities Act of
1990, and all requirements imposed by the regulations implementing
these acts and all amendments to the laws and regulations. The
regulations provide in part that no person in the United States shall
on the grounds of race, color, national origin, sex, age, disability,
political beliefs or religion be excluded from participation in, or
denied, any aid, care, service or other benefits, or be subjected to
any discrimination under any program or activity receiving federal
funds.
5.5.2 Texas Health and Safety Code Section 85.113 (relating to workplace and
confidentiality guidelines regarding AIDS and HIV).
5.5.3 The provisions of Executive Order 11246, as amended by 11375, relating
to Equal Employment Opportunity.
5.5.4 HMO shall not discriminate with respect to participation,
reimbursement, or indemnification as to any provider who is acting
within the scope of the provider's license or certification under
applicable State law, solely on the basis of such license
30 Dallas Service Area Contract
37
or certification. This requirement shall not be construed to prohibit
HMO from including providers only to the extent necessary to meet the
needs of the HMO's Members or from establishing any measure designed
to maintain quality and control costs consistent with HMO's
responsibilities.
5.6 HISTORICALLY UNDERUTILIZED BUSINESSES (HUBS)
5.6.1 TDH is committed to providing procurement and contracting
opportunities to historically underutilized businesses (HUBs), under
the provisions of Texas Government Code, Title 10, Subtitle D, Chapter
2161 and 1 TAC Section 111.11 (b) and 111.13(c)(7). TDH requires its
Contractors and Subcontractors to make a good faith effort to assist
HUBs in receiving a portion of the total contract value of this
contract.
5.6.2 The HUB good faith effort goal for this contract is 18.1% of total
premiums paid. HMO agrees to make a good faith effort to meet or
exceed this goal. HMO acknowledges it made certain good faith effort
representations and commitments to TDH during the HUB good faith
effort determination process. HMO agrees to use its best efforts to
abide by these representations and commitments during the contract
period.
5.6.3 HMO is required to submit HUB quarterly reports to TDH as required in
Article 12.11.
5.6.4 TDH will assist HMO in meeting the contracting and reporting
requirements of this Article.
5.7 BUY TEXAS
HMO agrees to "Buy Texas" products and materials when they are
available at a comparable price and in a comparable period of time, as
required by Section 48 of Article IX of the General Appropriations Act
of 1995.
5.8 CHILD SUPPORT
5.8.1 The Texas Family Code Section 231.006 requires TDH to withhold
contract payments from any for-profit entity or individual who is at
least 30 days delinquent in child support obligations. It is HMO's
responsibility to determine and verify that no owner, partner, or
shareholder who has at least at 25% ownership interest is delinquent
in child support obligations. HMO must attach a list of the names and
Social Security numbers of all shareholders, partners or owners who
have at least a 25% ownership interest in HMO.
31 Dallas Service Area Contract
38
5.8.2 Under Section 231.006 of the Family Code, the contractor certifies
that the contractor is not ineligible to receive the specified grant,
loan, or payment and acknowledges that this contract may be terminated
and payment may be withheld if this certification is inaccurate. A
child support obligor who is more than 30 days delinquent in paying
child support or a business entity in which the obligor is a sole
proprietor, partner, shareholder, or owner with an ownership interest
of at least 25% is not eligible to receive the specified grant, loan
or payment.
5.8.3 If TDH is informed and verifies that a child support obligor who is
more than 30 days delinquent is a partner, shareholder, or owner with
at least a 25% ownership interest, it will withhold any payments due
under this contract until it has received satisfactory evidence that
the obligation has been satisfied or that the obligor has entered into
a written repayment request.
5.9 REQUESTS FOR PUBLIC INFORMATION
5.9.1 This contract and Subcontractor contracts are subject to public
disclosure under the Public Information Act (Texas Government Code,
Chapter 552). TDH may receive Public Information requests related to
this contract, information submitted as part of the compliance of the
contract and HMO's application upon which this contract was awarded.
TDH agrees that it will promptly deliver a copy of any request for
public information to HMO.
5.9.2 If HMO believes that the requested information qualifies as a trade
secret or as commercial or financial information, HMO must notify TDH
-- within three (3) working days after TDH gives notice that a request
has been made for public information -- and request TDH to submit the
request for public information to the Attorney General for an Open
Records Opinion. The HMO will be responsible for presenting all
exceptions to public disclosure to the Attorney General if an opinion
is requested.
5.9.3 TDH may, in its sole discretion, request a decision from the office of
the Attorney General (AG opinion) regarding whether the information
requested is excepted from required public disclosure. TDH may rely on
HMO's written representations in preparing any AG opinion request, in
accordance with Texas Government Code Section 552.305. TDH is not
liable for failing to request an AG opinion or for releasing
information which is not deemed confidential by law, if HMO fails to
provide TDH with specific reasons why the requested information is
exempt from the required public disclosure. TDH or the Office of the
Attorney General will notify all interested parties if an AG opinion
is requested.
5.10 NOTICE AND APPEAL
32 Dallas Service Area Contract
39
HMO must comply with the notice requirements contained in 25 TAC
Section 36.21, and the maintaining benefits and services contained in
25 TAC Section 36.22, whenever HMO intends to take an action affecting
the Member benefits and services under this contract. See also the
Member appeal requirements contained in Article 8.7 of this contract.
ARTICLE VI SCOPE OF SERVICES
6.1 SCOPE OF SERVICES
HMO is paid capitation for all services included in the State of Texas
Title XIX State Plan and the 1915(b) waiver application for the SDA
currently filed and approved by HCFA, except those services which are
specifically excluded and listed in Article 6.1.8 (non-capitated
services).
6.1.1 HMO must pay for or reimburse for all covered services provided to
mandatory-enrolled Members for whom HMO is paid capitation.
6.1.2 TDH must pay for or reimburse for all covered services provided to SSI
voluntary Members who enrolled with HMO on a voluntary basis. It is at
HMO's discretion whether to provide value-added services to SSI
voluntary Members.
6.1.3 HMO must provide covered services described in the 1999 Texas Medicaid
Provider Procedures Manual (Provider Procedures Manual), subsequent
editions of the Provider Procedures Manual also in effect during the
contract period, and all Texas Medicaid Bulletins which update the
1999 Provider Procedures Manual and subsequent editions of the
Provider Procedures Manual published during the contract period.
6.1.4 Covered services are subject to change due to changes in federal law,
changes in Texas Medicaid policy, and/or responses to changes in
Medicine, Clinical protocols, or technology.
6.1.5 The STAR Program has obtained a waiver to the State Plan to include
three enhanced benefits to all voluntary and mandatory STAR Members.
Two of these enhanced benefits removed restrictions which previously
applied to Medicaid eligible individuals 21 years and older: the
three-prescription per month limit; and, the 30 day spell of illness
limit. One of these expanded the covered benefits to add an annual
adult well check.
33 Dallas Service Area Contract
40
6.1.6 Value-added Services. Value-added services that are approved by TDH
during the contracting process are included in the Scope of Services
under this contract. Value-added services are listed in Appendix C.
6.1.6.1 The approval request must include:
6.1.6.1.1 A detailed description of the service to be offered;
6.1.6.1.2 Identification of the category or group of Members eligible to receive
the service if it is a type of service that is not appropriate for all
Members. (HMO has the discretion to determine if voluntary Members are
eligible for the value-added services);
6.1.6.1.3 Any limits or restrictions which apply to the service; and
6.1.6.1.4 A description of how a Member may obtain or access the service.
6.1.6.2 Value-added services can only be added or removed by written amendment
of this contract. HMO cannot include a value-added service in any
material distributed to Members or prospective Members until this
contract has been amended to include that value-added service or HMO
has received written approval from TDH pending finalization of the
contract amendment.
6.1.6.2.1 If a value-added service is deleted by amendment, HMO must notify each
Member that the service is no longer available through HMO, and HMO
must revise all materials distributed to prospective Members to
reflect the change in covered services.
6.1.6.3 Value-added services must be offered to all mandatory HMO Members, as
indicated in Article 6.1.6.1.2, unless the contract is amended or the
contract terminates.
6.1.7 HMO may offer additional benefits that are outside the scope of
services of this contract to individual Members on a case-by-case
basis, based on medical necessity, cost-effectiveness, and
satisfaction and improved health/behavioral health status of the
Member/Member family.
6.1.8 Non-Capitated Services. The following Texas Medicaid program services
have been excluded from the services included in the calculation of
HMO capitation rate:
THSteps Dental (including Orthodontia)
Early Childhood Intervention Case Management/Service Coordination
MHMR Targeted Case Management
Mental Health Rehabilitation
34 Dallas Service Area Contract
41
Pregnant Women and Infants Case Management
THSteps Medical Case Management
Texas School Health and Related Services
Texas Commission for the Blind Case Management
Tuberculosis Services Provided by TDH-approved providers (Directly
Observed Therapy and Contact Investigation)
Vendor Drugs (out-of-office drugs)
Medical Transportation
TDHS Hospice Services
Refer to relevant chapters in the Provider Procedures Manual and the
Texas Medicaid Bulletins for more information.
Although HMO is not responsible for paying or reimbursing for these
non-capitated services, HMO remains responsible for providing
appropriate referrals for Members to obtain or access these services.
6.1.8.1 HMO is responsible for informing providers that all non-capitated
services must be submitted to TDH for payment or reimbursement.
6.2 PRE-EXISTING CONDITIONS
HMO is responsible for providing all covered services to each eligible
Member beginning on the effective date of the contract or the Member's
date of enrollment under the contract regardless of pre-existing
conditions, prior diagnosis and/or receipt of any prior health care
services.
6.3 SPAN OF ELIGIBILITY
The following outlines HMO's responsibilities for payment of Hospital
and free-standing psychiatric facility (facility) admissions:
6.3.1 Inpatient Admission Prior to Enrollment in HMO. HMO is responsible
for payment of physician and non-hospital facility charges for the
period for which HMO is paid a capitation payment for a Member. HMO is
not responsible for hospital/facility charges for Members admitted
prior to the date of enrollment in HMO.
6.3.2 Inpatient Admission After Enrollment in HMO. HMO is responsible for
all charges for Covered Services until the Member is discharged from
the hospital/facility or until the Member loses Medicaid eligibility.
35 Dallas Service Area Contract
42
6.3.2.1 If a Member regains Medicaid eligibility and the Member was enrolled
in HMO at the time the Member was admitted to the hospital, HMO is
responsible for charges as follows:
6.3.2.1.1 Member Re-enrolls into HMO After Regaining Medicaid Eligibility. HMO
is responsible for all charges for the period for which HMO receives a
capitation payment for the Member or until the Member is discharged or
loses Medicaid eligibility.
6.3.2.1.2 Member Re-enrolls in Another Health Plan After Regaining Medicaid
Eligibility. HMO is responsible for hospital/facility charges until
the Member is discharged or loses Medicaid eligibility.
6.3.3 Plan Change. A Member cannot change from one health plan to another
health plan during an inpatient hospital stay.
6.3.4 Hospital Transfer/Facility. Discharge from one acute care
hospital/facility and readmission to another acute care
hospital/facility within 24 hours for continued treatment is not a
discharge under this contract.
6.3.5 HMO insolvency or receivership. HMO is responsible for payment of all
services provided to a person who was a Member on the date of
insolvency or receivership to the same extent they would otherwise be
responsible under this Article 6.3.
6.4 CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS
6.4.1 HMO must ensure that the care of newly enrolled Members is not
disrupted or interrupted. HMO must take special care to provide
continuity in the care of newly enrolled Members whose health or
behavioral health condition has been treated by specialty care
providers or whose health could be placed in jeopardy if care is
disrupted or interrupted.
6.4.2 Pregnant Members with 12 weeks or less remaining before the expected
delivery date must be allowed to remain under the care of the Member's
current OB/GYN through the Member's postpartum checkup even if the
provider is out-of-network. If the Member wants to change her OB/GYN
to one who is in the plan, she must be allowed to do so if the
provider to whom she wishes to transfer agrees to accept her in the
last trimester.
6.4.3 HMO must pay a Member's existing out-of-network providers for covered
services until the Member's records, clinical information and care can
be transferred to a network provider. Payment must be made within the
time period required for network providers. HMO may pay any
out-of-network provider a reasonable and
36 Dallas Service Area Contract
43
customary amount determined by the HMO. This Article does not extend
the obligation of HMO to reimburse existing out-of-network providers
of ongoing care for more than 90 days after Member enrolls in HMO or
for more than nine months in the case of Member who at the time of
enrollment in HMO, have 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.
6.4.4 HMO must provide or pay out-of-network providers who provide covered
services to Members who move out of the service area through the end
of the period for which capitation has been paid.
6.4.5 HMO must provide assistance to providers requiring PCP verification 24
hours a day 7 days a week.
6.4.5.1 HMO must provide TDH with policies and procedures indicating how the
HMO will provide PCP verification as indicated in Article 6.4.5. HMOs
providing PCP verification via telephone must meet the requirements in
3.7.1
6.5 EMERGENCY SERVICES
6.5.1 HMO must pay for the professional, facility, and ancillary services
that are medically necessary to perform the medical screening
examination and stabilization of HMO Member presenting as an
emergency medical condition or an emergency behavioral health
condition to the hospital emergency department, 24 hours a day, 7 days
a week, rendered by either HMO's in-network or out-of-network
providers. HMO may elect to pay any emergency services provider an
amount negotiated between the emergency provider and HMO, or a
reasonable and customary amount determined by the HMO.
6.5.2 HMO must ensure that its network primary care providers (PCPs) have
after-hours telephone availability 24 hours a day, 7 days a week
throughout the service area.
6.5.3 HMO cannot require prior authorization as a condition for payment for
an emergency medical condition, an emergency behavioral health
condition, or for a labor and delivery.
6.5.4 Medical Screening Examination. A medical screening examination may
range from a relatively simple history, physical examination,
diagnosis, and treatment, to a complex examination, diagnosis, and
treatment that requires substantial use of hospital emergency
department and physician services. HMO must pay for the
37 Dallas Service Area Contract
44
emergency medical screening examination required to determine whether
an emergency condition exists, as required by 42 USC 1395dd. HMOs
must reimburse for both the physician's services and the hospital's
emergency services, including the emergency room and its ancillary
services.
6.5.5 Stabilization Services. HMO must pay for emergency services performed
to stabilize the Member as documented by the Emergency physician in
the Member's medical record. HMOs must reimburse for physician's
services and hospital's emergency services including the emergency
room and its ancillary services. With respect to an emergency medical
condition, to stabilize is to provide such medical care as to assure
within reasonable medical probability that no deterioration of the
condition is likely to result from or occur during discharge,
transfer, or admission of the Member from the emergency room.
6.5.6 Post-stabilization Services. Post-stabilization services are services
subsequent to an emergency that a treating physician views as
medically necessary after an emergency medical condition has been
stabilized. They are not "emergency services" and are subject to HMO's
prior authorization process. HMO must be available to authorize or
deny post-stabilization services within one hour after being contacted
by the treating physician.
6.5.7 HMO must provide access to the TDH-designated Level I and Level II
trauma centers within the State or hospitals meeting the equivalent
level of trauma care. HMO may make out-of-network reimbursement
arrangements with the TDH-designated Level I and Level II trauma
centers to satisfy this access requirement.
6.6 BEHAVIORAL HEALTH SERVICES - SPECIFIC REQUIREMENTS
6.6.1 HMO must provide or arrange to have provided to Members all behavioral
health care services included as covered services. HMO is responsible
for Behavioral health services provided by PCPs and other physicians
within the scope of their license. This includes screening for
behavioral health problems and arranging for or providing diagnosis,
treatment and medication management to STAR Members. PCPs are expected
to screen children for behavioral health problems as part of the
THSteps medical checkups, to screen adults during adult well checks,
and to provide treatment or referral to the NorthSTAR Program, as
medically appropriate.
Also included under HMO Capitation Payment:
6.6.1.1 Ambulatory laboratory and X-ray services related to behavioral health,
diagnosis and treatment.
38 Dallas Service Area Contract
45
6.6.1.2 Inpatient laboratory and X-ray services when the inpatient stay is
covered by the STAR Program.
6.6.1.3 Emergency room facility charges unless provided in a facility
designated especially for and primarily engaged in the treatment of
behavioral health emergencies.
6.6.1.4 Emergency medical transportation for behavioral health emergencies.
6.6.1.5 Laboratory tests which are designated by TDH as commonly used in
behavioral health diagnoses/treatment may be authorized by the BHO and
do not require prior authorization from HMO.
6.6.1.6 These services are described in detail in the Texas Medicaid Provider
Procedures Manual (and the Texas Medicaid Bulletins. Clinical
information regarding covered services are published by the Texas
Medicaid program in the Texas Medicaid Service Delivery Guide.
6.6.2 HMO must maintain a Member education process to help Members know
where and how to obtain behavioral health services.
6.6.3 HMO must require its PCPs to have medical history, screening and
evaluation procedures for behavioral health problems and disorders and
either treat or refer the Member for evaluation and treatment of known
or suspected behavioral health problems and disorders. PCPs may
provide any clinically appropriate behavioral health services within
the scope of their practice.
6.6.4 HMO must establish policies and procedures that require PCP and
behavioral health providers to coordinate HMO and behavioral health
organization (BHO) covered services.
6.6.5 HMO must have policies and procedures which allow confidential
information to be shared by the PCP and the behavioral health care
providers.
6.6.6 HMO must execute a Memorandum of Agreement (MOA) with
NorthStar-contracted BHOs in the service area. The MOA must contain
provisions for coordination of care and must address the following:
6.6.6.1 How HMO and BHO will provide education to Members regarding the
services that each will provide and how the Member can access the
services;
6.6.6.2 How HMO and BHO will provide education and information to providers
regarding which entity is responsible for claims processing and
payment;
39 Dallas Service Area Contract
46
6.6.6.3 How emergency services will be paid and coordinated;
6.6.6.4 Guidelines and procedures to monitor accessibility, availability,
referral and coordination to medically necessary and appropriate
physical and behavioral health care for Members with both physical and
behavioral health problems; and how claims will be processed and paid;
6.6.6.5 Members utilization of prescribed medicines from both HMO and BHO to
monitor psychopharmacological medications and prevent adverse drug
reactions;
6.6.6.6 Identify persons in HMO and BHO to coordinate services and provide
assistance to their respective providers;
6.6.6.7 How each entity will provide guidelines and education to providers
regarding the exchange of confidential medical record information,
with Member permission, between the PCPs and the behavioral health
providers, including mechanisms to protect confidentiality of medical
records;
6.6.6.8 Collaboration on any joint Quality Improvement studies, reviews or
other State required projects.
6.6.7 HMO must establish and implement policies and procedures to facilitate
its network PCPs to refer Members for BHO services.
6.6.8 When assessing Members for behavioral health services, HMO must use
the DSM-IV multi-axial classification and report axes I, II, III, IV,
and V to TDH. TDH may require use of other assessment instrument/
outcome measures in addition to the DSM-IV. Providers must document
DSM-IV and assessment/outcome information in the Member's medical
record.
6.7 FAMILY PLANNING - SPECIFIC REQUIREMENTS
6.7.1 Counseling and Education. HMO must require, through contract
provisions, that Members requesting contraceptive services or family
planning services are also provided counseling and education about
family planning and family planning services available to Members. HMO
must develop outreach programs to increase community support for
family planning and encourage Members to use available family planning
services. HMO is encouraged to include a representative cross section
of Members and family planning providers who practice in the community
in developing, planning and implementing family planning outreach
programs.
6.7.2 Freedom of Choice: HMO must ensure that the Member have the right to
choose any Medicaid participating family planning provider, whether
the provider chosen
40 Dallas Service Area Contract
47
by the Member is in or outside HMO provider network. HMO must provide
Member access to information about the providers of family planning
services available in the network and the Member's right to choose any
Medicaid family planning provider. HMO must provide access to
confidential family planning services.
6.7.3 Provider Standards and Payment. HMO must require all Subcontractors
who are family planning agencies to deliver family planning services
according to the TDH Family Planning Service Delivery Standards. HMO
must provide, at minimum, the full scope of services available under
the Texas Medicaid program for family planning services. HMO will
reimburse family planning agencies and out-of-network family planning
providers the Medicaid fee-for service amounts for family planning
services including medically necessary medications, contraceptives,
and supplies.
6.7.4 HMO must provide medically approved methods of contraception to
Members. Contraceptive methods must be accompanied by verbal and
written instructions on their correct use. HMO must establish
mechanisms to ensure all medically approved methods of contraception
are made available to the Member, either directly or by referral to a
Subcontractor. The following initial Member education content may vary
according to the educator's assessment of the Member's current
knowledge:
6.7.4.1 general benefits of family planning services and contraception;
6.7.4.2 information on male and female basic reproductive anatomy and
physiology;
6.7.4.3 information regarding particular benefits and potential side effects
and complications of all available contraceptive methods;
6.7.4.4 information concerning all of the health care provider's available
services, the purpose and sequence of health care provider procedures,
and the routine schedule of return visits;
6.7.4.5 information regarding medical emergencies and where to obtain
emergency care on a 24-hour basis;
6.7.4.6 breast self-examination rationales and instructions unless provided
during physical exam (for females); and
6.7.4.7 information on HIV/STD infection and prevention and safer sex
discussion.
41 Dallas Service Area Contract
48
6.7.5 HMO must require, through contractual provisions, that subcontractors
have mechanisms in place to ensure Member's (including minor's)
confidentiality for family planning services.
6.7.6 HMO must develop, implement, monitor, and maintain standards, policies
and procedures for providing information regarding family planning to
providers and Members, specifically regarding State and federal laws
governing Member confidentiality (including minors). Providers and
family planning agencies cannot require parental consent for minors to
receive family planning services.
6.7.7 HMO must report encounter data on family planning services in
accordance with Article 12.2.
6.8 TEXAS HEALTH STEPS (EPSDT)
6.8.1 THSteps Services. HMO must develop effective methods to ensure that
children under the age of 21 receive THSteps services when due and
according to the recommendations established by the American Academy
of Pediatrics and the THSteps periodicity schedule for children. HMO
must arrange for THSteps services to be provided to all eligible
Members except when a Member knowingly and voluntarily declines or
refuses services after the Member has been provided information upon
which to make an informed decision.
6.8.2 Member Education and Information. HMO must ensure that Members are
provided information and educational materials about the services
available through the THSteps program, and how and when they can
obtain the services. The information should tell the Member how they
can obtain dental benefits, transportation services through the TDH
Medical Transportation program, and advocacy assistance from HMO.
6.8.3 Provider education and training. HMO must provide appropriate training
to all network providers and provider staff in the providers' area of
practice regarding the scope of benefits available and the THSteps
program. Training must include THSteps benefits, the periodicity
schedule for THSteps checkups and immunizations, and Comprehensive
Care Program (CCP) services available under the THSteps program to
Members under age 21 years. Providers must also be educated and
trained regarding the requirements imposed upon the department and
contracting HMOs under the Consent Decree entered in ββββ β. ββββββββ,
et. al., Civil Action No. 3:93CV65, in the United States District
Court for the Eastern District of Texas, Paris Division. Providers
should be educated and trained to treat each THSteps visit as an
opportunity for a comprehensive assessment of the Member.
42 Dallas Service Area Contact
49
6.8.4 Member Outreach. HMO must provide an outreach unit that works with
Members to ensure they receive prompt services and are effectively
informed about available THStep services. Each month HMO must retrieve
from the Enrollment Broker BBS a list of Members who are due and
overdue THSteps services. Using these lists and their own internally
generated lists, HMOs will contact Members and encourage Members who
are periodically due or overdue a THSteps service to obtain the
service as soon as possible. HMO outreach staff must coordinate with
TDH THSteps outreach staff to ensure that Members have access to the
Medical Transportation Program, and that any coordination with other
agencies is maintained.
6.8.5 Initial Checkups upon enrollment. HMO must have mechanisms in place to
ensure that all newly enrolled Members receive a THSteps checkup
within 90 days from enrollment, if one is due according to the
American Academy of Pediatrics periodicity schedule, or if there is
uncertainty regarding whether one is due. HMO should make THSteps
checkups a priority to all newly enrolled Members.
6.8.6 Accelerated Services to Migrant Populations. HMO must cooperate and
coordinate with the department, outreach programs and THSteps
regional program staff and agents to ensure prompt delivery of
services to children of migrant farm workers and other migrant
populations who may transition into and out of HMOs program more
rapidly and/or unpredictably than the general population.
6.8.7 Newborn checkups. HMO must have mechanisms in place to ensure that all
newborn Members have an initial newborn checkup before discharge from
the hospital and again within two weeks from the time of birth. HMO
must require providers to send all THSteps newborn screens to the TDH
Bureau of Laboratories or a TDH certified laboratory. Providers must
include detailed identifying information for all screened newborn
Members and the Member's mother to allow TDH to link the screens
performed at the hospital with screens performed at the two week
follow-up.
6.8.7.1 Laboratory Tests: All laboratory specimens collected as a required
component of a THSteps checkup (see Medicaid Provider Procedures
Manual for age-specific requirements) must be submitted to the TDH
Laboratory for analysis. HMO must educate providers about THSteps
program requirements for submitting laboratory tests to the TDH Bureau
of Laboratories.
6.8.8 Coordination and Cooperation. HMO must make an effort to coordinate
and cooperate with existing community and school-based health and
education programs that offer services to school-aged children in a
location that is both familiar and convenient to the Members. HMO must
make a good faith effort to comply with Head Start's requirement that
members participating in Head Start
43 Dallas Service Area Contract
50
receive their THSteps checkup no later than 45 days after enrolling
into either program.
6.8.9 Immunizations. HMO must educate providers on the Immunization Standard
Requirements set forth in Chapter 161, Health and Safety Code; the
standards in the ACIP Immunization Schedule; and AAP Periodicity
Schedule.
6.8.9.1 ImmTrac Compliance. HMO must educate providers about and require
providers to comply with the requirements of Chapter 161, Health and
Safety Code, relating to the Texas Immunization Registry (ImmTrac), to
include parental consent on the Vaccine Information Statement.
6.8.10 Claim forms. HMO must require all THSteps providers to submit claims
for services paid (either on a capitated or fee-for service basis) on
the HCFA 1500 claim form and use the unique procedure coding required
by TDH.
6.8.11 Compliance with THSteps performance Benchmark. TDH will establish
performance benchmarks against which HMO's full compliance with the
THSteps periodicity schedule will be measured. The performance
benchmarks will establish minimum compliance measures which will
increase over time. HMO must meet all performance benchmarks required
for THSteps services.
6.8.12 Validation of Encounter Data. Encounter data will be validated by
chart review of a random sample of THSteps eligible enrollees against
monthly encounter data reported by HMO. Chart reviews will be
conducted by TDH to validate that all screens are performed when due
and as reported, and that reported data is accurate and timely.
Substantial deviation between reported and charted encounter data
could result in HMO and/or network providers being investigated for
potential fraud and abuse without notice to HMO or the provider.
6.9 PERINATAL SERVICES
6.9.1 HMO's perinatal health care services must ensure appropriate care is
provided to women and infants who are Members of HMO, from the
preconception period through the infant's first year of life. HMO's
perinatal health care system must comply with the requirements of
Health & Safety Code, Chapter 32 Maternal and Infant Health
Improvement Act and 25 TAC Section 37.233 et seq.
6.9.2 HMO must have a perinatal health care system in place that, at a
minimum, provides the following services:
6.9.2.1 pregnancy planning and perinatal health promotion and education for
reproductive age women;
44 Dallas Service Area Contract
51
6.9.2.2 perinatal risk assessment of nonpregnant women, pregnant and
postpartum women, and infants up to one year of age;
6.9.2.3 access to appropriate levels of care based on risk assessment,
including emergency care;
6.9.2.4 transfer and care of pregnant women, newborns, and infants to tertiary
care facilities when necessary;
6.9.2.5 availability and accessibility of obstetricians/gynecologists;
anesthesiologists, and neonatologists capable of dealing with
complicated perinatal problems;
6.9.2.6 availability and accessibility of appropriate outpatient and inpatient
facilities capable of dealing with complicated perinatal problems; and
6.9.2.7 compiles, analyzes and reports process and outcome data of Members to
TDH.
6.9.3 HMO must have a process to expedite scheduling a prenatal appointment
for an obstetrical exam for a TP40 Member no later than two weeks
after receiving the daily enrollment file verifying enrollment of the
Member into the HMO.
6.9.4 HMO must have procedures in place to contact and assist a
pregnant/delivering Member in selecting a PCP for her baby either
before the birth or as soon as the baby is born.
6.9.5 HMO must provide inpatient care and professional services related to
labor and delivery for its pregnant/delivering Members and neonatal
care for its newborn Members (see Article 14.3.1) at the time of
delivery and for up to 48 hours following an uncomplicated vaginal
delivery and 96 hours following an uncomplicated Caesarian delivery.
6.9.5.1 HMO must reimburse in-network providers, out-of-network providers, and
speciality physicians who are providing call coverage, routine, and/or
speciality consultation services for the period of time covered in
Article 6.9.5.
6.9.5.1.1 HMO must adjudicate provider claims for services provided to a newborn
Member in accordance with TDH's claims processing requirements using
the proxy ID number or State-issued Medicaid ID number (see Article
4.10). HMO cannot deny claims based on provider non-use of
State-issued Medicaid ID number for a newborn Member. HMO must accept
provider claims for newborn services based on mother's name and/or
Medicaid ID number with accommodations for multiple births, as
specified by the HMO.
45 Dallas Service Area Contract
52
6.9.5.2 HMO cannot require prior authorization or PCP assignment to adjudicate
newborn claims for the period of time covered by 6.9.5
6.9.6 HMO may require prior authorization requests for hospital or
professional services provided beyond the time limits in Article
6.9.5. HMO must respond to these prior authorization requests within
the requirements of 28 TAC Section 19.1710 - 19.1712 and Article
21.58a of the Texas Insurance Code.
6.9.6.1 HMO must notify providers involved in the care of pregnant/delivering
women and newborns (including out-of-network providers and hospitals)
regarding the HMO's prior authorization requirements.
6.9.6.2 HMO cannot require a prior authorization for services provided to a
pregnant/delivering Member or newborn Member for a medical condition
which requires emergency services, regardless of when the emergency
condition arises (see Article 6.5.6).
6.10 EARLY CHILDHOOD INTERVENTION
6.10.1 ECI Services. HMO must provide all federally mandated services
contained at 34 C.F.R. 303.1 et. seq., and 25 TAC Section 621.21 et.
seq., relating to identification, referral and delivery of health care
services contained in the Member's Individual Family Service Plan
(IFSP). An IFSP is the written plan which identifies a Member's
disability or chronic or complex conditions(s) or developmental delay,
and describes the course of action developed to meet those needs, and
identifies the person or persons responsible for each action in the
plan. The plan is a mutual agreement of the Member's Primary Care
Physician (PCP), Case Manager, and the Member/family, and is part of
the Member's medical record.
6.10.2 ECI Providers. HMO must contract with qualified providers to provide
ECI services to Members under age 3 with developmental delays. HMO may
contract with local ECI programs or non-ECI providers who meet
qualifications for participation by the Texas Interagency Council on
Early Childhood Intervention to provide ECI services.
6.10.3 Identification and Referral. HMO must ensure that network providers
are educated regarding the identification of Members under age 3 who
have or are at risk for having disabilities and/or developmental
delays. HMO must use written education material developed or approved
by the Texas Interagency Council on Early Childhood Intervention. HMO
must ensure that all providers refer identified Members to ECI service
providers within two working days from the day the Member is
identified. Eligibility for ECI services is determined by the local
ECI program using the criteria contained in 25 TAC Section 621.21 et.
seq.
46 Dallas Service Area Contract
53
6.10.4 Coordination. HMO must coordinate and cooperate with local ECI
programs which perform assessment in the development of the Individual
Family Service Plan (IFSP), including ongoing case management and
other non-capitated services required by the Member's IFSP.
Cooperation includes conducting medical diagnostic procedures and
providing medical records required to perform developmental
assessments and develop the IFSP within the time lines established at
34 C.F.R. 303.1 et. seq. ECI case management is not an HMO capitated
service.
6.10.5 Intervention. HMO must require, through contract provisions, that all
medically necessary health and behavioral health services contained in
the Member's IFSP are provided to the Member in amount, duration and
scope established by the IFSP. Medical necessity for health and
behavioral health services is determined by the interdisciplinary team
as approved by the Member's PCP. HMO cannot modify the plan of care or
alter the amount, duration and scope of services required by the
Member's IFSP. HMO cannot create unnecessary barriers for the Member
to obtain IFSP services, including requiring prior authorization for
the ECI assessment and insufficient authorization periods for prior
authorized services.
6.11 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND
CHILDREN (WIC) - SPECIFIC REQUIREMENTS
6.11.1 HMO must coordinate with WIC to provide certain medical information,
which is necessary to determine WIC eligibility, such as height,
weight, hematocrit or hemoglobin (See Article 7.15.4.2).
6.11.2 HMO must direct all eligible Members to the WIC program (Medicaid
recipients are automatically income-eligible for WIC).
6.11.3 HMO must coordinate with existing WIC providers to ensure Members have
access to the special supplemental nutrition program for women,
infants and children (WIC), or HMO must provide these services.
6.11.4 HMO may use the nutrition education provided by WIC to satisfy health
education and promotion requirements described in this contract.
6.12 TUBERCULOSIS (TB)
6.12.1 Education, screening, diagnosis and treatment. HMO must provide
Members and providers with education on the prevention, detection and
effective treatment of tuberculosis (TB). HMO must establish
mechanisms to ensure all procedures required to screen at-risk Members
and to form the basis for a diagnosis and proper prophylaxis and
management of TB are available to all Members, except services
referenced in Article 6.1.8 as non-capitated services. HMO must
develop policies
47 Dallas Service Area Contract
54
and procedures to ensure that Members who may be or are at risk for
exposure to TB are screened for TB. An at-risk Member refers to a
person who is susceptible to TB because of the association with
certain risk factors, behaviors, drug resistance, or environmental
conditions. HMO must consult with the local TB control program to
ensure that all services and treatments provided by HMO are in
compliance with the guidelines recommended by the American Thoracic
Society (ATS), the Centers for Disease Control and Prevention (CDC)
and TDH policies and standards.
6.12.2 Reporting and referral. HMO must implement policies and procedures
requiring providers to report all confirmed or suspected cases of TB
to the local TB control program within one working day of
identification of a suspected case, using the forms and procedures for
reporting TB adopted by TDH (25 TAC Section 97). HMO must require,
that in-state labs report mycobacteriology culture results positive
for M. Tuberculosis and M. Tuberculosis antibiotic susceptibility to
TDH required for in-state labs by 25 TAC Section 97.5(a). Referral to
state-operated hospitals specializing in the treatment of tuberculosis
should only be made for TB-related treatment.
6.12.3 Medical records. HMO must provide access to Member medical records to
TDH and the local TB control program for all confirmed and suspected
TB cases upon request.
6.12.4 Coordination and cooperation with the local TB control program. HMO
must coordinate with the local TB control program to ensure that all
Members with confirmed or suspected TB have a contact investigation
and receive Directly Observed Therapy (DOT). HMO must require, through
contract provisions, that providers report any Member who is
non-compliant, drug resistant, or who is or may be posing a public
health threat to TDH or the local TB control program. HMO must
cooperate with the local TB control program in enforcing the control
measures and quarantine procedures contained in Chapter 81 of the
Texas Health and Safety Code.
6.12.4.1 HMO must have a mechanism for coordinating a post-discharge plan for
follow-up DOT with the local TB program.
6.12.4.2 HMO must coordinate with the TDH South Texas Hospital and Texas Center
for Infectious Disease for voluntary and court-ordered admission,
discharge plans, treatment objectives and projected length of stay for
Members with multi-drug resistant TB.
6.12.4.3 HMO may contract with the local TB control programs to perform any of
the capitated services required in this Article.
6.13 PEOPLE WITH DISABILITIES OR CHRONIC OR COMPLEX CONDITIONS
48 Dallas Service Area Contract
55
6.13.1 HMO shall provide the following services to persons with disabilities
or chronic or complex conditions. These services are in addition to the
covered services described in detail in Article 6.1 Scope of Services.
6.13.2 HMO must develop and maintain a system and procedures for identifying
Members who have disabilities or chronic or complex medical and
behavioral health conditions. Once identified, HMO must have effective
health delivery systems to provide the covered services to meet the
special preventive, primary acute, and speciality health care needs
appropriate for treatment of the individual's condition. The guidelines
and standards established by the American Academy of Pediatrics, the
American College of Obstetrics/Gynecologists, the U.S. Public Health
Service, and other medical and professional health organizations and
associations' practice guidelines whose standards are recognized by TDH
must be used in determining the medically necessary services and plan
of care for each individual.
6.13.3 HMO must require, through contract provisions, that the PCP for all
persons with disabilities or chronic or complex conditions develops a
plan of care to meet the needs of the Member. The plan of care must be
based on health needs, specialist(s) recommendations, and periodic
reassessment of the Member's developmental and functional status and
service delivery needs. HMO must require providers to maintain record
keeping systems to ensure that each Member who has been identified with
a disability or chronic or complex condition has an initial plan of
care in the primary care provider's medical records, Member agrees to
that plan of care, and that the plan is updated as often as the
Member's needs change, but at least annually.
6.13.4 HMO must provide primary care and specialty care provider network for
persons with disabilities or chronic or complex conditions. Specialty
and subspecialty providers serving all Members must be Board
Certified/Board Eligible in their specialty. HMO may request exceptions
from TDH for approval of traditional providers who are not
board-certified or board-eligible but who otherwise meet HMO's
credentialing requirements.
6.13.5 HMO must have in its network PCPs and specialty care providers that
have documented experience in treating people with disabilities or
chronic or complex conditions, including children. For services to
children with disabilities or chronic or complex conditions, HMO must
have in its network PCPs and specialty care providers that have
demonstrated experience with children with disabilities or chronic or
complex conditions in pediatric specialty centers such as children's
hospitals, medical schools, teaching hospitals and tertiary center
levels.
6.13.6 HMO must provide information, education and training programs to
Members, families, PCPs, specialty physicians, and community agencies
about the care and
49 Dallas Service Area Contract
56
treatment available in HMO's plan for Members with disabilities or
chronic or complex conditions.
6.13.7 HMO must coordinate care and establish linkages, as appropriate for a
particular Member, with existing community-based entities and services,
including but not limited to Maternal and Child Health, Chronically Ill
and Disabled Children's Services (CIDC), the Medically Dependent
Children Program (MDCP), Community Resource Coordination Groups
(CRCGs), Interagency Council on Early Childhood Intervention (ECI),
Home and Community-based Services (HCS and HCS-O), Community Living
Assistance and Support Services (CLASS), Community Based Alternatives
(CBA), In Home Family Support, Primary Home Care, Day Activity and
Health Services (DAHS), Deaf/Blind Multiple Disabled waiver program and
Medical Transportation Program.
6.13.8 HMO must include TDH approved pediatric transplant centers, TDH
designated trauma centers, and TDH designated hemophilia centers in
its provider network. (See Appendices E, F, G for a listing of these
facilities.)
6.13.9 HMO must ensure Members with disabilities or chronic or complex
conditions have access to treatment by a multidisciplinary team when
determined to be medically necessary for effective treatment, or to
avoid separate and fragmented evaluations and service plans. The teams
must include both physician and non-physician providers determined to
be necessary by the Member's PCP for the comprehensive treatment of the
Member. The team must:
6.13.9.1 Participate in hospital discharge planning;
6.13.9.2 Participate in pre-admission hospital planning for non-emergency
hospitalizations;
6.13.9.3 Develop specialty care and support service recommendations to be
incorporated into the primary care provider's plan of care;
6.13.9.4 Provide information to the Member and the Member's family concerning
the specialty care recommendations; and
6.13.9.5 Develop and implement training programs for primary care providers,
community agencies, ancillary care providers, and families concerning
the care and treatment of a Member with a disability or chronic or
complex conditions.
6.13.10 HMO must identify coordinators of medical care to assist providers who
serve Members with disabilities and chronic or complex conditions and
the Members and their families in locating and accessing appropriate
providers inside and outside HMO's network.
50 Dallas Service Area Contract
57
6.13.11 HMO must assist, through information and referral, eligible Members in
accessing providers of non-capitated Medicaid services listed in
Article 6.1.8, as applicable.
6.13.12 HMO must require, through contract provisions, that Members who require
routine or regular laboratory and ancillary medical tests or procedures
to monitor disabilities or chronic or complex conditions are provided
the services by the provider in the provider's office or at a
contracted lab located at or near the provider's office.
6.14 HEALTH EDUCATION AND WELLNESS AND PREVENTION PLANS
6.14.1 Health Education Plan. HMO must develop, implement a Health Education
plan. The health education plan must tell Members how HMO system
operates, how to obtain services, including emergency care and
out-of-plan services. The plan must emphasize the value of screening
and preventive care and must contain disease-specific information and
educational materials.
6.14.2 Wellness Promotion Programs. HMO must conduct wellness promotion
programs to improve the health status of its Members. HMO may
cooperatively conduct Health Education classes for all enrolled STAR
members with one or more HMOs also contracting with TDH in the service
area to provide services to Medicaid recipients in all counties of the
service area. Providers and HMO staff must integrate health education
wellness and prevention training into the care of each Member. HMO must
provide a range of health promotion and wellness information and
activities for Members in formats that meet the needs of all Members.
HMO must:
(1) develop, maintain and distribute health education services
standards, policies and procedures to providers;
(2) monitor provider performance to ensure the standards for health
education services are complied with;
(3) inform providers in writing about any non-compliance with the plan
standards, policies or procedures;
(4) establish systems and procedures that ensure that provider's
medical instruction and education on preventive services provided to
the Member are documented in the Member's medical record; and
(5) establish mechanisms for promoting preventive care services to
Members who do not access care, e.g. newsletters, reminder cards, and
mail-outs.
51 Dallas Service Area Contract
58
6.14.3 Health Education Activities Report. HMO must submit, upon request, a
Health Education Activities Schedule to TDH or its designee listing the
time and location of classes, health fairs or other events conducted
during the time period of the request.
6.15 SEXUALLY TRANSMITTED DISEASES (STDS) AND HUMAN IMMUNODEFICIENCY VIRUS
(HIV)
HMO must provide STD services that include STD/HIV prevention,
screening, counseling, diagnosis, and treatment. HMO is responsible for
implementing procedures to ensure that Members have prompt access to
appropriate services for STDs, including HIV.
6.15.1 HMO must allow Members access to STD services and HIV diagnosis
services without prior authorization or referral by PCP. HMO must
comply with Texas Family Code Section 32.003, relating to consent to
treatment by a child.
6.15.2 HMO must provide all covered services required to form the basis for a
diagnosis and treatment plan for STD/HIV by the provider.
6.15.3 HMO must consult with TDH regional public health authority to ensure
that Members receiving clinical care of STDs, including HIV, are
managed according to a protocol which has been approved by TDH. (Also
see Article 7.15.1, relating to cooperative agreements with public
health authorities.)
6.15.4 HMO must make education available to providers and Members on the
prevention, detection and effective treatment of STDs, including HIV.
6.15.5 HMO must require providers to report all confirmed cases of STDs,
including HIV, to the local or regional health authority according to
25 Texas Administrative Code, Sections 97.131-97.134, using the
required forms and procedures for reporting STDs.
6.15.6 HMO must coordinate with the TDH regional health authority to ensure
that Members with confirmed cases of syphilis, chancroid, gonorrhea,
chlamydia and HIV receive risk reduction and partner
elicitation/notification counseling. Coordination must be included in
the subcontract required by Article 7.15.1. HMO may contract with local
or regional health authorities to perform any of the covered services
required in this subsection.
6.15.7 HMO's PCPs may enter into contracts or agreements with traditional HIV
service providers in the service area to provide services such as case
management, psychosocial support and other services. If the service
provided is a covered
52 Dallas Service Area Contract
59
service under this contract, the contract or agreement must include
payment provisions.
6.15.8 The subcontract with the respective TDH regional offices and city and
county health departments, as described in Article 7.15.1, must
include, but not be limited to, the following topics:
6.15.8.1 Access for Case Investigation. Procedures must be established to make
Member records available to public health agencies with authority to
conduct disease investigation, receive confidential Member information,
and follow up.
6.15.8.2 Medical Records and Confidentiality. HMO must require, through
contract provisions, that providers have procedures in place to protect
the confidentiality of Members provided STD/HIV services. These
procedures must include, but are not limited to, the manner in which
medical records are to be safeguarded; how employees are to protect
medical information; and under what conditions information can be
shared. HMO must inform and require its providers, who provide STD/HIV
services, to comply with all state laws relating to communicable
disease reporting requirements. HMO must implement policies and
procedures to monitor provider compliance with confidentiality
requirements.
6.15.8.3 Partner referral and treatment. Members who are named as contacts to an
STD, including HIV, should be evaluated and treated according to HMO's
protocol. All protocols must be approved by TDH. HMO's providers must
coordinate referral of non-Member partners to local and regional health
department STD staff.
6.15.8.4 Informed consent and counseling. HMO must have policies and procedures
in place regarding obtaining informed consent and counseling Members.
The Subcontracts with providers who treat HIV patients must include
provisions requiring the provider to refer Members with HIV infection
to public health agencies for in-depth prevention counseling, ongoing
partner elicitation and notification services and other prevention
support services. The Subcontracts must also include provisions that
require the provider to direct counsel or refer an HIV infected member
about the need to inform and refer all sex and/or needle-sharing
partners that might have been exposed to the infection for prevention
counseling and antibody testing.
6.16 BLIND AND DISABLED MEMBERS
6.16.1 HMO must arrange for all covered health and health related services
required under this contract for all voluntarily enrolled Blind and
Disable Members. HMO has the discretion to determine if Blind and
Disabled Members are to be provided value-added services.
53 Dallas Service Area Contract
60
6.16.2 HMO must perform the same administrative services and functions as are
performed for mandatory Members under this contract. These
administrative services and functions include but are not limited to:
6.16.2.1 Prior authorization of services;
6.16.2.2 All customer services functions offered Members in Mandatory
participation categories, including complaint process, enrollment
services, and hotline services;
6.16.2.3 Linguistic services, including providing Member materials in
alternative formats for the blind and disabled;
6.16.2.4 Health education;
6.16.2.5 Utilization management using TDH Claims Administrator encounter data to
provide appropriate interventions for Members through administrative
case management;
6.16.2.6 Quality assurance activities as needed and focused studies as required
by TDH;
6.16.2.7 Coordination to link Blind and Disabled Members with applicable
community resources and targeted case management programs (see
Non-Capitated Services in Article 6.1.8).
6.16.3 HMO must require network providers to submit claims for health and
health-related services to TDH's Claims Administrator for claims
adjudication and payment.
6.16.4 HMO must provide services to Blind and Disabled Members within HMO's
network unless necessary services are unavailable within network. HMO
must also allow referrals to out-of network providers if necessary
services are not available within HMO's network. Records must be
forwarded to Member's PCP following a referral visit.
ARTICLE VII PROVIDER NETWORK REQUIREMENTS
7.1 PROVIDER ACCESSIBILITY
7.1.1 HMO must enter into written contracts with properly credentialed health
care service providers. The names of all providers must be submitted to
TDH as part of HMO subcontracting process. HMO must have its own
credentialing process to review, approve and periodically recertify the
credentials of all participating
54 Dallas Service Area Contract
61
providers in compliance with 28 TAC 11.1902, relating to credentialing
of providers in HMOs.
7.1.2 HMO must require tax I.D. numbers from all providers. HMO is required
to do backup withholding from all payments to providers who fail to
give tax I.D. numbers, or who give incorrect numbers.
7.1.3 Timeframes for Access Requirements. HMO must have sufficient network
providers and establish procedures to ensure Members have access to
routine, urgent, and emergency services; telephone appointments; advice
and Member service lines. These services must be accessible to Members
within the following timeframes:
7.1.3.1 Urgent Care within 24 hours of request;
7.1.3.2 Routine care within 2 weeks of request;
7.1.3.3 Physical/Wellness Exams for adults must be provided within 8 to 10
weeks of the request;
7.1.3.4 HMO must establish policies and procedures to ensure that THSteps
Checkups be provided within 90 days of new enrollment, except newborns
Members should be seen within 2 weeks of enrollment, and in all cases
for all Members be consistent with the American Academy of Pediatrics
and THSteps periodicity schedule which is based on the American Academy
of Pediatrics schedule and delineated in the Texas Medicaid Provider
Procedures Manual and the bi-monthly Medicaid Bulletin (see also
Article 6.1, Scope of Services). If the Member does not request a
checkup, HMO must establish a procedure for contacting the Member to
schedule the checkup.
7.1.4 HMO is prohibited from requiring a provider or provider group to enter
into an exclusive contracting arrangement with HMO as a condition for
participation in its provider network.
7.2 PROVIDER CONTRACTS
7.2.1 All providers must have a written contract, either with an intermediary
entity or an HMO, to participate in the Medicaid program (provider
contract). HMO must make all contracts available to TDH upon request,
at the time and location requested by TDH. All standard formats of
provider contracts must be submitted to TDH for approval no later than
60 days after the effective date of this contract, unless previously
filed with TDH. HMO must submit 1 paper copy and 1 electronic copy in a
form specified by TDH. Any change to the standard format must
55 Dallas Service Area Contract
62
be submitted to TDH for approval no later than 30 days prior to the
implementation of the new standard format. All provider contracts are
subject to the terms and conditions of this contract and must contain
the provisions of Article V, Statutory and Regulatory Compliance, and
the provisions contained in Article 3.2.4.
7.2.1.1 TDH has 15 working days to review the materials and recommend any
suggestions or required changes. If TDH has not responded to HMO by the
fifteenth day, HMO may execute the contract. TDH reserves the right to
request HMO to modify any contract that has been deemed approved.
7.2.2 Primary Care Provider (PCP) contracts and specialty care contracts must
contain provisions relating to the requirements of the provider types
found in this contract. For example, PCP contracts must contain the
requirements of Article 7.8 of this contract relating to Primary Care
Providers.
7.2.3 Provider contracts that are requested by any agency with authority to
investigate and prosecute fraud and abuse must be produced at the time
and the place required by TDH or the requesting agency. Provider
contracts requested in response to public information request must be
produced within 48 hours of the request. Requested contracts and all
related records must be provided free of charge to the requesting
agency.
7.2.4 The form and substance of all provider contracts are subject to
approval by TDH. TDH retains the authority to reject or require changes
to any contract that do not comply with the requirements or duties and
responsibilities of this contract. HMO REMAINS RESPONSIBLE FOR
PERFORMING AND FOR ANY FAILURE TO PERFORM ALL DUTIES, RESPONSIBILITIES
AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER THE DUTY,
RESPONSIBILITY OR SERVICE IS CONTRACTED TO ANOTHER FOR ACTUAL
PERFORMANCE.
7.2.5 TDH reserves the right and retains the authority to make reasonable
inquiry and conduct investigations into patterns of provider and Member
complaints against HMO or any intermediary entity with whom HMO
contracts to deliver health services under this contract. TDH may
impose appropriate sanctions and contract remedies to ensure HMO
compliance with the provisions of this contract.
7.2.6 HMO must not restrict a provider's ability to provide opinions or
counsel to a Member with respect to benefits, treatment options, and
provider's change in network status.
7.2.7 To the extent feasible within HMO's existing claims processing systems,
HMO should have a single or central address to which providers must
submit claims. If a central processing center is not possible within
HMO's existing claims processing
56 Dallas Service Area Contract
63
systems, HMO must provide each network provider a complete list of all
entities to whom the providers must submit claims for processing and/or
adjudication. The list must include the name of the entity, the address
to which claims must be sent, explanation for determination of the
correct claims payer based on services rendered, and a phone number the
provider may call to make claims inquiries. HMO must notify providers
in writing of any changes in the claims filing list at least 30 days
prior to the effective date of change. If HMO is unable to provide 30
days notice, providers must be given a 30-day extension on their claims
filing deadline to ensure claims are routed to correct processing
center.
7.2.8 HMO, all IPAs, and other intermediary entities must include contract
language which substantially complies with the following standard
contract provisions in each Medicaid provider contract. This language
must be included in each contract with an actual provider of services,
whether through a direct contract or through intermediary provider
contracts:
7.2.8.1 [Provider] is being contracted to deliver Medicaid managed care under
the TDH STAR program. HMO must provide copies of the TDH/HMO Contract
to the provider upon request. [Provider] understands that services
provided under this contract are funded by State and federal funds
under the Medicaid program. Provider is subject to all state and
federal laws, rules and regulations that apply to all persons or
entities receiving state and federal funds. [Provider] understands that
any violation by a provider of a State or federal law relating to the
delivery of services by the provider under this HMO/Provider contract,
or any violation of the TDH/HMO contract could result in liability for
money damages, and or civil or criminal penalties and sanctions under
state and/or federal law.
7.2.8.2 [Provider] understands and agrees that HMO has the sole responsibility
for payment of covered services rendered by the provider under
HMO/Provider contract. In the event of HMO insolvency or cessation of
operations, [Provider's] sole recourse is against HMO through the
bankruptcy, conservatorship, or receivership estate of HMO.
7.2.8.3 [Provider] understands and agrees TDH is not liable or responsible for
payment for any Medicaid covered services provided to mandatory Members
under HMO/Provider contract. Federal and State laws provide severe
penalties for any provider who attempts to collect any payment from or
ββββ a recipient for a covered service.
7.2.8.4 [Provider] agrees that any modification, addition, or deletion of the
provisions of this contract will become effective no earlier than 30
days after HMO notifies TDH of the change in writing. If TDH does not
provide written approval within 30 days from receipt of notification
from HMO, changes can be considered
57 Dallas Service Area Contract
64
provisionally approved, and will become effective. Modifications,
additions or deletions which are required by TDH or by changes in state
or federal law are effective immediately.
7.2.8.5 This contract is subject to all state and federal laws and regulations
relating to fraud and abuse in health care and the Medicaid program.
[Provider] must cooperate and assist TDH and any state or federal
agency that is charged with the duty of identifying, investigating,
sanctioning or prosecuting suspected fraud and abuse. [Provider] must
provide originals and/or copies of any and all information, allow
access to premises and provide records to TDH or its authorized
agent(s), THHSC, HCFA, the U.S. Department of Health and Human
Services, FBI, TDI, and the Texas Attorney General's Medicaid Fraud
Control Unit, upon request, and free of charge. [Provider] must report
any suspected fraud or abuse including any suspected fraud and abuse
committed by HMO or a recipient to TDH for referral to THHSC.
7.2.8.6 [Provider] is required to submit proxy claims forms to HMO for services
provided to all STAR Members that are capitated by HMO in accordance
with the encounter data submissions requirements established by HMO and
TDH.
7.2.8.7 HMO is prohibited from imposing restrictions upon the provider's free
communication with Members about a Member's medical conditions,
treatment options, HMO referral policies, and other HMO policies,
including financial incentives or arrangements and all STAR managed
care plans with whom Provider contracts.
7.2.8.8 The Texas Medicaid Fraud Control Unit must be allowed to conduct
private interviews of [Provider] and its employees, contractors, and
patients. Requests for information must be complied within the form and
the language requested. [Provider] and its employees and contractors
must cooperate fully in making themselves available in person for
interviews, consultation, grand jury proceedings, pre-trial conference,
hearings, trial and in any other process, including investigations.
Compliance with this Article is at HMO's and provider's own expense.
7.2.8.9 HMO must include the method of payment and payment amounts in all
provider contracts.
7.2.8.10 All provider clean claims must be adjudicated within 30 days. HMO must
pay provider interest on all clean claims that are not paid within 30
days at a rate of 1.5% per month (18% annual) for each month the claim
remains unadjudicated.
58 Dallas Service Area Contract
65
7.2.8.11 HMO must prohibit network providers from interfering with or placing
liens upon the state's right or HMOs right, acting as the state's
agent, to recovery from third party resources. HMO must prohibit
network providers from seeking recovery in excess of the Medicaid
payable amount or otherwise violating state and federal laws.
7.2.9 HMO must comply with the provisions of Chapter 20A Section 18A of HMO
Act relating to Physician and Provider contracts, except Subpart (e),
which relates to capitation payments.
7.2.10 HMO must include its complaint and appeals process which complies with
Article 7.6 of this contract relating to Provider Complaint System in
all subcontracts. HMO's complaint and appeals process must be the same
for all contractors.
7.2.11 HMO must notify TDH no later than 90 days prior to terminating any
subcontract affecting a major performance function of this contract. If
HMO seeks to terminate a provider's contract for imminent harm to
patient health, actions against a license or practice, or fraud,
contract termination may be immediate. TDH will require assurances that
any contract termination will not result in an interruption of an
essential service or major contract function.
7.3 PHYSICIAN INCENTIVE PLANS
7.3.1 HMO may operate a physician incentive plan only if 1) no specific
payment may be made directly or indirectly under a physician incentive
plan to a physician or physician group as an inducement to reduce or
limit medically necessary services furnished to a Member, and 2) the
stop-loss protection, enrollee surveys and disclosure requirements of
this Article are met.
7.3.2 HMO must disclose to TDH information required by federal regulations
found at 42 C.F.R. Section 417.479. The information must be disclosed
in sufficient detail to determine whether the incentive plan complies
with the requirements at 42 C.F.R. Section 417.479. The disclosure must
contain the following information:
7.3.2.1 Whether services not furnished by a physician or physician group
(referral services) are covered by the incentive plan. If only services
furnished by the physician or physician group are covered by the
incentive plan, disclosure of other aspects of the incentive plan are
not required to be disclosed.
7.3.2.2 The type of incentive arrangement (e.g. withhold, bonus, capitation).
7.3.2.3 The percent of the withhold or bonus, if the incentive plan involves a
withhold bonus.
59 Dallas Service Area Contract
66
7.3.2.4 whether the physician or physician group has evidence of a stop-loss
protection, including the amount and type of stop-loss protection.
7.3.2.5 The panel size and the method used for pooling patients, if patients
are pooled.
7.3.2.6 The results of Member and disenrollee surveys, if HMO is required under
42 C.F.R. Section 417.479 to conduct Member and disenrollee surveys.
7.3.3 HMO must submit the information required in 7.3.2.1 - 7.3.2.5 to TDH by
the effective date of this contract and each anniversary date of the
contract.
7.3.4 HMO must submit the information required in 7.3.2.6 one year after the
effective date of initial contract or effective date of renewal
contract, and annually each subsequent year under the contract. HMO's
who put physicians or physician groups at substantial financial risk,
as defined in 42 C.F.R. Section 417.479, must conduct a survey of all
Members who have voluntarily disenrolled in the previous year. A list
of voluntary disenrollees may be obtained from the Enrollment Broker.
7.3.5 HMO must provide Members with information regarding Physician Incentive
Plans upon request. The information must include the following:
7.3.5.1 whether HMO uses physician incentive plan that covers referral
services;
7.3.5.2 the type of incentive arrangement (i.e., withhold, bonus, capitation);
7.3.5.3 whether stop-loss protection is provided; and,
7.3.5.4 results of enrollee and disenrollee surveys, if required under 42
C.F.R. Section 417.479.
7.3.5.5 HMO must ensure that IPAs and ANHCs with whom HMO contracts comply with
the above requirements. HMO is required to meet above requirements for
all levels of subcontracting.
7.4 PROVIDER MANUAL AND PROVIDER TRAINING
7.4.1 HMO must prepare and issue a Provider Manual(s), including any
necessary specialty manuals, to the providers in HMO network and to
newly contracted providers in HMO network within five (5) working days
from inclusion of the provider into the network. The Provider Manual
must contain sections relating to special requirements of the STAR
Program as required under this contract. See Appendix D, Required
Critical Elements, for specific details regarding content requirements
60 Dallas Service Area Contract
67
Provider Manual and any revisions must be approved by TDH prior to
publication and distribution to providers (see Article 3.4.1 regarding
the process for plan materials review).
7.4.2 HMO must provide training to all network providers and their staff
regarding the requirements of the TDH/HMO contract and special needs
of STAR Members.
7.4.2.1 HMO training for all providers must be completed no later than 30 days
after placing a newly contracted provider on active status. HMO must
provide on-going training to new and existing providers as required by
HMO or TDH to comply with this contract.
7.4.2.2 HMO must include in training for contracted PCPs how to screen for and
identify behavioral health disorders, HMO's referral process to
behavioral health services and clinical coordination requirements for
behavioral health. HMO must include training on coordination and
quality of care such as behavioral health screening techniques for PCPs
and new models of behavioral health interventions.
7.4.3 HMO must provide primary care providers with screening tools and
instruments approved by TDH.
7.4.4 HMO must maintain and make available upon request enrollment or
attendance rosters dated and signed by each attendee or other written
evidence of training of each network provider and their staff.
7.4.5 HMO must have its written policies and procedures for the screening,
assessment and referral processes between behavioral health providers
and physical medicine providers available for TDH review prior to the
effective date of this contract.
7.5 MEMBER PANEL REPORTS
HMO must furnish each PCP with a current list of enrolled Members
enrolled or assigned to that Provider no later than 5 days after HMO
receives the Enrollment File from the Enrollment Broker each month. If
the 5th day falls on a weekend or state holiday, the file must be
provided by the following working day.
7.6 PROVIDER COMPLAINT AND APPEAL PROCEDURES
7.6.1 HMO must develop, implement and maintain a provider complaint system.
The complaint and appeals procedure must be in compliance with all
applicable state and federal law or regulations. All Member complaints
and/or appeals of an adverse determination request by the enrollee, or
any person acting on behalf of the enrollee, or physician or provider
acting on behalf of the enrollee must comply with the
61 Dallas Service Area Contract
68
provisions of this Article. Modifications and amendments to the
complaint system must be submitted to TDH no later than 30 days prior
to the implementation of the modification or amendment.
7.6.2 HMO must include the provider complaint and appeal procedure in all
network provider contracts.
7.6.3 HMO's complaint and appeal process cannot contain provisions requiring
a provider to submit a complaint or appeal to TDH for resolution in
lieu of the HMO's process.
7.6.4 HMO must establish mechanisms to ensure that network providers have
access to a person who can assist providers in resolving issues
relating to claims payment, plan administration, education and
training, and complaint procedures.
7.7 PROVIDER QUALIFICATIONS - GENERAL
The providers in HMO network must meet the following qualifications:
FQHC A Federally Qualified Health Center meets the standards
established by federal rules and procedures. The FQHC must
also be an eligible provider enrolled in the Medicaid.
Physician An individual who is licensed to practice medicine as an MD or
a DO in the State of Texas either as a primary care provider
or in the area of specialization under which they will provide
medical services under contract with HMO; who is a provider
enrolled in the Medicaid; who has a valid Drug Enforcement
Agency registration number, and a Texas Controlled Substance
Certificate, if either is required in their practice.
Hospital An institution licensed as a general or special hospital by
the State of Texas under Chapter 241 of the Health and Safety
Code which is enrolled as a provider in the Texas Medicaid
Program. HMO will require that all facilities in the network
used for acute inpatient specialty care for people under age
21 with disabilities or chronic or complex conditions will
have a designated pediatric unit; 24 hour laboratory and blood
bank availability; pediatric radiological capability; meet
JCAHO standards; and have discharge planning and social
service units.
Non-Physician An individual holding a license issued by the applicable
Practitioner licensing agency of the State of Texas who is enrolled in the
Provider Texas Medicaid Program.
62 Dallas Service Area Contract
69
Clinical An entity having a current certificate issued under the
Laboratory Federal Clinical Laboratory Improvement Act (CLIA), and is
enrolled in the Texas Medicaid Program.
Rural Health An institution which meets all of the criteria for designation
Clinic (RHC) as a rural health clinic and is enrolled in the Texas Medicaid
Program.
Local Health A local health department established pursuant to Health and
Department Safety Code, Title 2, Local Public Health Reorganization Act
Section 121.031 ff.
Non-Hospital A provider of health care services which is licensed and
Facility credentialed to provide services and is enrolled in the Texas
Provider Medicaid Program.
School Based Clinics located at school campuses that provide on site
Health Clinic primary and preventive care to children and adolescents.
(SBHC)
7.8 PRIMARY CARE PROVIDERS
7.8.1 HMO must have a system for monitoring Member enrollment into its plan
to allow HMO to effectively plan for future needs and recruit network
providers as necessary to ensure adequate access to primary care and
specialty care. The Member enrollment monitoring system must include
the length of time required for Members to access care within the
network. The monitoring system must also include monitoring after-hours
availability and accessibility of PCPs.
7.8.2 HMO must maintain a primary care provider network in sufficient numbers
and geographic distribution to serve a minimum of forty-five percent
(45%) of the mandatory STAR eligibles in each county of the service
area. HMO is required to increase the capacity of the network as
necessary to accommodate enrollment growth beyond the forty-fifth
percentile (45%).
7.8.3 HMO must maintain a provider network that includes pediatricians and
physicians with pediatric experience in sufficient numbers and
geographic distribution to serve eligible children and adolescents in
the service area and provide timely access to the full scope of
benefits, especially THSteps checkups and immunizations.
7.8.4 HMO must comply with the access requirements as established by the
Texas Department of Insurance for all HMOs doing business in Texas,
except as otherwise required by this contract.
63 Dallas Service Area Contract
70
7.8.5 HMO must have in its provider network physicians with board
eligibility/certification in pediatrics available for referral for
Members under the age of 21.
7.8.5.1 Individual PCPs may serve more than 2,000 Members. However, if TDH
determines that a PCP's Member enrollment exceeds the PCP's
availability to provide accessible, quality care, TDH may prohibit the
PCP from receiving further enrollments. TDH may direct HMOs to assign
or reassign Members to another PCP's panel.
7.8.6 HMO must have PCPs available throughout the service area to ensure that
no Member must travel more than 30 miles to access the PCP, unless an
exception to this distance requirement is made by TDH.
7.8.7 HMO's primary care provider network may include providers from any of
the following practice areas: General Practitioners; Family
Practitioners; Internists; Pediatricians; Obstetricians/Gynecologists
(OB/GYN); Advanced Practice Nurses (APNs); Certified Nurse Midwives
Women Health (CNMs); Physician Assistants (PAs) practicing under the
supervision of a physician specializing in Family Practice, Internal
Medicine, Pediatrics or Obstetrics/Gynecology who also qualifies as a
PCP under this contract; or Federally Qualified Health Centers (FQHCs);
Rural Health Clinics (RHCs) and similar community clinics; and
specialists who are willing to provide medical homes to selected
Members with special needs and conditions (see 7.8.8).
7.8.8 The PCP for a Member with disabilities or chronic or complex conditions
may be a specialist who agrees to provide PCP services to the Member.
The specialty provider must agree to perform all PCP duties required in
the contract and PCP duties must be within the scope of the
specialist's license. Any interested person may initiate the request
for a specialist to serve as a PCP for a Member with disabilities or
chronic or complex conditions.
7.8.9 PCPs must either have admitting privileges at a hospital, which is part
of HMO network of providers, or make referral arrangements with an HMO
provider who has admitting privileges to a network hospital.
7.8.10 HMO must require, through contract provisions, that PCPs are accessible
to Members 24 hours a day, 7 days a week. The following are acceptable
and unacceptable phone arrangements for contacting PCPs after normal
business hours.
64 Dallas Service Area Contract
71
Acceptable:
(1) Office phone is answered after hours by an
answering service which meets language
requirements of the major population groups
and which can contact the PCP or another
designated medical practitioner. All calls
answered by an answering service must be
returned within 30 minutes.
(2) Office phone is answered after normal
business hours by a recording in the
language of each of the major population
groups served directing the patient to call
another number to reach the PCP or another
provider designated by the PCP. Someone must
be available to answer the designated
provider's phone. Another recording is not
acceptable.
(3) Office phone is transferred after office
hours to another location where someone will
answer the phone and be able to contact the
PCP or another designated medical
practitioner, who can return the call within
30 minutes.
Unacceptable:
(1) Office phone is only answered during office
hours.
(2) Office phone is answered after hours by a
recording which tells patients to leave a
message.
(3) Office phone is answered after hours by a
recording which directs patients to go to an
Emergency Room for any services needed.
(4) Returning after-hour calls outside of 30
minutes.
7.8.11 HMO must require PCPs, through contract provisions or
provider manual; to provide primary care services and
continuity of care to Members who are enrolled with
or assigned to the PCP. Primary care services are all
services required by a Member for the prevention,
detection, treatment and cure of illness, trauma,
disease or disorder, which are covered and/or
required services under this contract. All services
must be provided in compliance with generally
accepted medical and behavioral health standards for
the community in which services are rendered. HMO
must require PCPs, through contract provisions or
provider manual, to provide children under the age of
21 services in accordance with the American Academy
of Pediatric recommendations and the THSteps
periodicity schedule and provide adults services in
accordance with the U.S. Preventive Services Task
Force's publication "Put Prevention Into Practice".
65 Dallas Service Area Contract
72
7.8.11.1 HMO must require PCPs, through contract provisions or
provider manual, to assess the medical needs of
Members for referral to specialty care providers and
provide referrals as needed. PCP must coordinate care
with specialty care providers after referral.
7.8.11.2 HMO must require PCPs, through contract provisions or
provider manual, to make necessary arrangements with
home and community support services to integrate the
Member's needs. This integration may be delivered by
coordinating the care of Members with other programs,
public health agencies and community resources which
provide medical, nutritional, behavioral, educational
and outreach services available to Members.
7.8.11.3 HMO must require, through contract provisions or
provider manual, that the Member's PCP or HMO
provider through whom PCP has made arrangements, be
the admitting or attending physician for inpatient
hospital care, except for emergency medical or
behavioral health conditions or when the admission is
made by a specialist or hospitalist to whom the
Member has been referred by the PCP. HMO must
require, through contract provisions, that PCP assess
the advisability and availability of outpatient
treatment alternatives to inpatient admissions. HMO
must require, through contract provisions, that PCP
provide or arrange for pre-admission planning for
non-emergency inpatient admissions, and discharge
planning for Members. PCP must call the emergency
room with relevant information about the Member. PCP
must provide or arrange for follow-up care after
emergency or inpatient care.
7.8.11.4 HMO must require PCPs for children under the age of
21 to provide or arrange to have provided all
services required under Article 6.8 relating to Texas
Health Steps, Article 6.9 relating to Perinatal
Services, Article 6.10 relating to Early Childhood
Intervention, Article 6.11 relating to WIC, Article
6.13 relating to persons with disabilities or chronic
or complex conditions, and Article 6.14 relating to
Health Education and Wellness. PCP must cooperate and
coordinate with HMO to provide Member and the
Member's family with knowledge of and access to
available services.
7.8.12 PCP Selection and Changes. All Medicaid recipients
who are eligible for participation in the STAR
program have the right to select their PCP and HMO.
Medicaid recipients who are mandatory STAR
participants who do not select a PCP and/or HMO
during the time period allowed will be assigned to a
PCP and/or HMO using the TDH default process. Members
may change PCPs at any time, but these changes are
limited to four (4) times per year. If a PCP or
OB/GYN who has been selected by or assigned to a
Member is no longer in HMO's provider network, HMO
must contact the Member and provide them an
opportunity to reselect. If the Member does not want
to change the PCP or OB/GYN to another provider in
HMO
66 Dallas Service Area Contract
73
network, the Member must be directed to Enrollment
Broker for resolution or reselection. If a PCP or
OB/GYN who has been selected by or assigned to a
Member is no longer in an IPA's provider network but
continues to participate in HMO network, HMO or IPA
may not change the Member's PCP or OB/GYN.
7.8.12.1 Voluntary SSI Members. PCP changes cannot be
performed retroactively for voluntary SSI Members. If
an SSI Member requests a PCP change on or before the
15th of the month, the change will be effective the
first day of the next month. If an SSI Member
requests a PCP change after the 15th of the month,
the change will be effective the first day of the
second month that follows. Exceptions to this policy
will be allowed for reasons of medical necessity or
other extenuating circumstances.
7.8.12.2 Mandatory Members. Retroactive changes to a Member's
PCP should only be made if it is medically necessary
or there are other circumstances which necessitate a
retroactive change. HMO must pay claims for services
provided by the original PCP. If the original PCP is
paid on a capitated basis and services were provided
during the period for which capitation was paid, HMO
cannot recoup the capitation.
7.9 OB/GYN PROVIDERS
HMO must allow a female Member to select an OB/GYN
within its provider network or within a limited
provider network in addition to a PCP, to provide
health care services within the scope of the
professional specialty practice of a properly
credentialed OB/GYN. See Article 21.53D of the Texas
Insurance Code and 28 TAC Sections 11.506, 11.1600
and 11.1608. A Member who selects an OB/GYN must be
allowed direct access to the health care services of
the OB/GYN without a referral by the woman's PCP or a
prior authorization or precertification from HMO.
Health care services must include, but not be limited
to:
7.9.1 One well-woman examination per year;
7.9.2 Care related to pregnancy;
7.9.3 Care for all active gynecological conditions; and
7.9.4 Diagnosis, treatment, and referral for any disease or
condition within the scope of the professional
practice of a properly credentialed obstetrician or
gynecologist.
7.9.5 HMOs which allow its Members to directly access any
OB/GYN provider within its network must ensure that
the provisions of Articles 7.9.1 through 7.9.4
continue to be met.
67 Dallas Service Area Contract
74
7.9.6 OB/GYN providers must comply with, HMO's
procedures contained in HMO's provider manual or
provider contract for OB/GYN providers, including
but not limited to prior authorization procedures,
and provider accessibility guidelines (see Article
7.1.3 of this contract).
7.10 SPECIALTY CARE PROVIDERS
7.10.1 HMO must maintain specialty providers, including
pediatric specialty providers, within the network
in sufficient numbers and areas of practice to
meet the needs of all Members requiring specialty
care or services.
7.10.2 HMO must require, through contract provisions,
that specialty providers send a record of
consultation and recommendations to a Member's PCP
for inclusion in Member's medical record and
report encounters to the PCP and/or HMO.
7.10.3 HMO must ensure availability and accessibility to
appropriate specialists.
7.10.4 HMO must ensure that no Member is required to
travel in excess of 75 miles to secure initial
contact with referral specialists; special
hospitals; diagnostic and therapeutic services;
and single service health care physicians,
dentists or providers. Exceptions to this
requirement may be allowed when an HMO has
established, through utilization data provided to
TDH, that a normal pattern for securing health
care services within an area exists or HMO is
providing care of a higher skill level or
specialty than the level which is available within
the service area such as, but not limited to,
treatment of cancer, βββββ, and cardiac diseases.
7.11 SPECIALTY HOSPITALS AND SPECIALTY CARE FACILITIES
7.11.1 HMO must include all medically necessary specialty
services through its network specialists,
subspecialists and specialty care facilities
(e.g., children's hospitals, and tertiary care
hospitals).
7.11.2 HMO must include requirements for pre-admission
and discharge planning in its contracts with
network hospitals. Discharge plans for a Member
must be provided by HMO or the hospital to the
Member/family, the PCP and specialty care
physicians.
7.11.3 HMO must have appropriate multidisciplinary teams
for people with disabilities or chronic or complex
medical conditions. These teams must include the
PCP and any individuals or providers involved in
the day-to-day or ongoing care of the Member.
7.11.4 HMO must include in its provider network a
TDH-designated perinatal care facility, as
established by Section 32.042, Texas Health and
Safety Code, once the designated
68 Dallas Service Area Contract
75
system is finalized and perinatal care facilities
have been approved for the service area. Also see
Article 6.9.1 of this contract.
7.12 SIGNIFICANT TRADITIONAL PROVIDERS (STPS)
HMO must demonstrate a good faith effort to
include STPs in its provider network. ID40 must
seek participation in its provider network from:
7.12.1 Each health care provider in the service area who
has traditionally provided care to Medicaid
recipients;
7.12.2 Each hospital in the service area that has been
designated as a disproportionate share hospital
under Medicaid; and
7.12.3 Each specialized pediatric laboratory in the
service area, including those laboratories located
in children's hospitals.
7.12.4 HMO must include significant traditional providers
(STPs) as designated by TDH in its provider
network to provide primary care and specialty care
services. HMO must include STPs in its provider
network for at least three (3) years following the
Implementation Date in the service area.
7.12.5 STPs must agree to the contract requirements
contained in Article 7.2, unless exempted from a
requirement by law or rule. STPs must also agree
to the following contract requirements:
7.12.5.1 STP must agree to accept the standard
reimbursement rate offered by HMO to other
providers for the same or similar services.
7.12.5.2 STP must meet the credentialing requirements of
HMO. HMO must not require STPs to meet a different
or higher credentialing standard than is required
of other providers providing the same or similar
services. HMO may not require STPs to contract
with a subcontractor which requires a different or
higher credentialing standard than HMO, if the
application of the higher standard results in a
disproportionate number of STPs being excluded
from the subcontractor.
7.12.6 Failure to demonstrate a good faith effort to meet
TDH's compliance objectives to include STPs in
HMO's provider network, is a default under this
contract and may result in any or all of the
sanctions and remedies included in Article XVIII
of this contract. HMO's fulfillment of TDH's
compliance objectives for STP participation will
be monitored by TDH based on HMOs electronic file
submission to the Enrollment Broker as required in
Article 12.5.1 and other documentation submitted
by HMO, as needed.
69 Dallas Service Area Contract
76
7.13 RURAL HEALTH PROVIDERS
7.13.1 In rural areas of the service area, HMO must seek
the participation in its provider network of rural
hospitals, physicians, home and community support
service agencies, and other rural health care
providers who:
7.13.1.1 are the only providers located in the service
area; and
7.13.1.2 are Significant Traditional Providers.
7.13.2 In order to contract with HMO, rural health
providers must also:
7.13.2.1 agree to accept the prevailing provider contract
rate of HMO based on provider type; and
7.13.2.2 have the credentials required by HMO, provided
that lack of board certification or accreditation
by JCAHO may not be the only grounds for exclusion
from the provider network.
7.13.3 HMO must reimburse rural hospitals with 100 or
fewer licensed beds in counties, with fewer than
50,000 persons for acute care services at a rate
calculated using the higher of the prospective
payment system rate or the cost reimbursed
methodology authorized under the Tax Equity and
Fiscal Responsibility Act of 1982 (TEFRA).
Hospitals reimbursed under TEFRA cost principles
shall be paid without the imposition of the TEFRA
cap.
7.13.4 HMO must reimburse physicians who practice in
rural counties with fewer than 50,000 at a rate
using the current Medicaid fee schedule, including
negotiated fee for service.
7.14 FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) AND
RURAL HEALTH CLINICS (RHC)
7.14.1 HMO must make reasonable efforts to include FQHCs
and RHCs (Freestanding and hospital-based) in its
provider network.
7.14.2 FQHCs or RHCs will receive a cost settlement from
TDH and must agree to accept initial payments from
HMO in an amount that is equal to or greater than
HMO's payment terms for other providers providing
the same or similar services.
7.14.2.1 HMO must submit monthly FQHC and RHC encounter and
payment reports to all contracted FQHCs and RHCs,
and FQHCs and RHCs with whom there have been
encounters, not later than 21 days from the end of
the month for which the report
70 Dallas Service Area Contract
77
is submitted. The format will be developed by
TDH. The FQHC and RHC must validate the encounter
and payment information contained in the
report(s). Both HMO and the FQHC/RHC must sign the
report(s) after each party agrees that it
accurately reflects encounters and payments for
the month reported. HMO must submit the signed
FQHC and RHC encounter and payment reports to TDH
not later than 45 days from the end of the month
for which the report is submitted.
7.14.2.2 For FQHCs, TDH will determine the amount of the
interim settlement based on the difference
between: an amount equal to the number of Medicaid
allowable encounters multiplied by the rate per
encounter from the latest settled FQHC fiscal year
cost report; and, the amount paid by HMO to the
FQHC for the quarter. For RHCs, TDH will determine
the amount of the interim settlement based on the
difference between a reasonable cost amount
methodology provided by TDH and the amount paid by
HMO to the RHC for the quarter. TDH will pay the
FQHC or the RHC the amount of the interim
settlement, if any, as determined by TDH or
collect and retain the quarterly recoupment
amount, if any.
7.14.2.3 TDH will cost settle with each FQHC and RHC
annually, based on the FQHC or the RHC fiscal year
cost report and the methodology described in
paragraph 7.14.2.2. TDH will make additional
payments or recoup payments from the FQHC or the
RHC based on reasonable costs less prior interim
payment settlements.
7.15 COORDINATION WITH PUBLIC HEALTH
7.15.1 Reimbursed Arrangements. HMO must make a good
faith effort to enter into a subcontract for the
covered health care services as specified below
with TDH Public Health Regions, city and/or county
health departments or districts in each county of
the service area that will be providing these
services to the Members (Public Health Entities),
who will be paid for services by HMO, including
any or all of the following services or any
covered service which the public health department
and HMO have agreed to provide:
7.15.1.1 Sexually Transmitted Diseases (STDs) Services (See
Article 6.15);
7.15.1.2 Confidential HIV Testing (See Article 6.15);
7.15.1.3 Immunizations
7.15.1.4 Tuberculosis (TB) Care (See Article 6.12).
7.15.1.5 Family Planning Services (See Article 6.7);
71 Dallas Service Area Contract
78
7.15.1.6 THSteps checkups (See Article 6.8);
7.15.1.7 Prenatal services (see Article 6.9).
7.15.2 HMO must make a good faith effort to enter into
subcontracts with public health entities in the
service area. The subcontracts must be available
for review by TDH or its designated agent(s) on
the same basis as all other subcontracts. If any .
changes are made to the contract, it must be
resubmitted to TDH. If an HMO is unable to enter
into a contract with public health entities, HMO
must document current and past efforts to TDH.
Documentation must be submitted no later than 120
days after the execution of this contract. Public
health subcontracts must include the following
areas:
7.15.2.1 The general relationship between HMO and the
Public Health entity. The subcontracts must
specify the scope and responsibilities of both
parties, the methodology and agreements regarding
billing and reimbursements, reporting
responsibilities, Member and provider educational
responsibilities, and the methodology and
agreements regarding sharing of confidential
medical record, information between the public
health entity and the PCP.
7.15.2.2 Public Health Entity responsibilities:
(1) Public health providers must inform Members
that confidential health care information
will be provided to the PCP.
(2) Public health providers must refer Members
back to PCP for any follow-up diagnostic,
treatment, or referral services.
(3) Public health providers must educate Members
about the importance of having a PCP and
assessing PCP services during office hours
rather than seeking care from Emergency
Departments, Public Health Clinics, or other
Primary Care Providers or Specialists.
(4) Public health entities must identify a staff
person to act as liaison to HMO to
coordinate Member needs; Member referral,
Member and provider education, and the
transfer of confidential medical record
information.
7.15.2.3 HMO Responsibilities:
(1) HMO must identify care coordinators who will
be available to assist public health
providers and PCPs in getting efficient
referrals of Members to the
72 Dallas Service Area Contract
79
public health providers, specialists, and
health-related service providers either
within or outside HMO's network.
(2) HMO must inform Members that confidential
health care information will be provided to
the PCP.
(3) HMO must educate Members on how to better
utilize their PCPs, public health providers,
emergency departments, specialists, and
health-related service providers.
7.15.2.4 Existing contracts must include the provisions in
Articles 7.15.2.1 through 7.15.2.3.
7.15.3 Non-Reimbursed Arrangements with Public Health
Entities.
7.15.3.1 Coordination with Public Health Entities. HMOs
must make a good faith effort to enter into a
Memorandum of Understanding (MOU) with Public
Health Entities in the service area regarding the
provision of services for essential public health
care services. These MOUs must be entered into in
each service area and are subject to TDH approval.
If any changes are made to the MOU, it must be
resubmitted to TDH. If an HMO is unable to enter
into an MOU with a public health entity, HMO must
document current and past efforts to TDH.
Documentation must be submitted no later than 120
days after the execution of this contract. MOUs
must contain the roles and responsibilities of HMO
and the public health department for the following
services:
(1) Public health reporting requirements
regarding communicable diseases and/or
diseases which are preventable by
immunization as defined by state law;
(2) Notification of and referral to the local
Public Health Entity, as defined by state
law, of communicable disease outbreaks
involving Members;
(3) Referral to the local Public Health Entity
for TB contact investigation and evaluation
and preventive treatment of persons whom the
Member has come into contact;
(4) Referral to the local Public Health Entity
for STD/HIV contact investigation and
evaluation and preventive treatment of
persons whom the Member has come into
contact; and,
(5) Referral for WIC services and information
sharing;
(6) Coordination and follow-up of suspected or
confirmed cases of childhood lead exposure.
73 Dallas Service Area Contract
80
7.15.3.2 Coordination with Other TDH Programs. HMOs must
make a good faith effort to enter into a
Memorandum of Understanding (MOU) with other TDH
programs regarding the provision of services for
essential public health care services. These MOUs
must be entered into in each service area and are
subject to TDH approval. If any changes are made
to the MOU, it must be resubmitted to TDH. If an
HMO is unable to enter into an MOU with other TDH
programs, HMO must document current and past
efforts to TDH. Documentation must be submitted
no later than 120 days after the execution of
this contract. MOUs must delineate the roles and
responsibilities of HMO and the TDH programs for
the following services:
(1) Use of the TDH laboratory for THSteps
newborn screens; lead testing; and
hemoglobin/hematocrit tests;
(2) Availability of vaccines through the
Vaccines for Children Program;
(3) Reporting of immunizations provided to the
statewide ImmTrac Registry including
parental consent to share data;
(4) Referral for WIC services and information
sharing;
(5) Pregnant Women and Infant (PWI) Targeted
Case Management;
(6) THSteps outreach, informing and Medical Case
Management;
(7) Participation in the community-based
coalitions with the Medicaid-funded case
management programs in MHMR, ECI, TCB, and
TDH (PWI, CIDC and THSteps Medical Case
Management);
(8) Referral to the TDH Medical Transportation
Program; and,
(9) Cooperation with activities required of
public health authorities to conduct the
annual population and community based needs
assessment.
(10) Coordination and follow-up of suspected or
confirmed cases of childhood lead exposure.
7.15.4 All public health contracts must contain provider
network requirements in Article VII, as
applicable.
7.16 COORDINATION WITH TEXAS DEPARTMENT OF PROTECTIVE
AND REGULATORY SERVICES
74 Dallas Service Area Contract
81
7.16.1 HMO must cooperate and coordinate with the Texas Department of
Protective and Regulatory Services (TDPRS) for the care of a child
who is receiving services from or has been placed in the
conservatorship of TDPRS.
7.16.2 HMO must comply with all provisions of a court order or TDPRS
service plan with respect to a child in the conservatorship of TDPRS
(Order) entered by a Court of continuing jurisdiction placing a
child under the protective custody of the TDPRS or a service plan
voluntarily entered into by the parents or person having legal
custody of a minor and TDPRS, which relates to the health and
behavioral health services required to be provided to the Member.
7.16.3 HMO cannot deny, reduce, or controvert the medical necessity of any
health services included in an Order entered by a court. HMO may
participate in the preparation of the medical and behavioral care
plan prior to TDPRS submitting the health care plan to the Court.
Any modification or termination of ordered services must be
presented and approved by the court with jurisdiction over the
matter.
7.16.4 A Member or the parent or guardian whose rights are subject to an
Order or Service Plan cannot appeal the necessity of the services
ordered through HMO's complaint or appeal processes, or to TDH for a
fair hearing.
7.16.5 HMO must include information in its provider training and manuals
regarding:
7.16.5.1 providing medical records,
7.16.5.2 scheduling medical and behavioral health appointments within 14
days unless requested earlier by TDPRS,
7.16.5.3 recognition of abuse and neglect and appropriate referral to TDPRS.
7.16.6 HMO must continue to provide all covered services to a Member
receiving services from or in the protective custody of TDPRS until
the Member has been disenrolled from HMO as a result of loss of
eligibility in Medicaid managed care or placement into ββββββ care.
7.17 DELEGATED NETWORKS (IPAS, LIMITED PROVIDER NETWORKS AND ANHCS)
7.17.1 All HMO contracts with any of the entities described in Texas
Insurance Code Article 20A.02(ee) or a group of providers who are
licensed to provide the same health care services or an entity that
is wholly-owned or controlled by one or more
75 Dallas Service Area Contract
82
hospitals and physicians including a physician-hospital organization
(delegated network contracts) must:
7.17.1.1 contain the mandatory contract provisions for all subcontractors in
Article 3.2 of this contract,
7.17.1.2 comply with the requirements, duties and responsibilities of this
contract,
7.17.1.3 not creates a barrier for full participation to significant
traditional providers,
7.17.1.4 not interferes with TDH's oversight and audit responsibilities
including collection and validation of encounter data, or
7.17.1.5 be consistent with the federal requirement for simplicity in the
administration of the Medicaid program.
7.17.2 In addition to the mandatory provisions for all subcontracts under
Articles 3.2 and 7.2, all HMO/delegated network contracts must
include the following mandatory standard provisions:
7.17.2.1 HMO is required to include subcontract provisions in its delegated
network contracts which require the UM protocol used by an delegated
network to produce substantially similar outcomes, as approved by
TDH, as the UM protocol employed by the contracting HMO. The
responsibilities of an HMO in delegating UM functions to a delegated
network will be governed by Article 16.3.12 of this contract.
7.17.2.2 Delegated networks that have been delegated claims payment
responsibility by HMO must also have the responsibility to submit
encounter, utilization, quality, and financial data to HMO. HMO
remains responsible for integrating all delegated network data
reports into HMO's reports required under this contract. If HMO is
not able to collect and report all delegated network data for HMO
reports required by this contract, HMO must not delegate claims
processing to the delegated network.
7.17.2.3 The delegated network must comply with the same records retention
and production requirements, including Open Records requirements, as
HMO under this contract.
7.17.2.4 The delegated network is subject to the same marketing restrictions
and requirements as the HMO under this contract.
7.17.2.5 HMO is responsible for ensuring that delegated network contracts
comply with the requirements and provisions of the TDH/HMO contract.
TDH will impose appropriate sanctions and remedies upon HMO for any
default under the TDH/HMO
76 Dallas Service Area Contract
83
contract which is caused directly or indirectly by the acts or
omissions of the delegated network.
7.17.3 HMO cannot enter into contracts with delegated networks to provide
services under this contract which require the delegated network to
enter into exclusive contracts with the HMO as a condition for
participation with the HMO.
7.17.3.1 Provision 7.17.3 does not apply to providers who are employees or
participants in limited or closed panel provider networks.
7.17.4 All delegated networks that limit Member access to those providers
contracted with the delegated network (closed or limited panel
networks) with whom HMO contracts must either independently meet the
access provisions of 28 Texas Administrative Code Section 11.1607,
relating to access requirements for those Members enrolled or
assigned to the delegated network, or HMO must provide for access
through other network providers outside the closed panel delegated
network.
7.17.5 HMO cannot delegate to delegated network the enrollment,
reenrollment, assignment or reassignment of a Member.
7.17.6 In addition to the above provision HMO and approved Non-Profit
Health Corporations must comply with all of the requirements
contained in 28 TAC Section 11.1604, relating to Requirements of
Certain Contracts between Primary HMOs and ANHCs and Primary HMOs
and Provider HMOs.
7.17.7 HMO REMAINS RESPONSIBLE FOR PERFORMING ALL DUTIES, RESPONSIBILITIES
AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER THE DUTY,
RESPONSIBILITY OR SERVICE IS CONTRACTED OR DELEGATED TO ANOTHER.
HMO MUST PROVIDE A COPY OF THE CONTRACT PROVISIONS THAT SET OUT
HMO'S DUTIES, RESPONSIBILITIES, AND SERVICES TO ANY PROVIDER NETWORK
OR GROUP WITH WHOM HMO CONTRACTS TO PROVIDE HEALTH CARE SERVICES ON
A RISK SHARING OR CAPITATED BASIS OR TO PROVIDE HEALTH CARE
SERVICES.
ARTICLE VIII MEMBER SERVICES REQUIREMENTS
8.1 MEMBER EDUCATION
HMO must provide the Member education requirements as contained in
Article VI at 6.5, 6.6, 6.7, 6.8, 6.9, 6.10, 6.11, 6.12, 6.13, 6.14
and this Article of the contract.
77 Dallas Service Area Contract
84
8.2 MEMBER HANDBOOK
8.2.1 HMO must mail each newly enrolled Member a Member Handbook no later
than five (5) days after HMO receives the Enrollment File. If the
5th day falls on a weekend or state holiday, the Member Handbook
must be mailed by the following working day. The Member Handbook
must be written at a 4th - 6th grade reading comprehension level.
The Member Handbook must contain all critical elements specified by
TDH. See Appendix D, Required Critical Elements, for specific
details regarding content requirements. HMO must submit a Member
Handbook to TDH for approval prior to the effective date of the
contract unless previously approved (see Article 3.4.1 regarding the
process for plan materials review.)
8.2.2 Member Handbook Updates. HMO must provide updates to the Handbook to
all Members as changes are made to the Required Critical Elements in
Appendix D. HMO must make the Member Handbook available in the
languages of the major populations and in a format accessible to the
visually impaired served by HMO.
8.2.3 THE MEMBER HANDBOOK AND ANY REVISIONS OR CHANGES MUST BE APPROVED BY
TDH PRIOR TO PUBLICATION AND DISTRIBUTION TO MEMBERS. (See Article
3.4.1 regarding the process for plan materials review).
8.3 ADVANCE DIRECTIVES
8.3.1 Federal and state law requires HMOs and providers to maintain
written policies and procedures for informing and providing written
information to all adult Members 18 years of age and older about
their rights under state and federal law, in advance of their
receiving care (Social Security Act Section 1902(a)(57) and Section
1903(m)(1)(A). Written policies and procedures must contain
procedures for providing written information regarding the Member's
right to refuse, withhold or withdraw medical and mental health
treatment advance directives. HMO's policies and procedures must
comply with provisions contained in 42 C.F.R. Section 434.28 and 42
C.F.R. Section 489, SubPart I, relating to advance directives for
all hospitals, critical access hospitals, skilled nursing
facilities, home health agencies, providers of home health care,
providers of personal care services and hospices, as well as
following state laws and rules:
8.3.1.1 a Member's right to self-determination in making health care
decisions; and
8.3.1.2 the Advance Directives Act, Chapter 166, Texas Health and Safety
Code, which includes:
8.3.1.2.1 a Member's rights to execute an advance written directive to
physicians and family or surrogates, or to make a non-written
directive to administer, withhold or withdraw life sustaining
treatment in the event of a terminal or irreversible condition;
78 Dallas Service Area Contract
85
8.3.1.2.2 a Member's rights to make written and non-written Out-of-Hospital
Do-Not-Resuscitate Orders;
8.3.1.2.3 a Member's right to execute a Medical Power of Attorney to appoint
an agent to make health care decisions on Member's behalf if the
Member becomes incompetent; and
8.3.1.3 the declaration for Mental Health Treatment, Chapter 137, Texas
Civil Practices and Remedies Code, which includes: a Member's right
to execute a declaration for mental health treatment in a document
making a declaration of preferences or instructions regarding mental
health treatment.
8.3.2 HMO must maintain written policies for implementing a Member's
advance directive. Those policies must include a clear and precise
statement of limitations if HMO or a participating provider cannot
or will not implement a Member's advance directive.
8.3.2.1 A statement of limitation on implementing a Member's advance
directive should include at least the following information:
8.3.2.1.1 a clarification of any differences between HMO's conscience
objections and those which may be raised by the Member's PCP or
other providers;
8.3.2.1.2 identification of the state legal authority permitting HMO's
conscience objections to carrying out an advance directive; and
8.3.2.1.3 a description of medical and mental health conditions or procedures
affected by the conscience objection.
8.3.3 HMO cannot require a Member to execute or issue an advance directive
as a condition for receiving health care services.
8.3.4 HMO cannot discriminate against a Member based on whether or not the
Member executed or issued an advance directive.
8.3.5 HMO's policies and procedures must require HMO and Subcontractor to
comply with the requirements of state and federal laws relating to
advance directives. HMO must provide education and training to
employees, Members and the community on issues concerning advance
directives.
8.3.6 All materials provided to Members regarding advance directives must
be written at a 7th - 8th grade reading comprehension level, except
where a provision is required by state or federal law, and the
provision cannot be reduced or modified to a 7th - 8th
79 Dallas Service Area Contract
86
grade reading level, because it is a reference to the law or is
required to be included "as written" in the state or federal law.
HMO must submit to TDH any revisions to existing approved advanced
directive materials.
8.3.7 HMO must notify Members of any changes in state or federal laws
relating to advance directives within 90 days from the effective
date of the change, unless the law or regulation contains a specific
time requirement for notification.
8.4 MEMBER ID CARDS
8.4.1 A Medicaid Identification Form (Form 3087) is issued monthly by the
TDHS. The form includes the "STAR" Program logo and the name and
toll free number of the Member's health plan. A Member may have a
temporary Medicaid Identification (Form 1027-A) which will include a
STAR indicator.
8.4.2 HMO must issue a Member Identification Card (ID) to the Member
within five (5) days from the date the HMO receives the monthly
Enrollment File from the Enrollment Broker. If the 5th day falls on
a weekend or state holiday, the ID Card must be issued by the
following working day. The ID Card must include, at a minimum, the
following: Member's name; Member's Medicaid number; either the issue
date of the card or effective date of the PCP assignment; PCP's
name, address, and telephone number; name of HMO; name of IPA to
which the Member's PCP belongs, if applicable; the 24-hour, seven
(7) day a week toll-free telephone number operated by HMO; the
toll-free number for behavioral health care services; and directions
for what to do in an emergency. The ID Card must be reissued if the
Member reports a lost card, there is a Member name change, if Member
requests a new PCP, or for any other reason which results in a
change to the information disclosed on the ID Card.
8.5 MEMBER COMPLAINT PROCESS
8.5.1 HMO must develop, implement and maintain a Member complaint system
that complies with the requirements of Article 20A.12 of the Texas
Insurance Code, relating to the Complaint System, except where
otherwise provided in this contract or in federal law. The complaint
and appeals procedure must be the same for all Members and must
comply with the Texas Insurance Code, Article 20A.12 or applicable
federal law. Modifications and amendments must be submitted to TDH
at least 30 days prior to the implementation of the modification or
amendment.
8.5.2 HMO must have written policies and procedures for receiving,
tracking, reviewing, and reporting and resolving of Member
complaints. The procedures must be reviewed and approved in writing
by TDH. Any changes or modifications to the
80 Dallas Service Area Contract
87
procedures must be submitted to TDH for approval thirty (30) days
prior to the effective date of the amendment.
8.5.3 HMO must designate an officer of HMO who has primary responsibility
for ensuring that complaints are resolved in compliance with written
policy and within the time required. An "officer" of HMO means a
president, vice president, secretary, treasurer, or chairperson of
the board for a corporation, the sole proprietor, the managing
general partner of a partnership, or a person having similar
executive authority in the organization.
8.5.4 HMO must have a routine process to detect patterns of complaints and
disenrollments and involve management and supervisory staff to
develop policy and procedural improvements to address the
complaints. HMO must cooperate with TDH and TDH's enrollment broker
in addressing Member complaints relating to enrollment and
disenrollment.
8.5.5 HMO's complaint procedures must be provided to Members in writing
and in alternative communications formats. A written description of
HMO's complaint procedures must be in appropriate languages and easy
for Members to understand. HMO must include a written description of
the complaint procedures in the Member Handbook. HMO must maintain
at least one local and one toll-free telephone number for making
complaints.
8.5.6 HMO's process must require that every complaint received in person,
by telephone or in writing, is recorded in a written record and is
logged with the following details: date, identification of the
individual filing the complaint, identification of the individual
recording the complaint, nature of the complaint; disposition of the
complaint, corrective action required, and date resolved.
8.5.7 HMO's process must include a requirement that the Governing Body of
HMO reviews the written records (logs) for complaints and appeals.
8.5.8 HMO is prohibited from discriminating against a Member because that
Member is making or has made a complaint.
8.5.9 HMO cannot process requests for disenrollments through HMO's
complaint procedures. Requests for disenrollments must be referred
to TDH within five (5) business days after the Member makes a
disenrollment request.
8.5.10 HMO must develop, implement and maintain an appeal of adverse
determination procedure that complies with the requirements of
Article 21.58A of the Texas Insurance Code, relating to the
utilization review, except where otherwise provided in their
contract and in applicable federal law. The appeal of an adverse
81 Dallas Service Area Contract
88
determination procedure must be the same for all Members and must
comply with Texas Insurance Code, Article 21.58A or applicable
federal law. Modifications and amendments must be submitted to TDH
no less than 30 days prior to the implementation of the modification
or amendment. When an enrollee, a person acting on behalf of an
enrollee, or an enrollee's provider of record expresses orally or in
writing any dissatisfaction or disagreement with an adverse
determination, HMO or UR agent must regard the expression of
dissatisfaction as a request to appeal an adverse determination.
8.5.11 If a complaint or appeal of an adverse determination relates to the
denial, delay, reduction, termination or suspension of covered
services by either HMO or a utilization review agent contracted to
perform utilization review by HMO, HMO must inform Members they have
the right to access the TDH fair hearing process at any time in lieu
of the internal complaint system provided by HMO. HMO is required to
comply with the requirements contained in 1 TAC Chapter 357,
relating to notice and fair hearings in the Medicaid program,
whenever an action is taken to deny, delay, reduce, terminate or
suspend a covered service.
8.5.12 If Members utilize HMO's internal complaint or appeal of adverse
determination system and the complaint relates to the denial,
delay, reduction, termination or suspension of covered services by
either HMO or a utilization review agent contracted to perform
utilization review by HMO, HMO must inform the Member that they
continue to have a right to appeal the decision through the TDH fair
hearing process.
8.5.13 The provisions of Article 21.58A, Texas Insurance Code, relating to
a Member's right to appeal an adverse determination made by HMO or a
utilization review agent by an independent review organization, do
not apply to a Medicaid recipient. Federal fair hearing requirements
(Social Security Act Section 1902a(3), codified at 42 C.F.R. 431.200
et. seq.) require the agency to make a final decision, after a fair
hearing which conflicts with the State requirement that the IRO make
a final decision, therefore the State requirement is pre-empted by
the federal requirement.
8.5.14 HMO will cooperate with the Enrollment Broker and TDH to resolve all
Member complaints. Such cooperation may include, but is not limited
to, participation by HMO or Enrollment Broker and/or TDH internal
complaint committees.
8.5.15 HMO must have policies and procedures in place outlining the role of
HMO's Medical Director in the Member Complaint System and appeal of
an adverse determination. The Medical Director must have a
significant role in monitoring, investigating and hearing
complaints.
82 Dallas Service Area Contract
89
8.5.16 HMO must provide Member Advocates to assist Members in understanding
and using HMO's complaint system and appeal of an adverse
determination.
8.5.17 HMO's Member Advocates must assist Members in writing or filing a
complaint or appeal of an adverse determination and monitoring the
complaint or appeal through the Contractor's complaint process or
appeal of an adverse determination until the issue is resolved.
8.6 MEMBER NOTICE, APPEALS AND FAIR HEARINGS
8.6.1 HMO must send Members the notice required by 25 TAC, Chapter 36,
whenever HMO takes an action to deny, delay, reduce or terminate
covered services to a Member. The notice must be mailed to the
Member no less than 10 days before HMO intends to take an action. If
an emergency exists, or if the time within which the service must be
provided makes giving 10 days notice impractical or impossible,
notice must be provided by the most expedient means reasonably
calculated to provide actual notice to the Member, including by
phone, or through the provider's office.
8.6.2 The notice must contain the following information:
8.6.2.1 the Member's right to immediately access TDH's Fair Hearing process;
8.6.2.2 a statement of the action HMO will take;
8.6.2.3 the date the action will be taken;
8.6.2.4 an explanation of the reasons HMO will take the action;
8.6.2.5 a reference to the state and/or federal regulations which support
HMO's action;
8.6.2.6 an address where written requests may be sent and a toll-free number
Member can call to: request the assistance of a Member
representative, file a complaint, or request a Fair Hearing;
8.6.2.7 a procedure by which the Member may appeal HMO's action through
either HMO's complaint process or TDH's fair hearings process;
8.6.2.8 an explanation that the Member may represent themselves, or be
represented by HMO's representative, a friend, a relative, legal
counsel or another spokesperson;
8.6.2.9 an explanation of whether and under what circumstances services may
be continued if a complaint is filed or a Fair Hearing requested;
83 Dallas Service Area Contract
90
8.6.2.10 a statement that if the Member wants a TDH Fair Hearing on the
action, Member must make the request for a Fair Hearing within 90
days of the date on the notice or the right to request a hearing is
waived;
8.6.2.11 a statement explaining that HMO must make its decision within 30
days from the date the complaint is received by HMO; and
8.6.2.12 a statement explaining that a final decision must be made by TDH
within 90 days from the date a Fair Hearing is requested.
8.7 MEMBER ADVOCATES
8.7.1 HMO must provide Member Advocates to assist Members. The Member
Advocates must be physically located within the Service Area. Member
Advocates must inform Members of their rights and responsibilities,
the complaint process, the health education and the services
available to them, including preventive services.
8.7.2 The Member Advocates must assist Members in writing complaints and
are responsible for monitoring the complaint through HMO's complaint
process until the Member's issues are resolved or a TDH Fair Hearing
requested. (See Articles 8.6.15, 8.6.16 and 8.6.17.)
8.7.3 Member Advocates are responsible for making recommendations to
management on any changes needed to improve either the care provided
or the way care is delivered. Advocates are also responsible for
helping or referring Members to community resources available to
meet Member needs that are not available from HMO as Medicaid
covered services.
8.7.4 Member Advocates must provide outreach to Members and participate in
TDH-sponsored enrollment activities.
8.8 MEMBER CULTURAL AND LINGUISTIC SERVICES
8.8.1 Cultural Competency Plan. HMO must have a comprehensive written
Cultural Competency Plan describing how HMO will ensure culturally
competent services, and provide linguistic and disability related
access. The Plan must describe how the individuals and systems
within HMO will effectively provide services to people of all
cultures, races, ethnic backgrounds, and religions, as well as those
with disabilities, in a manner that recognizes, values, affirms, and
respects the worth of the individuals and protects and preserves the
dignity of each. HMO must submit a written plan to TDH prior to the
effective date of this contract unless previously submitted.
Modifications and amendments to the written plan must be submitted
to
84 Dallas Service Area Contract
91
TDH no less than 30 days prior to implementation of the modification
or amendment. The Plan must also be made available to HMO's network
of providers.
8.8.2 The Cultural Competency Plan must include the following:
8.8.2.1 HMO's written policies and procedures for ensuring effective
communication through the provision of linguistic services following
Title VI of the Civil Rights Act guidelines and the provision of
auxiliary aids and services, in compliance with the Americans with
Disabilities Act, Title III, Department of Justice Regulation
36.303. HMO must disseminate these policies and procedures to ensure
that both Staff and subcontractors are aware of their
responsibilities under this provision of the contract.
8.8.2.2 A description of how HMO will educate and train its staff and
subcontractors on culturally competent service delivery, and the
provision of linguistic and/or disability-related access as related
to the characteristics of its Members;
8.8.2.3 A description of how HMO will implement the plan in its
organization, identifying a person in the organization who will
serve as the contact with TDH on the Cultural Competency Plan;
8.8.2.4 A description of how HMO will develop standards and performance
requirements for the delivery of culturally competent care and
linguistic access, and monitor adherence with those standards and
requirements;
8.8.2.5 A description of how HMO will provide outreach and health education
to Members including racial and ethnic minorities, non-English
speakers or limited-English speakers, and those with disabilities;
and
8.8.2.6 A description of how HMO will help Members access culturally and
linguistically appropriate community health or social services
resources.
8.8.3 Linguistic, Interpreter Services, and Provision of Auxiliary Aids
and Services. HMO must provide experienced, professional
interpreters when technical, medical or treatment information is to
be discussed. See Title VI of the Civil Rights Act of 1964, 42
USC Sections 2000d, et seq. HMO must ensure the provision of
auxiliary aids and services necessary for effective communication;
as per the Americans with Disabilities Act, Title III, Department of
Justice Regulations 36.303.
8.8.3.1 HMO must adhere to and provide to Members the Member ββββ of Rights
and Responsibilities as adopted by the Texas Health and Human
Services Commission and contained at 1 Texas Administrative Code
(TAC) Sections 353.202-353.203. The Member ββββ of Rights and
Responsibilities assures Members the right "to have interpreters, if
needed, during appointments with [their] providers and when talking
85 Dallas Service Area Contract
92
to [their] health plan. Interpreters include people who can speak in
[their] native language, assist with a disability, or help [them]
understand the information."
8.8.3.2 HMO must have in place policies and procedures that outline how
Members can access face-to-face interpreter services in a provider's
office if necessary to ensure the availability of effective
communication regarding treatment, medical history or health
education for a Member. HMO must inform its providers on how to
obtain an updated list of participating, qualified interpreters.
8.8.3.3 A competent interpreter is defined as someone who is:
8.8.3.4 proficient in both English and the other language, and
8.8.3.5 has had orientation or training in the ethics of interpreting, and
8.8.3.6 has the ability to interpret accurately and impartially.
8.8.3.7 HMO must provide 24-hour access to interpreter services for Members
to access emergency medical services within HMO's network.
8.8.3.8 Family Members, especially minor children, should not be used as
interpreters in assessments, therapy or other medical situations in
which impartiality and confidentiality are critical, unless
specifically requested by the Member. However, a family member or
friend may be used as an interpreter if they can be relied upon to
provide a complete and accurate translation of the information being
provided to the Member; the Member is advised that a free
interpreter is available; and the Member expresses a preference to
rely on the family member or friend.
8.8.4 All Member orientation presentations, education classes and
materials must be presented in the languages of the major population
groups making up 10% or more of the Medicaid population in the
service area as specified by TDH. HMO must provide auxiliary aids
and services, as needed, including materials in alternative formats
(i.e., large print, tape or Braille), and interpreters or real-time
captioning to accommodate the needs of persons with disabilities
that affect communication.
8.8.5 HMO must provide access to Telecommunications Device for the Deaf to
Members who are deaf or hearing impaired, directly or through the
state's relay services.
8.9 CERTIFICATION DATE
8.9.1 On the date of the new Member's enrollment, TDH will provide HMOs
with the Member's Medicaid periodic review date.
86 Dallas Service Area Contract
93
ARTICLE IX MARKETING AND PROHIBITED PRACTICES
9.1 MARKETING MATERIAL MEDIA, AND DISTRIBUTION
HMOs may present their marketing materials to eligible Medicaid
recipients through any method or media determined to be acceptable
by TDH. The media may include but are not limited to: written
materials, such as brochures, posters, or fliers which can be mailed
directly to the client or left at Texas Department of Human Services
eligibility offices; TDH sponsored community enrollment events; and
paid or public service announcements on radio. All marketing
materials must be approved by TDH prior to distribution (see Article
3.4).
9.2 MARKETING ORIENTATION AND TRAINING
HMO must require that all HMO staff having direct contact with
Members as part of their job duties and their supervisors have
satisfactorily completed TDH's marketing orientation and training
program prior to engaging in marketing activities on behalf of HMO.
TDH will notify HMO of scheduled orientations.
9.3 PROHIBITED MARKETING PRACTICES
9.3.1 HMO and its agents, subcontractors and providers are prohibited from
engaging in the following marketing practices:
9.3.1.1 conducting any direct contact marketing to prospective Members
except through TDH-sponsored enrollment events;
9.3.1.2 making any written or oral statement containing material
misrepresentations of fact or law relating to HMO's plan or the
STAR program;
9.3.1.3 making false, misleading or inaccurate statements relating to
services or benefits of HMO or the STAR program;
9.3.1.4 offering prospective Members anything of material or financial value
as an incentive to enroll with a particular PCP or HMO; and
9.3.1.5 discriminating against an eligible Member because of race, creed,
age, color, sex, religion, national origin, ancestry, marital
status; sexual orientation, physical or mental handicap, health
status, or requirements for health care services.
9.3.2 HMO may offer nominal gifts with a retail value of no more than $10
and/or free health screens to potential Members, as long as these
gifts and free health screenings are offered whether or not the
client enrolls in HMO. Free health screenings cannot
87 Dallas Service Area Contract
94
be used to discourage less healthy potential Members from joining
HMO. All gifts must be approved by TDH prior to distribution to
Members. The results of free screenings must be shared with the
Member's PCP if the Member enrolls with HMO providing the screen.
9.3.3 Marketing representatives may not conduct or participate in
marketing activities for more than one HMO.
9.4 NETWORK PROVIDER DIRECTORY
9.4.1 The provider directory and any revisions must be approved by TDH
prior to publication and distribution to prospective Members (see
Article 3.4.1 regarding the process for plan materials review). The
directory must contain all critical elements specified by TDH. See
Appendix D, Required Critical Elements, for specific details
regarding content requirements.
9.4.2 If HMO contracts with limited provider networks, the provider
directory must comply with the requirements of 28 TAC
11.1600(b)(11), relating to the disclosure and notice of limited
provider networks.
9.4.3 Updates to the provider directory must be provided to the Enrollment
Broker at the beginning of each state fiscal year quarter. This
includes the months of September, December, March and June. HMO is
responsible for submitting draft updates to TDH only if changes
other than PCP information are incorporated. HMO is responsible for
sending three final paper copies and one electronic copy of the
updated provider directory to TDH each quarter. If an electronic
format is not available, five paper copies must be sent. TDH will
forward two updated provider directories, along with its approval
notice, to the Enrollment Broker to facilitate their distribution.
ARTICLE X MIS SYSTEM REQUIREMENTS
10.1 MODEL MIS REQUIREMENTS
10.1.1 HMO must maintain a MIS that will provide support for all functions
of HMO's processes and procedures related to the flow and use of
data within HMO. The MIS must enable HMO to meet the requirements of
this contract. The MIS must have the capacity and capability of
capturing and utilizing various data elements to develop information
for HMO administration.
88 Dallas Service Area Contract
95
10:1.2 HMO must maintain a claim retrieval service processing system that
can identify date of receipt, action taken on all provider claims or
encounters (i.e., paid, denied, other), and when any action was
taken in real time.
10.1.3 HMO must have a system that can be adapted to the changes in
Business Practices/Policies within a short period of time.
10.1.4 HMO is required to submit and receive data as specified in this
contract and HMO Encounter Data Submissions Manual. HMO must provide
encounter data for all capitated services within the scope of
services of the contract between HMO and TDH. Encounter data must
follow the format, data elements and method of transmission
specified in the contract and HMO Encounter Data Submissions Manual.
HMO must submit encounter data, including adjustments to encounter
data. The Encounter transmission will include all encounter data and
encounter data adjustments processed by HMO for the previous month.
Data quality validation will incorporate assessment standards
developed jointly by HMO and TDH. Original records will be made
available for inspection by TDH for validation purposes. Data which
does not meet quality standards must be corrected and returned
within a time period specified by TDH.
10.1.5 HMO must use the procedure codes, diagnosis codes, and other codes
used for reporting encounters and fee-for-service claims in the most
recent edition of the Medicaid Provider Procedures Manual or as
otherwise directed by TDH. Any exceptions will be considered on a
code-by-code basis after TDH receives written notice from HMO
requesting an exception. HMO must also use the provider numbers as
directed by TDH for both encounter and fee-for-service claims
submission.
10.1.6 HMO must have hardware, software, network and communications system
with the capability and capacity to handle and operate all MIS
subsystems.
10.1.7 HMO must notify TDH of any changes to HMO's MIS department dedicated
to or supporting this contract by Phase I of Renewal Review. Any
updates to the organizational chart and the description of
responsibilities must be provided to TDH at least 30 days prior to
the effective date of the change. Official points of contact must be
provided to TDH on an on-going basis. An Internet E-mail address
must be provided for each point of contact.
10.1.8 HMO must operate and maintain a MIS that meets or exceeds the
requirements outlined in the Model MIS Guidelines that follow:
10.1.8.1 Eight subsystems are used in the Model MIS Requirements to identify
specific functions or features required by HMO's MIS. These
subsystems focus on the
89 Dallas Service Area Contract
96
individual systems functions or capabilities to support the
following operational and administrative areas:
(1) Enrollment/Eligibility Subsystem
(2) Provider Subsystem
(3) Encounter/Claims Processing Subsystem
(4) Financial Subsystem
(5) Utilization/Quality Improvement Subsystem
(6) Reporting Subsystem
(7) Interface Subsystem
(8) TPR Subsystem
10.2 SYSTEM-WIDE FUNCTIONS
HMO MIS system must include functions and/or features which must
apply across all subsystems as follows:
(1) Ability to update and edit data.
(2) Maintain a history of changes and adjustments and audit trails
for current and retroactive data. Audit trails will capture
date, time, and reasons for the change, as well as who made the
change.
(3) Allow input mechanisms through manual and electronic
transmissions.
(4) Have procedures and processes for accumulating, archiving, and
restoring data in the event of a system or subsystem failure.
(5) Maintain automated or manual linkages between and among all MIS
subsystems and interfaces.
(6) Ability to relate Member and provider data with utilization,
service, accounting data, and reporting functions.
(7) Ability to relate and extract data elements into summary and
reporting formats attached as Appendices to contract.
90 Dallas Service Area Contract
97
(8) Must have written process and procedures manuals which document
and describe all manual and automated system procedures and
processes for all the above functions and features, and the
various subsystem components.
(9) Maintain and cross-reference all Member-related information with
the most current Medicaid number.
10.3 ENROLLMENT/ELIGIBILITY SUBSYSTEM
The Enrollment/Eligibility Subsystem is the central processing
point for the entire MIS. It must be constructed and programmed to
secure all functions which require Membership data. It must have
function and/or features which support requirements as follows:
(1) Identify other health coverage available or third party
liability (TPL), including type of coverage and effective dates.
(2) Maintain historical data (files) as required by TDH.
(3) Maintain data on enrollments/disenrollments and complaint
activities. This data must include reason or type of
disenrollment, complaint and resolution by incidence.
(4) Receive, translate, edit and update files in accordance with TDH
requirements prior to inclusion in HMO's MIS. Updates will be
received from TDH's agent and processed within two working days
after receipt.
(5) Provide error reports and a reconciliation process between new
data and data existing in MIS.
(6) Identify enrollee changes in primary care provider and the
reason(s) for those changes and effective dates.
(7) Monitor PCP capacity and limitations prior to connecting the
enrollee to PCP in the system, and provide a kick-out report
when capacity and limitations are exceeded.
(8) Verify enrollee eligibility for medical services rendered or for
other enrollee inquiries.
(9) Generate and track referrals, e.g., Hospitals/Specialists.
91 Dallas Service Area Contract
98
(10) Search records by a variety of fields (e.g., name, unique
identification numbers, date of birth, SSN, etc.) for
eligibility verification.
(11) Send PCP assignment updates to TDH in the format as specified
by TDH.
10.4 PROVIDER SUBSYSTEM
The provider subsystem must accept, process, store and retrieve
current and historical data on providers, including services,
payment methodology, license information, service capacity, and
facility linkages.
Functions and Features:
(1) Identify specialty(s), admission privileges, enrollee linkage,
capacity, facility linkages, emergency arrangements or contact,
and other limitations, affiliations, or restrictions.
(2) Maintain provider history files to include audit trails and
effective dates of information.
(3) Maintain provider fee schedules/remuneration agreements to
permit accurate payment for services based on the financial
agreement in effect on the date of service.
(4) Support HMO credentialing, recredentialing, and credential
tracking processes; incorporates or links information to
provider record.
(5) Support monitoring activity for physician to enrollee ratios
(actual to maximum) and total provider enrollment to physician
and HMO capacity.
(6) Flag and identify providers with restrictive conditions (e.g.,
limits to capacity, type of patient, and other services if
approved out of network, to include age restrictions).
(7) Support national provider number format (UPIN, NPIN, CLIA, etc.
as required by TDH).
(8) Provide provider network files 90 days prior to implementation
and updates monthly. Format will be provided by TDH to
contracted entities.
(9) Support the national CLIA certification numbers for clinical
laboratories.
92 Dallas Service Area Contract
99
(10) Exclude providers from participation that have been identified
by TDH as ineligible or excluded. Files must be updated to
reflect period and reason for exclusion.
10.5 ENCOUNTER/CLAIMS PROCESSING SUBSYSTEM
The encounter/claims processing subsystem must collect, process, and
store data on all health services delivered for which HMO is
responsible. The functions of these subsystems are claims/encounter
processing and capturing health service utilization data. The
subsystem must capture all health care services, including medical
supplies, using standard codes (e.g. CPT-4, HCPCS, ICD9-CM, UB92
Revenue Codes) rendered by health-care providers to an eligible
enrollee regardless of payment arrangement (e.g. capitation or
fee-for-service). It approves, prepares for payment, or may reject
or deny claims submitted. This subsystem may integrate manual and
automated systems to validate and adjudicate claims and encounters.
HMO must use encounter data validation methodologies prescribed by
TDH.
Functions and Features:
(1) Accommodate multiple input methods - electronic submission,
tape, claim document, and media.
(2) Support entry and capture of a minimum of all required data
elements specified in the Encounter Data Submissions manual.
(3) Edit and audit to ensure allowed services are provided by
eligible providers for eligible recipients.
(4) Interface with Member and provider subsystems.
(5) Capture and report TPL potential, reimbursement or denial.
(6) Edit for utilization and service criteria, medical policy, fee
schedules, multiple contracts, contract periods and conditions.
(7) Submit data to TDH through electronic transmission using
specified formats.
(8) Support multiple fee schedule benefit packages and capitation
rates for all contract periods for individual providers,
groups, services, etc. A claim encounter must be initially
adjudicated and all adjustments must use the fee applicable to
the date of service.
(9) Provide timely, accurate, and complete data for monitoring
claims processing performance.
(10) Provide timely, accurate, and complete data for reporting
medical service utilization.
(11) Maintain and apply prepayment edits to verify accuracy and
validity of claims data for proper adjudication.
(12) Maintain and apply edits and audits to verify timely, accurate,
and complete encounter data reporting.
93 Dallas Service Area Contract
100
(13) Submit reimbursement to non-contracted providers for emergency
care rendered to enrollees in a timely and accurate fashion.
(14) Validate approval and denials of precertification and prior
authorization requests during adjudication of
claims/encounters.
(15) Track and report the exact date a service was performed. Use of
date ranges must have State approval.
(16) Receive and capture claim and encounter data from TDH.
(17) Receive and capture value-added services codes.
(18) Capability of identifying adjustments and linking them to the
original claims/encounters.
10.6 FINANCIAL SUBSYSTEM
The financial subsystem must provide the necessary data for all
accounting functions including cost accounting, inventory, fixed
assets, payroll, general ledger, accounts receivable and payable,
financial statement presentation, and any additional data required
by TDH. The financial subsystem must provide management with
information that can demonstrate that the proposed or existing HMO
is meeting, exceeding, or falling short of fiscal goals. The
information must also provide management with the necessary data to
spot the early signs of fiscal distress, far enough in advance to
allow management to take corrective action where appropriate.
Functions and Features:
(1) Provide information on HMO's economic resources, assets, and
liabilities and present accurate historical data and
projections based on historical performance and current assets
and liabilities.
(2) Produce financial statements in conformity with Generally
Accepted Accounting Principles and in the format prescribed by
TDH.
(3) Provide information on potential third party payers;
information specific to the client; claims made against third
party payers; collection amounts and dates; denials, and
reasons for denials.
(4) Track and report savings by category as a result of cost
avoidance activities.
(5) Track payments per Member made to network providers compared to
utilization of the provider's services.
(6) Generate Remittance and Status Reports.
(7) Make claim and capitation payments to providers or groups.
94 Dallas Service Area Contract
101
(8) Reduce/increase accounts payable/receivable based on
adjustments to claims or recoveries from third party resources.
10.7 UTILIZATION/QUALITY IMPROVEMENT SUBSYSTEM
The quality management/quality improvement/utilization review
subsystem combines data from other subsystems, and/or external
systems, to produce reports for analysis which focus on the review
and assessment of quality of care given, detection of over and under
utilization, and the development of user defined reporting criteria
and standards. This system profiles utilization of providers and
enrollees and compares them against experience and norms for
comparable individuals. This system also supports the quality
assessment function.
The subsystem tracks utilization control function(s) and monitoring
inpatient admissions, emergency room use, ancillary, and out-of-area
services. It provides provider profiles, occurrence reporting, and
monitoring and evaluation studies. The subsystem may integrate HMO's
manual and automated processes or incorporate other software
reporting and/or analysis programs.
The subsystem incorporates and summarizes information from enrollee
surveys, provider and enrollee complaints, and appeal processes.
Functions and Features:
(1) Supports provider credentialing and recredentialing activities.
(2) Supports HMO processes to monitor and identify deviations in
patterns of treatment from established standards or norms.
Provides feedback information for monitoring progress toward
goals, identifying optimal practices, and promoting continuous
improvement.
(3) Supports development of cost and utilization data by provider
and service.
(4) Provides aggregate performance and outcome measures using
standardized quality indicators similar to HEDIS or as
specified by TDH.
(5) Supports focused quality of care studies.
(6) Supports the management of referral/utilization control
processes and procedures, including prior authorization and
precertifications and denials of services.
(7) Monitors primary care provider referral patterns.
(8) Supports functions of reviewing access, use and coordination of
services (i.e. actions of Peer Review and alert/flag for review
and/or follow-up; laboratory, x-ray and other ancillary service
utilization per visit).
(9) Stores and reports patient satisfaction data through use of
enrollee surveys.
(10) Provides fraud and abuse detection, monitoring and reporting.
95 Dallas Service Area Contract
102
(11) Meets minimum report/data collection/analysis functions of
Article XI and Appendix A of this Contract.
(12) Monitors and tracks provider and enrollee complaints and
appeals from receipt to disposition or resolution by provider.
10.8 REPORT SUBSYSTEM
The reporting subsystem supports reporting requirements of all HMO
operations to HMO management and TDH. It allows HMO to develop
various reports to enable HMO management and TDH to make decisions
regarding HMO activity.
Functions and Capabilities:
(1) Produces standard, TDH-required reports and ad hoc reports from
the data available in all MIS subsystems. All reports will be
submitted on hard copy or electronically in a format approved
by TDH.
(2) Have system flexibility to permit the development of reports at
irregular periods as needed.
(3) Generate reports that provide unduplicated counts of enrollees,
providers, payments and units of service unless otherwise
specified.
(4) Generate an alphabetic Member listing.
(5) Generate a numeric Member listing.
(6) Generate a client eligibility listing by PCP (panel report).
(7) Report on PCP change by reason code.
(8) Report on TPL (COB) information to TDH.
(9) Report on provider capacity and assignment from date of service
to date received.
(10) Generate or produce an aged outstanding liability report.
(11) Produce a Member ID Card.
(12) Produce client/provider mailing labels.
10.9 DATA INTERFACE SUBSYSTEM
10.9.1 The interface subsystem supports incoming and outgoing data from and
to other organizations. It allows HMO to maintain enrollee, benefit
package, eligibility, disenrollment/enrollment status, and medical
services received outside of capitated services and associated cost.
All interfaces must follow the specifications frequencies and
formats listed in the Interface Manual.
10.9.2 HMO must obtain access to the TexMedNet BBS. Some file transfers and
E-mail will be handled through this mechanism.
96 Dallas Service Area Contract
103
10.9.3 Provider Network File. The provider file shall supply Network
Provider data between an HMO and TDH. This process shall accomplish
the following:
(1) Provide identifying information for all managed care providers
(e.g. name, address, etc.).
(2) Maintain history on provider enrollment/disenrollment.
(3) Identify PCP capacity.
(4) Identify any restrictions (e.g., age, sex, etc.).
(5) Identify number and types of specialty providers available to
Members.
10.9.4 Eligibility/Enrollment Interface. The enrollment interface must
provide eligibility data between TDH and HMOs.
(1) Provides benefit package data to HMOs in accordance with
capitated services.
(2) Provides PCP assignments.
(3) Provides Member eligibility status data.
(4) Provides Member demographics data.
(5) Provides HMOs with cross-reference data to identify duplicate
Members.
10.9.5 Encounter/Claim Data Interface. The encounter/claim interface must
transfer paid fee-for-service claims data to HMOs and capitated
services/encounters from HMO, including adjustments. This file will
include all service types, such as inpatient, outpatient, and
medical services. TDH's agent will process claims for non-capitated
services.
10.9.6 Capitation Interface. The capitation interface must transfer premium
and Member information to HMO. This interface's basic purpose is to
balance HMO's Members and premium amount.
10.9.7 TPR Interface. TDH will provide a data file that contains
information on enrollees that have other insurance. Because Medicaid
is the payer of last resort, all services and encounters should be
billed to the other insurance companies for recovery. TDH will also
provide an insurance company data file which contains the name and
address of each insurance company.
10.9.8 TDH will provide a diagnosis file which will give the code and
description of each diagnosis permitted by TDH.
10.9.9 TDH will provide a procedure file which contains the procedures
which must be used on all claims and encounters. This file contains
HCPCS, revenue, and ICD9-CM surgical procedure codes.
97 Dallas Service Area Contract
104
10.9.10 TDH will provide a provider file that contains the Medicaid provider
numbers, and the provider's names and addresses. The provider number
authorized by TDH must be submitted on all claims, encounters, and
network provider submissions.
10.10 TPR SUBSYSTEM
HMO's third party recovery system must have the following
capabilities and capacities:
(1) Identify, store, and use other health coverage available to
eligible Members or third party liability (TPL) including type
of coverage and effective dates.
(2) Provide changes in information to TDH as specified by TDH.
(3) Receive TPL data from TDH to be used in claim and encounter
processing.
ARTICLE XI QUALITY ASSURANCE AND QUALITY IMPROVEMENT PROGRAM
11.1 QUALITY IMPROVEMENT PROGRAM (QIP) SYSTEM
HMO must develop, maintain, and operate a Quality Improvement
Program (QIP) system which complies with federal regulations
relating to Quality Assurance systems, found at 42 C.F.R.
Section 434.34. The system must meet the Standards for Quality
Improvement Programs contained in Appendix A.
11.2 WRITTEN QIP PLAN
HMO must have on file with TDH an approved plan describing its
Quality Improvement Plan (QIP), including how HMO will accomplish
the activities pertaining to each Standard (I-XVI) in Appendix A.
Modifications and amendments must be submitted to TDH no later than
60 days prior to the implementation of the modification or
amendment.
11.3 QIP SUBCONTRACTING
If HMO subcontracts any of the essential functions or reporting
requirements of QIP to another entity, HMO must maintain a file of
the subcontractors. The file must be available for review by TDH or
its designee upon request. HMO must notify TDH no later than 90 days
prior to terminating any subcontract affecting a major performance
function of this contract (see Article 3.2.1.2).
11.4 ACCREDITATION
98 Dallas Service Area Contract
105
If HMO is accredited by an external accrediting agency,
documentation of accreditation must be provided to TDH. HMO must
provide TDH with their accreditation status upon request.
11.5 BEHAVIORAL HEALTH INTEGRATION INTO QIP
HMO must integrate behavioral health into its QIP system and
include a systematic and on-going process for monitoring,
evaluating, and improving the quality and appropriateness of
behavioral health services provided to Members. HMO's QIP must
enable HMO to collect data, monitor and evaluate for improvements to
physical health outcomes resulting from behavioral health
integration into the overall care of the Member. All Memorandums of
Agreement (MOAs) between HMOs and BHOs addressing care coordination
must be adhered to.
11.6 QIP REPORTING REQUIREMENTS
HMO must meet all of the QIP Reporting Requirements contained in
Article XII.
ARTICLE XII REPORTING REQUIREMENTS
12.1 FINANCIAL REPORTS
12.1.1 Monthly MCFS Report. HMO must submit the Managed Care Financial
Statistical Report (MCFS) included in Appendix I. The report must be
submitted to TDH no later than 30 days after the end of each state
fiscal year quarter (i.e., Dec. 30, March 31, June 30, Sept. 30) and
must include complete financial and statistical information for each
month. The MCFS Report must be submitted for each claims processing
subcontractor in accordance with this Article. HMO must incorporate
financial and statistical data received by its delegated networks
(IPAs, ANHCs, Limited Provider Networks) in its MCFS Report.
12.1.2 For any given month in which an HMO has a net loss of $200,000 or
more for the contract period to date, HMO must submit an MCFS Report
for that month by the 30th day after the end of the reporting month.
The MCFS Report must be completed in accordance with the Instructions
for Completion of the Managed Care Financial-Statistical Report
developed by TDH.
12.1.3 An HMO must submit monthly reports for each of the first 6 months
following the Implementation Date. If the cumulative net loss for
the contract period to date after the 6th month is less than
$200,000, HMO may submit quarterly reports in
99 Dallas Service Area Contract
106
accordance with the above provisions unless conditions 12.1.2 or
12.1.3 exist, in which case monthly reports must be submitted.
12.1.4 Final MCFS Report. HMO must file two Final Managed Care Financial
Statistical Reports. The first final report must reflect expenses
incurred through the 90th day after the end of the contract. The
first final report must be filed on or before the 120th day after
the end of the contract. The second final report must reflect data
completed through the 334th day after the end of the contract and
must be filed on or before the 365th day following the end of the
contract.
12.1.5 Administrative expenses reported in the monthly and Final MCFS
Reports must be reported in accordance with Appendix L, Cost
Principles for Administrative Expenses. Indirect administrative
expenses must be based on an allocation methodology for Medicaid
managed care activities and services that is developed or approved
by TDH.
12.1.6 Affiliated Report. HMO must submit an Affiliated Report to TDH if
this information has changed since the last report was submitted.
The report must contain the following information:
12.1.6.1 A listing of all Affiliate; and
12.1.6.2 A schedule of all transactions with Affiliates which, under the
provisions of this Contract, will be allowable as expenses in
either Line 4 or Line 5 of Part 1 of the MCFS Report for services
provided to HMO by the Affiliate, including financial terms, a
detailed description of the services to be provided and an estimated
amount which will be incurred by HMO for such services during the
Contract period.
12.1.7 Annual Audited Financial Report. On or before June 30th of each
year, HMO must submit to TDH a copy of the annual audited financial
report filed with TDI.
12.1.8 Form HCFA-1513. HMO must file an updated Form HCFA-1513 regarding
control, ownership, or affiliation of HMO 30 days prior to the end
of the contract year. An updated Form HCFA-1513 must also be filed
within 30 days of any change in control, ownership, or affiliation
of HMO. Forms may be obtained from TDH.
12.1.9 Section 1318 Financial Disclosure Report. HMO must file an updated
HCFA Public Health Service (PHS) "Section 1318 Financial Disclosure
Report" within 30 days from the end of the contract year and within
30 days of entering into, renewing, or terminating a relationship
with an affiliated party. These forms may be obtained from TDH.
100 Dallas Service Area Contract
107
12.1.10 TDI Examination Report. HMO must furnish a copy of any TDI
Examination Report within 10 days after receipt from TDI.
12.1.11 IBNR Plan. HMO must furnish a written IBNR Plan to manage
incurred-but-not-reported (IBNR) expenses, and a description of the
method of insuring against insolvency, including information on all
existing or proposed insurance policies. The Plan must include the
methodology for estimating IBNR. The plan and description must be
submitted to TDH no later than 60 days after the effective date of
this contract, unless previously submitted to TDH. Changes to the
IBNR plan and description must be submitted to TDH no later than 30
days before changes to the plan are implemented by HMO.
12.1.12 Third Party Recovery (TPR) Reports. HMO must file quarterly (based
on State Fiscal Year quarters) Third Party Recovery (TPR) Reports in
accordance with the format developed by TDH. TPR reports must
include total dollars recovered from third party payers for services
to HMO's Members for each month and the total dollars recovered
through coordination of benefits, subrogation, and worker's
compensation.
12.1.13 Each report required under this Article must be mailed to: Bureau of
Managed Care; Texas Dept. Of Health; ββββ β. ββββ ββββββ; ββββββ, ββ
βββββ-ββββ (Exception: The MCFS Report may be submitted to TDH via
E-mail). HMO must also mail a copy of the reports, except for items
in Article 12.1.7 and Article 12.1.10 to Texas Department of
Insurance, Mail Code 106-3A, HMO Division, Attention: HMO Division
Director, β.β. βββ ββββββ, ββββββ, ββ βββββ-ββββ.
12.2 STATISTICAL REPORTS
12.2.1 HMO must electronically file the following monthly reports: (1)
encounter; (2) encounter detail; (3) institutional; (4)
institutional detail; and (5) claims detail for cost-reimbursed
services filed, if any, with HMO. Encounter data must include the
data elements, follow the format, and use the transmission method
specified by TDH in the Encounter Data Submission Manual. Encounters
must be submitted by HMO to TDH no later than 45 days after the date
of adjudication (finalization) of the claims.
12.2.2 Monthly reports must include current month encounter data and
encounter data adjustments to the previous month's data.
12.2.3 Data quality standards will be developed jointly by HMO and TDH.
Encounter data must meet or exceed data quality standards. Data that
does not meet quality standards must be corrected and returned
within the period specified by TDH. Original records must be made
available to validate all encounter data.
101 Dallas Service Area Contract
108
12.2.4 HMO cannot submit newborn encounters to TDH until the State-issued
Medicaid ID number is received for a newborn. HMO must match the proxy
ID number issued by the HMO with the State-issued Medicaid ID number
prior to submission of encounters to TDH and submit the encounter in
accordance to the HMO Encounter Data Submission Manual. The encounter
must include the State-issued Medicaid ID number. Exceptions to the
45-day deadline will be granted in cases in which the Medicaid ID
number is not available for a newborn Member.
12.2.5 HMO must require providers to submit claims and encounter data to HMO
no later than 95 days after the date services are provided.
12.2.6 HMO must use the procedure codes, diagnosis codes and other codes
contained in the most recent edition of the Texas Medicaid Provider
Procedures Manual and as otherwise provided by TDH. Exceptions or
additional codes must be submitted for approval before HMO uses the
codes.
12.2.7 HMO must use its TDH-specified identification numbers on all encounter
data submissions. Please refer to the TDH Encounter Data Submission
Manual for further specifications.
12.2.8 HMO must validate all encounter data using the encounter data
validation methodology prescribed by TDH prior to submission of
encounter data to TDH.
12.2.9 All Claims Summary Report. HMO must submit the "All Claims Summary
Report" identified in the Texas Managed Care Claims Manual as a
contract year-to-date report. The report must be submitted quarterly by
the last day of the month following the reporting period. The reports
must be submitted to TDH in a format specified by TDH.
12.2.10 Medicaid Disproportionate Share Hospital (DSH) Reports. HMO must file
preliminary and final Medicaid Disproportionate Share Hospital (DSH)
reports, required by TDH to identify and reimburse hospitals that
qualify for Medicaid DSH funds. The preliminary and final DSH reports
must include the data elements and be submitted in the form and format
specified by TDH. The preliminary DSH reports are due on or before June
1 of the year following the state fiscal year for which data is being
reported. The final DSH reports are due no later than July 15 of the
year following the state fiscal year for which data is being reported.
12.3 ARBITRATION/LITIGATION CLAIMS REPORT
HMO must submit an Arbitration/Litigation Claims Report in a format
provided by TDH (see Appendix M) identifying all provider or HMO
requests for arbitration or matters in litigation. The report must be
submitted within 30 days from the date the
102 Dallas Service Area Contract
109
matter is referred to arbitration or suit is filed, or whenever there
is a change of status in a matter referred to arbitration or
litigation.
12.4 SUMMARY REPORT OF PROVIDER COMPLAINTS
HMO must submit a Summary Report of Provider Complaints. HMO must also
report complaints submitted through its subcontracted risk groups
(e.g., IPAs). The complaint report must be submitted in two paper
copies and one electronic copy no later than 45 days after the end of
the state fiscal quarter using a form specified by TDH.
12.5 PROVIDER NETWORK REPORTS
12.5.1 Provide Network Reports. HMO must submit to the Enrollment Broker an
electronic file summarizing changes in HMO's provider network including
PCPs, specialists, ancillary providers and hospitals. The file must
indicate if the PCPs and specialists participate in a closed network
and the name of the delegated network. The electronic file must be
submitted in the format specified by TDH and can be submitted as often
as daily, but must be submitted at least weekly.
12.5.1.1 Provider Termination Report. HMO must submit a monthly report which
identifies any providers who cease to participate in HMO's provider
network, either voluntarily or involuntarily. The report must be
submitted to TDH in the format specified by TDH. HMO will submit the
report no later than thirty (30) days after the end of the reporting
month. The information must include the provider's name, Medicaid
number, the reason for the provider's termination, and whether the
termination was voluntary or involuntary.
12.6 MEMBER COMPLAINTS
HM0 must submit a quarterly summary report of Member complaints. HMO
must also report complaints submitted through its delegated networks
(e.g., IPAs). The complaint report format must be submitted to TDH as
two (2) paper copies and one (1) electronic copy on or before 45 days
following the end of the state fiscal quarter using a form specified by
TDH.
12.7 FRAUDULENT PRACTICES
HMO must report all fraud and abuse enforcement actions or
investigations taken against HMO and/or any of its Subcontractors or
providers by any state or federal agency for fraud or abuse under Title
XVIII or Title XIX of the Social Security Act or any State law or
regulation and any basis upon which an action for fraud or abuse
103 Dallas Service Area Contract
110
may be brought by a State or federal agency as soon as such information
comes to the attention of HMO.
12.8 UTILIZATION MANAGEMENT REPORTS - BEHAVIORAL HEALTH
Behavioral health (BH) utilization management reports are required on
a semi-annual basis. Refer to Appendix H for the standardized reporting
format for each report detailed instructions for obtaining the specific
data required in the report.
12.8.1 In addition, data files are due to the TDH External Quality Review
Organization five working days following the end of each State Quarter.
See Appendix H for submission instructions. The BH utilization report
and data file submission instructions may periodically be updated by
TDH to facilitate clear communication to the health plans.
12.9 UTILIZATION MANAGEMENT REPORTS - PHYSICAL HEALTH
Physical health (PH) utilization management reports are required on a
semi-annual basis. Refer to Appendix J for the standardized reporting
format for each report and detailed instructions for obtaining specific
data required in the report.
12.9.1 In addition, data files are due to the TDH External Quality Review
Organization five working days following the end of each State Quarter.
See Appendix J for submission instructions. The PH utilization report
and data file submission instruction may periodically be updated by TDH
to facilitate clear communication to the health plan.
12.10 QUALITY IMPROVEMENT REPORTS
12.10.1 HMO must conduct health Focused Studies in well child and pregnancy,
and a study chosen by HMO that may be performed in the areas of
behavioral health care, asthma, or other chronic conditions. Well child
and pregnancy studies shall be conducted and data collected using
criteria and methods developed by TDH. The following format shall be
utilized:
(1) Executive Summary.
(2) Definition of the population and health areas of concern.
(3) Clinical guidelines/standards, quality indicators, and audit
tools.
(4) Sources of information and data collection methodology.
104 Dallas Service Area Contract
111
(5) Data analysis and information/results.
(6) Corrective actions if any, implementation, and follow up plans
including monitoring, assessment of effectiveness, and methods
for provider feedback.
12.10.2 Annual Focus Studies. Focused Studies on well child, pregnancy, and a
study chosen by the plan must be submitted to TDH according to due
dates established by TDH.
12.10.3 Annual QIP Summary Report. An annual QIP summary report must be
conducted yearly based on the state fiscal year. The annual QIP
summary report must be submitted by March 31 of each year. This
report must provide summary information on HMO's QIP system and
include the following:
(1) Executive summary of QIP - include results of all QI reports
and interventions.
(2) Activities pertaining to each standard (I through XVI) in
Appendix A. Report must list each standard.
(3) Methodologies for collecting, assessing data and measuring
outcomes.
(4) Tracking and monitoring quality of care.
(5) Role of health professionals in QIP review.
(6) Methodology for collection data and providing feedback to
provider and staff.
(7) Outcomes and/or action plan.
12.10.4 Provider Medical Record Audit and Report. HMO is required to conform to
commonly accepted medical record standards such as those used by NCQA,
JCAHO, or those used for credentialing review such as the Texas
Environment of Care Assessment Program (TECAP), and have documentation
on file at HMO for review by TDH or its designee during an on-site
review.
12.11 HUB REPORTS
HMO must submit quarterly reports documenting HMO's HUB program
efforts and accomplishments. The report must include a narrative
description of HMO's program efforts and a financial report
reflecting payments made to HUB. HMO must use the format included in
Appendix B for HUB Quarterly reports. For HUB Certified Entities: HMO
must include the General Services Commission (GSC)
105 Dallas Service Area Contract
112
Vendor Number and the ethnicity/gender under which a contracting entity
is registered with GSC. For HUB Qualified (but not certified) Entities:
HMO must include the ethnicity/gender of the major owner(s) (51%) of
the entity. Any entities for which HMO cannot provide this information
cannot be included in the HUB report. For both types of entities, an
entity will not be included in the HUB Report if HMO does not list
ethnicity/gender information.
12.12. THSTEPS REPORTS
Minimum reporting requirements. HMO must submit, at a minimum, 80% of
all THSteps checkups on HCFA 1500 claim forms as part of the encounter
file submission to the TDH Claims Administrator within thirty (30) days
after the date of final adjudication (finalization) of the claims.
Failure to comply with these minimum reporting requirements will result
in Article XVIII sanctions and money damages.
ARTICLE XIII PAYMENT PROVISIONS
13.1 CAPITATION AMOUNTS
13.1.1 TDH will pay HMO monthly premiums calculated by multiplying the number
of Member months by Member risk group times the monthly capitation
amount by Member risk group. For additional information regarding the
actuarial basis and methodology used to compute the capitation rates,
please reference the waiver under the document titled "Actuarial
Methodology for Determination of Maximum Monthly Capitation Amounts".
HMO and network providers are prohibited from billing or collecting any
amount from a Member for health care services covered by this contract,
in which case the Member must be informed of such costs prior to
providing non-covered services.
13.1.2 Delivery Supplemental Payment (DSP). The monthly capitation amounts and
the DSP amount are listed below.
106 Dallas Service Area Contract
113
MONTHLY CAPITATION AMOUNTS
RISK GROUP SEPTEMBER 1, 2000 -
AUGUST 31, 2001
TANF Adults $131.03
TANF Children > 12 Months $ 58.03
of Age
Expansion Children > 12 $136.84
Months of Age
Newborns LESS THAN OR EQUAL TO 12 Months of $276.92
Age
TANF Children LESS THAN OR EQUAL TO 12 Months $276.92
of Age
Expansion Children LESS THAN OR EQUAL TO 12 $276.92
Months of Age
Federal Mandate Children $ 55.44
CHIP Phase 1 $ 94.31
Pregnant Women $232.66
Disabled/Blind $ 14.00
Administration
Delivery Supplemental Payment: A one-time per pregnancy supplemental
payment for each delivery shall be paid to HMO as provided below in the
following amount: $3,076.23.
13.1.2.1 HMO will receive a DSP for each live or still birth. The one-time
payment is made regardless of whether there is a single or multiple
births at time of delivery. A delivery is the birth of a liveborn
infant, regardless of the duration of the pregnancy or, a stillborn
(fetal death) infant of 20 weeks or more gestation. A delivery does not
include a spontaneous or induced abortion, regardless of the duration
of the pregnancy.
13.1.2.2 For an HMO Member who is classified in the Pregnant Women, TANF Adults,
or 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 section 13.1.2 for each month of
classification, plus the DSP amount.
107 Dallas Service Area Contract
114
13.1.2.3 HMO must submit a monthly DSP Report (report) that includes the data
elements specified by TDH. TDH will consult with contracted HMOs prior
to revising the report data elements and requirements. The reports must
be submitted to TDH in the format and time specified by TDH. The report
must include only unduplicated deliveries. The report must include only
deliveries for which HMO has made a payment for the delivery, to either
a hospital or other provider. No DSP will be made for deliveries which
are not reported by HMO to TDH within 210 days after the date of
delivery, or within 30 days from the date of discharge from the
hospital for the stay related to the delivery, whichever is later.
13.1.2.4 HMO must maintain complete claims and adjudication disposition
documentation, including paid and denied amounts for each delivery. HMO
must submit the documentation to TDH within five (5) days from the date
of a TDH request for documents.
13.1.2.5 The DSP will be made by TDH to HMO within twenty (20) state working
days after receiving an accurate report from HMO.
13.1.2.6 All infants of age equal to or less than twelve months (Newborns) in
the TANF Children, Expansion Children, and Newborns risk groups will be
capitated at the Newborns classification capitation amount in paragraph
13.1.2.
13.1.3 The monthly premium payment to HMO is based on monthly enrollments
adjusted to reflect money damages set out in Article 18.8 and
adjustments to premiums in Article 13.5.
13.1.4 The monthly premium payments will be made to HMO no later than the 10th
working day of the month for which premiums are paid. HMO must accept
payment for premiums by direct deposit into an HMO account.
13.1.5 Payment of monthly capitation amounts is subject to availability of
appropriations. If appropriations are not available to pay the full
monthly capitation amounts, TDH will equitably adjust capitation
amounts for all participating HMOs, and reduce scope of service
requirements as appropriate.
13.2 EXPERIENCE REBATE TO STATE
13.2.1 For the contract Period. HMO must pay to TDH an experience rebate
calculated in accordance with the tiered rebate method listed below
based on the excess of allowable HMO STAR revenues over allowable HMO
STAR expenses as measured by any positive amount on Line 7 of "Part 1:
Financial Summary, All Coverage Groups Combined" of the Final Managed
Care Financial Statistical Report set forth
108 Dallas Service Area Contract
115
in Appendix I, as reviewed and confirmed by TDH. TDH reserves the right
to have an independent audit performed to verify the information
provided by HMO.
Graduated Rebate
----------------
Experience Rebate as 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 Carry Forward of Prior Contract Period Losses: Losses incurred for one
contract period can only be carried forward to the next contract
period.
13.2.2.1 Carry Forward of Loss from one Service Delivery Area to Another: If HMO
operates in multiple Service Delivery Areas (SDAs), Losses in one SDA
cannot be used to offset net income before taxes in another SDA.
13.2.3 Experience rebate will be based on a pre-tax basis.
13.2.4 Population-Based Initiatives (PBIs) and Experience Rebates: HMO may
subtract from an experience rebate owed to the State, expenses for
population-based health initiatives that have been approved by TDH. A
population-based initiative (PBI) is a project or program designed to
improved some aspect of quality of care, quality of life, or health
care knowledge for the community as a whole: Value-added service does
not constitute a PBI. Contractually required services and activities do
not constitute a PBI.
13.2.5 There will be two settlements for payment of the experience rebate. The
first settlement shall equal 100 percent of the experience rebate as
derived from Line 7 of Part 1 (Net Income Before Taxes) of the first
Final Managed Care Financial Statistical (MCFS) Report shall be paid on
the same day the first Final MCFS Report is submitted to TDH. The
second settlement shall be an adjustment to the first settlement and
shall be paid to TDH on the same day that the second Final MCFS Report
is submitted to TDH if the adjustment is a payment from HMO to TDH. TDH
or its agent may audit or review the MCFS reports. If TDH determines
that corrections to the MCFS reports are required, based on a TDH
audit/review or other
109 Dallas Service Area Contract
116
documentation acceptable to TDH, to determine an adjustment to the
amount of the second settlement, then final adjustment shall be made
within two years from the date that HMO submits the second Final MCFS
report. HMO must pay the first and second settlements on the due dates
for the first and second Final MCFS reports respectively as identified
in Article 12.1.4. TDH may adjust the experience rebate if TDH
determines HMO has paid affiliates amounts for goods or services that
are higher than the fair market value of the goods and services in the
service area. Fair market value may be based on the amount HMO pays a
non-affiliate(s) or the amount another HMO pays for the same or similar
service in the service area. TDH will have final authority in auditing
and determining the amount of the experience rebate.
13.3 PERFORMANCE OBJECTIVES
13.3.1 Preventive Health Performance Objectives are contained in this contract
at Appendix K. HMO must accomplish the performance objectives or a
designated percentage in order to be eligible for payment of financial
incentives. Performance objectives are subject to change. TDH will
consult with HMO prior to revising performance objectives.
13.3.2 HMO will receive credit for accomplishing a performance objective upon
receipt of accurate encounter data required under article 10.5 and 12.2
of this contract and/or a Detailed Data Element Report from HMO with
report format as determined by TDH and aggregate data reported by HMO
in accordance with a report format as determined by TDH (Performance
Objectives Report). Accuracy and completeness of the detailed data
element report and the aggregate data Performance Objectives Report
will be determined by TDH through a TDH audit of HMO claims processing
system. If TDH determines that the Detailed Data Element Report and
Performance Objectives Report are sufficiently supported by the results
of the TDH audit, the payment of financial incentives will be made to
HMO. Conversely, if the audit results do not support the reports as
determined by TDH, HMO will not receive payment of the financial
incentive. TDH may conduct provider chart reviews to validate the
accuracy of the claims data related to HMO accomplishment of
performance objectives. If the results of the chart review do not
support HMO claims system data or HMO Detailed Data Element Report and
the Performance Objectives Report, TDH may recoup payments made to HMO
for performance objectives incentives.
13.3.3 HMO will also receive credit for performance objectives performed by
other organizations if a network primary care provider or HMO retains
documentation from the performing organization which satisfies the
requirements contained in Appendix K of this contract.
110 Dallas Service Area Contract
117
13.3.4 HMO will receive performance objective bonuses for accomplishing the
following percentages of performance objectives:
Percent of Each Performance Percent of Performance Objective
Objective Accomplished Allocations Paid to HMO
---------------------- -----------------------
60% to 65% 20%
65% to 70% 30%
70% to 75% 40%
75% to 80% 50%
80% to 85% 60%
85% to 90% 70%
90% to 95% 80%
95% to 100% 90%
100% 100%
13.3.5 HMO must submit the Detailed Data Element Report and the Performance
Objectives Reports regardless of whether or not HMO intends to claim
payment of performance objective bonuses.
13.4 PAYMENT OF PERFORMANCE OBJECTIVE BONUSES
13.4.1 Payment of performance objective bonus is contingent upon availability
of appropriations. If appropriations are not available to pay
performance objective bonuses as set out below, TDH will equitably
distribute all available funds to each HMO that has accomplished the
performance objectives.
13.4.2 In addition to the capitation amounts set forth in Article 13.1.2, a
performance premium of two dollars ($2.00) per Member month will be
allocated by TDH for the accomplishment of performance objectives.
13.4.3 HMO must submit the Performance Objectives Report and the Detailed Data
Element Report as referenced in Article 13.3.2, within 150 days from
the end of each State fiscal year. Performance premiums will be paid to
HMO within 120 days after the State receives and validates the data
contained in each required Performance Objectives Report.
111 Dallas Service Area Contract
118
13.4.4 The performance objective allocation for HMO will be assigned to each
performance objective, described in Appendix K. The percentages will
be determined following negotiation and agreement with all contracted
Medicaid managed care HMOs. At the time these percentages are
determined, this contract will be modified by written amendment.
13.5 ADJUSTMENTS TO PREMIUM
13.5.1 TDH may recoup premiums paid to HMO in error. Error may be either
human or machine error on the part of TDH or an agent or contractor
of TDH. TDH may recoup premiums paid to HMO if a Member is enrolled
into HMO in error, and HMO provided no covered services to Member for
the period of time for which premium was paid. If services were
provided to Member as a result of the error, recoupment will not be
made.
112 Dallas Service Area Contract
119
13.5.2 TDH may recoup premium paid to HMO if a Member for whom premium is
paid moves outside the United States, and HMO has not provided
covered services to the Member for the period of time for which
premium has been paid. TDH will not recoup premium if HMO has
provided covered services to the Member during the period of time for
which premium has been paid.
13.5.3 TDH may recoup premium paid to HMO if a Member for whom premium is paid
dies before the first day of the month for which premium is paid.
13.5.4 TDH may recoup or adjust premium paid to HMO for a Member if the
Member's eligibility status or program type is changed, corrected as a
result of error, or is retroactively adjusted.
13.5.5 Recoupment or adjustment of premium under 13.5.1 through 13.5.4 may be
appealed using the TDH dispute resolution process.
13.5.6 TDH may adjust premiums for all Members within an eligibility status or
program type if adjustment is required by reductions in appropriations
and/or if a benefit or category of benefits is excluded or included as
a covered service. Adjustment must be made by amendment as required by
Article 15.2. Adjustment to premium under this subsection may not be
appealed using the TDH dispute resolution process.
13.6 NEWB0RN AND PREGNANT WOMEN PAYMENT PROVISIONS
13.6.1 Newborns born to Medicaid eligible mothers who are enrolled in HMO are
enrolled into HMO for 90 days following the date of birth.
13.6.1.1 The mother of the newborn Member may change her newborn to another HMO
during the first 90 days following the date of birth, but may only do
so through TDH Customer Services.
13.6.2 MAXIMUS will provide HMO with a daily enrollment file which will list
all newborns who have received State-issued Medicaid ID numbers. This
file will include the Medicaid eligible mother's Medicaid ID number to
allow the HMO to link the newborn's State-issued Medicaid ID numbers
with the proxy ID number. TDH will guarantee capitation payments to HMO
for all newborns who appear on the MAXIMUS daily enrollment file as HMO
Members for each month the newborn is enrolled in the HMO.
13.6.3 All non-TP45 newborns whose mothers are HMO Members at the time of the
birth of the newborn will be retroactively enrolled into the HMO
through a manual process by DHS Data Control.
113 Dallas Service Area Contract
120
13.6.4 Newborns who do not appear on the MAXIMUS daily enrollment file before
the end of the sixth month following the date of birth will not be
retroactively enrolled into the HMO. TDH will manually reconcile
payment to the HMO for services provided from the date of birth for
TP45 and all other eligibility categories of newborns. Payment will
cover services rendered from the effective date of the proxy ID number
when first issued by the HMO regardless of plan assignment at the time
the State-issued Medicaid ID number is received.
13.6.5 MAXIMUS will provide HMO with a daily enrollment file which will list
all TP40 Members who have received State-issued Medicaid ID numbers.
TDH will guarantee capitation payments to HMO for all TP40 Members who
appear on the MAXIMUS daily enrollment file as HMO Members for each
month the TP40 Member enrollment is effective.
ARTICLE XIV ELIGIBILITY, ENROLLMENT, AND DISENROLLMENT
14.1 ELIGIBILITY DETERMINATION
14.1.1 TDH will identify Medicaid recipients who are eligible for
participation in the STAR program using the eligibility status
described below.
14.1.2 Individuals in the following categories who reside in any part of the
Service Area must enroll in one of the health plans providing services
in the Service Areas:
14.1.2.1 TANF ADULTS - Individuals age 21 and over who are eligible for the TANF
program. This category may also include some pregnant women.
14.1.2.2 TANF CHILDREN - Individuals under age 21 who are eligible for the TANF
program. This category may also include some pregnant women and some
children less than one year of age.
14.1.2.3 PREGNANT WOMEN receiving Medical Assistance Only (MAO) - Pregnant women
whose families' income is below 185% of the Federal Poverty Level
(FPL).
14.1.2.4 NEWBORN (MAO) - Children under age one born to Medicaid-eligible
mothers.
14.1.2.5 EXPANSION CHILDREN (MAO) - Children under age 18, ineligible for TANF
because of the applied income of their stepparents or grandparents.
14.1.2.6 EXPANSION CHILDREN (MAO) - Children under age 1 whose families' income
is below 185% FPL.
114 Dallas Service Area Contract
121
14.1.2.7 EXPANSION CHILDREN MAO - Children age 1-5 whose families' income is
at or below 133% of FPL.
14.1.2.8 FEDERAL MANDATE CHILDREN (MAO) - Children under age 19 born before
October 10, 1983, whose families' income is below the TANF income
limit.
14.1.2.9 CHIP PHASE I - Children's Health Insurance Program Phase I (Federal
Mandate Acceleration) Children are children under age nineteen (19)
born before October 1, 1983, with family income below 100% Federal
Poverty Income Level.
14.1.3 The following individuals are eligible for the STAR Program and are
not required to enroll in a health plan, but have the option to
enroll in a plan. HMO will be required to accept enrollment of those
recipients from this group who elect to enroll in HMO.
14.1.3.1 DISABLED AND BLIND INDIVIDUALS WITHOUT MEDICS - Recipients with
Supplemental Security Income (SSI) benefits who are not eligible for
Medicare may elect to participate in the STAR program on a voluntary
basis.
14.1.3.2 Certain blind or disabled individuals who lose SSI eligibility
because of Title II income and who are not eligible for Medicare.
14.1.4 During the period after which the Medicaid eligibility determination
has been made but prior to enrollment in HMO, Members will be
enrolled under the traditional Medicaid program. All Medicaid
eligible recipients will remain in the fee-for-service Medicaid
program until enrolled in or assigned to an HMO.
14.2 ENROLLMENT
14.2.1 TDH has the right and responsibility to enroll and disenroll eligible
individuals into the STAR program. TDH will conduct continuous open
enrollment for Medicaid recipients and HMO must accept all persons
who chose to enroll as Members in HMO or who are assigned as Members
in HMO by TDH, without regard to the Member's health status or any
other factor.
14.2.2 All enrollments are subject to the accessibility and availability
limitations and restrictions contained in the Section 1915(b) waiver
obtained by TDH. TDH has the authority to limit enrollment into HMO
if the number and distance limitations are exceeded.
14.2.3 TDH makes no guarantees or representations to HMO regarding the
number of eligible Medicaid recipients who will ultimately be
enrolled as STAR Members of HMO.
115 Dallas Service Area Contract
122
14.2.4 HMO must cooperate and participate in all TDH sponsored and announced
enrollment activities. HMO must have a representative at all TDH
enrollment activities unless an exception is given by TDH. The
representative must comply with HMO's cultural and linguistic
competency plan (see Cultural and Linguistic requirements in
Paragraph 8.9 of this contract). HMO must provide marketing
materials, HMO pamphlets, Member handbooks, a list of network
providers, HMO's linguistic and cultural capabilities and other
information requested or required by TDH or its Enrollment Broker to
assist potential Members in making informed choices.
14.2.5 TDH will provide HMO with at least 10 days written notice of all TDH
planned activities. Failure to participate in, or send a
representative to a TDH sponsored enrollment activity is a default of
the terms of the contract. Default may be excused if HMO can show
that TDH failed to provide the required notice, or if HMO's absence
is excused by TDH.
14.3 NEWBORN ENROLLMENT
The HMO is responsible for newborns who are born to mothers who are
enrolled in HMO on the date of birth as follows:
14.3.1 Newborns are presumed Medicaid eligible and enrolled in the mother's
HMO for at least 90 days from the date of birth.
14.3.1.1 A mother of a newborn Member may change plans for her newborn during
the first 90 days by contacting TDH Customer Services. TDH will
notify HMO of newborn plan changes made by a mother when the change
is made by TDH Customer Services.
14.3.2 HMO must establish and implement written policies and procedures to
require providers to notify HMOs of a birth of a newborn to a Member
at the time of delivery.
14.3.2.1 HMO must create a proxy ID number in the HMO'S Enrollment/Eligibility
and claims processing systems. HMO proxy ID number effective date is
equal to the date of birth of the newborn.
14.3.2.2 IB40 must match the proxy ID number and the State-issued Medicaid ID
number once the State-issued Medicaid ID number is received.
14.3.2.3 HMO must submit a Form 7484A to DHS Data Control requesting DHS Data
Control to research DHSs files for a Medicaid ID number if HMO has
not received a State-issued Medicaid ID number for a newborn within
30 days from the date of
116 Dallas Service Area Contract
123
birth. If DHS finds that no Medicaid ID number has been issued to the
newborn, DHS Data Control will issue the Medicaid ID number using the
information provided on the Form 7484A.
14.3.3 Newborns certified Medicaid eligible after the end of the sixth month
following the date of birth will not be retroactively enrolled to an
HMO, but will be enrolled in Medicaid fee-for-service. TDH will
manually reconcile payment to the HMO for services provided from the
date of birth for all Medicaid eligible newborns as described in
Article 13.6.4.
14.4 DISENROLLMENT
14.4.1 HMO has a limited right to request a Member be disenrolled from HMO
without the Member's consent. TDH must approve any HMO request for
disenrollment of a Member for cause. Disenrollment of a Member may be
permitted under the following circumstances:
14.4.1.1 The Member misuses or loans the Member's HMO membership card to
another person to obtain services.
14.4.1.2 The Member is disruptive, unruly, threatening or uncooperative to the
extent that the Member's membership seriously impairs HMO's or
provider's ability to provide services to the Member or to obtain
Members, and the Member's behavior is not caused by a physical or
behavioral health condition.
14.4.1.3 Member steadfastly refuses to comply with managed care restrictions
(e.g., repeatedly using emergency room in combination with refusing
to allow HMO to treat the underlying medical condition).
14.4.2 HMO must take reasonable measures to correct Member behavior prior to
requesting disenrollment. Reasonable measures may include providing
education and counseling regarding the offensive acts or behaviors.
14.4.3 HMO must notify the Member of HMO's decision to disenroll the Member
if all reasonable measures have failed to remedy the problem.
14.4.4 If the Member disagrees with the decision to disenroll the Member
from HMO, HMO must notify the Member of the availability of the
complaint procedure and TDH's fair hearing process.
14.4.5 HMO CANNOT REQUEST A DISENROLLMENT BASED ON ADVERSE CHANGE IN THE
MEMBER'S HEALTH STATUS OR UTILIZATION OF
117 Dallas Service Area Contract
124
SERVICES WHICH ARE MEDICALLY NECESSARY FOR TREATMENT OF A MEMBER'S
CONDITION.
14.5 AUTOMATIC RE-ENROLLMENT
14.5.1 Members who are disenrolled because they are temporarily ineligible
for Medicaid will be automatically re-enrolled into the same health
plan. Temporary loss of eligibility is defined as a period of 6
months or less.
14.5.2 HMO must inform its Members of the automatic re-enrollment procedure.
Automatic re-enrollment must be included in the Member Handbook (See
Article 8.2.1).
14.6 ENROLLMENT REPORTS
14.6.1 TDH will provide HMO enrollment reports listing all STAR Members
who have enrolled in or were assigned to HMO during the initial
enrollment period.
14.6.2 TDH will provide monthly HMO Enrollment Reports to HMO on or before
the first of the month.
14.6.3 TDH will provide Member verification to HMO and network providers
through telephone verification or TexMedNet.
ARTICLE XV GENERAL PROVISIONS
15.1 INDEPENDENT CONTRACTOR
HMO, its agents, employees, network providers and subcontractors are
independent contractors, and do not perform services under this
contract as employees or agents of TDH. HMO is given express, limited
authority to exercise the State's right of recovery as provided in
4.9.
15.2 AMENDMENT
15.2.1 This contract must be amended by TDH if amendment is required to
comply with changes in state or federal laws, rules, or regulations.
15.2.2 TDH and HMO may amend this contract if reductions in funding or
appropriations make full performance of either party impracticable or
impossible, and amendment
118 Dallas Service Area Contract
125
could provide a reasonable alternative to termination. If HMO does
not agree to the amendment, contract may be terminated under Article
XVIII.
15.2.3 This contract must be amended if either party discovers a material
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 paragraph 15.8 of this
contract.
15.2.4 This contract may be amended by mutual agreement at any time.
15.2.5 All amendments to this contract must be in writing and signed by both
parties.
15.2.6 No agreement shall be used to amend this contract unless it is made a
part of this contract by specific reference, and is numbered
sequentially by order of its adoption.
15.3 LAW, JURISDICTION AND VENUE
Venue and jurisdiction shall be in the state and federal district
courts of ββββββ County, Texas. The laws of the State of Texas shall
be applied in all matters of state law.
15.4 NON-WAIVER
Failure to enforce any provision or breach shall not be taken by
either party as a waiver of the right to enforce the provision or
breach in the future.
15.5 SEVERABILITY
Any part of this contract which is found to be unenforceable,
invalid, void, or illegal shall be severed from the contract. The
remainder of the contract shall be effective.
15.6 ASSIGNMENT
This contract was awarded to HMO based on HMO's qualifications to
perform personal and professional services. HMO cannot assign this
contract without the written consent of TDI and TDH. This provision
does not prevent HMO from subcontracting duties and responsibilities
to qualified subcontractors. If TDI and TDH consent to an assignment
of this contract, a transition period of 90 days will run from the
date the assignment is approved by TDI and TDH so that Members'
services are not interrupted and, if necessary, the notice provided
for in Article 15.7 can be
119 Dallas Service Area Contract
126
sent to Members. The assigning HMO must also submit a transition
plan, as set out in Article 18.2.1, subject to TDH approval.
15.7 MAJOR CHANGE IN CONTRACTING
TDH may send notice to Members when a major change affecting HMO
occurs. A "major change" includes, but is not limited to, a
substantial change of subcontractors and assignment of this contract.
The notice letter to Members may permit the Member to re-select their
plan and PCP. TDH will bear the cost of preparing and sending the
notice letter in the event of an approved assignment of the contract.
For any other major change in contracting, HMO will prepare the
notice letter and submit it to TDH for review and approval. After TDH
has approved the letter for distribution to Members, HMO will bear
the cost of sending the notice letter.
15.8 NON-EXCLUSIVE
This contract is a non-exclusive agreement. Either party may contract
with other entities for similar services in the same service area.
15.9 DISPUTE RESOLUTION
The dispute resolution process adopted by TDH in accordance with
Chapter 2260, Texas Government Code, will be used to attempt to
resolve all disputes arising under this contract. All disputes
arising under this contract shall be resolved through TDH's dispute
resolution procedures, except where a remedy is provided for through
TDH's administrative rules or processes. All administrative remedies
must be exhausted prior to other methods of dispute resolution.
15.10 DOCUMENTS CONSTITUTING CONTRACT
This contract includes this document and all amendments and
appendices to this document, the Request for Application, the
Application submitted in response to the Request for Application, the
Texas Medicaid Provider Procedures Manual and Texas Medicaid
Bulletins addressed to HMOs, contract interpretation memoranda issued
by TDH for this contract, and the federal waiver granting TDH
authority to contract with HMO. If any conflict in provisions between
these documents occurs, the terms of this contract and any amendments
shall prevail. The documents listed above constitute the entire
contract between the parties.
15.11 FORCE MAJEURE
TDH and HMO are excused from performing the duties and obligations
under this contract for any period that they are prevented from
performing their services as a
120 Dallas Service Area Contract
127
result of a catastrophic occurrence, or natural disaster, clearly
beyond the control of either party, including but not limited to an
act of war, but excluding labor disputes.
15.12 NOTICES
Notice may be given by any means which provides for verification of
receipt. All notices to TDH shall be addressed to Bureau Chief, Texas
Department of Health, Bureau of Managed Care, ββββ β. ββββ ββββββ,
ββββββ, ββ βββββ-ββββ, with a copy to the Contract Administrator.
Notices to HMO shall be add to CEO/President,
βββββ β. βββββββ ββ.
2730 β. ββββββββ Freeway,
Suite βββ ββββ βββββ
ββββββ, βββββ βββββ
15.13 SURVIVAL
The provisions of this contract which relate to the obligations of
HMO to maintain records and reports shall survive the expiration or
earlier termination of this contract for a period not to exceed six
(6) years unless another period may be required by record retention
policies of the State of Texas or HCFA.
ARTICLE XVI DEFAULT
16.1 DEFAULT BY TDH
16.1.1 FAILURE TO MAKE CAPITATION PAYMENTS
Failure by TDH to make capitation payments when due is a default
under this contract.
16.1.2 FAILURE TO PERFORM DUTIES AND RESPONSIBILITIES
Failure by TDH to perform a material duty or responsibility as set
out in this contract is a default under this contract.
16.2 REMEDIES AVAILABLE TO HMO FOR TDH'S DEFAULT
HMO may terminate this contract as set out in Article 18.1.5 of this
contract if TDH commits either of the events of default set out in
Article 16.1
16.3 DEFAULT BY HMO
121 Dallas Service Area Contract
128
16.3.1 FAILURE TO PERFORM AN ADMINISTRATIVE FUNCTION
Failure of HMO to perform an administrative function is a default
under this contract. Administrative functions are any requirements
under this contract that are not direct delivery of health or
health-related services, including claims payment, encounter date
submission, filing any report when due, cooperating in good faith
with TDH, an entity acting on behalf of TDH, or an agency authorized
by statute or law to require the cooperation of HMO in carrying out
an administrative, investigative, or prosecutorial function of the
Medicaid program, providing or producing records upon request or
entering into contracts or implementing procedures necessary to
carry out contract obligations.
16.3.1.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy
in whole or in part does not limit TDH in exercising all or part of
any remaining remedies.
For HMO's failure to perform an administrative function under this
contract, TDH may:
- Terminate the contract if the applicable condition set
out in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Assess liquidated money damages as set out in Article
18.4; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.2 ADVERSE ACTION AGAINST HMO BY TDI
Termination or suspension of HMO's TDI Certificate of Authority or
any adverse action taken by TDI that TDH determines will affect the
ability of HMO to provide health care services to Members is a
default under this contract.
16.3.2.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy
in whole or in part does not limit TDH in exercising all or part of
any remaining remedies.
For an adverse action against HMO by TDI, TDH may:
122 Dallas Service Area Contract
129
- Terminate the contract if the applicable condition set
out in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.3 INSOLVENCY
Failure of HMO to comply with state and federal solvency standards
or incapacity of HMO to meet its financial obligation as they come
due is a default under this contract.
16.3.3.1 REMEDIES AVAILABLE TO THD FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy
in whole or in part does not limit TDH in exercising all or part of
any remaining remedies.
For HMO's insolvency, TDH may:
- Terminate the contract if the applicable condition set
out in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.4 FAILURE TO COMPLY WITH FEDERAL LAWS AND REGULATIONS
Failure of HMO to comply with the federal requirements for Medicaid,
including but not limited to, federal law regarding
misrepresentation, or fraud, or abuse; and, by incorporation,
Medicare standards, requirements, or prohibitions, is a default of
this contract.
The following events are defaults under this contract pursuant to 42
USC Sections 1396b(m)(5), 1396u-2(e)(1)(A):
16.3.4.1 HMO's substantial failure to provide medically nary items and
services that are required under this contract be provided to
Members;
16.3.4.2 HMO's imposition of premiums or charges on Members in excess of the
premiums or charges permitted by federal law;
16.3.4.3 HMO's acting to discriminate among Members on the basis of their
health status or requirements for health care services, including
expulsion or refusal to enroll an
123 Dallas Service Area Contract
130
individual, except as permitted by federal law, or engaging in any
practice that would reasonably be expected to have the effect of
denying or discouraging enrollment with HMO by eligible individuals
whose medical condition or history indicates a need for substantial
future medical services;
16.3.4.4 HMO's misrepresentation or falsification of information that is
furnished to HCFA, TDH, a Member, a potential Member, or a health
care provider;
16.3.4.5 HMO's failure to comply with the physician incentive requirements
under 42 USC Section 1396b(m)(2)(A)(x); or
16.3.4.6 HMO's distribution, either directly or through any agent or
independent contractor, or marketing materials that contain false or
misleading information, excluding materials prior approved by TDH.
16.3.5 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. If HMO repeatedly fails
to meet the requirements of Article 16.3.4.1 through and including
16.3.4.6, TDH must, regardless of what other sanctions are provided,
appoint temporary management and permit Members to disenroll without
cause. Exercise of any remedy in whole or in part does not limit TDH
in exercising all or part of any remaining remedies.
For HMO's failure to comply with federal laws and regulations, TDH
may:
- Terminate the contract if the applicable conditions set
out in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Appoint temporary management as set out in Article 18.5;
- Initiate disenrollment of a Member or Members without
cause as set out in Article 18.6;
- Suspend or default all enrollment of individuals;
- Suspend payment to HMO;
- Recommend to HCFA that sanctions be taken against HMO as
set out in Article 18.7;
- Assets civil monetary penalties as set out in Article
18.8; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.6 FAILURE TO COMPLY WITH APPLICABLE STATE LAW
124 Dallas Service Area Contract
131
HMO's failure to comply with Texas law applicable to Medicaid,
including, but not limited to Article 32.039 of the Texas Human
Resources Code and state law regarding misrepresentation, fraud, or
abuse; is a default under this contract.
16.3.6.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy
in whole or in part does not limit TDH in exercising all or part of
any remaining remedies.
For HMO's failure to comply with applicable state law, TDH may:
- Terminate the contract if the applicable conditions set
out in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Assess administrative penalties as set out in Article
32.039, Texas Government Code, with the opportunity for
notice and appeal as required by Article 32.039; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.7 MISREPRESENTATION FRAUD OR ABUSE
HMO's misrepresentation or fraud under Article 4.8 of this contract
is a default under this contract.
16.3.7.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by laws or in equity, are joint and several, and
may be exercised concurrently or consecutively. Exercise of any
remedy in whole or in part does not limit TDH in exercising all or
part of any remaining remedies.
For HMO's misrepresentation or fraud under Article 4.8, TDH may:
- Terminate the contract if the applicable conditions set
out in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
and/or
- Require forfeiture of all or βββ of the TDI performance
bond as set out in Article 18.9.
16.3.8 EXCLUSION FROM PARTICIPATION IN MEDICARE OR MEDICAID
125 Dallas Service Area Contract
132
16.3.8.1 Exclusion of HMO or any of the managing employees or persons with an
ownership interest whose disclosure is required by Section 1124(a)
of the Social Security Act (the Act) from the Medicaid or Medicare
program, under the provisions of Section 1128(a) and/or (b) of the
Act, is a default of this contract.
16.3.8.2 Exclusion of any provider or Subcontractor or any of the managing
employees or persons with an ownership interest of the provider or
Subcontractor whose disclosure is required by Section 1124(a) of the
Social Security Act (the Act) from the Medicaid or Medicare program,
under the provisions of Section 1128(a) and/or (b) of the Act, is a
default of this contract if the exclusion will materially affect
HMO's performance under this contract.
16.3.8.3 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy
in whole or in part does not limit TDH in exercising all or part of
any remaining remedies.
For HMO's exclusion from Medicare or Medicaid, TDH may:
- Terminate the contract if the applicable conditions set
out in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.9 FAILURE TO MAKE PAYMENTS TO NETWORK PROVIDERS AND SUBCONTRACTORS
HMO's failure to make timely and appropriate payments to network
providers and Subcontractors is a default under this contract.
Withholding or recouping capitation payments as allowed or required
under other articles of this contract is not a default under this
contract.
16.3.9.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy
in whole or in part does not limit TDH in exercising all or part of
any remaining remedies.
For HMO's failure to make timely and appropriate payment to network
providers and subcontractors, TDH may:
126 Dallas Service Area Contract
133
- Terminate the contract if the applicable conditions set
out in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Assess liquidated money damages as set out in Article
18.4; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.10 FAILURE TO TIMELY ADJUDICATE CLAIMS
Failure of HMO to adjudicate (paid, denied, or external pended) at
least ninety (90%) of all claims within thirty (30) days of receipt
and ninety-nine percent (99%) of all claims within ninety (90) days
of receipt for the contract year is a default under this contract.
16.3.10.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to THD by law or in equity, are joint and several, and may
be exercised concurrently or consequently. Exercise of any remedy in
whole or in part does not limit TDH in exercising all or part of any
remaining remedies.
For HMO's failure to timely adjudicate claims, TDH may:
- Terminate the contract if the applicable conditions set
out in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.11 FAILURE TO DEMONSTRATE THE ABILITY TO PERFORM CONTRACT FUNCTIONS
Failure to pass any of the mandatory system or delivery functions of
the Renewal Review required in Article I of this contract is a
default under the contract.
16.3.11.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy
in whole or in part does not limit TDH in exercising all or part of
any remaining remedies.
For HMO's failure to demonstrate the ability to perform contract
functions, TDH may:
127 Dallas Service Area Contract
134
- Terminate the contract if the applicable conditions set
out in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.12 FAILURE TO MONITOR AND/OR SUPERVISE ACTIVITIES OF CONTRACTORS OR
NETWORK PROVIDERS
16.3.12.1 Failure of HMO to audit, monitor, supervise, or enforce functions
delegated by contract to another entity that results in a default
under this contract or constitutes a violation of state or federal
laws, rules, or regulations is a default under this contract.
16.3.12.2 Failure of HMO to properly credential its providers, conduct
reasonable utilization review, or conduct quality monitoring is a
default under this contract.
16.3.12.3 Failure of HMO to require providers and contractors to provide
timely and accurate encounter, financial, statistical and
utilization data is a default under this contract.
16.3.12.4 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy
in whole or in part does not limit TDH in exercising all or part of
any remaining remedies.
For HMO's failure to monitor and/or supervise activities of
contractors or network providers, TDH may:
- Terminate the contract if the applicable conditions set
out in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18:3;
and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.13 PLACING THE HEALTH AND SAFETY OF MEMBERS IN JEOPARDY
HMO's placing the health and safety of the Members in jeopardy is a
default under this contract.
16.3.13.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and may
be exercised concurrently or
128 Dallas Service Area Contract
135
consecutively. Exercise of any remedy in whole or in part does not
limit TDH in exercising all or part of any remaining remedies.
For HMO's placing the health and safety of Members in jeopardy, TDH
may:
- Terminate the contract if the applicable conditions set
out in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.14 FAILURE TO MEET ESTABLISHED BENCHMARK
Failure of HMO to meet any benchmark established by TDH under this
contract is a default under this contract.
16.3.14.1 REMEDIES AVAILABLE TO TDH FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDH by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy
in whole or in part does not limit TDH in exercising all or part of
any remaining remedies.
For HMO's failure to meet any benchmark established by TDH under
this contract, TDH may:
- Remove the THSteps component from the capitation paid to
HMO if the benchmark(s) missed is for THSteps;
- Terminate the contract if the applicable conditions set
out in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Assess liquidated money damages as set out in Article
18.4; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
ARTICLE XVII NOTICE OF DEFAULT AND CURE OF DEFAULT
17.1 TDH will provide HMO with written notice of default (Notice of
Default) under this contract. The Notice of Default may be given by
any means that provides verification of receipt. The Notice of
Default must contain the following information:
17.1.1 A clear and concise statement of the circumstances or conditions
which constitute a default under this contract;
129 Dallas Service Area Contract
136
17.1.2 The contract provision(s) under which default is being declared;
17.1.3 A clear and concise statement of how and/or whether the default may
be cured;
17.1.4 A clear and concise statement of the time period HMO may cure the
default if HMO is allowed to cure;
17.1.5 The remedy or remedies TDH is electing to pursue and when the remedy
or remedies will take effect;
17.1.6 If TDH is electing to impose money damages and/or civil monetary
penalties, the amount that TDH intends to withhold or impose and the
factual basis on which TDH is imposing the chosen remedy or
remedies;
17.1.7 Whether any part of money damages or civil monetary penalties, if
TDH elects to pursue one or both of those remedies, may be passed
through to an individual or entity who is or may be responsible for
the act or omission for which default is declared;
17.1.8 Whether failure to cure the default within the given time period, if
any, will result in TDH pursuing an additional remedy or remedies,
including, but not limited to, additional damages or sanctions
referral for investigation or action by another agency, and/or
termination of the contract.
ARTICLE XVIII REMEDIES AND SANCTIONS
18.1 TERMINATION
18.1.1 TERMINATION BY TDH
TDH may terminate this contract if:
18.1.1.1 HMO substantially fails or refuses to provide medically necessary
services and items that are required under this contract to be
provided to Members after notice and opportunity to cure;
18.1.1.2 HMO substantially fails or refuses to perform administrative
functions under this contract after notice and opportunity to cure;
18.1.1.3 HMO materially defaults under any of the provisions of Article XVI;
18.1.1.4 Federal or state funds for the Medicaid program are no longer
available; or
130 Dallas Service Area Contract
137
18.1.1.5 TDH has a reasonable belief that HMO has placed the health or
welfare of Members in jeopardy.
18.1.2 TDH must give HMO 90 days written notice of intent to terminate this
contract if termination is the result of HMO's substantial failure
or refusal to perform administrative functions or a material default
under any of the provisions of Article XVI. TDH must give HMO
reasonable notice under the circumstances if termination is the
result of federal or state funds for the Medicaid program no longer
being available. TDH must give the notice required under TDH's
formal hearing procedures set out in Section 1.2.1 in Title 25 of
the Texas Administrative Code if termination is the result of HMO's
substantial failure or refusal to provide medically necessary
services and items that are required under the contract to be
provided to Members or TDH's reasonable belief that HMO has placed
the health or welfare of Members in jeopardy.
18.1.2.1 Notice may be given by any means that gives verification of receipt.
18.1.2.2 Unless termination is the result of HMO's substantial failure or
refusal to provide medically necessary services and items that are
required under this contract to be provided to Members or is the
result of TDH's reasonable belief that HMO has placed the health or
welfare of Members in jeopardy, the termination date is 90 days
following the date that HMO receives the notice of intent to
terminate. For HMO's substantial failure or refusal to provide
services and items, HMO is entitled to request a pre-termination
hearing under TDH's formal hearing procedures set out in Section
1.2.1 of Title 25, Texas Administrative Code.
18.1.3 TDH may, for termination for HMO's substantial failure or refusal to
provide medically necessary services and items, notify HMO's Members
of any hearing requested by HMO and permit Members to disenroll
immediately without cause. Additionally, if TDH terminates for this
reason, TDH may enroll HMO's Members with another HMO or permit
HMO's Members to receive Medicaid-covered services other than from
an HMO.
18.1.4 HMO must continue to perform services under the transition plan
described in Article 18.2.1 until the last day of the month
following 90 days from the date of receipt of notice if the
termination is for any reason other than TDH's reasonable belief
that HMO is placing the health and safety of the Members in
jeopardy. If termination is due to this reason, TDH may prohibit
HMO's further performance of services under the contract.
18.1.5 If TDH terminates this contract, HMO may appeal the termination
under Section 32.034, Texas Human Resources Code.
131 Dallas Service Area Contract
138
18.1.6 TERMINATION BY HMO
HMO may terminate this contract if TDH fails to pay HMO as required
under Article XIII of this contract or otherwise materially defaults
in its duties and responsibilities under this contract. 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.
18.1.7 HMO must give TDH 90 days written notice of intent to terminate this
contract. Notice may be given by any means that gives verification
of receipt. The termination date will be calculated as the last day
of the month following 90 days from the date the notice of intent to
terminate is received by TDH.
18.1.8 TDH must be given 30 days from the date TDH receives HMO's written
notice of intent to terminate for failure to pay HMO to pay all
amounts due. If TDH pays all amounts then due within this 30-day
period, HMO cannot terminate the contract under this article for
that reason.
18.1.9 TERMINATION BY MUTUAL CONSENT
This contract may be terminated at any time by mutual consent of
both HMO and TDH.
18.2 DUTIES OF CONTRACTING PARTIES UPON TERMINATION
When termination of the contract occurs, TDH and HMO must meet the
following obligations:
18.2.1 TDH and HMO must prepare a transition plan, which is acceptable to
and approved by TDH, to ensure that Members are reassigned to other
plans without interruption of services. That transition plan will be
implemented during the 90-day period between receipt of notice and
the termination date unless termination is the result of TDH's
reasonable belief that HMO is placing the health or welfare of
Members in jeopardy.
18.2.2 If the contract is terminated by TDH for any reason other than
federal or state funds for the Medicaid program no longer being
available or if HMO terminates the contract based on lower
capitation rates for the second contract year as set out in Article
ββ.β.β.β:
18.2.2.1 TDH is responsible for notifying all Members of the date of
termination and how Members can continue to receive contract
services;
132 Dallas Service Area Contract
139
18.2.2.2 HMO is responsible for all expenses related to giving notice to
Members; and
18.2.2.3 HMO is responsible for all expenses incurred by TDH in implementing
the transition plan.
18.2.3 If the contract is terminated by HMO:
18.2.3.1 TDH is responsible for notifying all Members of the date of
termination and how Members can continue to receive contract
services;
18.2.3.2 TDH is responsible for all expenses related to giving notice to
Members; and
18.2.3.3 TDH is responsible for all expenses it incurs in implementing the
transition plan.
18.2.4 If the contract is terminated by mutual consent:
18.2.4.1 TDH is responsible for notifying all Members of the date of
termination and how Members can continue to receive contract
services
18.2.4.2 HMO is responsible for all expenses related to giving notice to
Members; and
18.2.4.3 TDH is responsible for all expenses it incurs in implementing the
transition plan.
18.3 SUSPENSION OF NEW ENROLLMENT
18.3.1 TDH must give HMO 30 days notice of intent to suspend new enrollment
in the Notice of Default other than for default for fraud and abuse
or imminent danger to the health or safety of Members. The
suspension date will be calculated as 30 days following the date
that HMO receives the Notice of Default.
18.3.2 TDH may immediately suspend new enrollment into HMO for a default
declared as a result of fraud and abuse or imminent danger to the
health and safety of Members.
18.3.3 The suspension of new enrollment may be for any duration, up to the
termination date of the contract. TDH will base the duration of the
suspension upon the type and severity of the default and HMO's
ability, if any, to cure the default.
18.4 LIQUIDATED MONEY DAMAGES
18.4.1 The measure of damages in the event that HMO fails to perform its
obligations under this contract may be difficult or impossible to
calculate or quantify. Therefore, should HMO fail to perform in
accordance with the terms and conditions of this contract, TDH may
require HMO to pay sums as specified below as liquidated
133 Dallas Service Area Contract
140
damages. The liquidated damages set out in this Article are not
intended to be in the nature of a penalty but are intended to be
reasonable estimates of TDH's financial loss and damage resulting
from HMO's non-performance.
18.4.2 If TDH imposes money damages, TDH may collect those damages by
reducing the amount of any monthly premium payments otherwise due to
HMO by the amount of the damages. Money damages that are withheld
from monthly premium payments are forfeited and will not be
subsequently paid to HMO upon compliance or cure of default unless a
determination is made after appeal that the damages should not have
been imposed.
18.4.3 Failure to file or filing incomplete or inaccurate annual,
semi-annual or quarterly reports may result in money damages of not
more than $11,000.00 for every month from the month the report is
due until submitted in the form and format required by TDH. These
money damages apply separately to each report.
18.4.4 Failure to produce or provide records and information requested by
TDH, an entity acting on behalf of TDH, or an agency authorized by
statute or law to require production of records at the time and
place the records were required or requested may result in money
damages of not more than $5,000.00 per day for each day the records
are not produced as required by the requesting entity or agency if
the requesting entity or agency is conducting an investigation or
audit relating to fraud or abuse, and not more than $1,000.00 per
day for each day records are not produced if the requesting entity
or agency is conducting routine audits or monitoring activities.
18.4.5 Failure to file or filing incomplete or inaccurate encounter data
may result in money damages of not more than $25,000 for each month
HMO fails to submit encounter data in the form and format required
by TDH. TDH will use the encounter data validation methodology
established by TDH to determine the number of encounter data and the
number of months for which damages will be assessed.
18.4.6 Failing or refusing to cooperate with TDH, an entity acting on
behalf of TDH, or an agency authorized by statute or law to require
the cooperation of HMO in carrying out an administrative,
investigative, or prosecutorial function of the Medicaid program may
result in money damages of not more than $8,000.00 per day for each
day HMO fails to cooperate.
18.4.7 Failure to enter into a required or mandatory contract or failure to
contract for or arrange to have all services required under this
contract provided may result in money damages of not more than
$1,000.00 per day that HMO either fails to negotiate in good faith
to enter into the required contract or fails to arrange to have
required services delivered.
134 Dallas Service Area Contract
141
18.4.8 Failure to meet the benchmark for benchmarked services under this
contract may result in money damages of not more than $25,000 for
each month that HMO fails to meet the established benchmark.
18.4.9 TDH may also impose money damages for a default under Article
16.3.9, Failure to Make Payments to Network Providers and
subcontractors, of this contract. These money damages are in
addition to the interest HMO is required to pay to providers under
the provisions of Articles 4.10.4 and 7.2.7.10 of this contract.
18.4.9.1 If TDH determines that HMO has failed to pay a provider for a claim
or claims for which the provider should have been paid, TDH may
impose money damages of $2 per day for each day the claim is not
paid from the date the claim should have been paid (calculated as 30
days from the date a clean claim was received by HMO) until the
claim is paid by HMO.
18.4.9.2 If TDH determines that HMO has failed to pay a capitation amount to
a provider who has contracted with HMO to provide services on a
capitated basis, TDH may impose money damages of $10 per day, per
Member for whom the capitation is not paid, from the date on which
the payment was due until the capitation amount is paid.
18.5 APPOINTMENT OF TEMPORARY MANAGEMENT
18.5.1 TDH may appoint temporary management to oversee the operation of HMO
upon a finding that there is continued egregious behavior by HMO or
there is a substantial risk to the health of the Members.
18.5.2 TDH may appoint temporary management to assure the health of HMO's
Members if there is a need for temporary management while:
18.5.2.1 there is an orderly termination or reorganization of HMO; or
18.5.2.2 are made to remedy violations found under Article 16.3.4.
18.5.3 Temporary management will not be terminated until TDH has determined
that HMO has the capability to ensure that the violations that
triggered appointment of temporary management will not recur.
18.5.4 TDH is not required to appoint temporary management before
terminating this contract.
18.5.5 No pre-termination hearing is required before appointing temporary
management.
135 Dallas Service Area Contract
142
18.5.6 As with any other remedy provided under this contract, TDH will
provide notice of default as is set out in Article XVII to HMO.
Additionally, as with any other remedy provided under this contract,
under Article 18.1 of this contract, HMO may dispute the imposition
of this remedy and seek review of the proposed remedy.
18.6 TDH-INITIATED DISENROLLMENT OF A MEMBER OR MEMBERS WITHOUT CAUSE
TDH must give HMO 30 days notice of intent to initiate disenrollment
of a Member of Members in the Notice of Default. The TDH-initiated
disenrollment date will be calculated as 30 days following the date
that HMO receives the Notice of Default.
18.7 RECOMMENDATION TO HCFA THAT SANCTIONS BE TAKEN AGAINST HMO
18.7.1 If HCFA determines that HMO has violated federal law or
regulations and that federal payments will be withheld, TDH will
deny and withhold payments for new enrollees of HMO.
18.7.2 HMO must be given notice and opportunity to appeal a decision of TDH
and HCFA pursuant to 42 C.F.R. Section 434.67.
18.8 CIVIL MONETARY PENALTIES
18.8.1 For a default under Article 16.3.4.1, TDH may assess not more than
$25,000 for each default;
18.8.2 For a default under Article 16.3.4.2, TDH may assess double the
excess amount charged in violation of the federal requirements for
each default. The excess amount shall be deducted from the penalty
and returned to the Member concerned.
18.8.3 For a default under Article 16.3.4.3, TDH may assess not more than
$100,000 for each default, including $15,000 for each individual not
enrolled as a result of the practice described in Article 16.3.4.3.
18.8.4 For a default under Article 16.3.4.4, TDH may assess not more than
$100,000 for each default if the material was provided to HCFA or
TDH and not more than $25,000 for each default if the material was
provided to a Member, a potential Member, or a health care provider.
18.8.5 For a default under Article 16.3.4.5, TDH may assess not more than
$25,000 for each default.
136 Dallas Service Area Contract
143
18.8.6 For a default under Article 16.3.4.6, TDH may assess not more than
$25,000 for each default.
18.8.7 HMO may be subject to civil money penalties under the provisions of
42 C.F.R. 1003 in addition to or in place of withholding payments
for a default under Article 16.3.4.
18.9 FORFEITURE OF ALL OR A PART OF THE TDI PERFORMANCE BOND
TDH may require forfeiture of all or a portion of the face amount of
the TDI performance bond if TDH determines that an event of default
has occurred. Partial payment of the face amount shall reduce the
total bond amount available pro rata.
18.10 REVIEW OF REMEDY OR REMEDIES TO BE IMPOSED
18.10.1 HMO may dispute the imposition of any sanction under this contract.
HMO notifies TDH of its dispute by filing a written response to the
Notice of Default, clearly stating the reason HMO disputes the
proposed sanction. With the written response, HMO must submit to TDH
any documentation that supports HMO's position. HMO must file the
review within 15 days from HMO's receipt of the Notice of Default,
Filing a dispute in a written response to the Notice of Default
suspends imposition of the proposed sanction.
18.10.2 HMO and TDH must attempt to informally resolve the dispute. If HMO
and TDH are unable to informally resolve the dispute, HMO must
notify the Bureau Chief of Managed Care that HMO and TDH cannot
agree. The Bureau Chief will refer the dispute to the Associate
Commissioner for Health Care Financing who will appoint a committee
to review the dispute under TDH's dispute resolution procedures. The
decision of the dispute resolution committee will be TDH's final
administrative decision.
ARTICLE XIX TERM
19.1 The effective date of this contract is September 1, 2000. This
contract will terminate on August 31, 2001, unless terminated
earlier as provided elsewhere in this contract.
19.2 This contract may be renewed for an additional one-year period by
written amendment to the contract executed by the parties prior to
the termination date of the present contract. TDH will notify HMO no
later than 90 days before the end of the contract period of its
intent not to renew the contract.
137 Dallas Service Area Contract
144
19.3 If either party does not intend to renew the contract beyond its
contract period, the party intending not to renew must submit a
written notice of its intent not to renew to the other party no
later than 90 days before the termination date set out in Article
19.1.
19.4 If either party does not intend to renew the contract beyond its
contract period and sends the notice required in Article 19.3, a
transition period of 90 days will run from the date the notice of
intent not to renew is received by the other party. By signing this
contract, the parties agree that the terms of this contract shall
automatically continue during any transition period.
19.5 The party that does not intend to renew the contract beyond its
contract period and sends the notice required by Article 19.3 is
responsible for sending notices to all members on how the Member can
continue to receive covered services. The expense of sending the
notices will be paid by the non-renewing party. If TDH does not
intend to renew and sends the required notice, TDH is responsible
for any costs it incurs in ensuring that members are reassigned to
other plans without interruption of services. If HMO does not
intend to renew and sends the required notice, HMO is responsible
for any costs TDH incurs in ensuring that Members are reassigned to
other plans without interruption of services. If both parties do not
intend to renew the contract beyond its contract period, TDH will
send the notices to Members and the parties will share equally in
the cost of sending the notices and of implementing the transition
plan.
SIGNED 31 day of August, 2000.
TEXAS DEPARTMENT OF HEALTH Americaid Texas, Inc.
dba Americaid Community Care HMO
BY: /s/ βββββββ β. ββββββ III, M.D. BY: /s/ βββ β. ββββββββ
------------------------------- -----------------------------
βββββββ β. ββββββ III, M.D. βββ β. ββββββββ
Commissioner of Health President and COO
Approved as to Form:
/s/ βββββββ ββββββ
-------------------------------
Office of General Counsel
138 Dallas Service Area Contract