Exhibit 10.42
[TEXAS HEALTH AND HUMAN SERVICES COMMISSION LOGO]
================================================================================
CONTRACT FOR SERVICES
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between
Texas Health and Human Services Commission
and
AMERIGROUP TEXAS, INC.
Contract #▇▇▇-▇▇-▇▇▇
in the
▇▇▇▇▇▇ Service Delivery Area
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TABLE OF CONTENTS
ARTICLE 1 PARTIES AND AUTHORITY TO CONTRACT............................................................... 7
ARTICLE 2 DEFINITIONS .................................................................................... 8
ARTICLE 3 PLAN ADMINISTRATIVE AND HUMAN RESOURCE REQUIREMENTS ............................................ 21
3.1 ORGANIZATION AND ADMINISTRATION......................................................................... 21
3.2 NON-PROVIDER SUBCONTRACTS............................................................................... 22
3.3 MEDICAL DIRECTOR........................................................................................ 25
3.4 PLAN MATERIALS AND DISTRIBUTION OF PLAN MATERIALS ...................................................... 25
3.5 RECORDS REQUIREMENTS AND RECORDS RETENTION................................................................ 27
3.6 HMO REVIEW OF HHSC MATERIALS............................................................................ 28
3.7 HMO TELEPHONE ACCESS REQUIREMENTS ........................................................................ 29
ARTICLE 4 FISCAL, FINANCIAL, CLAIMS AND INSURANCE REQUIREMENTS............................................ 30
4.1 FISCAL SOLVENCY......................................................................................... 30
4.2 MINIMUM NET WORTH......................................................................................... 31
4.3 PERFORMANCE BOND ....................................................................................... 31
4.4 INSURANCE .............................................................................................. 31
4.5 FRANCHISE TAX........................................................................................... 32
4.6 AUDIT................................................................................................... 32
4.7 PENDING OR THREATENED LITIGATION........................................................................ 32
4.8 MISREPRESENTATION AND FRAUD IN RESPONSE TO RFA AND IN HMO OPERATIONS ................................... 33
4.9 THIRD PARTY RECOVERY ................................................................................... 33
4.10 CLAIMS PROCESSING REQUIREMENTS........................................................................... 34
4.11 INDEMNIFICATION ......................................................................................... 36
ARTICLE 5 STATUTORY AND REGULATORY COMPLIANCE REQUIREMENTS ................................................... 37
5.1 COMPLIANCE WITH FEDERAL, STATE, AND LOCAL LAWS.......................................................... 37
5.2 PROGRAM INTEGRITY ...................................................................................... 38
5.3 FRAUD AND ABUSE COMPLIANCE PLAN......................................................................... 38
5.4 SAFEGUARDING INFORMATION ............................................................................... 40
5.5 NON-DISCRIMINATION...................................................................................... 41
5.6 HISTORICALLY UNDERUTILIZED BUSINESSES (HUBS)............................................................ 41
5.7 BUY TEXAS............................................................................................... 42
5.8 CHILD SUPPORT .......................................................................................... 42
5.9 REQUESTS FOR PUBLIC INFORMATION ........................................................................ 43
5.10 NOTICE AND APPEAL........................................................................................ 44
5.11 DATA CERTIFICATION....................................................................................... 44
ARTICLE 6 SCOPE OF SERVICES............................................................................... 44
6.1 SCOPE OF SERVICES....................................................................................... 44
6.2 PRE-EXISTING CONDITIONS................................................................................. 47
6.3 SPAN OF ELIGIBILITY .................................................................................... 47
6.4 CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS ........................................................ 48
6.5 EMERGENCY SERVICES ..................................................................................... 50
6.6 BEHAVIORAL HEALTH CARE SERVICES - SPECIFIC REQUIREMENTS................................................. 52
6.7 FAMILY PLANNING - SPECIFIC REQUIREMENTS ................................................................ 54
6.8 TEXAS HEALTH STEPS (EPSDT).............................................................................. 56
6.9 PERINATAL SERVICES ..................................................................................... 58
6.10 EARLY CHILDHOOD INTERVENTION (ECI)........................................... ........................... 60
6.11 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND
CHILDREN (WIC) - SPECIFIC REQUIREMENTS ................................................................. 61
6.12 TUBERCULOSIS (TB)........................................................................................ 62
6.13 PEOPLE WITH DISABILITIES OR CHRONIC OR COMPLEX CONDITIONS................................................ 63
6.14 HEALTH EDUCATION AND WELLNESS AND PREVENTION PLANS....................................................... 66
6.15 SEXUALLY TRANSMITTED DISEASES (STDS) AND HUMAN IMMUNODEFICIENCY VIRUS
(HIV)................................................................................................... 67
6.16 BLIND AND DISABLED MEMBERS .............................................................................. 68
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ARTICLE 7 PROVIDER NETWORK REQUIREMENTS .................................................................. 69
7.1 PROVIDER ACCESSIBILITY.................................................................................. 69
7.2 PROVIDER CONTRACTS ..................................................................................... 70
7.3 PHYSICIAN INCENTIVE PLANS............................................................................... 75
7.4 PROVIDER MANUAL AND PROVIDER TRAINING..................................................................... 76
7.5 MEMBER PANEL REPORTS ................................................................................... 77
7.6 PROVIDER COMPLAINT AND APPEAL PROCEDURES.................................................................. 78
7.7. PROVIDER QUALIFICATIONS................................................................................. 78
7.8 PRIMARY CARE PROVIDERS ................................................................................. 82
7.9 OB/GYN PROVIDERS........................................................................................ 86
7.10 SPECIALTY CARE PROVIDERS................................................................................. 87
7.11 SPECIAL HOSPITALS AND SPECIALTY CARE FACILITIES.......................................................... 87
7.12 BEHAVIORAL HEALTH - LOCAL MENTAL HEALTH AUTHORITY (LMHA)................................................. 88
7.13 SIGNIFICANT TRADITIONAL PROVIDERS (STPS) ................................................................ 90
7.14 RURAL HEALTH PROVIDERS................................................................................... 90
7.15 FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS) AND RURAL HEALTH CLINICS
(RHCS).................................................................................................. 91
7.16 COORDINATION WITH PUBLIC HEALTH ......................................................................... 92
7.17 COORDINATION WITH TEXAS DEPARTMENT OF PROTECTIVE AND REGULATORY
SERVICES................................................................................................ 95
7.18 DELEGATED NETWORKS (IPAs, LIMITED PROVIDER NETWORKS AND ANHCs) .......................................... 96
ARTICLE 8 MEMBER SERVICES REQUIREMENTS ................................................................... 98
8.1 MEMBER EDUCATION........................................................................................ 98
8.2 MEMBER HANDBOOK........................................................................................... 98
8.3 ADVANCE DIRECTIVES ..................................................................................... 99
8.4 MEMBER ID CARDS ........................................................................................ 100
8.5 MEMBER COMPLAINT AND APPEAL SYSTEM ..................................................................... 101
8.6 [THIS SECTION IS INTENTIONALLY LEFT BLANK] ............................................................. 109
8.7 MEMBER ADVOCATES........................................................................................ 109
8.8 MEMBER CULTURAL AND LINGUISTIC SERVICES................................................................. 110
8.9 CERTIFICATION DATE ..................................................................................... 112
ARTICLE 9 MARKETING AND PROHIBITED PRACTICES.............................................................. 112
9.1 MARKETING MATERIAL MEDIA AND DISTRIBUTION .............................................................. 112
9.2 MARKETING ORIENTATION AND TRAINING ..................................................................... 112
9.3 PROHIBITED MARKETING PRACTICES ......................................................................... 113
9.4 NETWORK PROVIDER DIRECTORY.............................................................................. 113
ARTICLE 10 MIS SYSTEM REQUIREMENTS ........................................................................... 114
10.1 MODEL MIS REQUIREMENTS .................................................................................. 114
10.2 SYSTEM-WIDE FUNCTIONS ................................................................................... 117
10.4 PROVIDER SUBSYSTEM....................................................................................... 119
10.5 ENCOUNTER/CLAIMS PROCESSING SUBSYSTEM ................................................................... 120
10.6 FINANCIAL SUBSYSTEM ..................................................................................... 121
10.7 UTILIZATION/QUALITY IMPROVEMENT SUBSYSTEM................................................................ 122
10.8 REPORT SUBSYSTEM ........................................................................................ 123
10.9 DATA INTERFACE SUBSYSTEM................................................................................. 124
10.10 TPR SUBSYSTEM .......................................................................................... 126
10.12 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) COMPLIANCE.................................. 126
ARTICLE 11 QUALITY ASSURANCE AND QUALITY IMPROVEMENT PROGRAM ................................................. 127
11.1 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM .................................................. 127
11.2 WRITTEN QIP PLAN ........................................................................................ 127
11.3 QIP SUBCONTRACTING ...................................................................................... 127
11.4 ACCREDITATION............................................................................................ 127
11.5 BEHAVIORAL HEALTH INTEGRATION INTO QIP................................................................... 128
11.6 QIP REPORTING REQUIREMENTS............................................................................... 128
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11.7 PRACTICE GUIDELINES .................................................................................. 128
ARTICLE 12 REPORTING REQUIREMENTS ............................................................................ 128
12.1 FINANCIAL REPORTS ..................................................................................... 128
12.2 STATISTICAL REPORTS ................................................................................... 131
12.3 ARBITRATION/LITIGATION CLAIMS REPORT................................................................... 132
12.4 SUMMARY REPORT OF PROVIDER COMPLAINTS.................................................................. 132
12.5 PROVIDER NETWORK REPORTS............................................................................... 132
12.6 MEMBER COMPLAINTS & APPEALS ........................................................................... 133
12.7 FRAUDULENT PRACTICES .................................................................................. 133
12.8 UTILIZATION MANAGEMENT REPORTS......................................................................... 133
12.10 QUALITY IMPROVEMENT REPORTS........................................................................... 134
12.11 HUB REPORTS .......................................................................................... 135
12.12 THSTEPS REPORTS....................................................................................... 135
12.14 MEMBER HOTLINE PERFORMANCE REPORT..................................................................... 135
12.15 SUBMISSION OF STAR DELIVERABLES/REPORTS............................................................... 135
ARTICLE 13 PAYMENT PROVISIONS................................................................................. 137
13.1 CAPITATION AMOUNTS .................................................................................... 137
13.2 EXPERIENCE REBATE TO STATE............................................................................. 139
13.3 PERFORMANCE OBJECTIVES ................................................................................ 141
13.4 ADJUSTMENTS TO PREMIUM................................................................................. 141
13.5 ▇▇▇▇▇▇▇ AND PREGNANT WOMEN PAYMENT PROVISIONS ......................................................... 142
ARTICLE 14 ELIGIBILITY, ENROLLMENT, AND DISENROLLMENT......................................................... 143
14.1 ELIGIBILITY DETERMINATION.............................................................................. 143
14.2 ENROLLMENT............................................................................................. 145
14.3 NEWBORN ENROLLMENT..................................................................................... 146
14.4 DISENROLLMENT.......................................................................................... 147
14.5 AUTOMATIC RE-ENROLLMENT................................................................................ 148
14.6 ENROLLMENT REPORTS..................................................................................... 148
ARTICLE 15 GENERAL PROVISIONS................................................................................. 148
15.1 INDEPENDENT CONTRACTOR ................................................................................ 148
15.2 AMENDMENT AND CHANGE REQUEST PROCESS................................................................... 149
15.3 LAW, JURISDICTION AND VENUE............................................................................ 150
15.4 NON-WAIVER ............................................................................................ 151
15.5 SEVERABILITY .................................................................................... 151
15.6 ASSIGNMENT ............................................................................................ 151
15.7 MAJOR CHANGE IN CONTRACTING ........................................................................... 151
15.8 NON-EXCLUSIVE.......................................................................................... 152
15.9 DISPUTE RESOLUTION..................................................................................... 152
15.10 DOCUMENTS CONSTITUTING CONTRACT....................................................................... 152
15.11 FORCE MAJEURE......................................................................................... 152
15.12 NOTICES .............................................................................................. 152
15.13 SURVIVAL.............................................................................................. 153
15.14 GLOBAL DRAFTING CONVENTIONS........................................................................... 153
ARTICLE 16 DEFAULT AND REMEDIES .............................................................................. 153
16.1 DEFAULT BY HHSC........................................................................................ 153
16.2 REMEDIES AVAILABLE TO HMO FOR HHSC'S DEFAULT........................................................... 154
16.3 DEFAULT BY HMO......................................................................................... 154
ARTICLE 17 NOTICE OF DEFAULT AND CURE OF DEFAULT ............................................................. 163
ARTICLE 18 EXPLANATION OF REMEDIES ........................................................................... 164
18.1 TERMINATION ........................................................................................... 164
18.2 DUTIES OF CONTRACTING PARTIES UPON TERMINATION......................................................... 166
18.3 SUSPENSION OF NEW ENROLLMENT........................................................................... 167
18.4 LIQUIDATED MONEY DAMAGES............................................................................... 167
18.5 APPOINTMENT OF TEMPORARY MANAGEMENT.................................................................... 169
18.6 HHSC-INITIATED DISENROLLMENT OF A MEMBER OR MEMBERS WITHOUT CAUSE ..................................... 170
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18.7 RECOMMENDATION TO CMS THAT SANCTIONS BE TAKEN AGAINST HMO ............................................. 170
18.8 CIVIL MONETARY PENALTIES............................................................................... 170
18.9 FORFEITURE OF ALL OR A PART OF THE TDI PERFORMANCE BOND................................................ 171
18.10 REVIEW OF REMEDY OR REMEDIES TO BE IMPOSED............................................................ 171
ARTICLE 19 TERM............................................................................................... 172
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APPENDICES
APPENDIX A ...........................Standards For Quality Improvement Programs
APPENDIX A-A ..........................Performance Improvement Program Worksheet
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 - Not Applicable
APPENDIX I ............................Managed Care Financial-Statistical Report
APPENDIX J -- Not Applicable
APPENDIX K .............................Preventive Health Performance Objectives
APPENDIX L ..........................Cost Principles For Administrative Expenses
APPENDIX M ........................................Arbitration/Litigation Report
APPENDIX O ........................................Standards for Medical Records
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CONTRACT FOR SERVICES
BETWEEN THE
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
AND HMO
This contract is entered into between the Texas Health and Human Services
Commission (HHSC) and Amerigroup Texas, Inc. (HMO or Contractor). The purpose of
this contract is to set forth the terms and conditions for HMO's participation
as a managed care organization in the HHSC STAR Program (STAR or STAR Program).
Under the terms of this contract HMO will provide comprehensive health care
services to qualified and Medicaid-eligible recipients through a managed care
delivery system. This is a risk-based contract. HMO was selected to provide
services under this contract under Texas Health and Safety Code, Title 2,
Section 12.011 and Section 12.021, and Texas Government Code Section 533.001 et
seq.
ARTICLE 1 PARTIES AND AUTHORITY TO CONTRACT
1.1 The Texas Legislature has designated the Texas Health and Human Services
Commission (HHSC) as the single State agency to administer the Medicaid
program in the State of Texas. HHSC has authority to contract with HMO to
carry out the duties and functions of the Medicaid managed care program
under Texas 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 843, Texas 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 HHSC and has received a Vendor Identification
number from the Texas Comptroller of Public Accounts.
1.3 This contract is subject to the approval and on-going monitoring of the
federal Centers for Medicare and Medicaid Services (CMS).
1.4 Renewal Review. At its sole discretion, HHSC may choose to conduct a
renewal review of HMO's performance and compliance with this contract as a
condition for retention and renewal.
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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 HHSC 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 that must be corrected and the timeline
within which the deficiencies must be corrected.
1.4.3 HHSC 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. HHSC may conduct at least one
complete on-site inspection of all systems and processes every three
years. HHSC will provide six weeks advance notice to HMO of the
three-year on-site inspection, unless HHSC enters into an MOU with
the TDI to accept the TDI report in lieu of a HHSC on-site
inspection. HHSC will notify HMO prior to conducting an onsite visit
related to a regularly scheduled review specifically described in
this contract. Even in the case of a regularly scheduled visit, HHSC
reserves the right to conduct an onsite review without advance
notice if HHSC believes there may be potentially serious or
life-threatening deficiencies.
1.5 AUTHORITY OF HMO TO ACT ON BEHALF OF HHSC. 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 that require providers or
subcontractors to produce records, reports, encounter data, public health
data, and other documents to comply with this contract and that HHSC has
authority to require under State or federal laws.
ARTICLE 2 DEFINITIONS
Terms used throughout this Contract have the following meaning, unless the
context clearly indicates otherwise:
ABUSE means provider practices that are inconsistent with sound fiscal,
business, or medical practices and result in an unnecessary cost to the Medicaid
program, or in reimbursement for services that are not medically necessary or
that fail to meet professionally recognized standards for health care. It also
includes Member practices that result in unnecessary cost to the Medicaid
program.
ACTION means the denial or limited authorization of a requested service,
including the type or level of service; the reduction, suspension, or
termination of a previously authorized service; the
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denial in whole or in part of payment for service; failure to provide services
in a timely manner, the failure of an HMO to act within the timeframes set forth
in this agreement and 42 C.F.R. Section 438.408(b); or for a resident of a rural
area with only one HMO, the denial of a Medicaid Members' request to obtain
services outside of the network.
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 HHSC 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 HHSC.
APPEAL means the formal process by which a Member or his or her representative
request a review of an HMO's action, as defined above.
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 CARE 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.
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 condition
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 amount of covered services used by the enrolled Member.
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CHEMICAL DEPENDENCY TREATMENT FACILITY means a facility licensed by the Texas
Commission on Alcohol and Drug Abuse (TCADA) under Sec. 464.002 of the Texas
Health and Safety Code to provide chemical dependency treatment.
CHEMICAL DEPENDENCY TREATMENT means treatment provided for a chemical dependency
condition by a Chemical Dependency Treatment Facility, Chemical Dependency
Counselor or Hospital.
CHEMICAL DEPENDENCY CONDITION means a condition that meets at least three of the
diagnostic criteria for psychoactive substance dependence in the American
Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders
(DSM IV).
CHEMICAL DEPENDENCY COUNSELOR means an individual licensed by TCADA under
Chapter 504, Texas Occupations Code to provide chemical dependency treatment or
a master's level therapist (LMSW-ACP, LMFT or LPC) or a masters level therapist
(LMSW-ACP, LMFT or LPC) with a minimum of two years of post licensure experience
in chemical dependency treatment.
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 that 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 claim submitted by a physician or provider for medical care
or health care services rendered to an enrollee, with documentation reasonably
necessary for the HMO or subcontracted claims processor to process the claim, as
set forth in Title 28, Chapter 21, Subchapter T of the Texas Administrative Code
and to the extent that these rules are not in conflict with the provisions of
this contract.
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.
CMS means the Centers for Medicare and Medicaid Services, formerly known as the
Health Care Financing Administration (HCFA), which is the federal agency
responsible for administering Medicare and overseeing state administration of
Medicaid.
COLD CALL MARKETING means any unsolicited personal contact by the HMO with a
potential Member for the purpose of marketing.
COMMUNITY MANAGEMENT TEAM (CMT) means interagency groups responsible for
developing and implementing the Texas Children's Mental Health Plan (TCMHP) at
the local level. A CMT
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consists of a parent representative and local representatives from the following
entities or their successors: TXMHMR, the Mental Health Association of Texas,
Texas Commission on Alcohol and Drug Abuse, Texas Department of Protective and
Regulatory Services, Texas Department of Human Services, Texas Health and Human
Services Commission, Juvenile Probation Commission, Texas Youth Commission,
Texas Rehabilitation Commission, Texas Education Agency, Council on Early
Childhood Intervention. This organizational structure is also replicated in the
State Management Team that sets overall policy direction for the TCMHP.
COMMUNITY RESOURCE COORDINATION GROUPS (CRCGS) means a statewide system of local
interagency groups, including both public and private providers, that 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.
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 HHSC and HMO and documents included by
reference and any of its written amendments, corrections or modifications.
CONTRACT ADMINISTRATOR means an entity contracting with HHSC 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, or a placement in a state-operated
facility as a condition of probation, as authorized by the Texas Family Code.
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 for this contract, and all Value-added Services described in Appendix C.
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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.
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.
Part 303. The State ECI rules are found at 25 TAC Chapter 621.21.
EFFECTIVE DATE means the date on which HHSC signs the contract following
signature of the contract by HMO. For purposes of this Agreement, the term
"Effective Date" will include any period under which work is performed in
accordance with a properly executed Letter of Intent between HHSC and HMO.
EMERGENCY BEHAVIORAL HEALTH CONDITION means any condition, without regard to the
nature or cause of the condition, that 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 that 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 recent onset and sufficient severity (including severe pain),
such that a prudent layperson, who
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possesses an average knowledge of health and medicine, could reasonably expect
the absence of immediate medical care could result in:
(a) placing the patient's health in serious jeopardy;
(b) serious impairment to bodily functions;
(c) serious dysfunction of any bodily organ or part;
(d) serious disfigurement; or
(e) in the case of a pregnant women, serious jeopardy to the health of a
woman or her unborn child.
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 HHSC by HMO in accordance with
HHSC's "HMO Encounter Data Claims Submission Manual".
ENROLLMENT BROKER means an entity contracting with HHSC to carry out specific
functions related to Member services (i.e., enrollment/disenrollment,
complaints, etc.) under HHSC'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 the portion of the HMO's net income before taxes
(financial Statistical Report, Part 1, Line 14) that is returned to the state in
accordance with Section 13.2 of this agreement.
EXPEDITED APPEAL means an appeal to the HMO in which the decision is required
quickly based on the Member's health status and taking the time for a standard
appeal could jeopardize the Member's life or health or ability to attain,
maintain, or regain maximum function.
EXPERIENCE REBATE PERIOD means each period within the Contract Period related to
the calculations and settlements of Experience Rebates to HHSC described in
Section 13.2. Because the effective date of this Agreement is June 1, 2004, the
first Experience Rebate Period applicable to this Agreement will be from June 1,
2004 to August 31, 2004.
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FAIR HEARING means the process adopted and implemented by the Texas Health and
Human Services Commission, 1 TAC Chapter 357, in compliance with federal
regulations and state rules relating to Medicaid Fair Hearings.
FQHC means a Federally Qualified Health Center that has been certified by CMS 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.
HEALTH CARE SERVICES means medically necessary physical medicine, behavioral
health care and health-related services that an enrolled population might
reasonably require in order to be maintained in good health, including, as a
minimum, emergency care and inpatient and outpatient services.
HEALTH-RELATED MATERIALS are materials that are developed by the HMO or obtained
from a third party relating to the diagnosis or treatment of medical conditions.
HHSC means the Texas Health and Human Services Commission or its designees.
HPO means the Health Plan Operations Division of the Texas Health and Human
Services Commission.
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.
JOINT INTERFACE PLAN (JIP) means a document used to communicate basic system
interface information of the Texas Medicaid Administrative System (TMAS) among
and across State TMAS Contractors and Partners so that all entities are aware of
the interfaces that affect their business. This information includes: file
structure, data elements, frequency, media, type of file, receiver and sender of
the file, and file I.D. The JIP must include each of the HMO's interfaces
required to conduct State TMAS business. The JIP must address the coordination
with each of the Contractor's interface partners to ensure the development and
maintenance of the interface; and the timely transfer of required data elements
between contractors and partners.
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.
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LOCAL HEALTH DEPARTMENT means a local health department established pursuant to
the Local Public Health Reorganization Act (Texas Health and Safety Code, Title
2, Chapter 121).
LOCAL MENTAL HEALTH AUTHORITY (LMHA) means an entity to which the TXMHMR board
or its successor delegates its authority and responsibility within a specified
region for planning, policy development, coordination, and resource development
and allocation and for supervising and ensuring the provision of mental health
care services to persons with mental illness in one or more local service areas.
MAJOR LIFE ACTIVITIES means functions such as caring for oneself, performing
manual tasks, walking, seeing, hearing, speaking, breathing, learning, and
working.
MAJOR POPULATION GROUP means any population that represents at least 10% of the
Medicaid population in any of the counties in the service area served by the
HMO.
MARKETING means any communication from an HMO to a Medicaid recipient who is not
enrolled with the HMO that can reasonably be interpreted as intended to
influence the recipient to enroll in that particular HMO's Medicaid product, or
either to not enroll in, or to disenroll from another HMO's Medicaid product.
MARKETING MATERIALS means materials that are produced in any medium by or on
behalf of an HMO and can reasonably be interpreted as intended to market to
potential enrollees.
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 HHSC's Medicaid managed care
program.
MEDICALLY NECESSARY BEHAVIORAL HEALTH CARE SERVICES means those behavioral
health care services that:
(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 that 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. (a)
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MEDICALLY NECESSARY HEALTH CARE SERVICES means health care services, other than
behavioral health care services that 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;
(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 OR ENROLLEE 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 COMPLAINT OR GRIEVANCE means an expression of dissatisfaction about any
matter other than an action, as defined above. As provided by 42 C.F.R. Section
438.400, possible subjects for complaints or grievances include, but are not
limited to, the quality of care of services provided, and aspects of
interpersonal relationships such as rudeness of a provider or employee, or
failure to respect the Member's rights.
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.
MENTAL HEALTH PRIORITY POPULATION means those individuals served by TXMHMR or
its successor agency who meet the definition of the priority population. The
priority population for mental health care services is defined as:
(a) Children and adolescents under the age of 18 who have a diagnosis of
mental illness who exhibit severe emotional or social disabilities
that are life-threatening or require prolonged intervention; or
(b) Adults who have severe and persistent mental illnesses such as
schizophrenia, major depression, manic depressive disorder, or other
severely disabling mental
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disorders that require crisis resolution or ongoing and long-term
support and treatment.
MIS means management information system.
NON-PROVIDER SUBCONTRACTS means contracts between HMO and a third party that
performs a function, excluding delivery of health care services that HMO is
required to perform under its contract with HHSC.
PENDED CLAIM means a claim for payment that requires additional information
before the claim can be adjudicated as a clean claim.
PERFORMANCE PREMIUM means an amount that 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.
POST-STABILIZATION CARE SERVICES means covered services, related to an emergency
medical condition that are provided after an Member is stabilized in order to
maintain the stabilized condition, or, under the circumstances described in 42
C.F.R. Section 438.114(b)&(e) and 42 C.F.R. Section 422.113(c)(2)(iii) to
improve or resolve the Member's condition.
PREMIUM means the amount paid by HHSC to a managed care organization on a
monthly basis and is determined by multiplying the Member months by 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 HHSC's Medicaid
managed care program.
PROVIDER CONTRACT means an agreement entered into by a direct provider of health
care services and HMO or an intermediary entity.
PROXY CLAIM FORM means a form submitted by providers to document services
delivered to Medicaid Members under a capitated 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.
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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 and
simultaneously translate 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; and it is usually used to interpret
spoken English into text English but may be used to translate other spoken
languages into text.
RENEWAL REVIEW means a review process conducted by HHSC 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.
RISK means the potential for loss as a result of expenses and costs of HMO
exceeding payments made by HHSC 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.
SED means severe emotional disturbance as determined by a local mental health
authority.
SERVICE AREA means the counties included in a site selected for the STAR
Program, within which a participating HMO must provide services.
SPMI means severe and persistent mental illness as determined by the Local
Mental Health Authority.
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 HEALTH CARE NEEDS means Member with an increased prevalence of risk of
disability, including but not limited to: chronic physical or developmental
condition; severe and persistent mental illness; behavioral or emotional
condition that accompanies the Member's physical or developmental condition.
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;
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(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.
STABILIZE means 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 from, or occur during discharge, transfer, or admission of the
Member.
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 that 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 or its successor agency,
which is the State agency responsible for licensing chemical dependency
treatment facilities. TCADA also contracts with providers to deliver chemical
dependency treatment services.
TEXAS CHILDREN'S MENTAL HEALTH PLAN (TCMHP) means the interagency, State-funded
initiative that plans, coordinates, provides and evaluates service systems for
children and adolescents with behavioral health needs. The Plan is operated at a
state and local level by Community Management Teams representing the major
child-serving state agencies.
TEXMEDNET means Texas Medical Network, which is the State's information system
that processes claims and encounters. TexMedNet's functions include, but are not
limited to eligibility verification, claims and encounters submissions, e-mail
communications, and electronic funds transfers.
TDD means telecommunication device for the deaf. It is interchangeable with the
term Teletype machine or TTY.
TDHS means the Texas Department of Human Services or its successor agency.
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TDI means the Texas Department of Insurance or its successor agency.
TDMHMR means the Texas Department of Mental Health and Mental Retardation or its
successor agency, 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.
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. HHSC'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 HHSC, 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.
TEXAS MEDICAID SERVICE DELIVERY GUIDE means an attachment to the Texas Medicaid
Provider Procedures Manual.
HHSC 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 1 TAC Chapter 354, Subchapter J, relating to Third Party
Resources).
THIRD PARTY RECOVERY (TPR) means the recovery of payments made on behalf of a
Member by HHSC or HMO from an individual or entity with the legal responsibility
to pay for the services.
TP 40 means Type Program 40, which is a TDHS Medicaid program eligibility type
assigned to pregnant women under 185% of the federal poverty level (FPL).
TP 45 means Type Program 45, which is a TDHS Medicaid program eligibility code
assigned to newborns (under 12 months) who are born to mothers who are Medicaid
eligible at the time of the child's birth.
TXMHMR means Texas Mental Health and Mental Retardation system, which includes
the state agency, Texas Department of MHMR or its successor agency, and the
Local Mental Health and Mental Retardation Authorities.
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UNCLEAN CLAIM means a claim that does not contain accurate and complete data in
all claim fields that are required by HMO and HHSC and other HMO-published
requirements for adjudication, such as medical records, as appropriate (see
definition of Clean Claim).
URGENT BEHAVIORAL HEALTH SITUATIONS means conditions that require attention and
assessment within 24 hours but that 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, including an urgent behavioral health
situation, that 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.
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 3 PLAN ADMINISTRATIVE AND HUMAN 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 (ADA) requirements for public buildings.
Member Advocates for the service area must be located in this
office (see Section 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 HHSC no later than 30 days after the effective
date of this contract of any changes in its organizational
chart as previously submitted to HHSC.
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3.1.5.1 HMO must notify HHSC 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.
3.1.6 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,
Chapter 533, Subchapter B. 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 subdivisions with a
constitutional or statutory obligation to provide health care
to indigent patients. HHSC will 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 HHSC 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
HHSC. 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 also make
non-provider subcontracts available to HHSC upon request, at
the time and location requested by HHSC.
3.2.1.1 HHSC has 15 working days to review the subcontract
and recommend any suggestions or required changes. If
HHSC has not responded to HMO by the fifteenth day,
HMO may execute the subcontract. HHSC reserves the
right to request HMO to modify any subcontract that
has been deemed approved.
3.2.1.2 HMO must notify HHSC 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
HHSC approval (see Section 15.7). HHSC may require
HMO to provide a transition plan
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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 5, Statutory and
Regulatory Compliance, and the provisions contained
in Section 3.2.4.
3.2.2 Subcontracts that 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 within 3 working days
from HHSC'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 HHSC. HHSC
retains the authority to reject or require changes to any
provisions of the subcontract that do not comply with the
requirements or duties and responsibilities of this contract
or create significant barriers for HHSC 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
HHSC.
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 HHSC/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.
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3.2.4.3 [Contractor] understands and agrees that neither
HHSC, nor the HMO's Medicaid Members, are liable or
responsible for payment for any services authorized
and 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 HHSC of the change. If HHSC 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. [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.
3.2.4.6 [Contractor] understands that the acceptance of funds
under this Contract acts as acceptance of the
authority of the State Auditor's Office ("SAO"), or
any successor agency, to conduct an investigation in
connection with those funds. [Contractor] further
agrees to cooperate fully with the SAO or its
successor in the conduct of the audit or
investigation, including providing all records
requested.
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 with, in the form and the
language requested. HMO employees and Contractors and
subcontractors and their 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.
3.2.6 In accordance with 42 C.F.R. Section 438.230(b)(3), all
subcontractors must be subject to a written monitoring plan,
for any subcontractor carrying out a major function of the
HMO's responsibility under this contract. For all
subcontractors carrying out a major function of the HMO's
contract responsibility, the HMO must prepare a formal
monitoring process at least annually. HHSC may request copies
of written monitoring plans and the results of the HMO's
formal monitoring process.
3.2.7 In accordance with 42 C.F.R. Section 438.210(e), HMO may not
structure compensation to utilization management
subcontractors or entities to provide
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incentives to deny, limit, reduce, or discontinue medically
necessary services to any Member."
3.3 MEDICAL DIRECTOR
3.3.1 HMO must have the equivalent of a full-time Medical Director
licensed under the Texas State Board of Medical Examiners
(M.D. or D.O.). 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 necessity decisions, including
prior authorization protocols, are rendered by
qualified medical personnel and are based on HHSC's
definition of medical necessity, and is in compliance
with the Utilization Review Act and Article 21.58a,
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 HHSC Fair Hearing process.
3.3.2 The Medical Director must exercise independent medical
judgment in all medical necessity decisions. HMO must ensure
that medical necessity decisions are not adversely influenced
by fiscal management decisions. HHSC may conduct reviews of
medical necessity decisions by HMO Medical Director at any
time.
3.4 PLAN MATERIALS AND DISTRIBUTION OF PLAN MATERIALS
3.4.1 Prior to distribution to (1) Members, (2) prospective Members,
(3) providers within HMO's network, or (4) potential providers
who HMO intends to recruit
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as network providers, and with the exception of Health-related
Materials, HMO must receive written approval from HHSC for all
written materials produced or authorized by HMO containing
information about the STAR Program. Health - related Materials
do not need to be submitted for review and approval. Per HHSC
request, and on an adhoc basis, HMOs will be required to
submit a listing of Health-related Materials currently being
used, or used previously; HHSC may request the review of
selected materials from that list. HHSC will provide HMO a
reasonable amount of time to respond to such requests,
generally no less than 10 business days.
3.4.2 Member materials must meet cultural and linguistic
requirements as stated in Article 8. Unless otherwise
required, Member materials must be written at a 4th - 6th
grade reading comprehension level, and translated into the
language of any major population group, except when HHSC
requires HMO to use statutory language (i.e., advance
directives, medical necessity, etc.).
3.4.3 With the exception of Health-related Materials, all plan
materials regarding the STAR Program, including Member
education materials, must be submitted to HHSC for approval
prior to distribution. HHSC has fifteen (15) working days to
review the materials and recommend any suggestions or required
changes. If HHSC has not responded to HMO by the fifteenth
(15th) day, HMO may print and distribute these materials. HHSC
reserves the right to request HMO to modify plan materials
that are deemed approved and have been printed or distributed.
These modifications can be made at the next printing unless
substantial non-compliance exists, as determined by HHSC. An
exception to the fifteen (15) working day timeframe may be
requested in writing by HMO for written provider materials
that require a quick turn-around time (e.g., letters). HHSC
will review such request within a reasonable amount of time,
generally within five (5) working days. HHSC reserves the
right to require revisions to materials if inaccuracies are
discovered or if changes are required by changes in policy or
law. These changes can be made at the next printing unless
substantial non-compliance exists, as determined by HHSC.
3.4.4 With the exception of Health-related Materials, HMO must send
HHSC-approved English versions of HMO's Member Handbook,
Member Provider Directory, newsletters, individual Member
letters, and any written information that applies to
Medicaid-specific services to TDHS for TDHS to translate into
Spanish. TDHS must provide the written and approved
translation into Spanish to HMO no later than 15 working days
after receipt of the English version by HHSC. HMO must
incorporate the approved translation into their materials. If
TDHS has not responded to HMO by the fifteenth day, HMO may
print and distribute these materials. HHSC reserves the right
to require revisions to materials if inaccuracies are
discovered or if changes are required by changes in policy or
law. These changes can be made at the next printing
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unless substantial non-compliance exists, as determined by
HHSC. HMO has the option of using the TDHS 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.
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 HHSC with at least three paper copies and one
electronic copy of their 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
handled as inserts 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 Agreement in accordance with the standards set
forth herein. Records related to Members served in the HMO's
service area(s) must be made available in HMO's local office
when requested by HHSC.
Original records, except paper claims, must be kept in the
form they were created in the regular course of business for a
minimum of three (3) years following the expiration of the
contract period, including any extensions. Paper claims may be
digitally copied from the time of initial receipt, if the HMO:
1) receives HHSC prior written approval; 2) certifies that an
unaltered copy of the original claim received can be produced
upon request; 3) the retention system is reliable and
supported by a retrieval system that allows reasonable
accurate records. HHSC may require the HMO to retain the
records for an additional period if an audit, litigation or
administrative action involving the records exists.
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 HHSC, HHSC's designee or HHSC
acting on behalf of any agency with regulatory or statutory
authority over Medicaid Managed Care, the requested records
must be made available
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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 that
have been stored or archived must be accessible and made
available within 10 calendar days from the date of a request
by HHSC 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 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 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 or provider manual, providers to create and keep
medical records in compliance with the medical records
standards contained in Appendix O, Standards for Medical
Records. 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 HHSC for
processing.
3.5.8 The use of Medicaid funds for abortion is prohibited unless
the pregnancy is the result of a rape, incest, or continuation
of the pregnancy endangers the life of the woman. A physician
must certify in writing that based on his/her professional
judgment, the life of the mother would be endangered if the
fetus were carried to term. HMO must maintain a copy of the
certification for at least three years.
3.6 HMO REVIEW OF HHSC MATERIALS
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HHSC 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 (including Behavioral Health
telephone services), HMO must ensure adequately-staffed
telephone lines. Telephone personnel must receive customer
service telephone training. HMO must ensure that telephone
staffing is adequate to fulfill the standards of promptness
and quality listed below:
1. 80% of all telephone calls must be answered
within an average of 30 seconds;
2. The lost (abandonment) rate must not exceed
10%;
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; and
4. Telephone services must meet cultural
competency requirements (see Section 8.8)
and provide "linguistic access" to all
members as defined in Article 2. 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
that members may call 24 hours a day, 7 days a week. An
answering service or other similar mechanism that 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 day, 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); and
10. Other services covered by member services.
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3.7.2.2 HMO must provide HHSC 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 Section 7.8). This includes PCP telephone coverage
(see 28 TAC Section 11.2001(a)(1)(A)).
3.7.4 Behavioral Health Hotline Services. HMO must have emergency
and crisis Behavioral Health hotline services available 24
hours a day, 7 days a week, toll-free throughout the service
area. Crisis hotline staff must include or have access to
qualified behavioral health professionals to assess behavioral
health emergencies. Emergency and crisis behavioral health
services may be arranged through mobile crisis teams. It is
not acceptable for an emergency intake line to be answered by
an answering machine. Hotline services must meet the
requirements described in Section 3.7.1
ARTICLE 4 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 that could adversely impact its
compliance with these requirements or its ability to pay its
debts as they come due, HMO must notify HHSC immediately in
writing. If HMO becomes aware of a take-over or assignment
that would require the approval of TDI or HHSC, HMO must
notify HHSC immediately in writing.
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 HHSC within
24 hours of a change in any of the preceding representations.
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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 Texas Insurance
Code.
4.2.2 The minimum equity must be maintained during the entire
contract period.
4.3 PERFORMANCE BOND
4.3 HMO has furnished HHSC with a performance bond in the form prescribed
by HHSC and approved by TDI, naming HHSC as Obligee, securing HMO's
faithful performance of the terms and conditions of this Agreement. The
performance bond must be issued in the amount of $100,000 for the
Contract Period, plus an additional 12 months after the expiration of
the Contract Period. If the Contract Period is renewed or extended
pursuant to Article 15, the HMO must replace the performance bond with
a separate bond covering performance during the renewal or extension
period, plus an additional 12 months. The bond must be issued by a
surety licensed by TDI, and specify cash payment as the sole remedy.
HMO must deliver the bond to HHSC at the same time the signed HMO
contract, renewal or extension is delivered to HHSC.
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.
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) that 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.
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4.4.4 Any exceptions to the requirements of this Article must be
approved in writing by HHSC 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 HHSC, TDI, or their designee have the right from time to time
to examine and audit books and records of HMO, or 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 HHSC
deems to be necessary to perform its regulatory function
and/or to enforce the provisions of this contract.
4.6.2 HHSC or its designee will conduct an audit of HMO at least
once every two years. HMO is responsible for paying the costs
of an audit conducted under this Article. The costs of the
audit paid by HMO are allowable costs under this Agreement.
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 HHSC, in writing, prior to the execution of this
contract. 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 HHSC of any litigation that is initiated or threatened after the
effective date of this contract within seven days of receiving service
or becoming aware of the threatened litigation.
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4.8 MISREPRESENTATION AND FRAUD IN HMO OPERATIONS
4.8.1 INTENTIONALLY LEFT BLANK.
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. HHSC 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 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 HHSC to obtain
information from other state and federal agencies and HMO must
cooperate with HHSC in obtaining information from commercial
third party resources. HMO must require all providers to
comply with the provisions of 1 TAC Chapter 354, Subchapter J,
relating to Third Party Recovery in the Medicaid program.
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 HHSC for HHSC to pursue collection
and recovery from these resources. HHSC will forward
information on all third party resources identified by HHSC to
HMO. HMO must coordinate with HHSC to obtain information from
other state and federal agencies, including CMS for Medicare
and the Child Support Enforcement Division of the Office of
the Attorney General for medical support. HMO
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must cooperate with HHSC in obtaining and exchanging
information from commercial third party resources.
4.9.4 Recovery. HMO must actively pursue and collect from third
party resources that have been identified, except when the
cost of pursuing recovery reasonably exceeds the amount that
may be recovered by HMO. HMO is not required to, but may
pursue recovery and collection from the excepted resources
listed in Section 4.9.3. HMO must report the identity of these
resources to HHSC, 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 HHSC 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 Section 12.1.12.
If HMO fails to pursue and recover from third parties no later
than 180 days after the date of service, HHSC may pursue third
party recoveries and retain all amounts recovered without
accounting to HMO for the amounts recovered. Amounts recovered
by HHSC will be added to expected third party recoveries to
reduce future capitation rates, except recoveries from those
excepted third party resources listed in Section 4.9.3.
4.10 CLAIMS PROCESSING REQUIREMENTS
4.10.1 HMO and claims processing subcontractors must comply with 28
TAC Chapter 21, Subchapter T regarding "Submission of Clean
Claims", to the extent these rules are not in conflict with
provisions of this contract.
4.10.2 HMO must use a HHSC approved or identified claim format that
contains all data fields for final adjudication of the claim.
The required data fields must be
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complete and accurate. The HHSC required data fields are
identified in HHSC's "HMO Encounter Data Claims Submission
Manual."
4.10.3 HMO and claims processing subcontractors must comply with
HHSC's Texas Medicaid Managed Care Claims Manual (Claims
Manual), as amended or modified. The Claims Manual is
incorporated herein by reference and contains HHSC's claims
processing and reporting requirements. HHSC will provide the
HMO reasonable notice of changes to the Claims Manual. For
purposes of this section only, "reasonable notice" will
generally mean 60 days advance written notice of system
changes and 30 days advance written notice of other changes,
unless in HHSC's sole discretion, changes in federal or state
laws, rules, regulations, or policies warrant a shorter time
period for notice.
4.10.4 HMO must forward claims submitted to HMO in error to either:
1) the correct HMO if the correct HMO can be determined from
the claim or is otherwise known to HMO; 2) the State's claims
administrator; or 3) the provider who submitted the claim in
error, along with an explanation of why the claim is being
returned.
4.10.5 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.
4.10.6 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. HMO must pay providers interest on a
claim that is not adjudicated within 30 days from either: (1)
the date the HMO receives the clean claim, or (2) the date the
claim becomes clean. HMO must pay providers interest at an 18%
annual rate, calculated daily for the full period in which the
clean claim remains unadjudicated beyond the 30-day claims
processing deadline. HMO must comply with the Texas Medicaid
Managed Care Claims Manual to determine the principal amount
for the interest payment computation. 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 this contract and
could lead to damages or sanctions as outlined in Article 17.
The performance levels are subject to changes if required to
comply with federal and state laws or regulations.
4.10.6.1 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
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claim, and the date by which the requested
information must be received from the provider.
4.10.6.2 Claims that are suspended (pended internally) must be
subsequently paid-adjudicated, denied-adjudicated, or
denied for additional information (pended 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.
4.10.6.3 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 no later than 30
days prior to the effective date of the 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 HHSC.
4.10.7 HMO is subject to Article 16, Default and Remedies, for claims
that are not processed on a timely basis as required by this
contract and the Claims Manual. Notwithstanding the provisions
of Section 4.10.4, HMO's failure to adjudicate (paid, denied,
or external pended) at least ninety percent (90%) of all
claims within thirty (30) days of receipt and ninety-nine
percent (99%) within ninety (90) days of receipt for the
contract year to date is a default under Article 16 of this
contract.
4.10.8 HMO must comply with the standards adopted by the U.S.
Department of Health and Human Services under the Health
Insurance Portability and Accountability Act of 1996 (HIPAA),
Public Law 104-191, regarding submitting and receiving claims
information through electronic data interchange (EDI) that
allows for automated processing and adjudication of claims
within the federally mandated timeframes (see 45 C.F.R. parts
160 through 164).
4.10.9 For claims requirements regarding retroactive PCP changes for
mandatory Members, see Section 7.8.12.2.
4.11 INDEMNIFICATION
4.11.1 HMO/HHSC: HMO must agree to indemnify HHSC and its agents for
any and all claims, costs, damages and expenses, including
court costs and reasonable attorney's fees that 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 covered services;
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4.11.1.2 Claims arising from HMO's, HMO's network provider's
or other subcontractor's negligent or intentional
conduct in not providing covered services; and
4.11.1.3 Failure, inability, or refusal of HMO to pay any of
its network providers or subcontractors for covered
services.
4.11.2 HMO/Provider: HMO is prohibited from requiring providers to
indemnify HMO for HMO's own acts or omissions that result in
damages or sanctions being assessed against HMO either under
this contract or under state or federal law.
ARTICLE 5 STATUTORY AND REGULATORY COMPLIANCE REQUIREMENTS
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 that have not been waived by CMS. HMO must comply with
all rules relating to the Medicaid managed care program
adopted by HHSC, TDI, MHMR 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 HHSC, TDI, MHMR 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 U.S.C. Section 7401, et seq. and 33 U.S.C. Section 1251, et
seq., respectively.
5.1.4 In accordance with Texas Government Code Section 2262.003, HMO
understands that acceptance of funds under this contract acts
as acceptance of the authority of the State Auditor's Office,
or any successor agency, to conduct an audit or investigation
in connection with those funds. HMO further agrees to
cooperate fully with the State Auditor's Office or its
successor in the conduct of the audit or investigation,
including providing all records requested. HMO will ensure
that this clause concerning the authority to audit funds
received indirectly by subcontractors through HMO and the
requirement to cooperate is included in any subcontract it
awards.
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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 1320a-7), or Executive
Orders 12549 and 12689. HMO must notify HHSC 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 and 12689.
5.2.2 HMO must comply with the provisions of, and file the
certification of compliance required by the ▇▇▇▇ Anti-Lobbying
Amendment, found at 31 U.S.C. Section 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 HHSC 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 HHSC or its
authorized agent(s), HHSC, CMS, the U.S. Department of Health
and Human Services, FBI, TDI, and 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 HHSC for approval a
written fraud and abuse compliance plan that 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 the 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 HHSC 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.
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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 HHSC, 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, HHSC, and will be
provided free of charge. HMO must 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 personnel have attended OIE training prior
to the effective date of this contract, they are not
required to attend additional OIE training unless new
training is required due to changes in federal and/or
state law or regulations. If additional OIE training
is required, HHSC will notify HMO to schedule this
additional training.
5.3.3.2 If HMO updates or modifies its written fraud and
abuse compliance plan, HMO must train its executive
and essential personnel on these updates or
modifications no later than 90 days after the
effective date of the updates or modifications.
5.3.3.3 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.
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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
HHSC'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
Sections 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. HMO must
submit information in a format as specified by HHSC.
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
subcontract. The required documentation required under this
provision is not subject to disclosure under Chapter 552,
Texas Government Code.
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 The use and disclosure of all Member information, records, and
data (Member Information) collected or provided to HMO by HHSC
or another state agency is protected by state and federal law
and regulations, including, but not limited to, the Health
Insurance Portability and Accountability Act of 1996 (HIPAA)
(42 U.S.C. Sections 1320d-1320d-8), Public law 104-191, and 45
CFR parts 160 through 164. HMO agrees to ensure that any of
its agents, including subcontractors, to whom HMO discloses
Member information, agrees to the same restrictions and
conditions that apply to HMO with respect to Member
Information.
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.
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5.4.3 HMO must assist network PCPs in developing and implementing
policies for protecting the confidentiality of AIDS and
HIV-related medical information and an anti-discrimination
policy for employees and Members with communicable diseases.
Also see Texas Health and Safety Code, Chapter 85, Subchapter
E, relating to the Duties of State Agencies and State
Contractors.
5.4.4 HMO must require that subcontractors have mechanisms in place
to ensure Member's (including minor's) confidentiality for
family planning services.
5.5 NON-DISCRIMINATION
▇▇▇ 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, Executive Order
11246 (Public Law 88-352); Section 504 of the Rehabilitation
Act of 1973 (Public Law 93-112); the Americans with
Disabilities Act of 1990 (Public Law 101-336), and all
amendments to each Act, and all requirements imposed by the
regulations issued pursuant to these Acts. In addition, ▇▇▇
agrees to comply with Title 40, Chapter 73 of the Texas
Administrative Code, "Civil Rights," to the extent applicable
to this Agreement. These laws provide in part that no persons
in the United States must, 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 provided by Federal or
State funding, or otherwise be subjected to any
discrimination.
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 or certification. This requirement shall not
be construed to prohibit HMO from including providers only to
the extent necessary to meet the needs of 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)
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5.6.1 In accordance with Texas Government Code Chapter 2161, 1 TAC
Chapter 111, Subchapter B, and 1 TAC Chapter 392, Subchapter
J, state agencies are required to make a good faith effort to
assist Historically Underutilized Businesses (HUBs) in
receiving contract awards issued by the State. The goal of
this program is to promote full and equal business opportunity
for all businesses in contracting with the state. It is HHSC's
intent that all contractors make a good faith effort to
subcontract with HUBs during the performance of their
contracts.
Important Note: The Health and Human Services Commission has
concluded that HUB subcontracting opportunities may exist in
connection with this contract. See Appendix B to the Agreement
for the following instructions and form: "Grant/Subcontract
Applications Client Services HUB Subcontracting Plan
Instructions" (C-IGA) and "Determination of Good Faith Effort
for Grant Contracts" (C-DGFE). If an approved HUB
Subcontracting Plan is not already on file with HHSC, the HMO
shall submit a completed C-DGFE with the signed contract or
renewal.
5.6.2 In accordance with Article 12.11, HMO is required to submit
HUB monthly reports, in the format set forth in Appendix B of
this contract.
If HMO decides after the award to subcontract any part of the
contracted work, the HMO shall notify the HHSC Health Plan
Manager prior to entering into any subcontract. The HMO shall
comply with the good faith effort requirements relating to
developing and submitting a modified HUB Subcontracting Plan.
5.6.3 HHSC 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 Texas Government Code Section 2155.4441.
5.8 CHILD SUPPORT
5.8.1 The Texas Family Code Section 231.006 requires HHSC 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.
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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 HHSC 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 all network provider and subcontractor
contracts are subject to public disclosure under the Public
Information Act (Texas Government Code, Chapter 552). HHSC may
receive Public Information requests related to this contract
and information submitted as part of the compliance of the
contract. HHSC agrees that it will promptly deliver a copy of
any request for Public Information to HMO.
5.9.2 HHSC 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. HHSC may rely on HMO's written representations in
preparing any AG opinion request, in accordance with Texas
Government Code Section 552.305. HHSC is not liable for
failing to request an AG opinion or for releasing information
that is not deemed confidential by law, if HMO fails to
provide HHSC with specific reasons why the requested
information is exempt from the required public disclosure.
HHSC or the Office of the Attorney General will notify all
interested parties if an AG opinion is requested.
5.9.3 If HMO believes that the requested information qualifies as a
trade secret or as commercial or financial information, HMO
may request that HHSC submit the request for public
information to the Attorney General for an Open Records
Opinion. HMO must submit this request to HHSC by the date
specified in HHSC's notice of the public information request.
The HMO will be responsible for presenting all exceptions to
public disclosure to the Attorney General if an opinion is
requested.
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5.10 NOTICE AND APPEAL
5.10 HMO must comply with the notice requirements contained in 1 TAC
Section 354.2211, and the maintaining benefits and services contained
in 1 TAC Section 354.2213, whenever HMO intends to take an action
affecting the Member benefits and services under this contract. Also
see the Member appeal requirements contained in Section 8.5 of this
Agreement.
5.11 DATA CERTIFICATION
5.11.1 In accordance with 42 C.F.R. Part 438, Subpart H, HMO must
certify in writing:
(a) encounter data;
(b) delivery supplemental data and other data submitted
pursuant to this agreement or State or Federal law or
regulation relating to payment for services.
5.11.2 The certification must be submitted to HHSC concurrently with
the certified data or other documents.
5.11.3 The certification must:
(a) be signed by the HMO's Chief Executive Officer; Chief
Financial Officer; or an individual with delegated
authority to sign for, and who reports directly to,
either the Chief Executive Officer or Chief Financial
Officer; and
(b) contain a statement that to the best knowledge,
information and belief of the signatory, the HMO's
certified data or information are accurate, complete,
and truthful.
ARTICLE 6 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 CMS, except those services that are
specifically excluded and listed in Section 6.1.8 (non-capitated
services).
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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 HHSC must pay for or reimburse for all covered services
provided to SSI voluntary Members who enroll with HMO on a
voluntary basis. It is at HMO's discretion whether to provide
value-added services to voluntary Members.
6.1.3 HMO must provide covered services described in the 2004 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 that update the 2004 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 that previously applied to Medicaid eligible
individuals 21 years and older: the three-prescriptions per
month limit; and, the 30-day spell of illness limit. The
remaining expanded benefit expands the covered benefits to add
an annual adult well check.
6.1.6 VALUE-ADDED SERVICES. Value-added services that are approved
by HHSC 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 that 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
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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 HHSC 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 Section 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;
- 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 HHSC-approved
providers (Directly Observed Therapy and Contact
Investigation);
- Vendor Drugs (out-of-office drugs);
- Medical Transportation; and
- 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 noncapitated services, HMO remains responsible for
providing appropriate referrals for Members to obtain or
access these services.
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6.1.8.1 HMO is responsible for informing providers that all
non-capitated services must be submitted to HHSC for
payment or reimbursement.
6.1.9 In accordance with 42 C.F.R. Section 438.102, HMO may file an
objection to provide, reimburse for, or provide coverage of,
counseling or referral service for a covered benefit, based on
moral or religious grounds.
6.1.9.1 HMO must work with HHSC to develop a work plan to
complete the necessary tasks to be completed and
determine an appropriate date for implementation of
the requested changes to the requirements related to
covered services. The work plan will include
timeframes for completing the necessary contract and
waiver amendments, adjustments to capitation rates,
identification of HMO and enrollment materials
needing revision, and notifications to Members.
6.1.9.2 In order to meet the requirements of Section 6.1.9.1,
HMO must notify HHSC of grounds for and provide
detail concerning its moral or religious objections
and the specific services covered under the
objection, no less than 120 days prior to the
proposed effective date of the policy change.
6.1.9.3 HMO must notify all current Members of the intent to
change covered services at least 30 days prior to the
effective date of the change in accordance with 42
C.F.R. Section 438.102(b)(1)(ii)(B).
6.1.9.4 HHSC will provide information to all current Members
on how and where to obtain the service that has been
discontinued by the HMO in accordance with 42 C.F.R.
Section 438.102(c).
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
6.3 The following outlines HMO's responsibilities for payment of hospital
and freestanding psychiatric facility (facility) admissions:
6.3.1 The payor responsible for the hospital/facility charges at the
start of an inpatient stay remains responsible for
hospital/facility charges until the time of discharge, or
until such time that there is a loss of Medicaid eligibility.
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6.3.2 HMO is responsible for professional charges during every month
for which the payor receives a full capitation payment.
6.3.3 HMO is not responsible for any services after effective date
of loss of Medicaid eligibility
6.3.4 Plan Change. A Member cannot change from one STAR health plan
to another STAR health plan during an inpatient hospital stay.
6.3.5 Hospital/Facility Transfer. Discharge from one acute care
hospital/facility and readmission to another acute care
hospital/facility within 24 hours for continued treatment is
not a discharge under this contract.
6.3.6 HMO insolvency or receivership. HMO is responsible for payment
of all services provided to a person who was a Member on the
date of insolvency or receivership to the same extent they
would otherwise be responsible under this Section 6.3.
6.3.7 For purposes of this Section 6.3, a Member "loses Medicaid
eligibility" when:
6.3.7.1 Medicaid eligibility is terminated and never regained
under one Medicaid Type Program with no subsequent
transfer of eligibility to another Medicaid Type
Program; or
6.3.7.2 Medicaid eligibility is terminated and there is a
lapse of at least one month in regular Medicaid
coverage. The term "regular Medicaid coverage" refers
to either traditional fee-for-service Medicaid or
Medicaid managed care coverage; or
6.3.7.3 A client re-applies for Medicaid eligibility and is
certified for prior Medicaid coverage, as defined by
TDHS, for any month(s) prior to the month of
application. The term "prior Medicaid coverage"
refers to Applicants who are eligible for Medicaid
coverage during the three-month period before the
month they apply for TANF or Medical Programs. Prior
Medicaid coverage may be continuous or there may be
interrupted periods of eligibility involving all or
some of the certified Members.
Administrative process limitations within the State's
application and recertification process do not
constitute a "loss of Medicaid eligibility".
6.4 CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS
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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
Member wants to change her OB/▇▇▇ 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. This Article does not extend the obligation
of HMO to reimburse the Member's existing out-of-network
providers for on-going care for more than 90 days after Member
enrolls in HMO or for more than nine months in the case of a
Member who at the time of enrollment in HMO has been diagnosed
with and is receiving treatment for a terminal illness. The
obligation of HMO to reimburse the Member's existing
out-of-network provider for services provided to a pregnant
Member with 12 weeks or less remaining before the expected
delivery date extends through delivery of the child, immediate
postpartum care, and the follow-up checkup within the first
six weeks of delivery.
6.4.3.1 [THIS SECTION IS INTENTIONALLY LEFT BLANK.]
6.4.3.2 For all out-of-network provider claims, HMO must pay
providers a reasonable and customary amount
consistent with a methodology approved by HHSC. HMO
will submit its proposed out-of-network payment
methodology for the ▇▇▇▇▇▇ Service Delivery Area to
HHSC no later than March 1, 2004. HMO must forward
any complaints by out-of-network providers to HHSC,
which will review all complaints. If HHSC determines
that payment is not consistent with the HMO's
approved methodology, the HMO must pay the provider a
rate, using the approved reasonable and customary
methodology, as determined by HHSC. Failure to comply
with this provision constitutes a default under
Article 16, Default and Remedies.
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 for the Member.
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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 HHSC with policies and procedures
indicating how the HMO will provide PCP verification
as indicated in Section 6.4.5. HMOs providing PCP
verification via a telephone must meet the
requirements of Section 3.7.1.
6.4.6 HMO must provide Members with timely and adequate access to
network services for as long as those services are necessary
and covered benefits not available within the network, in
accordance with 42 C.F.R. Section 438.206(b)(4). HMO will not
be obligated to provide a Member with access to out-of-network
services if such services become available from a network
provider.
6.4.7 HMO must require through contract provisions or the Provider
Manual that each Member have access to a second opinion
regarding the use of any health care service. A Member must be
allowed access to a second opinion from a network provider or
out-of-network provider if a network provider is not
available, at no additional cost to the Member, in accordance
with 42 C.F.R. Section 438.206(b)(3).
6.5 EMERGENCY SERVICES
6.5.1 HMO policy and procedures, covered benefits, claims
adjudication methodology, and reimbursement performance for
emergency services must comply with all applicable state and
federal laws and regulations including 42 C.F.R. Section
438.114, whether the provider is in network or out of network.
6.5.2 HMO must pay for the professional, facility, and ancillary
services that are medically necessary to perform the medical
screening examination and stabilization of HMO Member
presenting as an emergency medical condition or an emergency
behavioral health condition to the hospital emergency
department, 24 hours a day, 7 days a week, rendered by either
HMO's in-network or out-of-network providers.
6.5.2.1 For all out-of-network emergency services providers,
HMO will pay a reasonable and customary amount for
emergency services. HMO policies and procedures must
be consistent with this agreement's prudent layperson
definition of an emergency medical condition and
claims adjudication processes required under Section
4.10 of this agreement and 42 C.F.R. Section 438.114.
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6.5.2.2 For all out-of-network emergency services provider
claims, HMO must pay providers a reasonable and
customary amount consistent with a methodology
approved by HHSC. HMO will submit its proposed
out-of-network emergency services payment methodology
for the ▇▇▇▇▇▇ Service Delivery Area to HHSC no later
than March 1, 2004. HMO must forward any complaints
by out-of-network emergency services providers to
HHSC, which will review all complaints. If HHSC
determines that payment is not consistent with the
HMO's approved methodology, the HMO must pay the
emergency services provider a rate, using the
approved reasonable and customary methodology, as
determined by HHSC. Failure to comply with this
provision constitutes a default under Article 16,
Default and Remedies.
6.5.3 HMO must ensure that its network primary care providers (PCPs)
have after-hours telephone availability that is consistent
with Section 7.8.10 of this contract. This telephone access
must be available 24 hours a day, 7 days a week throughout the
service area.
6.5.4 HMO cannot require prior authorization as a condition for
payment for an emergency medical condition, an emergency
behavioral health condition, or labor and delivery. HMO cannot
limit what constitutes an emergency medical condition on the
basis of lists of diagnoses or symptoms. HMO cannot refuse to
cover emergency services based on the emergency room provider,
hospital, or fiscal agent not notifying the Member's primary
care provider or HMO of the Member's screening and treatment
within 10 calendar days of presentation for emergency
services. HMO may not hold the Member who has an emergency
medical condition liable for payment of subsequent screening
and treatment needed to diagnose the specific condition or
stabilize the patient. HMO must accept the emergency physician
or provider's determination of when the Member is sufficiently
stabilized for transfer or discharge.
6.5.5 Medical Screening Examination for emergency services. A
medical screening examination needed to diagnose an emergency
medical condition shall be provided in a hospital based
emergency department that meets the requirements of the
Emergency Medical Treatment and Active Labor Act (EMTALA) 42
C.F.R. Section 489.20, Section 489.24 and Section 438.114. HMO
must pay for the emergency medical screening examination, as
required by 42 U.S.C. Section 1395dd. HMOs must reimburse for
both the physician's services and the hospital's emergency
services, including the emergency room and its ancillary
services.
6.5.6 Stabilization Services. When the medical screening examination
determines that an emergency medical condition exists, HMO
must pay for emergency services performed to stabilize the
Member. The emergency physician must document these services
in the Member's medical record. HMOs must
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reimburse for both the physician's and hospital's emergency
stabilization services including the emergency room and its
ancillary services.
6.5.7 Post-stabilization Care Services. HMO must cover and pay for
post-stabilization care services in the amount, duration, and
scope necessary to comply with 42 C.F.R. Section 438.114 and
42 C.F.R. 422.113(c). The HMO is financially responsible for
post-stabilization care services obtained within or outside
the network that are not pre-approved by a plan provider or
other HMO representative, but administered to maintain,
improve, or resolve the Member's stabilized condition if:
(a) the HMO does not respond to a request for
pre-approval within 1 hour;
(b) the HMO cannot be contacted;
(c) or the HMO representative and the treating physician
cannot reach an agreement concerning the Member's
care and a plan physician is not available for
consultation. In this situation, the HMO must give
the treating physician the opportunity to consult
with a plan physician and the treating physician may
continue with care of the patient until an HMO
physician is reached or the HMO's financial
responsibility ends as follows: the HMO physician
with privileges at the treating hospital assumes
responsibility for the Member's care; the HMO
physician assumes responsibility for the Member's
care through transfer; the HMO representative and the
treating physician reach an agreement concerning the
Member's care; or the Member is discharged.
6.5.8 HMO must provide access to the HHSC-designated Level I and
Level II trauma centers within the State or hospitals meeting
the equivalent level of trauma care. HMOs may make
out-of-network reimbursement arrangements with the
HHSC-designated Level I and Level II trauma centers to satisfy
this access requirement.
6.6 BEHAVIORAL HEALTH CARE 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.
These services are described in detail in the Texas Medicaid
Provider Procedures Manual (Provider Procedures Manual) and
the Texas Medicaid Bulletins, which is the bimonthly update to
the Provider Procedures Manual. Clinical information regarding
covered services is published by the Texas Medicaid program in
the Texas Medicaid Service Delivery Guide.
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6.6.2 HMO must maintain a behavioral health provider network that
includes psychiatrists, psychologists and other behavioral
health providers. HMO must provide or arrange to have provided
behavioral health benefits described as covered services.
These services are indicated in the Provider Procedures Manual
and the Texas Medicaid Bulletins, which is the bi-monthly
update to the Provider Procedures Manual. Clinical information
regarding covered services is published by the Texas Medicaid
Program in the Texas Medicaid Service Delivery Guide. The
network must include providers with experience in serving
children and adolescents to ensure accessibility and
availability of qualified providers to all eligible children
and adolescents in the service area. The list of providers
including names, addresses and phone numbers must be available
to HHSC upon request.
6.6.3 HMO must maintain a Member education process to help Members
know where and how to obtain behavioral health care services.
6.6.4 HMO must implement policies and procedures to ensure that
Members who require routine or regular laboratory and
ancillary medical tests or procedures to monitor behavioral
health conditions are provided the services by the provider
ordering the procedure or at a lab located at or near the
provider's office.
6.6.5 When assessing Members for behavioral health care services,
HMO and network behavioral health providers must use the
DSM-IV multi-axial classification. HHSC may require use of
other assessment instrument/outcome measures in addition to
the DSM-IV. Providers must document DSM-IV and
assessment/outcome information in the Member's medical record.
6.6.6 HMO must permit Members to self refer to any in-network
behavioral health care provider without a referral from the
Member's PCP. HMO must permit Members to participate in the
selection or assignment of the appropriate behavioral health
individual practitioner(s) who will serve them. HMO previously
submitted a written copy of its policies and procedures for
self-referral to HHSC. Changes or amendments to those policies
and procedures must be submitted to HHSC for approval at least
60 days prior to their effective date.
6.6.7 HMO must require, through contract provisions, that PCPs have
screening and evaluation procedures for detection and
treatment of, or referral for, any known or suspected
behavioral health problems and disorders. PCPs may provide any
clinically appropriate behavioral health care services within
the scope of their practice. This requirement must be included
in all Provider Manuals.
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6.6.8 HMO must require that behavioral health providers refer
Members with known or suspected physical health problems or
disorders to their PCP for examination and treatment.
Behavioral health providers may only provide physical health
care services if they are licensed to do so. This requirement
must be included in all Provider Manuals.
6.6.9 HMO must require that behavioral health providers send initial
and quarterly (or more frequently if clinically indicated)
summary reports of Members' behavioral health status to PCP.
This requirement must be included in all Provider Manuals.
6.6.10 HMO must require, through contract provisions, that all
Members receiving inpatient psychiatric services are scheduled
for outpatient follow-up and/or continuing treatment prior to
discharge. The outpatient treatment must occur within 7 days
from the date of discharge. HMO must ensure that behavioral
health providers contact Members who have missed appointments
within 24 hours to reschedule appointments.
6.6.11 HMO must provide inpatient psychiatric Covered Services to
Members under the age of 21 who have been ordered to receive
the services by a court of competent jurisdiction under the
provisions of Title VII, Subtitle C of the Texas Health and
Safety Code, relating to court-ordered commitments to
psychiatric facilities, or a placement in a state-operated
facility as a condition of probation, as authorized by the
Texas Family Code.
6.6.11.2 A Member who has been ordered to receive treatment
under the provisions of Chapter 573 or 574 of the
Texas Health and Safety Code cannot appeal the
commitment through HMO's complaint or appeals
process.
6.6.12 HMO must comply with 28 TAC Chapter 3, Subchapter HH,
regarding utilization review of chemical dependency treatment.
6.6.13 Chemical dependency treatment must conform to the standards
set forth in the Texas Administrative Code, Title 28, Chapter
3, Subchapter HH.
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
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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 Members have the right
to choose any Medicaid participating family planning provider,
whether the provider chosen by the Member is in or outside HMO
provider network. HMO must provide Members access to
information about the providers of family planning services
available 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 HHSC 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
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6.7.4.7 information on HIV/STD infection and prevention and
safer sex discussion.
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 Section 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, the required elements of a THSteps
medical screen, providing or arranging for all required lab
screening tests (including lead screening), 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 ▇▇▇▇ v.
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McKinney, 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. HMO must report provider education
and training regarding THSteps in accordance with Section
7.4.4.
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 THSteps services. Each
month HMO must retrieve a list of Members who are due and
overdue THSteps services from the TexMedCentral HMO Library.
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 HHSC 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 HHSC
Laboratory for analysis. HMO must educate providers
about THSteps program requirements for submitting
laboratory tests to the HHSC Bureau of Laboratories.
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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 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, Texas Health
and Safety Code; the standards in the ACIP Immunization
Schedule; and the 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, Texas 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 HHSC.
6.8.11 Compliance with THSteps Performance Benchmark. HHSC 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 HHSC 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 the Maternal and Infant Health
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Improvement Act (Texas Health and Safety Code, Chapter 32) and
25 TAC Chapter 37, Subchapter M.
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;
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 HHSC.
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 Section
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 specialty physicians
who are providing call coverage, routine, and/or
specialty consultation services for the period of
time covered in Section 6.9.5.
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6.9.5.1.1 HMO must adjudicate provider claims for
services provided to a newborn Member in
accordance with HHSC's claims processing
requirements using the proxy ID number or
State-issued Medicaid ID number (see
Section 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.
6.9.5.2 HMO cannot require prior authorization or PCP
assignment to adjudicate newborn claims for the
period of time covered by Section 6.9.5
6.9.6 HMO may require prior authorization requests for hospital or
professional services provided beyond the time limits in
Section 6.9.5. HMO must respond to these prior authorization
requests within the requirements of 28 TAC 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 that requires
emergency services, regardless of when the emergency
condition arises (see Section 6.5.4).
6.10 EARLY CHILDHOOD INTERVENTION (ECI)
6.10.1 ECI Services. HMO must provide all federally mandated services
contained at 34 C.F.R. Part 303., and 25 TAC Chapter 621,
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 that
identifies a Member's disability or chronic or complex
condition(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.
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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
Chapter 621.
6.10.4 Coordination. HMO must coordinate and cooperate with local ECI
programs that perform assessment in the development of the
Individual Family Service Plan (IFSP), including on-going 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. Part 303. 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 care
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 care
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 that is necessary to determine WIC eligibility,
such as height, weight, hematocrit or hemoglobin (see Section
7.16.3.2).
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; or HMO must provide
these services.
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6.11.4 HMO may use the nutrition education provided by WIC to satisfy
health education 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
Section 6.1.8 as non-capitated services. HMO must develop
policies 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 HHSC
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 HHSC (25
TAC Chapter 97). HMO must require that in-state labs report
mycobacteriology culture results positive for M. Tuberculosis
and M. Tuberculosis antibiotic susceptibility to HHSC as
required for in-state labs by 25 TAC Chapter 97, Subchapter F.
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 HHSC 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 HHSC or the local TB control program. HMO must cooperate
with the local TB control
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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 HHSC 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
Section 6.12.
6.13 PEOPLE WITH DISABILITIES OR CHRONIC OR COMPLEX CONDITIONS
6.13.1 HMO shall provide the following services to persons with
disabilities, special health care needs, or chronic or complex
conditions. These services are in addition to the covered
services described in detail in the Texas Medicaid Provider
Procedures Manual (Provider Procedures Manual) and the Texas
Medicaid Bulletin, which is the bi-monthly update to the
Provider Procedures Manual. Clinical information regarding
covered services is published by the Texas Medicaid program in
the Texas Medicaid Service Delivery Guide.
6.13.2 HMO must develop and maintain a system and procedures for
identifying Members who have disabilities, special health care
needs 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 specialty 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 HHSC must be used in determining the medically
necessary services, assessment and plan of care for each
individual.
6.13.2.1 In accordance with 42 C.F.R. 438.208(b)(3), HMO shall
provide information that identifies Members who the
HMO has assessed as special health care needs Members
to the State's enrollment broker. The information
will be provided in a format to be specified by HHSC
and updated by the 10th day of each month. In the
event that a special health care needs Member changes
health plans, HMO will work with receiving HMO to
provide information
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concerning the results of the HMO's identification
and assessment of that Member's needs, to prevent
duplication of those activities.
6.13.3 HMO must require that the PCP for all persons with
disabilities, special health care needs or chronic or complex
conditions develop 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, that 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 a primary care and specialty care provider
network for persons with disabilities, special health care
needs, 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 HHSC 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, special health care needs, or chronic or complex
conditions, including children. For services to children with
disabilities, special health care needs, or chronic or complex
conditions, HMO must have in its network PCPs and specialty
care providers that have demonstrated experience with children
with disabilities, special health care needs, 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 treatment available in
HMO's plan for Members with disabilities, special health care
needs, or chronic or complex conditions.
HMO must ensure Members with disabilities, special health care
needs, or chronic or complex conditions have direct access to
a specialist.
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, Children with Special
Health Care Needs (CSHCN), the Medically Dependent Children
Program (MDCP), Community Resource Coordination Groups
(CRCGs), Interagency Council on Early Childhood Intervention
(ECI), Home and Community-based
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Services (HCS), 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 (MTP).
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, and 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 by the Member's PCP 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 HMO must 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.
6.13.11 HMO must assist, through information and referral, eligible
Members in accessing providers of non-capitated Medicaid
services listed in Section 6.1.8, as applicable.
6.13.12 HMO must ensure that Members who require routine or regular
laboratory and ancillary medical tests or procedures to
monitor disabilities, special health
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care needs, or chronic or complex conditions are allowed by
HMO to receive the services from 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 and 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 HHSC 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.
6.14.3 Health Education Activities Report. HMO must submit, upon
request, a Health Education Activities Schedule to HHSC or its
designee listing the time and location of classes, health
fairs or other events conducted during the time period of the
request.
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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 that has been
approved by HHSC (see Section 7.16 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 TAC Chapter 97, Subchapter F, using the
required forms and procedures for reporting STDs.
6.15.6 HMO must coordinate with the HHSC 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 Section
7.16.1. HMO may contract with local or regional health
authorities to perform any of the covered services required in
Section 6.15.
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
service under this contract, the contract or agreement must
include payment provisions.
6.15.8 The subcontract with the respective HHSC regional offices and
city and county health departments, as described in Section
7.16.1, must include, but not be limited to, the following
topics:
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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
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 HHSC. 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, on-going
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 Blind and disabled Members' SSI status is effective the date
of State's eligibility system, SAVERR, identifies the Member
as Type Program 13 (TP13). On this effective date, the Member
becomes a voluntary STAR enrollee.
The State is responsible for updating the State's eligibility
system within 45 days of official notice of the Members'
federal SSI eligibility by the Social Security Administration
(SSA).
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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 the
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 HHSC 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 HHSC; and
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
Section 6.1.8).
6.16.3 HMO must require network providers to submit claims for health
and health-related services to HHSC'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 7 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 HHSC as part of HMO
subcontracting process. HMO must have its own credentialing
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process to review, approve and periodically recertify the
credentials of all participating providers in compliance with
28 TAC Section 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 newborn 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 that
is based on the American Academy of Pediatrics
schedule and delineated in the Texas Medicaid
Provider Procedures Manual and the Medicaid
bi-monthly bulletins (see Section 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.
7.1.3.5 Prenatal Care within 2 weeks of request.
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 HHSC upon request, at the time and location
requested by HHSC.
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All standard formats of provider contracts must be submitted
to HHSC for approval no later than 60 days prior to the
effective date of this contract, unless previously filed with
HHSC. HMO must submit one paper copy and one electronic copy
in a form specified by HHSC. Any change to the standard format
must be submitted to HHSC 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 5,
Statutory and Regulatory Compliance, and the provisions
contained in Section 3.2.4.
7.2.1.1 HHSC has 15 working days to review the materials and
recommend any suggestions or required changes. If
HHSC has not responded to HMO by the fifteenth day,
HMO may execute the contract. HHSC 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 Section 7.8
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 place required by HHSC or the
requesting agency. Provider contracts requested in response to
a 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 HHSC. HHSC retains the authority to reject or
require changes to any contract that does 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 HHSC reserves the right and retains the authority to make
reasonable inquiry and conduct investigations into provider
and Member complaints against HMO or any intermediary entity
with whom HMO contracts to deliver health care services under
this contract. HHSC may impose appropriate sanctions and
contract remedies to ensure HMO compliance with the provisions
of this contract.
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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
system, 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 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 that 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 HHSC STAR program. HMO must
provide copies of the HHSC/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
HHSC/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.
7.2.8.2.1 [Provider] understands and agrees that the
HMO's Medicaid enrollees are not to be held
liable for the HMO's debts in the event of
the entity's insolvency in accordance with
42 C.F.R. Section 438.106(a).
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7.2.8.3 [Provider] understands and agrees HHSC 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 bill a Medicaid 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 HHSC of the change in writing. If HHSC does
not provide written approval within 30 days from
receipt of notification from HMO, changes can be
considered provisionally approved, and will become
effective. Modifications, additions or deletions that
are required by HHSC 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 HHSC 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 HHSC or its
authorized agent(s), HHSC, CMS, 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 Medicaid
recipient to HHSC for referral to HHSC.
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
HHSC.
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 [Providers] and the
[Providers'] employees, contractors, and patients.
Requests for information must be complied with, in
the form and language requested. [Providers] and
their 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.
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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
(finalized as paid or denied adjudicated) within 30
days from the date the claim is received by HMO. HMO
must agree to pay providers interest in accordance
with Article 4.10.6 for clean claims that are not
adjudicated within 30 days.
7.2.8.11 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.
7.2.8.12 [Provider] understands that the acceptance of funds
under this Contract acts as acceptance of the
authority of the State Auditor's Office ("SAO"), or
any successor agency, to conduct an investigation in
connection with those funds. [Provider] further
agrees to cooperate fully with the SAO or its
successor in the conduct of the audit or
investigation, including providing all records
requested.
7.2.9 HMO must follow the procedures outlined in Section 843.306 of
the Texas Insurance Code if terminating a contract with a
provider, including an STP. At least 30 days before the
effective date of the proposed termination of the provider's
contract, HMO must provide a written explanation to the
provider of the reasons for termination. HMO may immediately
terminate a provider contract if the provider presents
imminent harm to patient health, actions against a license or
practice, fraud or malfeasance.
7.2.9.1 Within 60 days of the termination notice date, a
provider may request a review of HMO's proposed
termination by an advisory review panel, except in a
case in which there is imminent harm to patient
health, an action against a private license, fraud or
malfeasance. The advisory review panel must be
composed of physicians and providers, as those terms
are defined in Section 843.306 of the Texas Insurance
Code, including at least one representative in the
provider's specialty or a similar specialty, if
available, appointed to serve on the standing quality
assurance committee or utilization review committee
of HMO. The decision of the advisory review panel
must be considered by HMO but is not binding on HMO.
HMO must provide to the affected provider, on
request, a copy of the recommendation of the advisory
review panel and HMO's determination.
7.2.9.2 A provider who is terminated is entitled to an
expedited review process by HMO on request by the
provider. HMO must make a good faith effort to
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provide written notice of the provider's termination
to HMO's Members receiving primary care from, or who
were seen on a regular basis by, the terminated
provider within 15 days after receipt or issuance of
the termination notice, in accordance with 42 C.F.R.
Section 438.10(f)(5). If a provider is terminated for
reasons related to imminent harm to patient health,
HMO must notify its Members immediately of the
provider's termination.
7.2.10 HMO must notify HHSC 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. HHSC will require assurances
that any contract termination will not result in an
interruption of an essential service or major contract
function.
7.2.11 HMO must include a complaint and appeals process that complies
with the requirements of Chapter 843, Subchapter G of the
Texas Insurance Code relating to Complaint Systems in all
provider contracts. HMO's complaint and appeals process must
be the same for all providers.
7.2.12 Notice to Rejected Providers. In accordance with 42 C.F.R.
Section 438.129(a)(2), if an HMO declines to include
individual or groups of providers in its network, it must give
the affected providers written notice of the reason for its
decision.
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 HHSC 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).
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7.3.2.3 The percent of the withhold or bonus, if the
incentive plan involves a withhold bonus.
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 Sections 7.3.2.1 -
7.3.2.5 to HHSC by the effective date of this contract and
each anniversary date of the contract.
7.3.4 HMO must submit the information required in Section 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. ▇▇▇'s who put physicians
or physician groups at substantial financial risk 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 a 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 requirements above. HMO is
required to meet the requirements above 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 (e.g. behavioral health) to the
providers in the HMO network and to newly contracted providers
in the HMO network within five
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(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.
Provider Manual and any revisions must be approved by HHSC
prior to publication and distribution to providers (see
Section 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 HHSC/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 HHSC to comply with this contract.
7.4.2.2 HMO must include in all PCP training how to screen
for and identify behavioral health disorders, HMO's
referral process to behavioral health care services
and clinical coordination requirements for behavioral
health. HMO must include in all training for
behavioral health providers how to identify physical
health disorders, HMO's referral process to primary
care and clinical coordination requirements between
physical medicine and behavioral health providers.
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 and behavioral health providers
with screening tools and instruments approved by HHSC.
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 HHSC review prior to the effective date of the
contract.
7.5 MEMBER PANEL REPORTS
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HMO must furnish each PCP with a current list of enrolled
Members enrolled or assigned to that Provider no later than 5
working days after HMO receives the Enrollment File from the
Enrollment Broker each month.
7.6 PROVIDER COMPLAINT AND APPEAL PROCEDURES
7.6.1 HMO must develop, implement and maintain a provider complaint
system. The complaint and appeal procedures must be in
compliance with all applicable state and federal laws or
regulations. All Member complaints and/or appeals of an
adverse determination requested by the enrollee, or any person
acting on behalf of the enrollee, or a physician or provider
acting on behalf of the enrollee must comply with the
provisions of this Article. Modifications and amendments to
the complaint system must be submitted to HHSC 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 or in the provider manual.
7.6.3 HMO's complaint and appeal process cannot contain provisions
requiring a provider to submit a complaint or appeal to HHSC
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
7.7.1 PROVIDER QUALIFICATIONS- GENERAL
The providers in HMO network must meet the following
qualifications:
PROVIDER QUALIFICATION
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
program.
Physician An individual who is licensed to practice medicine as an M.D. or a D.O. 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
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PROVIDER QUALIFICATION
provider enrolled in the Medicaid program; and 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 Texas Health and Safety Code that 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,
special health care needs, 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. HMO may request exceptions to this requirement for specific hospitals within
their networks, from HHSC.
Non-Physician An individual holding a license issued by the applicable licensing agency
Practitioner of the State of Texas who is enrolled in the Texas Medicaid Program.
Provider
Clinical An entity having a current certificate issued under the Federal Clinical Laboratory
Laboratory Improvement Act (CLIA), and enrolled in the Texas Medicaid Program.
Rural Health An institution that meets all of the criteria for designation as a rural health clinic,
Clinic (RHC) and enrolled in the Texas Medicaid Program.
Local Health A local health department established pursuant to the Local Public Health
Department Reorganization Act (Texas Health and Safety Code, Title 2, Chapter 121).
Non-Hospital A provider of health care services that is licensed and credentialed to provide
Facility Provider services, and enrolled in the Texas Medicaid Program.
School Based Clinics located at school campuses that provide on-site primary and preventive care
Health Clinic to children and adolescents.
(SBHC)
Chemical A facility licensed by the Texas Commission on Alcohol and Drug Abuse (TCADA)
Dependency under Section 464.002 of the Texas Health and Safety Code to provide chemical
Treatment Facility dependency treatment.
Chemical An individual licensed by TCADA under Chapter 504, Texas Occupations Code, to
Dependency provide chemical dependency treatment or a master's level therapist (LMSW-ACP,
Counselor LMFT or LPC) with a minimum of two years of post-licensure experience in
chemical dependency treatment.
7.7.2 PROVIDER CREDENTIALING AND RECREDENTIALING
In accordance with 42 C.F.R. Section 438.214, HMO's standard
credentialing and recredentialing process must include the
following provisions to determine whether physicians and other
health care professionals, who are licensed by the State and
who are under contract with HMO, are qualified to perform the
services.
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7.7.2.1 Written Policies and Procedures. HMO has written
policies and procedures for the credentialing process
that includes HMO's initial credentialing of
practitioners as well as its subsequent
recredentialing, recertifying and/or reappointment of
practitioners.
7.7.2.2 Oversight by Governing Body. The Governing Body, or
the group or individual to which the Governing Body
has formally delegated the credentialing function,
has reviewed and approved the credentialing policies
and procedures.
7.7.2.3 Credentialing Entity. The plan designates a
credentialing committee or other peer review body,
which makes recommendations regarding credentialing
decisions.
7.7.2.4 Scope. The plan identifies those practitioners who
fall under its scope of authority and action. This
shall include, at a minimum, all physicians,
dentists, and other licensed health practitioners
included in the review organization's literature for
Members, as an indication of those practitioners
whose service to Members is contracted or
anticipated.
7.7.2.5 Process. The initial credentialing process obtains
and reviews verification of the following
information, at a minimum:
a) The practitioner holds a current valid
license to practice;
b) Valid Drug Enforcement Agency (DEA) or
Controlled Substance Registration (CSR)
certificate, as applicable;
c) Graduation from medical school and
completion of a residency or other
post-graduate training, as applicable;
d) Work history;
e) Professional liability claims history;
f) The practitioner holds current, adequate
malpractice insurance according to the
plan's policy;
g) Any revocation or suspension of a state
license or DEA/Bureau of Narcotics and
Dangerous Drugs (BNDD) number;
h) Any curtailment or suspension of medical
staff privileges (other than for incomplete
medical records);
i) Any sanctions imposed by Medicaid and/or
Medicare; a)
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j) Any censure by the State or County Medical
Association;
k) HMO requests information on the practitioner
from the National Practitioner Data Bank and
the State Board of Medical Examiners;
l) The application process includes a statement
by the Applicant regarding: (This
information should be used to evaluate the
practitioner's current ability to practice.)
1) Any physical or mental health
problems that may affect current
ability to provide health care;
2) Any history of chemical
dependency/substance abuse;
3) History of loss of license and/or
felony convictions;
4) History of loss or limitation of
privileges or disciplinary
activity; and
5) An attestation to
correctness/completeness of the
application.
7.7.2.6 There is an initial visit to each potential primary
care practitioner's office, including documentation
of a structured review of the site and medical record
keeping practices to ensure conformance with HMO's
standards.
7.7.2.7 Recredentialing. A process for the periodic
reverification of clinical credentials
(recredentialing, reappointment, or recertification)
is described in HMO's policies and procedures.
7.7.2.7.1 There is evidence that the procedure is
implemented at least every three years.
7.7.2.7.2 HMO conducts periodic review of information
from the National Practitioner Data Bank,
along with performance data on all
physicians, to decide whether to renew the
participating physician agreement. At a
minimum, the recredentialing,
recertification or reappointment process is
organized to verify current standing on
items listed in "7.7.2.5(a)" through
"7.7.2.5(f)" and item "7.7.2.5(l)" above.
7.7.2.7.3 The recredentialing, recertification or
reappointment process also includes review
of data from: a) Member complaints and b)
results of quality reviews.
7.7.2.8 Delegation of Credentialing Activities. If HMO
delegates credentialing (and recredentialing,
recertification, or reappointment) activities, there
is a written description of the delegated activities,
and the delegate's accountability for
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these activities. There is also evidence that the
delegate accomplished the credentialing activities.
HMO monitors the effectiveness of the delegate's
credentialing and reappointment or recertification
process.
7.7.2.9 Retention of Credentialing Authority. HMO retains the
right to approve new providers and sites and to
terminate or suspend individual providers. HMO has
policies and procedures for the suspension, reduction
or termination of practitioner privileges.
7.7.2.10 Reporting Requirement. There is a mechanism for, and
evidence of implementation of, the reporting of
serious quality deficiencies resulting in suspension
or termination of a practitioner, to the appropriate
authorities. HMO will implement and maintain policies
and procedures for disciplinary actions including
reducing, suspending, or terminating a practitioner's
privileges.
7.7.2.11 Appeals Process. There is a provider appellate
process for instances where HMO chooses to reduce,
suspend or terminate a practitioner's privileges with
the organization.
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.
7.8.1.1 HMO must provide supporting documentation, as
required by 42 C.F.R. Section 438.207(b), as
specified and requested by the State, to verify that
their provider network meets the requirements of this
contract at the time the HMO enters into a contract
and at the time of a significant change as required
by 42 C.F.R. Section 438.207(c). A significant change
can be, but is not limited to, change in ownership
(purchase, merger, acquisition), new start-up,
bankruptcy, and/or a major subcontractor change
directly affecting a provider network such as (IPA's,
BHO, medical groups, etc.).
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%).
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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.
7.8.5 HMO must have 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 HHSC determines that a PCP's Member
enrollment exceeds the PCP's ability to provide
accessible, quality care, HHSC may prohibit the PCP
from receiving further enrollments. HHSC 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 HHSC.
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); Pediatric and Family
Advanced Practice Nurses (APNs) and Certified Nurse Midwives
Women Health (CNMs) practicing under the supervision of a
physician; 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 Section 7.10).
7.8.8 The PCP for a Member with disabilities, special health care
needs, 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, special health care needs, or
chronic or complex conditions
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7.8.9 PCPs must either have admitting privileges at a hospital that
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.
Acceptable:
1. Office phone is answered after-hours by an answering
service that meets language requirements of the major
population groups and that 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
that tells patients to leave a message.
3. Office phone is answered after-hours by a recording
that directs patients to go to an Emergency Room for
any services needed.
4. Returning after-hours 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
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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".
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 that
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 to whom the Member has been
referred by the PCP. HMO must require, through
contract provisions or provider manual, that PCP
assess the advisability and availability of
outpatient treatment alternatives to inpatient
admissions. HMO must require, through contract
provisions or provider manual, 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 Section 6.8 relating to Texas
Health Steps, Section 6.9 relating to Perinatal
Services, Section 6.10 relating to Early Childhood
Intervention, Section 6.11 relating to WIC, Section
6.13 relating to People With Disabilities, special
health care needs, or chronic or complex conditions,
and Section 6.14 relating to Health Education and
Wellness and Prevention Plans. PCP must cooperate and
coordinate with HMO to provide Member and the
Member's family with knowledge of and access to
available services.
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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 HHSC default process. Members may change
PCPs at any time, but these changes are limited to four (4)
times per year.
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 that 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/▇▇▇ 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.
HMO must allow Members to change OB/GYNs up to four times per year.
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
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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 that allow its Members to directly access any OB/GYN
provider within its network, must ensure that the provisions
of Section 7.9 continue to be met.
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.
7.10 SPECIALTY CARE PROVIDERS
7.10.1 HMO must maintain specialty providers, actively serving within
that specialty, including pediatric specialty providers and
chemical dependency specialty providers, within the network in
sufficient numbers and areas of practice to meet the needs of
all Members requiring specialty care services.
7.10.2 HMO must require, through contract provisions or provider
manual, 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, psychiatric 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 HHSC, 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 that is available within the service
area such as, but not limited to, treatment of cancer, ▇▇▇▇▇,
and cardiac diseases.
7.11 SPECIAL HOSPITALS AND SPECIALTY CARE FACILITIES
7.11.1 HMO must include all medically necessary specialty services
through its network specialists, sub-specialists and specialty
care facilities (e.g., children's hospitals, licensed chemical
dependency treatment facilities and tertiary care hospitals).
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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 on-going care of the
Member.
7.11.4 HMO must include in its provider network a HHSC-designated
perinatal care facility, as established by the Maternal and
Infant Health Improvement Act (Texas Health and Safety Code,
Chapter 32) once the designated system is finalized and
perinatal care facilities have been approved for the service
area (see Section 6.9).
7.12 BEHAVIORAL HEALTH - LOCAL MENTAL HEALTH AUTHORITY (LMHA)
7.12.1 Assessment to determine eligibility for rehabilitative and
targeted MHMR case management services is a function of the
LMHA. HMO must provide all covered services described in
detail in the Texas Medicaid Provider Procedures Manual
(Provider Procedures Manual) and the Texas Medicaid Bulletin,
which is the bi-monthly update to the Provider Procedures
Manual. Clinical information regarding covered services are
published by the Texas Medicaid program in the Texas Medicaid
Service Delivery Guide. Covered services must be provided to
Members with SPMI and SED, when medically necessary, whether
or not they are also receiving targeted case management or
rehabilitation services through the LMHA.
7.12.2 HMO will coordinate with the LMHA and state psychiatric
facility regarding admission and discharge planning, treatment
objectives and projected length of stay for Members committed
by a court of law to the state psychiatric facility.
7.12.3 HMO must enter into written agreements with all LMHAs in the
service area that describes the process(es) that HMO and LMHA
will use to coordinate services for STAR Members with SPMI or
SED. The agreement will contain the following provisions:
7.12.3.1 Describe the behavioral health covered services
indicated in detail in the Provider Procedures Manual
and the Texas Medicaid Bulletin, which is the
bimonthly update to the Provider Procedures Manual.
Clinical information
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regarding covered services are published by the Texas
Medicaid Program in the Texas Medicaid Service
Delivery Guide. Also include the amount, duration,
and scope of basic and value-added services, and
HMO's responsibility to provide these services;
7.12.3.2 Describe criteria, protocols, procedures and
instrumentation for referral of STAR Members from and
to HMO and LMHA;
7.12.3.3 Describe processes and procedures for referring
Members with SPMI or SED to LMHA for assessment and
determination of eligibility for rehabilitation or
targeted case management services;
7.12.3.4 Describe how the LMHA and HMO will coordinate
providing behavioral health care services to Members
with SPMI or SED;
7.12.3.5 Establish clinical consultation procedures between
HMO and LMHA including consultation to effect
referrals and on-going consultation regarding the
Member's progress;
7.12.3.6 Establish procedures to authorize release and
exchange of clinical treatment records;
7.12.3.7 Establish procedures for coordination of assessment,
intake/triage, utilization review/utilization
management and care for persons with SPMI or SED;
7.12.3.8 Establish procedures for coordination of inpatient
psychiatric services (including court ordered
commitment of Members under 21) in state psychiatric
facilities within the LMHA's catchment area;
7.12.3.9 Establish procedures for coordination of emergency
and urgent services to Members; and
7.12.3.10 Establish procedures for coordination of care and
transition of care for new HMO Members who are
receiving treatment through the LMHA.
7.12.4 HMO must offer licensed practitioners of the healing arts, who
are part of the Member's treatment team for rehabilitation
services, the opportunity to participate in HMO's network. The
practitioner must agree to accept the standard provider
reimbursement rate, meet the credentialing requirements,
comply with all the terms and conditions of the standard
provider contract of HMO.
7.12.5 Members receiving rehabilitation services must be allowed to
choose the licensed practitioners of the healing arts who are
currently a part of the Member's treatment team for
rehabilitation services. If the Member chooses
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to receive these services from licensed practitioners of the
healing arts who are part of the Member's rehabilitation
services treatment team, HMO must reimburse the LMHA at
current Medicaid fee-for-service amounts.
7.13 SIGNIFICANT TRADITIONAL PROVIDERS (STPS)
HMO must seek participation in its provider network from:
7.13.1 Each health care provider in the service area who has
traditionally provided care to Medicaid recipients;
7.13.2 Each hospital in the service area that has been designated as
a disproportionate share hospital under Medicaid; and
7.13.3 Each specialized pediatric laboratory in the service area,
including those laboratories located in children's hospitals.
7.14 RURAL HEALTH PROVIDERS
7.14.1 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:
7.14.1.1 are the only providers located in the service area;
and
7.14.1.2 are Significant Traditional Providers.
7.14.2 In order to contract with HMO, rural health providers must:
7.14.2.1 agree to accept the prevailing provider contract rate
of HMO based on provider type; and
7.14.2.2 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.
7.14.3 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.
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7.14.4 HMO must reimburse physicians who practice in rural counties
with fewer than 50,000 persons at a rate using the current
Medicaid fee schedule, including negotiated fee-for-service.
7.15 FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS) AND RURAL HEALTH CLINICS
(RHCS)
7.15.1 HMO must make reasonable efforts to include FQHCs and RHCs
(Freestanding and hospital-based) in its provider network.
7.15.2 FQHCs or RHCs will receive a cost settlement from HHSC 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.
7.15.2.1 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 is submitted. The format will be
developed by HHSC. The FQHC and RHC must validate the
encounter and payment information contained in the
report(s). HMO and the FQHC/RHC must both 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 HHSC not later than
45 days from the end of the month for which the
report is submitted.
7.15.2.2 For FQHCs, HHSC 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, HHSC will determine the amount of the
interim settlement based on the difference between a
reasonable cost amount methodology provided by HHSC
and the amount paid by HMO to the RHC for the
quarter. HHSC will pay the FQHC or the RHC the amount
of the interim settlement, if any, as determined by
HHSC or collect and retain the quarterly recoupment
amount, if any.
7.15.2.3 HHSC 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 Section
7.15.2. HHSC will make additional payments or recoup
payments from the FQHC or the RHC based on reasonable
costs less prior interim payment settlements.
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7.15.2.4 Cost settlements for RHCs, and HMO's obligation to
provide RHC reporting described in Section 7.15.
7.16 COORDINATION WITH PUBLIC HEALTH
7.16.1 REIMBURSED ARRANGEMENTS. HMO must make a good faith effort to
enter into a subcontract for the covered health care services
as specified below with HHSC 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 that the public health
department and HMO have agreed to provide:
7.16.1.1 Sexually Transmitted Diseases (STDs) Services (see
Section 6.15);
7.16.1.2 Confidential HIV Testing (see Section 6.15);
7.16.1.3 Immunizations;
7.16.1.4 Tuberculosis (TB) Care (see Section 6.12);
7.16.1.5 Family Planning Services (see Section 6.7);
7.16.1.6 THSteps checkups (see Section 6.8); and
7.16.1.7 Prenatal services (see Section 6.9).
7.16.2 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 HHSC 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 HHSC. If an HMO is unable to enter into a
contract with public health entities, HMO must document
current and past efforts to HHSC. Documentation must be
submitted no later than 120 days after the execution of this
contract. Public health subcontracts must include the
following areas:
7.16.2.1 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.
7.16.2.2 Public Health Entity responsibilities:
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(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
accessing 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.
7.16.2.3 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 public health
providers, specialists, and health-related
service providers either within or outside
HMO's network.
(2) HMO must inform Members that confidential
healthcare 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.
7.16.2.4 Existing contracts must include the provisions in
Sections 7.16.2.1 through 7.16.2.3.
7.16.3 NON-REIMBURSED ARRANGEMENTS WITH PUBLIC HEALTH ENTITIES.
7.16.3.1 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 HHSC approval. If any changes are made to
the MOU, it must be resubmitted to HHSC. If an HMO is
unable to enter into an MOU with a public health
entity, HMO must document current and past efforts to
HHSC. Documentation must be submitted no later than
120
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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 that 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.
7.16.3.2 Coordination with Other Health and Human Services
(HHS) Programs. HMOs must make a good faith effort to
enter into a Memorandum of Understanding (MOU) with
other HHSC 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 HHSC approval. If any changes are
made to the MOU, it must be resubmitted to HHSC. If
an HMO is unable to enter into an MOU with other HHSC
programs, HMO must document current and past efforts
to HHSC. 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 HHSC 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; (1)
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(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;
(9) Cooperation with activities required of
public health authorities to conduct the
annual population and community based needs
assessment; and
(10) Coordination and follow-up of suspected or
confirmed cases of childhood lead exposure.
7.16.4 All public health contracts must contain provider network
requirements in Article 7, as applicable.
7.17 COORDINATION WITH TEXAS DEPARTMENT OF PROTECTIVE AND REGULATORY
SERVICES
7.17.1 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.
7.17.2 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 TDPRS or a
Service Plan voluntarily entered into by the parents or person
having legal custody of a minor and TDPRS that relates to the
health and behavioral health care services required to be
provided to the Member.
7.17.3 HMO cannot deny, reduce, or controvert the medical necessity
of any health or behavioral health care 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 court ordered services must be
presented and approved by the court with jurisdiction over the
matter.
7.17.4 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 HHSC for a Fair Hearing.
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7.17.5 HMO must include information in its provider training and
manuals regarding:
7.17.5.1 providing medical records;
7.17.5.2 scheduling medical and behavioral health appointments
within 14 days unless requested earlier by TDPRS; and
7.17.5.3 recognition of abuse and neglect and appropriate
referral to TDPRS.
7.17.6 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
▇▇▇▇▇▇ care.
7.18 DELEGATED NETWORKS (IPAS, LIMITED PROVIDER NETWORKS AND ANHCS)
7.18.1 All HMO contracts with any of the entities described in Texas
Insurance Code Section 843.002(30) and 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
hospitals and physicians including a physician-hospital
organization (delegated network contracts) must:
7.18.1.1 contain the mandatory contract provisions for all
subcontractors in Sections 3.2 and 7.2 of this
contract;
7.18.1.2 comply with the requirements, duties and
responsibilities of this contract;
7.18.1.3 not create a barrier for full participation to
significant traditional providers;
7.18.1.4 not interfere with HHSC's oversight and audit
responsibilities including collection and validation
of encounter data; or
7.18.1.5 be consistent with the federal requirement for
simplicity in the administration of the Medicaid
program.
7.18.2 In addition to the mandatory provisions for all subcontracts
under Sections 3.2. and 7.2, all HMO/delegated network
contracts must include the following mandatory standard
provisions:
7.18.2.1 HMO is required to include subcontract provisions in
its delegated network contracts that require the UM
protocol used by a delegated network to produce
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substantially similar outcomes, as approved by HHSC,
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
Section 16.3.12 of this contract.
7.18.2.2 Delegated networks that are delegated claims payment
responsibilities 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.
7.18.2.3 The delegated network must comply with the same
records retention and production requirements,
including Open Records requirements, as the HMO under
this contract.
7.18.2.4 The delegated network is subject to the same
marketing restrictions and requirements as the HMO
under this contract.
7.18.2.5 HMO is responsible for ensuring that delegated
network contracts comply with the requirements and
provisions of the HHSC/HMO contract. HHSC will impose
appropriate sanctions and remedies upon HMO for any
default under the HHSC/HMO contract that is caused
directly or indirectly by the acts or omissions of
the delegated network.
7.18.3 HMO cannot enter into contracts with delegated networks to
provide services under this contract that require the
delegated network to enter into exclusive contracts with HMO
as a condition for participation with HMO.
7.18.3.1 Section 17.18.3 does not apply to providers who are
employees or participants in limited provider
networks.
7.18.4 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.
7.18.5 HMO cannot delegate to a delegated network the enrollment,
re-enrollment, assignment or reassignment of a Member.
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7.18.6 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.
7.18.7 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 8 MEMBER SERVICES REQUIREMENTS
8.1 MEMBER EDUCATION
HMO must provide the Member education requirements as contained in
Article 6 at 6.5 through 6.14, and this Article of the contract.
8.2 MEMBER HANDBOOK
8.2.1 HMO must mail each newly enrolled Member a Member Handbook no
later than 5 working days after HMO receives the Enrollment
File. The Member Handbook must be written at a 4th - 6th grade
reading comprehension level. The Member Handbook must contain
all critical elements specified by HHSC. See Appendix D,
Required Critical Elements, for specific details regarding
content requirements. HMO must submit a Member Handbook to
HHSC for approval prior to the effective date of the contract
unless previously approved (see Section 3.4 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 population
groups and the visually impaired served by HMO.
8.2.3 THE MEMBER HANDBOOK AND ANY REVISIONS OR CHANGES MUST BE
APPROVED BY HHSC PRIOR TO PUBLICATION AND DISTRIBUTION TO
MEMBERS (see Section 3.4 regarding the process for plan
materials review).
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8.2.4 In accordance with 42 C.F.R. Section 438.100, HMO must
maintain written policies and procedures for informing Members
of their rights and responsibilities. HMO must notify its
Members of their right to request a copy of these rights and
responsibilities.
8.3 ADVANCE DIRECTIVES
8.3.1 Federal and state law require 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)). The written policies
and procedures must contain procedures for providing written
information regarding the Member's right to refuse, withhold
or withdraw medical treatment and mental health treatment
advance directives. HMO's policies and procedures must comply
with provisions contained in 42 CFR Section 438.6(i) and 42
CFR Part 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 the 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 right 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;
8.3.1.2.2 a Member's right to make written and
non-written Out-of-Hospital
Do-Not-Resuscitate Orders; and
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 the Member's
behalf if the Member becomes incompetent;
and
8.3.1.3 the Declaration for Mental Health Treatment, Chapter
137, Texas Civil Practice 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.
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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 limitation 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 that
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 the 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 has 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 law 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 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 HHSC any revisions to
existing approved advance 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
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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) working days from the date the HMO receives
the monthly Enrollment File from the Enrollment Broker. 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 that results in a change to the information disclosed
on the ID Card.
8.5 MEMBER COMPLAINT AND APPEAL SYSTEM
HMO must develop, implement and maintain a Member complaint and appeal
system that complies with the requirements in applicable federal and
state laws and regulations, including 42 C.F.R. Section 431.200 and 42
C.F.R. Part 483, Subpart F, "Grievance System;" and the provisions of 1
T.A.C. Chapter 357 relating to managed care organizations. The
complaint and appeal system must include a complaint process, an appeal
process, and access to HHSC's Fair Hearing System. The procedures must
be reviewed and approved in writing by HHSC. Modifications and
amendments to the Member complaint and appeal system must be submitted
to HHSC at least 30 days prior to the implementation of the
modification or amendment.
For purposes of Section 8.5., an "authorized representative" is any
person or entity acting on behalf of the Member and with the Member's
written consent. A provider may be an "authorized representative."
8.5.1 MEMBER COMPLAINT PROCESS
8.5.1.1 HMO must have written policies and procedures for
receiving, tracking, responding to, reviewing,
reporting and resolving complaints by Members or
their authorized representatives.
8.5.1.2 HMO must resolve complaints within 30 days from the
date that the complaint was received. The complaint
procedure must be the same for all Members
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under this contract. The Member or Member's
authorized representative may file a complaint either
orally or in writing. HMO must also inform Members
how to file a complaint directly with HHSC.
8.5.1.3 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.
8.5.1.4 HMO must have a routine process to detect patterns of
complaints. The process must involve management,
supervisory, and quality improvement staff in the
development of policy and procedural improvements to
address the complaints.
8.5.1.5 HMO's complaint procedures must be provided to
Members in writing and through oral interpretive
services. A written description of HMO's complaint
procedures must be available in prevalent non-English
languages identified by HHSC, at a 4th to 6th grade
reading level. HMO must include a written description
of the complaint process in the Member Handbook. HMO
must maintain and publish in the Member Handbook, at
least one local and one toll-free telephone number
with TeleTypewriter/Telecommunications Device for the
Deaf (TTY/TTD) and interpreter capabilities for
making complaints.
8.5.1.6 HMO's process must require that every complaint
received in person, by telephone or in writing must
be acknowledged and recorded in a written record and
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 (i.e., how the HMO resolved the
complaint); corrective action required; and date
resolved.
8.5.1.7 HMO is prohibited from discriminating or taking
punitive action against a Member or his or her
representative for making a complaint.
8.5.1.8 If the Member makes a request for disenrollment, the
HMO shall give the Member information on the
disenrollment process and direct the Member to the
Enrollment Broker. If the request for disenrollment
includes a complaint by the Member, the complaint
will be processed separately from the disenrollment
request, through the complaint process.
8.5.1.9 HMO will cooperate with the Enrollment Broker, HHSC,
and HHSC's Member resolution service contractors to
resolve all Member complaints. Such cooperation may
include, but is not limited to, providing information
or assistance to internal complaint committees.
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8.5.1.10 HMO must provide designated staff to assist Members
in understanding and using HMO's complaint system.
HMO's designated staff must assist Members in writing
or filing a complaint and monitoring the complaint
through the HMO's complaint process until the issue
is resolved.
8.5.2 STANDARD MEMBER APPEAL PROCESS
8.5.2.1 HMO must develop, implement and maintain an appeal
procedure that complies with the requirements in
federal laws and regulations, including 42 C.F.R.
Section 431.200 and 42 C.F.R. Part 438, Subpart F,
"Grievance System." An appeal is a disagreement with
an "action" as defined in Article 2 of the Contract.
The appeal procedure must be the same for all
Members. When a Member or his or her authorized
representative expresses orally or in writing any
dissatisfaction or disagreement with an action, the
HMO must regard the expression of dissatisfaction as
a request to appeal an action.
8.5.2.2 A Member must file a request for an internal appeal
within 30 days from receipt of the notice of the
action. To ensure continuation of currently
authorized services, however, the Member must file
the appeal on or before the later of: 10 days
following the HMO's mailing of the notice of the
action or the intended effective date of the proposed
action.
8.5.2.3 HMO must designate an officer who has primary
responsibility for ensuring that appeals 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.
8.5.2.4 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. Section 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, Article 21.58A is pre-empted by the
federal requirement.
8.5.2.5 HMO must have policies and procedures in place
outlining the role of HMO's Medical Director for an
appeal of an action. The Medical Director must have a
significant role in monitoring, investigating and
hearing appeals. In accordance with 42 C.F.R. Section
438.406, the HMO's policies and procedures must
require that individuals who make decisions on
appeals were not
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involved in any previous level of review or
decision-making, and, are health care professionals
who have the appropriate clinical expertise, as
determined by HHSC, in treating the Member's
condition or disease.
8.5.2.6 HMO must provide designated staff to assist Members
in understanding and using HMO's appeal process.
HMO's designated staff must assist Members in writing
or filing an appeal and monitoring the appeal through
the HMO's appeal process until the issue is resolved.
8.5.2.7 HMO must have a routine process to detect patterns of
appeals. The process must involve management,
supervisory, and quality improvement staff in the
development of policy and procedural improvements to
address the appeals.
8.5.2.8 HMO's appeal procedures must be provided to Members
in writing and through oral interpretive services. A
written description of HMO's appeal procedures must
be available in prevalent non-English languages
identified by HHSC, at a 4th to 6th grade reading
level. HMO must include a written description in the
Member Handbook. HMO must maintain and publish in the
Member Handbook at least one local and one toll-free
telephone number with TTY/TTD and interpreter
capabilities for requesting an appeal of an action.
8.5.2.9 HMO's process must require that every oral appeal
received must be confirmed by a written, signed
appeal by the Member or his or her representative,
unless the Member or his or her representative
requests an expedited resolution. All appeals must be
recorded in a written record and logged with the
following details: date notice is sent; effective
date of the action; date the Member or his or her
representative requested the appeal; date the appeal
was followed up in writing; identification of the
individual filing; nature of the appeal; disposition
of the appeal; notice of disposition to Member.
8.5.2.10 HMO must send a letter to the Member within 5
business days acknowledging receipt of the appeal
request. Except as provided in Section 8.5.3.2, HMO
must complete the entire appeal process within 30
calendar days after receipt of the initial written or
oral request for appeal. The timeframe may be
extended up to 14 calendar days if the Member
requests an extension; or the HMO shows that there is
a need for additional information and how the delay
is in the Member's interest. If the timeframe is
extended, the HMO must give the Member written notice
of the reason for delay if the Member had not
requested the delay.
8.5.2.11 During the appeal process, HMO must provide the
Member a reasonable opportunity to present evidence,
any allegations of fact or law, in person as well as
in writing. The HMO must inform the Member of the
time available
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for providing this information, and in the case of an
expedited resolution, that limited time will be
available (see Section 8.5.3.2).
8.5.2.12 HMO must provide the Member and his or her
representative opportunity, before and during the
appeals process, to examine the Member's case file,
including medical records and any other documents
considered during the appeal process. HMO must
include, as parties to the appeal, the Member and his
or her representative or the legal representative of
a deceased Member's estate.
8.5.2.13 In accordance with 42.C.F.R. Section 438.420, HMO
must continue the Member's benefits currently being
received by the Member, including the benefit that is
the subject of the appeal, if all of the following
criteria are met: 1) the Member or his or her
representative files the appeal timely (as defined in
Section 8.5.2.2); 2) the appeal involves the
termination, suspension, or reduction of a previously
authorized course of treatment; 3) the services were
ordered by an authorized provider; 4) the original
period covered by the original authorization has not
expired; and 5) the Member requests an extension of
the benefits. If, at the Member's request, the HMO
continues or reinstates the Member's benefits while
the appeal is pending, the benefits must be continued
until one of the following occurs: the Member
withdraws the appeal; 10 days pass after the HMO
mails the notice, providing the resolution of the
appeal against the Member, unless the Member, within
the 10-day timeframe, has requested a State fair
hearing with continuation of benefits until a State
fair hearing decision can be reached; a state fair
hearing office issues a hearing decision adverse to
the Member; the time period or service limits of a
previously authorized service has been met.
8.5.2.14 In accordance with 42 C.F.R. Section 438.420(d), if
the final resolution of the appeal is adverse to the
Member, and upholds the HMO's action, then to the
extent that the services were furnished to comply
with Section 8.5.2.13, the HMO may recover such costs
from the Member.
8.5.2.15 If the HMO or state fair hearing officer reverses a
decision to deny, limit, or delay services that were
not furnished while the appeal was pending, the HMO
must authorize or provide the disputed services
promptly, and as expeditiously as the Member's health
condition requires.
8.5.2.16 If the HMO or state fair hearing officer reverses a
decision to deny authorization of services and the
Member received the disputed services while the
appeal was pending, the HMO will be responsible for
the payment of services.
8.5.2.17 HMO is prohibited from discriminating against a
Member or his or her representative for making an
appeal.
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8.5.3 EXPEDITED HMO APPEALS
8.5.3.1 In accordance with 42 C.F.R. Section 438.410, HMO
must establish and maintain an expedited review
process for appeals, when the HMO determines (for a
request from a Member) or the provider indicates (in
making the request on the Member's behalf or
supporting the Member's request) that taking the time
for a standard resolution could seriously jeopardize
the Member's life or health. HMO must follow all
appeal requirements for standard Member appeals, as
set forth in Section 8.5.2, except where differences
are specifically noted. Requests for expedited
appeals must be accepted orally or in writing.
8.5.3.2 HMO must complete investigation and resolution of an
appeal relating to an ongoing emergency or denial of
continued hospitalization: (1) in accordance with the
medical or dental immediacy of the case; and (2) not
later than one business day after the complainant's
request for appeal is received.
8.5.3.3 Members must exhaust the HMO's expedited appeal
process before making a request for an expedited
state fair hearing. After HMO receives the request
for an expedited appeal, it must hear an approved
requests for a Member to have an expedited appeal and
notify the Member of the outcome of the appeal within
3 business days, except as stated in 8.5.3.2. This
timeframe may be extended up to 14 calendar days if
the Member requests an extension; or the HMO shows
(to the satisfaction of HHSC, upon HHSC's request)
that there is a need for additional information and
how the delay is in the Member's interest. If the
timeframe is extended, the HMO must give the Member
written notice of the reason for delay if the Member
had not requested the delay.
8.5.3.4 If the decision is adverse to the Member, procedures
relating to the notice in Section 8.5.5 must be
followed. The HMO is responsible for notifying the
Member of their rights to access an expedited state
fair hearing. HMO will be responsible for providing
documentation to the State and the Member, indicating
how the decision was made, prior to state's expedited
fair hearing.
8.5.3.5 The HMO must ensure that punitive action is neither
taken against a provider who requests an expedited
resolution or supports a Member's request.
8.5.3.6 If the HMO denies a request for expedited resolution
of an appeal, it must: (1) transfer the appeal to the
timeframe for standard resolution set forth in
Section 8.5.2, and (2) make a reasonable effort to
give the Member prompt oral notice of the denial, and
follow up within two calendar days with a written
notice.
8.5.4 ACCESS TO STATE FAIR HEARING
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8.5.4.1 HMO must inform Members that they generally have the
right to access the state fair hearing process in
lieu of the internal appeal system provided by HMO
procedures set forth in Sections 8.5.2 and 8.5.3. The
notice must comply with the requirements of 1 T.A.C.
Chapter 357. In the case of an expedited State Fair
Hearing Process, the HMO must inform the Member that
he or she must first exhaust the HMO's internal
expedited appeal process.
8.5.4.2 HMO must notify Members that they may be represented
by an authorized representative in the state fair
hearing process.
8.5.5 NOTICES OF ACTION AND DISPOSITION OF APPEALS
8.5.5.1 NOTICE OF ACTION.
HMO must notify the Member, in accordance with 1
T.A.C. Chapter 357, whenever HMO takes an action as
defined in Article 2 of this contract. The notice
must contain the following information:
(a) the action the HMO or its contractor has taken
or intends to take; (b) the reasons for the
action;
(c) the Member's right to access the HMO internal
appeal process, as set forth in Sections 8.5.2
and 8.5.3, and/or to access to the State Fair
Hearing Process as provided in Section 8.5.4;
(d) the procedures by which Member may appeal HMO's
action;
(e) the circumstances under which expedited
resolution is available and how to request it;
(f) the circumstances under which a Member can
continue to receive benefits pending resolution
of the appeal (see Section 8.5.2.13), how to
request that benefits be continued, and the
circumstances under which the Member may be
required to pay the costs of these services;
(g) the date the action will be taken;
(h) a reference to the HMO policies and procedures
supporting the HMO's action;
(i) an address where written requests may be sent
and a toll-free number that the Member can call
to request the assistance of a Member
representative, file an appeal, or request a
Fair Hearing;
(j) an explanation that Members may represent
themselves, or be represented by a provider, a
friend, a relative, legal counsel or another
spokesperson;
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(k) a statement that if the Member wants a HHSC
Fair Hearing on the action, Member must make,
in writing, the request for a Fair Hearing
within 90 days of the date on the notice or the
right to request a hearing is waived;
(l) a statement explaining that HMO must make its
decision within 30 days from the date the
appeal is received by HMO, or 3 business days
in the case of an expedited appeal; and a
statement explaining that the hearing officer
must make a final decision within 90 days from
the date a Fair Hearing is requested; and
(m) any other information required by 1 T.A.C.
Chapter 357 that relates to a managed care
organization's notice of action.
8.5.5.2 TIMEFRAME FOR NOTICE OF ACTION
In accordance with 42 C.F.R. Section 438.404(c), the
HMO must mail a notice of action within the following
timeframes:
(1) For termination, suspension, or reduction of
previously authorized Medicaid-covered
services, within the timeframes specified in 42
C.F.R.Sections 431.211, 431.213, and 431.214.
(2) For denial of payment, at the time of any
action affecting the claim.
(3) For standard service authorization decisions
that deny or limit services, within the
timeframe specified in 42 C.F.R. Section
438.210(d)(1).
(4) If the HMO extends the timeframe in accordance
with 42 C.F.R. Section 438.210(d)(1), it must--
(a) Give the Member written notice of the
reason for the decision to extend the
timeframe and inform the Member of the
right to file a grievance if he or she
disagrees with that decision; and
(b) Issue and carry out its determination as
expeditiously as the Member's health
condition requires and no later than the
date the extension expires.
(5) For service authorization decisions not
reached within the timeframes specified
in 42 C.F.R. Section 438.210(d) (which
constitutes a denial and is thus an
adverse action), on the date that the
timeframes expire.
(6) For expedited service authorization
decisions, within the timeframes
specified in 42 C.F.R. Section
438.210(d).
8.5.5.3. NOTICE OF DISPOSITION OF APPEAL. In accordance with
42 C.F.R. Section 438.408(e), HMO must provide
written notice of disposition of all appeals
including expedited appeals. The written resolution
notice must include the results and date of the
appeal resolution. For decisions not wholly in the
Members favor, the notice must contain:
(a) the right to request a fair hearing,
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(b) how to request a state fair hearing,
(c) the circumstances under which the Member can
continue to receive benefits pending a hearing
(see Section 8.5.2.13),
(d) how to request the continuation of benefits,
(e) if the HMO's action is upheld in a hearing, the
Member may be liable for the cost of any
services furnished to the Member while the
appeal is pending; and
(f) any other information required by 1 T.A.C.
Chapter 357 that relates to a managed care
organization's notice of disposition of an
appeal."
8.5.5.4 TIMEFRAME FOR NOTICE OF RESOLUTION OF APPEALS. In
accordance with 42 C.F.R. Section 438.408, HMO must
provide written notice of resolution of appeals,
including expedited appeals, as expeditiously as the
Member's health condition requires, but the notice
must not exceed the timelines as provided in 8.5.2 or
8.5.3. For expedited resolution of appeals, HMO must
make reasonable efforts to give the Member prompt
oral notice of resolution of the appeal, and follow
up with a written notice within the timeframes set
forth in Section 8.5.3. If the HMO denies a request
for expedited resolution of an appeal, HMO must
transfer the appeal to the timeframe for standard
resolution as provided in Section 8.5.2. and make
reasonable efforts to give the Member prompt oral
notice of the denial, and follow up within two
calendar days with a written notice."
8.6 [THIS SECTION IS INTENTIONALLY LEFT BLANK]
8.7 MEMBER ADVOCATES
8.7.1 HMO must provide Member Advocates to assist Members. 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 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
HHSC Fair Hearing requested (see Sections 8.5.4).
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. Member 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.
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8.7.4 Member Advocates must provide outreach to Members and
participate in HHSC-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 HHSC prior to the
effective date of this contract unless previously submitted.
Modifications and amendments to the written plan must be
submitted to HHSC no later 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 regarding guidelines and the provision of
auxiliary aids and services, in compliance with the
Americans with Disabilities Act, Title III, and
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 HHSC
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
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8.8.2.6 A description of how HMO will help Members access
culturally and linguistically appropriate community
health or social service 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 U.S.C. Section 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
Bill of Rights and Responsibilities as adopted by the
Texas Health and Human Services Commission and
contained at 1 TAC Chapter 353, Subchapter C. The
Member Bill of Rights and Responsibilities assures
Members the right "to have interpreters, if needed,
during appointments with their providers and when
talking 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. HMOs 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;
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; provided that the Member is
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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 percent or more of the Medicaid
population in the service area, as specified by HHSC. 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 or arrange access to TDD to Members who are
deaf or hearing impaired.
8.9 CERTIFICATION DATE
8.9.1 On the date of the new Member's enrollment, HHSC will provide
HMOs with the Member's Medicaid certification date.
ARTICLE 9 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
HHSC. The media may include but are not limited to: written materials,
such as brochures, posters, or fliers that can be mailed directly to
the Member or left at Texas Department of Human Services eligibility
offices; HHSC-sponsored community enrollment events; and paid or public
service announcements on radio. All marketing materials must be
approved by HHSC prior to distribution (see Section 3.4).
9.1.1 HMO may not make any assertion or statement (orally or in
writing) that it is endorsed by the CMS, a Federal or State
government or agency, or similar entity.
9.2 MARKETING ORIENTATION AND TRAINING
9.2.1 HMO must require that all HMO staff having direct marketing
contact with Members as part of their job duties and their
supervisors satisfactorily complete HHSC's marketing
orientation and training program, conducted by HHSC or health
plan staff trained by HHSC, prior to engaging in marketing
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activities on behalf of HMO. HHSC will notify HMO of scheduled
orientations.
9.2.2 Marketing Policies and Procedures. HMO must adhere to the
Marketing Policies and Procedures as set forth by the Health
and Human Services Commission.
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 HHSC-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 potential Member enrolls in their HMO. Free
health screenings cannot be used to discourage less healthy
potential Members from joining HMO. All gifts must be approved
by HHSC 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
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9.4.1 The provider directory and any revisions must be approved by
HHSC prior to publication and distribution to prospective
Members (see Section 3.4.1 regarding the process for plan
materials review). The directory must contain all critical
elements specified by HHSC. 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 Except as provided in Section 9.4.4, 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 HHSC 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 HHSC each
quarter. If an electronic format is not available, five paper
copies must be sent. HHSC will forward two updated provider
directories, along with its approval notice, to the Enrollment
Broker to facilitate the distribution of the directories.
9.4.4 Beginning May 1, 2004, the HMO may update the provider
directories on a monthly basis to provide distribution of the
most accurate network to potential members. Such monthly
reprints will continue for no more than a total of four
months. During this time, HMO is responsible for submitting
draft updates to HHSC only if changes other than PCP
information are incorporated. HMO is responsible for sending
three final paper copies and one electronic copy of each
update to HHSC. If an electronic format is not available, five
paper copies must be sent. HHSC will forward two updated
provider directories, along with its approval notice, to the
Enrollment Broker to facilitate the distribution of the
directories.
ARTICLE 10 MANAGEMENT INFORMATION SYSTEM (MIS ) REQUIREMENTS
10.1 MODEL MIS (MMIS) REQUIREMENTS
10.1.1 HMO must maintain an 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.
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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 change in
Business Practices/Policies within the timeframe negotiated
between HHSC and the HMO.
10.1.3.1. HMO must notify and advise Health and Human Services
Commission Information Technology (HHSC-IT) of major
systems changes and implementations. HMO is required
to provide an implementation plan and schedule of
proposed system change at the time of this
notification.
10.1.3.2. HHSC-IT conducts a Systems Readiness test to
validate the contractor's ability to meet the MMIS
requirements. This is done through systems
demonstration and performance of specific MMIS and
subsystem functions. The System Readiness test may
include a desk review or an onsite review and is
conducted for the following events:
- A new plan is brought into the program;
- An existing plan begins business in a new SDA;
- An existing plan changes location; and
- An existing plan changes their processing
system.
10.1.3.3. Desk Review. HHSC will conduct an expedited
readiness desk review for the purposes of this
contract. HMO must complete and pass systems desk
review prior to onsite systems testing conducted by
HMO.
10.1.3.4. Onsite Review. HMO is required to provide a detailed
and comprehensive Disaster and Recovery Plan, and,
if onsite systems testing is requested by HHSC,
complete and pass an onsite Systems Facility Review
during the State's onsite systems testing.
10.1.3.5. HMO is required to provide a Corrective Action Plan
in response to HHSC Systems Readiness Testing
Deficiencies no later than 10 working days after
notification of deficiencies by HHSC.
10.1.3.6 HMO is required to provide representation to attend
and participate in the HHSC Systems Workgroup as a
part of the Systems Scan Call.
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 complete encounter data of all capitated services
within the scope of services of the contract between HMO and
HHSC. Encounter data must follow the format,
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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 HHSC.
Original records will be made available for inspection by HHSC
for validation purposes. Data that do not meet quality
standards must be corrected and returned within a time period
specified by HHSC.
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 HHSC. Any exceptions will
be considered on a code-by-code basis after HHSC receives
written notice from HMO requesting an exception. HMO must also
use the provider numbers as directed by HHSC for both
encounter and fee-for-service claims submissions.
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 HHSC 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 HHSC at
least 30 days prior to the effective date of the change.
Official points of contact must be provided to HHSC 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 The Contractor's system must be able to meet all
eight MIS Model Guidelines as listed below. The
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 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;
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5. Utilization/Quality Improvement Subsystem;
6. Reporting Subsystem;
7. Interface Subsystem; and
8. TPR Subsystem.
10.1.9 HMO must submit a joint interface plan (JIP) in a format
specified by HHSC. The JIP will include required information
on all contractor interfaces that support the Medicaid
Information Systems. The submission of the JIP will be in
accordance with the HMO's Readiness Review and submitted prior
to any major system changes thereafter.
10.2 SYSTEM-WIDE FUNCTIONS
HMO MIS system must include functions and/or features that 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;
8. Must have written process and procedures manuals that document
and describe all manual and automated system procedures and
processes for all the above functions and features, and the
various subsystem components; and
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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 that require Membership data. It must have functions and/or
features, that 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 HHSC;
3. Maintain data on enrollments/disenrollments and complaint
activities. The data must include reason or type of
disenrollment, complaint, and resolution by incident;
4. Receive, translate, edit and update files in accordance with
HHSC requirements prior to inclusion in HMO's MIS. Updates
will be received from HHSC'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;
10. Search records by a variety of fields (e.g., name, unique
identification numbers, date of birth, SSN, etc.) for
eligibility verification; and
11. Send PCP assignment updates to HHSC or its designee, in the
format as specified by HHSC or its designee. Updates can be
sent as often as daily but must be sent at least weekly.
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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, age restrictions, and
other services if approved out- of-network);
7. Support national provider number format (UPIN, NPIN, CLIA,
TPI, etc., as required by HHSC);
8. Provide Provider Network and Affiliation files 90 days prior
to implementation and updates monthly. Format will be provided
by HHSC to contracted entities;
9. Support the national CLIA certification numbers for clinical
laboratories; and
10. Exclude providers from participation that have been identified
by HHSC as ineligible or excluded. Files must be updated to
reflect period and reason for exclusion.
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10.5 ENCOUNTER/CLAIMS PROCESSING SUBSYSTEM
The encounter/claims processing subsystem must collect, process, and
store data on all health care 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 HHSC.
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 Submission Manual;
3. Edit and audit to ensure allowed services are provided by
eligible providers for Members;
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 HHSC 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; 1.
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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;
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 HHSC;
17. Receive and capture value-added services codes; and
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 100% of all
accounting functions including cost accounting, inventory, fixed
assets, payroll, general ledger, accounts receivable, accounts payable,
financial statement presentation, and any additional data required by
HHSC. 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;
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2. Produce financial statements in conformity with Generally
Accepted Accounting Principles (GAAP) and in the format
prescribed by HHSC;
3. Provide information on potential third party payers;
information specific to the Member; 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; and
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 that 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:
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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 HHSC;
5. [THIS SUBSECTION IS INTENTIONALLY LEFT BLANK]
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. [THIS SUBSECTION IS INTENTIONALLY LEFT BLANK]
10. Provides fraud and abuse detection, monitoring and reporting;
11. Meets minimum report/data collection/analysis functions of
Article 11 and Appendix A - Standards For Quality Improvement
Programs; and
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 HHSC. It allows HMO to develop various
reports to enable HMO management and HHSC to make decisions regarding
HMO activity.
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Functions and Capabilities:
1. Produces standard, HHSC-required reports and ad hoc reports
from the data available in all MIS subsystems. All reports
will be submitted as a paper copy or electronically in a
format approved by HHSC;
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 Member eligibility listing by PCP (panel report);
7. Report on PCP change by reason code;
8. Report on TPL (COB) information to HHSC;
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; and
12. Produce Member/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 site. Some file
transfers and E-mail will be handled through this mechanism.
10.9.3 Provider Network and Affiliation Files. The HMO will supply
network provider data to the Enrollment Broker and Claims
Administrator. This data will consist of a Provider Network
File and a Provider Affiliation File. The
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HMO will submit the Provider Network File to the Enrollment
Broker and the Provider Affiliation File to the Claims
Administrator. Both files shall accomplish the following
objectives:
1. Provide identifying information for all managed care
providers (e.g. name, address, etc.);
2. Maintain history on provider
enrollment/disenrollment;
3. Identify PCP capacity;
4. Identify any restrictions (e.g., age, sex, etc.);
5. Identify number and types of specialty providers
available to Members; and
6. Provide other Master Provider File information
identified by HHSC.
10.9.4 Eligibility/Enrollment Interface. The enrollment interface
must provide eligibility data between HHSC 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; and
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. HHSC'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. HHSC will provide a data file that contains
information on enrollees that have other insurance. Because
Medicaid is the payer of last
Page 125 of 173
resort, all services and encounters should be billed to the
other insurance companies for recovery. HHSC will also provide
an insurance company data file that contains the name and
address of each insurance company.
10.9.8 HHSC will provide a diagnosis file that will give the code and
description of each diagnosis permitted by HHSC.
10.9.9 HHSC will provide a procedure file that contains the
procedures that must be used on all claims and encounters.
This file contains HCPCS, revenue, and ICD9-CM surgical
procedure codes.
10.9.10 HHSC will provide a provider file that contains the Medicaid
provider numbers, and the provider's names and addresses. The
provider number authorized by HHSC must be submitted on all
claims, encounters, and network provider submissions.
10.10 TPR SUBSYSTEM
HMO's third party recovery (TPR) 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 HHSC as specified by HHSC;
and
3. Receive TPL data from HHSC to be used in claim and encounter
processing.
10.11 YEAR 2000 (Y2K) COMPLIANC[THIS SECTION IS INTENTIONALLY LEFT BLANK]
10.12 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) COMPLIANCE
10.12.1 HMO must provide its Members with a privacy notice as required
by HIPAA. The 4th to 6th grade reading level has been waived
for the notices and are allowable at a 12th grade reading
level. The HMO is not required to send the notice out in
Spanish but must reference on their English notice, in
Spanish, where to call to obtain a copy. HMO must provide HHSC
with a copy of their privacy notice for filing, but does not
need to have HHSC approval.
Page 126 of 173
10.12 Health Insurance Portability and Accountability Act (HIPAA) Compliance.
HMO's system must comply with applicable certificate of coverage and
data specification and reporting requirements promulgated pursuant to
the Health Insurance Portability and Accountability Act (HIPAA) of
1996, P.L. 104-191 (August 21, 1996), as amended or modified.
ARTICLE 11 QUALITY ASSURANCE AND QUALITY IMPROVEMENT PROGRAM
11.1 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM
HMO must develop, maintain, and operate a quality assessment and
performance improvement program consistent with the requirements of 42
C.F.R. Section 438.240 and Sections 10.7, 12.10 and Appendix A of this
agreement.
11.2 WRITTEN QIP PLAN
HMO must have on file with HHSC 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 HHSC 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 HHSC or its
designee upon request. HMO must notify HHSC no later than 90 days prior
to terminating any subcontract affecting a major performance function
of this contract (see Section 3.2.1.2).
11.4 ACCREDITATION
If HMO is accredited by an external accrediting agency, documentation
of accreditation must be provided to HHSC. HMO must provide HHSC with
their accreditation status upon request.
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11.5 BEHAVIORAL HEALTH INTEGRATION INTO QIP.
Behavioral Health Integration into QIP. If an HMO provides behavioral
health services, it must integrate behavioral health into its quality
assessment and performance improvement program and include a systematic
and on-going process for monitoring, evaluating, and improving the
quality and appropriateness of behavioral health care services provided
to Members. HMO must collect data, monitor and evaluate for
improvements to physical health outcomes resulting from behavioral
health integration into the overall care of the Member.
11.6 QIP REPORTING REQUIREMENTS
HMO must meet all of the QIP Reporting Requirements contained in
Article 12.
11.7 PRACTICE GUIDELINES
In accordance with 42 C.F.R. Section 438.236, HMO must adopt practice
guidelines, that are based on valid and reliable clinical evidence or a
consensus of health care professionals in the particular field;
consider the needs of the HMO's Members; are adopted in consultation
with contracting health care professionals; and are reviewed and
updated periodically as appropriate. The HMO must disseminate the
guidelines to all affected providers and, upon request to Members and
potential Members. The HMO's decisions regarding utilization
management, member education, coverage of services, and other areas
included in the guidelines, must be consistent with the HMO's
guidelines.
ARTICLE 12 REPORTING REQUIREMENTS
12.1 FINANCIAL REPORTS
12.1.1 MCFS Report. HMO must submit the Managed Care Financial
Statistical Report (MCFS) included in Appendix I. The report
must be submitted to HHSC no later than 30 days after the end
of each state fiscal year quarter (i.e., June 30, Sept. 30)
and must include complete and updated financial and
statistical information for each month of the state fiscal
year-to-date reporting period. 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,
Page 128 of 173
ANHCs, Limited Provider Networks) in its MCFS Report. For
purposes of completing the MCFS, HMO may report allowable
administrative expenses, as defined by HHSC's "Cost Principles
for Administrative Expenses," incurred on or after February
12, 2004, the date of the Parties' original Letter of Intent.
12.1.2 [THIS SUBSECTION IS INTENTIONALLY LEFT BLANK]
12.1.3 [THIS SUBSECTION IS INTENTIONALLY LEFT BLANK]
12.1.4 Final MCFS Reports. HMO must file two final MCFS Reports. The
first final report must reflect expenses incurred during the
contract period and paid through the 90th day after the end of
the contract period. The first final report must be filed on
or before the 120th day after the end of the contract period.
The second final report must reflect expenses incurred during
the contract period and paid through the 334th day after the
end of the contract period. The second final report must be
filed on or before the 365th day after the end of the contract
period.
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 HHSC.
12.1.6 Affiliate Report. HMO must submit an Affiliate Report to HHSC
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 Affiliates; and
12.1.6.2 A schedule of all transactions with Affiliates that,
under the provisions of this Contract, will be
allowable as expenses in Part 1 of the MCFS Report
for services provided to HMO by the Affiliates for
the prior approval of HHSC. Include financial terms,
a detailed description of the services to be
provided, and an estimated amount that will be
incurred by HMO for such services during the
Contract period.
12.1.7 [THIS SUBSECTION IS INTENTIONALLY LEFT BLANK]
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
HCFA1513 must also be filed no later than 30
Page 129 of 173
days after any change in control, ownership, or affiliation of
HMO. Forms may be obtained from HHSC.
12.1.9 Section 1318 Financial Disclosure Report. HMO must file an
updated CMS Public Health Service (PHS) "Section 1318
Financial Disclosure Report" no later than 30 days after the
end of the contract year and no later than 30 days after
entering into, renewing, or terminating a relationship with an
affiliated party. These forms may be obtained from HHSC.
12.1.10 [THIS SUBSECTION IS INTENTIONALLY LEFT BLANK]
12.1.11 ▇▇▇▇ ▇▇▇▇. HMO must furnish a written ▇▇▇▇ ▇▇▇▇ to manage
incurred-but-not-reported (IBNR) expenses, and a description
of the method of insuring against insolvency, including
information on all existing or proposed insurance policies.
The Plan must include the methodology for estimating IBNR. The
plan and description must be submitted to HHSC no later than
60 days after the effective date of this contract. Changes to
the IBNR plan and description must be submitted to HHSC no
later than 30 days before changes to the plan are implemented
by HMO.
12.1.12 Third Party Recovery (TPR) Reports. HMO must file quarterly
Third Party Recovery (TPR) Reports in accordance with the
format developed by HHSC. 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:
Medicaid HMO Contract Deliverables Manager, HPO Division,
Texas Health and Human Services Commission, P.O. Box 13247,
Austin, Texas 78711-3247 (Exception: The MCFS Report may be
submitted to HHSC via E-mail to ▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇▇▇.▇▇.▇▇).
12.1.14 Bonus and/or Incentive Payment Plan. The HMO must furnish a
written Bonus and/or Incentive Payments Plan to HHSC to
determine whether such payments are allowable administrative
expenses in accordance with Appendix L, "Cost Principles for
Administrative Expenses, 11. Compensation for Personnel
Services, i. Bonuses and Incentive Payments." The written plan
must include a description of the plan's criteria for
establishing bonus and/or incentive payments, the methodology
to calculate bonus and/or incentive payments, and the timing
as to when these bonus and/or incentive payments are to be
paid. The plan and description must be submitted to HHSC for
approval no later than 30 days after the execution of the
contract and any contract renewal. If the HMO revises the
Bonus and/or Incentive Payment Plan, the HMO must submit the
revised plan to HHSC for approval prior to implementing the
plan.
Page 130 of 173
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 HHSC in the Encounter
Data Submission Manual. Encounters must be submitted by HMO to
HHSC 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
HHSC. 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 HHSC.
Original records must be made available to validate all
encounter data.
12.2.4 HMO cannot submit newborn encounters to HHSC 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 HHSC 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 HHSC. Exceptions or additional codes must be submitted for
approval before HMO uses the codes.
12.2.7 HMO must use its HHSC-specified identification numbers on all
encounter data submissions. Please refer to the HHSC Encounter
Data Submission Manual for further specifications.
12.2.8 HMO must validate all encounter data using the encounter data
validation methodology prescribed by HHSC prior to submission
of encounter data to HHSC.
Page 131 of 173
12.2.9 Claims Reports. HMO must comply with Claims Reports submission
requirements specified in HHSC's Texas Managed Care Claims
Manual. The reports must be submitted to HHSC in a format
specified within the Texas Medicaid Managed Care Claims Manual
and/or report templates provided by HHSC.
12.2.10 Medicaid Disproportionate Share Hospital (DSH) Reports. HMO
must file preliminary and final Medicaid Disproportionate
Share Hospital (DSH) reports, required by HHSC 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
HHSC. 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 HHSC (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 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
12.4 HMO must submit a Summary Report of Provider Complaints. HMO must also
reports complaints submitted to its subcontracted risk groups (e.g.,
IPAs). The complaint report format must be submitted not later than 45
days following the end of the state fiscal quarter in a format
specified by HHSC.
12.5 PROVIDER NETWORK REPORTS
12.5.1 Provider Network Report. 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 HHSC and can be submitted
as often as daily but must be submitted at least weekly.
Page 132 of 173
12.5.2 Provider Termination Report. HMO must submit a monthly report
that identifies any providers who cease to participate in
HMO's provider network, either voluntarily or involuntarily.
The report must be submitted to HHSC in the format specified
by HHSC. 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.
12.5.3. PCP Error Report. HMO must submit to the Enrollment Broker an
electronic file summarizing changes in PCP assignments. The
file must be submitted in a format specified by HHSC and can
be submitted as often as daily but must be submitted at least
weekly. When HMO receives a PCP assignment Error Report/File,
HMO must send corrections to HHSC or its designee within five
working days.
12.6 MEMBER COMPLAINTS & APPEALS
HMO must submit a quarterly summary report of Member complaints and
appeals. HMO must also report complaints and appeals submitted to its
subcontracted risk groups (e.g., IPAs). The complaint and appeals
report must be submitted not later than 45 days following the end of
the state fiscal quarter in a format specified by HHSC.
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 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
12.8.1 Written Program Description. MCO has a written utilization
management program description that includes, at a minimum,
procedures to evaluate medical necessity, criteria used,
information sources and the process used to review and approve
the provision of medical services.
Page 133 of 173
12.8.2 Scope. The program has mechanisms to detect underutilization
as well as overutilization, including but not limited to
generation of provider profiles.
12.8.3 Preauthorization and Concurrent Review Requirements. For MCOs
with preauthorization or concurrent review program:
12.8.3.1 Qualified medical professionals supervise
preauthorization and concurrent review decisions.
12.8.3.2 Efforts are made to obtain all necessary
information, including pertinent clinical
information, and consult with the treating physician
as appropriate.
12.9 [THIS SUBSECTION IS INTENTIONALLY LEFT BLANK]
12.10 QUALITY IMPROVEMENT REPORTS
12.10.1 [THIS SUBSECTION IS INTENTIONALLY LEFT BLANK]
12.10.2 [THIS SUBSECTION IS INTENTIONALLY LEFT BLANK]
12.10.3 [THIS SUBSECTION IS INTENTIONALLY LEFT BLANK]
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 HHSC or its designee during an on-site review.
12.10.5 Written Annual Report. HMO must file a written annual report
with HHSC describing the HMO's quality assessment and
performance improvement projects
12.10.6 Encounter Data. In accordance with 42 C.F.R. 438.240(c)(2),
HMO must submit the encounter data identified in Section 10.5
of this agreement at least monthly to HHSC, so that HHSC may
complete a performance measurement report.
Page 134 of 173
12.11 HUB REPORTS
HMO must submit monthly reports documenting HMO's HUB program efforts
and accomplishments in a format provided by HHSC.
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 HHSC Claims Administrator no later than 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 18 sanctions and money damages.
12.14 MEMBER HOTLINE PERFORMANCE REPORT
HMO must submit, on a monthly basis, a Member Hotline Performance
Report that contains all required elements set out in Section 3.7 of
this Agreement in a formant approved by HHSC. The report is due on the
30th of the month following the end of each month.
12.15 SUBMISSION OF STAR DELIVERABLES/REPORTS
12.15.1 Electronic Mail. STAR deliverables and reports should be
submitted to HHSC via electronic mail unless HHSC expressly
provides that they must be submitted in a different manner.
Reports and deliverables that may not be submitted
electronically include, but are not limited to: Encounter
Data, Supplemental Delivery Payment data, UDT data, and
certain Member Materials.
12.15.1.1 The e-mail address for deliverables submission is
▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇▇▇.▇▇.▇▇.
12.15.1.2 Electronic Mail Restrictions:
File Size: E-mail file size is limited to 2.5 MB.
Files larger than that will need to be compressed
(zip file) or split into multiple files for
submission.
Confidentiality: Routine STAR deliverables/reports
should not contain any member specific data that
would be considered confidential.
Page 135 of 173
12.15.2 FQHC and RHC Deliverables. HMO may submit FQHC and RHC
deliverables by uploading the required information to the HMO
Deliverables Library on the TexMedCentral site. The uploaded
data must contain a unique 8-digit control number. HMO should
format the 8-digit control number as follows:
- 2 digit plan code identification number;
- Julian date; and then
- HMO's 3-digit report number (i.e., HMO's
first report will be 001).
After uploading the data to the TexMedCentral, the HMO must
notify HHSC via e-mail that it has uploaded the data, and
include the name of the file and the TexMedCentral Library in
which the deliverable was placed. HMO must also mail signed
original report summaries, including the corresponding 8-digit
control number, to HHSC within three (3) business days after
uploading the data to the TexMedCentral.
12.15.3 Special Submission Needs. In special cases where other
submission methods are necessary, HMO must contact the
assigned Health Plan Manager for authorization and
instructions.
12.15.4 Deliverables due via Mail. HMO should mail reports and
deliverables that must be submitted by mail to the following
address:
Electronic Mail:
▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇▇▇.▇▇.▇▇
General Mail:
Texas Health & Human Services Commission
HPO Contract Deliverables - H320
▇▇▇▇ ▇. ▇▇▇▇ ▇▇▇▇▇▇
▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇
Overnight Mail:
Texas Health & Human Services Commission
HPO Contract Deliverables - H320
▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇./▇▇▇▇. H
Austin, TX 78758
12.15.5 Texas Department of Insurance (TDI). The submission of
deliverables/reports to HHSC does not relieve the Plan of any
reporting requirements/ responsibility with TDI. The Plan
should continue to report to TDI as they have in the past."
Page 136 of 173
ARTICLE 13 PAYMENT PROVISIONS
13.1 CAPITATION AMOUNTS
13.1.1 HHSC 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, except as provided in Section
8.5.2.14, for health care services covered by this contract.
HMO and network providers must inform Member of costs for
non-covered services prior to rendering such services and must
obtain a signed Private Pay form from Member.
13.1.2 The monthly capitation amounts and the Delivery Supplemental
Payment (DSP) amount, as of the Effective Date, are listed
below.
MONTHLY
RISK GROUP CAPITATION AMOUNTS
------------------------------- ------------------
TANF Children (> 1 year of Age) $ 82.80
TANF Adults $170.86
Pregnant Women $342.49
Newborns* ((up to 12 Months of Age) $349.61
Expansion Children (> 12 Months of Age) $ 82.18
Federal Mandate Children $ 68.23
Disabled/Blind Administration $ 14.00
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: $2,817.00
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
Page 137 of 173
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, 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 identified in Section 13.1.2.
13.1.2.3 HMO must submit a monthly DSP Report (report) that
includes the data elements specified by HHSC. HHSC
will consult with contracted HMOs prior to revising
the report data elements and requirements. The
reports must be submitted to HHSC in the format and
time specified by HHSC. 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 that
are not reported by HMO to HHSC 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 HHSC within five (5) days from the
date of a HHSC request for documents.
13.1.2.5 The DSP will be made by HHSC 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
Section 13.1.2.
13.1.3 [THIS SUBSECTION IS INTENTIONALLY LEFT BLANK].
13.1.4 The monthly premium payment to HMO is based on monthly
enrollments adjusted to reflect money damages set out in
Section 18.8 and adjustments to premiums in Section 13.4.
13.1.5 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.
13.1.6 Payment of monthly capitation amounts is subject to
availability of appropriations. If appropriations are not
available to pay the full monthly
Page 138 of 173
capitation amounts, HHSC will equitably adjust capitation
amounts for all participating HMOs, and reduce scope of
service requirements as appropriate.
13.1.7 HMO rates include pass through funds for providers, as
appropriate by the 77th Texas Legislature. HMO must file
reports on pass through methodology expenditures as requested
by HHSC.
13.2 EXPERIENCE REBATE TO STATE
13.2.1 HMO must pay to HHSC an experience rebate for each Experience
Rebate Period. Experience Rebate Period 1 will begin on June
1, 2004 and end on August 31, 2004, unless extended by
contract amendment. The Parties may also amend the contract to
include additional Experience Rebate Periods. HMO will
calculate the experience rebate in accordance with the tiered
rebate formula listed below based on Net Income Before Taxes
(excess of allowable revenues over allowable expenses) as set
forth in Appendix I. The HMO's calculations are subject to
HHSC approval, and HHSC reserves the right to have an
independent audit performed to verify the information provided
by HMO.
GRADUATED REBATE FORMULA
------------------------------------------------------------------
NET INCOME BEFORE
TAXES AS A PERCENTAGE
OF REVENUES HMO SHARE HHSC 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 Experience Rebate Period Losses: Losses
incurred for one Experience Rebate Period can only be carried
forward as an offset to Net Income before Taxes in the next
Experience Rebate Period.
13.2.2.1 HMO shall calculate the experience rebate by applying the
experience rebate formula in Section 13.2.1.
Page 139 of 173
For SFY 2004 the experience rebate formula will be applied to
the sum of the Net Income Before Taxes for all CHIP, STAR
Medicaid, and STAR+PLUS Medicaid services areas contracted
between HHSC or TDHS and HMO.
13.2.3 Experience rebate will be based on a pre-tax basis. Expenses
for value-added services are excluded from the determination
of Net Income Before Taxes reported in the Final MCFS Report;
however, HMO may subtract from Net Income Before Taxes,
expenses incurred for value added services for the experience
rebate calculations.
13.2.4 [THIS SUBSECTION IS INTENTIONALLY LEFT BLANK]
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 Net Income Before Taxes
reduced by any value-added services expenses in the first
Final MCFS Report and shall be paid on the same day that the
first Final MCFS Report is submitted to HHSC. The second
settlement shall be an adjustment to the first settlement and
shall be paid on the same day that the second Final MCFS
Report is submitted to HHSC if the adjustment is a payment
from HMO to HHSC. If the adjustment is a payment from HHSC to
HMO, HHSC shall pay such adjustment to HMO within thirty (30)
days of receipt of the second Final MCFS Report. HHSC or its
agent may audit the MCFS Reports. If HHSC determines that
corrections to the MCFS Reports are required, based on an
audit of other documentation acceptable to HHSC, to determine
an adjustment to the amount of the second settlement, then
final adjustment shall be made within three (3) years from the
date that HMO submits the second Final MCFS Report. HMO must
pay the first and second settlements on the due dates for the
first and second Final MCFS Reports, respectively, as
identified in Section 12.1.4. HHSC may adjust the experience
rebate if HHSC determines HMO has paid (an) affiliate(s)
amounts for goods or services that are higher than the fair
market value of the goods and services in the service area.
Fair market value may be based on the amount HMO pays (a)
non-affiliate(s) or the amount another HMO pays for the same
or similar goods and services in the service area. HHSC has
final authority in auditing and determining the amount of the
experience rebate.
13.2.6 Interest on any experience rebate owed to HHSC shall be
charged beginning on the date that the first and/or second
settlements are overdue to the date of the respective payment.
In addition, if any adjusted amount is owed to HHSC at the
final settlement date, then interest is charged on the
adjusted amount owed beginning on the second settlement date
to the date of the final settlement payment. Interest charged
shall be calculated on an annual and
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simple basis using the current Prime Rate(s) established by
the federal government.
13.3 PERFORMANCE OBJECTIVES
13.3.1 Performance Objectives. Performance Objectives are contained
in Appendix K of this contract. HMO must meet the benchmarks
established by HHSC for each objective.
13.4 ADJUSTMENTS TO PREMIUM
13.4.1 HHSC may recoup premiums paid to HMO in error. Error may be
either human or machine error on the part of HHSC or an agent
or contractor of HHSC. HHSC 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.
13.4.2 HHSC 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. HHSC will not recoup
premium if HMO has provided covered services to the Member
during the period of time for which premium has been paid.
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13.4.3 HHSC 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.
13.4.4 HHSC 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.
13.4.5 Recoupment or adjustment of premium under Sections 13.4.1
through 13.4.4 may be appealed using the HHSC dispute
resolution process.
13.4.6 HHSC 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 Section 15.2. Adjustment
to premium under this subsection may not be appealed using the
HHSC dispute resolution process.
13.5 NEWBORN AND PREGNANT WOMEN PAYMENT PROVISIONS
13.5.1 Newborns born to Medicaid eligible mothers who are enrolled in
HMO are enrolled into HMO for 90 days following the date of
birth.
13.5.1.1 The mother of the newborn Member may request that
the newborn's health plan coverage be changed to
another HMO during the first 90 days following the
date of birth, but may only do so through the
Medicaid managed care Enrollment Broker.
13.5.2 ENROLLMENT BROKER will provide HMO with a daily enrollment
file that 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. HHSC will guarantee capitation payments
to HMO for all newborns who appear on the ENROLLMENT BROKER
daily enrollment file as HMO Members for each month the
newborn is enrolled in the HMO.
13.5.3 All non-TP45 newborns whose mothers are HMO Members at the
time of the birth will be retroactively enrolled into the HMO
by TDHS Data Control except as outlined in Section 13.5.4.
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13.5.4 Newborns who appear on the ENROLLMENT BROKER daily enrollment
file but do not appear on the ENROLLMENT BROKER monthly
enrollment or adjustment file before the end of the sixth
month following the date of birth will not be retroactively
enrolled into the HMO. HHSC 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.
13.5.5 The Enrollment Broker will provide a daily enrollment file
that will list all TP40 Members who received State-issued
Medicaid I.D. numbers, for each HMO. HHSC will guarantee
capitation payments to the HMOs for all TP40 Members who
appear on the capitation and capitation adjustment files. The
Enrollment Broker will provide a pregnant women exception
report to the HMOs that can be used to reconcile the pregnant
women daily enrollment file with the monthly enrollment,
capitation and capitation adjustment files.
13.5.6 HMO is responsible for payment for all covered services
provided to TP40 members by in-network or out-of-network
providers from the date of enrollment in HMO, but prior to HMO
receiving TP40 Member on monthly capitation file. HMO must
waive requirement for prior authorization (or grant
retroactive prior authorization) for medically necessary
services provided from the date of enrollment in HMO, but
prior to HMO receiving TP40 member on monthly capitation file.
ARTICLE 14 ELIGIBILITY, ENROLLMENT, AND DISENROLLMENT
14.1 ELIGIBILITY DETERMINATION
14.1.1 HHSC 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.
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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.
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 aged 6-18
whose families' income is below 100% Federal Poverty
Income Limit.
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 Medicaid recipients from this group who
elect to enroll in HMO.
14.1.3.1 DISABLED AND BLIND INDIVIDUALS WITHOUT MEDICARE -
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.
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14.2 ENROLLMENT
14.2.1 HHSC has the right and responsibility to enroll and disenroll
eligible individuals into the STAR program. HHSC 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 HHSC, 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 HHSC. HHSC has the
authority to limit enrollment into HMO if the number and
distance limitations are exceeded.
14.2.3 HHSC makes no guarantees or representations to HMO regarding
the number of eligible Medicaid recipients who will ultimately
be enrolled as STAR Members of HMO.
14.2.4 HMO must cooperate and participate in all HHSC sponsored and
announced enrollment activities. HMO must have a
representative at all HHSC enrollment activities unless an
exception is given by HHSC. The representative must comply
with HMO's cultural and linguistic competency plan (see
Cultural and Linguistic requirements in Section 8.9). 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
HHSC or its Enrollment Broker to assist potential Members in
making informed choices.
14.2.5 HHSC will provide HMO with at least 10 days written notice of
all HHSC planned activities. Failure to participate in, or
send a representative to a HHSC sponsored enrollment activity
is a default of the terms of the contract. Default may be
excused if HMO can show that HHSC failed to provide the
required notice, or if HMO's absence is excused by HHSC.
14.2.6 HHSC will notify existing enrollees in the ▇▇▇▇▇▇ Service
Delivery Area that, effective June 1, 2004, Amerigroup will be
available for choice as an HMO network provider through the
normal enrollment process. The notice will comply with CMS
requirements regarding such notification, and will include a
provider directory and comparison chart.
14.2.6.1 Beginning 90 days after HHSC mails the notice
described in Section 14.2.6, HHSC will conduct a
periodic evaluation to determine if HMO has been
assigned a disproportionate share of TP40 Members.
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In the event that HMO's TP40 Members make up 4.5% of the total
population of the ▇▇▇▇▇▇ Service Delivery Area, HHSC will
suspend default enrollment of TP40 Members in the HMO until it
has had an opportunity to review and, if necessary, revise the
standard HHSC default methodology to ensure that the level of
TP40 Members HMO receives is based on a proportion of the
▇▇▇▇▇▇ Service Delivery Area norm.
14.2.7 Effective June 1, 2004, new enrollees in the ▇▇▇▇▇▇ Service
Delivery Area will be subject to HHSC's normal enrollment
processes and the default methodologies specified below:
14.2.7.1 Beginning June 1, 2004, HHSC will assign HMO 100% of
the default general membership until, for two
consecutive months, HMO's enrollment reaches a level
of 15,000 Members.
14.2.7.2 After HMO's enrollment reaches a level of 15,000
Members for two consecutive months, HHSC's standard
default methodologies will apply.
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 request a plan
change for her newborn during the first 90 days by
contacting the Enrollment Broker. If a change is
approved, the Enrollment Broker will notify both
plans involved in the process. If no alternative to
the plan change can be reached, the Enrollment
Broker will notify the HMO of the newborn plan
change request received from the mother.
14.3.2 HMO must establish and implement written policies and
procedures to require professional and facility 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 HMO must match the proxy ID number and the
State-issued Medicaid ID number once the
State-issued Medicaid ID number is received.
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14.3.2.3 HMO must submit a Form 7484A to TDHS Data Control
requesting TDHS Data Control to research TDHS's
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 birth. If
TDHS finds that no Medicaid ID number has been
issued to the newborn, TDHS 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. HHSC will manually reconcile payment
to the HMO for services provided from the date of birth for
all Medicaid eligible newborns as described in Section 13.5.4.
14.4 DISENROLLMENT
14.4.1 HMO has a limited right to request a Member be disenrolled
from HMO without the Member's consent. HHSC 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 Member misuses or loans Member's HMO membership card
to another person to obtain services.
14.4.1.2 Member is disruptive, unruly, threatening or
uncooperative to the extent that Member's membership
seriously impairs HMO's or provider's ability to
provide services to Member or to obtain new Members,
and 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).
14.4.2.1 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.
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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 HHSC'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 services that 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 Section 8.2.1).
14.6 ENROLLMENT REPORTS
14.6.1 HHSC 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 HHSC will provide monthly HMO Enrollment Reports to HMO on or
before the first of the month.
14.6.3 HHSC will provide Member verification to HMO and network
providers through telephone verification or TexMedNet.
ARTICLE 15 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 HHSC. HMO is given express, limited authority
to exercise the State's right of recovery as provided in Section 4.9.
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15.2 AMENDMENT AND CHANGE REQUEST PROCESS
15.2.1 HHSC and HMO may amend this contract if reductions in funding
or appropriations make full performance by either party
impracticable or impossible, and amendment could provide a
reasonable alternative to termination. If HMO does not agree
to the amendment, the contract may be terminated under Article
18.
15.2.2 This contract must be amended if either party discovers a
material omission of a negotiated or required term that 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 Section 15.9.
15.2.3 This contract may be amended at any time by mutual agreement.
15.2.4 All amendments to this contract must be in writing and signed
by both parties.
15.2.5 Any change in either party's obligations under this contract
("Change") requires a written amendment to the contract that
is negotiated using the process outlined in Section 15.2.6.
15.2.6 Change Request Process.
15.2.6.1 If federal or state laws, rules, regulations,
policies or guidelines are adopted, promulgated,
judicially interpreted or changed, or if contracts
are entered into or changed, the effect of which is
to alter the ability of either party to fulfill its
obligations under this contract, the parties will
promptly negotiate in good faith, using the process
outlined in Section 15.2.6, appropriate
modifications or alterations to the contract and any
appendix (appendices) or attachments(s) made a part
of this contract.
15.2.6.2 Change Order Approval Procedure
15.2.6.2.1 During the term of this contract, HHSC
or HMO may propose changes in the
services, deliverables, or other aspects
of this contract ("Changes"), pursuant
to the procedures set forth in this
article.
15.2.6.2.2 If HHSC proposes a Change, it shall
deliver to the HMO a written notice
describing the proposed Change that
includes the State's estimated fiscal
impact on the HMO, if available ("Change
Order
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Request"). HMO must respond to such
proposal within 30 calendar days of
receipt by preparing and delivering to
HHSC, at no additional cost to HHSC a
written document (a "Change Order
Response") that specifies:
15.2.6.2.2.1 The financial impact, if
any, of the Change Order
Request on the HMO and the
manner in which such
impact was calculated;
15.2.6.2.2.2 The effect, if any, of the
Change Order Request on
HMO's performance of its
obligations under this
contract, including the
effect on the services or
deliverables;
15.2.6.2.2.3 The anticipated time
schedule for implementing
the Change Order Request;
and
15.2.6.2.2.4 Any other information
requested in the Change
Order Request or that is
reasonably necessary for
HHSC to make an informed
decision regarding the
proposal.
15.2.6.2.3 If HMO proposes a Change, it must
deliver a HMO Change Order Request to
HHSC that includes the proposed Change
and information described in Sections
15.2.6.2.2.1 - 15.2.6.2.2.4 for a Change
Order Response. HHSC must respond to HMO
within 30 calendar days of receipt of
this information.
15.2.6.2.4 Upon HHSC's receipt of a Change Order
Request or a Change Order Response, the
Parties shall negotiate a resolution of
the requested Change in good faith. The
parties will exchange information in
good faith in an attempt to agree upon
the requested Change.
15.2.6.3 No Change to the services or deliverables or any
other aspect of this contract will become effective
without the written approval and execution of a
mutually agreeable written amendment to this
contract by HHSC and the HMO. Under no
circumstances will the HMO be entitled to payment
for any work or services rendered under a Change
Order that has not been approved by HHSC in
accordance with the Change Order Procedures.
15.2.7 The implementation of an amendment to this contract is subject
to the approval of the Centers for Medicare and Medicaid
Services (CMS, formerly called HCFA).
15.3 LAW, JURISDICTION AND VENUE
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Venue and jurisdiction shall be in the state and federal district
courts of ▇▇▇▇▇▇ 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 that 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 HHSC. This provision does not
prevent HMO from subcontracting duties and responsibilities to
qualified subcontractors. If HHSC consents to an assignment of this
contract, a transition period of 90 days will run from the date the
assignment is approved by HHSC so that Members' services are not
interrupted and, if necessary, the notice provided for in Section 15.7
can be sent to Members. The assigning HMO must also submit a transition
plan, as set out in Section 18.2.1, subject to HHSC's approval.
15.7 MAJOR CHANGE IN CONTRACTING
HHSC 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 Members to re-select their plan and
PCP. HHSC 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 HHSC for review and approval. After HHSC has approved the
letter for distribution to Members, HMO will bear the cost of sending
the notice letter.
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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 HHSC in accordance with
Chapter 2260, Texas Government Code, will be used to attempt to resolve
all disputes arising under this contract. This process is located in 1
TAC Chapter 382, Subchapter C. All disputes arising under this contract
shall be resolved through HHSC's dispute resolution procedures, except
where a remedy is provided for through HHSC'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 HHSC for
this contract, and the federal waiver granting HHSC 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
HHSC 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 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 registered mail, facsimile, and/or hand
delivery. All notices to HHSC shall be addressed to: Medicaid HMO
Contract Deliverables Manager, HPO Division, Texas Health and
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Human Services Commission, P.O. Box 13247, Austin, Texas 78711-3247,
with a copy to the Contract Administrator. Notices to HMO shall be
addressed to President/CEO, ▇▇▇▇ ▇. ▇▇▇▇▇, M.D., AMERIGROUP Texas,
Inc., ▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇ ▇▇▇, ▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇.
15.13 SURVIVAL
The provisions of this contract that 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 CMS.
15.14 GLOBAL DRAFTING CONVENTIONS
15.14.1 The terms "include," "includes," and "including" are terms of
inclusion, and where used in the Agreement, are deemed to be
followed by the words "without limitation.
15.14.2 Any references to "Sections," "Exhibits," or "Attachments" are
deemed to be references to Sections, Exhibits, or Attachments
to the Agreement.
15.14.3 Any references to agreements, contracts, statutes, or
administrative rules or regulations in the Agreement are
deemed references to these documents as amended, modified, or
supplemented from time to time during the term of the
Agreement.
ARTICLE 16 DEFAULT AND REMEDIES
16.1 DEFAULT BY HHSC
16.1.1 FAILURE TO MAKE CAPITATION PAYMENTS
Failure by HHSC to make capitation payments when due is a
default under this contract.
16.1.2 FAILURE TO PERFORM DUTIES AND RESPONSIBILITIES
Failure by HHSC to perform a material duty or responsibility
as set out in this contract is a default under this contract.
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16.2 REMEDIES AVAILABLE TO HMO FOR HHSC'S DEFAULT
HMO may terminate this contract as set out in Section 18.1.5 of this
contract if HHSC commits either of the events of default set out in
Section 16.1.
16.3 DEFAULT BY HMO
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 care
services, including claims payment; encounter data submission;
filing any report when due; cooperating in good faith with
HHSC, an entity acting on behalf of HHSC, 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 HHSC for this HMO Default
All of the listed remedies are in addition to all
other remedies available to HHSC 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 HHSC in exercising
all or part of any remaining remedies.
For HMO's failure to perform an administrative
function under this contract, HHSC may:
- Terminate the contract if the
applicable conditions set out in
Section 18.1.1 are met;
- Suspend new enrollment as set out
in Section 18.3;
- Assess liquidated money damages as
set out in Section 18.4; and/or
- Require forfeiture of all or part
of the TDI performance bond as set
out in Section 18.9.
16.3.2 ADVERSE ACTION AGAINST HMO BY TDI
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Termination or suspension of HMO's TDI Certificate of
Authority or any adverse action taken by TDI that HHSC
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 HHSC for this HMO Default
All of the listed remedies are in addition to all
other remedies available to HHSC 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 HHSC in exercising
all or part of any remaining remedies.
For an adverse action against HMO by TDI, HHSC may:
- Terminate the contract if the
applicable conditions set out in
Section 18.1.1 are met;
- Suspend new enrollment as set out
in Section 18.3; and/or
- Require forfeiture of all or part
of the TDI performance bond as set
out in Section 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
obligations as they come due is a default under this contract.
16.3.3.1 Remedies Available to HHSC for this HMO Default
All of the listed remedies are in addition to all
other remedies available to HHSC 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 HHSC in exercising
all or part of any remaining remedies.
For HMO's insolvency, HHSC may:
- Terminate the contract if the
applicable conditions set out in
Section 18.1.1 are met;
- Suspend new enrollment as set out
in Section 18.3; and/or
- Require forfeiture of all or part
of the TDI performance bond as set
out in Section 18.9.
16.3.4 FAILURE TO COMPLY WITH FEDERAL LAWS AND REGULATIONS
Page 155 of 173
Failure of HMO to comply with the federal requirements for
Medicaid, including, but not limited to, federal law regarding
misrepresentation, fraud, or abuse; and, by incorporation,
Medicare standards, requirements, or prohibitions, is a
default under this contract.
The following events are defaults under this contract pursuant
to 42 U.S.C. Sections 1396b(m)(5), 1396u-2(e)(1)(A):
16.3.4.1 HMO's substantial failure to provide medically
necessary items and services that are required
under this contract to be provided to Members;
16.3.4.2 HMO's imposition of premiums or charges on Members
in excess of the premiums or charge 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 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 CMS, HHSC, 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
U.S.C. Section 1396b(m)(2)(A)(x); or
16.3.4.6 HMO's distribution, either directly or through any
agent or independent contractor, of marketing
materials that contain false or misleading
information, excluding materials prior approved by
HHSC.
16.3.4.7 HMO's failure to comply with requirements related
to Members with special health care needs in
Section 6.13 of this Contract, pursuant to 42
C.F.R. Section 438.208(c).
16.3.4.8 HMO's failure to comply with requirement in
Sections 7.2.6 and 7.2.8.7 of this Contract and 42
C.F.R. Section 438.102(a).
16.3.5 REMEDIES AVAILABLE TO HHSC FOR THIS HMO DEFAULT
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All of the listed remedies are in addition to all other
remedies available to HHSC 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 Sections
16.3.4.1 through and including 16.3.4.6, HHSC 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 HHSC
in exercising all or part of any remaining remedies.
For HMO's failure to comply with federal laws and regulations,
HHSC may:
- Terminate the contract if the applicable conditions
set out in Section 18.1.1 are met;
- Suspend new enrollment as set out in Section 18.3;
- Appoint temporary management as set out in Section
18.5;
- Initiate disenrollment of a Member of Members without
cause as set out in Section 18.6;
- Suspend or default all enrollment of individuals;
- Suspend payment to HMO;
- Recommend to CMS that sanctions be taken against HMO
as set out in Section 18.7;
- Assess civil monetary penalties as set out in Section
18.8; and/or
- Require forfeiture of all or part of the TDI
performance bond as set out in Section 18.9.
16.3.6 FAILURE TO COMPLY WITH APPLICABLE STATE LAW
HMO's failure to comply with Texas law applicable to Medicaid,
including, but not limited to, Section 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 HHSC for this HMO Default
All of the listed remedies are in addition to all
other remedies available to HHSC 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 HHSC in exercising
all or part of any remaining remedies.
For HMO's failure to comply with applicable state
law, HHSC may:
- Terminate the contract if the applicable
conditions set out in Section 18.1.1 are
met;
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- Suspend new enrollment as set out in Section
18.3;
- Assess administrative penalties as set out
in Section 32.039, Texas Human Resources
Code, with the opportunity for notice and
appeal as required by Section 32.039; and/or
- Require forfeiture of all or part of the TDI
performance bond as set out in Section 18.9.
16.3.7 MISREPRESENTATION OR FRAUD UNDER SECTION 4.8
HMO's misrepresentation or fraud under Section 4.8 of this
contract is a default under this contract.
16.3.7.1 Remedies Available to HHSC for this HMO Default
All of the listed remedies are in addition to all
other remedies available to HHSC 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 HHSC in exercising
all or part of any remaining remedies.
For HMO's misrepresentation or fraud under Section
4.8, HHSC may:
- Terminate the contract if the applicable
conditions set out in Section 18.1.1 are
met;
- Suspend new enrollment as set out in Section
18.3; and/or
- Require forfeiture of all or part of the TDI
performance bond as set out in Section 18.9.
16.3.8 EXCLUSION FROM PARTICIPATION IN MEDICARE OR MEDICAID
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 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 under
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 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 under
this contract if the exclusion will materially
affect HMO's performance under this contract.
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16.3.8.3 Remedies Available to HHSC for this HMO Default
All of the listed remedies are in addition to all
other remedies available to HHSC 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 HHSC in exercising
all or part of any remaining remedies.
For HMO's exclusion from Medicare or Medicaid, HHSC
may:
- Terminate the contract if the applicable
conditions set out in Section 18.1.1 are
met;
- Suspend new enrollment as set out in Section
18.3; and/or
- Require forfeiture of all or part of the TDI
performance bond as set out in Section 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 HHSC for this HMO Default
All of the listed remedies are in addition to all
other remedies available to HHSC 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 HHSC in exercising
all or part of any remaining remedies.
For HMO's failure to make timely and appropriate
payments to network providers and subcontractors,
HHSC may:
- Terminate the contract if the applicable
conditions set out in Section 18.1.1 are
met;
- Suspend new enrollment as set out in Section
18.3;
- Assess liquidated money damages as set out
in Section 18.4; and/or
- # Require forfeiture of all or part of the
TDI performance bond as set out in Section
18.9.
16.3.10 FAILURE TO TIMELY ADJUDICATE CLAIMS
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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 days of receipt for the contract year is a
default under this contract.
16.3.10.1 Remedies Available to HHSC for this HMO Default
All of the listed remedies are in addition to all
other remedies available to HHSC 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 HHSC in exercising
all or part of any remaining remedies.
For HMO's failure to timely adjudicate claims, HHSC
may:
- Terminate the contract if the applicable
conditions set out in Section 18.1.1 are
met;
- Suspend new enrollment as set out in Section
18.3; and/or
- Require forfeiture of all or part of the TDI
performance bond as set out in Section 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 Readiness Review required in Article 1 of
this contract is a default under the contract.
16.3.11.1 Remedies Available to HHSC for this HMO Default
All of the listed remedies are in addition to all
other remedies available to HHSC 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 HHSC in exercising
all or part of any remaining remedies.
For HMO's failure to demonstrate the ability to
perform contract functions, HHSC may:
- Terminate the contract if the applicable
conditions set out in Section 18.1.1 are
met;
- Suspend new enrollment as set out in Section
18.3; and/or
- Require forfeiture of all or part of the TDI
performance bond as set out in Section 18.9.
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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 HHSC for this HMO Default All
of the listed remedies are in addition to all other
remedies available to HHSC 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 HHSC in
exercising all or part of any remaining remedies.
For HMO's failure to monitor and/or supervise
activities of contractors or network providers, HHSC
may:
- Terminate the contract if the
applicable conditions set out in
Section 18.1.1 are met;
- Suspend new enrollment as set out
in Section 18.3; and/or
- Require forfeiture of all or part
of the TDI performance bond as set
out in Section 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 HHSC for this HMO Default
All of the listed remedies are in addition to all
other remedies available to HHSC 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 HHSC in exercising
all or part of any remaining remedies.
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For HMO's placing the health and safety of Members in
jeopardy, HHSC may:
- Terminate the contract if the
applicable conditions set out in
Section 18.1.1 are met;
- Suspend new enrollment as set out
in Section 18.3; and/or
- Require forfeiture of all or part
of the TDI performance bond as set
out in Section 18.9.
16.3.14 FAILURE TO MEET ESTABLISHED BENCHMARK
Failure of HMO to meet any benchmark established by HHSC under
this contract is a default under this contract.
16.3.14.1 Remedies Available To HHSC for this HMO Default All
of the listed remedies are in addition to all other
remedies available to HHSC 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 HHSC in
exercising all or part of any remaining remedies.
For HMO's failure to meet any benchmark established
by HHSC under this contract, or for failure to meet
improvement targets, as identified by HHSC, HHSC may:
- Remove all or part of the THSteps
component from the capitation paid to
HMO;
- Terminate the contract if the
applicable conditions set out in
Section 18.1.1 are met;
- Suspend new enrollment as set out
in Section 18.3;
- Assess liquidated money damages as
set out in Section 18.4; and/or
- Require forfeiture of all or part
of the TDI performance bond as set
out in Section 18.9.
16.3.15 FAILURE TO PERFORM A MATERIAL DUTY OR RESPONSIBILITY
Failure of HMO to perform a material duty or responsibility as
set out in this contract is a default under this contract and
HHSC may impose one or more of the remedies contained within
it provisions and all other remedies available to HHSC by law
or in equity.
16.3.15.1 Remedies Available to HHSC for this HMO Default
Page 162 of 173
All of the listed remedies are in addition to all
other remedies available to HHSC 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 HHSC in exercising
all or part of any remaining remedies.
For HMO's failure to perform an administrative
function under this contract, HHSC may:
- Terminate the contract if the
applicable conditions set out in
Section 18.1.1 are met;
- Suspend new enrollment as set out
in Section 18.3;
- Assess liquidated money damages as
set out in Section 18.4; and/or
- Require forfeiture of all or part
of the TDI performance bond as set
out in Section 18.9.
ARTICLE 17 NOTICE OF DEFAULT AND CURE OF DEFAULT
17.1 HHSC 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 that constitute a default under this contract;
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.l.4 A clear and concise statement of the time period during which
HMO may cure the default if HMO is allowed to cure;
17.1.5 The remedy or remedies HHSC is electing to pursue and when the
remedy or remedies will take effect;
17.1.6 If HHSC is electing to impose money damages and/or civil
monetary penalties, the amount that HHSC intends to withhold
or impose and the factual basis on which HHSC is imposing the
chosen remedy or remedies;
17.l.7 Whether any part of money damages or civil monetary penalties,
if HHSC elects to pursue one or both of those remedies, may be
passed
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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 HHSC 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 18 EXPLANATION OF REMEDIES
18.1 TERMINATION
18.1.1 TERMINATION BY HHSC
HHSC 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 16;
18.1.1.4 Federal or state funds for the Medicaid program are
no longer available; or
18.1.1.5 HHSC has a reasonable belief that HMO has placed
the health or welfare of Members in jeopardy.
18.1.2 HHSC 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 16. HHSC 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. HHSC
must give the notice required under HHSC's formal hearing
procedures set out in 1 TAC Chapter 357 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 HHSC's reasonable
belief that HMO has placed the health or welfare of Members in
jeopardy.
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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 HHSC'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 HHSC's
formal hearing procedures set out in 1 TAC Chapter
357.
18.1.3 HHSC 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 HHSC terminates for this reason, HHSC 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 Section 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 HHSC's reasonable
belief that HMO is placing the health and safety of the
Members in jeopardy. If termination is due to this reason,
HHSC may prohibit HMO's further performance of services under
the contract.
18.1.5 If HHSC terminates this contract, HMO may appeal the
termination under Section 32.034, Texas Human Resources Code.
18.1.6 TERMINATION BY HMO
HMO may terminate this contract if HHSC fails to pay HMO as
required under Article 13 of this contract or otherwise
materially defaults in its duties and responsibilities under
this contract, or by giving notice no later than 30 days after
receiving the capitation rates for the Contract Period.
Retaining premium, recoupment, sanctions, or penalties that
are allowed under this contract or that result from HMO's
failure to perform or HMO's default under the terms of this
contract is not cause for termination.
18.1.7 HMO must give HHSC 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
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last day of the month following 90 days from the date the
notice of intent to terminate is received by HHSC.
18.1.8 HHSC must be given 30 days from the date HHSC receives HMO's
written notice of intent to terminate for failure to pay HMO
all amounts due. If HHSC 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 HHSC.
18.2 DUTIES OF CONTRACTING PARTIES UPON TERMINATION
When termination of the contract occurs, HHSC and HMO must meet the
following obligations:
18.2.1 HHSC and HMO must prepare a transition plan that is acceptable
to and approved by HHSC, 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 HHSC's reasonable belief that HMO
is placing the health or welfare of Members in jeopardy.
18.2.2 If the contract is terminated by HHSC 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 Section ▇▇.▇.▇.▇:
18.2.2.1 HHSC is responsible for notifying all Members of
the date of termination and how Members can
continue to receive contract services;
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
HHSC in implementing the transition plan.
18.2.3 If the contract is terminated by HMO for any reason other than
based on lower capitation rates for the second or third
contract years as set out in Section ▇▇.▇.▇.▇:
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18.2.3.1 HHSC is responsible for notifying all Members of
the date of termination and how Members can
continue to receive contract services;
18.2.3.2 HHSC is responsible for all expenses related to
giving notice to Members; and.
18.2.3.3 HHSC 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 HHSC 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 HHSC is responsible for all expenses it incurs in
implementing the transition plan.
18.3 SUSPENSION OF NEW ENROLLMENT
18.3.1 HHSC 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 HHSC 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. HHSC 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
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accordance with the terms and conditions of this contract,
HHSC may require HMO to pay sums as specified below as
liquidated 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 HHSC's financial
loss and damage resulting from HMO's non-performance.
18.4.2 If HHSC imposes money damages, HHSC 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 HHSC. These money damages apply separately to each report.
18.4.4 Failure to produce or provide records and information
requested by HHSC, an entity acting on behalf of HHSC, 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 HHSC. HHSC will use the encounter data
validation methodology established by HHSC 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 HHSC, an entity acting
on behalf of HHSC, 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.
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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.
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 HHSC may also impose money damages for a default under Section
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 Sections 4.10.4 and 7.2.7.10 of this
contract.
18.4.9.1 If HHSC determines that HMO has failed to pay a
provider for a claim or claims for which the
provider should have been paid, HHSC 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 HHSC 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,
HHSC 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 HHSC 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 HHSC 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 Section
16.3.4.
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18.5.3 Temporary management will not be terminated until HHSC has
determined that HMO has the capability to ensure that the
violations that triggered appointment of temporary management
will not recur.
18.5.4 HHSC is not required to appoint temporary management before
terminating this contract.
18.5.5 No pre-termination hearing is required before appointing
temporary management.
18.5.6 As with any other remedy provided under this contract, HHSC
will provide notice of default as is set out in Article 17 to
HMO. Additionally, as with any other remedy provided under
this contract, under Section 18.1 of this contract, HMO may
dispute the imposition of this remedy and seek review of the
proposed remedy.
18.6 HHSC-INITIATED DISENROLLMENT OF A MEMBER OR MEMBERS WITHOUT CAUSE
HHSC must give HMO 30 days notice of intent to initiate disenrollment
of a Member of Members in the Notice of Default. The HHSC-initiated
disenrollment date will be calculated as 30 days following the date
that HMO receives the Notice of Default.
18.7 RECOMMENDATION TO CMS THAT SANCTIONS BE TAKEN AGAINST HMO
18.7.1 If CMS determines that HMO has violated federal law or
regulations and that federal payments will be withheld, HHSC
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 HHSC and CMS pursuant to 42 CFR Part 438, Subpart I.
18.8 CIVIL MONETARY PENALTIES
18.8.1 For a default under Section 16.3.4.1, HHSC may assess not more
than $25,000 for each default;
18.8.2 For a default under 16.3.4.2, for each default HHSC may assess
double the excess amount charged in the violation of the
federal requirements or $25,000, whichever is greater. HHSC
will deduct from the penalty the amount of the overcharge and
return it to the affected Member(s)
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18.8.3 For a default under Section 16.3.4.3, HHSC 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 Section 16.3.4.3.
18.8.4 For a default under Section 16.3.4.4, HHSC may assess not more
than $100,000 for each default if the material was provided to
CMS or HHSC 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 Section 16.3.4.5, HHSC may assess not more
than $25,000 for each default.
18.8.6 For a default under Section 16.3.4.6, HHSC may assess not more
than $25,000 for each default.
18.8.7 HMO may be subject to civil monetary penalties under the
provisions of 42 C.F.R. Part 1003 and 42 C.F.R. Part 438,
Subpart I in addition to or in place of withholding payments
for a default under Section 16.3.4.
18.9 FORFEITURE OF ALL OR A PART OF THE TDI PERFORMANCE BOND
HHSC may require forfeiture of all or a portion of the face amount of
the TDI performance bond if HHSC 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 HHSC 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 HHSC 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 HHSC must attempt to informally resolve a dispute. If
HMO and HHSC are unable to informally resolve a dispute, HMO
must notify the HPO Manager and Director of Medicaid/CHIP
Operations that HMO and HHSC cannot agree. The Director of
Medicaid/CHIP Operations will refer the dispute to the State
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Medicaid Director who will appoint a committee to review the
dispute under HHSC's dispute resolution procedures. The
decision of the dispute resolution committee will be HHSC's
final administrative decision.
ARTICLE 19 TERM
19.1 The effective date of this contract is June 1, 2004. This contract and
all amendments thereto will terminate on August 31, 2004, unless
extended or terminated earlier as provided for 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. HHSC will notify HMO no later
than 90 days before the end of the contract period of its intent not to
renew the contract.
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 Section 19.1.
19.4 If either party does not intend to renew the contract beyond its
contract period and sends the notice required in Section 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 Section 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 HHSC does not intend
to renew and sends the required notice, HHSC 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 HHSC 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, HHSC 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.
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19.6 Non-renewal of this contract is not a contract termination for purposes
of appeal rights under the Human Resources Code Section 32.034.
SIGNED:
__________________________________________ ___________________________________
Executive Commissioner AMERIGROUP Texas, Inc.
Texas Health and Human Services Commission President and CEO
Date Date
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