EXHIBIT 10.20
OR # 026889
DOC # 752603217*2001A 01
AMENDMENT NO. 2
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
THE TEXAS DEPARTMENT OF HEALTH AND HMO
This Amendment No. 2 is entered into between the Texas Department of Health
(TDH) and AMERICAID Texas, Inc., dba Americaid Community Care (HMO), to amend
the Contract for Services between the Texas Department of Health and HMO in the
▇▇▇▇▇▇ Service Area, dated September 1, 1999. The effective date of this
Amendment is the date TDH Signs this Amendment. All other contract provisions
remain in full force and effect.
1. Article II is amended by adding the BOLD AND ITALICIZED language
DEFINITIONS
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.
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.
2. Article VI is amended by adding the BOLD AND ITALICIZED language and deleting
the stricken language.
6.9 PERINATAL SERVICES
6.9.2 HMO must have a perinatal health care system in place that, at a
minimum, provides the following services:
6.9.3 HMO MUST HAVE A PROCESS TO EXPEDITE SCHEDULING A PRENATAL
APPOINTMENT FOR AN OBSTETRICAL EXAM FOR A TP40 MEMBER NO LATER
THAN TWO WEEKS AFTER RECEIVING THE DAILY ENROLLMENT FILE
VERIFYING ENROLLMENT OF THE MEMBER INTO THE HMO.
6.9.4 HMO must have procedures in place to CONTACT AND ASSIST A
PREGNANT/DELIVERING MEMBER IN SELECTING A PCP FOR HER BABY EITHER
BEFORE THE BIRTH OR AS SOON AS THE
BABY IS BORN.
6.9.5 HMO must provide inpatient care AND PROFESSIONAL SERVICES RELATED
TO LABOR AND DELIVERY for its pregnant/delivering Members and
NEONATAL CARE FOR ITS newborn Members (SEE ARTICLE 14.3.1) AT THE
TIME OF DELIVERY AND FOR UP TO 48 HOURS FOLLOWING AN
UNCOMPLICATED VAGINAL DELIVERY AND 96 HOURS FOLLOWING AN
UNCOMPLICATED CAESARIAN DELIVERY.
6.9.5.1 HMO MUST REIMBURSE IN-NETWORK PROVIDERS, OUT-OF-NETWORK
PROVIDERS, AND SPECIALTY PHYSICIANS WHO ARE PROVIDING CALL
COVERAGE, ROUTINE, AND/OR SPECIALTY CONSULTATION SERVICES FOR
THE PERIOD OF TIME COVERED IN ARTICLE 6.9.5.
6.9.5.1.1 HMO MUST ADJUDICATE PROVIDER CLAIMS FOR SERVICES PROVIDED TO A
NEWBORN MEMBER IN ACCORDANCE WITH TDH'S CLAIMS PROCESSING
REQUIREMENTS USING THE PROXY ID NUMBER OR STATE-ISSUED MEDICAID
ID NUMBER (SEE ARTICLE 4.10). HMO CANNOT DENY CLAIMS BASED ON
PROVIDER NON-USE OF STATE-ISSUED MEDICAID ID NUMBER FOR A NEWBORN
MEMBER. HMO MUST ACCEPT PROVIDER CLAIMS FOR NEWBORN SERVICES
BASED ON MOTHER'S NAME AND/OR MEDICAID ID NUMBER WITH
ACCOMMODATIONS FOR MULTIPLE BIRTHS, AS SPECIFIED BY THE HMO.
6.9.5.2 HMO CANNOT REQUIRE PRIOR AUTHORIZATION OR PCP ASSIGNMENT TO
ADJUDICATE NEWBORN CLAIMS FOR THE PERIOD OF TIME COVERED BY 6.9.5
6.9.6 HMO MAY REQUIRE PRIOR AUTHORIZATION REQUESTS FOR HOSPITAL OR
PROFESSIONAL SERVICES PROVIDED BEYOND THE TIME LIMITS IN ARTICLE
6.9.5. HMO MUST RESPOND TO THESE PRIOR AUTHORIZATION WITHIN THE
REQUIREMENTS OF 28 TAC SECTION 19.1710 - 19.1712
AND ARTICLE 21.58a OF THE TEXAS INSURANCE CODE.
6.9.6.1 HMO MUST NOTIFY PROVIDERS INVOLVED IN THE CARE OF
PREGNANT/DELIVERING WOMEN AND NEWBORNS (INCLUDING OUT-OF-NETWORK
PROVIDERS AND HOSPITALS) REGARDING THE HMO'S PRIOR AUTHORIZATION
REQUIREMENTS.
6.9.6.2 HMO CANNOT REQUIRE A PRIOR AUTHORIZATION FOR SERVICES PROVIDED TO
A PREGNANT/DELIVERING MEMBER OR NEWBORN MEMBER FOR A MEDICAL
CONDITION WHICH REQUIRES EMERGENCY SERVICES, REGARDLESS OF WHEN
THE EMERGENCY CONDITION ARISES (SEE ARTICLE 6.5.6).
3. Article VIII is amended by adding the BOLD AND ITALICIZED language and
deleting the stricken language.
8.4.2 HMO must issue a Member Identification Card (ID) to the Member
within five (5) days FROM THE DATE THE HMO RECEIVES the MONTHLY
Enrollment File from the Enrollment Broker. If the 5th day falls
on a weekend or state holiday, the ID Card must be issued by the
following working day. The ID Card must include, at a minimum,
the following: Member's name; Member's Medicaid number; either
the issue date of the card or effective date of the PCP
assignment; PCP's name, address, and telephone number; name of
HMO; name of IPA to which the Member's PCP belongs, if
applicable; the 24-hour, seven (7) day a week toll-free telephone
number operated by HMO; the toll-free number for behavioral
health care services; and directions for what to do in an
emergency. The ID Card must be reissued if the Member reports a
lost card, there is A Member name change, if Member requests a
new PCP, or for any other reason which results in a change to the
information disclosed on the ID Card.
4. Article XII is amended by adding the BOLD AND ITALICIZED language and
deleting the stricken language.
12.2 STATISTICAL REPORTS
12.2.4 HMO CANNOT SUBMIT NEWBORN ENCOUNTERS TO TDH UNTIL THE
STATE-ISSUED MEDICAID ID NUMBER IS RECEIVED FOR A NEWBORN. HMO
MUST MATCH THE PROXY ID NUMBER ISSUED BY THE HMO WITH THE
STATE-ISSUED MEDICAID ID NUMBER PRIOR TO SUBMISSION OF ENCOUNTERS
TO TDH AND SUBMIT THE ENCOUNTER IN ACCORDANCE TO THE HMO
ENCOUNTER DATA SUBMISSION MANUAL. THE ENCOUNTER MUST INCLUDE THE
STATE-ISSUED MEDICAID ID NUMBER. EXCEPTIONS TO THE 45-DAY
DEADLINE WILL BE GRANTED IN CASES IN WHICH THE MEDICAID ID NUMBER
IS NOT AVAILABLE FOR A NEWBORN MEMBER.
12.2.5 HMO must require providers to submit claims and encounter data to
HMO no later than 95 days after the date services are provided.
12.2.6 HMO must use the procedure codes, diagnosis codes and other codes
contained in the most recent edition of the Texas Medicaid
Provider Procedures Manual and as otherwise provided by TDH.
Exceptions or additional codes must be submitted for approval
before HMO uses the codes.
12.2.7 HMO must use its TDH-specified identification-numbers on all
encounter data submissions. Please refer to the TDH Encounter
Data Submission Manual for further specifications.
12.2.8 HMO must validate all encounter data using the encounter data
validation methodology prescribed by TDH prior to submission of
encounter data to TDH.
12.2.9 All Claims Summary Report. HMO must submit the "All Claims
Summary Report" identified in the Texas Managed Care Claims
Manual as a contract year-to-date report. The report must be
submitted quarterly by the last day of the month following the
reporting period. The reports must be submitted to TDH in a
format specified by TDH.
12.2.10 Medicaid Disproportionate Share Hospital (DSH) Reports. HMO must
file preliminary and final Medicaid Disproportionate Share
Hospital (DSH) reports, required by TDH to identify and reimburse
hospitals that qualify for Medicaid DSH funds. The preliminary
and final DSH reports must include the data elements and be
submitted in the form and format specified by TDH. The
preliminary DSH reports are due on or before June 1 of the year
following the state fiscal year for which data is being reported.
The final DSH reports are due on or before August 15 of the year
following the state fiscal year for which data is being reported.
5. Article XIII is amended by adding the BOLD AND ITALICIZED language.
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 CHANGE HER NEWBORN TO
ANOTHER HMO DURING THE FIRST 90 DAYS FOLLOWING THE DATE OF BIRTH,
BUT MAY ONLY DO SO THROUGH TDH CUSTOMER SERVICES.
13.5.2 MAXIMUS WILL PROVIDE HMO WITH A DAILY ENROLLMENT FILE WHICH WILL
LIST ALL NEWBORNS WHO HAVE RECEIVED STATE-ISSUED MEDICAID ID
NUMBERS. THIS FILE WILL INCLUDE THE MEDICAID ELIGIBLE MOTHER'S
MEDICAID ID NUMBER TO ALLOW THE HMO TO LINK THE NEWBORN'S
STATE-ISSUED MEDICAID ID NUMBERS WITH THE PROXY ID NUMBER. TDH
WILL GUARANTEE CAPITATION PAYMENTS TO HMO FOR ALL NEWBORNS WHO
APPEAR ON THE MAXIMUS DAILY ENROLLMENT FILE AS HMO MEMBERS FOR
EACH MONTH THE NEWBORN IS ENROLLED IN THE HMO.
13.5.3 ALL NON-TP45 NEWBORNS WHOSE MOTHERS ARE HMO MEMBERS AT
THE TIME OF THE BIRTH OF THE NEWBORN WILL BE RETROACTIVELY
ENROLLED INTO THE HMO THROUGH A MANUAL PROCESS BY DHS DATA
CONTROL.
13.5.4 NEWBORNS WHO DO NOT APPEAR ON THE MAXIMUS DAILY ENROLLMENT FILE
BEFORE THE END OF THE SIXTH MONTH FOLLOWING THE DATE OF BIRTH
WILL NOT BE RETROACTIVELY ENROLLED INTO THE HMO. TDH WILL
MANUALLY RECONCILE PAYMENT TO THE HMO FOR SERVICES PROVIDED FROM
THE DATE OF BIRTH FOR TP45 AND ALL OTHER ELIGIBILITY CATEGORIES
OF NEWBORNS. PAYMENT WILL COVER SERVICES RENDERED FROM THE
EFFECTIVE DATE OF THE PROXY ID NUMBER WHEN FIRST ISSUED BY THE
HMO REGARDLESS OF PLAN ASSIGNMENT AT THE TIME THE STATE-ISSUED
MEDICAID ID NUMBER IS RECEIVED.
13.5.5 MAXIMUS WILL PROVIDE HMO WITH A DAILY ENROLLMENT FILE WHICH WILL
LIST ALL TP40 MEMBERS WHO HAVE RECEIVED STATE-ISSUED MEDICAID ID
NUMBERS. TDH WILL GUARANTEE CAPITATION PAYMENTS TO HMO FOR ALL
TP40 MEMBERS WHO APPEAR ON THE MAXIMUS DAILY ENROLLMENT FILE AS
HMO MEMBERS FROM THE FIRST OF THE MONTH THE TP40 MEMBER
ENROLLMENT IS EFFECTIVE.
6. Article XIV is amended by adding the bold and italicized language.
14.3 NEWBORN ENROLLMENT
THE HMO IS RESPONSIBLE FOR NEWBORNS WHO ARE BORN TO MOTHERS WHO
ARE ENROLLED IN HMO ON THE DATE OF BIRTH AS FOLLOWS:
14.3.1 NEWBORNS ARE PRESUMED MEDICAID ELIGIBLE AND ENROLLED IN THE
MOTHER'S HMO FOR AT LEAST 90 DAYS FROM THE DATE OF BIRTH.
14.3.1.1 A MOTHER OF A NEWBORN MEMBER MAY CHANGE PLANS FOR HER NEWBORN
DURING THE FIRST 90 DAYS BY CONTACTING TDH CUSTOMER SERVICES. TDH
WILL NOTIFY HMO OF NEWBORN PLAN CHANGES MADE BY A MOTHER WHEN THE
CHANGE IS MADE BY TDH CUSTOMER SERVICES.
14.3.2 HMO MUST ESTABLISH AND IMPLEMENT WRITTEN POLICIES AND PROCEDURES
TO REQUIRE 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.
14.3.2.3 HMO MUST SUBMIT A FORM 7484A TO DHS DATA CONTROL REQUESTING DHS
DATA
CONTROL TO RESEARCH DHS'S FIRES 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 DHS FINDS THAT NO
MEDICAID ID NUMBER HAS BEEN ISSUED TO THE NEWBORN, DHS DATA
CONTROL WILL ISSUE THE MEDICAID ID NUMBER USING THE INFORMATION
PROVIDED ON THE FORM 7484A.
14.3.3 NEWBORNS CERTIFIED MEDICAID ELIGIBLE AFTER THE END OF THE SIXTH
MONTH FOLLOWING THE DATE OF BIRTH WILL NOT BE RETROACTIVELY
ENROLLED TO AN HMO, BUT WILL BE ENROLLED IN MEDICAID
FEE-FOR-SERVICE. TDH WILL MANUALLY RECONCILE PAYMENT TO THE HMO
FOR SERVICES PROVIDED FROM THE DATE OF BIRTH FOR ALL MEDICAID
ELIGIBLE NEWBORNS AS DESCRIBED IN ARTICLE 13.5.4.
14.4 DISENROLLMENT
14.4.1 HMO has a limited right to request a Member be disenrolled from
HMO without the Member's consent. TDH must approve any HMO
request for disenrollment of a Member for cause. Disenrollment of
a Member may be permitted under the following circumstances:
14.4.1.1 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.
14.4.4 If the Member disagrees with the decision to disenroll the Member
from HMO, HMO
must notify the Member of the availability of the complaint
procedure and TDH's Fair Hearing process.
14.4.5 HMO CANNOT REQUEST A DISENROLLMENT BASED ON ADVERSE CHANGE IN THE
MEMBER'S HEALTH STATUS OR UTILIZATION OF SERVICES WHICH ARE
MEDICALLY NECESSARY FOR TREATMENT OF A MEMBER'S CONDITION.
14.5 AUTOMATIC RE-ENROLLMENT
14.5.1 Members who are disenrolled because they are temporarily
ineligible for Medicaid will be automatically re-enrolled into
the same health plan. Temporary loss of eligibility is defined as
a period of 6 months or less.
14.5.2 HMO must inform its Members of the automatic re-enrollment
procedure. Automatic re-enrollment must be included in the Member
Handbook (see Article 8.2.1).
14.56 ENROLLMENT REPORTS
14.6.1 TDH will provide HMO enrollment reports listing all STAR Members
who have enrolled in or were assigned to HMO during the initial
enrollment period.
14.6.2 TDH will provide monthly HMO Enrollment Reports to HMO on or
before the first of the month.
14.6.3 TDH will provide Member verification to HMO and network providers
through telephone verification or TexMedNet.
AGREED AND SIGNED by AN authorized representative of the parties on _______2000.
TEXAS DEPARTMENT OF HEALTH AMERICAID Texas, Inc., dba
Americaid Community Care
By: /s/ ▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇ By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇
-------------------------------- -------------------------------
▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇, III, M.D. ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
Commissioner of Health President and Chief
Executive Officer
Approved as to Form:
/s/ ▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇
-------------------------
Office of General Counsel
DOC # 7526032317 * 2001A O/C
OR # 027272
AMENDMENT NO. 3
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
THE TEXAS DEPARTMENT OF HEALTH AND HMO
This Amendment No. 3 is entered into between the Texas Department of Health
(TDH) and AMERICAID Texas, Inc., dba Americaid Community Care (HMO), to amend
the Contract for Services between the Texas Department of Health and HMO in the
▇▇▇▇▇▇ Service Area, dated September 1, 1999. The effective date of this
Amendment is the date TDH Signs this Amendment. All other contract provisions
remain in full force and effect.
1. ARTICLE III is amended BY adding the new BOLD AND ITALICIZED language
and deleting the stricken language as follows:
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.
4. TELEPHONE SERVICES MUST MEET CULTURAL COMPETENCY
REQUIREMENTS (SEE ARTICLE 8.9) AND PROVIDE "LINGUISTIC
ACCESS" TO ALL MEMBERS AS DEFINED IN ARTICLE II. THIS
WOULD INCLUDE THE PROVISION OF INTERPRETIVE SERVICES
REQUIRED FOR EFFECTIVE COMMUNICATION FOR MEMBERS AND
PROVIDERS.
3.7.2 MEMBER HELPLINE: THE HMO MUST FURNISH A TOLL-FREE PHONE LINE
WHICH MEMBERS MAY CALL 24 HOURS A DAY, 7 DAYS A WEEK. AN
ANSWERING SERVICE OR OTHER SIMILAR MECHANISM, WHICH ALLOWS
CALLERS TO OBTAIN INFORMATION FROM A LIVE PERSON, MAY BE USED FOR
AFTER-HOURS AND WEEKEND COVERAGE.
3.7.2.1 HMO MUST PROVIDE COVERAGE FOR THE FOLLOWING SERVICES AT LEAST
DURING HMO'S REGULAR BUSINESS HOURS (A MINIMUM OF 9 HOURS A 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)
10. OTHER SERVICES COVERED BY MEMBER SERVICES.
3.7.2.2 HMO MUST PROVIDE TDH WITH POLICIES AND PROCEDURES INDICATING HOW
THE HMO WILL MEET THE NEEDS OF MEMBERS WHO ARE UNABLE TO CONTACT
HMO DURING REGULAR BUSINESS HOURS.
3.7.3 HMO MUST ENSURE THAT PCPS ARE AVAILABLE 24 HOURS A DAY, 7 DAYS A
WEEK (SEE ARTICLE 7.8). THIS INCLUDES PCP TELEPHONE COVERAGE (SEE
28 TAC 11.2001 (a)1A).
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 ARTICLE
3.7.1
2. ARTICLE V is amended by adding the new BOLD AND ITALICIZED language and
deleting the stricken language as follows:
5.9 REQUESTS FOR PUBLIC INFORMATION
5.9.3 If HMO believes that the requested information qualifies as a
trade secret or as commercial OR financial information, HMO must
notify TDH--within three (3) working days AFTER TDH GIVES NOTICE
THAT A REQUEST HAS BEEN MADE FOR PUBLIC INFORMATION -- AND
REQUEST TDH TO SUBMIT THE REQUEST FOR PUBLIC INFORMATION TO THE
ATTORNEY GENERAL FOR AN OPEN RECORDS OPINION. THE HMO WILL BE
RESPONSIBLE FOR PRESENTING ALL EXCEPTIONS TO PUBLIC DISCLOSURE TO
THE ATTORNEY GENERAL IF AN OPINION IS REQUESTED.
3. ARTICLE VI is amended by adding the new BOLD AND ITALICIZED
language as follows:
6.4 CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS
6.4.5 HMO MUST PROVIDE ASSISTANCE TO PROVIDERS REQUIRING PCP
VERIFICATION 24 HOURS A DAY, 7 DAYS A WEEK.
6.4.5.1 HMO MUST PROVIDE TDH WITH POLICIES AND PROCEDURES INDICATING HOW
THE HMO WILL PROVIDE PCP VERIFICATION AS INDICATED IN ARTICLE
6.4.5. HMOS PROVIDING PCP VERIFICATION VIA A TELEPHONE MUST MEET
THE REQUIREMENTS OF 3.7.1.
4. ARTICLE VII is amended by adding the new BOLD AND ITALICIZED
language and deleting the stricken language as follows:
7.6 PROVIDER COMPLAINT AND APPEAL PROCEDURES
7.6.3 HMO's complaint and appeal process cannot contain provisions
requiring a PROVIDER to submit a complaint or appeal to TDH for
resolution in lieu of the HMO's process.
7.18 DELEGATED NETWORKS (IPAs, LIMITED PROVIDER NETWORKS AND ANHCs)
7.18.2.1 HMO is required to include subcontract provisions in its
delegated network contracts which require the UM protocol used by
a delegated network to produce substantially similar outcomes, as
approved by TDH, as the UM protocol employed by the contracting
HMO. The responsibilities of an HMO in delegating UM functions to
a delegated network will be governed by Article 16.3.12 of this
contract.
5. ARTICLE VIII is amended by adding the new BOLD AND ITALICIZED language and
deleting the stricken language AS follows:
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)(l)(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 434.28 and 42 CFR Section 489,
SubPart I, relating to advance directives for all hospitals,
critical access
hospitals, skilled nursing facilities, home health agencies,
providers of home health care, providers of personal care
services and hospices, as well as the following state laws and
rules:
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.
8.3.2 HMO must maintain written policies for implementing a Member's
advance directive. Those policies must include a clear and
precise statement of limitations if HMO or a participating
provider cannot or will not implement a Member's advance
directive.
8.3.2.1.3 a description of the medical AND MENTAL HEALTH conditions or
procedures affected by the conscience objection.
8.5 MEMBER COMPLAINT PROCESS
8.5.1 HMO must develop, implement and maintain a Member complaint
system that complies with the requirements of Article 20A.12 of
the Texas Insurance Code, relating to the Complaint System,
except where otherwise provided in this contract and in
applicable federal law. The complaint and appeals procedure must
be the same for all Members and must comply with Texas Insurance
Code, Article 20A. 12 or applicable federal law. Modifications
and amendments must be submitted to TDH at least 30 days prior to
the implementation of the modification or amendment.
8.5.2 HMO must have written policies and procedures for receiving,
tracking, reviewing, and reporting and resolving of Member
complaints. The procedures must be reviewed and approved in
writing by TDH. Any changes or modifications to the procedures
must be submitted to TDH for approval thirty (30) days prior to
the effective date of the amendment.
8.5.3 HMO must designate an officer of HMO who has primary
responsibility for ensuring that complaints are resolved in
compliance with written policy and within the time required. An
"officer" of HMO means a president, vice president, secretary,
treasurer, or chairperson of the board for a corporation, the
sole proprietor, the managing general partner of a partnership,
or a person having similar executive authority in the
organization.
8.5.4 HMO must have a routine process to detect patterns of
complaints and disenrollments and involve management and
supervisory staff to develop policy and procedural improvements
to address the complaints. HMO must cooperate with TDH and TDH's
Enrollment Broker in Member complaints relating to enrollment and
disenrollment.
8.5.5 HMO's complaint procedures must be provided to Members in writing
and in alternative communication formats. A written description
of HMO's complaint procedures must be in appropriate languages
and easy for Members to understand. HMO must include a written
description in the Member Handbook. HMO must maintain at least
one local and one toll-free telephone number for making
complaints.
8.5.6 HMO's process must require that every complaint received in
person, by telephone or in writing, is recorded in a written
record and is logged with the following details: date;
identification of the individual filing the complaint;
identification of the individual recording the complaint; nature
of the complaint; disposition of the complaint; corrective action
required; and date resolved.
8.5.7 HMO's process must include a requirement that the Governing Body
of HMO reviews the written records (logs) for complaints and
appeals.
8.5.8 HMO is prohibited from discriminating against a Member because
that Member is making or has made a complaint.
8.5.9 HMO cannot process requests for disenrollments through HMO's
complaint procedures. Requests for disenrollments must be
referred to TDH within five (5) business days after the Member
makes a disenrollment request.
8.5.10 HMO must develop, implement and maintain an appeal of adverse
determination procedure that complies with the requirements of
Article 21.58A of the Texas Insurance Code, relating to the
utilization review, except where otherwise provided in this
contract and in applicable federal law. The appeal of an adverse
determination procedure must be the same for all Members and must
comply with Texas Insurance Code, Article 21.58A or applicable
federal law. Modifications and amendments must be submitted to
TDH no less than 30 days prior to the implementation of the
modification or amendment. When an enrollee, a person acting on
behalf of an enrollee, or an enrollee's provider of record
expresses orally or in writing any dissatisfaction or
disagreement with an adverse determination, HMO or UR agent must
regard the expression of dissatisfaction as a request to appeal
an adverse determination.
8.5.11 If a complaint or appeal of an adverse determination relates to
the denial, delay, reduction, termination or suspension of
covered services by either HMO or a utilization review agent
contracted to perform utilization review by HMO, HMO must inform
Members they have the right to access the TDH Fair Hearing
process at any time in lieu of the internal complaint system
provided by HMO. HMO is required to comply with the requirements
contained in 1 TAC Chapter 357, relating to notice and Fair
Hearings in the Medicaid program, whenever an action is taken to
deny, delay, reduce, terminate or suspend a covered service.
8.5.12 If Members utilize HMO's internal complaint or appeal of adverse
determination system and the complaint relates to the denial,
delay, reduction, termination or suspension of covered services
by either HMO or a utilization review agent contracted to perform
utilization review by HMO, HMO must inform the Member that they
continue to have a right to appeal the decision through the TDH
Fair Hearing process.
8.5.13 The provisions of Article 21.58A, Texas Insurance Code, relating
to a Member's right to appeal an adverse determination made by
HMO or a utilization review agent by an independent review
organization, do not apply to a Medicaid recipient. Federal fair
hearing requirements (Social Security Act Section 1902a(3),
codified at 42 C.F.R. 431.200 et. seq.) require the agency to
make a final decision after a fair hearing, which conflicts with
the State requirement that the IRO make a final decision.
Therefore, the State requirement is pre-empted by the federal
requirement.
8.5.14 HMO will cooperate with the Enrollment Broker and TDH to resolve
all Member complaints. Such cooperation may include, but is not
limited to, participation by HMO or Enrollment Broker and/or TDH
internal complaint committees.
8.5.15 HMO must have policies and procedures in place outlining the role
of HMO's Medical Director in the Member Complaint System and
appeal of an adverse determination. The Medical Director must
have a significant role in monitoring, investigating and hearing
complaints.
8.5.16 HMO must provide Member Advocates to assist Members in
understanding and using HMO's complaint system and appeal of an
adverse determination.
8.5.17 HMO's Member Advocates must assist Members in writing or filing a
complaint or appeal of an adverse determination and monitoring
the complaint or appeal through the Contractor's complaint or
appeal of an adverse determination process until the issue is
resolved.
8.6 MEMBER NOTICE, APPEALS AND FAIR HEARINGS
8.6.1 HMO must send Members the notice required by 1 Texas
Administrative Code Section 357.5, whenever HMO takes an action
to deny, delay, reduce or terminate covered
services to a Member. The notice must be mailed to the Member no
less than 10 days before HMO intends to take an action. If an
emergency exists, or if the time within which the service must be
provided makes giving 10 days notice impractical or impossible,
notice must be provided by the most expedient means reasonably
calculated to provide actual notice to the Member, including by
phone, direct contact with the Member, or through the provider's
office.
8.6.2 The notice must contain the following information:
8.6.2.1 Member's right to immediately access TDH's Fair Hearing process;
8.6.2.2 a statement of the action HMO will take;
8.6.2.3 the date the action will be taken;
8.6.2.4 an explanation of the reasons HMO will take the action;
8.6.2.5 a reference to the state and/or federal regulations which support
HMO's action;
8.6.2.6 an address where written requests may be sent and a toll-free
number Member can call to: request the assistance of a Member
representative, or file a complaint, or request a Fair Hearing;
8.6.2.7 a procedure by which Member may appeal HMO's action through
either HMO's complaint process or TDH's Fair Hearings process;
8.6.2.8 an explanation that Members may represent themselves, or be
represented by HMO's representative, a friend, a relative, legal
counsel or another spokesperson;
8.6.2.9 an explanation of whether, and under what circumstances, services
may be continued if a complaint is filed or a Fair Hearing
requested;
8.6.2.10 a statement that if the Member wants a TDH Fair Hearing on the
action, Member must make the request for a Fair Hearing within 90
days of the date on the notice or the right to request a hearing
is waived;
8.6.2.11 a statement explaining that HMO must make its decision within 30
days from the date the complaint is received by HMO; and
8.6.2.12 a statement explaining that a final decision must be made by TDH
within 90 days from the date a Fair Hearing is requested.
8.7 MEMBER ADVOCATES
8.7.1 HMO must provide Member Advocates to assist Members. 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 TDH
Fair Hearing requested (see Articles 8.6.15, 8.6.16,and 8.6.17).
8.7.3 Member Advocates are responsible for making recommendations to
management on any changes needed to improve either the care
provided or the way care is delivered. 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.
8.7.4 Member Advocates must provide outreach to Members and participate
in TDH-sponsored enrollment activities.
8.8 MEMBER CULTURAL AND LINGUISTIC SERVICES
8.8.1 Cultural Competency Plan. HMO must have a comprehensive written
Cultural Competency Plan describing how HMO will ensure
culturally competent services, and provide linguistic and
disability-related access. The Plan must describe how the
individuals and systems within HMO will effectively provide
services to people of all cultures, races, ethnic backgrounds,
and religions as well as those with disabilities in a manner that
recognizes, values, affirms, and respects the worth of the
individuals and protects and preserves the dignity of each. HMO
must submit a written plan to TDH prior to the effective date of
this contract unless previously submitted. Modifications and
amendments to the written plan must be submitted to TDH 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 guidelines and the
provision of auxiliary aids and services, in compliance with the
Americans with Disabilities Act, Title III, Department of Justice
Regulation 36.303. HMO must disseminate these policies and
procedures to ensure that both Staff and subcontractors are aware
of their responsibilities under this provision of the contract.
8.8.2.2 A description of how HMO will educate and train its staff and
subcontractors on culturally competent service delivery, and the
provision of linguistic and/or disability-related access as
related to the characteristics of its Members;
8.8.2.3 A description of how HMO will implement the plan in its
organization, identifying a person in the organization who will
serve as the contact with TDH on the Cultural Competency Plan;
8.8.2.4 A description of how HMO will develop standards and performance
requirements for the delivery of culturally competent care and
linguistic access, and monitor adherence with those standards and
requirements;
8.8.2.5 A description of how HMO will provide outreach and health
education to Members, including racial and ethnic minorities,
non-English speakers or limited-English speakers, and those with
disabilities; and
8.8.2.6 A description of how HMO will help Members access culturally and
linguistically appropriate community health or social 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. Sections 2000d, et. seq. HMO must ensure the provision of
auxiliary aids and services necessary for effective
communication, as per the Americans with Disabilities Act, Title
III, Department of Justice Regulations 36.303.
8.8.3.1 HMO must adhere to and provide to Members the Member ▇▇▇▇ of
Rights and Responsibilities as adopted by the Texas Health and
Human Services Commission and contained at 1 Texas Administrative
Code (TAC) Section 353.202-353.203. The Member ▇▇▇▇ 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 advised
that a free interpreter is available; and the Member expresses a
preference to rely on the family member or friend.
8.8.4 All Member orientation presentations education classes and
materials must be presented in the languages of the major
population groups making up 10% or more of the Medicaid
population in the service area, as specified by TDH. HMO must
provide auxiliary aids and services, as needed, including
materials in alternative formats (i.e., large print, tape or
Braille), and interpreters or real-time captioning to accommodate
the needs of persons with disabilities that affect communication.
8.8.5 HMO must provide 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, TDH will provide HMOs
with the Member's Medicaid periodic review.
6. ARTICLE XI1 is amended by adding the new BOLD AND ITALICIZED language
and deleting the stricken language as follows:
12.1 FINANCIAL REPORTS
12.1.4 Final MCFS Reports. HMO must file two Final Managed Care
Financial-Statistical Reports. The first final report must
reflect expenses incurred through the 90th day after the end of
the contract. The first final report must be filed on or before
the 120th day after the end of the contract. The second final
report must reflect data completed through the 334th day after
the end of the contract and must be filed on or before the
365th day following the end OF the contract.
12.2.9 Medicaid Disproportionate Share Hospital (DSH) Reports. HMO must
file preliminary and final Medicaid Disproportionate Share
Hospital (DSH) reports, required by TDH to identify and reimburse
hospitals that qualify for Medicaid DSH funds. The preliminary
and final DSH reports must include the data elements and be
submitted in the form and format specified by TDH. The
preliminary DSH reports are due on or before June 1 of the year
following the state fiscal year for which data is being reported.
The final DSH reports are due NO LATER
THAN JULY 15 of the year following the state fiscal year for
which data is being reported.
12.8 UTILIZATION MANAGEMENT REPORTS - BEHAVIORAL HEALTH
Behavioral health (BH) utilization management reports are
required on a semi-annual basis. Refer to Appendix H for the
standardized reporting format for each report and detailed
instructions for obtaining the specific data required in the
report.
12.8.1 IN ADDITION, FILES ARE DUE TO THE TDH EXTERNAL QUALITY REVIEW
ORGANIZATION FIVE (5) WORKING DAYS FOLLOWING THE END OF EACH
STATE QUARTER. SEE APPENDIX H FOR SUBMISSION INSTRUCTIONS. THE BH
UTILIZATION REPORT AND DATA FILE SUBMISSION INSTRUCTIONS MAY
PERIODICALLY UPDATED BY TDH TO FACILITATE CLEAR COMMUNICATION TO
THE HEALTH PLANS.
12.9 UTILIZATION MANAGEMENT REPORTS - PHYSICAL HEALTH
Physical health (PH) utilization management reports are required
on a semi-annual basis. Refer to Appendix J for the standardized
reporting format for each report and detailed instructions for
obtaining specific data required in the report.
12.9.1 IN ADDITION, DATA FILES ARE DUE TO THE TDH EXTERNAL QUALITY
REVIEW ORGANIZATION FIVE (5) WORKING DAYS FOLLOWING THE END OF
EACH STATE QUARTER. SEE APPENDIX J FOR SUBMISSION INSTRUCTIONS.
THE PH UTILIZATION REPORT AND DATA FILE SUBMISSION INSTRUCTION
MAY PERIODICALLY BE UPDATED BY TDH TO FACILITATE CLEAR
COMMUNICATION TO THE HEALTH PLAN.
7. ARTICLE XIII is amended by adding the new BOLD AND ITALICIZED language
and deleting the stricken language as follows:
13.1 CAPITATION AMOUNTS
13.1.1 TDH will pay HMO monthly premiums calculated by multiplying the
number of Member months by Member risk group times the monthly
capitation amount by Member risk group. FOR ADDITIONAL
INFORMATION REGARDING THE ACTUARIAL BASIS AND
METHODOLOGY USED TO COMPUTE THE CAPITATION RATES, PLEASE
REFERENCE THE WAIVER UNDER THE DOCUMENT TITLED "ACTUARIAL
METHODOLOGY FOR DETERMINATION OF MAXIMUM MONTHLY CAPITATION
AMOUNTS". HMO and network providers are prohibited from billing
or collecting any amount from a Member for health care services
covered by this contract, in which case the Member must be
informed of such costs prior to providing non-covered services.
13.2 EXPERIENCE REBATE TO STATE
13.2.1 For THE CONTRACT PERIOD, HMO must pay to TDH an experience rebate
calculated in accordance with the tiered rebate method listed
below based on the excess of allowable HMO STAR revenues over
allowable HMO STAR expenses as measured by any positive amount on
Line 7 of "Part 1: Financial Summary, All Coverage Groups
Combined" of the annual Managed Care Financial-Statistical Report
set forth in Appendix I, as reviewed and confirmed by TDH. TDH
reserves the right to have an independent audit performed to
verify the information provided by HMO.
13.2.5 There will be two settlements for payment(s) of the experience
rebate. The first settlement shall equal 100 percent of the
experience rebate as derived from Line 7 of Part 1 (Net Income
Before Taxes) of the FIRST FINAL Managed Care Financial
Statistical (MCFS) Report and shall be paid on the same day the
first FINAL MCFS Report is submitted to TDH. The second
settlement shall be an adjustment to the first settlement and
shall be paid to TDH on the same day that the second FINAL MCFS
Report is submitted to TDH if the adjustment is a payment from
HMO to TDH. TDH or its agent may audit or review the MCFS
reports. If TDH determines that corrections to the MCFS reports
are required, based on a TDH audit/review or other documentation
acceptable to TDH, to determine an adjustment to the amount of
the second settlement, then final adjustment shall be made within
two years from the date that HMO submits the second FINAL MCFS
report. HMO must pay the first and second settlements on the due
dates for the first and second FINAL MCFS reports respectively as
identified in Article 12.1.4. TDH may adjust the experience
rebate if TDH determines HMO has paid affiliates amounts for
goods or services that are higher than the fair market value of
the goods and services in the service area. Fair market value may
be based on the amount HMO pays a non-affiliate(s) or the amount
another HMO pays for the same or similar service in the service
area. TDH has final authority in auditing and determining the
amount of the experience rebate.
8. The Appendices are amended by deleting Appendix H, "Utilization Management
Report - Behavioral Health" and replacing it with new Appendix H,
"Utilization Management Report - Behavioral Health", as attached.
9. The Appendices are amended by deleting Appendix J, "Utilization Management
Report - Physical Health" and replacing it with new Appendix J,
"Utilization Management Report-
Physical Health", as attached.
10. The Appendices are amended by deleting Appendix K, "Preventative Health
Performance Objectives" and replacing it with new Appendix K, "Preventative
Health Performance Objectives", as attached.
AGREED AND SIGNED by an authorized representative of the parties on August 16,
2000.
TEXAS DEPARTMENT OF HEALTH AMERICAID Texas, Inc., dba
Americaid Community Care
By: /s/ ▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇ By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
--------------------------------- -------------------------
▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇, III., M.D. ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
Commissioner of Health President and CEO
Approved as to Form:
[ILLEGIBLE]
------------------------
Office of uneral Counsel
DOC # 7526032317 * 2001A 01D
OR # 027544
AMENDMENT NO. 4
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
THE TEXAS DEPARTMENT OF HEALTH AND HMO
This Amendment No.4 is entered into between the Texas Department of Health and
Americaid Texas, Inc. d/b/a Americaid Community Care (HMO), to amend the
Contract for Services between the Texas Department of Health and HMO in the
▇▇▇▇▇▇ Service Area, dated September 1, 1999. The effective date of this
Amendment is September 1, 2000. All other contract provisions remain in full
force and effect.
The Parties agree to amend the Contract to read as follows:
Article XIII is amended by adding the BOLD AND ITALICIZED language and deleting
the stricken language.
13.1.2 Delivery Supplemental Payment (DSP). The monthly capitation
amounts and the DSP amount are listed below.
RISK GROUP MONTHLY CAPITATION AMOUNTS
----------------------------------------------------------------------
TANF Adults $164.53
----------------------------------------------------------------------
TANF Children > 12 $ 61.22
Months of Age
----------------------------------------------------------------------
Expansion Children > 12 $ 76.68
Months of Age
----------------------------------------------------------------------
Newborns < or = #l2 Months of $500.94
Age
----------------------------------------------------------------------
TANF Children < or = #l2 $500.94
Months of Age
----------------------------------------------------------------------
Expansion Children < or = or #12 $500.94
Months of Age
----------------------------------------------------------------------
Federal Mandate $ 51.55
Children
----------------------------------------------------------------------
CHIP Phase I $ 92.71
----------------------------------------------------------------------
Pregnant Women $209.67
----------------------------------------------------------------------
Disabled/Blind $ 14.00
Administration
----------------------------------------------------------------------
Delivery Supplemental Payment: A one-time per pregnancy supplemental payment for
each delivery shall be paid to HMO as provided below in the following amount:
$3,060.18.
13.1.3 TDH will re-examine the capitation rates paid to HMO under this
contract during the first year of the contract period and will
provide HMO with capitation rates for the second year of the
contract period no later than 30 days before the date of the
one-year anniversary of the contract's effective date. Capitation
rates for state fiscal year 2001 will be re-examined based on the
most recent available traditional Medicaid cost data for the
contracted risk groups in the service area, trended forward and
discounted.
13.1.3.1 Once HMO has received their capitation rates established by TDH
for the second year of this contract, HMO may terminate this
contract as provided in Article 18.1.6 OF this contract.
13.1.4 The monthly premium payment to HMO is based on monthly enrollments
adjusted to reflect money damages set out in Article 18.8 and
adjustments to premiums in Article 13.5.
13.1.5 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 capitation amounts, TDH will equitably adjust
capitation amounts for all participating HMOs, and reduce scope of
service requirements as appropriate.
13.1.7 HMO renewal rates reflect program increases appropriated by the
76th legislature for physician (to include THSteps providers) and
outpatient facility services. HMO must report to TDH any change in
rates for participating physicians (to include THSteps providers)
and outpatient facilities resulting from this increase. The report
must be submitted to TDH at the end of the first quarter of the
FY2000 and FY2001 contract years according to the deliverables
matrix schedule set for HMO.
AGREED AND SIGNED by an authorized representative of the parties on
September 7, 2000.
TEXAS DEPARTMENT OF HEALTH Americaid Texas, Inc. d/b/a
Americaid Community Care
BY: /s/ ▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇, III., M.D. By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
---------------------------------- -----------------------------
▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇, III., M.D. ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
Commissioner of Health President and CEO
Approved as to Form:
/s/ [ILLEGIBLE]
-------------------------------
Office of General Counsel
TDH DOC. NO. 7526032317* 01A-01E
AMENDMENT NO. 5
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
THE TEXAS DEPARTMENT OF HEALTH AND HMO
This Amendment No. 5 is entered into between the Texas Department of Health
(TDH) and AMERICAID Texas, Inc., dba Americaid Community Care (HMO), to amend
the 1999 Contract for Services between the Texas Department of Health and HMO in
the ▇▇▇▇▇▇ Service Area. The effective date of this Amendment is the date TDH
signs this Amendment. All other contract provisions remain in full force and
effect.
1. ARTICLE II & IV is amended by adding the new BOLD AND ITALICIZED
language and deleting the stricken language as follows:
2.0 DEFINITION
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 28 TAC SECTION 21.2802(4) AND TO THE EXTENT THAT IT
IS NOT IN CONFLICT WITH THE PROVISIONS OF THIS CONTRACT.
4.10 CLAIMS PROCESSING REQUIREMENTS
4.10.1 HMO AND CLAIMS PROCESSING SUBCONTRACTORS MUST COMPLY WITH 28
TAC SECTIONS 21.2801 THROUGH 21.2816 "SUBMISSION OF CLEAN
CLAIMS" WITH THE EXCEPTION OF 28 TAC SECTIONS 21.2802 (25) AND
21.2807 (b) (3) & (4), AND TO THE EXTENT THEY ARE NOT IN
CONFLICT WITH PROVISIONS OF THIS CONTRACT.
4.10.2 HMO MUST USE A TDH APPROVED OR IDENTIFIED CLAIM FORMAT THAT
CONTAINS ALL DATA FIELDS FOR FINAL ADJUDICATION OF THE CLAIM.
THE REQUIRED DATA FIELDS MUST BE COMPLETE AND ACCURATE. THE
TDH REQUIRED DATA FIELDS ARE IDENTIFIED IN TDH'S "HMO
ENCOUNTER DATA CLAIMS SUBMISSION MANUAL."
4.10.3 HMO and claims processing subcontractors must comply with
TDH's Texas MEDICAID Managed Care Claims Manual (Claims
Manual), which contains TDH's claims processing requirements.
HMO must comply with any changes to the Claims Manual with
appropriate notice of changes from TDH.
4.10.4 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
clean claim which is not adjudicated within 30 days from the
date the claim is received by HMO or becomes clean at a rate
of 1.5% per month (18% annual) for each month the clean claim
remains unadjudicated. HMO will be held to a minimum
performance level of 90% of ail 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 XVII. 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 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.
Page 2 of 3
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 TDH.
4.10.7 HMO is subject to Article XVI, 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 Articles 4.10.4, 4.10.4.1 and 4.10.4.2, 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 XVI 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
submitting and receiving claims information through electronic
data interchange (EDI) that allows for automated processing
and adjudication of claims within two or three years, as
applicable, from the date the rules promulgated under HIPAA
are adopted.
4.10.9 For claims requirements regarding retroactive PCP changes for
mandatory Members, see Article 7.8.12.2.
AGREED AND SIGNED by an authorized representative of the parties on
April 2, 2001.
TEXAS DEPARTMENT OF HEALTH AMERICAID Texas, Inc., dba
Americaid Community Care
By: /s/ ▇▇▇▇▇▇▇ ▇. ▇▇▇▇, M.D. By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
-------------------------------- ------------------------------
▇▇▇▇▇▇▇ ▇. ▇▇▇▇, M.D. ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
Executive Deputy Commissioner of Health President and CEO
Approved as to Form:
/s/ [ILLEGIBLE] TDH DOC. NO. 7526032317* 01A-01E
----------------------------- --------------------
Office of General Counsel 12/21/00
Page 3 of 3
ORIG # 030267
"TDH DOC. # 7526032317* 2001A-01F
AMENDMENT NO. 6
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
THE TEXAS DEPARTMENT OF HEALTH AND HMO
This Amendment No. 6 is entered into between the Texas Department of Health
(TDH) and AMERICAID Texas, Inc. (HMO) in ▇▇▇▇▇▇ Service Area, to amend the 1999
Contract for Services between the Texas Department of Health and HMO. The
effective date of this Amendment is the date TDH Signs this Amendment. All other
contract provisions remain in full force and effect. The Parties agree to amend
the Contract as follows:
ARTICLE XII amended to read as follows:
12.8.1 In addition, data files are due to TDH or its designee no later
than the fifth working day following the end of each month. See
Utilization Data Transfer Encounter Submission Manual for
submission instructions. The BH utilization report and data file
submission instructions may periodically be updated by TDH to
facilitate clear communication to the health plans.
12.9.1 In addition, data files are due to TDH or its designee no later
than the fifth working day following the end of each month. See
Utilization Data Transfer Encounter Submission Manual for
submission instructions. The PH utilization report and data file
submission instructions may periodically be updated by TDH to
facilitate clear communication to the health plan.
AGREED AND SIGNED by an authorized representative of the parties on
August 23, 2001.
Texas Department of Health AMERICAID Texas, Inc.
By: /s/ ▇. ▇. ▇▇▇▇ M.D. By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
-------------------------------- ------------------------------
▇▇▇▇▇▇▇ ▇. ▇▇▇▇ M.D. ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
Executive Deputy Commissioner of Health President & CEO
Approved as to Form:
Sda 8/20/01
-----------------------------
Office of General Counsel
TDH DOC. # 7526032317* 2001A-01G ORIG # 030303
AMENDMENT NO. 7
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
THE TEXAS DEPARTMENT OF HEALTH AND HMO
This Amendment No. 7 is entered into between the Texas Department of Health
(TDH) and Americaid Texas, Inc. dba Americaid Community Care (Americaid) in the
▇▇▇▇▇▇ Service Area, to amend the 1999 Contract for Services between TDH and
Humana Health Plan of Texas, Inc. (Humana), Americaid's predecessor in interest,
dated as of August 30, 1999, as amended (the Humana contract).
TDH has contracts with multiple managed care organizations in the ▇▇▇▇▇▇ Service
Area for the provision of Medicaid Managed Care Services, including contracts
with Humana Health Plan of Texas, Inc. (Humana) and with Americaid. Pursuant to
a ▇▇▇▇ of Sale, Assignment and Assumption Agreement between Americaid and Humana
dated June 13, 2001 (▇▇▇▇ of Sale) and with the approval of TDH, the Humana
contract was assigned to Americaid with an effective date of August 1, 2001 (the
Effective Date). The result is the existence of two contracts between TDH and
Americaid, which cover the same time period and the same subject matter. It is
the intent of the parties to have only one contract and that the Humana contract
be merged into the existing Americaid contract.
Therefore, in consideration of the forgoing recitals, and for other good and
valuable consideration, the receipt and sufficiency of which are hereby
expressly acknowledged, the parties hereby agree as follows:
As of the Effective Date of the assignment of the Humana contract, all of
Humana's right, title and interest in and to the Humana contract is transferred
to Americaid and, except for the obligations and liabilities for which Humana
shall remain solely responsible as provided under the ▇▇▇▇ of Sale, Americaid
assumes and shall be solely responsible for the obligations of Humana's contract
accruing from that date forward. As of the Effective Date, the Humana contract
is hereby merged into the existing Americaid Contract between Americaid and TDH
so that there is only one contract between the parties and all services to
members of the Americaid health plan, including any Humana members that
transition to Americaid, will be delivered according to that contract.
The "Effective Date" of this amendment is August 1, 2001.
- 1 -
AGREED AND SIGNED by an authorized representative of the parties on August 23,
2001.
TEXAS DEPARTMENT OF HEALTH Americaid Texas, Inc.
dba Americaid Community Care
By: /s/ ▇. ▇. ▇▇▇▇ M. D. By: /s/ ▇▇▇ ▇. ▇▇▇▇▇▇▇
------------------------- -------------------------
▇▇▇▇▇▇▇ ▇. ▇▇▇▇ M. D. ▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
Executive Deputy Commissioner President and CEO
Approved as to Form:
Sda 8/20/01
Office of General Counsel
TDH DOC. # 7526032317* 2001A-01G
- 2 -
AMENDMENT NO. 8
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
HEALTH AND HUMAN SERVICES COMMISSION AND HMO
This Amendment No. 8 is entered into between the Health and Human Services
Commission (HHSC) and AMERIGROUP Texas, Inc. (HMO), to amend the Contract for
Services between the Health and Human Services Commission and HMO in the ▇▇▇▇▇▇
Service Area. The effective date of this amendment is September 1, 2001. The
Parties agree to amend the Contract as follows:
1. HHSC and HMO acknowledge the transfer of responsibility and the assignment
of the original Contract for Services from TDH to HHSC on September 1,
2001. Where the original Contract for Services and any Amendment to the
original Contract for Services assigns a right, duty, or responsibility to
TDH, that right, duty, or responsibility may be exercised by HHSC or its
designee.
2. The 1999 Contract for Services entered into between the Health and Human
Services Commission and AMERICAID Texas, Inc. in the ▇▇▇▇▇▇ Service Area is
hereby amended to reflect the name change of AMERICAID Texas, Inc. to
AMERIGROUP Texas, Inc. (HMO). All requisite documents have been filed with
the Texas Department of Insurance, the Texas Secretary of State, and the
State Comptroller's Office.
This Amendment No. 8 hereby substitutes AMERIGROUP Texas, Inc. in the place
of AMERICAID Texas, Inc. in the 1999 Contract for Services referenced
above. All terms and conditions of the contracts and the duly executed
amendments thereto remain in full force and effect.
3. Articles II, III, VI, VII, VIII, IX, X, XII, XIII, XV, XVI, XVIII and XIX
are amended to read as follows:
2.0 DEFINITIONS
Chemical Dependency Treatment Facility means a facility licensed by the
Texas Commission on Alcohol and Drug Abuse (TCADA) under Sec. 464.002
of the 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.
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Chemical Dependency Condition means a condition which 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 Sec. 504 of the Occupations Code to provide chemical dependency
treatment or a master's level therapist (LMSW-ACP, LMFT or LPC) or a
master's level therapist (LMSW-ACP, LMFT or LPC) with a minimum of two
years of post licensure experience in chemical dependency treatment.
Experience rebate means the portion of the HMO's net income before
taxes (financial Statistical Report, Part 1, Line 7) that is returned
to the state in accordance with Article 13.2.1.
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.
3.5 RECORDS REQUIREMENTS AND RECORDS RETENTION
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.
6.6 BEHAVIORAL HEALTH CARE SERVICES - SPECIFIC REQUIREMENTS
6.6.13 Chemical dependency treatment must conform to the standards set forth
in the Texas Administrative Code, Title 28, Part 1, Chapter 3,
Subchapter HH.
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6.8 TEXAS HEALTH STEPS (EPSDT)
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 ▇▇▇▇ vs. 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 Article
7.4.4.
7.2 PROVIDER CONTRACTS
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.
7.5 MEMBER PANEL REPORTS
7.5 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.
7.7 PROVIDER QUALIFICATIONS - GENERAL
The providers in HMO network must meet the following qualifications:
FQHC A Federally Qualified Health Center meets the standards
established by federal rules and procedures. The FQHC must
also be an eligible provider enrolled in the Medicaid.
--------------------------------------------------------------------------------
Physician An individual who is licensed to practice medicine as an
MD or a in DO the State of Texas either as a primary care
provider or in the area of specialization under which they
will provide medical services under
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contract with HMO; who is a provider enrolled in the
Medicaid; who has a valid Drug Enforcement Agency
registration number, and a Texas Controlled Substance
Certificate, if either is required in their practice.
--------------------------------------------------------------------------------
Hospital An institution licensed as a general or special hospital
by the State of Texas under Chapter 241 of the Health and
Safety Code which is enrolled as a provider in the Texas
Medicaid Program. HMO will require that all facilities in
the network used for acute inpatient specialty care for
people under age 21 with disabilities or chronic or
complex conditions will have a designated pediatric unit;
24 hour laboratory and blood bank availability; pediatric
radiological capability; meet JCAHO standards; and have
discharge planning and social service units.
--------------------------------------------------------------------------------
Non-Physician An individual holding a license issued by the
Practitioner applicable licensing agency of the State of Texas who
Provider is enrolled in the Texas Medicaid Program.
--------------------------------------------------------------------------------
Clinical An entity having a current certificate issued under the
Laboratory Federal Clinical Laboratory Improvement Act (CLIA), and is
enrolled in the Texas Medicaid Program.
--------------------------------------------------------------------------------
Rural Health An institution which meets all of the criteria for
Clinic (RHC) designation as a rural health clinic and is enrolled in
the Texas Medicaid Program.
--------------------------------------------------------------------------------
Local Health A local health department established pursuant to Health
Department and Safety Code, Title 2, Local Public Health
Reorganization Act Section 121. 031ff.
--------------------------------------------------------------------------------
Non-Hospital A provider of health care services which is licensed and
Facility credentialed to provide services and is enrolled in the
Provider Texas Medicaid Program.
--------------------------------------------------------------------------------
School Based Clinics located at school campuses that provide on site
Health Clinic primary and preventive care to children and adolescents.
(SBHC)
--------------------------------------------------------------------------------
Chemical A facility licensed by the Texas Commission on Alcohol and
Dependency Drug Abuse (TCADA) under Sec. 464.002 of the Health and
Treatment Safety Code to provide chemical dependency treatment.
Facility
--------------------------------------------------------------------------------
Chemical An individual licensed by TCADA under Sec. 504 of the
Dependency Occupations Code to provide chemical dependency treatment
Counselor or a master's level therapist (LMSW-ACP, LMFT or LPC) with
a minimum of two years of post-licensure experience in
chemical dependency treatment.
--------------------------------------------------------------------------------
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.
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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).
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 TDH. See Appendix D, Required Critical Elements, for specific
details regarding content requirements. HMO must submit a Member
Handbook to TDH for approval prior to the effective date of the
contract unless previously approved (see Article 3.4.1 regarding the
process for plan materials review).
8.4 MEMBER ID CARDS
8.4.2 HMO must issue a Member Identification Card (ID) to the Member within 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 which results in a change to the information
disclosed on the ID Card.
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 activities on behalf of HMO HHSC will notify
HMO of scheduled orientations.
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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.
10.1 MODEL MIS REQUIREMENTS
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 BIR 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 BIR 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 and/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
- An existing plan changes their processing system
10.1.3.3 Desk Review. HMO must complete and pass systems desk review prior to
onsite systems testing conducted by HHSC.
10.1.3.4 Onsite Review. HMO is required to provide a detailed and comprehensive
Disaster and Recovery Plan, and 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 weekly Systems Scan Call.
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
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coordination with plan's initial Readiness Review and any
major systems charge thereafter.
10.3 ENROLLMENT ELIGIBILITY SUBSYSTEM
(11) Send PCP assignment updates to HHSC or its designee, in the
format specified by HHSC or its designee. Updates can be sent
as often as daily but must be sent at least weekly.
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., Dec. 30, March 30,
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,
ANHCs, Limited Provider Networks) in its MCFS Report.
12.1.4 Final MCFS Reports. HMO must file two Final Managed Care
Financial-Statistical Reports after the end of the second
year of the contract for the first two-year portion of the
contract and again after the third year of the contract for
the third year (second portion) of the contract. The first
final report must reflect expenses incurred through the 90th
day after the end of the first two-year portion of the
contract and again after the end of the third year of the
contract for the third year (second portion) of the contract.
The first final report must be filed on or before the 120th
day after the end of each portion of the contract. The second
final report must reflect data completed through the 334th day
after the end of the second year of the contract for the first
two year portion of the contract and again after the end of
the third year of the contract for the third year (second
portion) of the contract and must be filed on or before the
365th day following the end of each portion of the contract
year.
12.5 PROVIDER NETWORK REPORTS
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.
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12.13 EXPEDITED PRENATAL OUTREACH REPORT
12.13 HMO must submit the Expedited Prenatal Outreach Report for
each monthly reporting period in accordance with a format
developed by HHSC in consultation with the HMOs. The report
must include elements that demonstrate the level of effort and
the outcomes of the HMO in outreaching to pregnant women for
the purpose of scheduling and/or completing the initial
obstetrical examination prior to 14 days after the receipt of
the daily enrollment file by the HMO. Each monthly report is
due by the last day of the month following each monthly
reporting period.
13.1 CAPITATION AMOUNTS
13.1.2 Delivery Supplemental Payment (DSP). The monthly capitation
amounts and the DSP amount are listed below.
---------------------------------------------------------------
Risk Group Monthly Capitation Amounts
---------------------------------------------------------------
TANF Adults $195.03
---------------------------------------------------------------
TANF Children > 12 Months of Age $ 82.78
---------------------------------------------------------------
Expansion Children > 12 Months $ 79.21
of Age
---------------------------------------------------------------
Newborns < or = 12 Months of Age $510.98
---------------------------------------------------------------
TANF Children < or = 12 Months $510.98
of Age
---------------------------------------------------------------
Expansion Children < or = 12 Months $510.98
of Age
---------------------------------------------------------------
Federal Mandate Children $ 66.69
---------------------------------------------------------------
CHIP Phase I $ 89.75
---------------------------------------------------------------
Pregnant Women $257.04
---------------------------------------------------------------
Disabled/Blind $ 14.00
Administration
---------------------------------------------------------------
Delivery Supplemental Payment: A one-time per pregnancy
supplemental payment for each delivery shall be paid to HMO as
provided below in the following amount: $3,060.18
13.1.3.1 Once HMO has received its capitation rates established by HHSC
for the second or third year of this contract, HMO may
terminate this contract as provided in Article 18.1.6.
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13.1.7 HMO renewal rates reflect program increases appropriated by
the 76th and 77th legislature for physician (to include
THSteps providers) and outpatient facility services. HMO must
report to HHSC any change in rates for participating
physicians (to include THSteps providers) and outpatient
facilities resulting from this increase. The report must be
submitted to HHSC at the end of the first quarter of the
FY2000, FY2001 and FY2002 contract years according to the
deliverables matrix schedule set for HMO.
13.2 EXPERIENCE REBATE TO THE STATE
13.2.1 For the contract period, HMO must pay to TDH an experience
rebate calculated in accordance with the tiered rebate method
listed below based on the excess of allowable HMO STAR
revenues over allowable HMO STAR expenses as measured by any
positive amount on Line 7 of "Part 1: Financial Summary, All
Coverage Groups Combined" of the annual Managed Care
Financial-Statistical Report set forth in Appendix I, as
reviewed and confirmed by TDH. TDH reserves the right to have
an independent audit performed to verify the information
provided by HMO.
--------------------------------------------------------------
Graduated Rebate Method
--------------------------------------------------------------
Net income before
taxes as a Percentage
of Revenues HMO Share State Share
--------------------------------------------------------------
0% - 3% 100% 0%
--------------------------------------------------------------
Over 3% - 7% 75% 25%
--------------------------------------------------------------
Over 7% - 10% 50% 50%
--------------------------------------------------------------
Over 10% - 15% 25% 75%
--------------------------------------------------------------
Over 15% 0% 100%
--------------------------------------------------------------
13.2.2.1 The experience rebate for the HMO shall be calculated by
applying the experience rebate formula in Article 13.2.1 to
the sum of the net income before taxes (Financial Statistical
Report, Part 1, Line 7) for all STAR Medicaid service areas
contracted between the State and HMO.
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13.2.4 Population-Based Initiatives (PBIs) and Experience Rebates:
HMO may subtract from an experience rebate owed to the State,
expenses for population-based health initiatives that have
been approved by HHSC. A population-based initiative (PBI) is
a project or program designed to improve some aspect of
quality of care, quality of life, or health care knowledge for
the Medicaid population that may also benefit the community as
a whole. Value-added service does not constitute a PBI.
Contractually required services and activities do not
constitute a PBI.
13.2.5 There will be two settlements for payment(s) of the experience
rebate for FY 2000-2001 and two settlements for payment(s) for
the experience rebate for FY 2002. The first settlement for
the specified tune period shall equal 100 percent of the
experience rebate as derived from Line 7 of Part 1 (Net Income
Before Taxes) of the first final Managed Care Financial
Statistical (MCFS) Report and shall be paid on the same day
the first final MCFS Report is submitted to HHSC for the
specified time period. The second settlement shall be an
adjustment to the first settlement and shall be paid to HHSC
on the same day that the second final MCFS Report is submitted
to HHSC for that specified time period 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 or review the MCFS report. If HHSC
determines that corrections to the MCFS reports are required,
based on a HHSC audit/review of other documentation acceptable
to HHSC, to determine an adjustment to the amount of the
second settlement, then final adjustment shall be made within
two years from the date that HMO submits the second final MCFS
report. HMO must pay the first and second settlements on the
due dates for the first and second final MCFS reports
respectively as identified in Article 12.1.4. HHSC may
adjust the experience rebate if HHSC determines HMO has paid
affiliates amounts for goods or services that are higher than
the fair market value of the goods and services in the service
area. Fair market value may be based on the amount HMO pays a
non-affiliate(s) or the amount another HMO pays for the same
or similar service in the service area. HHSC has final
authority in auditing and determining the amount of the
experience rebate.
13.3 PERFORMANCE OBJECTIVES\INCENTIVES
13.3.1 Preventive Health Performance Objectives. Preventive Health
Performance Objectives are contained in this contract at
Appendix K. HMO must accomplish the performance objectives or
a designated
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percentage in order to be eligible for payment of financial
incentives. Performance objectives are subject to change. HHSC
will consult with HMO prior to revising performance
objectives.
13.3.2 HMO will receive credit for accomplishing a performance
objective upon receipt of accurate encounter data required
under Article 10.5 and 12.2 of this contract and/or a
Detailed Data Element Report from HMO with report format as
determined by HHSC and aggregate data report by HMO in
accordance with a report format as determined by HHSC
(Performance Objective Report). Accuracy and completeness of
the Detailed Data Element Report and the Aggregate Data
Performance Objective Report will be determined by HHSC
through an HHSC audit of the HMO claims processing system. If
HHSC determines that the Detailed Data Element Report and
Performance Objectives Report are sufficiently supported by
the results of the HHSC audit, the payment of financial
incentives will be made to HMO. Conversely, if the audit
results do not support the reports as determined by HHSC, HMO
will not receive payment of the financial incentive. HHSC may
conduct provider chart reviews to validate the accuracy of the
claims data related to HMO accomplishment of performance
objectives. If the results of the chart review do not support
the HMO claims system data or the HMO Detailed Data Element
Report and the Performance Objectives Report, HHSC may recoup
payment made to the HMO for performance objectives incentives.
13.3.3 HMO will also receive credit for performance objectives
performed by other organizations if a network primary care
provider or the HMO retains documentation from the performing
organization which satisfies the requirements contained in
Appendix K of this contract.
13.3.4 HMO will receive performance objective bonuses for
accomplishing the following percentages of performance
objectives:
--------------------------------------------------------------
Percent of Each Performance Percent of Performance Objective
Objective Accomplished Allocations Paid to HMO
--------------------------------------------------------------
60% to 65% 20%
--------------------------------------------------------------
65% to 70% 30%
--------------------------------------------------------------
70% to 75% 40%
--------------------------------------------------------------
75% to 80% 50%
--------------------------------------------------------------
80% to 85% 60%
--------------------------------------------------------------
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--------------------------------------------------------------
85% to 90% 70%
--------------------------------------------------------------
90% to 95% 80%
--------------------------------------------------------------
95% to 100% 90%
--------------------------------------------------------------
100% 100%
--------------------------------------------------------------
13.3.5 HMO must submit the Detailed Data Element Report and the
Performance Objectives Report regardless of whether or not the
HMO intends to claim payment of performance objective bonuses.
13.3.6 Payment of performance objective bonus is contingent upon
availability of appropriations. If appropriations are not
available to pay performance objective bonuses as set out
below, HHSC will equitably distribute all available funds to
each HMO that has accomplished performance objectives.
13.3.7 In addition to the capitation amounts set forth in Article
13.1.2, a performance premium of two dollars ($2.00) per
Member month will be allocated by HHSC for the accomplishment
of performance objectives.
13.3.8 The HMO must submit the Performance Objectives Report and the
Detailed Data Element Report as referenced in Article 13.3.2,
within 150 days from the end of each State fiscal year.
Performance premiums will be paid to HMO within 120 days after
the State receives and validates the data contained in each
required Performance Objectives Report.
13.3.9 The performance objective allocation for HMO shall be assigned
to each performance objective, described in Appendix K, in
accordance with the following percentages:
-----------------------------------------------------------
Percent of Performance Objective
EPSDT SCREENS Incentive Fund
-----------------------------------------------------------
1. < 12 months 12%
-----------------------------------------------------------
2. 12 to 24 months 12%
-----------------------------------------------------------
3. 25 months - 20 years 20%
-----------------------------------------------------------
-----------------------------------------------------------
Percent of Performance Objective
IMMUNIZATIONS Incentive Fund
-----------------------------------------------------------
4. < 12 months 7%
-----------------------------------------------------------
5. 12 to 24 months 5%
-----------------------------------------------------------
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-----------------------------------------------------------
Percent of Performance Objective
ADULT ANNUAL VISITS Incentive Fund
-----------------------------------------------------------
6. Adult Annual Visits 3%
-----------------------------------------------------------
-----------------------------------------------------------------
Percent of Performance Objective
PREGNANCY VISITS Incentive Fund
-----------------------------------------------------------------
7. Initial prenatal exam 15%
-----------------------------------------------------------------
8. Visits by Gestational Age 14%
-----------------------------------------------------------------
9. Postpartum visit 12%
-----------------------------------------------------------------
13.3.10 Compass 21 Encounter Data Conversion Performance Incentive. A
Compass 21 encounter data conversion performance incentive
payment will be paid by the State to each HMO that achieves
the identified conversion performance standard for at least
one month in the first quarter of SFY 2002 as demonstration of
successful conversion to the C21 system. The encounter data
conversion performance standard is as follows:
----------------------------------------------------------------
Encounter Data Conversion
Performance Objective Performance Incentive
----------------------------------------------------------------
Percentage of encounters submitted 65%
that are successfully accepted into
C21
----------------------------------------------------------------
13.3.10.1 The amount of the incentive will be based on the total amount
identified by the state for the encounter data conversion
performance incentive pool ("Pool"). The pool will be equally
distributed between all the HMOs that achieve the performance
objective within the first quarter of SFY 2002. HMOs with
multiple contracts with HHSC are eligible to receive only one
allocation from the Pool. Required HMO performance for the
identified objectives will be verified by HHSC for accuracy
and completeness. The incentive will be paid only after HHSC
has verified that HMO performance has met the required
performance standard. Payments will be made in the second
quarter of the fiscal year.
13.5.4 NEWBORN AND PREGNANT WOMAN PAYMENT PROVISIONS
13.5.4 Newborns who appear on the MAXIMUS daily enrollment file but
do not appear on the MAXIMUS 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
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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.
15.6 ASSIGNMENT
15.6 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 Article 15.7 can be
sent to Members. The assigning HMO must also submit a
transition plan, as set out in Article 18.2.1, subject to
HHSC 's approval.
16.3 DEFAULT BY HMO
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 Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Assess liquidated money damages as set out in Article
18.4; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
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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
its 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
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 Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Assess liquidated money damages as set out in Article
18.4; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
18.1.6 TERMINATION BY HMO
18.1.6 HMO may terminate this contract if HHSC fails to pay HMO as
required under Article XIII 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 second or third
contract years. 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.
18.2 DUTIES OF CONTRACTING PARTIES UPON TERMINATION
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 or third contract years
as set out in Article ▇▇.▇.▇.▇:
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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 Article ▇▇.▇.▇.▇:
Article XIX TERM
19.1 The effective date of this contract is August 30, 1999. This
contract will terminate on August 31, 2002, unless terminated
earlier as provided for elsewhere in the contract.
4. The Appendices are amended by replacing page 10 of Appendix A "Standards
for Quality Improvement Programs" to incorporate a change in item F, number
1 on recredentialing.
5. The Appendices are amended by deleting Appendix D, "Required Critical
Elements, " and replacing it with new Appendix D, "Required Critical
Elements", as attached.
AGREED AND SIGNED by an authorized representative of the parties on August 24
2001.
Health and Human Services Commission AMERIGROUP Texas, Inc.
By: /s/ ▇▇▇ ▇. ▇▇▇▇▇▇▇ By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇,
------------------------------------ ------------------------
▇▇▇ ▇. ▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
President & CEO
Approved as to Form:
[ILLEGIBLE]
----------------------------
Office of General Counsel
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AMENDMENT NO. 9
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
THE HEALTH AND HUMAN SERVICES COMMISSION AND HMO
This Amendment No. 9 is entered into between the Health and Human Services
Commission (HHSC) and AMERIGROUP Texas, Inc. (HMO) in ▇▇▇▇▇▇ Service Area, to
amend the 1999 Contract for Services between the Health and Human Services
Commission and HMO. The effective date of this Amendment is the date HHSC Signs
this Amendment. All other contract provisions remain in full force and effect.
The Parties agree to amend the Contract as follows:
Article XVIII is amended to read as follows:
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
XVIII.
15.2.2 This contract must be amended if either party discovers a
material omission of a negotiated or required term, which is
essential to the successful performance or maintaining
compliance with the terms of the contract. The party
discovering the omission must notify the other party of the
omission in writing as soon as possible after discovery. If
there is a disagreement regarding whether the omission was
intended to be a term of the contract, the parties must submit
the dispute to dispute resolution under Article 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 Article 15.2.6.
15.2.6 Change Request Process.
October 30, 2001
1 of 3
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 Article 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 which includes
the State's estimated fiscal impact on the HMO, if available
("Change Order 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
which 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 Articles 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.
October 30, 2001
2 of 3
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).
AGREED AND SIGNED by an authorized representative of the parties on December 13
2001.
Health and Human Services Commission AMERIGROUP Texas, Inc.
By: /s/ ▇▇▇ ▇. ▇▇▇▇▇▇▇ By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇. Jr.
------------------ -------------------------
▇▇▇ ▇. ▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇. Jr.
President & CEO
Approved as to Form:
/s/ [ILLEGIBLE]
------------------
Office of General Counsel
October 30, 2001
3 of 3
AMENDMENT NO. 10
TO THE
1999 CONTRACT FOR SERVICES
BETWEEN
THE HEALTH AND HUMAN SERVICES COMMISSION AND HMO
This Amendment No. 10 is entered into between the Health and Human Services
Commission (HHSC) and AMERIGROUP Texas, Inc. (HMO), to amend the Contract for
Services between the HHSC and HMO in the ▇▇▇▇▇▇ Service Area. The effective date
of this amendment is January 1, 2002. The Parties agree to amend the Contract as
follows:
HHSC has contracts with multiple managed care organizations in the ▇▇▇▇▇▇
Service Area for the provision of Medicaid Managed Care Services, including
contracts with MethodistCare, Inc. (MethodistCare) and with Amerigroup Texas
Inc. (Amerigroup). Pursuant to a ▇▇▇▇ of Sale and Assignment and an Assumption
Agreement, each between Amerigroup and MethodistCare and dated November 15, 2001
(collectively, the "▇▇▇▇ of Sale and Assumption Agreements") and with the
approval of HHSC, the MethodistCare contract was assigned to Amerigroup with an
effective date of January 1, 2002 (the Effective Date). The result is the
existence of two contracts between HHSC and Amerigroup, which cover the same
time period and the same subject matter. It is the intent of the parties to have
only one contract and that the MethodistCare contract be merged into the
existing Amerigroup contract.
Therefore, in consideration of the forgoing recitals, and for other good and
valuable consideration, the receipt and sufficiency of which are hereby
expressly acknowledged, the parties hereby agree as follows:
As of the Effective Date of the assignment of the MethodistCare contract, all of
MethodistCare's right, title and interest in and to the MethodistCare contract
is transferred to Amerigroup and, except for the obligations and liabilities for
which MethodistCare shall remain solely responsible as provided under the ▇▇▇▇
of Sale and Assumption Agreements, Amerigroup assumes and shall be solely
responsible for the obligations of MethodistCare's contract accruing from that
date forward. As of the Effective Date, the MethodistCare contract is hereby
merged into the existing Amerigroup contract between Amerigroup and HHSC so that
there is only one contract between the parties and all services to members of
the Amerigroup health plan, including any MethodistCare members that transition
to Amerigroup, will be delivered according to that contract.
AGREED AND SIGNED by an authorized representative of the parties on DEC 12 2001.
Health and Human Services Commission AmerigroupTexas, Inc.
By: /s/ ▇▇▇ ▇. ▇▇▇▇▇▇▇ By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇. Jr.
------------------ -------------------------
▇▇▇ ▇. ▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇. Jr.
President & CEO
Approved as to Form:
/s/ [ILLEGIBLE]
------------------
Office of General Counsel
HHSC ▇▇▇▇▇▇▇▇ ▇▇. ▇▇▇-▇▇-▇▇▇
▇▇▇▇▇ ▇▇ ▇▇▇▇▇
▇▇▇▇▇▇ OF ▇▇▇▇▇▇
AMENDMENT 12
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
AMERIGROUP TEXAS, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR PROGRAM
IN THE
▇▇▇▇▇▇ SERVICE DELIVERY AREA
THIS CONTRACT AMENDMENT (the "Amendment") is entered into between the
HEALTH & HUMAN SERVICES COMMISSION ("HHSC"), an administrative agency within the
executive department of the State of Texas, and AMERIGROUP TEXAS, INC.
("CONTRACTOR"), a health maintenance organization organized under the laws of
the State of Texas, possessing a certificate of authority issued by the Texas
Department of Insurance to operate as a health maintenance organization, and
having its principal office at ▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇, ▇▇▇▇▇▇,
▇▇▇▇▇ ▇▇▇▇▇. HHSC and CONTRACTOR may be referred to in this Amendment
individually as a "Party" and collectively as the "Parties."
The Parties hereby agree to amend their Agreement as set forth in
Article 2 of this Amendment.
ARTICLE 1. PURPOSE.
SECTION 1.01 AUTHORIZATION.
This Amendment is executed by the Parties in accordance with Article
15.2 of the Agreement.
SECTION 1.02 GENERAL EFFECTIVE DATE OF CHANGES.
This Amendment is effective November 1, 2002.
ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES
SECTION 2.01 MODIFICATION OF ARTICLE 2 DEFINITIONS
The following term is added to amend the definitions set forth in
Article 2:
"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. The Contract Period consists of the following Experience
Rebate Periods:
- September 1, 1999 through August 31, 2001
(1st Experience Rebate Period)
- September 1, 2001 through August 31, 2002
(2nd Experience Rebate Period)
- September 1, 2002 through August 31, 2003
(3rd Experience Rebate Period)"
HHSC Contract ▇▇▇-▇▇-▇▇▇
Page 1 of 4
SECTION 2.02 MODIFICATION TO SECTION 13.2, EXPERIENCE REBATE TO STATE
Section 13.2 is replaced with the following language:
"13.2.1 HMO must pay to HHSC an experience rebate
for each Experience Rebate Period. 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 TOTAL
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 Article 13.2.1 as
follows:
For the 1st Experience Rebate Period, to the Net
Income Before Taxes for each STAR Medicaid service area
contracted between HHSC and HMO. The HMO will separately
calculate the experience rebate for each service area, and
losses in one service area cannot be used to offset Net Income
Before Taxes in another service area. Losses from the 1st
Experience Rebate Period can be carried forward to the 2nd
Experience Rebate Period for the same service area.
For the 2nd Experience Rebate Period, to the sum of
the Net Income Before Taxes for all STAR Medicaid service
areas contracted between HHSC and HMO. Losses from the 2nd
Experience Rebate Period can be carried forward to the 3rd
Experience Rebate Period.
For the 3rd Experience Rebate Period, to the sum of
the Net Income Before Taxes for all CHIP, STAR Medicaid, and
STAR+PLUS Medicaid service 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
HHSC Contract ▇▇▇-▇▇-▇▇▇
Page 2 of 4
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 Population-Based Initiatives (PBIs) and
Experience Rebates: HMO may subtract from an experience rebate
owed to HHSC, expenses for population-based health initiatives
that have been approved by HHSC. A PBI is a project or program
designed to improve some aspect of quality of care, quality of
life, or health care knowledge for the Medicaid population
that may also benefit the community as a whole. Value-added
service does not constitute a PBI. Contractually required
services and activities do not constitute a PBI.
13.2.5 There will be two settlements for payment(s)
of the experience rebate for the 1st Experience Rebate Period,
two settlements for payment(s) of the experience rebate for
the 2nd Experience Rebate Period, and two settlements for
payments) of the experience rebate for the 3rd Experience
Rebate Period. Settlement payments are payable to HHSC. The
first settlement for the specified Experience Rebate Period
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 for the specified time period. 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 for that specified time period 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 Article 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."
ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES
The Parties contract and agree that the terms of the Agreement will
remain in effect and continue to govern except to the extent modified in this
Amendment.
By signing this Amendment, the Parties expressly understand and agree
that this Amendment is hereby made a part of the Agreement as though it were set
out word for word in the Agreement.
HHSC Contract ▇▇▇-▇▇-▇▇▇
Page 3 of 4
IN WITNESS HEREOF, HHSC AND THE CONTRACTOR HAVE EACH CAUSED THIS
AMENDMENT TO BE SIGNED AND DELIVERED BY ITS DULY AUTHORIZED REPRESENTATIVE.
AMERIGROUP TEXAS, INC. HEALTH & HUMAN SERVICES COMMISSION
By: ________________________________ By: ______________________________
▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇. ▇▇▇ ▇. ▇▇▇▇▇▇▇
President and CEO Commissioner
Date: _________________________________ Date: ____________________________
HHSC Contract ▇▇▇-▇▇-▇▇▇
Page 4 of 4
AMENDMENT 13
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
AMERIGROUP TEXAS, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR PROGRAM
IN THE
▇▇▇▇▇▇ SERVICE DELIVERY AREA
1
AMENDMENT 13
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION AND AMERIGROUP TEXAS, INC.
FOR HEALTH SERVICES TO THE MEDICAID STAR PROGRAM
IN THE ▇▇▇▇▇▇ SERVICE DELIVERY AREA
TABLE OF CONTENTS
Page
ARTICLE 1. PURPOSE...................................................................................... 1
Section 1.01 Authorization.................................................................. 1
Section 1.02 General effective date of changes.............................................. 1
ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES.................................................. 1
Section 2.01 General........................................................................ 1
Section 2.02 Modification of Article 2, Definitions......................................... 2
Section 2.03 Modification to Article 3.2, Non-Provider Subcontracts......................... 4
Section 2.04 Modification to Section 3.5, Records Requirements and Records Retention........ 4
Section 2.05 Modification to Section 4.10, Claims Processing Requirements................... 5
Section 2.06 Addition to Article 5, Statutory and Regulatory Compliance Requirements........ 5
Section 2.07 Section 6.1, Scope of Services................................................. 5
Section 2.08 Addition to Section 6.4, Continuity of Care and Out-of-Network Providers....... 6
Section 2.09 Modification of Section 6.5, Emergency Services................................ 7
Section 2.10 Modification of Section 6.13, People with Disabilities, Special Health Care
Needs or Chronic or Complex Conditions......................................... 10
Section 2.11 Modification of Section 7.1.3, Time frames for Access Requirements............. 14
Section 2.12 Modification of Section 7.2, Provider Contracts................................ 14
Section 2.13 Modification of Section 7.7, Provider Qualifications - General................. 14
Section 2.14 Modification of Section 7.8, Primary Care Providers............................ 18
Section 2.15 Modification of Section 8.2, Member Handbook................................... 19
Section 2.16 Modification of Section 8.5, Member Complaints................................. 19
i
Section 2.17 Deletion of Section 8.6, Member Notice, Appeals and Fair Hearings.............. 30
Section 2.18 Modification of Section 9.01, Marketing Material Media and Distribution........ 30
Section 2.19 Modification of Section 10.7, Utilization/Quality Improvement Subsystem........ 30
Section 2.20 Modification of Section 10.12, Health Insurance Portability and
Accountability Act (HIPAA) Compliance.......................................... 30
Section 2.21 Modification of Section 11.1, Quality Assessment and Performance Improvement
Program........................................................................ 31
Section 2.22 Modification to Article 11, Quality Assurance and Quality Improvement Program.. 31
Section 2.23 Modification of Article 12, Reporting Requirements............................. 32
Section 2.24 Modification of Section 12.10, Quality Improvement Reports..................... 33
Section 2.25 Modification of Section 13.1, Capitation Amounts............................... 33
Section 2.26 Modification of Section 13.3, Performance Objectives........................... 34
Section 2.27 Modification of Section 13.5, Newborn and Pregnant Women Payment Provisions.... 34
Section 2.28 Modification of Section 14.1, Eligibility Determination........................ 35
Section 2.29 Modification of Article 15, General Provisions................................. 35
Section 2.30 Modification of Section 16.3, Default by HMO................................... 35
Section 2.31 Modification of Section 18.8, Civil Monetary Penalties......................... 36
Section 2.32 Modification of Article 19, Term............................................... 36
Section 2.33 Modification to Appendix A, Standards for Quality Improvement Programs......... 36
Section 2.34 Modification to Appendix D, Critical Elements.................................. 36
Section 2.35 Modification of Appendix E, Transplant Facilities.............................. 36
Section 2.36 Addition of New Appendix O, Standard for Medical Records....................... 36
Section 2.37 Modification to Appendix K, Performance Objectives............................. 37
ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES................................................. 38
ii
HHSC CONTRACT NO. 529-03-035-M
STATE OF TEXAS
COUNTY OF ▇▇▇▇▇▇
AMENDMENT 13
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
AMERIGROUP TEXAS, INC.
FOR HEALTH SERVICES
TO THE
STAR PROGRAM
IN THE
▇▇▇▇▇▇ SERVICE DELIVERY AREA
THIS CONTRACT AMENDMENT (the "Amendment") is entered into between the
HEALTH & HUMAN SERVICES COMMISSION ("HHSC"), an administrative agency within the
executive department of the State of Texas, and AMERIGROUP Texas, Inc.
("CONTRACTOR"), a health maintenance organization organized under the laws of
the State of Texas, possessing a certificate of authority issued by the Texas
Department of Insurance to operate as a health maintenance organization, and
having its principal office at ▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇, ▇▇▇▇▇▇,
▇▇▇▇▇ ▇▇▇▇▇. HHSC and CONTRACTOR may be referred to in this Amendment
individually as a "Party" and collectively as the "Parties."
The Parties hereby agree to amend their Agreement as set forth in
Article 2 of this Amendment.
ARTICLE 1. PURPOSE
SECTION 1.01 AUTHORIZATION.
This Amendment is executed by the Parties in accordance with Article
152 of the Agreement.
SECTION 1.02 GENERAL EFFECTIVE DATE OF CHANGES.
This Amendment is effective August 13, 2003.
ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES
SECTION 2.01 GENERAL
This Amendment is to incorporate Federal regulations pertaining to
recent amendments to the Balanced Budget Act. These regulations are found in 42
C.F.R. Parts 400, 430, 431, 434, 435, 438, 440, and 447.
1
SECTION 2.02 MODIFICATION OF ARTICLE 2, DEFINITIONS
The following provisions amend, mode and add to the definitions set
forth in Article 2:
"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 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.
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.
COLD-CALL MARKETING means any unsolicited personal
contact by the HMO with a potential Member for the purpose of
marketing.
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.
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 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.
2
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.
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.
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.
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 fire STAR Program.
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)(iii) to improve or resolve the Member's
condition.
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.
3
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."
SECTION 2.03 MODIFICATION TO ARTICLE 3.2, NON-PROVIDER SUBCONTRACTS
Section 3.2 is modified to amend Section 3.2.4.3 add new Sections 3.2.6
and 3.2.7 as follows:
"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.
3.2.6 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 incentives to
deny, limit, reduce, or discontinue medically necessary
services to any Member."
SECTION 2.04 MODIFICATION TO SECTION 3.5, RECORDS REQUIREMENTS AND RECORDS
RETENTION
Section 3.5.5, Medical Records, is modified as follows:
"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."
4
SECTION 2.05 MODIFICATION TO SECTION 4.10, CLAIMS PROCESSING REQUIREMENTS
Section 4.10.8 is modified as follows:
"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)."
SECTION 2.06 ADDITION TO ARTICLE 5, STATUTORY AND REGULATORY COMPLIANCE
REQUIREMENTS
Section 5.11 is added as follows:
"5.11 DATA CERTIFICATION
5.11.1 In accordance with 42 C.F.R.Sections
438.604 and 438.606, 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."
SECTION 2.07 SECTION 6.1, SCOPE OF SERVICES
5
Section 6.1 is modified to add new section 6.1.9 as follows:
"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 ▇▇▇▇ 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)(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)."
SECTION 2.08 ADDITION TO SECTION 6.4, CONTINUITY OF CARE AND OUT-OF-NETWORK
PROVIDERS
Section 6.4 is modified to add new Sections 6.4.6 and 6.4. 7 as
follows:
"6.4.6 HMO must provide Members with timely and
adequate access to out-of-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(6)(4). HM0 will not be obligated to provide a
Member with access to
6
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(6)(3)."
SECTION 2.09 MODIFICATION OF SECTION 6.5, EMERGENCY SERVICES
Section 6.5 is deleted in its entirety and replaced with the following
language:
"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 lay person definition
of an emergency medical condition and claims adjudication
processes required under Section 7.6 of this agreement and 42
C.F.R. Section 438.114.
HMO will pay a reasonable and customary amount for
services for all out-of-network emergency services provider
claims with dates of service between September 1, 2002 and
November 30, 2002. HMO must forward any complaints submitted
by out-of-network
7
emergency services providers during this time to HHSC. HHSC
will review all complaints and determine whether payments were
reasonable and customary. HHSC will direct the HMO to pay a
reasonable and customary amount, as determined by HHSC, if it
concludes that the payments were not reasonable and customary
for the provider.
6.5.2.2 For all out-of-network emergency services
provider claims with dates of service on or after December 1,
2002, HMO must pay providers a reasonable and customary amount
consistent with a methodology approved by HHSC. HMO must
submit its methodology, along with any supporting
documentation, to HHSC by September 30, 2002. HHSC will review
and respond to the information by November 15, 2002. 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
8
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(b)&(c). 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 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(b)&(e) and 42 C.F.R. 422.113(c)(iii).
The HMO is financially responsible for poststabilization 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
preapproval within 1 hour;
(b) the HMO cannot be contacted;
9
(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."
SECTION 2.10 MODIFICATION OF SECTION 6.13, PEOPLE WITH DISABILITIES, SPECIAL
HEALTH CARE NEEDS OR CHRONIC OR COMPLEX CONDITIONS
Section 6.13 is deleted in its entirety and replaced with the
following:
"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
10
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 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
11
boardeligible 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 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
12
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 Article 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,
13
special health 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."
SECTION 2.11 MODIFICATION OF SECTION 7.1.3, TIME FRAMES FOR ACCESS REQUIREMENTS
Section 7.1.3 is amended to add new Section 7.1.3.5, as follows:
"7.1.3.5 Prenatal Care within 2 weeks of request."
SECTION 2.12 MODIFICATION OF SECTION 7.2, PROVIDER CONTRACTS
Section 7.1.8.2.1 is added and Section 7.2.9.2 is modified, as follows:
"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).
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 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.
7.2.12 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."
SECTION 2.13 MODIFICATION OF SECTION 7.7, PROVIDER QUALIFICATIONS - GENERAL
The qualifications for a "Hospital" in Section 7.7 is replaced with the
following language. Section 7.7 is retitled Section 7.7.1 and new
Section 7.7.2, Provider Credentialing and Recredentialing is added to
Section 7.7:
"7.7.1 PROVIDER QUALIFICATIONS - GENERAL
14
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PROVIDER QUALIFICATION
--------------------------------------------------------------------------------
Hospital An institution licensed as a general or special hospital by the
State of Texas under Chapter 241 of the Health and Safety Code,
which is enrolled as a provider in the Texas Medicaid Program.
HMO will require that all facilities in the network used for
acute inpatient specialty care for people under age 21 with
disabilities, 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."
--------------------------------------------------------------------------------
"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 their services.
7.7.2.1 Written Policies and Procedures. MCO has
written policies and procedures for the credentialing process
that includes MCO'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
15
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 DEA or CDS 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/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;
j) Any censure by the State or County Medical
Association;
k) MCO 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 practitioners current ability to practice.)
m) Any physical or mental health problems that may
affect current ability to provide health care;
16
n) Any history of chemical dependency/substance
abuse;
o) History of loss of license and/or felony
convictions;
p) History of loss or limitation of privileges or
disciplinary activity; and
q) An attestation to correctness/completeness of the
application.
7.2.2.6 There is an initial visit to each potential
primary care practitioners office, including documentation of
a structured review of the site and medical record keeping
practices to ensure conformance with MCO's standards.
7.7.2.7 Recredentialing. A process for the periodic
reverification of clinical credentials (recredentialing,
reappointment, or recertification) is described in MCO's
policies and procedures.
7.7.2.8 There is evidence that the procedure is
implemented at least every three years.
7.7.2.9 MCO 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 "E-1"
through "E-7" and item "E-13" above.
7.7.2.10 The recredentialing, recertification or
reappointment process also includes review of data from: a)
Member complaints and b) results of quality reviews.
7.7.2.11 Delegation of Credentialing Activities. If
MCO delegates credentialing (and recredentialing,
recertification, or reappointment) activities, there is a
written description of the delegated activities, and the
delegate's accountability for these activities. There is also
evidence that the delegate accomplished the credentialing
activities. MCO monitors the
17
effectiveness of the delegate's credentialing and
reappointment or recertification process.
7.7.2.12 Retention of Credentialing Authority. MCO
retains the right to approve new providers and sites and to
terminate or suspend individual providers. MCO has policies
and procedures for the suspension, reduction or termination of
practitioner privileges.
7.7.2.13 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.
MCO will implement and maintain policies and procedures for
disciplinary actions including reducing, suspending, or
terminating a practitioner's privileges.
7.72.14 Appeals Process. There is a provider
appellate process for instances where MCO chooses to reduce,
suspend or terminate a practitioner's privileges with the
organization.
SECTION 2.14 MODIFICATION OF SECTION 7.8, PRIMARY CARE PROVIDERS
Section 7.8.1.1 is added and Sections 7.8.8 and 7.8.11.4 are modified
with the following language:
"7.8.1.1 HMO must provide supporting documentation,
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(b). 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.).
7.8.8 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
18
the request for a specialist to serve as a PCP for a Member
with disabilities, special health care needs, or chronic or
complex conditions.
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."
SECTION 2.15 MODIFICATION OF SECTION 8.2, MEMBER HANDBOOK
Section 8.2.4 is added with the following language:
"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."
SECTION 2.16 MODIFICATION OF SECTION 8.5, MEMBER COMPLAINTS
Section 8.5 is deleted in its entirety and replaced with the following
language:
"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
19
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
maybe 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 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
20
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.
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
21
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
22
require that individuals who make decisions on appeals were
not 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
23
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 bow 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 for
providing this information, end 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
24
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.
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.
25
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
26
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;
27
(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;
(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).
28
(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,
(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."
29
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."
SECTION 2.17 DELETION OF SECTION 8.6, MEMBER NOTICE, APPEALS AND FAIR HEARINGS
Section 8.6 is deleted in its entirety. (Information concerning Member
appeals and fair hearings is now located in Section 8.5 above.)
8.6 [deleted]
SECTION 2.18 MODIFICATION OF SECTION 9.01, MARKETING MATERIAL MEDIA AND
DISTRIBUTION
New Section 9.1.1 is added as follows:
"9.1.1 HMO may not make any assertion or statement
(orally or in writing) it is endorsed by the CMS, a Federal or
State government or agency, or similar entity."
SECTION 2.19 MODIFICATION OF SECTION 10.7, UTILIZATION/QUALITY IMPROVEMENT
SUBSYSTEM
In Section 10.7, requirements 5 and 9 from the "Functions and Features"
provision are deleted.
SECTION 2.20 MODIFICATION OF SECTION 10.12, HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT (HIPAA) COMPLIANCE
Section 10.12 is modified to add new Section 10.12.1 as follows:
"10.12.1 HMO must provide its Members with a privacy
notice as required by HIPAA. The 4th to 6th
30
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."
SECTION 2.21 MODIFICATION OF SECTION 11.1, QUALITY ASSESSMENT AND PERFORMANCE
IMPROVEMENT PROGRAM
Sections 11.1, and 11.5 are deleted and replaced with the following
language:
"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.
11.5 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."
SECTION 2.22 MODIFICATION TO ARTICLE 11, QUALITY ASSURANCE AND QUALITY
IMPROVEMENT PROGRAM
Article 11 is modified to add new Section 11.7, Practice Guidelines.
"11.7 PRACTICE GUIDELINES
In accordance with 42 C.F.R. Section 438.236, HMO
must adopt practice guidelines, that are based on valid &
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
31
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."
SECTION 2.23 MODIFICATION OF ARTICLE 12, REPORTING REQUIREMENTS
Section 12.6, Member Complaints is replaced with the following
language. Sections 12.8, Utilization Management Reports - Behavioral
Health and 12.9, Utilization Management Reports - Physical Health are
deleted and replaced with new Section 12.8, Utilization Management
Reports, as follows:
"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.
12.8 UTILIZATION MANAGEMENT REPORTS
12.8.1 Written Program Description. MCO has a
written utilization management program description, which
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.
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:
12.8.4 Qualified medical professionals supervise
preauthorization and concurrent review decisions.
32
12.8.5 Efforts are made to obtain all necessary
information, including pertinent clinical information, and
consult with the treating physician as appropriate.
12.9 [deleted]"
SECTION 2.24 MODIFICATION OF SECTION 12.10, QUALITY IMPROVEMENT REPORTS
Sections 12.10.1 through 12.10.3 are deleted. Sections 12.10.5 and
11.10.6 are added as follows:
"12.10.1 [deleted]
12.10.2 [deleted]
12.10.3 [deleted]
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."
SECTION 2.25 MODIFICATION OF SECTION 13.1, CAPITATION AMOUNTS
Section 13.1.2 is modified as follows:
13.1.2 The monthly capitation amorous and the
Delivery Supplemental payment (DSP) amount, effective as of
September 1, 2003, are listed below,
▇▇▇▇▇▇ SDA MONTHLY
RISK GROUP CAPITATION AMOUNTS
------------------------------------------------------------------
TANF CHILDREN (> 1 YEAR OF AGE) $ 82.33
------------------------------------------------------------------
TANF ADULTS $176.96
------------------------------------------------------------------
PREGNANT WOMEN $247.00
------------------------------------------------------------------
NEWBORNS* (UP TO 12 MONTHS OF AGE) $442.68
------------------------------------------------------------------
EXPANSION CHILDREN (> 1 YEAR OF AGE) $ 95.78
------------------------------------------------------------------
FEDERAL MANDATE CHILDREN $ 69.37
------------------------------------------------------------------
DISABLED/BLIND ADMINISTRATION $ 14.00
------------------------------------------------------------------
* Includes TANF Child & Expansion Children up to 12 months of Age.
33
Delivery Supplemental Payment. A one-time per
pregnancy supplemental payment for each delivery
shall be paid to HMO as provided below in the
following amount: $3,060.18.
SECTION 2.26 MODIFICATION OF SECTION 13.3, PERFORMANCE OBJECTIVES
Section 13.3.1 is amended as follows, and Sections 13.3.2 - 13.3.10 are
deleted in their entirety.
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.
13.3.2 [deleted]
13.3.3 [deleted]
13.3.4 [deleted]
13.3.5 [deleted]
13.3.6 [deleted]
13.3.7 [deleted]
13.3.8 [deleted]
13.3.9 [deleted]
13.3.10 [deleted]
13.3.10.1 [deleted]
SECTION 2.27 MODIFICATION OF SECTION 13.5, NEWBORN AND PREGNANT WOMEN PAYMENT
PROVISIONS
Section 13.5.5 is modified to comply with HIPAA requirements, as
follows:
"13.5.5 The Enrollment Broker will provide a daily
enrollment file, which 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, which can be used to reconcile the
pregnant women daily enrollment file
34
with the monthly enrollment, capitation and capitation
adjustment files."
SECTION 2.28 MODIFICATION OF SECTION 14.1, ELIGIBILITY DETERMINATION
Section 14.1.2.8 is modified as follows and 14.1.2.9 is deleted:
"14.1.2.8 FEDERAL MANDATE CHILDREN (MAO) - Children
aged 6-18 whose families' income is below 100% Federal Poverty
Income Limit.
14.1.2.9 [deleted]"
SECTION 2.29 MODIFICATION OF ARTICLE 15, GENERAL PROVISIONS
Article 15 is modified to add new Section 15.14, Global Drafting
Conventions, as follows:
"15.14 GLOBAL DRAFTING CONVENTIONS.
15.14.1 The teams "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 roles 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."
SECTION 2.30 MODIFICATION OF SECTION 16.3, DEFAULT BY HMO
Section 16.3.4, Failure to Comply with Federal Laws and Regulations, is
modified to add Section 16.3.4.7 with the following language:
"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, pursuant to 42
C.F.R. 438.102(a).
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SECTION 2.31 MODIFICATION OF SECTION 18.8, CIVIL MONETARY PENALTIES
Sections 18.8.2 and 18.8.7 are modified as follows:
"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)
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"
SECTION 2.32 MODIFICATION OF ARTICLE 19, TERM
Section 19.1 is modified as follows:
"19.1 The effective date of this contract is
August 31, 1999. This contract and all amendments thereto will
terminate on August 31, 2004, unless extended or terminated
earlier as provided for elsewhere in this contract."
SECTION 2.33 MODIFICATION TO APPENDIX A, STANDARDS FOR QUALITY IMPROVEMENT
PROGRAMS
Appendix A is replaced with the attached Appendix A
and Attachment A-A.
SECTION 2.34 MODIFICATION TO APPENDIX D, CRITICAL ELEMENTS
Appendix D is replaced with the attached Appendix D.
SECTION 2.35 MODIFICATION OF APPENDIX E, TRANSPLANT FACILITIES
Appendix E is replaced with the attached Appendix E.
SECTION 2.36 ADDITION OF NEW APPENDIX O, STANDARD FOR MEDICAL RECORDS
New Appendix O is added to the contract with the
attached Appendix O.
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SECTION 2.37 MODIFICATION TO APPENDIX K, PERFORMANCE OBJECTIVES
Appendix K is replaced with the attached Appendix K.
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ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES
The Parties contract and agree that the terms of the Agreement will
remain in effect and continue to govern except to the extent modified in this
Amendment.
By signing this Amendment, the Parties expressly understand and agree
that this Amendment is hereby made a part of the Agreement as though it were set
out word for word in the Agreement.
IN WITNESS HEREOF, HHSC AND THE CONTRACTOR HAVE EACH CAUSED THIS
AMENDMENT TO BE SIGNED AND DELIVERED BY ITS DULY AUTHORIZED REPRESENTATIVE.
AMERIGROUP TEXAS, INC. HEALTH & HUMAN SERVICES COMMISSION
By: ______________________________ By: ______________________________
▇▇▇▇▇. ▇. ▇▇▇▇▇▇▇, ▇▇. ▇▇▇▇▇▇ ▇▇▇▇▇▇▇
President and CEO Commissioner
Date: ____________________________ Date: ____________________________
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